The ACPE Research Network

Back to the Articles of the Month Index Page ]


June 2005 Articles of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Presbyterian, Philadelphia PA.


Delaney, C. "The Spirituality Scale: development and psychometric testing of a holistic instrument to assess the human spiritual dimension." Journal of Holistic Nursing 23, no. 2 (June 2005): 145-167.

Galek, K., Flannelly, K. J., Vane, A. and Galek, R. M. "Assessing a patient's spiritual needs: a comprehensive instrument." Holistic Nursing Practice 19, no. 2 (March-April 2005): 62-69. [A PDF of this article has been made available on-line to the Research Network by the principal author.] --Note: Related Items of Interest IV (below).


COMMENTS AND SUMMARIES: The possibility of using research measures as clinical assessments of spirituality has been mentioned in regard to a number of our Articles-of-the-Month, but here are two measures designed as broadly applicable clinical assessments that chaplains might also think of using for research. Both of these measures are reported in nursing journals, work with conceptualizations of spirituality from the health care literature, and attempt to capture multiple dimensions of patients’ spirituality with mid-sized questionnaires of 23 and 29 items (--shorter and simpler than, for instance, Fetzer’s 38-item Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research, which was addressed in the January 2004 Article-of-the-Month, but longer and more construct-complex than the measures of spiritual well-being considered in February 2004, March 2004, and December 2004). The assessment items and their organizing concepts are presented below in two tables to allow for some comparison.

In "The Spirituality Scale," Colleen Delaney presents a 23-item "holistic assessment instrument that focuses on the beliefs, intuitions, lifestyle choices, practices, and rituals that represent the human spiritual dimension," and "...that can be used to guide spiritual interventions" [p. 146]. The working definition of spirituality for this instrument is:

...a multidimensional phenomenon that is universally experienced, in part socially constructed, and individually developed throughout the life span. Spirituality encompasses a personal, interpersonal, and transpersonal context consisting of four interrelated domains: (a) higher power or universal intelligence--a belief in a higher power or universal intelligence that may or may not include formal religious practices; (b) self-discovery--the spiritual journey begins with inner reflection and a search for meaning and purpose; ...(c) relationships--an integral connection to others based on a deep respect and reverence for life and is known and experienced within relationships...; and (d) eco-awareness--an integral connection to nature based on a deep respect and reverence for the environment and a belief that the Earth is sacred. [p. 152]
This conceptualization of spirituality is rooted in the perspective of holistic nursing and recent health care literature, and it is marked by a sense of broad inclusiveness that is a salient nursing concern in the context of work with diverse populations.

The SS is in many ways practical, not only in its attempt at inclusiveness for spiritually diverse groups, but in terms of being user-friendly in employing language at a sixth-to-ninth grade reading level and a format of six-point Likert response scales, allowing patients to complete the questionnaire within ten minutes. "The SS can also be used as a semistructured interview to open up dialogue to allow personalized spiritual assessment, care, and evaluation of interventional outcomes" [p. 162]. The author goes on to address how the instrument may be used by nursing educators [pp. 160-161], nursing administrators [p. 163], and nursing researchers [pp. 163-164], in addition to its clinical applications [pp. 161-163 and passim].

What really makes Delaney's article stand out, though, is her fine attention to the psychometric characteristics of the instrument. Using a convenience sample of 226 patients with chronic illness, recruited from "two midsized hospitals, a multibranched extended care and assisted living agency, and a community wellness organization" [p. 153], the author collected data for the instrument's factorial structure, internal consistency, and two-week test-retest reliability (with a subgroup of 30 volunteers). A five-member panel of experts also checked for content validity. The data collection procedure is clearly lined out [p. 154], and results are presented in detail both in the narrative and in several tables [pp. 154-158]. Possible limitations related to generalizability from the convenience sample and to any halo effect are considered [p. 159], but overall the psychometric testing makes a good case for the validity and reliability of the SS.

This is an important article for chaplain researchers, and the multidimensional measure deserves attention. The Eco-Awareness subscale--which the author suggests is a special contribution of the SS--may be worth particular discussion within pastoral care circles. Note that the domain of "higher power or universal intelligence" was eventually collapsed into Eco-Awareness [--see the explanation on p. 157]. Chaplains might also want to discuss the suggestion of how the SS could be scored to indicate spiritual distress [p. 162].

Below are the 23 items in the Spirituality Scale, ordered here by factor. [Note, however, that the last item--"At times, I feel at one with the universe"--does not appear in the table of items on p. 158].

Self-Discovery - I find meaning in my life experiences.
- I have a sense of purpose.
- I am happy about the person I have become.
- I see the sacredness in everyday life.
Relationships - I believe that all living creatures deserve respect.
- I value maintaining and nurturing my relationships with others.
- I believe that nature should be respected.
- I am able to receive love from others.
- I strive to correct the excesses in my own lifestyle patterns/practices.
- I respect the diversity of people.
(including Higher Power/Universal Awareness)
- I meditate to gain access to my inner spirit.
- I live in harmony with nature.
- I believe there is a connection between all things that I cannot see but can sense.
- My life is a process of becoming.
- I believe in a Higher Power/Universal Intelligence.
- The earth is sacred.
- I use silence to get in touch with myself.
- I have a relationship with a Higher Power/Universal Intelligence.
- My spirituality gives me inner strength.
- My faith in a Higher Power/Universal Intelligence helps me cope during challenges in my life.
- Prayer is an integral part of my spiritual nature.
- I often take time to assess my life choices as a way of living my spirituality.
- At times, I feel at one with the universe.
[Assessment items noted here with permission. © Copyright 2003 by C. Delaney. Those interested in using the Spirituality Scale for clinical or research purposes are asked to contact Dr. Colleen Delaney, Associate Professor, University of Connecticut, e-mail: The author has made the instrument available to the Network, and a copy may be obtained from the Network Convener by e-mailing]

In the second of our featured articles this month, "Assessing a patient's spiritual needs: a comprehensive instrument," Kathleen Galek and her colleagues, in association with The HealthCare Chaplaincy in New York, offer a 29-item survey of patients' spiritual needs, "comprehensively" based on seven constructs suggested by the heath care literature published 1990-2004. The constructs and their constituent items are presented below:

("At any time while you were in the
hospital did you have a need:")
Feeling unconditionally accepted; connecting to self and others; giving and receiving respect and love - To be accepted as a person
- To give/receive love
- To feel a sense of connection with the world
- For companionship
- For compassion and kindness
- For respectful care of your bodily needs
Divine Prayer; religious rituals; being part of a community; connecting with the divine - To participate in religious or spiritual services
- To have someone pray with or for you
- To perform religious or spiritual rituals
- To read spiritual or religious material
- For guidance from a higher power
Peace; calm; sensing enjoyment in life; having hope; expressing humor and laughter - To feel hopeful
- To feel a sense of peace and contentment
- To keep a positive outlook
- To have a quiet space to meditate or reflect
- To be thankful or grateful
- To experience laughter and a sense of humor
and Purpose
Finding one's reason for living; finding meaning in one's personal history - To find meaning in suffering
- To find meaning and purpose in life
- To understand why you have a medical problem
and Ethics
Needing to live an ethical and responsible life - To live an ethical and moral life
of Beauty
Connecting with beauty, nature, art, music, and the creative process - To experience or appreciate beauty
- To experience or appreciate music
- To experience or appreciate nature
Addressing concerns about life after death; gaining a deeper understanding of death and dying; coming to resolution about letting go; putting closure on life; offering forgiveness - To address unmet issues before death
- To address concerns about life after death
- To have a deeper understanding of death and dying
- To forgive yourself and others
- To review your life
[Assessment items noted here with permission. Those interested in using the Spiritual Needs Survey for clinical or research purposes are asked to contact Kathleen Galek, PhD, The HealthCare Chaplaincy, 307 E. 60th St., New York, NY 10022; A copy of the instrument may be found on p. 67 of the article--see the PDF.]

The measure was designed to be "inclusive of both traditional religion and noninstitutionally based spirituality, for evaluating the spiritual needs of hospitalized patients" and "to be brief enough to include in clinical or epidemiological surveys, allowing for an extensive investigation of various indices" [p. 62]. To that end, the authors systematically identified 22 articles from the health care literature (1990-2004) that "enumerated the specific needs of hospitalized patients, including 12 qualitative studies, 7 quantitative studies, and 3 theoretical articles" [p.65] --17 of these were from nursing journals (which are listed in the bibliography) and the remainder from medical journals. From these articles, 339 descriptors of patients' spiritual needs were found, and "these...descriptors yielded 9 broad categories...that were independently derived by content analysis regardless of how they had been categorized in the original studies" [p. 65]. "However, two of the nine categories--those of 'control' [i.e., having the right to make decisions about one's own life; staying as independent as possible; desiring things to stay the same] and 'other' [i.e., needing comfort; needing to cope with physical pain]--were eventually eliminated "because they did not capture a spiritual dimension" [p. 65]. The categories/constructs are nicely summarized in a table [p. 65] and in separate paragraph descriptions [pp. 66-68] that tie them directly to the literature.

The instrument allows patients to respond in two ways to its 29 items: first, by choosing "yes" or "no" as to whether they had each need; and second, by indicating "How important it was to you," with the options of "slightly," "moderately," "very," and "extremely" [see p. 67]. The method of this two-part response format is not discussed, but it would seem to help patients think about each item in more detail than single responses would normally encourage. At least, this reader found it so in taking the survey, and perhaps this could be one of the qualities of the instrument to be explored in future psychometric analysis.

The authors observe from their literature review that "88% of spiritual needs articles were published after 1990" [p. 64], which raises a question of how much a literature base which has come so recently to this subject may be a good guide to basic constructs of spirituality in relation to heath and health care. Certainly articles like this one serve not only to present a practical application of spirituality constructs currently in the literature but also to help bring a reflective refinement to the general consideration of constructs by scholars in the field.

The authors have also developed variations on the measure. One version not only elicits information about needs but also about feelings (e.g., depressed, resentful, isolated, helpless, grief, guilt, and anxiety) during the hospital stay. A copy of this latter version of the instrument is available to the Network and may be obtained from the Network Convener by e-mailing For other versions, and for general inquiries about the instrument, e-mail Kathleen Galek at


Suggestions for the Use of the Articles for Discussion in CPE: 

Both articles are clear presentations that CPE students should be able to read easily, though Delaney’s discussion of psychometric analysis may be too technical for students new to research (--such students should be encouraged not to let themselves become bogged down in pp. 154-159 but to get a sense of the serious demands of instrument validation). Delaney’s article would be a good introduction to the steps of instrument development, and students might discuss how much of their own spiritual assessment technique could be challenged by the rigor of a scientific mindset. General discussion could also focus on how these measures attempt to transcend "limits" of traditional religious language and particular religious perspectives, and whether students feel comfortable with this trend in the field of spirituality & health research. The sections of the article by Galek, et al. on Spiritual Typologies and on Spirituality in Relation to Traditional Religion may be of special interest to new students. Discussion could also point up how these measures are largely shaped by the need to work across many lines of diversity in a hospital population, and how they may so reflect some of the concerns facing chaplains in the practice of interfaith pastoral care.


Related Items of Interest: 

I. Chaplains may also be interested in the following articles on spiritual assessment from the perspective of Social Work, by David R. Hodge, PhD. Much of the material in these articles is also covered in his book, Spiritual Assessment: A Handbook for Helping Professionals (Botsford, CT: North American Association of Christians in Social Work, 2003), 121pp., available from Most of these assessments are fairly elaborate and graphic (e.g., based on such models as genograms) and so may not be easily used for research data collection, but they are quite thought provoking on the topic of spiritual assessment methodology. Note, though, his six-item Intrinsic Spirituality Scale, which may be well suited for research.

[ADDED 12/27/05]: Hodge, D. R. "Developing a spiritual assessment toolbox: a discussion of the strengths and limitations of five different assessment methods." Health and Social Work 30, no. 4 (November 2005): 314-323. [The author discusses one verbal model (i.e., spiritual history) and four diagrammatic models (i.e., spiritual lifemaps, spiritual genograms, spiritual ecomaps, and spiritual ecograms), in each case describing strengths and weaknesses.]

Hodge, D. R. "The Intrinsic Spirituality Scale: a new six-item instrument for assessing the salience of spirituality as a motivational construct." Journal of Social Service Research 30, no. 1 (2003): 41-61. [The author has modified Allport & Ross' classic (1967) measure of intrinsic religion to accommodate the broad concept of spirituality and to work with theistic and non-theistic populations. The instrument, which uses ten-point Likert scales for its six-items, is presented on p. 48 of the article. Validity and reliability data are given in detail.]

Hodge, D. R. "Spiritual assessment: a review of major qualitative methods and a new framework for assessing spirituality." Social Work 46, no. 3 (July 2001): 203-214. [Beginning from a "spiritual anthropology" (see p. 207), the author presents a two-part framework for spiritual assessment (see Table 1, p. 208). The first part is an Initial Narrative Framework, comprised of three sets of questions that help a person "develop an autobiographical spiritual history" (p. 207). The second part is an Interpretive Anthropological Framework that consists of six sets of questions to explore domains of a person's spirituality--i.e., Affect, Behavior, Cognition, Communion, Conscience, and Intuition--and "to create an awareness of the potential" (p. 208) of a person's spirituality.]

Hodge, D. R. "Spiritual Ecograms: a new assessment instrument for identifying clients' in space and across time." Families in Society--The Journal of Contemporary Human Services 86, no. 2 (April-June 2005): 287-296. [The Spiritual Ecogram is diagrammatic assessment method, essentially combining the approaches of Spiritual Lifemaps and Spiritual Genograms, focusing on spiritual assets/strengths and on connections between the past and the present--between historical influences in a person's spiritual life and current influences.]

Hodge, D. R. "Spiritual Ecomaps: a new diagrammatic tool for assessing marital and family spirituality." Journal of Marital and Family Therapy 26, no. 2 (April 2000): 217-228. [Based on an anthropological framework, the Spiritual Ecomap seeks to depict and explore spirituality in current family relationships and may be used in relation to families with diverse spiritual traditions.]

Hodge, D. R. "Spiritual Genograms: a generational approach to assessing spirituality." Families in Society--The Journal of Contemporary Human Services 82, no. 1 (January-February 2001): 35-48. [Spiritual Genograms--following the general model of genograms--help individuals to see connections between their current spiritual lives and family histories and to focus on strengths. An illustrative case is presented.]

Hodge, D. R. "Spiritual Lifemaps: a client-centered pictorial instrument for spiritual assessment, planning, and intervention." Social Work 50, no. 1 (January 2005): 77-87. [The Spiritual Lifemap is a relatively straightforward pictorial method for tracing the course of a person's spiritual life and strengths.]

Hodge, D. R. "Spirituality and people with mental illness: developing spiritual competency in assessment and intervention." Families in Society--The Journal of Contemporary Human Services 85, no. 1 (January-March 2004): 36-44. [The article provides an overview of the place of spiritual assessment in mental health treatment, especially in light of JCAHO accreditation standards, and gives a framework for an initial spiritual assessment.]

[ADDED 12/27/05]: Hodge, D. R. and Ka'opua, L. S. "Spiritual assessment: an overview of its importance and six instruments for conducting assessments." Society for Spirituality and Social Work Forum 12, no. 1 (Fall 2005): 3-5. [This is a short outline, covering Brief Assessment, Value Based Spiritual Histories, Spiritual Lifemaps, Spiritual Genograms, Spiritual Ecomaps, and Spiritual Ecograms.]

II. The June 2005 issue of Science and Theology News (ISSN: 1530-6410) contains the article, "Researchers: spiritual scales need to measure up," by Julia C. Keller, pp. 8-9. This brief overview of issues regarding spirituality measures notes several recent instruments (e.g., the DSES, R-COPE, and SpREUK) and presents the 10-item Santa Clara Strength of Religious Faith Questionnaire.

III. Also note Hill, P. C. and Hood, R. W., eds., Measures of Religiosity (Birmingham: Religious Education Press, 1999). This collection of 126 scales--some now quite old--is rooted in the psychology of religion and geared to research. Each scale is presented in detail, complete with validity and reliability information. The book is available from such sources as at $99, but it is also widely available at research libraries.

IV. [ADDED 7/11/07]: See the Spring 2007 Newsletter (§5) regarding the following article refining the instrument put forward in our featured article by Galek, et al.:

Flannelly, K. J., Galek, K. and Flannelly, L. T. [HealthCare Chaplaincy, 307 E. 60th Street, New York, NY 10022, USA.]. "A test of the factor structure of the patient spiritual needs assessment scale." Holistic Nursing Practice 20, no. 4 (July-August 2007): 187-190. [(Abstract:) Factor analysis was conducted on the responses of 683 individuals who completed a 24-item version of the Patient Spiritual Needs Assessment Scale. The results provided strong support for 4 of the 6 dimensions of spiritual needs and weaker support for one of the others. The 6 dimensions were appreciation of art and beauty, meaning and purpose, love and belonging, death/resolution, positivity/gratitude/hope/peace, and the Divine. The coherence of the dimensions is discussed in the context of the scale's intended application.]


If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at .
Copyright © 2005
The ACPE Research Network. All rights reserved.