Paper 203

505
The
British
Psychological
British Journal of Health Psychology (2012), 17, 505–521

C 2011 The British Psychological Society
Society
www.wileyonlinelibrary.com
Occupational stress, job characteristics, coping,

and the mental health of nurses
G. Mark and A. P. Smith∗

School of Psychology, Cardiff University, UK
Objectives. This study investigated the relationships between job characteristics

and coping in predicting levels of anxiety and depression in nurses. The study was
based on current theories of occupational stress, and predictors included job demands,
social support, decision authority and skill discretion control, effort, over-commitment,
rewards, and ways of coping. It was predicted that job demands, extrinsic effort,
over-commitment, and negative coping behaviours would be positively associated with
depression and anxiety, and social support, rewards, decision authority, skill discretion
control, and positive coping would be negatively associated with depression and anxiety.
Methods. Participants were 870 nurses, who responded to a bulk mail sent randomly
to 4,000 nurses from the south of England.
Results. The results showed that job demands, extrinsic effort, and over-commitment
were associated with higher levels of anxiety and depression. Social support, rewards,
and skill discretion were negatively associated with mental health problems. Few
interactions were found between the variables. Coping behaviours significantly added
to the explanation of variance in anxiety and depression outcomes, over and above the
use of demand–control–support, and effort–reward factors alone.
Conclusion. The results from the study demonstrated the importance of coping
factors in work-stress research, in accordance with the multi-factorial premise of
transactional stress models. It is argued that multi-factor research is needed to help
develop effective organizational interventions.
Stress in health professionals

Research has shown that health professionals are a group at significant risk from the
negative effects of stressful workplaces (Kirkcaldy & Martin, 2000; Tyler & Cushway,
1998). Nurses are particularly at risk from stress-related problems, with high rates of
turnover, absenteeism, and burnout (Clegg, 2001; Kirkcaldy & Martin, 2000). Calnan,
Wainwright, Forsythe, Wall, and Almond (2001) administered the GHQ (General Health
Questionnaire) to health service staff and found that 27% of all hospital staff were
classified as suffering stress and mental ill health, compared to between 14% and 18% of
the general population. There is also evidence that nurses have higher than normal rates
∗ Correspondence should be addressed to Professor A. P. Smith, Centre for Occupational and Health Psychology, School of
Psychology, Cardiff University, 63 Park Place, Cardiff, UK (e-mail: SmithAP@cardiff.ac.uk).
DOI:10.1111/j.2044-8287.2011.02051.x
506 G. Mark and A. P. Smith
of physical illness, mortality, and psychiatric admissions (Kirkcaldy & Martin, 2000).
Figures from 1979 to 1983 show that suicide rates for nurses were significantly higher
than the national average, and life expectancy for nurses was approximately 72 years,
only 1 year more than miners (Clegg, 2001). Sickness absence in the health service
is about 4% (NHS Information Centre, 2011) and the Boorman review (Department of
Health, 2009) estimated that the direct cost of staff sickness was £1.7 billion. An analysis
by the Audit Commission (2011) found that nursing staff had above average rates of
absenteeism (4.82%). Another cost closely associated with sickness absence but much
harder to quantify is ‘presenteeism’. The Boorman review interim report found that 71%
of nurses reported presenteeism compared to 45% of staff in an age matched sample in
corporate services.
Psychosocial stressors in nursing

Nurses can be exposed on a daily basis to a large number of potent stressors, including
conflict with physicians, discrimination, high workload, and dealing with death, patients,
and their families (French, Lenton, Walters, & Eyles, 2000). McVicar (2003) states that
many such situations encountered by nurses at work have a high cost in ‘emotional
labour’. Lambert, Lambert, and Ito (2004) note that most research on nursing stress has
taken place in the United Kingdom and United States, and showed that Japanese nurses
can also suffer from negative mental health. Shift working and bullying are also common
stressors in nursing, and both are thought to be related to numerous health problems
(Ball, Pike, Cuff, Mellor-Clark, & Connell, 2002; Boggild & Knuttson, 1999).
Demands–control–support and effort–reward

It is clear that some of the working conditions that characterize nursing may be implicated
in stress-related issues. Two of the most influential theories commonly used in studying
work-related stress are the demands–control–support model (Karasek & Theorell, 1990)
and the effort–reward imbalance (ERI) model (Siegrist, 1996). Both models have been
found to predict many physical and psychological health outcomes, including mortality,
heart disease, and depression (Van Der Doef & Maes, 1999) and have also been used in
nursing populations (de Rijk, le Blanc, Schaufeli, & De Jonge, 1998; Weyers et al., 2006).
The DCS (Demands-Control-Support) model predicts that those exposed to high levels
of psychological demand, and low levels of social support, and job control (from the
sub-factors of decision authority and skill discretion) are likely to suffer negative health
outcomes. Karasek (1979) proposed an interaction between demands and control, so
that when demands are high and control is low, a high-strain situation develops, and
this is particularly likely to lead to negative health outcomes. High control (sometimes
summed from skill discretion and decision authority, although also these variables can
be considered individually) is also proposed to buffer the effect of high demands on
health outcomes. This model may be very appropriate for nursing samples, because a
lack of social support as well as excessive demands are common in nursing (Muncer,
Taylor, Green, & McManus, 2001) and control may well vary by occupational grade.
The ERI model (Siegrist, 1996) is also popular and influential in work-stress research.
Based on the concept of reciprocity, the ERI model proposes that high levels of work-
related effort should be matched by high levels of reward (economic, recognition,
promotion prospects, job security, etc). It is proposed that if efforts (external demands
or internal motivations) are high, but rewards are low, then strain and negative health
outcomes are likely to ensue. Like the DCS model, the relationship between efforts and
Stress and nurses 507
rewards is proposed to be an interaction, so that high levels of reward buffer high levels
of effort (Peter & Siegrist, 1999). The ERI model further predicts that ERI at work will
be experienced more frequently by those who are overly committed to their work.
Intrinsic effort and over-commitment are often used as equivalent terms, although over-
commitment is more likely to be used to represent a personality trait. This is the term that
will be used in the current paper. The ERI model may be suited to studying work-related
stress in nurses, as there is much evidence that nursing is a demanding occupation and
thus requires effort, and levels of pay in newly qualified nurses may be lower than other
high-stress occupational groups, such as teachers and police officers (Demerouti, Bakker,
Nachreiner, & Schaufeli, 2000).
Despite the popularity of the above two models, they are largely focused on job
characteristics or environmental factors (Cox, Griffiths, & Rial-Gonzalez, 2000) and
generally fail to take account of individual factors (over-commitment from ERI being an
exception). These models cannot readily explain, for example, how different individuals
exposed to the same levels of stressors, may suffer different health outcomes (Perrewe
& Zellars, 1999). It should be noted that despite purporting to ‘measure’ environmental
job factors (e.g. workload, levels of social support etc.) these models use subjective
individual ratings of job characteristics, rather than more objective measures (such as
supervisor ratings or objective workload measures).
Transactional theory and coping

As well as the job characteristics of nursing, it is important to understand how differences
between individuals may affect how they deal with stressors at work (Cox & Ferguson,
1991). Transactional theories of stress (e.g. Folkman & Lazarus, 1980), place emphasis not
just on job characteristics, but also on subjective perceptions of stressors, and individual
differences in ways of coping, viewing problems, past experience, personality-type etc.
All these may be important in informing and affecting the workplace–individual stress
interaction (Cox & Ferguson, 1991; Moos & Holahan, 2003; Moos, Holahan, & Beutler,
2003; Penley, Tomaka, & Wiebe, 2002).
In Folkman and Lazarus’ model (1980), individuals are proposed to appraise environ-
mental stressors, including their level of potential threats and costs (primary appraisal),
then to make potential plans to deal with stressors using known coping methods
and past experience (secondary appraisal), and then to initiate coping. ‘Coping’ has
been described as any cognitive or behavioural efforts to manage, minimize, or tolerate
events that individuals perceive as potentially threatening to their well-being (Folkman,
Lazarus, Gruen, & DeLongis, 1986). Coping does not imply success in dealing with
situations and coping responses to stressors can also be maladaptive. Methods may
include problem solving, self-blame, escape/avoidance, wishful thinking, seeking advice
and support, etc. (Folkman & Lazarus, 1980). Therefore coping occupies a dual role, both
as a process following on from appraisal, but also as an individual difference variable,
when people exhibit patterns of coping behaviours (carried out during the coping
stage of transactional theory) that many suggest may be stable, or slowly changing
over time (Folkman & Lazarus, 1980). For the purposes of this study (as in work by
others including Folkman and Lazarus), coping is treated as an individual difference
variable.
Folkman et al. (1986) claim that problem-focused forms of coping (so called positive
coping types) are likely to be associated with lower levels of negative health outcomes,
and that coping of an emotional-focused (or negative) type, such as self-blame, wishful
thinking, or escape/avoidance are likely to be associated with increased negative health.

For example, Healy and McKay (2000) found that avoidance coping predicted poor
mental health in nurses, and problem solving coping was positively related to satisfaction
and health. Evidence is more mixed for the relationship between seeking advice and
health outcomes.
Rationale
Nurses have been selected as the population for the current study due to the complex
array of stressors that they face, and the high levels of negative mental and physical
health they suffer from (Kirkcaldy & Martin, 2000). This is particularly important given
the funding and staffing challenges facing the UK health service.
The traditional models of demands–control–support, and ERI were tested simultane-
ously in this population, to see how much each contributes to the variance in mental
health outcomes. Ways of coping were also investigated, to see how much additional
variance this factor explains over the use of traditional job characteristics variables
alone. Coping is also central in transactional stress models (Folkman & Lazarus, 1980).
McVicar (2003) and Kirkcaldy and Martin (2000) suggest that there is a need for more
understanding of how individual variation in perceptions and reactions to stressors in
nurses affect health outcomes.
The relationships between the above variables were investigated in a nursing
population. It was hoped that assessing the relative importance of these factors, and
finding any interactions between them in the prediction of anxiety and depression, will
be useful for supporting the view that individual differences can add to the study of
work-related ill health, as suggested by transactional models. It was also hoped that
such information could help to provide empirical support for potential interventions to
combat work stress.
Hypotheses
Hypothesis one predicted that positive coping behaviours (problem-focused coping)
would be associated negatively with depression and anxiety in nurses, and negative
coping behaviours (self-blame, wishful thinking, escape/avoidance) would be associated
positively with anxiety and depression. No prediction was made about the relationship
between seeking advice and outcomes, due to mixed evidence.
Hypothesis two predicted that job demands would be positively associated with
anxiety and depression in nurses, and skill discretion, decision authority, and social
support would be negatively associated with depression and anxiety. A second part of the
Hypothesis (2a) predicted that control variables and social support would significantly
interact with the effect of demands in predicting anxiety and depression scores.
Hypothesis three predicted that extrinsic effort and over-commitment would be
associated positively with depression and anxiety in nurses, and intrinsic reward would
be negatively associated with anxiety and depression. It was also predicted that rewards
would significantly interact with the effect of over-commitment and extrinsic effort in
predicting anxiety and depression scores (Hypothesis 3a).
Hypothesis four predicted that there would be significant interactions between
negative job characteristics (high job demands, extrinsic efforts) and positive coping
behaviours (problem-focused coping) so that the latter would moderate the effects of
negative job characteristics on mental health outcomes.
Hypothesis five predicted that coping, efforts, rewards, demands, control variables,
and support would account for a significant amount of the variance in anxiety and
depression scores in nurses. It was also predicted that ways of coping would significantly
add to the explained variance in outcomes, over and above use of DCS and ERI alone
(Hypothesis 5a).
Method
Participants
The participants in this study were a sample of 870 nurses from all occupational grades
and roles employed in the UK health service. Four thousand nurses were selected at
random by the UK Royal College of Nursing, and these individuals were mailed a request
for participants for a study into health and safety at work, with a focus on stress and work
pressures. Eight hundred and seventy nurses responded (22% response rate). Those who
responded were 790 women and 80 men (mean age = 44.84, SD = 8.8). Participants
were treated in accordance with BPS ethical guidelines for treatment of participants
(British Psychological Society, 2004), and ethical approval was provided by the Cardiff
University School of Psychology ethics committee.
Materials
A 31-page questionnaire booklet was produced, containing an instruction page that
informed participants as to the purposes of the study, their right to withdraw, and the
anonymous treatment of data. The booklet also contained questions on demographic
data, work type (shift/contract/permanent), and five main questionnaires.
The 21-item version of the ERI Questionnaire (Siegrist, 1996) was as used in the
Whitehall II Study (Kuper, Singh-Manoux, Siegrist, & Marmot, 2002). Three subscales
were measured: over-commitment (internal motivations, e.g., ‘over-commitment’ to
work), extrinsic effort (external pressures), and internal reward (adequate rewards). Par-
ticipants responded on a 4-point Likert scale indicating to what extent (if experienced)
they found the suggested work situations distressing. Mean scores were converted to
percentages for each sub-factor. This was done for other scales (as below) to standardize
scores across different variables, and to make results easier to interpret. Cronbach’s ␣
scores were calculated as .80 for the over-commitment subscale, .74 for extrinsic effort,
and .84 for intrinsic reward.
A 27-item version of the Job Content Questionnaire (JCQ; Karasek et al., 1988) was
used. Four subscales were measured: job demands (workload, time pressure); decision
authority (control over decisions); skill discretion (opportunity to use skills); and levels
of social support. Participants responded how often they experienced the suggested
situations at work on a 4-point Likert scale. Scores were converted to percentages,
and Cronbach’s ␣ scores were calculated as .85 for the social support subscale, .81 for
decision authority, .68 for job demands, and .68 for skill discretion.
The Ways of Coping Checklist (WCCL; Folkman and Lazarus, 1980) is a well-known
68-item scale used to assess coping behaviours, and this study used Vitaliano, Russo, Carr,
Maiuro, and Becker’s (1985) 42-item revised version of this scale. The 42 items are used
to assess five factors, labelled: problem-focused coping (␣ = .84); seek advice (␣ = .82);
self-blame (␣ = .88); wishful thinking (␣ = .84); and escape/avoidance (␣ = .76).
Participants were asked to think of a recent stressful work experience and to indicate
on a 4-point Likert scale how often they used each of the suggested behaviours. Final
scores were converted to percentages of maximum scores.
The Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) is a
14-item scale that aims to measure self-reported anxiety and depression using two
subscales. Participants respond on a 4-point Likert scale how often they have felt or
experienced the suggested anxious or depressed feelings or situations in the past week.
Reliability scores were calculated as .84 for anxiety, and .78 for depression. Total scores
were calculated of 21 for each subscale, with 11 or more considered as a potential
clinical case, in line with recommendations by Zigmond and Snaith (1983).
Procedure
Those who responded with interest to the request for participants were sent a
questionnaire package containing the measures as described above, along with a freepost
return envelope. Instructions were given where appropriate as specified by (or adapted
from as relevant) the original questionnaire authors. Completion time was estimated at
20–30 min. It was emphasized that results were anonymous, and that any concerns about
mental health that came about as a result of completing the questionnaire, should be
raised with the participant’s doctor. Contact details were given for the research team, in
case participants had any other queries or requests for information about the research.
Analysis
Results were analysed to test the stated hypotheses, with a variety of statistical techniques
using the computer statistics package SPSS 13.
Descriptive statistics were first used to compare participants for anxiety and depres-
sion scores against the clinical cut-off scores for the HADS, and Pearson correlations were
used to examine the relationships between anxiety and depression, and the predictor
variables (coping, attributions, and job characteristics).
A range of multiple regressions was also carried out to investigate the effects of the
various potential predictors of depression and anxiety. Multiple regressions were used so
that variables could be entered simultaneously, including those from different theories
and models, to see their relative predictive power (using standardized beta weights).
Regressions were carried out in order of increasingly complexity to test the stated
hypotheses. The regressions were as follows: coping variables (from WCCL) against anx-
iety; coping variables against depression; JCQ variables against anxiety plus interaction
effects (four regressions, one main effects, and three with one interaction term); JCQ
variables against depression plus interactions (four regressions as above); ERI variables
(intrinsic and extrinsic efforts, intrinsic rewards) against anxiety plus interactions (three
regressions, one main effects, two with one interaction term); ERI variables against
depression with interactions (three regressions as above); all JCQ and ERI variables
entered simultaneously against anxiety; all JCQ and ERI variables against depression.
Finally, all predictor variables (IVs – Independent Variables) from the WCCL (coping)
JCQ (demands and controls) and ERI (efforts and rewards) were entered against anxiety
and depression, using hierarchical multiple regression, with JCQ variables in the first
block using entry method, ERI variables in the second block using entry method, and
WCCL variables in the third block using entry method. Additionally, a further set of
regressions were conducted to test interactions between positive coping behaviours
Table 1. Levels of clinical anxiety and depression in nurses, and correlations of coping and job
characteristics against anxiety and depression
Percentage with Percentage with Percentage claim illness

clinical anxiety clinical depression caused/worsened by
scores scores work stress
Nurses 26.3% 5.9% 44.8%
HAD-A HAD-D
Problem-focused coping .04 −.10∗

Self-blame .48∗∗ .38∗∗
Wishful thinking .34∗∗ .28∗∗
Seek advice .04 −.08
Escape/avoidance .34∗∗ .37∗∗
Job demands .33∗∗ .26∗∗
Social support −.34∗∗ −.40∗∗
Skill discretion −.21∗∗ −.26∗∗
Decision authority −.21∗∗ −.24∗∗
Extrinsic effort .43∗∗ .40∗∗
Over-commitment .57∗∗ .48∗∗
Intrinsic reward −.41∗∗ −.43∗∗
Note. ∗ p ⬍ .05; ∗∗ p ⬍ .01.
and negative job characteristics in the prediction of anxiety and depression, however
no significant interactions were found and results are not reported.
It can be seen that the regressions above increased in complexity, moving from using
predictor variables from single to multiple theoretical models. This was carried out so that
earlier models could provide context to later ones, and to show that individual coping
variables could be significant predictors even when more traditional job-characteristic
variables were present. Some of the models include significant interaction effects,
however those where significant interaction effects were not found (e.g., job demands
by social support in anxiety, or any JCQ variables in predicting depression) are not
included.
Results
Table 1 shows that for scores on the HADS, 26.3% of sampled nurses scored at clinical
levels for anxiety (11 or more; Zigmond & Snaith, 1983). For depression scores, 5.9%
of nurses scored above the clinical cut-off point. Additionally 44.8% of nurses indicated
that they believed that they had suffered an illness in the past year that had been caused
or made worse by stress at work.
Table 1 also shows Pearson correlations between all independent variables and anxi-
ety and depression. The table shows that ‘negative’ coping characteristics, such as self-
blame, escape/avoidance, and wishful thinking, show significant positive correlations
with anxiety and depression, with correlations of between .28 and .48. Problem-focused
coping has a small but significant negative correlation with depression.
The table shows that negative job characteristics such as job demands and extrinsic
effort correlate positively with anxiety and depression, as does over-commitment,
whereas positive job characteristics such as skill discretion, decision authority, intrinsic
Table 2. Regressions of coping against anxiety and depression
Beta Standard Standard beta

Anxiety weight error weight Significance
(Constant) 5.257 .507 .001

Problem-focused coping −.017 .010 −.059 .085
Self-blame .072 .007 .389 .001
Seeks advice −.001 .007 −.004 .915
Wishful thinking .008 .007 .049 .223
Escape/avoidance .030 .010 .117 .003
Model: R = .492, R2 = .242 F: 50.75 .001

Depression weight error weight Significance
(Constant) 3.790 .425 .001

Problem -focused coping −.018 .008 −.078 .026
Self-blame .043 .006 .283 .001
Seek advice −.015 .006 −.088 .016
Model: R = .457, R2 = .209 F: 41.93 .001
reward, and social support show significant negative correlations of between .26 and
.57 with anxiety and depression.
Table 2 shows two regressions where all coping variables (problem-focused coping,
seeking advice, self-blame, wishful thinking, escape/avoidance) were regressed against
anxiety and depression. Variables show similar associations with anxiety and depression
as those in the correlations. Self-blame and escape/avoidance predict increased levels
of anxiety. Problem-focused coping was not associated with significantly lower anxiety
scores (however this relationship becomes significant if seeking advice is removed,
suggesting there may be some collinearity between these variables). The above variables
accounted for 24.2% of the variance in anxiety scores, and self-blame was the most
important factor by standardized beta weight, followed by escape/avoidance and
problem-focused coping.
For the depression regression, self-blame and escape/avoidance had significant
positive associations with depression, and problem-focused coping and seeking ad-
vice had significant negative associations with depression scores. Self-blame and es-
cape/avoidance were again the most important predictors by standardized beta weight.
These factors accounted for 20.9% of the variance in depression scores.
Table 3 shows regressions of the JCQ variables of job demands, control (skill
discretion and decision authority), and social support, against anxiety and depression.
For anxiety, an initial regression showed that job demands were associated positively
with anxiety, and social support and skill discretion negatively with anxiety. Three
further anxiety regressions were then conducted, with these main effects, and entering
interactions between job demands and decision authority, demands and social support,
and demands and skill discretion. The interaction between decision authority and job
demands was found to be significant. This relationship is shown in Figure 1, and shows
that at low levels of job demands, anxiety levels are similar regardless of level of decision
Table 3. Regressions of job demands, control, and social support against anxiety and depression

(Constant) 7.645 1.686 .001

Job demands .102 .020 .465 .001
Social support −.033 .005 −.219 .001
Skill discretion −.048 .011 −.153 .001
Decision authority .045 .025 .234 .078
Job demands × decision authority −.001 .001 −.321 .028
Model: R = .462, R2 = .214 F: 43.81 .001

Depression weight Error weight Significance
(Constant) 9.682 .789 .001

Job demands .033 .006 .184 .001
Social support −.036 .004 −.287 .001
Decision authority −.010 .005 −.062 .065
Model: R = .473, R2 = .224 F: 58.47 .001
authority. However, at high demands, anxiety scores are significantly higher in those
with low decision authority.
For the depression regression, job demands had a significant positive relationship with
depression, and social support and skill discretion associated negatively with depression
scores. No interactions were found for depression.
For anxiety, job demands were the most important predictor by standardized beta
weight, followed by social support and skill discretion. However for depression, social
support was the most important predictor, with job demands and skill discretion of
15.5
15
14.5 Low Decision Authority

High Decision Authority
14
Anxiety
13.5
13
12.5
12
Low Job Demands High Job Demands
Figure 1. Interaction of job demands and decision authority in predicting anxiety.
Table 4. Regressions of intrinsic reward, extrinsic effort and over-commitment, against anxiety and
depression

(Constant) 9.656 1.255 .001

Intrinsic reward −.069 .014 −.344 .001
Extrinsic effort .027 .006 .142 .001
Over-commitment .029 .021 .175 .161
Over-commitment × intrinsic reward .001 .001 .251 .036
Model: R = .624, R2 = .390 F: 123.5 .001

(Constant) 5.568 .572 .001

Model: R = .582, R2 = .338 F: 132.3 .001
equal importance. The above variables accounted for 21.4% of the variance in anxiety,
and 22.4% of the variance in depression scores.
Table 4 shows regressions of intrinsic reward, extrinsic effort and over-commitment,
against anxiety and depression. Intrinsic reward was negatively associated with anxiety
and depression, extrinsic effort positively with anxiety and depression, and over-
commitment was positively associated with depression.
A significant interaction was found between over-commitment and intrinsic reward
in predicting anxiety. Using the same method as described for JCQ variables and anxiety,
the main-effect regression was calculated, and then two further regressions were carried
out entering interaction effects (intrinsic and extrinsic efforts by rewards). Figure 2
12
11
10
Anxiety 9 Low Intrinsic Reward

High Intrinsic Reward
8
5
Low over-commitment High over-commitment
Figure 2. Interaction of over-commitment and intrinsic reward in predicting anxiety.
Table 5. Regressions of demands, control, social support, extrinsic effort, over-commitment and
rewards against anxiety and depression

(Constant) 9.748 .950 .001

Job demands .017 .007 .078 .018
Social support −.014 .005 −.095 .005
Decision authority −.003 .006 −.016 .605
Model: R = .643, R2 = .413 F: 76.13 .001

(Constant) 9.122 .798 .001

Job demands .001 .006 .004 .912
Social support −.022 .004 −.175 .001
Decision Authority −.004 .005 −.028 .374
Model: R = .625, R2 = .390 F: 69.34 .001
shows those individuals who exhibit low levels of over-commitment are less anxious
when they feel more rewarded (thus respond well to rewards, and are more anxious
when rewards are low). However for those who are over-committed, anxiety is much
higher, and levels of reward make no difference to their anxiety levels.
For anxiety, intrinsic reward was the most important variable by standardized
beta weight (although in non-interaction regressions, over-commitment was the most
important), and in depression, over-commitment was the most important. The above
variables accounted for 39% of the variance in anxiety and 33.8% of the variance in
depression scores (compared to 21.4% of anxiety and 22.4% in depression with demands,
decision authority, skill discretion, and social support).
Two more major sets of regressions were conducted. The first set (shown in Table 5)
used entry method and entered all sub-factors from the DCS model together with those
from the ERI model against anxiety and depression.
Over-commitment and extrinsic effort were significantly positively associated with
anxiety and depression scores. Job demands were significantly positively associated
with anxiety, and social support, skill discretion, and intrinsic reward were all signifi-
cantly negatively associated with anxiety and depression scores. For both anxiety and
depression, over-commitment was the most important predictor by standardized beta
weight, followed by skill discretion in anxiety, and social support and skill discretion in
depression. No significant interactions were found.
These factors accounted for 41.3% of the variance in overall anxiety scores, and 39%
of the variance in depression scores. The unique variance added over demands, decision
Table 6. Regressions of ways of coping, demands, control, support, extrinsic effort, over-commitment
and rewards, against anxiety and depression

(Constant) 6.812 1.006 .001

Job demands .022 .007 .101 .002
Social support −.018 .005 −.118 .001
Seek advice .015 .006 .076 .018
Self-blame .041 .007 .224 .001
Model: R = .694, R2 = .482 F: 56.18 .001

(Constant) 7.290 .863 .000

Job demands .007 .006 .039 .235
Social support −.019 .004 −.154 .000
Seek advice −.006 .006 −.038 .251
Self blame .021 .006 .140 .000
Model: R = .659, R2 = .435 F: 46.48 .001
authority and skill discretion, and social support, by including efforts and rewards, is
18.9% in anxiety (or almost double the total amount of variance explained) and 16.6%
in depression (a three-quarter increase in variance explained).
The final regressions (Table 6) were hierarchical multiple regressions against anxiety
and depression, where job demands, social support, and skill discretion and authority
were entered by entry method in block one, intrinsic reward, extrinsic effort, and over-
commitment were entered by entry method in block two, and problem focused coping,
seeking advice, self-blame, wishful thinking, and escape/avoidance, were entered in
block three. The direction of association between significant variables and outcomes
are the same for almost all variables as those in previous regressions: problem-focused
coping, social support, skill discretion, and intrinsic reward were significantly negatively
associated with anxiety and depression scores, and self-blame and over-commitment
were both significantly positively associated with anxiety and depression. Additionally,
escape/avoidance and extrinsic effort associated positively with depression scores, and
seeking advice and job demands associated negatively with anxiety scores. Only decision
authority, extrinsic effort, wishful thinking, and escape/avoidance, were non-significant
predictors of anxiety, and only job demands, decision authority, wishful thinking, and
seeking advice, were non-significant predictors of depression.
By standardized beta weight, over-commitment was the most important predictor
of anxiety and depression, followed by self-blame for anxiety and social support in
depression. All other variables were of similar importance for anxiety and depression by
standardized beta. The above variables accounted for 48% of the variance in the anxiety
score, and 43.5% of the variance in the depression score. It can be seen by comparing
the results from Table 6 with the regressions in Table 5, that the unique overall variance
explained over just the DCS and ERI variables by ways of coping was 6.7% in anxiety
and 4.5% overall in depression (about one-sixth more variance explained in anxiety, and
one-eighth in depression).
Discussion
Descriptive statistics showed that overall 27.3% of nurses were above the clinical cut-off
for self-reported levels of anxiety or depression as measured by the HAD. This compares
to the 27% of hospital staff found to be suffering stress and mental ill health, by Calnan
et al. (2001) and the 14–18% they found in the general population. It was also shown
that 45% of nurses claimed that stress at work had caused, or made an existing illness
worse. Mark and Smith (2011) found that 40% of a sample of 307 university staff, and 26%
of a sample of 120 members of the general population, claimed that stress at work had
affected health negatively. Thus, a greater percentage of the sample of nurses believed
they had suffered stress-related illness compared to these two groups.
Hypothesis one predicted that positive coping would be negatively associated with
anxiety and depression and negative coping behaviours positively with anxiety and
depression in nurses. The reported correlations show majority of the predictions
of the experimental hypothesis were supported. These findings confirm those of
many researchers, particularly Folkman et al. (1986). The data showed that negative
coping behaviours were generally more important by standardized beta weight in the
regressions than positive coping behaviours, suggesting that an absence of negative
coping behaviours may in fact be more strongly associated with positive mental health
outcomes than the presence of positive coping behaviours.
Hypothesis two predicted that job demands would be positively associated with
anxiety and depression, and control variables and social support would be negatively
associated with outcomes. Also, significant interactions were predicted (Hypothesis 2a)
between demands and control variables, and demands and support. Job demands
correlated significantly with anxiety in almost all regression models. Job demands were
also positively associated with depression in the DCS-only main-effects model. Decision
authority did not emerge as a significant main-effects predictor in any regression, but did
have a significant interaction relationship with job demands in the prediction of anxiety.
This could suggest that skill discretion (chance to choose own skills) has an independent
relationship to mental health outcomes, but decision authority (control over workplace
events) is only related to outcomes through its relationship to job demands. These data
support the first part of the hypothesis and the interaction of DA (Decision Authority)
supports the second with regards to anxiety (as suggested by Karasek’s work, 1979).
Demands–control–support accounted for small to medium percentages of the variance in
anxiety and depression, with job demands and social support being the most important
factors by standardized beta weight.
Hypothesis three predicted that extrinsic effort and over-commitment would be
positively associated with depression and anxiety, and intrinsic reward would be
negatively associated with anxiety and depression. ERI accounted for more of the
variance overall in anxiety and depression than DCS. The regressions also showed that
by standardized beta weight, rewards, extrinsic effort and over-commitment appeared
to be as important as, or more important than DCS variables in the prediction of
anxiety and depression. Table 5 shows that over-commitment was the most important
predictor by beta weight for anxiety and depression. An interaction between over-
commitment and intrinsic reward was significant in the anxiety analysis (Hypothesis 3a).
However, as can be seen in Figure 2, this is unlikely to be a buffering effect, as the
anxiety scores at high levels of reward and commitment are the same, and rewards were
only associated with lower anxiety when over-commitment was low. This suggests
that in normal circumstances, high rewards are associated with improved mental
health, but when over-commitment is high, levels of reward are irrelevant or perhaps
overwhelmed.
Hypothesis four predicted that there would be significant interactions between
negative job characteristics (job demands and extrinsic effort), and positive coping
behaviours, so that problem-focused coping would moderate the effects of negative job
characteristics on mental health outcomes. However, no significant interactions were
found between these variables in the prediction of anxiety or depression.
Hypothesis five predicted that coping, efforts, rewards, and demand–control–support
would account for a significant amount of the variance in anxiety and depression, and
that ways of coping would significantly add to the explained variance in outcomes over
and above use of DCS and ERI alone. The regressions show that variables from all of the
experimental constructs (coping, DCS, and ERI) were represented in the final regression
equations for anxiety and depression. The variables shown in Table 6 accounted for
48% of the variance in anxiety scores, and 43.5% in depression scores, the highest
for any regressions. The inclusion of coping in the final regression models supports the
assertion that individual difference variables can significantly contribute, and account for
different percentages of the variance in depression and anxiety, over DCS and ERI factors
alone.
In summary, all but one of the hypotheses in this paper were fully or partially
supported. The data from this sample of nurses support previous findings reported
by Karasek (1979), Siegrist (1996), Folkman and Lazarus (1980) and others. The
various regressions showed that demand–controls–support, and efforts and rewards
both contributed separately to the overall regression models.
While over-commitment appears to be the most significant predictor by standardized
beta weight, the other sub-factors of the DCS and ERI models appear to be of importance.
It is evident that both of these models make distinct contributions to anxiety and
depression, and studies on nursing samples that use one construct and exclude the
other, may miss out explaining important parts of the variance in outcomes. In addition,
while the more traditional models of DCS and ERI accounted for the majority of variance,
there is clearly a significant contribution to be made by coping behaviours. These results
support the DRIVE model (Demands Resources and Individual Effects) as outlined in
Mark and Smith (2008). This research also suggests that a primary focus on individual and
social support factors, and a secondary focus on demand-type factors may be pertinent
in occupations where the reduction of demands is not a realistic option (such as for
nurses, fire fighters, doctors, police, etc.). Such recommendations cannot be made by
research that does not include coping or individual difference factors.
Conclusions
The results of this paper show that there are robust associations between ways of
coping, job demands, levels of control, social support, extrinsic effort, over-commitment,
rewards, and anxiety and depression in this sample of nurses. The data support much past
research and the simultaneous use of multiple theoretical constructs from popular stress
models, and shows that coping adds something new to the existing body of workplace
stress research. The results showed that no one group of factors emerged overall as being
the most important in accounting for variance in anxiety and depression, and DCS, ERI,
and coping, each added uniquely to the study of anxiety and depression in nurses. These
relationships, as well as the role of other individual differences in the stress process,
should be explored in future research.
The workplace is a complex environment, and stress at work is a complex process.
The fact that different individuals can respond to the same stressors in different ways,
shows that an understanding of how different individual difference factors and job
characteristics compare, interact, and influence one another is very important. The
result that nearly 45% of nurses believed that work stress had directly influenced their
health, shows the importance of studying stress in this population, and it is believed that
the best way to help both employees and employers alike, is through multi-factor stress
research, based on transactional stress models.
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505

Occupational stress, job characteristics, coping,

G. Mark and A. P. Smith∗

Objectives. This study investigated the relationships between job characteristics

Stress in health professionals

Psychosocial stressors in nursing

Demands–control–support and effort–reward

Transactional theory and coping

thinking, or escape/avoidance are likely to be associated with increased negative health.

Percentage with Percentage with Percentage claim illness

Problem-focused coping .04 −.10∗

Note. ∗ p ⬍ .05; ∗∗ p ⬍ .01.

Table 2. Regressions of coping against anxiety and depression

Beta Standard Standard beta

(Constant) 5.257 .507 .001

Beta Standard Standard beta

(Constant) 3.790 .425 .001

Beta Standard Standard beta

(Constant) 7.645 1.686 .001

Beta Standard Standard beta

(Constant) 9.682 .789 .001

14.5 Low Decision Authority

Beta Standard Standard beta

(Constant) 9.656 1.255 .001

Beta Standard Standard beta

(Constant) 5.568 .572 .001

Anxiety 9 Low Intrinsic Reward

Beta Standard Standard beta

(Constant) 9.748 .950 .001

Beta Standard Standard beta

(Constant) 9.122 .798 .001

Beta Standard Standard beta

(Constant) 6.812 1.006 .001

Beta Standard Standard beta

(Constant) 7.290 .863 .000

Received 28 April 2011; revised version received 9 August 2011

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