Timothy P. Daaleman

The Spirituality Index of Well-Being: A New Instrument for Health-Related Quality-of-Life Research

PURPOSE Despite considerable interest in examining spirituality in health-related quality-of-life studies, there is a paucity of instruments that measure this construct. The objective of this study was to test a valid and reliable measure of spirituality that would be useful in patient populations. METHODS We conducted a multisite, cross-sectional survey using systematic sampling of adult outpatients at primary care clinic sites in the Kansas City metropolitan area (N = 523). We determined the instrument reliability (Cronbach’s α, test-retest) and validity (confirmatory factor analysis, convergent and discriminant validation) of the Spirituality Index of Well-Being (SIWB). RESULTS The SIWB contains 12 items: 6 from a self-efficacy domain and 6 from a life scheme domain. Confirmatory factor analysis found the following fit indices: χ2 (54, n = 508) = 508.35, P <.001; Comparative Fit Index = .98; Tucker-Lewis Index = .97; root mean square error of approximation = .13. The index had the following reliability results: for the self-efficacy subscale, α = .86 and test-retest r = 0.77; for the life scheme subscale, α = .89 and test-retest r = 0.86; and for the total scale α = .91 and test-retest r = 0.79, showing very good reliability. The SIWB had significant and expected correlations with other quality-of-life instruments that measure well-being or spirituality: Zung Depression Scale (r = 0–.42, P <.001), General Well-Being Scale (r = 0.64, P <.001), and Spiritual Well-Being Scale (SWB) (r = 0.62, P <.001). There was a modest correlation between the religious well-being subscale of the SWB and the SIWB (r = 0.35, P <.001). CONCLUSIONS The Spirituality Index of Well-Being is a valid and reliable instrument that can be used in health-related quality-of-life studies.

Spirituality and well-being: an exploratory study of the patient perspective

Spirituality has become a construct of interest in American health care: however, there remains a limited understanding of how patients themselves describe spirituality and view its impact on their health and well-being. The purpose of this study was to identify and describe elements of patient-reported, health-related spirituality. A qualitative study utilized focus group interviews of 17 women with type 2 diabetes mellitus and 18 women with no self-identified illness. Purposeful sampling of participants who had prior experiences in healthcare settings, with or without a chronic illness, guided the sampling strategy. Editing analysis of the interview transcripts were coded into conceptual categories. Participant narratives were grouped into eight general categories: (1) change in functional status, (2) core beliefs, (3) medical/disease state information gathering and processing, (4) interpretation and understanding, (5) life scheme, (6) positive intentionality, (7) agency, and (8) subjective well-being. A change in functional status was the catalyst for two process-oriented categories; medical/disease state information gathering and processing, and the higher-order interpretation and understanding, or meaning making of life events. Core beliefs were sources that grounded and maintained an interpretative structure through which participants viewed their life events and positively framed their experiences. Life scheme described a heuristic framework through which all life events were viewed. Positive intentionality was participant belief in the capacity to execute a specific action that was required for a desired outcome. Participants tied the attitudes and practices of positive intentionality with agency, or the use or exertion of power through belief, practice, or community. Participants outlined both a positive affective and cognitive component of subjective well-being. Patients describe several interrelated elements and a process of events in their depiction of spirituality in healthcare settings. Patient-reported spirituality is predominantly a cognitive construct incorporating the domains of life scheme and positive intentionality.

An Exploratory Study of Spiritual Care at the End of Life

PURPOSE Although spiritual care is a core element of palliative care, it remains unclear how this care is perceived and delivered at the end of life. We explored how clinicians and other health care workers understand and view spiritual care provided to dying patients and their family members. METHODS Our study was based on qualitative research using key informant interviews and editing analysis with 12 clinicians and other health care workers nominated as spiritual caregivers by dying patients and their family members. RESULTS Being present was a predominant theme, marked by physical proximity and intentionality, or the deliberate ideation and purposeful action of providing care that went beyond medical treatment. Opening eyes was the process by which caregivers became aware of their patient’s life course and the individualized experience of their patient’s current illness. Participants also described another course of action, which we termed cocreating, that was a mutual and fluid activity between patients, family members, and caregivers. Cocreating began with an affirmation of the patient’s life experience and led to the generation of a wholistic care plan that focused on maintaining the patient’s humanity and dignity. Time was both a facilitator and inhibitor of effective spiritual care. CONCLUSIONS Clinicians and other health care workers consider spiritual care at the end of life as a series of highly fluid interpersonal processes in the context of mutually recognized human values and experiences, rather than a set of prescribed and proscribed roles.

Religion, Spirituality, and Health Status in Geriatric Outpatients

BACKGROUND Religion and spirituality remain important social and psychological factors in the lives of older adults, and there is continued interest in examining the effects of religion and spirituality on health status. The purpose of this study was to examine the interaction of religion and spirituality with self-reported health status in a community-dwelling geriatric population. METHODS We performed a cross-sectional analysis of 277 geriatric outpatients participating in a cohort study in the Kansas City area. Patients underwent a home assessment of multiple health status and functional indicators by trained research assistants. A previously validated 5-item measure of religiosity and 12-item spirituality instrument were embedded during the final data collection. Univariate and multivariate analyses were performed to determine the relationship between each factor and self-reported health status. RESULTS In univariate analyses, physical functioning (P <.01), quality of life (P <.01), race (P <.01), depression (P <.01), age (P = .01), and spirituality (P <.01) were all associated with self-reported health status, but religiosity was not (P = .12). In a model adjusted for all covariates, however, spirituality remained independently associated with self-appraised good health (P = .01). CONCLUSIONS Geriatric outpatients who report greater spirituality, but not greater religiosity, are more likely to appraise their health as good. Spirituality may be an important explanatory factor of subjective health status in older adults.

Physician Communication with Family Caregivers of Long‐Term Care Residents at the End of Life

OBJECTIVES: To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long‐term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions.

A Cross-Cultural Study of Physician Treatment Decisions for Demented Nursing Home Patients Who Develop Pneumonia

PURPOSE We wanted to explore factors that influence Dutch and US physician treatment decisions when nursing home patients with dementia become acutely ill with pneumonia. METHODS Using a qualitative semistructured interview study design, we collected data from 12 physicians in the Netherlands and 12 physicians in North Carolina who care for nursing home patients. Our main outcome measures were perceptions of influential factors that determine physician treatment decisions regarding care of demented patients who develop pneumonia. RESULTS Several themes emerged from the study. First, physicians viewed their patient care roles differently. Dutch physicians assumed active, primary responsibility for treatment decisions, whereas US physicians were more passive and deferential to family preferences, even in cases when they considered families’ wishes for care as inappropriate. These family wishes were a second theme. US physicians reported a perceived sense of threat from families as influencing the decision to treat more aggressively, whereas Dutch physicians revealed a predisposition to treat based on what they perceived was in the best interest of the patient. The third theme was the process of decision making whereby Dutch physicians based decisions on an intimate knowledge of the patient, and American physicians reported limited knowledge of their nursing home patients as a result of lack of contact time. CONCLUSION Physician-perceived care roles regarding treatment decisions are influenced by contextual differences in physician training and health care delivery in the United States and the Netherlands. These results are relevant to the debate about optimal care for patients with poor quality of life who lack decision-making capacity.

Measuring a Dimension of Spirituality for Health Research: Validity of the Spirituality Index of Well-Being

Health-related studies of spirituality are threatened by the lack of conceptual distinctions between religion and spirituality, the use of small, nongeneralizable samples, and by measurement error in many instruments that unreliably and invalidly capture this domain. The authors review the construct and validity evidence for the Spirituality Index of Well-Being (SIWB), an instrument designed to measure a dimension of spirituality linked to subjective well-being in patient populations. The SIWB was developed using qualitative research methods and subsequently conceptualized with two dimensions; self-efficacy and life scheme. Primary psychometric data from three sample populations are reviewed and summarized. A secondary, confirmatory factor analysis, using pooled data from all samples, supports the theoretical two-factor structure. In addition, SIWB scores correlate more strongly with established measures of well-being than the Spiritual Well-Being Scale (SWB) or other recognized religiosity instruments. The SIWB is a valid and reliable instrument that can be used in health-related studies.

Spiritual Care at the End of Life in Long-Term Care

Background:There is growing attention given to the spiritual needs of dying patients and long-term care (LTC) facilities are common settings in which patients receive care as they approach death. Objectives:To describe the sources of support, the structure and processes of spiritual care in LTC, and examine the relationship between these components and family ratings of overall care. Research Design:After-death interviews of family members of decedents. Subjects:Family members of 284 decedent residents from a stratified sample of 100 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina. Measures:Interview items included sources of spiritual support, processes of spiritual care, and the impression of overall care (4 = very good, 3 = good, 2 = fair, 1 = poor) for decedents. Facility-level data included demographics, counseling by clergy, on-site religious services, hospice services, and hospice unit. Results:Most decedents (87%) received assistance with their spiritual needs and those who received spiritual care were perceived by family members to have had better overall care (3.59 vs. 3.25, P = 0.002). Family ratings of care ratings were higher for those who received spiritual support or care from facility staff when compared with those who did not (3.76 vs. 3.49, P < 0.001) and better care was associated with the facilitation of individual devotional activities (3.87 vs. 3.53, P = 0.001). Conclusions:Spiritual support and care are associated with better overall care at the end of life for LTC residents, and interventions to improve this type of care may best target interactions between residents and facility staff.

Spirituality and depressive symptoms in primary care outpatients.

Background: Although many studies have examined the relationship between religiosity and depressive symptoms in patient populations, there has been little work to understand and measure the effect of spirituality on depressive symptoms. Objective: The purpose of this study was to examine the association of spirituality and symptoms of depression in primary care outpatients. Methods: A cross-sectional analysis was performed of a dataset using 509 primary care outpatients who participated in an instrument validity study in the Kansas City (US) area. Patients were administered the Zung Depression Scale (ZDS) and the Spirituality Index of Well-Being (SIWB) in the waiting area before or after their appointment. Bivariate and multivariate analyses were performed to determine the relationship between the factors of interest and depressive symptoms. Results: In bivariate analyses, less insurance coverage (P < 0.01) and greater spirituality (P < 0.01) were associated with less reported depressive symptoms. In a model adjusted for covariates, spirituality (P < 0.01) remained independently associated with less symptoms. Conclusion: Primary care outpatients who report greater spirituality are more likely to report less depressive symptoms.

Family Medicine and the Life Course Paradigm

A unique characteristic of family physicians is that they seek to understand individual patients within the context of their families and larger social environments. Unfortunately, the intellectual development of family medicine is hampered by the reliance on epidemiologic, health service, and biomedical paradigms that are limited in their contextual perspectives on patients’ lives. However, another paradigm, that of the life course, represents an interdisciplinary framework that views persons in context over time. It provides an ecological understanding of individual people by examining phenomena at the nexus of social pathways, developmental or health trajectories, and social change. A life course paradigm provides a way of thinking about patients in both proximal (eg, lived lives and family) and distal (eg, health care system) contexts over a life span. Five core principles define the life course as a paradigmatic framework: (1) human development and aging as lifelong processes, (2) human agency, (3) historical time and place, (4) the timing of events in a life, and (5) linked lives. At the individual level, the life course orients physicians to the opportunities and constraints that frame the health care choices, plans, and initiatives of people who maintain health and also face illness. At the organizational level, the life course offers an intellectual infrastructure for the New Model of Family Medicine by depicting an idealized delivery system that may be longitudinally integrated. It also emphasizes health and illness trajectories by linking health and other service organizations that assist individuals at different stages of their lives.