Mental health, depression, and burnout in healthcare workers during the second wave of COVID-19

From 2020 to 2022, the COVID‐19 pandemic had a robust negative impact on the mental health of the global populations, with increasing rates of depression, anxiety, acute stress and post‐traumatic stress disorders (Akay, 2022; Crocker et al., 2022). Among different subgroups, nurses and healthcare providers have been particularly investigated, in the light of their work in direct contact with patients infected with the COVID‐19 virus (Hurst et al., 2022; Liang et al., 2022; Sani et al., 2022; Veitch & Richardson, 2021; Zhang et al., 2021). They have been considered ‘heroes’ across different nations, especially during the first wave of pandemic (Brennan, 2020; Cox, 2020; Mascayano et al., 2022). However, various investigations assessed their mental health and found that these ‘heroes’ manifested symptoms such as traumatic stress, depression, anxiety, psychological (and physical) exhaustion, especially for frontline workers (Elgohary et al., 2021; Hurst et al., 2022; Labrague et al., 2021; Mascayano et al., 2022; Narita et al., 2023; Sani et al., 2022; Zhang et al., 2021). During the first wave of pandemic (when the COVID‐19 vaccines were not available and face masks and other personal protective equipment were scarce), health workers felt particularly vulnerable since they had to deal with an increased workload due to the massive contagion, and with an increased mortality rate among their patients (Crocker et al., 2022; Labrague et al., 2021; Pang et al., 2021; Sani et al., 2022; Webb, 2021).

Various studies (Butler, 2022; Carmassi et al., 2021; Crocker et al., 2022; Mendez‐Pinto et al., 2023) investigated the prevalence of depression in healthcare workers during the pandemic and found that major depressive disorder was common, particularly in female workers. Among female workers, those who worked as frontline nurses reported that the risk of transmitting the infection to their household members, and the fear of death were the factors that significantly affected their levels of depression, anxiety and stress (Maideen et al., 2022; Mendez‐Pinto et al., 2023; Pang et al., 2021).

Furthermore, across nations, a high percentage of health workers reported personal and professional burnout and work stress (Merino‐Godoy et al., 2022; O'Higgins et al., 2022; Wilson et al., 2022; Zhang et al., 2021), that were significantly associated with other psychopathological symptoms, as post‐traumatic stress depression and anxiety symptoms (Mendez‐Pinto et al., 2023; Narita et al., 2023; Pang et al., 2021; Webb, 2021). However, the pandemic has only exacerbated work stress and burnout, which have emerged as chronic problems in healthcare settings, with long‐term negative consequences (Crocker et al., 2022; Wilson et al., 2022).

Moreover, it has been previously observed that healthcare workers experiencing poor mental health are reluctant to seek help and treatment because they are afraid of being stigmatized and excluded by their colleagues and employers (Butler, 2022). Thus, depression, anxiety and burnout easily became chronic and vexing conditions for this populations.

Besides the assessment of risk factors for poor mental health during the pandemic, some investigations also explored healthcare workers' protective factors, such as coping strategies, resilience and positive mental health. Various investigations reported the use of positive coping strategies in healthcare workers during the pandemic, such as self‐care, family and social support (Maideen et al., 2022; Sani et al., 2022). Resilience was found to be a mediator for nurses' mental health during the first wave of pandemic (Labrague et al., 2021) and it was found to influence burnout via the mediation of positive and negative emotions in a sample of healthcare workers in Whuan (Zhang et al., 2021).

Bassi et al. (2021) explored positive mental health in a group of Italian health workers during the first wave of pandemic and found that those having higher levels of well‐being reported lower post‐traumatic stress symptoms. However, only a small proportion of them (33%) manifested flourishing mental health. According to the dual continuum model (Keyes, 2002), flourishing mental health can be diagnosed when individuals experience high levels of hedonic well‐being (positive affect and pleasure) and high levels of psychological and social well‐being. Conversely, the condition of languishing has been described as a state in which an individual is devoid of positive emotions towards life, and is not functioning well either psychologically or socially, without fulfilling the criteria for a DSM disorder (Keyes et al., 2012).

Flourishing mental health was shown to predict mental illness in the general population (e.g. the risk of developing anxiety and depressive disorders), to influence recovery from an affective disorder (Iasiello et al., 2019; Keyes et al., 2010; Vescovelli et al., 2020) and to provide a buffering effect when facing chronic and acute stress (Westerhof & Keyes, 2010). In a pre‐pandemic investigation with North American medical students, flourishing mental health was found to attenuate some adverse consequences of burnout, such as unprofessional behaviours or falsification of medical reports (Dyrbye et al., 2012). It was also documented that mental health predictors paralleled those of burnout (i.e. year of specialty; ethnicity, gender) (Morgan et al., 2020) and that burnout was inversely correlated to positive emotions (Zhang et al., 2021).

With few exceptions (Anozie et al., 2020; Bassi et al., 2021; Dyrbye et al., 2012; Morgan et al., 2020), no other investigations explored the mental health condition of healthcare workers using this dual continuum model, where indicators of psychopathology were evaluated with indicators of positive functioning. Furthermore, most of data on healthcare workers' mental health were collected before or during the acute phase of the pandemic, while the subsequent phases received less attention.

The aim of this investigation was to evaluate positive mental health (flourishing) in a sample of Italian healthcare workers during the second wave of the pandemic, when vaccines were just released, and personal protective equipment were largely available. In that phase of the pandemic, the COVID‐19‐emergency working conditions began to fade away, while chronic stressors and heavy workload persisted in healthcare settings. The purpose of the present investigation was to extend prior research by evaluating the role of positive mental health in protecting healthcare workers from depression, anxiety and burnout. The results of this investigations could imply an important role for mental health nurses in light of their expertise in assessing these symptoms and in implementing evidence‐based interventions for promoting positive mental health in healthcare systems.

A total of 173 healthcare workers completed the survey. After data cleaning, 5 participants were excluded due to missing data (one or more questionnaires not answered). The final dataset included 168 responders: n = 137 female (81.5%); n = 31 males (18.5%). Their mean age was 43.68 years (SD = 10.741; age range: 22–71). Based on the Italian classification system of health professions, participants were physicians (8.7%), nurses and midwives (23.7%), nurses working in ageing facilities (19.1%), psychologists (6.9%), social workers, professionals in technical (e.g. technicians in radiology, biomedical lab; 2.9%) and rehabilitation areas (e.g. physiotherapists), and healthcare assistants (25.4%). They were divided into two categories based on their workplace: the category ‘frontline workers’ included healthcare workers working directly in contact with hospitalized patients or in nursing facilities, or with outpatients, but with a physical contact with them. The category ‘second‐line workers’ comprised healthcare workers working in healthcare facilities, but without a direct/in person daily contact with patients (technicians in radiology, biomedical lab, administrative staff, etc.).

Regarding the three categories of the Mental Health Continuum, we found that 48% of the participants were in the flourishing category, 42% were in the moderate mental health category and 10% were in the languishing category. Their sociodemographic characteristics and working conditions are described in Table 1.

A MANOVA was performed to compare the three MHC categories according to their DASS scores and CBI scores. Simple main effects analysis showed that belonging to a certain category of MHC did have a statistically significant effect on all the DASS‐21 subscales: respectively on depression score (f_2,165 = 18.414; p ≤ .001, partial eta squared = 0.182), on anxiety score (f_2,165 = 7.131; p ≤ .001, partial eta squared = 0.080) and on stress score (f_2,165 = 11.479; p ≤ .001, partial eta squared = 0.122). Univariate tests and post hoc comparison showed that the flourishing healthcare workers had lower score on all the subscales (p < .05) compared to the languishing and moderate groups, except for the stress subscale, where the flourishing and languishing groups did not significantly differ (p = .377).

Simple main effects analysis showed that belonging to a certain category of MHC did have a statistically significant effect also on CBI subscales: respectively on personal burnout (f ₂₁₆₅ = 14.004; p ≤ .001, partial eta squared = 0.145) client burnout (f ₂₁₆₅ = 4.5; p ≤ .05, partial eta squared = 0.052) and work burnout (f ₂₁₆₅ = 15.546; p ≤ .001, partial eta squared = 0.159). Univariate tests and post hoc comparison showed that the flourishing healthcare workers had lower scores on all the subscales (p < .05) compared to the languishing and moderate groups, except for the client burnout subscale, where the flourishing and languishing groups did not significantly differ (p = .864) (Table 2).

Regarding the categories of depression, anxiety and burnout in the total sample of healthcare workers, we found only a minority of participants with high scores in depression (7.1%), in anxiety (11.3%) and with high risk of burnout (17.3%) (see Table 3). The chi‐square tests were used to assess the relationship between the categories of flourishing and ‘not flourishing’ and the levels of depression (low score = absence to moderate; or high score = severe to extremely severe); of anxiety (low score = absence to moderate; or high score = severe to extremely severe) and the risk of burnout (low = low to medium; high = moderate to high), respectively. Chi squared values were all significant: we found a significant association between mental health categories and depression (χ²_(1,168) = 8.474, p < .008), anxiety (χ²_(1,168) = 12.566, p < .001) and burnout risk (χ²_(1,168) = 8.539, p < .008). In particular, 91% of individuals with severe depression, 89% of individuals with severe anxiety and 75% of individuals with high risk of burnout were categorized as ‘not flourishing’.

The aim of this investigation was to evaluate positive mental health in a sample of Italian healthcare workers, after the acute phase of the COVID‐19 pandemic and to verify if the presence of well‐being might protect healthcare workers from depression, anxiety and risk of burnout. These conditions have been considered frequent and chronic problems in healthcare settings, that the pandemic has tremendously exacerbated (Akay, 2022; Crocker et al., 2022; Merino‐Godoy et al., 2022; Pang et al., 2021; Veitch & Richardson, 2021; Webb, 2021). The first important finding of the present research is that almost half of our sample of healthcare workers (48%) were diagnosed as flourishing (i.e. they reported high levels of hedonic well‐being and positive functioning in life), while only a minority (10%) were in the languishing condition (see Table 1). These data provide a novel, more positive picture of Italian health workers compared to the results emerged in recent publication (Bassi et al., 2021), where flourishing health workers were only 28% of the sample. Our data are more in line with those reported by Anozie et al. (2020), who documented 47% of flourishing individuals in a sample of African healthcare workers, while languishing individuals were almost 25% of their sample. This could be explained by the fact that the pandemic had a less severe impact on African countries, where hospitals were less stressed by COVID‐19 cases, because of the youthfulness of the population and its lower density (Vallée, 2023). In fact, the previous Italian investigation (Bassi et al., 2021), was conducted during the first wave of COVID‐19 pandemic, when healthcare workers were under severe conditions of stress and vulnerability because facial masks, protective devices and COVID‐19 vaccines were not available. Conversely, our results pertain to the actual state of healthcare workers, when the pandemic has become a chronic condition, without traumatic, life‐threatening aspects (Bassi et al., 2021). Another investigation conducted in the Italian population prior to the pandemic found that 28.5% of the adult sample was flourishing and 10.5% was languishing (Petrillo et al., 2015). Thus, as reported by other epidemiological studies (Capone et al., 2020; Keyes, 2006; Westerhof & Keyes, 2010) the condition of languishing is usually reported by a small proportion of individuals (around 10%), flourishing around one third of the samples, while the most frequent condition is moderate mental health. These frequencies provide important clinical data, since the presence/absence of well‐being was found to predict mood and anxiety disorders in several longitudinal investigations (Iasiello et al., 2019; Schotanus‐Dijkstra et al., 2019; Westerhof & Keyes, 2010; Wood & Joseph, 2010). Forty‐eight per cent of our sample of healthcare workers reported high levels of well‐being and positive functioning after the traumatic experience of the first acute phase of the pandemic. Thus, these findings depict a relevant number of resilient healthcare workers, who restored/maintained their well‐being also under stressful conditions, as already documented in previous investigations (Labrague et al., 2021; Merino‐Godoy et al., 2022; Toh et al., 2021; Zhang et al., 2021).

In fact, flourishing healthcare workers also reported lower levels of depression, anxiety, stress and burnout compared to the other two mental health groups as documented by the MANOVA. Interestingly, at post hoc analyses, individuals in the moderate mental health group did not differ significantly from those in the languishing condition (see Table 2). This is a novel, important finding of the present investigation, since previous research has documented that either the three mental health groups differed in terms of mental illnesses and stress (Capone et al., 2020) or that the languishing group was at higher risk of mental illness (Bassi et al., 2021; Iasiello et al., 2019).

The cross classification of the sample according to the categories of flourishing versus ‘not flourishing’ confirmed these results (see Table 3). For example, of the 82 flourishing individuals in our sample only 1 belonged to the group reporting high scores on the DASS depression subscale, 2 individuals belonged to the group reporting high scores on the DASS anxiety subscale and 7 flourishing individuals belonged to the group with high risk of burnout. Conversely, 11 out of 12 healthcare workers with severe or extremely severe depression were categorized in the ‘not flourishing’ group. Similar data were obtained for participants reporting severe anxiety symptoms (17 out of 19 in not flourishing group) and higher risk of burnout (see Table 3). In this case, only 8.5% of individuals in the flourishing group documented high scores of burnout.

Other authors in previous investigations decided to dichotomize mental health categories into flourishing or not flourishing group (Doré et al., 2020; Schotanus‐Dijkstra et al., 2019) and found similar results: individuals in the ‘not flourishing mental health’ condition had higher risks of manifesting high levels of anxiety and depressive symptoms (Doré et al., 2020), and a poorer recovery from an affective disorder (Iasiello et al., 2019; Schotanus‐Dijkstra et al., 2019) compared to those in the flourishing group. The present investigation confirms the conclusions of these previous research: the condition of flourishing is the only one that provides protection from common mental health problems (i.e. depressive and anxious symptoms), while moderate mental health (the most frequent condition in all studies) does not differ substantially from the languishing state.

The same considerations can be drawn for the risk of burnout: in our sample of health workers, 29 of them reported high levels of burnout, and most of them were categorized in the ‘not flourishing’ group. Previous investigations in healthcare workers documented the strong correlations between burnout, depressive and anxiety disorders (Barello et al., 2020; Ghio et al., 2021; Merino‐Godoy et al., 2022; Wang et al., 2023; Wilson et al., 2022), with concomitant manifestations of insomnia, fatigue and post‐traumatic stress symptomatology. At the same time, a recent investigation documented a robust, inverse relationship among burnout, purpose in life and personal fulfilment (two core dimensions of flourishing) in healthcare workers (O'Higgins et al., 2022). In this case, higher levels of purpose were related to increased levels of personal accomplishment, a sense of professional identity and job satisfaction that positively influenced healthcare workers' levels of burnout during the pandemic. Even though we did not assess purpose in life in details, the MHC questionnaire contains items for measuring the sense of personal and societal growth and meaning in life. Thus, our data confirm this recent research and sustain the role of personal growth and purpose in protecting healthcare workers from burnout, particularly under the stressful experience of COVID‐19 pandemic.

This study is limited by its preliminary nature, the self‐selected, homogenous sample and the use of self‐reports as assessment methodology. This fact leaves the possibility of self‐report bias to inflate some of the significant correlations and it limits the external validity of the findings. Furthermore, even though we have differentiated frontline and second‐line healthcare workers, we did not provide additional information on specific specialist areas (i.e. respiratory acute wards or intensive care wards) where the pandemic could have had a more detrimental effect on clinicians' mental health.

Finally, the cross‐sectional study design precluded conclusions about causality among variables. Follow‐up and longitudinal studies should be performed to monitor positive mental health over the chronic course of the COVID‐19 pandemic and its relationships with psychopathology and burnout in healthcare workers.

To the best of our knowledge, this is the first investigation during the second wave of the COVID‐19 pandemic that was specifically focused on health workers' mental health and its correlates in terms psychopathology and burnout. We found that almost 48% of our sample maintained their well‐being after the acute phase of the pandemic and only small proportions of them reported high levels of depression, anxiety and burnout. These individuals can be considered as more vulnerable (Veitch & Richardson, 2021; Webb, 2021), and they were mostly categorized under the ‘not flourishing’ group.

Considering that the pandemic has revealed the crucial role of health professionals in communities and societies around the world, this investigation provides confirmation to the importance of maintaining and/or promoting the well‐being of this population, particularly during health crises or under stressful working conditions (Buselli et al., 2021; Gray et al., 2021; Veitch & Richardson, 2021). A suitable model for addressing this issue was proposed by a group of European researchers (Tomlin et al., 2020). This phased model of mental health burden and responses suggests that different strategies to support clinicians' work and to prevent burnout could be applied according to the phase of crisis faced by the specific healthcare organization. Even though the model was developed during the COVID‐19 pandemic, it could be easily applied to other sources of psychosocial stress in the healthcare setting.

Even if psychological interventions to support healthcare workers' mental health have been implemented during the pandemic, only few countries have published specific protocols, and none of them was specifically tailored to the promotion of resilience and psychological well‐being (Buselli et al., 2021; Wang et al., 2023). Nowadays, various effective interventions to promote well‐being are available, ranging from meditation techniques, to yoga, lifestyle modification and positive psychotherapies (van Agteren et al., 2021). These interventions have been found to be feasible, cost‐effective and deliverable in various healthcare settings.

Unfortunately, healthcare workers are often hesitant to seek treatment for their poor mental health, because of stigmatization and negative stereotypes about psychiatric disorders in healthcare organizations (Butler, 2022). Mental health nurses or those working in mental health settings can have a crucial role as peer experts in evaluating symptoms of depression, anxiety, stress and burnout observed and reported by other healthcare workers. In fact, they possess the expertise in common mental health problems, they have specific training for active listening and for building a therapeutic relationship and they share the same (or similar) occupational conditions of those who are experiencing these type of problems (Sampaio et al., 2015). Moreover, previous investigations published in this journal have documented that mental health nurses can be actively involved in co‐designing more inclusive workplaces (Stab & Hacker, 2020) or in realizing multidisciplinary support groups for healthcare workers, that buffered distress and excessive workload during the acute phase of the pandemic (Veitch & Richardson, 2021). Another review article summarized the various mental health interventions delivered to healthcare workers during recent infectious disease outbreaks (Zace et al., 2021): most of those interventions included informational (training, guidelines, prevention programmes) and emotional support programmes (psychoeducation and training, mental health support team, peer support and counselling), which were provided (or coordinated) by mental health nursers. For example, during the SARS pandemic the management of a hospital in Canada asked healthcare workers within the mental health settings (nurses and doctors) to prepare a pamphlet identifying signs of anxiety and stress and information about support resources, which was distributed across hospital's units. Furthermore, mental health nurses activated a confidential telephone support line for all hospital staff and it was used effectively by those in quarantine (Maunder et al., 2003). More recently, Gonzales et al. (2020) reported the experience of another hospital during the COVID‐19 pandemic where mental health nurses were strategically charged with taking personal protective equipment orders throughout the institution. This assignment gave them the opportunity to offer in‐person support to healthcare staff, including meditations, empathic listening, encouragement and support resource flyers. In other experiences, mental health nurses were involved in delivering psychoeducation about stress, anxiety and depressive symptoms through digital platforms or via video conference (Zace et al., 2021). Thus, mental health nurses or coaches are in the ideal position for facilitating the implementation of interventions for promoting and restoring well‐being in vulnerable healthcare workers.

If future longitudinal research would replicate the findings of this study, these interventions may become essential tools to be implemented in healthcare settings in order to prevent burnout and to foster health workers' positive mental health.

From 2020 to 2022, the COVID‐19 pandemic had a robust negative impact on the mental health of healthcare providers, with increasing rates of depression, anxiety, acute stress and burnout. In this investigation, we found that these conditions persisted also in the second wave of the pandemic, in almost 10–20% of the sample. However, 48% of healthcare workers were able to restore their well‐being, and were classified with flourishing mental health. Specific subgroups of healthcare workers present vulnerabilities in their mental health and mental health nurses have the skills and expertise for evaluating early symptoms of psychological distress and for implementing interventions for promoting and restoring well‐being. These interventions may include informational campaign (i.e. preparing and distributing pamphlets and guidelines) and emotional support programmes (psychoeducation and training, mental health support team, peer support and counselling) that can be delivered also via digital platforms. Mental health nurses may also be actively involved in co‐designing more inclusive healthcare workplaces to address mental health stigma often experienced by vulnerable healthcare workers.

All authors significantly and equally contributed to the manuscript. CR and EC supervised the research and contributed to the study design and writing of the article. GLP and FV contributed to data collection data analyses and writing of the manuscript.

The study conforms to the Declaration of Helsinki standards and was approved by the ethical boards of the hospitals/clinical institutions enrolled for the study implementation and data collection.

The authors thanks Dr Rossano Maset, Mrs Patrizia Tessarin and the Maharishi Foundation, Italy for their contribution in implementing the research and collecting data from participants. Open access publishing facilitated by Universita degli Studi di Bologna, as part of the Wiley ‐ CRUI‐CARE agreement.

Ruini, C. , Pira, G. L. , Cordella, E. , & Vescovelli, F. (2025). Positive mental health, depression and burnout in healthcare workers during the second wave of COVID‐19 pandemic. Journal of Psychiatric and Mental Health Nursing, 32, 192–202. 10.1111/jpm.13099

Data available upon request to the authors.