J Egypt Public Health Assoc

Vol. 83 No. 3 & 4, 2008

Developing and Validating a Tool

to Assess Nurse Stress
Ashraf A. Zaghloul
Department of Health Administration and Behavioural Sciences
High Institute of Public Health, University of Alexandria
ABSTRACT
Nursing is generally perceived as a demanding profession. There
is a rising necessity for healthcare administrators to tackle the aspects
leading to nurse stress and work burnout as a means towards
maintaining a stable and continuous workforce at healthcare
institutions.The study aimed at the development of a reliable and
valid tool for measuring nursing staff stress and burnout at the
University Hospital of King Faisal University, Saudi Arabia. A crosssectional descriptive study was designed. All registered high nurses
working at the hospital were included in the study. The total number
accounted for 260 nurses. The study revealed a valid and reliable
scale. Such results were indicated through face validity, content
validity, and principal component analysis using the varimax
rotation for the fifteen statements included in the questionnaire. The
PCA explained 56.4% of the variance and concluded 3 main
components under which the statements would be categorized.
Dimensions were given suitable headings as follows; work aspects,
working conditions, and workload. Reliability was assessed and
revealed an internal consistency (Cronbach alpha=0.8) and a split-half
Spearman-Brown coefficient for unequal length r= 0.79. In
conclusion, the study demonstrated a short valid and reliable scale to
assess the stressful areas for nurses. The scale is convenient for use by
healthcare managers at different medical situations. Further studies
are recommended for the use of the tool on representative samples of
Saudi nurses.
Key words: Eigen value, nurse stress, factor analysis, varimax rotation, scale
Corresponding Author:
Dr. Ashraf Ahmad Zaghloul,
Department of Health Administration and Behavioural Sciences
High Institute of Public Health, Alexandria University
Email: grendol@hotmail.com

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Vol. 83 No. 3 & 4, 2008

INTRODUCTION
Nursing is generally perceived as a demanding profession. It
is both physically and psychologically challenging. Over the past
several years, signs of occupational stress appear to be
increasing among nurses which has been referred to many
factors ranging from downsizing, restructuring, and merging to
role boundary and responsibility.(1-3) Job stress is the harmful
emotional and physical reactions resulting from the interactions
between the worker and her/his work environment where the
demands of the job exceed the worker's capabilities and
resources.(1) It is well known that prolonged stress is a precursor
of burnout which is considered a major problem for many
professions, and nurses are considered to be particularly
susceptible. Literature on occupational stress indicate that
burnout affects mainly nurses, physicians, social workers and
teachers.

However,

studies

concluded

that

occupational

stressors, lack of professional latitude, and role of problems,

predicted nurses intention to quit their working healthcare
organizations.(4)
Some factors of the occupational stress include; working
conditions, relationships at work, role conflict and ambiguity,
organization structure and climate, work-home interface, career
development and nature of the job.(1-5) Research concluded that
the major sources of stress for nurses entail dealing with death
and dying, conflict with colleagues, inadequate preparation to
deal with the emotional needs of patients and their families, lack
of staff support, workload, and uncertainty concerning treatment
plans. Burnout seems to be caused by stressful working
conditions,

disproportional-high

efforts

(time,

emotional

involvement, and empathy) and dissatisfaction with jobs. (2,3,5,6)

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For the goals of lowering professional stress and improved

satisfaction, social support and improved team cooperation could
protect nurses against burnout.(7,8)
Within the same context, the aims of benefiting the quality of
patient care and the respective hospitals, possible remedies to
address these job stressors were improving nurses quality of life,
mental health, and decreasing the rate of turnover.(3)
Previous research related to stress among nurses has
highlighted several complex issues; however, a deeper analysis of
the valid and reliable existential components has been lacking.(9,10)
Eventually,

there

is

rising

necessity

for

healthcare

administrators to tackle the aspects leading to nurse stress and

work burnout as a means towards maintaining a stable and
continuous workforce at healthcare institutions.
The aim of the study was to develop a reliable and valid tool
for measuring nursing staff stress and burnout at the University
Hospital of King Faisal University.

MATERIAL AND METHODS

Study Setting:
The study took place at King Fahd Hospital of the University
(KFHU) at Al-Khobar, a 430 bed regional referral hospital for the
Eastern Province, Saudi Arabia.

Study Design:
A cross-sectional descriptive study was designed to assess
the validity and reliability of a scale developed to measure KFHU
nurses job occupational stress.

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Target Population:
Nurses operating at King Fahd Hospital of the University. All
registered high nurses working at the hospital were included at
the time of conducting the study (499 nurses). A total number of
260 questionnaires were eligible for statistical analysis.

Data Collection Method:

Data collection took place between the first week of March
till the end of April 2007. The nurse stress questionnaire was
developed to measure stress and burnout in clinical nursing
practice as a multidimensional construct after the review of
literature related to the topic under study(1-5,

8-10).

The total

number of dimensions organized on the scale were 15.

Scale Validity:
The total number of items generated from the literature on
nurse stress accounted for 35 items. A panel of 5 experts
examined the questionnaire for face and content validation. All
experts had at least 10 years of experience at University
Hospitals, and 3 had a master's degree in nursing sciences. For
face validity, experts were asked if all items were clearly worded
and would not be misinterpreted. For content validity, the
experts evaluated the nursing relevance of the 15 selected items
by using a scale ranging from 1 to 3, where, 1= not relevant, 2=
relevant but not necessary, 3=absolutely relevant. Inter-rater
reliability was assessed using Newman's test which resulted in a
coefficient r= 0.75. Experts were also asked if other relevant
items should be added to the scale. The remarks of the panel
were collected, categorized, discussed and revised in the scale
accordingly. The approval of the final version of the scale was
assured regarding its content and clarity. The Kaiser-MeyerOlkin value was KMO= 0.9, exceeding the recommended value of

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0.6(11), and the Bartlett's test of sphericity reached statistical

significance, supporting the factorability of the correlation
matrix.

Scale Reliability:
Internal consistency was established through calculating
Cronbach's alpha coefficient for the scale which indicated an
overall coefficient r= 0.88, and Spearman-Brown coefficient for
unequal length r= 0.79.
The instrument consisted of two parts:

Demographic data:
Which included: age, gender, marital status, number of
children, nationality, educational degree, years of experience,
working department and monthly income.

Occupational stress scale:

A three-point Likkert scale was used where low stress = 1,
moderate stress = 2, and extreme stress = 3. The total number of
statements included in the scale was 15; whereas, the total
mean score was calculated by summating all statements for
every nurse then dividing the total by 15. Cut-off points of the
scale were as follows; low stress : 1 to < 1.99, moderate stress: 2
to < 2.99; high stress : 3
The statements were namely,

workload, work underload,

fluctuation in workload, unrealistically high expectation by

others of my role, coping with new situations, uncertainty about
degree of responsibility, security of employment, exposure to
death in working condition, coping with technology, staff
shortage, poor physical conditions, lack of privacy, shortage of

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essential resources, poor quality of supporting staff, and difficult

patients.

Data Analysis:
Data entry and processing were performed using the
Statistical Package of the Social Science (SPSS) Software, version
10.0. Results were illustrated using descriptive tables, with the
relevant tests of significance. The 5% level of significance was
used throughout the statistical analysis for all relevant tests.

Ethical Considerations:

The identity of individuals from whom information was obtained in

the course of the study was kept strictly confidential. No
information revealing the identity of any individual was included in
the final report or in other communication prepared throughout the
course of the study.

All nurses who participated in the study were those who actually
agreed to complete the study. Nurses were approached with a full
description of the study and its aim, after which the nurses were
free to participate in the study or reject.

The study was conducted after gaining the approval of the scientific
committee as a first step followed by the research ethics committee
at the College of Applied Medical Sciences, King Faisal University,
Kingdom of Saudi Arabia.

RESULTS
Table (1) shows the demographic characteristics of the
sample of the nurses who participated in the study. The highest
frequency of nurses were those in the age group 30 to less than
40 years (38.5%) with a mean age for the whole sample 38.2
9.5. The majority of nurses were females (91.2%) whereas the

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highest frequency of nurses were from the Philippines (50.4%)

followed by Indians (42.3%). More than one third of the sample
(40.0%) had 0 to less than 10 years of experience. Nurses
working at the critical care were the highest represented in the
sample (33.1%). The majority of the sample earned a monthly
income less than 5000 SR.
Table (1): Demographic Characteristics of the Sample.
Characteristics

No.

62
100
56
42

23.8
38.5
21.5
16.2

237
23

91.2
8.8

60
195
5

23.1
75.0
1.9

131
110
9
10

50.4
42.3
3.5
3.8

139
121

53.5
46.5

104
96
60

40.0
36.9
23.1

86
77
38
11
48

33.1
29.6
14.6
4.2
18.5

241
19

92.7
7.3

Age
2030 40 50Gender
Female
Male
Marital status
Single
Married
Divorced/widowed
Nationality
Philippine
Indian
Saudi
Others
Educational level
Diploma
Baccalaureate
Years of experience
010 20 Working Department
Critical care
Surgery
Internal Medicine
Outpatient Department
Emergency Room
Monthly income
Less than 5000 SR
5000 SR +

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The 15 items of the stress scale were subjected to principal

component analysis (PCA) using (SPSS). Prior to performing PCA
the suitability of data for factor analysis was assessed. Analysis
of the correlation matrix revealed the presence of a sizable
number of coefficients r= 0.3 and above as shown in Table(2).
To aid in the interpretation of the three components, Table(3)
shows the principal components analysis (PCA) with components
of eigen values exceeding 1, explaining 56.4% of the variance
(20.7%, 19.4%, and 16.3% respectively).
Table (4) shows the results of the Varimax rotation analysis.
The rotation solution showed a number of strong variable
loadings on the three components. Component 1 comprised the
following loadings, coping with new technology 0.752, exposure
to death 0.693, coping with new situations 0.690, uncertainty
about the degree of responsibility 0.621, security of employment
0.573,

work

underload

0.524

respectively.

Component

comprised the following loadings, poor quality of supporting staff

0.748, shortage of essential resources 0.657, lack of privacy
0.655, poor physical conditions 0.626, difficult patients 0.605
respectively. Component 3 comprised the following loadings,
workload 0.710, staff shortage 0.473, fluctuation in workload
0.755, unrealistically high expectations by others of my role
0.720 respectively. The interpretation of the three components
was consistent with previous research on stress scales directed
for nurses and relevant to healthcare organizations. Component
1 would be categorized under the term work aspects while
component 2 would be categorized under the term working
conditions, and component 3 would be categorized under the
term workload.

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Table (4): Factor Analysis of Items of the Stress Scale.

Statements
Coping with new technology
Exposure to death
Coping with new situations
Uncertainty about degree of responsibility
Security of employment
Work underload
Poor quality of supporting staff
Shortage of essential resources
Lack of privacy
Poor physical conditions
Difficult patients
Workload
Staff shortage
Fluctuation in workload
Unrealistically high expectations by others of my role

1
.752
.693
.690
.621
.573

Component
2
3

.524
.748
.657
.655
.626
.605
.710
.473
.755
.720

Table 5 shows the reliability analysis of the 15 items of the

stress scale. The item mean and standard deviation ranged
between the highest for lack of privacy 2.50.6 and lowest for
shortage of essential resources 1.76 0.6. As regards the alpha if
item deleted ranged between 0.87 and 0.88 in relation to the
total alpha score for the scale (0.88), thus indicating the stability
of the scale with a high internal consistency of the scale items as
well as the relevance of the items composing the scale.

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Table (5): Total Reliability Analysis of Items of the Stress Scale

Item

Mean

SD

Coping with new technology

Exposure to death
Coping with new situations
Uncertainty about degree of responsibility
Security of employment
Work underload
Poor quality of supporting staff
Shortage of essential resources
Lack of privacy
Poor physical conditions
Difficult patients
Workload
Staff shortage
Fluctuation in workload
Unrealistically high expectations by others of my role

1.92
2.17
2.10
1.94
2.01
1.95
1.80
1.76
2.50
1.92
2.34
1.89
2.13
2.13
2.14

0.63
0.55
0.63
0.60
0.60
0.72
0.68
0.64
0.60
0.70
0.61
0.70
0.59
0.64
0.64

Corrected
item-total
correlation
0.42
0.49
0.50
0.62
0.68
0.64
0.53
0.60
0.42
0.49
0.51
0.64
0.55
0.58
0.53

Alpha
if item
deleted
0.88
0.88
0.88
0.87
0.87
0.87
0.88
0.87
0.88
0.88
0.88
0.87
0.87
0.87
0.88

Alpha = 0.88

DISCUSSION
Most studies using subjective psychometric tools lack a
pivotal start, that is to say the potency of the tool used to
measure the relevant construct. Consequently another point
would be raised, which would be the results conceded from such
tools and eventually the conclusions deducted. Developers of
attitude measuring instruments strive for an instrument with a
coefficient for reliability of 0.80 to 0.90 to clarify internal
consistency, while others state that a minimum coefficient of
0.70 is required to document that the variety of items included is
consistent in how the instrument taps the underlying concept.(12,13)
Reliability results of the current scale reveal the consistency with
the former studies on the way towards a stringently reliable
instrument. As regards construct validity, results revealed that
stress scale items were grouped under three components, a
number that is not in concordance with studies on stress scale

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development which indicate that the components on the scale would

range from 4 and 7 components to achieve valid results.(14-17) Yet,
other studies revealed 3 major components for stress among
nurses namely, lack of adequate staffing, dealing with difficult
patients, and high workload but failed to show evidence
regarding validity of the scales utilized.(18,19)
According to the results of the developed scale, it was
determined that the highest dimensions for stress were namely:
lack of privacy, staff shortage, workload, difficult patients, and
fluctuation in workload. The logical interpretation of the results
adds to the validity of the developed tool. Obviously, the former
dimensions are those facing nurses at hospitals, especially
University hospitals which deal with high volumes of patients
and a wide range of difficult cases being considered a tertiary
level hospital. Such dimensions were in concordance with other
research results on nurse stress.(16,17,20,21) Eventually, such high
workload which is the basic element for staff burnout and in
turn leads to increased staff turnover which was one of the major
current problems facing the hospital under study.
Important limitations arise for the tool, first, Saudi nurses
accounted for 3.5% of the sample under study giving an
indication that the tool could not be generalized for Saudi nurses
in other healthcare institutions of similar case-mix. The former
percentage of Saudi nurses raises another limitation, the aspects
of stress attaining the highest mean scores on the scale. Aspects
of stress could differ or coincide with the highest mean scores in
our study if the tool was introduced to representative sample of
Saudi nurses. Second, the total mean stress score for the sample
showed moderate stress, with a high percentage of expatriates
included in the samples, poses limitations to whether the nurses'

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responses were not influenced by the fear of any actions taken

towards their jobs at the hospital after the results were revealed.

CONCLUSION
The study demonstrated a valid and reliable scale to assess
the stressful areas for nurses. The scale is short, convenient for
use by healthcare managers at different medical situations.
Further studies using the developed tool are recommended to be
used for representative samples of Saudi nurses to identify the
dimensions of stress in Saudi nurses and compare them with
results included in the literature.

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