JOB-RELATED STRAIN : A FIELD INVESTIGATION ON FAMILY PHYSICIANS

The aim of this study is to determine the level of job-related strain of staff working in family health centers on some demographic characteristics. A questionnaire form was applied online to 371 family physicians working in family health centers in Istanbul. All surveyed surveys were included in sampling. A questionnaire consisting of two parts was used as data collection tool in the research. In the first part, the personal information form containing information on gender, date of birth and child ownership is presented in the second part of the Job-Related Strain Scale developed by Revicki, May and Whitley (1991) and adapted to Turkish by Aslan et al. (1998) and reliability and validity studies It is located. As a result of the study, it was determined that stress and strain related to job were high according to the scale scores of the family physicians participating in the study (64,31 ± 8,95), and job strain and strain scores did not show any significant difference according to sex, number of children and date of birth.


INTRODUCTION
Burnout syndrome is the depletion that occurs after a person's physical and mental exposure to a force that forces it.The person suffering from burnout syndrome is always forced to do the work he does, he can not find the mental and physical strength to do his work.It becomes insensitive to work and people, begins to ignore nothing, does not have the pleasure of life, does nothing, loses its enthusiasm to be productive and productive.Burnout, which is very common in health workers, is not a condition that develops in a person, but it is a syndrome that gradually develops, breaks the mental balance of the person after it emerges, and causes important problems in work, family and private life.
Health care is not only a medical activity between the patient and the doctor, but also is a social communication activity between the patient and the doctor.The mood and attitudes of the person providing the health service are effective on the patient (Turgu et al., 2018: 78).Family physicians who serve hundreds of patients every day live in distress due to inadequate conditions and inadequate equipment to serve more patients and mobbing frequently by patients and their relatives.As a result of all these reasons, the stresses and work-related tension of family doctors who can not serve the quality they desire are increasing (Esen et al., 2018: 34).The job satisfaction of family physicians is also low (Arslan et al., 2018: 781).According to the result of job satisfaction analysis with the participation of family physicians, 79,53% of the family physicians have medium job satisfaction and 20,20% of family physicians with high job satisfaction (Arslan et al., 2018: 155).This result supports Aras et al. (2018) 246% 70.6% of the results of the survey conducted with the participation of the family physician found that the average level of job satisfaction of family physicians was moderate.It is determined that 92.5% of those who believe that their profession has the right to society and 69.1% of those who have burnout (Aras et al., 2018: 105).The belief that job satisfaction is low, exhaustion is high, and that the job does not deserve the value it deserves, increases the tension that family physicians have to work.
Family physicians who provide health services in the first step are responsible for the outpatient clinics, children, pregnant and vaccination follow-ups and chronic patient follow-ups in the family health centers (Özcan and Erdal, 2017: 61).Problems and impossibilities experienced by family health centers in quality and quantity, verbal and physical violence by patients, pressures caused by legal practices and the impossibility of any sanctions for illness preventive health services play a role as work-related tension in family physicians.In this context, it is useful to examine the work-related strain of family physicians.

Job-Related Strain
Job-related strain is an emotional response to the stress sources of a person (De Croon, 2004: 443).Jobrelated strain is beginning to emerge when the workplace's expectations and demands exceed the employee's capacity and ability to work (Torres et al., 2009: 100).In other words, Job-related strain is beginning to occur when work stress resulting from workplace conditions or changes is greater than the employee can afford (Clegg, 2001: 9;Erçevik, 2010).Stress is a psychological phenomenon that expresses dissatisfaction of the person (Izgar, 2012: 127).Stress is an inevitable mood that stress can experience as a result of important life changes such as difficulties, problems, losses, deaths and illnesses that will last for the entire life of the person.(Stress, Hefferon and Boniwell, 2014: 114).Stress and jobrelated strain experienced by the occupation depending on the work are often closely related concepts.Stress creates psychological, mental or physical stress on one's person.Job-related strain is the result of stress (Tel et al., 2012: 48).Job-related strain is more prevalent in the business segments (such as health, the service sector) that are constantly in service to people (Düzyürek, 1992: 108).
There are two basic approaches to the emergence of job-related strain.The first of these approaches argues that job-related strain is due to organizational causes and the second is that job-related strain is caused by personal characteristics and the employee's view of events (Beehr and Newman, 1978: 666).Job-related strain can be organizationally sourced, or it can be attributed to the following characteristics or behaviors that an employee has (Byrd et al., 2012: 71); • Extreme perfectionism, • Aggressiveness, • Authoritarianism, • If there is too much control, • High demands and expectations, • Demonstrate command and rebellious behavior, • Making negative thinking and acting a habit, • Superior vision and liking, • Do not like the work done.
Considering the organizational context of job-related strain can be caused by different reasons (Kahn et al., 1964); • The person does not have the job (not working), • The characteristics of the work, such as the structure of the work, the method of doing it, • Employees' tasks are not clear and specific, • Role conflict, • Asking for work from the employees on their capacity and what they can do, • Communication among employees and managers, • Employees do not have the tools and tools to do their job, • Organizational climate, • Workload of employees is heavy, • Good working conditions and environment, The healthcare industry has many aspects that are stressful and increase the job-related strain of the employee.Factors leading to job-related strain in health workers are listed below in general (Tokuç et al., 2011: 42, Boswell 1992: 221, Tel et al., 2003: 14); • Risk of infection, • The weight of the spiritual burden given by the decision about the health of the patients, • Timelessness, • More workload, • Long working hours and busy working hours, • The difficulty of serving patients, • The pressure of the patient's relatives, • Irregular and less of sleep.
In Karasek, Demand Control Model, job-related strain is organizationally based (Karasek, 1979).The expected level of activity and level of control in the Demand Control Model determine the degree of job-related strain.In the model there are 4 job-related strain levels determined according to control, demand and activity level (Figure 1);  (Schnall et al., 1994: 383).
In the Karasek demand-control model, A and B represent two different levels of strain.Level A indicates the degree of strain that would occur if the level of control of employees' work was low or high.B level indicates the level of strain that will arise due to the high and low level of the job-related demand level, in which the employees' control levels are high.Based on this model, it can be said that as work demands increase and decision making authority decreases, job-related strain will increase.It is at the core of this model that active or passive employees will experience high or low job-related strain, depending on whether or not demand and control balances exist.(Karasek, 1976: 28).Karasek (1976) formulates jobrelated strain as in the following equation; Job Strain= Requirement -Level of Control Owned The negative effects of job-related strain on employees and organizations are listed below; • Job-related strain reduces employee job satisfaction (Yürür and Keser, 2010;Byrd et al., 2000).
• Job-related strain affects one's life satisfaction in terms of mental, physical and functional detriment (Lerner et al., 1994).
• Job-related strain leads to work stress and problems in private life (Jackson and Maslach, 1982).
• Job-related strain can cause people to experience heart and blood pressure disorders and sleep disorders (Qiao, 2018: 3).
Job-related strain needs to be analyzed on an individual basis, as it is a concept that occurs as a result of one's assessment of environmental events from the point of view of an individual.An event can lead to job-related strain in the other without causing any impact on one person (Beehr and Newman, 1978: 665).Just as the causes of job-related strain create different effects on each individual, the ways in which job-related strain can be handled also vary on a personal basis.For this reason, one should take necessary precautions by finding the factors that cause job-related strain in oneself (Güçlü, 2001: 109).

The Purpose and Importance of Research
The aim of this study is to determine the level of job-related strain of staff working in family health centers on some demographic characteristics.The research is expected to contribute to the theoretical and practical aspects of the literature.

Data Collection Technique and Scope of Research
A questionnaire consisting of two parts was used as data collection tool in the research.In the first part of the data collection tool, the information form is composed of the family physicians' gender, number of children, date of birth (generation).Every person who comes to the world depending on the date of birth belongs to a generation.When we examine the related literature, it is seen that there are different classifications belonging to the periods belonging to the generations.In our study, 1946-1964 period was used as bayby boomers, 1965-1979 period was used as generation X period and 1980-1999 period was classified as generation Y period (Twenge, 2013, 13).In the second part of the questionnaire, Job-Related Strain Scale developed by Revicki, May and Whitley (1991) and adapted to Turkish by Aslan et al. (1998) and reliability and validity studies were conducted.The scale consists of 18 items and one dimension in a five-point likert type (5-me not at all, 1-totally suitable to me) in order to determine stress and strain related to job.The high score of total score obtained by inverse coding of 6 positive items (m2, 4, 8, 9, 11, 15) on the scale indicates job-related strain and stress.In this study, the Cronbach Alpha coefficient of the scale was calculated to be 0.75.

Data Analysis Technique
The data were analyzed using the Statistical Package Program for Social Science (SPSS) 21.0 program.Demographic information of employees is shown as frequency and percentage table.In the normality test of the scale scores, the skewness coefficient was used.It can be interpreted that the scores within ± 1 of the skewness coefficient used in the normal distribution feature of constantly varying scores do not show a significant deviation from the normal distribution (Büyüköztürk, 2011: 40).Since it was determined that the scale scores were normally distributed in the normality test, two independent sample t tests were used to compare scale scores according to gender.one-way analysis of variance (ANOVA) was used in comparison of the number of children and the date of birth (birthday).The confidence interval in the analyzes was 95% (p <0.05).

Findings of Comparing Scale Scores According to Demographic Characteristics
According to the independent two sample t test results of gender scale comparison of scale scores; jobrelated strain and stress scores were not significantly different according to gender (p> 0,05) (Table 2).

ANOVA Test Results According to the Number of Children in Scale Scores
According to the ANOVA test results of the comparison of scale scores according to the number of children; job-related strain and stress scores were not significantly different according to the number of children (p> 0,05) (Table 3).

RESULTS AND DISCUSSION
Increasing work stress, occupational unhappiness and burnout syndrome have caused increased interest in job-related strain.The healthcare industry in which the family physicians are involved is stressful and has many aspects that increase the job-related strain of the employee.Negative legislative changes since the beginning of pilot practice in Düzce in 2006, decline in remuneration, performance discontinuities and punishment points application, making classroom inspections unclassified, ignoring the motivations of family physicians, and inspections not being made with mutual respect and understanding Family physicians' it gives rise to life.Nevertheless, when the related field literature is examined, it is seen that there are not many studies on this subject.
Observation of preventive measures to prevent these problems, examination of inspection and reimbursement systems, improvement of motivation and happiness of family physicians as well as stress, exhaustion and job-related strain experienced by family doctors and non-governmental organizations will be decreased if opinions, requests and feedbacks are taken into account .At the same time, a family medicine system that is shaped according to needs will be created.
The research is restricted to family physicians in 371 Family Health Centers in Istanbul and prevents the results to be generalizable.The research will provide more generalized results with more participant groups and a closer interaction with the job-related strain, such as burnout, job satisfaction and jobrelated perception concepts.

Table 1 .
Descriptive Statistics on Job-Related Strain

Table 2 .
Test Results of Scale Scores by Gender

Table 3 :
ANOVA Test Results by Number of Children in Scale Scores 4.4.

ANOVA Test Results According to Date of Birth (Generationt) of Scale Points
According to the ANOVA test results of the comparison of the scale scores with the date of birth It was found that job-related strain and stress scores did not differ significantly from birth date (p> 0,05) (Table4).

Table 4 .
ANOVA Test Results According to Date of Birth (Generation) of Scale Points