STRESS MEDICINE, VOL. 11: 243-251 (1995)

STRESS IN NURSES: THE EFFECTS OF COPING AND SOCIAL SUPPORT

PATRICK TYLER, PhD AND DELIA CUSHWAY, PhD, CClinPsychol University of' Birmingham, Birmingham. U K

SUMMARY Sources of stress, job satisfaction and coping were investigated in 245 general hospital nurses using standardized questionnaires. It was hypothesized that coping strategies, social support and job satisfaction would moderate or buffer the effects of the stressor on psychological distress, such that those who were lower in coping skills, social support and job satisfaction would be more reactive to stress effects. Negative main effects on mental well-being, as measured by the General Health Questionnaire, were found for workload, lack of social support, inadequate preparation, conflict with other nurses, conflict with doctors and use of avoidance coping strategies. Proposed buffering effects were investigated using multiple regression analysis to control for the main effects. Although consistently in the predicted direction, the buffering effects were found to be very small and non-significant. It was concluded that for stress in nurses the results supported a transactional model rather than an interactive model for social support and coping.

KEY worms-stress; nurses; job satisfaction; social support; coping; transactional model

In recent years, a considerable body of evidence has accumulated on the effect of stress on health in a variety of health professions.' In particular, hospital nurses have been well studied and found to be under high levels of stress from a number of source^.^,^ For example, Hipwell et d4 found dealing with death and dying patients and excessive workload to be especially salient stressors in NHS general nurses, and Tyler et ~ 1 . ~ showed that in addition to these sources, conflict with doctors was an important stressor for nurses in the private sector. In several studies, work overload has been the most significant predictor of poor mental health o ~ t c o m e . ~

It might be expected that, in a stressful occupa- tion such as nursing, the perception of being under high levels of stress from heavy workload, conflict with other professionals, etc, would be strongly associated with poor health outcome. In fact, there is evidence for such an association across occupa- tions, as nursing has one of the highest rates of suicide and psychiatric outpatient referrals,6 and nurses have the lowest life expectancy of any of the professions. Moreover, the GHQ caseness mea- sure, which is a good predictor of psychiatric

Address for correspondence: P. A. Tyler, School of Psychology, University of Birmingham, Birmingham B15 2TT, UK. Tel: 021 4144924. Fax: 021 4144897. Email: p.a.tyler@bham.ac.uk.

CCC 0748-8386/95/040243-09 0 1995 by John Wiley 8c Sons, Ltd.

admissions, is consistently found to be above threshold for about 30 per cent of nurses sampled across several different populations of general nurses.3 We have also found that by using the 64 items on two stress questionnaires we could discriminate perfectly between cases and non-cases on the General Health Questionnaire. However, within nursing (as in other professions), stressor measures never account for a large proportion of the variance in measures of psychological distress. In our previous studies the total proportion of variance in the GHQ accounted for by the sources of stress has been less than 10 per cent. This may be because occupational stressors are less potent causes of psychological distress than has been thought, because our measures of stress are less encompassing than we have thought or because some individuals are better able to cope with occupational stress without displaying emotional distress than are others.

The way in which we all cope with common stressors is through a variety of coping strategies which include active problem-solving or planning, talking to friends or engaging in other activities, and denying that there is a problem or avoiding it by various means. Moos and his colleagues' have labelled these three strategies active cognitive, active behavioural and avoidance coping, respec- tively. Lazarus and Folkman* have proposed

Received February 1993 Accepted February 1994

244 P. TYLER A N D D. CUSHWAY

another widely used and similar categorization of coping ‘functions’ into problem-focused and emo- tion-focused coping. Probably the coping strategy which is cited by nurses and by other health profes- sionals as most effective for them is talking to a friend or colleague at This strategy is well known to psychologists and has been extensively studied under the rubric of social support.’0*”

Our studies of stress in nurses have found that the strongest association between psychological dis- tress and any of the coping strategies is a positive one with avoidance ~ o p i n g . ~ The relationship with active cognitive and active behavioural coping is usually low and inconsistent in sign. Most of the general stress literature, however, suggests that social support is usually (but not always) negatively associated with measures of psychological strain or distress.12 These findings might be interpreted as showing that avoidance coping strategies increase and social support decreases the strength of psychological distress. However, caution should be exercised when drawing causal inferences from these non-experimental field studies. Moreover, if there are direct effects of coping strategies on health outcomes, these seem to be quite selective. For example, we found that active behavioural coping (which includes social support seeking) was nega- tively related to severe depression, but not to the somatic symptoms, anxiety and insomnia or social dysfunction scales of the GHQ-28.3 Beehr and McGrath12 reported an early finding that anxiety was negatively related to social support from coworkers but not to support from supervisors or from people outside the organization.

The direct effects of coping on mental well-being could be considered the classical or traditional model of coping. In general, if positive coping strategies are effective, we would expect them to result in an improvement in health (or reduction in distress) regardless of the source or amount of stress, whether work-related or not. An alternative model which has gained favour recently, particu- larly in studies of social support, views a coping strategy as a buffer which interacts with a stressor to predict mental health outcome^.'^^^^ The model generally predicts that people with low levels of social support (or low positive coping skills) will have a stronger negative reaction to a stressor than will those with high social support and coping. As in the analysis of variance statistical mode, if the interaction is strong enough it can dampen any main effects of the stressor or the coping strategy and contribute substantially to the variance in the

outcome measure. Whether or not this happens is a matter of some controversy in the general stress literature. Cohen and Wills’O reviewed a substan- tial number of studies which found significant buffering effects. These included only two studies of occupational stress which provided evidence for a buffering model, while a third study found no interactions. Beehr,l49I2 on the other hand, also reviewed the work-related stress literature and found mixed results for the buffering hypothesis. Among the few significant interactions found were some that went in the ‘wrong’ direction: that is, social support sometimes seems to enhance the negative effects of the stressor, rather than diminishing them. Boumans and L a n d e ~ e e r d ’ ~ in a study of Dutch nurses found the buffering effects of social support and coping to be weak relative to their direct effects.

In our previous studies of stress in health professionals, we have followed the majority of investigators in adopting the direct effects model. Our work may thus be criticized for not consider- ing the possible buffering effects of coping on stress. The present study has therefore been designed both to look at the main effects of stress and coping strategies on mental health in nurses and to test the hypothesis that there are interac- tions among these effects.

METHOD

Participants

All qualified nurses in two general hospitals in the English Midlands were invited to take part in the study. From approximately 640 nurses who were circulated and requested to fill in a questionnaire, there were 245 who agreed to participate and completed usable returns. Thus the response rate was 38 per cent; because the responses were anonymous it was not possible to follow up non- responders except by general appeals. There were 227 females (93 per cent), 15 males and three declined to say; 10 were students, 157 (64 per cent) were level 1 nurses (SRN), 44 (18 per cent) were level 2 (SEN) and 29 (12 per cent) were nursing assistants (unqualified); five did not say. The average age of the nurses was 34.0+ 10.25 years (range 19-60); they had spent 12.9k8.5 years in nursing and 4.5 4.7 years on their present unit. Their grades ranged from student to grade H, with most falling in grades D (24 per cent), E (22 per cent), F (12 per cent), G (1 7 per cent) and A (10 per

STRESS IN NURSES 245

cent). Asked about previous experience, 129 (53 per cent) nurses had post-qualification training, 106 (43 per cent) did not and 10 did not say. Forty- four (18 per cent) said they did not intend to remain in their present job for another year (these included the students). Forty-seven (19 per cent) of the nurses were single, 29 (12 per cent) were separated, divorced or widowed and the remaining 169 (69 per cent) were married or living with a partner. ,About half the sample (124 or 51 per cent) had at least one child living at home; 12 of these were single parents, all from the separated/ divorcedlwidowed group. On average, nurses reported having taken 10.2 k 7.4 days holiday leave and 3.5k8.5 days off for illness in the previous 6 months.

Questionnaire

A questionnaire package was made up, consisting of five component questionnaires, always pre- sented in the same order. The components were:

Background information. The initial page asked for information about the respondent’s age, grade,

gender, training, partnership status and number of children, absences from work, length of time in nursing and availability of social support.

Nursing Stress Scale (NSS) . ‘6 This scale con- sisted of 34 items which are answered on a four- point frequency response scale, scored 0-3 (‘never’, ‘occasionally’, ‘frequently’, ‘very frequently’). There were seven subscales of the NSS.

Job satisfaction.” Five items were measured on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree); the higher the score, the higher the level of job satisfaction. The items included statements which probed satisfaction about the current working situation, involvement and staff support and thoughts of finding another position.

General Health Questionnaire (GHQ 28) . I 8 Each of the 28 items was answered on a four-point response scale of relative ill-health (feeling worse than usual), ranging from 0 to 3. There were four subscales of the GHQ (see Table l), and in addition the overall GHQ mean was calculated using the Likert method. A ‘caseness’ score was also

Table 1-Means and standard deviations for all respondents of item scores for all subscales in the questionnaire

Scale N Mean SD

Nursing Stress Scale (possible range 0-3)

Workload Inadequate preparation Death and dying Uncertainty over treatment Conflict with doctors Conflict with other nurses Lack of social support NSS mean

239 239 239 239 239 239 239 239

1.35 1 .oo 0.97 0.86 0.82 0.72 0.71 0.94

0.62 0.55 0.51 0.45 0.42 0.46 0.63 0.38

Stress level (possible range 1-7) 235 3.41 1.56

Job satisfaction (possible range 1-5) 235 3.29 0.87

General Health Questionnaire (possible range 0-3)

Somatic symptoms Anxiety and insomnia Social dysfunction Severe depression G H Q mean

Coping strategies (possible range 0-3)

Active cognitive coping Active behavioural coping Avoidance coDing

240 0.89 240 0.72 240 1.04 240 0.16 240 0.70

0.54 0.54 0.29 0.34 0.33

232 1.73 232 1.32 232 0.59

0.65 0.51 0.46

246 P. TYLER A N D D. CUSHWAY

obtained for each person; a score of 5 or more overall is taken as an indication of poor mental health (there is found to be 87 per cent concurrence with psychiatric assessment, according to the GHQ manual).

Coping questionnaire. A coping questionnaire devised by Moos et a1.’ was used in two previous studies on general n ~ r s e s . ~ ’ ’ ~ The original 34 items were increased to 39 by the addition of several items on help-seeking. The data from these studies were factor analysed, resulting in three factors which were easily identified with Moos et al.’s three methods of coping, i.e. active cognitive, active behavioural and avoidance coping. No evidence was found for Moos et al.’s foci of coping (problem-solving, etc) being psychometrically separate scales. The number of items was then reduced to 25 by discarding all items which had low loadings on, or reduced the internal consistency of the three scales. Each item on the coping questionnaire was answered on a four-point scale, scored from 0 to 3 (‘no’, ‘yes, once or twice’, ‘yes, sometimes’ and ‘yes, fairly often’). There were three subscales representing different response strategies (active cognitive coping, active behavioural coping and avoidance coping).

A single question placed after the coping schedule asked nurses to rate on a six-point scale how stressed they felt they were as a result of their present job (‘stress level’).

Procedure

With the cooperation of the hospital management, the questionnaire packages were distributed to all nurses, qualified and unqualified, in all areas of the two hospitals. They were accompanied by a letter explaining the purposes of the study and requesting cooperation. The questionnaires were completed anonymously. The questionnaire data were ana- lysed using the SPSS-PC+ software package. Because each of the individual questionnaires had several scales which normally correlate with one another, it was thought best to control for Type 1 errors by initially analysing the data using multi- variate analysis of variance. If differences were found within a questionnaire, these were investi- gated further using univariate F-tests, as recom- mended by the SPSS manual. Significant univariate comparisons have only been included in the results if the relevant multivariate analysis resulted in a

significant F value. A similar analysis was carried out on the four global measures (NSS mean, GHQ mean, job satisfaction and the self-rated stress level) and another on six demographic variables (age, time in nursing, time on ward area, grade, qualification and number of children).

RESULTS

R e ~ a ~ ~ 5 ~ s ~ ~ p of stress to gender, grade and experience

There were few differences due to gender. Males were more likely to be looking for another job (x: = 8.36, p<0.005) . Males had spent less time than females in their present position ( 2 years vs 4.7 years; F1.210 = 4.50, p < 0.05) and less time than females in nursing (7.9 years vs 13.1 years; F I , ~ I O = 5.39, p<O.O5). No gender differences were found in stressors, coping strategies or mental well- being on the GHQ.

Level 1 nurses (SRN) had the highest and level 3 (unqualified nurses) the lowest NSS mean score (F2.213 = 6.57, p < 0.005), ‘conflict with doctors’ (F2.224 = 32.01, p<O.OOl), ‘conflict with other nurses’ (F2,224 = 4.89, p<O.Ol), ‘workload’ (F2.224 = 9.89, p < O . O O l ) , ‘uncertainty over treat- ment’ = 12.27, p<O.OOl) and stress level ( F 2 , 2 1 3 = 11.98, p < 0.001). Qualified nurses (SRN and SEN) were less satisfied with their jobs than were unqualified (F2,213 = 3.38, p<0.05) .

In qualified nurses (grades C-H) there were differences between the grades on the NSS (Pillais’ F35,955 = 1.91, p < 0.001) and in self-reported stress level (F5,186 = 3.98, p < 0.005). As grade increased there was a linear increase in self-rated stress level (linear F1,190 = 13.93, p<O.OOl), ‘conflict with doctors’ (linear F1.193 = 4.08, p < 0.05) and ‘work- load’ (linear F1,193 = 12.64, p<O.OOl). There were non-linear differences in ‘death and dying’ (non- linear F4.193 = 2.76, p<0 .05) and ‘conflict with doctors’ (quadratic F1,193 = 7.35, p<O.Ol) caused by lower than expected stress in the highest grades. Differences between grades in GHQ, coping and job satisfaction were not significant.

Those nurses who expected to leave their jobs within 1 year were in lower grades, had spent less time in their present job, less time in nursing, had fewer children and were younger (26 vs 35) than those expecting to stay (Pillais’ F6.202 = 6.95, p<O.OOl ) . They did not differ in the stress scales, coping strategies or GHQ. Those who had received post-qualification training had higher stress scale

STRESS IN NURSES 247

frequencies overall (Pillais’ F7.224 = 5.74, p <O.OOl) , and specifically higher ‘conflict with doctors’ (F1.230 = 12.03, p<O.OOI) and ‘workload’ (Fl,230 = 3.87, p < 0.001). Nurses with post-qualifi- cation training used cognitive coping strategies (F1.222 = 16.68, p < O . O O l ) and behavioural coping strategies (Fl,222 = 11.57, p < O . O O I ) more often.

Relationship of stressors to GHQ

Five sources of stress on the NSS were found to correlate significantly with the GHQ mean. The first was ‘lack of social support’ ( r = 0.33), while the others were ‘workload’ ( r = 0.26), ‘conflict with doctors’ ( r = 0.23), ‘inadequate preparation’ ( r = 0.19) and ‘conflict with other nurses’ ( r = 0.17). Multiple regression of the GHQ mean on the seven NSS stressors indicated that they largely accounted for a common portion of the variance in the GHQ, as only the partial regression coefficient for ‘lack of social support’ was sig- nificant (p = 0.29, p<O.OOl; r2 = 0.16). However, ‘death and dying’ acted as a weak suppressor variable as its partial regression coefficient was negative (p = -0.18, p<0.05), indicating that nurses who were more at risk for psychiatric problems felt less stress than might be expected from death and dying. When the three coping strategies were added to the equation, only avoidance coping was significantly related to the GHQ mean (p = 0.25, p<O.OOl, r2 = 0.22).

GHQ caseness. Seventy-five (31 per cent) of the nurses met the GHQ criterion for ‘caseness’ of 5 or more. ‘Cases’ reported significantly higher frequencies for all the NSS stressors except for ‘death and dying’ and ‘uncertainty over treat- ment’ (Pillais’ F7,234 = 3.05, p<0.005) as well as for the NSS mean (F1,226 = 12.19, p < O . O O l ) . They also had a higher self-rated stress level (F1,226 = 23.94, p<O.OOl) and lower job satisfac- tion (FL,226 = 18.11, p<O.OOl). They did not differ significantly from non-cases in any of the demographic variables.

Stress level

In response to the item asking how stressed the nurses felt as a result of their present job, 123 (52 per cent) were not very stressed (points 1-3 on the seven-point scale), 48 (20 per cent) were moder- ately stressed (point 4) and 64 (27 per cent) were stressed or very stressed (points 5-7); 10 did not

respond. We were interested to know whether people who are asked how stressed they feel base their response on their impression of the stressors observed, the symptoms experienced or their engagement of their coping resources. A stepwise multiple regression analysis with stress level as the dependent variable and NSS scales, GHQ scales and coping scales as the predictors showed that all three factors were involved. NSS scale ‘workload’ was entered on step 1 (in the final equation p = 0.21, p<0.005), GHQ scale ‘anxiety and insomnia’ on step 2 (p = 0.26, p<O.OOI), active behavioural coping on step 3 (p = 0.16, p<O.Ol) and NSS scale ‘lack of support’ on step 4 (p = 0.13, p < 0.05), and together they accounted for 27 per cent of the variance in stress level (F4.227 = 2 I . 18, p < 0.00 1).

Social support

Those who had partners or spouses were older, had more children and had spent more time in their present job and more time in nursing; they were not significantly more highly trained or in higher grades (Pillais’ F12.414 = 7.66, p<O.OOl). Single people were most stressed by ‘uncertainty over treatment’, separated or divorced ones least (F2,239 = 4.35, p<O.O5). People with a spouse or partner had a higher somatic symptoms score than single or separated ones (F2,240 = 3.19, p<O.O5). Males with a partner displayed more anxiety, social dysfunction and severe depression while females with partners showed fewer of these symptoms than single people (Pillais’ F8.464 for sex x partner interaction = 3.05, p < 0.005).

While 85 (3 1 per cent) of the nurses reported that they were not living with a spouse or partner, only 24 (10 per cent) said that they could not talk to their partner about problems at work. Fifteen of these were living with a spouse or partner. Those who got no support from a partner had signifi- cantly fewer children living at home (F2.210 = 4.88, p < 0.01), had lowest job satisfaction (F2.224 = 5.11, p < 0.0 1) and experienced most severe depression (F2.239 = 3.35, p<0.05) . Those who had no sup- port from other family members were in higher grades (but not significantly older), had spent longer in nursing (16.3 vs 11.7 years), were better qualified and had more children at home (Pillais’ F6.207 = 4.27, p<O.OOl); they also had a higher self-rated stress level (F1.226 = 6.00, p < 0.05), more ‘workload’ stress (F1,240 = 12.25, p<O.OOI) and lower job satisfaction (F,,226 = 6.29, p<O.O5) and

248 P. T Y L E R A N D D. CUSHWAY

Table 2-Interactions showing buffering effects of five moderator variables between four sources of stress and psychological distress (GHQ mean score). These are the partial regression coefficients and their associated R’ for the interaction terms in the multiple regression analysis, after the main effects of the respective stressor and moderator have been removed. Column 2 displays the correlation of the stressor with the GHQ mean score

Stressor r Moderator JOBSAT COGCOP BEHCOP AVOICOP SOCSUP

P R’ P R? B R2 P R’ s R? CONDOC 0.23 -0.17 0.027 -0.08 0.007 -0.08 0.006 0.05 0.002 0.06 0.003 INADPR 0.19 -0.02 0.001 -0.03 0.001 -0.07 0.005 -0.01 0 -0.07 0.004 CONNUR 0.17 -0.04 0.008 -0.14 0.02 -0.14 0.018 -0.07 0.005 -0.05 0.002 WORKL 0.26 -0.14 0.021 -0.11 0.01 -0.08 0.005 -0.04 0.002 0.09 0.007

Notes I , Stressors: CONDOC, conflict with doctors; INADPR, inadequate preparation; CONNUR, conflict with other nurses; WORKL, workload. 2. Moderators: JOBSAT, job satisfaction; COGCOP, active cognitive coping; BEHCOP, active behavioural coping; AVOICOP, avoidance coping: SOCSUP, social support.

higher mean GHQ (F1,226 = 5.52, p<0.05). Those with no friends for support had lower behavioural coping scores (F1,232 = 7.64, p<O.Ol).

Bufering

In order to examine the contribution, if any, of the interaction between each stressor and each of the coping strategies, a series of multiple regression analyses was performed, in which the chosen stressor and coping strategy were entered first, followed by the interaction between them. Inter- actions were calculated by first transforming both stressor and coping variables to z-scores and then multiplying them together. A significant change in r2 would indicate a significant interaction. The criterion variable for all the multiple regression analyses was the GHQ mean. Two-way interac- tions were examined between four sources of stress, ‘conflict with doctors’, ‘conflict with nurses’, ‘inadequate preparation’, and ‘workload’, and five moderator variables, ‘active cognitive coping’, ‘active behavioural coping’, ‘avoidance coping’, ‘job satisfaction’ and ‘social support’. Lack of social support is considered as a source of stress on the NSS, but for this analysis it was entered as a possible moderator variable because of the pre- vious literature on the subject summarized in the introduction.

Table 2 shows, for each combination of stressor and moderator, the partial regression coefficient and r2 for their interaction. The interaction effects were all small and non-significant, but mainly negative, indicating that the moderator variables were working in the predicted direction (1 7 out of 20 were negative, binomial p < 0.01). The interac-

tions of ‘conflict with other nurses’ with the two active coping strategies and of ‘conflict with doctors’ and ‘workload’ with job satisfaction were the largest, and all four would have been significant individually at the 0.05 level. However, when a Bonferroni correction was applied to correct for the inflation of the alpha level by multiple tests, it ensured that none of them reached significance on a family-wise basis.

DISCUSSION

The main results of this study corresponded reasonably well with what has been found pre- viously. As a source of stress, ‘death and dying’ was not quite as important as was found by Hipwell et ~ 2 1 . ~ or Tyler and C ~ s h w a y . ~ However, ‘workload’, the other source found to be high previously, was the strongest by some margin in this population. The change may reflect the result of recent upheavals and reorganization of the NHS. ‘Lack of social support’ was the least important overall of the seven sources of stress studied. Tyler and Cushway3 made a distinction between stressors like dealing with death and dying patients, which are intrinsic to nursing and which might respond to individual measures such as stress management methods, and those like work overload, which are structural and require organi- zational intervention for their relief. This study suggests that the intrinsic stressors may have received more attention recently than the structural ones. The overall level of satisfaction with social support may also help to explain the lower stressfulness of the intrinsic stressors.

STRESS I N NURSES 249

The increase in amount of stress with grade and status, and with the amount of post-qualification training, has also been found b e f ~ r e . ~ , ’ ~ More experienced and more highly trained nurses per- ceive more stress from certain sources, particularly from ‘conflict with doctors’ and ‘workload’. It is to be expected that with increasing seniority and training comes more responsibility and therefore more work pressure and the possibility of conflict with other professionals over the treatment of patients. l 9 Concomitant with increased stress, however, comes a wider range and more frequent use of adaptive coping techniques. It is noteworthy that seniority and training are not associated with increased psychological distress; the sample size of this study would have provided sufficient power to detect even a low degree of association. Overall, there is, as expected, an association between frequency of reported stress and amount of psychological distress, as measured by the GHQ. Thus the improved coping techniques of the more experienced nurses appear to be effective in protecting them from the negative psychological effects of stress.

The correspondence of these results with those reported earlier, and especially the finding that the caseness frequency of 3 1 per cent is almost identical to that found previously in nurses in our region, goes some way to ameliorate the rather disappoint- ing return rate of the questionnaires. The most common explanation that we heard was ‘ques- tionnaire fatigue’, but an element of distrust of management, whose help was enlisted to distribute the questionnaires, was indicated by the number of respondents who declined to give some potentially identifying information such as age and grade. Strong assurances of anonymity were given in the covering letter, and these in fact prevented us from following up non-responders individually. It is probably inevitable that there is some sampling bias, as is always the case with volunteer samples in psychological studies, in this case in the direction of excluding the extremes of good and ill health. However, the comparisons with other studies indicate that such bias has not seriously influenced the main conclusions of the study.

The main aim of this study was to determine whether there were buffering or interactive effects of social support and coping techniques. Even though lack of social support was an unimportant source of stress overall, it did have a strong direct effect on psychological distress as measured by the correlation with the GHQ measure: the more social

support nurses had within the organization, the better they felt. This finding corresponds well with many studies in social psychology which have found that higher levels of social support increase feelings of well-being, and the strong relationship with other stressors provides some evidence for Beehr and McGrath’sl’ suggestion that i t is lack of social support which is stressful. On the other hand, there was no evidence that social support interacts with any of the other sources of stress; those without social support were not more reactive to stress than those who had a great deal. This finding is slightly counterintuitive and contra- dicts the bulk of studies reviewed by Cohen and Willsio on general stress. However, it does support the findings reviewed by Beehr and McGrath” on occupational stress. Two possible explanations suggest themselves: either nurses always have an adequate level of social support available, by the nature of their profession, so a relatively small decrease in its availability is insufficient to have much impact; or the type of occupational stressor which affects psychological well-being in nurses is not very susceptible to amelioration by social support. The direct effects of social support on well-being would seem to argue against the first explanation, and the results of other s t u d i e ~ l ~ ~ ’ ~ ~ ’ ~ of occupational stress favour the second.

Interactions of the positive, or adaptive, coping strategies with particular stressors were small but consistently negative. The largest involved the NSS subscale ‘conflict with other nurses’, which mainly picks up stress caused by conflicts between more junior and more senior nurses (eg staff nurse and ward sister). It is not immediately clear why the buffering effect of coping seemed more applicable to conflict with nurses. However, inspection of the data analysis suggests a statistical reason. The interactions with conflict with nurses contributed only an additional 2 per cent to the proportion of variance accounted for in the GHQ mean. The interactions of coping strategies with stressors were in the predicted direction, but they accounted for too little of the residual variance after the main effects were removed to achieve significance. There is very little power in multiple regression analysis to detect interactions, especially if the main effects are fairly marked. Even so, in this study the sample size was sufficiently large to have detected interac- tions if they had had any substantial explanatory value. So it must be concluded that for stress in nurses the buffering effects of social support and coping are unimportant.

250 P. TYLER AND D. CUSHWAY

As Lazarus and Folkman’ have emphasized, stress is a transactional process involving the presence of disruptive environmental forces, such as excessive workload or demands from super- visors, the appraisal of these as potentially harmful by the individual and the secondary appraisal by the individual of their coping resources. If the demands exceed the coping resources, which may include personality factors and social support availability as well as specific coping strategies, then there may be negative consequences for mental health. This transactional model receives some support from our results. For example, it is clear that environmental stressors such as ‘death and dying’ may be appraised as present and unpleasant without them having negative conse- quences for mental health; other factors like ‘lack of social support’ are unimportant for most nurses, but when present they are seen as very disruptive for mental health.

These results then raise the question of what we mean when we say we are stressed. Are we saying that work pressures are high, that we are aware of engaging our coping strategies, or that we are feeling anxious and depressed, with symptoms such as headaches, sleeplessness or palpitations? Analy- sis of responses to the question ‘How stressed do you feel as a result of your job?’ suggests that all of these factors are involved. A general feeling of anxiety, associated with an appraisal that there is too much work to do, the use of behavioural coping strategies and accompanied by a feeling that insufficient social support is coming from superiors and colleagues, gives rise to a feeling of being stressed at work. Consequently, it should perhaps be emphasized that a ‘stress’ question- naire, such as the Gray-Toft and Anderson Nursing Stress Scale, which assesses the presence of stressors in the nursing environment, cannot be used by itself to evaluate stress. At a minimum an outcome measure such as the General Health Questionnaire is also needed, so that the presence of the environmental stressor can be related to the mental health outcome. Of the other potential outcome measures that we took, absenteeism due to ill-health or other reasons was unrelated to anything else, even GHQ caseness; intention to stay in the job seemed to be related to mobility and ambition rather than to stress. Job satisfaction was moderately related to the GHQ measure and to the stressors. Most nurses have been found in a number of studies to be reasonably well satisfied with their vocation and unwilling to contemplate

another occupation, even when they feel them- selves to be under stress. There was a low negative correlation between the job satisfaction scale and the GHQ mean of -0.33. This is similar to the correlation found in other occupationsZo between global job satisfaction and mental health, and suggests that employees whose perceptions of their job are generally positive tend to have good mental health. We thought that job satisfaction might act as a moderator variable comparable to coping and social support, but although there was a hint of a buffering effect, especially with ‘workload’ and ‘conflict with doctors’, it was once again so small as to be negligible.

In conclusion, a transactional model such as that proposed by Lazarus and Folkman* and favoured by many workers in the field of stress research today received strong support from the results of this study. An ongoing process of assessment of the strength and potentially damaging consequences of the stressors and of the availability of coping resources and social support does not, however, imply that these two major factors have to interact in a statistical sense to influence psychological well- being.

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