You are on page 1of 10



Development and psychometric testing of the Spiritual Care Inventory

Lisa Burkhart, Lee Schmidt & Nancy Hogan

Accepted for publication 5 February 2011

Correspondence to L. Burkhart: B U R K H A R T L . , S C H M I D T L . & H O G A N N . ( 2 0 1 1 ) Development and psycho-

e-mail: metric testing of the Spiritual Care Inventory instrument. Journal of Advanced
Nursing 67(11), 2463–2472. doi: 10.1111/j.1365-2648.2011.05654.x
Lisa Burkhart PhD RN
Associate Professor
Marcella Niehoff School of Nursing, Loyola
University Chicago, Illinois, USA Aim. This article is a report of the development and psychometric testing of the
Spiritual Care Inventory.
Lee Schmidt PhD RN Background. Research supporting the positive association between spirituality and
Assistant Professor, Director of PhD Program health has lead to interest in providing spiritual care in healthcare settings. Few
Marcella Niehoff School of Nursing, Loyola instruments exist that measure the provision of spiritual care.
University Chicago, Illinois, USA Method. In February/March 2007, a convenience sample of 298 adult and paedi-
atric acute care, ambulatory, home health, hospice staff and rehab nurses at two
Nancy Hogan PhD RN FAAN
hospitals (n = 248) and graduate students at a school of nursing (n = 50) completed
Distinguished Professor, Associate Dean for
Research a 48-item initial version of the Spiritual Care Inventory. In study 2 from July
Marcella Niehoff School of Nursing, Loyola through August 2007, 78 staff nurses at one hospital (n = 30) and a different cohort
University Chicago, Illinois, USA of graduate students at a school of nursing (n = 48) completed the 18-item second
version of the Spiritual Care Inventory.
Results. Exploratory factor analysis in study 1 supported a 3-factor solution
(spiritual care interventions, meaning making and faith rituals) with internal con-
sistency measures for the subscales above 0Æ80. In study 2, internal consistency
remained high.
Conclusion. Factor structures identify that spiritual care is a process of interven-
tion, meaning making and faith rituals.

Keywords: instrument development, spiritual care, Spiritual Care Inventory,


Spirituality is a complex phenomenon grounded in philos-

ophy and is defined and perceived differently depending on
Spiritual care has been and continues to be recognized as an an individual’s worldview and culture and can include
integral part of nursing care, recognized by professional existential and religious perspectives (Pesut 2006, Pesut &
nursing organizations [United Kingdom Central Council for Thorne 2007, Paley 2008, Lim & Yi 2009, Yang & Wu
Nursing, Midwifery, and Health Visiting (UKCC) 2000, 2009, Yousefi et al. 2009, Van Dierendonck et al. 2010). In
American Nurses Association (ANA) 2001, ANA 2003, the two research studies presented in this article, spirituality
2004] and healthcare organizations (Clark et al. 2003, Joint is defined as a dimension of human beings associated with the
Commission on Accreditation of Healthcare Organizations human expression of meaning, purpose and transcendence in
2003, Burkhart et al. 2008). life (Lane 1987, Reed 1987, Narayanasamy 1996, Burkhart

 2011 Blackwell Publishing Ltd 2463

L. Burkhart et al.

& Solari-Twadell 2001, Burkhardt & Nagai-Jacobson 2002, (McClain et al. 2003). Research has consistently demon-
Tanyi 2006). This differs from religiosity in that religiosity is strated that spirituality and spiritual coping is important to
associated with the rites and rituals of a faith tradition health in western societies (Hilbers et al. 2010, Motyka et al.
(Easterling et al. 2000, Gamino et al. 2000, Burkhart & 2010, Van Dierendonck et al. 2010), Asia (Lim & Yi 2009,
Solari-Twadell 2001, Tuck et al. 2001). Expressing one’s Mok et al. 2009, Shih et al. 2009, Yang & Wu 2009,
spirituality includes personal practices that promote a sense Lundberg & Kerdonfag 2010), and the Middle-east (Lazar
of connectedness with self, others and/or a power greater 2009, Yousefi et al. 2009). This suggests that spirituality is
than oneself, which may or may not include religious not only important in coping with disease, but also has the
practices (Reed 1987, Narayanasamy 1996, Burkhart & potential to improve quality of life, relieve symptoms and
Solari-Twadell 2001, Burkhardt & Nagai-Jacobson 2002, lower mortality rates.
Buck 2006, Taylor 2006, Pesut & Thorne 2007). Research has operationalized spiritual well-being using the
Spiritual care in nursing practice is a complex interpersonal Spiritual Well-being Scale (SWBS) (Ellison 1983, Paloutzian
relationship between nurse and patient intended to promote & Ellison 1991), Functional Assessment of Chronic Illness
patient spirituality (Tanyi 2006, Taylor 2006, Pesut & Therapy – Spirituality (FACIT-sp/FACIT-sp-12) (Brady et al.
Thorne 2007, Burkhart & Hogan 2008). These care encoun- 1999), and the Spiritual Perspectives Scale (Reed 1986). The
ters can affect nurses’ spirituality, which can affect nurses’ SWBS (Ellison 1983) is a 20-item tool defining spiritual well-
decision to engage in spiritual care in the future (Chung et al. being in terms of both religious (ten items) and existential
2007, Duggleby & Wright 2007, Burkhart & Hogan 2008). (ten items) perspectives. Psychometric properties have been
This relationship between the provision of spiritual care and supported in over 300 studies (Paloutzian & Ellison 1991).
the effect of that care on nurse spirituality needs to be further The FACIT instruments are a series of tools measuring
studied, as it may impact future spiritual care provision. This different aspects of health, originally developed for patients
research is hampered by lack of empirically developed, with enduring illness. The FACIT-sp-12 measures spiritual
psychometrically sound measurement tools. The Spiritual well-being and is comprised of two subscales: faith and
Care Inventory (SCI) was designed to measure spiritual care meaning/purpose (Brady et al. 1999, Peterman et al. 2002).
in nursing practice from the nurses’ perspective. The SCI The FACIT organization ( publishes
items were derived from the concepts that comprise the over 100 studies demonstrating the tool’s strong psychomet-
Spiritual Care in Nursing Practice grounded theory (Burkhart rics. The Spiritual Perspectives Scale measures participants’
& Hogan 2008). perceptions of the extent to which they hold certain spiritual
views and engage in spiritually related interactions, where
spirituality refers to an awareness of one’s inner self and a
sense of connection to a higher being, nature, others, or to
The body of spirituality research suggests that spirituality and some dimension or purpose greater than oneself. Findings
spiritual care are important aspects of health and health care. supporting criterion-related validity and discriminant validity
People who have higher levels of spiritual well-being are have been reported (Reed 1986, 1987).
physically, psychologically and socially healthier. Specifically, A few instruments exist that measure the provision of
spiritual well-being is associated with better adherence to spiritual care. Taylor (2006) published a 42-item instru-
treatment regimen (Simoni et al. 2006), and is associated ment (eight subscales) measuring spiritual interventions for
with less symptom distress (Younger et al. 2004, Manning- oncology patients and their caregiver(s), called SPIRIT.
Walsh 2005, Meraviglia 2006), less pain (Kaplar et al. 2004), This instrument was developed based on her previous
lower anxiety (Etnyre et al. 2006), better quality of life research, and the psychometric evidence of the instrument
(WHOQOL SRPB Group 2006) and lower mortality rates included content validity (0Æ88) and coefficient alphas of
(Strawbridge et al. 1997, Kaplar et al. 2004). Particularly for 0Æ76–0Æ96 (Taylor 2006). This tool was designed to
the oncology patient population, higher levels of spiritual specifically measure nursing interventions for patients at
well-being are associated with higher levels of well-being end-of-life.
(Meraviglia 2006), hope (Gibson & Parker 2003), coping The instrument described in this article, the SCI, was
(Bowie et al. 2004), social functioning (Coleman 2003), self- developed using data collected through a grounded theory
rated health (Krause 2006) and quality of life (Motyka et al. study of the provision of spiritual care by nurses (Burkhart &
2010) and less psychological stress (Mullen et al. 1993), Hogan 2008). Previous research has shown that empirically
depression (Daaleman & Kaufman 2006, Edward et al. derived instruments increase the opportunity of creating
2009), financial strain (Krause 2006) and suicidal ideation items that represent a reliable and valid representation of the

2464  2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH Development and psychometric testing of SCI

phenomenon of interest and decrease the likelihood of nursing classes, answered questions and collected completed
contaminating naturalistic data with instrument author(s) surveys without the faculty member for the course present.
biases (Hogan et al. 2001). All graduate students were currently employed and practicing
as Registered Nurses. At all three sites, 450 surveys were
distributed and a total of 298 surveys were completed,
The studies
yielding a response rate of 66%.
In the second study, a convenience sample of Registered
Nurses was obtained in two sites: a hospital and graduate
The aim of the two studies was to develop and test the nursing students in a school of nursing from July to August
psychometric properties of the SCI. 2007. Data collection procedures were similar to the first
study. None of the participants who gave data in study 1
participated in study 2. Data were obtained from an
anonymous demographic questionnaire and the 18-item
In the first study, the initial 48-items were evaluated using SCI. Study surveys were distributed to 131 with 78 surveys
exploratory factor analysis to compare the underlying con- returned (59% response rate). The samples for the two
structs in the instrument to the original grounded theory on studies are described in Table 1.
which it was based. Psychometric properties – including
construct validity and internal consistency – were assessed.
A second smaller study was conducted to assess the
psychometric evidence of the instrument in study 1. In Table 1 Sample descriptive statistics
the second study, one additional item was added to measure Initial SCI Revised SCI
the theoretical category of ‘recognition of patient cue’, and Study sample (n = 298) (n = 78)
was stated as follows: ‘I can tell when a patient is needing Mean age of respondent 40 34
spiritual care’. This second study was conducted with a new Gender of respondent
sample to measure the psychometric properties of the Female 277 77
resulting 18-item instrument. Male 7 1
No answer 14 0
Sample/participants Caucasian 216 51
African-American 15 6
For the first study, a targeted useable minimum sample size of Hispanic 14 3
240 was projected, based on the 48-item measure and a need Asian 41 12
for 5–10 usable responses per item to conduct exploratory Other 2 6
No answer 10 0
factor analysis (Polit 1996). Allowing for non-response an
estimated response rate of 40–50% was anticipated. A Catholic 161 34
convenience sample of Registered Nurses practising in an Non-Catholic Christian 88 35
urban area in the United States was obtained from three sites: Jewish 8 1
two hospitals (in two different health systems) and one school Muslim 4 0
None 21 5
of nursing from February to March 2007. In the hospitals, the
Other 7 2
PI attended staff meetings and posted flyers describing the
No answer 9 1
study. The PI visited hospital units on both 12-hour day and Highest level of nursing education
evening shifts to distribute survey booklets to all Registered Associate degree 44 8
Nurses working on that particular shift, described the study Diploma 28 4
and answered all questions. The following speciality units BSN 184 65
MSN 24 1
were visited: medical/surgical, ICU, paediatrics, obstetrics,
Doctorate 2 0
rehabilitation, skilled nursing, home health, ambulatory care, No answer 16 0
GI diagnostic testing, operating room and emergency room. Level of income
Nurses who chose to complete the anonymous survey, 25,000–49,999 23
deposited the completed survey in an envelope on the unit, 50,000–74,000 91
75,000+ 164
which was later collected by the PI. In the school of nursing,
No answer 20
the PI presented the research study to four graduate-level

 2011 Blackwell Publishing Ltd 2465

L. Burkhart et al.

(93% and 99%, respectively) and Caucasian (72.4% and

65%, respectively). The majority of participants were Cath-
Items for the SCI were initially derived from data collected to olic (54%, 44%) or non-Catholic Christian (30%, 45%). The
generate a grounded theory to conceptualize the process of majority of the participants described their highest level of
nurses who give spiritual care in a clinical setting (Burkhart education as baccalaureate (62%, 83%). Sample statistics are
& Hogan 2008). Participants in that study included 26 staff described in Table 1.
nurses who worked across the continuum of care. The In the first study, exploratory factor analysis (EFA)
resulting Burkhart/Hogan Spiritual Care in Nursing Practice procedures were used to assess the underlying dimensions
theory consisted of seven categories describing the process of of the 48 items comprising the measure. Principal axis
spiritual care in nursing practice. These theoretical categories factoring with varimax rotation was used in the analyses.
were labelled recognition of patient cue, decision to engage/ Criteria used to determine the number of factors to retain
not engage in spiritual care, spiritual care intervention, included parallel analysis (Hayton et al. 2004), examination
immediate emotional response, searching for meaning, for- of the scree plot, interpretability and the congruence between
mation of meaningful memory and spiritual well-being. the items and the original hypothesized factors. In addition,
Findings from the grounded theory study showed that for an item to be retained, the factor loading needed to meet
spiritual care is an intentional and interactive process or exceed the 0Æ40 threshold, without evidence of important
between the nurse and patient to promote the patient’s cross-loading across two or more factors. After the explor-
spiritual well-being, and that these spiritual encounters can atory factor analysis was completed, internal consistency
lead to positive or negative spiritual memories that can reliability was computed for each of the factors. A minimum
increase or decrease the nurse’s spiritual well-being (Burkhart value of 0Æ70 for the internal consistency reliability was
& Hogan 2008). Items for the SCI included at least three established, consistent with a value for measures in a newer
statements per category. The wording of items directly area of inquiry (Nunnally & Bernstein 1994).
mirrored words and phrases from nurse participants. The results of the parallel analysis suggested ten factors in
An initial set of 48 items was developed. Two experts in which real-data eigenvalues exceeded random-data eigen-
instrument and nursing theory development reviewed items values. However, the differences between the random and
for clarity and consistency. The instrument was constructed real-data eigenvalues were more pronounced for factors one
to measure the nurses’ perceived belief of the extent they give through five, with only minimal differences (0Æ04–0Æ20) noted
spiritual care. Items were scrambled to avoid systematic bias in the differences for factors six through ten. A decision was
in responses. Nurses were asked to read each statement and made to request a ten-factor solution to examine the scree
score how much s/he agreed the statement described how the plot and also get a sense of the pattern of factor coefficients
nurse gave spiritual care to patients. Items were measured for the 48 items of the measure. This ten-factor solution did
using a Likert-type scale, where 1 = strongly disagree to not converge, and the scree plot generated in this analysis
5 = strongly agree. Higher scores implied a greater perceived suggested a three-factor solution.
belief of the extent they gave spiritual care. Since the parallel analysis suggested a five-factor solution
might also be plausible, this solution was requested through
EFA. An examination of the pattern of factor coefficients
Ethical considerations
revealed eight items with no coefficient greater than the 0Æ40
For both studies, Human Subjects Review Board approval threshold and an additional two items that loaded on the fifth
was obtained from one health system and the university factor, but were not deemed conceptually related. After
associated with the school of nursing. The second hospital removing these ten items, an additional five-factor EFA
accepted the university IRB approval and gave administrative solution was generated, with a clearer factor structure pattern
approval. At the time of data collection, the PI did not teach beginning to emerge. Through examination of the factor
in the graduate programme nor served on graduate pro- loadings and the scree plot, it became clear a three-factor
gramme committees, thus minimizing any coercive influences. solution was needed.
Several iterations of three-factor solutions were obtained,
removing items that did not meet the 0Æ40 item loading
threshold after each analysis. This process continued until a
The average age of the study participants was 40 in study 1 final, three-factor solution was obtained in which items
(SD = 11, range = 22–66) and 34 in study 2 (SD = 11, possessed sufficient loading (>0Æ40) on a single factor
range = 23–60). The majority of participants were women without evidence of cross loading, along with conceptual

2466  2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH Development and psychometric testing of SCI

Table 2 Exploratory factor analysis results (n = 298)

Spiritual care Meaning
Item Mean SD interventions making Faith rituals

I am present to patients when they express 3Æ96 0Æ62 0Æ67 0Æ17 0Æ03
meaning in situations
I listen to patients when they express meaning 4Æ15 0Æ55 0Æ69 0Æ12 0Æ05
in situations
I listen to patients when they are searching 3Æ99 0Æ65 0Æ76 0Æ23 0Æ04
for meaning in situations
I give patients an opportunity to express 3Æ99 0Æ65 0Æ75 0Æ18 0Æ10
spiritual aspects of themselves
After providing spiritual care, I take time to 3Æ24 0Æ92 0Æ03 0Æ64 0Æ32
think about it during quiet time
After providing spiritual care, I think about 3Æ61 0Æ88 0Æ22 0Æ76 0Æ12
what I learned from the situation
After providing spiritual care, I think about it 3Æ53 0Æ98 0Æ24 0Æ74 0Æ28
when I am by myself
Reflection helps me find meaning after 3Æ49 0Æ90 0Æ14 0Æ72 0Æ21
providing spiritual care
Reflection helps me accept distressing 3Æ76 0Æ80 0Æ22 0Æ64 0Æ15
spiritual care experiences
I learned how to provide spiritual care by 3Æ59 0Æ89 0Æ13 0Æ57 0Æ20
reflecting on past spiritual care experiences
Providing spiritual care is one of the things 2Æ96 1Æ15 0Æ12 0Æ61 0Æ27
that keeps me in nursing
After providing spiritual care, I find inner 3Æ44 1Æ02 0Æ23 0Æ56 0Æ27
peace and understanding by talking with
friends/family outside of work
Reflection helps me grow spiritually after 3Æ54 0Æ94 0Æ20 0Æ76 0Æ27
providing spiritual care in distressing
Good memories of providing spiritual care 3Æ72 0Æ93 0Æ22 0Æ70 0Æ23
make me feel proud that I am a nurse
After providing spiritual care, I find inner 2Æ58 1Æ15 0Æ04 0Æ26 0Æ72
peace and understanding by reading
After providing spiritual care, I find support 3Æ21 1Æ10 0Æ07 0Æ44 0Æ78
through prayer
After providing spiritual care, I find inner 2Æ98 1Æ23 0Æ02 0Æ34 0Æ76
peace and understanding by attending
Subscale; mean (SD ) 16Æ06 (2Æ00) 34Æ90 (7Æ09) 8Æ75 (3Æ05)
Cronbach’s alpha internal consistency 0Æ82 0Æ92 0Æ86

Underlined value is the item assigned to the factor.

similarities among items in a factor. The final solution, in situations’. The Spiritual Care Interventions subscale
consisting of 17 items (listed in Table 2), explained 57Æ33% consisted of four items, with an internal consistency reliabil-
of the variance. Subscales were constructed and internal ity of 0Æ82. Inter-item correlations ranged from 0Æ46 to 0Æ61,
consistency estimates through Cronbach’s alpha and item with item-total correlations ranging from 0Æ60 to 0Æ68.
correlations were examined. Subscale 1 was labelled Spiritual Subscale 2 was labelled Meaning Making and was concep-
Care Interventions and was conceptually defined as inten- tually defined as nurse spiritual reflective practices and
tional nursing care interventions to promote the patient’s meaning interpretations of nurse–patient spiritual encoun-
spirituality. The items relate to being present to the patient ters. These items identify specific reflective practices and the
and facilitating the search for meaning in the situation; for effect of those practices on the nurse’s perception of the
example, ‘I am present to patients when they express meaning spiritual care encounter; for example, ‘Reflection helps me

 2011 Blackwell Publishing Ltd 2467

L. Burkhart et al.

accept distressing spiritual care experiences’. This subscale patients want spiritual care. Nurses are in a position to give
consisted of ten items, and had an internal consistency this type of care as they are the most widely accessible care
reliability of 0Æ92. Item intercorrelations ranged from 0Æ37 to provider, and the profession embraces a wholistic view of
0Æ63, with item-total correlations ranging from 0Æ62 to 0Æ79. health. The SCI gives a means by which to measure the
Subscale 3 was labelled Faith Rituals and was conceptually perceived ability of providing spiritual care and the impact of
defined as nurse faith rituals in response to nurse-patient that care on nurse spirituality. These studies demonstrate
spiritual encounters; for example, ‘After providing spiritual acceptable construct validity evidence and internal consis-
care, I find support through prayer’. This subscale consisted tency estimates for the SCI.
of three items, with an internal consistency reliability of 0Æ86, This study further develops the Spiritual Care in Nursing
inter-item correlations ranging from 0Æ63 to 0Æ74, and item- Practice theory (Burkhart & Hogan 2008). The grounded
total correlations ranging from 0Æ69 to 0Æ78. The three-factor theory category, ‘Search for Meaning’ is conceptually similar
solution, including descriptive statistics for each item, is to the subscale ‘Making Meaning’ and demonstrates consis-
detailed in Table 2. tency with the theory. In the grounded theory, ‘Faith Rituals’
In study two, the internal consistency reliability for the was a subcategory under ‘Search for Meaning’, as performing
three subscales was as follows: Spiritual Care Interventions faith rituals was one way to search for meaning. The
subscale was 0Æ87, Meaning Making was 0Æ94 and Faith psychometric analysis recognized Faith Rituals as a separate
Rituals was 0Æ88. Subscale intercorrelations between Mean- category, albeit highly correlated (0Æ76) with Meaning
ing Making and Spiritual Care Interventions was r = 0Æ51 Making. Both studies reflect a close relationship between
(P < 0Æ001), Faith Rituals and Spiritual Care Interventions these two categories. The faith and meaning subscales in the
was r = 0Æ39 (P < 0Æ001), and Meaning Making and Faith SCI are also conceptually consistent with subscales in other
Rituals was r = 0Æ76 (P < 0Æ001). In examining the addi- spirituality tools in the literature; for example, the FACIT-
tional item included to assess the theoretical category of sp-12 has faith and meaning subscales and the SWBS has
recognition of patient cue, 69% of the respondents agreed or existential well-being and religious well-being subscales
strongly agreed with the item, while 19% were neutral, and (Paloutzian & Ellison 1991, Brady et al. 1999). Also, items
12% disagreed with the item (no participant chose strongly from properties of two theory categories, Recognizing Patient
disagreed). This distribution of responses indicates that a Cue and Decision to Engage in Spiritual Encounter, were
majority of participants can recognize a cue. Based on these eliminated from the tool. While the data did not support
findings this item was deleted from the final set of instrument items reflecting these theoretical categories in the first study
items. and the additional item in the second study, heuristically it is
reasonable to assume that nurses identify a spiritual need and
are motivated to engage in an intervention. The fact that
statistical analysis did not identify a separate category is an
The sample, although sufficient in size for exploratory factor interesting finding. Evidence that the nurse recognized a need
analysis, was a convenience sample and was limited to one for spiritual care is included in the provision of a spiritual
geographical region and urban health systems in the United intervention.
States. Nurses who give spiritual care may have been more It is also interesting that two items in the Meaning Making
inclined to complete the survey. The majority of the sample subscale suggest that providing spiritual care positively
was Christian and women. In these studies men are under- affects the nurses’ perception of their profession: ‘Providing
reported, as there were only 2Æ5% and 1% of men in each spiritual care is one of the things that keeps me in nursing’
study, while there were 7% of men in nursing in the United and ‘Good memories of providing spiritual care makes me
States (Health Resources and Services Administration 2008). feel proud that I am a nurse’. This is consistent with research
Also, the sample population was younger than working demonstrating an association between providing spiritual
nurses, as the average age of the participants was 40 and 35 care and nurse job satisfaction (Lazar 2009). Future research
respectively, and the national average age of working nurses could further explore the relationship between spiritual care
from 2004 to 2008 was 45Æ5 (Health Resources and Services and nurse burnout. Providing spiritual care, meaning making
Administration 2008). Future research is needed with a more and faith rituals could buffer burnout, but this relationship
heterogeneous sample with regard to religious preference, requires additional study.
gender and age. Researchers can further study spiritual care in nursing
Research has shown that higher levels of spiritual well- practice, operationalized with the SCI, in other theoretical
being are associated with better health and that many frameworks that have a nursing care intervention component.

2468  2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH Development and psychometric testing of SCI

the SCI can measure spiritual interventions designed to

What is already known about this topic promote spiritual health/wellness and resistance to stressors
• People who have greater spiritual well-being have less (Neuman & Fawcett 2002). The SCI gives a method to
physical symptom distress, pain and lower mortality measure a dimension of care that has not historically been
rates. They have psychologically less depression, more measured.
hope and better coping, and they have better social Research comparing nurse perception of providing spiri-
functioning, less financial strain and are healthier. tual care with actual nurse spiritual care can also support the
• Nursing has historically recognized spiritual care validity of the SCI intervention subscale and give additional
conceptually, but more recently, professional nursing methods of measuring spiritual interventions. One way to
organizations have operationalized this recognition by measure actual spiritual care given is by tabulating docu-
integrating spiritual care language in policy statements, mented spiritual assessments and interventions in the health
and healthcare organizations have developed policies in record. The use of electronic health records (EHR) can
providing spiritual care. simplify this calculation if the EHR separately lists spiritual
• Many instruments exist to measure spiritual well-being, assessments and interventions as documented areas (Burkhart
but few psychometrically sound instruments exist to & Androwich 2009).
measure the provision of spiritual care.

What this paper adds The literature supports the importance of spirituality and
• The Spiritual Care Inventory is a 17-item tool with three spiritual care in promoting patient health and well-being.
subscales: spiritual nursing interventions, meaning This research has led to professional and institutional policy
making and faith rituals. changes to promote the provision of spiritual care. Future
• Analysis of the initial 48-item Spiritual Care Inventory research is needed to determine effective methods to carry out
demonstrated evidence of acceptable construct validity this policy. The SCI can help measure the effectiveness of
using exploratory factor analysis and acceptable these programme initiatives, using a pre-post test design with
internal consistency for the three subscales. nurses practicing in hospital, home health, or ambulatory
• Analysis of the resulting tool from the first study with a care settings. The studies reported in this article give
new sample of nurses supported acceptable internal acceptable psychometric evidence to use of the SCI in urban,
consistency for the three subscales. western societies.
Many nursing schools integrate spiritual care into entry-
level nursing curricula (American Association of Colleges of
Implications for practice and/or policy Nurses 2008). The literature has described examples of
• The Spiritual Care Inventory instrument gives a method curricula and courses integrating spiritual care (Narayanas-
to measure nursing spiritual care practice patterns, and amy 1999, Catanzaro & McMullen 2001, Wallace et al.
the effect of spiritual encounters on the nurse. The 2008), but there is little evidence as to the impact of those
Spiritual Care Inventory gives opportunities to study the programmes on students’ perceived ability to give spiritual
relationship between spiritual care practice patterns and care. The SCI has the potential to measure the effectiveness of
nurse burnout. spiritual care curricular content. However, this type of
• The Spiritual Care Inventory can be used to measure the research requires additional SCI psychometric testing with
effectiveness of educational initiatives designed to nursing students.
promote spiritual care. Previous research indicates that although patients and
nurses view spirituality and spiritual care to be important, the
level and perception of importance differs between cultures.
The SCI measures the process of providing spiritual care from Future research is needed to test the psychometric properties
the nurses’ perspective. Spiritual care is a nursing care process of the SCI in different cultures.
and would be compatible with theories that represent the Research has led to policy and programme initiatives to
process of providing nursing care. The SCI could measure the promote spiritual care as one strategy to promote patient
spiritual dimension of that care. For example, the SCI could health. Future research is needed to measure the effectiveness
operationalize nurse perception or action in King’s theory of of these institutional and educational policies and programme
goal attainment (King 1981). In the Neuman Systems Model, initiatives. The SCI can help further this line of research.

 2011 Blackwell Publishing Ltd 2469

L. Burkhart et al.

Chung L.Y.F., Wong F.K.Y. & Chan M.F. (2007) Relationship of

Funding nurses’ spirituality to their understanding and practice of spiritual
care. Journal of Advanced Nursing 58(2), 158–170.
This research received no specific grant from any funding
Clark P.A., Drain M. & Malone M.P. (2003) Addressing patients’
agency in the public, commercial, or not-for-profit sectors. emotional and spiritual needs. Joint Commission Journal of
Quality Improvement 29(12), 659–670.
Coleman C.L. (2003) Spirituality and sexual orientation: relationship
Conflict of interest to mental well-being and functional health status. Journal of
No conflict of interest has been declared by the authors. Advanced Nursing 43(5), 457–464.
Daaleman T.P. & Kaufman J.S. (2006) Spirituality and depressive
symptoms in primary care outpatients. Southern Medical Journal
Author contributions 99(12), 1340–1344.
Duggleby W. & Wright K. (2007) The hope of professional care-
LB, LS and NH were responsible for the study conception givers caring for persons at the end of life. Journal of Hospice and
and design. LB, LS and NH performed the data collection. Palliative Nursing 9(1), 42–49.
Easterling L.W., Gamino L.A., Sewell K.W. & Stirman L.S. (2000)
LB, LS and NH performed the data analysis. LB, LS and NH
Spiritual experience, church attendance, and bereavement. The
were responsible for the drafting of the manuscript. LB, LS Journal of Pastoral Care 54(3), 263–275.
and NH made critical revisions to the paper for important Edward K., Welch A. & Chater K. (2009) The phenomenon of
intellectual content. LS gave statistical expertise. resilience as described by adults who have experienced mental
illness. Journal of Advanced Nursing 65(3), 587–595.
Ellison C.W. (1983) Spiritual well-being: conceptualization and
References measurement. Journal of Psychological Theology 11(4), 330–
American Association of Colleges of Nurses (2008) Essentials of Etnyre A., Rauschhuber M., Gilliland I., Cook J., Mahon M.,
Baccalaureate Education for Professional Nursing Practice. Allwein D., Sethness R., Lowry J. & Jones M.E. et al. (2006)
American Association of Colleges of Nurses, Washington, DC. Cardiovascular risk among older Hispanic women: a pilot study.
American Nurses Association (2001) Code of Ethics for Nurses with AAOHN Journal 54(3), 120–128.
Interpretive Statements. American Nurses Association, Washing- Gamino L.A., Sewell K.W. & Easterling L.W. (2000) Scott and white
ton, DC. grief study – phase 2: toward an adaptive model of grief. Death
American Nurses Association (2003) Nursing’s Social Policy State- Studies 24, 633–660.
ment, 2nd edn. American Nurses Association, Washington, DC. Gibson L.M.R. & Parker V. (2003) Inner resources as predictors of
American Nurses Association (2004) Nursing Scope and Standards of psychological well-being in middle-income African American
Practice. American Nurses Association, Washington, DC. breast cancer survivors. Cancer Control 10(5), 52–58.
Bowie J.V., Sydnor K.D., Granot M. & Pargament K. (2004) Spiri- Hayton J.C., Allen D.G. & Scarpello V. (2004) Factor retention
tuality and coping among survivors of prostate cancer. Journal of decisions in exploratory factor analysis: a tutorial on parallel
Psychosocial Oncology 22(2), 41–56. analysis. Organizational Research Methods 7(2), 191–205.
Brady M.J., Peterman A.H., Fitchett G. & Cella D. (1999) The Health Resources and Services Administration (2008) National
expanded version of the functional assessment of chronic illness Sample Survey of Registered Nurses: 2008. Retrieved from http://
therapy – spiritual welling scale (FACIT-Sp-Ex): initial report of on 15 April 2010.
psychometric properties. Annals of Behavioral Medicine 21, 129. Hilbers J., Haynes A.S. & Kivikko J.G. (2010) Spirituality and
Buck H.G. (2006) Spirituality: concept analysis and model develop- health: an exploratory study of hospital patients’ perspectives.
ment. Holistic Nursing Practice 20(6), 288–292. Australian Health Review 34, 3–10.
Burkhardt M. & Nagai-Jacobson M.G. (2002) Spirituality: Living Hogan N.S., Greenfield D.A. & Schmidt L.A. (2001) The develop-
our Connectedness. Delmar, New York, NY. ment and validation of the Hogan Grief Reaction Checklist. Death
Burkhart L. & Androwich I. (2009) Measuring spiritual care with Studies 25, 1–32.
informatics. Advances in Nursing Science 32(3), 200–210. Joint Commission on Accreditation of Healthcare Organizations
Burkhart L. & Hogan N. (2008) An experiential theory of spiritual (2003) Joint Commission Resources: 2003 Comprehensive
care in nursing practice. Qualitative Health Research 18(7), 928– Accreditation Manual for Hospitals: The Official Handbook. The
938. Joint Commission, Oakbrook Terrace, IL.
Burkhart L. & Solari-Twadell P.A. (2001) Differentiating spirituality Kaplar M.E., Wachholt A.B. & O’Brien W.H. (2004) The effect of
and religiousness through a review of the nursing literature. religious and spiritual intervention on biological, psychological,
International Journal of Nursing Terminologies and Classifications and spiritual outcomes of oncology patients: a meta-analytic
12(2), 45–54. review. Journal of Psychosocial Oncology 22(1), 39–49.
Burkhart L., Solari-Twadell P.A. & Haas S. (2008) Addressing King I.M. (1981) A Theory for Nursing: Systems, Concepts, Process.
spiritual leadership: an organizational model. Journal of Nursing Delmar, Albany, NY.
Administration 38(1), 33–39. Krause N. (2006) Exploring the stress-buffering effects of church-
Catanzaro A.M. & McMullen K.A. (2001) Increasing nursing stu- based and secular social support on self-rated health in late life.
dents’ spiritual sensitivity. Nurse Educator 26(5), 221–226.

2470  2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH Development and psychometric testing of SCI

Journals of Gerontology Series B: Psychological Sciences and the functional assessment of chronic illness therapy – spiritual
Social Sciences B(1), S35–S43. well-being scale (FACIT-Sp). Annals of Behavioral Medicine 24(1),
Lane J.A. (1987) The care of the human spirit. Journal of Profes- 49–58.
sional Nursing 3, 332–337. Polit D.F. (1996) Data Analysis & Statistics for Nursing Research.
Lazar A. (2009) Spirituality and job satisfaction among female Jewish Prentice Hall, Upper Saddle River, NJ.
Israeli hospital nurses. Journal of Advanced Nursing 66(2), 334– Reed P.G. (1986) Religiousness among terminally ill and healthy
344. adults. Research in Nursing and Health 9, 35–42.
Lim J. & Yi J. (2009) The effects of religiosity, spirituality, and social Reed P. (1987) Spirituality and well-being in terminally ill hospital-
support on quality of life: a comparison between Korean American ized adults. Research in Nursing and Health 10, 335–344.
and Korean breast and gynecologic cancer survivors. Oncology Shih F., Lin J., Gau M., Chen C., Hsiao S., Shih S. & Sheu S. (2009)
Nursing Forum 36(6), 699–708. Spiritual needs of Taiwan’s older patients with terminal cancer.
Lundberg P.C. & Kerdonfag P. (2010) Spiritual care provided by Oncology Nursing Forum 36(1), E31–E38.
Thai nurses in intensive care units. Journal of Clinical Nursing 19, Simoni J.M., Frick P.A. & Huang B. (2006) A longitudinal evalua-
1121–1128. tion of a social support model of medication adherence among
Manning-Walsh J.K. (2005) Psychospiritual well-being and symptom HIV-positive men and women on antiretroviral therapy. Health
distress in women with breast cancer. Oncology Nursing Forum Psychology 25(1), 74–81.
32(3), E56–E62. Strawbridge W.J., Cohen R.D., Shema S.J. & Kaplan G.A. (1997)
McClain C.S., Rosenfeld B. & Breitbart W. (2003) Effect of spiritual Frequent attendance at religious services and mortality over
well-being on end-of-life despair in terminally-ill cancer patients. 28 years. American Journal of Public Health 87(6), 957–961.
Lancet 361, 1603–1607. Tanyi R.A. (2006) Spirituality and family nursing: spiritual assess-
Meraviglia M. (2006) Effects of spirituality in breast cancer survi- ment and interventions for families. Journal of Advanced Nursing
vors. Oncology Nursing Forum 33(1), E1–E7. 53(3), 287–294.
Mok E., Wong F. & Wong D. (2009) The meaning of spirituality and Taylor E.J. (2006) Prevalence and associated factors of spiritual
spiritual care among the Hong Kong Chinese terminally ill. Journal needs among patients with cancer and family caregivers. Oncology
of Advanced Nursing 66(2), 360–370. Nursing Forum 33(4), 729–735.
Motyka C.L., Nies M.A., Walker D. & Schim S.M. (2010) Improving Tuck I., McCain N.L. & Elswick R.K. (2001) Spirituality and psy-
the quality of life of African Americans receiving palliative care. chosocial factors in persons living with HIV. Journal of Advanced
Home Health Care Management and Practice 22(2), 96–103. Nursing 33(6), 776–783.
Mullen P.M., Smith R.M. & Hill E.W. (1993) Sense of coherence as a United Kingdom Central Council for Nursing, Midwifery, and
mediator of stress for cancer patients and spouses. Journal of Health Visiting (2000) Requirements for Pre-registration Nursing
Psychosocial Oncology 11(3), 23–46. Programs. UKCC, London, England.
Narayanasamy A. (1996) Spiritual care of chronically ill patients. Van Dierendonck D., Rodriguez-Carvajal R., Moreno-Jimenez B. &
British Journal of Nursing 5(7), 411–416. Dijkstra M.T.M. (2010) Goal integration and well-being: self-
Narayanasamy A. (1999) ASSET: a model for actioning spirituality regulation through inner researches in the Netherlands and Spain.
and spiritual care education and training in nursing. Nurse Edu- Journal of Cross-Cultural Psychology 40(5), 746–760.
cation Today 19, 274–285. Wallace M., Campbell S., Grossman S.C., Shea J.M., Lange J.W. &
Neuman B. & Fawcett J. (2002) The Newman Systems Model. Pre- Quell T.T. (2008) Integrating spirituality into undergraduate
ntice Hall, Upper Saddle River, NJ. nursing curricula. International Journal of Nursing Education
Nunnally J.C. & Bernstein I.H. (1994) Psychometric Theory, 3rd Scholarship 5(1), 1–13.
edn. McGraw-Hill, New York, NY. WHOQOL SRPB Group (2006) A cross-cultural study of spirituality,
Paley J. (2008) Spirituality and secularization: nursing and the soci- religion, and personal beliefs as components of quality of life.
ology of religion. Journal of Clinical Nursing 17(2), 175–186. Social Science & Medicine 62, 1486–1497.
Paloutzian R.F. & Ellison C.W. (1991) Manual for the Spiritual Yang K. & Wu X. (2009) Spiritual intelligence of nurses in two
Well-being Scale. Life Advance, New York, NY. Chinese social systems: a cross-sectional comparison study. Journal
Pesut B. (2006) Fundamental or foundational obligation? Proble- of Nursing Research 17(3), 189–198.
matizing the ethical call to spiritual care in nursing. Advances in Younger J.W., Piferi-Jobe R.L. & Lawler K.A. (2004) Dimensions of
Nursing Science 29(2), 125–133. forgiveness: the views of laypersons. Journal of Social and Personal
Pesut B. & Thorne S. (2007) From private to public: negotiating Relationships 21(6), 837–885.
professional and personal identities in spiritual care. Journal of Yousefi H., Abedi H.A., Yarmohammadian M.H. & Elliott D.
Advanced Nursing 58(4), 396–403. (2009) Comfort as a basic need in hospitalized patient in Iran: a
Peterman A.H., Fitchett G., Brady M., Hernandez L. & Cella D. hermeneutic phenomenology study. Journal of Advanced Nursing
(2002) Measuring spiritual well-being in people with cancer: 65(9), 1891–1898.

 2011 Blackwell Publishing Ltd 2471

L. Burkhart et al.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance
and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original
research reports and methodological and theoretical papers.

For further information, please visit JAN on the Wiley Online Library website:

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal and with an Impact Factor of 1Æ540 – ranked 9th of 70 in the 2010
Thomson Reuters Journal Citation Report (Social Science – Nursing). JAN has been in the top ten every year for a decade.
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries
worldwide (including over 6,000 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Early View: rapid online publication (with doi for referencing) for accepted articles in final form, and fully citable.
• Faster print publication than most competitor journals: as quickly as four months after acceptance, rarely longer than seven months.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).

2472  2011 Blackwell Publishing Ltd