10.

1177/0898010105276180
JOURNALOF
Delaney / THEHOLISTIC
SPIRITUALITY
NURSING
SCALE
/ June 2005

The Spirituality Scale

Development and Psychometric
Testing of a Holistic Instrument to
Assess the Human Spiritual Dimension

Colleen Delaney, Ph.D., R.N., H.N.C.

Western Connecticut State University

The purpose of this study was to develop, refine, and evaluate the psychometric char-
acteristics of the Spirituality Scale (SS). The SS is a holistic instrument that attempts
to measure the beliefs, intuitions, lifestyle choices, practices, and rituals representa-
tive of the human spiritual dimension and is designed to guide spiritual interven-
tions. A researcher-developed instrument was designed to assess spirituality from a
holistic perspective. Items were generated to measure four conceptualized domains of
spirituality. The SS was completed by 240 adults with chronic illness. Psychometric
analysis of the SS provided strong evidence of the reliability and validity of the instru-
ment. Three factors of spirituality that supported the theoretical framework were
identified: Self-Discovery, Relationships, and Eco-Awareness. These findings can as-
sist in facilitating the inclusion of spirituality in health care and have the potential to
provide a transforming vision for nursing care and a vehicle to evoking optimal
patient outcomes.

Keywords: spirituality; instrument development; holism; spiritual assessment

Spirituality, an important and integral aspect of nursing care, is sup-

ported in nursing history and theory and validated in research and
practice (Taylor, 2002). In addition, the provision of spiritual care is
incorporated in the American Nurses Association (1985) Code for
Nurses and required by the Joint Commission on Accreditation for
Healthcare Organizations (JCAHO) (2000). Spirituality is also
referred to as the cornerstone of holistic nursing, and spiritual care is

JOURNAL OF HOLISTIC NURSING, Vol. 23 No. 1, March 2005 1-

DOI: 10.1177/0898010105276180
© 2005 American Holistic Nurses’ Association

1
2 JOURNAL OF HOLISTIC NURSING / June 2005

considered an ethical obligation (Burkhardt & Nagai-Jacobson, 2005).

Moreover, health care consumers rank spiritual care as a high priority
during hospitalization, yet research indicates that patients’ spiritual
needs are not adequately addressed in most health care institutions,
often resulting in poor health outcomes (Koening, 2003).
Mounting evidence of the relationship between spirituality and
positive health outcomes has brought spirituality to the borders of
mainstream health care and indicates its reunion with science. Taken
together, these points suggest that spiritual assessment is an impor-
tant consideration for health care professionals and underscores the
significance of developing effective instruments to assess the human
dimension of spirituality.
The Spirituality Scale (SS) (Delaney, 2003) is a holistic assessment
instrument that focuses on the beliefs, intuitions, lifestyle choices,
practices, and rituals that represent the human spiritual dimension.
The SS is designed to assess the essence of spirituality in a format that
can be used to guide spiritual interventions. The purpose of this study
was to develop, refine, and evaluate the psychometric characteristics
of the SS. Applications to nursing education, clinical practice, admin-
istration, and research are presented.

CONCEPT ANALYSIS AND CONCEPTUAL

FRAMEWORK OF SPIRITUALITY

The development of the SS followed the process outlined in classi-

cal test theory (Crocker & Algina, 1986). Prerequisite steps of review
of literature, concept analysis, and the construction of theoretical defi-
nitions and a conceptual map preceded instrument development. Lit-
erature presented in this review is categorized into four broad sec-
tions that illustrate the historical evolution of the construct, represent
the four subscales of the SS, and present selected spirituality assess-
ment instruments consistent with each subscale.

Spirituality and Religion

“Spirituality is an abstract concept with many facets. It is the core of
a person’s being involving one’s relationship with God or a higher
power” (Mauk & Schmidt, 2004, p. 15). The metaphysical aspect of
human spirituality has been linked to religion since antiquity and is
Delaney / THE SPIRITUALITY SCALE 3

manifested in numerous religions based on a faith in the existence of

God or Creator or Allah or Supreme Being or the like (Taylor, 2002).
Nursing finds its foundation in religious and charitable organiza-
tions. In the beginning of the 20th century, nurses openly acknowl-
edged and followed religious or spiritual precepts. However, by the
mid-20th century spirituality became less visible as a component of
nursing as technological advances served to devalue interventions
that could not be easily controlled or quantified (Taylor, 2002). Nurs-
ing’s recent increased interest in providing holistic care to clients has
encouraged diverse approaches to the conceptualization and under-
standing of human spirituality. These diverse but interrelated
approaches have shed light on the different facets of spirituality and
are not without some controversy (Carson, 1989). This controversy
revolves around religion. As Burkhardt and Nagai-Jacobson (2002)
pointed out, spirituality is often described in terms of religious beliefs
and practices, and many people consider they or others are not spiri-
tual if they do not attend religious services or believe in God. How-
ever, most holistic nurses agree that one of the major difficulties in
defining spirituality is its perceived synonymous relationship with
religion. Numerous authors have discussed the distinction between
spirituality and religion (Burkhardt & Nagai-Jacobson, 2002; Dyson,
Cobb, & Forman, 1997; McSherry & Draper, 1998; Narayanasamy,
1999; Pargament, 1997). The description of religion as a narrow term
pertaining to an organized system of beliefs in contrast to spirituality,
which is a much broader multidimensional term, is well documented
in the holistic nursing literature. Though contemporary holistic nurs-
ing theory provides a distinction between spirituality and formal reli-
gion, the integral relationship between the two is acknowledged.
Many people express and experience their spirituality within the con-
text of religion. However, many find their spirituality only partially
nurtured or not at all within the construct of religion (Burkhardt &
Nagai-Jacobson, 2002).
Several instruments to assess spirituality have focused on the reli-
gious aspects of spirituality. The Spiritual Well-Being Scale (SWB)
(Paloutzian & Ellison, 1982) is an instrument that represents the meta-
physical and religious aspect of spirituality. The SWB is a 20-item,
self-administered scale with two dimensions: religion and existential.
Psychometric testing by the authors provided evidence of its reliabil-
ity and validity. Though numerous instruments have been developed
over the past 20 years, an extensive review of the literature by the
researcher revealed that the SWB Scale remains the most widely used
4 JOURNAL OF HOLISTIC NURSING / June 2005

instrument to assess spirituality as well as the one most frequently

referred to and applied in studies examining spirituality.
However, in spite of its popularity, the SWB Scale has several limi-
tations. Fulton and Carson (1995) stated that in spite of its wide use,
the scale reflects a Judeo-Christian bias. In addition, Scott and Agresti
(1998) noted that there are several methodological flaws in the instru-
ment that suggest possible threats to content and construct validity
and reliability of the instrument: (a) In the initial exploratory factor
analysis the authors conceptualized three domains; however, only
two had eigenvalues greater than 1.0, yet the items on Factor III were
retained with the rationale of theoretical consistency; (b) the use of an
orthogonal factor rotation rather than an oblique rotation when the
subscales are clearly correlated; and (c) the probability of a ceiling
effect that skews data in certain populations. The oblique rotation
method is used when subscales are assumed to be correlated as
opposed to the orthogonal method, which assumes subscales are
unrelated (George & Mallery, 2001). Spirituality is a complex phe-
nomenon with interrelating dimensions, thus, the oblique method
would be most appropriately applied. The SWB extends the assess-
ment of spirituality to include existential spirituality, which is rooted
in the search for meaning and purpose in life.
Several other instruments emphasize the religious aspect of spiri-
tuality. Examples include the Spiritual Assessment Scale (O’Brien,
1982) and the Index of Core Spiritual Experiences (Kass, Freidman,
Lererman, Zuttermeister, & Benson, 1991). The major limitations of
these instruments are the exclusive focus on religious beliefs and
experiences.

Spirituality and Meaning and Purpose

“The spiritual unconscious is what links us to the transcendent and
in these spiritual depths, the great existential choices are made”
(Frankl, 1959/2000, p. 40). The existential aspect of spirituality, as the
search for meaning and purpose, is well documented in the literature.
Frankl (1959/2000) was among the first to equate spirituality to man’s
search for meaning. In Frankl’s early work, he identified the search
for meaningfulness in life as central to the human experience. Frankl
stated that the major problem of society in the 21st century was a lack
of meaning in life that he termed the “existential vacuum” (p. 34).
Recognizing that meaning and purpose in life is a core element of
spirituality is inherent in holistic nursing theory. Within our spiritual
Delaney / THE SPIRITUALITY SCALE 5

core, a discovery of life’s meaning, our purpose in being, and inner

resources occur (Burkhardt & Najai-Jacobson, 2002). The discovery of
meaning and purpose in life is facilitated through self-care, a central
tenant in holistic nursing theory. Self-care leads to self-awareness and
self-knowledge, which in turn leads to growth, healing, and transfor-
mation (Lauterbach & Becker, 1996). Furthermore, holistic nurses rec-
ognize the importance of educating their patients in self-care activi-
ties to find meaning in the human health experience.
The Spiritual Perspective Scale (SPS) (Reed, 1987) is an instrument
that represents the existential aspect of spirituality. The SPS is a 10-
item instrument with a 6-point Likert-type scale that can also be used
as a semistructured interview. The SPS was tested on 300 adults who
were either terminally ill and hospitalized, nonterminally ill and hos-
pitalized, or healthy nonhospitalized patients. Reliability, estimated
by Cronbach’s alpha, was rated consistently above .90 with very little
redundancy among the items. Construct validity, according to Reed
(1987), was supported, as women in the study who reported having a
religious background scored higher on the SPS. Descriptive data gen-
erated by open-ended questions with hospitalized adults also indi-
cated the validity of the SPS for participants in the study. The instru-
ment demonstrates versatility, as it can be used with many methods.
However, psychometric testing was not performed to demonstrate
the factor structure of the SPS.
There are other instruments that emphasize the existential aspect
of spirituality. Examples include the JAREL (initials of the four
authors) Spiritual Well-Being Scale (Hunglemann, Kenkel-Rossi,
Klassen, & Stollenwerk, 1996) and the Spiritual Involvement and
Beliefs Scale (SIBS) (Hatch, Burg, Naberhaus, & Hellnich, 1998).
Though these instruments are broader than those presented in the
previous section, the assessment of spirituality is limited to religious
and existential aspects of spirituality.

Spirituality and Relationships

“Spirituality is all about relationships—God to human, human to
human, human to nature, human to cosmic reality” (Caleb, 2003). The
relational aspect of spirituality is demonstrated through science. The
pure science of physics demonstrates the evolution of the philosophy
of science and the emergent worldview of holism that served to link
science and spirituality through relationships. A mechanistic
worldview that separated body, mind, and spirit and viewed human
6 JOURNAL OF HOLISTIC NURSING / June 2005

beings as a machine that could be understood by breaking down and

examining the parts began to change in the 19th century with Ein-
stein’s theories of special relativity and general relativity. His famous
E = mc2 revolutionized the world and resulted in an understanding
that matter and energy are different manifestations of the same thing
(Kaku, 1995). Einstein believed in classical physics and universal laws
but his work brought him to quantum physics in a world determined
by probability and uncertainty. Quantum physics reveals the interde-
pendent, relational, and spiritual aspect of life (Capra, 1996). The new
physics perspective of complexity provides a foundation for a clearer
understanding of the universe as holistic, complex, and dynamic; a
universe that is interdependent and relational, where the observer
cannot be separated from the observed and the future is open and
always changing (Ray, 1994).
Though nursing finds its roots in the holistic philosophy of Night-
ingale, nursing’s journey parallels physics in that it utilizes a particu-
lar-deterministic approach evolving to an integrative-interactive
model and then to a unitary transformative model (Newman, Sime, &
Corcoran-Perry, 1991). The unitary transformative nursing models
such as Rogers (1991), Watson (1985), and Newman (1998) are consis-
tent with modern physics. Inherent in quantum physics and unitary
transformative nursing theories is a spiritual realm, a reality not
explained through empirical knowledge alone.
The Spiritual Assessment Scale (SAS) (Howden, 1992) is an instru-
ment that represents the relational aspect of spirituality. The SAS is a
28-item instrument based on a conceptualization of spirituality as a
phenomenon with four critical attributes: purpose and meaning in
life, inner resources, unifying interconnectedness, and transcen-
dence. Psychometric testing resulted in a high internal consistency for
the total instrument (alpha = .9164) and an acceptable level for each of
the four subscales (alphas = .7824-.810) providing evidence of reliabil-
ity. Principal component analysis (PCA) revealed a six-factor solution
that was collapsed into four subscales explaining 64% of the variance.
This instrument has both strength and weakness. Its broader defini-
tion of spirituality from a holistic perspective gives the SAS a concep-
tual advantage over most instruments. However, the author does not
offer suggestions on applications to clinical settings, or how scoring
of the instrument could guide spiritual care (Burkhardt & Nagai-
Jacobson, 2002). In addition, PCA instead of principal factor analysis
(PFA) is used to evaluate the factorial structure of the instrument.
According to instrument development experts, PFA is the
Delaney / THE SPIRITUALITY SCALE 7

appropriate method for evaluating instruments as it reflects the

unique variance items contribute to the overall scale rather than the
shared variance reflected in PCA, thereby adding error (Tabachnick &
Fidell, 1996).

Spirituality and Ecology

The earth does not belong to man, man belongs to the earth. This we
know. All things are connected. Whatever befalls the earth befalls the
sons of the earth. Man did not weave the web of life, he is merely a
strand in it. Whatever he does to the web, he does to himself. (Chief Se-
attle, 2000, p. 21)

The concept of eco-awareness is present in many disciplines and be-

lief systems such as theology, Native American philosophy, quantum
physics, deep ecology, ecofeminism, and holistic philosophy. The
connection among these belief systems is a fundamental assumption
of holism and an awareness of the connection between spirituality
and a concern for the environment. These advances require a para-
digm shift from a nonliving, ready-made universe to a living universe
in process (Berry, 1993) and bring into focus the integral connection
between humans and the environment. As Berry (1993) states,
environmental health is primary, human health is derived.
Within nursing, the concept of environment has been central to
nursing’s paradigm since Florence Nightingale, along with person,
health, and nursing. However, there has been little emphasis on this
concept in nursing literature or in nursing curricula (Quinn, 1992),
and the ecological aspect of spirituality is rarely addressed in assess-
ment instruments. Howden’s (1992) SAS is the only quantitative
instrument that includes this aspect of spirituality.
In summary, from a review of the literature it was apparent that the
construct of spirituality has evolved from a term synonymous with
religion, moving to an association with a search for meaning and pur-
pose, extending to the inclusion of relationships and recognition of
holism, and finally to a connection to the environment and cosmos.
Several spirituality assessment instruments are currently available.
All of the instruments available demonstrate strengths and provide a
valuable contribution to the body of knowledge related to spirituality.
However, none was found that simultaneously incorporated a holis-
tic approach in a format that could be used as an assessment in care
planning with applicability to education, research, administration,
8 JOURNAL OF HOLISTIC NURSING / June 2005

and practice. It was with this multifaceted objective in mind that the
development of the SS was undertaken.

Conceptual Framework
Following concept analysis and synthesis and a period of reflec-
tion, theoretical definitions and a conceptual map were constructed
that served as an organizing framework from which to generate the
items of the SS. Spirituality was defined in this study as a multidimen-
sional 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 intelli-
gence 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. This process of self-discovery leads
to growth, healing, and transformation; (c) relationships—an integral
connection to others based on a deep respect and reverence for life
and is known and experienced within relationships (Burkhardt &
Nagai-Jacobson, 2005); and (d) eco-awareness—an integral connec-
tion to nature based on a deep respect and reverence for the environ-
ment and a belief that the Earth is sacred. Eco-awareness is rooted in
deep ecology and the Gaia hypothesis (Lovelock, 2000). Within the
framework of the Gaia hypothesis, the Earth is viewed as a living
organism. MacGillis (1994) extends this notion by postulating that
humans are the Earth consciously evolved to experience itself. The
four domains of spirituality are conceptualized as interconnected and
interdependent within a dynamic relationship. Personal and demo-
graphic variables such as age, gender, culture and ethnicity, and per-
sonal characteristics are theorized to be major influences in the devel-
opment and manifestation of human spirituality.

PSYCHOMETRIC TESTING

Method
A methodological research design was used in this study. The
study was approved by the university and research committees at all
Delaney / THE SPIRITUALITY SCALE 9

data collection sites. Procedures for the protection of human partici-

pants were approved and followed.

Research Questions
This study examined the following research questions:

(a) What is the content validity of the SS?

(b) What is the factorial structure of the SS?
(c) What is the alpha internal consistency of the SS?
(d) What is the 2-week test-retest reliability of the SS?

Sample and Setting

The target population selected for this study was adults with
chronic illness. More than 90 million Americans live with chronic ill-
nesses (Centers for Disease Control and Prevention, 2002). Chronic
disease is a formidable problem that has significant physical, psycho-
logical, social, economic, and spiritual effects on the individual as
well as substantial aggregate effects. According to the World Health
Organization, chronic diseases have one or more of the following
characteristics: They are permanent, leave residual disability, are
caused by nonreversible pathological alteration, require special train-
ing of the patient for rehabilitation, or may be expected to require a
long period of supervision, observation, or care (Timmreck, 1986).
An accessible sample of 240 patients with chronic illness who met
the stated criteria were selected to participate in the study from a
group of patients in inpatient, outpatient, and community settings
within the five organizations participating in the study. Inclusion cri-
teria for the study were (a) age 21 years or older, (b) diagnosis of a
chronic disease, (c) ability to read and write in English, and (d) will-
ingness to participate. Two midsized hospitals, a multibranch
extended care and assisted living agency, and a community wellness
organization participated in the study. Participants were recruited in
inpatient settings on medical, surgical, and critical care units. Several
outpatient settings including cardiac rehabilitation, pulmonary reha-
bilitation, oncology, and medical therapies were used to recruit eligi-
ble participants. Community settings included screening events,
wellness fairs, and educational programs. The use of multiple sites
allowed for a diverse sample of patients with varied chronic illnesses
10 JOURNAL OF HOLISTIC NURSING / June 2005

and ages who were experiencing different stages of chronic illness

progression.
A minimum sample size of 190 was needed, as there should be at
least 5 times as many participants as items or at least 200 respondents,
whichever is greater (Crocker & Algina, 1986; Ferketich & Muller,
1990; Nunnally & Bernstein, 1994). Scales that were missing
responses to items were not included in factor analysis to maintain
the integrity of the data (Tabachnick & Fidell, 1996). Of the 240 indi-
viduals who participated in the study, 226 individuals submitted
completed scales and were included in psychometric testing.
The majority of the 226 participants were female (63%) with ages
ranging from 21-91 years and a mean age of 64 years (SD = 18.83).
Most were Caucasian (83.2%), married (54.5%), and had earned an
associate degree (44.6%). In terms of religion, 15 denominations were
represented. However, the sample was predominately Catholic
(49.4%) and described themselves as moderately religious (65.2%)
and moderately spiritual (48.7%). Table 1 displays selected back-
ground characteristics of the study participants.

Data Collection Procedure

Data collection occurred over approximately a 3-month period
from April to June 2003. Eligible participants were recruited in person
by the researcher or assistant in inpatient, outpatient, and community
settings in Connecticut. Data collection at all sites was conducted ac-
cording to established research protocol and following outline:

(1) Researcher introduced and rapport established.

(2) Purpose and rationale for study explained to potential participants.
(3) Study instructions reviewed with participants and written instruc-
tions distributed.
(4) SS administered.
(5) Demographic questionnaire administered.
(6) Discussion and/or comments regarding SS invited.

RESULTS

Content validity. The findings of this study support the content

validity of the SS. An expert panel of five members with expertise in
the area of spirituality rated each item on the scale in regard to clarity
and relevance, using a 4-point Likert-type scale. Three doctoral
Delaney / THE SPIRITUALITY SCALE 11

TABLE 1
Selected Background Characteristics of the Study
Participants Completing the Spirituality Scale (N = 240)

Variable n %

Age 240
M 64.0
SD 18.83
Gender 240
Female 152 63.3
Male 88 36.7
Education 224
Grade school 13 5.4
High school 3 1.3
Associate 107 44.6
Bachelor’s 72 30
Master’s 17 7.1
Doctorate 1 0.4
Other 11 4.6
Religion 240
Baptist 8 4.1
Roman Catholic 116 49.4
Christian 9 4.7
Congregational 2 0.8
Eastern Orthodox 1 0.4
Episcopal 19 7.8
Hebrew 1 0.4
Hindu 1 0.4
Jehovah 1 0.4
Jewish 2 0.8
Lutheran 6 2.9
Methodist 8 4.1
Pentecostal 1 0.4
Protestant 64 27.3
Spiritualist 1 0.4
Chronic illness 230
Allergies 1 0.4
Anemia 2 0.8
Anxiety 1 0.4
Arthritis 38 14.2
Arrhythmia 1 0.4
Asthma 9 3.7
Atrial fibrillation 2 0.8
Blood dyscrasia 2 0.8
Coronary artery disease 9 3.4
Cancer 8 2.1
Cardiac 49 20.5
(continued)
12 JOURNAL OF HOLISTIC NURSING / June 2005

TABLE 1 (continued)

Variable n %

CHF 14 5.8
Cholestrolemia 1 0.4
Chiron’s disease 2 0.8
Colitis 2 0.8
COPD 11 6.2
Depression 1 0.4
Diabetes 33 12.8
Emphysema 1 0.4
GI 1 0.4
Heart block 2 0.8
Hypertension 22 9.2
Kidney 1 0.4
Lyme disease 1 0.4
Lymphoma 1 0.4
Lupus 1 0.4
Migraine 1 0.4
Multiple sclerosis 1 0.4
Osteoporosis 2 0.8
Pagets 1 0.4
Pain 3 1.2
Pancreatitis 1 0.4
Stroke 1 0.4
Thyroid 2 0.8%
Ulcerative colitis 1 0.4
NOTE: CHF = congestive heart failure; COPD = chronic obstructive pulmonary dis-
ease; GI = gastrointestinal.

nursing students with expertise in spirituality, one nursing professor-

minister, and one Dominican sister recognized as a national expert in
ecospirituality were invited to participate in the study. Wording of
items was deemed clear by all panel members. An acceptable level of
interrater agreement of .7 was achieved for relevance in 36 out of 38
items. The two items with questionable relevance were retained for
further psychometric evaluation and later eliminated due to low fac-
tor loadings supporting the judgment of the panel.
The content validity index (Grant & Davis, 1997) was then calcu-
lated by determining the number of items that received either a rele-
vance rating of 3 or 4 on the 4-point Likert-type scale divided by the
number of total items and expressed as a percentage. In this study, as
36 of the 38 items were judged to represent the construct of
Delaney / THE SPIRITUALITY SCALE 13

spirituality, the content validity index of the SS was .94, or 94%. An a

priori level of 90% for domain placement was established based on
recommendations by DeVellis (2003). All items on the SS attained an
acceptable level of agreement.
Descriptive feedback from the expert panel led to the rewording of
two items. These changes reflected actions relative to spiritual rela-
tionships in one item and introduced the concept of faith as it relates
to a belief in a higher power or universal intelligence in the other item.

Item analysis. Three methods were used to assess individual items

and associations, among them, item means, item variance, and item-
to-item correlations. Analyses of an item’s performance indicated
that the full range of responses was used to respond to each item with
means slightly higher than the theoretical midpoint of 3 on the 1- to 6-
point Likert-type scale. In addition, a moderate variance (0.99 to 3.9)
was demonstrated, and a moderate to strong correlation (.25 to .75)
among items was found.

Factor structure. PFA using an oblique rotation method provided

evidence to support the factorial structure of the SS. Statistical
assumptions related to performing a factor analysis were examined
and satisfied. The goals of factor analysis are the achievement of a
parsimonious simple structure, factors with eigenvalues greater than
1.0 that are in agreement with visualization of the scree plot, and a
meaningful solution that explains greater than 50% of the variance
(Cattell, 1966; Thurstone, 1989; Tinsley & Tinsley, 1987). Following
initial factor analysis, 15 items were dropped due to loadings at or
below the recommended criteria of .40, leaving a 23-item scale. Using
PFA, three factors emerged with eigenvalues greater than 1.0 that
were visually consistent with the scree plot. The final solution consist-
ing of 23 items supported the conceptual framework and explained
57% of the variance. The pattern matrix of the final three factors and
their respective loadings are noted on Table 2.
It is interesting to note that two factors, Eco-Awareness and Higher
Power/Universal Intelligence, collapsed into Factor III. This was not
surprising, as both factors reflected the transpersonal aspect of spiri-
tuality. Though the solution was not exactly as originally proposed,
the researcher and expert panel concurred that it remained conceptu-
ally congruent. As eco-awareness was described as the highest level
of spirituality, encompassing an awareness of the interconnectedness
of all life, the factor label Eco-Awareness was retained, and the factor
14
TABLE 2
Principal Factor Analysis With Oblimin Rotation: Spirituality Scale Final Items and Loadings

Item Factor I Factor II Factor III

1. I find meaning in my life experiences. .64

2. I have a sense of purpose. .73
3. I am happy about the person I have become. .58
4. I see the sacredness of everyday life. .42
17. I believe that all living creatures deserve respect. .48
20. I value maintaining and nurturing my relationships with others. .76
22. I believe that nature should be respected. .67
25. I am able to receive love from others. .42
34. I strive to correct the excesses in my own lifestyle patterns/practices. .43
35. I respect the diversity of people. .72
8. I meditate to gain access to my inner spirit. .74
9. I live in harmony with nature. .59
10. I believe there is a connection between all things that I cannot see but can sense. .74
11. My life is a process of becoming. .62
16. I believe in a Higher Power/Universal Intelligence. .82
19. The earth is sacred. .42
21. I use silence to get in touch with myself. .52
23. I have a relationship with a Higher Power/Universal Intelligence. .97
24. My spirituality gives me inner strength. .84
28. My faith in a Higher Power/Universal Intelligence helps me cope with challenges in my life. .72
36. Prayer is an integral part of my spiritual nature. .78
38. I often take time to assess my life choices as a way of living my spirituality. .68
Delaney / THE SPIRITUALITY SCALE 15

label Higher Power/Universal Intelligence was eliminated. Figure 1

presents the revised conceptual map. This finding brought to the
researcher’s awareness that the main challenge in developing an
instrument to assess spirituality is attempting to separate that which
is whole and interconnected.

Internal reliability. Findings support the reliability of the SS. Inter-

nal consistency of the SS was evaluated using Cronbach’s (1988) coef-
ficient alpha. The Cronbach’s alpha coefficient for the total SS was .94.
Coefficients of the three subscales ranged from .81 to .94.

Test-retest reliability. The temporal stability of the SS was supported.

A second measure of the reliability of the SS was evaluated with test-
retest reliability. Asubgroup of 30 volunteer participants representing
each of the five data collection sites retook the SS within 2 weeks of
completing the initial scale. Statistical analysis of the SS using
Pearson’s coefficient r revealed that the SS demonstrated an accept-
able level of .84, signifying its stability over a short time period and
reliability when measured in a 2-point data collection format. Table 3
presents a summary of the psychometric characteristics of the SS.

LIMITATIONS

Two factors may be considered limitations in this study. First, the

use of a convenience sample limits generalizability of the study. The
recruitment of a diverse group of participants was attempted to
obtain the widest possible variation in levels of spirituality. Second,
the halo effect was also a possible limitation of the study due to the
use of a self-report format (Polit & Beck, 2004). Though an assumption
of the study was that participants would report their perceptions
truthfully, there is a possibility that responses reflected socially desir-
able responses rather than actual responses.

NURSING IMPLICATIONS

The findings of this study provide evidence of the reliability and

validity of the SS and support the feasibility of using the instrument in
diverse patient settings. The positive results of this study, coupled
with national survey findings that demonstrate that patients rank
16 JOURNAL OF HOLISTIC NURSING / June 2005

Personal and
Demographic
Characteristics

Self-Discovery Spirituality Relationships

Spirituality

Eco-Awareness

Figure 1: Conceptual Map of the Spirituality Scale

spiritual assessment and care as a priority and when these needs are
unmet there is a negative correlation with health outcomes, support
further exploration of spiritual assessment instruments such as the SS
in nursing education, practice, administration, and research. The fol-
lowing suggestions for applications are based on the conceptual
framework and theoretical scoring used in the study, consistent with
interventions described by JCAHO (Clark, Drain, & Malone, 2003)
and Press Ganey (Koenig, 2003), and can serve as an entry point to
integrate spirituality in various health care settings.

Recommendations for Nursing Education

It was apparent from a review of the literature and the researcher’s
professional experiences that many nurses are uncomfortable with
integrating spirituality in practice due to inadequate academic prepa-
ration. In addition, during the course of data collection several pa-
tients indicated an interest in spirituality and spiritual care, and the
instrument generated numerous discussions with the participants,
Delaney / THE SPIRITUALITY SCALE 17

TABLE 3
Summary of Psychometric Characteristics
of the 23-Item Spirituality Scale (SS)

Subscale No. of Items Validity Eigenvalues Reliability

Self-Discovery 4 1.01 .8113

Relationships 6 1.84 .8409
Eco-Awareness 13 10.33 .9439
Total SS 23 Cumulative
variance 57% .9450

providing further validation of the need for the inclusion of spiritual-

ity in all levels of nursing education. The SS can be applied as a learn-
ing tool in several ways to address the lack of spiritual education in
nursing.

· The conceptual model of the SS can be used as a theoretical model that

represents the emerging understanding of spirituality as it is currently
defined in the literature.
· The SS can be used as an example of a broadened perspective of this defi-
nition through the inclusion of eco-awareness.
· The SS can be administered to students and faculty to assess their own
level of spirituality and to increase spiritual awareness in nursing
students.
· The SS can be used as a vehicle to assess spirituality as part of nursing
care planning.

Nursing students who have been educated in the emerging under-

standing of spirituality as it is manifested in adult populations are
more likely to integrate spiritual assessment and care in both their
own lives and their practice settings than nurses who are not edu-
cated in spirituality.

Recommendations for Clinical Practice

Although there is general agreement in nursing that greater atten-
tion should be paid to the spiritual dimension of persons in the con-
text of nursing care, many nurses express discomfort in spiritual
assessment and care (Brush & Daly, 2000). Perceived barriers to pro-
viding spiritual care include lack of time, ability, knowledge, and
18 JOURNAL OF HOLISTIC NURSING / June 2005

preparation for spiritual caregiving, nursing care that emphasizes the

biologic, and confusion about what spiritual care is (Taylor, 2002). In
addition, organizational and professional barriers exist, as many
institutions do not place value on spiritual assessment and care, and it
is viewed by some nurses as outside the scope of nursing practice
(Van Dover & Bacon, 2001). Caring for the spirit in nursing practice
has the potential to improve patient outcomes both physiologically
and psychologically.
The SS is presented in a user-friendly format, with the majority of
items assessed to be written at a sixth- to ninth-grade reading level,
and can be completed within 10 minutes by most patient populations;
thus, the instrument lends itself to applications in diverse patient
populations and settings. The SS can also be used as a semistructured
interview to open up dialogue to allow personalized spiritual assess-
ment, care, and evaluation of interventional outcomes.
Possible scoring on the 23-item SS ranged from 23-138. Scores indi-
cate how important or to what extent the phenomenon of spirituality
is to, or manifested by, the person. It was theorized that scores be-
tween 23-60 indicated very low levels of spirituality and corre-
sponded with the nursing diagnosis of spiritual distress, 61-91 indi-
cated low spirituality and corresponded with the nursing diagnosis
of potential for spiritual distress, 92-117 indicated moderate spiritual-
ity and was also considered as a possible potential for spiritual dis-
tress, and 118-138 suggested high levels of spirituality or spiritual
wellness. Spiritual nursing care can be guided by both overall score
and scores on the three subscales. Nurses in practice can evaluate the
total score and provide generalized spiritual care and further evalu-
ate scores on the three subscales to plan intervention specific to a cer-
tain domain of spirituality. Thus, different approaches can be utilized
to individualize spiritual care. They include:

· Individuals who score low in the Self-Discovery domain can be assisted

to explore meaning and purpose in life by incorporating self-care activi-
ties to facilitate self-knowledge and self-awareness through practices
such as reflection, journaling, listening to music, meditation, and relax-
ation techniques to enhance the existential aspect of their spirituality.
· Individuals who score low in the Relationships aspect of spirituality can
be assisted in building healthy relationships through counseling and
participation in support groups, including family and friends in health
care, and experiencing energy therapies that bring into consciousness
the interconnectedness of life, such as Reiki. In addition, simple gestures
Delaney / THE SPIRITUALITY SCALE 19

of caring through active listening, presence, and empathy can nurture

feelings of connection to others.
· The Eco-Awareness aspect of spirituality can be nurtured for individu-
als to appreciate the sacredness of the environment by creating caring
environments, encouraging the individual to spend time in natural set-
tings that are perceived as healing by the individual and to surround
themselves with nature through plants and art work, and participating
in activities that facilitate an understanding of the transpersonal nature
of spirituality. The religious aspect inherent in this domain can be facili-
tated through prayer, meditation, and referrals to clergy when
indicated.

Recommendations for Nursing Administration

For the provision of spiritual assessment and care to reach its full
potential, nursing administrators must support it. It was difficult to
assess the level of administrative support for spirituality due to a lack
of literature pertaining to spirituality in nursing administration and
management literature. This is an important deficit, as attending to
patients’ spiritual needs is no longer an option for health care organi-
zations that are undergoing JCAHO (2000) evaluation. JCAHO rec-
ommends that health care organizations acknowledge patients’
rights to spiritual care and provide for these needs through pastoral
care and a diversity of services by certified individuals.
Nurse administrators can apply the SS in multiple ways:

· the development of policies that create a context for spiritual assessment

and care using the SS;
· the inclusion of spiritual care in nurse competencies and job descriptions
based on the framework of the SS;
· the creation of task force and unit committees that conduct research us-
ing the SS;
· the tracking of the levels of spirituality in diverse patient populations;
· the monitoring of spiritual outcomes using the SS on admission and re-
peated at discharge.

Recommendations for Nursing Research

Research applications of the SS are numerous and varied. They
include
20 JOURNAL OF HOLISTIC NURSING / June 2005

· further examination of the reliability and validity of the SS with diverse

healthy, chronic, acute, and terminal illness patient populations;
· exploration of the feasibility of using the SS with adolescents and an
adapted version for children;
· concurrent validity of the SS with other instruments to assess spirituality
in adult populations;
· research examining demographic differences regarding age, gender,
ethnicity, socioeconomic status, education, and religion relative to the
SS;
· multivariate studies using the SS to determine relationships and allow
predictions of spirituality with several patient outcome indicators such
as the relationship between spirituality and healing, quality of life, and
coping;
· confirmatory factor analysis research of the three domains of the SS and
item response theory analysis for further analysis of construct validity.

CONCLUSION

This study presented a holistic instrument to assess spirituality

and established the initial reliability and validity of the SS with a
chronic illness population. Findings suggest that the SS is a reliable
and valid instrument worthy of further exploration. The SS uniquely
contributes to the emerging understanding of spirituality by intro-
ducing the subscale of Eco-Awareness and offers several conceptual,
methodological, and pragmatic advantages over other current instru-
ments. These findings can assist in facilitating the inclusion of spiritu-
ality in health care and have the potential to provide a transforming
vision for nursing care and a vehicle to evoke optimal patient
outcomes.

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Colleen Delaney, R.N., Ph.D., A.H.N.-C. is an assistant professor of nursing at

Western Connecticut State University and the co-coordinator of the Western at Wa-
terbury R.N.-B.S.N. Program. She teaches community health and holistic nursing
with B.S.N. and R.N.-B.S.N. students. She is certified in advanced holistic nursing
and is a Reiki master/teacher. Her research interests include spirituality and
innovations in nursing education.