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Publication Date: August 25, 2021
DOI:10.14738/assrj.88.10782. Williams, G., Pendlebury, H., & Smith, A. P. (2021). Stress and the Well-Being of Nurses: An Investigation Using the Demands- Resources- Individual Effects (DRIVE) Model and the Well-Being Process Questionnaire (WPQ). Advances in Social Sciences Research
Journal, 8(8). 575-586.
Services for Science and Education – United Kingdom
Stress and the Well-Being of Nurses: An Investigation Using the
Demands-Resources- Individual Effects (DRIVE) Model and the
Well-Being Process Questionnaire (WPQ)
Gary Williams
Centre for Occupational and Health Psychology
School of Psychology, Cardiff University, 63 Park Place
Cardiff CF10 3AS, UK
Hannah Pendlebury
Centre for Occupational and Health Psychology
School of Psychology, Cardiff University, 63 Park Place
Cardiff CF10 3AS, UK
Andrew P Smith
Centre for Occupational and Health Psychology
School of Psychology, Cardiff University, 63 Park Place
Cardiff CF10 3AS, UK
ABSTRACT
Previous research shows that nurses have high levels of stress, but less is known
about their well-being. The present research used an adapted version of the
Demands-Resources-Individual Effects (DRIVE) model to investigate these areas.
The Well-Being Process Questionnaire (WPQ), which consists of single items
derived from longer scales, was also used. One hundred and seventy-seven British
nurses (160 female, 17 male) participated in an online survey. The results showed
that work characteristics could be grouped into three factors (resources; demands;
and role/change/bullying), as were personality scores (positive personality;
openness, agreeable, conscientious; and extraversion, emotional stability). Coping
(positive and negative coping) and outcomes (positive and negative outcomes, and
positive and negative job appraisals) had a two-factor solution. Results from logistic
regressions showed that well-being outcomes were predicted by high positive
personality and low negative coping. Positive job appraisals were predicted by high
resources and low demands. These findings confirm that the use of the DRIVE model
and a single short item measuring instrument can quickly provide information
about factors predicting the well-being of nurses.
Key words: DRIVE model; Nurses; Stress; Well-being; WPQ.
INTRODUCTION
The aim of the present study was to investigate stress and well-being in nurses using the
Demands-Resources-Individual Effects (DRIVE) model [1] and a measuring instrument using
short versions of established questionnaires (the Wellbeing Process Questionnaire – WPQ
Short Form, [2,3]). The next section briefly reviews the stress and well-being of nurses.
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Stress and well-being of nurses
Research in the last 20 years has shown that health professionals are at significant risk from
the negative effects of stressful workplaces [4, 5]. Calnan et al. [6] administered the GHQ 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. Of health
workers, nurses are particularly at risk from stress-related problems, with high rates of
turnover, absenteeism and burnout [5, 7]. Clegg [7] cites statistics from 1979-83 showing that
suicide rates for nurses were significantly higher than the national average, and life expectancy
for nurses was approximately 72, only one year more than miners. Lambert et al. [8] note that
most research on nursing stress has taken place in the UK and USA, and they then showed that
Japanese nurses also face similar issues.
Mark and Smith [9] reviewed the literature on stress in nurses, and this can be briefly
summarised as follows. 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 [10] as well as working shifts and bullying [11]. McVicar [12] states that many nursing
work situations are high in "emotional labour", where they are expected to regulate their
emotions during interactions with patients, colleagues and their managers according to the
health care system's guidelines.
Both the Demands-Control-Support model (DCS: [13]) and the Effort-Reward imbalance model
(ERI: [14]) have been used in research involving nursing populations [15, 16]. These models
largely focus only on job characteristics [17] and often do not take account of individual
differences. Transactional models of stress included coping styles as an initial individual
difference in the stress process. Folkman et al. [18] claim that problem-focused forms of coping
are associated with lower levels of negative health outcomes and that coping of an emotional- focused type, such as self-blame or escape/avoidance, is associated with poor mental health.
This view has been tested with nurses. Healy & McKay [19] found that avoidance coping
predicted poor mental health, whereas active problem solving was positively related to
satisfaction.
Mark and Smith [9] investigated the relationships between job characteristics and coping in
predicting levels of anxiety and depression in nurses. Their 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 was associated with fewer mental
health problems. Coping behaviours significantly added to the explanation of variance in
anxiety and depression outcomes. The above effects were largely independent, and there were
few significant interactions.
Since the Mark and Smith [9] study, other research has added to the knowledge of stress in
nursing. This more recent research has been carried out in different countries, and, in general,
similar results have been found across cultures. Cross-national differences often occur because
the professional roles and duties vary. For example, in Italy, nursing is often considered as an
auxiliary profession, with nurses' expertise not receiving accreditation and recognition [20].
Happell et al. [21] used focus groups to identify sources of occupational stress in nursing.
Sources included: high workloads, unavailability of doctors, unsupportive management, human
resource issues, interpersonal issues, patients' relatives, shift work, car parking, handover
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Williams, G., Pendlebury, H., & Smith, A. P. (2021). Stress and the Well-Being of Nurses: An Investigation Using the Demands-Resources- Individual
Effects (DRIVE) Model and the Well-Being Process Questionnaire (WPQ). Advances in Social Sciences Research Journal, 8(8). 575-586.
URL: http://dx.doi.org/10.14738/assrj.88.10782
procedures, no common area for nurses, not progressing at work and patient mental health.
Suggestions for stress reduction included: workload modification, non-ward-based initiatives,
changing shift hours, forwarding suggestions for change, music, special events, organisational
development, ensuring nurses get breaks, massage therapists, acknowledgement from
management and effective leadership within wards. Similar research has been carried out in
other countries. For example, Adib-Hajbaghery et al. [22] carried out a content analysis of
interviews to identify stress in Iranian nurses. Three categories emerged: "nurses' perceptions
of job stress", "professional interest", and "prioritising career over family life". The first
category included the following subcategories of "being in a constant alarm situation," "lack of
experience", "dignity and social status", "lack of proper logistics", "shortage of nurses",
"Irregularities in the organisation," "directors of nursing performance," "undesirable relations
among colleagues," and "the patients' conditions". All of these factors affected the nurses' level
of professional stress.
Other research [23] also examined sources of stress and linked these to job turnover intentions.
The results showed that a third of hospital nurses rated their occupational stress as high. The
major sources of stress were inadequate pay, inequality at work, too much work, staff shortage,
lack of promotion, job insecurity and lack of management support. Occupational stress was
positively associated with nurses' turnover intentions, with more than 35% of nurses
considering leaving the hospital if they could find another job opportunity. Suresh et al. [24]
concluded that stress continues to be a problem for nurses in the clinical setting. Excessive
workload requires urgent attention by hospital managers in view of widespread retention
difficulties. The themes identified could provide a framework for possible interventions for
improving the clinical environment for nurses. Research [25] has also aimed to improve the
resilience of nurses using techniques such as mindfulness or cognitive-behavioural
interventions [26]. These approaches can be incorporated into general training and may
generally reduce stress and also be important in specific changes (e.g. the transition from
student to graduate nurse).
There have been few studies of positive outcomes (life satisfaction; positive affect; happiness)
in nurses. The aim of the present study was to provide information on this topic. Other research
has examined positive resources such as control and support and shown that these can reduce
negative outcomes such as burnout [27]. There has also been a call to improve positive features
of nursing rather than just reduce negative features [28, 29]. Others [30] argue that one must
make a distinction between emotional work and emotional labour in nursing. Findings support
the Conservation of Resources Theory [31] with "emotional work" (emotional response
behaviours performed for the benefit of the nurse's relationships with others – e.g.
companionship, help and regulation), rather than "emotional labour" (emotional regulation as
part of their professional role largely for the benefit of the organisation), enabling the uptake
of resources and leading to positive occupational health and well-being.
Nurses have been selected as the population for the current study, given the many stressors
they face and the high levels of negative health outcomes they suffer from [5]. The traditional
models of Demands-Control-Supportand Effort-Reward-Imbalance were tested simultaneously
in this population to see how much each contributes to the variance in different well-being
outcomes. Ways of coping are also being investigated due to their centrality in transactional
stress models and to see how much additional variance they explain over the use of DCS and
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ERI. McVicar 12] and Kirkcaldy & Martin [5] also suggest that there is a need for more
understanding of how individual variation in reactions to stressors in nurses affects health
outcomes. This is examined here by considering aspects of personality.
The Demands-Resources-Individual Effects (DRIVE) Model
Mark and Smith [1] suggested that an ideal approach is to have a model of the stress process
that accounts for circumstances, individual experiences, and subjective perceptions without too
much complexity. Research using the DRIVE model has supported the direct effects of these
variable groups on outcomes, although little support was found for interactions [9, 32]. The
DRIVE model can also be easily adapted by adding or removing factors relevant to the
circumstances they are applied to. In the present study, the model (see Figure 1) added
personality measures, as it has been suggested that personality is a significant predictor of
emotional well-being [33-35] and that taking personality into account is important for
increasing well-being [3, 36].
Figure 1: The adapted DRIVE model used in the present study.
The model used here also includes subjective well-being (SWB) more directly, with satisfaction
(both life and job) and positive affect as separate components as recommended by prior
research [37]. The other outcomes were stress (both life stress and job stress), negative mood,
depression, and anxiety: the most commonly assessed negative aspects of well-being. Although
these outcomes are measured individually, they can also be conceptually grouped in terms of
positive, negative, cognitive (appraisals), and emotional categories, and more broadly as
aspects of well-being as a whole. As a result, the present application provides a simpler but
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Williams, G., Pendlebury, H., & Smith, A. P. (2021). Stress and the Well-Being of Nurses: An Investigation Using the Demands-Resources- Individual
Effects (DRIVE) Model and the Well-Being Process Questionnaire (WPQ). Advances in Social Sciences Research Journal, 8(8). 575-586.
URL: http://dx.doi.org/10.14738/assrj.88.10782
broader approach to well-being than the original DRIVE model, although there is also an
increased potential for redundant variables.
Development of single-item measures of well-being and associated variables
The variables that were chosen represent those used in previous research applying a multi- faceted approach to workplace well-being [9, 32, 38, 39]. Variables were congruent with
international and national well-being definitions [40, 41], had strong research evidence for
their association with well-being [32, 42-45] and were recommended for well-being
assessment [46, 47].
Overall, this review suggests that there is a need to provide more information on the predictors
of positive well-being of nursing staff. In summary, the present research involved nursing staff,
representing 1 out of 3 occupations with the highest estimated prevalence of work-related
stress in the UK [48]. Previous work on the DRIVE model also used a nursing sample [9];
therefore, the application of this approach in this research sample is already established,
providing a suitable foundation for further research using the WPQ. There is much smaller
literature on positive well-being in nurses. Most studies on this topic have looked at job
satisfaction and considered factors that alter it. Quite often, factors that improve job satisfaction
(e.g. rewards, social support, control, positive coping and attributions) also lead to a reduction
in negative outcomes (e.g. anxiety and depression [32]). However, the relative contributions of
individual characteristics and features of the work require further investigation.
METHOD
This research was approved by the Ethics committee, School of Psychology, Cardiff University,
and carried out with the informed consent of the participants. Participants were recruited
through the Royal College of Nursing. The study involved an online survey presented using
SurveyTracker that they could complete in their own time. Participants were instructed that
they could skip any questions that they were not comfortable answering, although all data were
provided anonymously. Informed consent was achieved within the questionnaire, where
participants without agreeing could not continue beyond the consent page. Following the
consent page, participants were presented with an instructions sheet and a debrief sheet.
Participants
One hundred and seventy-seven nursing staff members (160 female; 17 male) aged 19-69
(mean age: 40 years) participated in the study. This number of participants was considered
satisfactory to identify the large effect sizes based on previous research and to provide a
meaningful cases-to-IV ratio for regression analysis [49]. The majority of the volunteers were
married or living with a partner (66%) and were educated to degree or higher degree level
(86.6%). Participants from all areas of nursing responded to the survey, including practitioners,
educators and managers.
Materials
A questionnaire (the WPQ) consisting of single-item measures was used. The variables
included:
• Previous DRIVE model variables – work demands, effort and over-commitment;
resources: control, support and reward at work; coping style.
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• Additional work characteristics: role understanding, consultation on change (HSE
Management Standards), bullying [50] and supervisor relationship [51].
• Personality - Extraversion, emotional stability, conscientiousness, agreeableness, and
openness (the "Big 5"); optimism, self-esteem, and self-efficacy.
• Outcomes: Job stress, life stress, negative affect, depression, and anxiety; positive
mood, happiness, job satisfaction and life satisfaction.
Table 1 shows the complete set of single-item questions. Previous research with university staff
[3] has shown that these items have good reliability and validity.
Table 1: Single item questions
Work characteristics
(Effort) I feel that I do not have the time I need to get my work done (for example: I am under constant
time pressure, interrupted in my work, or overwhelmed by responsibility or work demands)
(Reward) I feel that I have been rewarded for my efforts (for example: The respect, role, and job
prospects I receive are suitable for my efforts and achievements)
(Demands) I feel that my work is too demanding (for example: I have to work very fast, I have to
work very hard, I have conflicting demands)
(Control) I feel that I get adequate control over my work (for example: I have a choice in what I do or
how I do things, I am able to learn new things, I am able to be creative)
(Support) I feel that I am supported by my colleagues (for example: there is a good atmosphere at
work, I get along with my colleagues, my colleagues understand me)
(Bullying) I feel that I have been subjected to bullying in the workplace in the past 12 months (for
example: unjustified criticism, verbal/non-verbal threats, violence, humiliation or exclusion)
(Change) I feel that I am not consulted about changes at work (for example: There is no opportunity
to question managers about change, I am unclear about how the change will work out in practice).
(Role) I feel that I don't understand my role clearly ( For example: I am not clear of what is expected
of me and what tasks I need to perform)
(Supervisor relationship) I feel that I get along well with my supervisor ( For example: I know where
I stand in terms of their opinion of me, my supervisor understands me, my supervisor recognises my
potential)
Coping
(Positive Coping) When I find myself in stressful situations, I try to deal with them in a pro-active
way (For example: by taking one step at a time, by changing something so that it would work out, by
learning from the situation, by asking someone for help)
(Negative Coping) When I find myself in stressful situations, I tend to look inwardly (For example: I
blame myself for the situation, wish that I had the power to change what has happened, wish the
situation would go away, try to forget the whole thing)
Personality
(Optimism) In general, I feel optimistic about the future (For example: I usually expect the best, I
expect more good things to happen to me than bad, It's easy for me to relax)
(Self-efficacy) I am confident in my ability to solve problems that I might face in life (For example: I
can usually handle whatever comes my way, If I try hard enough I can overcome difficult problems, I
can stick to my aims and accomplish my goals)
(Self-esteem) Overall, I feel that I have positive self-esteem (For example: On the whole, I am satisfied
with myself, I am able to do things as well as most other people, I feel that I am a person of worth)
(Extraversion) I consider myself to be outgoing (For example: Talkative, comfortable with myself,
confident in social situations)
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Williams, G., Pendlebury, H., & Smith, A. P. (2021). Stress and the Well-Being of Nurses: An Investigation Using the Demands-Resources- Individual
Effects (DRIVE) Model and the Well-Being Process Questionnaire (WPQ). Advances in Social Sciences Research Journal, 8(8). 575-586.
URL: http://dx.doi.org/10.14738/assrj.88.10782
(Agreeableness) I feel that I have an agreeable nature (For example: I feel sympathy toward people
in need, I like being kind to people, I'm co-operative)
(Conscientiousness) I feel that I am a conscientious person (For example: I am always prepared, I
make plans and stick to them, I pay attention to details)
(Emotional stability) I feel that I can get on well with others (For example: I'm usually relaxed
around others, I tend not to get jealous, I accept people as they are)
(Openness) I feel that I am open to new ideas (For example: I enjoy philosophical discussion, I like to
be imaginative, I like to be creative)
Outcomes
(Positive affect) Thinking about myself and how I normally feel, in general, I mostly experience
positive feelings (For example: I feel alert, inspired, determined, attentive)
(Negative affect) Thinking about myself and how I normally feel, in general, I mostly experience
negative feelings (For example: I feel upset, hostile, ashamed, nervous)
(Job Satisfaction) Overall, I feel that I am satisfied with my job (For example: In most ways, my job is
close to my ideal, so far I have gotten the important things I want in my job)
(Life Satisfaction) Overall, I feel that I am satisfied with my life (For example: In most ways, my life
is close to my ideal, so far, I have gotten the important things I want in life)
(Depression) On a scale of one to ten, how depressed would you say you are in general? (e.g. feeling
'down', no longer looking forward to things or enjoying things that you used to)
(Anxiety) On a scale of one to ten, how anxious would you say you are in general? (e.g. feeling tense
or 'wound up', unable to relax, feelings of worry or panic)?
(Job Stress) In general, how stressful do you find your job?
(Life Stress) In general, how stressful do you find your life?
Analysis Procedure
Analyses were carried out using the IBM SPSS 23 package. Guidance from Tabachnick and Fidell
[49] was followed with the data assessed for outliers, missing values and normality. Factor
analyses were carried out for the groups of variables (work demands; resources; personality;
coping and outcomes) related to the DRIVE model. Factor scores were then dichotomised, and
logistic regressions were then performed to examine associations between the predictor
variables and outcomes.
RESULTS
Separate factor analyses were performed for the job characteristics, personality variables,
coping scores and outcomes. These involved principal components analyses extracting factors
with Eigenvalues greater than one and with varimax rotation.
The analysis of the job characteristics revealed three factors accounting for 62% of the
variance:
1. Resources (35.1% of the variance; support, control, rewards).
2. Demands (17.9% of the variance; demands, effort and over-commitment).
3. Role/Change/Absence of Bullying (9.3%)
The analysis of the personality variables also revealed a three-factor solution accounting for
66% of the variance:
1. Positive personality (36.4% of the variance; self-esteem, optimism, and self-efficacy).
2. Openness, Agreeable and Conscientious (16.8% of the variance).
3. Extraversion/Emotional stability (12.9%).
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Williams, G., Pendlebury, H., & Smith, A. P. (2021). Stress and the Well-Being of Nurses: An Investigation Using the Demands-Resources- Individual
Effects (DRIVE) Model and the Well-Being Process Questionnaire (WPQ). Advances in Social Sciences Research Journal, 8(8). 575-586.
URL: http://dx.doi.org/10.14738/assrj.88.10782
– [52-54]). The profile of results found here was different from that seen in other professions
(e.g., university staff – [3]). This suggests that it may be appropriate to maintain most of the
WPQ items when investigating new samples or to consider samples from a wide range of
occupational sectors.
Summary
In summary, both the older literature and more recent research suggest that nurses report high
levels of stress and reduced well-being. The present study has shown that a DRIVE model,
encompassing job characteristics and individual effects, can identify predictors of these
outcomes. The WPQ has the ability to measure these factors very quickly and is an ideal tool to
use in both audits of psychosocial factors and the assessment of interventions. These
interventions could involve changes in job characteristics, development of coping skills or
therapeutic approaches dealing with established problems. The presence of an underlying
model and short measuring instrument will enable more effective prevention and management
of negative influences and outcomes and also allow promotion of positive well-being.
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