The negative impact of pandemic COVID 19 on health professionals in primary, secondary and tertiary health care in Greece-the survey

 Corresponding author: Kanellakopoulou Athina Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. The negative impact of pandemic COVID 19 on health professionals in primary, secondary and tertiary health care in Greece-the survey Kanellakopoulou Athina 1, *, Andrikopoulos Andreas 2, Koutsojannis Constantinos 2 and Triantafyllou Vasilios 3 1 Department of Electrical and Computer Engineering, University of Peloponnese, Patras, Greece. 2 Health Physics and Computational Intelligence Laboratory, Department of Physiotherapy, School of Health Rehabilitation Sciences, University of Patras, Patras, Greece. 3 Digital Transformation lab, Electrical and Computer Engineering Dpt., University of Peloponnese. Patras, Greece. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 041-054 Publication history: Received on 18 February 2025; revised on 25 March 2025; accepted on 27 March 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.22.1.0337 Abstract A sample survey was carried out in 2022 among health professionals of the health structures of seven regions in the context of the new corona pandemic. The research concerned the fatigue experienced by health professionals of many specialties within public health structures from 2020 to 2022, from the moment of the appearance of the first case, until the waves of the disease subside. Globally, the descriptions of the conditions that prevailed immediately after the outbreak of the disease in many countries were terrifying, since its invasion caused strong negative feelings and reactions. The fear of the unknown pathogenic entity and the extreme symptoms it caused manage to synthesize a negative psychology in the society and a negatively charged climate among health professionals, as a result of which many were led to absolute despair. Anxiety, worry, fear of the unknown characteristics of the disease, of the complications, symptoms and consequences, as well as the large volume of patients who were admitted to the hospitals were the reasons that the health staff were intensely tested, emotionally and physically, reaching overwork and exhaustion. The research tool was a questionnaire that resulted from the synthesis of the two others questionnaire-tools that focus on the study of occupational burnout of health professionals, the DASS 21 and the CBI. The results showed that health professionals in Greece experienced intense negative emotions such as anxiety and worry, at a high level, but not very high, as happened in other countries around the world hit by COVID 19. Keywords: Health Professionals; Social Workers; Research; Anxiety; Worry; Fear; Burnout, COVID-19; Epidemic; Protective Measures; Resilience; Primary/Secondary/Tertiary Health Care; Vaccination; Resignation; Suicide 1. Introduction The infectious respiratory disease, which severely affected almost the entire planet at the end of 2019, was named by the World Health Organization COVID 19 and crossed the Greek border at the end of February 2020. China first reported World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 041-054 42 to the World Health Organization about the development of cases of pneumonia of unknown etiology on December 31, 2019, as Sumit Kumar [2] noticed and declared a pandemic on March 11, 2020 (Sumit Kumar 2020). This was the milestone of the beginning of the spread and the care of patients with the new coronavirus. It was found that it was a virus that strikes the respiratory system and belongs to the category of coronaviruses. Many researchers, observing the magnitude of the health crisis caused both during the outbreak and during the waves of spread of the disease, proceeded to organized studies in order to collect data that will help the scientific community in health crises, in the long term. This paper concerns the stress and burnout experienced by health professionals in primary, secondary and tertiary health care structures, on the occasion of the onslaught of the new infectious disease, which knocked on the door of the global community at the end of 2019. As Fayeza Alameri [3] observed during the pandemic, all modes of healthcare faced similar obstacles, such as limited availability of special staff and the possibility of transmitting SARS-CoV-2 between patients and staff. Managing the unpredictable scenario of the COVID-19 pandemic posed an unprecedented challenge for healthcare leadership, which had to act quickly to structure and deliver the key resources and personnel needed to manage throughout this health crisis (Fayeza Alameri et al.2022). No matter how well prepared the health system was, the onset of the disease, combined with its rapid spread, brought about many changes in the organization and operation of nursing units. These changes also brought changes in the way health professionals work both during the first wave of the spread and during the three other waves of dispersion and transmission that followed. The consequence of this was fatigue on their part and exhaustion, physical and psychological. The exhaustion, or burnout, of health professionals is a condition that is described with concepts and emotions that carry a negative sign. Such are anxiety, lack of joy, the existence of unpleasant thoughts, anxiety for the health of themselves and members of their families, anxiety to avoid the transmission of the disease, constant effort to take appropriate measures for self-protection and protection of family members, bad dreams, morning awakening followed by muscle pain, frequent headaches, mental fatigue and questions about the duration of this "evil". Also, the feeling of intense physical and mental pressure, the fear of avoiding transmission of the disease from patient to patient through tools and other objects, through the respiratory tract or mucous membranes, the painful experiences of hospitalization and care in intensive care units with severe cases and the feeling of deep sadness with the counting of losses or worsening of cases. As recorded [4] in the 2021 Community Care Quality Committee report in June 2021 a report by the Samaritans June of 2021 identified health workers as one of five groups whose risk of suicide may worsen as a result of the pandemic. The report outlined how healthcare workers faced feelings of stress, trauma and mental fatigue from their work during the pandemic, alongside the impact of being surrounded by serious illness and death at unprecedented levels, while often struggling for support and resources (Care Quality Commission 2022). Physical and mental stress are risk factors for the development of serious health problems for each health professional, but at the same time according to Negin Talee [5], it is associated with the frequency of medical errors and the quality of health services provided (Negin Talee et al 2022). The health professional that experiences such experiences in his daily life is victimized. He also becomes a "victim" of the given situation, and as Sumit Kumar writes [2], another cause and effect of burnout is the 'Second Victim Syndrome' which involves emotional trauma suffered by health workers due to adverse events, usually leads to poor patient outcomes, and the doctor becomes the second victim (Sumit Kumar 2020). According to the Karasek and Theorell Work Requirements Control Support Model, there is a relationship between cardiovascular risk factors and burnout, which is mediated by life and work stressors. Occupational stress and burnout can cause persistent symptoms of fatigue, as well as an increased risk of cardiovascular disease. Fayeza Alameri [3] underlined that in addition, overall occupational burden has been linked to cardiovascular risk in physicians (Fayeza Alameri et al.2022). And it's not just the doctor who takes care of the COVID patient, of course. It is both the nurse and the physiotherapist and the social worker and the health visitor who are by his side. Therefore, everyone who is in these professional categories and worked very closely with the COVID patient found himself or was at risk of finding himself in the role of the second victim. The price of wear and tear and exhaustion can be the same for doctors and nurses, but also for paramedical professions such as the social worker, who deals with the proper functioning of the patient within the nursing structure, within his family environment, within the wider society, who experiences feelings of intense anxiety, isolation, emotional oppression, lack of communication with family members, etc. As characteristically reported by Megan R Holmes [6] social workers are in a unique position as they experience the stress of the COVID 19 pandemic in their professional lives, providing services to clients who often find themselves in situations of crisis or adversity, while at the same time experiencing the same trauma in their personal lives (Megan R Holmes 2021). It is possible that social workers themselves are in the same or similar mental state and are charged with the need to support and support patients for the same reason! World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 041-054 43 As Negin Talee supported [5] given the fact of the outbreak of the epidemic disease, the unforeseen conditions and the extensive workload experienced by health professionals due to the pandemic disease (Negin Talee et al 2022), in our country, the motivation was given to investigate their situation. Common ground of the findings is physical fatigue, psychological fatigue, boredom, frustration, lack of self-interest and other related negative emotions. The most intense emotions and severe psychological exhaustion came for most of them from the anxiety of contracting the disease, the anxiety of transmission from the health professional himself e.g. nurse or doctor to the non-COVID patient, the anxiety to avoid transmission to his family members, the anxiety about his personal abilities to respond to the needs of patients, the anxiety about the unknown of this virus, etc. The extent of human body infestation, the speed of infection, the speed of death, the anxiety about the duration of the pandemic, the anxiety to find ways to deal with it. The extremely severe symptoms of the disease, the need for many hours or even days for sedation of patients in the Intensive Care Units, the multiple complications and side effects are just some of the causes that exacerbated the negative emotional state of the health staff. The frequent natural outcome in death as a natural consequence of the total infection of the human body by the severity of the virus, combined with the lack of a suitable antidote for the disease are important causes of mental distress, anxious behavior, emotional disorders with intense fear and deep sadness. The literature review identified hundreds of studies conducted from the beginning of the pandemic in some countries 2020 until 2022 and capture with the help of research tools the magnitudes of worry, anxiety, depersonalization, anxiety, frustration and despair and symptoms of post-traumatic stress disorder that according to Graziella Orru [7] include avoidance, overstimulation and insomnia (Graziella Orru 2021). Such tools are the MBI, CBI, DASS 21 questionnaires and others that delve into the psychological introspection of health workers during the pandemic. Burnout has been shown to exist across the spectrum of health professionals, led by doctors and nurses. In many cases it is at very high levels. Burnout syndrome can be traced into eleven symptoms, as Maria Ulfa noticed [8], including fatigue and loss of energy accompanied by exhaustion (Maria Ulfa 2022). The causes that cause it are those that perhaps determine the rate of burnout. In tertiary hospitals and generally in units with a large number of COVID patients, anxiety, stress, fear, psychological fatigue and physical exhaustion seem to be higher than secondary care hospitals or with fewer COVID beds, in general. Research conducted at a tertiary hospital in Lisbon, Portugal. During the research emotional exhaustion, depersonalization and personal fulfillment were measured by the Maslach Burnout Inventory. Linear regression analyses were performed to investigate the relationships between burnout dimensions and sociodemographic variables. The survey involved 106 people (95% response rate). As the writer Helena Sofia Antio supported [9] high emotional exhaustion and depersonalization were reported by 33.0% and 18.4% of participants, respectively. 21.4% reported low personal achievement. Work tenure was associated with depersonalization and personal fulfillment (Helena Sofia Antio et al 2022). Also, the state of the organization, the inadequacy of supplies and the management of inpatient situations seem to have played a serious role in the daily wear and tear of health personnel. It is important to mention that the pandemic was dealt with by health structures during particularly difficult times. The lack of appropriate and sufficient medical equipment e.g. ventilators, COVID beds, ICU beds, understaffing, lack of personal protective equipment, were conditions that made the situation in our country's hospitals very difficult. Also, the overtime caused by the COVID era is also due to the lack of staff, but vice versa, the lack of staff caused overtime from the COVID era onwards. Similar situations are experienced by other countries whose health systems seemed to have many shortcomings. And certainly, the damage was caused not only during the recovery of patients, but also during the prevention of the disease. Let us not forget that the vaccination was also an intense and time-consuming process, burdening all levels of health, with primary health care being a pioneer. A survey conducted in China found that 20.8% of staff involved with vaccination had experienced burnout. Wenwen Gu’s study referred [10] that the vaccination staff experienced a high degree of emotional exhaustion, cynicism and low personal satisfaction. Professional status and engagement time to prevent and manage COVID were tied to personal fulfillment (Wenwen Gu et al 2023). In many countries, health professionals, especially those in the nursing category, as at some point of the Care Quality Commission’s report it is mentioned, participated in additional roles voluntarily during the pandemic – for example, they covered COVID-19 vaccination centers on days off. While admirable, there were potential negative impacts on staff wellbeing that should be taken seriously [4] (Care Quality Commission 2022). World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 041-054 44 It is therefore a given that there has been significant physical and psychological deterioration of health professionals in the health structures that were actively involved in dealing with the pandemic. Let us not forget that the treatment was based on three areas: treatment, diagnosis and prevention. The order of wording is proportional to the facts. First patients were admitted for treatment in tertiary and secondary hospitals, then gradually diagnosis passed in addition to the Emergency Department COVID and in Health Centers and then the process of prevention through vaccination occurred. Each stage concealed its own rate of burnout among health workers. 2. Research methodology The concept of burnout dominated the research of many scholars in pro-COVID eras. Determining characteristics for the definition of burnout have been given by many of them. Almost everyone agrees on a common point, that meaning has been defined as a symptom of emotional exhaustion, depersonalization and a sense of low personal success that leads to reduced effectiveness at work...it seems to occur mainly in professions that involve interaction with people, such as doctors, nurses, social workers and teachers, as noted by Stefan de Hert [11] (Stefan de Hert. 2020), while it is underlined by the same researcher that the symptomatοlogy off occupational burnout seems to be rather complicated. The aim of the research is to detect the signs of burnout during the pandemic in Greek health professionals working in public health structures. In order to achieve the research, an investigative tool was needed that would be able to detect, as reliably as possible, the emotional burden of these professionals and to attribute the relationship between their profession and this burden in emergency conditions, as well as natural disaster. At the research level, several tools are available to detect emotions related to professional burnout. In order to better assess the physical and emotional symptoms in this work, two internationally recognized and standardized questionnaires were used as tools, which concern the signs of burnout. The two questionnaires were consolidated and became one to which demographic questions were added. There is no personal data in the questionnaire that was created and the research that was conducted was done with all the necessary precautions to protect personal data. This is the DASS21 (Depression Anxiety Stress Scale 21) questionnaire and a part of the Copenhagen Burnout Inventory questionnaire, the work-related burnout section. A synthesis was made of these and the formation of a new, unified questionnaire resulted. The questionnaire with which the research was conducted consists of three parts. First, from the demographic questions section (i.e. gender, occupation, employment agency, etc.). Then, the second section, consisting of twenty-one questions, is the questionnaire used to measure anxiety and burnout, the DASS-21 (Depression, Anxiety and Stress Scale-21). This particular tool consists of three subscales, each consisting of seven questions [5] (Negin Talee et al 2022). As for the third section, a subgroup, work-related burnout, from the CBI (Copenhagen Burnout Inventory) questionnaire was used, i.e. seven questions for the assessment of occupational burnout in healthcare professionals. The aim is to highlight the burnout of health professionals during a pandemic. In more detail: The Dass21 scale as Brown supported [12](Brown, Chorpita, Korotisch & Barlow 1997) is a shortened form of the 42-question questionnaire developed by Lovibond & Lovibond. This scale has been standardized for a Greek audience by Pezirkianidis [13] and his colleagues, while its translation was done by Professor Lyrakou's team. It has been used in the works of Greek scholars and its reliability and validity have been proven. Such studies are diploma theses in some Postgraduate Programs such as the ones mentioned below: • "Emotional Memory in Patients with Multiple Sclerosis", Chryssi Lafi, Diploma Thesis, P.M.S. "Applied Clinical Neuropsychology", Aristotle University of Thessaloniki [14]. • "Elements of Attention Deficit Hyperactivity Disorder in Adults and Internet Use" Filiou Areti-Irini, Diploma Thesis-University of Macedonia, Thessaloniki 2020 [15] • "Effect of Hops Extract HOPs on stress and anxiety levels in adults" Christou Emilia-Varvara, Postgraduate Thesis at the M.P.S. "Applied Dietetics-Nutrition" Athens, June 2016 [16]. The interest in using the DASS 21 scale lies in the total score, which essentially assesses the negative emotional mood of the respondents. It consists of three subscales, each consisting of 7 questions. The Depression scale assesses negative emotions such as discomfort, hopelessness and a tendency to devalue life. The anxiety rating scale "records" the arousal World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 041-054 45 of the autonomic nervous system and the existence of anxiety as an existing state, while the stress scale detects increased arousal and irritability tendencies as well as difficulty relaxing. It is rated based on a Likert-type 4-point scale. It starts from 0 (Does not apply to me at all) to 3 (Applies to me a lot or most of the time). The second questionnaire used is a subscale of the Copenhagen Burnout Inventory, work-related burnout. The main questionnaire was designed to meet research needs not only on the prevalence and contribution of burnout, but also on the risk of burnout. The main core of the questionnaire is fatigue and exhaustion. The team that developed it, regarding the work-related burnout subscale, has defined it as the degree of physical and psychological fatigue and exhaustion, perceived by the individual as being related to their work. In formulating this definition, the group of developers emphasizes the focus on the individual's own attribution of symptoms to their work. Tage S. Kristensen [17] underlined that the dimension of work-related burnout is based on how people perceive their own psychological and physical symptoms (Tage S. Kristensen et all, 2005). The research questionnaire is a "match" precisely because the goal is to investigate fatigue and perceived physical and mental exhaustion of healthcare professionals. Therefore, it may be a good combination for the best possible recording and capturing of feelings of anxiety and exhaustion. The questions in both the first and second questionnaires constitute, in the researcher's opinion, a new tool for better capturing the psycho-emotional state of healthcare professionals. It is a tool that more closely approaches the stressful emotion, which exhausts the soul and body. The first two questionnaires have been used many times in research on burnout among healthcare professionals in periods of “normalcy,” i.e., pro-COVID times. However, research has also been conducted that focuses on the effects of the COVID outbreak and the pandemic it caused. Specifically, in 2022, a Negin Talee’s study [5] was published online entitled “Stress and burnout in health care workers during COVID-19 pandemic: validation of a questionnaire” [5](Negin Talee et all, 2022). Similarly, studies have also been conducted with only one of the two questionnaires. For example, with the Copenhagen Burnout Inventory in the article “Burnout among Healthcare Workers during COVID 19 Pandemic in India: Results of a Questionnaire-based Survey” [18] (Ruchira W khasne et all. 2020) and “Prevalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: A national cross-sectional survey study” [19] (Kriti Prasad et all 2021). Many studies have been conducted with the DASS 21, including the detection of the mental state of health professionals, and this questionnaire has been used in conjunction with other research tools to determine their professional burnout. Such studies are, for example, the study [20] “Resilience and stress in frontline social workers during the COVID-19 pandemic in Singapore” written by Boon Kheng Seng et all (2021) Another tool, the MBI (Maslach Burnout Inventory), has been used in many studies to measure burnout. This tool has been used in studies both before and during the pandemic. As an exploratory tool, Jeroen HM Kleijweg [21] believes that the practical implication is that the MBI should not be used alone as a diagnostic tool in a patient population, due to the high likelihood of overdiagnosis of burnout (Jeroen HM Kleijweg et all, 2021). It is also considered by Kelly Williamson [22] as ‘’the gold standard” for measuring burnout, depersonalization, and personal accomplishment (Kelly Williamson et all, 2018). And as another researcher, Chung-Ying Lin, [23] adds that it has good psychometric properties for accurately assessing burnout among health professionals across the three dimensions of emotional exhaustion, personal accomplishment, and depersonalization (Chung-Ying Lin et all, 2022). While these tools seem to have much in common, they differ significantly in their exact objectives. Both investigate burnout, but highlighting different parameters. As Efstathios Papaefstathiou [24] characteristically wrote about the CBI, in 2019, calculates a) personal involvement b) work involvement and c) customer involvement in burnout. Personal exhaustion refers to both physical and psychological characteristics that are measured in a person during the day, e.g. How often do you feel physically exhausted?? (Efstathios Papaefstathiou et al 2019). Therefore, it is based on three dominant areas: a) personal exhaustion, b) work-related exhaustion and c) patient-centered exhaustion. The reason, therefore, that the CBI questionnaire was preferred in this work is that exhaustion is measured through the prism of both personal and work-related wear and tear, but also the service-providing relationship, i.e. the provider, the caregiver and the cared for, i.e. the service recipient. In detail, the first questionnaire (DASS 21) is divided into three subscales that focus on the overall assessment of the emotional state of healthcare professionals. The first subscale is the Depression Scale, the second subscale is the Stress Scale, and the third is the Anxiety Scale. 2.1. More specifically, the Depression subscale includes the following seven questions: • I could not seem to experience any positive feelings at all World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 041-054 46 • I found it difficult to work up the initiative to do things • I felt that I had nothing to look forward to • I felt down-hearted and blue • I was unable to become enthusiastic about anything • I felt that I was n’t worth much as a person • I felt that life was meaningless The Stress subscale includes the following questions: • I found it hard to wind down • I tended to over-react to situations • I felt that I was using a lot of nervous energy • I found myself getting agitated • I found it difficult to relax • I was tolerant of anything that kept me from getting on with what I was doing • I felt that I was rather touchy 2.2. And the Anxiety subscale includes the questions: • I was aware of dryness of my mouth • I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion) • I experienced trembling (e.g. in the hands) • I was worried about situations in which I might panic and make a fool of myself • I felt I was close to panic • I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat) • I felt scared without any good reason Common findings include physical fatigue, psychological fatigue, boredom, frustration, lack of interest in oneself, and other related negative emotions. The difference between these and the findings of studies that have been conducted so far on the correlation between the spread of the new coronavirus and the burnout of healthcare professionals is that some negative emotions are also present, but they differ from the anxiety and distress experienced by healthcare professionals in normal times, i.e. without the impact of pandemic situations and natural disasters. These are the anxiety of contracting the disease, the anxiety of transmission from the health professional himself, e.g. a nurse or doctor to the non-COVID patient, the anxiety of avoiding transmission to his family members, the anxiety of his personal ability to respond to the needs of patients, the anxiety of the unknown of this virus, i.e. the extent of the attack on the human body, the speed of infection, the speed of the onset of death, the anxiety of the duration of the pandemic, the anxiety of finding ways to deal with it. It is very difficult for a healthcare professional to distance themselves and think while maintaining balance in their mental world, when their experiencesespecially in the early days-in COVID clinics and COVID ICUs were only negative. The severe symptoms, the heavy sedation, the constant complications and death compose an extremely difficult scenario that emotionally burdens them with pessimism, anxiety, disappointment and fear. This directly causes their emotional vulnerability and weakness, which, in conjunction with social distancing, intensifies the feeling of widespread disappointment. At that point, as Stefan de Hert [11] comments, when people see no way out of this situation, they become resigned and indifferent (Stefan de Hert 2020). In this specific study, the emotions identified are: fear of the unknown, intense anxiety and intense worry-especially in the early stages, disappointment and lack of joy. 3. Sampling-disposal of questionnaires For the best and most formal compliance with the procedure, a request was submitted to the Scientific Council of the 6th Ministry of Health in order to obtain permission to conduct the research in Primary Health Care structures, at an initial stage. Primarily, the structures included in the research were those that were designated in early 2020 as "COVID 19 structures" and were directly involved in the diagnosis, referral or monitoring of patients with the new respiratory disease. Subsequently, after permission was granted by the Scientific Council, the researcher contacted either the World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 041-054 47 administrative staff of each Health Center or the scientific managers by telephone in order to inform them about the conduct of the research, its purpose and the method of collecting the responses to the questionnaire. The responses were collected by sending the link to the responsible administrative employee of each Health Center, who then forwarded the questionnaire link via email to the email addresses of the health professionals. As mentioned above, the questionnaire does not contain personal data and information, and thus in many health centers the process went smoothly. In hospitals, the process followed was almost the same as in health centers. The researcher submitted a request to the Departments of Education and Research. Subsequently, the request went through the scientific councils of the hospitals and approval was issued by each institution. In the same way, as in health centers, nursing service executives, either executives of the Education and Research offices or the secretaries of the Scientific Councils took over and sent the link to the questionnaire to health professionals via electronic addresses. In the first stage, the research was conducted in structures of the 6th Ministry of Health. Subsequently, the team of collaborators deemed it appropriate to proceed with the research in more structures of the country in order to obtain conclusions from health professionals in other areas where the organization and treatment of patients with COVID-19 was not as methodical as within the framework of the 6th Ministry of Health. The aim was to investigate both the physical and mental state of healthcare professionals who faced thousands of cases, especially in areas where there was a shortage of medical and nursing staff, as well as shortages in ICU beds and simple beds for healthcare services to citizens. Regarding the distribution of questionnaires to hospitals, the relevant requests were submitted, accompanied by the documents required for each hospital. The positive thing was that the Health Regions gave approval for the Health Centers relatively faster compared to the same process required by hospitals. A total of 288 questionnaires were collected. Regarding the participants, 78.2% were women and 21.8% were men. The largest percentage was doctors (50.2%) and then nurses (24.6%) and the rest belonged to other specialties. Regarding the analysis of the DASS 21 questionnaire: The following data apply to the Depression subscale: A significant percentage of participants 32.4% responded that they could not experience any positive feeling for a short period of time, while 16% of them responded that they could not experience any positive feeling for a longer period of time. If we consider that the onset of the pandemic occurred in three major waves and there were two long periods of social isolation, it becomes clear why this negative mental state arises both during the initial period, when the disease broke out in Greece, and for some time later, when there was no recession. 37.2% of participants reported difficulty in taking the initiative to do some things for a short period of time, while 17.4% stated that they had difficulty for a much longer period of time. Figure 1 I found it difficult to work up the initiative to do things A percentage of respondents, 28.1%, initially felt that they had nothing positive to look forward to, while 17.5% felt the same for a longer period of time. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 041-054 48 As in other studies that dealt with the negative emotions experienced by healthcare professionals during the outbreak of the disease, frustration and melancholy took the top positions, so in this study too, respondents answered that in the first months they felt melancholy and frustration (33.9%). Of course, there are also those who experienced these two emotions more intensely and for a longer period of time (25.7%). These responses are consistent with another consequence, related to the lack of motivation to make participants feel excited. 28.6% admitted that they felt that nothing could arouse feelings of excitement in them at the beginning of the pandemic. The same was felt by 18.9% of respondents for a longer period. A similar emotional state was found in 15% of healthcare professionals who participated in the survey and stated that they felt they were not worth much as individuals, an indication of depersonalization that is also found in other similar surveys. While a similar percentage of those who stated that they felt that life had no meaning (14.7%). In the anxiety subscale, questions are related to intense anxiety experienced by participating healthcare professionals. For example, 41.1% stated that they could not calm themselves down for a period of time, while 24.2% stated that they felt this way for a considerable period of time. Figure 2 I found it hard to wind down They also tended to overreact to situations they encountered (39.4% of respondents), and 18.8% overreacted particularly overly and for a longer period of time. Figure 3 I tended to over react to situations The percentage of those who admitted to feeling nervous often (38.7%) is similar, while 22.6% often felt nervous more than in the first few months. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(01), 041-054 49 Figure 4 I was using a lot of nervous energy Nervousness and exaggerated reactions show the mental state that health professionals in our country, as well as in other countries that were faced with the deadly coronavirus COVID 19, had reached. The majority of them found themselves getting agitated by 41.6%. Figure 5 I found myself getting agitated Among the negative emotions they experienced, 34.4% admitted that they could not tolerate anything that kept them from continuing with what they were doing, and 17% could not show such tolerance for several months. Another mental state that is encountered as a symptom of burnout is irritability, which was found to have high rates in this study. This means that to the question “I felt that I was rather touchy” 42.2% of respondents answered positively for a few months and 19.7% for several months. Figure 6 I felt I was rather touchy The anxiety subscale includes questions in which the involvement of physical elements is strongly evident. Professional fatigue and burnout are directly related to many physical symptoms such as the feeling of dry mouth. When asked “I felt my mouth dry,” 21.9% of healthcare professionals who participated in the survey responded that they experienced it and it affected them a little, while 13.7% had it as a physical symptom for quite some time.