Western Journal of Nursing
A Critical Review of a Spirituality Intervention
West J Nurs Res 2012 34: 712 originally published online 6 February 2012
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2004) has had limited success. Many health professionals are reticent to provide spiritual care and have minimally met this standard. There remains an
overreliance on documenting religious preferences and faith practices and
referrals made to clergy or chaplains as major spiritual interventions. The
lack of spiritual interventions tested in health care further limits the full
implementation of this standard of care. The purpose of this article is to
describe the development and testing of a spiritual intervention. Furthermore, the author recommends useful strategies to further this area of research.
There are several factors that contribute to the paucity of spirituality interventions available in practice. A primary reason is the lack of agreement
regarding the concept of spirituality. There is a wide array of definitions
found in the literature. Burkhardt (1989) described three descriptive characteristics of spirituality: inner strength, unfolding mystery (meaning and purpose), and harmonious interconnectedness. Coyle (2002) later described three
different attributes of spirituality as transcendent (belief in God or higher
power), structuralist behaviorist (religious practices), and value guidance
(personal values). The author posits that although many scholars have contributed to the literature, there is not a consensus regarding the definition of
spirituality and its parameters or characteristics. Such conceptual limitations
may have implications for measurement and testing.
Second, nurses are reluctant to provide spiritual care. The author and
colleagues in a series of related studies (Pullen, Tuck, & Mix, 1996; Tuck,
Wallace, & Pullen, 2001; Wallace, Tuck, Boland, & Witucki, 2002) examined the spiritual perspectives and interventions made by mental health and
parish nurses and found that nurses reported their personal affiliation with a
religion and high levels of spirituality and yet, both groups reported reluctance in making spiritual interventions. Mental health nurses reported a
greater reluctance. The findings from this series of studies indicated that one
of the major barriers was the lack of knowledge and discomfort related to the
appropriateness of providing spiritual care. Likewise, Vance (2001) reported
that acute care nurses perceived themselves to be highly spiritual, but only
slightly more than one fourth of them provided adequate spiritual care to
their patients. Barriers reported by Vance were lack of time, education and
training, and confidence; differences in faith between patient and nurse; and
confusion over the difference between proselytizing and spiritual care.
Anandarajah and Hight (2001) also found that a majority of health care providers failed to perform spiritual assessments. These studies consistently
documented nurses’ reticence to provide spiritual care. Nurses’ lack of
knowledge of appropriate spiritual interventions was a consistent finding of
Western Journal of Nursing Research 34(6)
Third, there are limited number of spiritual interventions available and
there is a lack of evidence to support their effectiveness. This article describes
the development and testing of one spiritual intervention over a 14-year
period and briefly reports study findings. In this evidence-based culture of
health care, until nurses are assured that spiritual interventions are valid and
reliable, spiritual practices will likely remain relegated to clergy or to a few
nurses who are comfortable with broaching the subject with patients and
families. Clearly, these efforts are inadequate to fulfill the mandate of providing spiritual care to every patient.
The author developed a spirituality intervention, and a systematic
approach is proposed to describe its development. First of all, the spiritual
intervention is described and linked to an array of clinical problems and
research findings. Second, the author will briefly provide the conceptual
background for the intervention. Third, a four-phase research model is used
to describe the testing of the intervention, including study designs and the
instruments used to measure outcomes and demonstrate treatment effect.
The research model offers an approach to critique internal and external
validity. Finally, the findings of these studies are briefly discussed along with
implications for future research and practice.
The Development of a Spiritual Intervention
Linkage of Spirituality and Clinical Practice
In the 1990s, the author studied the experience of living with chronic fatigue
syndrome and schizophrenia, two stigmatizing illnesses, and found that
participants described spirituality and religious beliefs as an essential source
of support during difficult times (Tuck, duMont, Evans, & Shupe, 1997;
Tuck, Wallace, Casalenuovo, & May, 2000). Although spirituality was not a
study variable, it proved to be a figural part of the experience most notably
found in the qualitative responses. Participant’s stories became the impetus
for the author’s scholarly interest in spirituality and healing.
Later, the author conducted regional and national surveys of nurses and an
ethnography to examine spiritual interventions used in practice. Study findings included “being with” and being fully present with patients and offering
religious materials and prayer. A significant finding of the ethnographic
study was a taxonomy of spiritual interventions (Tuck & Wallace, 2000).
While these descriptive qualitative studies elucidated lists of spiritual interventions used by nurses, their use was reported as infrequent and without
empirical support of their effectiveness.
Grounding a Spirituality Intervention in Research
Early studies related spirituality with a number of chronic illnesses, including cancer and HIV/AIDS (Reed, 1986; Sowell et al., 2000). Spirituality was
identified as a factor in maintaining health and well-being (Coleman &
Holzemer, 1999; Smith, 1993). Hawks, Hull, Thalman, and Richins (1995)
described spiritual health and its relationship to behavioral, emotional, and
physical outcomes. Peri (1995) found that having a greater awareness of
one’s spirituality resulted in an increase in the spiritual well-being of persons
living with HIV. Kendall (1994) reported the core process of wellness spirituality in her grounded theory as essential to health and well-being. Other
studies documented spirituality as a contributor to positive health outcomes
and wellness (Gray, 1997; Kass et al., 1991; Levin, Chatters, & Taylor, 1995).
Other studies conducted during the latter part of the 20th century explored
the relationship of spirituality, stress, and coping. Regan-Kubinski and ShartsHopko (1995) interviewed 38 HIV-infected women from the perspective of
the cognitive-transactional stress process (Lazarus & Folkman, 1984) and
found that coping was related to newfound spirituality, a renewed spiritual
commitment, or a reexamination of spiritual beliefs. Folkman (1997) in her
work with persons with HIV disease asserted that under conditions of chronic
and severe stress, spirituality and religiosity facilitate positive reappraisals
of the difficult situation, and these reappraisals in turn support positive
psychological states. . . . The use of spiritual beliefs and experiences at all
stages of an enduring stressful condition is an aspect of coping that deserves
systematic investigation. (p. 1214)
Support for a Group Intervention
A literature search in CINAHL and Medline/PubMed using the keywords
of spiritual interventions yielded a small number of research studies that
explored spirituality using a group approach. Reports of findings from two
studies contributed to the author’s initial work in 1997. Germer (1996)
offered a spiritual awareness group to 17 adult participants who reported the
experience of discussing their spirituality as rare and beneficial. The qualitative findings indicated that learning from others, being able to express difficult emotions concerning spirituality in a supportive atmosphere, and
gaining motivation to work on this area of one’s life were unanticipated outcomes of the intervention. Astin (1997), using an 8-week stress reduction
meditation study, indicated a decline in physical and psychological symptoms
random assignment and statistical controls for covariance. The studies were
longitudinal in nature using repeated measures with most requiring participant
enrollment for 1 year. Data were collected with valid and reliable measures.
Evidence of the strength of the intervention is best found in the qualitative
responses elicited in the final session of the intervention. Participants respond
to open-ended questions regarding the value of the intervention and the
responses were overwhelmingly positive. In addition, open-ended questions
were added to the recent clinical trial to gather data regarding religion to
more fully understand the religious dimensions. A subsample of participants was randomly selected for qualitative interviews by an independent
researcher to ascertain responses to the intervention free of the facilitator’s
involvement. The transcriptions of the interviews are currently being analyzed independently of the interventionists.
These studies did confirm that the intervention protocol is replicable
across settings and populations and facilitator training is feasible. The
detailed intervention operation manual facilitates the ease of delivery and
describes approaches to intervention dose (participants were required to participate in 80% of the intervention, including booster sessions when available). Treatment integrity was consistently monitored across studies using a
variety of techniques, including videotaping randomly selected sessions. An
independent audit of those videotaped sessions indicated compliance with
the written protocol. Human subject protection was granted for each study
and adverse events were monitored but none were reported. The appropriate
time to enroll for the best effect of the intervention is yet to be determined.
The most recent study with women undergoing breast cancer treatment was
proposed to determine its effectiveness as an early treatment intervention.
Determining External Validity of the Intervention
External validity of an intervention is determined by recruitment, sampling
methods, retention rates, and the effective measurement of outcomes. This
group intervention is best suited for 10 to 12 members at a time. Although
the format limits the overall sample size, the use of repeated measures in
longitudinal studies somewhat buffers this limitation. Random assignment
to intervention groups strengthens the findings as well. Aggressive strategies to recruit and retain participants over time are necessary. Efforts were
made to recruit samples for these studies from diverse backgrounds although
race and ethnicity were primarily limited to African Americans and
Caucasians. The following examples illustrate the team’s efforts to recruit
and enroll diverse samples with a particular focus on underserved populations. The convenience sample of healthy participants ranged in age between
Description of Instruments and Psychometric Properties
Health-related quality of life is defined as the impact of illness experiences on physical, psychological, social, and spiritual or existential
well-being. The FAHI is a multidimensional measure of quality of life in people with HIV infection (Cella, 1994; Cella et al., 1996; Peterman,
Mo, Cella, & McCain, 1997). The FAHI has demonstrated excellent psychometric performance (α = 0.85-0.92), including sensitivity to
stage of illness and to intervention in the previous studies (McCain et al., 1996, McCain et al., 1998), as well as other studies (Cella et al.,
1996; Peterman et al., 1997). The HIV-specific FAHI has been revised to the current (version 4) format and is expected to provide more
sensitive data for the dimension of HIV-specific quality of life. The 44 items of the current FAHI are grouped into subscales of physical,
functional and global, and social well-being; emotional well-being/living with HIV; and cognitive functioning. Thus, the scale reflects both
general health-related and HIV-specific quality of life, with higher scores indicating greater quality of life (Peterman et al., 1997).
The DIS is comprised of 20 items reflecting negative emotions, positive interpersonal experiences, negative life changes, and loss of control
(McCain & Gramling, 1992) as revised in 1994 and 1999. The DIS was qualitatively derived with persons with HIV disease. The DIS is
comprised of Stress and Coping subscales. Modeled after the Life Experiences Survey (LES; Sarason, Johnson, & Siegel, 1978), the format
for the Stress subscale captures the process of cognitive appraisal by enabling respondents to indicate the desirability or undesirability
and the personal impact of experienced events (perceived stress). Participants indicate perceived stress specifically related to HIV
disease for two time periods: since the time of their diagnoses and within the past month. Positive and Negative Stress subscale scores
are derived by separately summing the items indicated as having a positive or negative personal impact. Previous psychometric analyses
indicated that the 20 items of the 1994 version of the subscale comprised 4 factors involving negative emotions, positive interpersonal
experiences, negative life changes, and loss of control.
IES is a 15-item instrument with response options that indicate how frequently within the past 7 days each distressing thought has
occurred. Using the IES, psychological distress specific to living with HIV disease has been previously documented in the form of avoidant
and/or intrusive thoughts related to the illness (Horowitz, Wilner, & Alvarez, 1979; Ironson et al., 1990; McCain & Cella, 1995; McCain,
Zeller, Cella, Urbanski, & Novak, 1996; Perry, Fishman, Jacobsberg, & Frances, 1992). The IES has excellent psychometric properties, is
not confounded with physical symptoms, and yields an index of illness-related psychological distress. Higher scores on the subscales of
Intrusive and Avoidant thinking indicate higher psychological distress.
The FAHI scale is a disease-specific extension of the general version of the Functional Assessment of Cancer Therapy (FACT-G) scale
(Cella & Tulsky, 1993), measuring the quality of life in people with HIV infection. The 55-item revised FAHI (version 3) includes subscales
of physical, social/family, emotional, and functional well-being; relationship with physician; and additional concerns specific to HIV infection.
Higher scores indicate greater quality of life. The FAHI has demonstrated excellent psychometric performance, including sensitivity to
stage of illness and to intervention in previous studies (Cella, McCain, Peterman, Mo, & Wolen, 1996; McCain et al., 1996).
Table 1. (continued)
The revised 24-item SPS is a measure of six social provisions or components of social support including reliable alliance, attachment,
guidance, nurturance of others, social integration, and reassurance of worth. The SPS has demonstrated excellent construct validity and
internal consistency in other populations (Cutrona & Russell, 1987). Higher scores indicate a higher level of social support.
Description of Instruments and Psychometric Properties
The revised 40-item Coping subscale was modeled on the Revised Ways of Coping Checklist (Vitaliano, Maiuro, Russo, & Becker, 1985). For
these 40 of the original 60 items, psychometric analyses revealed 3 empirical factors related to maintaining a positive attitude, adapting
to illness, and withholding, with items approximately equally distributed across the original, theoretical dimensions of problem-focused,
emotion-focused, and appraisal-focused coping. Scoring schemes for the coping subscale enable assessment of both the theoretical foci of
coping and the factor-analytically derived coping methods. Higher scores reflect more frequent use of the various coping strategies. The
reliability (Stress subscale α = .83, Coping subscale α = .80-.87) and validity of the DIS for the study population have consistently been
supported (Cella et al., 1996; McCain & Cella, 1995; McCain et al., 1996; McCain et al., 1998).
Table 1. (continued)
need for spiritual measures that discriminate change over time in this heightened state of popular spirituality.
Second, although the intervention is well grounded theoretically, in efforts
to be sensitive to a pluralistic culture, the intervention might dilute the influence of spiritual or religious views and may instead elicit commonly shared
humanistic worldviews. Third, the amount of time spent in the intervention
on a weekly basis may not be sufficient to capture the essence of the experience. Assignments during the week and daily practice may be required to
reinforce spirituality. The strongest effects were reported retrospectively or
when the participants were further away from the illness experience; possibly suggesting new methods of data collection.
As investigators, we must refine the phenomenon of interest. Many studies
continue to link spirituality and religion as one construct and then measure it as religion. A recent example, a longitudinal study by Gall, Kristjansson, Charbonneau,
and Florack (2009), examined the role of spirituality in women with breast cancer. Although the focus of the study was on spirituality, they measured religion/spirituality as religious salience, the level of participation in religion, and
the strength of religious views. They also explored positive and negative views of
God as a study variable. Other studies too numerous to cite here have likewise
combined the two constructs. The question remains whether these are distinct
ideas or have been artificially separated. Efforts made to solicit definitions directly
from participants have value and may help clarify these terms (Tuck & Thinganjana,
The mechanism for spirituality remains unclear as to whether there are
direct or indirect effects. Gall et al. (2009) found no support for Pargament’s
(1997) spiritual mobilization hypothesis during illness or that religion served
as a protective factor. They found that distress increases over time and proposed that the strength of religious beliefs was only protective if they were
strong beliefs prior to the illness and that mobilization of these beliefs in
absence of a strong base during the crises promoted distress instead.
Research is needed to explain the recurring strength of the relationships
between measures in cross-sectional studies and the relative lack of effect
noted in some longitudinal studies. In a recent cross-sectional study,
Kandasamy, Chaturvedi, and Desai (2011) found the strong positive relationships between spirituality and quality of life and inverse relationships with
depression and anxiety. They also reported highly significant negative relationships between spiritual well-being and distress, fatigue, memory disturbances, and loss of appetite. Shah et al. (2010) in another cross-sectional
study reported that the strengths of the spiritual beliefs were positive contributors to coping. In an attempt to understand the mechanism, it is noted
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author received financial support for the
series of research studies cited in this manuscript. Intramural funding was provided by
the A. W. Williams Foundation at Virginia Commonwealth University and the Department of Integrative Systems, School of Nursing, Virginia Commonwealth University. The
first clinical trial was funded by the National Institutes of Health’s National Center for
Complementary and Alternative Medicine Grant 5R01 AT000331 to Nancy L. McCain,
Principal Investigator, and facilitated by the General Clinical Research Center, Virginia
Commonwealth University Health System (5M01 RR000065; J.N. Clore, Director).
The second clinical trial was funded by the National Institutes of Health’s National
Cancer Institute grant 5R01 CA114718 to Nancy L. McCain, Principal Investigator,
and facilitated by the General Clinical Research Center, Virginia Commonwealth
University Health System (5M01 RR000065; J. N. Clore, Director).
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