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