Journal of Religion and Health, Vol. 44, No.

1, Spring 2005 (Ó 2005)

DOI: 10.1007/s10943-004-1145-6

A Review of Spiritual
and Religious Measures in
Nursing Research Journals:
1995–1999
SHELLEY DEAN KILPATRICK, ANDREW J. WEAVER,
MICHAEL E. MCCULLOUGH, CHRISTINA PUCHALSKI,
DAVID B. LARSON, JUDITH C. HAYS, CAROL J. FARRAN,
and KEVIN J. FLANNELLY
ABSTRACT: Background: A series of systematic reviews has revealed relatively high levels of
interest in religion and spirituality in different nursing specialties, but not in general nursing
research journals. Purpose: To identify the extent to which spirituality and religiousness were
measured in all quantitative and qualitative research articles published in Research in Nursing
and Health, Nursing Research, Advances in Nursing Science (ANS), and Image: The Journal of
Nursing Scholarship from 1995 to 1999. Methods: A full-text search was conducted of ANS and
Image using the Ovid search system. Nursing Research and Research in Nursing and Health were
hand searched for spiritual/religious measures. Characteristics of selected studies, the measures
taken, and their uses were coded for data analysis. Results: A total of 564 research studies were
identified, of which 67 (11.9%) included at least one measure of spirituality or religiousness. A
significant difference was found between the percentage of qualitative and quantitative studies
that contained measures of these concepts. Of the 119 qualitative studies, 23 (19.3%) contained a
measure of religion or spirituality, compared to 44 of the 445 (9.9%) quantitative studies. Nominal
indicators of religious affiliation were the most commonly used measures in the quantitative
studies and measures of religion and spirituality were rarely used in the analyses. Although only a
few quantitative or qualitative studies intended to focus on religion or spirituality, these themes
often emerged spontaneously in the qualitative research. Conclusions: Research in Nursing and
Health, Advances in Nursing Science, Nursing Research, and Image: The Journal of Nursing
Scholarship all published research measuring spirituality and religiousness during the time-
period studied. The rate at which spirituality and religion appeared in these nursing research
articles is substantially higher than that found in most fields outside of nursing. Even more

Shelley Dean Kilpatrick, Ph.D., UCLA/RAND Center for Adolescent Health Promotion, Andrew
J. Weaver, M.Th., Ph.D., The HealthCare Chaplaincy, Michael E. McCullough, Ph.D., Interna-
tional Center for the Integration of Spirituality and Health and University of Miami, Christina
Puchalski, M.D., M.S., International Center for the Integration of Spirituality and Health and
George Washington University, David B. Larson, M.D., M.S., MSPH, International Center for the
Integration of Spirituality and Health, Judith C. Hays, Ph.D., R.N., Duke University Medical
Center, Carol J. Farran, DNSc., R.N., FAAN, Rush-Presbyterian-St. Luke’s Medical Center, Kevin
J. Flannelly, Ph.D., The HealthCare Chaplaincy.
Correspondence to Kevin J. Flannelly, Ph.D., Associate Director of Research, 307 East 60th
Street, New York, New York 10022, Kflannelly@healthcarechaplaincy.org.
This project was supported by grants from the Nathan Cummings Foundation, New York, NY
and the Fetzer Institute, Kalamazoo, MI.

55 Ó 2005 Blanton-Peale Institute

56 Journal of Religion and Health

frequent inclusion of spiritual and religious variables and richer measures of spirituality and
religiousness would help to increase the available scientific information on the role of spirituality
and religion in nursing care.

KEY WORDS: nursing; religion; review; spirituality.

Introduction

Americans report that spirituality and religion are important factors in

their lives in national surveys. According to a recent Gallup Poll, approxi-
mately 86% of Americans believe in God, 8% believe in a universal spirit,
45% attended church or religious services in the last week, approximately
66% belong to a local religious congregation, and 90% state that religion is
‘‘very important’’ or ‘‘fairly important’’ in their lives (Newport, 1999). In
addition, 81% of American adults identify with a formal religious tradition
and 75% of Americans identified their outlook on life as religious or
somewhat religious (Kosmin et al., 2001). Although 60% of Americans
identify themselves as religious or both religious and spiritual, 30% of
Americans state explicitly that they are spiritual, but not religious (New-
port, 1999).
Nursing has long recognized the importance of spirituality in the lives of
people seeking health care. Reed described spirituality as an integral and
basic part of nursing, saying: ‘‘Spirituality, in its broadest sense, is a part of
the ontologic foundation of nursing; it is regarded as a basic characteristic of
humanness important in human health and well-being’’ (Reed, 1992, p. 349).
Studies indicate that nurses from a broad variety of specialties incorporate
spirituality in their personal life, being active in their religion and regularly
attending religious services (Boutell and Bozett, 1987). Nurses also make
religion part of their professional life, as Taylor, Amenta, and Highfield (1995)
found. In their study of oncology nurses they found that 83% prayed privately
for their patients. Moreover, nurses make the vast majority of patient refer-
rals to hospital chaplains. In one study, 88% of all referrals to chaplains came
from nurses, compared to 8% from physicians, and 4% from social workers
(Koenig et al., 1991).
The nursing literature has discussed spirituality and religion in various
contexts, including chronic illness (O’Neill and Kenny, 1998; Rehm, 1999),
women’s health (Lauver, 2000), HIV disease (Flannelly and Inouye, 2001;
Woodard and Richard, 2001), and nursing education concerning the spiritual
care of patients and clients (Narayanasamy, 1999a). Nurses have also ad-
dressed the professional, ethical, and legal implications of spirituality for the
nursing field (Wright, 1998); and the application of spirituality to nursing
Shelley Dean Kilpatrick et al. 57

perspectives or paradigms (Narayanasamy, 1999b; Reed, 1992). The concept of

spirituality in the nursing literature is broader than the concept of religion.
Although religion is considered by some to be a manifestation of spirituality,
the term spirituality need not include religious beliefs or practices (Bays,
2001; Emblen, 1992; Sumner, 1998). As described in the Multidimensional
Measurement of Religiousness/Spirituality for Use in Health Research (John
E. Fetzer Institute, 1999, p. 2), religiousness has specific behavioral, social,
doctrinal, and denominational characteristics that are shared by a group. By
contrast, spirituality is concerned with the transcendent, addressing ultimate
questions about life’s meaning, with the assumption that there is more to life
than what we see or understand.
A series of systematic reviews has revealed relatively high levels of interest
in religion and spirituality in different nursing specialties, as evidenced by the
percentage of research studies that measure some aspect of these concepts. A
study by Weaver et al. (1998c) found that 10% of the quantitative studies
published between 1991 and 1995 in Archives of Psychiatric Nursing, Journal
of Psychosocial Nursing, and Issues in Mental Health Nursing contained a
measure of religion/spirituality. By comparison, similar reviews of the psy-
chological and psychiatric literature found that less than 3% contained reli-
gious or spiritual measures (Craigie et al., 1990; Weaver et al., 1998b; Weaver
et al., 1998a). Similarly, Sherrill et al. (1993), found that 3.6% of quantitative
studies in gerontological medicine measured religion/spirituality, whereas
Weaver et al. (2001) found the percentage to be 6.8% among quantitative
studies in two gerontological nursing journals. The percentage was somewhat
higher among qualitative articles (10.7%) in gerontological nursing. A review
of three oncology nursing journals found that qualitative studies were sig-
nificantly more likely to measure religion or spirituality (27%) than quanti-
tative studies (14%).
To obtain a more general picture of the scope of interest in religion and
spirituality in nursing research we decided to conduct a systematic review
of four general research journals in nursing, as opposed to specialty jour-
nals. The four journals we chose were Research in Nursing and Health,
Advances in Nursing Science, Nursing Research, and Image: The Journal of
Nursing Scholarship. The first three journals were selected because they
are the three most prominent non-specialty research journals in nursing,
according to McCloskey and Swanson (1982) and Swanson, McCloskey and
Bodensteiner (1991). While these authors did not list Image as a research
journal in their classification and description of 92 to 100 journals, a fairly
large percentage of its articles are research and it covers a broad range of
topics.
The time-frame covered by the study was 1995 through 1999. Based on the
findings of previous research (Weaver et al., 2001), we hypothesized that
qualitative studies would be more likely to contain a measure of religion or
spirituality than quantitative studies.
58 Journal of Religion and Health

Method

Identification of articles
We attempted to identify all research studies that included one or more
measures of the participants’ spirituality or religiousness published between
1995 through 1999 in Research in Nursing and Health, Advances in Nursing
Science, Nursing Research, and Image: The Journal of Nursing Scholarship,
from 1995 to 1999. Research articles were defined as those containing a
description of research methods and results. There was greater than 98%
agreement between two Ph.D. trained researchers on whether an article was
research or not, with some disagreements arising when there was no specific
headings for these sections. Research articles were classified as being either
qualitative or quantitative research. Research reports that presented
descriptive or inferential statistics were classified as quantitative, with
greater than 95% agreement on the classification of studies as being either
qualitative or quantitative. To be consistent with previous systematic reviews
of this nature in nursing (Flannelly et al. 2002; Weaver et al., 2001; Weaver
et al., 1998c) and medical journals (McCullough et al., 2002 (unpublished
manuscript); Puchalski et al., In Press) three articles that used qualitative
methodology were classified as quantitative because they presented statistical
findings.
Full text of two of the journals, Advances in Nursing Science and Image –
The Journal of Nursing Scholarship were searched electronically using Ovid
(Ovid Technologies, 2000) to identify articles that measured religion and
spirituality. The other two journals were searched manually, because they
were not available in full text on Ovid. Search terms related to spirituality
included the terms spirit*, transcendence, existential, meaning of life, hope,
prayer, and meditation. Search terms related to religion included the terms
religio*, faith, church, and particular religious groups (Jewish, Muslim,
Christian, etc.).

Characteristics of articles and measures

For each article that included a measure of spirituality or religion, we re-
corded the primary topic of the article and the number of citations concerning
spirituality and religion. Each measure of spirituality or religion was cate-
gorized as belonging to one of eleven mutually exclusive categories as devel-
oped previously (McCullough et al., 2002 (unpublished manuscript);
Puchalski et al., In Press): (a) religious affiliation (e.g., Catholic, Protestant,
Jewish, Muslim, other, none); (b) public religious or spiritual involvement
(e.g., church attendance, social support from membership in a religious or
spiritual group); (c) private religious or spiritual involvement (e.g., prayer/
meditation, scripture reading, religious coping); (d) spiritual well-being,
meaning, or transcendence; (e) importance of one’s spirituality or religion
(e.g., ratings of strength or importance of faith); (f) specific spiritual or
Shelley Dean Kilpatrick et al. 59

religious beliefs (e.g., belief in life after death); (g) the relevance of one’s
spirituality or religion to suffering, hope, or despair; (h) spiritual/religious
staffing (e.g., inclusion of chaplain on care team); (i) services provided (e.g.,
screening patients for spiritual distress); (j) the use of multi-item measures of
spirituality or religiousness (i.e., measures which contain items representing
two or more categories from a–h above); or (k) other. In the case of qualitative
articles, the religious/spiritual themes were coded. If no themes were pre-
sented, we classified and recorded specific quotes or behavioral descriptions in
their respective categories. If more than one item (quote or description) fell
into the same category they were treated as a single instance of that category.
Finally, the presentations of spirituality or religion in the quantitative
articles were classified into five categories with respect to how they were used.
The five categories were whether spirituality/religion were used to: (1) de-
scribe the sample, (2) describe religious/spiritual services; or examined the
association of spirituality/religion with (3) physical health, (4) mental health
(including self-reported coping and quality of life), or (5) attitudes. Two au-
thors coded all article and measure characteristics independently. The two
judges resolved coding discrepancies through discussion until consensus was
reached. Initial agreement rates for all study variables ranged from 71% to
100% (M ¼ 94.5%, Mdn ¼ 96%, Mode ¼ 100%).

Results

Identification of articles
A total of 845 articles were published in the four journals between 1995 and
1999, excluding editorials, commentaries, and regularly published columns.
Of the 845 articles published during this time-frame, two-thirds (n ¼ 564)
were research studies. More than three quarters of the research articles were
classified as quantitative studies (n ¼ 445) and the remainder were classified
as qualitative (n ¼ 119).
As hypothesized, qualitative studies were significantly more likely to con-
tain a measure of religion or spirituality than quantitative studies,
v2(1) ¼ 13.15, p < 0.001. Table 1 shows the percentage of quantitative and
qualitative studies that measured religion and/or spirituality. The percentage
of articles that included measures of spirituality or religion did not differ
significantly across years or among journals.

Characteristics of the articles

Although a total of 67 research articles measured religion or spirituality,
these concepts were the focus of only five of the quantitative and three of the
qualitative studies. Not surprisingly, studies that focused on some aspect of
religion or spirituality were significantly more likely to cite published litera-
ture related to these concepts, v2(1) ¼ 7.76, p < 0.01. The quantitative studies
60 Journal of Religion and Health

TABLE 1

Number and Percentage of Studies that Measured Religion and/or

Spirituality out of 445 Quantitative and 119 Qualitative Studies
Published Between 1995–1999

Quantitative Qualitative
Kind of Measure n % n %

Religion 27 6.1 10 8.4

Spirituality 11 2.5 1 0.8
Religion and Spirituality 6 1.3 12 10.1
Total 44 9.9 23 19.3

in our sample of 67 research articles were somewhat more likely to cite prior
articles on religion or spirituality (22 of 44) than were qualitative studies (8 of
23), but this difference was not statistically significant.
Table 2 presents the number of studies that addressed different topics.
Coping with illness was the most common topic addressed by quantitative
studies, followed by research on health status and risk factors for different
populations and health problems. These two topics accounted for almost 60%
of all articles in our sample of 44 quantitative studies. Coping was also the
most common topic addressed by the 23 qualitative studies.

TABLE 2

Number and Percentage of Spiritual and Religious Measure Types

Reported in Quantitative and Qualitative Studies

Quantitative Qualitative
Topic n % n %

Coping and Support 14 31.8 6 26.1

Health Status and Risk Factors 12 27.3 – –
Health Promotion and Awareness – – 5 21.7
Healthcare Decision Making – – 5 21.7
Scale Development 6 13.6 – –
Healthcare Attitudes – – 3 13.0
Intervention Tested 4 9.1 – –
Quality of Life 3 6.8 – –
Other 5 11.4 4 17.4
All Studies 44 100.0 23 100.0
Shelley Dean Kilpatrick et al. 61

Characteristics of spirituality/religion measures

There were 61 separate uses of spirituality/religion in the 44 quantitative
studies (see Table 3). The majority of articles (80%) contained only a single use
or measure of spirituality or religiousness, and in 15 of these the only measure
was religious affiliation. Religious affiliation was the most commonly reported
measure, followed by descriptions of private spiritual or religious practice, and
descriptions of spiritual well-being or meaning.
Among the qualitative studies, religion or spirituality was presented in the
form of emergent themes, descriptions of behaviors, or verbatim quotes from
study participants. Of the 53 uses of spiritual/religious terms that were
counted, the most common ones fell into the category of spiritual well-being,
meaning, and transcendence. Most of the items included in the other category
represent expressions about a general belief in God or reliance on faith and
religion.

Use of measures in quantitative studies

As seen in Table 4, the measures were used primarily to describe the reli-
giousness/spirituality of the sample. In addition to religious affiliation, these

TABLE 3

Different Kinds of Spiritual and Religious Measures Reported in

Quantitative and Qualitative Studies as a Percentage of All Measures
Reported in Each Type of Study

Quantitative Qualitative
Type of Measure n % n %

Religious Affiliation 20 32.8 2 3.8

Private Religious Involvement 11 18.0 4 7.5
Spiritual Well-being, Meaning, Transcendence 9 14.8 17 32.1
Importance of Spiritual/Religious Belief 4 6.6 4 7.5
Public Religious Involvement 2 3.3 3 5.7
Multi-item Measures of Spirituality/Religiousness 2 3.3 – –
Spiritual/ Religious Services Provided 1 1.6 1 1.9
Suffering, Hope, Despair 1 1.6 8 15.1
Specific Spiritual or Religious Belief 1 1.6 5 9.4
Other 10 16.4 9 17.0
Total Number of Measures Reported 61 100.0 53 100.0

Note: The total of measure uses (n = 61) is larger than the actual number of
measures recorded (n = 44) because the categories in the table are not
mutually exclusive. Each study measure could have multiple uses.
62 Journal of Religion and Health

TABLE 4

Uses of the 61 Measures of Spirituality and Religion in the 44

Quantitative Studies in the Sample

Use of Measure Instances1 %

Description of spirituality/religiousness of the sample 42 68.9

Associations with mental health/coping/adjustment/ 17 27.9
quality of life
Associations with physical health 9 14.8
Associations with attitudes 4 6.6
Description of spiritual/religious services provided 3 4.9
1
The total is larger than the actual number of measures recorded (n = 61)
because the categories in the table are not mutually exclusive: 61 was the
denominator used in calculating the percentages.

included measures of religious involvement and activity, and measures of

religiosity and spirituality. Measures of spirituality/religion were commonly
used in association with measures of mental health and, less commonly, in
association with measures of physical health. Six of the measures (10%) were
not used as measures in and of themselves, but were single items or subscales on
longer instruments. While many types of measures were used to examine an
association with mental health, coping, or adjustment, only four types of mea-
sures associated spirituality or religion with physical health—private religious
involvement, spiritual well-being/meaning/transcendence, multi-item mea-
sures of general spirituality/religiousness, and suffering/hope/despair. Because
the categories were not mutually exclusive and measures could have multiple
uses in the articles reviewed, the numbers total to more than 61 measure uses.

Discussion

Our systematic review of all research published between 1995 and 1999 in
Research in Nursing and Health, Advances in Nursing Science, Nursing Re-
search, and Image: The Journal of Nursing Scholarship, identified 67 articles
(11.9% of all research articles) that contained a measure of participants’
spirituality or religiousness. This is somewhat higher than found in a recent
systematic review of research published in gerontological nursing journals
(7.7%) (Weaver et al., 2001), but lower than that found in oncology nursing
journals (16.9%) (Flannelly et al., 2002).
When quantitative and qualitative studies were analyzed separately we
found that 9.9% of quantitative studies and 19.3% of qualitative studies
Shelley Dean Kilpatrick et al. 63

contained at least one measure of religion or spirituality. The latter percent-

age is higher than that found in gerontological nursing (10.7%), but lower than
that found in oncology nursing (27.3%). The percentage of quantitative studies
in our sample that measured some aspect of religion or spirituality (9.9%) is
higher than that found in the palliative care literature (6.3%) (Puchalski
et al., In Press), and other health-care journals outside of nursing, including
primary care (1%), psychiatry (1%), and gerontology (4%) (Weaver et al.,
1998c). The greater inclusion of spiritual and religious measurement in the
nursing literature probably stems from the convergence of a number of factors,
including nursing’s recognition of patient’s spirituality, the tradition of
holistic care in nursing, and its historical roots. Florence Nightingale con-
sidered spirituality an intrinsic part of human nature and thought spirituality
and science were compatible ways of viewing the world (Macrae, 1995;
Widerquest, 1992). The results of our review are enlightening and encourag-
ing because they demonstrate that spiritual and religious variables are still
being addressed in the leading research journals of the nursing field with a
frequency that suggests that nurses continue to be at the forefront of research
in spirituality and health.
However, most of the measures served only a descriptive purpose and typ-
ically were not included in the analyses. This suggests that spirituality or
religion is not yet completely integrated into the purpose and background of
many research studies, even when measures of these concepts are taken. This
is further evidenced by the fact that only four of the quantitative studies had
explicit hypotheses related to spirituality or religion (Crigger, 1996; Miller and
Champion, 1996; Sherman, 1996; Sinclair et al., 1998). On the other hand,
many studies that included religion and spirituality did make reference to the
existing literature on these topics, especially when they were the focus of
study.
Of the six articles that were concerned primarily with the development of
measures, three articles focused on measures that included spirituality or
religion as an important component. These measures included the Spiritual
Care Scale (Carrigg and Weber, 1997), the Sense of Belonging Instrument
(Hagerty and Patusky, 1995), and the Functional Performance Inventory
(Leidy, 1999). With the publication of these scale development studies, future
researchers will have tools to use which incorporate spirituality as an integral
part of measurement. Other sources for high quality, multi-item measurement
of spirituality and religion are also available in the published literature (John
E. Fetzer Institute, 1999; Hill and Hood, 1999).
The studies that included measures of spirituality and religion covered a
range of nursing topics. For both the quantitative and qualitative studies,
however, the most common topic was coping with illness, with 31.8% and
26.1%, respectively, of the quantitative and qualitative research focusing on
this topic. Aside from this common ground, the qualitative and quantitative
studies tended to look at different research areas. While a quarter of the
64 Journal of Religion and Health

quantitative studies examined health status and risk factors, more than four
out of ten qualitative studies looked at health promotion and awareness or
making healthcare decisions. Thus, it appears, the two methodological ap-
proaches are making their own distinct contributions to nursing research in
terms of topics as well as content.
The emergence of religious and spiritual themes in qualitative studies on a
broad range of topics not explicitly related to these concepts is particularly
fascinating. It provides striking evidence of the importance of religion and
spirituality in the lives of patients and their caregivers. Although one would
expect these themes to appear in studies investigating severe or life-threat-
ening diseases they emerged in many different contexts and they were a
common part of patients’ and caregivers’ stories about their everyday expe-
riences.
The results suggest several ideas for future research with respect to religion
and spirituality. Our understanding of individual’s overall health could be
expanded if that person’s spiritual or religious background were examined
more fully. To this end, including multi-item measures that capture various
aspects of religion and spirituality, rather than just religious affiliation would
strengthen future quantitative studies. Our understanding of the link be-
tween spiritual health and physical, mental, and social health also would be
improved if studies included spiritual measures along with outcome measures
of physical, mental, and social health (e.g., pain, coping with terminal illness,
the role of the community in preventative healthcare, etc.). Nursing science
has long heralded the critical role played by spirituality and religion in the
personal health and well-being of individuals. Nurse investigators are stra-
tegically placed to design and conduct studies that will enhance our under-
standing in this area.

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