Joumal of Advanced Nursing, 1992,17, 1251-1259
Abbreviated instrument to measure hope: development and psychometric evaluation Kaye Herth PhD RN Associate Professor, Graduate Program, School of Nursing, Northem Illinois Umversity, 1240 Normal Road, DeKalb, Illinois 60115-2894, USA
Accepted for publication 17 February 1992
HERTH K (1992) joumal of Advanced Nursmg 1 7 , 1251-1259 Abbreviated instrument to measure hope, development and psychometric evaluation The purpose of this research was to develop and evaluate psychometncally an abbreviated mstrument to assess hope m adults in clinical settings The Herth Hope Index (HHI), a 12-item adapted version of the Herth Hope Scale (HHS), was tested with a convenience sample of 172 ill adults Alpha coefficient was 0 97 with a 2-week test-^retest rehabihty of 0 91 Cntenon-related validity was established by correlating the HHI with the parent HHS (r = 0 92), the Existential Well-Bemg Scale (r = 0 84) and the Nowotny Hope Scale (r = 0 81) Divergent validity with the Hopelessness Scale was estabhshed ( r = — 0 73) Construct validity was supported through the factonal isolation of three factors (a) temporality and future, (b) positive readiness and expectancy, (c) mterconnectedness These three factors accounted for 41% of the total variance in the measure
INTRODUCTION
REVIEW OF LITERATURE
Despite increasing recognition that hope influences the adaptation to illness and promotes wellness, there is a lack of instruments specifically designed to measure this construct m adult dients m clinical settings (Gottschalk 1985, Hmds 1988a,b, Kim 1989, Miller 1989, Rideout & Montemuro 1986) Nurses have had to rely pnmanly on intuihon when assessing hope and have thus been unable to validate specific strategies designed to foster hope in their chents As with most clinical nursing research, the pnonty in the study of hope is the need for a concise, simple and psychometncally sound instrument with which to conduct dmical research studies mvolving the administration of a battery of instruments and the use of repeated-measure designs to assess hope (Stoner 1988) The purpose of this study was to develop and evaluate psychometncally an abbreviated mstrument to assess hope, which would be feasible for such research
Interest in the concept of hope, the psychosociodemographic antecedents and correlates of hope and the measurement of hope is evident m the health care literature, which reflects the commitment and concem of the nursing profession to foster hope in dients (Foote et al 1990, Fan-an & Popovich 1990, Hall 1990, Herth 1989, 1990a, Hickey 1986, Kim 1989, Miller 1985, VaiUot 1970, Watson 1979) A number of instruments with which to measure hope have been developed dunng the past 2 decades Several conceptual and methodological issues that may influence the usefubess of these instruments m clinical research, however, have recently been identified
Conceptual issues Histoncally, the development of instruments to measure hope has paralleled the conceptual understandings of the construct The first instruments (Beck et al 1974, Enckson 1251
K. Herth
et al 1975, Gottschalk 1974, Stoner 1982) were based on Stotland's (1969) narrow conceptuahzation of hope as 'an expectation of goal achievement' The complehon of quahtahve studies (Haberland 1972, Miller 1983, 1985, Raleigh 1980, Stanley 1978) explonng dimensions of hope dunng the late 1970s and early 1980s in well and chronically ill adult populations descnbed additional elements common to the expenence of hope and laid the foundation for the development of the first multidimensional measures of hope Specific dimensions of hope identified in these studies were the interpersonal element, the hme-onented, future focus of hope, and the goalachievement expectation of hope The Hope Index Scale (Obayuwana et al 1982), the Stoner Hope Scale (SHS) (Stoner 1988), the Miller Hope Scale (MHS) (Miller & Powers 1988) and the Nowotny Hope Scales (NHS) (Nowotny 1989) address these multiple dimensions of hope Studies completed since the mid-1980s (Dufault & Martocchio 1985, Ferran et al 1990, Herth 1990a, Hinds 1988a,b, Hinds & Martin 1988, O'Malley & Menke 1988, Owen 1989) with the ill and the elderly population suggest that, m addition to the multidimensional elements of hope identified earher, a number of conceptual issues remain to be addressed Concepts that are not included in the existing hope instruments include (a) a more global, non-timeoriented sense of hope, (b) hope despite diminished or absent interpersonal relationships, (c) hope as a sense of 'being' available and engaging m relationships, as opposed to 'doing' for oneself and others, and (d) potential of hope for controlling behavioural or emotional responses as opposed to the control of events or expienences The Herth Hope Scale (Herth 1991) was designed to incorporate not only the cnhcal elements incorporated in the other scales, but also more recently identified concepts Thus, the Herth Hope Scale, because of its broader conceptual basis, has increased potential for use m clmical situations with the ill and elderly populahons (Herth 1991) Methodological issues Methodologically, the majority of hope studies involve the administration of multiple instruments of considerable length to clinical populations Little considerahon has been given to the time, effort or energy required to complete the instruments In addition, potenhal mild discomfort when directly confronting one's feehngs about hope and the amount of self-disclosure required in responding to these items place additional burdens on respondents For these reasons, the dimcal utility of exishng instruments to measure hope is open to queshon 1252
To be climcally useful, an instrument should (a) measure the mulhdimensional aspects of a concept, (b) demonstrate validity and reliability with mdividuals of vanous ages, educational, cultural and socio-economic backgrounds, (c) reduce subject response burden in terms of time and energy involved to complete the instrument, (d) lessen administrative time, cost and skill needed to administer and score the instrument, (e) be amenable to serial examinations so as to enable evaluahon of hope over time, and (f) have direct clinical relevance (Jacobson 1989, Poht & Hungler 1991, Vermeersch 1990) Instruments currently available to measure hope vary in format and length from the 60-item dichotomous Hope Index Scale developed by Obayuwana et al (1982) to the 30-item four-point rating Herth Hope Scale (Herth 1991) All available hope scales, with the exception of the Herth Hope Scale, lack reliability and validity testing with the senously ill and elderly populations Farran et al (1990) used only two of the three subscales of the Stoner Hope Scale in a study of hope m the elderly population, after which they expressed concems about the appropnateness of the items with this age group Scoring of instruments also vanes considerably m complexity The instruments developed by Enckson et at (1975) and Stoner (1982) require calculation of both an unportance and probability score, the Herth Hope Scale is a more simple summated rating schema Qualitative data obtamed on the Herth Hope Scale suggest that the clanty and complexity of the items and the length of the scale, though shorter than other available hope scales, may also limit its dimcal utility The methodological and conceptual issues associated with existing hope instruments tend to limit their clinical usefulness This limitation provided the lmputus for adapting the Herth Hope Scale to a more feasible, dimcal instrument
DEVELOPMENT OF THE HERTH HOPE INDEX The Herth Hope Index (HHI) is an adaptation of the Herth Hope Scale (HHS) designed specifically for use m the clinical setting The objective of the adaptahon was to capture the multidimensionality of hope as represented on the HHS, to reflect clearly the unique dunensions of hope in the dimcal populations, and to reduce the number and complexity of items and so render the tool more clinically useful The HHI is designed to faahtate the examination of hope at vanous intervals so that changes in levels of hope can be identified Given adequate validity and rehabihty estimates, the HHI could potenhally aid researchers and clinicians in the assessment of hope states within dients and
Instrument to measure hope
m the evaluation of the effectiveness of hope-enhancing strategies Charactenstics of the parent tool The parent tool, the Herth Hope Scale (HHS), is a 30-item, four-point scale (Herth 1991) based upon the six dimensions of hope conceptualized in Dufault and Martocchio's Model of Hope (Dufault & Martocchio 1985) The six dimensions of hope were combined and used as a framework for generating items for the HHS (a) cognitivetemporal (the perception that a positive, desired outcome IS realistically probable m the near or distant future), (b) affechve-behavioural (a feelmg of confidence with initiation of plans to affect the desired outcome), (c) affiliative-contextual (the recognition of the interdependence and mterconnectedness between self and others and between self and spirit) (Herth 1991) Hope, as defined m this model, is 'a multi-dimensional dynamic life force charactenzed by a confident yet uncertain expectation of achieving good, which to the hoping person, is realistically possible and personally significant' (Dufault & Martocchio 1985) The HHS has been completed by 180 cancer patients (Herth 1989), 185 well adults (Herth 1988a), 40 well elderly (Herth 1988b) and 75 elderly widow(er)s (Herth 1990b) The alpha reliability coeffiaents for the total scale ranged from 0 75 to 0 94 with a 3-week test-retest reliability of 0 89 to 0 91 A negahve correlahon (r= —0 69) was found between the HHS and the Beck Hopelessness Scale Three factors as originally conceptualized were identified through factonal analysis procedure factor 1, temporality and future (cognitive-temporal dimension), factor 2, positive readiness and expectancy (affective-behavioural dimension), and factor 3, mterconnectedness (affihative— contextual dimension)
Construction of the Herth Hope Index Twelve items were developed for the shortened mstrument from items on the HHS In an effort to increase clinical usefulness, specific attention was given to designing simple items and to relating items to adults expenencmg alterations m health status The items of the HHI are in Likert-format and are divided over the three subscales paralleling those of the HHS Each item was scored on an ordinal scale from 1 to 4, where a score of 1 indicates 'strongly disagree' and a score of 4 indicates 'strongly agree' Items were ordered so as to reduce response set, that is, no two consecutive items are from the same subscale, and no more than two consecutive
items are keyed m the same direction For analysis, all negative items were reverse scored so that a higher score would mdicate a higher level of hope Total scores could range from 12 to 48 Larger-than-normal print was used for improved readability with ill and/or elderly dients
Content validation of the Herth Hope Index Empincal vahdation of the HHI was accomplished by followmg the general approach advocated by Nunnally (1978) Two review panels evaluated the face and content validity of the HHI An Expert Research/Measurement Panel, consisting of four university members with expertise in research and instrument development, addressed (a) the congruence of each item with the conceptual definition of hope, (b) the clarity and readability of each item, and (c) the explicitness and simplicity of instructions A 12member Client/Nurse Clinician Panel, addressed the face validity, language, clanty and simplicity of the HHI The panel consisted of six clients of diverse educational and socio-economic background who were diagnosed with either an acute, chronic or terminal illness and six nurse clinicians employed at vanous settings (hospital, hospice and home care agency) All suggested revisions m format and wording were made Reading level was established at sixth grade according to the Flesch Readability Formula (Flesch 1974)
Pilot test of the Herth Hope Index The HHI was pilot tested with a convenience sample of 20 physically ill adults from a small community hospital in the Northem Illinois areas of the US The subjects ranged in age from 22 to 82 years (x = 51 years), 70% were female, 30% were male and 95% Caucasian The educational levels, length of illness and diagnoses of subjects represented a wide spectrum Fatigue was measured by a categoncal scale none, little, moderate or severe This was because fatigue has been identified m the literature as possibly interfering with completion of instruments and postulated to correlate with a lowered hope level Sixty-five per cent of the subjects reported expenencmg a moderate to high level of fatigue, all subjects, however, completed the instrument As expected, fatigue significantly ( P < 0 05) affected the HHI score subjects who reported experiencing high fatigue had significantly lower mean hope scores than did those experiencing moderate, little or no fatigue All subjects reported that the wording of the HHI and the mstructions were clear Additional comments were related to how well selected items
1253
K.Herth Table 1 Descnptive and inferential statistics summary for the samples (n = 192)
Descnphve data
Variables Sample size Mean age Age range % Male % Female % Caucasian % Black % Oriental % < Hs Education % Hs Diploma % Varying levels of college % Protestant % Catholic % lewish % Employed % Unemployed % Retired HHI mean HHI range HHISD
Pilot test acutely ill sample
Acute illness
Chronic illness
Terminal illness
20 51
70 48
71 52
31 51
Entire sample 172
22-82
18-86
24-94
22-90
50 3 22-94
30 70 95 3 1 19 44 37 34 52 9 92 5 3
56 44 74 25 1 20 49 31 48 45 7 96 2 2
41 59 68 22 10 21 52 27 39 50 11 88 10 12
42 58 72 26 2 24 57 19 41 47 12 58 22 20
50 50 71 25 4 22 53 25 43 47 5 81 8 11
3123 12-48 8 22
36 87 20-48 9 96
34 38 18-48 8 84
32 19 12-48 10 03
34 49 12-48
0 96
0 94
0 97 0 91
961
Inferential data Alpha coefficient Test—retest (2 weeks) Pearson r HHI and HHS HHI and NHS HHI and HS
HHI and EWS
expressed the subjects' hope The initial mtemal consistency rehabihty was supported by a Cronbach alpha of 0 94, and the item means mdicated that there were no 'ceiling' or 'floor' effects in the instrument Completion time ranged from 1 to 4 minutes
P S Y C H O M E T R I C E V A L U A T I O N OF THE HERTH H O P E INDEX Sample characteristics The HHI and the construct vahciation instruments were acimmistered to a convemence sample of 172 adults, of 1254
0 94
0 98
0 92 0 81 - 0 73 0 84
which 70 were acutely ill, 71 were chromcally ill and 31 were termmally ill The sample was drawn from inner city, suburban and rural hospitals («= 103), from out-patient settings (n = 20), and from those receiving care at home through a visiting nurse association or hospice home-care programme (n = 47) A deliberate attempt was made to obtain the most heterogeneous population possible through the use of a variety of pubhc and pnvate agencies Evidence of this heterogeneity of age (22-94 years, x = 50 30), ethnic and racial mix, educahonal levels £md soao-economic background IS depicted in Table 1 The background characteristics were fairly evenly distnbuted across the sample A
Instrument to measure hope
vanety of diagnostic categones (n = 14), lengths of ilbess ( > 2 months to 18 years) and levels of fahgue ('none' to 'overwhelming') were represented
Procedure
The proposal for the present study was reviewed and approved by the University Review Board and the appropnate individuals and committees of the partiapahng agencies The purpose of the study and the elements of Validating mstruments informed consent were explained to the potential participant by the inveshgator or her research assistant Those The Herth Hope Scale (HHS) (Herth 1991), the Existential Well-Bemg Scale (EWS) (Paloutzian & Ellison 1982) and individuals mdicatmg a desire to participate were given the Nowotny Hope Scale (NHS) (Nowotny 1989) were a packet containing a cover letter, the Background used to determme concurrent criterion-related validity Information Form, the five questionnaires (HHI, HHS, The HHI was compared with the HHS because, when NHS, HS, EWS) arranged m random order so as to allow for reducing the number of items m a scale, high concurrent the possible effects of fahgue, and an envelope for the validity with the ongmal scale protects against the loss of completed forms Completion of the entire packet took an significant mformahon The NHS was used m order to average of 40 mmutes, the subjects were given 1 hour, compare the HHI with another measure of hope that had however, to accommodate for possible intervening treatbeen used with ill adults Companson with the EWS was ments or fatigue level The sealed envelopes containing the completed because existential well-being has been theore- anonymously completed forms were collected at the end of tically hnked to hope (McGee 1984) The Hopelessness the hour Twenty randomly chosen subjects were given Scale (HS) (Beck et al 1974) was used to determine divergent the HHI twice within a 2-week interval to determine test-retest rehabihty validity of the HHI The HHS was used in the validation study because it was the parent instrument for the HHI As noted previously, it has estabhshed reliability and validity with the elderly and ill population (Herth 1991) The EWS IS a 10-item, six-point Likert subscale of the Spintual Well-Bemg Scale (Paloutzian & Ellison 1982), which IS considered a valid measure of a construct integral to hope (McGee 1984) The range of scores of the EWS is 10 to 60, with high scores indicating high existential wellbeing The mtemal consistency alpha coefficient is 0 78 with a 2-week, test-pretest rehabihty of 0 86 (Paloutzian & Ellison 1982) The revised NHS is a 29-item, four-point Likert scale based on a review of the theoretical perspectives of hope (Nowotny 1989) Scores can range from 0 to 116, with a high score indicating high hope The original NHS of 47 items was tested with 306 adults (well individuals and individuals with cancer), the followmg findings were based on an analysis of the final 29 items Cronbach alpha of 0 89 and concurrent vahdity with the HS of r = -047 The HS IS a 20-item, true-false scale, in which scores range from 0 to 20 and high scores indicate high hopelessness (Beck et al 1974) The initial mtemal consistency rehabihty using KR-20 (Kuder-Richardson) was 0 93, with a reported concurrent validity of r = 0 74 between clmical ratings of hopelessness and instrument rating of hopelessness (Beck et al 1974) These findmgs have been substantiated m numerous studies usmg the scale (Patnck 1989)
FINDINGS Construct validity Construct validity of the HHI was assessed by using a maximum likelihood factor analysis with vanmax rotation The resulting three-factor solution was determined by eigenvalues greater than 1, a lack of trivial factors, and residual matnx values of less than 0 1 The cntenon selected for factor loadings was 0 40 According to Tabachmck & Fidell (1983), a factor loading of 0 40 indicates at least a 20% overlap in vanance between the Vcinable and factor A total of 61% of the vanance was explained by a three-factor solution Eigenvalues for the three factors were 2 02,157 and 1 35 respectively Table 2 illustrates the factor pattem and loadings of the HHI items All 12 items had a significant loading on one of the three factors as was ongmally conceptuahzed, and these correspond to the three ongmally fonned subscales of the HHS (a) temporality and future, (b) positive readiness and expectancy, and (c) interconnecteciness Factor 1, labelled temporality and future, consists of four items hypothesized to measure the cognitive—temporal dimension of hope Representative items include, 'I beheve that each day has potential' and 'I have specific possible short, intermediate or long range goals' Factor 2, labelled posihve readmess and expectancy, IS formed from four items hypothesized to measure the affective—behavioural dimension of hope Examples of 1255
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Table 2 Factor loadings, mean standard deviahons and corrected item-total correlahons for Herth Hope Index items (« = 172)
Item
Items on HHI
Corrected item-total correlation
Mean
SD
Factor 1 inner sense of temporality and future Presence of goals 0 72 Posihve outlook on hfe 0 76 Each day has potenhal 0 54 Scared about the future -081
31 39 36 12
0 92 0 64 0 79 10
0 54 0 69
Factor 2 inner positive readmess and expectancy cy See a light m a tunnel 0 81 A sense of direchon 041 Life has value and worth 0 72 Recall happy/joyful times 0 59
29 27 31 30
0 93 0 84
0 70 0 50
060
047
0 96
0 62
Fador 3 lnterconnectedness with self and others rs Feel all alone - 0 70 Faith that comforts 0 63 Deep inner strength 0 58 Give and receive canng/love 0 60
23 30 27 25
0 84 0 97
061
items within the factor include, 'I see a light in a tunnel' and 'I have a sense of direction' Factor 3, labelled lnterconnectedness, consists of four items hypothesized to measure the affihative-contextual dimension of hope Examples of items in this factor mclude, 'I have a faith that gives me comfort' and 'I am able to give and receive canng/love' Factors 1 and 2 had the highest lntercorrelation (r = 0 42) The correlahon between factors 1 and 3 were 0 21 and that between 2 and 3 was 0 18 Other validity measures The construct validation of the HHI involved the admmistration of a vanety of companson instruments (Table 1) Concurrent cntenon-related validity was assessed by calculating the correlahons of the HHI to the HHS (r = 0 92), the EWS (r = 0 84), and the NHS (r = 0 81) Divergent vahdity was assessed by calculating the correlation of the H H I t o t h e H S ( r = - 0 73) Internal consistency Data were analysed for mtemal consistency on the first administration and for stabihty on repeat admmistrahon 2 weeks later The Cronbach coeffiaent alpha was 0 97 on 1256
Factor loachngs
10
0 90
061 051
0 67 0 53 0 42
the HHI, which indicated mtemal consistency Test-retest correlation was 0 91, indicahve of stability over time Each of the three factors were examined for the reliability as subscales, alpha coefficients were found to range from 0 78 to 0 86 The Cronbach alpha coefficients for the other instruments used m the study were 0 95 on the HHS, 0 90 on the EWS, 0 88 on the NHS and 0 89 on the HS The alpha for the total HHI ranged across educahonal, age, fatigue and phase of illness subgroups from 0 72 to 0 89
Descriptive profile of the Herth Hope Index The scores on the HHI ranged from 12 to 48 The overall mean for the HHI was 32 39 (SD = 9 61) As shown m Table 2, the item means fall slightly above the midpoint of 2 0 for this scale, with standard deviations fluctuating around 100 The item means suggest that there are no ceding or floor effects for any of the items The standard deviations support the vanabihty of each item, indicating that the respondents were usmg the full range of scores The means of the other validatmg instruments used m the study were as follows the HHS was 90 90 (SD = 30 36, range 32-120), the EWS was 4198 (SD = 1643, range 10-60), the NHS was 84 08 (SD = 16 43, range 24-116) and the HS was 6 02 (SD = 8 29, range 0-20)
Instrument to measure hope
Table 3 Stepwise mulhple regression analysis of the Herth Hope Index for selected background variables
Variables'
Mulhple R
Length of illness Income Fahgue level Mantal status
0 40 0 47 051
0 54
R^ change
016
015
0 22 0 26 0 29
0 21 0 25 0 27
Significance
3132 23 20 1951 16 30
0 01) in the level of hope according to mantal status, diagnosis, length of illness, income status and fatigue level The significant findings were further evaluated through the use of the Tukey HSD post hoc test Subjects who were mamed had a significantly higher mean hope score than the subjects who were separated, divorced, widowed or cohabiting Those subjects who were diagnosed with AIDS had a significantly lower mean hope score than did the subjects in the following diagnostic categones cardiovascular, gastrointestinal, musculoskeletal, neurological, haematological and respiratory
Subjects who reported a duration of an illness greater than 12 months had a significantly lower mean score than did the subjects whose illness had been present fewer than 2 months or from 2 to 12 months In addihon, the subjects who reported inadequate income had a significantly lower mean score than did the subjects who reported adequate or very adequate incomes Fatigue significantly affected hope Subjects who reported expenencing high or overwhehning fatigue had significantly lower mean hope scores than did those expenencing little fatigue These findings are supported m the literature on hope (Foote et al 1990, Herth 1990a,b, Miller 1989, O'Malley & Menke 1988, Rideout & Montemuro 1986, Stoner & Keampfer 1985) A stepwise mulhple regression was conducted to determme which of the 10 variables (mantal status, diagnosis, length of llhiess, phase of illness, income, fatigue level, educational level, gender, race and age) were the best predictors for the level of hope Four variables (length of illness, income, fatigue level and mantal status) accounted for 27% of the vanance m hope level (Table 3) DISCUSSION Researchers and clinicians have identified the need for a measurement tool that is concise, clear and therefore practical for use in screening adults for different levels of hope m the clinical setting (Nowotny 1989, Obayuwana & Carter 1982, Stoner 1988) The HHI is a carefully constructed tool for use by clinical researchers and nurse clinicians with adult clients in clinical settings The consistent reliability of the total HHI and the three subscales across these subgroups indicate that it could be used with adults of varying educational levels, ages, fatigue levels and/or phase of illness The nature of this tool is such that the nurse is able to examine the response to each item and associate the individual's hope in relation to the particular area represented by the item The items could potentially serve as 'probes' to help identify areas that the nurse could explore further with the client for developing speafic, hope-enhancing interventions 1257
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Prehminary results support the mtemal consistency reliability, test—retest reliability and the content validity of the HHI Support for concurrent cntenon-related validity is demonstrated by the high correlahon of the HHI with the original Herth Hope Scale (r = 0 92) and the moderate correlation with the Nowotny Hope Scale (r = 0 81), and the Existential Well-Bemg Scale (r = 0 84) The high correlahon of 0 92 between the shortened HHI and the HHS and between the subscales of the HHI and the subscales of the HHS suggests that the HHI is as comprehensive and rehable as the longer 30-item version and that the HHI is tapping essentially the same dimensions as the HHS The moderate correlation betweeen the HHI and the NHS suggests that the HHI is measunng hope but is different conceptually from the NHS In addition, the positive correlation of the HHI with the EWS, a measure of a construct theoretically related to hope, supports its valichty Divergent validation, as evidenced by a negahve correlation (r = — 0 73) of the HHI to hopelessness, was confirmed
areas from the view point of the individual This type of systematic inquiry may help clients to organize their thoughts and to articulate more clearly their feelings of hope This hypothesis needs, however, to be subjected to systemahc mveshgahon It is anticipated that the HHI will become a useful tool, both as a screening device and eventually as a diagnostic mstrument, in the assessment of hope states within dients and m the planning and the evaluahon of the effectiveness of hope-enhancmg shategies
Acknowledgements This research was funded by grants from Sigma Theta TauBeta Omega Chapter and Northem Illinois University The author is grateful to Lorys Oddi for her editonal assistance, to Yvonne Eaves for assistance m data gathenng and to Deonne Johnson and Ron Leifheit for their assistance in preparation of the manuscnpt and graphics, and to the staff and dients from the participating agencies, institutions and community groups
Three factors of hope Three factors of hope — temporality and future, posihve readiness and expectancy, and lnterconnectedness — were identified through factonal analysis These factors correspond to the three subscales of the ongmal Herth Hope Scale Comparability and consistency with the longer version of the factor structure suggests that the 12-item version IS as powerful a measure as the 30-item version Efforts should continue to be directed at obtaimng more extensive assessments of the constmct vahdity of the HHI The apphcabihty of the current form of the scale to vanous other subpopulations (e g adolescents and children, people with vanous cultural backgrounds and health problems) should be mveshgated Only with extensive descnphve apphcahon of the HHI will norms be estabhshed and its suitability for apphcation to varied clinical populations and settings be validated In the future, predichve validity studies that will correlate dimcal health outcomes suggestive of mcreased or decreased hope need to be completed The instrument should enable the nurse researcher to screen levels of hope quickly in a diverse adult population and to examine the psychosociodemographic antecedents and correlates of hope Because the HHI requires only a few mmutes to admimster, chents may expenence less fatigue and thus be more willing to complete the instrument, parhcularly m a repeated-measures research design In addition, the items could provide a checklist of areas for a focused assessment, together with some information about the relahve extent of hope/hopelessness m each of these 1258
References Beck A , Weissman A , Lester D & Trexler L (1974) The measure of pessimism the hopelessness scale Joumal of Consulttng artd Cltntcal Psychology 4, 861-865 Dufault K & Martocchio B (1985) Hope its spheres and dimensions Nurstng Climes of North Amenca 20(2), 379-391 Enckson R, Post R & Paige A (1975) Hope as a psychiatnc vanable Joumal of Clinical Psychology 3 1 , 3324-3330 Farran C & Popovich ] (1990) Hope a relevant concept for genatnc psychiatry Archives of Psychiatnc Nursing FV, 124-130 Farran C, Salloway J & Clark D (1990) Measurement of hof>e in a community-based older population Westem foumal of Nurstng Research 12(1), 42-59 FleschR (1974) The Art of Readable Wnting McGraw-Hill, New York Foote A , Piazza D , Holcombe J, Paul P & Daffm P (1990) Hope, self-esteem and social support m persons with mulhple sclerosis Joumal of Neurosaence Nursing 22(3), 155-159 Gottschalk L (1974) A hope scale apphcable to verbal samples Archives of General Psychtatry 30, 779-785 Gottschalk L (1985) Hope and other deterrents to illness Amencan Joumal of Psychotherapy 39, 515-524 Haberland H (1972) Psychological dimensions of hope in the aged relationship to adaptation, survival and lnshtutionahsm Unpubhshed doctoral dissertation University of Chicago, Ilhnois Hall B (1990) The struggle of the diagnosed terminally ill person to maintain hope Nursing Saence Quarterly 4(3), 177—184
Instrument to measure hope Herth K (1988a) Psychometnc testing of the revised Herth Hope Scale with well adults Unpublished manuscript University of Oklahoma, Tulsa, Oklahoma Herth K (1988b) Relahonship of hope to wellness in the nonmstituhonalized well elderly Unpubhshed manuscript University of Oklahoma, Oklahoma City, Oklahoma Herth K (1989) The relahonship between level of hope and level of coping response and other variables in pahents with cancer Oncology Nursmg Forum 16(1), 67-72 Herth K (1990a) Fostenng hope in tenninally-ill people Joumal of Advanced Nursing 15(11) 1250-1259 Herth K (1990b) The relahonship between hope, coping style, concurrent losses, and setting to grief resolution in elderly widow(er) Research m Nursmg and Health 13, 109-117 Herth K (1991) Development and refinement of an instrument to measure hope Scholarly Inquiry for Nursing Practtce An International Joumal 5(1), 39-51 Hickey S (1986) Enabling hope CancerNwrsm^ 9 3 , 133-137 Hinds P (1988a) Adolescent hopefulness m illness and health Advances in Nursing Saence 10(3), 79—88 Hinds P (1988b) Inducing a definition of hope through the use of grounded theory methodology Joumal of Advanced Nursing 9(24), 357-362 Hinds P & Martin ) (1988) Hopefubess and the self-sustainmg process in adolescents with cancer Nursing Research 37(6),
O'Malley P & Menke E (1988) Relationship of hope and stress after M I Heart and Lung 17(2), 184-190 Obayuwana A , Colhngs J, Carter A , Rao M , Mathura C & Wilson S (1982) Hope index scale an instrument for the objechve assessment of hope Joumal of the Nattonal Medical Assoaation 74(8), 761-765 Owen D (1989) Nurses' perspectives on the meaning of hope m patients with cancer a qualitative study Oncology Nursing Forum 16(1), 75-79 Paloutzian R & EUison C (1982) Lonehness, spiritual well-being and the quality of life In Loneliness A Sourcebook of Current Theory, Research, and Therapy (Peplau L & Perlman D eds), John Wiley & Sons, New York, pp 224-235 Patnck M (1989) Psychometnc information on Hopelessness Scale Unpubhshed manuscnpt Center for Cognihve Therapy, Philadelphia Poht D & Hungler B (1991) Nursing Research Pnnciples and Methods Lippincott, New York Raleigh E (1980) An investigation of hope as rruimfested in the physically ill adult Dissertation Abstracts International 42, 422204-1313B (University Microfilms No 80-22, 786) Rideout E & Montemuro M (1986) Hope, morale, and adaptation in patients with chronic heart failure Joumal of Advanced Nursing 1 1 , 429-438 Stanley A (1978) The lived experience of hope the lsolahon 336-339 of discreet descriptive elements common to the expenence Jacobson S (1989) Evaluating instruments for use in chnical nursof hope in healthy young adults Dissertation Abstracts ing research In Instruments for Clinical Nursing Research International 39(3), 12312B (University Microfilms No 78-16, (Stromborg M ed), Appleton & Lange, Norwalk, Connecticut, 899) pp 3-19 Stoner M (1982) Hope and Cancer Patients Dissertation Abstracts Kim T (1989) Hojje as a mode of coping in amyotrophic lateral International 4 3 , 1983B-2592B (University Microfilms No 83-12, 243) sclerosis Joumal of Neurosaence Nursing 21(6), 342-347 Kubler-Ross E (1974) Questions and Answers on Death and Dying Stoner M (1988) Measuring hope In Instruments for Clinical Nursmg Practice (Stromborg M ed), Appleton & Lange, MacMillan, New York Norwalk, Connecticut, pp 133-140 McGee R (1984) Hope a factor influencing crisis resolution Stoner M & Keampfer S (1985) Recalled hfe expectancy, phase Advances in Nursing Saence 6(7), 34—44 Miller J (1983) Inspiring hope In Coping With Chrontc Illness of illness, and hope in cancer patients Research in Nursing and Health 8, 269-274 Overcoming Powerlessness (Miller J ed), FA Davis, Stotland E (1969) The Psychology of Hope Jossey-Bass, San Philadelphia Francisco Miller J (1985) Hope Amertcan Joumal of Nursing 85(1), 23-25 Tabachmck B & Fidell L (1983) Usmg Multwanate Stattsttcs Miller J (1989) Hope-inspinng strategies of the cntically ill Harper & Row, New York Applied Nursing Research 2(1), 23-29 VaiUot M (1970) Hope the restoration of being Amencan Miller J & Powers M (1958) Development of an instrument to Joumal of Nursing 70(2), 268-273 measure hope Nursing Research 37(1), 6—10 Vermeersch P (1990) The chnical assessment of confusion-A Nowotny M (1989) Assessment of hope m patients with cancer Applied Nursing Research 3(3), 128-133 development of an mshument Oncology Nursmg Forum 16(1), Watson J (1979) Nursing The Philosophy and Saena of Canng 57-61 Little, Brown, Boston Nunnally J (1978) Psychometric theory McGraw-Hill, New York
1259
Abbreviated instrument to measure hope: development and psychometric evaluation Kaye Herth PhD RN Associate Professor, Graduate Program, School of Nursing, Northem Illinois Umversity, 1240 Normal Road, DeKalb, Illinois 60115-2894, USA
Accepted for publication 17 February 1992
HERTH K (1992) joumal of Advanced Nursmg 1 7 , 1251-1259 Abbreviated instrument to measure hope, development and psychometric evaluation The purpose of this research was to develop and evaluate psychometncally an abbreviated mstrument to assess hope m adults in clinical settings The Herth Hope Index (HHI), a 12-item adapted version of the Herth Hope Scale (HHS), was tested with a convenience sample of 172 ill adults Alpha coefficient was 0 97 with a 2-week test-^retest rehabihty of 0 91 Cntenon-related validity was established by correlating the HHI with the parent HHS (r = 0 92), the Existential Well-Bemg Scale (r = 0 84) and the Nowotny Hope Scale (r = 0 81) Divergent validity with the Hopelessness Scale was estabhshed ( r = — 0 73) Construct validity was supported through the factonal isolation of three factors (a) temporality and future, (b) positive readiness and expectancy, (c) mterconnectedness These three factors accounted for 41% of the total variance in the measure
INTRODUCTION
REVIEW OF LITERATURE
Despite increasing recognition that hope influences the adaptation to illness and promotes wellness, there is a lack of instruments specifically designed to measure this construct m adult dients m clinical settings (Gottschalk 1985, Hmds 1988a,b, Kim 1989, Miller 1989, Rideout & Montemuro 1986) Nurses have had to rely pnmanly on intuihon when assessing hope and have thus been unable to validate specific strategies designed to foster hope in their chents As with most clinical nursing research, the pnonty in the study of hope is the need for a concise, simple and psychometncally sound instrument with which to conduct dmical research studies mvolving the administration of a battery of instruments and the use of repeated-measure designs to assess hope (Stoner 1988) The purpose of this study was to develop and evaluate psychometncally an abbreviated mstrument to assess hope, which would be feasible for such research
Interest in the concept of hope, the psychosociodemographic antecedents and correlates of hope and the measurement of hope is evident m the health care literature, which reflects the commitment and concem of the nursing profession to foster hope in dients (Foote et al 1990, Fan-an & Popovich 1990, Hall 1990, Herth 1989, 1990a, Hickey 1986, Kim 1989, Miller 1985, VaiUot 1970, Watson 1979) A number of instruments with which to measure hope have been developed dunng the past 2 decades Several conceptual and methodological issues that may influence the usefubess of these instruments m clinical research, however, have recently been identified
Conceptual issues Histoncally, the development of instruments to measure hope has paralleled the conceptual understandings of the construct The first instruments (Beck et al 1974, Enckson 1251
K. Herth
et al 1975, Gottschalk 1974, Stoner 1982) were based on Stotland's (1969) narrow conceptuahzation of hope as 'an expectation of goal achievement' The complehon of quahtahve studies (Haberland 1972, Miller 1983, 1985, Raleigh 1980, Stanley 1978) explonng dimensions of hope dunng the late 1970s and early 1980s in well and chronically ill adult populations descnbed additional elements common to the expenence of hope and laid the foundation for the development of the first multidimensional measures of hope Specific dimensions of hope identified in these studies were the interpersonal element, the hme-onented, future focus of hope, and the goalachievement expectation of hope The Hope Index Scale (Obayuwana et al 1982), the Stoner Hope Scale (SHS) (Stoner 1988), the Miller Hope Scale (MHS) (Miller & Powers 1988) and the Nowotny Hope Scales (NHS) (Nowotny 1989) address these multiple dimensions of hope Studies completed since the mid-1980s (Dufault & Martocchio 1985, Ferran et al 1990, Herth 1990a, Hinds 1988a,b, Hinds & Martin 1988, O'Malley & Menke 1988, Owen 1989) with the ill and the elderly population suggest that, m addition to the multidimensional elements of hope identified earher, a number of conceptual issues remain to be addressed Concepts that are not included in the existing hope instruments include (a) a more global, non-timeoriented sense of hope, (b) hope despite diminished or absent interpersonal relationships, (c) hope as a sense of 'being' available and engaging m relationships, as opposed to 'doing' for oneself and others, and (d) potential of hope for controlling behavioural or emotional responses as opposed to the control of events or expienences The Herth Hope Scale (Herth 1991) was designed to incorporate not only the cnhcal elements incorporated in the other scales, but also more recently identified concepts Thus, the Herth Hope Scale, because of its broader conceptual basis, has increased potential for use m clmical situations with the ill and elderly populahons (Herth 1991) Methodological issues Methodologically, the majority of hope studies involve the administration of multiple instruments of considerable length to clinical populations Little considerahon has been given to the time, effort or energy required to complete the instruments In addition, potenhal mild discomfort when directly confronting one's feehngs about hope and the amount of self-disclosure required in responding to these items place additional burdens on respondents For these reasons, the dimcal utility of exishng instruments to measure hope is open to queshon 1252
To be climcally useful, an instrument should (a) measure the mulhdimensional aspects of a concept, (b) demonstrate validity and reliability with mdividuals of vanous ages, educational, cultural and socio-economic backgrounds, (c) reduce subject response burden in terms of time and energy involved to complete the instrument, (d) lessen administrative time, cost and skill needed to administer and score the instrument, (e) be amenable to serial examinations so as to enable evaluahon of hope over time, and (f) have direct clinical relevance (Jacobson 1989, Poht & Hungler 1991, Vermeersch 1990) Instruments currently available to measure hope vary in format and length from the 60-item dichotomous Hope Index Scale developed by Obayuwana et al (1982) to the 30-item four-point rating Herth Hope Scale (Herth 1991) All available hope scales, with the exception of the Herth Hope Scale, lack reliability and validity testing with the senously ill and elderly populations Farran et al (1990) used only two of the three subscales of the Stoner Hope Scale in a study of hope m the elderly population, after which they expressed concems about the appropnateness of the items with this age group Scoring of instruments also vanes considerably m complexity The instruments developed by Enckson et at (1975) and Stoner (1982) require calculation of both an unportance and probability score, the Herth Hope Scale is a more simple summated rating schema Qualitative data obtamed on the Herth Hope Scale suggest that the clanty and complexity of the items and the length of the scale, though shorter than other available hope scales, may also limit its dimcal utility The methodological and conceptual issues associated with existing hope instruments tend to limit their clinical usefulness This limitation provided the lmputus for adapting the Herth Hope Scale to a more feasible, dimcal instrument
DEVELOPMENT OF THE HERTH HOPE INDEX The Herth Hope Index (HHI) is an adaptation of the Herth Hope Scale (HHS) designed specifically for use m the clinical setting The objective of the adaptahon was to capture the multidimensionality of hope as represented on the HHS, to reflect clearly the unique dunensions of hope in the dimcal populations, and to reduce the number and complexity of items and so render the tool more clinically useful The HHI is designed to faahtate the examination of hope at vanous intervals so that changes in levels of hope can be identified Given adequate validity and rehabihty estimates, the HHI could potenhally aid researchers and clinicians in the assessment of hope states within dients and
Instrument to measure hope
m the evaluation of the effectiveness of hope-enhancing strategies Charactenstics of the parent tool The parent tool, the Herth Hope Scale (HHS), is a 30-item, four-point scale (Herth 1991) based upon the six dimensions of hope conceptualized in Dufault and Martocchio's Model of Hope (Dufault & Martocchio 1985) The six dimensions of hope were combined and used as a framework for generating items for the HHS (a) cognitivetemporal (the perception that a positive, desired outcome IS realistically probable m the near or distant future), (b) affechve-behavioural (a feelmg of confidence with initiation of plans to affect the desired outcome), (c) affiliative-contextual (the recognition of the interdependence and mterconnectedness between self and others and between self and spirit) (Herth 1991) Hope, as defined m this model, is 'a multi-dimensional dynamic life force charactenzed by a confident yet uncertain expectation of achieving good, which to the hoping person, is realistically possible and personally significant' (Dufault & Martocchio 1985) The HHS has been completed by 180 cancer patients (Herth 1989), 185 well adults (Herth 1988a), 40 well elderly (Herth 1988b) and 75 elderly widow(er)s (Herth 1990b) The alpha reliability coeffiaents for the total scale ranged from 0 75 to 0 94 with a 3-week test-retest reliability of 0 89 to 0 91 A negahve correlahon (r= —0 69) was found between the HHS and the Beck Hopelessness Scale Three factors as originally conceptualized were identified through factonal analysis procedure factor 1, temporality and future (cognitive-temporal dimension), factor 2, positive readiness and expectancy (affective-behavioural dimension), and factor 3, mterconnectedness (affihative— contextual dimension)
Construction of the Herth Hope Index Twelve items were developed for the shortened mstrument from items on the HHS In an effort to increase clinical usefulness, specific attention was given to designing simple items and to relating items to adults expenencmg alterations m health status The items of the HHI are in Likert-format and are divided over the three subscales paralleling those of the HHS Each item was scored on an ordinal scale from 1 to 4, where a score of 1 indicates 'strongly disagree' and a score of 4 indicates 'strongly agree' Items were ordered so as to reduce response set, that is, no two consecutive items are from the same subscale, and no more than two consecutive
items are keyed m the same direction For analysis, all negative items were reverse scored so that a higher score would mdicate a higher level of hope Total scores could range from 12 to 48 Larger-than-normal print was used for improved readability with ill and/or elderly dients
Content validation of the Herth Hope Index Empincal vahdation of the HHI was accomplished by followmg the general approach advocated by Nunnally (1978) Two review panels evaluated the face and content validity of the HHI An Expert Research/Measurement Panel, consisting of four university members with expertise in research and instrument development, addressed (a) the congruence of each item with the conceptual definition of hope, (b) the clarity and readability of each item, and (c) the explicitness and simplicity of instructions A 12member Client/Nurse Clinician Panel, addressed the face validity, language, clanty and simplicity of the HHI The panel consisted of six clients of diverse educational and socio-economic background who were diagnosed with either an acute, chronic or terminal illness and six nurse clinicians employed at vanous settings (hospital, hospice and home care agency) All suggested revisions m format and wording were made Reading level was established at sixth grade according to the Flesch Readability Formula (Flesch 1974)
Pilot test of the Herth Hope Index The HHI was pilot tested with a convenience sample of 20 physically ill adults from a small community hospital in the Northem Illinois areas of the US The subjects ranged in age from 22 to 82 years (x = 51 years), 70% were female, 30% were male and 95% Caucasian The educational levels, length of illness and diagnoses of subjects represented a wide spectrum Fatigue was measured by a categoncal scale none, little, moderate or severe This was because fatigue has been identified m the literature as possibly interfering with completion of instruments and postulated to correlate with a lowered hope level Sixty-five per cent of the subjects reported expenencmg a moderate to high level of fatigue, all subjects, however, completed the instrument As expected, fatigue significantly ( P < 0 05) affected the HHI score subjects who reported experiencing high fatigue had significantly lower mean hope scores than did those experiencing moderate, little or no fatigue All subjects reported that the wording of the HHI and the mstructions were clear Additional comments were related to how well selected items
1253
K.Herth Table 1 Descnptive and inferential statistics summary for the samples (n = 192)
Descnphve data
Variables Sample size Mean age Age range % Male % Female % Caucasian % Black % Oriental % < Hs Education % Hs Diploma % Varying levels of college % Protestant % Catholic % lewish % Employed % Unemployed % Retired HHI mean HHI range HHISD
Pilot test acutely ill sample
Acute illness
Chronic illness
Terminal illness
20 51
70 48
71 52
31 51
Entire sample 172
22-82
18-86
24-94
22-90
50 3 22-94
30 70 95 3 1 19 44 37 34 52 9 92 5 3
56 44 74 25 1 20 49 31 48 45 7 96 2 2
41 59 68 22 10 21 52 27 39 50 11 88 10 12
42 58 72 26 2 24 57 19 41 47 12 58 22 20
50 50 71 25 4 22 53 25 43 47 5 81 8 11
3123 12-48 8 22
36 87 20-48 9 96
34 38 18-48 8 84
32 19 12-48 10 03
34 49 12-48
0 96
0 94
0 97 0 91
961
Inferential data Alpha coefficient Test—retest (2 weeks) Pearson r HHI and HHS HHI and NHS HHI and HS
HHI and EWS
expressed the subjects' hope The initial mtemal consistency rehabihty was supported by a Cronbach alpha of 0 94, and the item means mdicated that there were no 'ceiling' or 'floor' effects in the instrument Completion time ranged from 1 to 4 minutes
P S Y C H O M E T R I C E V A L U A T I O N OF THE HERTH H O P E INDEX Sample characteristics The HHI and the construct vahciation instruments were acimmistered to a convemence sample of 172 adults, of 1254
0 94
0 98
0 92 0 81 - 0 73 0 84
which 70 were acutely ill, 71 were chromcally ill and 31 were termmally ill The sample was drawn from inner city, suburban and rural hospitals («= 103), from out-patient settings (n = 20), and from those receiving care at home through a visiting nurse association or hospice home-care programme (n = 47) A deliberate attempt was made to obtain the most heterogeneous population possible through the use of a variety of pubhc and pnvate agencies Evidence of this heterogeneity of age (22-94 years, x = 50 30), ethnic and racial mix, educahonal levels £md soao-economic background IS depicted in Table 1 The background characteristics were fairly evenly distnbuted across the sample A
Instrument to measure hope
vanety of diagnostic categones (n = 14), lengths of ilbess ( > 2 months to 18 years) and levels of fahgue ('none' to 'overwhelming') were represented
Procedure
The proposal for the present study was reviewed and approved by the University Review Board and the appropnate individuals and committees of the partiapahng agencies The purpose of the study and the elements of Validating mstruments informed consent were explained to the potential participant by the inveshgator or her research assistant Those The Herth Hope Scale (HHS) (Herth 1991), the Existential Well-Bemg Scale (EWS) (Paloutzian & Ellison 1982) and individuals mdicatmg a desire to participate were given the Nowotny Hope Scale (NHS) (Nowotny 1989) were a packet containing a cover letter, the Background used to determme concurrent criterion-related validity Information Form, the five questionnaires (HHI, HHS, The HHI was compared with the HHS because, when NHS, HS, EWS) arranged m random order so as to allow for reducing the number of items m a scale, high concurrent the possible effects of fahgue, and an envelope for the validity with the ongmal scale protects against the loss of completed forms Completion of the entire packet took an significant mformahon The NHS was used m order to average of 40 mmutes, the subjects were given 1 hour, compare the HHI with another measure of hope that had however, to accommodate for possible intervening treatbeen used with ill adults Companson with the EWS was ments or fatigue level The sealed envelopes containing the completed because existential well-being has been theore- anonymously completed forms were collected at the end of tically hnked to hope (McGee 1984) The Hopelessness the hour Twenty randomly chosen subjects were given Scale (HS) (Beck et al 1974) was used to determine divergent the HHI twice within a 2-week interval to determine test-retest rehabihty validity of the HHI The HHS was used in the validation study because it was the parent instrument for the HHI As noted previously, it has estabhshed reliability and validity with the elderly and ill population (Herth 1991) The EWS IS a 10-item, six-point Likert subscale of the Spintual Well-Bemg Scale (Paloutzian & Ellison 1982), which IS considered a valid measure of a construct integral to hope (McGee 1984) The range of scores of the EWS is 10 to 60, with high scores indicating high existential wellbeing The mtemal consistency alpha coefficient is 0 78 with a 2-week, test-pretest rehabihty of 0 86 (Paloutzian & Ellison 1982) The revised NHS is a 29-item, four-point Likert scale based on a review of the theoretical perspectives of hope (Nowotny 1989) Scores can range from 0 to 116, with a high score indicating high hope The original NHS of 47 items was tested with 306 adults (well individuals and individuals with cancer), the followmg findings were based on an analysis of the final 29 items Cronbach alpha of 0 89 and concurrent vahdity with the HS of r = -047 The HS IS a 20-item, true-false scale, in which scores range from 0 to 20 and high scores indicate high hopelessness (Beck et al 1974) The initial mtemal consistency rehabihty using KR-20 (Kuder-Richardson) was 0 93, with a reported concurrent validity of r = 0 74 between clmical ratings of hopelessness and instrument rating of hopelessness (Beck et al 1974) These findmgs have been substantiated m numerous studies usmg the scale (Patnck 1989)
FINDINGS Construct validity Construct validity of the HHI was assessed by using a maximum likelihood factor analysis with vanmax rotation The resulting three-factor solution was determined by eigenvalues greater than 1, a lack of trivial factors, and residual matnx values of less than 0 1 The cntenon selected for factor loadings was 0 40 According to Tabachmck & Fidell (1983), a factor loading of 0 40 indicates at least a 20% overlap in vanance between the Vcinable and factor A total of 61% of the vanance was explained by a three-factor solution Eigenvalues for the three factors were 2 02,157 and 1 35 respectively Table 2 illustrates the factor pattem and loadings of the HHI items All 12 items had a significant loading on one of the three factors as was ongmally conceptuahzed, and these correspond to the three ongmally fonned subscales of the HHS (a) temporality and future, (b) positive readiness and expectancy, and (c) interconnecteciness Factor 1, labelled temporality and future, consists of four items hypothesized to measure the cognitive—temporal dimension of hope Representative items include, 'I beheve that each day has potential' and 'I have specific possible short, intermediate or long range goals' Factor 2, labelled posihve readmess and expectancy, IS formed from four items hypothesized to measure the affective—behavioural dimension of hope Examples of 1255
K Herth
Table 2 Factor loadings, mean standard deviahons and corrected item-total correlahons for Herth Hope Index items (« = 172)
Item
Items on HHI
Corrected item-total correlation
Mean
SD
Factor 1 inner sense of temporality and future Presence of goals 0 72 Posihve outlook on hfe 0 76 Each day has potenhal 0 54 Scared about the future -081
31 39 36 12
0 92 0 64 0 79 10
0 54 0 69
Factor 2 inner positive readmess and expectancy cy See a light m a tunnel 0 81 A sense of direchon 041 Life has value and worth 0 72 Recall happy/joyful times 0 59
29 27 31 30
0 93 0 84
0 70 0 50
060
047
0 96
0 62
Fador 3 lnterconnectedness with self and others rs Feel all alone - 0 70 Faith that comforts 0 63 Deep inner strength 0 58 Give and receive canng/love 0 60
23 30 27 25
0 84 0 97
061
items within the factor include, 'I see a light in a tunnel' and 'I have a sense of direction' Factor 3, labelled lnterconnectedness, consists of four items hypothesized to measure the affihative-contextual dimension of hope Examples of items in this factor mclude, 'I have a faith that gives me comfort' and 'I am able to give and receive canng/love' Factors 1 and 2 had the highest lntercorrelation (r = 0 42) The correlahon between factors 1 and 3 were 0 21 and that between 2 and 3 was 0 18 Other validity measures The construct validation of the HHI involved the admmistration of a vanety of companson instruments (Table 1) Concurrent cntenon-related validity was assessed by calculating the correlahons of the HHI to the HHS (r = 0 92), the EWS (r = 0 84), and the NHS (r = 0 81) Divergent vahdity was assessed by calculating the correlation of the H H I t o t h e H S ( r = - 0 73) Internal consistency Data were analysed for mtemal consistency on the first administration and for stabihty on repeat admmistrahon 2 weeks later The Cronbach coeffiaent alpha was 0 97 on 1256
Factor loachngs
10
0 90
061 051
0 67 0 53 0 42
the HHI, which indicated mtemal consistency Test-retest correlation was 0 91, indicahve of stability over time Each of the three factors were examined for the reliability as subscales, alpha coefficients were found to range from 0 78 to 0 86 The Cronbach alpha coefficients for the other instruments used m the study were 0 95 on the HHS, 0 90 on the EWS, 0 88 on the NHS and 0 89 on the HS The alpha for the total HHI ranged across educahonal, age, fatigue and phase of illness subgroups from 0 72 to 0 89
Descriptive profile of the Herth Hope Index The scores on the HHI ranged from 12 to 48 The overall mean for the HHI was 32 39 (SD = 9 61) As shown m Table 2, the item means fall slightly above the midpoint of 2 0 for this scale, with standard deviations fluctuating around 100 The item means suggest that there are no ceding or floor effects for any of the items The standard deviations support the vanabihty of each item, indicating that the respondents were usmg the full range of scores The means of the other validatmg instruments used m the study were as follows the HHS was 90 90 (SD = 30 36, range 32-120), the EWS was 4198 (SD = 1643, range 10-60), the NHS was 84 08 (SD = 16 43, range 24-116) and the HS was 6 02 (SD = 8 29, range 0-20)
Instrument to measure hope
Table 3 Stepwise mulhple regression analysis of the Herth Hope Index for selected background variables
Variables'
Mulhple R
Length of illness Income Fahgue level Mantal status
0 40 0 47 051
0 54
R^ change
016
015
0 22 0 26 0 29
0 21 0 25 0 27
Significance
3132 23 20 1951 16 30
0 01) in the level of hope according to mantal status, diagnosis, length of illness, income status and fatigue level The significant findings were further evaluated through the use of the Tukey HSD post hoc test Subjects who were mamed had a significantly higher mean hope score than the subjects who were separated, divorced, widowed or cohabiting Those subjects who were diagnosed with AIDS had a significantly lower mean hope score than did the subjects in the following diagnostic categones cardiovascular, gastrointestinal, musculoskeletal, neurological, haematological and respiratory
Subjects who reported a duration of an illness greater than 12 months had a significantly lower mean score than did the subjects whose illness had been present fewer than 2 months or from 2 to 12 months In addihon, the subjects who reported inadequate income had a significantly lower mean score than did the subjects who reported adequate or very adequate incomes Fatigue significantly affected hope Subjects who reported expenencing high or overwhehning fatigue had significantly lower mean hope scores than did those expenencing little fatigue These findings are supported m the literature on hope (Foote et al 1990, Herth 1990a,b, Miller 1989, O'Malley & Menke 1988, Rideout & Montemuro 1986, Stoner & Keampfer 1985) A stepwise mulhple regression was conducted to determme which of the 10 variables (mantal status, diagnosis, length of llhiess, phase of illness, income, fatigue level, educational level, gender, race and age) were the best predictors for the level of hope Four variables (length of illness, income, fatigue level and mantal status) accounted for 27% of the vanance m hope level (Table 3) DISCUSSION Researchers and clinicians have identified the need for a measurement tool that is concise, clear and therefore practical for use in screening adults for different levels of hope m the clinical setting (Nowotny 1989, Obayuwana & Carter 1982, Stoner 1988) The HHI is a carefully constructed tool for use by clinical researchers and nurse clinicians with adult clients in clinical settings The consistent reliability of the total HHI and the three subscales across these subgroups indicate that it could be used with adults of varying educational levels, ages, fatigue levels and/or phase of illness The nature of this tool is such that the nurse is able to examine the response to each item and associate the individual's hope in relation to the particular area represented by the item The items could potentially serve as 'probes' to help identify areas that the nurse could explore further with the client for developing speafic, hope-enhancing interventions 1257
K Herth
Prehminary results support the mtemal consistency reliability, test—retest reliability and the content validity of the HHI Support for concurrent cntenon-related validity is demonstrated by the high correlahon of the HHI with the original Herth Hope Scale (r = 0 92) and the moderate correlation with the Nowotny Hope Scale (r = 0 81), and the Existential Well-Bemg Scale (r = 0 84) The high correlahon of 0 92 between the shortened HHI and the HHS and between the subscales of the HHI and the subscales of the HHS suggests that the HHI is as comprehensive and rehable as the longer 30-item version and that the HHI is tapping essentially the same dimensions as the HHS The moderate correlation betweeen the HHI and the NHS suggests that the HHI is measunng hope but is different conceptually from the NHS In addition, the positive correlation of the HHI with the EWS, a measure of a construct theoretically related to hope, supports its valichty Divergent validation, as evidenced by a negahve correlation (r = — 0 73) of the HHI to hopelessness, was confirmed
areas from the view point of the individual This type of systematic inquiry may help clients to organize their thoughts and to articulate more clearly their feelings of hope This hypothesis needs, however, to be subjected to systemahc mveshgahon It is anticipated that the HHI will become a useful tool, both as a screening device and eventually as a diagnostic mstrument, in the assessment of hope states within dients and m the planning and the evaluahon of the effectiveness of hope-enhancmg shategies
Acknowledgements This research was funded by grants from Sigma Theta TauBeta Omega Chapter and Northem Illinois University The author is grateful to Lorys Oddi for her editonal assistance, to Yvonne Eaves for assistance m data gathenng and to Deonne Johnson and Ron Leifheit for their assistance in preparation of the manuscnpt and graphics, and to the staff and dients from the participating agencies, institutions and community groups
Three factors of hope Three factors of hope — temporality and future, posihve readiness and expectancy, and lnterconnectedness — were identified through factonal analysis These factors correspond to the three subscales of the ongmal Herth Hope Scale Comparability and consistency with the longer version of the factor structure suggests that the 12-item version IS as powerful a measure as the 30-item version Efforts should continue to be directed at obtaimng more extensive assessments of the constmct vahdity of the HHI The apphcabihty of the current form of the scale to vanous other subpopulations (e g adolescents and children, people with vanous cultural backgrounds and health problems) should be mveshgated Only with extensive descnphve apphcahon of the HHI will norms be estabhshed and its suitability for apphcation to varied clinical populations and settings be validated In the future, predichve validity studies that will correlate dimcal health outcomes suggestive of mcreased or decreased hope need to be completed The instrument should enable the nurse researcher to screen levels of hope quickly in a diverse adult population and to examine the psychosociodemographic antecedents and correlates of hope Because the HHI requires only a few mmutes to admimster, chents may expenence less fatigue and thus be more willing to complete the instrument, parhcularly m a repeated-measures research design In addition, the items could provide a checklist of areas for a focused assessment, together with some information about the relahve extent of hope/hopelessness m each of these 1258
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