Anxiety, commonly defined as a state of worry and unease without a concrete danger or clear cause [1], can manifest as work-related anxiety, such as hypochondriacal anxiety, phobia, fear of inadequacy, social anxiety, or general anxiety towards work, colleagues, or superiors [1]. In a study that evaluated employees using the Mini-International Neuropsychiatric Interview (MINI) work anxiety questions based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, 67.4% of employees reported work-related concerns, with situational workplace phobia being the most common [2,3]. Anxiety is particularly prevalent among healthcare workers in high-stress environments [4]. During the coronavirus disease-2019 (COVID-19) pandemic, when healthcare workers experienced a significant increase in workload, numerous studies examined anxiety in healthcare workers [1-3,5]. The most common psychiatric disorders observed in healthcare workers working in emergencies were anxiety and depression [6,7]. Although anxiety among healthcare workers, especially during the pandemic, has been widely investigated, there is a lack of descriptive studies in the literature, particularly on the incidence and types of anxiety among emergency service workers. This study aimed to determine the work- or shift-related anxiety scores of healthcare workers in the emergency department (ED) and to evaluate the factors affecting work- or shift-related anxiety.

This study was conducted with 147 healthcare workers. Twelve of the questionnaires were not included in the study due to blank answers and five were excluded due to more than one marking. The median age of the total 130 participants included in the study was 33 years (20-55). The median duration of active employment was 8.5 (1-29) years and the median duration of employment in the ED was 4 (1-20) years. The median BAI score of the participants was calculated as 6 (0-58). A significant correlation (R=-0.186, p=0.034) was found between the participants’ BAI scores and age. In order to explain the correlation between the BAI scores and age, z values were calculated for the BAI scores and three questionnaire results that were considered outliers were excluded from the study, and the data were fit to the normal distribution. Regression analysis was performed (y=-0.2461x+16.451, R²=0.0581) (Figure 1). The relationship between the descriptive characteristics of the people who volunteered to participate in the survey and the BAI scores was analyzed using Mann- Whitney U tests, as shown in Table 1. Among the participants, 85 (65.4%) were male and 45 (34.6%) were female, and the median BAI score was significantly higher in female (median: 11.0 [0-52]) than in male (median: 4.0 [0-58]; p<0.001).

A total of 77 participants (59.2%) were married and 53 participants (40.8%) were single; the median BAI score of single participants was 9.0 (0-52) and the median BAI score of married participants was 4.0 (0-58). The anxiety scores of the married participants were significantly lower than those of the single participants (p=0.004). In total, 11 (8.5%) participants reported having an ongoing diagnosis of anxiety disorder or depression and were receiving treatment. Overall, 23 (17.7%) participants reported that they had previously used medication for anxiety disorders or depression and had recovered. The median BAI score of participants with ongoing anxiety disorder or depression was calculated as 25.0 (5-58), and the median BAI score of participants with a history of anxiety disorder or depression was calculated as 14.0 (1-58). In both groups, the BAI scores were significantly higher than in those without a diagnosis or history of anxiety or depression (p<0.001).

Of the ED healthcare workers who participated in the study, 25 (19.2%) were doctors and 105 (80.8%) were nondoctors. The median BAI score for doctors was 12.0 (0-33) and the BAI score was higher than that of non-doctors (p=0.002). A total of 86 (66.2%) survey participants stated that they were satisfied with their jobs, and the median BAI score of those who were satisfied with their jobs was 4.0 (0-32), whereas the median BAI score of those who were dissatisfied with their jobs was 12.5 (0-58), and the BAI score of those who were dissatisfied with their jobs was significantly higher (p<0.001). Of the volunteers who participated in the survey, 55 (42.3%) stated that they were satisfied with their salaries, whereas 75 (57.7%) stated that they did not think they were financially compensated for their work. The median BAI score of participants who were dissatisfied with their salary was 8.0 (0-58), which was significantly higher than that of participants who were satisfied with their salary (median: 3.0 [0-32]; p=0.002). Only 20 (15.4%) respondents reported working ≤40 hours per week. Of the 110 (84.6%) participants who stated that they worked overtime, 38 (35.8%) stated that they worked overtime voluntarily and 68 (64.2%) stated that they worked overtime involuntarily.

The median BAI score of participants who did not work overtime hours was 6.5 (0-52) and the median BAI score of participants who reported working overtime hours was 6.0 (0-58), and there was no statistically significant difference between them (p=0.925). However, it was found that participants who worked overtime involuntarily (median: 8.5 [0- 52]) were significantly different from those who worked overtime voluntarily (median: 3.5 [0-58]; p=0.022). When the BAI test results were grouped according to the suspicion of anxiety, the BAI scores were similar. Cross-tabulations and significance levels (using chi-square or Fisher’s exact test) are shown in Table 2. Suspicion of anxiety was higher in single participants than in married participants (p=0.007). Anxiety was significantly higher in those with a diagnosis of anxiety or depression and in those who had previously received treatment for these diagnoses (p<0.001). Suspicion of moderate and high anxiety was higher in patients with a current diagnosis of anxiety or depression, and suspicion of low and moderate anxiety was higher in patients with a history of anxiety or depression. Suspicion of anxiety was higher in doctors than in other healthcare professionals (p=0.002). Those who were satisfied with their job and salary had more anxiety than those who were unsatisfied (p=0.001 and p=0.022, respectively). While there was no significant difference in suspicion of anxiety between those who worked overtime and those who worked normal hours in the ED (p=0.481), suspicion of anxiety was higher in those who worked overtime and those who worked overtime reluctantly than in those who worked overtime voluntarily (0.046).

The effects of the demographic characteristics of the participants on anxiety were analyzed using univariable and multivariable regressions. According to univariable regression analyses, those with a history of anxiety disorder or depression were 6.277 times more likely to be suspected of anxiety than those without a history of anxiety disorder or depression (odds ratio: 6.277; 95% confidence interval [CI] 2.161-18.229; p<0.001). The age of the participants was analyzed by drawing the ROC curve according to the suspicion of anxiety according to the BAI, and a cutoff value of 35.5 was calculated with a sensitivity of 0.754 and a specificity of 0.521 according to the Youden index. Participants below 35.5 years of age were considered one group, and participants aged 35.5 years and above were considered another group and subjected to univariable regression. Those younger than 35.5 years were 3.335 times more likely to have suspected anxiety (odds ratio: 3.335; 95% CI 1.563-7.117; p=0.002). The univariable regression results for the other parameters are given in Table 3. According to univariable analysis, the factors that had a statistical effect on anxiety were subjected to multiple regression analyses, and a model was created to explain the suspicion of anxiety. In the model, having a history of anxiety disorder or depression, female sex, and/or being under 35.5 years of age explained 29.8% of the probability of anxiety suspicion (Negelkerke R²=0.298). The data for the three-parameter model are listed in Table 4.

In this study, the distribution of possible anxiety types obtained as a result of the MINI job anxiety interview in participants with a BAI score greater than 7 (n=57) was analyzed by preparing a cross-tabulation, as shown in Table 5. Responses to the MINI work anxiety interview predicted work-related posttraumatic stress disorder in 22 (38.6%) participants, situational workplace phobia in 17 (29.8%) participants, work-related panic disorder in 16 (28.1%) participants, work-related generalized anxiety disorder in 15 (26.3%) participants, discriminative work-related social phobia in 8 (14.0%) participants, and indiscriminative work-related social phobia in 3 (5.3%) participants. Of the 16 participants with work-related panic disorder, 7 (43.8%) had a moderate level of suspicion of anxiety according to the BAI, and the BAI results differed significantly from the expected distribution (p=0.006). The distribution of the other anxiety types did not differ significantly from the expected distribution (p>0.05).

The average cost of generalized anxiety disorder alone per individual is more than 5,000 euros, and three-fourth of this cost consists of indirect costs [9]. These costs increase even more for employees who ensure the flow of services and production. In the literature, job anxiety has been examined under many different headings, and studies investigating the job anxiety of both healthcare workers and other employees have focused on the level of anxiety. Anxiety was higher in healthcare workers than in community samples [10]. Moreover, anxiety among healthcare workers is likely to cause disruptions in healthcare services, which may have serious consequences as well as financial costs. For these reasons, it has become necessary to give special importance to anxiety among healthcare workers and analyze it in detail.

During the COVID-19 pandemic period, the BAI was studied in healthcare personnel working in the ED, and it was found that the BAI score was higher in the female sex compared to the male sex and in nurses and doctors compared to other healthcare professionals. In the same study, the ages of the participants were examined in two groups, and no statistically significant difference was found between these two groups [11]. In our study, similar to this study, females had higher BAI scores, but when the groups were evaluated according to the results of the test, no significant difference was found according to sex. We think that the BAI score was found to be higher in female as a result of the fact that female are more active in housework than male due to social structure and physiologically as a result of hormonal changes related to the menstrual cycle. In addition, our results showed a negative correlation between age and BAI score. Similar to our study, in a study conducted on anxiety in emergency healthcare workers, the probability of anxiety suspicion was found to be high in older age groups [7]. We anticipate that reasons such as the fact that young people have just started their professional lives and a lack of experience lead to this result.

During the COVID-19 pandemic, prolonged working hours, increased workload, and increased work stress have been shown to increase anxiety among healthcare workers [12]. We did not make a comparison measuring workload in our study; however, in our study, anxiety levels were found to be signifcantly lower in participants who said that they were satisfied with their jobs and that their salaries paid for their work. We believe that people who love their jobs by nature will be able to solve problems at work and work more easily, making them less of a problem. Therefore, we believe that this inverse correlation between job satisfaction and anxiety is expected. A cohort study showed that the risk of anxiety and depression was higher in shift workers than in non-shift workers [13]. Similarly, in a study conducted on anxiety and sleep quality in nurses, 38.7% of the participants were suspected of having anxiety, according to the BAI. Anxiety was suspected in 26.5% of nurses working only during the day, 34.3% of nurses working only at night, and 49.1% of nurses working rotationally during the day and night. In the same study, a significant relationship was found between age, years of employment, parental status, and anxiety [14]. In another study, a statistically significant difference was found between insomnia and chronic fatigue between nurses who worked at night and those who did not work at night, but no statistically significant difference was found, although working at night increased anxiety and depression [15]. These studies examining nurses, who constitute the most important population among healthcare workers and play a key role in the rotation of the system, have shown the importance of anxiety in EDs that work in shifts by nature.

In a study conducted in the United Arab Emirates (UAE), similar to ours, approximately 66% of the participants were male, 50% were aged between 30-40 years and the majority were nurses (37%). It was found that 23.7% of the participants had mild anxiety, 20.7% had moderate anxiety, and 7.4% had severe anxiety disorder risk, and the results were similar to our population. However, in contrast to our study, a positive correlation was found between age and anxiety scores. In addition, anxiety scores were found to be higher among healthcare workers than among doctors and nurses. Healthcare workers’ professional experience and nationality were not found to be associated with high anxiety scores [7]. In contrast to our study, a positive correlation was found between age and anxiety scores. In addition, anxiety scores were found to be higher among healthcare workers than among doctors and nurses. Healthcare workers’ professional experience and nationality were not found to be associated with high anxiety scores [7]. Another important feature of this UAE study is that most healthcare workers were foreign nationals due to the conditions of the country. In the aforementioned study, it was reported that anxiety increases with age. However, this result does not support our results. In a study conducted in a radiology unit on BAI, a positive correlation was found between age and tenure among healthcare workers [16]. In our study, a negative correlation was observed between age and BAI. We believe that the main reason for this difference between the results is that the studies were conducted on different branches, and each branch has its own difficulties. In other words, in radiology workers, there is an increase in mood disorders due to anxiety caused by health problems that may develop due to radiation and impaired circadian rhythm due to working in a dark environment for a long time [17]. whereas in ED workers, inexperience at a young age and malpractice anxiety are at the forefront. Again, suspicion of anxiety was found to be lower in doctors working in community health centers, which are non-emergency healthcare units, than in other healthcare professionals working in community health centers [18]. The fact that there were no critical patients in community health centers and that most of the workload consisted of routine and relatively low-risk procedures for physicians may explain this result.

In a univariable analysis performed in a review study on the prevalence of anxiety disorders, anxiety disorder was 2.2 times higher in the female sex, and anxiety disorder was 0.8 times higher in those over 55 years of age [19]. In our study, we similarly found that females and younger age groups had higher odds ratios for anxiety disorder. In addition, we showed that the regression model created using age, sex, and anxiety disorder/depression history parameters can detect a significant proportion of ED patients with suspected anxiety. We believe that these parameters will enable hospital or ED clinical managers to perform more efficient, focused, and sustainable screening in terms of anxiety risk. In another study analyzing the depression scores of nurses working in hospitals, univariable regression analysis showed that nurses who were more satisfied with their jobs had lower depression scores [20]. Similarly, job satisfaction was associated with lower anxiety scores in our study. Although attempts have been made to identify the possible causes of work-related anxiety, few studies have investigated which type of anxiety is associated with work-related anxiety.

Our colleagues who developed the MINI work anxiety interview, which we also used in our study, investigated the types of work anxiety observed in the general population in the same publication. In this study, in which participants were randomly selected from professions, they predicted that the most common type of work-related anxiety was situational workplace phobia (53.8%) and work-related generalized anxiety disorder (39.4%) and the least common type was work-related posttraumatic stress disorder (1.5%) [2]. In our study, in which we conducted the same interview with emergency healthcare workers, we evaluated work-related stress disorder as the most common type and indiscriminative work-related social phobia as the rarest type. The risk of exposure to emotional and physical trauma is higher in emergency service workers than in healthcare workers working in other units [21]. We believe that the main reason we obtained different results from the general population according to the MINI job anxiety interview in this study is the risk of exposure to violence among ED workers.