HEALTH POLICY AND SYSTEMS

Job-Related Stress and Sickness Absence Among Belgian Nurses:

A Prospective Study
Jeroen Trybou, PhD1 , Sofie Germonpre, MSc2 , Heidi Janssens, MSc3 , Annalisa Casini, PhD4 ,
Lutgart Braeckman, PhD5 , Dirk De Bacquer, PhD6 , & Els Clays, PhD7
1 Post-doctoral research fellow, Department of Public Health, Ghent University, Belgium
2 Lecturer, Department of Healthcare, HU Brussel, Brussels, Belgium
3 Doctoral researcher, Department of Public Health, Ghent University, Ghent, Belgium
4 Post-doctoral researcher, Department of Epidemiology and Health PromotionSchool of Public Health, Free University of Brussels, Brussels, Belgium
5 Professor, Department of Public Health, Ghent University, Ghent, Belgium
6 Professor, Department of Public Health, Ghent University, Ghent, Belgium
7 Assistant professor, Department of Public Health, Ghent University, Ghent, Belgium

Key words Abstract

Job-related stress, sickness absence,
demand-control support,
effort-reward-imbalance, overcommitment
Correspondence
Jeroen Trybou, De Pintelaan 185, 9000 Ghent,
Belgium. E-mail: jeroen.trybou@ugent.be
Accepted: January 17, 2014
doi: 10.1111/jnu.12075
Purpose: The purpose of this study was to investigate the influence of
job stress on sickness absence of nurses and determine the predictive power
of the Demand-Control-Support (DCS) model, the Effort-Reward Imbalance-
Overcommitment (ERI-OC) model, and a combination of both.
Design: A survey was conducted to measure job stress in a sample of 527 Bel-
gian nurses, followed by prospective data collection of sickness absence (long-
term, short-term, and multiple episodes).
Findings: Perceptions of job strain and ERI increased the odds for long-term
(adjusted odds ratio [OR] = 2.26; 99% confidence interval [CI; 1.27–4.04])
and multiple episodes of sickness absence (adjusted OR = 1.64; 95% CI [1.01–
2.65]). Iso-strain and ERI-OC increased the odds for long-term (OR = 1.75;
95% CI [0.98–3.11]), multiple episode (adjusted OR = 1.93; 95% CI [1.14–
3.26]), and short-term (adjusted OR = 1.69; 95% CI [1.03–2.76]) sickness
absence.
Conclusions: The combined model of DCS and ERI-OC predicts the odds for
long-term and short-term sickness absence and multiple episodes.
Clinical Relevance: This study has implications for human resources man-
agement in nursing organizations. Nursing administrators are advised to mon-
itor and balance nurses’ job demands and efforts. They should recognize the
importance of social support, job control, job rewards, and overcommitment
in order to reduce the job stress of nurses.

Nursing is characterized by high levels of job-related
stress (McVicar, 2003). In recent decades, nursing job
demands have increased remarkably and continue to in-
crease due to a growing aging population, the rapid evo-
lution of medical technologies, and higher patient ex-
pectations (Simoens, Villeneuve, & Hurst, 2005). In this
challenging environment, healthcare organizations strug-
gle to find and retain an adequate number of nurses
(World Health Organization, 2011). This issue is a global
research and policy priority (Van den Heede & Aiken,
2013). Specifically, high levels of sickness absence have
contributed to the nursing shortage (Buchan & Aiken,
2008). Several studies have demonstrated that the way
work and jobs are organized has an influence on em-
ployee health (e.g., Weyers, Peter, Boggild, Jeppesen,
& Siegrist, 2006) and sickness absence (e.g., Schreuder,
Roelen, Koopmans, Moen, & Groothoff, 2010). Different
job characteristics such as the level of job demands, the
degree of control (e.g., Verhaeghe, Mak, Van Maele, Kor-
nitzer, & De Backer, 2003), and the (im)balance between
effort and reward (e.g., Lavoie-Tremblay, O’Brien-Pallas,
Gelinas, Desforges, & Marchionni, 2008) have received

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Trybou et al.
attention in previous nursing studies. Since healthcare
organizations struggle with a shortage of nursing staff,
these insights are of major importance to reduce absen-
teeism. Moreover, the absence of nurses causes greater
pressure of work for the remaining nurses who are
present at work. In turn, this could result in a vicious
circle of absenteeism and a chronic shortage of nursing
staff. Sickness absence is not only associated with addi-
tional costs but could also have consequences for patients.
Previous research has revealed that sickness absence can
result in patient dissatisfaction and lower quality of care
(Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).
This prospective study investigated the relationship
between work characteristics of nurses and sickness
absence. To define work characteristics, we built on
two well-established but competing theoretical mod-
els: the Job Demand-Control-Support (DCS) model
(Karasek, 1979) and the Effort-Reward Imbalance-
Overcommitment (ERI-OC) model (Siegrist, Siegrist, &
Weber, 1986). Unlike most previous research building
on these models, this study combined both models.
Both models have received attention in previous em-
pirical research. Overall, it can be concluded that scien-
tific evidence exists in support of the DCS model ( de
Lange, Taris, Kompenier, Houtman, & Bongers, 2003)
and the ERI-OC model (van Vegchel, de Jonge, Bosma, &
Schaufeli, 2005) on a large range of health outcomes and
well-being measures. However, a central issue in contem-
porary research studies is whether these two models can
be considered complementary, and thus advantageous to
combine, or overlapping, and therefore mutually exclu-
sive. This has led to a call for additional research combin-
ing both models. This study is one of the first to exam-
ine the combined impact of these work characteristics on
sickness absence in nursing using in a single model using
a prospective design.
Conceptual Framework
Two theoretical models explaining job stress and the
related sickness absence have received major attention
in past research: the DCS model, developed by Karasek
(1979), and the ERI-OC model, conceived by Siegrist et
al. (1986). Both models build on the psychosocial work
environment to analyze the relationship between work-
ing conditions and health outcomes.
The Job Demand-Control-Support Model
The basic Job Demand-Control model considers psy-
chological job demands and job control as essential job
characteristics that affect employee well-being. Job de-
mands refer to stressors in the work environment, such
Journal of Nursing Scholarship, 2014; 46:4, 292–301.
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Job-Related Stress Among Nurses
as work load, time pressure, and role conflict. Job control
represents the extent to which the individual employee
has control over his or her tasks and the way work is per-
formed (being able to make task-related decisions and to
apply specific skills). Accordingly, different combinations
of job demand and job control result in different types of
work environments. In particular, jobs characterized by
high demands and low control are stressful. This situa-
tion is referred to as high job strain (Karasek, 1979). The
basic model was extended with “social support at work”
and, accordingly, this theoretical framework is referred
to as the extended DCS model (Johnson & Hall, 1988).
Social support at work refers to the assistance provided
by supervisor and colleagues, which can lower the per-
ceived stress induced by high job demands and low job
control. Accordingly, jobs with high job strain (jobs with
high demands and low control) combined with low social
support bear the greatest risks for maladjustment and ill-
nesses. This situation is referred to as iso-strain (van Der
Doef & Maes, 1999). Figure 1a provides an overview of
the theoretical model.
The Effort-Reward Imbalance-Overcommitment
Model
The basic ERI model emphasizes the perceived imbal-
ance in effort and reward by nurses. Effort represents
job demands or obligations imposed by the employer.
Reward consists of wage, esteem, job security, and career
opportunities. The model is based on the assumption
that high effort in combination with low reward leads
to continuous tension and a stressful imbalance (van
Vegchel et al., 2005). In addition to these characteristics,
overcommitment was incorporated as a third dimen-
sion in the extended ERI model. This is a personality
characteristic based on the cognitive, emotional, and mo-
tivational elements of behavior and reflects an exorbitant
ambition in combination with the need to be approved
and esteemed (Siegrist, 1998). Accordingly, Siegrist
(2002) argued that an imbalance between high effort and
low reward increases the risk for poor health and sickness
absence (the extrinsic ERI hypothesis) and assumes that
an extrinsic ERI in combination with a high level of
overcommitment leads to the highest risk for poor health
and sickness absence (the interaction hypothesis). A high
level of overcommitment is also supposed to increase the
risk for poor health (the intrinsic overcommitment hy-
pothesis). Figure 1b provides an overview of the model.
A Conceptual Comparison Between DCS and
ERI-OC
In general, both models integrate sociological and
psychological theories to conceptualize the relationship
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Job-Related Stress Among Nurses
Job Demand Control Support -model
High Job Low Job
DC
Demands Control
- -
+ Social
DCS
Support
Job Stress
DC= Demand-Control
DCS= Demand-Control-Support
Figure 1. a: Job Demand-Control-Support model. b: Effort-Reward Imbalance model.
between psychosocial working conditions and health out-
comes or behavior. Although there are overlapping fea-
tures between them, notable important differences can
also be identified. Nonetheless, theoretical and empirical
arguments in support of both models exist, and accord-
ingly they can be considered equivalent.
Firstly, while the focus of the DCS model is exclusively
on workplace characteristics, the components of the ERI-
OC model (salaries, career opportunities, and job secu-
rity) are also linked to labor market factors and the work
role in a macro-social and macro-economic perspective
(Rydstedt, Devereux, & Sverke, 2007).
Secondly, it also can be argued that ERI-OC offers a
broader approach in comparison with DCS because it in-
cludes both a stress dimension in relation to health (per-
ceived ERI) and a motivational dimension in relation to
active behavior and learning (overcommitment). This im-
plies that the subjective meaning of the work experi-
ence is taken into account in the development process of
job stress (Calnan, Wainwright, & Almond, 2000). Since
nurses are professional employees, partly driven by pro-
fessional motives, the way they interpret and react to
an organizational context could be very different from
that of nonprofessional employees (Trybou, Gemmel,
Pauwels, Hennick, & Claeys, 2013), making overcommit-
ment theoretically a potentially important component.
Thirdly, while the DCS model is focused on the critical
need of task control, the ERI-OC model is mainly focused
on the broader concept of reciprocity and fairness in the
social exchange process (Siegrist, 1996). This is based
on the assumption that organizational members tend to
reciprocate beneficial (detrimental) treatment they ex-
perience with positive (negative) work-related behavior
(Gouldner, 1960).
These three elements mentioned above highlight the
difference between both theoretical models and show
that the focus of the ERI-OC model is broader than that
of the DCS model. On one hand, this broader focus in-
creases our holistic understanding of job stress. Therefore,
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Trybou et al.
Effort Reward Imbalance -model
High Low
Extrinsic
Effort Reward
- Overcommitment
Interac on
Job Stress
this can be considered an advantage of the ERI-OC model
when compared with the DCS model. However, on the
other hand, this induces a less delineated conceptualiza-
tion of job stress (compared with the clear focus of the
DCS model on job characteristics), which could be detri-
mental in explaining sickness absence.
Methods
Study Design and Sampling
The data used in this study were collected as part of a
larger Belgian cohort study (the BELSTRESS III study) in-
vestigating risk factors for sickness absence (Clays, Kittel,
Godin, De Bacquer, & De Backer, 2009). Data on sickness
absence were collected prospectively through the records
of the employer of the participants over 12 months. The
study was approved by the medical ethics committee
of the University Hospital of Ghent and the Faculty of
Medicine of the Université Libre de Bruxelles.
Measurement
The questionnaire was composed of existing instru-
ments with sound psychometric properties. The ques-
tionnaire included standardized measures for the char-
acteristics of the work environment (based on the DCS
and ERI-OC models), individual characteristics (gender,
age, and educational level), and health indicators (over-
weight, smoking, drinking behavior, and suffering from
chronic illnesses).
Perceptions of job stress by nurses were measured us-
ing validated instruments of the DCS (Karasek et al.,
1998) and the ERI-OC (Siegrist, 1996) models. Adequate
levels of reliability and construct validity were demon-
strated in past research, and the use of both measures of
work-related stress is therefore justified. Previous studies
clearly distinguished job demands, job control, and so-
cial support by factor analysis, and Cronbach’s α of the
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DCS instruments was satisfactory (Pelfrene et al., 2001).
Similarly, previous studies confirmed the factorial struc-
ture of effort, reward, and overcommitment. Cronbach’s
α of the ERI instruments was sufficiently high (Siegrist
et al., 2004). In the DCS model, psychological job de-
mands (Cronbach’s α = 0.76) were measured by five
items that are related to mental work load, organizational
constraints on task completion, and conflicting demands.
Job control (Cronbach’s α = 0.69) consists of the sub-
scales “skill discretion” (six items) and “decision author-
ity” (three items). Social support (Cronbach’s α = 0.85)
was also composed of two subscales, namely “social sup-
port from colleagues” (four items) and “social support
from supervisor” (four items).
Using the ERI-OC model, effort (Cronbach’s α = 0.79)
was measured by the sum score of five items, compris-
ing time pressure, interruptions, responsibility, working
overtime, and increasing demands. Reward (Cronbach’s
α = 0.75) consists of the sum score of 11 items with three
subscales: esteem (five items), wage (two items), and job
security and career opportunities (four items). Overcom-
mitment (Cronbach’s α = 0.82) was composed of the sum
score of six items.
Prospective data of sickness absence were collected
over 12 months. The registered data were obtained from
the human resources departments. Because the record-
ing of sickness absence in Belgium is strictly ruled by
law and requires medical certification, we may assume
that the sickness absence registration is highly accurate.
In our study, the outcome variables duration (short-term
and long-term) and frequency of sickness absence were
used. Short-term sickness absence corresponds to a min-
imum of one episode of 1 to 7 \days of sickness ab-
sence during a full calendar year. Long-term sickness ab-
sence corresponds to a minimum of one episode of 15 or
more \days of sickness absence. Finally, multiple episodes
of sickness absence correspond to two or more episodes
of sickness absence during a full calendar year (regardless
of the length of the absence).
Gender, age, educational level, smoking, overweight,
alcohol consumption, and suffering from chronic illnesses
are known risk factors for sickness absence and were
therefore considered as possible confounding variables
(Allebeck & Mastekaasa, 2004). In our sample, smoking,
overweight (body mass index > 25 kg/m2 ), excessive al-
cohol consumption (for men an average of four glasses
a day; for women an average of two glasses a day), and
suffering from chronic illnesses (e.g., chronic bronchitis,
diabetes) were not predicting sickness absence. In addi-
tion, these variables were not related to the psychosocial
stressors of the ERI-OC and DCS models and were there-
fore not retained as confounders. In accordance with
contemporary research studies, besides the crude odds
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ratios (ORs), the ORs while adjusting for basic confound-
ing sociodemographic characteristics were also calculated.
Gender (male or female), age (continuous variable), and
educational level (continued secondary school or univer-
sity/college) were retained as control variables to calcu-
late the adjusted OR.
The ERI score was calculated following the established
method of Siegrist et al. (2004) using the formula e/(r∗c),
with e as the effort sum score, r as the reward sum score,
and c as the correction factor for different numbers of
items in the nominator and the denominator, in this case
11/5. To define job strain, a ratio of demands and control
was calculated according to the procedure used in recent
studies: the sum score measuring demand is divided by
the sum score measuring control, with higher values in-
dicating higher control (Peter et al., 2002). Specifically,
to calculate the job strain score, the formula d/(jc∗c) was
applied, with d as the sum score for demand, jc as the job
control sum score, and c as the correction factor, which
here is 9/5. The cut-off for the binary variables ERI and
job strain were determined by the median of the frequen-
cies for the ERI score and the job strain score. In this
sample of nursing professionals, the cut-off was 1.10 for
ERI and 0.82 for job strain. Subsequently, the variables
ERI-OC and iso-strain (job strain combined with low so-
cial support) were created. In line with previous research
(e.g., Clays et al., 2009), dichotomous variables (low vs.
high) were created for social support and overcommit-
ment based on the median values.
Data Analysis
Chi-square tests were conducted to assess significant
differences in sociodemographic variables (gender, age,
and educational level). The relation between job stress
and sickness absence was examined by means of logis-
tic regression analysis. The ORs and corresponding 95%
confidence intervals (CIs) were calculated.
Firstly, the association between the different stress
models and sickness absence was studied. This was
investigated using both the ERI-OC model and the DCS
model individually and subsequently by combining both
models. Secondly, the relationship between the several
components of both stress models and absenteeism
was examined. This analysis was performed for the basic
models (ERI and demand-control [DC]) and the extended
stress models (ERI-OC and DCS). Four exposure cate-
gories were made: (a) a category not exposed to any stres-
sor according to the stress models (the reference group),
(b) a group of nursing professionals exposed to only job
or iso-strain, (c) a category exposed to only ERI/ERI-OC,
and (d) a group exposed to both stressors (combined
model). Figure 2 provides an overview. Besides studying
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Figure 2. Empirical model.
the crude associations, the relationships were evaluated
after adjustment for potential confounding variables
(gender, age, and educational level). All analyses were
conducted using SPSS 20.0 (SPSS Inc., Chicago, IL, USA).
Results
Participants
This study focuses on 527 nurses (86.0% women),
who were employed in a hospital (65.1%), a general ser-
vice center for persons with disabilities (27.5%), and a
nursing home (7.4%). The participants belonged to ran-
domly chosen healthcare organizations in Belgium. The
response rate was 25.5%. Nonrespondents did not differ
from respondents with respect to gender or age. Unfor-
tunately, we were not able to test whether nonrespon-
dents differed from respondents with respect to the level
of sickness absence. The mean age of the sample was
43.5 years. Table 1 shows an overview of the sample
characteristics.
Descriptive Statistics
Table 2 summarizes the frequency of the work char-
acteristics and sickness absence in the study population.
296
Trybou et al.
High ERI combined with overcommitment was experi-
enced by approximately one third of the nursing profes-
sionals (n = 179). Similarly, about one third of the par-
ticipants (n = 176) perceived iso-strain (DC score higher
than 0.82 combined with low social support). The com-
bination of a DC score of more than 0.82 and ERI higher
than 1.10 was perceived by 35.4% (n = 174) and 19.8%
(n = 96) of the nurses also experienced overcommitment
and low social support.
Regarding sickness absence, only 42.5% (n = 220)
of the nurses were absent a single day due to sick-
ness; 43.6% (n = 226) were absent for a short term (1–
7 \days); and 18.9% (n = 98) were absent for a long pe-
riod (>15 \days); 28.8% (n = 149) were absent multiple
times (at least two episodes). No significant differences
in gender, age, and educational level were apparent in
short-term, long-term, and multiple episodes of sickness
absence.
ERI and Job Strain in Relation to Sickness
Absence
The basic stress indicator of an ERI (extrinsic hypoth-
esis) was not associated with any type of sickness ab-
sence (short-term, long-term, and multiple episodes). In
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Table 1. Means, Standard Deviations, Cronbach’s α, and Correlation of Variables

Mean SD JD JC Ef Re SS OC

Job demand (JD) 31.94 6.31 0.76

Job control (JC) 67.97 9.15 −0.068 0.69
Effort (Ef) 14.98 2.69 0.645∗∗ 0.098∗∗ 0.85
Reward (Re) 29.39 4.80 −0.361∗∗ 0.339∗ −0.253∗∗ 0.75
Social support (SS) 22.61 3.74 −0.274∗∗ 0.343∗∗ −0.130∗∗ 0.709∗∗ 0.79
Overcommitment (OC) 15.57 3.50 0.520∗∗ −0.061 0.554∗∗ −0.391∗∗ −0.258∗∗ 0.82

∗
p < .05; ∗∗ p < .01. Italics = Cronbach’s α.

Table 2. Demographic and Nursing Job Characteristics ERI With Overcommitment and Iso-strain in
n %
Relation to Sickness Absence

Male 74 14
Similar to the null result of the isolated effects of an
Female 453 86 ERI, ERI-OC (interaction hypothesis) also demonstrated
Age (yr) SD: 6.9 Mean: 43.5 no significant association with any type of sickness
Educational level absence (short-term, long-term, and multiple episodes
Continued secondary school 126 24 of sickness absence). The same result was found for
University/college 400 76 iso-strain (high demands combined with low control
Organization
and low social support). However, when ERI-OC and
Hospital 343 65.1
Disability center 145 27.5
iso-strain were combined, a borderline significant OR
Nursing home 39 7.4 was revealed for long-term sickness absence (OR = 1.75;
Sickness absence 95% CI = 0.98–3.11). Nurses who experienced ERI-OC
Short-term 226 43.6 and iso-strain had a 1.93 times higher odds for multiple
Long-term 98 18.9 episodes of sickness absence (95% CI = 1.14–3.26) and
Multiple episodes 149 28.8 a 1.69 times higher odds for short-term sickness absence
Effort-reward imbalancea 250 49.9
(95% CI = 1.03–2.76). Table 4 gives an overview of
Effort-reward imbalancea and 179 35.8
overcommitment
these results.
High job strainb 259 50.3
Iso-strainb 176 34.6
Effort-reward imbalancea and high job 174 35.4 Discussion
strainb
Effort-reward imbalancea and 96 19,.8 This paper provides an overview of psychological work
overcommitment and iso-strainb characteristics (measured by the DCS and ERI-OC mod-
a
els) that could lead to sickness absence in nursing. The
Effort-reward imbalance score > 1.10.
b analyses support the hypothesized model only partially.
Demand-control score > 0.82.
Our results confirm previous evidence demonstrating
that the way nursing work and jobs are organized has an
influence on sickness absence (Schreuder et al., 2010).
contrast, after adjusting for gender, age, and educational Our study adds to this knowledge by demonstrating the
level, nurses with high job strain (high demands com- supplementary value of combining the DCS and ERI-
bined with low control) had a 2.30 times higher odds OC models. The combined models predict long-term and
for long-term sickness absence (95% CI = 1.12–4.70). multiple episodes of sickness absence significantly. The
When both components of ERI and the DC model are OR is increased when compared with the application of
combined, nurses with high levels of job stress had a 2.26 the isolated models. This is in accordance with the studies
times higher odds for long-term sickness absence (99% of Griep, Rotenberg, and Chor (2010) and Schreuder
CI = 1.26–4.04). In addition, a significant positive asso- et al. (2010), which concluded that combining the
ciation was revealed between the combination of high ERI-OC and DCS models predicts sickness absence to a
job strain and ERI and multiple episodes of sickness ab- greater degree.
sence (OR = 1.63; 95% CI = 1.01–2.65). This implies Remarkably, the isolated ERI-OC model was not sig-
higher odds for sickness absence compared with the iso- nificantly associated with any of the sickness absence pa-
lated stress models. Table 3 gives an overview of these rameters under study (short-term, long-term, and multi-
results. ple episodes). This finding contrasts with several previous

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Table 3. Results Effort-Reward Imbalance (ERI) and Job Strain

Crude odds ratio Adjusted odds ratioa

Short-term SA No ERI ERI No ERI ERI

No job strain 1 1.36 (0.78–2.37) 1 1.31 (0.75–2.30)

Job strain 1.40 (0.80–2.43) 1.10 (0.71–1.69) 1.33 (0.76–2.35) 1.11 (0.72–1.72)
Long-term SA No ERI ERI No ERI ERI
No job strain 1 1.60 (0.75–3.41) 1 1.63 (0.76–3.48)
Job strain 2.21 (1.09–4.49)∗ 2.29 (1.29–4.07)∗∗ 2.30 (1.12–4.70)∗ 2.26 (1.27–4.04)∗∗
Multiple SA No ERI ERI No ERI ERI
No job strain 1 1.57 (0.85–2.89) 1 1.53 (0.82–2.84)
Job strain 1.35 (0.73–2.51) 1.62 (1.01–2.62)∗ 1.26 (0.67–2.36) 1.64 (1.01–2.65)∗

Note. SA = sickness absence.

a
Adjusted for age, gender, and educational level.
∗
p < .05; ∗∗ p < .01.

Table 4. Results of Effort-Reward Imbalance-Overcommitment (ERI-OC) and Iso-Strain

Crude odds ratio Adjusted odds ratioa

Short-term SA No ERI-OC ERI-OC No ERI-OC ERI-OC

No iso-strain 1 1.41 (0.68–1.91) 1 1.19 (0.71–2.01)

Iso-strain 1.34 (0.77–2.31) 1.58 (0.97–2.56) 1.39 (0.79–2.43) 1.69 (1.03–2.76)b
Long-term SA No ERI-OC ERI-OC No ERI-OC ERI-OC
No iso-strain 1 0.99 (0.50–1.96) 1 0.97 (0.49–1.94)
Iso-strain 1.48 (0.76–2.88) 1.77 (1.00–3.16) 1.55 (0.79–3.03) 1.74 (0.98–3.11)
Multiple SA No ERI-OC ERI-OC No ERI-OC ERI-OC
No iso-strain 1 1.51 (0.87–2.63) 1 1.58 (0.90–2.76)
Iso-strain 1.34 (0.74–2.45) 1.81 (1.08–3.03)b 1.34 (0.73–2.47) 1.93 (1.14–3.26)b

Note. SA = sickness absence.

a
Adjusted for age, gender, and educational level.
b
p < .05.

studies that found significant associations with sickness
absence frequency (Schreuder et al., 2010) and long-term
sickness absence (Derycke, Vlerick, Van de Ven, Rots, &
Clays, 2013). However, our results are similar to the find-
ings of Griep et al. (2010), whose study did not reveal
any positive association. Our study therefore confirms the
limited predictive value of the ERI-OC model and high-
lights the importance of studying job stress and sickness
absence in greater depth by extending the ERI-OC model
with other work characteristics.
Similarly, the limited predictive value of the DC(S)
model was demonstrated in our study. Job strain (low de-
mand and low control) and iso-strain (low demand, low
control, and low support) were only associated with long-
term sickness absence during follow-up. This finding con-
trasts with several previous studies that found significant
associations of job strain and iso-strain with sickness ab-
sence frequency (Schreuder et al., 2010). However, the
limited value of applying the DCS model in an isolated
way is illustrated by our study.
We contend that job stress and sickness absence are de-
termined by a multitude of working conditions. There-
fore, we may conclude that combining or extending the
existing stress models is an important avenue for further
research.
When considering our results of the sickness absence
analyses, it is important to note that short-term sickness
absence was only explained significantly by the combined
and extended model ERI + overcommitment and iso-
strain. The isolated ERI, ERI-OC, DC (job strain), and
DCS (iso-strain) and the combination of DC (job strain)
and ERI-OC showed no significantly higher odds of short-
term sickness absence. As demonstrated in the study of
Aronsson and Gustafsson (2005), this could be explained
in part by the high sense of responsibility character-
izing nurses. It can be argued that these professionals
experience pressures to go to work, even if they are sick,
because patients depend on their care. Similarly, since
nursing is characterized by a chronic shortage and there-
fore nursing managers experience difficulties to replace

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Trybou et al.
them, sickness absence causes greater pressure of work
for nurses who are present at work. Collegial obligations
toward coworkers could also increase the pressure to go
to work. This in turn could also contribute to prolonged
sickness absence and multiple episodes and explains why
we did not find statistically significant higher odds for
short-term sickness absence.
In addition, the nonsignificant findings of short-term
sickness absence when both job strain (high demands
and low control) and ERI-OC are present contrasts with
the significant findings of long-term sickness absence and
multiple episodes of absenteeism. It can be argued that
these finding are in line with the conclusions of Bakker,
Demerouti, de Boer, and Schaufeli (2003). Indeed, while
sickness absence duration can be seen as an indicator
of health problems, sickness absence frequency could be
related to motivational and behavioral features of the
nurses. The latter is then considered to be a way to
withdraw from adverse work conditions. Therefore, long-
term sickness absence is considered as “involuntary ab-
senteeism,” resulting from the inability (i.e., due to ill-
ness) rather than the unwillingness to work (Steel, 2003).
In contrast, absence frequency is considered as an indi-
cator of “voluntary absenteeism” and can be interpreted
as a coping behavior (Schaufeli, Bakker, & Van Rhenen,
2009). From this we can assume that both coping behav-
ior as well as associated health problems can be the rea-
son for absenteeism (Schaufeli et al., 2009).
Although the results of this study are significant, it
has several limitations. First, the participation rate was
relatively low, which may have resulted in a selection
bias. However, when comparing the group of partici-
pants with the total population of nurses, it appeared
that respondents did not differ from nonrespondents in
terms of gender or age. Nevertheless, we acknowledge
that it is possible that nonrespondents had higher levels
of stress and sickness absence. Unfortunately, we were
not able to measure this aspect. Even if this was the case,
there is no reason to assume that the results presented
here would be overestimated as a result of this. Second,
due to our limited sample size (527 nurses), we were
not able to include both sociodemographic characteristics
(gender, age, and educational level) and health indicators
(overweight, smoking, drinking behavior, and suffering
from chronic illnesses). However, these health indicators
were not significant predictors of absenteeism in our
sample. The impact of omitting these variables is there-
fore limited. Finally, the studied constructs job demands
and job effort correlated highly. Indeed, when nurses
experience high job demands, they can be expected to
Journal of Nursing Scholarship, 2014; 46:4, 292–301.
C 2014 Sigma Theta Tau International
Job-Related Stress Among Nurses
perceive high job effort. In addition, overcommitment
correlated highly with job demands and job effort. One
could argue that ambitious nurses who have a high need
for being approved and esteemed are more sensitive to
perceptions of high job demands and high job effort.
However, we showed that although both models (DCS
and ERI-OC) are partly overlapping, they are advanta-
geous to combine. Bundled, they increase insight into
the relationship between work characteristics of nursing
and sickness absence.
Implications of the Study
Our study shows that a considerable number of nurses
experience high levels of job stress, which increases sick-
ness absence. Subsequently, the absence of nurses causes
greater pressure of work for the remaining nurses who
are present, possibly resulting in a vicious circle of absen-
teeism and a chronic staff shortage.
Since the way nursing work and jobs are organized
clearly has an influence on employee health and sickness
absence, this can be considered to be a management and
policy priority for head nurses, nurse leaders, and nurse
executives. They should recognize the importance of so-
cial support (e.g., a friendly work environment), job re-
ward (e.g., job appreciation by the head nurse), overcom-
mitment (e.g., preserving a healthy work-life balance),
and an adequate level of job control (e.g., adequate de-
cision latitude) in order to reduce job stress and pre-
vent sickness absence. In practice, nursing leaders and
managers are advised to monitor and balance job de-
mands and efforts experienced by nurses (e.g., by en-
abling nurses to give feedback on these issues). Since a
multitude of work characteristics can contribute to per-
ceived job stress and absenteeism of nursing profession-
als, a holistic approach concentrating on all identified
aspects is advisable.
Conclusions
The present findings increase insight into the impor-
tance of several work characteristics of nursing to sick-
ness absence. Since the nursing shortage is considered
a global research priority, this can be considered an im-
portant finding. Furthermore, our study shows that the
two dominant models of job stress (DCS and ERI-OC) are
complementary and thus advantageous to combine. The
combined model of DCS and ERI-OC predicts the odds for
long-term, short-term, and multiple episodes of sickness
absence significantly.
299
Job-Related Stress Among Nurses
Clinical Resources
r Stress at the workplace: http://www.who.int/
occupational health/topics/stressatwp/en/
r Protecting workers’ health: work organization and
stress: http://www.who.int/occupational health/
publications/stress/en/
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