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Asia-Pacific Journal of Public Health
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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

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Asia-Pacific Journal of Public Health
22(4) 501 506
2010 APJPH
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DOI: 10.1177/1010539510380560
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The Bahasa Melayu Version
of the Nursing Stress Scale
Among Nurses: A Reliability
Study in Malaysia
Muhamad Robat Rosnawati, MD, MPH
1
,
Htay Moe, MPH, FRIPH
1
,
Retneswari Masilamani, MBBS, MMed, FAOEMM, FFOM
1
,
and A. Darus, MBBS, MPH
1
Abstract
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: Cronbachs , SpearmanBrown, Guttman
split-half, and standardized item coefficients. The total response rate was 70%. Testretest
reliability 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 Melayu version of the NSS is a reliable and useful instrument for
measuring 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.
1
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
worker.
2
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
1
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
Email: tiq0672@yahoo.com
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502 Asia-Pacic 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,
3,4
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.
5
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.
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.
8
Before conducting any study it is important to have a
reliable and valid instrument.
9
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 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-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 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 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).
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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 (; r = 0 vs r 0), and its internal consistency, through 4 measuresCronbachs , Spear-
manBrown, Guttman split-half, and standardized item coefficients.
Results
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)
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)
<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)
Workplace
Hospital 6 (28.6)
Health center 15 (71.4)
Abbreviations: SD, standard deviation; IQR, interquartile range.
a
Median was used for variables with skewed distribution.
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504 Asia-Pacic Journal of Public Health 22(4)
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 used
in 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. 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.
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 Anderson
5
reported a testretest 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), 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 Scores
a
NSS
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
preparation
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
physicians
8.43 7.63 0.06 .95
7. Conflict with other
nurses
7.42 6.64 0.07 .94
Abbreviation: NSS, Nursing Stress Scale.
a
All 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,
5
with 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 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
Cronbachs s ranged from .87 to .93.
10-16
With 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 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
Scale
No. of
Items
TestRetest
Reliability ()
Internal Consistency Reliability
95% CI SpearmanBrown
Guttman
split-half Cronbach
Standardized
item
Total scale 34 .70 .86 .86 .86 .86 .66-.94
Subscales
1. Workload 6 .71 .68 .68 .68 .68 .20-.87
2. Death and
dying
7 .77 .87 .86 .86 .87 .67-.94
3. Inadequate
preparation
3 .70 .80 .79 .79 .80 .49-.92
4. Lack of staff
support
3 .75 .81 .81 .81 .81 .53-.92
5. Uncertainty
concerning
treatment
5 .76 .87 .87 .87 .87 .68-.95
6. Conflict
with
physicians
5 .77 .85 .84 .84 .85 .60-.94
7. Conflict
with other
nurses
5 .74 .86 .85 .85 .86 .63-.94
Abbreviation: CI, confidence interval.
a
All scales showed significant correlations at p < .05.
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506 Asia-Pacic Journal of Public Health 22(4)
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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