June 2005 Articles of the Month
Delaney, C. "The Spirituality Scale: development and psychometric testing of a holistic instrument to assess the human spiritual dimension." Journal of Holistic Nursing 23, no. 2 (June 2005): 145-167.
Galek, K., Flannelly, K. J., Vane, A. and Galek, R. M. "Assessing a patient's spiritual needs: a comprehensive instrument." Holistic Nursing Practice 19, no. 2 (March-April 2005): 62-69. [A PDF of this article has been made available on-line to the Research Network by the principal author.] --Note: Related Items of Interest IV (below).
COMMENTS AND SUMMARIES: The possibility of using research measures as clinical assessments of spirituality has been mentioned in regard to a number of our Articles-of-the-Month, but here are two measures designed as broadly applicable clinical assessments that chaplains might also think of using for research. Both of these measures are reported in nursing journals, work with conceptualizations of spirituality from the health care literature, and attempt to capture multiple dimensions of patients’ spirituality with mid-sized questionnaires of 23 and 29 items (--shorter and simpler than, for instance, Fetzer’s 38-item Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research, which was addressed in the January 2004 Article-of-the-Month, but longer and more construct-complex than the measures of spiritual well-being considered in February 2004, March 2004, and December 2004). The assessment items and their organizing concepts are presented below in two tables to allow for some comparison.
In "The Spirituality Scale," Colleen Delaney presents a 23-item "holistic assessment instrument that focuses on the beliefs, intuitions, lifestyle choices, practices, and rituals that represent the human spiritual dimension," and "...that can be used to guide spiritual interventions" [p. 146]. The working definition of spirituality for this instrument is:
...a multidimensional phenomenon that is universally experienced, in part socially constructed, and individually developed throughout the life span. Spirituality encompasses a personal, interpersonal, and transpersonal context consisting of four interrelated domains: (a) higher power or universal intelligence--a belief in a higher power or universal intelligence that may or may not include formal religious practices; (b) self-discovery--the spiritual journey begins with inner reflection and a search for meaning and purpose; ...(c) relationships--an integral connection to others based on a deep respect and reverence for life and is known and experienced within relationships...; and (d) eco-awareness--an integral connection to nature based on a deep respect and reverence for the environment and a belief that the Earth is sacred. [p. 152]This conceptualization of spirituality is rooted in the perspective of holistic nursing and recent health care literature, and it is marked by a sense of broad inclusiveness that is a salient nursing concern in the context of work with diverse populations.
The SS is in many ways practical, not only in its attempt at inclusiveness for spiritually diverse groups, but in terms of being user-friendly in employing language at a sixth-to-ninth grade reading level and a format of six-point Likert response scales, allowing patients to complete the questionnaire within ten minutes. "The SS can also be used as a semistructured interview to open up dialogue to allow personalized spiritual assessment, care, and evaluation of interventional outcomes" [p. 162]. The author goes on to address how the instrument may be used by nursing educators [pp. 160-161], nursing administrators [p. 163], and nursing researchers [pp. 163-164], in addition to its clinical applications [pp. 161-163 and passim].
What really makes Delaney's article stand out, though, is her fine attention to the psychometric characteristics of the instrument. Using a convenience sample of 226 patients with chronic illness, recruited from "two midsized hospitals, a multibranched extended care and assisted living agency, and a community wellness organization" [p. 153], the author collected data for the instrument's factorial structure, internal consistency, and two-week test-retest reliability (with a subgroup of 30 volunteers). A five-member panel of experts also checked for content validity. The data collection procedure is clearly lined out [p. 154], and results are presented in detail both in the narrative and in several tables [pp. 154-158]. Possible limitations related to generalizability from the convenience sample and to any halo effect are considered [p. 159], but overall the psychometric testing makes a good case for the validity and reliability of the SS.
This is an important article for chaplain researchers, and the multidimensional measure deserves attention. The Eco-Awareness subscale--which the author suggests is a special contribution of the SS--may be worth particular discussion within pastoral care circles. Note that the domain of "higher power or universal intelligence" was eventually collapsed into Eco-Awareness [--see the explanation on p. 157]. Chaplains might also want to discuss the suggestion of how the SS could be scored to indicate spiritual distress [p. 162].
Below are the 23 items in the Spirituality Scale, ordered here by factor. [Note, however, that the last item--"At times, I feel at one with the universe"--does not appear in the table of items on p. 158].
In the second of our featured articles this month, "Assessing a patient's spiritual needs: a comprehensive instrument," Kathleen Galek and her colleagues, in association with The HealthCare Chaplaincy in New York, offer a 29-item survey of patients' spiritual needs, "comprehensively" based on seven constructs suggested by the heath care literature published 1990-2004. The constructs and their constituent items are presented below:
The measure was designed to be "inclusive of both traditional religion and noninstitutionally based spirituality, for evaluating the spiritual needs of hospitalized patients" and "to be brief enough to include in clinical or epidemiological surveys, allowing for an extensive investigation of various indices" [p. 62]. To that end, the authors systematically identified 22 articles from the health care literature (1990-2004) that "enumerated the specific needs of hospitalized patients, including 12 qualitative studies, 7 quantitative studies, and 3 theoretical articles" [p.65] --17 of these were from nursing journals (which are listed in the bibliography) and the remainder from medical journals. From these articles, 339 descriptors of patients' spiritual needs were found, and "these...descriptors yielded 9 broad categories...that were independently derived by content analysis regardless of how they had been categorized in the original studies" [p. 65]. "However, two of the nine categories--those of 'control' [i.e., having the right to make decisions about one's own life; staying as independent as possible; desiring things to stay the same] and 'other' [i.e., needing comfort; needing to cope with physical pain]--were eventually eliminated "because they did not capture a spiritual dimension" [p. 65]. The categories/constructs are nicely summarized in a table [p. 65] and in separate paragraph descriptions [pp. 66-68] that tie them directly to the literature.
The instrument allows patients to respond in two ways to its 29 items: first, by choosing "yes" or "no" as to whether they had each need; and second, by indicating "How important it was to you," with the options of "slightly," "moderately," "very," and "extremely" [see p. 67]. The method of this two-part response format is not discussed, but it would seem to help patients think about each item in more detail than single responses would normally encourage. At least, this reader found it so in taking the survey, and perhaps this could be one of the qualities of the instrument to be explored in future psychometric analysis.
The authors observe from their literature review that "88% of spiritual needs articles were published after 1990" [p. 64], which raises a question of how much a literature base which has come so recently to this subject may be a good guide to basic constructs of spirituality in relation to heath and health care. Certainly articles like this one serve not only to present a practical application of spirituality constructs currently in the literature but also to help bring a reflective refinement to the general consideration of constructs by scholars in the field.
The authors have also developed variations on the measure. One version not only elicits information about needs but also about feelings (e.g., depressed, resentful, isolated, helpless, grief, guilt, and anxiety) during the hospital stay. A copy of this latter version of the instrument is available to the Network and may be obtained from the Network Convener by e-mailing firstname.lastname@example.org. For other versions, and for general inquiries about the instrument, e-mail Kathleen Galek at email@example.com.
Suggestions for the Use of the Articles for Discussion in CPE:
Both articles are clear presentations that CPE students should be able to read easily, though Delaney’s discussion of psychometric analysis may be too technical for students new to research (--such students should be encouraged not to let themselves become bogged down in pp. 154-159 but to get a sense of the serious demands of instrument validation). Delaney’s article would be a good introduction to the steps of instrument development, and students might discuss how much of their own spiritual assessment technique could be challenged by the rigor of a scientific mindset. General discussion could also focus on how these measures attempt to transcend "limits" of traditional religious language and particular religious perspectives, and whether students feel comfortable with this trend in the field of spirituality & health research. The sections of the article by Galek, et al. on Spiritual Typologies and on Spirituality in Relation to Traditional Religion may be of special interest to new students. Discussion could also point up how these measures are largely shaped by the need to work across many lines of diversity in a hospital population, and how they may so reflect some of the concerns facing chaplains in the practice of interfaith pastoral care.
Related Items of Interest:
I. Chaplains may also be interested in the following articles on spiritual assessment from the perspective of Social Work, by David R. Hodge, PhD. Much of the material in these articles is also covered in his book, Spiritual Assessment: A Handbook for Helping Professionals (Botsford, CT: North American Association of Christians in Social Work, 2003), 121pp., available from Amazon.com. Most of these assessments are fairly elaborate and graphic (e.g., based on such models as genograms) and so may not be easily used for research data collection, but they are quite thought provoking on the topic of spiritual assessment methodology. Note, though, his six-item Intrinsic Spirituality Scale, which may be well suited for research.
II. The June 2005 issue of Science and Theology News (ISSN: 1530-6410) contains the article, "Researchers: spiritual scales need to measure up," by Julia C. Keller, pp. 8-9. This brief overview of issues regarding spirituality measures notes several recent instruments (e.g., the DSES, R-COPE, and SpREUK) and presents the 10-item Santa Clara Strength of Religious Faith Questionnaire.
III. Also note Hill, P. C. and Hood, R. W., eds., Measures of Religiosity (Birmingham: Religious Education Press, 1999). This collection of 126 scales--some now quite old--is rooted in the psychology of religion and geared to research. Each scale is presented in detail, complete with validity and reliability information. The book is available from such sources as Amazon.com at $99, but it is also widely available at research libraries.
IV. [ADDED 7/11/07]: See the Spring 2007 Newsletter (§5) regarding the following article refining the instrument put forward in our featured article by Galek, et al.:
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