Perceived Social Support as a Predictive Factor of Fatigue and Quality of Life Among Healthcare Professionals in Greece

The multitude of stressful factors in the work environment, combined with work burnout and the absence of social support, significantly degrades the quality of life of health professionals. And while studies focus individually on each variable, the purpose of the present research is to classify and simultaneously correlate them, in the case of healthcare professionals in the post-pandemic era. The quantitative method with a structured questionnaire was selected to conduct the research in 506 health workers, from 14 hospitals of the 6th HealthCare Region of Greece. A fairly high level of fatigue, an alarmingly low level of social support and a moderate to high level of general health were found. Physical, mental, and overall fatigue were found to be significantly negatively correlated with family, friends, significant others, and overall social support. Their correlation was found to be significantly positive in terms of general health, as well as its individual subscales. Further investigation of the cumulative effects of fatigue and the low level of quality of life of health professionals on the efficiency and level of healthcare services provided, will contribute to the formation of new approaches to dealing with and preventing the phenomenon.


Introduction
The Covid-19 pandemic had, among other things, the fatigue of health professionals, leading to burnout, withdrawal from the National Health System (NHS), or even retirement from the profession.Even before the pandemic, it was found that health professionals belong to a professional category with high exposure to stress factors, fatigue and exhaustion.sources of social support on emotional exhaustion, but also the short-term effect of family and colleagues.
Nurses' burnout with a position of responsibility in association with various coping strategies, including social support, were investigated by Steege et al. [10] .The study was conducted through semi-structured interviews and the Occupational Fatigue Exhaustion Recovery Scale, with 21 hospital managers and nurse executives in one US state.Most leaders/in positions of responsibility experience fatigue.Nurse managers in particular reported higher levels of chronic fatigue.
Fatigue had an impact on decision-making, work-life balance and intention to leave.Participants identified multiple sources of fatigue, including 24-hour accountability and intense role expectations, and used a combination of wellness, rehabilitation, social support, and boundary-setting strategies to cope with fatigue.
Tzeletopoulou et al. [15] in their study investigated the relationship of perceived social support and fatigue as predictors of aggressive behaviors among mental health professionals.A cross-sectional study was conducted on 104 mental health professionals with the following three online questionnaires: the Greek version of the Fatigue Assessment Scale (FAS), the Greek version of the Multidimensional Scale of Perceived Social Support (MSPSS) and the Greek version of the Aggression Questionnaire (G-AQ).Mental health professionals reported high rates of fatigue and aggression and low levels of social support.Mental and physical fatigue were found to be significant predictors of aggressive behavior, in contrast to social support.
Theofilou, Iona and Tzavella [16] investigated the relationship of health professionals' general health, perceived level of fatigue and social support.The survey was conducted on 165 health professionals working in hospitals in the region of Eastern Macedonia-Thrace and in the urban centers of Athens and Thessaloniki.Data were collected with the General Health Questionnaire (GHQ-28), the Fatigue Assessment Scale (FAS) and the Multidimensional Scale of Perceived Social Support (MSPSS).The research found a positive correlation between general health and fatigue, as well as a negative correlation between mental fatigue and social support.
The mediating role of social support in the relationship between secondary trauma and emotional exhaustion was examined by Brugman et al. [17] , in 593 health professionals in the Netherlands.Emotional exhaustion was chosen as it is caused by exposure to prolonged stress-related work conditions such as secondary injury.It was hypothesized that social support is a protective factor for the development of emotional exhaustion, while higher levels of social support are associated with lower levels of secondary injury.In this cross-sectional study emotional exhaustion was measured with the Utrecht Burn-out Scale-C, secondary trauma with ten questions from the Professional Quality of Life scale, and social support with the Perception and Assessment of Labor 2.0 questionnaire.The research found that the relationship between secondary trauma and emotional exhaustion is partially mediated by social support.This means that health professionals have access to and use social support, preventing emotional exhaustion.
The relationship between compassion fatigue and perceived social support was examined by Pergol-Metko et al. [9] in a sample of 862 nurses in Poland.The professional quality of life scale (Quality of Life scale -ProQOL) and the Multidimensional Scale of Perceived Social Support (MSPSS) were used to collect the data.The presence of compassion satisfaction, compassion fatigue and burnout in nurses was demonstrated.Higher levels of perceived social support were associated with lower compassion fatigue, higher job satisfaction, and lower risk of burnout.While several studies have been conducted that individually examine health professionals' fatigue, their quality of life, and the importance of social support in these two variables, fewer studies have investigated the association of these three variables.This issue, however, is particularly important as reduced levels of quality of life and correspondingly high levels of fatigue on the part of health professionals can lead to medical errors, errors in nursing practice and reduced levels in the quality of care provided.The above in turn result in reduced patient satisfaction and negative effects on their health.
For this reason, the provision of social support, both on a personal and organizational level, can have significant positive effects in the prevention and treatment of fatigue, but also in improving the quality of life of health care workers.
Therefore, the purpose of this research is to examine the levels of fatigue, quality of life and social support in the case of healthcare professionals in the post-pandemic environment, as well as the correlation between them.The findings of this study will be useful in submitting proposals for practical application and at a preventive level, mainly through the creation of social support networks.

Method
This is a quantitative cross -sectional study investigating the variables of social support, fatigue and quality of life.The questionnaire used in this research consists of the following sections: Section A -Demographic data: the demographic data questionnaire consists of eight questions aimed at capturing the demographic profile of the survey participants (gender, age, education level, marital status, specialty, years of service, work per week, position of responsibility), but also through statistical tests to examine the second research hypothesis.
Section B -Fatigue Assessment Scale: the Greek version of the Fatigue Assessment Scale (FAS) was used, as it has been translated and culturally adapted to the Greek population by Theophilou [18] .The scale was created in 2003 by Michielsen et al. and consists of ten (10) questions, where five(1-5) examine physical fatigue and five (6-10) mental exhaustion, while overall this tool examines the level of overall fatigue.Responses are given on a five-point Likert scale as follows: 1=Never, 2=Sometimes, 3=Always, 4=Often, 5=Always.Questions 4 and 10 are reversed.The total score ranges from 10 to 50.In the event that the total score is up to 22 the respondents fall into the "no fatigue" group, if it is 22-34 then they are categorized as "tired", while if it is more than 35 then they are categorized as " too exhausted."Alikari et al. [19] examined the internal reliability of the Greek version of the scale, where it was found equal to 0.761, while Theofilou et al. [20] report that the internal reliability of the scale is 0.91.In the present work, the Cronbach's a index was found equal to 0.869.
Section C -Social support of nursing staff: the Greek version of the Multidimensional Scale of Perceived Social Support (MSPSS) was used, as it has been translated and culturally adapted to the Greek population by Theofilou [21] .The scale was created in 1988 by students Zimmet et al. and consists of 12 questions that assess three sources of perceived social support: family (3, 4, 8, 11), friends (6, 7, 9, 12)and significant others (1, 2, 5, 10).Responses are given on a seven-point Likert scale as follows: 1=Strongly Disagree, 2=Strongly Disagree, 3=Disagree, 4=Neutral, 5=Agree, 6=Strongly Agree, 7=Strongly Agree.The total score ranges from 12 to 84 with higher scores indicating greater social support.Specifically, a score of 65 or less is considered indicative of sufficiently low levels of perceived social support.Mourdoukouta et al. [22] used this scale in their research and found that the internal reliability coefficient is 0.80.In the present work, the Cronbach's a index was found equal to 0.944.
Section D -General Health Questionnaire: the Greek version of the General Health Questionnaire (GHQ) scale 28 was used, as it has been translated and culturally adapted to the Greek population by Garyfallos et al. [23] .The scale was created in 1978 by Goldberg and consists of 28 questions concerning the respondent's overall health during the last two weeks.These questions are categorized into four groups: a) physical symptoms, b) anxiety and insomnia, c) social dysfunction, d) severe depression.Answers are given on a four-point Likert scale from 0 (best score) to 3 (worst score).
The total score ranges from 8 to 84, with higher scores indicating less mental and physical well-being.Garyfallos et al. [23] report that the internal reliability of the scale is equal to 0.93, while Kokkinis et al. [24] 0.89.In the present work, the Cronbach's an index was found equal to 0.899.
The research population consists of all public secondary care health professionals.The research sample consists of a part of this population and a total of 506 employees.In some questions there were missing values.As a result of this, answers from 504 healthcare professionals were presented.On the basis of convenience (opportunity) sampling, health workers working in 14 hospitals in the 6th Health Region (Peloponnese and Ionian Islands, Epirus and Western Greece) were selected.The criteria for entering the respondents into the sample were: a) over 18 years old, b) understanding of the Greek language, c) health professionals as a qualification, d) voluntary participation.Accordingly, exclusion criteria from the sample were: a) insufficient understanding of the Greek language, b) status other than that of a health professional, c) unwillingness to participate in the research voluntarily.
The researcher initially obtained permission from the administration of the 6th Ministry of Health for the research regarding the safeguarding of personal data protection and the method of data collection.Similarly, permission was then obtained from the scientific board of each nursing organization to distribute the questionnaires.Finally, permission was also obtained from the creators of the questionnaires in order to use them in this research.At the same time, together with the questionnaire there was attached a letter addressed to the health professionals and informing them about the following: a) the identity of the researcher and the purpose of the research, b) the assurance of their anonymity and the confidentiality of the data, c) the fact that the data will be analyzed and presented grouped, d) their voluntary participation in the research and their right to withdraw from the research until a specific date (15.01.2024), after which the processing of the questionnaires will begin, e) the estimated time to complete the questionnaire.
Afterwards, the researcher coded the data into the statistical program SPSS 26, in order to process them.Descriptive statistics (tables of descriptive measures and frequencies) as well as inductive statistics (correlation coefficients, mean differences of respondents' opinions) were used to test the hypotheses.For all controls the level of statistical significance was set equal to α=0.05.

Results
Demographics Most of the participants in the survey are women (65.6%), university graduates (49.4%), married (65.8%), members of the nursing staff (36.2%) and who do not hold a position of responsibility (71.7%).
In terms of age, the respondents are 24-66 years old with an average of 45.39 years (SD=8.782).

Graph 1. Age of respondents
Regarding the years of work in their specialty, the range is 1-38 years with an average of 16.36 years (TA=9.502).
Regarding the weekly working hours, they range from 8-120 hours, with an average of 43.98 hours (TA=10.404).As can be seen from Table 2, more than half of the respondents (55.9%) fall into the 22-34 score category and are therefore categorized as "fatigued".The percentage of those categorized as "non fatigued" is also large (37%).Only a small percentage of 7.1% are categorized as "extremely fatigued".where a statistically significant relationship between the three variables is established.Specifically, a statistically significant negative correlation is found between physical, mental and overall fatigue with family, friends, significant others and overall social support.There is also a statistically significant positive correlation between physical, mental and overall fatigue with general health, as well as its individual subscales (physical symptoms, anxiety and insomnia, social dysfunction and severe depression).Finally, a statistically significant negative correlation was found between general health and total social support, as well as three of its individual subscales (anxiety and insomnia, social dysfunction and severe depression).Regarding physical symptoms, a statistically significant negative correlation was found only with significant others.Then it is examined whether social support and its subscales are predictors of overall fatigue.For this reason, a regression was carried out, the results of which are presented in the tables below.The dependent variables explained 8.9% of the dependent variable, with friends, significant others and overall social support being a determinant of overall fatigue (p<0.05).Subsequently, it is examined whether social support is a predictive factor of social dysfunction.For this reason, a regression was carried out, the results of which are presented in the tables below.The dependent variables explain 13% of the dependent variable, with family and significant others being determinants of social dysfunction (p>0.05).Finally, it is examined whether social support is a predictive factor of severe depression.For this reason, a regression was carried out, the results of which are presented in the tables below.The dependent variables explain 12.6% of the dependent, with family, significant others and overall social support being determinants of major depression (p>0.05).

Discussion
The purpose of the research was to examine the levels of fatigue, quality of life and social support in the case of health professionals in the post-pandemic environment, but also the relationship between these variables.For this reason, a quantitative questionnaire survey was conducted on a sample of 506 employees from 14 hospitals in the 6th Health Region.
According to the results of the statistical analysis, the main findings of this research are: 1.The respondents are generally characterized by fatigue, especially physical fatigue and then by mental exhaustion.
2. Respondents reported low levels of perceived social support which in descending order are as follows in terms of its individual dimensions: significant others, family, friends.
3. Respondents reported moderate to high levels of overall health which, in descending order, are as follows in terms of its individual dimensions: severe depression, social dysfunction, physical symptoms, anxiety and insomnia.
4. There is a statistically significant negative correlation between physical, mental and overall fatigue with family, friends, significant others and overall social support.
5. There is a statistically significant positive correlation between physical, mental and overall fatigue with general health, but also its individual subscales (physical symptoms, anxiety and insomnia, social dysfunction and severe depression).
6.There is a statistically significant negative correlation between general health and total social support, as well as three individual subscales of it (anxiety and insomnia, social dysfunction and severe depression).
Research participants reported moderate to high levels of quality of life, which was not found in previous research [4][16] .
Specifically, anxiety and insomnia problems were found, as in the study by Kandula and Wake [25] but in contrast to the study by Pérez-Valdecantos et al. [3] , but not depression, found in the research by Kandula and Wake [25] and Zhan et al. [26] .Moderate levels of anxiety were also found in the study by Latsou et al. [2] , while higher in the study by Zhan et   al. [26] and Sampaio et al. [27] .On the other hand, studies were also identified [3] that found a satisfactory level of quality of life, as found in the present research.
In addition, in the present research a higher score was found in physical fatigue compared to psychological exhaustion, contrary to the findings of Rashid et al. [28] who found a higher score in physical and then psychological quality of life.
Overall fatigue was found, similar to other studies [1][15] .Regarding social support, a high level was not found, which is in agreement with the results of previous studies [15] , but contrary to the findings of Theofilou et al. [16] .
Fatigue has been found to negatively affect quality of life in several studies [1][11] , which was also found in this research.
Similarly, social support has been found to positively influence quality of life both in this research and in previous ones [11][27] , as well as in mental health [14] and fatigue [10] .After all, from the regressions conducted it was found that: a) friends, significant others and overall social support are determinants of overall fatigue, b) significant others are a determinant of physical fatigue, c) overall social support is a determinant factor of mental exhaustion.
A correlation between stress and quality of life was also found in the study by Sampaio et al. [27] , a correlation between fatigue and general health was found in the study by Theofilou et al. [16] , while a correlation between quality of life and social support was found in the study by Fradelos et al. [11] .Similar to the present research, stress and mental health were found to be negatively related to social support in previous studies as well [16] .After all, from the regressions conducted it was found that: a) family is a determinant of overall general health, b) significant others are a determinant of physical symptoms, c) family and significant others are determinants of social dysfunction, d) family, significant others, and overall social support are determinants of major depression.
In the post-pandemic environment, a high level of fatigue, a low level of social support and a moderate to high level of general health are found.Similar findings have been reported in previous research on quality of life [3] , social support [15] and fatigue [15] .The pandemic has had a significant negative impact on the physical fatigue of healthcare professionals, and possibly this accumulation of burnout and fatigue is reflected in existing levels of fatigue.Stress and sleep problems experienced by healthcare professionals are a consequence of high levels of fatigue [11] .However, the mental health of the research participants was found to be at better levels, especially in terms of depression, but also social functioning.These findings cannot be interpreted only by the demographic characteristics of the respondents.
Instead, the reasons should be sought in the organizational factors and in the wider work environment of health professionals that have been found by other research to have a significant impact on fatigue and quality of life of health professionals, such as for example working hours and shifts [4] , work-life balance [10] , fear of contamination [25] .
Of particular concern is the finding of low levels of social support, particularly from family and friends.The importance of social support in the overall health and quality of life of health professionals has been demonstrated through several studies [11][27] and for this reason we should there should be initiatives to strengthen support networks, both at the individual level (e.g.interpersonal relationships) and at the organizational level (e.g.work groups).The cooperation of health units with professional counselors (e.g.psychologists) could be a way of strengthening the support of workers.
Similarly, it is important to encourage health professionals to participate in peer networks, with the ultimate goal of exchanging opinions, experiences, difficulties, negative events, which will lead to the strengthening of positive emotions and the reduction of their psychological discomfort.
The present research is subject to certain limitations.The first limitation is that the sample of health professionals comes from a specific geographical region, which means that the results cannot be generalized to the wider research population.
Therefore, there is a need for further investigation of this issue, involving a sample of healthcare professionals that is more representative of the wider population.The second limitation is that specific scales were used to collect the data, which examine specific dimensions of the variables under consideration.Possibly the use of other tools would (and) lead to other conclusions.Therefore, in the future it is worth using other tools to collect the data.Another limitation related to the data collection method is that quantitative research does not provide the possibility of in-depth investigation of respondents' opinions, attitudes and behaviors based on their experiences and the meaning they attribute to them, as in qualitative research.Consequently, the future conduct of a qualitative research, or even a mixed method research, could perhaps also lead to the production of new knowledge.

Conclusion
Even after the end of the pandemic, health professionals continue to suffer from fatigue, as well as general health problems.Various factors such as low level of social support, individual characteristics / socio-demographic and professional variables, organizational factors, interact and affect the fatigue and quality of life of health professionals.This means that measures should be taken to prevent and address fatigue and low quality of life, given their impact on the efficiency of health professionals and the level of health services provided.
Considering the importance of social support, health units can invest in initiatives to create networks (e.g. with health professionals of other units through virtual environments), strengthen interpersonal relationships, work-life balance (e.g.care for employees' children), self-care training, but also the provision of counseling services by psychologists and social workers within the workplace.
As the health sector is constantly changing and given that it is influenced by various factors in the wider environment, it is necessary to carry out continuous research that examines the views, needs and also the proposals of the health professionals themselves, in order to formulate policies that respond to them needs, reducing the negative emotions of health workers and increasing their overall well-being.

Table 3
presents the descriptive measures of the MSPSS scale and its subscales.It is observed that for the individual scales and overall, the average is less than 65, which indicates low levels of perceived social support.The lowest levels of social support are found in friends (M=19.35,TA=4.193), then in family (M=20.41,TA=4.446) and highest in significant others (M=21.09,TA=4.236).Overall, however, there is not a high level of social support.

Table 4
presents the descriptive measures of the GHQ scale and its subscales.It is observed that there are moderate to high levels of mental and physical well-being in the individual scales.Higher average and therefore lower levels of mental and physical well-being are recorded in the anxiety and insomnia subscale (M=14.76,TA=4.267), then in physical symptoms (M=14.39,TA=3.951) and then in social dysfunction (M=14.30,TA=2.79).Conversely, a lower mean is noted in the depression subscale (M=10.36,TA=3.169).Overall, however, it is observed that the average of the entire scale is above average.

Table 5 .
Correlations of variables Qeios, CC-BY 4.0 • Article, February 19, 2024 Qeios ID: N3U7W8.2 • https://doi.org/10.32388/N3U7W8.2 10/19 Then it is examined whether social support and its subscales are predictors of physical fatigue.For this reason, a regression was carried out, the results of which are presented in the tables below.The dependent variables explain 4.2% of the dependent, with significant others being a determinant of physical fatigue (p<0.05).It is also examined whether social support is a predictive factor of physical symptoms.For this reason, a regression was carried out, the results of which are presented in the tables below.The dependent variables explain 1.7% of the dependent, with significant others being a determinant of physical symptoms (p>0.05). is examined whether social support is a predictor of anxiety and insomnia.For this reason, a regression was carried out, the results of which are presented in the tables below.The dependent variables explain 1.4% of the dependent variable, but none is a determinant of anxiety and insomnia (p>0.05).After all, the model does not fit the data (p>0.05).
Qeios, CC-BY 4.0 • Article, February 19, 2024 Qeios ID: N3U7W8.2 • https://doi.org/10.32388/N3U7W8.2 11/19Then it is examined whether social support and its subscales are predictors of mental fatigue.For this reason, a regression was carried out, the results of which are presented in the tables below.The dependent variables explain 12.3% of the dependent variable, with overall social support being a determining factor of mental fatigue (p<0.05).It also examines whether social support is a predictor of overall general health.For this reason, a regression was carried out, the results of which are presented in the tables below.The dependent variables explain 7.5% of the dependent, with Qeios, CC-BY 4.0 • Article, February 19, 2024 Qeios ID: N3U7W8.2 • https://doi.org/10.32388/N3U7W8.2 12/19 the family being a determining factor of overall general health (p>0.05).Qeios, CC-BY 4.0 • Article, February 19, 2024 Qeios ID: N3U7W8.2 • https://doi.org/10.32388/N3U7W8.2 13/19