Material and Method: In our study, emergency service physicians were provided to fill in the Job Satisfaction Scale, Maslach Burnout Scale and Beck Depression Scale on a voluntary basis through an online questionnaire. SPSS 22.0 package program was used in the analysis of the data.

Results: Fifty three, four% (n =86) of the 161 emergency physicians participating in our study were male, with a mean age of 30.1±7.3 years. It was determined that 44.1% (n =71) of the physicians had low job satisfaction, 12.4% (n =20) had high emotional exhaustion, 22.4% (n =36) had high depersonalization and 9.3% (n =15) had severe depression. It was determined that job satisfaction was higher in physicians with higher income levels (p =0,001). It was determined that moderate and high emotional exhaustion was 53.7% (n =88) in public hospital workers and 20.0% (n =32) in university hospital workers (p =0,035). It was observed that the level of moderate and severe depression was 58.5% (n =94) in smokers and 40.7% (n =66) in non-smokers (p =0,005).

Conclusion: It is seen that there is a significant relationship between the job satisfaction, burnout, and depression levels of the physicians in our study and their income, smoking, appreciation and job satisfaction.

Job satisfaction is defined as the employees’ satisfaction with their job and the positive emotional evaluation of themselves and their job. The concept of job satisfaction is a concept related to how physically and psychologically employees are satisfied with the work they undertake². Factors such as having life-threatening duties and responsibilities, working under intense stress and pressure cause them to be in a higher risk group in terms of job satisfaction³.

First introduced in the 1920s, the concept of job satisfaction not only directly affects the physical and mental health of individuals, but also has positive effects on increasing efficiency and productivity in business life⁴. Insufficient job satisfaction can cause negative situations such as stress and group cohesion problems. Among the situations that indicate job dissatisfaction of the individual are low productivity, increase in complaints and grievances, increase in the rate of absenteeism and lateness⁴.

The concept of burnout was first mentioned by Herbert J. Freudenberger of German origin in 1974. It is defined as the physical and mental fatigue caused by an individual's professional life, and the loss of power and energy due to excessive demands and demands⁵. Burnout is derived from the English word burnout, which means a decrease in energy. There is a decrease in productivity in individuals experiencing burnout. The concept of burnout, which was first propounded by Herbert Freudenberger, of German origin, in 1974, was defined as exhaustion in individuals who are exposed to high levels of stress as a result of unfulfilled desires along with failure, weariness, loss of energy and power⁶. According to the widely accepted definition made by Maslach et al.⁷ burnout is addressed in three different dimensions that categorise the emotions related to emotional exhaustion, depersonalisation and personal success, which express the changes that occur in the life of the individual. According to this approach, burnout in the individual occurs with the increase of emotional exhaustion and depersonalization, and the decrease in personal achievement.

Emergency physicians work in an extremely stressful environment and under intense pressure. Reasons such as heavy workload, caring for severe and terminally ill patients, and having to give emotional support to patients and their relatives, when necessary, cause stress and tension in emergency physicians. Inadequate working conditions and uneven distribution of service and personnel may also cause loss of energy, tension and an increase in the feeling of burnout⁸.

Depression is a disease in which the desire and pleasure of living is lost, leading the person to feel deep sadness, to pessimistic thoughts about the future, and carry a sense of regret and guilt about the past, and in which sometimes thoughts of death, sometimes suicide (suicide) attempts and ultimately death can occur, accompanied with related physiological disorders such as sleep, appetite, sexual desire, etc.⁹. Depression is a phenomenon of loss of interest, including the state of being anxious and sad, up to the physiological inability to work. Some of the symptoms of depression are: Negative feelings and thoughts about the self, depressed or sad mood, loss of love and interest and lack of pleasure, suicidal thoughts, poor concentration, pessimism, crying spells, self-blame and criticism, difficulty in making decisions, sleep, and appetite disorders, etc.¹⁰.

Emergency physicians are adversely affected by many factors such as increased workload, life-threatening duties and responsibilities, insomnia, fear of making mistakes, risks stemming from the work environment, and negative business relationships¹¹. As a result, the defence mechanism formed from intense stress can reach pathological dimensions and bring problems such as depression¹².

Physicians are under more stress than other healthcare professionals due to unhealthy physical working conditions, longer working hours, frequent shifts based on longer hours, mobbing, inability to take leave after shift, and working with lower wages ¹³. As a result, insufficiency in job satisfaction, increase in burnout levels and the frequency of depression appear as important problems in physicians. In our study, determining the job satisfaction levels, burnout levels and depression frequencies of emergency physicians, and the factors affecting them was aimed.

The Job Satisfaction Scale (ISS) that we used in our research is a five-choice, 14-item self-report scale developed by Hackman and Oldham to measure the satisfaction of individuals with their jobs, adapted to Turkish by Güler, who also performed the reliability study¹⁴. It is scored on a Likert-type 5-point scale. Since all of the scale items are positive, the highest score is 70 and the lowest score is 14. The higher the scores, the greater the job satisfaction is. Scores between 14-32 indicate low, 33-52 normal, and 53-70 high levels of job satisfaction.

The Maslach Three-Dimensional Burnout Model, which is the most accepted and widely used burnout model today, was defined by Dr Christina Maslach, a psychology professor. Its adaptation to our language, validity and reliability study was performed by Ergin ¹⁵. In the study conducted with a sample group of 235 people from 6 different professions, it was seen that the 7-step answer options in the original form were not suitable for Turkish culture and the number of options was reduced to 5. Validity studies for the Turkish form of the scale revealed that the three-factor structure is valid in our culture. The Cronbach Alpha internal consistency coefficients for the sub-dimensions of the scale were 0.83 for Emotional Exhaustion, 0.65 for Depersonalization, and 0.72 for Personal Achievement; and the test-retest reliability coefficients were 0.83 for Emotional Exhaustion, 0.72 for Depersonalization, and 0.67 for Personal Success.

Beck Depression Inventory, which was used to measure the depression levels of emergency physicians in our study was developed by Beck et al.¹⁶ and measures an individual's risk of depression, levels of depressive symptoms, and change in severity. It consists of 21 items and is in 4-point Likert type. In the scale, individuals are asked to evaluate and answer their last week's situation, including the present day. Scale items score between 0-3 points and the total score is obtained by summing the item scores. The lowest score to be taken from the scale is 0, and the highest score is 63. Higher total score indicates the severity of depression. 0-9 points from the scale were classified as minimal, 10-16 points as mild, 17-29 points as moderate and 30-63 points as severe depressive symptoms.

The data of the patients obtained for the study were entered into the Statistical Package for the Social Sciences (SPSS) version 20.0 statistical package program and the data were analysed in this program. Number, percentage, mean value, median value, standard deviation, and highest and lowest values were used for descriptive statistics in statistical analysis. Before the analytical tests, the normal distribution of the data was examined by Kolmogorow Smirnow analysis. Tamhane analysis was used in post hoc analyses. Pearson Chi-Square test was used in the analysis of independent qualitative data. In statistical analyses, p values less than 0.05 were considered significant.

No support was received from any financial institution in the planning and execution of the research.

Permission was obtained from Mustafa Kemal University non-ınterventional clinical research ethics committee with decision no 11 dated 24.09.2020.

Those who did not want to fill out the questionnaire were excluded from the study.

It was detected that, 44.1% (n =71) of the participants in our study has low job satisfaction. According to the Maslach Burnout Scale, while 12.4% (n =20) of the participants had a high level of emotional exhaustion and 22.4% (n =36) had a high level of depersonalization, 94.4% (n =152) had a high level of personal achievement. Physicians' mean emotional exhaustion score was 21.7±6.7, depersonalization mean score was 9.6±3.5, and personal achievement mean score was 18.5±3.5. According to the Beck Depression Inventory, 9.3% (n =15) of the participants had severe depression and 39.1% (n =63) had moderate depression (Table 1).

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Table 1: Participants' Job Satisfaction, Burnout Levels and Depression Status by Scales.

While none of the women participating in our study had high job satisfaction, 4.7% of the men (n =8) had high job satisfaction (Table 2).

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Table 2: Comparison of Participants' Sociodemographic Characteristics and Job Satisfaction Levels.

While the frequency of low job satisfaction is 46.7% (n =75) among participants with a monthly income of 5-10 thousand Turkish Lira (TL), there is no participant with low job satisfaction in those with a monthly income of 20 thousand TL or more. There is a significant relationship between income level increase and job satisfaction (p =0.001).

In terms of the institution they work, the low job satisfaction of the emergency physicians working at the first place of duty was 39.4% (n =64), while the low job satisfaction of the participants who is not working in their first place of duty was 53.8% (n =94) (p =0.024) (Table 3).

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Table 3: Comparison of Participants' Working Conditions and Tasks with Job Satisfaction Levels.

While 55.6% (n =90) of those who previously worked in another unit had low job satisfaction, this rate was 39.7% (n =64) (p =0.010) in those who did not work in another unit.While high job satisfaction is 10.7% (n =17) for those who have graduated from medical school 10 years ago or more, this rate is 1.8% (n =3) (p =0.008) for those who have graduated within the last 0-1 years. While low job satisfaction is 14.3% (n =23) in those working in the daynight shift system, it is 45.5% (n =73) (p =0.001) in those working in the 24-hour system.While low job satisfaction is 32.4% (n =52) in those who have experienced physicians whom they can consult in the emergency department, this rate is 64.4% (n =103) (p =0.001) in those who do not.

It was determined that there was a significant relationship between the ages of the participants and their job satisfaction (p =0.001). According to the Tamhane analysis, there was a significant age difference between low and high job satisfaction, and there was a significant age difference between normal and high job satisfaction (p <0.05). A significant relationship was found between the number of patients examined daily and the job satisfaction levels (p =0.002). As a result of the paired analyses, it was determined that there was a significant difference between low and normal job satisfaction in terms of the number of patients examined daily (p =0.002). A significant relationship was found between the participants' home ownership and their job satisfaction levels (p =0.014). Participants who own a home have a higher job satisfaction level than those who do not. It was determined that there was a significant relationship between the participants in our study being exposed to verbal, physical and sexual violence and their job satisfaction levels (p <0.05). It was observed that low job satisfaction levels were significantly higher in those who were exposed to violence than those who were not. A significant correlation was found between the appreciation of emergency physicians by their supervisors, colleagues, patients and patient relatives and their job satisfaction levels (p =0.001). It was determined that the job satisfaction levels of the appreciated emergency physicians were significantly higher. A significant relationship was also found between being happy to be an emergency medicine physician and job satisfaction levels (p =0.001). While the high job satisfaction level is 8.5% (n =12) in those who are happy with being an emergency physician, the high job satisfaction level is 0.0% (n =0) in those who are not sure or unhappy. A significant relationship (p <0.05) was found between the period passed since the emergency physicians graduated from medical school and the period they have been working in the emergency department, and the emotional exhaustion.High level of emotional exhaustion is higher in those who have graduated from medical school 10 years ago or more and who have being working in the emergency department for 10 years or more. In addition, while there is high level of emotional exhaustion n =50.0% for those whose work environment is not harmonious, this rate is significantly lower n =8.3% (p =0.001) for those whose work environment is harmonious. There is a significant relationship (p <0.05) between the number of monthly shifts, the number of patients examined daily, and the emotional exhaustion of emergency physicians. There was no significant relationship (p >0.05) between the social and economic status of the participants and their emotional exhaustion levels. A significant relationship (p <0.05) was found between the emergency physicians’ status of being appreciated by their supervisors, colleagues, patients and their relatives and their emotional exhaustion levels.It is seen that those who are appreciated have less high-level emotional exhaustion and more low-level emotional exhaustion. In addition, it was determined that emotional exhaustion was significantly higher in those who were not happy with being an emergency medicine physician (p=0.001).

According to Beck depression inventory, a significant relationship was found between gender and severity of depression (p =0.015). While severe depression in men is 12.8% (n =18), this rate is 5.3% in women (n =10). It is noteworthy that women have moderate depression more than men. There was no significant relationship between other variables and the severity of depression. It was observed that there was a significant relationship between the period passed since the participants graduated from medical school and the period they have been working in the emergency department and their depression levels (p <0.05). Severe depression levels were found to be higher in those who graduated from medical school 10 years ago or more and those who have worked in the emergency department. While the level of severe depression is 6.9% (n =11) in those who work in harmony in the working environment, it is 31.2% (n =51) in those who do not (p =0.004).It was found that the depression levels of the emergency physicians in our study were not significantly related to the age, the number of monthly shifts, the number of patients examined daily, and the number of physicians working in the emergency department (p >0.05).There was a significant relationship between smoking and depression levels (p =0.005). Moderate and severe depression levels are higher in smokers than non-smokers. There was no significant relationship between other variables and depression levels (p >0.05). Among the participants in our study, mild, moderate or severe depression level was 75.9% (n =120) in those who were exposed to verbal violence, while this rate was 0.0% (n =0) in those who did not experience verbal violence (p =0.003). Although severe depression levels were higher in those who were exposed to physical violence, those who were threatened, and those who were exposed to sexual violence, no significant relationship was observed (p >0.05). A significant relation was found between emergency physicians’ status of being appreciated by their supervisors, colleagues, patients and patient relatives and their depression levels (p =0.001) (Table 4).

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Table 4: Comparison of Participants' Status of Being Appreciated and Happy with Emotional Exhaustion Levels.

It was observed that the rates of severe and moderate depression in the underappreciated emergency physicians were higher than those that were appreciated. In addition, while the level of severe depression is 2.1% (n =3) in those who are happy with being an emergency physician, the level of severe depression is n =20.3% (n =33) in those who are not (p =0.001).

One of the important factors affecting the quality of life of individuals is the level of being satisfied with their work. Intensive working conditions can negatively affect the job satisfaction of physicians. In a study conducted by Kurçer on physicians working at Mustafa Kemal University Faculty of Medicine, it was reported that physicians' job satisfaction levels were low¹⁸. In our study, similar to the literature, it was observed that the level of job satisfaction was lower in physicians who worked on a 24-hour basis and examined more patients. Working conditions of emergency physicians working under intense stress should be relieved, their physical conditions should be improved and unnecessary applications to emergency services should be prevented.

Burnout syndrome is more common in individuals working in difficult work conditions. Burnout syndrome is common in physicians who work face-to-face with people for a long time due to their profession. In a study they conducted on all emergency service workers, Erol et al.^19, found that emotional burnout was lower in those working in training and research hospitals than those working in university hospitals In another study, it was revealed that as the number of patients who were examined daily increased, the level of emotional exhaustion also increased²⁰. It is stated that those who choose their profession consciously and willingly will be more successful in fulfilling the requirements of the profession, and this will reduce the burnout syndrome²¹. Studies have shown that burnout increases in those who do not choose their profession voluntarily ¹⁰. In our study, emotional exhaustion is higher in physicians working in state hospitals than in those working in university hospitals.

Depersonalisation is the condition in which professionals show insensitive attitudes and behaviours towards the people they serve, without caring that they are a "person". In the study conducted by Özkan et al.^22, on research assistant doctors, the mean score of depersonalisations was found to be 12 Taking the studies conducted into consideration, it can be said that the level of depersonalisation in the physicians in our study was lower than in the literature. In a study conducted among research assistants at Mustafa Kemal University Faculty of Medicine, it was found that depersonalisation levels were significantly higher in those who were not happy with their profession²³. In our study, similar to the literature, it was found that depersonalisation was higher in those who were not happy with being an emergency medicine physician.

Presence of depression is an important factor affecting working conditions. In the literature, the frequency and severity of depression in health care workers vary^24,25. It is stated that the frequency of depression in health workers is higher than in other occupational groups²⁶. In a study conducted in Sweden, it was determined that the frequency of depression in women was 2 times higher than in men²⁷. Studies which indicate that smoking is common in emergency physicians have reported that smoking is associated with depression²⁸. In the study conducted by Çete A^23, the BDI score of the research assistant doctors was found to be higher in those who smoke and used alcohol. In studies conducted among emergency medicine physicians or research assistants in the literature, it has been determined that the frequency of depression is significantly higher in physicians who do not have work peace, experience mobbing and are not appreciated²³. Also in our study, it has been determined that the level of severe depression is higher in men than in women, but moderate depression is higher in women, the frequency of depression is higher in smokers, and those who cannot work in harmony in the working environment, those who are not appreciated by their supervisors, colleagues, patients and patient relatives have a higher level of severe depression.

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