Journal of BehavioralAssessment, Vol.3, No.

1, 1981

The Nursing Stress Scale: Development

of an Instrument

P a m e l a G r a y - T o f t 1'3 and J a m e s G. A n d e r s o n ~

Accepted December 12, 1981

Despite increased recognition o f the stress experienced by hospital nursing

staffs and its effects on burnout, j ob satisfaction, turnover, and patient
care, f e w instruments exist that can be used to measure stress. This paper
describes the development o f an instrument, the Nursing Stress Scale (NSS).
It consists o f 34 items that describe situations that have been identified as
causing stress fo r nurses in the performance o f their duties. It provides a
total stress score as well as scores on each o f seven subscales that measure
the frequency o f stress experienced by nurses in the hospital environment.
The Nursing Stress Scale was administered to 122 nurses on five hospital
units. Factor analysis indicated seven major sources o f stress that closely
paralleled the conceptual categories o f stress on which the scale was based.
Test-retest reliability as well as four measures o f internal consistency
indicated that the Nursing Stress Scale and its seven subscales are reliable.
Validity was determined by correlating the total score from the Nursing
Stress Scale with measures o f trait anxiety, job satisfaction, and nursing
turnover hypothesized to be related to stress. In addition, the ability o f the
scale to differentiate hospital units and groups of nurses known to experience
high levels o f stress resulting in staff turnover was examined.

KEY WORDS: nursing stress; staff burnout; anxiety; job satisfaction; turnover.

'Department of Medical Research, Methodist Hospital of Indiana, Inc., Indianapolis, Indiana

46202.
2Department of Sociology and Anthropology, Purdue University, West Lafayette, Indiana
47907.
3Address all correspondence to P. Gray-Toft, Department of Medical Research, Methodist
Hospital of Indiana, Inc., Indianapolis, Indiana 46202.
11
0164-0305/81/0300-0011503.00/0 1981 Plenum Publishing Corporation
12 Gray-Toft and Anderson

INTRODUCTION

During the last decade there has been increasing recognition of the
stress experienced by hospital nursing staff (Bates and Moore, 1975;
Beszterczey, 1977; Cassem and Hackett, 1972; Hay and Oken, 1972;
Kornfeld, 1971; Quinby and Bernstein, 1971; Wertzel et al., 1977).
Although some stressful situations are specific to a particular type of hospital
unit, nurses are subject to more general stress which arises from the physical,
psychological, and social aspects of the work environment (Edelstein, 1966;
Hay and Oken, 1972; Kornfeld, 1971; Malone, 1964; Menzies, 1960; Price
and Bergen, 1977; Schulz and Aderman, 1976; Vreeland and Ellis, 1969).
High levels of stress result in staff burnout (Cartwright, 1979; Freudenberger,
1974; Maslach, 1976, 1979)and turnover (Kramer, 1974; National Commis-
sion on Nursing and Nursing Education, 1970; Nichols, 1971) and adversely
affect patient care (Meyer, 1962; Meyer and Mendelson, 1961; Revans, 1959).
While awareness of nursing stress and its consequences has grown,
there has been little effort to develop a reliable and theoretically valid instru-
ment that can be used to measure frequency and sources of nursing stress.
Cassem and Hackett (1972) reported an instrument developed to measure
psychological stress in a coronary care unit. While they report summary
scores for seven general areas of conflict, no empirical data are provided to
justify their groupings of items and their report contains no evidence of the
reliability and validity of the instrument.
The purpose of this study was to develop a nursing stress scale which
would measure the frequency and the major sources of stress experienced by
nurses on hospital units.

METHOD

Stress was defined as an internal cue in the physical, social, or

psychological environment that threatens the equilibrium of an individual
(Appley and Trumbull, 1967; Lazarus, 1966). The Nursing Stress Scale
(NSS) that was developed was based on 34 potentially stressful situations
that were identified from the literature and from interviews with nurses,
physicians, and chaplains. These items are shown in Table I.
The scale was administered to a sample of 122 nurses on five units of a
large, private, general hospital. The units were medicine, surgery, cardio-
vascular surgery, oncology, and hospice. These units were chosen because
their patients represent a range of medical conditions requiring different
types of nursing care and exposing nurses to various sources of stress. The
sample represented 90% of the nursing staff on these units. Nurses not
Nursing Stress Scale 13

Table I. Items and Item Statistics for the Nursing Stress Scale a
Item correlation with
Total scale Subscale
Item Mean SD score score

Factor I: Death and dying

3 Performing procedures that patients
experience as painful 2.44 0.71 0.41 0.45
4 Feeling helpless in the case of a patient who
fails to improve 2.41 0.69 0.42 0.51
6 Listening or talking to a patient about his/her
approaching death 2.23 0.75 0.39 0.51
8 The death of a patient 2.26 0.62 0.25 0.60
12 The death of a patient with w h o m you
developed a close relationship 2.26 0.73 0.37 0.48
13 Physician not being present when a
patient dies 1.88 0196 0.15 0.36
21 Watching a patient suffer 2.81 0.76 0.45 0.56
Factor II: Conflict with physicians
2 Criticism by a physician 2.12 0.76 0.51 0.49
9 Conflict with a physician 1.75 0.70 0.55 0.54
10 Fear o f making a mistake in treating
a patient 2.03 0.69 0.28 0.33
14 Disagreement concerning the treatment
of a patient 2.02 0.61 0.49 0.40
19 Making a decision concerning a patient
when the physician is unavailable 1.84 0.80 0.42 0.44
Factor III: Inadequate preparation
15 Feeling inadequately prepared to help with
the emotional needs o f a patient's family 2.25 0.70 0.47 0.57
18 Being asked a question by a patient for which
I do not have a satisfactory answer 2.21 0.62 0.27 0.48
23 Feeling inadequately prepared to help with
the emotional needs of a patient 2.22 0.58 0.48 0.70
Factor IV: Lack of support
7 Lack of an opportunity to talk openly with
other unit personnel about problems
on the unit 2.13 0.86 0.44 0.42
11 Lack of an opportunity to share experiences
and feelings with other personnel on the unit 1.83 0.68 0.29 0.58
16 Lack of an opportunity to express to other
personnel on the unit m y negative
feelings toward patients 1.70 0.64 0.33 0.38
Factor V: Conflict with other nurses
5 Conflict with a supervisor 1.66 0.64 0.41 0.43
20 Floating to other units that are short-staffed 2.44 1.07 0.29 0.39
22 Difficulty in working with a particular nurse
(or nurses) outside the unit 1.77 0.68 0.42 0.48
24 Criticism by a supervisor 1.86 0.72 0.53 0.47
29 Difficulty in working with a particular nurse
(or nurses) on the unit 2.03 0.75 0.40 0.50
14 Gray-Toft and Anderson

Table I. Continued.
Item correlation with
Total scale Subscale
Mean SD score score
Factor VI: Work load
1 Breakdown of computer 3.23 0.86 0.30 0.38
25 Unpredictable staffing and scheduling 2.97 0.87 0.52 0.52
27 Too many nonnursing tasks required,
such as clerical work 2.22 0.95 0.53 0.56
28 Not enough time to provide emotional
support to a patient 2.83 0.80 0.39 0.53
30 Not enough time to complete all of my
nursing tasks 2.52 0.80 0.47 0.58
34 Not enough staff to adequately cover the unit 3.20 0.81 0.39 0.55
Factor VII" Uncertainty concerning treatment
17 Inadequate information from a physician
regarding the medical condition of
a patient 2.09 0.75 0.51 0.57
26 A physician ordering what appears to be
inappropriate treatment for a patient 2.02 0.63 0.50 0.57
31 A physician not being present in a
medical emergency 2.15 0.81 0.62 0.69
32 Not knowing what a patient or a patient's
family ought to be told about the patient's
condition and its treatment 2.31 0.81 0.41 0.58
33 Uncertainty regarding the operation and
functioning of specialized equipment 2.06 0.64 0.39 0.49

"Item correlations with the total scale score and the subscale score are item-remainder correlations.

included in the sample were on leave during the period the scale was
a d m i n i s t e r e d . A d e s c r i p t i o n o f t h e s a m p l e is c o n t a i n e d i n T a b l e II.
Nurses were given the following directions:

Below is a list of situations that commooly occur on a hospital unit. For each item
indicate by means of a check (~,-) how often on your present unit you have found the
situations to be stressful. Your responses are strictly confidential.

F o u r r e s p o n s e c a t e g o r i e s w e r e p r o v i d e d f o r e a c h i t e m : n e v e r (0), o c c a s i o n a l l y
(1), f r e q u e n t l y (2), a n d v e r y f r e q u e n t l y (3).

RESULTS

Subscales

The scale items were factor analyzed using squared multiple correla-
t i o n s as i n i t i a l e s t i m a t e s o f c o m m u n a l i t i e s . F a c t o r s w i t h e i g e n v a l u e s g r e a t e r
Nursing Stress Scale 15

Table II. Sample for the Stress Study (N = 122)

Hospital unit
Type of Cardiovascular
nurse Medicine Surgery surgery Oncology Hospice
Registered
nurse 10 (10) 9 (10) 10 (10) 13 (13) 8 (8)
Licensed
practical
nurse 7 (7) 8 (8) 8 (9) 10(10) 5 (5)
Nursing
assistant 2 (6) 10(16) 6 (8) 12(12) 4 (4)
Total 19 (23) 27 (34) 24 (27) 35 (35) 17(17)
Beds 27 51 42 54 11
aActual number of nurses.

than one were rotated using a quartimax rotation. A quartimax rotation

was used because it tends to result in high loadings on one factor and almost
zero loadings on others. However, the same factor structure emerged when
a varimax rotation was used (Rummel, 1970).
The analysis identified seven major sources of stress. Factor loadings
are shown in Table III. Only loadings of 0.30 or higher are shown, since
smaller loadings represent less than 10% of the variance (Nunnally, 1967, p.
357). One factor relates to the physical environment; four factors arise from
the psychological environment and two from the social environment of the
hospital.

The Physical Environment

Factor VI: Work Load. This factor includes stressful situations that
arise from the nurse's work load, staffing and scheduling problems, a n d
inadequate time to complete nursing tasks and to support patients
emotionally.

The Psychological Environment

Factor I: Death and Dying. This factor appears largely to measure

stressful situations resulting from the suffering and death of patients. Four
of the seven items that load on this factor are related to the death of a
patient. Two other items are associated with patients who fail to improve or
who suffer. The performance of painful procedures on patients is also
potentially stressful.
Factor III: Inadequate Preparation to Deal with the Emotional Needs
of Patients and Their Families. The three items that load heavily on this
16 Gray-Toft and Anderson

Table III. Quartimax Rotated Factor Matrix Factor Loadings a

Item I II III IV V VI VII
1 0.37 0.36
2 0.61
3 0.49
4 0.55
5 0.45
6 0.65
7 0.35
8 0.80
9 0.63
10 0.45
11 0.86
12 0.55
13 0.43
14 0.49
15 0.61
16 0.51
17 0.39
18 0.66
19 0.50
20 0.54
21 0.59
22 0.60
23 0.70
24 0.35 0.42
25 0.47
26 0.38 0.50
27 0.61
28 0.70
29 0.40
30 0.66
31 0.34 0.64
32 0.59
33 0.67
34 0.61
70 C o m m o n
variance 39.3 11.8 9.1 7.2 6.5 5.6 5.5
aOnly factor loadings _>0.30 are reported.

factor concern nurses' attempts to meet the emotional needs of patients and
their families. Feeling inadequately prepared to deal with these
psychological and emotional needs may lead to stress.
Factor IV: Lack of Staff Support. This fourth subscale measures the
nurse's assessment of the extent to which opportunities are available to
share experiences with other nurses and to vent negative feelings of anger
and frustration. The lack of such opportunities may result in stress for
nurses.
Factor VII." Uncertainty Concerning Treatment. Stressful situations
also arise where there is uncertainty concerning the treatment of patients.
Nursing Stress Scale 17

This may develop when the physician fails to adequately communicate to

the nurse information concerning a patient's medical condition. When this
occurs the nurse does not know what to tell a patient or the patient's family
about the medical condition and its treatment. A third potentially stressful
situation occurs when a physician is not present in a medical emergency.

The Social Environment

Factor II: Conflict with Physicians. Factor II consists of stressful

situations that arise from the nurse's interactions with physicians. The two
items that load highest on this factor are criticism by a physician and
conflict with a physician. The other items pertain to the nurse's fear of
making mistakes concerning treatment in the absence of a physician and
disagreement concerning treatment.
Factor V: Conflict with Other Nurses and Supervisors. The items that
load on this factor are associated with conflictual situations that arise
between nurses and supervisors. Two of the items involve conflict with or
criticism by a supervisor; the other three items have to do with conflict with
nurses on the same or other hospital units.
Based on these seven factors, subscales were created by adding the
individual nurse's scores on the items that loaded on each factor.
Intercorrelations a m o n g the seven stress subscales are presented in Table
IV. Factor analysis of these intercorrelations, using a quartimax rotation,
revealed a c o m m o n stress factor since all seven subscales loaded highly on
a single factor. Factor loadings for each subscale are also presented in Table
IV. As a result, a total score that measures the overall frequency of stress
experienced by a nurse can be created by adding the individual's responses
to all 34 items. Total scores range f r o m 0 to 102, with higher scores indicat-
ing more frequent stress.

Reliability

Two estimates of the reliability of the Nursing Stress Scale were deter-
mined: test-retest and internal consistency. The scale was readministered to
a sample of 31 nurses after 2 weeks. This sample was taken proportionately
f r o m the five units originally studied. The test-retest coefficient for the
total scale was 0.81. Four measures of internal consistency were obtained: a
S p e a r m a n - B r o w n coefficient of 0.79, a G u t t m a n split-half coefficient of
0.79, a coefficient a of 0.89, and a standardized item o~ of 0.89. All four
measures indicated a satisfactory level o f consistency a m o n g items.
The factor analysis described earlier revealed seven subscales that
measure different sources of stress. Test-retest reliability coefficients for
18 Gray-Toft and Anderson

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b~

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0 0

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0

"~.o

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"0

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Nursing Stress Scale 19

Table V. ReliabilityMeasures for Subscales of the Nursing Stress Scale

Internal consistency reliability
No. of Test-retest Spearman- Guttman Standardized
Scale items reliability Brown split half ~ item c
Total
Stress 34 0.81 0.79 0.79 0.89 0.89
Subscale
Death and dying 7 0.83 0.77 0.76 0.77 0.78
Conflict with physicians 5 0.72 0.71 0.68 0.68 0.68
Inadequate preparation 3 0.42 0.84 0.74 0.75 0.76
Lack of support 3 0.65 0.57 0.46 0.64 0.65
Conflict with other nurses 5 0.86 0.73 0.70 0.68 0.70
Work load 6 0.74 0.77 0.77 0.77 0.77
Uncertainty concerning 5 0.68 0.78 0.74 0.80 0.80
treatment

four of the seven subscales exceeded 0.70. Internal consistency measures

exceeded 0.70 for all components with the exception of two subscales (see
Table V).

Validity

The validity of the Nursing Stress Scale was determined by empirically

investigating its relationship to other important criteria to which stress is
theoretically related, namely, trait anxiety, state anxiety, job satisfaction,
and turnover. The ability o f the scale to differentiate hospital units and
groups of nurses known to experience high levels of stress and turnover was
also investigated (Gray-Toft and Anderson, 1981).
It was hypothesized that nurses with high levels of anxiety would
experience more frequent stress in the performance o f their nursing duties
than other nurses (Appley and Trumbull, 1967; Lazarus, 1966). In order to
test this hypothesis, trait anxiety was measured with the I P A T Anxiety Scale
Questionnaire (Krug et al., 1976) and state anxiety with the potent negative
affect c o m p o n e n t of the Affect Rating Scale (Sipprelle et al., 1976). The
I P A T is a 40-item scale that includes indicators o f worry, tension, low self-
control, emotionality, and suspiciousness. The Affect Rating Scale consists
o f 30 bipolar adjectives designed to measure transitory changes in anxiety.
Furthermore, it was hypothesized that nurses who experienced high
levels of stress in their work would report significantly less job satisfaction
(Davis, 1974; Kramer, 1974). The W o r k Subscale of the J o b Description
Index was used to test this hypothesis (Smith et al., 1969). Respondents
indicated their degree of satisfaction with their work by responding to 18
adjectives that describe jobs in general.
20 Gray-Toft and Anderson

Table VI. Correlations of the Nursing

Stress Scale with Trait Anxiety,
State Anxiety, and Job Satisfaction
(N = 122)
Correlation
Variable with NSS
Trait anxiety (IPAT) 0.39 a
State anxiety (ARS) 0.35a
Job satisfaction (JDI) -0.15
~'P _< 0.01.

Table VI contains the product moment correlations of each of these

measures with the total score from the Nursing Stress Scale. As hypothesized,
two of the three correlations are significant.
Validity also was determined by examining turnover among the
nursing staff of the five units included in this study. Turnover was
considered to be an important indicator of staff burnout resulting from
high levels of stress. Consequently, it was hypothesized that nurses in units
experiencing high rates of turnover would score significantly higher on the
Nursing Stress Scale.
Data in Table VII generally support this hypothesis. Mean scores on
the Nursing Stress Scale are shown for each hospital unit as well as turnover
rates for a 5-month period. As the level of stress among the nursing staff
increased, the turnover increased correspondingly.
Finally, it was hypothesized that registered nurses (RNs) would score
highest on the Nursing Stress Scale and nursing assistants (NAs) would
score lowest. This hypothesis was based on the fact that registered nurses
have the major responsibility for implementing physicians' orders and for
supervising licensed practical nurses and nursing assitants. Nursing
assistants' primary responsibility is bedside care. Moreover, hospitals are
experiencing significant problems in recruiting and retaining registered

Table VII. Mean Scores on the Nursing Stress Scale

and Nursing Turnover Rates by Hospital Unit,
November 1978-March 1979
Mean
Hospital score Percentage
unit (NSS) turnover
Hospice 84.59 0
Surgery 85.07 6
Oncology 88.71 11
Cardiovascularsurgery 91.21 15
Medicine 94.11 30
Nursing Stress Scale 21

Table VIII. Mean Scores on the Nursing Stress Scale

and Nursing Turnover Rates by Level of Training,
November 1978-March 1979
Mean
Level of score Percentage
training (NSS) turnover
Registered nurses 92.46 16
Licensed practical nurses 88.16 13
Nursing assistants 83.65 9

nurses (Kramer, 1974; National Commission on Nursing and Nursing

Education, 1970).
Table VIII contains turnover rates for RNs, LPNs, and NAs as well as
mean scores on the Nursing Stress Scale for each group. As hypothesized, a
two-way analysis of variance controlling for race found significant
differences among the three groups of nurses [F(2,114) -- 3.65, P _< 0.03].
The highest stress scores and turnover rates were among registered nurses.
Nursing assistants appeared to experience the least stress and evidenced the
lowest turnover rates.

DISCUSSION

The Nursing Stress Scale developed in this study is self-administered,

requiring less than 10 min of the nurse's time. It provides a total score that
is indicative of the frequency with which nurses experience stress in the
performance of nursing duties. It also provides seven subscales that can be
used to identify specific sources of stress for the nurse. Scoring is simple.
Individual item responses are added together for groups of items and for all
34 items in order to obtain subscale scores and the total score, respectively.
The results o f this study indicate that the Nursing Stress Scale is
reliable. Nurses's scores were consistent when the scale was readministered
after a period of 2 weeks. The total scale and subscales appear to be
internally consistent. Preliminary evidence suggests that the scale is valid.
Nursing stress scores were found to be positively correlated with trait
anxiety among hospital nursing staff and inversely correlated with job
satisfaction. The scale differentiated hospital units and groups o f nurses
that appeared to be experiencing burnout, as evidenced by high turnover
rates.
As presented here, the Nursing Stress Scale is an experimental scale
which requires additional field testing and validation before its properties
can be fully assessed. However, the initial results suggest that the scale has
potential for personnel management and research. In its present form, it
22 Gray-Toft and Anderson

c o u l d be utilized b y h o s p i t a l a d m i n i s t r a t o r s in m a k i n g decisions r e g a r d i n g
the s t a f f i n g o f h o s p i t a l units. F o r e x a m p l e , it c o u l d be used to i d e n t i f y
p a r t i c u l a r l y stressful units o f the h o s p i t a l so t h a t in-service t r a i n i n g a n d
s u p p o r t p r o g r a m s c o u l d be d e s i g n e d a n d i n i t i a t e d in o r d e r to p r e v e n t s t a f f
b u r n o u t ( G r a y - T o f t , 1980). It c o u l d also be used to i d e n t i f y i n d i v i d u a l
nurses w h o are u n d e r excessive stress t h a t m a y result in a b s e n t e e i s m a n d
s t a f f t u r n o v e r a n d to assign nurses to units w h e r e they w o u l d experience less
stress.
F i n d i n g s f r o m the field testing o f the N u r s i n g Stress Scale as well as
results f r o m o t h e r studies suggest t h a t n u r s i n g stress affects j o b s a t i s f a c t i o n ,
s t a f f t u r n o v e r , a n d p a t i e n t care. This scale c o u l d b e used in f u t u r e r e s e a r c h
t h a t e x a m i n e s these r e l a t i o n s h i p s .
T h e N u r s i n g Stress Scale d e v e l o p e d in this s t u d y was d e s i g n e d to
m e a s u r e the f r e q u e n c y with which c e r t a i n n u r s i n g s i t u a t i o n s were p e r c e i v e d
as stressful b y nurses. It does n o t m e a s u r e the intensity o f stress e x p e r i e n c e d
b y the i n d i v i d u a l . F u t u r e r e s e a r c h s h o u l d be d i r e c t e d at m o d i f y i n g the
N u r s i n g Stress Scale to i n c l u d e a n intensity d i m e n s i o n . M o r e o v e r ,
p h y s i o l o g i c a l m e a s u r e s o f stress m i g h t be used to v a l i d a t e a n d e x t e n d the
scale, especially as t e c h n o l o g y m a k e s this m o r e feasible.

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