Spirituality in Persons with Heart Failure

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2002 20: 5J Holist NursTheresa A. Beery, Linda S. Baas, Christopher Fowler and Gordon Allen

Spirituality in Persons with Heart Failure

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JOURNAL OF HOLISTIC NURSING / March 2002Beery et al. / SPIRITUALITY AND HEART FAILURE

Spirituality in PersonsWith Heart Failure

Theresa A. Beery, Ph.D., R.N.Linda S. Baas, Ph.D., R.N., C.S.-A.C.N.P.

Christopher Fowler, R.N., M.S.N.,C.S.-A.C.N.P., C.C.R.N.

University of Cincinnati

Gordon Allen, Ph.D.Miami University

Spiritual expression has been proposed as a dimension of quality of life. Persons withchronic diseases such as AIDS or cancer have described the value of spiritual expres-sion in living with their illnesses. The authors examined the role spirituality plays inthe lives of 58 people with heart failure being treated medically or by transplant. In-struments used included the Medical Outcome Survey Short Form 36 and Index ofWell-Being measures of quality of life, the Spiritual Well-Being Scale, and the Rela-tive Importance Scale. Combined spirituality scores predicted 24% of the variance inglobal quality of life. There were no significant gender differences in spiritual well-being or quality of life.

Heart failure is a chronic disease that is increasing in incidence andprevalence. Currently, about 4.7 million Americans (2.3 million menand 2.4 million women) are living with heart failure, with about550,000 new cases being diagnosed each year. In 1998, 285,000 peopledied from this disease (American Heart Association, 2001). Because ofthe growing numbers, there has been considerable interest in thequality of life of those afflicted. Avariety of factors has been examinedin relation to well-being in the chronically ill heart failure population,but comparatively little attention has been paid to the contributionsspirituality makes to quality of these patients’ lives. A recent

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qualitative phenomenological study highlighted the importance of asearch for meaning and reclaiming of optimism for the advancedheart failure population (Westlake & Dracup, 2001). Spiritual beliefsserve as a buffer for stressful physical and emotional events associ-ated with chronic illnesses (Mytko & Knight, 1999). Examining spiri-tuality in people with heart failure may provide useful informationleading to interventions that improve patient outcomes.

Heart failure patients are initially treated with pharmacologicaland lifestyle regimens, but long-standing heart failure can reach apoint where it can no longer be treated medically. Heart transplantmay be the only viable treatment option for some individuals withirreversible heart damage; however, transplants are limited by thenumber of potential donors. In the United States, 2,184 heart trans-plants were performed in 1999, a number that has remained relativelystable for the past 5 years. About 70% of these patients will survive forat least 5 years (American Heart Association, 2000). Spirituality hasbeen described as a “beacon of light” providing hope for cardiactransplant patients (Walton & St. Clair, 2000). This may have a pro-found effect on their ability to thrive despite this chronic condition.

Large numbers of Americans report a belief in God (95%), and 84%describe their beliefs as either “spiritual” or “religious.” Sixty-eightpercent say they belong to a church or synagogue; this number issomewhat lower than the high of 76% reported in 1947 (Gallup, 2001).Despite the large number of people reporting religious or spiritualpractices in their lives, spirituality is not consistently included inquality-of-life studies. A search for the phrase spiritual well-beingusing CINAHL directed the authors to psychological well-beingbecause the only listing for spiritual well-being could be found in theIOWA Nursing Classification System (Johnson & Maas, 1997). Spiri-tual well-being apparently did not warrant a separate listing.

Authors (Brady, Perman, Gitchett, Mo, & Cella, 1999; Mytko &Knight, 1999; Teno, 1999) have called for the inclusion of a spiritualdimension in current measures of quality of life, but most reports ofthe effect of spiritual belief on suffering and outcomes have been lim-ited to the hospice or palliative care literature and focused on canceror HIV patients (Brady et al., 1999; Hall, 1997; Mickley, Soeken, &Belcher, 1992). Little is known about spirituality among persons withheart failure even though this chronic condition results in sufferingand disability, which could be buffered by spiritual expression. Thepurpose of this study was to examine self-reported spirituality in a

6 JOURNAL OF HOLISTIC NURSING / March 2002



sample of persons with this chronic and progressive disease and toexplore its relative importance and effect on overall quality of life.

LITERATURE REVIEW

Spirituality has been defined in a number of ways. Ross (1995)described the spiritual dimension as “the need for meaning, purposeand fulfillment in life: hope/will to live, belief and faith” (p. 457). Theneed for spiritual integrity is basic to human beings, and confronta-tion with serious illness may present the individual with a first experi-ence of loss of control. This loss of control may inspire a first effort atfinding meaning or purpose in life. In Ross’s model, a failure to iden-tify or misidentify a spiritual problem is a pivotal factor leading to apatient’s incomplete or prolonged recovery.

Dilemmas in Definition

The study of spirituality in the chronically ill has been challengedat the most fundamental operational level. There are a myriad ofvague and inconsistent definitions of what spirituality is. Some havelikened this dilemma to that of defining quality of life when its impor-tance was first recognized but efforts to quantify it were theoreticallyvaried and unclear (Brady et al., 1999). One of the dilemmas has beendistinguishing spirituality from religiosity. Distinctions and com-monalities between these two concepts are often evasive. Religiositycan be seen as membership in a group that describes itself as a reli-gion, regular attendance at religious services, and participation inpractices such as prayer that are also seen as religious.

Spirituality may be a more basic subjective experience that doesnot require group membership, specific practices, or service atten-dance. It may have a more existential aspect that includes a valuing ofultimate meaning and purpose in life (Anandarajah & Hight, 2001;Brady et al., 1999). Clearly, there is a connection between religion andspirituality, but many self-proclaimed spiritual people would denythat they are religious. Although many demographic forms list prac-tices such as Buddhism under the category of religions, Buddhism isnot considered a “religion” by its adherents. But there is an importantlink between spirituality, religion, and existential well-being. Reli-gion and spiritual practice may assist people in finding or creating a

Beery et al. / SPIRITUALITY AND HEART FAILURE 7



personal meaning that can help to make sense of an illness (Mickleyet al., 1992).

Spirituality has been described as having dimensions that are cog-nitive, experiential, and behavioral (Anandarajah & Hight, 2001).Religion has been proposed as an expression of one’s spirituality butnot the only expression possible. Spiritual expression takes on manyforms, and current definitions of religion are widening to include lessmainstream groups such as nature-based religions (e.g., Wicca) andthose based in personal psychological attainment (e.g., Scientology).

Religion and Spirituality in Healing

Religion has been shown to have a positive and protective effect onmorbidity (Levin, 1996). Terminally ill persons have reported thatfeelings of fear, suffering, and hopelessness are mitigated by spiritualexperiences and replaced by a clearer understanding of meaning andstrength (Hall, 1998). Less depression, less anxiety, and fewer suicideshave been seen among people who describe themselves as religious(Koenig, 1998; Koenig, George, & Siegler, 1988). In a study of 542patients age 60 or older who were medically ill, religious coping wasby far the most dominant coping style (Koenig, 1998).

Two thirds of 1,200 studies looking at epidemiological and clinicalrelationships between religion and health found significant positiveassociations. Both physical and mental health were better, and use ofhealth services was lower in persons who reported a religious com-mitment (Matthews et al., 1998). A sense of meaning and purpose inlife are present in people who describe themselves as religious, andthis sense of purpose results in better outcomes. Existential anxiety, ora profound concern that one’s life has no purpose or meaning, hasbeen described as the ultimate stressor (Morse, 1998). The effect ofchronic stress on health through neurohormonal mechanisms is wellknown.

A large number of studies linking spirituality and health arereadily available, most reporting a positive association between reli-gious commitment and improvement of deleterious health outcomesincluding depression, substance abuse, physical illness, and death(Anandarajah & Hight, 2001; Larson et al., 1992; Matthews et al., 1998).Both personal and intercessory prayers have also been associatedwith health benefits (Dossey, 1993). Dossey (1993) critically reviewedthe literature on prayer and prayerful states and healing and reportedimpressive results in human, animal, and cellular studies.




Reports correlating spirituality or religion and health outcomes arenot always positive. ABritish study of 250 patients found that a stron-ger spiritual belief was an independent predictor of poorer outcomesat 9 months following discharge for patients admitted to cardiologyand gynecology services (King, Speck, & Thomas, 1999). The authorssuggested several possible explanations. The more gravely ill patientsmight have felt a stronger spiritual need due to their worsening ill-ness, or people with strong spiritual beliefs that include the promiseof a joyful afterlife may not have struggled as much to recover. Fur-thermore, the presence of religious struggle centering around an ill-ness has been shown to increase the risk of death in elderly men andwomen (Pargament, Koenig, Tarakeshwar, & Hahn, 2001).

Spirituality as a Dimension of Quality of Life

Quality of life is an important outcome measure for a variety ofmedical and nursing interventions. It is subjective, with many dimen-sions, but there is continuing discussion about which concepts areappropriately included in this construct (Spilker, 1996). Questionsabout life’s meaning and how it is affected by chronic illness havebecome of increasing interest both to patients and their caregivers.Interviews with persons with chronic or terminal illnesses haveunderscored the importance of spiritual well-being to these individu-als (Kuhl, 1998; Thomas & Retsas, 1999; VanWalberg et al., 1998). Itseems intuitively clear that spirituality and religion are importantcomponents of quality of life, but it may not be this simple.

The relationship of spirituality and quality of life may be morecomplex than it first appears to be. Cotton and colleagues (Cotton,Levine, Fitzpatrick, Dold, & Targ, 1999) studied 142 women withbreast cancer and found a positive correlation between spiritual well-being and quality of life. But when doing regression analysis and con-trolling for demographics and style of adjustment, they found thatspiritual well-being accounted for only a small portion of the variancein quality of life.

Studies describing the relationship between spirituality and qual-ity of life are limited (Brady et al., 1999; Cunningham, Burton, Hawes-Dawson, Kington, & Hays, 1999; Gioiella, Berkman, & Robinson,1998). Brady and colleagues (1999) found that a high degree of spiri-tual well-being permitted people to enjoy life even though theyreported a high physical burden from cancer symptoms. It is clearlyan area where more studies are needed. The current work makes a




contribution to existing knowledge about spirituality in chronic ill-ness and addresses the specific and burgeoning population of heartfailure patients.

In past work, the authors have defined quality of life as a multidi-mensional, subjective, personal evaluation of and satisfaction withthe physical, social, psychological, and vocational aspects of one’s life(Baas, Beery, Fontana, & Wagoner, 1999). Spilker (1996) proposed thatquality of life is not only multidimensional, it should also be consid-ered as consisting of multiple levels. Global quality of life is a verybroad and general evaluation of one’s life. However, quality of life canbe affected by general health status and even more dramatically by aspecific disease. Measures of health-related quality of life are oftenused to evaluate how a health problem changes the quality of life inthe aforementioned dimensions. Health-related quality of life toolsare general and can be used in samples of individuals with variousdiseases or health problems. Disease-specific measures of quality oflife often focus on the changes imposed by the symptoms or disease-related limitations associated with the disorder. Because of the com-plexity of understanding quality of life, measures that reflect thedimensions and levels are often included in a single study to obtain amore complete picture of the relationship among variables (Baas,Fontana, & Bhat, 1997). In this study, spirituality was examined inrelation to all three levels of quality of life.

METHOD

Design

This cross-sectional descriptive study was the final data collectionpoint in a 3-year longitudinal study of quality of life in persons withheart failure treated medically or with transplantation. Spiritualitywas examined at this time because many participants included writ-ten comments about God, religion, or spiritual beliefs in previousrounds of data collection. This study received institutional reviewboard approval from the University of Cincinnati. The specific re-search questions were the following:

Research Question 1: Is there a difference in religious or existential well-being between those with heart failure who are treated medically andthose who have undergone heart transplant?




Research Question 2: Is there a gender difference in religious well-being orexistential well-being?

Research Question 3: What is the relative importance of spirituality in thesepatients’ lives?

Research Question 4: Is the relative importance of spirituality related to reli-gious and existential well-being?

Research Question 5: What are the relationships between religious well-being and existential well-being and global, health-related, and dis-ease-specific measures of quality of life in persons with heart failuretreated medically or with transplant?

Procedures

One of the investigators or a research assistant approached eachparticipant during a regularly scheduled clinic visit. Potential partici-pants were given complete information about the study. They wereprovided with a packet that included the instruments and stampedenvelopes for return of the questionnaires. Also included was aninformed consent document that was explained verbally and in detailto the potential participant. No forms were completed at this time,and patients were encouraged to take the materials home and care-fully consider participation in the study. If they chose to participate,they could sign the consent form and return it to the investigators inthe enclosed envelope. Inclusion criteria were age older than 18 years,a diagnosis of heart failure, and the ability to read and write in Eng-lish. An exclusion criterion was a diagnosis of mental illness.

Clinic staff members were unaware of who chose to participate andwho did not. As part of the longitudinal study, participants wouldreceive similar packets of forms at quarterly intervals during the yearafter entering the study and biannually for 2 more years. The datareported in this arm of the study were collected at 3 years from entry,which was the final data collection point. Initially, 152 participantswere recruited for the study. Over the 3 years, 10 (6.5%) wrote andrequested that they be withdrawn from the study, 39 (25.6%) died,and another 30% were either lost to follow-up or did not return forms.The 58 who continued in the study for 3 years represented 38.2% ofthe original sample.

Sample

Fifty-eight persons were included in the final sample for this study.The mean age of the predominantly male sample (60%) was 57 years,




with a range of 22 to 68. Over the 3 years since recruitment into thestudy, 20 (34%) participants underwent a heart transplant. Of theremaining 38 participants, 7 (18%) were awaiting transplantation.Most participants were European American (90%), and the remaining10% were African American. These patients were being seen at a ter-tiary care heart failure/transplant clinic in a large midwestern urbanhospital.

Instruments

The scales used for this aspect of the study were the Spiritual Well-Being Scale (SWB), the Index of Well-Being (IWB), the Medical Out-come Survey (MOS) Short Form 36, the Minnesota Living With HeartFailure Questionnaire (LFHQ), and the Relative Importance Survey(RIS). Demographic information was also requested. Questionsincluded religious affiliation, frequency of attendance at a religiousservice, and frequency of prayer.

The Spiritual Well-Being Scale provided a measure of both reli-gious and existential well-being. The Index of Well-Being assessedglobal quality of life. The MOS Short Form 36 was used to measure thephysical and emotional aspects of health-related quality of life. TheMinnesota Living With Heart Failure Questionnaire provided a dis-ease-specific measure of the emotional and physical dimensions ofdisease-specific quality of life. Specific items from the Relative Impor-tance Scale were examined to describe important relationshipsamong the variables of interest. The format and psychometric proper-ties of each instrument are described next.

Spiritual Well-Being Scale. Ellison (1983) developed the SpiritualWell-Being Scale to provide a more complete measurement of spiri-tual expression. The scale is a 20-item Likert-type scale that has two10-item subscales measuring religious well-being (RWB) and existen-tial well-being (EWB). Items on the RWB subscale reference God andinclude statements such as “I have a meaningful relationship withGod.” Items on the EWB subscale have no God reference but measurea sense of purpose or meaning to life. Examples are “I feel that life is apositive experience” and “I believe there is some purpose to my life.”This scale was validated with college students from colleges with areligious orientation. Internal consistency reliability was measured at.78 to .89, and test-retest reliability was measured at .86 to .96. A ceil-ing effect has been reported when the scale is used among




populations of very religious people such as monastics or clerics(Bufford, Paloutzian, & Ellison, 1991). Recent work has criticized thetwo- dimensionality of the scale. In a sample of psychiatric patients, athree-factor model seemed to fit, and in a study using a particularlyreligious sample, the factor structure was not clear (Ledbetter, Smith,Fischer, Vosler-Hunter, & Chew, 1991; Scott, Agresti, & Fitchett, 1998).Studies using this scale have found that spiritual well-being was neg-atively correlated with individualism, success, and personal freedom(Ellison, 1983). Each item is assigned a value from 1 to 6 based on thesubject’s responses, with the higher number indicating more agree-ment with the statement. Negative items are reversed, and then the 10items are summed to determine the subscale scores, which can rangefrom 10 to 60. The scores for each of the subscales can be addedtogether to determine the overall spiritual well-being score. The pos-sible range of scores is from 20 to 120, with the higher scores indicat-ing more spiritual well-being.

The internal consistency of the existential and religious subscalesfor this sample was .83 and .90, respectively. The ranges of possiblescores on the measures of interest are provided in Table 1, with themean scores found in this sample.

Index of Well-Being. The IWB is a nine-item semantic differentialscale devised by Campbell, Converse, and Rodgers (1976). Each itemis rated on a 7-point rating system that has a positive anchor at oneend and a negative anchor at the other. It includes eight items such as‘My present life is useless . . . worthwhile” or “My present life is enjoy-able . . . miserable.” The final item is a measure of overall life satisfac-tion. The weighted sum of the two scores is then calculated. The meanfor the first eight items is weighted at 1.0 and added to the score for thelast item, which is weighted at 1.1. The range of possible scores is 2.1(indicating lowest life satisfaction) to 14.7 (indicating highest life sat-isfaction). Strong reliability and validity have been reported in thepast by the original authors and by this research group (Baas et al.,1997, 1999). This tool was used in this study to measure global qualityof life. The Cronbach’s alpha for this sample was .96.

Medical Outcome Survey Short Form 36. The Medical Outcome Sur-vey Short Form 36 was developed by Ware (1996; Ware & Shelbourne,1992) to examine the health-related quality of life of individuals witha health problem. Over the past 15 years, this tool has become verypopular and is frequently used as a measure of quality of life in




research and as an outcome measure in practice. The tool reliabilityand validity of the tool is well documented, and large enough sam-ples have been administered the tool to develop age-, gender-, anddisease-specific norms. The 36 items can be scored to form eightsubscales and two composite scores (physical composite score and amental composite score). The latter scoring was used for this study.The overall Cronbach’s alpha for this sample was .92.

Living With Heart Failure Questionnaire. Minnesota LHFQ is a 21-item Likert-type instrument designed to measure health-related qual-ity of life for people with heart failure. The tool was developed by Rec-tor and Banks (1996) and used in many large clinical drug trials. Overthe past decade, it has gained widespread acceptance as the instru-ment that measures the effect of heart failure on the emotional and


TABLE 1

Range, Means, and Standard Deviations of Spiritualityand Quality of Life (QOL) Scores Among Persons

Treated for Heart Failure

Possible Range Range of Scores StandardTitle of Scores in This Sample Mean Deviation

Existential well-being 10 to 60 30 to 60 47.1 8.5Religious well-being 10 to 60 23 to 60 48.7 9.8Index of Well-Being 2.1 to 14.7 3.9 to 14.7 10.8 2.8

(global QOL)Mental composite score 0 to 100 23 to 69 48.0 10.9

of Medical OutcomeSurvey Short Form 36(health-related QOL)

Physical composite score of 0 to 100 19 to 57 39.4 10.6Medical Outcome SurveyShort Form 36(health-related QOL)

Minnesota Living With 0 to 24 0 to 24 8.7 6.3Heart Failure QuestionnaireEmotional subscale(disease-specific QOL)

Minnesota Living With Heart 0 to 40 0 to 38 15.2 10.0Failure QuestionnairePhysical subscale(disease-specific QOL)



physical dimensions of life. The two subscales (physical and emo-tional) have strong reliability and validity reported by the originalauthor (Rector, Kubo, & Cohn, 1987). Each item is rated from 0 (didnot) to 5 (very much preventing me from living as I wanted). The physicalitems included typical heart failure symptoms such as fatigue, short-ness of breath, swelling, and difficulty sleeping while also addressingrole function with items that queried the person as to the difficulty inperforming work or social activities. The emotional items includedworry, depression, feeling like a burden on others, and losing self-control. Unlike the other quality-of-life instruments, a high score oneither subscale of this tool represents lower quality of life. In this sam-ple, the Cronbach’s alpha was .95 for the Physical subscale and .88 forthe Emotional subscale.

The Relative Importance Scale. This tool was recently developed bythe investigators to examine the importance of select dimensions ofquality of life. Eleven questions address the importance of social, psy-chological, physical, economic, and spiritual domains in the rating ofoverall quality of life. Each item is rated from 0 (not important at all) to 5(very important to my quality of life). The intent of this tool is to usescores from each domain to devise a weighting system that can beused with other instruments to provide a personalized view of qual-ity of life. For instance, if a measure of activity is used to assess qualityof life, it may be more appropriate to weight the score based on howimportant that dimension of quality of life is to the person. A personwith a low activity level may or may not find that it is important to hisor her overall quality of life to be as physically active. In a sample of 57persons with severe heart disease, the five theoretical domains weresupported by exploratory factor analysis. A larger sample is needed,and stability testing is planned (Baas, Beery, Fontana, & Allen, 2001).However, for the purpose of this study, two items were used toexplore the importance of ability to fulfill spiritual needs and abilityto participate in religious activities.

RESULTS

Sixty-two percent of the participants described themselves asProtestant, and 29% said that they were Catholic. Another 9%reported other. No one indicated that they were Jewish, Hindu, Mus-lim, Buddhist, atheist, or agnostic. Most of those who indicated other




wrote in that they belonged to a particular Christian sect. Sixteen per-cent reported that they attend religious services two or more times perweek. Twenty-eight percent attended once each week, whereas 28%did not attend religious services. Forty-one percent prayed two or moretimes each day, and only 7% reported that they did not pray at all.

Research Question 1 asked if there were a difference in religious orexistential well-being between those with heart failure who aretreated medically and those who have undergone heart transplant.The group of participants who underwent a transplant for treatmentof heart failure (n = 20) had slightly higher scores of religious well-being than those (n = 38) being treated medically (51.2 vs. 47.5), butthis difference was not significant (t = 1.34, p = .18). Similarly, whenexistential well-being was examined, the transplant group againreported higher scores (48.6 vs. 46.3), but this even smaller differencewas also not significant (t = 0.99, p = .33).

Research Question 2 asked if there were a gender difference in reli-gious well-being or existential well-being. Women reported slightlyhigher religious well-being than men (50.6 vs. 47.6), but this differ-ence was not significant (t = –1.14, p = .26). Existential well-being wasalso only slightly higher in women (47.2 vs. 46.9), and the differencewas not significant (t = –0.10, p = .92). In addition, gender and treat-ment group scores on the three measures of quality of life were exam-ined. No significant differences were found. Because the gender andtreatment groups were not significantly different, the groups werecombined to answer the remainder of the research questions.

Research Question 3 examined the relative importance of spiritual-ity in these patients’ lives. This sample rated the relative importanceof two aspects of spirituality as high in terms of determining qualityof life. Specifically, when asked, “How important is it to the overallquality of your life” to participate in religious activities, respondentsrated the item as moderately important. Reponses ranged from thelowest to highest possible scores (0 to 4), with a mean of 2.2 (SD = 1.4).When the same question was posed in terms of importance of fulfill-ing spiritual needs, participants again responded across the spec-trum, but the mean score was higher, 2.75 (SD = 1.2), and nearer thequite important rating (3).

Research Question 4 asked about the relative importance of dimen-sions of spirituality related to religious and existential well-being. Thescores on the Relative Importance Scale were correlated with partici-pant scores on the religious and existential subscales as well as thetotal score on the Spiritual Well-Being Scale. Table 2 provides the




correlation matrix for this analysis. Although rating of the importanceof fulfilling spiritual needs was significantly correlated with the twosubscales and the overall Spiritual Well-Being Scale, the need to par-ticipate in religious activities was not significantly related to existen-tial well-being. This supports the validity of the theoretical constructthat spirituality and religious practices are separate concepts.

Research Question 5 examined the relationships between religiouswell-being and existential well-being and global, health-related, anddisease-specific measures of quality of life in persons with heart fail-ure treated medically or with transplant. To answer the final question,religious well-being and existential well-being were correlated withthe measures of global, health-related, and disease-specific quality oflife (see Table 3). Existential well-being had a slightly stronger rela-tionship with global quality of life than did religious well-being. Thecombined spirituality score predicted 24% of the variance in globalquality life.

LIMITATIONS

This study was limited to a small number of patients in a relativelyhomogenous geographic area. Most respondents were self-describedas Protestant or Catholic. A wider diversity of expressions of religionor spirituality would have strengthened the study. Geographic diver-sity would contribute to an understanding of regional trends. Spiri-tual expression may differ depending on location. The Midwest issometimes referred to as the Bible Belt, whereas California is reputedto be more open to what some describe as unconventional spiritualpractices. It would be useful to know how less mainstream spiritualpractices and beliefs affect quality of life in patients with heart failure.


TABLE 2

Correlations Between Spiritual Well-Being, Religious Well-Being,and Existential Well-Being Subscales and Selected Items of the

Relative Importance Survey in Persons Treated for Heart Failure

Religious Existential SpiritualRelative Importance Survey Well-Being Well-Being Well-Being

Participate in religious activities .40* .24 .34*Fulfill my spiritual needs .48** .39* .47*

*p ≤ .01. **p ≤ .001.



The data reported by these patients were limited to the items on thescales provided. There may be broader and more complex issuesrelated to both religious and existential well-being that were not cap-tured by the tools used for this study. Although the quality-of-lifemeasures used in this study have had broad application, limited dataare available supporting the reliability and validity of the SpiritualWell-Being Scale.

DISCUSSION

Spirituality (both religious and existential) contributed signifi-cantly to the quality of life in these people with heart failure. This isnot surprising; the idea to conduct this study arose from goal state-ments addressing the importance of God and religion reported byparticipants in a longitudinal quality of life in heart failure study. It isclear that a sense of purpose and meaning in one’s life is important. Itis not known whether spirituality changed for these people over time


TABLE 3

Correlations Between the Spiritual Well-Being Total andSubscale Scores and the Global, Health-Related, and Disease-

Specific Measures of Quality of Life Among Persons Treated forHeart Failure

Religious Existential SpiritualWell-Being Well-Being Well-Being

Global quality of lifeIndex of Well-Being .45*** .47*** .49***

Health-related quality of lifeMedical Outcome Survey .13 .21 .18

Short Form 36(physical composite score)

Medical Outcome Survey Short .30* .31* .34*Form 36 (mental composite score)

Disease-specific quality of lifeMinnesota Living With Heart –.34** –.035** –.37**

Failure Questionnaire(physical symptoms)

Minnesota Living With Heart –.40** –.47*** –.47***Failure Questionnaire(emotional symptoms)

*p ≤ .05. **p ≤ .01. ***p ≤ .001.



and over the courses of their illness. There were neither gender nortreatment group differences at this point in time, and one cannot saywhether these group similarities existed previously. Longitudinalanalysis of spirituality, especially examined in terms of worsening ofphysical functioning, would have provided interesting informationabout the construct in relationship to deteriorating function and dif-ferent treatments. Although this study was part of a longitudinalinvestigation, unfortunately these data were collected only at the end.It would have been interesting to see how spirituality changes overtime with chronic disease.

Differences were noted in relationships between religious andexistential well-being and other variables. The importance of fulfill-ing spiritual needs was significantly correlated with the twosubscales and the overall Spiritual Well-Being Scale, but the need toparticipate in religious activities was not significantly related to exis-tential well-being. This supports the validity of the theoretical con-struct that spirituality and religious practices are separate concepts.In their study of 52 adult men with HIV, Tuck, McCain, and Elswick(2001) used three measures of spirituality and five psychosocial ques-tionnaires. They found that the Existential Well-Being subscale of theSpiritual Well-Being Scale best captured the relationship of spiritual-ity to psychosocial variables and quality of life.

Health-related quality of life had a weaker relationship with spiri-tuality than global quality of life. Disease-specific quality of liferevealed more complex relationships with spirituality. A higher scoreon the Living With Heart Failure Questionnaire meant that partici-pants had more distress and less quality of life resulting from thesymptoms of the disease. Thus, an inverse relationship exists.

The relationship between disease-specific quality of life and spiri-tuality is stronger than the health-related measures but not as strongas the global quality-of-life indicator. Physical aspects of the health-related and disease-specific quality of life had weaker relationshipswith components of spirituality than the emotional aspects of thequality of life. The mental component had a weaker but still signifi-cant relationship with both existential and religious well-being. Spiri-tuality may not have an effect on specific disease symptoms butaffects instead the emotional and/or mental responses to disease;however, Brady and colleagues (1999) found that contentment withthe quality of one’s life correlated identically with not only spiritualwell-being and emotional well-being but also with physical well-being (all aspects were measured by the Functional Assessment of




Chronic Illness Therapy System). In Brady et al.’s study, spiritualwell-being was an independent predictor of quality of life.

In this study, global quality of life had a stronger relationship tospirituality than either disease-specific (changes brought about bysymptoms) or health-related (the effect of a health problem) quality oflife. Global measures are more general and reflect a sense of one’s lifeencompassing but not specific to the effects of illness. As such, it is amore transcendent measure that could be more reflective of the broadeffects of spirituality. Although spiritual well-being cannot directlychange symptoms or alter a health problem, it can have a profoundeffect on the person’s ability to place such difficulties in perspective.This study supports the conclusion of others that spirituality is animportant and integral component of quality of life, and a measure ofspirituality should be included in all quality-of-life examinations(Brady et al., 1999; Erickson, Tomlin, & Swain, 1983; Mytko & Knight,1999; Tuck et al., 2001).

RECOMMENDATIONS

Further study should examine a broader range of spiritual expres-sions in more diverse populations to see how they affect quality of lifein chronic disease. Qualitative study further exploring the effect of arange of personal expressions of spiritual practice and faith can pro-vide increased insight into this complex construct. It would be helpfulto have data on other types of spiritual expression, including lessmainstream practices. Participation in spiritual groups may includegroup meditation, retreats, or other kinds of celebrations that wouldnot have been reported in the survey used for this study. The Buddhistliterature is filled with the importance of the spiritual community orSangha. This kind of involvement may be similar in its effect to that ofparticipation in Christian religious services, but it might also be dif-ferent. Personal spiritual expression may include individual or groupreading of spiritual literature or poetry, attendance at talks, or doingphysical practices such as tai chi or yoga. Spiritual practices differwidely, and variations in practice may produce varying effects onhealth. One study describing the use of tai chi for heart failure patientshas been reported (Fontana, Colella, Baas, & Ghazi, 2000), but the ben-efits of practices such as tai chi, with a strong spiritual quality, may bemore than just physical. The effect of spiritual and religious expres-sions on patients’ health is just being uncovered.




There may be limits on the appropriateness of spirituality-basedinterventions. There are some areas that can have a positive effect on aperson’s health that are not ethically within the purview of outsideintervention from a health care professional. One would not recom-mend marriage to patients as a way of improving their health out-comes although being married has been associated with health bene-fits. Perhaps becoming involved with a patient’s spirituality or lack ofit is also inappropriate or at least restricted by social and ethical norms(Koenig, 2001). The American Holistic Nurses Association (2001)standards of practice recognize the importance of respecting a per-son’s individuality and creating a mutually agreed-on plan of care.Attending to patient cues about spiritual expressions or struggle isessential. Spirituality and healing are intertwined in holistic practice.This is reflected in the theories recognized by the American HolisticNurses Association. Modeling and role modeling is one example(Erickson et al., 1983). In this theory, spiritual drive is the core of theindividual.

CONCLUSION

Spiritual expression has been shown to provide important emo-tional and psychological support for people with chronic and termi-nal diseases. Spirituality is a personal and variable form of expres-sion, but it is clear that it has an important effect on quality of life evenin persons experiencing heart failure.

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Theresa A. Beery, Ph.D., R.N., is an assistant professor at the University ofCincinnati College of Nursing–Department of Adult Health and associate director ofthe Institute for Nursing Research. Her research interests include adjustment to im-planted medical devices and symptom self-management in heart failure. She has pub-lished in Heart and Lung, AACN Clinical Issues, Issues in Mental HealthNursing, and the American Journal of Critical Care.

Linda S. Baas, Ph.D., R.N., C.S.-A.C.N.P., is an associate professor at the Univer-sity of Cincinnati College of Nursing–Department of Adult Health, director of theAcute Care Nurse Practitioner Program, and a nurse practitioner in the UniversityHospital Heart Failure Clinic. Her research focuses on body awareness and symptomself-management in heart failure. She has published in Heart and Lung, AACNClinical Issues, Progress in CV Nursing, and the American Journal of CriticalCare.




Christopher Fowler, M.S.N., R.N., C.S.-A.C.N.P., C.C.R.N., is a doctoral studentat the University of Cincinnati College of Nursing. He has published in the NursePractitioner Journal. His research interests are spirituality, noninvasive measuresof cardiac output, and finding meaning in illness.

Gordon Allen, Ph.D., is an associate professor of psychology at Miami Universityin Oxford, Ohio. His research focuses on cognition. He has contributed to the statisti-cal analysis of this study and other studies by these authors. He has published inNursing Clinics of North America and Journal of Cardiac Failure.




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Spirituality in Persons with Heart Failure