University students usually experience different stressful situations due to overloaded activities, longer study hours, mandatory academic requirements, low participation in recreational activities, among others [1,2]. Especially, health science students are likely to present higher levels of stress because they begin to clinically care for patients as part of their professional training at an early age, with a lack of knowledge and experience [3]. In addition, they have courses that involve a greater emotional effort in dealing with other people [4]. In the academic health field, there is a strong demand for access to the best medical residency programs; this implies that students, throughout their academic training, participate in different activities (e.g., exams, lectures, health promotion campaigns, among others) to gain acceptance [5].

These aspects can develop higher levels of burnout throughout university studies since they promote prolonged and constant exposure to emotional and interpersonal stressors [6]. Specifically, academic burnout presents three dimensions that explain the appearance of feelings of emotional exhaustion, cynical attitudes, and academic ineffectiveness [7]. One of the major consequences of burnout in university students is cynicism, which refers to an attitude of inhibition, indifference, and detachment towards academic activities, as well as demotivation and rejection of studies [8,9]. It is considered as the cognitive dimension of burnout due to a perception of a certain injustice or an assessment of incongruence between the effort given and the rewards obtained [10].

Another characteristic of increased prevalence in university students with burnout is emotional exhaustion, which is defined as a feeling of nervousness, frustration, fatigue, and lack of energy, due to the overload of academic demands [7], as well as the loss of emotional and physical resources [11]. In addition, mild transitory ailments (e.g., headache, back pain, among others) and psychosomatic problems experienced by students are considered as another predictive aspect of emotional exhaustion, as referred to in the theoretical model of emotional exhaustion by González Ramírez and Landero Hernández12 In a meta-analysis conducted by Kaggwa et al. [3], it was reported that 27.8% of health science students experienced stress due to the overload of their activities. In another meta-analytic study conducted in students of clinical specialties on various continents, it was shown that 40.8% of university students experienced feelings of fatigue and loss of energy due to multiple academic factors, such as starting the preprofessional internship (PI) program or the development of competencies that serve in clinical practice [13].

Likewise, evidence has been reported that 30.2% of students reported emotional exhaustion in the face of academic demands, leading to a higher manifestation of stress in a study of 1,600 university students from 6 countries [14]. This central component of burnout is of greater concern in Latin American university students who tend to carry out extracurricular activities such as volunteering and social work related to health, where they show a greater physical and psychological effort to provide better emotional treatment to the people they serve, which can lead to higher levels of academic burnout [15].

Perceived stress is based on the theory of interaction between the subject and his environment [16], which postulates that stress develops within a situation that the person values as demanding and lacks the resources to cope with it [17]. In the academic context, students’ stress occurs due to a greater mismatch between the resources needed to meet academic demands and the requirements of the activity itself [18,19]. Students who report elevated levels of stress tend to exhibit emotional and cognitive impairment, which manifests itself as a greater perception of emotional exhaustion [12,20]. Furthermore, having high levels of stress will make it difficult for them to control their behaviors and obtain adequate academic performance, which favors the appearance of academic ineffectiveness [21].

Emotional exhaustion is one of the most prevalent predictors of cynicism, especially in South American university students who have more stressful experiences (somatic and physiological) in the face of economic and social demands [18]. Since it is more difficult for them to pay the expenses required for their professional training and basic needs, many students are forced to work to finance their subsistence [22]; while in social demands we can recognize the negative relationship with teachers or peers, as well as the increase in academic demands due to changes in student policies (e.g., increased hours in PI, more formative or extracurricular course) [23].

The lack of resources to cope with these demands, along with the overexertion of health professionals, favors the manifestation of physiological and emotional reactions experienced as negative, which generate an imbalance between perceived expectations and the reality of the university environment. This, in turn, can promote disaffection with academic activities and even desertion or abandonment of studies [10,22].

González Ramírez and Landero Hernández [12] report that one of the most prevalent symptoms of emotional exhaustion in university students is difficulty sleeping or getting up (insomnia) due to the overload of tasks that brings with it states of drowsiness and daytime sleepiness that affect motivation for studies, which can foster rejection or disinterest in university life [24,25]. This, together with the perception of a lack of reciprocity between the effort made and the achievements obtained, can reinforce greater cynicism [12,26]. Specifically, health sciences students start their professional training with the intention of helping others; however, when they start PI and realize the limitations of the healthcare system (e.g., precarious infrastructure, prolonged daily hours of unpaid PI, poor delimitation of rights and obligations), they generate greater feelings of frustration, rejection, indifference, and emotional distancing from academic activities [15,25-27].

It has also been recorded that the reduction in mood experienced by university students in certain areas of health sciences influences the appearance of cynicism, especially allowing the development of a contemptuous or cynical mood that helps them to deflect negative feelings inherent to clinical care [28,29]. This is in line with González Ramírez and Landero Hernández [12] who reinforced the concept of emotional exhaustion by adding certain somatic, emotional, and physiological symptoms that are the product of stress and tend to increase cynical attitudes.

Academic ineffectiveness is also considered as a cognitive dimension of burnout, since it is defined as the tendency to perceive negatively or pessimistically the achievements experienced in relation to studies [7]. Likewise, it is determined as the lack of competencies that people must solve problems, achieve their goals, or participate in the academic context [30]. Unlike other dimensions, academic inefficiency has an independent development because it is usually generated because of a lack of personal resources, while emotional exhaustion and cynicism are due to the overload of student work and situations of conflict with peers [6,10,11]. Consequently, there are proposals that identify academic ineffectiveness as a predictor of cynicism [31,32], since the latter is conceived as a negative coping strategy that helps students overcome unpleasant events. These strategies are generated due to the increased incidence of emotional fatigue and the low efficacy in the face of studies [26].

It should be noted that PI is a crucial period in student training because it allows them to develop competencies that help them build their professional identity within the real work environment, which is a requirement to obtain a professional degree [15,33]. In addition, it is a medium that triggers greater feelings of burnout in students due to the large number of demands required [34]. Despite this, no studies have been found that analyze the moderating effects of PI on the relationship of emotional exhaustion with stress and cynicism in university students of health sciences, making this study a pioneer in South America. Students who do PI in health care settings are likely to experience a higher mental workload, impaired cognitive skills, and less time for studies [35]. In turn, subjects who begin their training in the field of health sciences tend to show a certain degree of idealism, as they are oriented toward helping other people and doing the right thing [36].

However, when PI is performed, idealism tends to disappear, due to a greater experience of emotional fatigue, the development of insensitive attitudes, and less interest in helping their patients, and cynicism toward academic activities increases [27,37]. For example, Chacaltana Linares and Rojas Cama38 reported that university students in clinical training who do their internship have a high degree of burnout and a reduction in the performance of recreational activities. Likewise, the study by Miranda-Ackerman et al. [39] reported a higher prevalence of burnout, especially in the dimensions of emotional exhaustion and cynicism, in bachelor’s degree students in the health field who take PI during the last internship period, as opposed to students who are just starting their university studies.

Consequently, the present study proposed the following hypotheses: (H1) Emotional exhaustion maintains a significant indirect effect on the relationship of perceived stress with cynicism. (H2) Academic ineffectiveness maintains a significant indirect effect on the relationship of perceived stress with cynicism. (H3) PI performance moderates the relationship between perceived stress and emotional exhaustion. (H4) PI performance moderates the relationship of emotional exhaustion with cynicism (Figures 1 and 2).

Table 1 reports the descriptive data of the study variables that refer to a nonnormal distribution of the data regarding health care self-efficacy and psychological distress. The study variables presented adequate reliability values (ω>0.70). The correlational validity of the variables was considered using a confirmatory factor analysis as a preliminary step for predictive models with indirect effects. Which reported significant relationships between the variables used (Table 2) and adequate goodness of fit indices (χ²/df=1.11, SRMR=0.012, RMSEA=0.026 [0.019-0.036], CFI=0.99, and TLI=0.99). The structural predictive model with indirect effects of the research objective presented adequate goodness of fit indices (χ²/df=1.41, SRMR=0.022, RMSEA=0.056 [0.029-0.076], CFI=0.99, and TLI=0.99).

The indirect effects obtained were significant for the mediating variables, emotional fatigue, and academic ineffectiveness. Specifically, two indirect pathways were found to predict cynicism: stress-exhaustion-cynicism (β=0.133, p<0.001) and stress-inefficacy-cynicism (β=0.052, p<0.001). This allows us to conclude that both predictive models refer to total mediation, since the direct effect (stress-cynicism) was reduced to a nonsignificant relationship (β=0.004, p=0.931). The dependent variable of emotional exhaustion had an explained variance of 0.326 considering a measure of medium effect (0.25≥R2≥ 0.50) that is above the minimum recommended value of practical significance in clinical research (R2≥0.04) [50] and provides greater causal predictive validity (Table 3).

In Table 4, our objective was to assess whether the indirect effects of perceived stress on cynicism are moderated by the execution of PI. It is recognized that PI significantly moderated the effect of perceived stress on emotional exhaustion (β=0.086, p<0.05), such that perceived stress had a greater positive effect for students who performed PI (β=0.159, p<0.01) compared to those who did not perform PI (β=0.076, p<0.05). Furthermore, PI moderated the relationship of emotional exhaustion with cynicism (β=0.241, p<0.05), given that emotional exhaustion had a greater positive effect on cynicism in students who performed PI (β=0.253, p<0.01) as opposed to those who did not perform (β=0.153, p<0.05). Therefore, the hypothesis that PI moderates the effect of perceived stress on emotional exhaustion and the relationship between emotional exhaustion and cynicism in Peruvian university students is significantly confirmed.

The present study is of great importance to the scientific literature, as it addresses for the first time, in the Latin American context, a structural model of cynicism in health sciences students. It is recognized that within the university environment there are demands related to studies, social and financial aspects, which generate physiological and emotional reactions that hinder the fulfillment of academic work [18,22]. Among these demands are long study hours, exam demands, pressure to behave professionally, work overload, conflicts with teachers or classmates, family responsibilities and duties, lack of financial resources to pay for their studies, and personal expenses [23,51,52]. One of the most stressful academic demands is the completion of PI, as students experience greater stress when combining the demands of the work environment (with mostly no economic benefits) and academics, since they tend to prioritize only one goal, that of an intern or students [34,53]. On the other hand, the university context not only poses demands, but also provides specific resources that are positively valued and facilitate the fulfillment of academic objectives, which allow personal growth and development [18]. Students with greater resources can counteract the negative effects of academic demands [54].

The model allowed us to successfully verify the proposed hypotheses. The first hypothesis was confirmed, where emotional exhaustion significantly mediated the relationship between stress and cynicism (H1). Similarly, Basri et al. [19] showed that emotional exhaustion was able to explain to a greater extent the relationship between academic stress and study rejection in a group of Indian university students. For several authors, emotional exhaustion is a strong predictor of cynicism throughout academic life [9,27,55]. According to Lee et al. [26], university students who are more emotionally exhausted due to the overload of academic work become less enthusiastic and find it difficult to concentrate on their studies, leading to a state of cynicism and even feelings of hatred about university activities. Additionally, academic demands and the lack of resources to cope with them can reinforce the prevalence of somatic, emotional, and physiological symptoms more characteristic of emotional exhaustion [12] as a result, the student tends to lose interest and enthusiasm for his or her professional education [21]. Likewise, emotional exhaustion can lead to different psychological reactions (for example, anxiety, depression, compassion fatigue, among others) and alter the relationship that students have with teachers or with their peers, leading to greater cynical attitudes towards studies [52].

The second research hypothesis confirms the indirect relationship of academic ineffectiveness on the relationship of perceived stress with cynicism (H2). This can be explained by Lesener et al. [18], who report that university students who lack personal resources (e.g., low self-efficacy or loss of commitment) to cope with stressful situations (academic, economic, or social demands) are more likely to experience cynical attitudes and to distance themselves from their studies. The results are similar to those reported by Gonzaga and Oblianda [21], who identified that the relationship between stress and cynicism was explained to a greater extent by a negative perception of self-efficacy in achieving academic goals. Other studies report similar findings in university students from different sociocultural contexts such as China and North America [56,57]. A meta-analytic review revealed that university students who adapt favorably to the educational context have higher perceptions of academic effectiveness and lower levels of study stress [58]. In addition, academic ineffectiveness influences the cynical attitudes of university students in the health sciences, as it facilitates the deterioration of their academic performance and the loss of interest in their professional careers [31,32]. From what has been said, it is evident that academic ineffectiveness is a link in the relationship between stress and cynicism, given that it may favor a perception of uselessness with respect to their abilities to face academic demands and the contribution that their participation in the class may have, which is related to the loss of interest and enthusiasm [18]. This may promote greater detachment and indifferent attitudes towards studies [21].

Another finding of the study was that PI performance had a moderating effect on the relationship between perceived stress and emotional exhaustion (H3). Therefore, although various authors point out that perceived stress may be related to emotional exhaustion in health science students [59,60], the magnitude of this effect may be modulated by various social factors such as studying and working simultaneously. Corrales et al. [53] report that students who complete PI have more homework overload and physical exhaustion when they have to attend classes after completing their daily PI day, as well as less time to do their homework, study for exams and obtain good grades. This is due to the increased responsibilities during the last semesters of university and the fulfillment of certain baccalaureate requirements that include attending workshops and seminars for professional specialization, as well as the development of an academic research project (thesis) and constant evaluation by professors or internship supervisors [51]. Such academic situations reinforce a higher degree of stress on emotional exhaustion in students completing PI compared to the other group. Therefore, university students in the last cycles of their professional training are not only affected by symptoms of an emotional nature, but also by the physiological, somatic and cognitive symptoms described in the theoretical model of emotional exhaustion of González Ramírez and Landero Hernández [12]. The latter have greater experiences of stress, discomfort, and exhaustion than workers, since when the weekend arrives, the latter can forget about their work and carry out other activities; however, students must perform their homework at the end of classes and during the weekend simultaneously while completing PI [15,34].

It was confirmed that the completion of the PI had a moderating effect on the relationship between emotional exhaustion and cynicism in university students (H4). In particular, students who present feelings of exhaustion, lack of energy, low mood, and homework overload tend to experience a view of pessimism, rejection, contempt, and indifference towards their studies [26,61]. Furthermore, according to a longitudinal study by Kim et al. [9], it was shown that emotional exhaustion promotes cynicism over time. Students who start with the PI program are exposed to a greater occurrence of academic demands that intensify feelings of nervousness or emotional exhaustion [53], which lead to physical and mental deterioration that generates cynical attitudes to relieve stress, let off steam or cope with the negative feelings inherent to clinical practice (e.g., contemptuous or cynical humor) [28]. From this, it can be argued that the cynicism developed by students performing PI may be linked to the disillusionment between the expectations for starting clinical care and the reality that exists within the hospital context [27,36]. This is caused by disappointment and frustration in the face of altruistic expectations to perform PI, because in this context, situations of indifference in patientphysician care are manifested by more experienced professionals [35,62]. Therefore, university students who observe such experiences are more likely to develop a high degree of academic cynicism [4,38,39].