INTRODUCTION

In recent years, psychological resilience has become a prominent concept in various domains of professional life, holding importance from the perspective of behavioural and medical sciences.1,2 It is defined as the ability to withstand and effectively cope with stressful and negative situations.3 Psychological resilience represents the personality traits that facilitate individual growth and development following a problem or traumatic event. Individuals labelled as ‘resilient’ demonstrate the ability to overcome challenges, transform negative memories and experiences into positive teachings and return to their initial emotional state.4

Recent studies indicate that the concept of resilience is a determinant of individual happiness and an independent factor in academic success.5,6 Professional quality of life (ProQoL) is the professional counterpart to the impact exerted by work life on individuals. In the field of healthcare, it refers to the positive (compassion satisfaction [CS]) and negative (burnout [BO] and compassion fatigue [CF]) aspects of working as a professional healthcare provider.7 Professional satisfaction can be described as the occupational fulfilment derived from assisting others and providing healthcare services in one’s professional life.8 CF can be defined as the secondary trauma resulting from dealing with an individual who has experienced trauma or distress, although the observer has not directly undergone the traumatic event.9 BO can be summarized as feeling hopeless and inadequate due to work performance.9 Instances where ProQoL is low, characterized by high levels of CF and BO, not only give rise to emotional symptoms such as depression and low concentration amongst healthcare professionals but also contribute to physical symptoms, including headaches and sleep disorders.7,8,10

Physicians working in emergency departments operate in an environment inherently characterized by high stress, where feelings of BO and CF are commonly experienced. This situation affects the ProQoL and sense of professional satisfaction amongst emergency medicine physicians, playing an important role in patient-centred care.11

We examined the relationship between resilience and ProQoL through specified surveys and to identify the correlation with sociodemographic characteristics that may affect both concepts.

METHODS Study design and data collection

The study was conducted during 5–15 December 2023, amongst physicians working in different emergency departments across Türkiye. The survey was distributed to all those who agreed to participate in the study. An online questionnaire was used to collect data (www.docs.google.com) that took approximately 6 minutes to complete. At the beginning of the form, the purpose of the study was explained to the participants, and informed consent was obtained from all participants. The questionnaire had 3 parts. The first part had 10 questions on the demographic characteristics and working conditions of the participating physicians, including the physician’s age, gender, marital status, presence of children, duration of emergency department practice, medical title of the physician (general practitioner, resident or specialist physician or academician), the number of physicians working during a shift in the emergency department, number of patients treated daily and whether the physicians had received any training to enhance their resilience and motivation and if so, the nature of the training.

The second part consisted of the ‘Connor–Davidson Resilience Scale’ (CDRS), a 10-item scale using a 5-point Likert scale, which measures the psychological resilience of physicians.12 The scale was translated into Turkish and validated by Kaya and Odaci in 20214 based on the original scale developed by Connor and Davidson.12

The third part comprised the ‘Professional Quality of Life Scale (ProQoL scale)’,13 a 30-item questionnaire using a 6-point Likert scale, which measures physicians’ CS, BO and CF. This scale was translated into Turkish and validated by Yesil et al. in 2010 based on the original scale.14 As specified in The Concise ProQoL Manual (2010), scores for the subscales of ProQoL, namely CS, BO and CF, were categorised as follows: ≤22 low; 23–41 moderate and ≥42 high levels.9

Selection of participants

The study included general practitioners, residents, specialists and academicians (assistant professor, associate professor or professor) working in the emergency department. Physicians who refused to participate in the survey, those who worked in other units and were temporarily assigned to the emergency department and those who did not answer all the questions in the questionnaire were excluded from the study.

Outcome

The primary outcome of the study was to examine the relationship between psychological resilience and ProQoL amongst physicians working in the emergency department through questionnaires. The secondary outcome was to determine the relationship between both psychological resilience and ProQoL with sociodemographic and occupational characteristics.

Statistical analysis

It was done using Jamovi version 2.3.28. The Shapiro–Wilk test was used to assess whether the variables conformed to normal distribution. For descriptive statistics, categorical variables were presented as number and frequency while continuous variables were presented as mean and standard deviation for normally distributed variables and median and interquartile range for non-normally distributed variables. Chi-square test was used to compare categorical variables. For the comparison of continuous variables, Student’s t-test was used for normally distributed variables and Kruskal–Wallis H test was used for non-normally distributed variables. The Dwass–Steel– Critchlow–Fligner test was used for post hoc analyses of continuous variables. The Spearman’s correlation test was used to examine the correlation between two continuous variables. p<0.05 was considered statistically significant for all analyses.

RESULTS

The questionnaire reached a total of 292 participants. However, 2 participants declined to fill it and hence was completed by 290 participants (99.3%). The median age of the participants was 30 (26–37) years, and 40.7% (118) of the participants were females. Although 52.4% (152) of the participants were married, 36.2% (105) had children. Moreover, 30.7% (89) of the participants were general practitioners, and 40.7% (118) had 1–5 years of experience working in the emergency department. Although 90.3% of the participants (262) stated that they did not receive any training to enhance psychological resilience, 5.5% (16) reported receiving such training during residency, and another 5.5% (16) reported receiving psychological resilience training during conferences or symposiums (Table 1).

TABLE 1. Characteristics of sociodemographics and working conditions (n=290)

Characteristic n(%) Median age (years) [Q1–Q3] 30 (26–37) Gender Female 118 (40.7) Male 172 (59.3) Presence of children Yes 105 (36.2) No 185 (63.8) Working title Academician 21 (7.2) Specialist physician 81 (27.9) Resident 99 (34.1) General practitioner 89 (30.7) Marital status Single 138 (47.6) Married 152 (52.4) Duration of emergency department practice <1 year 52 (17.9) 1–5 years 118 (40.7) 6–10 years 54 (18.6) >10 years 66 (22.8) Number of patients treated daily 0–499 58 (20) 500–999 65 (22.4) 1000–1500 104 (35.9) >1500 63 (21.7) Number of physicians in the shift 8 (5–12) Training to increase resilience None 262 (90.3) During residency 16 (5.5) Congress/Symposium 16 (5.5) Podcast 1 (0.3) Social media 4 (1.4) Written material 3 (1.0)

When the relationship between age and CDRS scores was examined, no significant correlation was found between both groups (p=0.91). Similarly, no significant correlation was found between the number of physicians working during a shift and CDRS scores (p=0.21).

When the relationship between gender and CDRS scores was analysed, it was found that the median score of men was 28 (24–31), and it was significantly higher than that of women (p<0.001). No significant difference was observed in CDRS scores with respect to marital status, presence of children, duration of emergency department practice, title and the status of receiving training to enhance psychological resilience (Table 2).

TABLE 2. Comparison of sociodemographic characteristics with the Connor–Davidson Resilience Scale

Characteristic Connor–Davidson Resilience Scale p value Female 25 (21–29) <0.001* Male 28 (24–31) Marital status Single 26 (21–29) 0.169 Married 27 (22–31) Presence of children Yes 28 (22–31) 0.092 No 26 (22–29) Duration of emergency department practice (years) <1 26 (21–29) 0.946 1–5 26 (28–30) 6–10 26 (22–30) >10 28 (21–30) Working title General practitioner 26 (21–29) 0.582 Resident 27 (23–30) Specialist physician 26 (21–29) Academician 28 (21–31) Training to increase resilience Yes 28 (26–31) 0.109 No 26 (21–30)

When the relationship between CDRS and ProQoL subscale scores was examined, there was a significant difference in CDRS scores between the low, moderate and high groups in all three of the subscales (CS, BO and CF) of the ProQoL scale (p=0.003, <0.001 and <0.001, respectively). When the BO subscale was examined, the median CDRS score of participants with high BO scores was 18 (15–20), and this was found to be lower than the median score of participants with low and moderate BO scores in the post hoc analyses (p=0.013 and 0.009, respectively). When the CS subscale was examined, the median CDRS score was 19 (15–28) for participants with low CS scores, 26 (22–29) for participants with moderate CS scores and 29 (27–34) for participants with high CS scores. In post hoc analyses, it was found that the median scores of all 3 groups were statistically different, and the highest median score belonged to the high group (p<0.001 for all 3 groups). When the CF subscale was examined, the median CDRS score was found to be 13 (9–16) for participants with high CF scores, and this value was found to be significantly lower than the CDRS score of participants with low and moderate CF scores (p<0.017 and <0.032, respectively; Table 3).

TABLE 3. Comparison of professional quality of life scale, CDRS and sociodemographic characteristics

Parameter Burnout p value Low1 Moderate2 High3 CDRS 28 (23–32) 26 (22–29) 18 (15–20) 0.003 1–2=0.23 1–3=0.01 2–3=0.009 Median age (years) [Q1–Q3] 31 (27–38) 29 (26–36) 40 (27–43) 0.11 Gender (female) 13 (22.0) 100 (44.2) 5 (100.0) <0.001 1–2=0.006 1–3<0.001 2–3=0.05 Marital status (single) 26 (44.1) 110 (48.7) 2 (40.0) 0.77 Presence of children (yes) 25 (42.4) 78 (34.5) 2 (40.0) 0.53 Duration of emergency department practice (years) <1 7 (11.9) 45 (19.9) 0 (0) 0.66 1–5 24 (40.7) 92 (40.7) 2 (40.0) 6–10 12 (20.3) 41 (18.1) 1 (20.0) >10 16 (27.1) 48 (21.2) 2 (40.0) Number of patients treated daily 0–499 15 (25.4) 43 (19.0) 0 (0) 0.53 500–999 11 (18.6) 52 (23.0) 2 (40.0) 1000–1500 17 (28.8) 85 (37.6) 2 (40.0) >1500 16 (27.1) 46 (20.4) 1 (20.0) Working title General practitioner 13 (22.0) 74 (32.7) 2 (40.0) 0.09 Resident 21 (35.6) 78 (34.5) 0 (0) Specialist physician 23 (39.0) 55 (24.3) 3 (60.0) Academician 2 (3.4) 19 (8.4) 0 (0) Compassion satisfaction CDRS 19 (15–28) 26 (22–29) 29 (27–34) <0.001 1–2<0.001 1–3<0.001 2–3<0.001 Median age (years) [Q1–Q3] 30 (27–37) 29 (27–37) 30 (27–36) 0.80 Gender (female) 17 (37.8) 74 (39.2) 27 (48.2) 0.44 Marital status (single) 21 (46.7) 88 (46.6) 29 (51.8) 0.78 Presence of children (yes) 15 (33.3) 67 (35.4) 23 (41.1) 0.68 Duration of emergency department practice (years) <1 5 (11.1) 36 (19.0) 11 (19.6) 0.92 1–5 20 (44.4) 75 (39.7) 23 (41.1) 6–10 10 (22.2) 34 (18.0) 10 (17.9) >10 10 (22.2) 44 (23.3) 12 (21.4) Number of patients treated daily 0–499 10 (22.2) 31 (16.4) 17 (30.4) 0.10 500–999 13 (28.9) 44 (23.3) 8 (14.3) 1000–1500 10 (22.2) 73 (38.6) 21 (37.5) >1500 12 (26.7) 41 (21.7) 10 (17.9) Working title General practitioner 10 (22.2) 60 (31.7) 19 (33.9) 0.88 Resident 18 (40.0) 62 (32.8) 19 (33.9) Specialist physician 13 (28.9) 53 (28.0) 15 (26.8) Academician 4 (8.9) 14 (7.4) 3 (5.4) Compassion fatigue CDRS 28 (24–31) 24 (20–28) 13 (9–16) <0.001 1–2<0.001 1–3=0.02 2–3=0.03 Median age (years) [Q1–Q3] 29 (27–35) 30 (26–38) 38 (33–39) 0.61 Gender (female) 70 (34.1) 45 (54.9) 3 (100) <0.001 1–2<0.001 1–3=0.12 2–3=0.76 Marital status (single) 96 (46.8) 40 (48.8) 2 (66.7) 0.77 Presence of children (yes) 76 (37.1) 29 (35.4) 0 (0) 0.41 Duration of emergency department practice (years) <1 35 (17.1) 17 (20.7) 0 (0.0) 0.54 1–5 91 (44.4) 26 (31.7) 1 (33.3) 6–10 36 (17.6) 17 (20.7) 1 (33.3) >10 43 (21.0) 22 (26.8) 1 (33.3) Number of patients treated daily 0–499 38 (18.5) 19 (23.2) 1 (33.3) 0.80 500–999 44 (21.5) 21 (25.6) 0 (0.0) 1000–1500 76 (37.1) 27 (32.9) 1 (33.3) >1500 47 (22.9) 15 (18.3) 1 (33.3) Working title General practitioner 60 (29.3) 27 (32.9) 2 (66.7) 0.26 Resident 75 (36.6) 24 (29.3) 0 (0) Specialist physician 59 (28.8) 21 (25.6) 1 (33.3) Academician 11 (5.4) 10 (12.2) 0 (0)0

When the relationship between sociodemographic characteristics and the ProQoL subscales was analysed, there was a significant relationship between the BO subscale and gender (p<0.001). Post hoc analysis revealed that 22% (13) of the participants with low BO scores were females while this rate was significantly lower compared with that amongst participants with moderate and high BO scores (p=0.006 and <0.001, respectively). For the CS subscale, no statistically significant difference was found between the participants with low, moderate and high scores with respect to sociodemographic characteristics. Similar to the BO subscale, a statistically significant difference was found in gender distribution of participants with low, moderate and high CF scores (p<0.001). Post hoc analysis revealed that this difference was due to the difference between low and moderate groups. Although 34.1% (70) of participants with low CF scores were females, this rate was 54.9% (45) in the moderate group, which was significantly higher than the low group (p<0.001; Table 3).

DISCUSSION

In this study, when the relationship between CDRS and ProQoL scores was examined, significant differences were found for all 3 subscales (BO, CF and CS) evaluated using the ProQoL scale. Accordingly, significant differences were observed in the BO subscale between the moderate and high as well as low and high subgroups. For the compassion satisfaction and CF subscales, significant differences were observed between all subgroups. This suggests that higher resilience leads to higher occupational satisfaction and lesser feelings of BO and CF. Wong et al. in 2022 did a study among healthcare professionals working in the emergency department during the Covid-19 pandemic, and observed a similar relationship between resilience and ProQoL scores as in our study.8 Resilience is not solely associated with response to traumatic or distressing events; it is also linked to the ability to transform negative experiences and feelings into positive teachings and quickly return to the initial state of well-being.4 Therefore, an individual considered ‘resilient’ may experience less BO, be less exposed to secondary trauma or be less affected by it and consequently may have a less clouded sense of occupational satisfaction.

In our study, a significant relationship was revealed between gender and BO and CF subscales, whereas no significant relationship was observed between gender and the CS subscale. In addition, a significant relationship was found between gender and CDRS, with women having lower CDRS scores compared with those of men. Previous reports indicate different results regarding the relationship between gender and ProQoL and resilience. Similar to our study, female gender was associated with high BO, CF and low resilience in some studies.14,15 In fact, the only personal characteristic of participants found to be related to negative aspects of the scale is being female in another study.16 Although it is known that women physicians constitute almost half of the workforce in the healthcare sector today, they are still underrepresented in academic terms compared with men.17 In a 2021 meta-analysis of academic physicians, it was revealed that women face disparities such as fewer publications, lower pay and reduced opportunities to advance to department head positions compared to their male counterparts.18 Studies have highlighted the elevated levels of BO experienced by women due to factors including gender discrimination, bias and the deferral of personal decisions such as marriage and parenthood for social reasons.19 Furthermore, societal expectations regarding traditional gender roles, such as caregiving and household responsibilities, serve as stressors, undermining women’s control over their work-life balance and diminishing their sense of professional fulfilment and recognition. These compounding stressors contribute to BO amongst women in professional settings.19,20

When sociodemographic characteristics and work-related factors are evaluated, different results are reported in terms of both resilience and ProQoL. While some studies identify young age, low years of experience in the emergency department and the intensity of the work area as risk factors for CF and BO,21,22 a meta-analysis published in 2018 found no significant relationship between ProQoL and sociodemographic characteristics and work-related factors.23 In a study by Peng et al. in 2022, being married was identified as a protective factor for well-being and resilience.24 In a study conducted by Carmassi et al. in 2020, working role, work experience, age and marital status were determined as factors affecting psychological resilience.25 In the study, no significant relationship was found between age, marital status, presence of children, years of experience, patient caseload, working title and the number of physicians working during a shift with ProQoL and resilience. This may be due to the fact that the studies were conducted amongst different groups of healthcare workers, in different countries, and in different periods (before and after Covid-19). The ProQoL subscales and the concept of resilience are highly complex and involve multifactorial concepts that can be influenced by several variables, ranging from societal gender perception to the perspective on professions.

Limitations

These include the small sample size and the existence of confounders that could affect the concepts of resilience and ProQoL. The presence of participants with different titles may not accurately represent the study’s actual population limits. This study was conducted after the Covid-19 pandemic, a time when physicians working in emergency departments worldwide were impacted. There is an anticipated rise in CF and BO, which may continue to affect physicians’ psychological resilience.

Conclusion

The resilience scores of physicians working in the emergency department and the quality of their professional lives are interrelated. Physicians who have high scores for BO and CF, which are negative sub-factors of the professional quality of life scale, have lower resilience; on the contrary, those who have high scores for CS, which is a positive indicator of the quality of life, have higher resilience. In addition, from demographic data, female gender can be considered a risk factor for low resilience. Efforts aimed at enhancing psychological resilience can contribute to improving the professional quality of life of physicians working in the emergency department.