The Relationship between Core Competence, Job Stressor and Depression in Chinese Specialist Nurses

Background To this day, the professional training for Specialist Nurse have covered 9 directions in Anhui, China. This paper aims to determine the association of socio-demographic variables, core competence,job stressor and depression in Chinese specialist nurses. Methods 302 specialist nurses in Anhui province participated in this descriptive correlation study, all data were collected through questionnaire survey including Socio-demographic and Professional Information surveys, Competency Inventory for Registered Nurse, Chinese Nursing Stressor Scale and Self-Rating Depression Scale.


Abstract Background
To this day, the professional training for Specialist Nurse have covered 9 directions in Anhui, China. This paper aims to determine the association of socio-demographic variables, core competence,job stressor and depression in Chinese specialist nurses.
Methods 302 specialist nurses in Anhui province participated in this descriptive correlation study, all data were collected through questionnaire survey including Socio-demographic and Professional Information surveys, Competency Inventory for Registered Nurse, Chinese Nursing Stressor Scale and Self-Rating Depression Scale.

Results
The total score range of core competence was 57-210(2.53 ± 0.50).The total score of job stressors was 43-123(88.05 ± 12.69). Specialist nurses had more job stressors than general clinical nurses in dimensions of professional and career issues, workload and time pressure, interpersonal relationships and management issues (P < 0.05), but they had less job stressors than norm in dimension of resource and environmental problems(P < 0.05). The range of total scores in SDS for specialist nurses was 26-95 (47.80 ± 10.59).

Conclusion
There were signi cant relationships between core competence, job stressor and depression. This nding highlights potential foci in their joint consideration to improve competitiveness of specialist nurses.

Implications for Practice:
The status of the core competence, job stressors and depression of Chinese specialist nurses is presented to the global clinical community. This paper provides intervention direction to increase the core competence of specialist.

Background
In China, specialist nurse is de ned as someone who have obtained a specialized post certi cate after professional training, they can provide high-quality nursing services to the clients according to their own judgment in the complex and uncertain nursing situation, the services provided by them are different from general clinical nurses [1]. To this day, the professional training for Specialist Nurse have covered 9 directions in Anhui, China, such as intensive care, blood puri cation, wound/ostomy, tumor, diabetes, pediatric intensive care, emergency, orthopedics and operating. The main purpose of professional training for specialist nurses is to develop their core competence. The core competence of nurses refers to the organic combination of the three basic attributes: professional knowledge, professional skills and service attitude. It is re ected in the seven dimensions of critical thinking/research aptitude, clinical care, leadership, interpersonal relation, legal/ethical practice, professional development and teachingcoaching [2][3][4]. In recent years, the research on the core competence of nurses has attracted the attention of researchers in the world, but, it is not systematic and comprehensive to study the core competence of specialist nurses. What are the relevant factors of core competence in specialist nurses?
The negative effects of job stressors on health have been extensively reported [5], and all the reports indicated that increasingly job stressors affect the workforce [6]. Nurses work with sick people, their work includes mental and physical nursing and they always have to face patients, family members, doctors and other health workers. Nursing has been considered as the profession highly susceptible to stress.
Nursing stress has been considered as a problem which affects practice [7]. The effect of stress has been considered as an important cause of decreasing health and reduction in the level of e ciency of nursing [8].
Several studies have shown that job stress of nurses was mainly caused by critical condition of patients, high requirements of patients and their families, heavy work burden, insu cient nurses on duty, and con icts with colleagues, patients and their families and so on [9,10].The result of nurses' job stress was job burnout [11,12]. Job burnout often manifested as indifference to work, even leaving or changing jobs [13,14] .The main job stressors of nurses in China can be divided into ve aspects as following: (1) professional and career issues, such as the low social status, less opportunities for promotion and further study, frequent night shifts, low salary and welfare, less independence of work, etc. ;(2) workload and time pressure: insu cient stuff on duty, heavy workload, too much non-nursing work, etc.; (3) resource and environmental problems: too crowded working environment, insu cient equipment, etc.; (4) patient care and interaction: fear of errors or accidents, unadmitted nursing contributions by patients and family members, bad manners of patients and family members, uncooperative patients, and the implementation of operations that will cause pain to patient, etc.; (5) interpersonal relationships and management issues: less understanding and support from nursing managers, lack understanding and respect from other medical staffs, and con icts with doctors, etc.. These factors contribute the high working pressure to nurses in China [15].
The professional nature, special environment and complex interpersonal relationship of nursing work can cause great pressure on nurses and affect their physical and mental health directly. The incidence of depression is higher in nurses than the general population, 49.7% of nurses have different levels of depression, job stressors such as unrecognized work by the patients and their families, heavy workload and frequent shifts have been reported to associate with the depression of nurses [16].However, little is known about how job stressors affect depressions of specialist nurses in China.
As such, the core competence, job stressors and depression of specialist nurses might differ from general clinical nurses in China. Therefore, rstly, we investigated the status of the core competence, job stressors and depression of Chinese specialist nurses. Secondly, we explored the relationship between sociodemographic variables, job stressor, core competence and depression in Chinese specialist nurses.

Participants
This research was approved by the Institutional Review Board of Xs University. 302 specialist nurses from hospitals in Anhui (China) were enrolled in this study and completed the questionnaire. The inclusion criterion: having a specialized post certi cate after professional training; working in hospital as a nurse; willing to participate in and complete the tests. Totally, 93.0% participants were female with mean age of 30.06 years (SD =2.87). Most participants were married (86.1%), and had children (77.2%).

Procedure
Firstly, researchers explained the purpose of this study to the participants. After obtaining informed consent, questionnaires were distributed to them while assuring them that their responses were anonymous, voluntary and con dential. And researchers collected all questionnaires when they were nished. A total of 320 were invited to this survey between June 2017 and June 2018, 18 invalid data had been excluded. Finally, 302 specialist nurses were enrolled successfully. The overall response rate was 94.4%.

Measures
Socio-demographic and professional information Personal details were obtained about age, sex, marital status, got any kids, educational level, job status (work experience, job title, position, level, employment form, specialist direction, hospital category).

Competency Inventory for Registered Nurse (CIRN)
CIRN is comprised 7 dimensions (critical thinking/research aptitude, clinical care, leadership, interpersonal relation, legal/ethical practice, professional development and teaching-coaching). Each item is rated on a 5-point Likert-type scale, higher scores indicate stronger competency. In this 55-item scale, Cronbach's coe cient is 0.91 [2].

interpersonal relationships and management issues (27-35). Each item is rated on a 4-point
Likert-type scale, higher scores indicate more stress. The coe cient is 0.94 for the general scale [17].

Self-rating Depression Scale (SDS)
SDS (Wang,1999) consists of 20 items selected by the factor analysis. It has been translated into a wide variety of languages and its validity and reliability across cultures have been thoroughly assessed. and reliability [18].

Data analysis
Data were analyzed with SPSS Version 24.0 statistical software. Descriptive analyses were carried out to examine socio-demographic variables, core competence, job stressors and depression. Descriptive statistics were analyzed by one sample t-test; the values between groups were analyzed by independent sample t-test or ANOVO. Pearson correlation coe cients were computed to examine the relationship of core competence, job stressors and depression. A p-value of less than 0.05 was considered statistically signi cant. All p-values were two-tailed.

Results
Core competence, job stressors and depression of specialist nurses The core competence of specialist nurses was presented in Table1, the total score range was 57-210 139.17±27.44 , and the mean score of each item was 2.53±0.50).
The total score of job stressors was 43-123 88.05±12.69). Specialist nurses had more job stressors than general clinical nurses in dimensions of professional and career issues, workload and time pressure, interpersonal relationships and management issues(P<0.05), but they had less job stressors than norm in dimension of resource and environmental problems(P<0.05) [19], see Table2.
The range of total scores in SDS for specialist nurses was 26-95 47.80±10.59). Of all participants, 182 60.3% were below the cut-off for depression, 82 27.2% were slight to mild depression, 30 9.9% were moderate depression and 8 2.6% were severe depression.
Demographics characteristics and core competence, job stressors, depression Differences in core competence and job stressors by demographics characteristics were presented in Table3-4. Specialist nurses get kids, having long work experience, working in primary position and level 4 had stronger core competence(P<0.05). Participants whose specialist was intensive care had more job stressors than other directions (P<0.05). Participants working as ordinary nurses (49.00±10.74) had more severe depression than primary nurses (46.55±10.31) and head nurses (47.80±10.59) (F=3.118, P=0.046).

Correlations between job stressors, core competence and depression
The correlations were presented in Table 5, it can be seen that signi cant positive relationships were found between job stressors (total score, professional and career issues, workload and time pressure, patient care and interaction, interpersonal relationships and management issues) and core competence (legal/ethical practice). Job stressors (total score, patient care and interaction, interpersonal relationships and management issues) and core competence (professional development) were positively related to depression. Negative relationships were found between job stressors (interpersonal relationships and management issues) and core competence (clinical care, leadership); Job stressors (patient care and interaction) was negatively related to core competence(teaching-coaching); There were also signi cant negative correlations between core competence (total score, critical thinking/research aptitude, clinical care, leadership, interpersonal relation, legal/ethical practice, teaching-coaching).

Discussion
The total score of our participants' core competence is lower than registered nurses' in Grade A hospitals of Anhui province(P < 0.05) [20]. It means that even specialist nurses have accepted professional training, their core competence still lower than those from high grade hospitals, this maybe because specialist nurses in our study come from different level hospitals, the basis competence of them is not uniform. It suggests that much more attention should be paid on a series of follow-up training for core competence,especially focus on weak links in critical thinking/research aptitude and clinical care.
Specialist nurses getting kids, having long work experience, working in primary position and at level 4 have stronger core competence, which may because being a mother in a family or being a backbone in a hospital will keep improving core competence to be quali ed the role.
The results of our study revealed that there are negative relationships between core competence and job stressors, we can improve their core competence in clinical care and leadership by reducing the job stressors from interpersonal relationships and management issues. We can also improve their core competence in teaching-coaching by reducing the job stressors from patient care and interaction.
Job stressors of participants have more job stressors in dimensions of professional and career issues, workload and time pressure, interpersonal relationships and management issues than general clinical nurses, but they have less job stressors in dimension of resource and environmental problems [19]. This could be because hospitals, where their coming from, set high expectations for specialist nurses, provide resources and environment for their needing, and expect the higher standard of work from them.
Sometimes too much attention from workmates will also bring them more stressors.
Specialist nurses of intensive care have more job stressors than others. ICU is a department for the treatment of severe patients. High-intensity work and completely closed environment make the psychological pressure of ICU nurses signi cantly higher than that of ordinary ward nurses [21].
Job stressors were positively relevant to core competence in the dimension of legal/ethical practice. It is very interesting that the result was not consistent with our original assumption. Perhaps it re ects specialist nurses in high stress situation will be more gingerliness, they are very scared to make a mistake, so they have high score in legal/ethical practice.
The average score in SDS for specialist nurses was higher than the general population [22], which is in accordance with most previous research results [16,23]. Mental state of nurses is poor, especially in specialist nurses, this point was con rmed by our result: 39.9% participants were in depression. We also found that participants working as ordinary nurses had more severe depression than others, it re ects a possible situation in which work is heavy, and they have to charge the department's chores at the same time. Daily repetitive and tedious overload makes nurses physically and mentally tired. Because most of them have not received the corresponding psychological training, when they meet the setbacks form work and life, they are often not good at using psychological knowledge for self-psychological adjustment, then they will be depression, in accordance with previous study [24].
The depression is negatively relevant to core competence, and it is also positively relevant to job stressors, that means we can decreasing their depression by enhancing core competence and decreasing job stressors of specialist nurses.

Conclusions
This study shows the relevance of socio-demographic variables, core competence, job stressor and depression in Chinese specialist nurses. Every variable is relevant, their joint consideration is important to reach a better explanation.

Limitations
The study is limited by its descriptive nature and a convenience sample. While the sample from Anhui province is re ective of the wider population of China, ndings cannot be generalized. Furthermore, the cross-sectional nature of this study limits the ability to understand change over time.

Declarations
Ethics approval and consent to participate This study received Institutional Review Board approval of Anhui Medical University No:20180067 .

Consent for publication
Not applicable.

Availability of data and material
The raw data required to reproduce these ndings cannot be shared at this time as the data also forms part of an ongoing study.

Competing interests
We declare that we do not have any commercial or associative interest that represents a con ict of interest in connection with the work submitted.