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Revista chilena de pediatría

versión impresa ISSN 0370-4106

Rev. chil. pediatr. vol.90 no.4 Santiago ago. 2019 


Validation of “The Parental Stressor Scale Infant Hospitalization modified, to Spanish” in a pediatric intensive care unit

Sandra Navarro-Tapia1 

Muriel Ramírez2 

Cristián Clavería3 

Yerko Molina4  5 

1 Nurse, MSc in Social Psychology, High Risk Newborn specialist. Associate Professor, Nursing School, Pontificia Universidad Católica de Chile, Chile.

2 Nurse, Pediatric Intensive Care Unit, Hospital Clínico de la Red de Salud UC CHRISTUS, Chile.

3 MD, Pediatric Cardiologist and Intensivist. School of Medicine Pontificia Universidad Católica de Chile. Hospital Clínico de la Red de Salud UC CHRISTUS, Chile.

4 Psychologist, MSc in Health Psychology. Nursing School, Pontificia Universidad Católica de Chile, Chile.

5 School of Psychology, Universidad Adolfo Ibáñez, Chile.



Intensive care units are known as high-stress environments for family members, this can be higher when the patient is a son or daughter and the parents must face the disease along with everything that the hospital environment implies. The Parental Stressor Scale Infant Hospitalization (PSSIH) instrument is a tool used to measure stressors in Pediatric Intensive Care Units (PICU), however, the scale is not validated in Chile. The objective of this study is to culturally validate and adapt the instrument “the modified Parental Stressor Scale Infant Hospitalization” in mothers/fathers of hospitalized children in the PICU of a University Hospital.


Instrumental validation study. After translating and counter-translating the English version of the instrument, a group of 10 expert professionals evaluated the Spanish adaptation. Then, 10 parents of hospitalized children in the PICU evaluated the understanding of the instrument. The psychometric properties of the instrument were evaluated using exploratory factorial analysis and Cronbach’s alpha.


The Chilean version of the “modified PSSIH” was applied to a sample of 221 parents, with minimal semantic modifications and the expert judges considered the instrument adequate, therefore, it was not necessary to delete any item. The 3-dimensional solution was chosen, which explained 48.89% of the total instrument variance. The Cronbach’s alpha was 0.885, 0.902, and 0.703 respectively for each dimension.

Con clusion:

The modified PSSIH has proved to be a reliable and valid instrument in a sample of Chilean children hospitalized in a Pediatric Intensive Care Unit of a university hospital. The name in Spanish of the scale is “Escala de Evaluación de Estresores Parentales en niños hospitalizados en Unidades de Cuidados Intensivos Pediátricos” (EEEP - UCIP).

Keywords: Parental stress; hospitalization; pediatric intensive care; parental stressors


The admission of a child to a Pediatric Intensive Care Unit (PICU) is a situation where parents experience anxiety and stress, altering their role at times when their child requires it most. Understanding and identifying which factors can facilitate the establish ment and maintenance of a health team therapeutic intervention is an ethical imperative in the humanized care setting at PICU1.

There are many causes of stress in a hospita lized child, his/her parents, and family that can be prevented such as ignorance about the impli cations of illness, medical procedures or rules, and routines in the hospital context. Currently, in Chile, there is still a time restriction in the PICU for parents or caregivers to be with the child 24 hours a day2.

A study carried out by Ramirez, Navarro, Clavería, Molina, and Cox3 on 217 parents of children admitted to a PICU in the Metropolitan Region iden tified the main parental stressors in that Unit, which were grouped into three dimensions: Clinical, Emo tional, and Communication with the professional team, where the clinical dimension was the biggest stressor. These results correspond to the secondary analysis of the Educational Assistance Research Pro ject # 201403 of the UC School of Nursing during the Instrument Validation process of The Parental Stres sor Scale Infant Hospitalization in Spanish” (modi fied PSSIH).

This instrument was the only one found upon searching in scientific databases. The results were mostly instruments that evaluate stress in parents, but do not measure parental stressors. We found only one work that measures the hospitalization situation of a child, developed by Carter and Miles4, called “The Parental Stressor Scale Infant Hospitalization” (PSSIH) made up of 28 items, grouped into six fac tors: a) appearance of the child, b) lights and sounds, c) procedures, d) communication with professional team, e) behavior and emotional response of the child, and f) parental role. This scale was modified by Saied5 in his doctoral thesis “Stress, Coping, Support, and Adjustment among Families of CHD Children in PICU After Heart Surgery” which incorporates the factor “Behavior of professionals” allowing to know and evaluate the relationship of clinical health per sonnel with parents6,7,8,9,10,11, resulting in an instrument of seven factors and 37 items. This instrument was used in this research.

The objective of this study is to validate the ins trument The Parental Stressor Scale Infant Hospitalization modified by Saied, for the Chilean popu lation.



Validation of the modified measurement instru ment “The Parental Stressor Scale Infant Hospitaliza tion” (“modified PSSIH”) for the Chilean population.

Adaptation and validation process of the modified PSSIH

Two independent translations into Spanish were done, followed by two counter-translations by native English speakers. After individual analysis by the members of the research team, the opinions were agre ed upon in a final instrument that was sent to the ex pert professionals.

Once the scale was translated, the validation pro cess was carried out in a sequential way: (1) content validity (2) linguistic adaptation (3) pre-test of the instrument’s adapted version, and (4) construct validi ty and psychometric properties analysis.

Instruments and data collection

The modified PSSIH consists of 37 items grouped into seven factors, with a Likert like response moda lity: 1) appearance of the child; 2) images or sounds; 3) procedures or interventions; 4) behavior of the pro fessional team; 5) communication of the professional team; 6) behavior and/or emotional response of the child; 7) role of the parents.

Content validity and linguistic adaptation

At this stage, the modified counter-translated PSSIH, was evaluated by ten expert professionals (three Pediatric Nurses, two Intensive Care Pediatricians, two Psychologists, one Anesthesiologist, one Neonatologist, and one Midwife Nurse) who answered a ques tionnaire regarding the adequacy of the item to the measured construct, comprehension, and writing. The data analysis considered the estimation of the Content Validity Coefficient (CVC) and the Lynn Index (LI) for each item, using as criteria for item adequacy a mini mum of 0.6 for the CVC and 0.8 for the LI.

Subsequently, the changes suggested by the ex perts in writing were incorporated and the item “that a machine breathes for my child” is added to the factor “procedures and interventions” and an open question. Afterward, ten interviews were conducted with parents of children hospitalized at PICU and they were asked to assess the clarity of language, concepts, writing, and understanding of each question. With the suggestions, the instrument was modified to obtain the third ver sion in Spanish, which was applied as a pilot in ten mothers/fathers of children hospitalized at PICU. In this last stage, the instrument had no modifications, obtaining the final version in Spanish of the Evalua tion Scale of Parental Stressors in PICU made up of 38 items plus an open question.

Validity and reliability study

The sample size was determined according to Brislin’s criteria which indicates a minimum of five subjects for each item of the instrument. The study was conducted at the PICU of a University Hospital in the Metropolitan Region. The recruitment time was seven months (October 2015 - April 2016) to fulfill the required sample.

Construct validity

An exploratory factorial analysis was performed where the items were analyzed according to their as ymmetry. 18 of the 38 items presented excessive as ymmetry levels (asymmetry coefficient higher than 1 in absolute value) thus the factorial analysis was per formed on a polychoric matrix, using the extraction method of unweighted least squares. To determine the number of optimal dimensions, the scree plot and Horn’s parallel analysis were used, along with an analysis of the explained variance and the goodness- of-fit statistic Root Mean Square of Residuals (RMSR), considering a 0.0674 maximum for this indicator. To estimate the belonging of the items to the dimension, the oblimin rotation was used, since the dimensions correlated with each other (r higher than 0.4) and a minimum correlation of 0.3 was used as a criterion to incorporate an item to the dimension.

Reliability study

In order to evaluate internal consistency, Cronbach’s Alfa was used, also incorporating a discriminatory capacity analysis of the items through the correlation of each one of the reagents with the score of each dimension of the instrument. It was conside red for its interpretation that values between 0.60 and 0.69 represent acceptable reliability, from 0.70 to 0.79 a high reliability, and higher than 0.8 an optimal relia bility.

Data analysis

For socio-demographic variables, descriptive sta tistics were calculated using the statistical software SPSS (SPSS for Windows, version 22, 2012; SPSS Inc., Chicago, IL, USA), while for factor analysis of the ins trument, the statistical software FACTOR was used.

This project has been approved by the Catholic University of Chile’s Medical Ethics Committee and the participants signed an Informed Consent.


The study included a total of 221 participants.

I. Evaluation of Content validity, linguistic adequacy, and piloting

The judges evaluated positively all the items of the instrument. The minimum CVC recorded for an item was 0.75 and for the LI was 0.85, concluding that no item was eliminated at this stage, only some minor changes were made in phrasing. Regarding linguistic adaptation, minor changes were registered in the following items: 1, 2, 3, 4, 5, 8, 9, 13, 20, 23, 25, 32. With respect to piloting, the average response time of the questionnaire was 25 minutes, without reporting pro blems with self-application. (Table 1) shows the original instrument and the version subsequent to expert vali dation, linguistic adequacy, and piloting.

Table 1 Items in the instrument before and after validation and adaptation. 

II. Evaluation of construct validity, reliability, discrimination, and homogeneity

Sample characterization:

Characteristics of the child

Age of children from 0 to 18 years, with an avera ge of 2.98 and a standard deviation of 4.3. (Table 2). Regarding hospitalization, 44% was the first time they were hospitalized, 34% had had three or more hospi talizations, and 61.5% had a scheduled admission. In relation to the causes, 60% correspond to heart pro blems, 14.2% to neurological problems, and the rest to oncological, respiratory, and other problems.

Table 2 Characteristics of the Children. 

Caregiver Characteristics

Age between 18 and 61, with an average of 34.6. 61% are mothers, 62.7% have university education. Regarding marital status, 53.4% were married and 64.5% have another child in addition to the hospitalized one. 57.6% live in the Metropolitan Region (Table 3).

Table 3 Characteristics of the Caregiver. 

Factor analysis

The method of least-squares factor extraction was used in the FACTOR software for the analysis of polychoric matrices. The polychoric matrix adequacy es timated a Kaiser Meyer Olkin (KMO) from 0.866 > to 0.8 indicating optimal conditions for analysis. In addi tion, Bartlett’s test gave a value of 4,498.4 associated with a p < 0.001, that is, the polychoric matrix to be analyzed is not an identity matrix, because the items do correlate with each other.

Regarding the number of factors, Horn’s parallel analysis showed that three factors have a higher self value than that provided at random. These factors ex plain 48.894% of the total variance of the instrument and are congruent with the scree plot as can be seen in the sedimentation graph (Graph 1). The RMSR for this solution was 0.0627, lower than the criterion of 0.0674 which indicates an adequate fit of the resulting 3-di mensional factorial structure.

Graph 1 Contrast criteria of fall. 

With respect to factorial loads, (Table 4) shows the result of the analysis using oblimin rotation.

In relation to discrimination and homogeneity, the observation of the items behavior shows that they all present adequate discrimination levels (correlations over 0.25 in their dimension), however, an ambiguous factorial load of the original scale is observed in the items: “Inability to speak or cry” of the “Emotional responses of the child” dimension; “Not being able to care for my child myself’ and “Not being able to be when my child is crying” of the “Role of parents” dimension that could affect the instrument homogeneity.

Table 4 Factor loadings using least squares and oblimin rotation (showing only factor loadings higher than 0.3). 

Regarding the factors proposed by the authors, compared to the one proposed in this work, it can be observed that the factors “appearance of the child”, “images or sound”, “procedures or interventions” and “behavior of the professional team” tend to be grou ped into a single dimension, which will be called the “clinical dimension”. The original factor “emotional behavior or responses of the child” and “role of pa rents” are loaded in the “emotional dimension” with respect to the role factor of parents. This decision was made with clinical criteria since the items of this factor also load in the Clinical dimension. The original factor “communication of the professional team” loads in the Communication of the professional team dimension, preserving the same name. Cronbach alpha was used to evaluate the reliability of the internal consistency dimension. (Table 5) shows this indicator of the original factors and dimensions resulting from this analysis.

Table 5 Cronbach's alpha for original dimensions and factorial structure. 

Likewise, it can be seen that the factor reliability analyses of the original instrument present an adequa te level of internal consistency above 0.7. Analyzing the resulting three dimensions Clinical, Emotional and Communication, a clear increase in Cronbach’s alpha is evident in the first two factors mentioned with an alpha of 0.885 and 0.902 respectively, while the third dimension since it remains intact, it presents the same level of internal consistency as in the original factorial structure (0.703).


In general terms, the results of this research provide a validity analysis of the modified PSSIH instrument for a sample of Chilean children treated in a PICU of a University hospital in the Metropolitan Region. The adaptations made met the standards suggested by spe cialized literature, considering linguistic and cultural differences of context. It was obtained an instrument made up of 38 items, grouped in three dimensions: 1. Clinic consisting of four original factors (appearance of the child; images and sounds; procedures or interventions, and team behaviors); 2. Communication with the clinical team, which includes an original fac tor (professional team), and 3. Emotional with two original factors (behavior and/or emotional responses and parental role). In addition, adequate reliability le vels were observed in both the original factors and the dimensions resulting from this study.

Technological advances contribute effectively to the treatment of children at PICU, however, there is an increasingly automated professional-patient rela tionship, with restricted access to the family, focused on procedures and medical treatment12. Therefore, the environmental assessment is essential, constituting a humanized care strategy. Literature13 refers to the im plementation of activities that favor the relationship of professionals with the family and children, allowing for the establishment of spaces where technical efficiency is combined with the quality of care. From this pers pective, validating an instrument that measures paren tal stressors responds to the health institutions’ needs.

The dimensions addressed by this instrument agree with what is referred to in the literature as environ mental stressors14. Involving the family in the care of a seriously ill child can optimize outcomes for the child, family, and the Institution15. Having a validated ins trument allows the health team to assess their ability to communicate effectively, to identify what parents need to be involved in the decision-making process, and to participate in the care of their children.

It is also a support tool for the development of indi cators to assess the quality of care and helps to identify and share good practices.

Regarding validation, two studies were found in which the factorial structure of the instrument is evaluated, a validation to the Portuguese language16 and another one carried out in a sample of caregivers in the United States17.

In the case of the Portuguese16 validation, only 26 of the 37 items were added to the factorial analysis. The extraction method used was that of main components, a method criticized for not being considered a factorial analysis as such. However, the factorial structure pre sented is congruent with the resulting one in this study. Regarding the results of the study by Agazio and Buckley17, an analysis of main components was also carried out, testing solutions with 5, 6, 7 and 8 factors and the structure of 7 factors was chosen because it fit adequa tely with the original structure, however, the explained variance is not reported nor other criteria to delimit the number of factors, thus the comparison of results becomes difficult.

Finally, in relation to the internal consistency analyses, it was observed that in general, the original scale presents adequate reliability values18,19 that are congruent with those found in this study.

Study limitations

Application of the instrument in a single PICU and sampling was not random.


This study is not only a contribution to PICU re search but also, the use of validated and reliable instru ments is a tool for health teams that allows them to de liver safe and quality care to children and their parents. This is how the modified Parental Stressor Scale Infant Hospitalization instrument has proven to be reliable and valid in a sample of Chilean children hospitalized in a Pediatric Intensive Care Unit of a university hos pital, whose Spanish name is Escala de Evaluación Estresores Parentales de niños hospitalizados en Unidades Cuidados Intensivos Pediátricos (EEEP - UCIP), made up of 38 items, grouped into three dimensions: “Cli nical Dimension”, “Communication with the Clinical Team Dimension “, and “Emotional Dimension”, plus an open question.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed ac cording to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regu lations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This document is in the possession of the correspondence author.

Financial Disclosure: Authors state that no economic support has been asso ciated with the present study.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

Scale for the Evaluation of Parental Stressor in Pediatric Intensive Care Units (PICU)

(The Parental Stressor Scale: Infant Hospitalization (PSS:IH) Miles & col., modified by Saied, validated for Chilean population, IDA Project No. 15-096.

School of Nursing. Faculty of Medicine Catholic University of Chile. Navarro-Tapia, S., Ramirez, M., Clavería, C., Molina, Y.)

It is of great interest for nurses and other professionals working in the PICU to know the effect that the PICU environment has on their experience as parents.

The following questionnaire includes a series of situations that can be considered stressful for parents during their child's stay in the PICU.

We are very interested in knowing your perception or experience regarding the stress situations experienced by you, in the present hospitalization of your child.

We understand stressful situations, all those lived experiences that make us feel anxious, upset or tense.

In the following questionnaire, you are asked to circle the number that best represents how stressful this situation has been for you.

In those items that are described below and that have not been part of your experience, you should check "Not Experienced" (0).

0 = Not experienced 3 = Moderately stressful

1 = It was not stressful 4 = Very stressful

2 = Minimally stressful 5 = Extremely stressful

Clinical Dimension

I. The following is a list of items that could be used to describe the appearance of your child. Using the following scale of measurement, circle the number which best describes how stressful these situations have been for you.

II. Below you will find a list of items that describes situations that you could have observed during the hospitalization of your child in the PCCU, such as images or sounds. Indicate how stressful each of the factors was for you.

III. Below you will find a list of items that describe a series of procedures or interventions that could have been used to treat your child. Indicate how stressful these were for you.

IV. Below you will find a list of different types of Behaviour by the Medical Team (doctors and nurses) that you might have observed during the hospitalization of your child in the PCCU.

Dimension communication with the clinical team

V. Below you will find a list of items that describes different situations in which the Medical Team (doctors and nurses) communicated with you about your child's condition. Indicate how stressful these were for you.

Emotional dimension

VI. Below you will find a list of items that describes different ways of behaviour and/or emotional responses that your child may have demons trated during their hospitalization in the PCCU. Indicate how stressful these were for you.

VII. The following list refers to the role of the parents. Indicate how stressful the following factors were for you.

IX. Is there any other situation that you found stressful and that has not been included in the questionnaire? Please describe it below: (new item)


1. Thompson V, Hupcey J, Clark M. The Development of Trust in Parents of Hospitalized Children. J Spec Pediatr Nurs. 2003;8(4):137-47. [ Links ]

2. Ochoa B, Polaino-Lorente A. El estrés de los padres como consecuencia de la hospitalización de sus hijos: una revisión. Estudios de Psicología 1999;20:63-64,147-161, DOI: 10.1174/02109399960256829. [ Links ]

3. Ramirez, M., Navarro, S., Clavería, C., Molina, Y. & Cox, A. Estresores parentales en Unidades de Cuidados Intensivos Pediátricos. Rev Chil Pediatr 2018;89(2):182-9. [ Links ]

4. Carter MC, Miles MS, Buford TH, Hassanein RS. Parental environmental stress in pediatric intensive care units. Dimens Crit Care Nurs. 1985;4(3):180-8. [ Links ]

5. Saied H. Stress, Coping, Social Support and Adjustment Among Families of CHD Children in PICU After Heart Surgery. Electronic Thesis or Dissertation. Case Western Reserve University, 2006. Ohio: LINK Electronic Theses and Dissertations Center. Mar 2015. [ Links ]

6. Costa JB, Felicetti CR, Costa CR, Miglioranza DC, et al. Fatores estressantes para familiares de pacientes críticamente enfermos de uma unidade de terapia intensiva. J Bras Psiquiatr 2010;59(3):182-9. [ Links ]

7. Parra Falcón F, Moncada Z, Oviedo Soto S, Marquina M. Estrés en padres de los recién nacidos hospitalizados en la Unidad de Alto Riesgo Neonatal. Index Enferm 2009;18(1):13-7. [ Links ]

8. Melnyk BM, Alpert-Gillis L, Hensel P, Cable-Beiling R, Rubenstein JS. Helping mothers cope with a critically ill child: a pilot test of the COPE intervention. Res Nurs Health 1997;20(1):3-14. [ Links ]

9. Fernández Castillo A, López Naranjo I. Estrés parental en la hospitalización infantil. Ansiedad estrés 2006;12(1):1-17. [ Links ]

10. Ochoa Linacero B, Polaina Lorente A. El estrés de los padres como consecuencia de la hospitalización de sus hijos: una revisión. Estud Psicol 1999;20(63-64):147-62. [ Links ]

11. Ruiz A, Ceriani Cernadas J, Cravedi V, Rodríguez D. Estrés y depresión en madres de prematuros: un programa de intervención. Arch Argent Pediatr. 2005;103(1):36-45. [ Links ]

12. Board R, Ryan-Wenger N. Long-term effects of pediatric intensive care unit hospitalization on families with young children. Heart Lung 2002;31(1):53-66. [ Links ]

13. Marques IR, Souza AR. Tecnologia e humanização em ambientes intensivos. Rev Bras Enferm. 2010;63(1):141-4. [ Links ]

14. Shudy M, de Almeida ML, Ly S, Landon C, et al. Impact of pediatric critical illness and injury on families: a systematic literature review. Pediatrics 2006;118 Suppl 3:S203-18. [ Links ]

15. Portella J, Calcagno G, Buss M. Health facility environment as humanization strategy care in the pediatric unit: systematic review. Rev Esc Enferm USP 2014;48(3):527-36 [ Links ]

16. Corlett J, Twycross A. Negotiation of parental roles within family-centred care: A review of the research. J Clin Nurs. 2006;15(10):1308-16. doi: 10.1111/j.1365-2702.2006.01407.x. [ Links ]

17. De Souza S, Dupas G, Ferreira Gomes M. Cultural adaptation and validation for the Portuguese language of the Parental Stress Scale: Neonatal Intensive Care Unit (PSS:NICU). Acta Paul Enferm. 2012;25(2):171-6. [ Links ]

18. Agazio J, Buckley K. Revision of a Parental Stress Scale for Use On a Pediatric General Care Unit. Pediatr Nurs. 2012;38(2):82-7. [ Links ]

19. Mansson C, Jakobsson U, Lundqvist P. Translation and psychometric evaluation of a Swedish version of the parental stressor scale PSS: NICU. Scand J Caring Sciences 2016;30:193-201. [ Links ]

Received: December 20, 2018; Accepted: March 21, 2019

Correspondence: E. Sandra Navarro T. E-mail:

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