Portuguese HCWs followed the trend of burnout seen in studies from other countries [18,36]. Our findings show that more than half of HCWs experienced high levels of personal and work-related burnout, while most participants (64.6%) had low rates of client-related burnout. The results of psychological variables showed moderate resilience in 50.8% of the sample and normal levels for anxiety (66.9%), depression (70.6%) and stress (63.4%) in most of the participants. Notably, 74.9% of participants had six or more years of professional experience, which could contribute to a greater ability to manage anxiety and stress. Professional experience improves one’s clear awareness to solve problems, which can increase one’s confidence in professional actions, thus inducing less stress and anxiety.
The COVID-19 pandemic seems to have had an impact on the physical and psychological wellbeing of HCWs worldwide . It is not unexpected that this new coronavirus has posed unprecedented challenges to HCWs. Previous research on burnout has already found that the highest prevalence rate of burnout occurs among HCWs in hospital emergencies . Without comparing this situation to the pandemic, we emphasize that HCWs in hospital emergencies also deal with crisis situations. Thus, in a pandemic, exacerbation of this situation would be inevitable.
Emotional exhaustion related to low levels of mental health has been reported [6,10], and effective interventions to support health care professionals are needed. Although the demands of medical practice may be a significant contributor to burnout, personal and family stressors may impose additional pressures. The COVID-19 pandemic has disrupted healthcare systems worldwide. A prolonged response period to the pandemic will lead to additional stress for HCWs, which will permeate further throughout the healthcare system .
Our findings reinforce the multidimensionality of the burnout syndrome. Indeed, each of the three burnout dimensions was associated with a specific set of covariates. Thus, consideration of these three dimensions is important when designing future burnout prevention programs for HCWs.
The contributions of socio-demographic and psychological variables on the three burnout dimensions were explored. We found that sex, marriage status, parental status, frontline worker positions, and direct contact with infected people significantly contributed to the outcomes. Our findings suggest that female sex is associated with higher levels of personal burnout, which is in line with previous research [38,39]. These results might be explained by the double-workload role of women in society between their professions and home lives. These multiple responsibilities could result in a greater perception of personal burnout.
People who were single, widowed or divorced seemed to be were less susceptible to personal burnout than those who were married. This finding could be related to the dual role that married HCWs play, especially women, who were most of participants (83.6%) in this study. Such an association has been reported previously in a study on nurses .
HCWs with children under 12 years old were more likely to experience personal burnout than HCWs without children or children older than 12 years (during the period of data collection, the state allowed parents who had children up to the age of 12 years to work from home . This was an interesting finding of the study since the roles of HCWs as parents and primary caregivers at home have rarely been investigated. With the spread of the coronavirus and the suspension of classes in schools, teleworking was encouraged. Parents have to juggle their roles as parents, workers, and many times, as teachers to help their children. Teleworking during the COVID-19 pandemic requires separating work and personal time, which could cause family obligations to intrude on work and work obligations to bleed into family time. This might lead teleworkers to work extra hours, resulting in burnout.
Working on the “frontline” is one of the few covariables that was significantly associated with all three dimensions of burnout. In a study conducted in China, the prevalence of burnout was high among frontline nurses . The COVID-19 outbreak has led to a sharp increase in admissions and presentations to hospitals, which has impacted the workload of HCWs. Prior to this pandemic situation, these professionals were already considered as one of the groups most exposed to psychosomal risks . The pandemic has exacerbated existing risks and triggered new risks, including risk of exposure to the pathogen, long working hours, increased volume and severity of patients, critical decision making, psychological distress, fatigue and the high concern that professionals could be potential vectors of disease transmission to their families.
Exposure to these risk factors can jeopardize the mental, physical, emotional, and social wellbeing of these professionals as well as the care process. It can also make it difficult for professionals to establish adequate therapeutic relationships. In the same direction, the significant determinants of personal and work-related burnout were health problems and directly participation in the diagnosis, treatment, and care for COVID-19 patients. A study carried out in Switzerland with HCWs demonstrated higher levels of burnout in the group that was in direct contact with patients .
Resilience, satisfaction with life, depression and stress were found to be potential predictors for all burnout dimensions, and anxiety was a potential predictor for personal burnout. The relationship between burnout and psychological dimensions has been documented in recent studies . In this context, it can be argued that life satisfaction is a protector against developing burnout . In this study, satisfaction with life seems to be a protective factor for burnout, which confirms previous research in this field.
A significant relationship was found between depression and all the dimensions of burnout, which highlights the importance of the problem and its prevention. Our findings are in line with the results from other studies [20,21]. Several studies [19,20] found consistent medium to high correlations between depression and burnout. According to our results, depression was identified as a potential predictor of burnout. Depression can have a negative impact on the health, performance, and productivity of workers, which can influence the quality of care provided and patients’ health . To prevent negative impacts, coping strategies and resilience could have important roles . In fact, according to our results, resilience was found to be a potential protective factor against burnout. In previous research, resilience was also found to be a protective factor for regulating and preventing burnout . Resilience can be a psychological resource in performing emotional labor, and resilience-promotion programs should be implemented.
Stress also seems to be a risk factor for burnout. High levels of stress have serious consequences for the wellbeing of individuals and can lead to mental fatigue, difficulty in concentration, loss of immediate memory, and anxiety . On the other hand, it could also empower an individual to deal with changing and adverse situations. Stress and burnout seem to be inseparable . In a randomized controlled trial, Stier-Jarmer et al.  found that a program for stress reduction and burnout prevention was effective. The program aimed at reducing currently perceived stress, as well as providing strategies for dealing with stressors. The optimization of stress-management skills should be required.
Anxiety can be considered a reaction to threatening situations that acts as a protective factor . However, if the anxiety is prolonged over the time it can result in suffering with an impact on the individual's functioning . According Spielberger , anxiety is divided in two types, trait anxiety and state anxiety. Trait anxiety is the individual proneness to anxiety, that is, the level how the person perceives stressful situations as threatening, and state anxiety is the reaction toward a situation after having judged it as threatening . Anxiety seems to be a potential risk factor for personal burnout but not for work and client-related burnout. Personal burnout subscale measures physical and psychological fatigue, work-related burnout assesses the level of exhaustion and fatigue that derive from work, and client-related burnout analyze exhaustion because of the relation with clients . Our findings suggest that exhaustion and fatigue does not derive from work or relation with the clients, but a consequence from physical and psychological fatigue. As stated, 69.7% of the study participants were frontline workers which required more personal effort and may have contributed to greater physical and psychological exhaustion. In addition, in the frontline, workers are faced with stressful situations and the level how the person perceives these situations as threatening can be higher. The literature in this field, in addition to advancing the existence of a correlation between anxiety and burnout, argues that this relationship is still unclear and further research is needed .
This study offered several interesting discoveries. However, some limitations should be considered. Firstly, this study used a cross-sectional online survey, which might have limited the accessibility of people less familiar with the internet or less prone to using it. Secondly, the sample was obtained by a snowball technique and might have not reached some classes or individuals. Thirdly, the study was carried out during a one-month period and is related to only a specific pandemic period, which corresponded to a relief of lockdown measures.