BURNOUT AND COPING STRATEGIES AMONG FUTURE HEALTHCARE PROFESSIONALS: A STRUCTURAL EQUATION MODELLING APPROACH

Background/Aim. To reduce the risk of burnout development of medical professionals, it is important to identify the contributing factors as early as in their schooling years. The aim of this research is to propose a model that will determine the relationship between the coping strategies medical high school and medical faculty students use, and burnout. Methods . The cross-sectional study included 164 medical high school students (80.5% female and 19.5% male students) and 344 students of the University of Belgrade – Faculty of Medicine (76.9% female and 23.1% male students). The model exploring the relationship between coping strategies (measured by Brief COPE scale) and burnout (measured by CBI-S scale) was tested using structural equation modelling (SEM) analysis. Results. When coping with stress, medical high school students use Acceptance, Venting, Behavioural Disengagement, and Planning that increase their burnout, and they do not use any strategies that would help them reduce burnout. When coping with stress, medical faculty students use Planning, Acceptance, Humour, Venting, Behavioural Disengagement, Self-Blame, and Substance Use that increase their burnout and Positive Reframing which helps them reduce burnout. Conclusion. The results of this research show an evident lack of use of adaptive coping strategies with both groups of respondents. Proper education would help them replace these dysfunctional coping strategies with more constructive ones.


Introduction
Medical professions involve high risks of burnout development 1,2,3,4 . The figures show that 25 to 80% of all healthcare professionals experience mild to severe burnout 5 while 30-50% of nurses demand clinical intervention regarding burnout 6 . The presence of burnout levels of physicians and nurses is indicated as early as in medical schools 7 , with increasing rates over time predicting lower vocational preparedness and the actual clinical achievement 8 .
More specifically, burnout prevalence among medical faculty students reaches up to 75.2% worldwide 9 with 19% of them suffering from high or very high overall burnout 10 . As for nursing students, the research showed that around 25% of them experience overall burnout 11 with 6% experiencing high burnout 12 and almost 90% of them reporting low levels of professional efficacy 11 . Student burnout development is proven to be related to the ways individuals cope with stressful situations 3,13 . Moreover, poor coping can influence students' success, satisfaction, and career development before leading to burnout 3 , while efficacious and adequate coping can significantly reduce the risk of burnout development 14 . The exploration of the relationship between coping strategies and burnout occurrence within medical high school students and medical faculty students has, so far, received insufficient attention 15 , both in Serbia and globally, and has been recommended for the research 16 .
Therefore, the present study aims to develop a conceptual model which will unveil how specific coping strategies impact the levels of different types of burnout among medical high school and medical faculty students. The model we propose is based on the literature review of what could be identified as a distinctive field of study, proposing several analogous models so far. For example, in 2020, de la Fuente et al. 17 , using Structural equation modelling (SEM) analysis, verified a model that explores a mediating role of coping strategies with respect to achievement emotions and engagement-burnout variables, thus making a methodological advance since such predictive relationships could not be identified with the use of classic analyses. Similarly, in 2019, Vizoso et al. 18 used SEM analysis to propose a model which examines the effects of optimism and adaptive and maladaptive coping on exhaustion, cynicism, and efficacy (as burnout dimensions) as well as on the performance of undergraduate students. Following these examples, we designed a model that would test the impact of 14 distinct coping strategies 19 on medical student overall burnout as well as on their personal, colleagues-related, studies-related, and teachers-related burnout 20 .
The aims of the presented model could be multifold. Firstly, the verification of the proposed conceptual model would be done on two different populationsmedical high school students and medical faculty students. Secondly, the findings would contribute to the existing body of literature as the influence of the 14 examined coping strategies on specific medical students' burnout types has not been examined yet. Finally, as the effectiveness of coping strategies is shown to be occupation-specific 4,21 , the identification of the beneficial as well as maladaptive coping strategies that are related to medical students' burnout should provide a basis for the appropriate training that would enable them to deal with stress more effectively 22 both at school and university, and later, once they become doctors and nurses 23 .

Methods
This study was designed as cross-sectional and included the students of the High School of Medicine, Belgrade, and the students of the University of Belgrade, Faculty of Medicine, who were willing to participate and gave their written informed consent. The survey was anonymous and was conducted by filling in provided online questionnaires in January and February 2020. The study protocol was approved by the Ethic committee of the Faculty of Organizational Sciences and carried out in accordance with the principles of the declaration of Helsinki.

Instruments
Socio-demographic characteristics were investigated by the 5-item socio-demographic selfreported questionnaire designed for this study. Five items were gender, age, academic year, tuition payment source (budget of the Republic of Serbia, self-funding or other), hometown schooling (yes or no). Student burnout syndrome was assessed with the use of the student version of the Copenhagen Burnout Inventory (CBI-S) 20 . CBI-S inventory is composed of four scales -Personal burnout, Studies-related burnout, Colleagues-related burnout, and Emotional Support, Using Instrumental Support, Self-Distraction, Denial, Venting, Substance Use, Behavioral Disengagement and Self-blame 19 . Responses are assessed on the four-point scale ranging from 0 (I have not been doing this at all) to 3 (I have been doing this a lot).
To identify the relationship between coping strategies and specific and overall burnout we

Sample characteristics
The socio-demographic characteristics of the participants are presented in

Comparison of burnout levels between medical high school and medical faculty students
The comparison of the levels of burnout between medical high school and medical faculty students is presented in Table 2. Medical high school students are significantly more prone to studies-related, teachers-related, and overall burnout.

Validation of the proposed conceptual models
The initial step in the SEM analysis is to inspect the internal consistency of the proposed constructs using Cronbach's alpha 24 . In respect to medical high school students, it ranges from 0.573 (Venting) to 0.942 (Substance Use). For medical faculty students, the internal consistency ranges from 0.421 (Venting) to 0.950 (Substance Use). Interestingly, for both groups of respondents, the same constructs have the highest and the lowest consistency.
These results showed that the data is suitable for SEM analysis.
Herein we assessed four SEM models: models of the impact of coping strategies on overall burnout and on specific burnout dimensions for medical high school students and medical faculty students.
The first model we assessed was the model of the impact of coping strategies on overall burnout for medical high school students. The initial model had a low fit to the data (Chi-square=1345.552, p<0.000, SRMR=0.129). In the next steps, we modified the model, by removing the paths which were not statistically significant. To assess the significance of the paths, we employed bootstrapping with 1000 samples. We first removed the paths which had the highest p-value. The final model had a better fit to the data (Chi-square=150.090, p<0.000, SRMR=0.089). In the final model, three coping strategies proved to have a statistically significant impact: Acceptance, Venting, and Behavioural Disengagement with standardized coefficients 0.169, 0.191, and 0.274. All coefficients are positive, indicating that the increase in employing these coping strategies increases burnout. The adjusted R square is 0.188 indicating that 18.8% of the variability of overall burnout can be explained with the three predictors ( Table 3). The second observed model was the model of the impact of coping strategies on specific burnout dimensions for high school students. The initial model had a low fit to the data (Chi-square=1302.753, p<0.000, SRMR=0.078). In the next steps, we modified the model, in the same manner as the previous model. The final model had a better fit to the data (Chi-square=231.376, p<0.000, SRMR=0.070). The obtained equations are given in Table 3.
Personal burnout proved to have three predictors, Planning, Venting, and Behavioural Disengagement. All coping strategies have a positive statistically significant impact on this particular burnout meaning that these coping strategies slightly increase burnout. The adjusted R square is 0.209, showing that these three coping strategies are responsible for 20.9% of the variability of personal burnout. When it comes to teachers-related burnout, the obtained model is of low quality as the one significant predictor, coping strategy Behavioural Disengagement, explains only 5.6% of this specific burnout. Two coping strategies have a statistically significant impact on colleagues-related burnout: Acceptance and Behavioural Disengagement. The coefficients are stable and explain 13.1% of the variability. Finally, the only strategy that has an impact on studies-related burnout is Venting. Nevertheless, the sole predictor explains 12.2% of the variability. Now we proceed to the SEM analysis on the medical faculty students. The third model we assessed was the model of the impact of coping strategies on overall burnout. The initial model had a low fit to the data (Chi-square=1941.671, p<0.000, SRMR=0.066). In the next steps, we modified the model. The final model had a better fit to the data (Chi-square=887.480, p<0.000, SRMR=0.083), and its assessment is given in Table 4.
In the case of the faculty students, the overall burnout proved to have seven predictors: Planning, Positive Reframing, Acceptance, Humour, Venting, Behavioural Disengagement, and Self-Blame. All coefficients are positive, except Positive Reframing. Therefore, the remaining six coping strategies lead to increased burnout, while the coping strategy Positive Reframing decreases burnout. Some of the coefficients are quite low and close to zero, but they were not removed from the model as we aimed to create a model of high quality and find as many predictors as possible 25 . The coefficients on the original sample and the mean coefficients do not differ indicating that the coefficients are stable. The fourth observed model was the model of the impact of coping strategies on specific burnout dimensions for faculty students. The initial model had a low fit to the data (Chi-square=2024.310, p<0.000, SRMR=0.059). In the next steps, we modified the model, in the same manner as the previous models. The final model had a better fit to the data (Chi-square=874.919, p<0.000, SRMR=0.059). The obtained equations are given in Table 5. All indicators are positive, stable, and statistically significant.
Personal burnout of the faculty students is impacted by coping strategies Humour, Venting, Substance Use, and Self-Blame. All coefficients are positive, meaning that they increase this burnout. The four predictors explain 30.8% of the variability thus creating a model of solid quality. Similarly, teachers-related burnout can be predicted with the use of coping strategies Humour, Venting, Behavioural Disengagement, and Self-Blame. Again, the obtained model is of solid quality as the adjusted R square is 0.215. Burnout related to colleagues has just two predictors, Humour and Behavioural Disengagement that explain more than 10% of the variability (13.8%). Burnout related to studies has the most predictors, five, which create a model of the highest quality that explains 31.7% of the variability.

Discussion
There is a visible disproportion in the number of male and female students in both samples.
This could have been expected as more female students enrol high school of medicine 26 , and the University of Belgrade 27 .
The first conspicuous insight provided by the proposed conceptual model is that both medical high school and medical faculty students do not use coping strategies that could help them reduce burnout occurrence risk (namely faculty students use only one of such strategies while high school students use none). The strategies they use to combat stress are dysfunctional and serve only to increase their risk of experiencing burnout. Both groups of students use Acceptance, Venting, and Behavioural disengagement, which are herein shown to be positively related to their overall burnout.
As for Acceptance, the finding is in line with the results of Shin's 4 meta-analysis showing that Acceptance is positively related to burnout. This finding might seem counter-intuitive as accepting the reality of a situation might imply an individual's attempt to consequently deal with the stressor 19 , which makes it a positive coping strategy. Indeed, there are few studies proving its negative relation to burnout 28 . However, as Lazarus 29 observed, Acceptance can be an adaptive strategy only in such circumstances that nothing an individual would do can change them, the relation later confirmed for medical professionals 30 facing dying patients, for example. Since Acceptance leads to burnout with our examined groups, it leads us to the conclusion that the stressors could be changed and that Acceptance herein is rather a passive strategy that should be replaced and/or coupled with an active strategy. With regard to Venting and Behavioural Disengagement, both of them are confirmed to be positively related to students' overall burnout, which is in congruence with a number of other studies testing their relations to burnout and distress 31,32 . The ineffectiveness of both of the strategies is referred to in the Carver's 19 study that provided this very instrument (Brief COPE). Chao 33 states that using Venting of emotions dominantly suggests that emotions are focused on distress with no adaptive behavioral strategies. On the other hand, when people tend to use Behavioural Disengagement, they have stopped attempting to deal with stressors, while the stress has remained 34 (p.268).
Thus, both strategies are unfruitful and should be replaced with effective ones.
Apart from these three dysfunctional strategies, medical faculty students also use Planning, Humour, and Self-Blame which increase their burnout, and only one strategy that is negatively related to their burnout -Positive Reframing.
Planning as a strategy, occurs during secondary appraisal and is different from active coping, and mainly involves thinking about the potential active strategies and the solutions for dealing with the problem 34 . Previous studies found that planning itself is perceived as stressful by some medical students and trainees, and not following the plan is seen as even more stressful 35 . Herein, it has been shown not only to be positively related to faculty students' overall and studies-related burnout but also to high school students' personal burnout. It may also indicate that 'a delay' in action-based coping has a deteriorating effect on the younger generations. Previous results of using Humour as a coping strategy are ambivalent, suggesting both its negative correlation with various burnout dimensions 36 and its ineffectiveness in burnout reduction 37 . Other studies suggest that different types of humour can either decrease or increase job burnout 38 , and that, for example, selfenhancing humour is negatively correlated to burnout, while self-defeating humour positively 39 . In addition, using humour to make fun of the situation can be a marker of cynicism which can be a sign of burnout. Humour was also linked with the increased levels of emotional exhaustion 40 . Since it is linked with all dimensions of faculty students' burnout herein, it should be substituted with a more effective strategy. Self-Blame has been shown to be the most or one of the most maladaptive coping strategies in the medical profession 32 . Overuse of Self-blame can be indicative of the lack of self-confidence and the increased levels of insecurities in students who can inaccurately perceive errors as selfmade, which can in return paralyze them from moving further and learning how to behave in less-than-ideal situations with patients 31 . Self-blame, along with Venting and Disengagement, has been found to be connected to elevated depersonalization as well as emotional exhaustion scores 31 . On the other hand, counseling interventions aiming to reduce self-blame have been proven to reduce emotional exhaustion as a burnout component 41 , and this approach should be applied to Serbian medical students as well.
Positive Reframing or as Lazarus and Folkman 42 named it Positive Reappraisal, is, according to them, an emotional coping strategy that manages stress-induced emotions and does not focus on the stressor per se. In addition, as Carver et al. 34  The last strategy that appeared to be related to burnout herein is Substance Use. It is positively related to faculty students' personal burnout. Van der Merwe et al. 43 confirm that students who use maladaptive coping strategies, like Substance Use, have decreased resilience to stress. Since high rates of substance abuse have frequently been reported among both medical students and health care professionals 44 , this result confirms that the deteriorating effect of this dysfunctional mechanism should be communicated more seriously at the university level and students taught to use more functional strategies instead.
If the models of overall burnout are compared, the three predictors in the model of high school students (Acceptance, Venting, and Behavioural disengagement) are among the seven predictors in the model of faculty students. This result indicates that faculty students use more coping strategies that can increase burnout than high school students and that they use one coping strategy which decreases it. When it comes to comparing the models for each specific burnout, there are some similarities. For personal and studies-related burnout, both of the groups use Venting. For teachers-related and colleagues-related burnout, both of the groups use Behavioural disengagement. As seen, behavioural disengagement is herein used for people-related burnout and venting for the dimensions of burnout which are more under the control of the self, but both strategies have already been associated with burnout and lower personal accomplishment of future physicians 40 and are therefore very dysfunctional.
Finally, our results show that medical high school students are statistically significantly more prone to personal, studies-related, teachers-related, and overall burnout than medical faculty students, while both groups have the same level of colleagues-related burnout. This is an interesting insight emphasizing the increased need to work with medical high school students on developing functional coping strategies and thus prevent future nurses' burnout.

Conclusion and Limitations
The results of this study show an evident lack of the use of adaptive coping strategies, such as active coping or the use of instrumental or emotional support, which would help students effectively deal with stress, thus decreasing the risk of developing burnout. On the contrary, the proven positive relationship between a large number of the strategies the students use and burnout is alarming and should be a red flag to educators and the medical community. The training should be created to help students substitute these dysfunctional ways of reacting to stress to more functional ones which they would be able to use once they become part of the professional workforce.
This study has some limitations. It should be followed by a qualitative one to obtain more thorough insights into why certain strategies, like humour or planning, are positively linked to burnout. Also, a larger sample of students including those from other medical schools and universities in Serbia should be included in the research, to get more representative results for the entire future Serbian healthcare workforce. Coping strategies (second seven) Using Instrumental Support   2 Assessment of the model on the impact of coping strategies on the level of overall burnout among medical students: construct, predictors, obtained standardised coefficients, mean standardized coefficient, standard deviation, t statistics, and the R square Table 5 Coping strategies' impact on different burnout levels of medical faculty students 3 Accepted November 5, 2021.

SuS
3 Assessment of the model on the impact of coping strategies on the level of different types of burnout among medical students: construct, predictors, obtained standardised coefficients, mean standardized coefficient, standard deviation, t statistics, and the R square