Validation of the Nursing Stress Scale: Current Stressors in the Health Care Environment in the USA and Spain

Abstract

Background:

Nursing is one of the most stressful occupations today and the pandemic brought new stressors that still prevail.

Objective:

The present study aimed to adapt and validate the Nursing Stress Scale. The adaptation consists of 2 main aspects: (1) including stressors that arose during the COVID-19 pandemic and remain and (2) reducing the length of the scale to make it easier and faster to respond to.

Methods:

This cross-sectional study was conducted in 2 countries: Spain and the United States. The invariant structure of the 5 dimensions of the scale has been tested through a multigroup confirmatory factor analysis (CFA), using a sample of 660 nurses from different countries and hospitals. Content validity was established through expert judgment. Construct, convergent, and discriminant validity were tested through confirmatory factor analyses, average variance extracted (AVE), and correlations, and reliability was tested with Cronbach alphas and composite reliability.

Results:

Results from the CFA supported the construct validity and the invariant structure of the 5 dimensions of the questionnaire. Convergent validity was assessed using the AVE, which yielded values above 0.50. Discriminant validity was also established, as the square root of the AVE for each dimension exceeded the intercorrelations among the dimensions in the model. Finally, internal consistency of the scale was verified through Cronbach’s alpha coefficients, all exceeding .70.

Conclusions:

Stress among nurses continues to be a serious problem that has been aggravated after COVID-19. This scale is a valuable tool for quickly and reliably assessing current stressors for nurses.

Keywords

nurses psychometrics measurement scale validation stressors

Introduction

Nurses are fundamental for the health system. Nursing personnel have played an essential role in patient care, collaborating closely with other health care professionals to ensure individuals receive the care needed for recovery and overall well-being. The COVID-19 pandemic brought their vital contributions into sharper focus, as nurses faced unprecedented demands in hospitals and other health care settings. They navigated intense work pressures, alongside emotional challenges such as anxiety, fear, and the trauma of witnessing patient suffering and loss, underscoring the critical importance of the nursing profession in times of crisis.

Recognizing the critical role of the nursing profession in delivering high-quality care, it is essential to assess the stress experienced by nursing staff to prevent negative outcomes for individuals, patients, and health care organizations. Accurate stress evaluation requires reliable and valid measurement tools that capture the unique challenges faced by nurses. While specific instruments have been adapted and validated in Spanish, evolving job demands, such as those introduced by the COVID-19 pandemic, necessitate updates to these tools. The pandemic introduced additional stressors, particularly the fear of contagion, making it crucial to adapt current measures to reflect these new realities. This study aimed to update and validate the Nursing Stress Scale (NSS),¹ incorporating a subscale focused on fear of contagion—one of the primary stressors faced by health care professionals during the pandemic.²

Statement of the Problem

Nurses work under immense physical and emotional strain, often putting their own lives at risk to fulfill their duties.³ Kang et al⁴ observed that health care workers frequently experience a variety of psychological challenges in high-pressure, high-risk pandemic situations. Similarly, research conducted in the aftermath of the COVID-19 outbreak revealed that health care workers not only feared transmitting the virus to their families and colleagues but also faced uncertainty, stigmatization, and reported reluctance to continue working, with some even considering resignation. High levels of stress, anxiety, and depression were prevalent during this period,^5-7 potentially leading to long-lasting psychological effects.

Numerous studies have shown that nursing is among the most stressful professions, due to the complexity of the work and the need to handle emergency situations.^2,8,9 In fact, Chan et al¹⁰ examined job stress levels across 6 professional groups and found that nurses experienced the highest overall stress levels compared with the average of other professions.⁹ The COVID-19 pandemic exacerbated the risk of burnout among frontline nurses, and this risk remains elevated, along with other contributing factors.¹¹

In a recent study, Wang et al¹¹ found that over 75% of the 2210 frontline nurses surveyed scored above the threshold for burnout, highlighting the alarming prevalence of stress within the nursing profession. Stress among nurses remains a critical and concerning issue today. A survey conducted by Nursing Times reported that 2 out of 5 nursing staff indicated their mental health is currently worse than it was during the peaks of the COVID-19 pandemic.¹² This decline in well-being is attributed to the constant exposure to numerous stressors,¹³ which affect not only nurses’ physical and mental health but also their professional performance.^2,14

The literature highlights several key causes of stress in nursing.^15-17 One major factor is the workload, as nurses are often required to manage multiple patients, perform complex tasks, and work long hours, including 24-hour shifts and weekends. Additionally, hospital environments are inherently stressful due to the fast pace, frequent emergencies, and the need for quick, critical decisions. Nurses are also exposed to emotionally challenging situations, such as caring for seriously or terminally ill patients, those in chronic pain, and dealing with their anxious families, which can be emotionally exhausting. Staff shortages or inadequately trained personnel further exacerbate the situation, increasing individual workloads and reducing opportunities for rest. Interpersonal conflicts and violence in the workplace also add to the stress, with relationships among colleagues, physicians, patients, and their families often being sources of tension. Job insecurity and administrative demands, such as the need to constantly update knowledge and skills, contribute additional stress. Moreover, nurses face significant health risks, particularly during pandemics, when concerns for their own well-being and that of their families intensify. These factors, taken together, explain why nursing is such a highly stressful profession.

Stress among nurses has been linked to various negative outcomes, including psychological distress, burnout, depression, anxiety, low back pain, and musculoskeletal issues.^18-20 These issues not only affect the well-being of nurses but also contribute to a decline in the quality of patient care²¹ and a decrease in hospital productivity.²²

The consequences of stress manifest in several ways. In terms of physical health, chronic stress can lead to serious conditions such as hypertension, cardiovascular disorders, headaches, and gastrointestinal problems. Regarding mental health, stress can trigger anxiety, depression, emotional exhaustion, and sleep disturbances. Professionally, high stress impairs concentration, increases the likelihood of medical errors, and negatively impacts the quality of patient care, team dynamics, and the overall functioning of health care facilities. Finally, in terms of job satisfaction, prolonged stress reduces nurses’ job satisfaction, leading to higher turnover rates and increased absenteeism.

In conclusion, addressing nurses’ stress is critical when designing and implementing interventions aimed at optimizing the working conditions of health care personnel. Doing so can lead to improved health outcomes, enhanced performance, and cost savings for health care organizations. However, before implementing any intervention, it is essential to thoroughly evaluate stress levels within this occupational group. Accurate and appropriate stress assessment is imperative to ensure that interventions are effectively targeted and impactful.

Evaluating Stressors in the Health Care Environment

There are numerous scales designed to measure workplace stress, and among nursing staff, one of the most widely used is the NSS.¹ The authors defined stress as “an internal cue in the physical, social, or psychological environment that threatens an individual’s equilibrium” (p. 12) and identified several dimensions of stress specific to nursing: death and dying, conflicts with physicians, inadequate preparation, lack of support, issues with other nursing staff, workload, and uncertainty concerning patient care. The NSS was translated and validated into Spanish by Escribà et al.²³ As the pandemic significantly altered the nature of nurses’ work and introduced new stressors, an adaptation that considers new stressors that emerged during the COVID-19 pandemic becomes highly relevant and necessary. Additionally, the adapted scale must be shortened to reduce the time needed for completion, making it easier for nurses to complete the assessment accurately and efficiently.

The adapted NSS, which was tested in this present study, includes the following scales: (1) Work Overload: This scale captures stress arising from excessive workloads, staffing, and scheduling issues, as well as inadequate time to complete nursing tasks and provide emotional support to patients. (2) Insufficient Preparation for Work Demands: This dimension reflects the stress caused by feeling unprepared to meet patients’ emotional needs or lacking sufficient information to handle job responsibilities effectively. (3) Lack of Support: This scale measures the extent to which nurses feel they have opportunities to share experiences with colleagues and express negative emotions such as anger and frustration. (4) Death and Dying: This dimension assess the stress related to caring for suffering or terminally ill patients, as well as dealing with patient death. (5) Fear of Infection: Although not part of the original NSS, this dimension was added during the COVID-19 pandemic to reflect the stress stemming from the fear of contracting or spreading infections. Numerous studies and media reports highlighted this fear as a significant source of stress for nurses during the pandemic, making it a crucial addition to the scale.

Methods

Sample and Procedures

This cross-sectional study was conducted in 2 countries at different points in time: in Spain in May 2020 and in the United States in May 2022. The final sample included 438 nurses in Spain and 222 in the United States.

The Spanish sample consisted primarily of women (93.8% women, 6.2% men), with a mean age of 36 years (SD = 10.5). Participants had an average of over 12 years of nursing experience (SD = 10.1). In terms of tenure, 47.3% had more than 3 years in their current position, 18.5% had between 1 and 3 years, and 34.3% had <1 year. Finally, the sample represented more than 100 workplaces (including health centers and hospitals) distributed throughout Spain; more specifically, data were collected from 38 of the 50 provinces in Spain.

In the US sample, 71.2% were women, 28.4% were men, and 0.5% identified as another gender. The mean age was 41 years (SD = 12.1), and participants averaged over 13 years of nursing experience (SD = 10.4). Regarding tenure, 69.8% had over 3 years in their current position, 20.7% had between 1 and 3 years, and 9.5% had <1 year.

Before distributing the scale online, content validity was established through expert judgment by clinicians and professors in work psychology specialized in stress and occupational health, and by several senior nursing staff. All experts expressed satisfaction with all the items of the scale.

For the Spanish sample, data collection occurred through nursing associations in various Spanish cities. Researchers reached out to these associations to explain the study’s objectives and procedures, and the associations distributed information and a questionnaire link among their contacts (mainly via e-mail and WhatsApp). Additionally, researchers used their personal and professional networks to further disseminate the study. The questionnaire was active from April 1 to May 25, 2020, a period marking Spain’s peak COVID-19 death rate. Nurses received a link to the questionnaire, along with a presentation of the research team (name, university affiliation, and research interests), instructions for completion, an informed consent form, and a motivational note thanking them for their efforts and encouraging participation. Confidentiality and anonymity were strictly maintained: IP addresses were not recorded, identifying information was not requested, and data were coded. The survey was created using LimeSurvey (LimeSurvey GmbH, Hamburg, Germany) and accessible on any electronic device.

For the US sample, participants were recruited via Qualtrics’ panel service (Qualtrics, Inc, Provo, UT, USA), which provided access to a large, diverse pool of respondents within the target population of actively working nurses in health care facilities aged 18 or older. Participants received an online questionnaire with general information about the project, along with an informed consent form detailing the study’s purpose, risks, and benefits. Because the recruitment was conducted through an online panel provider, participants were not drawn from a single geographic site but rather from multiple locations across the United States. The service ensured diversity in the sample based on the demographic we specified. Confidentiality and the voluntary nature of participation were emphasized, and participants were assured no identifying information would be collected. Once consent was given, participants proceeded to the questionnaire. Ethics committee approval was obtained for both samples.

Instruments

Stressors

In the Spanish sample, stressors were assessed using the Spanish adaptation of the NSS² originally developed by Gray-Toft and Anderson.¹ The same scale, but in English, was used to asses stressors in the American sample by applying the back-translation technique with bilingual experts in organizational psychology for the newly developed items in the fear of infection dimension. The scale includes 5 factors: (1) Work Overload, measured with 8 items (eg, “I could not predict staff and schedule changes”); (2) Insufficient Preparation, measured with 5 items (eg, “I was asked a question by a patient for which I did not have a satisfactory answer”); (3) Lack of Support, measured with 2 items (eg, “I lacked the opportunity to openly discuss unit problems with other personnel”); (4) Death and Dying, measured with 5 items (eg, “I felt helpless in cases where a patient failed to improve”); and (5) Fear of Infection, measured with 3 items assessing concerns about self-infection or transmitting infection to others (eg, “I have been afraid of getting infected and infecting my family”). Items were rated on a 6-point Likert scale, from 0 (never) to 5 (always). Original reliability (Cronbach’s alpha) scores were 0.77 for Work Overload, 0.76 for Insufficient Preparation, 0.65 for Lack of Support, and 0.78 for Death and Dying. Higher scores indicated higher perceived stress.

Psychological Distress

In the Spanish sample, anxiety, depression, and stress were measured using the Spanish validation of the DASS-21,²⁴ originally used by Antony et al²⁵ for American sample. Each subscale includes 7 items: Stress (eg, “I found myself getting upset by trivial things”), Depression (eg, “I felt sad and depressed”), and Anxiety (eg, “I experienced difficulty breathing”). Responses were recorded on a 6-point Likert scale, from 0 (never) to 5 (always). Original alphas were 0.87 for Stress, 0.94 for Depression, and 0.91 for Anxiety, with higher scores indicating greater psychological distress.

Self-Efficacy

Self-efficacy was measured, in both languages, using the General Self-Efficacy Questionnaire.²⁶ Using the study performed by Suárez et al,²⁷ 3 items were selected based on a combination of the highest factor loadings and the lowest alpha-if-item-deleted values, ensuring both strong construct representation and internal consistency (eg, “I can solve most problems if I invest the necessary effort”). In studies measuring many variables, shorter questionnaires maximize data collection efficiency.²⁸ Responses were rated on a 6-point Likert scale from 0 (totally disagree) to 5 (totally agree), with original alpha values²⁶ ranging from 0.75 to 0.90.

Statistical Analysis

To adapt and validate the NSS,¹ analyses were conducted using IBM SPSS and AMOS Statistics (IBM Corp, Armonk, NY, USA). First, descriptive analyses, including means, standard deviations, and Cronbach’s alpha coefficients, were calculated for individual samples as well as the combined sample. We used a significance level of P < .05 for all analyses.

Second, confirmatory factor analysis (CFA) was performed to assess the scale’s internal structure and factorial validity. Convergent and discriminant validity were evaluated using average variance extracted (AVE), with values above 0.50 considered acceptable.²⁹ Discriminant validity was also confirmed when the square root of the AVE for each factor pair exceeded the correlation between those factors. Additionally, discriminant validity was examined by correlating stressors with 2 variables: psychological distress, which has a positive and significant relationship with stressors among nurses,² and self-efficacy, which shows a negative and significant relationship with stressors.³⁰

Third, to test the invariant structure of the scale’s 5 dimensions, a multigroup CFA was conducted. To test the invariant structure of the questionnaire, we followed the procedure outlined by Meredith,³¹ comparing progressively constrained models of factorial invariance. Model fit was assessed using both absolute and relative fit indices. The absolute fit indices included (1) the χ² goodness-of-fit statistic, (2) the Goodness-of-Fit Index (GFI), and (3) the root mean square error of approximation (RMSEA). Additionally, the Comparative Fit Index (CFI), the Tucker-Lewis Index, and the Incremental Fit Index served as a relative fit index. Given that the distribution of the GFI is unknown, no critical value is available.³² An RMSEA below 0.06 suggests acceptable fit, while a relative index close to 0.95 indicates good fit.³³ The expected outcome supporting invariance is that imposing constraints does not result in a significant deterioration of model fit. Specifically, invariance is supported when, comparing Model 1 with Models 3 and 4, the change in CFI does not exceed 0.01 and the change in RMSEA does not exceed 0.015.³⁴ Finally, internal consistency reliability was demonstrated through Cronbach’s alpha and composite reliability values, with scores above 0.70 deemed adequate.²⁹

Results

Table 1 presents the means, standard deviations, and Cronbach’s alpha coefficients for both samples, both separately and combined. An independent samples t-test was conducted to compare stressors between the 2 groups. The results indicate that nurses in the US sample reported higher levels of self-efficacy and stress, with significant differences observed in the dimensions of work overload, insufficient preparation, lack of support, and death and dying compared to their Spanish counterparts. Conversely, Spanish nurses reported higher levels of psychological distress. Notably, there were no significant differences between the samples in the fear of infection dimension, with both groups exhibiting medium-high levels of fear.

Table 1.

Descriptive Statistics of Variables in the Study (n_SP = 438 and n_USA = 222).

Variables	Mean			SD			α			t
Variables	SP	USA	TO	SP	USA	TO	SP	USA	TO	t
Work overload	2.19	3.34	2.58	0.82	0.92	1.01	0.82	0.86	0.88	−16.20*
Insufficient preparation	2.07	2.97	2.37	0.89	1.03	1.03	0.78	0.85	0.84	−11.51*
Lack of support	1.43	3.10	1.99	1.06	1.22	1.36				−18.11*
Death and dying	2.46	3.19	2.71	0.82	0.95	0.93	0.75	0.82	0.79	−10.19*
Fear infection	3.09	2.95	3.04	1.08	1.22	1.09	0.64	0.72	0.65	1.59
Psychological distress	2.08	1.86	2.00	0.82	0.61	0.76	0.94	0.95	0.94	3.85*
Self-efficacy	3.68	4.70	4.02	0.91	0.81	1.01	0.83	0.74	0.84	−14.01*

Abbreviations: α, Cronbach’s alpha; SD, standard deviation; SP, Spanish nurses; USA, United States nurses; TO, samples combined.

P < .001.

To establish construct validity based on the internal structure of the scale, confirmatory factor analyses were conducted. Table 2 shows 3 models: (1) a 1-factor model where all items load onto a single factor; (2) a 5-factor model reflecting the proposed 5 dimensions; and (3) an improved 5-factor model that incorporates covariances between 2 items in the work overload dimension—specifically, between items 1 and 6, and between items 6 and 7. Given that the 2 covariances belong to the same dimension and share not only a latent factor but also assess highly similar aspects of that factor, including them is not only permissible but also theoretically justified.³⁵ As shown in Table 2, the improved 5-factor model (Model 3) yielded the best fit.

Table 2.

Confirmatory Factorial Analysis (N = 660).

Model	χ²	df	GFI	RMSEA	TLI	CFI	IFI	Δχ²	Δdf
Model 1	2115.52	230	0.74	0.11	0.73	0.74	0.74
Model 2	936.16	220	0.88	0.07	0.89	0.90	0.90	M₁-M₂ = 1179.36*	10
Model 3	825.60	218	0.90	0.06	0.90	0.91	0.92	M₂-M₃ = 110.56*	2

Abbreviations: Δχ², change in chi-square; Δdf, change in degrees of freedom; CFI, Comparative Fit Index; GFI, Goodness-of-Fit Index; IFI, Incremental Fit Index; Model 1: 1-factor; Model 2: 5 factors; Model 3: improved 5 factors; RMSEA, root mean square error of approximation; TLI, Tucker-Lewis Index.

P < .001.

To test the invariant structure of the 5 dimensions of the questionnaire, a multigroup CFA was performed with the Spanish and US samples. Four models were examined: (1) a free model with all paths free; (2) an all-constrained model where all paths are constrained; (3) an equal factor loadings model where paths are constrained while covariances remain free; and (4) an equal covariances model, which is the opposite of the previous model. Table 3 summarizes the results for each of these models, all of which displayed acceptable fit. The best fit was achieved by the free model, followed by the expected improved 5-factor model (Model 3). Moreover, differences in CFI between models are around 0.01 and differences in RMSEA between models are <0.015, confirming the invariant structure of the scale.³⁴

Table 3.

Multigroup Confirmatory Factorial Analysis (N = 660).

Model	χ²	df	GFI	RMSEA	TLI	CFI	IFI	Δχ²	Δdf
Model 1	1119.05	436	0.86	0.049	0.87	0.885	0.89
Model 2	1419.34	494	0.83	0.053	0.84	0.844	0.78	M₂-M₁ = 300.29*	58
Model 3	1175.37	454	0.85	0.049	0.87	0.879	0.88	M₃-M₁ = 56.32*	18
Model 4	1262.80	469	0.85	0.051	0.86	0.866	0.80	M₄-M₁ = 143.75*	33

Abbreviations: CFI, Comparative Fit Index; GFI, Goodness-of-Fit Index; IFI, Incremental Fit Index; Model 1: free model; Model 2: constrained model; Model 3: equal factor loadings model; Model 4: equal covariance model; RMSEA, root mean square error of approximation; TLI, Tucker-Lewis Index.

P < .001.

Results from the assessment of convergent validity indicate that the 5 dimensions of the scale achieved an AVE of ~0.50 or higher,³⁶ with values of 0.47 for work overload, 0.44 for insufficient preparation, 0.53 for lack of support, 0.43 for death and dying, and 0.82 for fear of infection. Furthermore, discriminant validity results revealed that the square root of the AVE exceeded the intercorrelation of all dimensions in the model,²⁹ with the exception of the work overload factor. Additionally, all stressors were positively and significantly correlated with psychological distress, while most exhibited a significant negative relationship with self-efficacy. These findings further support the scale’s discriminant and convergent validity (see Table 4).

Table 4.

Correlations Among Variables Under Study (n_SP = 438 and n_USA = 222).

Variable	1	2	3	4	5	6	7
1. Work overload	1	0.385**	0.348**	0.557**	0.426**	0.428**	−0.028
2. Insufficient preparation	0.647**	1	0.349**	0.316**	0.389**	0.486**	−0.445**
3. Lack of support	0.645**	0.693**	1	0.248**	0.222**	0.378**	−0.112*
4. Death and dying	0.651**	0.626**	0.641**	1	0.281**	0.397**	−0.022
5. Fear infection	0.630**	0.695**	0.650**	0.586**	1	0.461**	−0.201**
6. Psychological distress	0.492**	0.510**	0.485**	0.435**	0.510**	1	−0.392**
7. Self-efficacy	−0.111	−0.217**	−0.154*	−0.046	−0.159*	−0.272**	1

Abbreviations: SP, Spanish nurses; USA, US nurses.

SP sample is above the diagonal. US sample under the diagonal; Numbers 1 to 7 correspond with variables.

P < .05. **P < .001.

Finally, the internal consistency of the scale was confirmed through Cronbach’s alpha values, all exceeding 0.70, except for the fear of infection factor in the Spanish sample, which had an alpha of 0.64 (see Table 1). Composite reliability scores were also adequate, measuring 0.88 for work overload, 0.80 for insufficient preparation, 0.85 for lack of support, 0.68 for death and dying, and 0.90 for fear of infection, with values above 0.70 considered satisfactory.²⁹

Discussion

Nursing has always been a high-stress profession, but stress levels have intensified since the COVID-19 pandemic.³⁷ This is a global issue, not limited to any 1 region. Given the high prevalence of stress in nurses’ daily work, accurate and thorough assessment is essential. Evaluating psychosocial risks prior to any intervention is crucial for identifying specific stressors and designing targeted interventions. In this study, we aimed to validate and adapt the NSS¹ with 3 main objectives: (1) to reduce the number of items, allowing for quick and manageable data collection that minimizes participant burden; (2) to focus on key stress dimensions relevant to the COVID-19 period; and (3) to specifically address the fear of infection, a major stressor for nurses during the pandemic. The final scale includes 5 dimensions with a total of 23 items and has successfully met all standards for invariant structure across 2 samples, as well as for convergent and discriminant validity and internal consistency.

In this study, we also analyzed stress among nurses from 2 countries at 2 distinct time points following the COVID-19 outbreak. Our findings reveal medium-to-high stress levels across the board, with notable differences between countries. Among Spanish nurses, the fear of infection was the highest source of stress, whereas, for nurses in the United States, the work overload factor registered the highest stress levels. These results are striking. One might expect that stress levels among Spanish nurses would be higher overall, given that data collection took place during the pandemic’s peak, a period marked by the highest recorded deaths. In contrast, data collection among US nurses occurred later, after the worst of the pandemic had subsided, when more information was available, and vaccinations were already underway. Yet, despite these differences in timing, the fear of infection factor yielded similar stress levels in both samples, with no statistically significant difference.

Furthermore, US nurses scored higher than Spanish nurses across most other stressors. Additionally, US nurses reported significantly higher levels of perceived lack of support than their Spanish counterparts, potentially reflecting structural challenges within the profession and variations in resources between the 2 countries. Alternatively, these elevated scores may indicate the prolonged exhaustion experienced by this population during and after the pandemic. Future research should reassess Spanish nurses several years post-pandemic to determine whether symptoms of exhaustion or burnout have since emerged.

Limitations

This cross-sectional study relies on self-reported measures, and one of the measures, self-efficacy, has undergone variations. The completed general self-efficacy scale³⁸ was not administered. Instead, 3 items were selected based on psychometric information, specifically those with the highest factor loadings and the most favorable alpha-if-item-deleted values. While this reduction may limit the comprehensiveness of the self-efficacy measurement, it offers practical advantages, such as shorter questionnaires that reduce participant burden. Importantly, the reliability of the scale and the validity evidence obtained from the data were not compromised by this selection. Therefore, although the use of a reduced number of items represents a methodological limitation, it does not undermine the robustness of the scale or the credibility of the results.

Moreover, as a cross-sectional study, results should be interpreted as nurses’ perceptions at a specific point in time. Notably, the timing of data collection differed between the 2 samples. Spanish nurses completed the questionnaire during a particularly critical phase of the COVID-19 pandemic, when death rates were at their peak and health care systems were under extreme pressure. In contrast, American nurses responded at a later stage, after the initial waves of the pandemic had subsided. This temporal difference represents a limitation of the study, as it may have introduced systematic differences between the 2 groups. For instance, variations in vaccine availability, access to and adherence to protective protocols, the accumulation of COVID-19-related knowledge, and professional experience over time could all have influenced responses, particularly on work-related stressors. Such differences complicate direct comparisons between the samples for certain work-related variables, since the contextual conditions in which participants experienced the pandemic were not identical.

Nevertheless, this temporal variation also offers an advantage for the purpose of validating a work stress scale. By including participants exposed to different stages of the pandemic, the study effectively tests the scale under a wider range of stress conditions and environmental contexts. This allows for an assessment of the instrument’s robustness and applicability across varying levels of professional exposure, crisis intensity, and organizational response. In other words, while the timing gap introduces potential confounding factors, it simultaneously strengthens the scale’s external validity, demonstrating that it can reliably capture work-related stress across diverse real-world conditions. Thus, the questionnaire’s consistent behavior across different conditions, contexts, and countries demonstrates its robustness, allowing its use in other contexts with confidence in its validity and reliability.

Implications for Nursing Practice and Health and Social Care Policy

Interventions aimed at reducing stress and enhancing well-being among nurses are essential.³⁹ Thorough evaluation of psychosocial risks is critical for identifying potential hazards and designing effective interventions to mitigate these risks. By assessing the work environment and identifying stressors that contribute to psychological distress, burnout, and other related issues, organizations can implement targeted strategies that support employee well-being. This proactive approach not only improves workforce health and productivity but also fosters a supportive and resilient organizational culture, ultimately enhancing overall performance and reducing absenteeism.

The COVID-19 pandemic introduced new sources of stress for nurses, including fears of self-infection, death, and transmitting the virus to loved ones.⁴⁰ Additionally, it has brought long-standing structural issues within the profession to light, as the health system faced unprecedented strain.⁴¹ Given these developments, studying the working conditions and psychosocial risks faced by nurses is more vital than ever.

Conclusion

The aim of this study was to adapt and validate the NSS¹ to meet the current needs of the profession. Updated, brief, and easy-to-use tools are essential for effectively evaluating stress in this occupational group, where managing stress levels is crucial for improving nurses’ health, performance, and quality of care, as well as for reducing costs for hospitals and society as a whole.

Footnotes

ORCID iDs

Laura Lorente

María Vera

Ethical Considerations

The study conducted in Spain was approved by the Ethics Committee on Research in Humans of the Ethics Commission in Experimental Research of the València University (approved on April 2, 2020). The study conducted in the United States was approved by the Institutional Review Board (IRB) of Kennesaw State University (IRB-FY22-509).

Consent to Participate

Participants received an online questionnaire with general information about the project, along with an informed consent form detailing the study’s purpose, risks, and benefits. Informed consent to participate in the study was obtained electronically. Participants were required to indicate their agreement by selecting an online checkbox confirming their consent to take part in the project. They were explicitly informed that all data would be used solely for research purposes and that anonymity and confidentiality would be strictly maintained throughout the study.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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