Factors related to the probability of suffering mental health problems in emergency care professionals

Objectives: to evaluate the influence of burnout and coping strategies used by health professionals of the hospital emergency service on their mental health status and to determine sociodemographic and labor characteristics. Method: descriptive cross-sectional study in a sample of 235 nursing professionals and physicians who worked in four hospital emergency services. The Maslach Burnout Inventory, the General Health Questionnaire and the Inventario Breve de Afrontamiento-cope 28 were used as data collection instruments and specific and original questionnaires of sociodemographic and labor variables. Descriptive, quantitative and multivariate statistics were applied. Results: the dimension of depersonalization, avoidance-centered coping and being a physician were related to the presence of somatic symptoms, anxiety, social dysfunction and depression. Increased professional experience was associated with greater social dysfunction among health personnel and increased number of patients was related to depressive symptoms among health professionals. Conclusions: the dimensions of emotional exhaustion and depersonalization, avoidance-centered coping, being a physician and a daily smoker increase the risk of a psychiatric case. The practice of daily physical exercise is a protective factor.

Average level of burnout is found in the rest of the cases.
The General Health Questionnaire (GHQ-28) was applied in its validated version to the Spanish language (22) to assess the subjects' mental health.
It consists of 28 items divided into four subscales of seven items: somatic symptoms (psychological somatic symptoms, such as tiredness, fatigue, headaches or general malaise), anxiety (difficulty falling asleep, frequent arousals, irritability or psychic tension), social dysfunction (inability to make decisions or to perform organized development of work, leading to worse daily functioning) and depression (mood-related symptoms that even include suicidal ideation). The subscales represent dimensions of the symptomatology, therefore do not correspond to psychiatric diagnoses. Each item is evaluated using a scale of four possible responses, ranging from zero (less than normal) to three (much more than normal). For the evaluation of the results, the bimodal response scale was used, in which different positions share a score. In this way, possible errors due to the choice of extreme or central responses are avoided. Thus, zero is scored if either of the first two options is answered, and one is scored if either of the latter two is answered (0011). For each of the subscales, the score can vary from zero (absence of symptoms) to seven (maximum frequency of symptoms). Scores ≤6 show absence of metal changes, while scores equal to 7 are indicative of the presence of a probable psychiatric case.

The subjects' coping was measured with the
Inventario breve de afrontamiento -COPE 28, adapted to the Spanish language (23) . The questionnaire was used in a dispositional manner, and the subjects responded by referring to how they deal with stressful situations. The questionnaire consists of 28 items with four response options on a Likert scale ranging from zero (I do not do any of this) to three (I do this very often). The items are grouped into fourteen scales of two items each. These scales represent three types of coping: problem-centered coping (consisting of active coping scales, planning and finding instrumental support, with a total of six items), emotion-focused coping (consisting of emotional support search scales, positive reinterpretation, denial, acceptance, religion, and humor, with a total of 12 items) and avoidance-focused coping (consisting of Rev. Latino-Am. Enfermagem 2019;27:e3144. scales of self-distraction, venting, behavioral withdrawal, substance use, self-incrimination, with a total of 10 items). In order to obtain the total score of the coping types, the scores of the items that make up each of them are added and divided by the number of items that make up each type of coping. Thus, the types of coping vary between 0 and 3 points. High scores indicate greater use of the strategy.
The questionnaires were handed out to each participant at the beginning of the work shift and   personal fulfillment, problem-centered coping, emotioncentered coping, and avoidance-centered coping.
In each model, by means of the Wald statistic, the variables with p ≥ 0.15 were eliminated one by one. The continuous variables scale was evaluated by the Box-Tidwell test. The possible interactions between all the variables were studied. The variables with significance greater than 0.05 were studied as possible confounding factors, considering them as if the percentage variation of the coefficients was greater than 15%. In the multiple linear regression models, the residue normality was verified by the Kolmogorov-Smirnov test. We did not consider the existence of collinearity problems among the independent variables if the factor of increase in the variance was less than or equal to 10. As a diagnostic test of extreme cases, the analysis of student residues was used. The adjusted coefficient of determination R 2 was used to evaluate the adequacy of adjustment.

Results
A total of 235 professionals participated in the study.  the professionals (32.3%) were likely to suffer from psychiatric disorder. The bivariate analysis (Table 2) (Table 5).

Discussion
In this study, on the one hand, the variables related to the presence of somatic symptoms in health professionals were on the dimension of depersonalization, avoidancecentered coping and being a physician. These last two variables were also related to the symptomatology of anxiety, social dysfunction and depression. In addition, the depersonalization dimension was related to anxiety; professional experience and problem-centered coping were related to social dysfunction and to the number of patients treated daily with depressive symptomatology.
On the other hand, the risk of being a psychiatric case was determined by the level of emotional exhaustion, depersonalization, the use of avoidance-centered coping, daily consumption of tobacco and being a physician, while daily physical exercise was a protective factor.
The mean burnout scores placed the sample at a low level of emotional exhaustion and a means of depersonalization and personal fulfillment. These findings are similar to those obtained in previous studies (13,24) . Although the level of burnout was average, according to a recent study (9) , the highest prevalence rate of burnout was found in the hospital emergency ward (71%).
The proportion of possible psychiatric cases among the health professionals studied was 32.3%, similar to that obtained in another study (3) . The problem-centered coping was the most commonly used strategy, which could explain the relative low morbidity found. This finding is consistent with that obtained in another study (25) . The avoidance-centered coping strategy was related to somatic symptomatology, anxiety, social and depressive dysfunction in professionals. In addition, it increased the risk of being a psychiatric case. These findings are in agreement with the results of another study (18) . However, this type of coping may be the best option for emergency personnel working outside the hospital environment, especially when the event occurs, in order to avoid emotional involvement (29) . In addition, a negative relationship was found between the use of the problem-focused coping strategy and social dysfunction. Evidence indicates that there is a significant relationship between a good level of mental health and the use of the problem-focused coping strategy. On the other hand, and more specifically, those who have trouble maintaining or initiating a relationship with others (socialization) tend to experience inadequate emotional growth, loneliness, depression and do not get used to using types of active coping (30) .
Regarding the sociodemographic and labor characteristics related to mental health status, it was found that medical personnel had a higher risk of being a psychiatric case than nursing professionals. In addition, being a physician was related to the four subscales that make up the GHQ-28 (somatic symptoms, anxiety, social dysfunction and depression). Although it is true that nursing is considered one of the most stressful occupations, which may increase the risk of suffering psychiatric disorders (31) , several studies conclude that in the emergency service, medical personnel are more likely to report justified psychological adverse outcomes based on their responsibility (32) , while nursing professionals point to a higher level of job dissatisfaction (8,24) . Although nursing professionals do not present mental changes, they appear to be influenced by coping strategies. In this sense, the person-environment adjustment can moderate the perceived stress, the work-family conflict and the level of mental health. In addition, clinical supervision seems to mediate stress and mental health in this group (33) . In addition, it was found that the daily increase in the number of patients seen in the emergency department was related to the greater presence of depressive symptoms manifested by professionals. The literature has shown that increasing numbers of patients and of professionals' overload increase the risk of depressive symptoms among health professionals (36) . Similarly, in emergencies, the constant flow of patients cared for by nursing staff is considered a factor associated with burnout in this group (37) .
The risk of being a psychiatric case was reduced in professionals who practiced daily exercise and increased among those who consumed tobacco daily.
Evidence indicates that physical exercise attenuates the anxious response to emotional stimuli (38) and that depression and anxiety rates are higher among nicotine dependents (39) .