Safety and Health at Work xxx (xxxx) xxx
ailable at ScienceDirectContents lists avSafety and Health at Work
journal homepage: www.e-shaw.orgOriginal ArticleEffect of Workload on Job Stress of Ghanaian OPD Nurses: The Role of
Coworker Support
Emmanuel Kokoroko 1,*, Mohammed A. Sanda 1,2
1Department of Organisation and Human Resource Management, University of Ghana Business School, Legon, Accra, Ghana
2 Luleå University of Technology, Luleå, Swedena r t i c l e i n f o
Article history:
Received 20 September 2018
Received in revised form
24 March 2019
Accepted 12 April 2019
Available online xxx
Keywords:
Coworker support
Job stress
Workload* Corresponding author. Department of Organisatio
E-mail address: emmanuelkok@gmail.com (E. Kok
2093-7911/$ e see front matter 
 2019 Occupational S
ND license (http://creativecommons.org/licenses/by-n
https://doi.org/10.1016/j.shaw.2019.04.002
Please cite this article as: Kokoroko E, Sanda
and Health at Work, https://doi.org/10.1016a b s t r a c t
Background: Although the concept of workload is important to nursing practice, only a few nursing
researchers have focused on the issue of workload within the nursing context. Knowledge of how the
dynamics of workload affects the job stress of nurses working in a specific unit or department in a
hospital setting, and the influence of coworker support on this relationship, still remains limited. This
study, therefore examined the effect of workload on job stress of Ghanaian outpatient department nurses
and the moderating effect of coworker support on this relationship.
Methods: A cross-sectional survey design was used, and questionnaire was used to collect data from a
sample of 216 outpatient department nurses from four major hospitals in Ghana. The data collected
measured workload, job stress, and coworker support using National Aeronautics and Space Adminis-
tration (NASA) Task Load Index, job stress scale, and coworker support scale, respectively. Data were
analysed using descriptive statistics, correlation, and hierarchical regression.
Results: High levels of workload were associated with high levels of job stress of the nurses. Also, higher
levels of workload were related to higher levels of job stress for nurses who received high levels of
coworker support, but this was not the case for those who received low levels of coworker support
(reserve buffering effect).
Conclusion: The finding reiterates the adverse effect of workloads on employees’ health, and the reverse
buffering effect implies that supporting a colleague at work should be conveyed in a positive manner
devoid of negative appraisal.

 2019 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).1. Introduction
In recent times, higher demands on nurses and health-care
workers in terms of work output have been a concern to govern-
ment, researchers, and other stakeholders in the health sector. As a
result, there is a growing interest in understanding the workload of
health workers and its consequent effect on their health. Hospitals
by their nature are stressful organisations [1], and nursing is also
considered as a demanding profession [2] characterized by occu-
pational stress and extreme workload [3,4].
Studies in the health sector have found that nurses experience
the highest workload comparable with other health workers such
as paramedics, support staff, and even doctors [5,6]. According to
Needham [7], nursing workload is “the time taken to carry outn and Human Resource Managem
oroko).
afety and Health Research Institute
c-nd/4.0/).
MA, Effect ofWorkload on Job
/j.shaw.2019.04.002‘direct’ and ‘indirect’ care as well as other activities, including ward
and organization management” (p. 84). Researchers have attrib-
uted the demanding nature of nurses’ work to factors consisting of
work interruptions, procedures, and processes involved in treating
patients, prolonged work hours as well as facing work-related un-
certainties [6,8]. More so, nurses are often confronted with
emotional tasks emanating from making critical decisions under
intense time pressure and caring for patients in critical conditions
[9]. In Ghana, although there have been some significant im-
provements in the nurseepatient ratios from 1:1,251 in 2012 to
1:542 in 2016 [10], a previous report shows that nurses are still
working under intense time pressure to deliver health-care services
[11] According to Aiken et al. [12], aside nurses’ core duties, they
also undertake other responsibilities such as carrying food toent, University of Ghana Business School, P. O. Box LG 78, Legon, Accra, Ghana.
, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-
Stress of Ghanaian OPDNurses: The Role of Coworker Support, Safety
2 Saf Health Work xxx (xxxx) xxx
Co-Worker 
Support
Workload Job Stress
NB: Direct effect;                             Moderation effect
Fig. 1. A model of workload, coworker support, and job stress.patients, house-keeping works and transporting patients among
others. The workload of nurses, therefore comprises of both pro-
fessional and nonprofessional tasks and duties.
A plethora of studies have shown that the workload of nurses
directly and positively relates to job stress with some associated
negative emotions and feelings [13e15]. Nurses’ job stress ac-
cording to Nedd [16] and as adopted in this study refers to “the
emotional and physical reactions resulting from the interactions
between the nurse and his or her work environment where the
demands of the job exceed capabilities and resources” (p.13). High
levels of workload have been reported as one of the primary factors
contributing to nurses’ job stress [17]. Wazqar et al [18], in an
integrative review of the influence of job stress on work perfor-
mance of nurses, identified nurses’ workload levels as the key
determinant of their job stress. In Ghana, the case is similar; studies
have attributed the nurses’ job stress levels to their workload levels
[11,19,20]. According to Donkor [20], 44.2 percent of the sources of
nurses’ stress in Ghana is related to high workload levels.
However, available evidence suggests that the presence of social
supports in organisations provide extra resources that have enabled
and empowered nursing staffs to better cope with their job stress
[21e23]. The concept of social support is amultidimensional concept
encompassing levels of support (low, moderate, or high), kinds of
support (instrumental, emotional, or informational), and sources of
support (spouse, friends, kin, coworkers, or supervisor). Specifically,
coworker support refers to helpful social interactions with work
colleagues in the workplace [24]. The coworker and supervisor
supports are consideredasorganization-based support [25]. Ellis and
Miller [26] further argued that organisation-based supports are far
more efficient inmitigating the adverse effect of workloads and job-
related stress at work than nonework-based supports. According to
Almendra [21], it is easier andmore practical to provide a supportive
work environment for employees than attempting to reduce
stressors atwork. For instance, in a study involvingnurses fromsome
selected Spanish hospitals and health-care centres, Blanco-Donoso,
Garrosa, Demerouti and Moreno-Jimenez found that although
nurses’ emotion regulation difficulties at work negatively affected
their well-being resulting in fatigue and emotional exhaustion,
availability of coworker support was found to have considerably
minimised those health issues [23]. Other researchers have also
found high levels of coworker support to be associatedwith reduced
job stress levels among the nurses [27,28]. Relatedly, Winning et al.
[29], found nurses’ supports from coworkers moderate the positive
relationship between their daily workload and anxiety and depres-
sion, such that low levels of anxiety and depression was associated
with reduceddailyworkload fornurseswho reportedhigher levels of
coworker support but vice versa when supports were low, an indi-
cation of a buffering effect. However, Jenkins and Elliott found
coworker support levels of nurses to strengthened the positive
relationshipbetweenwork stressorsanddepersonalization such that
high levels of depersonalizationwere associated with high stressors
for nurses who reported higher levels of social support, but this was
not the case for thosewho reported low levels of social support. This
is an indication of a clear case of a reverse buffering effect [28].
Threemodels of the processes throughwhich social support acts
to offset workload pressures and job-related stress have been
identified. The main effect or direct effect model argues that social
support improves a person’s health conditions because it enables
basic human needs, such as needs for security, approval, belonging,
and affection to be met irrespective of the volumes of work de-
mands or pressures a person is exposed to [30]. Contrastively, the
indirect effect model maintains that social support acts directly to
reduce work stressors or demands, thereby reducing their adverse
impact indirectly [25]. The buffering or interaction effect model
theorizes that social support buffers or moderates the effects ofPlease cite this article as: Kokoroko E, SandaMA, Effect ofWorkload on Job
and Health at Work, https://doi.org/10.1016/j.shaw.2019.04.002work demands or stressors on strains [25]. Hence, the relationships
between work stressors and work stress will be weaker for in-
dividuals with high levels of social support than those with low
levels of such support.
Notwithstanding that studies have examined different aspects of
the impact of work demand on job stress of health workers globally,
there appear tobevery limited studies conducted inGhanaonnurses’
workload and its consequential effect on their health to guide health-
care policies and practices [11,19,20]. Again, even though the
moderating effect of social support has received major attention in
stressmanagement literature, very limited studies have examined its
moderating effect on job stress within the Ghanaian nursing context.
This study sought to fill these gaps by examining the effect of work-
load on job stress of Ghanaian outpatient department (OPD) nurses,
and the moderating effect of coworker support on this relationship.
Based on the aforementioned text, the following hypotheses and
corresponding conceptual models are shown in Fig. 1
Hypotheses
H1. There will be a significant positive relationship between the
workload and job stress of Ghanaian OPD nurses.
H2. There will be a significant negative relationship between the
coworker support and job stress of Ghanaian OPD nurses.
H3. Coworker support will significantly weaken the positive
relationship between the workload and job stress of Ghanaian OPD
nurses.2. Materials and methods
2.1. Study design and sampling
The study used a cross-sectional design to sample 216 OPDnurses
from 4 major hospitals in the Greater Accra region of Ghana: Ridge
hospital, La General Hospital, Lekma hospital, and Police hospital.
Aside the Greater Accra region being the highest populated region in
Ghana, it also has a good representation of the nursing population in
Ghana serving a large number of patients daily [11]. Subsequently, a
convenience sampling technique was used to select the respondents
because nurses work in rotation or shift; therefore, only those
available during the time of data collection were sampled.2.2. Measures
The study data were collected using self-administered question-
naires with 4 sections: demography, workload, job stress, andStress of Ghanaian OPDNurses: The Role of Coworker Support, Safety
E. Kokoroko and M.A. Sanda / Effect of Workload 3
Table 1
Demographic characteristic of respondents
Characteristics N (%) Workload Job stress CWS
Mean SD p Mean SD p Mean SD P
Sex .11 .38 .42
Male 11 (5) 23.73 3.90 46.18 8.95 46.73 6.80
Female 205 (95) 25.18 2.86 43.55 9.72 45.08 6.63
Age: .00 .00 .00
>1824 years 20 22.80 2.44 34.30 12.68 50.00 4.91
>2534 years 147 25.43 2.91 43.83 8.88 43.23 6.26
>3544 years 16 24.81 2.88 49.69 7.47 48.00 8.48
>4555 years 16 24.25 2.74 44.44 8.93 49.88 2.58
>55 years 17 26.06 2.59 47.06 7.94 49.06 4.70
Work hours: .03 .00 .00
>57 hours 93 25.74 2.44 44.43 9.53 43.06 7.15
>810 hours 117 24.57 3.17 43.06 9.67 46.38 5.61
>1012 hours 4 25.00 3.46 47.00 13.98 55.00 3.46
>12 hours 2 25.10 3.53 38.50 13.44 55.50 6.36
Work experience .00 .00 .00
<1 21 22.38 2.20 35.05 11.50 48.81 4.27
>13 70 25.11 3.30 42.77 9.69 41.69 6.63
>46 57 25.44 2.29 46.79 8.40 47.00 2.96
>79 20 26.75 3.02 39.45 10.06 38.85 10.45
>10 48 25.19 2.57 46.85 6.77 49.08 3.72
SD, Standard deviation; p, significance level; CWS, coworker support.
Table 2
Normality testing of the measured variables
Variables Skewness Std. error Z-scores Kurtosis Std. error Z-scores
Workload -0.180 0.166 -1.084 0.024 0.330 0.073
Job stress -0.098 0.166 -0.590 -0.185 0.330 -0.561
Co-worker support -0.234 0.166 -1.410 0.282 0.330 0.855
Std. error, standard error.coworker support. The demographic section includes items such as
sex, age, and so on. Workload was measured using the National
Aeronautics and Space Administration (NASA) Task Load Index (TLX)
developed by Hart and Staveland [31] and scored on a 5-point Likert
scale from1¼ very low to 5¼ very high. An example of an itemon the
scale is “Thephysical demandofmyassigned job is?”TheNASATLXhas
a reported Cronbach’s alpha of 0.66 [11]; however, the Cronbach alpha
for this study is 0.75. Job stresswasmeasuredwith a 13-item job stress
scale developed by Parker and DeCotiis and has a Likert scale ranging
from1¼ strongly disagree to 5¼ stronglyagree [32]. Anexample of an
itemon the scale is “I have feltfidgety or nervous as a result ofmy job”.
The reported Cronbach’s alpha for this instrument among the nursing
populations are 0.84 [33] and 0.91 [21], but for this study, the reported
Cronbach alpha is 0.91. A coworker support scale developed by
Spooner-Lane [25] was adopted to measure the nurses’ coworker
support level. The items were scored on a 5-point Likert scale format,
ranging from1¼ stronglydisagree to5¼ stronglyagree.Anexampleof
an itemon the scale is “I feel comfortable askingmycoworkers forhelp
if I have a problem”. Cronbach’s alpha was 0.86 among the nursing
population [25]. The new Cronbach alpha for this study is 0.90.
2.3. Control variables
The participants’ demographic characteristics comprising of age,
work experience, and work hours are used as control variables.
According to Kowalski et al. [34], demographic variables such as
age, work experience, and work hours of a person produces mixed
results as to which variables increase the risk, are protective, and
the magnitude of job stress effects, if any. For instance, Nabirye et al
[35] also found a statistical significant difference in the age cate-
gories of nurses and job stress in Uganda, and their results showed
the youngest age group to be less stressed than the oldest age
group. Also, Mosadeghrad [36] found older nurses with more years
of experience reporting less occupational stress than their younger
colleagues with less years of experience. According to Caruso [37],
long work hours of nurses did not only result in low performance or
injuries but also culminated in a wide range of chronic diseases
including stress. As a result, these variables are controlled for in this
study to avoid their conflicting effects on the study results.
2.4. Data collection and analysis
Copies of the questionnaires were administered to the nurses
working at the OPDs after an approval was obtained from Greater
Accra Regional Health Directorate of Ghana Health Service and the
Administrators of participating hospitals. In addition, ethical con-
cerns such as privacy, anonymity, informed consent, and the right
of withdrawal were keenly taken into consideration. The nurses
were then given ample time of one to two weeks to complete the
questionnaires by themselves and submit. The data collection
period ranged from February to April 2017. Data were analysed
using the IBM Statistical Package for Social Sciences (SPSS), version
22. The demographic characteristics of the respondents were ana-
lysed descriptively. Correlation analysis was used to examine the
relationship among the study variables, whereas hierarchical
multiple regression analysis was used to examine the moderating
effect of coworker support on the relationship between workload
and job stress of the OPD nurses.
3. Results
3.1. Demographic description of respondents
The demographic characteristics of respondents are analysed
from the perspective of gender, age, work hours, and workPlease cite this article as: Kokoroko E, SandaMA, Effect ofWorkload on Job
and Health at Work, https://doi.org/10.1016/j.shaw.2019.04.002experience as presented in Table 1. From Table 1, it can be observed
that the majority of the respondents are females, 205 (95%), with
the rest 11 (5%) being males. Most respondents fall within the age
bracket of 25 to 34 years and work for 8 to 10 hours daily. The result
further showed that most of the respondents had 1 to 3 years of
work experience. The demographic description of the respondents
is a true reflection of domination of the nursing profession in Ghana
and globally by females.
3.2. Assumption testing
To ensure that the data set fits the choice of analysis, the
assumption of normality was tested. From Table 2, the z-scores of
skewness for workload, job stress, and coworker support were
-1.084, -0.590, and -1.410, respectively. Also, the z-scores for kur-
tosis were 0.073, -0.561, and 0.855 for workload, job stress, and
coworker support, respectively. The results showed that the z-
scores of skewness and kurtosis of the study variables fell within
the recommended values of þ1.96 and -1.96 [38]. Therefore, the
data set is normally distributed and fit for further analyses.3.3. Bivariate relationships among the study variables
The intercorrelations among the study variables as seen in
Table 3 indicate low and moderate correlation coefficients between
the independent variables which means there is no case of multi-
collinearity to the analysis. From the results, there exist a significant
positive correlation between workload and job stress (r ¼ .37,
p < 0.01). Although coworker support negatively correlated with
workload, this association is not statistically significant (r ¼ -.10,
p > 0.05). Interestingly, coworker support has a positive but
insignificant correlation with job stress (r ¼ .04, p > 0.05).3.4. Predicting job stress
.
Stress of Ghanaian OPDNurses: The Role of Coworker Support, Safety
4 Saf Health Work xxx (xxxx) xxx
Table 3
Correlation matrix of the relationship among the study variables
Variables Mean SD 1 2 3 4 5 6
1. Age 2.37 1.02 d
2.WE 3.02 1.30 .73** d
3. WH 2.61 0.57 .30** .13* d
4. WL 25.10 2.93 .10 .19** -.15* d
5. JS 43.68 9.68 .23** .24** -.06 .37** d
6. CWS 45.16 6.64 .21** .18** .33** -.10 .04 d
SD, standard deviation; WE, work experience; WH, work hours; WL, workload; JS,
job stress; CWS, coworker support.
**Correlation is significant at the 0.01 level (2-tailed); *Correlation is significant at
the 0.05 level (2-tailed).3.5. Testing the hypotheses
Hypothesis 1. There will be a significant positive relationship
between the workload and job stress of Ghanaian OPD Nurses.
The first hypothesis which looks at the relationship between
workload and job stress of Ghanaian OPD nurses was tested using
Pearson’s product moment correlation analysis. From Table 3, the
result showed a significant positive correlation between workload
and job stress (r ¼ .37, p < 0.01). In addition, a regression analysis
was carried out to determine if the nurses’workload level predicted
their job stress level. As shown in Table 4 (Step 2), the level of
workload has a significant positive effect on job stress level
(b ¼ .333, p < 0.01) after controlling for age, work experience, and
work hours. Workload explained 18% (DR2 ¼ .104) of variance in job
stress. As a result, Hypothesis 1 was supported.Table 4
A hierarchical regression showing predictors of job stress
Step 1 B Std error b p R R2 DR2
(Constant) 42.738 3.163 .000 .280 .078 .078
Age 1.609 .962 .170 .096
WE .976 .725 .132 .179
WH -2.229 1.171 -.133 .058
Step 2
(Constant) 41.733 2.994 .000 .426 .182 .104
Age 1.636 .909 .172 .073
WE .437 .692 .059 .529
WH -1.244 1.122 -.074 .269
WL 1.102 .213 .333 .000
Step 3
(Constant) 42.587 3.189 .000 .429 .184 .002
Age 1.626 .910 .171 .075
WE .380 .697 .051 .586
WH -1.497 1.169 -.089 .202
WL 1.117 .214 .338 .000
CWS .076 .098 .052 .434
Step 4
(Constant) 44.768 3.075 .000 .512 .262 .078
Age 1.009 .877 .106 .251
WE .932 .675 .126 .168
WH -2.318 1.128 -.138 .041
WL 1.301 .208 .393 .000
CWS .037 .094 .025 .693
WL*CWS .129 .028 .301 .000
a. Dependent variable: Job stress.
B, unstandardized beta; std. Error, standard error; b, standardized beta; R2, R square;
DR2, R square change; p, significance level; WE, work experience; WH, work hour;
WL, workload; CWS, coworker support.
Please cite this article as: Kokoroko E, SandaMA, Effect ofWorkload on Job
and Health at Work, https://doi.org/10.1016/j.shaw.2019.04.002Hypothesis 2. There will be a significant negative relationship
between the coworker support and job stress of Ghanaian OPD
nurses.
The second hypothesis which looks at the relationship between
coworker support and job stress of Ghanaian OPD nurses was
examined using Pearson’s product moment correlation analysis. As
shown in Table 3, the result indicated that the level of coworker
support among the respondents did not significantly correlate with
their level of job stress (r¼ .04, p> 0.05). Also, a regression analysis
showed no significant effect of the level of coworker support on job
stress level (b ¼ .052, p > 0.05), see Table 4 (Step 3). Therefore,
Hypothesis 2 was not supported.
Hypothesis 3. Coworker support will significantly weaken the
positive relationship between workload and job stress of Ghanaian
OPD nurses
The third hypothesis aims to determine the moderating effect of
coworker support on the relationship between workload and job
stress level of the nurses. This hypothesis was tested using hierar-
chical multiple regression as suggested by Baron and Kenny.
However, workload and job stress were centered before creating
their product or interaction term (workload*coworker support) to
prevent high multicollinearity [39]. As shown in Table 4, in Step 4,
the interaction term of workload and coworker support had a sig-
nificant positive effect on job stress (b ¼ .301, p < 0.01) and
accounted for 7.8% of variance in job stress (DR2 ¼ .078). The result,
therefore, showed amoderating effect of coworker support level on
the relationship between workload level and job stress level of the
nurses.
To examine the nature of this interaction, the coworker support
level was split into two groups (low and high) using the median
value of the total coworker support level (47). The job stress level
was regressed on workload level for each split coworker support
group. Surprisingly, as shown in Table 5, the workload significantly
predicted job stress for high level coworker support group
(b¼ .497, p< 0.01), but this was not the case for low level coworker
support group (b ¼ .180, p > 0.05). The result means that high
workload levels predicted high job stress levels for nurses reporting
high levels of coworker support but not for nurses with low levels
coworker support (reverse buffering effect).4. Discussions
One of the key challenges nurses face globally is high work
demands and the resultant ill effect on their health. This study
aimed to determine the effect of workload on job stress of Ghanaian
OPD nurses and the effect of coworker support on this relationship.
The findings from the bivariate correlation showed significant
positive relationship between workload and job stress levels of the
OPD nurses; however, coworker support did not significantly
correlate with the job stress level of the respondents. Further
analysis showed that coworker support strengthened the positive
relationship between workload level and job stress level of the
respondents.
4.1. The effect of workload of OPD nurses on job stress
The findings show that the workload of OPD nurses has a pos-
itive effect on their job stress, such that as the workload of nurses
increases their level of stress relating to their job also increases.
This finding supports research theorists who posited that adverse
work conditions such as high workloads can lead to job stress
among workers [40]. The finding is also consistent with the strain
hypothesis which states that high job demands facilitate job strains
[24]. Again, the result corroborates the finding of Almendra whoStress of Ghanaian OPDNurses: The Role of Coworker Support, Safety
E. Kokoroko and M.A. Sanda / Effect of Workload 5reported that increases in psychological and physical demands of
nurses lead to increased job stress levels [21]. Likewise, Kwansah
et al., Cudjoe, and Donkor arrived at a similar conclusion that
nurses’ job stress is associated with their workload [11,19,20]. In
Ghana, although there have been some improvements in the
doctor-to-patient ratio as well as the nurse-to-patient ratio, nurses
are still under intense time pressure to deliver health-care services
as they are overwhelmed with large number of patients [11]. This
pressurised work environment characterizing the nurses work
conditions may contribute to their job stress. With workload being
a crucial and important factor for employees because of its effects
on their health both physically and psychologically, it is not sur-
prising that the result of the study found it to predict the OPD
nurses’ job stress. In most hospitals in Ghana, OPD nurses are the
first point of call for patients and emergency situations and are,
therefore, required to respond to these emergencies as well as
provide information to families of these patients. Handling these
tasks in addition to their assigned duties could add up to their
workload resulting in the job stress.4.2. The effect of coworker support on job stress of OPD nurses
Coworker support levels did not significantly correlate with job
stress levels of the OPD nurses. More surprisingly, a close look at the
result showed a positive relationship between coworker support
levels and job stress levels. This finding is inconsistent with the
main effect model of social support, whereby research theorists
posited that individuals with low levels of social support will be
more vulnerable to stress, whereas those with high levels of social
support will be shielded from stress-related effects [26,30]. The
finding is also not in linewith findings by several other researchers:
Blanco-Donoso et al and AbAlRub who all found high levels of
coworker support decreased high job stress levels [23,27]. This
contrary finding to what was hypothesized could mean that the
support the nurses reported receiving from their colleagues rather
served as a source of distraction for them such that the more
support they received, the more they were distracted on their job
leading to the increased stress level. In addition, nurseswho receive
more support than required might develop a sense of guilt and
indebtedness which could be the reason why their stress level
increased. According to Bowling et al. [41], an individual who ex-
periences over-reciprocation, thus receiving more than giving, de-
velops a feeling of remorse, guilt, and dishonour which can lead to
stress.Table 5
Multiple regression showing predictors of job stress for split groups of coworker
support
Low CWS B Std error b p R R2 Adjusted R2
(Constant) 23.623 9.360 .013 .327 .107 .076
Age 3.877 1.817 .217 .035
WE .368 .857 .044 .669
WH -.902 1.744 -.049 .606
WL .545 .293 .180 .066
High CWS
(Constant) -4.773 8.961 .596 .598 .307 .329
Age .348 1.364 .045 .799
WE 1.484 1.190 .210 .216
WH -1.763 1.453 -.111 .228
WL 1.895 .329 .497 .000
a. Dependent variable: Job stress.
B, unstandardized beta; std. error, standard error; b, standardized beta; R2, R-
square; p, significance level; WE, work experience; WH, work hour; WL, workload;
CWS, coworker support.
Please cite this article as: Kokoroko E, SandaMA, Effect ofWorkload on Job
and Health at Work, https://doi.org/10.1016/j.shaw.2019.04.0024.3. How coworker support strengthens the positive relationship
between workload and job stress of Ghanaian OPD nurses
The finding showed that coworker support strengthened the
positive relationship between workload and job stress (reverse
buffering effect). This means that higher job stress levels are related
to higher workload levels for OPD nurses reporting higher levels of
coworker support but not the case for those reporting lower levels
of coworker support. This finding is sharply in contrast with that of
Winning et al. [29], who found coworker support to weaken the
positive relationship between workload and job stress levels of
nurses. Beehr [42], in explaining this occurrence, attributed it to
communication issues with employees when deliberating on work
issues. According to Beehr, coworkers in some instances change
their colleagues’ perspectives from positive to negative andmaking
them believe that things are actually worse than they first believed
[42]. Another possible explanation could be, as the support levels
for the nurses’ increase, they might possibly overrate their work-
load as being difficult, hence, the main reason for the support that
may be offered. This perception could place more burden on them
which might further increase their job stress levels. Liang et al.
asserted that negative self-image due to situations where a person
solely relies on someone for help, and also not being able to take
charge over one’s affairs during stressful situations because of
overrating of one’s own problems, may not only detract the person
from the benefits of any support given but also increase the per-
son’s psychological distress [43].4.4. Implications/recommendations
The findings of this study have some practical implications. First,
it has reinforced the point that nurses’ workload is a key deter-
minant of their job stress. Health-care managers including hospital
administrators and nurse managers need to closely pay attention to
the amount of work duties assigned to nurses per their shift period.
Because nurses with high levels of workload are susceptible to high
levels of job stress, recruitment of more nurses to improve the
nurse-to-patient ratio will help reduce the work burden on the
existing staff.
Second, the reverse buffering effect indicates that receiving
more support from a colleague at work might not automatically
help deal with work-related issues. Hence, nurses should not be
over reliant on their colleagues for assistance because if this sup-
port is not well communicated, it could alter their perceptions of
the problem at hand or fuel an already negative appraisal of work
situations. Therefore, nurses when discussing patient-care issues
with their colleagues are advised not to dwell much on the chal-
lenges they encounter.4.5. Conclusions
The following conclusions are drawn based on the research
findings: the job stress of Ghanaian OPD nurses was found to be
related to their workload. Job resources such as role clarity, au-
tonomy, and supervisor support if provided could help the nurses
manage their workload. The surprising exacerbation effect of
coworker support on the positive relationship between workload
and job stress bespeaks the crucial role of coworker support in
stress management interventions; however, the reported case of
the reverse buffering effect questions the success of such inter-
vention within some contexts. It can be concluded that for support
to be effective, nurses would have to focus on discussions relating
to successful patient management ideas and drastically reduce
negative appraisal of patient management related issues.Stress of Ghanaian OPDNurses: The Role of Coworker Support, Safety
6 Saf Health Work xxx (xxxx) xxx4.6. Limitations of the study
The use of a cross-sectional design to collect the study data
limit a definite conclusion about the causal relationship between
the study variables. Future studies should collect data across
different time periods to minimize this limitation. In addition, the
use of the convenience sampling technique could result in self-
selection bias and selection of respondents that are unrepresenta-
tive of the population. It could also be that most of the nurses who
availed themselves for the study are those that felt being stressed
by their workload; therefore, see the study as a means to express
their feeling, hence exaggeration of their workload and job stress
levels. The use of probability sampling technique in future studies
could help minimise this potential effect. The use of a quantitative
approach limits the detailed explanation of some of the research
findings. Therefore, future studies should use a qualitative
approach to get an in-depth understanding of the reverse buffering
effect.
Conflicts of interest
None.
Acknowledgments
We would like to thank the management and hospital author-
ities for granting us access to their staffs and also the nurses for
participating in the study.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.shaw.2019.04.002.
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