Occupational mental health: a study of work-relateddepression among nurses in the Caribbean

Vishwanath V. Baba*, Bella L. Galperin, Terri R. Lituchy

Department of Management, Concordia University, 1455 de Maisonneuve Blvd. West, Montreal, QC, Canada H3G 1M8

Received 25 September 1998; accepted 13 November 1998

Abstract

This study addresses issues of occupational mental health among nurses in the Caribbean. A linear model linking

role, work and social factors, stress, burnout, depression, absenteeism and turnover intention guides the research.Data were collected from 119 nurses working for major hospitals located in St. Vincent and Trinidad & Tobagousing a ®eld survey. Psychometrically sound instruments with proven cross-cultural validity were utilized in thequestionnaire. Descriptive statistics, correlations, and path analysis were used to analyze the data. The results

indicated fairly strong support for the proposed model which is tested for the ®rst time among a Caribbeanpopulation. Role con¯ict, role overload and social support predicted stress, which along with social supportpredicted burnout. Burnout was the sole predictor of depression which in turn predicted both absenteeism and

turnover intention. Implications of these ®ndings for research and practice are discussed. # 1999 Elsevier ScienceLtd. All rights reserved.

Keywords: Work; Depression; Stress; Burnout; Caribbean

1. Introduction

Occupational mental health (OMH) has been grow-

ing in importance in recent years as evidenced by

major conferences on the topic, special topic issues in

journals, workshops focussing on various aspects of

OMH, as well as a variety of employee assistance pro-

grams in major corporations, hospitals, schools and

colleges. Current reports in popular press focus on

stress-related depression and its social and economic

costs to society. In Canada alone, it has been estimated

that the costs due to poor mental health and the result-

ing loss of productivity amounts to $1.5 billion. It has

also been pointed out that people who engage in occu-

pations that have a large human service component

are particularly susceptible to the problems of OMH

(Baba and Jamal, 1991). These include nurses, tea-

chers, social workers and other service sector employ-

ees who for a major part of their job deal with people

needing their help.

Research on OMH has suggested that episodes of

depression can be triggered by factors associated with

work (Arsenault et al., 1991; Baba et al., 1998).

Empirical studies show that stress is related to burn-

out, and that burnout can lead to depression, which in

turn, can precipitate other forms of withdrawal

(Motowidlo et al., 1986; Landsbergis, 1988; Kawakami

et al., 1992; Snapp, 1992; Lee and Ashforth, 1996;

Molassiotis and Haberman, 1996). While the literature

clearly underscores the importance of depression in

understanding OMH, it is nevertheless fraught with a

number of theoretical and empirical problems.

Speci®cally, the studies reported are largely correla-

International Journal of Nursing Studies 36 (1999) 163±169

0020-7489/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.

PII: S0020-7489(99 )00002-4

* Corresponding author. Tel.: +1-514-848-2933; fax: +1-

514-848-4292.

E-mail address: baba@vax2.concordia.ca (V.V. Baba)

tional and atheoretical. There are very few models that

link depression to its work-related antecedents andconsequences (Kelloway and Barling, 1991). Finally,most theoretical and empirical work in this area is

done with North American or European populations.Cross-cultural portability of these ®ndings remain lar-gely speculative (Laungani, 1996; Zanotti, 1996).

The purpose of the present study is to address cer-tain aspects of occupational mental health amongnurses who work in major hospitals in St. Vincent andTrinidad & Tobago. In particular, the study attempts

to understand the relationship between work and de-pression, identify work-related antecedents and conse-quences of depression and investigate the portability of

Western models to the developing world.Although the study is primarily sample driven, it is

nevertheless guided by the imbalance theory of stress

which states that an imbalance between the demandsone faces at work and the resources available to meetthose demands result in stress; and that constraints ex-

acerbate the stress and support mitigates it (Johnsonand Hall, 1988; Karasek and Theorell, 1990). Thisimplies that role pressures, such as role con¯ict and

role overload, contribute toward imbalance, and unre-solved stress leads to deterioration in mental healthmanifested by depression and burnout. Further, con-

tinued strain results in withdrawal behavior such asabsenteeism and turnover. The literature has amplydocumented the positive e�ect of stress on burnoutand depression, as well as the positive impact of role

stressors on stress (Landsbergis, 1988; Arsenault et al.,1991; Jamal and Baba, 1992a, 1992b; Kawakami et al.,

1992; Krausz and Koslowsky, 1995). The e�ect of

social factors, such as social support, on stress, burn-out and depression have also been explored in theempirical literature (Snapp, 1992; Jansen et al., 1996;

Schmieder and Smith, 1996). More recently there hasbeen theoretical attempts to develop work-related con-sequences of depression (Galperin and Baba, 1994).They include di�erent forms of withdrawal. These

theoretical connections have also been subject to someempirical testing and support (Fang and Baba, 1993;Armstrong-Stassen et al., 1994; Lee and Ashforth,

1996).Speci®cally, the study proposes a model of work-re-

lated depression and tests it empirically among a popu-

lation of nurses in the Caribbean. A linear modellinking role, work and social factors, stress, burnout,depression and withdrawal cognitions was developedbased on the literature in occupational mental health

(Johnson and Hall, 1988; Karasek and Theorell, 1990)and is shown in Fig. 1. The model suggests that rolecon¯ict, role overload, decision latitude and social sup-

port contribute to stress variously, which in turn, leadsto burnout and depression resulting in withdrawal cog-nitions such as absenteeism and turnover intention.

2. Method

2.1. Participants

The sample consisted of 119 nurses (11 men and 108women) from 23 hospitals and clinics in St. Vincent

Fig. 1. Theoretical model of antecedents and consequences of depression.

V.V. Baba et al. / International Journal of Nursing Studies 36 (1999) 163±169164

and Trinidad & Tobago. The typical respondent wasabout 37 years of age and had been in the present job

between 5 and 10 years. Among the participants, 7.6%obtained a nursing certi®cate, 66.4% received adiploma and 5.0% had bachelor degrees in basic nur-

sing; 1.7% of the nurses did not have any formal nur-sing education and 19.3% did not respond to thequestion.

2.2. Procedure

The data were gathered through a ®eld survey usingquestionnaires. The human resource directors of thehospitals were initially contacted. The nature of thestudy and its importance were explained over the tele-

phone. Once the hospitals agreed to participate in thestudy, a total of 250 questionnaires were hand deliv-ered to the hospitals. The questionnaires, taking ap-

proximately 35±40 min to complete, were ®lled by thenurses at their own time and were sealed in envelopesto ensure con®dentiality. The questionnaires were then

returned to a contact person in the hospital and latercollected by a member of the research team. Of the250 questionnaires delivered, 119 usable questionnaires

were returned for a response rate of 47.6%.

2.3. Measures

2.3.1. AbsenteeismAbsenteeism was assessed using an eight-item

measure of absence intentions (Baba and Harris,

1989). The items measured the likelihood of beingabsent from work for a variety of reasons such as ``toget relief from a dissatisfying work situation'', ``to

spend leisure time with family''. The responses wereobtained on a seven-point Likert-type scale rangingfrom ``highly unlikely'' to ``highly likely''. A higherscore indicated a higher level of absenteeism. The

Cronbach a is 0.74.

2.3.2. Turnover intention

Turnover intention was assessed using three itemsadopted from Mobley (1977). The items used tomeasure turnover intention were: ``Have you been

actively looking for a job, but unable to ®nd one?'',``If no: do you plan to look for a job in the next 6months?'', and ``Are you actively looking for another

job at present?''. A value of `1' was assigned for a `yes'response and a value of `2' for a `no' response. Allitems were reverse-coded. The Cronbach a is 0.76.

2.3.3. Role overloadRole overload referred to having too much work to

do within the time available and was measured using

®ve items taken from Beehr et al. (1976), such as ``Itoften seems I have too much work for one person to

do''. Responses were obtained on a ®ve-point Likert-type scale ranging from ``strongly agree'' to ``strongly

disagree''. A higher score on this scale indicates agreater degree of work role overload. The Cronbach ais 0.49.

2.3.4. Role con¯ictRole con¯ict referred to incompatible or incongruent

expectations and was assessed using six items adoptedfrom Rizzo et al. (1970). A sample item would be ``Ihave to do things that should be done di�erently''.

Responses were obtained on a ®ve-point Likert-typescale ranging from ``strongly agree'' to ``strongly dis-agree''. A higher score on this scale indicates a greaterdegree of role con¯ict. The Cronbach a is 0.73.

2.3.5. Decision latitudeDecision latitude referred to the degree of in¯uence

and say in decision making and was measured usingthree items from the scale of Beehr et al. (1976). Asample item would be ``My job allows a lot of de-

cisions to be made on my part''. Responses were on a®ve-point Likert-type scale ranging from ``stronglyagree'' to ``strongly disagree''. A higher score indicates

higher decision latitude. The Cronbach a is 0.70.

2.3.6. Social supportSocial support referred to the support one receives

from supervisor, coworkers and family and wasassessed using 10 items taken from House and Wells(1978). For example, the participants were asked to

assess the support received from their immediate super-visor, other people at work, their spouse/partner andrelatives/friends in terms of ``How much can each of

these people be relied on when things get tough atwork?'' Responses were on a four-point scale rangingfrom ``not at all'' to ``very much''. A higher score indi-cates higher social support. The Cronbach a is 0.81.

2.3.7. StressStress referred to feelings when one has to deviate

from normal functioning in the workplace due to workdemands and constraints and was assessed by a 13-item scale adopted from Parker and DeCotiis (1983).

A sample item would be ``There are lots of times whenmy job drives me right up a wall''. Responses wereobtained on a ®ve-point Likert-type scale ranging from

``strongly agree'' to ``strongly disagree''. A higher scoreindicates higher levels of stress. The Cronbach a is0.79.

2.3.8. BurnoutBurnout referred to emotional exhaustion, deperso-

nalization and a diminished sense of accomplishment

and was assessed using 22 items taken from theMaslach Burnout Inventory developed by Maslach and

V.V. Baba et al. / International Journal of Nursing Studies 36 (1999) 163±169 165

Jackson (1986). Sample items pertaining to each of theabove dimensions would be ``I feel emotionally drained

from my work''; ``I feel I treat some patients as if theywere impersonal objects'' and ``I deal very e�ectivelywith the problems of my patients'', respectively.

Responses were on a ®ve-point scale ranging from ``afew times a year'' to ``every day''. A higher score indi-cates a higher level of burnout. The Cronbach a is

0.84.

2.3.9. DepressionDepression referred to prolonged negative feelings,

inability to concentrate or function normally and otherrelated depressive symptomatology. It was measuredusing 20 items from the CES-D scale developed by

Radlo� (1977). A sample item would be ``I felt that Icould not shake o� the blues even with help from myfamily and friends''. Responses were on a four-point

scale ranging from ``rarely or none of the time'' to``most or all of the time''. A higher score indicateshigher levels of depression. The Cronbach a is 0.82.

2.3.10. Demographic variablesThe questionnaire also included demographic and

work-related information regarding the participants'

age, gender, basic nursing education and job tenure.Descriptive statistics, correlations, and path analysis

were used to analyze the data.

3. Results

Table 1 shows descriptive statistics and correlations

among the study variables. Depression showed signi®-cant positive correlations with gender, role overload,

role con¯ict, stress, burnout, absenteeism and turnoverintention and signi®cant negative correlations withsocial support. Stress was signi®cantly and positively

correlated with role overload, role con¯ict, burnoutand turnover intention and negatively with decisionlatitude and social support. Social support was nega-

tively correlated with burnout and absenteeism. These®ndings are in line with stress theory predictions.Turnover intention was positively related to absentee-ism attesting to the consistency of withdrawal cogni-

tions among the nurses. Decision latitude was alsonegatively correlated with turnover intention indirectlyadding con®dence to the Karasek (1979) model. Other

®ndings included signi®cant positive correlationsbetween gender and absenteeism suggesting that malenurses were more absent-prone than female nurses.

The last observation notwithstanding, these ®ndingsare consistent with the empirical literature and maketheoretical sense.

Table 2 shows the results of the multistage pathanalysis used to test the theoretical model shown inFig. 1. The results indicated fairly strong support forthe proposed model which is tested for the ®rst time

among a Caribbean population. Speci®cally, role over-load (b=0.31), role con¯ict (b=0.33) and social sup-port (b = ÿ 0.19) demonstrated signi®cant links to

stress in the direction predicted explaining 30% of thevariance in the ®rst stage of the model. Stress wasfound to be a signi®cant positive predictor of burnout

(b=0.34). Twenty-®ve percent of the variance in burn-out was explained at the second stage of the model.

Table 1

Descriptive statistics and correlationsa(�pR0.05; ��pR0.01; ���pR0.001.)

Variables Means S.D. 1 2 3 4 5 6 7 8 9 10 11 12 13

(1) Age 37.29 8.87

(2) Gender 1.09 0.29 0.16

(3) Education 1.93 0.49 ÿ0.07 0.12

(4) Job tenure 5.20 1.50 0.32��� 0.11 0.09

(5) Role overload 2.37 0.77 0.03 0.06 ÿ0.15 0.06 0.49b

(6) Role con¯ict 3.17 0.91 ÿ0.03 ÿ0.01 0.05ÿ0.90 0.22� 0.73

(7) Decision latitude 3.54 0.95 ÿ0.01 ÿ0.05 ÿ0.15 0.12ÿ0.24��� ÿ0.31��� 0.70

(8) Social support 3.19 0.52 ÿ0.03 ÿ0.11 ÿ0.90 0.18ÿ0.17 ÿ0.11 0.34��� 0.81

(9) Stress 2.63 0.72 ÿ0.13 ÿ0.07 0.02ÿ0.02 0.40��� 0.41��� ÿ0.19� ÿ0.26�� 0.79

(10) Burnout 2.01 0.50 0.04 0.17 ÿ0.01ÿ0.34 0.15 0.26�� ÿ0.30 ÿ0.30�� 0.43��� 0.84(11) Depression 1.57 0.42 ÿ0.02 0.18� 0.06ÿ0.09 0.19� 0.20� ÿ0.16 ÿ0.29��� 0.32��� 0.33��� 0.82(12) Absenteeism 2.28 1.14 0.15 0.36�� 0.09 0.00 0.16 0.00 ÿ0.09 ÿ0.25�� 0.08 0.38��� 0.19� 0.74(13) Turnover intention 1.06 0.22 0.00 0.01 ÿ0.04ÿ0.10 0.10 0.15 ÿ0.20� ÿ0.15 0.24�� 0.32��� 0.08 0.18� 0.76

a Gender was dummy-coded, with woman=1 and man=2. Education was coded, with none=0, certi®cate=1, diploma=2,

bachelor=3. Job tenure was coded with, 1=less than 6 months, 2=6 months to 1 year, 3=1±2 years, 4=2±5 years, 5=5±10

years, 6=10±15 years, 7=over 15 years.b Those in bold are a reliabilities.

V.V. Baba et al. / International Journal of Nursing Studies 36 (1999) 163±169166

Burnout showed a signi®cant positive link to de-

pression (b=0.19) and explained 19% of the variance

at the third stage of the model. Depression also

showed a signi®cant positive impact on absenteeism (b= 0.34) as well as on turnover intention (b= 0.28)

explaining 19 and 15% of the variance, respectively. In

addition, other signi®cant links not proposed in the

model were observed. Speci®cally, social support had a

signi®cant direct e�ect on burnout (b=ÿ 0.25). The

revised path model is shown in Fig. 2.

Fig. 2. Revised path model antecedents and consequences of depression.

Table 2

Results of multiple regression analyses (�pR0.05; ��pR0.01; ���pR0.001.)

DV IV F R 2 b T

Stress 12.10��� 0.30

role overload 0.31 3.73���

role con¯ict 0.33 4.00���

decision latitude 0.05 0.61

social support ÿ0.19 ÿ2.25�Burnout 7.59��� 0.25

stress 0.34 3.50���

role overload ÿ0.03 ÿ0.28role con¯ict 0.14 1.55

decision latitude 0.16 1.72

social support ÿ0.25 ÿ2.85��Depression 4.24��� 0.19

burnout 0.19 1.95�

stress 0.15 1.40

role overload 0.05 0.55

role con¯ict 0.04 0.43

decision latitude ÿ0.04 ÿ0.44social support ÿ0.17 ÿ1.75

Absenteeism 3.78��� 0.19

depression 0.34 3.64���

burnout 0.10 0.95

stress ÿ0.12 ÿ1.07role overload 0.12 1.25

role con¯ict ÿ0.09 ÿ0.91decision latitude ÿ0.01 ÿ0.15social support ÿ0.13 ÿ1.34

Turnover intention 2.83�� 0.15

depression 0.28 2.84��

burnout ÿ0.09 ÿ0.84stress 0.18 1.59

role overload ÿ0.04 ÿ0.45role con¯ict 0.02 0.18

decision latitude ÿ0.13 ÿ1.31social support ÿ0.01 ÿ0.11

V.V. Baba et al. / International Journal of Nursing Studies 36 (1999) 163±169 167

4. Discussion

The results suggest that as role pressures mount,nurses experience stress and tend to burnout. This pro-

cess sets the stage for work-related depression and itsdysfunctional consequences such as absenteeism andturnover. While this observation has been made

empirically within the North American context, wehave made an attempt to verify it in a di�erent culturalmilieu with some success. Arguably this study adds

value to the literature by extending a predominantlyWestern theoretical framework (Johnson and Hall,

1988; Karasek and Theorell, 1990) to a developingworld context and demonstrating its usefulness fornursing administration research and practice in the

Caribbean.More speci®cally, the correlations suggest that the

theoretical associations mentioned in the literaturebetween role overload, role con¯ict and stress can beextended to nursing work in the Caribbean. Similarly,

the strong correlations among the mental health vari-ables, stress, burnout and depression establish validityto a more global notion of mental health encompassing

the three variables within the nursing sector in theCaribbean. The ®ndings also reinforce the theoretical

connections between mental health and withdrawalbehavior.The theoretical model proposed was empirically sup-

ported through signi®cant amounts of varianceexplained at each stage of the model. Yet, caution

must be exercised in interpreting the causal impli-cations as alternate interpretations are indeed possible.Since this study is based on cross-sectional data, the

sequential locations of burnout and depression in themodel could not be empirically established. Whilethere is some theoretical support to the notion that

burnout, which is context dependent, should precededepression which is a more general construct (Leiter

and Durup, 1994), we really need a longitudinal designwith repeated measures to empirically address thisissue. However, based on testing competing models, it

is our contention that the data ®t the present modeloptimally.The study is based on a small sample using largely

perceptual and self-report measures. These impose cer-tain methodological constraints in interpreting the

®ndings. The ®ndings involving role overload and gen-der have to be treated as tentative as the reliability ofrole overload in the Caribbean context was below

acceptable levels. Since the gender of the sample wassubstantially skewed, correlations between gender, de-pression and absenteeism also have to be interpreted

with some degree of circumspection.The research uses a mediational paradigm of mental

health where mental health is viewed to mediate the re-lationships between its antecedents and its conse-

quences. Within this framework, we need to extend thescope of research by clarifying the theoretical roles of

stress, burnout, and depression and explicitly testingfor the nature of mediation and moderation in occu-pational mental health. Culture as a contingent vari-

able in this context requires further study.The ®ndings clearly support the cross-cultural port-

ability of theoretical models derived from North

American empirical research. The results also add con-®dence to attempts toward developing global strategiesfor the improvement of occupational mental health.

More speci®cally, the study lends support to under-standing depression in the context of work and sets thestage for enlightened intervention strategies for com-batting depression and burnout among nurses. Such

strategies should be comprehensive and take intoaccount both the antecedents and consequences ofburnout and depression (Baba et al., 1998). For

example, the ®ndings suggest that supervisory trainingwith the accent on providing social support on the jobcould bene®t both the nurses and the hospitals in

terms of alleviating stress and burnout. The resultsalso point out that job design and job assignmentsshould become sensitive to their potential e�ects on

stress and depression by taking into account theimpact of role pressures on mental health. Further, thestudy provides an empirical basis for developing inter-vention strategies such as Employee Assistance

Programs that are appropriate for minimizing stressand burnout, managing work-related depression, aswell as reducing absenteeism and turnover among

nurses.

Acknowledgements

Financial support for this study from FCAR grant

(97-ER-0506) and SSHRC (410-92-0203) to the ®rstauthor is gratefully acknowledged.

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