Supportive Care

The State of Spirituality Scale as a Screening Tool for Spiritual Distress

Pam Stephenson

Denice Sheehan

Dana Hansen

spirituality, hospice care, spiritual care, spiritual distress, spiritual screening
CJON 2022, 26(6), 593-596. DOI: 10.1188/22.CJON.593-596

Patients and families facing serious and life- threatening illnesses are at risk for spiritual distress. Screening for spiritual distress is an efficient way of identifying issues. The State of Spirituality scale takes a unique, multidimensional approach to spirituality screening.

At a Glance

  • Spirituality is often neglected by healthcare providers, who may lack the time or training to provide spiritual care.
  • Spiritual screenings are an efficient way of identifying spiritual distress during serious illness and are simple enough for most clinicians to complete.
  • The State of Spirituality scale takes a unique, multidimensional approach by reducing spirituality into five lower-level dimensions.

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    C oping with serious illness can trigger deep spiritual reflection for families receiving hospice care (Ellington et al., 2015). Unfortunately, spiritual care is challenged by the abstract, subjective, and contextual nature of spirituality among patients, family members, and providers (Egan et al., 2017). Spiritual screenings are an efficient way of identifying spiritual distress during serious illness and are simple enough for most clinicians to complete. Spiritual assessments or spiritual histories are more sophisticated forms of information gathering and are usually completed by chaplains or healthcare providers with specialized training (Balboni et al., 2017). Most spiritual screening tools look for the presence of a single identifier, such as peace (Steinhauser et al., 2006) or spiritual pain (Mako et al., 2006).

    The State of Spirituality Scale

    The State of Spirituality (SOS) scale screens for spirituality by reducing the broad construct into five lower-level dimensions. These five dimensions, identified in previous research, include meaning, beliefs, connections, self-transcendence, and value (Stephenson & Berry, 2015). When translating the dimensions to the SOS scale, the dimensions of connections and self-transcendence were changed to “relationships” and “acceptance,” respectively. These terms were believed to be more easily understood because they better reflected participants’ everyday language. The SOS scale places each dimension on its own visual analog scale (see Figure 1). Scales are anchored with “well-being” on one end and “distress” on the other. All scales are arranged horizontally and side-by-side on one page. Using standardized prompts, patients receiving hospice care and their family members are advised to mark their current state on each dimension. Articulating spiritual distress is difficult for some patients, but the SOS scale allows for the spiritual state to be illustrated visually rather than verbally. When viewed together, the completed scales create a snapshot for providers to see which dimensions are problematic to individuals in real time. Responses to the SOS scale can guide follow-up conversations.

    FIGURE1

    As a screening tool, the SOS scale is not intended to collect statistical data but to visually indicate what is most distressing to the participant in the moment. This screening procedure creates a visual depiction of the participant’s spiritual state in a way that might be hard for some people to convey verbally. Rather than ask a patient, “What is bothering you the most today?” the provider can see for themselves which spiritual dimension is scored closer to distress, which can then be the focus of a follow-up conversation. This strategy could help to streamline providers’ time, which is frequently reported to be one of the biggest barriers to engaging in spiritual care (Kelly et al., 2021).

    Methods

    Cognitive interviews were used to assess the feasibility of the SOS scale as a clinical screening tool for spiritual distress. Cognitive interviewing is useful for new tool development because it allows researchers to assess how well participants interpret and complete the SOS scale when used for the first time (Beatty & Willis, 2007; Willis, 1999). For this pilot feasibility study, the SOS scale was used with patients in hospice and their family members who were at risk for spiritual distress before implementing it with a larger study sample.

    Participants and Setting

    Four families receiving hospice care or bereavement services were recruited to examine the feasibility of the SOS scale as a screening tool for spiritual distress. Families consisted of a parent diagnosed with a life-limiting illness, a primary family caregiver (a spouse or relationship partner), and adolescent children who lived at home during the illness. All three family groups were included for the following reasons: (a) younger families have unique needs and vulnerabilities during the serious illness of a parent (e.g., shifts in parenting and adolescent caregiving roles), and (b) these family groups are studied by the authors’ research team.

    A sampling strategy that recruits for a wide range of experiences relevant to the concept being measured is recommended for cognitive interviewing. Small sample sizes of between 5 and 15 participants are adequate to identify serious problems with the measure (Peterson et al., 2017). Therefore, this pilot feasibility study provided an opportunity to test the potential of the SOS scale with all family groups investigated by this research team.

    Procedures

    After obtaining approval from the university’s institutional review board, purposive sampling was used to recruit participants from a large hospice in the midwestern United States. Written informed consent (parents) and assent (adolescents) were obtained before data collection. To instruct them on how to score each dimension of the SOS scale’s visual analog scale, standardized prompts were read to participants (see Figure 2). Prompts guided participants to think about how they felt regarding a specific dimension before marking their current state between well-being and distress on the corresponding visual analog scale. This procedure was repeated for each of the five dimensions. Individual interviews were conducted after the SOS scale was completed and were digitally recorded and transcribed verbatim.

    FIGURE2

    Results

    A total of 11 family members from four families completed the SOS scale and cognitive interviews. The mean age for adult parents was 48.2 years, and there were three female and two male participants. The mean age for adolescents was 16.8 years, with three female and three male participants. Examples of how the SOS scale was used to screen for spiritual distress are provided in the following three case studies.

    Case Study 1

    One bereaved spouse, aged 50 years, had SOS scale scores indicating that the dimension of meaning was associated with the most distress for him at that time. The investigator asked if he could elaborate on what he was thinking about when he scored meaning as distressing. He explained, “It’s like, God . . . why do you take a person like my wife . . . who was a good person, [then] you see on the news that a guy is killing people and everything else, but he lives a whole happy life without any type of suffering.”

    Case Study 2

    The SOS scale helped some participants recognize sources of distress of which they were previously unaware. One bereaved spouse, aged 54 years, explained how the SOS scale helped her see problem areas of spirituality of which she had been unaware. “I wouldn’t have been able to tell you, ‘I’m really having trouble with acceptance,’” she said, pointing to her completed SOS acceptance scale, “but there it is!” Upon deeper reflection, she acknowledged that acceptance was the aspect of her husband’s death that she currently struggled with the most. She explained, “Obviously it happened, you know. I can’t deny it, but sometimes I forget. Like something happens, and the first thing I want to do is tell [my husband].”

    Case Study 3

    The SOS scale also tested well with adolescent spirituality. One adolescent, aged 17 years, scored the beliefs scale as distressing. When asked what he was thinking about, he said, “[My dad] has done so many great things and then he’s the one that gets jacked over—like, that’s not fair. So I kinda feel like I’ve been betrayed, because I was raised Christian. . . . I hope there’s a God, but that’s all I can hope for—I don’t see any proof of it.” When asked if he talked to anyone about this he replied, “Not really,” making this the first time he was able to articulate these feelings.

    Discussion

    Cognitive interviews showed that the five spiritual dimension identifiers and corresponding prompts were understandable, accurate, and relevant to participants’ experiences in hospice. Based on these study results, the SOS scale has demonstrated feasibility as a method to screen for spiritual distress, which is needed in clinical practice (Balboni et al., 2017). Although the stories elicited by the SOS scale might have emerged naturally in conversations among providers and patients or families, this study’s findings indicated that using the SOS scale can help to discover salient information.

    Based on the results of this pilot feasibility study, use of the SOS scale is particularly promising for adolescents, for whom no screening tools for spiritual distress have been identified. It is estimated that approximately 2.9 million adolescents will experience the death of a parent by the time they are 18 years old (Burns et al., 2020). For many, this will be their first experience with someone’s death, increasing their risk of spiritual distress. Additional research is needed to assess the SOS scale with a larger sample, but these early findings show that this type of multidimensional screening tool holds promise.

    Conclusion

    Nurses who care for patients and their families in crisis may encounter evidence of spiritual distress, but they frequently report a lack of adequate time and training to deliver effective care. By using a multidimensional screening tool such as the SOS scale, clinicians can efficiently screen for spiritual distress and improve patient and family outcomes.

    The authors gratefully acknowledge Betty Ferrell, RN, PhD, MA, CHPN®, FAAN, FPCN®, and Barbara Broome, PhD, RN, FAAN, for sharing their expertise as consultants to this project, and the Palliative Care Research Cooperative Group for their assistance with all phases of research and dissemination.

    About the Authors

    Pam Stephenson, PhD, RN, is an associate professor, Denice Sheehan, PhD, RN, FPCN®, is a professor, and Dana Hansen, PhD, APRN, ACHPN®, is an associate professor, all in the College of Nursing at Kent State University in Ohio. The authors take full responsibility for this content. This project was supported, in part, by the Palliative Care Research Cooperative Group through funding from the National Institute of Nursing Research (U24NR014637). Stephenson can be reached at pstephe2@kent.edu, with copy to CJONEditor@ons.org.

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