Depressive symptoms and occupational stress among Chinese female nurses: The mediating effects of social support and rational coping†
Version of Record online: 2 AUG 2011
Copyright © 2011 Wiley Periodicals, Inc.
Research in Nursing & Health
Volume 34, Issue 5, pages 401–407, October 2011
How to Cite
Wu, H., Ge, C. X., Sun, W., Wang, J. N. and Wang, L. (2011), Depressive symptoms and occupational stress among Chinese female nurses: The mediating effects of social support and rational coping. Res. Nurs. Health, 34: 401–407. doi: 10.1002/nur.20449
We would like to thank administrators at the hospitals involved for their assistance with data collection.
- Issue online: 12 SEP 2011
- Version of Record online: 2 AUG 2011
- Manuscript Accepted: 20 JUN 2011
- depressive symptoms;
- occupational stress;
- social support;
- rational coping;
The study reported here was designed to investigate the relationship between depressive symptoms and occupational stress in female nurses in China during the period June–July 2008. The hypothesis tested was that social support and rational coping would mediate the effects of occupational stress on depressive symptoms. Our structural equation modeling revealed that social support and rational coping were negatively correlated with depressive symptoms. Social support and rational coping mediated the effects of occupational stress on depressive symptoms. Role overload, role insufficiency, and role boundary were predictive of depressive symptoms. These results indicated that lessening occupational stress and strengthening social support and rational coping could decrease depressive symptoms among Chinese female nurses. © 2011 Wiley Periodicals, Inc. Res Nurs Health 34:401–407, 2011
Depression has become the most common mental health problem around the world. Depressive symptoms are associated with unemployment, absenteeism, low productivity, loss of family income, and increased costs and utilization of health care (Adler et al., 2006; Tsutsumi, Kayaba, Theorell, & Siegrist, 2001; Whooley et al., 2002). For those who stay at work, depressive symptoms also have an impact on their decision-making and ability to get along with others (Elinson, Houck, Marcus, & Pincus, 2004) and may damage the quality of their lives (De Jonge, Bosma, Peter, & Siegrist, 2000; Godin, Kittel, Coppieters, & Siegrist, 2005; Kudielka et al., 2005).
Occupational stress has been identified as a risk factor for depressive symptoms (Cho et al., 2008; Nakata et al., 2004; Park, Min, Chang, Kim, & Min, 2009). It is generally believed that nurses experience more stress in comparison to other occupational groups as a result of caring for suffering and dying patients, the need to hide negative emotions, the risk of litigation, role conflicts among professionals they work with, and organizational changes (Pang et al., 2004; Shen, Cheng, Tsai, Lee, & Guo, 2005; Sveinsdóttir, Biering, & Ramel, 2006). Researchers have found that components of occupational stressors including workload, role conflict, and job demands were positively associated with depressive symptoms (Acker, 2004; Lambert, Lambert, & Itano, et al., 2004; Lambert, Lambert, & Ito, 2004). For example, in hierarchical multiple regressions occupational stress was the major predictor for nurses' depressive symptoms in a sample of 150 female medical-surgical hospital nurses in USA (Welsh, 2009).
Few studies have been done to test the potential mediators of the occupational stress-depressive symptoms relationship among nurses although the direct effects of occupational stress on depressive symptoms have tested in other occupational populations. For example, occupational stress was found to be directly related to depressive symptoms among Chinese doctors (Wang, Sun, Chi, Wu, & Wang, 2010). In this study, we investigated both direct and indirect effects of occupational stress on depressive symptoms among Chinese female nurses. In addition, as depressive symptoms have been associated with both occupational stress and available personal resources (Wang et al., 2010). We also focused on two types of personal resources: social support and rational coping.
The associations between social support, rational coping, and depressive symptoms are well-established. Social support and rational coping have been found to be negatively associated with depressive symptoms (Choenarom, Williams, & Hagerty, 2005; Ross et al., 2005; Shields, 2006). However, the mediating effect of social support and rational coping in the occupational stress-depressive symptoms relationship has rarely been investigated. Some researchers have reported that social support and rational coping played mediating roles between stressful events and stress outcomes (e.g., burnout; Roman, Joanna, Jan, & Magdalena, 2008). The mediating effect of social support and rational coping in the occupational stress-depressive symptoms relationship needs further investigation.
The present study was designed to explore the relationship between depressive symptoms and occupational stress among Chinese female nurses. We hypothesized that social support and rational coping could lessen the effects of occupational stress on depressive symptoms. The hypothesis tested is depicted in Figure 1.
A cross-sectional study was conducted in Liaoning Province, China, during June and July 2008. Liaoning Province has three metropolitan cities (population ≥1,000,000), seven medium-sized cities (population = 500,000–1,000,000), and four small cities (population = 200,000–500,000). We randomly selected four cities including one metropolitan, two medium-sized, and one small, and randomly selected two “grade one” hospitals (>500 beds) and three “grade two” hospitals (101–500 beds) from each chosen city. From each selected hospital, we randomly sampled one-half of the nurses as our study subjects. Males are <1% of nurses in the Chinese nursing population (Tian, Yan, & Liu, 2009). Thus, female nurses were our focus. A pool of 2,534 female nurses from 20 selected hospitals constituted the potential study sample. After written informed consent to participate in this study was obtained, a self-administered questionnaire was distributed to each of the nurses. Responses were received from 1,986 individuals (effective response rate: 78.4%) who became our final subjects. The study procedures were in accordance with the ethical standards of the Committee on Human Experimentation of China Medical University.
Three demographic characteristics—age, education, and marital status—were obtained. Education was categorized as professional school, junior college, or college or above. Marital status was categorized as single or married.
Measurement of Depressive Symptoms
Depressive symptoms were measured by the 20-item Chinese version of the Center for Epidemiologic Studies Depression Scale (CES-D; Liu & Tang, 1995; Radloff, 1977). Each item has four possible responses: (0) never, (1) sometimes, (2) frequently, and (3) always. Each item is graded on a four-point scale ranging from 0 to 3, with a total score of 60. The CES-D measures symptoms during the week previous to administration of the questionnaire. The standard CES-D Scale employs a cutoff of 16 points for depressive symptoms (CES-D ≥ 16). The CES-D includes four factors: depressed affect (blues, depressed, lonely, crying, sad; items 1, 3, 6, 9, 10, 14, 17, and 18), positive affect (good, hopeful, happy, enjoying; items 4, 8, 12, and 16), somatic and retarded activity (bothered, appetite, effort, sleep, get going; items 2, 5, 7, 11, 13, and 20), and interpersonal (unfriendly, dislike; items 15 and 19). A Cronbach's alpha of .85 was reported for internal consistency reliability of the total scale (Radloff, 1977). The CES-D has been translated, back-translated, and revised to make the items culturally and linguistically applicable in China. The Chinese version of the CES-D has been used widely in Chinese populations (X.Y. Li, Guo, Lu, Wang, & Chen, 2006; Yu et al., 2006; Zhang et al., 2010). For example, a Cronbach's alpha of .88 has been reported for internal consistency reliability (X.Y. Li et al., 2006). Zhang et al. (2010) demonstrated the reliability and validity of the Chinese version of CES-D, which was administrated to 16,047 community participants aged 11–100 years in 21 provinces in China. Results showed the Cronbach's alpha was .90 for the scale, and .68–.86 for its factors. A confirmatory factor analysis (CFA) supported the original four-factor structure (RMSEA = .057, CFI = .976, GFI = .948; Zhang et al., 2010). In our study, the reliability and validity of the Chinese version of the CES-D were assessed. The Cronbach's alpha for the total scale was .85. After adjusting item 4, CFA confirmed that the Chinese version of CES-D had goodness-of-fit (RMSEA = .063, CFI = .953, GFI = .937).
Measurement of Occupational Stress
The Chinese version of the Occupational Stress Inventory-revised edition (OSI-R; Osipow, 1998) was used to measure occupational stress. Items included in the OSI-R are role overload (RO, 10 items), role insufficiency (RI, 10 items), role ambiguity (RA, 10 items), role boundary (RB, 10 items), and responsibility (R, 10 items), and all were used in this study. The response was scored on a scale of 1–5. Role overload measures the extent of an increasing, unreasonable, and unsupported workload experienced by employees; role insufficiency measures the extent of a poor fit between employee's skills and the job they were performing; role ambiguity measures an unclear sense of what the employees are expected to do and how they will be evaluated; role boundary measures a feeling caught between conflicting supervisory demands and factions; and responsibility measures the extent to which the employee has, or feels, a great deal of responsibility for work performance and activities of subordinates. A Cronbach's alpha of .88 has been reported for internal consistency reliability (Osipow, 1998). The questionnaire was translated, back-translated, and revised to make the items culturally and linguistically congruent in China. The Chinese version of OSI-R has been applied widely in the Chinese population (Xu, Yang, Chen, & Ni, 2008; Yang, Jin, Wang, & Yao, 2005; Yang et al., 2006). J. Li et al. (2001) demonstrated the reliability and validity of Chinese version of OSI-R. A total of 319 participants were sampled from various occupations, such as factories, offices, and schools, in China. The Cronbach alpha was .76 for the scale, and .59–.86 for its factors. These researchers also demonstrated structure validity of the OSI-R (Li et al., 2001). In our study, the Cronbach's alpha was.92. After revising seven items, the confirmatory factor analysis confirmed that the Chinese version of OSI-R had goodness-of-fit (RMSEA = .058, CFI = .949, GFI = .932).
Measurement of Personal Resources
To measure personal resources, social support (SS, 10 items) and rational coping (RC, 10 items) included in OSI-R were used in this study. Social support measures the extent to which the individual feels support and help from those around her; rational coping measures the extent to which the individual possesses and uses cognitive skills to deal with work-related stresses. The responses were scored from 1 to 5. The Cronbach's alpha for the two combined scales was .90 in our study. After revising three items, confirmatory factor analysis confirmed the validity of the scale (RMSEA = .055, CFI = .962, GFI = .941).
Structural equation modeling (SEM) was used to identify the model of relationship between depressive symptoms and occupational stress. The hypothesized model consisted of seven latent variables (role overload, role insufficiency, role ambiguity, role boundary, responsibility, social support, and rational coping), which were loaded by the respective observed variables. Before SEM analyses were conducted, the normal distribution of the variables was tested. The P-P-plot analyses and K-S-tests of normal distribution indicated that the variables fulfilled the postulation of normal distribution. All SEM analyses were performed with AMOS 6.0, using the maximum likelihood method. The aim of the analysis was to evaluate whether the hypothesized model fit the data well. The goodness-of-fit was assessed with a normed fit index (NFI), comparative fit index (CFI), goodness-of-fit (GFI), adjusted goodness-of-fit index (AGFI), and root mean square error of approximation (RMSEA). For NFI, CFI, GFI, and AGFI, values close to 1.00 indicate a goodfit of model. A RMSEA value of .08 or less shows a good data model fit (Byrne, 2001). The mediating effects of social support and rational coping in the relationship between occupational stress and depressive symptoms were evaluated using a Sobel z-test. The statistical significance was defined as p < .05.
Internal consistency reliability was assessed with Cronbach's alpha coefficient using SPSS 11.5 for Windows. Confirmatory factor analysis was performed using Amos 6.0.
The average age of subjects was 34.5 ± 9.6 years; 66.6% had received at least junior college education, and 66.3% were married.
Mean scores and correlations of the variables are shown in Table 1. Role overload, role insufficiency, and role boundary were positively correlated with depressive symptoms, whereas social support and rational coping were negatively correlated with depressive symptoms.
|1. Role overload||24.76 (4.94)|
|2. Role insufficiency||25.64 (4.58)||.09**|
|3. Role ambiguity||18.29 (4.22)||.14**||.31**|
|4. Role boundary||19.49 (4.89)||.21**||.28**||.39**|
|5. Responsibility||23.47 (5.43)||.20**||.07*||.05*||.38**|
|6. Social support||36.83 (6.38)||−.02||−.28**||−.26**||−.11**||.03|
|7. Rational coping||32.59 (6.71)||−.06*||−.30**||−.35**||−.03||−.15**||.04|
|8. Depressive symptoms||16.60 (7.78)||.20**||.19**||.01||.13**||.02||−.17**||−.10**|
Fit indices of the hypothesized model showed acceptable data model fit (NFI = .90, CFI = .92, GFI = .95, AGFI = .94, RMSEA = .04). Significant path coefficients are displayed in Figure 2. The results showed that: (a) role overload, role insufficiency, and role boundary predicted depressive symptoms; (b) role insufficiency, role ambiguity, and role boundary predicted social support. Role overload, role insufficiency, role ambiguity, and responsibility predicted rational coping; (c) social support and rational coping predicted depressive symptoms. In conclusion, social support mediated the effects of role insufficiency, role ambiguity, and role boundary on depressive symptoms, whereas rational coping mediated the effects of role overload, role insufficiency, role ambiguity, and responsibility on depressive symptoms.
To further test whether the effects of occupational stress on depressive symptoms were mediated by social support and rational coping, Sobel tests were performed. Results showed that social support mediated the effects of role insufficiency, role ambiguity, and role boundary on depressive symptoms (z = 8.45, p < .001; z = 9.08, p < .001; and z = 7.94, p < .001, respectively). Rational coping mediated the effects of role overload, role insufficiency, role ambiguity, and responsibility on depressive symptoms (z = 4.07, p < .001; z = 8.38, p < .001; z = 9.28, p < .001; and z = 2.71, p = .007, respectively). These analyses corroborated the results obtained from the structural equation modeling depicted in Figure 2.
In this study, subjects were selected from all grades of hospitals in every sized city in Liaoning Province. These study subjects were representative, enhancing the generalization of the study conclusions.
The association between occupational stress and depressive symptoms has been demonstrated (Cho et al., 2008; Lambert, Lambert, Petrini, Li, & Zhang, 2007; Park et al., 2009). We also found that role overload, role insufficiency, and role boundary had significant direct effects on depressive symptoms. Moreover, role overload showed the highest loading (.200) on depressive symptoms, compared with role insufficiency (.186) and role boundary (.125). This is the first report indicating that role overload is the strongest predictor of depressive symptoms for female Chinese nurses.
In China, the healthcare system is undergoing a transformation, highlighted by transition of the traditional disease-centered nursing care model to the patient-centered holistic nursing care model (Wu, Chi, Chen, Wang, & Jin, 2010). Nurses accept the roles of guardian, coordinator, instructor, and advocate in the course of their work, while also continuing to gain knowledge to improve their ability to suit needs of the work (Pang et al., 2004).
Presently, China is facing a severe shortage of nurses due to the population of 1.3 billion (Wu et al., 2010). This shortage, together with the nursing care model transition, has resulted in overwhelming workloads for nurses. In addition, patient demands contribute to the overall workload because medical disputes often occur due to patient dissatisfaction. These combined effects have increased friction between nurses and patients. When job demands exceed the capabilities of nurses, it can adversely affect both their physical and mental health, which can lead to depressive symptoms.
Thus, these findings should urge hospital administrators to be aware of the risk of occupational stress. Efforts should be made to reduce role overload and to improve role insufficiency and role boundary in nurses to reduce depressive symptoms. For example, hospital administrators could improve work conditions, such as increasing staff and giving nurses opportunities to enhance their technical skills to better fit in a high-tech environment. Professional organizations could collect positive feedback from patients to improve nurse–patient relationships, and seek ways to increase the diversity of the work assignments of nurses. Participating in health education and occupational training programs may help decrease occupational stress and improve the quality of life among female Chinese nurses.
Our study also demonstrated that role insufficiency, role ambiguity, and role boundary may have adverse effects on social support; and that role overload, role insufficiency, role ambiguity, and responsibility may have similar effects on rational coping. These results agree with other studies showing adverse effects on social support and rational coping following exposure to occupational stress (Nakata et al., 2004; Lambert et al., 2007; Ross et al., 2005; Wang & Patten, 2001; Xiao, 2008). Our findings also reveal that social support mediated the effects of role insufficiency, role ambiguity, and role boundary on depressive symptoms, and rational coping mediated the effects of role overload, role insufficiency, role ambiguity, and responsibility on depressive symptoms. Social support and rational coping-mediated occupational stress, indicating that they played beneficial roles in the prevention of depressive symptoms. Therefore, strengthening social support and rational coping may be effective ways of both reducing occupational stress and depressive symptoms, and improving quality of life among female Chinese nurses.
This study has limitations that should be considered. First, data were obtained by self-reports, which can introduce bias. Participants may have underestimated or overestimated the relationship between depressive symptoms and occupational stress. Second, a causal relationship between depressive symptoms and occupational stress cannot be established because of the nature of the cross-sectional study. All findings obtained in the current study should be confirmed by a prospective study.
In summary, role overload, role insufficiency, and role boundary were significantly associated with depressive symptoms. Social support and rational coping were negatively correlated with depressive symptoms. The effects of occupational stress and depressive symptoms were mediated by social support and rational coping. These data demonstrate that social support and rational coping are important in predicting and understanding the development of depressive symptoms. Hence, social support and rational coping should be included in depression management programs designed for female Chinese nurses.
- 2004). The effect of organizational conditions (role conflict, role ambiguity, opportunities for professional development, and social support) on job satisfaction and intention to leave among social workers in mental health care. Community Mental Health Journal, 40, 65–73. (
- 2006). Job performance deficits due to depression. American Journal of Psychiatry, 163, 1569–1576. , , , , , & (
- 2001). Structural equation modeling with AMOS. Mahwah, NJ: Erlbaum. (
- 2008). Occupational stress and depression in Korean employees. International Archives of Occupational and Environmental Health, 82, 47–57. , , , , , , … (
- 2005). The role of sense of belonging and social support on stress and depression in individuals with depression. Archives of Psychiatric Nursing, 19, 18–29. , , & (
- 2000). Job strain, effort-reward imbalance and employee well-being: A large-scale cross-sectional study. Social Science and Medicine, 50, 1317–1327. , , , & (
- 2004). Depression and the ability to work. Psychiatric Services, 55, 29–34. , , , & (
- 2005). A prospective study of cumulative job stress in relation to mental health. BMC Public Health, 5, 67. , , , & (
- 2005). Health-related quality of life measured by the SF12 in working populations: associations with psychosocial work characteristics. Journal of Occupational Health Psychology, 10, 429–440. , , , , , & (
- 2004). Cross-cultural comparison of workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health among hospital nurses in Japan. Thailand, South Korea and the USA (Hawaii). International Journal of Nursing Studies, 41, 671–684. , , , , , , … (
- 2004). Workplace stressors, ways of coping and demographic, characteristics as predictors of physical and mental health of Japanese hospital nurses. International Journal of Nursing Studies, 41(1), 85–97. , , & (
- 2007). Workplace and personal factors associated with physical and mental health in hospital nurses in China. Nursing and Health Sciences, 9, 120–126. , , , , & (
- 2006). Associations between social psychological factors and depressive symptoms among healthcare workers. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi, 24, 454–457. , , , , & (
- 2001). The test of occupational stress inventory revised edition. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi, 19, 190–193. , , , , , & (
- 1995). The comparison of SDS and CES-D on college students' depressive symptoms. Chinese Mental Health Journal, 9, 19–21. , & (
- 2004). Job stress, social support, and prevalence of insomnia in a population of Japanese daytime workers. Social Science and Medicine, 59, 1719–1730. , , , , , , & (
- 1998). Occupational stress inventory revised edition (Professional Manual). Odessa, Ukraine: Psychological Assessment Resources, Inc. (
- 2004). Towards a Chinese definition of nursing. Journal of Advanced Nursing, 46, 657–670. , , , , , , & (
- 2009). Job stress and depressive symptoms among Korean employees: The effects of culture on work. International Archives of Occupational and Environmental Health, 82, 397–405. , , , , & (
- 1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. (
- 2008). Burnout predictors among prison officers: The moderating effect of temperamental endurance. Personality and Individual Differences, 45, 666–672. , , , & (
- 2005). Depression, stress, emotional support, and self-esteem among baccalaureate nursing students in Thailand. International Journal of Nursing Education Scholarship, 2, Article 25. , , , , , & (
- 2005). Occupational stress in nurses in psychiatric institutions in Taiwan. Journal of Occupational Health, 47, 218–225. , , , , & (
- 2006). Stress and depression in the employed population. Health Reports, 17(4), 11–29. (
- 2006). Occupational stress, job satisfaction, and working environment among Icelandic nurses: A cross-sectional questionnaire survey. International Journal of Nursing Studies, 43, 875–889. , , & (
- 2009). Exploring superiority of male nurses in nursing specialty development. Chinese Nursing Research, 23, 539–540. , , & (
- 2001). Association between job stress and depression among Japanese employees threatened by job loss in a comparison between two complementary job-stress models. Scandinavian Journal of Work, Environment and Health, 27, 146–153. , , , & (
- 2001). Perceived work stress and major depression in the Canadian employed population, 20–49 years old. Journal of Occupational Health Psychology, 6, 283–289. , & (
- 2010). Prevalence and associated factors of depressive symptoms among Chinese doctors: A cross-sectional survey. International Archives of Occupational and Environmental Health, 83, 905–911. , , , , & (
- 2009). Predictors of depressive symptoms in female medical-surgical hospital nurses. Issues in Mental Health Nursing, 30, 320–326. (
- 2002). Depressive symptoms, unemployment, and loss of income: The CARDIA Study. Archives of Internal Medicine, 162, 2614–2620. , , , , , & (
- 2010). Occupational stress among hospital nurses: cross-sectional survey. Journal of Advanced Nursing, 66, 627–634. , , , , & (
- 2008). Coping resources of nurses' occupational stress. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi, 26, 526–528. (
- 2008). Structural equation model analysis of relationship between occupational stress and work ability. Wei Sheng Yan Jiu 37, 59–62. , , , & (
- 2005). Appraisal of occupational stress and its influential factors in executive group. Wei Sheng Yan Jiu, 34, 744–746. , , , & (
- 2006). A study of the occupational stress norm and its application for the technical group and scientific research group. Wei Sheng Yan Jiu, 35, 781–784. , , , , , , & (
- 2006). Relationship between depression symptoms and stress in occupational populations. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi, 24, 129–133. , , , , , & (
- 2010). Development of the Chinese age norms of CES-D in an urban area. Chinese Mental Health Journal, 24, 139–143. , , , , , & (