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A Study of Spirituality and Life Satisfaction Among Persons with Spinal Cord Injury
The purpose of this study was to investigate the relationship of spirituality and life satisfaction among persons with spinal cord injury. A nationwide sample of 230 persons with long-term spinal cord injury completed the Satisfaction With Life Scale (SWLS), the Quality of Life Index (QLI), and a demographic data form. Data analysis also indicated that there was a significant positive correlation between life satisfaction and psychological/spiritual factors of the QLI instrument. Nurses are mandated by the International Council of Nurses, the Joint Commission on Accreditation of Healthcare Organizations, and the Patient’s Bill of Rights (Maddox, 2001) to provide spiritual care for clients. Rehabilitation nurses have the opportunity to support spirituality and life satisfaction as we assist our clients with disabilities to redefine their lives and explore new life opportunities.
Rehabilitation nurses have the opportunity to work closely with clients and their families over fairly long periods of time. This type of association gives rehabilitation nurses opportunities to assess and plan care for clients and families as biological, cognitive, emotional, intellectual, and spiritual beings. As rehabilitation nurses prepare their clients and families for life with chronic health issues, they need to pay attention to spirituality and life satisfaction as important motivating elements for coping and adjusting to these changes.
Spirituality comes from the Latin for “breath of life.” Spirituality is the sense of harmony and interconnectedness of the self, others, nature, and the ultimate Other. It is achieved through a dynamic and integrative growth process that leads to the ultimate purpose and meaning of life. Spirituality is the source of inspiration, energy, motivation, and the natural tendency toward healing and growth (Meraviglia, 1999; Riley et al., 1998). It gives a person a profound sense of the self as an unique human being (Meraviglia). A basic interpretation of spirituality is the way that a person leads his or her life, thinks, acts, and lives.
Characteristics of spirituality include unconditional love, trust, forgiveness, hope, and imagination. Those with a sense of spirituality experience life purpose, life meaning, and a sense of awe and wonder regarding life (Kearns, 2002). Those with a commitment to spirituality participate in the enhancement of the future, in part by finding meaning in suffering and giving and receiving love.
Questions regarding spirituality take on an additional meaning for people with disabilities. Byrd (1997) writes that recovery from disability requires interventions to the entire person that include physical, cognitive, affect, and spiritual components. People with spinal cord injury survive and live longer lives, thus requiring of them and their families constant attitude adjustment and changes in their approach to life (Davidhizar, 1997). Spiritual growth is possible in the face of personal damage by redirecting and channeling one’s energy and revisioning one’s life.
Long (1997) wrote that spirituality is necessary in each person’s search for the discovery of truth about the self, plus the meaning and purpose of life. Spirituality is used in forming the commitment to actualization of the positive potential of all aspects of life. Spirituality among those with disability exerts influence, raises personal energy, produces developmental growth, and promotes regenerative growth and healing.
Treloar (2000) found in a study she conducted that although 97% of registered nurses surveyed in 1990 thought spirituality should be addressed with their patients, only 66% felt they were adequately prepared for this type of intervention. Treloar found that 77% of hospitalized patients thought that physicians should consider their patients’ spiritual needs, but 68% of physicians never discussed the topic. She also reported that nearly half (48%) of the patients wanted the physician to pray with them.
An individual achieves life satisfaction through subjective evaluation. Influences on life satisfaction include life circumstances, personal functioning, and level of self-esteem (Tzonichaki & Kleftaras, 2002). Life satisfaction also is associated with mobility, education status, employment status, and perceived health (Dowler, Richards, Putzke, Gordon, & Tate, 2001; Pierce, Richards, Gordon, & Tate, 1999; Putzke, Richards, Hicken, & DeVivo, 2002). Chase, Cornille, and English (2000) added that life satisfaction is linked to perceived control, communication skills, and marital status. Spirituality is part of the relationship between mind and body as it constitutes the essence of the person, and is based upon personal values and priorities (Hammell, 2001).
The purpose of this study is to investigate the relationship of spirituality and life satisfaction among persons with spinal cord injury (SCI).
There will be a positive relationship between spirituality and life satisfaction among persons with SCI. Kearns (2002) wrote that holistic nursing includes the spiritual needs of patients. Spiritual well-being infuses the total person with physical, mental, and emotional well-being. Nurses can guide clients through a spiritual life review. During such a review, clients identify persons of warmth in their lives, determine their acceptance of the sense of a higher power, and examine their positive and negative life experiences. Nurses support the spirituality of their clients through active listening, prayer, acceptance, respect, hope, presence, and touch.
Kearns (2002) also stated that nurses have difficulty in meeting the spiritual needs of hospitalized persons due to limited time for client contact. Nurses are encouraged to be a presence to enhance connectiveness with clients even when doing routine patient care. Nurses in home health or parish nursing have opportunities to support spirituality among their clients and families as they form longer, trusting, mutual relationships (Hemmila, 2002).
Treloar (1999) conducted a qualitative study with persons coping with disabilities to investigate connections between spiritual beliefs and responses to lived experiences. Participants in the study were 13 parents of children with disabilities, eight family members of persons with disabilities, and nine adults with disabilities. Results of interviews indicated that parents of children with disabilities experienced more shame, inadequacy, guilt, and blame from family members and society when compared with adults with disabilities. Some parents thought their child’s disability was God’s punishment. Children with disabilities described how their perceptions differed from those of their parents because parents or family members had less suffering. Participants spoke about actions that promoted spiritual well-being: caring by those attending them, sharing feelings, listening, wishing to help others, and treating those with disability as individuals with value and worth. Interventions promoting spirituality included: 1) resources for spiritual needs, 2) communication to promote the underlying feelings of trust, value, and worth, 3) respect for beliefs and culture, and 4) prayer with clients.
Maddox (2001) wrote that nurses have the professional responsibility to provide spiritual care as set forth by the International Council of Nurses’ Code for Nurses, the Joint Commission on Accreditation of Healthcare Organizations, and the Patient’s Bill of Rights. The spiritual status of the client should be part of the total assessment and care. Maddox recommended a short assessment tool with open-ended questions that focus on a client’s faith as a part of life, the influence of faith on one’s health and care considerations, involvement with a religious community, and permission to address spiritual issues. This tool can be used with initial and continued client contact.
In a qualitative study with 30 adults, Freijat (1998) investigated the lived experience and meaning of spirituality following SCI. The concepts identified through data analysis were real faith, real submission, and real peace of mind, self, and good care. Real faith was categorized as beliefs and a higher being’s will. Real submission concepts were handing over oneself to the higher being’s will and worshipping.
Howlett (1999) wrote that having an SCI was a life-changing event. After injury, the person must heal physically and must reexamine the purpose of life. Spirituality is necessary to heal the whole person and permit a life satisfaction. Members of the healthcare team should accept spirituality as a component of healing.
Riley et al. (1998) investigated the relationships among spiritual well-being, life satisfaction, and quality of life. Subjects with disability or chronic illness (n = 216), including 34 with SCI, completed the following tools: Spiritual Well-Being Scale, Functional Assessment of Cancer Therapy, Functional Living Index, Sickness Impact Profile, Medical Outcomes Survey Short Form, and Satisfaction With Life Scale. Results of the study indicated that subjects fit into one of three groups based upon the degree of importance of personal spirituality: 1) religious, 2) existential, or 3) nonspiritual. The nonspiritual group reported significantly lower quality of life and lower life satisfaction, and had the highest rate of health status decline.
The theoretical framework for this study was the Roy’s Adaptation Model (Andrews & Roy, 1991) by which the person/family is considered to be composed of biopsychosocial factors that relate to form the whole. The person/family reacts to and interacts with the internal and external environments using the cycle of input, throughput, and output. Stimuli that influence the person/family are a combination of 1) focal, which has an immediate impact, 2) contextual, which is a composite of all stimuli, and 3) residual, which comprise attitudes, values, and cultural beliefs. The adaptive modes are physiologic function, self-concept, role function, and interdependence. A key concept for the self-concept mode is the spiritual self, which includes one’s belief system and evaluation of the self. Coping by the person/family is achieved as the regulator subsystem uses internal and external stimuli to develop self-concept, role function, and interdependence. The output of the cognator subsystem includes perception, judgment, information processing, and learning.
The person with a spinal cord injury may have internal stimuli, such as discomfort, and sensory loss, but also may have a sense of independence and achievement. External stimuli incorporate factors, such as environmental barriers or employment and socialization, plus acceptance or stigma. All internal and external factors influence evaluation of life satisfaction. The concept of spirituality is part of the personal self, which also is composed of self-consistency and self-ideal. Spirituality is one factor of the many components influencing life satisfaction for those with SCI.
Subjects of this study (n = 230) were community-dwelling persons with SCI. They were contacted through National Spinal Cord Association chapters; the Veterans Administration Medical Center of Seattle, WA; St. Joseph Hospital-Rehabilitation Unit of Phoenix, AZ; and the Arizona State University Disability Resources for Students Office in Tempe, AZ. Power analysis for the sample size exceeded 0.98 (Cohen, 1988). The mean age for subjects was 44.6 years (SD = 10.6 years). Table 1 contains the demographic data for these subjects. This study was approved by the Human Subjects’ Committee of Arizona State University and St. Joseph Hospital.
Subjects were mailed three questionnaires, the Satisfaction With Life Scale (SWLS), the Quality of Life Index (QLI), and a demographic data form.
The SWLS is a Likert-like questionnaire with 5 variables that are evaluated on a 6-point scale ranging from strongly agree to strongly disagree. The 5 variables are life status compared with the ideal, conditions of life, satisfaction with life, gains in life, and desired changes with life. Test-retest correlation coefficient reliability for this questionnaire was .82 and the coefficient alpha was .87. Validity of the questionnaire was established by comparisons with other measures of well-being with moderate to strong correlations (r = .58 to .75); (Diener, 1984).
The QLI is a 64-item questionnaire that measures satisfaction with life and importance of life domains, including spirituality. Satisfaction infers that there is a judgment or cognitive experience used for evaluating life. Importance of life domains varies and does not make an equal impact on all domains of life. Those who are satisfied with important domains of their life have a higher quality of life as compared with those who are very dissatisfied with important domains of life. In addition, those who have greater satisfaction with a less important domain of life would see less impact on life compared with those having dissatisfaction with important life domains (Ferrans & Powers, 1985). Factor III of the questionnaire focuses on psychological/spiritual domains. Peace of mind has a positive correlation with life satisfaction assessment (r = 65). Personal faith in God has a positive correlation with life satisfaction assessment (r = .47); (Ferrans & Powers, 1992). The other components of the QOL instrument include health and functioning, socioeconomic, and family.
Data analysis was completed using the SPSS program for descriptive statistics and the Pearson Correlation Coefficient.
The mean score for the SWLS was 19.403 (SD = 0.560, n = 230). The mean score for Factor III of the QLI was 35.8 (SD = 33.4, n = 230). The SWLS and the Factor III of psychological/spiritual of the QLI had a positive, significant correlation (n = 230, r = 0.621, p = 0.001).
There was a moderately positive correlation between SWLS and the factors of psychological/spiritual with the QLI, Factor III. The satisfaction of life among those with disabilities increased as their spirituality increased. The findings of this study support Freijat’s (1998) research that indicated spirituality among those with SCI included the concepts of real faith, submission, and peace of mind. Results also support the Riley et al. (1998) study that indicated levels of life satisfaction correlated with levels of spirituality.
The findings of this study also supported Roy’s Adaptation Model (Andrews & Roy, 1991) that postulates a person is composed of biopsychosocial factors, which include spirituality. Many subjects of this study wrote personal notes when completing questionnaires that indicated their high level of life satisfaction, except for the frustration with being in a wheelchair. The subjects considered multiple factors in their lives when evaluating life satisfaction, such as health, functioning, socioeconomic status, psychological/spiritual status, and family.
Limitations of this study include data analysis only of persons motivated to return the questionnaire. Replication of this study ideally would survey a larger sample size that would be more likely to represent persons with a large variety of views toward spirituality. Subjects were not asked to give their religious affiliation or how actively they practice their religion. Replication of the study could address the impact of active religious participation on spirituality and life satisfaction.
Implications for nursing
Rehabilitation nurses have opportunities to assist patients with SCI redefine their lives, form purpose in life, support individual strengths, and actualize life goals. Rehabilitation nurses also have opportunities to establish rapport, trust, and personal commitment because they spend longer periods of time in contact with patients and families than other healthcare professionals. Specific nursing interventions that may promote spirituality and life satisfaction are to promote client self-management and control, role achievement, socialization, employment, and emotional sharing with family and friends (Atkin, 1999; Tzonichaki & Kleftareas, 2002). Hicken, Putzke, Novack, Sherer, and Richards (2002) state that intact marital status was a predictor of life satisfaction; therefore, family counseling could be an important intervention. Tate and Forchheimer (2001) associated spirituality with life satisfaction, which directs nurses to encourage the enrichment of both of these factors. Nurses can help the client and family explore reassessment, value clarification, and asset confirmation to support spiritual well-being and a higher satisfaction with life.
Nurses are mandated by the International Council of Nurses, the Joint Commission on Accreditation of Healthcare Organizations, and the Patient’s Bill of Rights to provide spiritual care of our clients (Maddox, 2001). Nurses currently have assessment instruments and general guidelines for interventions focusing on spirituality and life satisfaction (Riley et al., 1998; Treloar, 2000). The challenge for nurses is to investigate the most effective means of facilitating spirituality and life satisfaction for individual clients and their families. Nursing educators should prepare current and future nurses to promote spiritual care and life satisfaction for their clients. Nurse researchers should investigate the effectiveness of specific interventions that promote higher levels of spirituality and life satisfaction for those with chronic illnesses.
This study was funded with Faculty Grant In Aid (FGIA) funding from Arizona State University in Tempe. I would like to express my appreciation to Laura Heard, MSN RN CRRN, Marilyn Ricci, MSN RN, and James Hemauer, CA, who assisted me in contacting subjects for this study.
About the Authors
Barbara Brillhart is an associate professor at Arizona State University, College of Nursing, Tempe, AZ. Address correspondence to her at Box 872602, Tempe, AZ 85287-2602, or via e-mail to firstname.lastname@example.org
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