1. Western Journal of Nursing
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A Critical Review of a Spirituality Intervention
Inez Tuck
West J Nurs Res 2012 34: 712 originally published online 6 February 2012
DOI: 10.1177/0193945911433891
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2. Articles
A Critical Review of a
Spirituality Intervention
Western Journal of Nursing Research
34(6) 712­–735
© The Author(s) 2012
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DOI: 10.1177/0193945911433891
http://wjn.sagepub.com
Inez Tuck1
Abstract
Although there is a growing interest in the topic of spirituality, there are
few reports of spiritual interventions and limited empirical data to support
their effectiveness. As health care practices become increasingly evidence
based, the reliance on empirical data is critical. This article describes the
spiritual intervention developed by the author and documents the testing of
its effectiveness with clinical and nonclinical populations. The findings from
a series of studies have been mixed. Preliminary studies reported that the
intervention positively influenced patients’ outcomes, including overall quality of life and reduced selected stress responses. Significant positive trends
were found that supported the potential effectiveness of the intervention
for a variety of populations and clinical settings. However, subsequent testing
in clinical trials indicated limited effect of the intervention although there
were several noteworthy findings. The author discusses the implications of
these findings for future investigations.
Keywords
spirituality, intervention, HIV, clinical trials
The author believes that efforts to provide spiritual care as mandated by the
Joint Commission for Accreditation of Healthcare Organizations (JCACHO,
1
North Carolina Agricultural and Technical State University, Greensboro, USA
Corresponding Author:
Inez Tuck, School of Nursing, North Carolina Agricultural and Technical State University, 1601
East Market Street, Greensboro, NC 27411, USA
Email: ituck@ncat.edu

3. Tuck
713
2004) has had limited success. Many health professionals are reticent to provide spiritual care and have minimally met this standard. There remains an
overreliance on documenting religious preferences and faith practices and
referrals made to clergy or chaplains as major spiritual interventions. The
lack of spiritual interventions tested in health care further limits the full
implementation of this standard of care. The purpose of this article is to
describe the development and testing of a spiritual intervention. Furthermore, the author recommends useful strategies to further this area of research.
There are several factors that contribute to the paucity of spirituality interventions available in practice. A primary reason is the lack of agreement
regarding the concept of spirituality. There is a wide array of definitions
found in the literature. Burkhardt (1989) described three descriptive characteristics of spirituality: inner strength, unfolding mystery (meaning and purpose), and harmonious interconnectedness. Coyle (2002) later described three
different attributes of spirituality as transcendent (belief in God or higher
power), structuralist behaviorist (religious practices), and value guidance
(personal values). The author posits that although many scholars have contributed to the literature, there is not a consensus regarding the definition of
spirituality and its parameters or characteristics. Such conceptual limitations
may have implications for measurement and testing.
Second, nurses are reluctant to provide spiritual care. The author and
colleagues in a series of related studies (Pullen, Tuck, & Mix, 1996; Tuck,
Wallace, & Pullen, 2001; Wallace, Tuck, Boland, & Witucki, 2002) examined the spiritual perspectives and interventions made by mental health and
parish nurses and found that nurses reported their personal affiliation with a
religion and high levels of spirituality and yet, both groups reported reluctance in making spiritual interventions. Mental health nurses reported a
greater reluctance. The findings from this series of studies indicated that one
of the major barriers was the lack of knowledge and discomfort related to the
appropriateness of providing spiritual care. Likewise, Vance (2001) reported
that acute care nurses perceived themselves to be highly spiritual, but only
slightly more than one fourth of them provided adequate spiritual care to
their patients. Barriers reported by Vance were lack of time, education and
training, and confidence; differences in faith between patient and nurse; and
confusion over the difference between proselytizing and spiritual care.
Anandarajah and Hight (2001) also found that a majority of health care providers failed to perform spiritual assessments. These studies consistently
documented nurses’ reticence to provide spiritual care. Nurses’ lack of
knowledge of appropriate spiritual interventions was a consistent finding of
these studies.

4. 714
Western Journal of Nursing Research 34(6)
Third, there are limited number of spiritual interventions available and
there is a lack of evidence to support their effectiveness. This article describes
the development and testing of one spiritual intervention over a 14-year
period and briefly reports study findings. In this evidence-based culture of
health care, until nurses are assured that spiritual interventions are valid and
reliable, spiritual practices will likely remain relegated to clergy or to a few
nurses who are comfortable with broaching the subject with patients and
families. Clearly, these efforts are inadequate to fulfill the mandate of providing spiritual care to every patient.
The author developed a spirituality intervention, and a systematic
approach is proposed to describe its development. First of all, the spiritual
intervention is described and linked to an array of clinical problems and
research findings. Second, the author will briefly provide the conceptual
background for the intervention. Third, a four-phase research model is used
to describe the testing of the intervention, including study designs and the
instruments used to measure outcomes and demonstrate treatment effect.
The research model offers an approach to critique internal and external
validity. Finally, the findings of these studies are briefly discussed along with
implications for future research and practice.
The Development of a Spiritual Intervention
Linkage of Spirituality and Clinical Practice
In the 1990s, the author studied the experience of living with chronic fatigue
syndrome and schizophrenia, two stigmatizing illnesses, and found that
participants described spirituality and religious beliefs as an essential source
of support during difficult times (Tuck, duMont, Evans, & Shupe, 1997;
Tuck, Wallace, Casalenuovo, & May, 2000). Although spirituality was not a
study variable, it proved to be a figural part of the experience most notably
found in the qualitative responses. Participant’s stories became the impetus
for the author’s scholarly interest in spirituality and healing.
Later, the author conducted regional and national surveys of nurses and an
ethnography to examine spiritual interventions used in practice. Study findings included “being with” and being fully present with patients and offering
religious materials and prayer. A significant finding of the ethnographic
study was a taxonomy of spiritual interventions (Tuck & Wallace, 2000).
While these descriptive qualitative studies elucidated lists of spiritual interventions used by nurses, their use was reported as infrequent and without
empirical support of their effectiveness.

5. Tuck
715
Grounding a Spirituality Intervention in Research
Early studies related spirituality with a number of chronic illnesses, including cancer and HIV/AIDS (Reed, 1986; Sowell et al., 2000). Spirituality was
identified as a factor in maintaining health and well-being (Coleman &
Holzemer, 1999; Smith, 1993). Hawks, Hull, Thalman, and Richins (1995)
described spiritual health and its relationship to behavioral, emotional, and
physical outcomes. Peri (1995) found that having a greater awareness of
one’s spirituality resulted in an increase in the spiritual well-being of persons
living with HIV. Kendall (1994) reported the core process of wellness spirituality in her grounded theory as essential to health and well-being. Other
studies documented spirituality as a contributor to positive health outcomes
and wellness (Gray, 1997; Kass et al., 1991; Levin, Chatters, & Taylor, 1995).
Other studies conducted during the latter part of the 20th century explored
the relationship of spirituality, stress, and coping. Regan-Kubinski and ShartsHopko (1995) interviewed 38 HIV-infected women from the perspective of
the cognitive-transactional stress process (Lazarus & Folkman, 1984) and
found that coping was related to newfound spirituality, a renewed spiritual
commitment, or a reexamination of spiritual beliefs. Folkman (1997) in her
work with persons with HIV disease asserted that under conditions of chronic
and severe stress, spirituality and religiosity facilitate positive reappraisals
of the difficult situation, and these reappraisals in turn support positive
psychological states. . . . The use of spiritual beliefs and experiences at all
stages of an enduring stressful condition is an aspect of coping that deserves
systematic investigation. (p. 1214)
Support for a Group Intervention
A literature search in CINAHL and Medline/PubMed using the keywords
of spiritual interventions yielded a small number of research studies that
explored spirituality using a group approach. Reports of findings from two
studies contributed to the author’s initial work in 1997. Germer (1996)
offered a spiritual awareness group to 17 adult participants who reported the
experience of discussing their spirituality as rare and beneficial. The qualitative findings indicated that learning from others, being able to express difficult emotions concerning spirituality in a supportive atmosphere, and
gaining motivation to work on this area of one’s life were unanticipated outcomes of the intervention. Astin (1997), using an 8-week stress reduction
meditation study, indicated a decline in physical and psychological symptoms

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Western Journal of Nursing Research 34(6)
and an increased sense of self-control and spiritual awareness among the
study’s participants.
Several years later, Levine and Targ (2002) conducted a clinical trial of a
sample of 191 women with breast cancer enrolled in a 12-week intervention
and found that measures of spirituality and spiritual well-being accounted
for 40% of the variance in functional well-being of the study’s participants.
Phillips, Lakin, and Pargament (2002) offered a 7-week semistructured, spiritual, psychoeducational intervention in which participants discussed religious resources, spiritual struggles, forgiveness, and hope. In addition,
Lechner et al. (2003) tested the effects of a 10-week group spiritually based
cognitive-behavioral stress management (CBSM) group and an individual
psychoeducation intervention and found that both interventions increased
the quality of life. In conclusion, group facilitated approaches designed to
provide spiritual care have significantly influenced the health outcomes for
persons living with chronic diseases. The evidence for a group intervention
was well documented in the literature.
Description of the Spiritual Intervention
The development of the spiritual intervention began in the late 1990s and at
the same time there was a growing body of evidence that supported the
relationship between spirituality and health outcomes. The spiritual growth
group, SPIRIT©, was developed to fill the void of available spiritual interventions for research and practice. SPIRIT© was initially designed as an
8-week experience and was grounded in the substantive and research literature, the findings from previous studies conducted by the author, and her
prior group therapy experience. The intervention included interpersonal,
self-awareness, and interpretive approaches (Tuck, 2004). The intervention
builds on the definition of spirituality as “the essence of an individual and is
expressed in the outward manifestations of thoughts, feelings, and behaviors
that allows meaning making, peace, hope and connectedness with self, others, nature, and God or higher power” (Tuck, 1998, p. 1). The theoretical
underpinning of the spiritual intervention is an integrative framework that is
based on the premises and assumptions of symbolic interactionism (Blumer,
1969), phenomenology (Husserl, 1970; Schultz, 1962, 1964, 1970), existentialism (Sartre, 1953), and social learning theory (Bandura, 1977; Grusec,
1992). The 11 assumptions for the intervention derived from these frameworks focus on exploring, apprehending, sharing, appreciating, and connecting with spirituality (Tuck, 2004).

7. Tuck
717
The intervention was designed for participants to share personal and communal views of spirituality in a group format and supports both secular and
religious views. The participants meet weekly for 90 minutes, which includes
20 minutes for reflection and 70 minutes for structured activities designed to
facilitate understanding and appreciation of spirituality. The reflection time
is accompanied by selections of music. The members are asked to focus their
attention on the “here and now” experience of being present in the group
while monitoring their breathing and limiting their thoughts. After a brief
discussion, the group participates in an activity designed to explore their
spirituality. For instance, participants are asked to respond to spiritual readings, watch video clips, and engage in creative activities that allow the
expression of spirituality. The session is concluded with the discussion of the
activity that allows sharing with others. The participants are encouraged to
acknowledge and clarify their insights. The facilitator follows the written
protocols and an instruction manual that details the specific activities for
each session and critical points regarding group process (Tuck, 2005).
Testing of the Spiritual Intervention
Whittemore and Grey (2002) discussed the four phases of clinical trials
identified by the U.S. National Institutes of Health (NIH) and linked these
phases to the development of nursing interventions. They suggested that
Phase I trials are designed to test the effectiveness and feasibility of the
intervention. The first phase also includes the conceptual development of the
intervention and the definition of clinical problems. Phase II pilot studies
use larger samples to test the efficacy of the intervention, determine the
effect size, and refine the protocol. Phase III includes prospective randomized clinical trials with well-designed experimental designs with large
samples, and in this phase, the research protocol is highly defined. Internal
and external validity of the intervention is refined in this stage. Phase IV
allows the intervention to be tested in actual practice and includes the consideration of the generalizability of the intervention to practice situations.
These NIH guidelines imply a positivistic approach to research. Whittemore
and Grey (2002) added the interpretative qualitative paradigm in their conceptualization of intervention development. These NIH guidelines will be
used to structure this report of testing the intervention.
SPIRIT© has been implemented with 29 groups of participants of varying
sizes. Three versions of SPIRIT© intervention, 6, 8, and 10 weeks, have been
tested for feasibility and acceptability (Tuck, Alleyne, & Thinganjana, 2006;
Tuck, McCain, & Elswick, 2001; Tuck, McCain, Elswick, & Baliko, 2002).
The initial version of 8 weeks was expanded to 10 weeks based on the

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Western Journal of Nursing Research 34(6)
qualitative findings and later, a 6-week intervention was developed as a
health promotion and stress management activity for healthy community
dwelling adults. The author’s work began with preliminary pilot studies as
proposed in the NIH model and advanced to Phase III clinical trials to test
the effectiveness of this intervention.
The protocols for conducting SPIRIT-6©, -8, and -10 are identical.
Essentially, there is one intervention that ranges from 6 to 10 sessions. The
differences in the number of sessions offer variations in the “dosage” of spirituality. Four additional sessions serve as booster sessions in longitudinal
studies. The choice for the length of the intervention is based on the preference of the investigator, the design of the study, or consideration of the population being studied. Detailed findings of these studies have been previously
reported elsewhere (Tuck et al., 2002; Tuck, McCain, et al., 2001; Tuck,
McCain et al., 2008). However, a brief synopsis and selected findings from
these studies illustrate the NIH classification scheme.
Phase I Preliminary Trial and Descriptive Pilots
Consistent with the intent of Phase I trials, the initial study was designed to
determine the acceptability and feasibility of the intervention with a sample
of persons living with HIV disease (N = 28). A subset of participants from a
larger study (NIH No. R01 NR04395, McCain, PI; McCain et al., 2008) who
were randomly assigned to the CBSM, social support, and the control
groups were matched with newly recruited participants enrolled in SPIRIT-8©
as a third intervention group. Pre- and posttest measures were administered
to participants in the four groups following a standard research protocol.
This limited sample yielded evidence of trends in the direction of significant
effects for the spirituality group on psychosocial measures although there
were no apparent effects noted on the physiological measures (Tuck, 2004;
Tuck et al., 2002). The acceptability of the spiritual intervention was confirmed by participants’ statements that they enjoyed being in the group and
desired additional sessions to further develop their spirituality.
A cross-sectional study was conducted to determine the appropriate measures to use in future longitudinal studies. Secondary analysis of pretest data
in a sample of 52 persons living with HIV explored the relationships among
spirituality and selected psychosocial measures. Spirituality was measured
with three instruments: Spiritual Perspective Scale (SpS), Spiritual Health
Inventory (SHI), and Spiritual Well-Being Scale (SWBS). Tuck, McCain,
et al. (2001) found a strong positive relationship between SWBS and social
support, appraisal focused coping (effective coping strategy), emotional,
social, physical, and functional well-being, and total quality of life. There

9. Tuck
719
was an inverse relationship between spirituality and perceived stress, uncertainty, psychological distress, and emotion-focused coping. The results of
these analyses provided data essential to selecting spirituality instruments
and health outcome measures for subsequent studies. Of the three instruments, only the SWBS had significant results.
A Phase II Clinical Trial
SPIRIT-6© was studied as a stress reduction intervention with a convenience
sample of adults from three local Protestant churches (two predominantly
Caucasian and one African American). The study allowed for the refinement
of the intervention protocol, explored the relationship among study variables, and tested the efficacy of the intervention using a pre- and posttest
design with follow-up booster sessions over 12 months (Tuck et al., 2006).
Participants completed three measures, SpS, SWBS, and Perceived Stress
Scale (PSS), at the start of the 6-week intervention (T1), at 6 weeks (T2), 12
weeks (T3), 6 months (T4), and 1 year (T5). The findings indicated a significant decrease in participants’ levels of perceived stress from Time 1 to Time
3, F(2, 34) = 4.21, p < .05, and a significant increase in participants’ levels
of spirituality from Time 1 to Time 3, as measured by the SpS, F(2, 34) =
3.60, p < .05, suggesting a significant effect for the intervention. There was
a significant negative correlation between the measure of perceived stress
and spiritual well-being at Time 1 (r = −.613, p < .01), Time 2 (r = −.638,
p < .01), and Time 3 (r = −.855, p < .01; Tuck, McCain, et al., 2005). Due
to small sample size, analysis were unavailable for Times 4 and 5.
Phase III Randomized Clinical Trials
Phase III studies are prospective randomized clinical trials with welldesigned experimental designs with large samples. Data from the preliminary studies warranted the inclusion of the intervention in this level of
research. The first of two studies was a randomized clinical trial grounded
in the psychoneuroimmunology (PNI) theoretical framework. The clinical
trial included three interventions: (a) CBSM, (b) SPIRIT-10©, and (c) a
10-week version focused Tai Chi and a wait-control group of persons living
with HIV disease. The study, conducted by a multidisciplinary team (NIH
No. R01 AT000331, McCain, PI), used multiple PNI indicators to measure
the three outcomes of psychosocial functioning, quality of life, and physical
health along with neuroendocrine mediation and immune function. Details
of the study aims, design and procedures, and study findings are beyond the

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Western Journal of Nursing Research 34(6)
scope of this article and are reported elsewhere (McCain et al., 2008), and
only the results of spiritual growth group are reported here.
A total of 66 participants completed the SPIRIT-10© intervention group
with complete data sets. Using paired t tests, the pre- to postintervention
comparisons indicated that the spiritual subgroup had higher overall quality
of life (p ≤ 0.01), largely accounted for by higher emotional well-being (p ≤
0.01) and higher physical well-being (p ≤ 0.01) upon completion of the intervention. They also had lower perceptions of social support on the dimension
of allegiance (p ≤ 0.05) at postintervention. There were no significant
changes in the spiritual well-being measures. Control group participants (n =
57) reported significantly higher perceived stress levels (p ≤ .01), but no
other psychosocial–spiritual changes over the 10-week period. Thus, these
data indicate that the SPIRIT-10© intervention may account for clinically
meaningful improvements in psychosocial functioning.
A second Phase III clinical trial used two interventions, focused Tai Chi
and SPIRIT-10©, and a wait-control group in a sample of women diagnosed
with early stage breast cancer. The women were undergoing chemotherapy
and/or radiation. The study explored the effects of these two mind–body–
spirit interventions and psychobehavioral and neuroimmunological factors
(endorphins, urinary cortisol, NK cell cytotoxicity, and cytokine production)
on adaptational outcomes. Preliminary data indicated no treatment or group
effects noted for the spirituality group. An interesting finding was at pretest
(Time 1), all participants reported moderately high spiritual perspective
scores (M = 4.9, SD = 0.9, no group differences noted) and low spiritual
well-being scores (M = 42.6, SD = 16.2). No interaction effects were noted
between the spirituality scales and selected study variables. Data from this
study are currently being analyzed and when completed, findings of the
entire study will be disseminated by the research team.
Exploring the Scientific
Rigor of the Spiritual Intervention
Determining Internal Validity of the Intervention
Internal validity of the intervention is determined by the study designs and
strength of the intervention, protocol delivery, and treatment integrity. These
studies were designed and sequenced in a manner consistent with the corresponding phases of research. Multiple designs were used to explore the efficacy and effectiveness of the intervention. Studies used experimental and
quasi-experimental designs in an effort to create controlled conditions, that is,

11. Tuck
721
random assignment and statistical controls for covariance. The studies were
longitudinal in nature using repeated measures with most requiring participant
enrollment for 1 year. Data were collected with valid and reliable measures.
Evidence of the strength of the intervention is best found in the qualitative
responses elicited in the final session of the intervention. Participants respond
to open-ended questions regarding the value of the intervention and the
responses were overwhelmingly positive. In addition, open-ended questions
were added to the recent clinical trial to gather data regarding religion to
more fully understand the religious dimensions. A subsample of participants was randomly selected for qualitative interviews by an independent
researcher to ascertain responses to the intervention free of the facilitator’s
involvement. The transcriptions of the interviews are currently being analyzed independently of the interventionists.
These studies did confirm that the intervention protocol is replicable
across settings and populations and facilitator training is feasible. The
detailed intervention operation manual facilitates the ease of delivery and
describes approaches to intervention dose (participants were required to participate in 80% of the intervention, including booster sessions when available). Treatment integrity was consistently monitored across studies using a
variety of techniques, including videotaping randomly selected sessions. An
independent audit of those videotaped sessions indicated compliance with
the written protocol. Human subject protection was granted for each study
and adverse events were monitored but none were reported. The appropriate
time to enroll for the best effect of the intervention is yet to be determined.
The most recent study with women undergoing breast cancer treatment was
proposed to determine its effectiveness as an early treatment intervention.
Determining External Validity of the Intervention
External validity of an intervention is determined by recruitment, sampling
methods, retention rates, and the effective measurement of outcomes. This
group intervention is best suited for 10 to 12 members at a time. Although
the format limits the overall sample size, the use of repeated measures in
longitudinal studies somewhat buffers this limitation. Random assignment
to intervention groups strengthens the findings as well. Aggressive strategies to recruit and retain participants over time are necessary. Efforts were
made to recruit samples for these studies from diverse backgrounds although
race and ethnicity were primarily limited to African Americans and
Caucasians. The following examples illustrate the team’s efforts to recruit
and enroll diverse samples with a particular focus on underserved populations. The convenience sample of healthy participants ranged in age between

12. 722
Western Journal of Nursing Research 34(6)
20 and 77 years (mean age was 52 years); 14 (51%) were African American
and 24 participants were female and reported at least 14 years of education.
The sample of 66 participants who completed the SPIRIT-10© intervention
in the first clinical trial consisted of 26 females and 40 males and was predominantly African American (79%; 52/66). The average age of the sample
was 43.0 years. Brief descriptions of other samples are found in Table 2.
Retention of participants is critical in longitudinal studies. There was
some attrition noted in these studies. For instance, only 11 of the healthy
adults had complete data available at 12 months (retention rate of 41%). The
volunteer nature of this convenience sample without the benefit of incentives
may have contributed to the attrition rate. A limitation of this intervention as
well as other nursing and social science interventions is that it is offered in
community settings and not in the controlled conditions of clinical laboratories. Group interventions in longitudinal studies raise pragmatic issues of the
cost of the intervention, participant recruitment and retention, and covariance questions due to time and subject maturation even with control groups.
There are a variety of instruments used to measure spirituality and psychosocial variables in these studies. Participant burden in the studies ranged
from 15 to 40 min. Efforts were made in the pilot studies to determine the
appropriate spirituality instruments to use. As previously discussed, three
instruments were initially used to measure spirituality: SpS, a measure of the
significance of spirituality in one’s life and the extent to which one engages
in spiritually related interactions; SWBS, a general measure of spiritual wellbeing; and SHI, a measure of healthy aspects of spirituality. The SHI, which
added minimally to the study findings, was used only in the first pilot intervention study testing SPIRIT-8©. In the subsequent studies, the SpS was used
as a measure of the intensity of engagement in the SPIRIT© group. The
scores reflect the frequency of expressing spiritually oriented thoughts or
behaviors.
Likewise, efforts were made to select other suitable measures. The psychosocial instruments used to measure health/illness outcomes were the
Mishel Uncertainty in Illness Scale (MUIS), Dealing With Illness Scale
(DIS), Social Provisions Scale (SPS), Impact of Events Scale (IES),
Functional Assessment of HIV Infection Scale (FAHI), Revised Ways of
Coping Checklist (COPE), PSS, and Depression Scale (CES-D). The PSS is
an example of an appropriate scale for these samples as it is widely used to
measure stress, does not require a clinical population for its use, and was
selected due to its length. This scale was designed for use with community
samples with at least a junior high school education (Cohen, Kamarck, &
Mermelstein, 1983) and therefore was well suited for the study with healthy
adults. These scales were used in various combinations in these studies and

13. 723
Perceived
Stress Scale
(PSS)
Spiritual
Health
Inventory
(SHI)
Uncertainty in
Illness Scale
(MUIS)
Spiritual WellBeing Scale
(SWBS)
Spiritual
Perspective
Scale (SpS)
Instrument
Name
(continued)
SpS is a 10-item, Likert-type scale developed to measure the significance of spirituality in one’s life and the extent to which one engages
in spiritually related interactions. The SpS is scored by calculating the arithmetic mean. Total scores range from 1.0 to 6.0. Reliability of
the scale has been documented by a Cronbach’s alpha of .90; criterion-related validity and discriminate validity have been previously
demonstrated (Reed, 1986, 1987).
SWBS is a 20-item Likert-type scale consisting of 11 positively worded items and 9 negatively worded items. It was developed by Paloutzian
and Ellison (1982) as a general measure of spiritual well-being. Possible scores range from 20 to 120. Subscale scores are derived for
religious well-being and existential well-being, with higher scores indicating greater well-being. The scale has been used with persons with
HIV disease as a predictor of hardiness (Carson & Green, 1992; Carson, Soeken, & Belcher, 1991). Reliability has ranged from alpha = .78
to .96. Construct validity is suggested by the examination of item content, as well as theoretically meaningful interrelationships among the
existential well-being subscale scores and scores of other psychosocial measures (Paloutzian & Ellison, 1982). Subscale scores are derived
for religious well-being and existential well-being, with higher scores indicating greater well-being.
SHI was developed by Highfield (1992) and has been used primarily to study patients with cancer. The patient’s version of the instrument is
a self-report of spiritual health that includes positive and negative expressions. The 31-item Likert-type scale measures three factors: selfacceptance, relationships, and hope. Total scores range from 31 to 155. Cronbach’s alpha for the SHI has been reported at .77. Content
and construct validity have been supported by literature review, expert panel, and factor analysis (Highfield, 1992).
The MUIS is a well-validated, reliable measure of uncertainty associated with illness (Mishel, 1981, 1984). Higher scores on this 33-item
scale indicate higher uncertainty in the areas of symptomatology, diagnosis, treatment, relationships with caregivers, and prognosis (Mishel,
1990). The MUIS has been shown to be reliable in research with individuals living with HIV (McCain & Cella, 1995; McCain, Zeller, Cella,
Urbanski, & Novak, 1996).
The PSS is a 14-item measure that measures the degree to which one appraises situations in one’s life as stressful. This scale was designed
for use with community samples with at least a junior high school education (Cohen, Kamarck, & Mermelstein, 1983). It is composed of 7
positive items (e.g., In the past month, how often have you dealt successfully with irritating life hassles?) and 7 negative items (e.g., In the
past month, how often have you been upset because of something that happened unexpectedly?). Scores for this scale are obtained by
reversing the scores on the positive items and then summing across all 14 items, so that higher scores indicate higher levels of perceived
stress.
Description of Instruments and Psychometric Properties
Table1. Selected Instruments Used in Studies Testing SPIRIT© Intervention

14. 724
Dealing With
Illness Scale
(DIS)
Functional
Assessment
of HIV
Infection
Scale (FAHI)
Version 3
FAHI Version
4
Impact of
Events Scale
(IES)
Instrument
Name
Description of Instruments and Psychometric Properties
Health-related quality of life is defined as the impact of illness experiences on physical, psychological, social, and spiritual or existential
well-being. The FAHI is a multidimensional measure of quality of life in people with HIV infection (Cella, 1994; Cella et al., 1996; Peterman,
Mo, Cella, & McCain, 1997). The FAHI has demonstrated excellent psychometric performance (α = 0.85-0.92), including sensitivity to
stage of illness and to intervention in the previous studies (McCain et al., 1996, McCain et al., 1998), as well as other studies (Cella et al.,
1996; Peterman et al., 1997). The HIV-specific FAHI has been revised to the current (version 4) format and is expected to provide more
sensitive data for the dimension of HIV-specific quality of life. The 44 items of the current FAHI are grouped into subscales of physical,
functional and global, and social well-being; emotional well-being/living with HIV; and cognitive functioning. Thus, the scale reflects both
general health-related and HIV-specific quality of life, with higher scores indicating greater quality of life (Peterman et al., 1997).
The DIS is comprised of 20 items reflecting negative emotions, positive interpersonal experiences, negative life changes, and loss of control
(McCain & Gramling, 1992) as revised in 1994 and 1999. The DIS was qualitatively derived with persons with HIV disease. The DIS is
comprised of Stress and Coping subscales. Modeled after the Life Experiences Survey (LES; Sarason, Johnson, & Siegel, 1978), the format
for the Stress subscale captures the process of cognitive appraisal by enabling respondents to indicate the desirability or undesirability
and the personal impact of experienced events (perceived stress). Participants indicate perceived stress specifically related to HIV
disease for two time periods: since the time of their diagnoses and within the past month. Positive and Negative Stress subscale scores
are derived by separately summing the items indicated as having a positive or negative personal impact. Previous psychometric analyses
indicated that the 20 items of the 1994 version of the subscale comprised 4 factors involving negative emotions, positive interpersonal
experiences, negative life changes, and loss of control.
IES is a 15-item instrument with response options that indicate how frequently within the past 7 days each distressing thought has
occurred. Using the IES, psychological distress specific to living with HIV disease has been previously documented in the form of avoidant
and/or intrusive thoughts related to the illness (Horowitz, Wilner, & Alvarez, 1979; Ironson et al., 1990; McCain & Cella, 1995; McCain,
Zeller, Cella, Urbanski, & Novak, 1996; Perry, Fishman, Jacobsberg, & Frances, 1992). The IES has excellent psychometric properties, is
not confounded with physical symptoms, and yields an index of illness-related psychological distress. Higher scores on the subscales of
Intrusive and Avoidant thinking indicate higher psychological distress.
The FAHI scale is a disease-specific extension of the general version of the Functional Assessment of Cancer Therapy (FACT-G) scale
(Cella & Tulsky, 1993), measuring the quality of life in people with HIV infection. The 55-item revised FAHI (version 3) includes subscales
of physical, social/family, emotional, and functional well-being; relationship with physician; and additional concerns specific to HIV infection.
Higher scores indicate greater quality of life. The FAHI has demonstrated excellent psychometric performance, including sensitivity to
stage of illness and to intervention in previous studies (Cella, McCain, Peterman, Mo, & Wolen, 1996; McCain et al., 1996).
Table 1. (continued)

15. 725
The revised 24-item SPS is a measure of six social provisions or components of social support including reliable alliance, attachment,
guidance, nurturance of others, social integration, and reassurance of worth. The SPS has demonstrated excellent construct validity and
internal consistency in other populations (Cutrona & Russell, 1987). Higher scores indicate a higher level of social support.
Social
Provisions
Scale (SPS)
Description of Instruments and Psychometric Properties
The revised 40-item Coping subscale was modeled on the Revised Ways of Coping Checklist (Vitaliano, Maiuro, Russo, & Becker, 1985). For
these 40 of the original 60 items, psychometric analyses revealed 3 empirical factors related to maintaining a positive attitude, adapting
to illness, and withholding, with items approximately equally distributed across the original, theoretical dimensions of problem-focused,
emotion-focused, and appraisal-focused coping. Scoring schemes for the coping subscale enable assessment of both the theoretical foci of
coping and the factor-analytically derived coping methods. Higher scores reflect more frequent use of the various coping strategies. The
reliability (Stress subscale α = .83, Coping subscale α = .80-.87) and validity of the DIS for the study population have consistently been
supported (Cella et al., 1996; McCain & Cella, 1995; McCain et al., 1996; McCain et al., 1998).
Ways of
Coping
Scale
(WOC)
Instrument
Name
Table 1. (continued)

16. 726
Western Journal of Nursing Research 34(6)
had demonstrated high validity and reliability in previous studies. See Table 1
for a list of selected measures used and the psychometric properties as available. Table 2 indicates the specific instruments that were used in each study.
Whittemore and Grey (2002) suggested that the systematic development
of a nursing intervention includes the following:
(a) a well-defined problem, (b) a strong theoretical base, (c) a research
approach to establish the content, strength, and timing of innovative
and pragmatic interventions, (d) refinement of the intervention, (e)
determination of clinical efficacy, and (f) determination of clinical
effectiveness. (p. 116)
The spiritual intervention was designed and tested according to these criteria across various phases of research. The intervention has been offered to
clinical and nonclinical populations of adults. Treatment integrity has been
well documented. Studies have used a way array of spiritual, psychosocial, and
physiological measures. The psychosocial measures have sought to determine
positive and negative outcomes, including benefit finding, quality of life,
depression, and perceived stress. Early findings were significant for the
SPIRIT© intervention on a number of psychosocial measures in the hypothesized directions. The phase II trial studies have indicated trends in findings in
the expected directions. However, findings from the recent clinical trials were
inconclusive. Few significant findings were noted in the randomized clinical
trials.
There are several strengths of the intervention. One strength is the multimodal approach that allows for the expression of spiritual views and religious doctrine, a choice left to the individual. Another is the clear evidence
that the intervention can be replicated and reproduced with other populations. Treatment integrity is also maintained by adhering to the intervention
protocol. Additional measures particularly related to health and well-being
can be added or substituted in future research studies.
What might explain why a well-designed and tested intervention is found
to have little significant treatment effect? What explains the inconsistent
findings of spirituality with other measures of mind–body–spirit outcomes?
A number of possible explanations are offered for consideration. First of all,
there was limited variance in spirituality scores between groups. In general,
the participants’ spirituality scores were moderately high at pretest. One possible explanation for these scores is that having the lived experience of lifealtering illnesses such as cancer and HIV disease may raise spiritual or
religious concerns in everyone in an existential way. If this is true, there is a

17. 727
52
Quasiexperimental,
pretest–posttest,
control group,
nonrandom
assignment
Cross-sectional,
correlational
Longitudinal, onegroup repeated
measures
Phase I Pilot
SPIRIT-8©
Intervention
Study
Descriptive
Exploratory
Study
Phase II Pilot
SPIRIT-6©
Intervention
Study
27
28
Study Designs
Type of Study
Total
Number of
Participants
in the Study
Table 2. Summary of Spirituality Intervention Studies
27
NA
7
Number of
Participants
Enrolled
in SPIRIT©
Intervention
Healthy adults
Adult males living
with HIV disease
Adult males living
with HIV disease
Type of Population
24 Females, 3 Males
All males
All males
Gender of
Participants
in SPIRIT©
Intervention
SpS
SHI
SWBS
DIS
SPS
IES
MUIS
FAHI
SpS
SHI
SWBS
DIS
SPS
IES
MUIS
FAHI
SpS
SWBS
PSS
(continued)
Psychosocial and
Spiritual Measures
Used

18. 728
Experimental
with repeated
measures;
control group
and random
assignment
Experimental
with repeated
measures;
control group
and random
assignment
Phase III
Randomized
Clinical Trial
SPIRIT-10©
Intervention
Phase III
Randomized
Clinical Trial
SPIRIT-10©
Intervention
145
298
Total
Number of
Participants
in the Study
38
66
Number of
Participants
Enrolled
in SPIRIT©
Intervention
Women diagnosed
with early stage
breast cancer
Adults living with
HIV disease
Type of Population
38 Females
26 Females, 40
males
Gender of
Participants
in SPIRIT©
Intervention
SpS
SWBS
IES
PSS
SPS
FACT-B
WOC
CES-D
SpS
SWBS
DIS
IES
SPS
FAHI
Psychosocial and
Spiritual Measures
Used
Note: SpS = Spiritual Perspective Scale; SHI = Spiritual Health Inventory; SWBS = Spiritual Well-Being Scale; DIS = Dealing With Illness Scale; SPS =
Social Provisions Scale; IES = Impact of Events Scale; MUIS = Mishel Uncertainty in Illness Scale; FAHI = Functional Assessment of HIV Infection Scale;
PSS = Perceived Stress Scale; FACT-B = Functional Assessment of Cancer Therapy; WOC = Ways of Coping Scale; CES-D = Depression Scale.
Study Designs
Type of Study
Table 2. (continued)

19. Tuck
729
need for spiritual measures that discriminate change over time in this heightened state of popular spirituality.
Second, although the intervention is well grounded theoretically, in efforts
to be sensitive to a pluralistic culture, the intervention might dilute the influence of spiritual or religious views and may instead elicit commonly shared
humanistic worldviews. Third, the amount of time spent in the intervention
on a weekly basis may not be sufficient to capture the essence of the experience. Assignments during the week and daily practice may be required to
reinforce spirituality. The strongest effects were reported retrospectively or
when the participants were further away from the illness experience; possibly suggesting new methods of data collection.
As investigators, we must refine the phenomenon of interest. Many studies
continue to link spirituality and religion as one construct and then measure it as religion. A recent example, a longitudinal study by Gall, Kristjansson, Charbonneau,
and Florack (2009), examined the role of spirituality in women with breast cancer. Although the focus of the study was on spirituality, they measured religion/spirituality as religious salience, the level of participation in religion, and
the strength of religious views. They also explored positive and negative views of
God as a study variable. Other studies too numerous to cite here have likewise
combined the two constructs. The question remains whether these are distinct
ideas or have been artificially separated. Efforts made to solicit definitions directly
from participants have value and may help clarify these terms (Tuck & Thinganjana,
2007).
The mechanism for spirituality remains unclear as to whether there are
direct or indirect effects. Gall et al. (2009) found no support for Pargament’s
(1997) spiritual mobilization hypothesis during illness or that religion served
as a protective factor. They found that distress increases over time and proposed that the strength of religious beliefs was only protective if they were
strong beliefs prior to the illness and that mobilization of these beliefs in
absence of a strong base during the crises promoted distress instead.
Research is needed to explain the recurring strength of the relationships
between measures in cross-sectional studies and the relative lack of effect
noted in some longitudinal studies. In a recent cross-sectional study,
Kandasamy, Chaturvedi, and Desai (2011) found the strong positive relationships between spirituality and quality of life and inverse relationships with
depression and anxiety. They also reported highly significant negative relationships between spiritual well-being and distress, fatigue, memory disturbances, and loss of appetite. Shah et al. (2010) in another cross-sectional
study reported that the strengths of the spiritual beliefs were positive contributors to coping. In an attempt to understand the mechanism, it is noted

20. 730
Western Journal of Nursing Research 34(6)
that the numerous studies, including those previously reported by the author,
demonstrate strong relationships with a wide range of variables but provide
limited support for causality and treatment effect.
It is likely that the strength of one’s beliefs and whether the strongly held
views are spiritual or religious in nature will both have implications for
future testing of the SPIRIT© intervention. Tate (2011) in an integrative
review of 13 studies found that spirituality or belief in God was an integral
part of the cultural identity of African American women with breast cancer
suggesting that there is a contextual feature. Pargament (1997) proposed that
the spirituality needed to be integrated in a sense of the person. A key feature
of the SPIRIT© intervention was to help participants become increasingly
aware of the relevance of spirituality to their everyday lives; however, reflection and insight may not be sufficient to promote physiological and immunological changes. The overreliance on spirituality and religion to significantly
influence negative outcomes might be counter to its mechanisms of action.
Perhaps, paper-and-pencil tests and logical samples might not be direct measures of the effects.
The development and testing of the SPIRIT© spirituality intervention has
taken more than a decade. This spirituality intervention has met the criteria
suggested by Whittemore and Grey (2002): the spirituality intervention was
linked with the available literature and clinical problems, the content of the
intervention was described, the strengths were identified, and finally, it was
tested for efficacy and effectiveness. The components of the intervention are
readily available, transferable, and implemented in many holistic nursing
practices.
According to the interpretation of the NIH guidelines described by
Whittemore and Grey (2002), Phase III clinical trials are viewed as pivotal
to support the value of the intervention. Phase IV trials allow the intervention
to be tested in actual practice and examines clinical utility and cost effectiveness. Studies at this level often are clinical trials with two or more interventions. In reality, Phases III and IV may not be as distinct in studies with
human subjects as in bench science. Nursing studies must also offer some
benefit (some degree of effectiveness) or at least cause no harm whenever
they are offered and often clinical implications are discussed even after pilot
studies are conducted. The application of nursing research occurs with the
translation of the findings to practice across multiple settings and in welldeveloped standards of practice. The intervention can benefit from recent
research and refinements made before clinical implementation. The intervention requires more definitive testing over time.

21. Tuck
731
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author received financial support for the
series of research studies cited in this manuscript. Intramural funding was provided by
the A. W. Williams Foundation at Virginia Commonwealth University and the Department of Integrative Systems, School of Nursing, Virginia Commonwealth University. The
first clinical trial was funded by the National Institutes of Health’s National Center for
Complementary and Alternative Medicine Grant 5R01 AT000331 to Nancy L. McCain,
Principal Investigator, and facilitated by the General Clinical Research Center, Virginia
Commonwealth University Health System (5M01 RR000065; J.N. Clore, Director).
The second clinical trial was funded by the National Institutes of Health’s National
Cancer Institute grant 5R01 CA114718 to Nancy L. McCain, Principal Investigator,
and facilitated by the General Clinical Research Center, Virginia Commonwealth
University Health System (5M01 RR000065; J. N. Clore, Director).
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