| IntroductionPersonal strain is defined as occupational people's physical, psychological or behavioral expression caused by social psychological factors. It is a nonspecific response stimulated from external environment and an unbalance between perceived occupational demand and personal ability. With our social and economic development, the society increasingly fierce competition, the social life rhythm, especially the increasing of industrial upgrade and occupational skills, personal strain was rising. Personal strain becomes the new important question of occupational health which threaten the health, operation ability, and the quality of life of occupational people, except traditional physical, chemical and biological occupational harmful factors.It also becomes one of the most important questions of occupational health facing in the 21st century.Depression is a complex negative emotion that consists of depressed, indifference, pessimistic and disappointments. According to the prediction of global burden of disease by WHO, by 2020, China's total nervous spirit disease burden would occupy one fifth of the total disease burden. Depressive symptoms were main problem in spiritual disease burden in the future. Depression can reduce the body's immune function, decline human body's physiological activity and living and working ability, and can delay the vocational rehabilitation of chronic disease. Depression is main mental illness influencing work efficiency and quality of life. Depression is a kind of sub clinical form which is different from the clinical depression. Depression is a serious mental health problem which can affect people's work, study and life. Only when the depressive symptoms develop into serious degree, and for a long time, and the serious harm the social vocational ability can be diagnosed clinical depression.Hospital staffs as special occupational group, bearing the formidable task of saving, need often faced disease and death, dealing with various kinds of emergency medical health events, their the daily work are in state of tension. Due to the particularity of working content and high risk among hospital staffs, the work environment needed hospital staffs with high concentration state; slightly negligence may endanger the life safety of patients. Accordingly, high tension state in the body and spirit among the hospital staffs can easily cause fidgety, irritability and anxiety and other negative emotions, resulting in personal strain and depressive symptoms. At present, with the socioeconomic transformation and the increasing population health demand, the medical model is undergoing a transformation from traditional disease-centered care model to patient-centered care model. The changes greatly improve requirements of patients with the medical service content and service quality, increased workload of hospital staffs and psychological stress. As China's Liaoning province is heavy industrial province, with the high-speed development of economic and social undertakings recently, high level, patients need constantly improve the medical service demands. Hospital staffs not only bear heavy workload, but also shoulder the important responsibilities and risk. Due to the high level of medical service to not meet the growing needs of society, the relationship between doctors (nurses) and patients was tense and the contradiction was heavy. Hospital staffs have to face strong psychological and physical stress, which can easily lead to occupational stress and depressive symptoms.Now the most important and commonly methods of assessing occupational stress is the questionnaire. The questionnaire including Generic Job Stress Questionnaire, Occupational Stress Indicator, JOB Content Questionnaire, Effort-reward imbalance measure and Mclean's Job Stress Questionnaire, et al. This study used Occupational Stress Inventory Revised Edition (OSI-R) introducing by WangZhiMing. It is created by Osipow, which was revised by 7 times. Questionnaire includes 3 sub scales,14 factors and 140 items. Each factor consists of 10 items; each item was 1-5. This questionnaire is comprehensive, applying in more than 20 countries currently with good reliability and validity in Chinese occupational people. The questionnaire assessed depressive symptoms include Center for Epidemiological Survey, Depression Scale (CES-D), Symptom Check List-90 (SCL-90) and Self-Rating Depression Scale (SDS). CES-D produced by National Institute of Mental Health (NIMH) is frequently used for epidemiological survey. The Chinese version of this questionnaire compiled in 1990 by Zhang MingYuan. It comprises 20 items which respectively measure 20 symptoms. Each item was 0-3. We defined the'depressive symptoms'group as CES-D >16. Higher CES-D score indicates higher level of depressive symptoms. CES-D has been widely used among Chinese populations with good reliability and validity.Now, due to the later beginning of domestic occupational stress research, there are many deficiencies respect of empirical research especially among hospital staffs. Firstly, most design of occupational stress among health care staff were in small size sample and can't accord with the maximize principle of system variation which made some factors weakly associated with occupational stress was difficult to show. Secondly, the small sample did not have good representation and certainly influence the external validity of the results and made the results be lack of universality. Finally, due to the market economic system reform of medical institutions in China, the development of hospitals scale and speed exists difference, the service ability, social prestige, number of patients, hospital benefits income among hospitals are significant differences. Therefore, the research design of the theory value and practical value is very limited if the sampling survey was localized dialog. As the medical resources in Liaoning province is rich in the medical rescores, the studies of personal strain and depressive symptoms are blank. Facing the new forms and the change of the social demand growth, doctors and nurses role is undergoing significant changes, which would undoubtedly cause tremendous influence on the physical and mental health of hospital staffs, which lead to personal strain and depressive symptoms and harm their psychosomatic health. Therefore, the present study designed to investigate 20 hospitals in Liaoning province with OSI-R and CES-D, descript the degree of personal strain and prevalence of depressive symptoms, analyzes main occupational stressors, builds the theory model with SEM, explore the relationship between personal strain, occupational stress and depressive symptoms. The theory and application value of this study are providing scientific evidence for government and medical administrative departments to develop health promotion policies, creating health supportive environment, protect mental and physical health and increase life quality among hospital staffs.Objects and Methods一,ObjectsDuring the period of May/June 2009, a survey was conducted in Liaoning province, and 4 metropolitan cities, medium-size cities; small cities were randomly selected for study.4602 doctors and nurses become our study objects (1989 doctors and 2613 nurses). We received effective responses from 3657 (1587doctors,2070 nurses) with effective response rate 79.5%.二,Methods and contents(一) MethodA cross-sectional survey was conducted in Liaoning province.(二) Study Indicators1,Personal strainChinese Version Personal Strain Questionnaire (PSQ) was used to assess personal strain. PSQ comprises 40 items and included 4 indicators:Vocational Strain (VS), Psychological Strain (PSY), Interpersonal Strain (IS), and Physical Strain (PHS). Each indicator was 10items.The response was scored from 1 to 5. Higher score denotes greater personal strain.2,Depressive symptomsDepressive symptoms were measured by Chinese Version of Center for Epidemiologic Studies Depression Scale (CES-D) consisting of 20 items. Each item is graded on a 4-point scale ranging from 0 to 3 and total score was 60. Depressive. symptoms were defined as CES-D>16.3,Demographic characteristicsDoctor:included gender, age, marital status, education, and chronic disease. Nurses:included age, education, marital status, monthly income, and chronic disease.4,Work situationsDoctor:included hospital grade, job rank, weekly work time, night shift, and doctor-patient relationship.Nurses:included hospital grade, job rank, weekly work time, night shift, and nurses-patient relationship.5,Occupational rolesOccupational roles comprised role overload (10 items), role insufficiency (10 items), role boundary (10 items), and responsibility (10 items). The response was scored from 1 to 5.6,Personal resourcesPersonal resources included recreation (10 items), self-care (10 items), social support (10 items) and, rational/cognitive coping (10 items). The response was scored from 1 to 5.(三) Statistical analysisAll data were analyzed by SPSS 11.5 for windows (SPSS Inc. Chicago, IL, USA), SAS.Ver.8.2, and Amos 6.0. 1,Reliability and validity evaluation of OSI-RThis research through the internal consistency measure OSI-R reliability. By confirmatory factor analysis to the OSI-R 3 questionnaires were more than the single factor and structural factors validity analysis2,Distribution of personal strain and factors associated with personal strainDescription of hospital staffs included demographic characteristics, work conditions, occupational roles and personal resources. Distribution of PSQ in demographic characteristics, work conditions, occupational roles and personal resources was analyzed. Personal strain as dependent variable, demographic characteristics, work situations, occupational roles, and personal resources as independent variables, to analysis factors associated with personal strain among hospital staffs.3,Distribution of depressive symptoms and factors associated with depressive symptomsDescription of hospital staffs included demographic characteristics, work conditions, occupational roles and personal resources. Distribution of depressive symptoms in demographic characteristics, work conditions, occupational roles and personal resources was analyzed.4,Relationship between occupational stress, personal strain and depressive symptomsPersonal strain may be a mediator in occupational roles affecting depressive symptoms. Occupational roles as dependent variable, personal strain as a mediator and depressive symptoms as independent variable, to use SEM to build theory model of occupational stress influence depressive symptoms, analyses the direct and indirect function among hospital staffs. 1,reliability and validity of OSI-R questionnaireCronbach's alpha coefficients were all> 0.70 (0.72-0.93) whether of the whole questionnaire or of each items. It demonstrates OSI-R has good reliability. Single-factor structure validity analysis found each loading of relevant item of OSI-R had statistically significance, and values are larger than 0.30. Multiple-factor structure validity analysis results showed a good fitting effect. It demonstrates OSI-R has good validity.2,PSQ among hospital staffsMale doctors had the highest PSQ score than female doctors, nurses had the highest PSQ score than female doctors, and difference had statistically significances.3,Demographic characteristics affect PSQ among hospital staffsAs for male doctors, difference in PSQ score had statistically significances among age, education, and chronic disease.<30 age group had the highest and>40 age group had the lowest PSQ score; Under graduate course group had the highest PSQ score, whereas junior college course group had the lowest score; Chronic disease group had higher PSQ score than without chronic disease.As for female doctors, difference in PSQ score had statistically significances among age, marital status, and chronic disease. The 30-40 age group had the highest PSQ score and>40 age group had the lowest PSQ score; unmarried group had higher PSQ score than married/cohabitation, divorced and widowed group; chronic disease group had higher PSQ score than without chronic disease.As for nurses, difference in PSQ score had statistically significances among age, education, and chronic disease.<30 age group had the highest PSQ score and>51 age group had the lowest PSQ score; under graduate course group had the highest PSQ score, whereas junior college course group had the lowest score; chronic disease group had higher PSQ score than without chronic disease. 4,Work situations affect PSQ among hospital staffsAs for male doctors, weekly work time>40 hours had higher PSQ score and serious doctor-patient relationship group had higher PSQ score.As for female doctors, grade three hospital had higher PSQ score than grade two hospital; general doctors had higher strain than head doctor; night shift group had higher score than no night shift group; serious doctor-patient relationship group had higher PSQ score than genera doctor-patient relationship.As for nurses, grade three hospital had higher PSQ score than grade two hospital; general nurse had higher strain than head nurse; weekly work time>40 hours had higher PSQ score than≤40 hours; night shift group had higher score than no night shift group; serious nurse-patient relationship group had higher PSQ score than genera nurse-patient relationship.5,Occupational role and personal resources affect PSQ among hospital staffsOccupational role and prsonal resources were closely related with PSQ among doctors and nurses.6,Factors associated with PSQThe factors associated with male doctors'PSQ were, in Beta sequence, role boundary, role insufficiency, responsibility, social support, rational coping, doctor-patient relationship, and role overload; the factors associated with female doctors'PSQ were, in Beta sequence, role insufficiency, role boundary, social support, responsibility, self-care, role overload, education, chronic disease, and doctor-patient relationship; the factors associated with nurses'PSQ were, in Beta sequence, role boundary, role insufficiency, responsibility, social support, self-care, nurse-patient relationship, chronic disease, role overload, rational coping and night shift.7,The prevalence depressive symptoms among hospital staffsDoctors had the highest depressive symptoms than nurses, and difference had statistically significances. Prevalence of depressive symptoms had no significant statistically difference between male doctors and female doctors.8,Demographic characteristics affect depressive symptoms among hospital staffsAs for doctors, the group of graduate course had higher prevalence of depressive symptoms than other groups. The prevalence of depressive symptoms had no significant difference in age, gender, and marital status.As for nurses, divorced/widowed/separation group had higher prevalence of depressive symptoms than married/cohabitation and unmarried group. The prevalence of depressive symptoms had no significant difference in age and education9,Work situations affect depressive symptoms among hospital staffsAs for doctors, grade three hospital had higher prevalence of depressive symptoms than grade two hospital; general doctor had higher prevalence of depressive symptoms than head doctor; night shift group had higher prevalence of depressive symptoms than no night shift group; weekly work time>40 hours group had higher prevalence of depressive symptoms than≤40 hours group. The prevalence of depressive symptoms had no significant difference in job rank.As for nurses, grade three hospital had higher prevalence of depressive symptoms than grade two hospital; general nurse had higher prevalence of depressive symptoms than head nurse. The prevalence of depressive symptoms had no significant difference in weekly work time.10,Occupational role and personal resources affect depressive symptoms among hospital staffsThe prevalence of depressive symptoms was higher in high occupational role than that in low occupational role, and the prevalence of depressive symptoms was higher in low personal resources than in high personal resources among hospital staffs. 11,Occupational roles affect depressive symptoms by personal strainAs for doctors and nurses, Beta had statistically significances between depressive symptoms and role overload, role insufficiency, role boundary, responsibility, recreation, self-care, social support and, rational/cognitive coping.As for doctors and nurses, Beta had statistically significances between personal strain and role overload, role insufficiency, role boundary, responsibility, recreation, self-care, social support and rational/cognitive coping.As for doctors and nurses, Beta in occupational roles and personal resources had decreased compared with no personal strain. Beta had statistically significances between depressive symptoms and role overload, role boundary, and social support. Beta had no statistically significances between depressive symptoms and role insufficiency, responsibility, recreation, self-care, and rational/cognitive coping.12,Test fitting effect of theory model of occupational stress influence depressive symptomsAs for doctors, the final fitting indicators are:RMSEA=0.028, SRMR=0.050, CFI=0.912, TLI=0.901, IFI=0.913.As for nurses, the final fitting indicators are:RMSEA=0.025, SRMR=0.048, TLI=0.900, CFI=0.911, IFI=0.913.It showed that fitting effect of theory model of occupational stress influence depressive symptoms was good.13,Effect of occupational stress influence depressive symptomsAs for doctors, role boundary was the most important factors associated with depressive symptoms. Role boundary and role overload mainly directly affect depressive symptoms, and role insufficiency affect depressive symptoms fully by personal strain. Social support mainly directly affects depressive symptoms, and rational/cognitive coping affect depressive symptoms fully by personal strain.As for nurses, role overload was the most important factors associated with depressive symptoms. Role boundary affects depressive symptoms mainly by personal strain. Role overload mainly directly affect depressive symptoms. Role insufficiency affects depressive symptoms fully by personal strain. Social support mainly partly affects depressive symptoms and rational/cognitive coping affect depressive symptoms fully by personal strain.Conclusions1,Male doctors and nurses has higher personal strain than female doctors among hospital staffs in Liaoning province. The level of personal strain differed in demographic characteristics, work conditions, occupational roles and personal resources. Role boundary in male and nurses, and role insufficiency in female doctors were most important factors associated with personal strain. Chronic disease and social support was strongly associated with personal strain in female doctors and nurses. Doctor-patient relationship was strongly associated with personal strain among hospital staffs.2,The prevalence of depressive symptoms had no gender difference in doctors among hospital staffs in Liaoning province. The prevalence of depressive symptoms differed in demographic characteristics, work conditions, occupational roles and personal resources. The prevalence of depressive symptoms increased with education in doctors and decreased with education in nurses; grade three hospital and general doctor had higher prevalence of depressive symptoms than grade two hospital; doctors working longer time or having night shift had higher prevalence of depressive symptoms; occupational roles was a risk factor of depressive symptoms, and personal resources was a protective factor of depressive symptoms.3,As for doctors, role boundary was the most important factors associated with depressive symptoms. Role boundary and role overload mainly directly affect depressive symptoms, and role insufficiency affect depressive symptoms fully by personal strain. Social support mainly directly affects depressive symptoms, and rational/cognitive coping affect depressive symptoms fully by personal strain.As for nurses, role overload was the most important factors associated with depressive symptoms. Role boundary affects depressive symptoms mainly by personal strain. Role overload mainly directly affect depressive symptoms. Role insufficiency affects depressive symptoms fully by personal strain. Social support mainly partly affects depressive symptoms and rational/cognitive coping affect depressive symptoms fully by personal strain.
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