Depressive symptoms and workplace-violence-related risk factors among otorhinolaryngology nurses and physicians in Northern China: a cross-sectional study

Objectives Workplace violence is relatively frequent among medical professionals who work in otorhinolaryngology units. This phenomenon reduces the quality of provided medical care and increases the incidence of depressive symptoms among physicians and nurses, seriously affecting their job satisfaction and work efficiency with a negative attitude towards providing treatment. Few existing studies have assessed workplace-violence-related factors associated with depressive symptoms among otorhinolaryngology physicians and nurses. Methods We conducted a cross-sectional study in grade A tertiary hospitals of Heilongjiang province in Northern China, to evaluate the occurrence and level of depressive symptoms among otorhinolaryngology physicians and nurses and to analyse the relationship between them and workplace-violence-related risk factors and demographic variables. Results Of all our participating professionals, (379 otorhinolaryngologists and 273 nurses), 57.2% were found to have depressive symptoms, whereas, of the respondents who had suffered from physical violence, 71.25% had depressive symptoms. Professionals with less than 1 year of experience, as well as professionals who more frequently worked alone, were more likely to suffer from depressive symptoms than their colleagues. Conclusions This research addresses an emerging issue of clinical practice, and its results differ from those of previous studies; specifically, it indicates that the frequency of depressive symptoms among otorhinolaryngology physicians and nurses may be influenced by physical violence, the number of coworkers they have for more than half of their working hours and other workplace-violence-related factors. To reduce the depressive symptoms caused by workplace violence and improve the quality of medical services, medical institutions should implement effective measures to prevent the occurrence of physical violence, strengthen team cooperation ability and increase peer support.

Workplace physical violence among otorhinolaryngologists is relatively high among medical professions. This increased risk not only reduces the quality of provided medical services, but also increases the incidence of depression. Depressive symptoms among these physicians and nurses can seriously affect their job satisfaction, work efficiency, and overall happiness, resulting in a negative attitude toward providing treatment. We found few existing studies related to otorhinolaryngology physicians and nurses suffering from depressionFrelated factors.
Therefore, this study seeks to assess the level of depression in otorhinolaryngology physicians and nurses in northern China and to identify associations among depressive symptoms and workplace violence related risk factors.
we conducted a crossFsectional study and make logistic regression analysis to investigate the relationship between workplace violence related risk factors and depressive symptoms.
Of the 652 participating otorhinolaryngologists and nurses in tertiary hospitals in Heilongjiang Province, China, 57.2% were found to have depressive symptoms, and of the respondents who had suffered from physical violence, 71.25% had depressive symptoms. Respondents who suffered from physical violence were more likely to suffer from depressive symptoms than those who had not.
This research indicates that the mental health of otorhinolaryngology physicians and nurses should be investigated to improve workplace relationships among physicians and nurses, as well as with their patients, and prevent the  Qiqihar City, Heilongjiang Province, China, was beaten to death during examination of a patient. In China, the frequency and severity of workplace violence among medical professionals has increased, as has its public attention [2]. Workplace violence (WPV) refers to the physical and psychological harm that professionals may face while performing their duties [3,4]. The number of WPV incidents in health care facilities accounts for almost oneFquarter of the total number of violent incidents in all workplace types [5], making healthcare workers the most vulnerable group to workplace violence [6]. The occurrence of hospital violence may affect the health of physicians and nurses and hinder their professional performance, resulting in a negative impact on patient services and overall health [7F9]. Differences in violence have been found across different departments in hospitals [10]; for example, many studies have focused on the high incidence of violence in emergency rooms [11,12]; however, we found comparable rates of violent incidences in otorhinolaryngology departments. The China Hospital Association 2014 data show that from 2008 to 2012, the incidences of severe hospital violence increased from 47.7% to 63.7% [13]. Upon examining 30 cases of physicians and nurses who were victims of fatal WPV in China over the past 10 years, those working in otorhinolaryngology departments accounted for more than 10% of the total. The main causes of violence against  [14]. Therefore, the working environment of otorhinolaryngology physicians and nurses should be a concern for hospital administrations, both from a mental health and WPV perspective.
Previous studies have shown that workplace violence is a contributing factor to employees suffering from mental illnesses, such as depression [15F17]. Further, the incidence of depression among adults in lowF to middleFincome countries was 11.1%, compared to 14.6% in highFincome countries [18,19]; specifically, the incidences of depression in the United States, Canada, and the UK was 12%, 19.3%, and 15.5%, respectively [20,21]. In Canada, 1 in 10 nurses was found to have depressive symptoms [22], and in France the situation is even more serious, with oneFthird of nurse managers suffering from depressive symptoms [23]. Depressive symptoms can negatively affect job satisfaction, work efficiency, and overall happiness, resulting in a negative attitude toward providing medical treatment. Over the long term, this will not only affect the development of human resources in health fields, but also reduce the quality of medical care [8,9,24]. Related research shows that Chinese physicians and nurses experience different degrees of psychological issues, with the incidence of depression at 34.2% [25]. In southern China, Guangdong Province, depressive symptoms are associated with workplace violence, long working hours, shift frequency, and departmental operations [7]. Previous studies reveal a difference in the proportion of depressive symptoms among nurses in different hospital departments; as such, managers should account for these differences among departments in their employee relations and processes [7]. Existing research primarily assesses the overall situation of a hospital, although few researches focus on specialized departments, primarily the emergency department. However, that the department of otolaryngology suffered a comparable amount of violent phenomena as emergency rooms and more than other departments; therefore, the occurrence of depressive symptoms among these staff should be taken seriously.
Otolaryngology is a key department in most hospitals, and has distinct differences from other departments. First, there are many types of otolaryngologyFrelated diseases, each in unique anatomical locations, which affect patients' breathing, speech, smell, and hearing. Many such diseases have long cure times; therefore, providing patients with a fast and effective treatment is not always possible. Second, the patient population of an otolaryngology department can span a wide range of age groups, resulting in relatively large workloads for physicians and nurses. Third, otolaryngology involves a variety of specializations, requiring these physicians and nurses to engage in continual learning to improve their professional and technological skills [14,26].
For these reasons, we hypothesized that the proportion of otolaryngology physicians and nurses suffering from depressive symptoms would be higher than that of other hospital departments. While some scholars have studied the influencing  Otorhinolaryngology to conduct the study. The association then organized 9 experts to conduct a preliminary test of the questionnaire to ensure clarity, readability, and completeness of content. Second, the association provided a list of Grade A tertiary hospitals and their physicians' email contact information, from which we first contacted the otolaryngology director to seek help in getting the nurses' email addresses. We then sent an introductory email with a link to the informed consent form and questionnaire. After the initial eFmail was sent, a reminder eFmail was sent to those physicians and nurses who did not respond initially. Through this process, we obtained 652 valid questionnaires (total efficiency of 83.6%). The data were collected from January 10, 2017, to February 15, 2017.

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After obtaining written permission, we used a questionnaire developed by the  Depression Scale (SDS), which was able to reveal subjective feelings using 20 entries with a severity score ranging from 1 (very seldom presence of anxiety/depressive symptoms) to 4(anxiety/depressive symptoms are almost always present). The total score was recorded as the original score, then the scores of the 20 entries were added, and finally the resulting score was multiplied by 1.25 to get the standard score.
Results with greater than or equal to 53 points were considered to have depressive symptoms [28,29].

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Descriptive statistical calculations were conducted on demographic characteristics and frequency of depressive symptoms; in addition, the chiFtest was

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All respondents received an informed consent form, which included the goal of data collection and its use, the method of data collection, and consent for confidentiality. All respondents who agreed to the informed consent form then filled   1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 13 )$   [30] and the Netherlands (29%) [31]. The results in China were also higher than the prevalence of depressive symptoms among the US nurses (41%) [32] and Iranian physicians and nurses (28.76%) [33]. Moreover, this number is slightly higher than the incidence of depressive symptoms among emergency department nurses in Taiwan [1]. shown that social support can reduce the incidence of depressive symptoms, help individuals manage stress, and promote good mental health [40]. Peer support intervention, in particular, can effectively reduce depressive symptoms, as they not only can be done through daily interactions, but may also have the same effect as group cognitive behavioural therapy [41]. Therefore, the working status of medical staff (such as avoidance of working alone) should be considered to strengthen peer support and effectively prevent and improve depressive symptoms.
Third, this study revealed that physical violence is an important predictor of the incidence of depressive symptoms within the department of otolaryngology. Our findings suggest that the risk of depressive symptoms of physicians and nurses who have suffered physical violence is 1.82 times greater than those who have not.
Previous surveys also indicate that workplace violence is a strong predictor of psychological problems such as depressive symptoms [15]. Depression is one of several negative yet likely consequences of physicians and nurses who suffer from workplace violence [42]. Among them, physical violence is more likely to cause physicians and nurses to experience depressive symptoms [39]. The reasons for the high rate of physical violence within otolaryngology departments are varied, as otorhinolaryngologyFrelated diseases are often complex and involve longer courses of treatment, which can lead to patient insomnia, anxiety, and other psychological problems, leading to a loss of trust in their physicians and nurses. As such, these patients can be prone to adverse emotions [43]. Due to the nature of many otorhinolaryngology diseases, which affect speech and hearing, patients are often unable to effectively express their dissatisfaction, making them more inclined to choose physical violence to express their discomfort or psychological distress [44].
Therefore, otorhinolaryngology physicians and nurses were found to suffer a higher frequency of severe physical violence (i.e., fatal or nearFfatal attacks).

Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 5-7 Objectives 3 State specific objectives, including any prespecified hypotheses 7-8

Study design 4
Present key elements of study design early in the paper 9 Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection 9-11 Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of participants 9   We conducted a crossFsectional study in Grade A tertiary hospitals of    15 Thus, considering these dangers, it is clear that the working environment of otorhinolaryngology physicians and nurses should be a concern for hospital administrations, both from a mental health and WPV perspective. Previous studies have shown that WPV is a contributing factor to employees suffering from mental illnesses such as depression. 16F18 It is wellFknown that depression is a common illness, and it seems to be more prevalent in highFincome countries; the incidence rate of depression among adults in lowF to middleFincome countries is 11.1%, compared to 14.6% in highFincome countries 19,20 ; specifically, the incidences of depression in the United States, Canada, and the UK are 12%, 19.3%, and 15.5%, respectively. 21,22 In Canada, one in 10 nurses have been found to have depressive symptoms, 23 and in France the situation is even more serious, with oneFthird of nurse managers suffering from such symptoms. 24 Depressive symptoms can negatively affect job satisfaction, work efficiency, and overall happiness, resulting in a negative attitude toward providing medical treatment. Over the long term, this can not only affect the development of human resources in health fields, but also reduce the quality of medical care provided. 9,10,25 Research shows that Chinese physicians and nurses experience various psychological issues, with the incidence of depression determined to be 34.2%. 26 In a study based in southern China, (specifically, Guangdong Province), depressive symptoms were found to be associated with WPV, long working hours, shift frequency, and departmental operations. 8 Also notable is the fact that studies have revealed a difference in the proportion of depressive symptoms among nurses in different hospital departments, which strongly suggests that managers should seek to determine the reason for these differences between departments through the use of their employee relations and other suitable processes. 8 email addresses, which allowed us to contact otolaryngology directors to seek assistance in acquiring related nurses' email addresses. We then sent these individuals an introductory email with a link to the informed consent form and questionnaire.
After the initial eFmail was sent, a reminder eFmail was sent to any physicians and nurses who did not respond initially. Through this process, we obtained 652 valid questionnaires, (total efficiency of 83.6%). The data were collected from January 10,  29 We translated the questionnaire into Mandarin and then back into English to verify the accuracy of the Mandarin version. We then invited the aforementioned experts identified by the  SDS is usually used to measure the level of depressive symptoms in the general population over the previous week, and is widely used in research into WPV and depressive symptoms. 8,30 Specifically, it facilitates the revealing of subjective feelings

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All respondents received an informed consent form, which described the goal and method of the data collection, how the data would be handled, and also an assurance of confidentiality. All respondents who gave their informed consent completed the questionnaire. The study protocol was reviewed and approved by the Research Ethics Committee of Harbin Medical University.

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In In Table 3, the variables related to depressive symptoms, determined using a multiple logistic model, an adjusted odds ratio, (OR), and a 95% confidence interval, (CI), are shown.Our otorhinolaryngology physicians and nurses who suffered from physical violence, (OR = 1.82, 95% CI = 1.06 3.12), were more likely to suffer from depressive symptoms than those who had not. Moreover, participants with less than one year of experience were also more likely to suffer from depressive symptoms, while those with more experience were progressively less likely to suffer from depressive symptoms. Otorhinolaryngology physicians and nurses who worked alone for more than half of their working hours were more likely to suffer from depressive symptoms than those who worked frequently with other colleagues. Relative to the seniority of otorhinolaryngology physicians and nurses, formal staff and those with junior and intermediate titles showed protective factors for depressive symptoms.

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Our study examined the association between depressive symptoms and WPV related risk factors in regard to otorhinolaryngology physicians and nurses in these results show a significantly higher prevalence of depressive symptoms than that found among general physicians and nurses in the United States, (11.3%), 33 US nurses (41%), 35 general physicians in the Netherlands, (29%), 34 and Iranian physicians and nurses, (28.76%). 36 Further, this number is also slightly higher than the incidence of depressive symptoms reported among emergency department nurses in Taiwan because it can be implemented through daily interactions, but also because it can have the same effect as group cognitive behavioural therapy. 43 Support at work is a socialFnetwork resource associated with the work environment, and employees at all levels can benefit from the support of their colleagues. In the demandFcontrolFsupport model, it has been highlighted that social support is similar to job control, and may have a buffering or reinforcing effect on individuals' psychological responses; for example, work friendship between colleagues has been reported to be an important social support. 44 Therefore, the working status of medical staff, (e.g. time spent working alone), should be considered in order to strengthen peer support, (as well as team cooperation), and thereby effectively prevent and improve depressive symptoms.
Third, this study revealed that physical violence is an important predictor of incidences of depressive symptoms within the otolaryngology department. Our findings suggest that the risk of physicians and nurses who have suffered physical violence developing depressive symptoms is 1.82 times greater than that for professionals who have not experienced such violence. This is supported by previous surveys, which have also indicated that WPV is a strong predictor of psychological problems such as depressive symptoms. 16 Depression is one of several negative yet common consequences experienced by physicians and nurses who suffer from WPV. 45 Among them, physical violence is more likely to cause physicians and nurses to experience depressive symptoms. 39 The reasons for the high rate of physical violence within otolaryngology departments are varied, but an important factor is that    944F9.

Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 6-8 Objectives 3 State specific objectives, including any prespecified hypotheses 8-9

Discussion
Key results 18 Summarise key results with reference to study objectives 14-15
Professionals with less than one year of experience, as well as professionals who more frequently worked alone, were more likely to suffer from depressive symptoms than their colleagues.
Previous studies have shown that WPV is a contributing factor to employees suffering from mental illnesses such as depression. 16F18 It is wellFknown that depression is a common illness, and it seems to be more prevalent in highFincome countries; the incidence rate of depression among adults in lowF to middleFincome countries is 11.1%, compared to 14.6% in highFincome countries 19,20 ; specifically, the incidences of depression in the United States, Canada, and the UK are 12%, 19.3%, and 15.5%, respectively. 21,22 In Canada, one in 10 nurses have been found to have depressive symptoms, 23 and in France the situation is even more serious, with oneFthird of nurse managers suffering from such symptoms. 24 Depressive symptoms can negatively affect job satisfaction, work efficiency, and overall happiness, resulting in a negative attitude toward providing medical treatment. Over the long term, this can not only affect the development of human resources in health fields, but also  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y 8 reduce the quality of medical care provided. 9,10,25 Research shows that Chinese physicians and nurses experience various psychological issues, with the incidence of depression determined to be 34.2%. 26 In a study based in southern China, (specifically, Guangdong Province), depressive symptoms were found to be associated with WPV, long working hours, shift frequency, and departmental operations. 8 Also notable is the fact that studies have revealed a difference in the proportion of depressive symptoms among nurses in different hospital departments, which strongly suggests that managers should seek to determine the reason for these differences between departments through the use of their employee relations and other suitable processes. 8 Further, it should also be noted that much of the existing research primarily assesses the overall situations of hospitals, with few studies focusing on specialised departments. Of the latter studies, the focus has primarily been placed on the emergency department; however, as mentioned above, the department of otolaryngology witnesses a similar number of violent phenomena as emergency rooms, and more than that found in other departments; therefore, the occurrence of depressive symptoms among otolaryngology staff should be taken seriously.
Otolaryngology is a key department in most hospitals, and has a number of unique characteristics when compared with other departments. First, there are many types of otolaryngologyFrelated diseases, each presenting in unique anatomical locations, and these can affect patients' breathing, speech, smell, and hearing. Many such diseases have long cure times; therefore, providing patients with fast and effective treatment is not always possible. Second, the patient population of an (1) to investigate the prevalence of depressive symptoms among otorhinolaryngology physicians and nurses; and (2) to assess the risk factors that influence depressive symptoms, including WPVFrelated risk factors and demographic variables, and to present some specific suggestions.

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/.-. " We conducted a retrospective crossFsectional survey of otorhinolaryngologists and nurses from Grade A tertiary hospitals in Heilongjiang Province. Grade A tertiary hospitals are classified in accordance with China's current 'hospital classification management approach', which is designed to implement the division of medical institutions. When a medical institution has over 501 beds, it has the capability to provide highFlevel, specialised medical and health services in several areas, and also consequently provided a list of Grade A tertiary hospitals and associated physicians' email addresses, which allowed us to contact otolaryngology directors to seek assistance in acquiring related nurses' email addresses. We then sent these individuals an introductory email with a link to the informed consent form and questionnaire.
After the initial eFmail was sent, a reminder eFmail was sent to any physicians and nurses who did not respond initially. Through this process, we obtained 652 valid questionnaires, (total efficiency of 83.6%). The data were collected from January 10, 2017, to February 15, 2017.

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After obtaining written permission, we sent the respondents a questionnaire that

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All respondents received an informed consent form, which described the goal and method of the data collection, how the data would be handled, and also an assurance of confidentiality. All respondents who gave their informed consent completed the questionnaire. The study protocol was reviewed and approved by the Research Ethics Committee of Harbin Medical University.

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In Additionally, of the respondents who had suffered physical violence, 71.25% had depressive symptoms. We then assessed associations between sample characteristics and depressive symptoms using Pearson chiFsquare tests and determined that years of work experience, seniority, number of coFworkers for more than half of the working hours, anxiety experienced at work, and physical violence are significantly associated with depressive symptoms. In Table 3, the variables related to depressive symptoms, determined using a multiple logistic model, an adjusted odds ratio, (OR), and a 95% confidence interval, (CI), are shown.Our otorhinolaryngology physicians and nurses who suffered from physical violence, (OR = 1.82, 95% CI = 1.06 3.12), were more likely to suffer from depressive symptoms than those who had not. Moreover, participants with less than one year of experience were also more likely to suffer from depressive symptoms, while those with more experience were progressively less likely to suffer from depressive symptoms. Otorhinolaryngology physicians and nurses who worked alone for more than half of their working hours were more likely to suffer from depressive symptoms than those who worked frequently with other colleagues. Relative to the seniority of otorhinolaryngology physicians and nurses, formal staff and those with junior and intermediate titles showed protective factors for depressive symptoms.

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Our study examined the association between depressive symptoms and WPV related risk factors in regard to otorhinolaryngology physicians and nurses in northern China. Our results confirm that depressive symptoms are common among these results show a significantly higher prevalence of depressive symptoms than that found among general physicians and nurses in the United States, (11.3%), 33 US nurses (41%), 35 general physicians in the Netherlands, (29%), 34 and Iranian physicians and nurses, (28.76%). 36 Further, this number is also slightly higher than the incidence of depressive symptoms reported among emergency department nurses in Taiwan and 47.2%, respectively 37, 38 ; however, the incidence of depression differs between departments. Compared with other departments, otorhinolaryngology physicians and nurses have a higher incidence of depressive symptoms than most other departments outside of emergency, and also report higher than normal levels 8,30 ; however, it should be noted that few previous studies have focused on the incidence of depressive symptoms among these professionals in China. Unfortunately, in China, the frequency of violence (which is a major predictor of depression) within otorhinolaryngology department is relatively high due to various factors involving treatment options and professional skill levels 15 ; therefore, research into the association between depressive symptoms and WPV related risk factors is essential for preserving not only the mental health of practitioners, but also for ensuring quality of care.

Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 6-8 Objectives 3 State specific objectives, including any prespecified hypotheses 8-9

Study design 4
Present key elements of study design early in the paper 9 Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection 9-13 Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of participants 9-10