10.

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

The Spirituality Scale

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

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

Western Connecticut State University

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

Keywords: spirituality; instrument development; holism; spiritual assessment

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

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

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

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

1
2 JOURNAL OF HOLISTIC NURSING / June 2005

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

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

CONCEPT ANALYSIS AND CONCEPTUAL

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

Spirituality and Religion

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

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

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

instrument to assess spirituality as well as the one most frequently

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

Spirituality and Meaning and Purpose

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

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

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

Spirituality and Relationships

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