**5. Discussion**

The results demonstrated us how the burnout syndrome is currently affecting more those aspects related to depersonalization than the rest of the subscales of the MBI. Unlike other studies [15,111–114] it is striking that, during this health crisis, no differences are seen in relation to sex and age as it does on non-exceptional occasions, where it most affects older female health professionals [115].

On the other hand, in relation to the depersonalization scale, we observed a relationship between people who present higher levels in this subscale as a result of the absence of PPE and their subjective perception that it can produce an increase in stress and anxiety levels. Recent studies related to mental health in the face of the COVID-19 pandemic address this phenomenon, demonstrating the fact that health workers face challenges such as the risk of infection, excessive care burden, exposure to family distress and ethical and moral dilemmas [23,57].

This is not a trivial issue, nor is the fact that during the most critical weeks for the health care system, where daily deaths reached almost 1000 people and new infections were counted in the thousands, health care workers lacked PPE, posing a risk to their own health as a group, a point that concurs with the study by Xiang et al. These elements are key to understand that increased anxiety as a result of gaps in pandemic planning and prevention has had an impact on health workers in their personal, family and community spheres, recording burnout values above those found in Spain in previous times [27,115,116]

Moreover, in a remarkable way, in the subscale of emotional exhaustion, we observed from the logistic regression carried out, the higher probability of suffering burnout concentrates in physicians and nurses over other health professionals. The fact that they surpass the clinical assistants, personnel who carry out the most elemental care of the patients, stands out. However, this risk of suffering emotional exhaustion is not the result of the lack of cohesion between the different professional categories, but rather of the lack of foresight from competent professionals regarding the general lack of individual protective equipment among health professionals, especially those who were most exposed to the virus due to increased contact with patients. This can be understood within a context where emotional exhaustion is linked to the capacity to respond to the disease from a more scientific perspective than that of companion and care. In this sense, the work done would be aimed, mainly in certain units such as the intensive care unit, where the demand for beds was higher than the existing capacity, to save the lives of infected patients who, although many could be saved, many others did not. That is to say, the absence of an effective response to COVID-19 disease on the part of these professionals has led to greater emotional exhaustion. Similar results were found in recent studies such as that of Li et al. [117] which indicate that physicians in China experienced an increase in mental health symptoms and fear of violence and a decrease in mood after the outbreak of COVID-19.

On the other hand, a singular fact is taking place in relation to the subjective perception of the need to receive psychological and psychiatric treatment. In this case, the people who have a greater risk of suffering emotional exhaustion are precisely those who, at the time of carrying out the study, consider that they will not need it, a sign of the pressure in which they currently work. This finding is analogous to the results found by Chen et al. [118] who expressed that health professionals were concerned about the insufficiency of PPE and feelings of helplessness when faced with critical patients. Many indicated that they did not need psychological help, but rather more uninterrupted rest and sufficient protective equipment.

It is not difficult to think that this situation will not have repercussions on professionals in the long term, since on many occasions the individual himself is not prepared to face limited situations at the time of greatest tension; often these consequences appear in the future. As Albaladejo and others point out [111], after 10 years from the beginning of a stressful situation, a process of sensitization or de-motivation can occur, losing the vocation that, at the time, made the person choose this profession.

At this point, professional treatment can have significant benefits for the individuals concerned, producing both personal and occupational rewards. In this particular case, characterized by an unprecedented health crisis where there has been a lack of adequate response from health institutions in providing essential PPE to their workers, psychological treatment emerges as a plausible and reasoned need for those health workers who believe they may need this treatment in the future.

In other words, health professionals who do not perceive the need for these treatments, in the face of the adverse health crisis situation, are what may need them most in the future since their emotional exhaustion is increasing without obtaining any compensatory mechanism for the situation of stress and emotional anxiety. Studies such as that previously cited by Chen et al. [106] found similar data; at the first stage of the illness, health professionals were reluctant to participate in the group or individual psychological interventions provided to them for various reasons: becoming infected was not the main concern when they began to work; they were more concerned about the possibility of their relatives worrying about them and about the possibility of bringing the virus home; and finally, the health workers did not know how to act with patients who did not want to be quarantined in the hospital, sometimes because of the panic that ignorance of the disease caused and they did not collaborate with the medical measures.

In this sense, in an emergency context such as the one that occurred during the key months of the COVID-19 outbreak, the measures carried out and the prevention actions at the beginning of the process are more effective. In relation to this issue, Withey [119] considers an emergency situation as a type of stress in which the appearance of several factors lead to the existence of different degrees of fear, anxiety and concern that result in adaptive or non-adaptive efforts; these factors are: the severity of the event, the probability of occurrence and the individual's ability to cope with the crisis and the existing stress. Factors existing during the coronavirus outbreak.

It is also worth asking whether there could be training, both initial and ongoing, for health professionals in dealing with these extreme contingencies, in such a way as to enable them to face these situations with techniques to control their stress, fear and emotions. Academic offerings of specific subjects during the university career or training modules in continuous training processes could be a possibility, but the experiences obtained so far in other scenarios of extreme circumstances do not show that satisfactory results can be guaranteed. As presented by Dreison et al. [76], in a meta-analysis of the effectiveness of interventions against burnout syndrome, the effectiveness is very relative. It is true that training/education appeared in their study as the most effective subtype of organizational intervention, but this was dependent on the context. These authors even recommended that the different interventions carried out be adjusted to the specific needs of the organization and staff, and in long follow-up periods.

However, as we have presented in this study, the situation in which Spanish health professionals have found themselves in this COVID-19 pandemic is what has led to the burnout syndrome having more effect on those aspects related to emotional exhaustion. Further, this has been due, above all, to the fact that they lacked the resources to deal with the virulence of SARS-CoV-2 rather than the lack of prior training or preventive measures in training. The lack of resources of individual protection was one of the highest risks that health professionals have had to face in their professional work, being aware that they were risking their lives and, naturally, those of their loved ones, to whom they could infect. Nevertheless, the work carried out has been admirable, always focusing on the care of patients above their own concerns. In this context, the appearance of the burnout syndrome is evident. If the situation caused by the pandemic has significantly increased the levels of anxiety and stress in the general population, for which interventions are requested [120–122], the experiences of health professionals in Spain, faced in the front line with the most terrible aspects of this disease, and in so many cases without sufficient protection, represent a limited scenario on the psychological level.

Thus, in relation to its meaning, is necessary to emphasize that, unlike the subscales of emotional exhaustion and depersonalization, no significant results were observed in terms of personal accomplishment, neither through the cross tables nor through logistic regression. This is a relevant finding since it can be considered that the previous variables that health professionals highlight as generating stress and anxiety are the lack of PPE and the possible transfer of the virus to relatives and not so much the excessive workload or lack of motivation, which, according to the data, appears intact, despite being in an unprecedented health crisis.

Finally, it should be noted that this research was limited by the accessibility to health professionals at that critical time as a result of the declaration of the state of alarm and the extreme conditions in which they carried out their job. Despite not having developed a stratified research in all the Spain territory, and with a greater sample (the mentioned limitations made it impossible) the results allow access to information of vital importance both for the current management of the health crisis and to design, plan and execute actions to improve the mental health of the health professionals subjected to high levels of anxiety and stress at work. In the context, as we say, of how difficult it has been to carry out the field work, we consider it necessary and essential for all that it could bring us.

Understanding depersonalization as the unemotional and impersonal response to patients, development of negative attitudes and feelings, insensitivity, distancing of patients and colleagues even blaming them for their own frustrations, we find that in this study, the main finding lies in the relationship with the lack of resources of individual protection and the risk of health care workers to

be infected and not as a response to fatigue resulting from high workload, time with patients or lack of recognition. In this case, changes in management related to schedules, work shifts, service rotation, training in effective stress management and conflict resolution, tolerance to frustration, as well as the importance of companion and quality of care, would help to minimize this feeling of tiredness and cynicism.
