ORIGINAL PAPER

Effect of social support

and coping strategies Journal of Research
on the relationship between in Nursing
©2008
SAGE PUBLICATIONS
health care-related Los Angeles, London,
New Delhi and Singapore
VOL 13 (6) 498–524
occupational stress and health DOI: 10.1177/
1744987107087390

Lori A Button
Research Officer

Abstract The role of social support and individual coping strategies (problem-
focused, emotion-focused) in the moderation of the relationship between health care-
related occupational stress and health was examined in a survey of 212 midwives and
nurses. Results indicate that neither of the coping strategies was influential, whereas
social support levels were either detrimental or beneficial based on the reported level
of job stress. High support in conjunction with high job stress was associated with
poorer health. Conversely, when support was low, high stress was associated with
better health. This implied that it was the level of overall social support in
conjunction with the level of job stress that was associated with psychological and
physical health levels. Subsequent to the findings of this research, a call to examine
specific factors that may influence the personal formation of support networks
(i.e., gender, causality), as well as causality, was emphasised.

Key words coping strategies; occupational stress; physical health; psychological

health; social support

Introduction
There is growing international recognition that job-related stress negatively affects the
health of workers, subsequently disturbing staff recruitment and retention (Bradley
and Cartwright, 2002; Stacciarini and Tróccoli, 2004). Particular concern has been
expressed regarding health care professionals, especially nurses (McVicar, 2003; Hsu
and Kernohan, 2006). Consequently, there is increasing evidence relating to the neg-
ative affects that job-related strains within nursing have on physical and psychological
health of nurses (McNeely, 2005; Piko, 2006).
However, not everyone reacts to stress in the same way. In response, studies have
attempted to identify personal aspects that diminish or intensify the influence of
occupational stress on health such as social support and coping strategies. Debates have
risen regarding the effectiveness of coping strategies (Tyson, et al., 2002; Patterson,

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2003) versus social support (Schmieder and Smith, 1996; Shen, et al., 2005). One
rationale is that the influence of each stress buffer may differ according to the circum-
stance. Current literature in this area has not sufficiently addressed this inconsistency,
particularly pertaining to health care-related job stress. Therefore, the aim of the present
study was to explore social support and coping strategies as independent factors that may
influence the relationship between occupational stressors and health in the health care
field.

Antecedents of health care-related occupational stress

Globally, the nature of health care jobs are changing (Bartezzaghi, 1999; Ball and
Pike, 2005) with occupational stress becoming an increasing problem in various
countries such as the UK (McVicar, 2003; Verhaeghe, et al., 2003; Costello, 2006),
United States of America (McNeely, 2005), Hungary (Piko, 2006), Taiwan (Shen,
et al., 2005) and Brazil (Hsu and Kernohan, 2006). Jobs within the health services
are characterised by high emotional demands, high workloads and low control (Lusa,
et al., 2002; Michie and Williams, 2003). Particularly in nursing, individuals are
confronted with additional emotional stress determinants such as death and dying
(Costello, 2006). Hingley (1984) contended, ‘Nursing is, by its very nature, an
occupation subject to a high degree of stress. Everyday the nurse confronts stark suf-
fering, grief, and death as few other people do’ (p. 20). Administratively, health care
work has been further disconcerted by dramatic cuts to hospital budgets resulting in
inadequate staffing and mandatory overtime (Laschinger, et al., 2001; Jenkins and
Elliott, 2004).
Ball and Pike (2005) reported that in the United Kingdom alone, 37% of nurses
who responded stated leaving their positions because of job dissatisfaction, with a
further 28% leaving because of job-related stress. When the UK National Health Ser-
vice (NHS) was assessed as a whole, 49% of those who left their jobs did so because
of stress, with 75% of respondents asserting insufficient staffing necessary to provide
a ‘good standard of care’ (p. 49). As a result, health care-related stress has been linked
to anxiety, mental fatigue and burnout (Bradley and Cartwright, 2002; Michie and
Williams, 2003; Jenkins and Elliott, 2004), cardiovascular disease and gastrointestinal
disorders (Michie and Cockcroft, 1996; Heslop, et al., 2002) and higher rates of sui-
cide and psychiatric admissions than the general population (Hillhouse and Adler,
1997). Subsequently, the profession is in a reported crisis of staff recruitment and
retention (McNeely, 2005; Hsu and Kernohan, 2006). In general, research indicates
that the nursing profession as a whole is experiencing staff shortages because of
the stress-related absences, whereas the occupation is getting increasingly stressful
because of insufficient staffing, thus, propagating a debilitating cycle.

Debates regarding coping strategies and social support as moderators

of occupational stress and health
Any particular situation may induce a stress response in one person but not in
another person, indicating that stress is individual (Lazarus, 1966). This is typified
in the findings of Hillhouse and Adler (1997) who found that even within a ward
or unit nurses showed highly individualised perceptions and responses to work
stress. Consequently, stress researchers have sought to identify personal factors that
moderate the relationship between job stress and health. Within the literature, two
such factors have overshadowed all others: social support and coping strategies.

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Hopkinson, et al. (2005) defined coping strategies as ‘cognitive and behaviour
styles or strategies that counter the negative consequences of stress’ (p. 126). Coping
strategies have been further divided into emotion-focused coping and problem-
focused coping. Problem-focused coping is notable for the elimination of a stressor
through problem solving (Skinner, 1996) and/or direct physical action (Tobin, et al.,
1984). Conversely, emotion-focused coping has been characterised by the reinterpre-
tation of the stressor such as denial (Skinner, 1996), anger (Lowe and Bennett, 2003)
and/or attempting to consciously block the perception of the stressor (Suls and
Fletcher, 1985; Patterson, 2003).
Coping strategy research has ranged from cross-sectional explorations of the
relationship between coping strategies, stress and health (Healy and McKay, 2000;
Tyson, et al., 2002) to studies exploring the influence of coping strategies on long-term
versus short-term stresses (Suls and Fletcher, 1985; Patterson, 2003; LeSergent and
Haney, 2005). Suls and Fletcher (1985) explored how the perceptions of long-term and
short-term stressors effect the adoption of coping strategies. Although participants did
not report a preference for either coping strategy, for short-term stressors, emotion-
focused strategies were more beneficial. Conversely, problem-focused strategies were
superior in deliberating long-term stressors. The authors theorised that for a chronic
stressor, the optimum coping strategy was to avoid the stressor (emotion-focused) until
it could be properly confronted (problem-focused). Alternatively, some researchers pro-
pose that when a situation is perceived as unalterable using problem-focused coping,
then emotion-focused coping strategies are adopted (Patterson, 2003; LeSergent and
Haney, 2005). Moreover, contrary to the previous findings of Suls and Fletcher (1985),
problem-focused coping has been found to result in increased stress (Patterson, 2003).
Patterson contended that trying to solve a problem (problem-focused) with no
perceivable solution created additional stress.
Healy and McKay (2000) and Tyson, et al. (2002) examined the cross-sectional
effect of coping strategies in nurses. Tyson, et al. (2002) discovered that problem-
focused coping among nurses with low job satisfaction acted as a buffer to occupa-
tional stress. However, Healy and McKay (2000) reported no significant link between
participants’ use of problem-focused coping and health, whereas emotion-focused
coping resulted in higher levels of psychological disturbance.
Despite the empirical attention, there remain inconsistencies regarding the buffer-
ing effect of independent coping strategies on alleviating the effects of occupational
stress. Furthermore, there are indices that particular coping strategies in certain cir-
cumstances are detrimental (Healy and McKay, 2000; Patterson, 2003).
In addition to coping strategies, it is maintained that the availability of others to
care and help is key in mediating the relation between stress and health. In response,
the buffering theory of social support has attracted considerable attention and debate.
Cobb (1976) and Sarason, et al. (1987) contended that one’s social support network
is central to the perception that he/she is cared for, valued and belong to a network
of communication and mutual obligation. Specifically, Schwarzer and Gutiérrez-Doña
(2005) proposed that social relationships include the perceived availability of help
and/or support actually received. Accordingly, perceived support is described as the
prospective anticipation of help in time of need, whereas received support is retro-
spective in that it is the actual help that was provided within a given time.
Intrinsic to the buffering theory of social support is the premise that persons with
strong support networks are unlikely to be as negatively affected by high stress and
the consequential deterioration of psychological and physical health compared with
those with inadequate support (Lazarus, 1999; Väänänen, et al., 2005). This is sup-

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ported by Shen, et al. (2005) who reported that among psychiatric nurses in Taiwan,
higher workplace support was associated with better mental health compared with
nurses with lower workplace support. Similarly, Jenkins and Elliott (2004) reported
a significant buffering effect for a cross-sectional sample of nurses reporting higher
levels of support. The authors found that higher levels of social support from co-
workers were related to lower levels of emotional exhaustion.
Conversely, low support has been linked with poor psychological health. Specifi-
cally, Stansfeld, et al. (1998) reported that low work social support increased
participants’ susceptibility to and degree of psychiatric-related sickness. Moreover,
longitudinal studies have showed that increased social support over a 12-month
period benefited psychological health (Bradley and Cartwright, 2002). However,
Bradley and Cartwright (2002) concluded that although social support acted as a
stress buffer, it only benefited those with high levels of stress.
Divergent to the buffering theory of social support, there is an evidence that high
support can be detrimental (Vedhara, et al., 2000; Dirkzwager, et al., 2003). Although
a considerably less frequent phenomenon, reverse buffering (Väänänen, et al., 2005)
is encountered when high levels of social support exacerbate rather than alleviate the
effects of stress. For instance, Vedhara, et al. (2000) investigated the relationship
between social support and emergency medical treatments. Although the level of sup-
port did not differ between groups, participants who were accompanied to the clinic
reported significant more anxiety than those who were unaccompanied. Consistent
with reverse buffering, the close proximity of a supportive other increased the
patient’s anxiety. Similarly, Dirkzwager, et al. (2003) reported that after a stressful
event, high levels of positive/helpful social interactions over time were correlated
with improved psychological health, whereas high levels of negative social interac-
tions were associated with diminished psychological health.
Consequently, empirical findings regarding social support have been inconsistent
with some effects limited to specific groups (e.g., Schwarzer and Gutiérrez-Doña,
2005) and/or stress levels (Stansfeld, et al., 1998; Bradley and Cartwright, 2002).
Thus, alike coping strategies, evidence for the buffering effect of social support is
conflicting.
Despite advances made in the field, evidence identifying the relationship between
work stressors, stress buffers and a range of health outcomes remains scarce and
inconsistent. Furthermore, few if any, studies have assessed the individual impacts
of coping strategies and social support within the same sample. Is one proposed stress
buffer more influential than the others? Subsequently, the aim of the study was to
investigate the association of the independent factors (problem-focused coping,
emotion-focused coping and social support) on the relationship between health
care-related occupational stressors and health in Wales, UK.

The current study

Building on preceding research, the main objective of the study was to investigate the
individual effects of social support, emotion-focused coping and problem-focused
coping on the relationship between occupational stress and health in health care
workers.
A quantitative self-report measure comprising all the desired stressor variables sur-
veyed in previous research could not be found; therefore, separate standardised scales
were used. A range of psychological and physical health measures were used to cover
previous inconsistencies regarding the interactive effect of stress buffers and stress on

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health outcomes. The design of the study was cross-sectional and consisted of a
collection of standardised scales and demographic items to assess levels of social
support, use of coping strategies, occupational stressors and health. An opportunity
sample of midwives and nurses was used. The data was collected in 2002.

Hypothesis 1
The interaction between high social support and occupational stressor levels will be
associated with beneficial health outcomes.

Hypothesis 2
The interaction between low social support and occupational stressor levels will be
associated with poorer health outcomes.

Hypothesis 3
The interaction between emotion-focused coping and occupational stressor levels will
be associated with beneficial health outcomes.

Hypothesis 4
The interaction between problem-focused coping and occupational stressor levels will
be associated with poorer health outcomes.

Methods
Participants
Five hospitals in Wales, UK, agreed to participate in the study. Of the 212 respon-
dents, 91 per cent were female and 7 per cent were male (3 per cent gender
unknown). The age of the participants ranged from 21–62 years (mean
age = 36.89, SD = 8.40). Respondents consisted of, in descending order of job grade
(Ball and Pike, 2005), 11 midwives (mean age = 42.73, SD = 9.19), 13 ward sisters
(mean age = 39.69, SD = 7.69), 20 senior nurses (mean age = 36.80, SD = 7.06),
160 staff nurses (mean age = 36.33, SD = 8.26) and 8 auxiliary nurses (mean
age = 35.63, SD = 12.02). The inclusion criteria were full-time hospital staff respon-
sible for various aspects of patient care.

Measures
Demographics
Information regarding the respondents’ age, gender, marital status and job grade was
collected. Participants also reported the amount of hours contracted to work per week
and the amount of hours actually worked per week.

Job insecurity
Job insecurity was measured using a four-item scale (Karasek, 1985) assessing the
perceived level of threat of job termination (α = 0.68). Questions encompassed the
steadiness and security of the job, as well as the frequency with which respondents
have been faced with layoffs.

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Workload
Workload was measured using a four-item questionnaire based on the Standard Shift-
work Index (SSISSI: Barton, et al., 1995) that assessed perceived physical workload,
mental workload, time pressure and emotional stress.

Control of job pacing

Control of job pacing was assessed by one-item that asked participants to rate the
extent to which they believe that the pacing of their job was under their control.

Social support
Social support (Sarason, et al., 1987) was assessed through a 12-item questionnaire
measuring the quantity (α = 0.95) and quality (α = 0.96) of perceived social support
provided in various situations. The quantity of available support in the various situa-
tions was calculated by summing the number of people reported. Quality of support
was calculated by summing the 6-items relating to support satisfaction.

Work support
Work support was measured using the 11-item Job Content Questionnaire (JCQ)
Social Support Scale (Karasek, 1985) that assessed the level of positive social interac-
tions with supervisors and co-workers (α = 0.84). Five questions were related to
supervisor support, and six questions were related to co-worker support. Co-worker
and supervisor scores were combined to create one score.

Coping strategies
The eight-item Coping Strategy Questionnaire (Barton, et al., 1995) was a revised ver-
sion of the Coping Strategies Inventory (CSQCSQ: Tobin, et al., 1984), measuring the
degree to which the respondent used engagement (problem-focused) (α = 0.72) and
disengagement (emotion-focused) (α = 0.76) coping strategies when faced with a
problem.

Chronic mental fatigue

Chronic mental fatigue (Bentall, et al., 1993) was assessed through nine items
(α = 0.82) measuring symptoms such as confusion, energy levels and the ability
to make decisions. Individual scores were calculated by the extent to which the
respondent had been affected by various symptoms during the last month.

Cognitive–somatic anxiety
The 14-item Cognitive–Somatic Anxiety Questionnaire (Schwartz, et al., 1978) sepa-
rately assessed somatic (α = 0.78) and cognitive (α = 0.90) components of trait anx-
iety. Respondents were asked to rate the degree to which they experienced each of
the described symptoms when they had felt anxiety. Seven items were related to cog-
nitive anxiety and seven items were related to somatic anxiety.

General mental health

The General Health Questionnaire (GHQ12: Goldberg, 1972) consisted of 12-items
(α = 0.84) encompassing the respondent’s levels of self-confidence, sleep loss,
depression and problem solving. There were four response options, with a higher
frequency of poor health represented by higher scores.

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Physical health
Physical health was assessed using the 16-item questionnaire (Barton, et al., 1995)
composed of two sub-scales measuring cardiovascular (α = 0.83) and gastrointestinal
(α = 0.83) disorders. Respondents were asked to rate how frequently they experi-
enced physical symptoms such as stomach upsets and shortness of breath. Two
additional scales relating to minor infections and joint pain were included. Minor
infection was assessed by one item that asked participants to rate how often they suf-
fered from minor infectious diseases, for example, colds, flu. The joint pain scale
consisted of four items (α = 0.72) measuring how often the respondent suffers
from shoulder, back, arm and leg joint pain. Cardiovascular health, gastrointestinal
health, joint pain and minor infections were scored separately.

Procedure
Five hospitals in Mid and South Wales, UK, participated in the study. The Ethics
Committees of the hospitals approved the research protocol. Permission to distribute
the questionnaires was granted by the Human Resource Department at each site.
Questionnaire packets were sent to the hospitals and then distributed to the wards.
Each packet contained an information letter outlining the study, the questionnaire,
consent form and a pre-paid envelope. Nurses and midwives were asked to complete
the questionnaires and return them in the pre-paid envelopes. Of the 2310 question-
naires distributed, 212 were returned, a response rate of 10.9 per cent. Participation
was completely voluntary and anonymous.

Analyses
The data were analysed using SPSS version 13.0. To reach a more appropriate
variable-to-participant number ratio, principle component factor analyses with Vari-
max rotation were used to examine the factor structure of the individual items relat-
ing to 1) social support, 2) occupational stressors and 3) health measures.
To test for possible differences in stressor factors and health factors that emerged
from the principle component analyses between job grades, one-way between-group
ANOVAs were performed. Then, because of the imbalance in the representation from
the job grades, an independent–sample t-test was performed to compare the levels of
stressor factors and health factors between the larger represented staff nurse group
(n = 160) and the combined remaining job grades.
The next analyses used hierarchical regressions to test for interactions among the
proposed moderators (social support, problem-focused coping and emotion-focused
coping) and stressor variables (time stress, job stress) in the prediction of the health
measures. Hierarchical analysis was conducted for each of the dependent health fac-
tors: psychological and physical health. The variables age, gender and each job grade
were placed in the first step of the regression to control for possible confounding
effects. The job stress and time stress variables were placed in the second step of the
equation to test for main effects. Next, job stress and each of the proposed modera-
tors and time stress and each of the proposed moderators were placed in the third
step of the regression to test for two-way interactions. In accordance with the proce-
dures outlined by Aiken and West (1991), interactions were explored by plotting the
regression equations at one standard deviation below the mean of the proposed mod-
erator (stress buffer) and one standard deviation above the mean. The t-tests were
then calculated to determine whether the slopes of the simple regression lines were

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significantly different from zero. All final analyses adopted a significance criterion of
P < 0.05. Unless stated otherwise, higher scores were associated with a higher level
of the problem measured.

Results
Principle component analysis
Initial inspection of the data indicated a normal distribution. The data were subjected
to principle component analysis and Varimax rotations (Tables 1–3). When the
stressor variables were analysed (Table 1), the first factor was weighted with the vari-
ables: hours contracted to work per week and actual hours worked per week. It was
labelled time stress. The variables that weighted heavily on the second factor were
mental workload, emotional workload, physical workload, time pressure, job insecu-
rity and control of job pacing. The relationship between the coefficients in factor two
suggested that individuals who had a higher overall workload reported lower control
over the pacing of the job and higher job insecurity. Factor two was labelled job
stress.
When health measures were analysed (Table 2), the first factor was heavily
weighted with chronic mental fatigue, cognitive anxiety, somatic anxiety and GHQ.
Component one was retained as the variable: psychological health. The variables that
weighted most heavily on the second factor were gastrointestinal health, cardiovascu-
lar health, joint pain and minor infections. This second component was labelled
physical health. It must be noted gastrointestinal health and cardiovascular health
had coefficients of above 0.3 in both components (Table 2). This was not wholly
unexpected as psychological symptoms and cardiovascular and gastrointestinal experi-
ences together are associated with the autonomic central nervous system with emo-
tions such as anxiety resulting in changes in cardiovascular symptoms (Benton,
1987).
As shown in Table 3, when the moderator variables were factor analysed, the first
factor was heavily weighted with JCQ social support, social support quality and social
support quantity. Component one was retained as the variable: social support.
Emotion-focused coping emerged as the exclusive variable in the second factor,
whereas problem-focused coping emerged as a separate variable in factor three.

Table 1 Job-related stress variables rotated component matrix

Variables Factor 1 Factor 2
Time stress Job stress
Hours contracted per week 0.93a 0.03
Actual hours worked per week 0.92a 0.16
Mental workload −0.04 0.80a
Emotional workload −0.06 0.80a
Time pressure −0.12 0.75a
Physical workload 0.03 0.46a
Job insecurity 0.04 0.31a
Control of job pacing 0.03 0.30a
% Variance 23.69 22.84
Total variance (%) 46.53
a
Indicates heavily weighted factors.

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Table 2 Health variables rotated component matrix
Variables Factor 1 Factor 2
Psychological health Physical health
Cognitive anxiety 0.82a −0.29
Somatic anxiety 0.78a −0.27
General health questionnaire 0.69a −0.25
Chronic mental fatigue 0.64a −0.22
Minor infection 0.27 0.80a
Joint pain 0.27 0.73a
Gastrointestinal health 0.40 0.64a
Cardiovascular health 0.51 0.58a
% Variance 32.88 25.34
Total variance (%) 58.21
a
Indicates heavily weighted factors.

Therefore, components two and three were retained as the variables emotion-focused
coping and problem-focused coping, respectively.

Differences between participant groups

Possible differences in stressors and health levels between job grades were examined
using ANOVAs. As seen in Table 4, there was a significant difference in time stress
levels, with ward sisters reporting higher time stress than auxiliary nurses, staff
nurses and midwives [F(4,207) = 6.72, P < 0.005]. In addition to ward sisters,
auxiliary nurses also reported lower time stress than senior nurses. Between job
grades, there were no significant differences in levels of psychological health
[F(4,182) = 1.35, P = 0.252, ns], physical health [F(4,182) = 0.71, P = 0.586, ns]
or job stress [F(4,207) = 0.78, P = 0.538, ns].
An independent–sample t-test was then performed to compare work stress and
health levels between staff nurses and the remaining job grades. As indicated in
Table 5, there were no significant differences in levels of psychological health
[t(185) = 0.622, P = 0.535, ns], physical health [t(185) = 0.494, P = 0.622, ns],
time stress [t(210) = 1.858, P = 0.065, ns] or job stress [t(210) = 0.683,
P = 0.495, ns].

Table 3 Stress buffer variables rotated component matrix

Variables Factor 1 Factor 2 Factor 3
Social support Emotion-focused Problem-focused
coping coping
JCQ social support 0.744a
Social support: quality 0.712a 0.348
Social support quantity 0.706a
Emotion-focused coping 0.936a
Problem-focused coping 0.964a
% Variance 31.44 20.83 20.10
Total variance (%) 72.36
JCQ, Job Content Questionnaire.
a
Indicates heavily weighted factors.

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Table 4 Difference (ANOVA) in time stress levels depending on job grade
Auxiliary nurses Staff nurses Ward sisters Senior nurses Midwives
Mean −0.56 a,b
0.01 c
0.99 0.50 −0.33d
SD 0.86 0.91 0.26 0.54 1.05
N 8 160 13 20 11
a
Ward sister versus auxiliary nurse P < 0.001.
b
Auxiliary nurse versus senior nurse P < 0.05.
c
Ward sister versus staff nurse P < 0.001.
d
Ward sister versus midwife P < 0.005.
e
Overall time stress scores ranged from −3.71 (low) to 1.60 (high).

Interactions among occupational stressors, moderators and health

Social support
After a series of hierarchical regression analyses, two significant associations emerged:
social support × job stress regarding psychological health [F(1,104) = 8.19,
P < 0.005] and social support × job stress regarding physical health
[F(1,104) = 9.21, P < 0.01]. Post-hoc probing of the interactions indicated the pres-
ence of two significant relationships between job stress levels and psychological
health, among high [t(89) = 3.08, P < 0.01] and low [t(89) = 2.62, P < 0.01] social
support levels (Figure 1). When social support was high, a high level of job stress
was associated with poorer psychological health compared with a low level of job
stress. When social support was low, a higher level of job stress was associated with
better psychological health.
A second significant interaction emerged between job stress levels and high social
support regarding physical health [t(89) = 4.08, P < 0.01]. When support was high,
a high level of job stress was associated with poorer physical health (Figure 2). There
was no significant relationship found between low social support and job stress levels
regarding physical health.
On the basis of the results, the hypotheses were partially supported. In relation to
the hypothesis that the interaction between high social support and occupational
stressor levels will be associated with beneficial health outcomes, a high level of sup-
port and low job stress was associated with better psychological and physical health.
However, contrary to the hypothesis, when support and job stress levels were both
high, health levels were poor. In relation to the hypothesis that the interaction

Table 5 Levels of stress and health factors between staff nurse and other job grade
Psychological health Physical health Time stress Job stress
Staff nurse
Mean 0.14 −0.04 0.28 0.09
SD 0.97 0.97 0.86 0.95
Other job grades
Mean 0.03 0.04 0.01 −0.01
SD 1.02 1.01 0.91 1.01
N 187 187 212 212
Overall psychological health scores ranged from −1.82 (good health) to 3.44 (poor health).
a

Overall physical health scores ranged from −2.32 (good health) to 3.77 (poor health).
Overall time stress scores ranged from −3.71 (low) to 1.60 (high).
Overall job stress scores ranged from −3.31 (low) to 2.00 (high).

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Figure 1 Interaction between social support and job stress in the prediction of
psychological health. The solid line denotes that slopes differ significantly from zero.
*Psychological health scores ranged from −1.82 (good health) to 3.44 (poor health).

between low social support and occupational stressor levels will be associated with
poorer health outcomes, low support and low job stress was associated with poor
psychological health. Divergent to the hypothesis, low support and high job stress
was associated with better psychological health but had no significant relationship
with physical health.

Coping strategies
The role of coping strategies on the relationship between occupational stressors and
physical health was then explored. Subsequent to regression analyses, no significant
interactions emerged for time stress × emotion-focused coping [F(12,84) = 0.461,
P = 0.932, ns] or time stress × problem-focused coping [F(12,84) = 0.351,
P = 0.976, ns] regarding psychological health. Similarly, no significant interactions
emerged for job stress × emotion-focused coping [F(12,84) = 0.882, P = 0.568, ns]
or job stress × problem-focused coping [F(12,84) = 1.004, P = 0.453, ns] regarding
physical health. Consequently, neither of the hypotheses regarding the interactive
effect of coping strategies and occupational stressor levels on health outcomes was
supported.

Figure 2 Interaction between social support and job stress in the prediction of physical
health. The solid line denotes that slopes differ significantly from zero. *Physical health scores
ranged from −2.32 (good health) to 3.77 (poor health).

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Discussion
Investigators have suggested that problem-focused coping is physically and psycho-
logically the most advantageous coping strategy. Specifically, Tyson, et al. (2002)
reported that problem-focused coping among nurses with low job satisfaction acted
as a buffer to occupational stress. However, Patterson (2003) concluded that
problem-focused coping resulted in increased stress. Contrary to preceding findings,
neither coping strategies emerged as influential, positively or negatively, in relation
to the health outcomes. Although there were no significant effects in the current
study, it does not mean that coping strategies do not act as stress buffers. For exam-
ple, as the current findings reflected cross-sectional data, long-term influences could
not be assessed. It could be argued that the coping strategies are most influential in
relation to the duration of the stressor (e.g., Suls and Fletcher, 1985; LeSergent and
Haney, 2005) and/or perceived chance of resolution over time (Patterson, 2003).
Accordingly, neither of the hypotheses regarding the influence of independent coping
strategies was supported.
On the basis of the results, social support had a significant association with the
relationship between work stressors and health levels. As shown in Figures 1 and 2,
a high level of support in conjunction with high job stress was associated with
poorer psychological and physical health. Conversely, for respondents with high sup-
port, having lower job stress was associated with better health. Alternatively, low
support and low stress was related to poorer psychological health, whereas low sup-
port with high stress was related to better psychological health. As shown in Figure 3,
the level of support emerged as detrimental or beneficial to health based on the level
of job stress.
The findings provide a degree of support for the conjecture that high social sup-
port is beneficial (Jenkins and Elliott, 2004; Shen, et al., 2005). Conversely, when the
stress level was high, higher support was detrimental to both psychological and phys-
ical health (Figures 1 and 2) indicating a reverse buffering effect. This is consistent
with Vedhara, et al. (2000) and Dirkzwager, et al. (2003) who reported that in some
cases social support contributed to more distress than relief. They contended that in
certain situations, supportive others may provide inadequate and/or poor support,
thereby, adding more stress to an already stressful situation. In line with previous
research (e.g., Vedhara, et al., 2000; Dirkzwager, et al., 2003) and based on the cur-
rent findings, it can be proposed that for individuals with high work stress, having

Figure 3 A theoretical model of the interaction between social support, job stress and
health.

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supportive individuals may create additional strain in an already stressful situation.
However, when the work environment is not demanding or stressful, individuals
may be more able to benefit from social support.
The effect of social support had a greater complex dependency upon the level of
work stress than previously theorised. Contrary to the previous research advocating
that poor social support networks are detrimental to health (e.g., Stansfeld, et al.,
1998; Jenkins and Elliott, 2004), the current findings indicate that psychological
health of respondents improved when job stress was high and support was low
(Figure 1). This outcome, in conjunction with the finding that low stress and low
support was associated with poor psychological health (Figure 1), predicts that for
individuals with a poor support network, high work stress may act as a psychological
diversion from being alone or with non-supportive individuals.
When possible differences between groups were explored, participants were found
to differ only in the amount of hours contracted/actually worked per week, with
ward sisters reporting the highest time stress levels (Table 4). When the over-
represented staff nurse sample was compared with the rest of the staff grades, there
were no significant differences in health or stress levels experienced (Table 5). These
findings simply indicate that although one group worked more hours, they did not
have more stress or poorer health than any other group.
For the most part, the results that there were no significant relationships between
social support/coping strategies, time stress and health suggest that an influential
work stressor may not be the amount of hours at work but rather what is experienced
while working (i.e., emotional workload, physical workload, control of job pacing).

Limitations and future research

At 89.1%, the non-response rate was high, with possible implications on the results.
The limited response rate and the imbalance in the participant numbers from job
positions have the potential for the findings to over-represent a certain staff grade
(i.e., 160 staff nurses, 13 ward sisters, 8 auxiliary nurses). Moreover, because of
the limited sample size, analyses assessing gender differences could not be performed.
Noticeably, a majority of nursing and health care studies have tended to use a
predominantly female nursing population (e.g., Bradley and Cartwright, 2002;
Verhaeghe, et al., 2003). Future research must be expanded to incorporate various
personal aspects such as age and gender to generalise results to the ever-expanding
non-homogenous work force. Furthermore, because of the cross-sectional nature of
the data, no definitive statements can be made about the causal relationship among
the variables. For instance, is one stress buffer more effective than another in coping
with long-term versus short-term work strains?

Practical implications and conclusions

The current research explored the effect of social support/coping strategies and
health care-related work stress on the health. The results of this research raised inter-
esting avenues for subsequent stress buffer research. Although cross-sectional in
nature, these findings emphasise possible unexposed and/or under-represented
aspects in the current conceptualisations about social support. On the basis of the
additional information, it could be argued that the level of overall support in conjunction
with the level of job stress is associated with health levels.

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In relation to the findings and limitations of this study, a few additional questions
have emerged. First, as the data were cross-sectional, the study was unable to deter-
mine causality. Such as the longitudinal influence of job stress and social support on
health. Do individuals with a deficient support system choose to work more or are
individuals who work more are unable to form supportive relationships? Moreover,
does the influence of social support on work-related stress and health differ between
males and females? Future research would benefit from larger and more diverse sam-
ples to accommodate these additional factors. Ultimately, further identification and
strengthening of influential support structures have the potential to help organisations
to limit stress-related absenteeism and improve staff retention.
The current study determined that social support and occupational stress have an
intricate relationship in regard to health. The findings of this study not only add to
the current base of knowledge but further advance the field by exposing the deeper
and more complex relationship that exists between social support and occupational
stress levels and their influence on health.

Key points
 On the basis of the study, the use of either coping strategy did not
influence the relationship between occupational stress and health.
 For individuals with a high level of social support, high work-related
stress was associated with poorer psychological and physical health.
Conversely, for respondents with high support, a low level of work-
related stress was associated with better health.
 For individuals with a low level of social support, low work-related
stress predicted poorer psychological health, and low support together
with high work-related stress predicted better psychological health.
 Findings draw attention to the importance of further research examining
the causal relationship between use of stress buffers and reported stress
levels.

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Lori Button (PhD, BSc Ass CSci) currently works as a research officer in the School of
Health Sciences, Swansea University, UK. She is a research psychologist, with partic-
ular interest in exploring the influence of stress buffers (coping strategies, social sup-
port) on the relationship between occupational stress and health. In addition, she has
a keen interest in researching the influence of various social support sources (friends,
family, peers) on the transference of HIV/AIDS information, quality of life and treat-
ment adherence for individuals with HIV/AIDS. Her current research projects involve
investigating the relationship between health and work and the provision and effec-
tiveness of work retention and rehabilitation interventions.
Email: L.A.Button@swansea.ac.uk

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