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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Berry, T. (1993). Into the future. In F. Hall (Ed.), Earth and spirit: The spiritual di-
mension of the environmental crisis. New York: Continuum.
Brush, B. L., & Daly, P. R. (2000). Assessing spirituality in primary care: Is there
time? Clinical Excellence in Nursing Practice, 4(2), 67-71.
Burkhardt, M. A., & Nagai-Jacobson, M.G. (2002). Spirituality: Living our
connectedness. Albany, NY: Delmar.