579609 research-article2015
CNRXXX10.1177/1054773815579609Clinical Nursing ResearchWu et al.
Article
Development and Validation of the Spiritual Care Needs Inventory for Acute Care Hospital Patients in Taiwan
Clinical Nursing Research 2016, Vol. 25(6) 590–606 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773815579609 cnr.sagepub.com
Li-Fen Wu, RN, PhD1, Malcolm Koo, PhD2,3, Yu-Chen Liao, RN, MSc4, Yuh-Min Chen, RN, PhD5, and Dah-Cherng Yeh, MD4
Abstract Spiritual care is increasingly being recognized as an integral aspect of nursing practice. The aim of this study was to develop a new instrument, Spiritual Care Needs Inventory (SCNI), for measuring spiritual care needs in acute care hospital patients with different religious beliefs. The 21-item instrument was completed by 1,351 adult acute care patients recruited from a medical center in Taiwan. Principal components analysis of the SCNI revealed two components, (a) meaning and hope and (b) caring and respect, which together accounted for 66.2% of the total variance. The internal consistency measures for the two components were 0.96 and 0.91, respectively. Furthermore, younger age, female sex, Christian religion, and regularly attending religious activities had significantly higher mean total scores in both components. The SCNI was found to be a simple instrument with
1National
Taichung University of Science and Technology, Taichung, Taiwan Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan 3University of Toronto, Ontario, Canada 4Taichung Veterans General Hospital, Taiwan 5China Medical University, Taichung, Taiwan 2Dalin
Corresponding Author: Malcolm Koo, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2 Minsheng Road, Dalin, Chiayi, 62247 Taiwan. Email: [email protected]
Wu et al.
591
excellent internal consistency for measuring the spiritual care needs in acute care hospital patients. Keywords acute disease, hospital–patient relations, patient, spirituality validation studies
Introduction Spirituality is a vital aspect of wellness. It can provide a sense of meaning and purpose in life, particularly during times of crisis and illness. Spirituality can be defined as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred” (p.887), (Puchalski et al., 2009). It is also an important determinant of physical, emotional, and social health (Hassed, 2008) and constitutes one of the six quality of life domains in the World Health Organization Quality of Life (WHOQOL) Instrument (World Health Organization, 1998). Within the context of nursing practice, spiritual care can broadly be defined as the aspect of care that attends to the needs of the human spirit brought on by an illness or injury. When spiritual care needs of hospitalized patients are not met, they are at an increased risk of depression (Pearce, Coan, Herndon, Koenig, & Abernethy, 2012). It should be noted that spirituality is a much broader phenomenon than simply a formal religious expression. It is a universal concept, unique to all people, such as creativity, art, and selfexpression (McSherry, Draper, & Kendrick, 2002). Thus, although people may not have a religious affiliation, they may still have spiritual needs. A number of instruments are available for measuring spiritual care needs. Burkhart, Schmidt, and Hogan (2011) developed the 17-item “Spiritual Care Inventory” to assess the process of providing spiritual care from the nurses’ perspective. The psychometric properties of the instrument were tested in a sample of registered nurses. The authors suggested that future research is needed to test the psychometric properties of the instrument in different cultures because their study sample consisted of only nurses in urban, Western societies. Galek, Flannelly, Vane, and Galek (2005) analyzed the literature pertaining to patient spiritual needs and constructed a 29-item instrument for assessing traditional religion as well as non-institutional-based spirituality. The modified version of the instrument “Patient Spiritual Needs Assessment Scale” with 24 items was tested on 683 chaplains and pastoral care directors (Flannelly,
592
Clinical Nursing Research 25(6)
Galek, & Flannelly, 2006). Another widely used rating scale for measuring levels of spiritual care perception is the 17-item “Spirituality and Spiritual Care Rating Scale” (SSCRS). It includes four subscales of spirituality, spiritual care, religiosity, and personalized care (McSherry et al., 2002). It has previously been used to explore nurses in Hong Kong for their perceptions of spirituality and spiritual care (Wong, Lee, & Lee, 2008), and it was translated into Chinese and tested in nurse students in Taiwan (Wu, Liao, & Yeh, 2012). Most studies on spirituality and spiritual care needs have been focusing on the needs of patients with advanced illness (Meraviglia, Sutter, & Gaskamp, 2008; Pearce et al., 2012; Wallace & O’Shea, 2007) and chronic diseases (Büssing, Balzat, & Heusser, 2010; Büssing, Zhai, Peng, & Ling, 2013), or from the perspective of health care professionals (Battey, 2012; Lundmark, 2006; Nixon, Narayanasamy, & Penny, 2013; Wu & Lin, 2011). However, although acute care hospital patients should also have spiritual care needs, little is known about their needs (Ellis, Thomlinson, Gemmill, & Harris, 2012). Transition theory can provide a framework to explain the spiritual care needs of acute care hospital patients. When people are facing a health crisis such as undergoing surgical procedures, they go through multiple and simultaneous transitions into a state of increased vulnerability and potentially negative health outcomes (Meleis, Sawyer, Im, Hilfinger Messias, & Schumacher, 2000). Such transition can disrupt one’s connection with the reality and lead to the feeling of hopelessness and cutoff from self and others (Selder, 1989). Morse (1997) further emphasized the notion of instantaneous disruptions in acute health situations in which spiritual wellness could be negatively affected. Spiritual needs were also identified as one of the three themes experienced by patients undergoing an excisional breast biopsy (Demir, Donmez, Ozsaker, & Diramali, 2008). Furthermore, in an interview study on 39 experienced clinical nurses, which was a part of an unpublished secondary study of clinical nurses’ perceptions of spirituality and spiritual care (Wu & Lin, 2011), these nurses indicated that no suitable instruments were available for assessing the spiritual care needs of acute hospitalized Chinese patients. These nurses were also concerned that because the existing spiritual care needs instruments were developed in Western populations and mostly in non-acute care settings, one that is developed specifically with Taiwanese patients might be needed to better reflect the cultural, linguistic, and multi-faith environment of Taiwan. Therefore, this study was designed to investigate the psychometric properties of a new instrument, the Spiritual Care Needs Inventory (SCNI), which was developed specifically to assess the spiritual care needs in Taiwanese acute care hospital patients. This study also compared whether spiritual care needs varied among patients with different religious beliefs.
Wu et al.
593
Method Development of the SCNI The guidelines of scale development outlined by DeVellis (2012) were adopted in this study. First, we defined the aim of the scale to measure the “spiritual care needs in acute care hospital patients.” Second, we generated an item pool from both a critical review of the literature and a review of the items from existing patient’s spiritual care needs instruments. A total of 105 items were obtained from 149 published articles and three patient’s spiritual care needs instruments. Third, the 105 items were reviewed by an expert panel consisting of five spiritual care professionals and researchers. Each item was evaluated for its clarity and relevance. Eighty items were merged or eliminated based on a priori criteria, such as undesirable similarity to other items, lack of clarity, ambiguous, or questionable relevance. A total of 25 items related to spiritual care were identified. Fourth, a panel that consisted of seven experts, including four nurse educators and three experienced clinical nurses, examined the items for their content validity. The content validity index (CVI) was calculated for each item based on a 4-point ordinal scale; 1 = not relevant, 2 = needs major revision that it would no longer be relevant, 3 = relevant but needs minor revision, and 4 = relevant. The CVI for the individual item was calculated as the proportion of experts who rated each item a 3 or 4, and the instrument-level CVI was calculated as the proportion of total items that received a rating of 3 or 4. Of the 25 items, 21 of them achieved the recommended cutoff value of 0.80 (Polit & Hungler, 1999). Four items considered ambiguous or repetitive were eliminated from the instrument. The item-level CVIs for the 21-item instrument ranged from 0.82 to 1.00 and the instrument-level CVI was 0.87. In the next phase, the 21-item instrument was pilot tested with a convenience sample of 30 adult acute care hospital patients. The clarity of the items and the flow of the whole instrument were evaluated. Each item was rated on a 5-point Likert-type scale ranging from 1 (not needed at all) to 5 (strongly needed); therefore, a higher score indicates a higher level of spiritual care needs. The Cronbach’s alpha coefficient for the SCNI was .96, demonstrating a high level of internal consistency. In addition, results from the pilot study indicated that the entire questionnaire could be completed within 15 min. This final 21-item version of the SCNI (the items are listed in Table 2) was then evaluated with a large sample of adult acute care hospital patients described below.
Study Participants and Design A random sample of patients who were hospitalized for acute care was recruited with stratification by patient wards from a medical center in central
594
Clinical Nursing Research 25(6)
Taiwan. The 16-week recruitment period started on February 1, 2013 and ended on May 31, 2013. Ten patients were randomly selected weekly from each of the 16 adult patient wards in the hospital. A total of 1,850 patients agreed to participate in the study and provided informed consent. The inclusion criteria were adult patients with acute disease and able to respond to our questionnaire either in written or verbal form. The sample size was adequate for principal components analysis according to DeVellis’s (2012) guideline of 5 to 10 participants per item. A structured questionnaire was used to obtain information on age, sex, educational level, religious beliefs, and frequency of attending religious activities from the participants. In addition, spiritual care needs of the participants were ascertained using the final version of SCNI. The 21-item final version of SCNI demonstrated a high level of internal consistency and clarity. General information about the study and instructions for filling the questionnaire were provided in the beginning of the questionnaire. The purpose of the study and the time required (5-10 min) to fill in questionnaire were included. In addition, respondents are reminded to complete the questionnaire based on their true opinion. Most of participants completed the survey on their own except 23 participants who had to provide verbal response because they had surgery performed on their dominant hand. Participants were asked to return the completed questionnaire into a locked box located next to the nursing station.
Ethical Considerations Ethical approval was granted by the institutional review board of the study hospital. The questionnaire contained no names or identification numbers to prevent breach of confidentiality. Informed consents were obtained from the 1,850 eligible patients of the main study and all the members of the expert panel and the 30 patients involved in the developmental phase of the SCNI.
Data Analysis Descriptive statistics, ANOVA with Bonferroni post hoc test, principal components analysis, and multiple linear regression analysis were conducted using SPSS for Windows version 18.0 (SPSS Inc, Chicago, IL, USA). Principal components analysis was performed to identify components of SCNI. Extraction was based on eigenvalue >1 and PROMAX rotation with Kaiser normalization. ANOVA and multiple linear regression analyses were conducted separately for each of the components obtained from the principal components analysis. The dependent variable for each component was the
Wu et al.
595
sum of the item scores, linearly transformed to a scale of 0 to 100, of the corresponding component. Independent variables evaluated in the regression model include age group, sex, education level, religious belief, and pattern of religious activities attendance. The entry and removal probabilities for the stepwise variable selection were set at .05 and .10, respectively. The presence of multicollinearity was tested using variance inflation factor (VIF). Effect sizes for the group comparison in the ANOVA and regression analyses were expressed as Cohen’s d statistic and standardized regression coefficients, respectively. A p value of
CNRXXX10.1177/1054773815579609Clinical Nursing ResearchWu et al.
Article
Development and Validation of the Spiritual Care Needs Inventory for Acute Care Hospital Patients in Taiwan
Clinical Nursing Research 2016, Vol. 25(6) 590–606 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773815579609 cnr.sagepub.com
Li-Fen Wu, RN, PhD1, Malcolm Koo, PhD2,3, Yu-Chen Liao, RN, MSc4, Yuh-Min Chen, RN, PhD5, and Dah-Cherng Yeh, MD4
Abstract Spiritual care is increasingly being recognized as an integral aspect of nursing practice. The aim of this study was to develop a new instrument, Spiritual Care Needs Inventory (SCNI), for measuring spiritual care needs in acute care hospital patients with different religious beliefs. The 21-item instrument was completed by 1,351 adult acute care patients recruited from a medical center in Taiwan. Principal components analysis of the SCNI revealed two components, (a) meaning and hope and (b) caring and respect, which together accounted for 66.2% of the total variance. The internal consistency measures for the two components were 0.96 and 0.91, respectively. Furthermore, younger age, female sex, Christian religion, and regularly attending religious activities had significantly higher mean total scores in both components. The SCNI was found to be a simple instrument with
1National
Taichung University of Science and Technology, Taichung, Taiwan Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan 3University of Toronto, Ontario, Canada 4Taichung Veterans General Hospital, Taiwan 5China Medical University, Taichung, Taiwan 2Dalin
Corresponding Author: Malcolm Koo, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2 Minsheng Road, Dalin, Chiayi, 62247 Taiwan. Email: [email protected]
Wu et al.
591
excellent internal consistency for measuring the spiritual care needs in acute care hospital patients. Keywords acute disease, hospital–patient relations, patient, spirituality validation studies
Introduction Spirituality is a vital aspect of wellness. It can provide a sense of meaning and purpose in life, particularly during times of crisis and illness. Spirituality can be defined as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred” (p.887), (Puchalski et al., 2009). It is also an important determinant of physical, emotional, and social health (Hassed, 2008) and constitutes one of the six quality of life domains in the World Health Organization Quality of Life (WHOQOL) Instrument (World Health Organization, 1998). Within the context of nursing practice, spiritual care can broadly be defined as the aspect of care that attends to the needs of the human spirit brought on by an illness or injury. When spiritual care needs of hospitalized patients are not met, they are at an increased risk of depression (Pearce, Coan, Herndon, Koenig, & Abernethy, 2012). It should be noted that spirituality is a much broader phenomenon than simply a formal religious expression. It is a universal concept, unique to all people, such as creativity, art, and selfexpression (McSherry, Draper, & Kendrick, 2002). Thus, although people may not have a religious affiliation, they may still have spiritual needs. A number of instruments are available for measuring spiritual care needs. Burkhart, Schmidt, and Hogan (2011) developed the 17-item “Spiritual Care Inventory” to assess the process of providing spiritual care from the nurses’ perspective. The psychometric properties of the instrument were tested in a sample of registered nurses. The authors suggested that future research is needed to test the psychometric properties of the instrument in different cultures because their study sample consisted of only nurses in urban, Western societies. Galek, Flannelly, Vane, and Galek (2005) analyzed the literature pertaining to patient spiritual needs and constructed a 29-item instrument for assessing traditional religion as well as non-institutional-based spirituality. The modified version of the instrument “Patient Spiritual Needs Assessment Scale” with 24 items was tested on 683 chaplains and pastoral care directors (Flannelly,
592
Clinical Nursing Research 25(6)
Galek, & Flannelly, 2006). Another widely used rating scale for measuring levels of spiritual care perception is the 17-item “Spirituality and Spiritual Care Rating Scale” (SSCRS). It includes four subscales of spirituality, spiritual care, religiosity, and personalized care (McSherry et al., 2002). It has previously been used to explore nurses in Hong Kong for their perceptions of spirituality and spiritual care (Wong, Lee, & Lee, 2008), and it was translated into Chinese and tested in nurse students in Taiwan (Wu, Liao, & Yeh, 2012). Most studies on spirituality and spiritual care needs have been focusing on the needs of patients with advanced illness (Meraviglia, Sutter, & Gaskamp, 2008; Pearce et al., 2012; Wallace & O’Shea, 2007) and chronic diseases (Büssing, Balzat, & Heusser, 2010; Büssing, Zhai, Peng, & Ling, 2013), or from the perspective of health care professionals (Battey, 2012; Lundmark, 2006; Nixon, Narayanasamy, & Penny, 2013; Wu & Lin, 2011). However, although acute care hospital patients should also have spiritual care needs, little is known about their needs (Ellis, Thomlinson, Gemmill, & Harris, 2012). Transition theory can provide a framework to explain the spiritual care needs of acute care hospital patients. When people are facing a health crisis such as undergoing surgical procedures, they go through multiple and simultaneous transitions into a state of increased vulnerability and potentially negative health outcomes (Meleis, Sawyer, Im, Hilfinger Messias, & Schumacher, 2000). Such transition can disrupt one’s connection with the reality and lead to the feeling of hopelessness and cutoff from self and others (Selder, 1989). Morse (1997) further emphasized the notion of instantaneous disruptions in acute health situations in which spiritual wellness could be negatively affected. Spiritual needs were also identified as one of the three themes experienced by patients undergoing an excisional breast biopsy (Demir, Donmez, Ozsaker, & Diramali, 2008). Furthermore, in an interview study on 39 experienced clinical nurses, which was a part of an unpublished secondary study of clinical nurses’ perceptions of spirituality and spiritual care (Wu & Lin, 2011), these nurses indicated that no suitable instruments were available for assessing the spiritual care needs of acute hospitalized Chinese patients. These nurses were also concerned that because the existing spiritual care needs instruments were developed in Western populations and mostly in non-acute care settings, one that is developed specifically with Taiwanese patients might be needed to better reflect the cultural, linguistic, and multi-faith environment of Taiwan. Therefore, this study was designed to investigate the psychometric properties of a new instrument, the Spiritual Care Needs Inventory (SCNI), which was developed specifically to assess the spiritual care needs in Taiwanese acute care hospital patients. This study also compared whether spiritual care needs varied among patients with different religious beliefs.
Wu et al.
593
Method Development of the SCNI The guidelines of scale development outlined by DeVellis (2012) were adopted in this study. First, we defined the aim of the scale to measure the “spiritual care needs in acute care hospital patients.” Second, we generated an item pool from both a critical review of the literature and a review of the items from existing patient’s spiritual care needs instruments. A total of 105 items were obtained from 149 published articles and three patient’s spiritual care needs instruments. Third, the 105 items were reviewed by an expert panel consisting of five spiritual care professionals and researchers. Each item was evaluated for its clarity and relevance. Eighty items were merged or eliminated based on a priori criteria, such as undesirable similarity to other items, lack of clarity, ambiguous, or questionable relevance. A total of 25 items related to spiritual care were identified. Fourth, a panel that consisted of seven experts, including four nurse educators and three experienced clinical nurses, examined the items for their content validity. The content validity index (CVI) was calculated for each item based on a 4-point ordinal scale; 1 = not relevant, 2 = needs major revision that it would no longer be relevant, 3 = relevant but needs minor revision, and 4 = relevant. The CVI for the individual item was calculated as the proportion of experts who rated each item a 3 or 4, and the instrument-level CVI was calculated as the proportion of total items that received a rating of 3 or 4. Of the 25 items, 21 of them achieved the recommended cutoff value of 0.80 (Polit & Hungler, 1999). Four items considered ambiguous or repetitive were eliminated from the instrument. The item-level CVIs for the 21-item instrument ranged from 0.82 to 1.00 and the instrument-level CVI was 0.87. In the next phase, the 21-item instrument was pilot tested with a convenience sample of 30 adult acute care hospital patients. The clarity of the items and the flow of the whole instrument were evaluated. Each item was rated on a 5-point Likert-type scale ranging from 1 (not needed at all) to 5 (strongly needed); therefore, a higher score indicates a higher level of spiritual care needs. The Cronbach’s alpha coefficient for the SCNI was .96, demonstrating a high level of internal consistency. In addition, results from the pilot study indicated that the entire questionnaire could be completed within 15 min. This final 21-item version of the SCNI (the items are listed in Table 2) was then evaluated with a large sample of adult acute care hospital patients described below.
Study Participants and Design A random sample of patients who were hospitalized for acute care was recruited with stratification by patient wards from a medical center in central
594
Clinical Nursing Research 25(6)
Taiwan. The 16-week recruitment period started on February 1, 2013 and ended on May 31, 2013. Ten patients were randomly selected weekly from each of the 16 adult patient wards in the hospital. A total of 1,850 patients agreed to participate in the study and provided informed consent. The inclusion criteria were adult patients with acute disease and able to respond to our questionnaire either in written or verbal form. The sample size was adequate for principal components analysis according to DeVellis’s (2012) guideline of 5 to 10 participants per item. A structured questionnaire was used to obtain information on age, sex, educational level, religious beliefs, and frequency of attending religious activities from the participants. In addition, spiritual care needs of the participants were ascertained using the final version of SCNI. The 21-item final version of SCNI demonstrated a high level of internal consistency and clarity. General information about the study and instructions for filling the questionnaire were provided in the beginning of the questionnaire. The purpose of the study and the time required (5-10 min) to fill in questionnaire were included. In addition, respondents are reminded to complete the questionnaire based on their true opinion. Most of participants completed the survey on their own except 23 participants who had to provide verbal response because they had surgery performed on their dominant hand. Participants were asked to return the completed questionnaire into a locked box located next to the nursing station.
Ethical Considerations Ethical approval was granted by the institutional review board of the study hospital. The questionnaire contained no names or identification numbers to prevent breach of confidentiality. Informed consents were obtained from the 1,850 eligible patients of the main study and all the members of the expert panel and the 30 patients involved in the developmental phase of the SCNI.
Data Analysis Descriptive statistics, ANOVA with Bonferroni post hoc test, principal components analysis, and multiple linear regression analysis were conducted using SPSS for Windows version 18.0 (SPSS Inc, Chicago, IL, USA). Principal components analysis was performed to identify components of SCNI. Extraction was based on eigenvalue >1 and PROMAX rotation with Kaiser normalization. ANOVA and multiple linear regression analyses were conducted separately for each of the components obtained from the principal components analysis. The dependent variable for each component was the
Wu et al.
595
sum of the item scores, linearly transformed to a scale of 0 to 100, of the corresponding component. Independent variables evaluated in the regression model include age group, sex, education level, religious belief, and pattern of religious activities attendance. The entry and removal probabilities for the stepwise variable selection were set at .05 and .10, respectively. The presence of multicollinearity was tested using variance inflation factor (VIF). Effect sizes for the group comparison in the ANOVA and regression analyses were expressed as Cohen’s d statistic and standardized regression coefficients, respectively. A p value of
