Research in Nursing & Health, 2008, 31, 576–585

Perceived Stress in Survivors

of Suicide: Psychometric
Properties of the Perceived
Stress Scale
Ann M. Mitchell,1* Patricia A. Crane,2** Yookyung Kim3{

1
Department of Health and Community Systems, University of Pittsburgh School of Nursing and
School of Medicine, 3500 Victoria Street, 415 Victoria Building, Pittsburgh, PA 15261
2
School of Nursing, University of Texas Medical Branch Galveston, Galveston, TX 77555
3
Center for Research and Evaluation, University of Pittsburgh School of Nursing and Graduate School of
Public Health, Pittsburgh, PA 15261
Accepted 17 March 2008

Abstract: The purpose of this study was to evaluate the psychometric

properties of three versions of the Perceived Stress Scale (PSS; ß American
Sociological Association) in adults who had survived the death of a family
member or significant other by suicide. Reliability and validity were
examined. Exploratory factor analysis was conducted to assess dimension-
ality of the underlying constructs. All three versions of the PSS demonstrated
acceptable reliability. Two shorter versions retained good psychometric
properties and demonstrated convergent and concurrent validity with
measures of posttraumatic stress symptoms and mental health quality of
life. Factor analysis provided further evidence of their usefulness as brief and
valid measures of perceived stress in acutely bereaved adult survivors of
suicide. In a sub-sample of closely related survivors, the psychometric
properties of the 4-item version of the PSS were retained. ß 2008 Wiley
Periodicals, Inc. Res Nurs Health 31:576–585, 2008

Keywords: Perceived Stress Scale; psychometric properties; stress; survivors of suicide

Suicide is a major public health problem, 15 and 24 years and the ninth leading cause of
occurring most often as a consequence of a serious death in the United States (U.S. Department of
mental disorder (National Institute of Mental Health and Human Services, 2000), accounting
Health, 2003). Suicide is the third leading cause for approximately 30,000 deaths annually. For
of death in young people between the ages of each person who dies by suicide, there may be as
This work was made possible by the generous support of the American Foundation
for Suicide Prevention, New York, NY, and the University of Pittsburgh Central
Research Development Fund, Pittsburgh, PA. The authors wish to acknowledge the
support of David Brent, MD, Department of Psychiatry, Pediatrics, and Epidemio-
logy at the University of Pittsburgh School of Medicine and Graduate School of Public
Health, Karen Evanczuk, PhD, CRNP, Family Nurse Practitioner, Department of
Community Outreach, University of Pittsburgh Medical Center, UPMC McKeesport,
and American Sociological Association (ASA).
Correspondence to Ann M. Mitchell.
*Assistant Professor of Nursing and Psychiatry.
**Assistant Professor.
{
Adjunct Associate Professor and Biostatistician.
Published online 30 April 2008 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/nur.20284

ß 2008 Wiley Periodicals, Inc.

 PSYCHOMETRIC PROPERTIES OF PERCEIVED STRESS SCALE / MITCHELL ET AL.
many as six or more persons who must cope with
the loss, resulting in about 4.64 million American
survivors of suicide (American Association of
Suicidology, 2002). For this study, survivors of
suicide were defined as persons who had survived
a death by suicide of a family member or
significant other. Bereaved survivors of suicide
may be affected adversely by their global percep-
tions of stress, which may then alter daily
functioning and quality of life. Although survivors
of suicide share many of the same reactions as
survivors of other types of unexpected deaths,
Jordon (2001) highlighted important theoretical
differences related to suicide bereavement. The
purpose of this study was to evaluate the psycho-
metric properties of three versions of the Per-
ceived Stress Scale (PSS; American Sociological
Association) (Cohen, Kamarck, & Mermelstein,
1983), a global assessment of stress developed and
used in other situations, in adults who had survived
the death of a family member or significant other
by suicide.
Bereavement following any sudden, unnatural
death, including the suicide of a family member or
significant other, is usually extremely stressful.
Suicide bereavement is distinct from other types of
bereavement in three significant ways: the the-
matic content of the grief, the social processes
surrounding the survivor, and the impact suicide
has on family systems. Unlike survivors of natural
deaths, survivors of suicide often deal with the
difficult questions of meaning-making around
the death, that is, the whys surrounding the
death; feelings of responsibility, guilt, shame,
and blame; heightened feelings of rejection, anger
associated with abandonment of the family; and
social stigma and the often-negative reactions
of others.
During the period of bereavement there may
be an increased risk for health problems.
Although it is accepted that the loss of a family
member is stressful and may have severe
consequences for the bereaved, little is known
about the factors that determine the effects of
the death on those who must cope with the loss. In
an effort to determine the significance of the loss
to the family, Cleiren, Diekstra, Kerkhof, and
Van der Wal (1994) examined the consequences
of a loss after suicide, traffic fatality, or long-term
illness for first-degree family members. They
found that the influence of the mode of death
was not as significant as the kinship relationship
to the deceased, which played a significant role in
all aspects of functioning. Relationship charac-
teristics also played a role in the level of
problems after the death, with early adaptation
Research in Nursing & Health
577
being predictive of longer-term adaptation
(Cleiren et al.).
A global approach to measuring perceived
stress may help to determine if a person is
experiencing stress during a particular period
of time, regardless of the specific cause. Perceived
stress is defined as the degree to which situations
in one’s life are appraised as unpredictable,
uncontrollable, and overwhelming (Cohen et al.,
1983). One’s perceived stress on a global level has
been shown to have a negative impact on life
events and to influence depression levels and other
mental and physical health symptoms (Wang &
Patten, 2001). Kuiper, Olinger, and Lyons (1986)
found that for people with high levels of perceived
stress, negative life changes led to increased
depression symptom levels. For those with low
perceived stress, negative life changes had only
a minimal impact on depression symptom levels.
High levels of perceived stress, in certain circum-
stances, may overwhelm the individual’s ability to
adapt and cope with an event. Thus, perceived
stress could be expected to have an effect on how
one copes with a death by suicide.
Assessment of perceived stress and under-
standing the usefulness of perceived stress mea-
sures in survivors of suicide is important for health
care professionals because of the potential for
associated health risks (Mitchell & Kim, 2002) and
the negative effects of stress on functional status
and quality of life. The PSS was used in this study
to measure the level of global stress experienced
by survivors of suicide because perceived stress is
also associated with a number of health-related
outcomes. If shown to be psychometrically sound,
the PSS (Cohen et al., 1983) could enable
researchers to enhance their understanding of
bereaved individuals at risk for developing com-
plicated patterns of grief or symptoms of mental
and/or physical distress (Mitchell, Kim, Prigerson,
& Mortimer-Stephens, 2004).
Application and utilization of a global question-
naire with a new population require confirmation
of its reliability and validity for the target
population being studied (Walsh & Betz, 2001).
The PSS has been used for more than 15 years in a
variety of health-related contexts and with various
populations. Despite its long history of application
and because of the lack of repeated analyses
of its psychometric properties, re-evaluation of
its psychometrics in the population of suicide
survivors was considered essential before using it
in further research or intervention development.
The PSS measures the degree to which situa-
tions are perceived to be stressful. It taps into
how unpredictable, uncontrolled, and overloaded
578 RESEARCH IN NURSING & HEALTH
respondents find their lives. The scale has
been found to predict a wide range of physical
symptoms, independent of psychological distress
levels (Cohen et al., 1983; Cohen & Williamson,
1988; Marsland, Cohen, Rabin, & Manuck, 2001).
As a global assessment of stress, the PSS does
not measure the same concept as psychological
distress; it measures the degree to which situations
in an individual’s life are appraised as stressful
(Cohen et al., 1983). If, however, people have
perceived stress that is high, they may then be at
risk for future psychological distress. Concurrent
psychological distress could then be an additional
predictor of clinical outcomes like functional
status and quality of life.
The original PSS is based on Lazarus and
Folkman’s (1984) transaction model of stress.
This model posits information on relationships
among variables, such as stressful events, percep-
tions of stress, health, and the interactions among
them. It was designed to assess the importance of
the subjective interpretation of life events. The
experience of stress is assessed in a global, rather
than event-specific manner. The items are scored
on a Likert-type scale ranging from never (0);
almost never (1); sometimes (2); fairly often (3);
to very often (4). The sum of the item scores
represents the total score, with a possible range
from 0 to 56, and higher scores reflecting greater
perceived stress. Cohen and colleagues (1983;
1988) reported the following reliability coef-
ficients for the three versions of the PSS: the 14-
item version, alpha ¼ .75; the 10-item version,
alpha ¼ .78; and a 4-item version, alpha ¼ .60.
Test–retest reliability coefficients with the 14-
item version were .84 to .86 over three adminis-
trations within a 2-week time period.
Construct validity and factorial validity of the
14-item version were supported by items loading
on three factors, the first two of which accounted
for 41.6% of the variance (Cohen & Williamson,
1988). Dropping the four lowest loading items,
the 14-item version was refined and tested as a
10-item scale and then as a 4-item scale. Factor
analysis of the 10-item scale resulted in all items
loading on one factor that explained 48.9% of the
variance. This led the authors of the scale to
recommend that the 10-item scale be used for
future research. Further analysis of the 4-item
version revealed a single factor, accounting
for 45.6% of the variance (see Cohen et al.,
1983; Cohen & Williamson, 1988, for a detailed
description of their development of the short
versions of the PSS). The 4-item scale was
suggested for research projects when there was a
concern with time constraints or subject burden.
Research in Nursing & Health
After an extensive review of the literature, the
authors were unable to find any studies utilizing
the PSS with survivors of suicide or other types of
traumatic death. Therefore, the purpose of this
study was to evaluate and confirm the psycho-
metric properties of the two short versions of the
PSS (the 10-item and 4-item scales) and compare
them to the original 14-item version in a popula-
tion of adult survivors of suicide during the acute
phase of bereavement (within 1 month of a death
by suicide). The specific aims were to: (a) estimate
the reliability of the three versions of the PSS;
(b) test the convergent and concurrent validity of
the three versions of the PSS by examining their
relationships with other mental health and quality
of life measures; and (c) examine the dimension-
ality of the three versions of the PSS using factor
analysis.
METHODS
Design and Setting
Analyses were performed on cross-sectional,
baseline data from a study of a modified, family-
focused critical incident stress debriefing inter-
vention for adult survivors (N ¼ 60) within
1 month of the death by suicide of a family
member or significant other (Mitchell & Lucke,
2001). The purpose was to examine the efficacy of
a crisis intervention program during the acute
phase of bereavement. Participants were recruited
with the assistance of local coroner’s offices,
funeral homes, community mental health centers,
and other social service agencies.
All data reported here were collected from 1997
to 2000 and before any intervention was adminis-
tered. The study received university Institutional
Review Board approval prior to being conducted,
and informed consent was obtained from all
participants.
Sample
The sample for the present study included
60 survivors of suicide (100% White) who
completed baseline measures in the parent
study. The sample included 43 females (72%)
and 17 males (28%), with a mean age of 43.3 years
(SD ¼ 13.7) ranging from 18 to 78 years (inter-
quartile range: 17.5). The majority of the partic-
ipants (55%) was married or widowed (20%).
Nearly all (95%) lived with a spouse, partner,
children, or another relative. They were predom-
inantly Catholic (67%) or Protestant (23%). Most
 PSYCHOMETRIC PROPERTIES OF PERCEIVED STRESS SCALE / MITCHELL ET AL.
participants had a high school education (40%),
technical/vocational diploma (13%), bachelor’s
degree (32%), or master’s degree (12%) and
worked full-time (65%) or part-time (33%).
Of the total sample, 27 (45%) were classified as
closely related. These relationships included
spouses, parents, children, and siblings. The other
33 (55%) survivors were classified as distantly
related, and these relationships included in-laws,
aunts/uncles, nieces/nephews, and friends or
co-workers. The categorization of relationships
(closely versus distantly related) was based solely
on kinship and social relationship and did not
take into consideration the level of emotional
attachment to the suicide victim. Of the 27 closely
related survivors, 9 (33%) were spouses, 6 (22%)
were parents, 5 (19%) were children, and 7 (26%)
were siblings. Of the 33 distantly related sur-
vivors, 18 (55%) were in-laws, 1 (3%) was a niece/
nephew, and 14 (42%) were friends or co-workers
(Mitchell et al., 2004).
Measures Used for Validity Testing
Impact of Event Scale (IES; Horowitz, Wilner, &
Alvarez, 1979; Zilberg, Weiss, & Horowitz, 1982)
is a self-report measure developed to assess
the degree of subjective impact of a particular
stressful psychological event. The most frequently
used statements describing distress by people
seeking psychotherapy in the clinical setting were
used to derive the 15 items of the IES. It has
two subscales: intrusion (ideas, images, feelings,
and dreams) and avoidance (avoiding ideas,
feelings, and situations). Total scores were used
as indicators of general psychological distress.
Zilberg and colleagues validated the IES as
reflective of posttraumatic stress disorder (PTSD),
which was included in the third edition of the
Diagnostic and Statistical Manual of Mental
Disorders III (American Psychiatric Association,
1980). The internal consistency reliability for
the two subscales of the IES was acceptable
(alpha ¼ .78 intrusion, and avoidance ¼ .82), and
the split-half reliability of the total scale was
high (r ¼ .86). A correlation of .42 between the
intrusion and avoidance subscale scores indicates
that they are associated, but do not measure
identical dimensions (Horowitz et al.). Test–retest
reliability from two time points was high (r ¼ .87
total; .89 intrusion, and .79 avoidance; Horowitz
et al.; Zilberg et al.). The IES taps two of the
dimensions of PTSD, but not the dimension of
hyperarousal. The subscales had high respondent
endorsements of 80% and detected change in
Research in Nursing & Health
579
respondents’ status over time and relevant dif-
ferences in the response to traumatic events
(Horowitz et al.; Weiss & Marmar, 1997), sup-
porting content and criterion validity.
Sundin and Horowitz (2003) evaluated the IES
after over 20 years of use in a meta-analysis. A
review of 20 different studies supported the value
of the instrument. Psychological impact of life
events and the associated stress experienced by
individuals decreased over time and differed
by type of event. Overall, the meta-analysis
supported the reliability and validity of the IES
for assessing psychological stress reactions after
negative life events, including loss and bereave-
ment. Little variation was attributable to age,
gender, or cultural differences.
Posttraumatic Stress-Arousal Symptoms Scale
(PTS-AS; Ursano, Kao, & Fullerton, 1992) is a 12-
item scale that has been highly correlated (r ¼ .58
to .80) with other PTSD scales (Ursano, Fullerton,
Kao, & Bhartiya, 1995). The 12-item PTS-AS
asks the subject to rate the level of distress
experienced in the past week due to hyperarousal
symptoms of PTSD, using a 5-point Likert-
type scale ranging from not at all (0) to extremely
(5). These items allow for a more complete
assessment of all dimensions of PTSD than use
of only the intrusion and avoidance items in
the IES.
Medical Outcomes Study-Short Form36 (MOS-
SF36; Ware, Johnston, & Davis-Avery, 1979;
Ware & Sherbourne, 1992; Ware, Snow, Kosinski,
& Grandek, 1993) is a generic measure that
evaluates health concepts appropriate to an indi-
vidual’s quality of life. The 36-item self-report
scale assesses eight health concepts, including:
physical functioning, role functioning (physical
and emotional), bodily pain, general health,
vitality, social functioning, and mental health. It
has shown good internal consistency (alpha ¼
.62–.96 with a median of .80) and a reasonable
test–retest reliability (r ¼ .43–.90 with a median
of r ¼ .64) for 6 months (McHorney, Ware, Lu, &
Sherbourne, 1994). The items and scales are
scored so that a higher score indicates a better
health state. Two subscales of the MOS-SF36,
mental health and the physical health, were used
for this study.
Data Analyses
Internal consistency reliability of the three versions
of the PSS was examined using Cronbach’s alpha,
Spearman Brown split-half, and Standard Error of
Measurement. Convergent and concurrent validity
580 RESEARCH IN NURSING & HEALTH
were assessed using correlation analyses. Concur-
rent validity of the PSS was estimated by examining
its relationship with the present status of mental
and physical health-related quality of life (as the
criterion variable) as measured by the mental
health component score and the physical health
component score of the MOS-SF36.
Exploratory factor analysis (EFA) was con-
ducted to assess dimensionality of the three
versions of the PSS using principal component
extraction with varimax rotation methods. The
primary function of EFA is to explore and reduce
information from many measured variables into
a smaller set of components in order to better
classify and explain the variables, and thus make
the global perception of stress measurable. If the
conceptualization of stress is uni-dimensional,
then the internal consistency or homogeneity of
the PSS could be evidence of construct validity.
The original PSS was designed to measure one
global concept, and its items appear to be
homogeneous. Each of the three versions of the
PSS was examined for uni-dimensionality.
RESULTS
Reliability
In the present study sample, all three versions of
the PSS had Cronbach’s alpha reliability coef-
ficients that met criteria for a mature scale
(Nunnally & Bernstein, 1994). The Cronbach’s
alphas for the 14-item, 10-item, and 4-item
versions were .89, .91, and .82, respectively.
These results indicate that the items in the scales
are highly homogeneous and that 82–91% of the
variance is true score variance, with the remainder
due to error variance.
The Spearman Brown split-half reliability
coefficient was acceptable for all three versions
(the 14-item, 10-item, and 4-item) of the PSS (.86,
Table 1. Correlations Between the PSS and Validity Measures
Measurement Scales
IES .51**
12-item PTS-arousal scale .68**
MOS-SF36, mental health component .65**
MOS-SF36, physical health component .27*
PSS, Perceived Stress Scale (N ¼ 60); IES, Impact of Event Scale (N ¼ 60);
PTS-AS, Posttraumatic Stress-Arousal Scale (N ¼ 60); MOS-SF36, Medical
Outcomes Scale-Short Form 36 (N ¼ 55).
*p < .05; **p < .01.
Research in Nursing & Health
.90, and .87, respectively). In addition, the
Standard Error of Measurement for each of the
three versions of the PSS was small (3.20, 2.48,
and 1.59, respectively), indicating that the true
scores fall within the given intervals around the
test scores.
Construct Validity: Convergent Validity
All three of the versions of the PSS were
moderately correlated (p < .01) with the IES
indicating that they measure a similar concept,
but not the same type of stress. Convergent validity
was further confirmed by the significant associa-
tions (p < .01) of all three versions of the PSS with
the 12-item PTS-AS scale. The three versions
of the PSS had stronger relationships with the
12-item PTS-AS scale than with the IES.
Criterion-Related Validity:
Concurrent Validity
The correlations among the three versions of the
PSS and the mental health component score of the
MOS-SF36 were significant (p < .05) providing
evidence of concurrent validity (r ¼ .65, .70,
and .70, respectively). The correlations among
the three versions of the PSS and the physical
health component score of the MOS-SF36
were low and inconsistent across the 3 versions
(14-item, r ¼ .27, p < .05; 10-item, r ¼ .21, ns;
4-item, r ¼ .23, ns, respectively). Thus, during
the acute phase of bereavement in these par-
ticipants, the PSS was more highly negatively
associated with mental health quality of life than
with physical health quality of life (Table 1).
Construct Validity: Uni-Dimensionality
EFA was used to assess for uni-dimensionality
of each version of the PSS. The criteria used to
PSS PSS PSS
14-Item 10-Item 4-Item
.54** .58**
.69** .70**
.70** .70**
.21 .23
 PSYCHOMETRIC PROPERTIES OF PERCEIVED STRESS SCALE / MITCHELL ET AL. 581

examine dimensionality were: eigenvalues, scree
plots, and total explained variance over 50%.
Factor loading values greater than or equal to
.40 were considered significantly related to that
factor or construct. The EFA for the PSS 14-item
version retained the three factors with eigenvalue
criteria > 1. However, the primary factor (i.e.,
global perception of stress) accounted for a
sufficient amount (51%) of the total variance,
and scree plots showed a clear break after the
primary factor in the plot of eigenvalues, support-
ing the uni-dimensionality of the scale. The EFA
for the PSS 10-item version retained one factor
with eigenvalue criteria > 1, with the primary
factor accounting for 56.6% of the total variance.
With the PSS 4-item scale, all four items loaded on
the primary factor, accounting for 65.2% of the
total variance. For the PSS 14-item version, items
1, 2, 3, 5, 6, 7, 8, 9, 10, 11, and 14 loaded on the
primary factor, with loadings ranging from .45 to
.88 (see Table 2 for item content). The items in the
14-item version with factor loadings less than
.40 on the primary factor were items not included
in the two short versions. The items with the
lowest loadings, 4, 5, 12, and 13, were dropped for
the 10-item version. This resulted in values higher
than .40 for all the remaining 10 items loading
on the primary factor. In the 10-item version, the
primary factor explained slightly more variance
(56.6%) than in the 14-item version, and the factor
loadings ranged from .66 to .85. In the PSS 4-item
version, the primary factor accounted for more
variance (65.2%) than in the two longer versions
of the PSS and the factor loadings ranged from
.60 to .75.
In summary, the results of this analysis were
consistent with previous findings. The items
retained in the 10-item and 4-item versions of
the PSS were the same items that were retained
in Cohen and Williamson’s (1988) original
10-item and 4-item versions. The primary factor
explained 56.6% of the total variance for the
10-item version, which was higher than Cohen
and Williamson’s (48.9%), and the primary
factor explained 65.2% of the total variance
for the 4-item version, which was also higher than
Cohen and Williamson’s (45.6%). Although
the current sample was small, the EFA supported
the uni-dimensionality of each version of the PSS,
and all versions demonstrated adequate internal
reliability and validity. The associations among
the 14-item, the 10-item, and the 4-item versions
of the PSS were significant (p < .01) and ranged
from r ¼ .92 to r ¼ .98 (see Table 3), indicating
that they were measuring the same underlying
construct.
To examine whether only the closely related
survivors carry the reliability and validity of the
scale, we performed post hoc analyses on the
closely related and distantly related survivor
groups. The aims of these analyses were to
estimate the reliability and test the validity of the
three versions of the PSS in the closely related and
distantly related groups of survivors.

Table 2. Perceived Stress Scale Items With Principal Component Factor Loadings on Primary Factor

PSS PSS PSS

Item Item Content 14-Item 10-Item 4-Item

7 You felt things were going your way .88 .77 .60
10 You felt that you were on top of things .85 .84 —
2 You were unable to control the important things in your life .82 .85 .75
1 You were upset because something happened unexpectedly .67 .67 —
8 You found you could not cope with all the things you had to do .67 .80 —
6 You felt confident about your ability to handle personal problems .61 .76 .65
3 You felt nervous and stressed .60 .77 —
11 You have been angered because of things that happened that were .59 .66 —
outside of your control
14 You felt difficulties were piling up so high you could not overcome them .52 .69 .61
9 You were able to control irritations in your life .48 .68 —
5 You felt you were effectively coping with important changes that were .45 — —
occurring in your life
13 You were able to control the way you spend your time .25 — —
12 You found yourself thinking about things you have to accomplish .01 — —
4 You dealt successfully with irritating life hassles .22 — —
Amount of explained total variance per scale 51.0% 56.6% 65.2%

PSS, Perceived Stress Scale. All items have been adapted from the PSS (Cohen et al., 1983).
Significant factor loadings are bolded.

Research in Nursing & Health

582 RESEARCH IN NURSING & HEALTH
Table 3. Correlations Among the Three Versions of
the Perceived Stress Scale
PSS PSS PSS
PSS Versions 14-Item 10-Item 4-Item
PSS 14-item 1.00 .98* .92*
PSS 10-item 1.00 .95*
PSS 4-item 1.00
PSS, Perceived Stress Scale.
*p < .05.
Post Hoc Sub-Sample Analyses
Nearly half of the sample (45%) were closely
related survivors (defined as spouses, parents,
children, and siblings), and thus were most at risk
of perceived stress and subsequent stress-related
health problems following the suicide of a
significant other. We had combined the closely
related and distantly related survivors of suicide
to maximize the sample size and enhance the
statistical validity of the findings. To determine
whether there were important differences between
these two groups of survivors, we examined
the two group’s mean scores on the PSS. For the
sample of closely related survivors (N ¼ 27) the
mean score on the PSS was 32.63, SD ¼ 8.64; for
the distantly related survivors (N ¼ 33) the mean
score on the PSS was 22.82, SD ¼ 8.01,
F(1,58) ¼ 17.74, p < .003. Thus, closely related
survivors of suicide experienced significantly
higher levels of perceived stress than those
survivors in the distantly related relationship
group (defined as in-laws, aunts/uncles, nieces/
nephews, and friends or co-workers).
Post Hoc Sub-Sample Reliability
Cronbach’s alpha, Spearman Brown split-half,
and Standard Error of Measurement were used to
confirm internal consistency reliability of the
three versions of the PSS in the closely related
subjects. The Cronbach’s alphas for the 14-item,
10-item, and 4-item versions were .90, .92, and
.87, respectively. All three versions of the PSS had
Cronbach’s alpha reliability coefficients that met
criteria for a mature scale (Nunnally & Bernstein,
1994).
The Spearman Brown split-half reliability
coefficient was acceptable for all three versions
(the 14-item, 10-item, and 4-item) of the PSS in
the closely related survivors (.89, .92, and .90,
respectively). In addition, the Standard Error of
Measurement for the 14-item and 4-item versions
Research in Nursing & Health
of the PSS was small (3.16 and 3.42, respectively).
However, the Standard Error of Measurement for
the 10-item version was 8.28, indicating that a
wider variability of scores could be expected from
this version of the PSS used for closely related
survivors.
Post Hoc Sub-Sample Criterion-Related
Validity: Concurrent Validity
The correlations among the three versions of
the PSS and the mental health component score
of the MOS-SF36 were significant for the PSS
10-item version (r ¼ .77, p < .001) and the
4-item version (r ¼ .82, p < .001), but not for
the 14-item version (r ¼ .19, ns), providing
evidence of concurrent validity for the 4- and
10-item versions for those survivors most at risk
(i.e., the sub-sample of closely related survivors).
The correlations among the three versions of the
PSS and the physical health component score
of the MOS-SF36 were non-significant across
all three versions, 14-item (r ¼ .09, ns); 10-item
(r ¼ .06, ns); and 4-item (r ¼ .10, ns).
Post Hoc Sub-Sample Construct
Validity: Uni-Dimensionality
For confirmation of the validity of the PSS 4-item
version with the sub-sample of closely related
survivors, the EFA was repeated. The four factors
loaded onto one component with a very narrow
range of factor loadings, from .88 to .90, and
accounted for 73.78% of the variance, supporting
the uni-dimensionality of the PSS 4-item version.
Post Hoc Sub-Sample of Distantly
Related Survivor Reliability
Confirmation of the reliability of the PSS with the
distantly related survivor sub-sample was sought
to assure the usefulness of the PSS. In the distantly
related survivors (N ¼ 33) the Cronbach’s alpha
was comparable to the closely related survivors
on the 14-item and 10-item versions of the PSS
(.80 and .72, respectively). The Spearman Brown
split-half reliability coefficient was acceptable
for the 14-item and 10-item versions of the
PSS (.84 and .72, respectively). In addition, the
Standard Error of Measurement for the 14-item
and 10-item versions of the PSS was small
(3.13 and 2.90, respectively). The reliability of
the 4-item version of the PSS did not hold up in the
 PSYCHOMETRIC PROPERTIES OF PERCEIVED STRESS SCALE / MITCHELL ET AL.
distantly related group of survivors, meaning the
items had little in common, were measuring
different dimensions, or that this version was too
short to be useful in this group of survivors
(Nunnally & Bernstein, 1994).
DISCUSSION
There was a high correlation among the PSS, the
IES, and the 12-item PTS-AS scales. Cohen
and Williamson (1988) found PSS scores to be
associated with physical health outcomes, inde-
pendent of levels of psychological distress. In
contrast, in the current sample, the PSS was more
highly negatively correlated with the mental
health quality of life component than with the
physical health quality of life component of the
MOS-SF36. Bereavement following the death of a
significant other from suicide may be a different
experience from that following other types of
losses. In this study, the survivors were assessed
within 1 month of the death, during the acute
phase of bereavement, which is an extremely
stressful time and a period during which physical
symptoms may not yet have appeared. Bailley,
Kral, and Dunham (1999) found that survivors
of suicide, compared to other groups of bereaved,
experienced more unique reactions including
frequent feelings of rejection, responsibility,
shame, and perceived stigmatization. These reac-
tions are similar in nature to the content of the
items that loaded on the 4-item scale and are
related to items on the mental health component
scale. Interestingly, a similar trend was seen with
the IES. There was a significant negative relation-
ship between the IES and the MOS-SF36, mental
health component score. However, the IES was not
correlated with the MOS-SF36 physical health
component score, perhaps because it was so early
in the bereavement process.
In this study, closely related survivors of suicide
experienced significantly higher levels of per-
ceived stress than those survivors in the distantly
related relationship group. When working with
individuals, especially in a highly distressed
population like survivors of a family member’s
or significant other’s suicide, one must be highly
cognizant of the issue of participant burden. There
is often a problem with participant recruitment,
retention, and attrition rates. Because the mea-
surement qualities of the two shorter versions are
as reliable and valid as the longer 14-item version,
it seems that these shorter versions could be
used in a variety of settings, providing a good
alternative to the longer version. The shorter
versions are particularly relevant when working
Research in Nursing & Health
583
with traumatized individuals who have had a
recent stressful life event in order to reduce
participant burden without sacrificing efficiency,
as they can be included easily in a complete
assessment battery. The shortened forms are well-
suited to administer in both clinical and research
settings, as they remain comprehensive in their
assessment of perceived stress in this population.
For comparison purposes, the utilization of a
single question which asks participants to rate
their perceived stress on a 10-point scale ranging
from no stress to high stress could be the focus for
future research with similar populations.
Relational health involves a process of forming
an intimate circle of persons who respond to the
presence of unmet needs and who provide social
support (Cohen & Herbert, 1996). First-degree
relatives, because of primary socialization that
stresses a value of being responsive to immediate
family members, are most likely to have been
invested in a relationship with the suicide
victim. The abrupt end to that relationship could
be expected to contribute to higher levels of
perceived stress in this group of survivors. In the
future, it will also be important to take into
consideration and assess levels of psychological
closeness or emotional attachment, as well as
kinship to the suicide victim.
With intervention development in mind, the
higher stress levels in closely related survivors
indicate a need to focus and direct initial
interventions with this important group. On the
basis of examining early adaptation and kinship
relationship Cleiren, Diekstra, Kerkhof, and Van
der Wal (1994) were able to identify those most at
risk for future problems coping with the loss.
Further, multi-faceted measurement strategies are
important for eliciting unique responses that guide
the refinement and development of preventive
interventions for varied levels of stress and the
individuals experiences (Gottlieb, 2000). Specifi-
cally, the concepts of control and confidence in
one’s abilities could be utilized as a focus in the
development of a preventive intervention. Further,
higher perceptions of stress in these survivors also
may indicate that physical symptoms could
worsen (Dunne, 2004; Williams, 2005), which
means they are worthy of close observation and
assessment over time following the death of a
significant other.
Limitations
In this study, closely related and distantly related
survivors were first combined for the purpose of
584 RESEARCH IN NURSING & HEALTH
psychometric analyses. Even so, this was an
admittedly small sample for an exploratory factor
analysis. Although this does not present a problem
with the 4-item version, it is a limitation of the
study with the 10-item and 14-item versions.
This is more of a limitation for the analysis of the
sub-sample of closely related survivors, who are
the people most likely to be at risk for stress and
stress-related illnesses. It should be noted, how-
ever, that we had a sound sampling plan and were
able to recruit a good number of very difficult to
access participants in a sensitive area of inquiry.
SUMMARY
Results provide evidence for the reliability and
validity of the PSS in the present sample of adult
survivors of suicide. The three versions of the PSS
were highly correlated and reflect one construct of
stress. The four instruments utilized for validity
evidence measure different types and qualities of
stress (i.e., IES and PTS-AS) and quality of life
(i.e., mental health component scale and physical
health component scale of the MOS-SF36) and
confirm convergent and concurrent validity of
the PSS. The PSS measures a global, subjective,
perceived stress construct; the IES and 12-item
PTS-AS measure the three PTSD symptom
clusters of avoidance and intrusion (on the IES)
and hyperarousal (on the PTS-AS); while the
MOS-SF36 is a generic measure of quality of life,
including both a mental health and a physical
health component.
Ongoing reliability and validity testing of the
PSS is necessary for clinicians and researchers
to determine its usefulness in assessing global
perceived stress in survivors of suicide. The results
of this study confirmed that the three versions (the
14-item, 10-item, and 4-item) of the PSS were
reliable and valid for use with survivors of suicide,
and that the two shorter versions retained
good psychometric properties. In this study, the
participants (i.e., spouses, parents, children, and
siblings) who were closest to the deceased,
reported higher levels of perceived stress than
the distantly related participants. When adminis-
tered to the sub-sample of closely related survi-
vors, the psychometric properties of the 4-item
version of the PSS were retained, although this
was not true in the distantly related survivors. For
distantly related survivors, the 14-item or 10-item
version of the PSS was more useful. Levels of
perceived stress will vary over time and circum-
stance, and given the evidence for the association
between stress and disease, gaining a greater
Research in Nursing & Health
understanding of the link between an individual’s
ability to cope with a death by suicide and long-
term health outcomes is an important next step.
Replication of this study with a larger sample size
would be important to confirm that the scales can
be used in further study of this topic.
REFERENCES
American Association of Suicidology. (2002). Re-
trieved September, 3, 2005 from http://suicidology.
org/associations/1045/files/Suicide2002.pdf.
American Psychiatric Association. (1980). Diagnostic
and statistical manual of mental disorders. 3rd
edition. Washington, DC: Author.
Bailley, S.E., Kral, M.J., & Dunham, K. (1999).
Survivors of suicide do grieve differently: Empirical
support for a common sense proposition. Suicide and
Life-Threatening Behavior, 29, 256–271.
Cleiren, M., Diekstra, R., Kerkhof, A., & Van der Wal, J.
(1994). Mode of death and kinship in bereavement:
Focusing on ‘‘who’’ rather than ‘‘how’’. Crisis, 15,
22–36.
Cohen, S., & Herbert, T.B. (1996). Health psychology:
Psychological factors and physical disease from the
perspective of human psychoneuroimmunology.
Annual Review of Psychology, 47, 113–142.
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A
global measure of perceived stress. Journal of Health
and Social Behavior, 24, 385–396.
Cohen, S., & Williamson, G.M. (1988). Perceived stress
in a probability sample of the United States. In
S. Spacapan & S. Oskamp (Eds.), The social
psychology of health (pp. 31–67). Newbury Park,
CA: Sage.
Dunne, K. (2004). Grief and its manifestations. Nursing
Standard, 18, 45–52.
Gottlieb, B.H. (2000). Selecting and planning support
interventions. In S. Cohen, L.U. Gordon, & B.H.
Gottlieb (Eds.), Social support measurement and
intervention: A guide for health and social scientists
(pp. 195–218). Oxford, UK: Oxford University
Press.
Horowitz, M., Wilner, N., & Alvarez, W. (1979). Impact
of event scale: A measure of subjective stress.
Psychosomatic Medicine, 41, 209–218.
Jordon, J.R. (2001). Is suicide bereavement different? A
reassessment of the literature. Suicide and Life-
Threatening Behavior, 31, 91–102.
Kuiper, N.A., Olinger, L.J., & Lyons, L.M. (1986).
Global perceived stress level as a moderator of
the relationship between negative life events
and depression. Journal of Human Stress, 12, 149–
153.
Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal,
and coping. New York: Springer.
Marsland, A.L., Cohen, S., Rabin, B.S., & Manuck, S.B.
(2001). Associations between stress, trait negative
affect, acute immune reactivity, and antibody
 PSYCHOMETRIC PROPERTIES OF PERCEIVED STRESS SCALE / MITCHELL ET AL.
response to hepatitis B injection in healthy young
adults. Health Psychology, 20, 4–11.
McHorney, C.A., Ware, J.E. Jr., Lu, J.F., & Sherbourne,
C.D. (1994). The MOS 36-item short form
health survey (SF-36). III. Tests of data quality,
scaling, assumptions, and reliability across
diverse patient groups. Medical Care, 32, 240–
266.
Mitchell, A.M., & Kim, Y. (2002). Depression,
traumatic grief, stress, and quality of life in survivors
of suicide: Use of generalized linear modeling
(GLM). Quality of Life Research, 11, A669.
Mitchell, A.M., Kim, Y., Prigerson, H.G., & Mortimer-
Stephens, M. (2004). Complicated grief in survivors
of suicide. Crisis, 25, 12–18.
Mitchell, A.M., & Lucke, J.F. (2001). A Critical
Incident Stress Debriefing (CISD) intervention for
survivors of suicide. Proceedings of the American
Association of Suicidology 34th Annual Conference,
Atlanta, GA, p. 64.
National Institute of Mental Health. (2003). In
harms way: Suicide in America. Retrieved September
3, 2005 from http://www.nimh.nih.gov/publicat/
harmaway.cfm.
Nunnally, J.C., & Bernstein, I.H. (1994). Psychometric
theory. 3rd edition. New York: McGraw-Hill.
Sundin, E.C., & Horowitz, M.J. (2003). Horowitz’s
impact of event scale: Evaluation of 20 years use.
Psychosomatic Medicine, 65, 870–876.
Ursano, R.J., Fullerton, C.S., Kao, T.C., & Bhartiya,
V.R. (1995). Longitudinal assessment of posttrau-
matic stress disorder and depression after exposure to
traumatic death. Journal of Nervous and Mental
Disease, 18, 36–42.
Ursano, R.J., Kao, T.C., & Fullerton, C.S. (1992).
Posttraumatic stress disorder and meaning: Structur-
ing human chaos. Journal of Nervous and Mental
Disease, 180, 756–775.
Research in Nursing & Health
585
U.S. Department of Health and Human Services.
(2000). Healthy People 2010 (2nd edition), Vol. I:
Understanding and improving health and Vol. II:
Objectives for improving health. Washington, DC:
U.S. Government Printing Office.
Walsh, W.B., & Betz, N.E. (2001). Tests and assess-
ment. 4th edition. Englewood Cliffs, NJ: Prentice
Hall.
Wang, J., & Patten, S.B. (2001). Perceived work stress
and major depression in the Canadian employed
populations, 20–49 years old. Journal of Occupa-
tional Health Psychology Special Issue, 6, 283–289.
Ware, J.E., Johnston, S.A., & Davies-Avery, A. (1979).
Conceptualization and measurement of health for
adults in the Health Insurance Study: Mental health
(vol. 3). Santa Monica, CA: Rand Corporation.
Ware, J.E., & Sherbourne, C.D. (1992). The MOS 36-
item short form health survey (SF-36): Conceptual
framework and item selection. Medical Care, 30,
473–483.
Ware, J.E., Snow, K.K., Kosinski, M., & Grandek, B.
(1993). The SF-36 Health Survey Manual and
Interpretation Guide. Boston, MA: Nimrod Press.
Weiss, D., & Marmar, C. (1997). The impact of event
scale-revised. In J. Wilson & T. Keane (Eds.),
Assessing psychological trauma and PTSD (pp.
399–410). New York: Guildford.
Williams, J.R. Jr. (2005). Depression as a mediator
between spousal bereavement and mortality from
cardiovascular disease: Appreciating and managing
the adverse health consequences of depression in an
elderly surviving spouse. Southern Medical Journal,
98, 90–95.
Zilberg, N.J., Weiss, D.S., & Horowitz, M. (1982).
Impact of event scale: A cross-validation study and
some empirical evidence supporting a conceptual
model of stress response syndromes. Journal of
Consulting and Clinical Psychology, 50, 407–414.