Psychometric Evaluation of the Spiritual Care-Giving Scale Arabic Version in Saudi

Nursing Students

Abstract

Aim: To evaluate the psychometric properties of an Arabic version of the Spiritual Care-Giving

Scale (SCGS) in a sample of Saudi nursing students.

Method: A convenience sample of 202 Saudi nursing students was included in this descriptive,

cross-sectional study. The 35-item Spiritual Care-Giving Scale Arabic version (SCGS-A) was

tested for internal consistency, stability reliability, content validity and construct validity.

Findings: The SCGS-A manifested acceptable internal consistency and stability reliability with

computed Cronbachs alpha ranges from 0.94 to 0.97 and an Intraclass correlation coefficient of

0.90. The Item-level content validity index ranged from 0.83 to 1 and the Scale-level content

validity index (Average) was 0.98. The Principal Component Analysis revealed five dominant

components with eigenvalues greater than 1 and a cumulative contribution rate of 79.2%. The

five factors were moderately to strongly correlated (r = 0.35-0.61, p<0.001) with each other and

with the overall SCGS-A score (r=0.61-0.81; p<0.001).

Conclusion: The SCGS-A manifested an acceptable reliability and validity in Saudi nursing

students, which support its sound psychometric properties. With the establishment of this valid

and reliable tool, timely and accurate assessment of student nurses perception about spirituality

and spiritual care can be facilitated.

Introduction

Nurses are expected to render holistic care to the patients regardless of their religious and

cultural backgrounds. Nurses practice holistic nursing in every part of care based on the idea that

1
recognizes the relationship of the body, mind and spirit of the individual (Frisch, 2001). It is

therefore critical to consider the multi-dimensionality of an individual and the relationship

among these dimensions in the planning and implementation of care for every patient. In the

clinical setting, nurses are confronted with various spiritual needs of the patients. They are asked

on a daily basis to attend to these needs and failure to do so may discourage patients to comply

with treatment and may hinder them from drawing on a powerful inner source for health and

healing (Sawatzky & Pesut, 2005). Hence, spiritual consideration and spiritual nursing care

should not be neglected when adopting holistic care and should be underscored in all facets of

nursing care.

Spiritual care is an integral element of holistic nursing (MinerWilliams, 2006). Spiritual

nursing care is an instinctive, interpersonal, selfless and integrative expression that is dependent

on the understanding of the nurse on the transcendent aspect of life (Sawatzky & Pesut, 2005).

Various nursing leaders and nursing theorists, such as Florence Nightingale, Neuman and

Watson, recognized and practiced spirituality in relation to health and nursing care (Burkhart &

Hogan, 2008; Carr, 2008). At present, there is a continued growth of studies in nursing and other

health-related fields that focus on spirituality and its relationship to health (Matusek & Knudson ,

2009; Cruz et al., 2015; Cruz, Alquwez & Baldacchino, 2016). Spirituality has shown to be

commonly associated with mortality, coping and recovery of patients (Puchalski, 2001).

Although the significance of providing spiritual nursing care has been acknowledged in the past

years, it is still the most undervalued and neglected aspect of nursing care (Narayanasamy,

2006). Previous studies have reported that significant number of nurses infrequently respond to

the spiritual aspect of care of patients and tend to perceive themselves as unskilled and

unprepared to render spiritual care. Furthermore, spiritual care is usually done by referral to

2
chaplain, pastors and other religious facilitators in the hospital (Kuuppelomki, 2001;

Narayanasamy & Owens, 2001).

The nursing education is positioned to prepare future nurses to assume their duties and

responsibilities in the nursing profession competently. Adequate learning on spirituality and the

provision of spiritual care can result to a better integration of spiritual care to nursing practice.

However, several research studies have reported that the spiritual aspect of nursing practice is

not officially incorporated within the nursing education programs of various nursing schools

(Narayanasamy & Owens, 2001; Ross, 2006). Thus, nursing students receive little education on

the spiritual aspect of nursing care. This may result to the feeling of unpreparedness to provide

spiritual care. Similarly, nursing education in Saudi Arabia is commissioned to prepare future

Saudi nurses to competently assume nursing responsibilities. Presently, majority of the nursing

workforce in the kingdom are expatriates. These foreign nurses came from different countries

with varied cultures, beliefs, and values. They may not have adequate knowledge of the Saudi

culture and religion; hence, neglecting the significance of Islamic beliefs and values of the local

patients. As a result, Saudi nurses are seen to be more appropriate in providing holistic care to

Saudi population (Almalki, FitzGerald & Clark, 2011). Even with this situation, spiritual nursing

care is undervalued in the nursing education in the kingdom. At present, nursing education in the

kingdom has not integrated spiritual care to the core curriculum of nursing education.

The perception of student nurses on the spiritual dimension of care has been relatively

neglected (Tiew & Creedy, 2012). Having an understanding on how the nursing students

perceive spirituality and spiritual care, their relationship to health, and barriers in integrating

spiritual care to actual practice can assist in curriculum and course content development and

educational interventions to shape the right attitude and practice towards spiritual care of nursing

3
students (Tiew & Creedy, 2012; Chism & Magnan, 2009). However, studies assessing the

perceptions of nursing students toward spirituality and spiritual care are limited. Most of these

existing studies were focused on describing spiritual content in curricula and effects of

educational interventions such as educational modules and teaching strategies to the perception

of nursing students (Tiew & Creedy, 2012). Very limited studies solely focused on the

understanding of nursing students to spirituality and spiritual nursing care. Bulk of these studies

has been concentrated in western and Asian countries with Judeo-Christian orientation, which

are inadequate to provide a generalized picture about this topic (Tiew, Drury & Creedy, 2011;

Wu, Liao & Yeh, 2012; Tiew, Creedy & Chan, 2013). The same situation is observed in the

Middle East region where Saudi Arabia is located. No studies have been found to investigate the

perception of Saudi nursing students towards spiritual nursing care. Furthermore, no available

tool is available that can accurately measure the perception of Saudi nursing students towards

spirituality and spiritual care. Therefore, to address this gap, this study was conducted to evaluate

the psychometric properties of an Arabic version of the Spiritual Care-Giving Scale (SCGS) in a

sample of Saudi nursing students. The establishment of the validity and reliability of the tool will

facilitate the conduct of more research studies in this topic in the kingdom and other Arabic-

speaking nations.

Method

Design

This study utilized descriptive, cross-sectional design.

Setting and Sample

The study was conducted in a government-run university in Saudi Arabia. A convenience

sample of 202 nursing students was included in this study. This sample size is adequate for factor

4
analysis (DeVellis, 2003). The inclusion criteria for the participants cover nursing students who

are (1) male or female Saudi national, (2) registered in the nursing program of the university, (3)

registered in the second to fourth year of the nursing program, (4) at least 18 years old, and (5)

full-time student.

Instruments

Respondents Characteristics

A demographic information form attached to the survey questionnaire solicited data on

the characteristics of the respondents, which included (1) age, (2) gender, (3) academic level, and

(4) civil status. Additional information such as previous experience in providing spiritual care to

patients, attendance to educational activities about spirituality or spiritual care, and integration of

topics about spiritual care in classroom or clinical discussions were likewise gathered in this

section.

Spiritual Care-Giving Scale (SCGS)

The Spiritual Care-Giving Scale (SCGS) is a tool that assesses the understanding of

spirituality and spiritual care among nursing students. This scale considers the multidimensional

nature of spirituality and spiritual care. It is a 35-item scale that elicits responses using a 6-point

Likert scale from 1 (strongly disagree) to 6 (strongly agree). It measures 5 dimensions namely

(1) Attributes for Spiritual Care; (2) Spiritual Perspectives; (3) Defining Spiritual Care; (4)

Spiritual Care Attitudes; and (5) Spiritual Care Values. The development of this scale is

secondary to the absence of a composite tool that can measure all the dimension of spirituality.

The scales computed Cronbachs alpha and testretest reliability is 0.96 and 0.81, respectively.

The scale has also a good concurrent validity (Tiew & Creedy, 2012).

Translation of the Spiritual Care-Giving Scale

5
 The translation of the SCGS to Arabic language was guided by the cross-cultural

adaptation of self-report measures guidelines for translation (Beaton, Bombardier, Guillemin &

Ferraz, 2002). The SCGS English version was separately presented to two bi-lingual professional

translators. Both the translators produced their own version of the scale and later synthesized it to

create a single tentative Arabic version. The tentative Arabic version was presented to another 2

translators whose native tongue is English for the back translation phase. They were unaware of

the concept being explored. Each of the translators produced their own version and was later

synthesized to create a single back translated version. Then, the SCGS in its original version, the

tentative Arabic version and the back translated version was presented to a panel of expert

consisting of six members to examine the cultural and religious considerations of the scale. After

critical examination, the panel came to an agreement on the final Arabic version. The panel

evaluated the content validity of the scale. The Spiritual Care-Giving Scale Arabic version

(SCGS-A) was then subjected to pilot testing in 30 Saudi nursing students who were not part of

the main study. In the pilot study, the respondents determined items which are difficult to

understand. None of the items were modified after the pilot study hence the SCGS-A was

subjected to psychometric evaluation.

Data Collection

Collection of data was done between October and November 2015. The questionnaires

were distributed to the respondents during their morning classes. Proper coordination with the

female college was observed in respect with the gender sensitivity in the kingdom. Adequate

information about the study was presented to the respondents before they were allowed to answer

the questionnaire. Approximately 10 to 15 minutes were provided to the respondents to answer

6
the questionnaire. After 2 weeks from the initial data collection, the SCGS-A was re-

administered to the respondents following the same process.

Ethical Consideration

The study was approved by the research committee and the dean of the college of nursing

in the said university. A written consent was solicited from each respondent before participation

to signify their understanding of the study and their voluntary participation. Confidentiality of

the respondents was assured throughout the research process. Permission to use and translate the

scale was permitted by the copy right holder via email.

Statistical Analysis

All statistical analyses were performed using the SPSS version 21.0. Cronbachs alpha

coefficient was calculated to support the internal consistency of the scale. A coefficient of 0.70

was considered acceptable; however, 0.80 or higher is more preferred (Nunnally & Bernstein,

1994; Waltz, Strickland & Lenz, 2005). The Intra-class Correlation (ICC) was calculated to

determine the test-retest reliability of the scale (Stability reliability). An ICC 0.80 was

acceptable (Vincent, 1999).

The content validity of the scale was supported by the item level- (I-CVI) and scale level-

(S-CVI/Ave) content validity index. For a panel with 6 members, an I-CVI of 0.78 and S-

CVI/Ave of 0.90 is acceptable (Lynn, 1986; Polit & Beck, 2006). For internal structure validity

of the scale, the item to total correlation (ITC) was calculated. The following criteria were

considered in interpreting the ITC values (removal or modification of item): (1) corrected ITC

<0.30, (2) the item will cause 10% drop in the scales Cronbach's alpha score when removed,

and (3) ITC >0.80 (Nunnally & Bernstein, 1994; DeVellis, 2003). A principal component

analysis (PCA) with Varimax rotation was performed for construct validity. KaiserMeyer

7
Olkin (KMO) index was calculated to ensure sampling adequacy (KMO value 0.60). The

Barletts test of sphericity was computed to determine the appropriateness of the factor model. A

Barletts test of sphericity with p< 0.05 indicated that the variables are uncorrelated in the

population and the data are factorable. For factor analysis, item values of communality of 0.30

were considered as the cutoff. Factors with an eigenvalue >1 and factor loading of >0.40 were

extracted (DeVellis, 2003).

Results

Sample characteristics

Of the 213 questionnaires distributed, 202 were sufficiently responded, giving a 94.8%

response rate. The mean age of the respondents was 24.755.05. Nearly half of them were

registered in the third year level of the BSN program (47.5%) and majority were male (52.0%)

and single (72.3%). In terms of spiritual care background, majority of the respondents had a prior

experience in providing spiritual care to patients (51.5%). However, majority of them have not

attended any educational activities on spiritual care in the past 6 months (79.7%) and have not

encountered spiritual care during their classroom or clinical discussions (60.4%) (See Table 1).

Reliability of the SCGS-A

As shown in Table 2, the computed Cronbachs alpha of the entire scale was 0.93 and

0.84 to 0.94 for its components (internal consistency). The ICC of the 2 weeks test-retest scores

was 0.97 (stability reliability).

Validity of the SCGS-A

For the content validity of the scale, both the item-level (I-CVI) and scale-level (S-

CVI/Ave) CVI were calculated based from the responses of the 6 experts. The I-CVI of the 35

items ranged from 0.83 to 1 and the S-CVI/Ave was 0.98.

8
 The computed corrected ITC values of the 35 items of the scale ranged from 0.313 to

0.700. All the 35 items were entered in a PCA with varimax rotation to extract the components

of the scale (See Table 3). A KMO value of 0.875 was calculated and the Barletts test of

sphericity was highly significant (p<0.001). The analysis revealed five dominant components

with eigenvalues greater than 1 and a cumulative contribution rate of 61.97% (See Table 4). As

reflected in Table 3, all factor loadings were adequate for each factor based on the rotated matrix.

Following the original version of the scale, the factors were labeled Attribute for Spiritual Care

(Factor 1), Defining Spiritual Care (Factor 2), Spiritual Care Attitude (Factor 3), Spiritual

Perspective (Factor 4), and Spiritual Care Values (Factor 5).

Table 5 shows the correlation of the five factors of the scale. As shown, all the five

factors were significantly correlated with the overall SCGS-A score (r=0.57 to r=0.77;

p<0.001). Moreover, the five factors were moderately to strongly correlated with each other with

r values ranging from 0.29 to 0.56 (p<0.001).

Discussion

This study was conducted to evaluate the psychometric properties of the SCGS-A in

Saudi nursing students. We have supported the reliability of the scale by establishing its internal

consistency and stability reliability. Validity, on the other hand, was supported by the

computation of the content validity, corrected ITCs and factor analysis employing PCA with

varimax rotation. The establishment of the validity and reliability of the scale supports the sound

psychometric properties of the SCGS-A.

We reported a computed cronbachs alpha coefficients of the entire scale and its

subscales which are greater than the acceptable value. This finding is congruent with the alpha

reported in the validation study of the original version of the scale (Tiew & Creedy, 2012). This

9
suggests that the SCGS-A had a satisfactory internal consistency hence items in the scale were

coherent. Cronbachs alpha is the most commonly used measure of internal consistency and

should be reported in all measurement methods (Nunnally & Bernstein, 1994). However,

Cronbachs alpha is an insufficient measure of reliability (Sijtsma, 2009). It is incapable of

measuring the unidimensionality of the scale and may underestimate reliability of

multidimensional scales (Schmitt, 1996). Therefore, to support our findings, we also reported the

ICC of the two weeks test-retest scores of the scale. As reported, the computed ICC is greater

than the acceptable value. This implies that the scale is capable of measuring the constructs being

measured consistently over time, thus supporting its stability reliability. The computation of ICC

is the most desirable method of establishing the stability reliability of a scale because it takes into

consideration the consistency of the scores from both test and retest as well as the changes in the

average group performance over time (Bland & Altman, 2003). Stability reliability is

undoubtedly an important psychometric property that should be considered and reported in all

assessments of scale quality (McCrae, Kurtz, Yamagata & Terracciano, 2010). The evaluation of

both internal consistency and stability reliability was previously proposed to be used for general

reliability measure (Schmidt, Le & Ilies, 2003). The SCGS-A manifested acceptable internal

consistency and stability reliability hence its reliability was strongly supported.

For the content validity of the scale, we reported acceptable I-CVIs and S-CVI/Ave. Six

experts evaluated the relevance of each items on the construct being measured by the scale by

responding in a 4-point scale from 1 (not relevant) to 4 (highly relevant). From the 35 items

evaluated, 5 items received one rating of either 1 or 2 hence I-CVI for those items was 0.83. This

resulted in an S-CVI/Ave of 0.98. In order to consider a scale to have an excellent content

validity, I-CVIs should be at least 0.78 (for 6 to 10 panel members) and S-CVI/Ave of at least

10
0.90 (Lynn, 1986; Polit & Beck, 2006). Therefore, our findings suggest that the SCGS-A have an

excellent content validity.

Furthermore, the corrected ITC values were within the acceptable limits. None of the

items were modified or removed based from the criteria set earlier. Moreover, the computed

KMO value and the Barlett's test of sphericity supported the sample size adequacy and

appropriateness of the factor model, respectively. The PCA with varimax rotation revealed 5

distinct factors, namely attributes for spiritual care, defining spiritual care, spiritual care attitude,

spiritual perspectives and spiritual care values. The five factors had a cumulative contribution

rate of 61.97%, which indicates good construct validity (Tabachnick & Fidell, 2007). The factor

loadings were adequate for the current sample size (Yong & Pearce, 2013). However, two items

were split loaded on two factors. Item 40 loaded both in Factors 1 and 3, while item 12 loaded in

Factors 1 and 5. According to Nunnally and Bernstein (2003), split loaded items should be

retained in the factors where they correlated highly. Moreover, split loaded items can be retained

with the assumption that it is the latent nature of the variable (Young & Pearce, 2013). Item 40

talks about team approach as an important component of spiritual care. On the other hand, item

12 talks about spiritual care as more than religious care. With these considerations, we have

decided that item 40 be included in Factor 3, which items that explore an individuals attitude

towards spirituality and spiritual care-giving and item 12 in Factor 5, which contained items that

assess ones values toward spiritual care. Moreover, these items were likewise included in the

said factors in the original version.

The five factors extracted in this study are congruent to the findings of the validation

study of the original version. However, the order of the five factors extracted in our study differs

from the earlier study (Tiew & Creedy, 2012). Nine of the items loaded in factor 1, which

11
describe the pre-requisites for spiritual care. This factor composed of spiritual awareness,

experiences, empathy and trusting relationship, which depicts key fundamental pre-cursor in

providing effective spiritual care to patients. Factor 2 contained seven items that portrayed

spiritual care as related to nature and attributes. These attributes included respecting patients

religious or personal beliefs, being sensitive and intuitive, being present for the patient, and

active listening. Factor 3, on the other hand, is six items which examines the attitude of nurses

towards spirituality and providing spiritual care to patients. Items in this factor explored ones

perspective about the reasons for performing spiritual care and its importance. Factor 4 contained

eight items that define the construct of spirituality. It considered the multidimensional standpoint

regarding the nature of spirituality, which reflected the humanistic, existential and pragmatic

views. Finally, five-item factor 5 examined the beliefs about spiritual care among the

respondents. It can assess an individual's spiritual understanding and well-being (Tiew &

Creedy, 2012). These 5 factors showed logical and implied relationship of ones perceived

spirituality, spiritual care and application to practice (Tiew & Creedy, 201). Previous studies

have reported the distinct relationships of understanding of an individuals spirituality, spiritual

care and its application to practice (Baldacchino, 2008; Wallace et al., 2008). As reported earlier,

positive correlations were also found among the 5 factors of the scale. Spiritual care attributes,

spiritual care perspectives, spiritual care constructs, attitude towards spiritual care and spiritual

care values were shown to be interrelated with each other. These findings are similar to

previously reported studies (Van Leeuwen, Tiesinga, Post & Jochemsen, 2006; Baldacchino,

2008; Wallace et al., 2008; Mamier, 2009; Chan, 2010; Ronaldson, Hayes, Aggar, Green &

Carey, 2012; van Leeuwen & Schep-Akkerman, 2015; Labrague, McEnroe-Petitte, Achaso,

Cachero & Mohammad, 2015). Nurses perspective with their own spirituality was shown to

12
influence their understanding of spiritual care as well as their delivery of spiritual care (van

Leeuwen & Schep-Akkerman, 2015; Labrague et al, 2015). Likewise, nurses who have better

understanding of attributes and fundamental aspects of spiritual care provides more appropriate

and better spiritual care (Labrague et al, 2015). Moreover, personal history and experiences of

nurses and their spiritual experience play a significant role in their being sensitive to the spiritual

needs of their patients (Van Leeuwen et al., 2006).These further strengthen the validity of the

SCGS-A.

We acknowledge some limitations of the study. We only performed factor analysis to

support the construct validity of the scale. This is because there are no available scales in Arabic

language that measure the same construct as the SCGS. Future studies are recommended to be

conducted to examine other methods to establish the construct validity of the scale such as

convergent and divergent validity. Although the sample size met the criteria set for a factor

analysis (5 to 10 participants per item) (DeVilles, 2003), there is a need for a larger sample size

to improve the generalizability of the result. The study was only conducted in a single Saudi

university, which might not represent the population of Saudi nursing students in the country.

Future study should also employ the scale to understand the Saudi nursing students perspectives

on spirituality and spiritual care, which was not reported in this study. Nevertheless, the findings

of this study revealed valuable data supporting the sound psychometric properties of the SCGS-

A when used in nursing students in Saudi Arabia.

Conclusion and Implications

Literature asserts that the spiritual dimension of patients is the most neglected aspect in

patient care and spiritual care is the least attended nursing care. The provision of holistic nursing

care is far from reality if spiritual aspect of care is continuously neglected by healthcare

13
professionals particularly nurses who have the most contact with the patients. Nursing students

should be well prepared to assume their responsibilities of providing holistic care to their

patients. With this study, we were able to report an acceptable reliability and validity of the

SCGS-A in Saudi nursing students, which support its sound psychometric properties. With the

establishment of this valid and reliable tool in measuring the multidimensional aspect of

spirituality and spiritual care perspective, timely and accurate assessment of student nurses

perception about spirituality and spiritual care can be facilitated. The data that will be collected

using the scale can be used for planning and implementing interventions to improve the

provision of spiritual care by nursing students hence enhancing the quality of care provided to

patients. The tool can also be used to understand the individual needs of nursing students in

terms of spirituality, spiritual care and its clinical application, which can be used in curriculum

building in the Kingdom and other countries in the Middle-East. The SCGS-A can also be used

by researchers to conduct studies in this area in Saudi Arabia and other Arabic speaking

countries in the Middle-East in order to expand the limited knowledge about this topic in the

region.

14