Introduction
The relationship between spirituality and health has received increasing attention in recent decades; the rate of publications on spirituality and health has increased by 688% in the last 30 years (Weaver et al.
2006). Many people experience spirituality as an important support aid while trying to cope with a chronic or life-threatening disease (Stefanek et al.
2005). Spiritual orientation has been shown to be associated with mental health (Sawatzky et al.
2005; Koenig et al.
2001), and the association is especially strong among people facing stressful life events, such as a chronic or life-threatening disease (Smith et al.
2003).
Nevertheless, knowledge on the role of spirituality among patients and their caregivers is in a certain sense limited, as most research is based on measures of religiosity rather than spirituality (George et al.
2000; Baldacchino and Draper
2001). These religiosity questionnaires rely predominantly on monotheistic terminology inquiring, for example, about belief in God or experience of God (MacDonald et al.
1995). Such questionnaires may be appropriate in North America, where 83% of inhabitants consider God as highly important in their lives (Carballo
1999). However, this type of questionnaire would not be suitable in Western Europe, where only 49% of inhabitants consider God as highly important (Carballo
1999). Although many people in Western Europe do not believe in God, many people are interested in spirituality. Books and magazines on personal growth, meaning and spirituality, for example, are popular, as are publications on practicing meditation or yoga. Both religious and non-religious people could have spiritual experiences in which they are, for example, deeply touched by nature or cultural expression. A questionnaire that transcends specific beliefs, therefore, is a prerequisite for quantifying the importance of spirituality among people who adhere to a religion or no religion at all. In this review, we focussed on spirituality questionnaires that are suitable for a broad group of people with various religious or secular backgrounds and questionnaires that consider spirituality as a universal human experience.
Spirituality scales have already been described in several reviews (e.g. Hill and Hood
1999; MacDonald et al.
1999a,
b; Shorkey et al.
2007; King and Crowther
2004). However, most reviews discuss only a few spirituality questionnaires without a religious focus, which in itself warrants a new review. The reviews by MacDonald et al. (
1995,
1999a,
b) discuss several spirituality questionnaires that transcend a specific religion, but although MacDonald et al. pay attention to the persistent flaw that most questionnaires are based on the Jewish and Christian traditions, they do not systematically evaluate the questionnaires in relation to the
viewpoints of these traditions. In addition, reviews do not discuss the formulation of the items. In scale construction, the formulation of items is important; items should be comprehensible, have a consistent meaning and answerable by all respondents (Fowler
1995). Spirituality is often described in vague terms, and it is therefore important to check whether the items are comprehensible and have a consistent meaning. Finally, most reviews neglect the inclusion of well-being items, which we consider to be another flaw in some questionnaires. For nursing and health research, it would certainly be interesting to investigate whether a spiritual attitude is associated with well-being, but to prevent tautology, a questionnaire on spirituality should not question itself about well-being (Koenig et al.
2001).
In the present review, we focussed on spirituality questionnaires that are suitable for both religious and non-religious people. We excluded questionnaires with too many religious or belief items. Because spirituality has a religious component for people adhering to a faith, questionnaires were allowed to have a maximum of one religious subscale.
In the following part of the article, we will first define spirituality, next we will describe the method of instrument selection, followed by criteria for the evaluation of the instruments. We will then discuss the spirituality questionnaires with respect to the following three themes: psychometric properties, item formulation and confusion with well-being and distress. We will discuss separately one- or two-dimensional questionnaires and multidimensional questionnaires. Depending on the specificity of the research question, a researcher will be more interested in the first type of questionnaires, which are global measures of spirituality, or the second type of questionnaires, which delineate the different elements of spirituality.
Defining Spirituality
Spirituality is a complex multidimensional concept (Cook
2004; Hill et al.
2000; George et al.
2000; Moberg
2002). The concept defies clear-cut boundaries, which also applies to other latent constructs that are often used, such as character, well-being and health (Miller and Thoresen
2003). Many definitions of spirituality have been proposed from different disciplines and perspectives. For example, spirituality has been described as “the way in which people understand and live their lives in view of their ultimate meaning and value” (Muldoon and King
1995), p. 336), as “a subjective experience of the sacred” (Vaughan
1991, p. 105), and as “a quality that goes beyond religious affiliation, that strives for inspirations, reverence, awe, meaning and purpose, even in those who do not believe in any good.” (Murray and Zenter
1989). It seems almost impossible to find a description with which the majority of people would agree. Zinnbauer et al. (
1999) described five studies in which various groups of people were asked to define spirituality. They concluded that differences in the responses of the participants outweighed by far the similarities. McSherry and Cash (
2004) even stated that we should accept that the word ‘spirituality’ has different meanings.
Our approach in this review has been to use a comprehensive definition that covers several dimensions. The advantage of a broad definition is that it could be used to formulate various facets of spirituality. Empirical research could then assess the validity of the theoretically proposed facets, which would contribute to the clarification of the concept. We looked for a definition of spirituality that reflects the experiences of people from different religious or secular backgrounds and that reflects current (western) culture, where many people are searching for profundity and meaning in life on the basis of personal experiences and insight, instead of on the basis of external rules, norms and expectations (Heelas
2005). In current (western) culture, more and more people are searching for a connection with the divine within themselves, instead of a connection with an external almighty power (Heelas
2000).
In view of this, we have defined spirituality as one’s striving for and experience of connection with oneself, connectedness with others and nature and connectedness with the transcendent. Conceptual analyses (Dyson et al.
1997; Cook
2004; Chiu et al.
2004; Reed
1992) and qualitative research (Hungelmann et al.
1985; Fisher
1998, cited in Gomez and Fisher
2003) have shown that connectedness is an essential element of spirituality. Furthermore, several authors, who approach spirituality as a universal human experience, define spirituality in terms of connectedness or relatedness. For example, the National Interfaith Coalition on Aging (
1975) described spiritual well-being as the affirmation of life in a relationship with self, community, environment and God. This working definition emerged from several meetings with representatives from various religions. In nursing research, spirituality is also often defined in terms of connectedness. Reed (
1992) defined spirituality on the basis of conceptual, empirical and clinical nursing literature as “the propensity to make meaning through a sense of relatedness to dimensions that transcend the self in such a way that empowers and does not devalue the individual. This relatedness may be experienced intrapersonally (as a connectedness within oneself), interpersonally (in the context of others and the natural environment) and transpersonally (referring to a sense of relatedness to the unseen, God, or power greater than the self and ordinary source)” (Reed
1992, p 350).
Connectedness encompasses various aspects that can play a role in every human. Connectedness with oneself is expressed by aspects such as authenticity, inner harmony/inner peace, consciousness, self-knowledge and experiencing and searching for meaning in life (Elkins et al.
1988; Young-Eisendrath and Miller
2000; Hungelmann et al.
1985; Howden
1992; Mahoney and Graci
1999; Chiu et al.
2004). Connectedness with others and with nature is related to compassion, caring, gratitude and wonder. Connectedness with the transcendent includes connectedness with something or someone beyond the human level, such as the universe, transcendent reality, a higher power or God. Aspects related to this last theme are awe, hope, sacredness, adoration of the transcendent and transcendental experiences (Cook
2004).
Methods
Articles on spirituality were collected by searching for “spiritual*’ in the title, abstract and keywords from the last 10 years, using Current Contents for the Behavioral Sciences (1998–2008). Relevant, new references found in these articles were also tracked. In addition, we searched for “questionnaire”, “scale” or “inventory” in combination with “spirit*”, “transcendent*”, “transperson*” or “connectedness” in the title of articles, using Web of Science (Science Citation Index Expanded, Social Sciences Citation Index Arts and Humanities Citation Index). Over eight hundred articles were collected. One hundred and twenty of these articles reported on the development or validity of spirituality questionnaires, including 12 reviews (Egbert et al.
2004; Hill and Hood
1999; King and Crowther
2004; MacDonald et al.
1995,
1999a,
b; Shorkey et al.
2007; Tuck et al.
2001; Stanard et al.
2000; Lukoff et al.
1993; Garssen et al.
2001; Hill
2005). The total number of questionnaires covered by these 120 articles exceeds well over 120, as some reviews report about numerous questionnaires. MacDonald et al., for example, mention 76 questionnaires and they already excluded questionnaires focusing on religion (MacDonald et al.
1995,
1999a,
b).
As it is hardly practical to discuss all the available questionnaires on spirituality, their number was limited by selecting questionnaires with the following properties: (a) suitability to a broad group of people with various religious or secular backgrounds, (b) having a broad scope and (c) at least some psychometric data have been published.
We used the following criteria to define whether a questionnaire is suitable to a broad group of people: to be suitable for non-religious individuals, a questionnaire should consist of at least one non-religious subscale and no more than one religious subscale. A religious subscale was defined as a scale containing more than 25% items about religion or belief. An item was considered to refer to religion if it contained one or more words such as “religiosity” or “faith” or words referring to a religious person such as “God” or “Mohammed” or to religious customs or objects such as “praying” or “synagogue”. Unless, these words were presented as an example and were combined with non-religious examples, such as: “How long have you been making use of an activity for obtaining inner peace (e.g. meditation, yoga, prayer etc.)?” (Mental, Physical and Spiritual well-being scale; Vella-Brodrick and Allen
1995). To be suitable for people with various backgrounds, the items of a questionnaire should also not inquire about a specific belief, such as belief in afterlife, witchcraft, or destiny. Items inquiring about opinions relating to values in one’s personal life were allowed. Questionnaires that are only suited to one specific group were also omitted; for example, we did not include the Spirituality Transcendence Measure (Leung et al.
2006), because it is only suited to terminal patients. It includes questions such as “Fulfill last wishes with the assistance of family or professional caregivers”. We did, however, include questionnaires that were originally developed for a specific group but had also been used effectively among various groups, such as the Self-Transcendence Scale (Reed
1991), which was developed for elderly people.
Having a broad scope was operationalized as addressing at least two of the three connectedness themes (connectedness with oneself, the environment and the transcendent).
Finally, we used the criterion that at least data about either internal consistency or factor structure should have been published.
The inclusion criteria were applied to all spirituality questionnaires that were mentioned in the 120 articles (including the 13 reviews). Ten questionnaires fulfilled our inclusion criteria and were included in this review. Additional information on all questionnaires was looked for by searching under the name of the questionnaire in Web of Science.
The spirituality questionnaires will be discussed in relation to the following three themes: psychometric properties, item formulation and confusion with well-being and distress.
The first theme concerns psychometric properties, namely (a) reliability (internal consistency), (b) factorial validity and (c) convergent validity. The following criteria were used: (a) Cronbach’s α ≥ .70; (b) Factor analytic confirmation of the clustering of items into subscales, as based on theoretical assumptions or earlier factor analytic findings; (c) Moderate or strong associations (
r ≥ .30; Cohen
1988) with other spirituality measures. Subscales that measure transcendental aspects are moderately or strongly associated (
r ≥ .30) with religiosity measures. We will also report about other psychometric aspects, namely other forms of convergent validity (such as the relationship between the subscales of a questionnaire), discriminant validity and normal distribution of scale scores. Formal criteria were not used, because information about these aspects was often lacking or provided in a different manner. When information was available about these psychometric aspects, we mentioned it in the text, but we did not use it to compare the instruments with each other.
To evaluate the formulation of the items, we determined whether the items are comprehensible, have a consistent meaning and are answerable by all respondents. To evaluate this, we used the following three criteria of Fowler (
1995): (a) Items should inquire about firsthand experiences and not about, for example, hypothetical behavior or about causality; (b) items include a single question, questions should, for example, not include hidden contingencies; and (c) items have to be formulated such that they have a consistent meaning; therefore, words have to be used which are generally understandable and have the same meaning for respondents. Words that have different meanings to respondents should be either omitted or explained. Because people have different understandings of the words “spirit”, “spiritual” or “spirituality”, such words should be omitted or explained in the questions. More than 75% of the items should fulfill all three criteria.
The last theme concerns confusion with well-being and distress. Items should not ask directly about positive or negative affect, because this will artificially inflate the relationship between spirituality and well-being (less than 25% of the items).
General Discussion
In this review, we focused on the relatively few spirituality questionnaires that measure spirituality as an experience or attitude that transcends any particular religion. These questionnaires have the advantage that they can be used among people who adhere to a faith or no faith at all. In nursing and health studies, these questionnaires are indispensable as researchers generally do not want to exclude people on the basis of their religious background. Questionnaires were only included in this review if they contained none or a limited number of religious or belief items. Questionnaires were allowed to have a maximum of one religious subscale. Popular spirituality questionnaires such as the Daily Spiritual Experience Scale (DSE; Underwood and Teresi
2002), the Index of Core Spiritual Experience (INSPIRIT; Kass et al.
1991) and the Brief Multidimensional Measure of Religiousness/Spirituality, Fetzer Institute/NIA (BMMRS; Fetzer Institute
1999; Idler et al.
2003) were therefore not included. These questionnaires contain many items that assume that the respondent believes in God, as illustrated in items such as “I feel God’s love for me, through others” (DSES) and “I work together with God as partners” (BMMRS). These questionnaires might be applicable in the USA, because its inhabitants are predominantly religious, but applicability of such scales in a society less grounded in a monotheistic tradition is doubtful. Some questionnaires do not contain items about God but instead ask about other kinds of belief. The Spiritual Orientation Inventory (SOI; Elkins et al.
1988) is an example of such a questionnaire. Examples of its items are “The universe is not yet done but is unfolding in a meaningful way” and “Humans are sometimes “called” to fulfill a certain spiritual destiny”. In our opinion, people with certain beliefs are not necessarily more spiritual than people without these beliefs. The questionnaires in this review instead refer to universal experiences and attitudes, such as connectedness with nature, compassion, gratitude, mystical experiences and self-actualization.
The quality of the spirituality questionnaires appeared to be low. We may seem overcritical, but the NIA/Fetzer panel that has reviewed more than 200 religiosity and spirituality measures, reached a similar conclusion (George et al.
2000).
One flaw in most scales is that the psychometric evaluation is limited or unsatisfactory. Most questionnaires are not factor-analyzed or the factor solutions appeared inconsistent. In addition, information about convergent validity is lacking for most multidimensional questionnaires. Information about discriminant validity and about the association between the subscales was so often lacking that we chose not to include these validation types as formal criteria. Future research, however, should also pay attention to these forms of validation, as they are important in the delineation of the construct of spirituality. Theoretically proposed spirituality facets should be highly related to each other as they all are indicators of the same construct. Furthermore, spiritual facets should be discriminated from other psychological constructs such as well-being, social support, or personality factors. It is encouraging that some evidence was found for the delineation of the construct. For example, the four subscales of the SWBQ could be discriminated from personality factors and social desirability, and a single underlying factor was found for the four dimensions.
A second flaw is that most questionnaires use inappropriate questions. Particularly, the criterion of having a consistent meaning was often unmet. In several questionnaires, this criterion was unmet because words such as spirit or spirituality were often used. The item of the SIBS-R “I have been through a time of suffering that led to spiritual growth”, for example, will be answered affirmatively by a person who interprets the word spirituality in a positive way, referring to living in accordance with one’s values and involvement in society. Another person may answer the question negatively, because he or she is not familiar with the term or has a negative association. Consequently, two respondents that have had the same experience could possibly give contrary answers. Inconsistent meaning of items was also often the result of using metaphors or abstract concepts, e.g. “I have the ability to rise above or beyond a physical or psychological condition” (SAS), “The death means returning ‘home’” (PSQ), or “There is an order to the universe that transcends human thinking” (STS of (Piedmont
1999).
A third conceptual flaw is the inclusion of well-being items in scales that are sometimes described as “spiritual well-being” scales. Therefore, to avoid tautology when investigating the relationship with well-being, we advise against four questionnaires (FACIT-sp12, STS, Reed
1991, SWB and WHOQOL-SRPB).
In summary, this paper presents a critical discussion on a selection of questionnaires that can be used to assess spirituality as a universal phenomenon. Four global and six multidimensional questionnaires were evaluated. None of the questionnaires fulfilled all our criteria. Only the multidimensional Spiritual Well-being Questionnaire (SWBQ) from Gomez and Fisher (
2003) is promising. Its validity and reliability have been proven in student samples, most items are appropriately formulated, and it does not include well-being items. In addition, the questionnaire consists of only twenty short items and will therefore easily be administrated in clinical nursing samples. With the SWBQ, scholars can investigate whether a spiritual orientation can help people to cope with the consequences of a serious disease, without excluding people on the basis of their religious background.