Although spirituality has heen determined to be an essential component of each individual, little attention is given to the spirituality of clients by health care professionals (Astedt-Kurki, 1995; Burkhard t, 1989, 1994; Forbes, 1994; Heriot, 1992; Leetun, 1996; Neuman, 1995; Reed, 1986; Robinson, 1994; Sodestrom & Martinson, 1987). In 1993, Mansen elucidated several reasons for the neglect of the spiritual domain by health care professionals including: the private and emotional nature of spirituality, a fear of imposing one's own philosophy on others, and a limited personal understanding of the abstract. Pullen, Tuck, and Mix (1996) suggested that nurses have historically attempted to meet clients' spiritual needs, but the increasing emphasis on technology and scientific advancement has resulted in less attention being given to spiritual aspects of nursing care.
Belief in the supernatural related to health and illness existed before the birth of Christ (Kalestro, 1972). The Hebrews viewed healing as part of their religion, and the priests and Levites were responsible for the practice of medicine. A tenet of Christianity is care of people who are sick, and the New Testament affirms the connection between healing and religion (Devine, 1980; Ferngren, 1992; Kalestro, 1972; McCullough, 1995). In Plato's era, health care providers were encouraged to care for the whole person (Leetun, 1996). Furthermore, spirituality was a motivating force in the work of Florence Nightingale (Widerquist, 1992).
Spirituality is at the core of one's existence and affects, connects, and transcends all aspects of being (Clark, Cross, Deane, & Lowry, 1991; Heriot, 1992). In 1989, Dossey postulated that because of the possibility of the nonlocal nature of the mind, unlimited by time and space, and united to the soul, prayer may be shared and benefit both human and nonhuman life forms. McCullough (1995) suggested that research on the relationship between prayer and health confirms that prayer promotes a variety of healthy outcomes. Unfortunately, many of the studies are characterized by weak methodologies. Nevertheless, the renewed interest in faith healing, intercessory prayer, and alternative medicine could be related to the dissatisfaction of the public with health care services and reimbursement methods.
Neglecting the spiritual needs of older adult clients is particularly problematic because research has indicated the elderly population is a highly spiritual and religious group. Spirituality is used as a coping mechanism, assisting them to cope with painful or unexpected events (Astedt-Kurki, 1995; Bearon & Koenig, 1990; Clark et al., 1991; Mull, Cox, & Sullivan, 1987; Young, 1993). Spirituality enables older adults to be more productive and adaptive in a threatening environment (Young, 1993). In addition, there is no evidence that the spirit succumbs to the aging process, even in the presence of debilitating illness (Heriot, 1992). Consequently, a purpose of this study was to determine the importance of spiritual wellbeing among older adults who dwell in the community.
The following research questions were addressed:
* Is there a correlation between the two subscales of the Spiritual Well-Being scale (SWB) (Paloutzian & Ellison, 1982)? What is the level of spiritual well-being in older adults living in the community as measured by the SWB?
* Are there gender differences between older adults and spiritual well-being?
* Is there a difference in age, related to spiritual well-being in older adults who live in the community?
* Is there a difference in ethnic group related to spiritual well-being among older adults who live in the community?
* Are there differences between religious affiliation and spiritual well-being in older adults who live in the community?
The spiritual care of clients has been neglected not only by educators and practitioners but also by theorists (Oldnall, 1995). Oldnall (1995) reported that only three nursing theorists explicitly acknowledge the impact of spirituality in holistic care or describe the influence of the human spirit in health and illness. Neuman (1995) is a nursing theorist who includes spirituality in her framework, adding the spiritual dimension to her original framework published in 1970. Selected spiritual concepts described by Neuman (1995) were used to view the information in this study. Additionally, an eclectic approach was used to describe related study variables.
According to Neuman (1995), clients are composed of physiological, psychological, developmental, sociocultural, and spiritual variables. These five variables are part of the core of each individual, and all are viewed as parts of the whole. There is a constant, dynamic interaction among these variables in response to internal and external stresses. Development of the individual's central core is dependent on the degree of development of each of the variables. According to Neuman (1995), the spiritual variable many never be recognized or developed in an individual.
Similar descriptions of spirituality have been reported by Astedt-Kurki (1995), Berggren-Thomas and Griggs (1995), Burkhardt (1989), Leetun (1996), Pullen et al. (1996), and Reed (1992). Spiritual variables can be defined as the influence of spiritual beliefs on an individual, the creative aspects of one's personality, and the essence of an individual's life. Spirituality allows individuals to find meaning in life, relate to a supreme power, experience joy and hope, and develop relationships.
People are energized by their spirit, resulting in energy moving toward wellness and flowing between individuals. Neuman (1995) suggested that energy is depleted through illness, grief, pain, and suffering. The body can be nourished by the spirit with positive thoughts and diminished with negative ideas. The spirit should be considered the primary locus of healing, with the ability to influence general health (Neuman, 1995). Reed (1992) reported that spirituality is a basic characteristic of humanness, needed for health and well-being.
Well-being or quality of life has been described as the experience of finding meaning in life and has been associated with employment, health, income, and education (Bufford, Paloutzian, & Ellison, 1991; Ellison, 1983; Paloutzian & Ellison, 1982). Well-being also has been identified as satisfaction with life, productivity, happiness, and energy level (AstedtKurki, 1995; Forbes, 1994; Glik, 1986; Kass, 1996; Poloma & Pendleton, 1991). According to Estby, Freel, Hart, Reese, and Clow (1994), spiritual health is necessary for physical, emotional, and mental well-being.
Nurses act to conserve energy in clients, impede movement toward illness, and facilitate wellness (Neuman, 1995). The practice of nursing is concerned with all variables affecting the client system, including the spiritual domain and its response to stress.
The influence of spirituality on the well-being and coping ability of older adult care recipients and caregivers was investigated by Forbes (1994). The results indicated a high correlation between spirituality and adjustment. The findings also suggested that the majority of the subjects had found meaning in their lives that moved beyond the chronic health problems they were experiencing. According to Forbes (1994), Black individuals tend to be more religious than White individuals, and women may be more religious than men. Similar findings were reported by Levin, Taylor, and Chatters (1994). According to Levin et al. (1994), Black individuals considered religion more important than other ethnic groups did. However, all older adults exhibited relatively high degrees of spirituality.
Glik (1986) reported no differences related to gender, in contrast to the results found by Mull et al. (1987), Reed (1986), and Levin et al. (1994), whose research indicated greater religiosity among women, compared to men. Religiosity can be defined as participation in religious activities and services (Levin et al., 1994; Mull et al., 1987). According to Levin et al. (1994), the higher levels of religiosity in older women than in older men may be related to the social structure in which women's roles typically involved church activities, caregiving, and nurturing. It is important to note that Levin et al.'s (1994) study involved the analyses of data from national surveys of older adults (N = 1,209) conducted in the 1970s and 1980s.
Studies similar to Forbes' (1994) have examined the association between spirituality and well-being among older adults (Black, 1995; Mull et al., 1987; Reed, 1986; Young, 1993). Mixed results were reported by the researchers. Black (1995) found a negative association between spiritual matters and well-being. One group perceived spirituality as a waste of time and effort (Black, 1995). In contrast to Black's (1995) findings, Mull et al.'s (1987) study concluded that 94% responded that religion was important in their lives. Reed (1986) found a positive relationship between religiousness and well-being in a healthy group of adults (r = .43, p < .001) but not in the group of hospitalized terminally ill.
Several investigations have been conducted to determine the influence of religious practices on health and illness (Astedt-Kurki, 1995; Bearon & Koenig, 1990; Burkhardt, 1994; Byrd, 1988; Clark et al., 1991; Clark & Heidenreich, 1995; Glik, 1986; King & Bushwick, 1994; Schmied & Jost, 1994; Sodestrom & Martinson, 1987). Schmied and Jost (1994) found no correlation between church attendance and illness during the preceding year. In contrast, Byrd's (1988) study revealed a significant difference in health-related outcomes (p < .0001) between the group of hospitalized patients who received intercessory prayer and the group who did not.
A study similar to Byrd's (1988) was conducted by Glik (1986) to determine health outcomes related to religious intervention including metaphysical healing, charismatic, and none. Findings suggested participation in specific healing systems had a positive effect on the subjects health and wellness (Glik, 1986).
Clark and Heidenreich (1995) examined factors that contribute to the provision of spiritual care for patients. Subjects were interviewed in the participants' homes after discharge from the hospital. Themes that related to expectations of patients from health care providers included: developing a trusting relationship; conducting an indepth spiritual assessment; conveying technical competence; and acting as a facilitator among family, clergy, and other providers (Clark & Heidenreich, 1995).
To avoid bias toward the JudeoChristian perspective, Clark et al. (1991) used more universal terms to describe the religious experience. Some words used included: meditation, higher power, transcendent, and supreme being. Spiritually sensitive words recognize the religious diversity of most client populations.
Sodestrom and Martinson (1987) interviewed hospitalized patients who had cancer and their nurses to assess spiritual coping strategies of the patients. The results indicated that patients used a variety of coping strategies and that nurses were only aware of some of the strategies. The patients indicated that the nurse's role in spiritual care should be to:
* Allow the patient the opportunity to share feelings about God.
* Be willing to listen.
* Refer to clergy when indicated.
* Provide privacy.
* Be kind, positive, and gentle.
* Provide good physical care.
There are conflicting reports in the research concerning the healthrelated benefits to older adults from religious practices. Similar contradictions are reported between spirituality and well-being among older adults. However, those subjects who indicated higher levels of spirituality were found to have improved healing and greater ability to prevent illnesses. Many of the studies included a limited number of subjects and few methodological controls.
This exploratory study examined the level of spiritual well-being in healthy older adults who lived in the community. Permission to conduct the study was obtained from all institutions involved. The subjects were selected from four Senior Action Centers located in the upstate area of a small, semirural state in the southeastern United States.
To participate in this research, subjects were required to understand English, and be able to write and complete a questionnaire. Some participants had chronic conditions; however, they did not experience any acute episodes of illness during the 2-week data collection period.
There were 37 subjects in this study, whose ages ranged from 56 to 88, with a mean of 74, and the majority were women (57%). All subjects were Protestant, and the majority (57%) specified they were Baptist. The sample comprised White (68%), Black (27%), and other (5%) ethnicities. Although one of the Senior Action Centers was attended primarily by Black individuals, few were interested in completing the survey. It is unknown why so few Black individuals elected to participate in the study, but it may be related to a lack of understanding or difficulty relating to a young White female researcher.
To collect data for this study, two instruments were used: the SWB and a demographic data tool. Paloutzian and Ellison developed the SWB, using all age groups in a variety of settings (Ellison, 1983). The purpose of the SWB is to determine the selfperceived spiritual well-being of subjects. The SWB consists of two subscaies: religious well-being (RWB) and existential well-being (EWB). The RWB measures subjects' sense of well-being with God or a higher power. The EWB assesses participants' sense of purpose in life, energy source, or health status. Total RWB and EWB scores provide the spiritual well-being score. The SWB is a Likert scale with 20 items and six choices for each response. The range of scores is from 20 to 120, with 120 representing the highest possible well-being score. Reliability and validity scores of the SWB have been reported by several researchers and were consistently high (Bufford et al., 1991; Ellison, 1983).
The SWB is the most widely used spiritual evaluation tool, despite its Judeo-Christian bias. However, there are some potential disadvantages in using this tool with an older age group. The SWB has been found to have a ceiling effect that limits the highest possible score participants can obtain (Bufford et al., 1991; Ledbetter, Smith, Vosler-Hunter, & Fischer, 1991). In addition, a Likerttype scale designed for older adults should be limited to no more than three possible choices for each item, whereas the SWB has six choices. In addition, self-report questionnaires similar to the SWB limit the possibility of obtaining indepth information in an area. In this research, 14 SWB questionnaires had to be discarded because the participants could not understand the negative wording of some of the items or could not understand the instructions.
A cross-sectional approach was used to administer the data collection instruments. A researcher (D.I.) was present for questions before and during data collection. Completion of the tools required approximately 15 minutes for each participant.
The Microsoft Excel program (1997) was used to score, code, and analyze the data. Descriptive statistics were calculated for demographic data, and a Pearson correlation coefficient was calculated to determine if a relationship existed between the SWB subscale scores (i.e., RWB, EWB). The level of significance was set at p < .05.
To address the first research question, "Is there a correlation between the two subscaies of the SWB?", a correlation coefficient was calculated. The correlation coefficient between RWB and EWB scores was .84 (p < .05). This high correlation indicated that the two subscaies of the SWB measured the spiritual well-being of older adults.
The second part of the first question related to the degree of self-perceived spiritual well-being present in older adults. Table 1 presents data related to this question. The statistics indicated that the subjects in this study perceived themselves to have high levels of spiritual well-being. The lowest score for this sample was 69 on the SWB, 36 on the RWB, and 33 on the EWB. The lowest possible score for the SWB is 20. For both the RWB and EWB, the lowest score is 10. The lowest score selected on the SWB by subjects in this sample was 49 points higher than the lowest possible score. Therefore, the lowest level of self-perceived spirituality and well-being was determined.
The statistics confirmed that this instrument has a ceiling effect, in which subjects are limited in the highest level of spiritual well-being they may select. The mode was 120 for the SWB and 60 for both the RWB and EWB, which are the highest levels possible for this instrument.
Table 2 presents the statistics related to the next three research questions. The second research question concerned possible gender differences in spiritual well-being. The findings indicated that the average SWB score for women was higher (104) than men (102). Both the RWB and EWB scores were higher for women, suggesting that involvement in religious activities may be more prevalent among women, who have a greater sense of well-being.
The third research question related to age differences in the level of selfperceived spiritual wellbeing (Table 2). The percentage of older adults in the two age groups was similar. The SWB score was the same for both age groups, indicating the importance of spirituality and purpose in life in both age groups. The RWB was higher in the younger age group, suggesting a strong spiritual connection to a higher being. The EWB scores were higher in the older age group, indicating a greater sense of well-being.
SELF-PERCEIVED LEVEL OF SPIRITUAL WELL-BEING AMONG OLDER ADULTS USING SWB SCALE (N = 37)
CHARACTERISTICS, SWB, RWB, AND EWB SCORES FOR OLDER ADULTS (N= 37)
The fourth research question concerned perceived differences in spiritual well-being scores between ethnic groups (Table 2). The White group scored slightly higher on the SWB, RWB, and EWB scales than the Black group. These findings may have resulted from the greater number of White individuals in the sample.
The fifth research question related to perceived differences in level of spiritual well-being and religious affiliation. The findings indicated that all participants in this study were of the same religious affiliation - Protestant. Consequently, no conclusions could be obtained from this sample concerning religious affiliation and degree of spiritual wellbeing. The religious affiliation selected by participants in this study reflect the trends in the southeastern area of the United States.
This study examined spiritual well-being among older adults living in the community. It also investigated similarities and differences between SWB scores and age, gender, race, and religious affiliation. The findings from this study generally are consistent with those of previous studies and add evidence that older adults perceive themselves to be highly spiritual (Astedt-Kurki, 1995; Bearon & Koenig, 1990; Clark et al., 1991; Mull et al., 1987; Young, 1993).
The results of this investigation indicated a high correlation between the two subscaies of the SWB. Similar findings have been reported in the literature (Bufford et al., 1991; Ellison, 1983). According to Bufford et al. (1991), the SWB and both subscaies (i.e., RWB, EWB) are correlated positively with a positive self-concept, sense of purpose in life, physical health, and emotional adjustment. They are correlated negatively with ill health, emotional maladjustment, and lack of purpose in life (Bufford et al., 1991). Several studies have reported positive healthy outcomes as a result of spiritual intervention (Byrd, 1988; Clark et al., 1991; Clark & Heidenreich, 1995; Glik, 1986; Schmied & Jost, 1994; Sodestrom & Martinson, 1987), despite the fact that many of the studies used small, nonrandom samples, and most were influenced by a Judeo-Christian perspective.
Another finding of this study confirmed the ceiling effect of the SWB (Bufford et al., 1991; Ledbetter et al., 1991). In this study, the most frequently selected spiritual wellbeing score was at the top of the scale. Consequently, it is not possible, using the SWB, to determine if older adults perceive their spiritual well-being to be higher than the parameters provided. However, the results of this study indicated that the SWB measures the lower amount of spirituality and well-being for older adults.
Gender differences found in this study were similar to previously reported research (Forbes, 1994; Levin et al., 1994; Mull et al., 1987; Reed, 1986). The scores in this research suggested that women had higher levels of spirituality and wellbeing than men.
This research indicated that individuals in the younger age group, age 56 to 74, perceived their spirituality to be the same as those in the age 75 and older age group. However, the older age group had higher spiritual well-being scores. This was not an anticipated finding, but it was anticipated that both age groups would have high scores on the SWB. Heriot (1992) suggested that spirituality does not diminish with aging.
In this research, findings related to ethnic group indicated that White subjects' scores were slightly higher than Black subjects' scores. However, this probably was a consequence of the low number of subjects who were Black. Previously reported research suggested that Black individuals are more religious than individuals of other ethnic groups (Forbes, 1994; Levin et al., 1994).
The findings of this study provide a crucial link to previous findings concerning the importance of spiritual well-being among older adults. In addition, the results of this study contribute to the developing interest in the association between spirituality and health. However, several factors have limited the validity of this study, including the size of the sample, the nonrandom method of selecting participants, and the use of only one instrument to measure spiritual well-being. The SWB was difficult for many older adults to read and understand. It included too many choices for each item, contributing to the problems this sample had in completing the SWB. The interview method may be more effective with older adults than a questionnaire. Another limitation may have been the inexperience of the researcher.
Several findings from this study have implications for nurses working with older adults. Nurses should be aware of the importance of spirituality to most older adults, particularly women. There is a need to include a spiritual assessment in all health examinations, in all health care settings. When spiritual needs are identified nurses can make referrals to ministers, priests, and others who provide spiritual services. Nurses can provide for privacy and protection of older adults from noise and other interruptions during religious observances and spiritual experiences. Health care professionals should be aware of cultural and spiritual differences among people.
Another implication for nurses confirmed by this study is the need for additional research to determine the physical, mental, and psychosocial outcomes related to spirituality and religious practices. Research is needed that uses large, random samples in a variety of health care settings. Research that adheres to standard research methodologies, develops instruments to measure the highest amount of spirituality present in older adults, and accesses spirituality not related to JudeoChristian concepts should be conducted over time.
Nurses, who represent the largest number of health care providers and who are in frequent contact with older adults, can influence others to be aware of spiritual needs. Case managers can ensure the spiritual aspect of client care is coordinated and involves an interdisciplinary approach. Teachers of professional health care students need to include spiritual factors in the curricula. Health care providers can benefit from information about spiritual well-being as an important aspect of holistic care.
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SELF-PERCEIVED LEVEL OF SPIRITUAL WELL-BEING AMONG OLDER ADULTS USING SWB SCALE (N = 37)
CHARACTERISTICS, SWB, RWB, AND EWB SCORES FOR OLDER ADULTS (N= 37)