Asia-Pacific Journal of Public Health
The online version of this article can be found at:
DOI: 10.1177/1010539510380560
2010 22: 501 Asia Pac J Public Health
Muhamad Robat Rosnawati, Htay Moe, Retneswari Masilamani and A. Darus
Study in Malaysia
The Bahasa Melayu Version of the Nursing Stress Scale Among Nurses: A Reliability
Published by:
On behalf of:
Asia-Pacific Academic Consortium for Public Health
can be found at: Asia-Pacific Journal of Public Health Additional services and information for
 Email Alerts: Subscriptions: Reprints: Permissions: Citations:
What is This?
- Oct 7, 2010 Version of Record >>
by guest on June 7, 2012 Downloaded from
Asia-Pacific Journal of Public Health
22(4) 501 –506
© 2010 APJPH
Reprints and permission: http://www.
DOI: 10.1177/1010539510380560
The Bahasa Melayu Version
of the Nursing Stress Scale
Among Nurses: A Reliability
Study in Malaysia
Muhamad Robat Rosnawati, MD, MPH
Htay Moe, MPH, FRIPH
Retneswari Masilamani, MBBS, MMed, FAOEMM, FFOM
and A. Darus, MBBS, MPH
The Nursing Stress Scale (NSS) has been shown to be a valid and reliable instrument to assess
occupational 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 Melayu version of the NSS among nurses for future studies in this
country. The reliability of the NSS was assessed after its readministration to 30 nurses with
a 2-week interval. The Spearman coefficient was calculated to assess its stability. The internal
consistency was measured through 4 measures: Cronbach’s α, Spearman–Brown, Guttman
split-half, and standardized item α coefficients. The total response rate was 70%. Test–retest
reliability showed remarkable stability (Spearman’s ρ 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 Melayu version of the NSS is a reliable and useful instrument for
measuring the possible stressors at the workplace among nurses.
reliability, Nursing Stress Scale, stress, nurses
Stress is an increasingly important occupational health problem and a significant cause of eco-
nomic loss.
Occupational 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
Occupational 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
University 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
by guest on June 7, 2012 Downloaded from
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,
these 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 not
measure 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.
They 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.
In Malaysia, the scale’s transcultural adaptation was carried out by means of the transla-
tion and back-translation method (English–Malay–English) in 1994, but there was no reliabil-
ity test or any other validation test done.
Before conducting any study it is important to have a
reliable and valid instrument.
The 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 the Bahasa Melayu version of the NSS among nurses in 2 centers—Selangor 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 test–retest method was conducted for
reliability measurement.
The self-administered Bahasa Melayu version 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-week
intervals. 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 scale—never (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 for
each 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).
by guest on June 7, 2012 Downloaded from
Rosnawati et al. 503
Statistical Analysis
Data entry and analysis was done using the Statistical Package for Social Sciences, version 12.
Means and standard deviations for normally distributed variables and medians and interquartile
ranges 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 (ρ; r = 0 vs r ≠ 0), and its internal consistency, through 4 measures—Cronbach’s α, Spear-
man–Brown, Guttman split-half, and standardized item α coefficients.
Sociodemographic and Work Characteristics
A 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)
Duration of working at present unit (years) 4.0 (6.0)
Marital status
Single 1 (4.8)
Married 19 (90.5)
Separated/divorced/widowed 1 (4.8)
Total income per month (RM)
<2000 5 (23.8)
2000-<3000 8 (38.1)
≥3000 8 (38.1)
Education level
Certificate in nursing 9 (42.9)
Diploma in nursing 9 (42.9)
Degree in nursing 3 (14.3)
Job rank
Sister 3 (14.3)
Staff nurse 12 (57.1)
Assistant nurse 2 (9.5)
Community nurse/midwife 4 (19.0)
Shift work
No 16 (76.2)
Yes 5 (23.8)
Hospital 6 (28.6)
Health center 15 (71.4)
Abbreviations: SD, standard deviation; IQR, interquartile range.
Median was used for variables with skewed distribution.
by guest on June 7, 2012 Downloaded from
504 Asia-Pacific Journal of Public Health 22(4)
was 35.1 ± 6.6 years. Age ranged from 25 to 51 years. The majority were married and non–shift
workers. Most of them were either certificate or diploma holders in nursing.
Test–Retest Mean Scores
Table 2 shows the test–retest mean scores obtained from the NSS. The differences between
the test–retest 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 used
in the NSS.
Test–Retest Reliability (Correlation Coefficient and Internal Consistency)
The test–retest reliability and internal consistency measures for all 7 subscales of the NSS are
given in Table 3. The test–retest 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: ρ = .70) and the highest values concerning items 2 and 6 (death
and dying and conflict with physicians: ρ = .77). The correlation coefficient tests were all statisti-
cally significant at the .05 level. Four measures of internal consistency were obtained. Internal
consistency 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.
The test–retest reliability proved to be satisfactory. Nurses’ scores were consistent when the scale
was readministered after a period of 2 weeks, with Spearman’s ρ for the 7 subscales being .70
and more. Gray-Toft and Anderson
reported a test–retest reliability coefficient over a 2-week
period for the total scale of .81. They presented 4 measures of internal consistency: a Spearman–
Brown (.79), Guttman split-half (.79), α coefficient (.89), and the standardized item α (.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 Scores
Test Mean
Rank Scores
Retest Mean
Rank Scores z Value P Value
1. Workload 7.80 10.71 −0.07 .94
2. Death and dying 6.80 6.29 −0.40 .69
3. Inadequate
6.36 6.70 −0.46 .64
4. Lack of staff support 4.81 8.25 −1.14 .25
5. Uncertainty
concerning treatment
7.29 6.67 −0.40 .69
6. Conflict with
8.43 7.63 −0.06 .95
7. Conflict with other
7.42 6.64 −0.07 .94
Abbreviation: NSS, Nursing Stress Scale.
All scales showed mean differences not significant at P < .05 using Wilcoxon’s test.
by guest on June 7, 2012 Downloaded from
Rosnawati et al. 505
findings were almost similar to the Gray-Toft and Anderson study findings,
with 4 of our subscales
(inadequate preparation, lack of staff support, uncertainty concerning treatment, conflict with
physicians) showing higher Spearman ρ value than that obtained in the Gray-Toft and
Anderson study.
No other results of the coefficient test–retest reliability could be compared as most of the
other available published studies did not report the test–retest 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, Cronbach’s α for the total
scale was lower if compared with other studies from other Asian Countries, United States
(Hawaii), British Columbia, Australia, New Zealand, and Southern Spain, wherein their
Cronbach’s αs ranged from .87 to .93.
With regard to Cronbach’s α on 7 subscales, our
study appeared to have higher value (.68-.87) compared when with a study done in Southern
Spain (.49-.83).
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 Melayu version of the NSS
was reliable. The total scale and subscales appeared to be stable and internally consistent. There-
fore, the Bahasa Melayu version 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
No. of
Reliability (ρ)
Internal Consistency Reliability
95% CI Spearman–Brown
split-half Cronbach α
item α
Total scale 34 .70 .86 .86 .86 .86 .66-.94
1. Workload 6 .71 .68 .68 .68 .68 .20-.87
2. Death and
7 .77 .87 .86 .86 .87 .67-.94
3. Inadequate
3 .70 .80 .79 .79 .80 .49-.92
4. Lack of staff
3 .75 .81 .81 .81 .81 .53-.92
5. Uncertainty
5 .76 .87 .87 .87 .87 .68-.95
6. Conflict
5 .77 .85 .84 .84 .85 .60-.94
7. Conflict
with other
5 .74 .86 .85 .85 .86 .63-.94
Abbreviation: CI, confidence interval.
All scales showed significant correlations at p < .05.
by guest on June 7, 2012 Downloaded from
506 Asia-Pacific Journal of Public Health 22(4)
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.
The study was funded by the University of Malaya Short Term Grant P0106/2006C.
1. Seward JP. Program management: occupational stress. In: La Dou J, ed. Current Occupational and
Environmental Medicine. New York, NY: McGraw Hill; 2004:603-618.
2. National Institute for Occupational Safety and Health. Stress . . . At Work. Atlanta, GA: Centers for
Disease Control and Prevention; 1999. NIOSH Publication 99-101
3. Chen CJ, Jallaludin RL. Knowledge and perception of oral health promotion in schools among dental
nurses in Sarawak, Malaysia. Asia Pac J Public Health. 2000;12:12-16.
4. Tan NC, Lim NMLH, Gu K. Effectiveness of nurse counseling in discouraging the use of the infant
walkers. Asia Pac J Public Health. 2004;16:104-107.
5. Gray-Toft P, Anderson JG. The Nursing Stress Scale: development of an instrument. J Behav Assess.
6. Huda BZ, Rusli BN, Naing L, Winn T, Tengku MA, Rampal KG. Job strain and its associated factors
among lecturers in the School of Medical Sciences, Universiti Sains Malaysia and Faculty of Medicine,
Universiti Kebangsaan Malaysia. Asia Pac J Public Health. 2004;16:32-40.
7. Maizura H, Masilamani R, Aris T. Reliability (internal consistency) of the job content questionnaire
on job stress among office workers of a multinational company in Kuala Lumpur. Asia Pac J Public
Health. 2009;21:216-222.
8. Rokiah M. Prevalence and Causes of Occupational Stress Among Staff Nurses in HKL [master’s thesis].
Selangor: Universiti Kebangsaan Malaysia; 1994.
9. Quek KF. Statistics in medical research: an introduction. ASEAN J Anaesthesiol. 2004;5:129-137.
10. Lee JK. Job stress, coping and health perceptions of Hong Kong primary care nurses. Int J Nurs Pract.
11. Lambert VA, Lambert CE, Ito M. Workplace stressors, ways of coping and demographic characteristics
as predictors of physical and mental health of Japanese hospital nurses. Int J Nurs Stud. 2004;41:85-97.
12. Lambert VA, Lambert CE, Petrini M, Li XM, Zhang YJ. Predictors of physical and mental health in
hospital nurses within the People’s Republic of China. Int Nurs Rev. 2007;54:85-91.
13. Lambert VA, Lambert CE, Itano J, et al. Cross-cultural comparison of workplace stressors, ways of
coping and demographic characteristics as predictors of physical and mental health among hospital
nurses in Japan, Thailand, South Korea and the USA (Hawaii). Int J Nurs Stud. 2004;41:671-684.
14. LeSergent CM, Haney CJ. Rural hospital nurse’s stressors and coping strategies: a survey. Int J Nurs
Stud. 2005;42:315-324.
15. Chang EM, Bidewell JW, Huntington AD, et al. A survey of role stress, coping and health in Australian
and New Zealand hospital nurses. Int J Nurs Stud. 2007;44:1354-1362.
16. Augusto Landa JM, Lopez-Zafra E, Berrios Martos MP, Aguilar-Luzon Mdel C. The relationship
between emotional intelligence, occupational stress and health in nurses: a questionnaire survey.
Int J Nurs Stud. 2008;45:888-901.
by guest on June 7, 2012 Downloaded from