Religion and spirituality play vital roles throughout a person's life span, especially in times of crisis (Pargament, 1997). Religious beliefs and practices provide a means of coping with illness (Herth, 1989; Northouse, 1989) and loss (O'Hara, Harper, Chartrand, & Johnston, 1996; Roberts & Messenger, 1993), while religious communities provide social (Chin-Sang & Alien, 1991) and spiritual support (Cacace & Willilamson, 1996). Religious and spiritual beliefs are an essential component of hope (Gaskins, & Forte, 1995; Haase, Britt, Coward, Leidy, & Penn, 1992), particularly for individuals with serious illnesses (Mickley, Soeken, & Belcher, 1992).
Religious beliefs and practices are especially important for older adults. Polls have found 80% of elderly Americans belong to a church or synagogue, 52% of them worship once a week or more (Gallup, 1994), and 73% of Americans older than age 64 believe religion to be "very important" in their lives (Gallup, 1996). More than half of the older adults in one study reported they met 80% or more of their closest friends at church (Koenig, Moberg, & Kvale, 1988), making their religious community central to their personal support system. Other research has shown that religious commitment increases as individuals grow older. In a recent study, for instance, 60% of older adults said they became more devout as they grew older, however, only 5% said religion became less important to them as they grew older (Koenig, 1995).
The present study reviewed and assessed the extent to which the concepts of religion and spirituality are explored in the nursing literature on gerontology, by examining all the articles appearing in the Journal of Gerontological Nursing and Geriatric Nursing between 1991 and 1997. The study sought to accomplish the following:
* Compare the exploration of the concepts of religion and spirituality in non-research, qualitative research and quantitative research articles, including a comparison of the percentage of articles in each category addressing religion and spirituality.
* Evaluate the research sophistication of studies employing religious and spiritual concepts and variables.
* Assess the relative importance of these concepts and variables to the research itself, and its application to nursing practice.
* Compare the proportion of gerontological nursing research addressing religion and spirituality to research in other disciplines addressing these concepts.
The concepts of religion and spirituality, and their relationship to health, have been widely discussed in the nursing literature in the past (Berggren-Thomas & Griggs, 1995; Hall, 1997; 1998; Mickley, Carson, & Soeken, 1995; Murray, 1995; Oldnall, 1995). The concept of spirituality, in the nursing literature, is broader than religion, per se. While religion is considered to be by some a manifestation of spirituality, the expression of spirituality need not include religious beliefs or practices (Emblen, 1992; Peri, 1995; Sumner, 1998). Nevertheless, religion may be the primary, or even the sole way, most people express their spirituality (Forbes, 1994; Roberts & Messenger, 1993).
The practice of religion and spirituality is partly influenced by culture and various demographic factors. Some studies indicate, for instance, that Black and Hispanic Americans tend to express their spirituality more through church attendance and related religious practices than White individuals (Levin, Chatters, & Taylor, 1995; Levin, Markides, & Ray, 1996). These and other studies (e.g., Bearson & Koenig, 1990; ChinSang & Alien, 1991; Ortega, Crutchfield, & Rushing, 1983) also suggest religion plays a large role in the lives of Black and Hispanic Americans, affecting their sense of life satisfaction. Research results demonstrate mental and physical health benefits of religious and spiritual practices and beliefs for older Black Americans (Johnson & Barer, 1990; Levin et al., 1995), Hispanic Americans (Levin et al., 1996; Maldonado, 1994), and Asian Americans (Die & Seelbach, 1988).
It has been suggested that some of the cultural influences on religious observance may be related to socioeconomic factors, such as education and income (Ai, Dunkle, Peterson, Sc Boiling, 1998). Yet Bearson and Koenig (1990) have found that reliance on religious and spiritual beliefs and activities in times of illness span income and educational levels. Two demographic variables, gender and age, repeatedly have been found to affect the practice of religion. With respect to gender, studies have consistently found that women are more likely to engage in religious practices than men (Levin & Taylor, 1993; Oman & Reed, 1998). Koenig (1995) reported that 60% of older adults surveyed said they became more devout as they grew older. This tendency to increase religious devotion with age has been found in other studies also (Levin et al., 1996; Oman & Reed, 1998; Zorn & Johnson, 1997). While church attendance may decrease among those who are very old or ill (Oman & Reed, 1998), most elderly individuals continue other religious and spiritual practices, such as prayer (Koenig, Pargament, & Nielsen, 1998).
Prayer is one of the most commonly used coping mechanisms among individuals who are seriously ill, regardless of their age or religious beliefs (Guillory, Sowell, Moneyham, & Seals, 1997; Kaplan, Marks, & Mertens, 1997). The use of religion and spirituality as coping mechanisms appears to increase in times of stress and illness (Pargament, 1997). One recent study suggests the increased use of religious and spiritual coping strategies are directly related to the severity of illness (Koenig et al., 1998). More important, a number of studies have shown an inverse relationship between the use of religious and spiritual coping and the expression of negative affective symptoms associated with stress and illness among elderly patients who are hospitalized (Koenig & Weaver, 1997). Further studies indicate that one quarter to one third of older adults find religion to be the most important factor enabling them to cope successfully with physical illness, mental illness, and life Stressors (Koenig, George, & Siegler, 1988; Koenig de Weaver, 1997).
A comparison of the literature in nursing and other health-related fields suggests nursing research is more likely to explore religious and spiritual concepts than other health professions (Weaver, Flannelly, Flannelly, Koenig, & Larson, 1998; Weaver, KIine, et al., 1998; Weaver, Samford, et al-, 1998). However, some prominent nursing leaders have suggested that greater attention should be given to religious and spiritual variables (Corcoran, 1993; Gaffin, 1995; Rothrock, 1994). The present study attempted to determine the proportion of articles addressing religion and spirituality that have been published in the gerontological nursing literature in recent years.
All articles in the journal of Gerontologicai Nursing and Geriatric Nursing during the years 1991 to 1997 were visually examined, and classified as being either research or non-research articles. News stories, literary works (e.g., poems), letters to the editor, editorials and commentaries, regular columns by the same writer, and personal biographies that were not part of a research study were excluded from the survey. Research articles were defined as those containing a statement of purpose and a description of research methods and findings or results, regardless of whether such topical headings were present (Moore, Newsome, Payne, & Tiansawad, 1993; O'Leary, McGiIl, Jones, & Paul, 1990).
Articles were examined by at least two researchers who served as judges. If the two judges could not agree, a third judge examined the article and consensus was reached. Initial agreement on the articles to be included in the survey and their classification as research or non-research articles were both greater than 95%.
Research articles were classified as either qualitative or quantitative. Research studies were classified as quantitative if they met the criteria for being a research study and the reported results included descriptive or inferential statistics. This classification is consistent with that used in other research reviews on religion and spirituality (Weaver, Flannelly, Flannelly, Koenig, & Larson, 1998; Weaver, Samford, Kline, Lucas, Larson, & Koenig, 1997). This approach made it possible to compare the current results with previous findings. Although this definition caused some studies to be classified as quantitative even though they employed ethnographic, grounded theory, and other qualitative methods (Brandriet, 1994; Strauss, 1991), only 14 studies were affected. There was 98% agreement between the judges on the classification of research articles as qualitative or quantitative studies.
Number of Articles Published in Two Gerontological Nursing Journals from 1991 through 1997 that Mentioned Religion/Spirituality
Content analysis was used to classify articles in terms of their religious and spiritual content in a method similar to that used by Larson, Pattison, Blazer, Omran, and Kaplan (1986); Sherrill, Larson, and Greenwood (1993); and Weaver et al. (1998). The analysis identified religious and spiritual concepts and terms such as spiritual health, spiritual distress, spiritual needs, religious beliefs, religious affiliation (e.g., specific religious denominations), religious practices (e.g., church attendance, scripture reading), spiritual health, spiritual distress, spiritual needs, prayer, and faith in God. As mentioned above, the concept of spirituality is viewed as being broader than, but not mutually exclusive from, religion in the nursing literature (Emblen, 1992; Peri, 1995; Summer, 1998). Overall differences between the use of the two concepts are reported below, although they are combined for most analyses. Articles were not counted if their only reference to spirituality was the word "spirit," as in the phrase "mind, body, and spirit." The judges were 96% in agreement on which articles mentioned religion or spirituality.
The publications under review contained a total of 784 articles, of which 362 (46.2%) were classified as research articles and 422 (53.8%) were classified as non-research articles (Table 1). A total of 40 (5.1%) of all articles in the survey referred to religion or spirituality. Twenty one (52.5%) of these forty articles refered to religious denomination, practices, or beliefs, but did not refer to spirituality. Six (15.0%) addressed spirituality, but did not refer to religion. The remaining 13 articles (32.5%) refered to both religion and spirituality. The frequency of articles that mentioned religion or spirituality did not differ significantly between the Journal of Gerontologicai Nursing and Geriatric Nursing.
RESEARCH VERSUS NONRESEARCH COMPARISONS
Research articles were significantly more likely to mention religion or spirituality than were non-research articles (chi square = 8.80, p < .01). Of the 362 research articles, 28 (7.7%) mentioned religion or spirituality, as compared to 12 (2.8%) of the 422 non-research articles (Table 1). No significant difference was found between the two journals in terms of the percentage of research or non-research articles referring to religion and spirituality.
Number and Percentage of Quantitative and Qualitative Research Articles Published in Two Cerontological Nursing Journals from 1991 through 1997 that Mentioned Religion/Spirituality
Among the 12 non-research articles that mentioned religion or spirituality, 3 made only passing reference to the importance of spiritual wellbeing or fulfillment, 2 noted the value of church membership as a mechanism of social support, and 3 discussed the general importance of religious beliefs in the context of cultural practices. Spirituality was a major theme of the four other non-research articles (33%), all of which discussed the importance of spiritual and religious beliefs among elderly individuals and nursing interventions to support spiritual well-being (BerggrenThomas & Griggs, 1995; Evans & Cunningham, 1996; Forbes, 1994; Schank, Weis, & Matheus, 1996). Spirituality was a major focus of 16 of the 28 research articles (57.1%).
QUALITATIVE VERSUS QUANTITATIVE COMPARISONS
Of the 84 qualitative studies examined, 9 (10.7%) mentioned religion or spirituality, whereas 19 (6.8%) of the 278 quantitative studies did so (Table 2). This difference was not statistically significant, however.
Seven of the nine qualitative studies that mentioned religion or spirituality studied their importance to elderly individuals (Burgener, Shimer, & Murrell, 1993; Cacace & Williamson, 1996; Daley, 1993), the use of spiritual support as an intervention (Galíienne, Moore, & Brennan, 1993; Johnson & Hlava, 1994), or both (Roberts, & Messenger, 1993; Young, 1993). One of the remaining studies examined parish nursing (Schank, Weis & Matheus, 1 996). The other mentioned religion, but it was not central to the study (Pinch & Parsons, 1993).
Spirituality was a major focus in 9 of the 19 quantitative studies addressing religion or spirituality. Eight of these nine studies explored the use of religion and spirituality as a coping mechanism (Chin-Sang & Alien, 1991; Gaskins Si Forte, 1995; Nores, 1997; O'Hara et al., 1996; Rusinak & Murphy, 1995) or their value in providing a sense of wellbeing and meaning to life (Burbank, 1992; Coleman, Piles & Poggenpoel, 1994; Forbes, 1994). The remaining study reported on the development of a scale to measure spiritual wellbeing (Hungelmann, Kenkel-Rossi, Klassen & Stollenwerk, 1996).
Types of Measures of Religion/Spirituality Used in Research Articles
QUANTITATIVE AND QUALITATIVE MEASURES OF RELIGION AND SPIRITUALITY
Six of the nine (67%) qualitative studies addressing religion and spirituality categorized participants in terms of their religious denomination (a nominal scale), whereas eleven of the nineteen (58%) quantitative studies did so (Table 3).
In 1 of the 9 (11.1%) qualitative studies and in 7 of the 19 (36.8%) quantitative studies, religious denomination was the only measure of religion and spirituality. Five of the nineteen (26.3%) quantitative studies used a single measure of religion and spirituality other than religious denomination. Three of these five studies used interval scales to measure religiosity (Rusinak & Murphy, 1995), religious practice (Lee, Kirn & You, 1997), or the importance of religion (Burbank, 1992). The seven remaining quantitative studies (36.8%) used more than one measure of religion and spirituality. Five of the seven employed two or more nominal measures of religion and spirituality, while the last two used Likert-type interval scales of spiritual well-being (Forbes, 1994; Hungelmann et al., 1996).
COMPARISON OF NURSING AND OTHER JOURNALS
The percentage of quantitative research studies addressing religion examined in the Journal of Gerontological Nursing and Geriatric Nursing (6.8%) was significantly higher than that found by Sherrill, Larson, and Greenwood (1993) for other gerontological journals (i.e., Journal of Gerontology, Gerontologist) (3.6%) (chi square = 4.46,/) < .05). It was also significantly higher than the percentage of studies involving religion that have been reported in fields of medicine, including psychiatry (1.2% to 2.5%) (Larson et al., 1986; Weaver, Samford, et al., 1998) and family medicine (3.5%) (Craigie, Liu, Larson & Lyons, 1988).
As mentioned previously, roughly 37% of the 19 quantitative studies addressing religion or spirituality in the primary nursing journals on gerontology used two or more measures of religion and spirituality. This percentage is substantially higher than those percentages reported for other journals in gerontology (18%) (Sherrill et al., 1993) and psychiatry (17% to 21%) (Larson et al., 1986; Weaver, Samford, et al., 1998).
The results of a systematic review of the Journal of Gerontological Nursing and Geriatric Nursing reveal that religion and spirituality are examined relatively often in gerontological nursing research compared to other gerontological journals or journals in other health sciences. The frequency of nursing research articles in the present study that included a religious or spiritual variable was nearly twice than that found in other journals of gerontology (Sherrill et al., 1993) or family medicine (Craigie et al., 1988), and far greater than that found in psychiatric (Larson et al., 1986; Weaver, Samford, et al., 1998) or psychological journals (Weaver, Kline, et al., 1998).
Many of the nursing articles examined used a single, nominal measure of religion or spirituality. Several used multiple measures of these concepts, employing nominal or interval scales. Two used Likert-type scales of spiritual well-being composed of 20 or more questions. Overall, the nursing research in this area uses more multiple measures and multiple-item scales than other health professional research that has been assessed (Gartner, 1996; Larson, Swyers & McCullough, 1998). The 37% of quantitative studies that used multiple indices in the present survey exceeds that reported by literature surveys of other health fields employing the same methodology (Craigie et al., 1988; Larson et ai., 1986; Sherrill et al, 1993; Weaver, Kline, et al., 1998; Weaver, Samford, et al., 1998). Authors of nursing studies in gerontology were also more likely to use the available literature on religion and spirituality outside their own field than were authors of studies in other health fields surveyed.
Although a dozen studies collected information on the religious denomination of participants, few studies included this variable in their analyses of the data. As a general suggestion, when one collects demographic data, it is worthwhile to examine how demographic differences within a sample affect the dependent variable or variables being studied. This is usually performed with chi-square analyses on cross-tabulated frequency data, or by performing non-parametric or parametric forms of analysis of variance when the dependent variables are measured on ordinal or interval/ratio scales, respectively. Such exploratory analyses can provide insights for understanding the phenomenon under study.
Most of the research on religion and spirituality is exploratory, because these concepts have not been studied extensively in relation to health. Overall, the research on religion and spirituality in the medical and related literature tends to be quantitative and relies more on the hypothetico-deductive model (to some extent, hypothesis driven), whereas nursing research is more often qualitative or descriptive. It would be helpful in the future for quantitative studies to follow-up on some of the qualitative findings on the importance of religion and spirituality and, perhaps, on cultural influences in religion and spirituality and health.
Following the example of O'Leary et al. (1990), the authors examined how the literature on religion and spirituality related to nursing practice. Three major themes emerged. One was the need for sensitivity to cultural differences in religious practices and beliefs, which was discussed in seven research and non-research articles. The second theme was the need to encourage support services for caregivers and community-dwelling elderly individuals, which was examined in eight of the research articles. The third basic theme was the importance of recognizing the individual cognitive, emotional, physical, and spiritual needs of older adults to provide individualized care. There are several clinically useful studies in this review of gerontological nursing journals that add important data to the literature (e.g., Haight, 1995; Krack & Brooks, 1995; Sutherland &: Murphy, 1995).
There were higher rates of research on religious variables in gerontological nursing than other disciplines (e.g., psychology, psychiatry, medical). A number of factors may contribute to this finding. Nurses are more likely to receive training in religious and spiritual issues than are other professionals. For example, in a stratified national sample of registered nurses, more than 60% indicated that spiritual care issues had been addressed to some degree in their education, while 9 of 10 thought the topic of spiritual care should be addressed in all basic nursing programs (Piles, 1990).
In a similar survey of 409 clinical psychologists, only 5% had religious or spiritual issues addressed hi their professional training (Shafranske & Malony, 1990). Other research has shown that relatively few American medical schools offer courses that include spirituality or religion in their curricula (Sansone, Khatain, & Rodenhauser, 1990), although the number has began to increase (Puchalski St Larson, 1998).
Another reason for the higher rate of research on religious variables in nursing may be that nurses themselves show a high rate of interest and involvement in religion. In a study of registered nurses in Oklahoma, half attended church weekly and approximately three of four indicated they were active in their religion (Boutell & Bozett, 1987). In a separate study of a stratified, random sample of 181 members of the Oncology Nursing Society from 40 states, 44% attended religious services weekly and 63% did so at least once a month (Taylor, Amenta & Highfield, 1995). A third study of hospice nurses working in New York, New Jersey, and Pennsylvania reponed that 99% were very or somewhat spiritual (Millison Si Dudley, 1992).
When academics are surveyed, nursing faculty are much more likely to indicate a religious affiliation than faculty in psychology or medicine. Half of psychology and a quarter of medical faculty reported having no religious preference ("Politics," 1991) - a proportion approximately seven to three times greater, respectively, than that found in the American population as a whole (Gallup, 1994). By contrast, 12% of nursing faculty indicated no religious affiliation ("Politics," 1991). These figures suggest it is more likely, for example, for academic nursing faculty, who are publishing research and responsible for training students in research, to be more aware of the religious variable and its relevance to empirical studies than psychology or medical professors.
As mentioned earlier, studies of the general population consistently have found that women are more religious and spiritual than men are. These findings, along with the fact that nursing, unlike medicine, is a predominantly female profession, offer yet another possible explanation for the differences between the degree to which nursing and medicine have studied the effects of religious and spiritual variables. On a fundamental level, the gender difference between the professions may account, in part, for the finding that nursing is more inclined to study the concepts of religion and spirituality than medicine is.
A final, potential reason for the differences between nursing's and medicine's attention to religion and spirituality may be related to the historical influences on each profession. Florence Nightingale, the founder of modern nursing, emphasized that spirituality was an intrinsic part of the human experience (Macrae, 1995). Nightingale's writings about religion and spirituality document her struggle to reconcile her religious and spiritual beliefs with scientific tradition (Macrae, 1995; Widerquist, 1992). In short, Nightingale, viewed spirituality and science as compatible ways of seeking truth in life. In contrast, modern medicine and the related fields of psychiatry and psychology have been influenced heavily by the views of Sigmund Freud, who saw religion and spirituality as pathological traits (Ellis, 1980; Freud, 1962).
Nurses have a history of recognizing and affirming the clinical value of religion and spirituality in the lives of those for whom they care. Since 1988, "spiritual distress" has been an official nursing diagnosis according to the North American Nursing Diagnosis Association (NANDA, 1992). Research has consistently shown that nurses have high personal involvement in their own religion and spirituality and are likely to have studied religious factors in their professional training. In addition, religion and spirituality play vital roles in the lives of older adults (Weaver, Koenig & Roe, 1998), particularly when they are suffering from an illness and are the most likely to interact with nurses. For these reasons, gerontoiogical nursing is in a unique position among health professions to make contributions to the understanding of religion and spirituality in mental and physical health assessment and care.
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Number of Articles Published in Two Gerontological Nursing Journals from 1991 through 1997 that Mentioned Religion/Spirituality
Number and Percentage of Quantitative and Qualitative Research Articles Published in Two Cerontological Nursing Journals from 1991 through 1997 that Mentioned Religion/Spirituality
Types of Measures of Religion/Spirituality Used in Research Articles