ARTICLE IN PRESS

International Journal of Nursing Studies 44 (2007) 758–769

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The relationship between different work-related sources of

social support and burnout among registered and assistant
nurses in Sweden: A questionnaire survey
Lisa Sundina,b,, Jacek Hochwälderc, Carina Bildta, Jan Lisspersd
a
National Institute for Working Life, Studentplan 1, Hus A, Campus, 831 40 Östersund, Sweden
b
Department of Clinical Neuroscience, Section of Psychology, Karolinska Institute, Sweden
c
Unit of Mental Health, Stockholm Center of Public Health, Karolinska Institute, Sweden
d
Research Group for Behavioral Medicine and Health Psychology, Department of Social Sciences, MidSweden University, Sweden
Received 14 September 2005; received in revised form 18 January 2006; accepted 22 January 2006

Abstract

Background: This cross-sectional study addresses the relationship between organisational and social factors and
burnout in a group of registered and assistant nurses in Sweden.
Objective: The main objective of the study was to analyse the relationship (and the specific relationship patterns)
between three different work-related sources of social support and Maslach’s three burnout dimensions, while taking
the dimensions in the Karasek job-demand-control model, emotional demands, workload outside the work situation
and demographic factors into account.
Data and method: Data was collected using a questionnaire which was based on validated instruments, in accordance
with the job-demand-control model and Maslach’s Burnout Inventory. Descriptive statistics, correlation analysis and
three hierarchical regression analyses were conducted using a sample of 1561 registered and assistant nurses in Sweden.
Results: The results showed statistically significant correlations between the three support indicators and all three
burnout dimensions. In the regression analyses, co-worker and patient support were statistically significantly related to
all three burnout dimensions, whereas supervisor support was only statistically significantly related to emotional
exhaustion. In accordance with prior findings, high levels of psychological demands were most strongly related to high
emotional exhaustion. Further, high levels of emotional demands showed the strongest correlations with high personal
accomplishment.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Burnout; Control; Demand; Nurses; Social support

What is already known about the topic?

Corresponding author. National Institute for Working Life,
Studentplan 1, Hus A, Campus, 831 40 Östersund, Sweden.
Tel.: +46 63 55 13 23; fax: +46 63 55 13 20.
E-mail address: lisa.sundin@arbetslivsinstitutet.se
(L. Sundin).
 Registered and assistant nurses may be exposed to
various work-related stress factors such as high
workload, diffuse work demands and traumatic
experiences. Prolonged exposure to such stressors
can be related to symptoms of burnout.

0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2006.01.004
 ARTICLE IN PRESS
L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769
 Social support is a multidimensional concept, which
has been shown to play an important role in relation
to an individual’s health, and is a relevant factor to
consider in the prevention of burnout.
What this paper adds
 Different work-related sources of support varied with
regards to Maslach’s three burnout dimensions; this
was studied in a group of registered and assistant
nurses in Sweden while taking psychological- and
emotional demands and two dimensions of job
control into account.
 In the regression models, co-worker and patient
support were statistically significantly related to all
three burnout dimensions, whereas supervisor sup-
port was only statistically significantly related to
emotional exhaustion. Different job demands were
the strongest predictor of burnout.
1. Introduction
Extended exposure to work-related stressors can be
related to burnout symptoms (Maslach et al., 2001). A
third of all reported occupational diseases within the
Swedish health care sector during 2004 were related to
organisational or social factors such as workload,
incompatible and diffuse work demands and traumatic
experiences (threats and fears). Registered nurses had
the highest frequency of such reported cases, followed
by assistant nurses. Approximately 8% of the reported
cases of occupational diseases within the health care
sector stated burnout symptoms (Bengtsson and Sollen-
berg, 2005). Work-related social support can be seen as
one relevant factor in the minimisation of the adverse
health effects which are associated with work-related
stressors (House, 1981). The relation between social
support and various health outcomes has been investi-
gated in numerous theoretical and empirical studies (for
some relevant summaries see e.g., Cohen and Syme,
1985; Schwarzer and Leppin, 1989). However, theore-
tical and methodological disagreements of how social
support should be defined and measured still exist (e.g.,
Callaghan and Morrissey, 1993; Hupcey, 1998). Payne
and Jones (1987) emphasise, for example, that different
sources of support, e.g., from co-workers and super-
visors, should be differentiated in order to make
investigations of the concept more clear. There is one
major theoretical distinction which has been thoroughly
investigated and published in the social support
literature: the main- or direct-effect hypothesis and the
buffering effect hypothesis. The ‘‘main-or direct-effect
hypothesis’’ indicates that ‘‘social resources have a
beneficial effect irrespective of whether persons are under
759
stress’’ (Cohen and Wills, 1985, p. 310) and the
‘‘buffering effect hypothesis’’ indicates that social
support will be related to an individuals’ well-being
‘‘only (or primarily) for persons under stress’’ (Cohen and
Wills, 1985, p. 310). In other words, there is empirical
support for both the main and buffer models of social
support (Cohen and Wills, 1985), however the under-
pinning of a buffering effect of social support incorpo-
rated in the job-demand-control-model on well-being
(Van der Doef and Maes, 1999) has been inconsistent.
One of the most dominating occupational stress
models is the job demand-control model (JDC) devel-
oped by Karasek (1979) and Karasek and Theorell
(1990). The central tenet of this model regards the
assumption that high levels of psychological demands
combined with low degrees of decision latitude is related
to adverse health effects (Karasek and Theorell, 1990).
Johnson and Hall (1988) later expanded the model to
include social support. In the expanded job demand-
control-support model, social support refers to ‘‘overall
levels of helpful social interaction available on the job
from both co-workers and supervisors’’ (Karasek and
Theorell, 1990, p. 69). The JDC-model has been
extensively studied with respect to the risk of cardiovas-
cular disease (for a comprehensive and good review see
Belkic et al., 2004), psychological well-being (for an
good review see Van der Doef and Maes, 1999), but to a
lesser extent to burnout (Rafferty et al., 2001).
Burnout can be defined as a ‘‘psychological syndrome
of emotional exhaustion, depersonalisation, and reduced
personal accomplishment that can occur among indivi-
duals who work with other people in some capacity’’
(Maslach, 1993, p. 20). The burnout concept has
however been appointed to some conceptual debates
(cf. Maslach et al., 2001; Maslach and Schaufeli, 1993).
Issues that have been addressed concerns whether
burnout should be regarded as a state or as a process
(Hallsten, 1993), whether it is a distinct concept or has
overlapping features with e.g., occupational stress,
depression and fatigue (Schaufeli and Enzmann, 1998).
The three burnout dimensions in Maslach’s (1993)
definition are presented in the standardised measure of
burnout (i.e., the Maslach Burnout Inventory (MBI)),
which is the most commonly used measure of burnout
(Densten, 2001) and which has dominated research in
the field (Schaufeli and Enzmann, 1998). Maslach’s
three dimensions of burnout cannot be summarised and
viewed as a single combined scale of burnout (Maslach
et al., 1996) and the dimensions seem to be differently
associated to each other (Lee and Ashforth, 1996) and to
different job characteristics (Janssen et al., 1999), e.g.,
job demands, participation in decision making, auton-
omy and social support (Lee and Ashforth, 1996;
Schaufeli and Enzmann, 1998). Furthermore, some
relatively recent studies have also investigated the
relationship between the job-demand-control-(support)
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760 L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769
model and burnout (for examples within the nursing
profession see e.g., Bourbonnais et al., 1999; De Jonge et
al., 1996; Tummers et al., 2002).
Based on earlier research, Rafferty et al. (2001) argue
that there are some indications that there is a stronger
association between job demands and emotional exhaus-
tion than is the case for job control, which instead seems
to be more strongly related to depersonalisation and
personal accomplishment. The relationship between
social support and burnout seems to be established,
although the relationship is primarily supported in cross-
sectional analyses (Schaufeli and Enzmann, 1998). For
example, in their meta-analysis of employees of foremost
human service providers, Lee and Ashforth (1996)
showed that supervisory support was most strongly
related to emotional exhaustion, whereas co-worker
support seemed to be just as strongly related to both
emotional exhaustion and depersonalisation. Of the three
burnout dimensions, personal accomplishment seemed be
the dimension that was least associated with both
supervisor and co-worker support. In nursing samples,
Bourbonnais et al. (1999), De Jonge et al. (1996) and
Tummers et al. (2002) found that work-related social
support had significant main effects on emotional
exhaustion; Janssen et al. (1999) found that both super-
visor and co-worker support had significant associations
with emotional exhaustion, whereas non-significant
relationships were found with personal accomplishment.
Rafferty et al. (2001), on the other hand, found no
significant main effects of social support in a sample of
human service employees when demographic variables,
work control and job demands were controlled.
1.1. Research questions
There are indications that different work-related
sources of social support seem to be related to different
burnout dimensions, although these relationships seem
to vary. This cross-sectional study therefore poses the
following two questions:
(1) Do different work-related sources of social support
have any significant main effects on the three burnout
dimensions (i.e., above the variance that can be
explained by demographic variables, workload outside
the work situation, job demands and job control)?
(2) Are there different patterns of relationships between
the indicators of work-related social support and the
three burnout dimensions?
2. Methods
2.1. Participants
The sample consisted of 1561 registered and assistant
nurses from three hospitals and two primary health care
centres in the Stockholm area. The demographic
characteristics of the study group were as follows: the
average age was 43.87 years (SD 10.62 years, min–max:
21–65 years); 94.7% of the group were women and 5.3%
men; 60.3% were registered nurses and 39.7% were
assistant nurses; 75% were married/cohabiting and 25%
were not married/cohabiting; on average, the respon-
dents had 1.0 children (min–max: 0–5 children); 80.9%
did not have children under the age of 7 years, while
19.1% had children under the age of 7 years. 90.6% of
the participants were not on sick-leave when the study
was performed.
2.2. Procedure
The Ethics committee of the Karolinska Institute (in
Stockholm) approved the study. The participants were
informed about the purpose of the study, confidentiality
and voluntary participation in writing. A questionnaire
with written instructions, together with a stamped
envelope and a consent form for their signature was
sent to the homes of the participants. The data was
collected in spring 2003, where necessary two reminders
were sent 3 weeks apart. A total of 1561 registered- and
assistant nurses participated voluntarily in the study.
The overall response rate in the study was 58%.
2.3. Instrument
The participants were asked to complete a question-
naire assessing demographic variables, workload outside
work, job demands, job control, work-related social
support and burnout.
Demographic variables consisted of age (measured as a
continuous variable), gender (women ¼ 0, men ¼ 1),
marital status (married/cohabiting ¼ 0, not married/
cohabiting ¼ 1), profession (registered nurses ¼ 0, assis-
tant nurses ¼ 1) and sick-leave status (not on sick
leave ¼ 0, on sick leave ¼ 1). Workload outside work
was operationalised in terms of number of children
(measured as a continuous variable), number of children
under the age of 7 years (coded as the whole family has
no children under the age of seven years ¼ 0, and the
whole family has at least one child under the age of 7
years ¼ 1), taking care of and supporting relatives
(measured in terms of average number of hours per
week), domestic load (measured in terms of average
number of hours spent per week on domestic work).
These variables were considered as control variables
since prior research has shown that some of them are
related to the criterion variables (cf. Hallsten et al., 2002;
Schaufeli and Enzmann, 1998).
Psychological demands were operationalised according
to the (JDC(S)-model (Karasek, 1979; Stockholm
MUSIC 1, 1991, 1993). The scale consisted of five items
(e.g. does your work demand too much effort?). The
 ARTICLE IN PRESS
L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769
responses were then indicated on a 4-point Likert scale
ranging from 1 (no, almost never) to 4 (yes, often).
Emotional demands were measured by a scale con-
structed for this study, based on the argumentation put
forward by De Jonge et al. (1999, 2000) who suggests
that the (JDC(S)-model needs to include measures of
diversified job demands that are related to different
occupational groups. One such example is the specific
emotional demands that are evident within human
service occupations, e.g., the demands that are derived
from the interpersonal relationship with patients or
clients (cf. De Jonge and Dormann, 2003; Van Vegchel
et al., 2004). The scale consisted of three items, each
measuring the extent to which the following tasks
occurred at work, i.e., ‘‘that one would have to have
discussions, give information and support to relatives’’,
‘‘that one would have to face and carry much of the
patients worries/burdens/destinies of life’’, and ‘‘that one
would have to face and carry much of the relatives
worries/burdens/destinies of life’’. The responses were
then indicated on a 4-point Likert scale ranging from 1
(no, almost never) to 4 (often).
Skill discretion was operationalised according to the
JDC(S)-model (Karasek, 1979; Stockholm MUSIC 1,
1991, 1993), using a scale consisting of four items (e.g.,
do you have the possibility of learning new things
through your work?). Authority over decisions (Karasek,
1979; Stockholm MUSIC 1, 1991, 1993) was measured
on a scale consisting of two items (e.g., do you have a
choice in deciding how you do your work?). The
responses on both scales were indicated on a 4-point
Likert scale ranging from 1 (no, almost never) to 4 (yes,
often). In line with suggestions made by Rafferty et al.
(2001), job control was measured as two independent
indicators.
Social support at work was operationalised in terms of
‘‘supportive work atmosphere’’, ‘‘supervisory support’’
and ‘‘co-worker and patient support’’. Supportive work
atmosphere was measured according to the (JDC(S)-
model (Stockholm MUSIC 1, 1991, 1993) and consists
of six items (e.g., ‘‘I get on well with my supervisors’’,
‘‘my co-workers support me’’). The responses were
indicated on a 4-point Likert scale ranging from 1
(strongly disagree) to 4 (strongly agree). ‘‘Supervisory
support’’ and ‘‘co-worker and patient support’’ (i.e., how
registered- and assistant nurses perceive the possibility
to receive support and encouragement from supervisors,
as well as from both co-workers and patients) were
measured in terms of the scales which were formed from
two questions, respectively. The measurements were
conducted by Statistics Sweden. For supervisory sup-
port; ‘‘Are you able to receive support and encouragement
from your supervisor, when you find work difficult?’’,
‘‘Does it occur that your supervisor show appreciation for
anything you have done?’’ For co-worker and patient
support ‘‘Are you able to receive support and encourage-
761
ment from your co-workers, when you find work
difficult?’’, ‘‘Does it occur that other persons show
appreciation for anything you have done (e.g., co-workers,
patients)?’’ The responses for both scales were indicated
on a 4-point Likert scale ranging from 1 (never) to 4
(always).
Burnout was analysed as three different dimensions,
which were developed and measured by the MBI
(Maslach et al., 1996). The MBI consisted of 22 items
divided into the three dimensions, i.e., emotional
exhaustion (9 items, e.g., I feel emotionally drained
from my work), depersonalisation (5 items, e.g., I feel
that I treat some patients as if they were impersonal
objects), and personal accomplishment (8 items, e.g., in
my work, I deal with emotional problems very calmly).
The response scale was a 7-point Likert scale ranging
from 0 (never) to 6 (every day).
2.4. Statistical analysis
Quantitative analyses were conducted and all vari-
ables were described in terms of arithmetic means,
standard deviations, correlation coefficients and Cron-
bach’s alpha reliabilities. The missing values per item
varied between 0% (e.g. for profession) and 7% (for
domestic load). The missing values of the continuous
items were replaced with serial means (see SPSS,
1990a, b). For each respondent an average value on
each scale was computed after some items had been
reversed into the right direction. For each of the 10
predictor and criterion variables, higher values corre-
spond to higher degrees of the construct being mea-
sured, with the exception of personal accomplishment,
where lower values indicate higher levels of burnout.
Factor analyses were conducted for the predictor and
criterion variables. All factor analyses, except for job
control, confirmed the expected factor structure. How-
ever, based on theoretical consideration and on previous
research (Rafferty et al., 2001) it was nevertheless
decided that it would be interesting to keep two job
control indicators.
In order to estimate how much of the total variance in
the criterion variables could be explained by a group of
predictor variables when the effect of other groups of
predictor variables had been accounted for, three
hierarchical multiple linear regression analyses were
conducted (see e.g. Kleinbaum et al., 1988), one for each
burnout dimension. The intention was also to study the
pattern of the regression coefficients with respect to the
relationship between the criterion variables and the
predictor variables. In step one of the analyses, the five
demographic variables were entered, followed by the four
variables of workload outside the work situation. The two
job demand measures were added in step three and were
followed by the two measures of job control in step four.
The three indicators of work-related social support were
 ARTICLE IN PRESS
762 L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769
entered in the final step. The hierarchical ordering of
entered predictor variables in a regression analysis can
be discussed; see e.g. Tabachnick and Fidell (1989) and
Newton and Rudestam (1999). The order of inclusion
was based upon the research questions as well as on the
manner in which the investigated variables have been
included in prior burnout studies (e.g., Rafferty et al.,
2001). The data were checked for multicollinarity using
tolerance and the variance inflation factor (VIF) (see e.g.
Kleinbaum et al., 1988). VIF-values greater than 10 and
tolerance-values smaller that 0.10 may indicate multi-
collinarity. There were no signs of multicollinarity in any
of the three regression models. All analyses were
performed with the SPSS-program (SPSS, 1990a, b).
3. Results
3.1. Descriptive statistics
In this study, burnout reports ranged from 0 to 54 for
emotional exhaustion (M ¼ 17:20, SD ¼ 10.25), from 0
to 29 for depersonalisation (M ¼ 4:43, SD ¼ 4.52), and
from 1 to 48 for personal accomplishment (M ¼ 37:89,
SD ¼ 7.09). In relation to the scores presented by
Maslach et al. (1996) for the subgroup ‘‘medicine’’
(i.e., physicians and nurses), the scores were lower for
emotional exhaustion (M ¼ 22:19, SD ¼ 9.53) and
depersonalisation (M ¼ 7:12, SD ¼ 5.22), as well as
more consistent, with scores for personal accomplish-
ment being M ¼ 36:53 and SD ¼ 7.34.
Descriptive statistics for all variables are presented in
Table 1. All 10 scales had Cronbach0 s alpha reliabilities
which were greater than 0.70, with the exception of skill
discretion (0.45) and co-worker and patient support
(0.56). Thus, by common standards (e.g. Kline, 2000)
the Cronbach’s alpha reliabilities for the majority of the
scales were acceptable. The correlation coefficients for
variables within a group or block of variables showed
the following results. There were low levels of inter-
correlation between the demographic variables. For the
four indicators of workload outside work, the highest
correlation was between the categories ‘‘number of
children’’ and ‘‘having children under the age of 7 years’’
(r ¼ 0:45). Relatively low correlations were found for
the two indicators of job demands (r ¼ 0:22) and job
control (r ¼ 0:19), respectively. The correlation coeffi-
cients for the three indicators of social support at work
varied between r ¼ 0:37 and 0:48. For the three burnout
indicators, the highest correlation was between ‘‘emo-
tional exhaustion’’ and ‘‘depersonalisation’’ (r ¼ 0:55).
Thus, variables within a group or block may, by
somewhat liberal standards, be considered as different,
but nevertheless related, indicators of a given construct.
The correlations between the predictor variables and
the three criterion variables indicated the following
relationships. Twelve out of 16 predictors were statisti-
cally significant (po0:05) in relation to emotional
exhaustion. Psychological demands showed the strongest
correlation (r ¼ 0:51), followed by the three indicators
of work-related social support. Nine out of 16 predictors
were statistically related to depersonalisation. Psycholo-
gical demands were also most strongly correlated to
depersonalisation (r ¼ 0:23), followed by the three
indicators of work-related social support and authority
over decisions. Ten out of 16 predictors had statistical
correlations to personal accomplishment. Emotional
demands (r ¼ 0:26) had the strongest correlation,
followed by the job control variables and work-related
social support. Thus, there are enough predictors with
satisfactorily strong relations to the three criterion
variables to estimate and evaluate the three proposed
regression models.
3.2. Regression analysis
Tables 2–4 show the relations between the predictors
and the three burnout dimensions, when adjustments
were made for demographic factors and workload
outside the work situation. The indicators of job
demands gave the largest additional proportion of
explained variance to all burnout dimensions, but the
explained variance varied between the three dimensions.
Job demands (mainly psychological demands) explained
25% of the variability which was associated with
emotional exhaustion (see Table 2) and 5% of that
associated with depersonalisation (see Table 3). On the
other hand, job demands (mainly emotional demands)
explained 7% of the variation in personal accomplish-
ment (see Table 4). It was also observed in this model,
but not in the previous two, that while psychological
demands were negatively related to personal accom-
plishment, emotional demands were positively related to
personal accomplishment. The inclusion of the two job
control dimensions showed associations in the expected
direction on all three burnout dimensions, and also more
homogeneous patterns of added explained variance than
did the two job demand dimensions. When including
work-related support, the results indicated that support
had statistically significant effects on all three burnout
dimensions. However, the relationship patterns differed.
For emotional exhaustion all three indicators of social
support exhibited statistically significant and negative
betas (see Table 2) and explained additional 5% of the
variation. The highest beta among the three indicators
was observed for supportive work atmosphere (.17).
For depersonalisation (see Table 3) only betas for co-
worker and patient support and supportive work atmo-
sphere were statistically significant. The highest beta
among the three support indicators was observed for co-
worker and patient support (.10). In the regression
model for personal accomplishment (see Table 4)
Table 1
Means (M), standard deviations (SD), Cronbach’s alpha reliabilities (a) and correlation coefficients for all variablesa

Variables M SD a 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Demographic variables
1. Age 43.87 10.62 na 1.00
2. Genderb na na na .06 1.00
3. Marital statusc

L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769

na na na .03 .02 1.00
4. Professiond na na na .14 .03 .01 1.00
5. On sick leavee na na na .09 .05 .01 .12 1.00
Workload outside work
6. Number of children 1.01 1.10 na .25 .04 .30 .02 .07 1.00
7. Children under 7 years?f na na na .38 .01 .21 .09 .06 .45 1.00
8. Support for relatives 1.01 3.72 na .02 .02 .03 .04 .02 .02 .01 1.00

ARTICLE IN PRESS
9. Domestic load 13.76 9.23 na .06 .11 .19 .05 .00 .33 .14 .03 1.00
Job demands
10. Psychological demands 2.68 0.48 .72 .03 .01 .00 .05 .08 .04 .01 .04 .06 1.00
11. Emotional demands 2.86 0.80 .83 .11 .05 .01 .19 .02 .01 .02 .03 .04 .22 1.00
Job control
12. Skill discretion 3.05 0.39 .45 .12 .06 .02 .20 .01 .04 .03 .01 .01 .15 .22 1.00
13. Authority over decisions 2.77 0.72 .75 .08 .04 .01 .05 .04 .04 .06 .05 .06 .16 .07 .19 1.00

Social support at work

14. Supervisory support 2.76 0.74 .82 .01 .01 .03 .01 .06 .01 .00 .03 .01 .29 .04 .10 .22 1.00
15. Co-worker and patient support 3.17 0.46 .56 .07 .00 .01 .11 .04 .01 .02 .02 .02 .21 .06 .12 .17 .37 1.00
16. Supportive work atmosphere 3.20 0.47 .84 .04 .03 .05 .03 .08 .05 .03 .03 .02 .34 .03 .15 .24 .44 .48 1.00
Burnout
17. Emotional exhaustion 1.91 1.14 .90 .02 .02 .06 .05 .10 .11 .08 .02 .00 .51 .16 .05 .21 .32 .28 .40 1.00
18. Depersonalisation 0.89 0.90 .72 .17 .03 .03 .06 .03 .08 .00 .00 .03 .23 .11 .04 .19 .17 .19 .21 .55 1.00
19. Personal accomplishment 4.74 0.89 .80 .02 .00 .05 .14 .05 .06 .01 .02 .01 .01 .26 .19 .12 .11 .17 .14 .16 .18 1.00
a
Correlation coefficientsX|.05| are significant at the 5% significance level (n ¼ 1502 to 1561). Correlation coefficients for the relationships between the criterion variables and the
predictor variables are underlined.
b
Women ¼ 0, Men ¼ 1.
c
Married/Cohabiting ¼ 0, Not married/Not cohabiting ¼ 1.
d
Registered nurses ¼ 0, Assistant nurses ¼ 1.
e
No ¼ 0, Yes ¼ 1.
f
Have no children under 7 years ¼ 0, Have children under 7 years ¼ 1.

763
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764 L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769

Table 2
Regression results predicting emotional exhaustion
a
Variables bStep 1 bStep 2 bStep 3 bStep 4 bStep 5

Step 1: Demographic variables

Age .03 .08** .04 .04 .06*
Genderb .03 .03 .02 .01 .02
Marital statusc .06* .02 .03 .03 .02
Professiond .06* .06* .02 .05* .03
On sick leavee .12*** .11*** .06** .06** .05*
Step 2: Workload outside work
Number of children .12*** .07** .07* .07**
Children under 7 years?f .06* .06* .07** .07**
Support for relatives .00 .01 .02 .02
Domestic load .06* .01 .01 .01
Step 3: Job demands
Psychological demands .49*** .48*** .38***
Emotional demands .05* .09*** .10***
Step 4: Job control
Skill discretion .13*** .08***
Authority over decisions .12*** .08***
Step 5: Social support at work
Supervisory support .07**
Co-worker and patient support .08**
Supportive work atmosphere .17***
Model summary
Model F 6.06*** 6.37*** 52.89*** 52.41*** 53.48***
(df) (5, 1465) (9, 1461) (11, 1459) (13, 1457) (16, 1454)
R2 .02 .04 .29 .32 .37
Adjusted R2 .02 .03 .28 .31 .36
DR2 .02*** .02*** .25*** .03*** .05***

***po0.001, **po0.01, *po0.05.

a
b is the standardised regression coefficient.
b
Women ¼ 0, Men ¼ 1.
c
Married/Cohabiting ¼ 0, Not married/Not cohabiting ¼ 1.
d
Registered nurses ¼ 0, Assistant nurses ¼ 1.
e
No ¼ 0, Yes ¼ 1.
f
Have no children under 7 years ¼ 0, Have children under 7 years ¼ 1.

only beta for co-worker and patient support was
statistically significant (.11). The inclusion of the three
support indicators explained additional 2% of the
variation for both depersonalisation and personal
accomplishment. Finally, the results indicated that
demographic variables (mainly age and profession), as
well as workload outside work (mainly having children)
were related to burnout.
4. Discussion
This study investigated two main questions regarding
the relationship between different work-related sources
of support and Maslach’s three burnout dimensions and
their specific relationship patterns. The study was
performed using a sample of registered and assistant
nurses from hospitals and primary health care centres in
the Stockholm area. The study had a response rate of
58%, thus generalisations and application of the
findings to other populations should be made with
caution. Work-related social support has, however, been
suggested to be a relevant factor to consider in the
stressor–strain relationship in different occupations (see
e.g., Karasek and Theorell, 1990) and the relevance of
social support within the field of nursing (e.g., Stewart,
1993) and in relation to burnout is presented by
European (e.g., De Jonge et al., 1996; Janssen et al.,
1999; Tummers et al., 2002), American (e.g., Cronin-
Stubbs and Brophy, 1985; Cronin-Stubbs and Rooks,
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L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769 765

Table 3
Regression results predicting depersonalisation
a
Variables bStep 1 bStep 2 bStep 3 bStep 4 bStep 5

Step 1: Demographic variables

Age .17*** .21*** .20*** .19*** .20***
Genderb .02 .02 .02 .03 .02
Marital statusc .04 .00 .00 .00 .00
Professiond .05 .05 .03 .05 .03
On sick leavee .05 .04 .02 .02 .01
Step 2: Workload outside work
Number of children .13*** .11*** .11*** .11***
Children under 7 years?f .03 .03 .04 .04
Support for relatives .01 .02 .02 .03
Domestic load .04 .02 .01 .01
Step 3: Job demands
Psychological demands .21*** .19*** .14***
Emotional demands .04 .07** .08***
Step 4: Job control
Skill discretion .08** .06*
Authority over decisions .15*** .12***
Step 5: Social support at work
Supervisory support .03
Co-worker and patient support .10***
Supportive work atmosphere .06*
Model summary
Model F 10.85*** 8.89*** 14.85*** 16.96*** 16.16***
(df) (5, 1465) (9, 1461) (11, 1459) (13, 1457) (16, 1454)
R2 .04 .05 .10 .13 .15
Adjusted R2 .03 .05 .09 .12 .14
DR2 .04*** .02*** .05*** .03*** .02***

***po0.001, ** po0.01, * po0.05.

a
b is the standardised regression coefficient.
b
Women ¼ 0, Men ¼ 1.
c
Married/Cohabiting ¼ 0, Not married/Not cohabiting ¼ 1.
d
Registered nurses ¼ 0, Assistant nurses ¼ 1.
e
No ¼ 0, Yes ¼ 1.
f
Have no children under 7 years ¼ 0, Have children under 7 years ¼ 1.

1985) and Caribbean (Baba et al., 1999) researchers in
nursing studies.
The results from this Swedish study indicated that the
perception of the possibility of receiving a high level of
support from supervisors and co-workers and patients
was related to lower levels of emotional exhaustion,
depersonalisation and higher levels of personal accom-
plishment. These relationships showed some specific
patterns in the regression analyses and indicated that
above the variance that was explained by demographics,
workload outside work, job demands and job control;
social support seemed to be most strongly related to
emotional exhaustion. Supervisor support exhibited
main effects only on this burnout dimension. Co-worker
and patient support, on the other hand, was the single
support indicator that was statistically significantly
related to all three burnout dimensions.
A cautionary note is nevertheless needed in relation to
our findings, i.e., that the Cronbach0 s alpha for co-
worker and patient support was relatively low (0.56).
Further that, as in any other study where results are
based on data from self-reported correlation designs,
this study is limited to associations and no causal
interpretation can be conducted. With these limitations
in mind, the results are still in line with some previous
research. In their meta-analysis, for example, Lee and
Ashforth (1996) found that supervisor support was most
strongly related to emotional exhaustion. Janssen et al.
(1999) also found a significant main effect between
supervisory support and emotional exhaustion. In
 ARTICLE IN PRESS
766 L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769

Table 4
Regression results predicting personal accomplishment
a
Variables bStep 1 bStep 2 bStep 3 bStep 4 bStep 5

Step 1: Demographic variables

Age .00 .00 .03 .03 .05
Genderb .00 .00 .02 .00 .01
Marital statusc .05* .05 .04 .04 .04
Professiond .13*** .13*** .09*** .06* .08**
On sick leavee .03 .03 .04 .04 .03
Step 2: Workload outside work
Number of children .06* .06* .06* .07*
Children under 7 years?f .03 .02 .02 .02
Support for relatives .01 .01 .02 .02
Domestic load .02 .03 .02 .02
Step 3: Job demands
Psychological demands .07** .07** .03
Emotional demands .27*** .24*** .23***
Step 4: Job control
Skill discretion .14*** .11***
Authority over decisions .06* .04
Step 5: Social support at work
Supervisory support .04
Co-worker and patient support .11***
Supportive work atmosphere .02
Model summary
Model F 6.42*** 4.10*** 13.28*** 14.37*** 13.54***
(df) (5, 1465) (9, 1461) (11, 1459) (13, 1457) (16, 1454)
R2 .02 .03 .09 .11 .13
Adjusted R2 .02 .02 .08 .11 .12
DR2 .02*** .00 .07*** .02*** .02***

***po0.001, **po0.01, *po0.05.

a
b is the standardised regression coefficient.
b
Women ¼ 0, Men ¼ 1.
c
Married/Cohabiting ¼ 0, Not married/Not cohabiting ¼ 1.
d
Registered nurses ¼ 0, Assistant nurses ¼ 1.
e
No ¼ 0, Yes ¼ 1.
f
Have no children under 7 years ¼ 0, Have children under 7 years ¼ 1.

agreement with the results of the study conducted by Lee
and Ashforth (1996) and in partial agreement with the
findings in the study conducted by Janssen et al. (1999),
the results also indicated significant relationships be-
tween co-worker support and depersonalisation. Raff-
erty et al. (2001), on the other hand, found that neither
supervisor nor co-worker support had any significant
main effects on the three burnout dimensions when
demographics, job demands, skill discretion and deci-
sion authority were controlled for. In this study, the
social support indicators did show such main effects
after controlling for job demands and the level of job
control.
The inclusion of job demands exhibited the strongest
relations with all three burnout dimensions, especially
prominent was the relationship between high psycholo-
gical demands and emotional exhaustion, which is in line
with previously conducted research (e.g., Lee and
Ashforth, 1996, Rafferty et al., 2001). On the other
hand, high emotional demands exhibited the strongest
and positive associations with personal accomplishment.
This relationship is a bit difficult to interpret, since the
direction of the relationship with the other two dimen-
sions is also positive, indicating an association between
high emotional demands and high burnout levels. A
speculative interpretation could, however, lie in the
professional role of nurses and assistant nurses, i.e., that
meeting patients and their families, giving them support
and information and sharing some of their burdens
might not be perceived as something demanding, but
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L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769
rather as something that is part of the daily work-related
tasks. Recognition of such work could create a sense of
competence and achievement.
The argumentation made by Rafferty et al. (2001) in
favour of dividing the two dimensions of decision
latitude (since they showed different relationships with
the three burnout dimensions) was also investigated in
this study. Prior research (Theorell et al., 1993) has
shown low Cronbach’s alpha coefficients in different
occupational groups when the two control dimensions
are separated; this was also evident for skill discretion in
our study, which could have effected the relationship
with the burnout dimensions. However, our results are
in line with Rafferty et al. (2001) and also showed the
strongest relationship between skill discretion and
personal accomplishment. A high degree of authority
over decisions was, on the other hand, related to lower
levels of emotional exhaustion and depersonalisation,
which are not in line with results reported by Rafferty
et al. (2001) but in agreement with those presented by
Taris et al. (1999).
The concept of social support is complex in one sense
that there are disagreements on how social support
should be defined and measured (e.g., Callaghan and
Morrissey, 1993; Hupcey, 1998). Payne and Jones (1987)
mention that social support could be more system-
atically investigated if different sources and functions of
support are differentiated in the analysis. Hence, there
might be other functional aspects of support that are
related to burnout but which were not investigated in
this study.
Different work-related sources of support were
analysed in this study. However, in our measurement
of co-worker and patient, a question regarding the level
of appreciation shown by both co-workers and patients
was included. Prior research has shown the importance
of co-worker support (Lee and Ashforth, 1996: Schaufeli
and Enzmann, 1998) on burnout. Further, Le Blanc and
Schaufeli (2003) indicated that a positive outlook on the
nurse–patient relationship (rewarding contacts) is re-
lated to lower levels of emotional exhaustion. Maslach
(1978) expressed that ‘‘burn-out rates are lower for health
care practitioners who actively express, analyze, and share
their personal feelings with their colleagues’’ (p. 116).
This statement could be viewed in line with the
reciprocal aspects of social support, i.e., to both receive
and provide support to others within one’s social
network. In our study, however, only one direction of
this reciprocal relationship was analysed, i.e., how the
recipient perceived the possibility of receiving work-
related support. Future analyses could reveal whether
this perception is based on mutually exchanged pro-
cesses of support at work or not.
It should also be noted that 95% of the respondents in
this study were women; although there was no
significant correlation between gender and burnout, this
767
fact calls for further attention. Prior social support
research has suggested, albeit with some inconsistent
findings, that women tend to utilise more diversified
social networks to mobilise support; furthermore, they
also provide more social support than men (see Belle,
1987 for a good summary). Hence, the women in our
study may perceive that they can rely on additional
social support providers, i.e., other than those that were
investigated in our study. In a sample of female nurses,
however, Bourbonnais et al. (1999) found that low
satisfaction with work-related social support was more
strongly related to the increased prevalence risks of
emotional exhaustion than was the case with low levels
of satisfaction with non-work support.
The results in this study seem to be in line with prior
findings and can add some value to current research on
working life and to the assembled burnout research
conducted within the nursing profession, provided that
the results are confirmed in future studies, preferably
longitudinal ones. Co-worker and patient support was
the only support dimension that was related to all three
burnout dimensions and could therefore be worth
highlighting. However, the inclusion of social support
in the regression analyses increased the explained
variability associated with the three burnout dimensions
by 2–5%, which implies that there are additional
variables that are valuable in clarifying factors that are
related to burnout. It could be relevant to include more
personal measures in the analysis of both social support
and burnout. Zellars and Perrewé (2001) found for
example relations between affective personality, emo-
tional support and job-related burnout in a sample of
nurses. Further, current research on burnout in Sweden
(Hallsten et al., 2005) is, for example, addressing which
role performance-based self-esteem plays in the process
of burning out.
The work situation for parts of the Swedish labour
force has been the focus of public debate and in policies
in recent years. Some has been due to the increased
levels of absences due to long-term sick leave. The
Swedish Work Environment Authority has listed health
care work as one employment sector with significant
work environment problems and an area that is to
receive prioritised attention (Swedish Work Environ-
ment Authority). The work environment that registered
nurses and assistant nurses face each day can be
diversified and the practical implications of our results
can only be broad and general. Schaufeli and Enzmann
(1998) have written a good summary about different
burnout interventions aimed at the individual, indivi-
dual/organisational and organisational levels, which
could be used as a relevant guide for nursing practi-
tioners that are addressing the problematic situation of
combating burnout. In line with their recommendations,
we would like to highlight two examples, the first being
job redesign: job rotation and the illumination and
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768 L. Sundin et al. / International Journal of Nursing Studies 44 (2007) 758–769
refinement of job descriptions and work roles could act
as possible solutions to minimise workload. Further-
more, peer support groups are mentioned as a potential
solution to increase the opportunities for reciprocal
support between colleagues at the workplace.
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