A_review_of_spiritual_and_religious_meas.pdf

Journal of Religion and Health, Vol. 44, No. 1, Spring 2005 (Ó 2005) DOI: 10.1007/s10943-004-1145-6

A Review of Spiritual and Religious Measures in Nursing Research Journals: 1995–1999 SHELLEY DEAN KILPATRICK, ANDREW J. WEAVER, MICHAEL E. MCCULLOUGH, CHRISTINA PUCHALSKI, DAVID B. LARSON, JUDITH C. HAYS, CAROL J. FARRAN, and KEVIN J. FLANNELLY ABSTRACT: Background: A series of systematic reviews has revealed relatively high levels of interest in religion and spirituality in different nursing specialties, but not in general nursing research journals. Purpose: To identify the extent to which spirituality and religiousness were measured in all quantitative and qualitative research articles published in Research in Nursing and Health, Nursing Research, Advances in Nursing Science (ANS), and Image: The Journal of Nursing Scholarship from 1995 to 1999. Methods: A full-text search was conducted of ANS and Image using the Ovid search system. Nursing Research and Research in Nursing and Health were hand searched for spiritual/religious measures. Characteristics of selected studies, the measures taken, and their uses were coded for data analysis. Results: A total of 564 research studies were identified, of which 67 (11.9%) included at least one measure of spirituality or religiousness. A significant difference was found between the percentage of qualitative and quantitative studies that contained measures of these concepts. Of the 119 qualitative studies, 23 (19.3%) contained a measure of religion or spirituality, compared to 44 of the 445 (9.9%) quantitative studies. Nominal indicators of religious affiliation were the most commonly used measures in the quantitative studies and measures of religion and spirituality were rarely used in the analyses. Although only a few quantitative or qualitative studies intended to focus on religion or spirituality, these themes often emerged spontaneously in the qualitative research. Conclusions: Research in Nursing and Health, Advances in Nursing Science, Nursing Research, and Image: The Journal of Nursing Scholarship all published research measuring spirituality and religiousness during the timeperiod studied. The rate at which spirituality and religion appeared in these nursing research articles is substantially higher than that found in most fields outside of nursing. Even more Shelley Dean Kilpatrick, Ph.D., UCLA/RAND Center for Adolescent Health Promotion, Andrew J. Weaver, M.Th., Ph.D., The HealthCare Chaplaincy, Michael E. McCullough, Ph.D., International Center for the Integration of Spirituality and Health and University of Miami, Christina Puchalski, M.D., M.S., International Center for the Integration of Spirituality and Health and George Washington University, David B. Larson, M.D., M.S., MSPH, International Center for the Integration of Spirituality and Health, Judith C. Hays, Ph.D., R.N., Duke University Medical Center, Carol J. Farran, DNSc., R.N., FAAN, Rush-Presbyterian-St. Luke’s Medical Center, Kevin J. Flannelly, Ph.D., The HealthCare Chaplaincy. Correspondence to Kevin J. Flannelly, Ph.D., Associate Director of Research, 307 East 60th Street, New York, New York 10022, [email protected]. This project was supported by grants from the Nathan Cummings Foundation, New York, NY and the Fetzer Institute, Kalamazoo, MI. 55

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frequent inclusion of spiritual and religious variables and richer measures of spirituality and religiousness would help to increase the available scientific information on the role of spirituality and religion in nursing care. KEY WORDS: nursing; religion; review; spirituality.

Introduction Americans report that spirituality and religion are important factors in their lives in national surveys. According to a recent Gallup Poll, approximately 86% of Americans believe in God, 8% believe in a universal spirit, 45% attended church or religious services in the last week, approximately 66% belong to a local religious congregation, and 90% state that religion is ‘‘very important’’ or ‘‘fairly important’’ in their lives (Newport, 1999). In addition, 81% of American adults identify with a formal religious tradition and 75% of Americans identified their outlook on life as religious or somewhat religious (Kosmin et al., 2001). Although 60% of Americans identify themselves as religious or both religious and spiritual, 30% of Americans state explicitly that they are spiritual, but not religious (Newport, 1999). Nursing has long recognized the importance of spirituality in the lives of people seeking health care. Reed described spirituality as an integral and basic part of nursing, saying: ‘‘Spirituality, in its broadest sense, is a part of the ontologic foundation of nursing; it is regarded as a basic characteristic of humanness important in human health and well-being’’ (Reed, 1992, p. 349). Studies indicate that nurses from a broad variety of specialties incorporate spirituality in their personal life, being active in their religion and regularly attending religious services (Boutell and Bozett, 1987). Nurses also make religion part of their professional life, as Taylor, Amenta, and Highfield (1995) found. In their study of oncology nurses they found that 83% prayed privately for their patients. Moreover, nurses make the vast majority of patient referrals to hospital chaplains. In one study, 88% of all referrals to chaplains came from nurses, compared to 8% from physicians, and 4% from social workers (Koenig et al., 1991). The nursing literature has discussed spirituality and religion in various contexts, including chronic illness (O’Neill and Kenny, 1998; Rehm, 1999), women’s health (Lauver, 2000), HIV disease (Flannelly and Inouye, 2001; Woodard and Richard, 2001), and nursing education concerning the spiritual care of patients and clients (Narayanasamy, 1999a). Nurses have also addressed the professional, ethical, and legal implications of spirituality for the nursing field (Wright, 1998); and the application of spirituality to nursing

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perspectives or paradigms (Narayanasamy, 1999b; Reed, 1992). The concept of spirituality in the nursing literature is broader than the concept of religion. Although religion is considered by some to be a manifestation of spirituality, the term spirituality need not include religious beliefs or practices (Bays, 2001; Emblen, 1992; Sumner, 1998). As described in the Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research (John E. Fetzer Institute, 1999, p. 2), religiousness has specific behavioral, social, doctrinal, and denominational characteristics that are shared by a group. By contrast, spirituality is concerned with the transcendent, addressing ultimate questions about life’s meaning, with the assumption that there is more to life than what we see or understand. A series of systematic reviews has revealed relatively high levels of interest in religion and spirituality in different nursing specialties, as evidenced by the percentage of research studies that measure some aspect of these concepts. A study by Weaver et al. (1998c) found that 10% of the quantitative studies published between 1991 and 1995 in Archives of Psychiatric Nursing, Journal of Psychosocial Nursing, and Issues in Mental Health Nursing contained a measure of religion/spirituality. By comparison, similar reviews of the psychological and psychiatric literature found that less than 3% contained religious or spiritual measures (Craigie et al., 1990; Weaver et al., 1998b; Weaver et al., 1998a). Similarly, Sherrill et al. (1993), found that 3.6% of quantitative studies in gerontological medicine measured religion/spirituality, whereas Weaver et al. (2001) found the percentage to be 6.8% among quantitative studies in two gerontological nursing journals. The percentage was somewhat higher among qualitative articles (10.7%) in gerontological nursing. A review of three oncology nursing journals found that qualitative studies were significantly more likely to measure religion or spirituality (27%) than quantitative studies (14%). To obtain a more general picture of the scope of interest in religion and spirituality in nursing research we decided to conduct a systematic review of four general research journals in nursing, as opposed to specialty journals. The four journals we chose were Research in Nursing and Health, Advances in Nursing Science, Nursing Research, and Image: The Journal of Nursing Scholarship. The first three journals were selected because they are the three most prominent non-specialty research journals in nursing, according to McCloskey and Swanson (1982) and Swanson, McCloskey and Bodensteiner (1991). While these authors did not list Image as a research journal in their classification and description of 92 to 100 journals, a fairly large percentage of its articles are research and it covers a broad range of topics. The time-frame covered by the study was 1995 through 1999. Based on the findings of previous research (Weaver et al., 2001), we hypothesized that qualitative studies would be more likely to contain a measure of religion or spirituality than quantitative studies.

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Method Identification of articles We attempted to identify all research studies that included one or more measures of the participants’ spirituality or religiousness published between 1995 through 1999 in Research in Nursing and Health, Advances in Nursing Science, Nursing Research, and Image: The Journal of Nursing Scholarship, from 1995 to 1999. Research articles were defined as those containing a description of research methods and results. There was greater than 98% agreement between two Ph.D. trained researchers on whether an article was research or not, with some disagreements arising when there was no specific headings for these sections. Research articles were classified as being either qualitative or quantitative research. Research reports that presented descriptive or inferential statistics were classified as quantitative, with greater than 95% agreement on the classification of studies as being either qualitative or quantitative. To be consistent with previous systematic reviews of this nature in nursing (Flannelly et al. 2002; Weaver et al., 2001; Weaver et al., 1998c) and medical journals (McCullough et al., 2002 (unpublished manuscript); Puchalski et al., In Press) three articles that used qualitative methodology were classified as quantitative because they presented statistical findings. Full text of two of the journals, Advances in Nursing Science and Image – The Journal of Nursing Scholarship were searched electronically using Ovid (Ovid Technologies, 2000) to identify articles that measured religion and spirituality. The other two journals were searched manually, because they were not available in full text on Ovid. Search terms related to spirituality included the terms spirit*, transcendence, existential, meaning of life, hope, prayer, and meditation. Search terms related to religion included the terms religio*, faith, church, and particular religious groups (Jewish, Muslim, Christian, etc.). Characteristics of articles and measures For each article that included a measure of spirituality or religion, we recorded the primary topic of the article and the number of citations concerning spirituality and religion. Each measure of spirituality or religion was categorized as belonging to one of eleven mutually exclusive categories as developed previously (McCullough et al., 2002 (unpublished manuscript); Puchalski et al., In Press): (a) religious affiliation (e.g., Catholic, Protestant, Jewish, Muslim, other, none); (b) public religious or spiritual involvement (e.g., church attendance, social support from membership in a religious or spiritual group); (c) private religious or spiritual involvement (e.g., prayer/ meditation, scripture reading, religious coping); (d) spiritual well-being, meaning, or transcendence; (e) importance of one’s spirituality or religion (e.g., ratings of strength or importance of faith); (f) specific spiritual or

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religious beliefs (e.g., belief in life after death); (g) the relevance of one’s spirituality or religion to suffering, hope, or despair; (h) spiritual/religious staffing (e.g., inclusion of chaplain on care team); (i) services provided (e.g., screening patients for spiritual distress); (j) the use of multi-item measures of spirituality or religiousness (i.e., measures which contain items representing two or more categories from a–h above); or (k) other. In the case of qualitative articles, the religious/spiritual themes were coded. If no themes were presented, we classified and recorded specific quotes or behavioral descriptions in their respective categories. If more than one item (quote or description) fell into the same category they were treated as a single instance of that category. Finally, the presentations of spirituality or religion in the quantitative articles were classified into five categories with respect to how they were used. The five categories were whether spirituality/religion were used to: (1) describe the sample, (2) describe religious/spiritual services; or examined the association of spirituality/religion with (3) physical health, (4) mental health (including self-reported coping and quality of life), or (5) attitudes. Two authors coded all article and measure characteristics independently. The two judges resolved coding discrepancies through discussion until consensus was reached. Initial agreement rates for all study variables ranged from 71% to 100% (M ¼ 94.5%, Mdn ¼ 96%, Mode ¼ 100%).

Results Identification of articles A total of 845 articles were published in the four journals between 1995 and 1999, excluding editorials, commentaries, and regularly published columns. Of the 845 articles published during this time-frame, two-thirds (n ¼ 564) were research studies. More than three quarters of the research articles were classified as quantitative studies (n ¼ 445) and the remainder were classified as qualitative (n ¼ 119). As hypothesized, qualitative studies were significantly more likely to contain a measure of religion or spirituality than quantitative studies, v2(1) ¼ 13.15, p < 0.001. Table 1 shows the percentage of quantitative and qualitative studies that measured religion and/or spirituality. The percentage of articles that included measures of spirituality or religion did not differ significantly across years or among journals. Characteristics of the articles Although a total of 67 research articles measured religion or spirituality, these concepts were the focus of only five of the quantitative and three of the qualitative studies. Not surprisingly, studies that focused on some aspect of religion or spirituality were significantly more likely to cite published literature related to these concepts, v2(1) ¼ 7.76, p < 0.01. The quantitative studies

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TABLE 1 Number and Percentage of Studies that Measured Religion and/or Spirituality out of 445 Quantitative and 119 Qualitative Studies Published Between 1995–1999 Quantitative Kind of Measure Religion Spirituality Religion and Spirituality Total

Qualitative

n

%

n

%

27 11 6 44

6.1 2.5 1.3 9.9

10 1 12 23

8.4 0.8 10.1 19.3

in our sample of 67 research articles were somewhat more likely to cite prior articles on religion or spirituality (22 of 44) than were qualitative studies (8 of 23), but this difference was not statistically significant. Table 2 presents the number of studies that addressed different topics. Coping with illness was the most common topic addressed by quantitative studies, followed by research on health status and risk factors for different populations and health problems. These two topics accounted for almost 60% of all articles in our sample of 44 quantitative studies. Coping was also the most common topic addressed by the 23 qualitative studies. TABLE 2 Number and Percentage of Spiritual and Religious Measure Types Reported in Quantitative and Qualitative Studies

Topic Coping and Support Health Status and Risk Factors Health Promotion and Awareness Healthcare Decision Making Scale Development Healthcare Attitudes Intervention Tested Quality of Life Other All Studies

Quantitative

Qualitative

n

%

n

%

14 12 – – 6 – 4 3 5 44

31.8 27.3 – – 13.6 – 9.1 6.8 11.4 100.0

6 – 5 5 – 3 – – 4 23

26.1 – 21.7 21.7 – 13.0 – – 17.4 100.0

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Characteristics of spirituality/religion measures There were 61 separate uses of spirituality/religion in the 44 quantitative studies (see Table 3). The majority of articles (80%) contained only a single use or measure of spirituality or religiousness, and in 15 of these the only measure was religious affiliation. Religious affiliation was the most commonly reported measure, followed by descriptions of private spiritual or religious practice, and descriptions of spiritual well-being or meaning. Among the qualitative studies, religion or spirituality was presented in the form of emergent themes, descriptions of behaviors, or verbatim quotes from study participants. Of the 53 uses of spiritual/religious terms that were counted, the most common ones fell into the category of spiritual well-being, meaning, and transcendence. Most of the items included in the other category represent expressions about a general belief in God or reliance on faith and religion. Use of measures in quantitative studies As seen in Table 4, the measures were used primarily to describe the religiousness/spirituality of the sample. In addition to religious affiliation, these

TABLE 3 Different Kinds of Spiritual and Religious Measures Reported in Quantitative and Qualitative Studies as a Percentage of All Measures Reported in Each Type of Study Quantitative Qualitative Type of Measure Religious Affiliation Private Religious Involvement Spiritual Well-being, Meaning, Transcendence Importance of Spiritual/Religious Belief Public Religious Involvement Multi-item Measures of Spirituality/Religiousness Spiritual/ Religious Services Provided Suffering, Hope, Despair Specific Spiritual or Religious Belief Other Total Number of Measures Reported

n

%

n

%

20 11 9 4 2 2 1 1 1 10 61

32.8 18.0 14.8 6.6 3.3 3.3 1.6 1.6 1.6 16.4 100.0

2 4 17 4 3 – 1 8 5 9 53

3.8 7.5 32.1 7.5 5.7 – 1.9 15.1 9.4 17.0 100.0

Note: The total of measure uses (n = 61) is larger than the actual number of measures recorded (n = 44) because the categories in the table are not mutually exclusive. Each study measure could have multiple uses.

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TABLE 4 Uses of the 61 Measures of Spirituality and Religion in the 44 Quantitative Studies in the Sample Use of Measure Description of spirituality/religiousness of the sample Associations with mental health/coping/adjustment/ quality of life Associations with physical health Associations with attitudes Description of spiritual/religious services provided

Instances1

%

42 17

68.9 27.9

9 4 3

14.8 6.6 4.9

1

The total is larger than the actual number of measures recorded (n = 61) because the categories in the table are not mutually exclusive: 61 was the denominator used in calculating the percentages. included measures of religious involvement and activity, and measures of religiosity and spirituality. Measures of spirituality/religion were commonly used in association with measures of mental health and, less commonly, in association with measures of physical health. Six of the measures (10%) were not used as measures in and of themselves, but were single items or subscales on longer instruments. While many types of measures were used to examine an association with mental health, coping, or adjustment, only four types of measures associated spirituality or religion with physical health—private religious involvement, spiritual well-being/meaning/transcendence, multi-item measures of general spirituality/religiousness, and suffering/hope/despair. Because the categories were not mutually exclusive and measures could have multiple uses in the articles reviewed, the numbers total to more than 61 measure uses.

Discussion Our systematic review of all research published between 1995 and 1999 in Research in Nursing and Health, Advances in Nursing Science, Nursing Research, and Image: The Journal of Nursing Scholarship, identified 67 articles (11.9% of all research articles) that contained a measure of participants’ spirituality or religiousness. This is somewhat higher than found in a recent systematic review of research published in gerontological nursing journals (7.7%) (Weaver et al., 2001), but lower than that found in oncology nursing journals (16.9%) (Flannelly et al., 2002). When quantitative and qualitative studies were analyzed separately we found that 9.9% of quantitative studies and 19.3% of qualitative studies

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contained at least one measure of religion or spirituality. The latter percentage is higher than that found in gerontological nursing (10.7%), but lower than that found in oncology nursing (27.3%). The percentage of quantitative studies in our sample that measured some aspect of religion or spirituality (9.9%) is higher than that found in the palliative care literature (6.3%) (Puchalski et al., In Press), and other health-care journals outside of nursing, including primary care (1%), psychiatry (1%), and gerontology (4%) (Weaver et al., 1998c). The greater inclusion of spiritual and religious measurement in the nursing literature probably stems from the convergence of a number of factors, including nursing’s recognition of patient’s spirituality, the tradition of holistic care in nursing, and its historical roots. Florence Nightingale considered spirituality an intrinsic part of human nature and thought spirituality and science were compatible ways of viewing the world (Macrae, 1995; Widerquest, 1992). The results of our review are enlightening and encouraging because they demonstrate that spiritual and religious variables are still being addressed in the leading research journals of the nursing field with a frequency that suggests that nurses continue to be at the forefront of research in spirituality and health. However, most of the measures served only a descriptive purpose and typically were not included in the analyses. This suggests that spirituality or religion is not yet completely integrated into the purpose and background of many research studies, even when measures of these concepts are taken. This is further evidenced by the fact that only four of the quantitative studies had explicit hypotheses related to spirituality or religion (Crigger, 1996; Miller and Champion, 1996; Sherman, 1996; Sinclair et al., 1998). On the other hand, many studies that included religion and spirituality did make reference to the existing literature on these topics, especially when they were the focus of study. Of the six articles that were concerned primarily with the development of measures, three articles focused on measures that included spirituality or religion as an important component. These measures included the Spiritual Care Scale (Carrigg and Weber, 1997), the Sense of Belonging Instrument (Hagerty and Patusky, 1995), and the Functional Performance Inventory (Leidy, 1999). With the publication of these scale development studies, future researchers will have tools to use which incorporate spirituality as an integral part of measurement. Other sources for high quality, multi-item measurement of spirituality and religion are also available in the published literature (John E. Fetzer Institute, 1999; Hill and Hood, 1999). The studies that included measures of spirituality and religion covered a range of nursing topics. For both the quantitative and qualitative studies, however, the most common topic was coping with illness, with 31.8% and 26.1%, respectively, of the quantitative and qualitative research focusing on this topic. Aside from this common ground, the qualitative and quantitative studies tended to look at different research areas. While a quarter of the

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quantitative studies examined health status and risk factors, more than four out of ten qualitative studies looked at health promotion and awareness or making healthcare decisions. Thus, it appears, the two methodological approaches are making their own distinct contributions to nursing research in terms of topics as well as content. The emergence of religious and spiritual themes in qualitative studies on a broad range of topics not explicitly related to these concepts is particularly fascinating. It provides striking evidence of the importance of religion and spirituality in the lives of patients and their caregivers. Although one would expect these themes to appear in studies investigating severe or life-threatening diseases they emerged in many different contexts and they were a common part of patients’ and caregivers’ stories about their everyday experiences. The results suggest several ideas for future research with respect to religion and spirituality. Our understanding of individual’s overall health could be expanded if that person’s spiritual or religious background were examined more fully. To this end, including multi-item measures that capture various aspects of religion and spirituality, rather than just religious affiliation would strengthen future quantitative studies. Our understanding of the link between spiritual health and physical, mental, and social health also would be improved if studies included spiritual measures along with outcome measures of physical, mental, and social health (e.g., pain, coping with terminal illness, the role of the community in preventative healthcare, etc.). Nursing science has long heralded the critical role played by spirituality and religion in the personal health and well-being of individuals. Nurse investigators are strategically placed to design and conduct studies that will enhance our understanding in this area.

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