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