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http://aph.sagepub.com/Asia-Pacific Journal of Public Health

http://aph.sagepub.com/content/22/4/501Theonline version of this article can be foundat:

DOI: 10.1177/1010539510380560

2010 22: 501Asia Pac J Public HealthMuhamad Robat Rosnawati, Htay Moe, Retneswari Masilamani and A. Darus

Study in MalaysiaThe Bahasa Melayu Version of the Nursing Stress Scale Among Nurses: A Reliability

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Asia-Pacific Journal of Public Health22(4) 501506 2010 APJPH

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DOI: 10.1177/1010539510380560http://aph.sagepub.com

The Bahasa MelayuVersionof the Nursing Stress ScaleAmong Nurses: A Reliability

Study in Malaysia

Muhamad Robat Rosnawati, MD, MPH1,

Htay Moe, MPH, FRIPH1,

Retneswari Masilamani, MBBS, MMed, FAOEMM, FFOM1,

and A. Darus, MBBS, MPH1

Abstract

The Nursing Stress Scale (NSS) has been shown to be a valid and reliable instrument to assessoccupational stressors among nurses. The NSS, which was previously used in the English version,was translated and back-translated into Bahasa Melayu. This study was conducted to assess

the reliability of the Bahasa Melayuversion of the NSS among nurses for future studies in thiscountry. The reliability of the NSS was assessed after its readministration to 30 nurses witha 2-week interval. The Spearman coefficient was calculated to assess its stability. The internal

consistency was measured through 4 measures: Cronbachs , SpearmanBrown, Guttman

split-half, and standardized item coefficients. The total response rate was 70%. Testretestreliability showed remarkable stability (Spearmans exceeded .70). All 4 measures of internal

consistency among items indicated a satisfactory level (coefficients in the range of .68 to .87).In conclusion, the Bahasa Melayuversion of the NSS is a reliable and useful instrument formeasuring the possible stressors at the workplace among nurses.

Keywords

reliability, Nursing Stress Scale, stress, nurses

Introduction

Stress is an increasingly important occupational health problem and a significant cause of eco-

nomic loss.1Occupational stress is defined as the harmful physical and emotional responses that

occur when the requirements of the job do not match the capabilities, resources, or needs of the

worker.2Occupational stress has long been recognized as a challenge for the nursing profession.

They are susceptible to physical and mental health problems and even suicide. Although there

1University of Malaya, Kuala Lumpur, Malaysia

Corresponding Author:

Rosnawati Muhamad Robat, Occupational and Environmental Health Unit, Department of Social and Preventive

Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia

Email: [email protected]

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502 Asia-Pacific Journal of Public Health 22(4)

have been published studies among nurses in the country that addressed nurses role, perceptions,

or capabilities in performing their duties,3,4these did not address stress at the workplace.

In the study of occupational stress among nurses, the Nursing Stress Scale (NSS) is the best

known and most widely used scale. The scale is use to assess the frequency with which nurses

experienced occupational stress and to identify the sources of occupational stress. It does notmeasure the intensity of stress experienced by the individual. It is a self-administered question-

naire. It was developed based on 34 potentially stressful situations by Gray-Toft and Anderson

in 1981.5They identified 7 major sources of stress. One factor relates to the physical environ-

ment (workload), 4 factors arise from the psychological environment (death and dying, inade-

quate preparation to deal with the emotional needs of patients and their families, lack of staff

support, and uncertainty concerning treatment), and 2 factors from the social environment (con-

flict with physicians and conflict with other nurses and supervisors). For the purpose of the

study, the NSS appears to be more suitable as it encompasses area of concerns specific to nurses,

such as those studied in the Malaysian setting. Other instruments for assessing workplace stress,

such as the Job Content Questionnaire, has been translated to the Malay language and used in

other studies in the country.6,7

In Malaysia, the scales transcultural adaptation was carried out by means of the transla-

tion and back-translation method (EnglishMalayEnglish) in 1994, but there was no reliabil-

ity test or any other validation test done.8Before conducting any study it is important to have a

reliable and valid instrument.9The reliability refers to the stability or consistency of informa-

tion. It determines whether the instrument produces the same results each time it is adminis-

tered to the same person in the same setting. Therefore, this study was conducted to assess the

reliability of theBahasa Melayuversion of the NSS among nurses in 2 centersSelangor and

Kuala Lumpur.

Materials and Methods

Study Design and Sample Size

This descriptive study was conducted at a health center in Selangor and a teaching hospital in

Kuala Lumpur (pediatric, psychiatric, and outpatient departments). The questionnaire was ran-

domly distributed among the nurses in the aforementioned centers. For this study, after consid-

ering the most practical measurement to be used, the testretest method was conducted for

reliability measurement.

The self-administeredBahasa Melayuversion of the NSS was distributed to 30 nurses, with 15

nurses from each center. The first and second sets of questionnaires were administered at 2-weekintervals. The nurses who returned the completed questionnaires implied that they had con-

sented for the study. The returned questionnaires were checked for completeness. The total

response rate was 70% (N = 21). The study protocol was approved by the Medical and Research

Committee of University Malaya Medical Centre and the Ministry of Health, Malaysia.

Nursing Stress Scale Assessment

The NSS is scored on a 4-point Likert-type scalenever (0), occasionally (1), frequently (2), and

very frequently (3)according to the perceived occurrence based on 34 potentially stressful situ-

ations in the workplace. Scoring is conducted by adding up the individual item responses foreach subscale. This provides a score for each subscale. High scores indicate the frequent pres-

ence of a specific source of stress. To obtain a total score, responses from all 34 items are added

(ranging from 0 to 102).



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Rosnawati et al. 503

Statistical Analysis

Data entry and analysis was done usingthe Statistical Package for Social Sciences, version 12.Means and standard deviations for normally distributed variables and medians and interquartileranges for skewed variables were used for continuous variables; frequencies and percentages

were used for categorical variables. Two components of instrument reliability were determined:

its stability, through the correlation coefficient test using the Spearman rank correlation coeffi-

cient (; r= 0 vs r0), and its internal consistency, through 4 measuresCronbachs , Spear-

manBrown, Guttman split-half, and standardized item coefficients.

Results

Sociodemographic and Work CharacteristicsA total of 21 nurses participated in this study. Table 1 summarizes the sociodemographic and work

characteristics of the study population. All participants were Malays and females. The mean age

Table 1.Sociodemographic and Work Characteristics of Nurses (N =21)

Variables Frequency (%) Mean (SD) Median (IQR)

Age (years) 35.1 (6.6)

Total duration of working as a nurse (years) 11.0 (8.0)a

Duration of working at present unit (years) 4.0 (6.0)a

Marital status

Single 1 (4.8)

Married 19 (90.5)

Separated/divorced/widowed 1 (4.8)

Total income per month (RM)


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was 35.1 6.6 years. Age ranged from 25 to 51 years. The majority were married and nonshift

workers. Most of them were either certificate or diploma holders in nursing.

TestRetest Mean Scores

Table 2 shows the testretest mean scores obtained from the NSS. The differences between

the testretest mean scores were calculated using Wilcoxon signed rank test. The findings

showed that mean scores of both test and retest were not significant for all the 7 scales usedin the NSS.

TestRetest Reliability (Correlation Coefficient and Internal Consistency)

The testretest reliability and internal consistency measures for all 7 subscales of the NSS are

given in Table 3. The testretest correlation coefficient for the total scale was .70 (P< .01). Indi-

vidual items had good Spearman rank correlation coefficient, with the lowest value concerning

item 3 (inadequate preparation: = .70) and the highest values concerning items 2 and 6 (death

and dying and conflict with physicians: = .77). The correlation coefficient tests were all statisti-

cally significant at the .05 level. Four measures of internal consistency were obtained. Internalconsistency measures exceeded .70 for all components with the exception of 1 subscale (Table 3).

The internal consistency was also carried out using the intraclass classification method, showing

similar results.

Discussion

The testretest reliability proved to be satisfactory. Nurses scores were consistent when the scale

was readministered after a period of 2 weeks, with Spearmans for the 7 subscales being .70

and more. Gray-Toft and Anderson5reported a testretest reliability coefficient over a 2-week

period for the total scale of .81. They presented 4 measures of internal consistency: a SpearmanBrown (.79), Guttman split-half (.79), coefficient (.89), and the standardized item (.89). They

also examined the validity of the NSS comparing it with other stress measures such as state

anxiety (increase arousal due to environmental factors). The resulting correlation was .39. Our

Table 2.Descriptive of Test-Retest Mean Rank Scoresa

NSSTest Mean

Rank ScoresRetest MeanRank Scores zValue PValue

1. Workload 7.80 10.71 0.07 .94

2. Death and dying 6.80 6.29 0.40 .693. Inadequate

preparation6.36 6.70 0.46 .64

4. Lack of staff support 4.81 8.25 1.14 .25

5. Uncertaintyconcerning treatment

7.29 6.67 0.40 .69

6. Conflict withphysicians

8.43 7.63 0.06 .95

7. Conflict with othernurses

7.42 6.64 0.07 .94

Abbreviation: NSS, Nursing Stress Scale.aAll scales showed mean differences not significant at P< .05 using Wilcoxons test.



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Rosnawati et al. 505

findings were almost similar to the Gray-Toft and Anderson study findings,5with 4 of our subscales

(inadequate preparation, lack of staff support, uncertainty concerning treatment, conflict with

physicians) showing higher Spearman value than that obtained in the Gray-Toft and

Anderson study.

No other results of the coefficient testretest reliability could be compared as most of the

other available published studies did not report the testretest reliability but reported more of

internal consistency.

The total scale and subscales of the 4 measures in our study appeared to be internally con-

sistent. The findings showed higher value of all coefficients as compared with the Gray-Toft

and Anderson study in total scale as well as subscales. However, Cronbachs for the totalscale was lower if compared with other studies from other Asian Countries, United States

(Hawaii), British Columbia, Australia, New Zealand, and Southern Spain, wherein their

Cronbachs s ranged from .87 to .93.10-16With regard to Cronbachs on 7 subscales, our

study appeared to have higher value (.68-.87) compared when with a study done in Southern

Spain (.49-.83).16

The major limitation of this study was the small sample size and that the subjects were

from restricted categories of work unit and ethnicity. It would be desirable to examine the

reliability of the NSS over a broader range of work unit and ethnicity and on a large number

of subjects.

In conclusion, the results of this study indicate that the Bahasa Melayuversion of the NSSwas reliable. The total scale and subscales appeared to be stable and internally consistent. There-

fore, theBahasa Melayuversion of the NSS is a useful instrument for measuring the possible

stressors at the workplace among Malaysian nurses.

Table 3.Reliability Measures for Subscales of the Nursing Stress Scale

ScaleNo. ofItems

TestRetestReliability ()

Internal Consistency Reliability

95% CISpearmanBrownGuttmansplit-half Cronbach

Standardizeditem

Total scale 34 .70 .86 .86 .86 .86 .66-.94Subscales

1. Workload 6 .71 .68 .68 .68 .68 .20-.87 2. Death and

dying7 .77 .87 .86 .86 .87 .67-.94

3. Inadequatepreparation

3 .70 .80 .79 .79 .80 .49-.92

4. Lack of staffsupport

3 .75 .81 .81 .81 .81 .53-.92

5. Uncertaintyconcerningtreatment

5 .76 .87 .87 .87 .87 .68-.95

6. Conflictwithphysicians

5 .77 .85 .84 .84 .85 .60-.94

7. Conflictwith othernurses

5 .74 .86 .85 .85 .86 .63-.94

Abbreviation: CI, confidence interval.aAll scales showed significant correlations at p


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Acknowledgement

The authors wish to thank Professor James G. Anderson for the permission granted to use the Nursing Stress

Scale. We also wish to extend our appreciation to the Ministry of Health and the Ministry of Higher Educa-

tion for their cooperation throughout the conduct of this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of

this article.

Funding

The study was funded by the University of Malaya Short Term Grant P0106/2006C.

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