Journal of Holistic Nursing

http://jhn.sagepub.com/ Spirituality and Stress Management in Healthy Adults

Inez Tuck, Renee Alleyne and Wantana Thinganjana J Holist Nurs 2006 24: 245 DOI: 10.1177/0898010106289842 The online version of this article can be found at: http://jhn.sagepub.com/content/24/4/245

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Spirituality and Stress Management in Healthy Adults

Inez Tuck, RN, PhD Renee Alleyne, MS Wantana Thinganjana, MS, RN
Virginia Commonwealth University

Journal of Holistic Nursing Volume 24 Number 4 December 2006 245-253 2006 American Holistic Nurses Association 10.1177/0898010106289842 http://jhn.sagepub.com hosted at http://online.sagepub.com

The purposes of this longitudinal, descriptive pilot study were to (a) test the acceptability and feasibility of a 6-week spiritual intervention; (b) determine the relationship between spirituality and stress; (c) explore the effects of the intervention on measures of perceived stress, spiritual perspective, and spiritual well-being; and (d) explore the meaning of spirituality. The sample consisted of 27 community-dwelling adults. Six categories emerged from the qualitative data as descriptors of the meaning and significance of spirituality. The survey data indicated that there were significant negative correlations between perceived stress and spiritual well-being at three time intervals, a significant decline in the levels of perceived stress, and a significant increase in spiritual perspective from the pretest to the 6-week follow-up. There were no significant changes in spiritual well-being. The intervention proved effective in reducing stress in this healthy adult sample. Keywords: spirituality; stress management; spiritual intervention; health promotion; spiritual well-being

eligion, spirituality, and health have recently become the foci of scientific inquiry, although the use of spirituality and religion during illness dates back thousands of years, when religious leaders often served as healers in many cultures (Torosian & Biddle, 2005). There are a number of studies that support the beneficial effects of spirituality and religion on health (Kim & Seidlitz, 2002). These health benefits include both physical and mental well-being (Torosian & Biddle, 2005; Walton & Sullivan, 2004). However, most of the literature focuses on the relationship between spirituality, religion, and chronic illnesses (Koenig, Pargament, & Nielsen, 1998; Targ & Levine, 2002; Tuck, McCain, & Elswick, 2001). Religious commitment, strength of ones faith, and prayer have often been linked with improved recovery and healing from major illnesses (Koenig, 2004; Torosian & Biddle, 2005). Religious beliefs and activities have been associated with better immune function, lower death rates from cancer, fewer incidences of heart disease, lower blood pressure and levels of cholesterol, better health behaviors (e.g., increased levels of exercise), and greater compliance with medical treatment (Koenig, 2004). Perhaps this is related to the notion that many individuals with serious illnesses rely on their spiritual beliefs as a

source of guidance and coping (Hebert, Jenckes, Ford, OConnor, & Cooper, 2001). Although findings suggest that effective spiritual coping strategies help individuals find meaning and purpose in their illnesses, individuals may have employed the same strategies before they became ill (Baldacchino & Draper, 2001). For instance, one study shows that healthy older adults believe that a higher power supports them and that having a relationship with God forms a foundation for their psychological well-being (Mackenzie, Rajagopal, Meilbohm, & Lavizzo-Mourey, 2000). Thus, spirituality plays an important role in the lives of healthy individuals. In fact, approximately 96% of adults in the United States expressed a belief in God, and 72% identified religion and spirituality as having the most important influence in their lives (Ano & Vasconcelles, 2004; Graham, Furr, Flowers, & Burke, 2001). Levin and Taylor (1997) reported that prayer is the most frequently used religious activity. In fact, many Americans, regardless of their health status, rely on their religious and spiritual beliefs to cope with stressful life events (Graham et al., 2001; Levin, 1994). Religiosity or religiousness (a term preferred by the authors) is often represented by devotion to the beliefs and practices of established, organized religion,
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whereas spirituality is a broader term that denotes beliefs, experiences, and practices that involve an individuals relationship with a higher being or the universe (Rose, Westefeld, & Ansley, 2001). Spirituality is an essential component of each individual (Isaia, Parker, & Murrow, 1999; Narayanasamy, 1999) and is a universal, human dimension (Goddard, 1995, p. 809). Spiritual activities provide a release from fears and worries, meaning and purpose, and a focus on the small joys of everyday life (Benson, 1997). Although some individuals express their spirituality through religion, others do not. The term spirituality often refers to both spirituality and religion and is used interchangeably in this study. The purposes of this longitudinal, descriptive pilot study were to (a) test the acceptability and feasibility of a 6-week spiritual intervention; (b) determine the relationship between spirituality and stress; (c) explore the effects of the intervention on measures of perceived stress, spiritual perspective, and spiritual well-being; and (d) explore the meaning of spirituality as voiced by the participants. Healthy adults were recruited to participate in the pilot study designed to explore spirituality as a possible approach for stress reduction.

Stress and Spirituality

Stress, a familiar term in nursing, refers to ones response to an event that is considered dangerous or threatening to ones well-being (Auerbach & Gramling, 1998). Stress can be experienced in the form of feelings of discomfort (emotional), changes in behavior (body language and facial expressions, speech, and actions), and physical responses (muscle tension, increased heart rate, difficulty breathing, fatigue, physical illness, and increased susceptibility to disease). High rates of stress can lead to feelings of failure, loss of interest, and emotional and physical exhaustion. Individuals may experience anger, anxiety, restlessness, depression, boredom, feelings of guilt, and in extreme cases, psychiatric illness (Auerbach & Gramling, 1998; Friedman, 1991). Therefore, employing positive and effective strategies to manage stress can be beneficial to ones overall health. Several researchers have identified spirituality as an effective means of managing stress (Baldacchino & Draper, 2001; Kim & Seidlitz, 2002). In general, strong beliefs (whether spiritual or nonspiritual, positive or negative) can have powerful effects on the body and the mind and can bring a sense of comfort (Joseph,

1998). Individuals with a positive spiritual identity are more likely to report a meaningful and purposeful life than those who do not express such views (Graham et al., 2001). Likewise, in a meta-analysis of literature that examined the relationship between religious coping strategies and psychological adjustment, Ano and Vasconcelles (2004) found that the use of religion as a coping strategy was associated with positive outcomes to stressful life events. Individuals who used religion to cope experienced more positive affect and spiritual growth and less depression, anxiety, and distress than individuals who did not use religion as a coping strategy (Pargament, 1997). Even when study results did not indicate a direct relationship between spirituality and stress levels, spirituality was found to be a buffer against the adverse effects of daily life stressors. In a study of the relationship of spirituality with emotional and physical adjustment to daily stress, Kim and Seidlitz (2002) found that spirituality moderated the effects of stress regardless of religious affiliation. There is growing empirical evidence to support the association between spirituality and stress management. The lay literature abounds with references to the positive effects of spirituality on overall well-being and quality of life (Ano & Vasconcelles, 2004; Kim & Seidlitz, 2002). Spiritual well-being is the foundation of holistic health care (Sherwood, 2000). A holistic approach to health involves the interrelationships of the biopsycho-social-spiritual dimensions of persons, recognizing that the whole is greater than the sum of its parts (Jackson, 2004). Thus, there is reason to believe that efforts toward health promotion should incorporate a holistic approach to enhance overall health and well-being.

Conceptual Framework
The background for this study is based on the stress-coping model proposed by Lazarus (Lazarus & Folkman, 1984) and theories of human development. Lazarus (1996) described two approaches to managing stress as problem- or emotion-focused coping. Problemfocused coping allows the individual to manage threats and reduce stress by changing the situation when confronted with it. The process is a cognitive approach to problem solving. Emotion-focused coping requires that the individual transforms or reframes the threatening situation. In essence, the individual finds meaning in the experience and reduces the threat to personal integrity by altering the perception of the event. Although both approaches may result in the

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reduction in stress, the meaning making and transformative aspects of emotion-focused coping has relevance for spirituality as evidenced in the definition reported by Benzein, Norberg, and Saveman (1998). In a theory of human development, Labouvie-Vief (as cited in Dunn & Horgas, 2000) indicated that as we mature, we gain a greater ability to integrate cognitive problem solving and emotional coping. Spirituality, as defined, allows the individual to integrate coping approaches and derive meaning from experiences. A conceptual connection is apparent with Lazaruss longestablished and accepted model of coping with stress and the potential positive effects of spiritual growth on reducing stress-related outcomes.

Method
Procedures
Approval from the Institutional Review Board was received for this study prior to enrollment. Data were collected as part of a 12-month study to explore the relationship between perceived stress, spiritual perspective, and spiritual well-being in healthy adults. Participants were recruited from three local church congregations in a southeastern city. Two congregations were predominantly Caucasian and one was African American. Of the three churches, two were Episcopalian and one was Baptist. One month prior to the start of the intervention, flyers were posted and announcements were placed in the churches bulletins inviting adult members of the congregations to participate in a 6-week spiritual-growth group. There were no incentives provided for participation in the study other than the opportunity to explore ones spiritual growth. All participants gave written consent before participating in the study. Participants were asked to attend a 90-minute session once a week for 6 weeks (SPIRIT-6). Session content included topics such as the meaning and importance of spirituality and religion, expression of spirituality to others, creative expression of spirituality, infusion of knowledge and spirituality, multisensory experience and spiritual awareness, and forgiveness and spiritual well-being. Four booster sessions were held during the year that the participants were enrolled in the study to reinforce the effects of the intervention over time. Data were collected at five different time points: on admission to the study (prior to the start of the intervention for baseline data), at the completion of

the 6-week spiritual growth intervention, 6 weeks after completing the intervention (instruments were mailed to participants), during a booster session offered at 6 months into the study, and during the final booster session at 12 months. The booster sessions were structured in the same format and were offered in a predetermined sequence for all groups. Questionnaires were coded with four digits known only to the participants to track their scores over time. The responses of the participants to the two openended questions asked in the first session were entered into a computer file for future analysis. The qualitative data were analyzed using features in Microsoft Word software. Two investigators reviewed data independently during a period of several weeks to ensure that the categories were exclusive and reflected all the data. Although both investigators were familiar with definitions of spirituality found in the literature, the categories that emerged were grounded in the data. The process of content analysis was iterative and rigorous in determining the categories.

Study Participants
The convenience sample consisted of 27 participants who enrolled in the study and completed the survey instruments at Time 1. Five participants withdrew during the 6-week intervention because of scheduling conflicts, and 2 female participants did not return the surveys at Time 3. Two participants relocated from the area after completing the intervention and the 6-week follow-up survey (Time 3). At 6 months postintervention, 10 participants had withdrawn from the study because of scheduling conflicts or relocations. Eleven participants remained in the study for 12 months. The participants ages ranged from between 20 and 77 years old, with a mean age of 52 years (SD = 11.3). Fourteen of the participants were African American, 11 were Caucasian, 1 was Asian, and 1 did not report race/ethnic identity. Twenty-four of the participants were female and 3 were male. All of the participants reported that they completed high school and had a minimum of 2 years of college (14-plus years). All participants were members of the Protestant faith except 1 participant who practiced Buddhism (see Table 1).

Measures
Demographic information (age, race, gender, and years of education) was gathered from the partici-

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Table 1 Demographic Information

Variable 1. Gender Male Female 2. Race African American Caucasian Asian Not reported 3. Age 20 40-59 years 60 and older Number of Participants 3 24 14 11 1 1 1 20 6 Percentage 11 89 52 41 4 4 4 74 22

Note: Total exceeds 100% due to rounding percentages.

pants after obtaining their written consent. Three measures were used at each of the five data collection points: The Perceived Stress Scale (PSS), the Spiritual Perspectives Scale (SpS), and the Spiritual Well-Being Scale (SWBS). The PSS is a 14-item scale designed for use with community samples with at least a junior high school education (Cohen, Kamarck, & Mermelstein, 1983). This scale measures the degree to which one appraises situations in ones life as stressful. It is composed of 7 positive items (e.g., In the past month, how often have you dealt successfully with irritating life hassles?) and 7 negative items (e.g., In the past month, how often have you been upset because of something that happened unexpectedly?). Responses are obtained using a Likert-type scale ranging from 0 (never) to 4 (very often). Scores for the PSS are obtained by reversing the scores on the positive items and then summing across all 14 items so that higher scores indicate higher levels of perceived stress. Cronbachs alphas reported across previous studies were .84 to .86 (Cohen et al., 1983). Cronbachs alpha for this study was .87. The SpS is a 10-item instrument used to measure the significance of spirituality in ones life and the extent to which one engages in spiritual interactions (Reed, 1987, 1992). The scale uses a 6-point, Likerttype response format ranging from not at all to about once a day for the first 4 items and a 6-point scale from strongly disagree to strongly agree for items 5 through 10. Items include statements such as In talking with your family and friends, how often do you mention spiritual matters? and My spiritual views have had an influence upon my life. Scores for

this scale are obtained by calculating the arithmetic mean across all items for a total score. Total scores range from 1 to 6, with higher scores indicating higher levels of spiritual perspectives. A previous report of reliability in studies with populations of healthy, hospitalized, and seriously ill adults of all ages was .90. The Cronbachs alpha for this sample was .86. The SWBS is a 20-item scale developed to measure individuals spiritual well-being without the limits of specific theological issues (Carson & Green, 1992). It is based on the definition of spiritual well-being developed in 1975 by the National Interfaith Coalition on Aging, which defines spiritual well-being as The affirmation of life in the relationship with God, self, community, and environment that nurtures and celebrates wholeness (quoted in Carson & Green, 1992, p. 213). The SWBS has two subscales: Religious WellBeing (RWB) and Existential Well-Being (EWB). Responses for this measure are obtained on a 6-point, Likert-type response scale ranging from strongly agree to strongly disagree. The measure consists of 11 positively worded items and 9 negatively worded items. Positively worded items include statements such as I believe that God loves me and cares about me. Negatively worded items include statements such as I dont get much personal strength and support from my God. Total scores for this scale are obtained by reverse scoring the negatively worded items and summing across all 20 items. Higher scores represent higher levels of spiritual well-being. The scale has been frequently used with samples of religious groups, college students, and counseling patients, with reports of alpha scores ranging from .82 to .99 (Buford, Paloutzian, & Ellison, 1991; Paloutzian & Ellison, 1982). In this study, the Cronbachs alpha was .89. The qualitative data collected during the first session of the intervention was in response to two questions: (a) What is the meaning of spirituality to you? and (b) How important is spirituality to you in your daily life?

Spiritual Intervention SPIRIT-6

The 6-week SPIRIT-6 intervention is an adaptation of a 10-week spiritual-growth group intervention that was used in a study exploring stress reduction in persons living with HIV disease (Tuck, 2004). The intervention is based on a broad definition of spirituality that allows secular and religious views of spirituality to be expressed in a group format. Each of the six sessions is designed to explore an aspect of

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spirituality and includes the intellectual process of knowing or apprehending spirituality; the experiential component of interconnecting ones spirit with self, others, nature, God, or a higher power; and an appreciation of the multisensory experience of spirituality. The facilitator uses the first session to determine the spiritual and religious views of the participants. The five remaining sessions focus on different aspects of spirituality. In the 90-minute sessions, members share their perspectives in discussions facilitated by the leader. Each activity encourages exploration of spirituality and reflection regarding the relevance to ones spiritual growth. Awareness and appreciation of ones spirituality is the goal of the intervention. Following each session, the facilitator summarizes the content and process to ensure the consistency in the protocol and assess the feasibility of the intervention. The detailed descriptions of the protocol for the sessions are available to the group facilitator/interventionist in the SPIRIT Intervention Operations Manual.

the SWB, seven mean substitutions were made for items not completed at Times 2, 4, and 5 (Tabachnick & Fidell, 2001).

Results and Discussion

Quantitative Findings
Correlations among the variables in this study are presented in Table 2. Correlational analyses indicated that as participants age increased, there was also an increase in participants level of education (r = .426, p < .05). There was a significant negative correlation between the measure of perceived stress (PSS) and spiritual well-being, such that participants who reported higher levels of stress at Time 1 reported lower levels of spiritual well-being at Time 1 (r = .613, p < .01). A similar inverse relationship was found between levels of perceived stress at Time 2 and spiritual wellbeing at Time 2 (r = .638, p < .01) and levels of perceived stress at Time 3 and spiritual well-being at Time 3 (r = .855, p < .01). In addition, participants who reported higher levels of PSS at Time 2 also reported significantly lower levels of spiritual wellbeing at Time 3 (r = .516, p < .05). Also, participants scores on the measure of spiritual perspective (SpS) at Times 1, 2, and 3 were significantly correlated to spiritual well-being at Time 1 (r = .572, p < .01; r = .578, p < .01; r = .483, p = .05). SpS was highly correlated with religious well-being (RWB) at Time 1 and existential well-being (EWB) at Time 5. Similar relationships were found between participants reports of spiritual perspective at Time 2 with SWB Time 2 (r = .509, p < .05) and SpS at Time 3 and SWB Time 3 (r = .499, p < .05). There is only one significant correlation between SpS and perceived stress. SpS Time 4 was correlated with PSS at Time 5 (r = .679, p = .05). Descriptive analyses including means, standard deviations, and ranges are presented in Table 3. Participants reported moderate levels of perceived stress across all time intervals. Fairly high levels of spirituality were reported at all time points as well. To test for significant differences in levels of perceived stress, spiritual perspective, and spiritual well-being across all time points, repeated-measures ANOVAs were conducted (pretest vs. immediate posttest vs. 6-week follow-up) as a within-participants factor. The first analysis examined levels of perceived stress. The sphericity assumption was met for this analysis. The results of this analysis revealed significant

Data Analysis
To determine the acceptability and feasibility of the pilot study, the facilitators evaluated the ease with which the intervention was implemented and reviewed the group summaries and the informal comments made about the intervention by the group participants. In the final session, members describe what the experience has meant to them. Other unsolicited comments were noted when made by participants enrolled in the study during the year. Demographic variables were analyzed by descriptive statistics. Correlational analyses were used to determine the relationship among the variables. Repeated-measure ANOVAs were used to determine the effect of the intervention on three measures during the five data collection points. In effect, the pretest data served as the control for changes occurring in the 12-month period. Statistical analyses were conducted using the SPSS 12.0 program. After completing a power analysis and measuring effect size, it was determined that data collected at Times 4 and 5 did not yield adequate power or the sufficient effect size to reject the null hypotheses. Therefore, primarily the data from Times 1 to 3 will be reported in the results of this study. The data show that the means for PSS and SpS are in the direction predicted for Times 4 and 5, even though the overall models are not significant at those times. Only two significant correlations were found at Times 4 and 5. To correct for random missing data in

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Table 2 Correlations Among Study Variables

Variable 1. Age 2. Race/ethnicity 3. Gender 4. Level of education 5. Perceived stress T1 6. Perceived stress T2 7. Perceived stress T3 8. Spiritual perspectives T1 9. Spiritual perspectives T2 10. Spiritual perspectives T3 11. Spiritual well-being T1 12. Spiritual well-being T2 13. Spiritual well-being T3 1 2 .065 3 4 5 6 .170 .207 .117 .048 .604** 7 .200 .423 8 9 .234 .015 .048 .033 .208 .059 .115 .901** 10 .394 .078
.a

11 .283 .262 .225 .073 .613** .288 .408 .572** .578** .483*

12 .234 .305 .062 .006 .392 .638** .516* .418 .509* .326 .747**

13 .275 .216
.a

.050 .426* .102 .115 .392* .274 .227 .231 .000

.282 .088 .155 .a .100 .102 .564** .224 .507* .083 .249

.200 .098 .147 .379 .884** .720**

.048 .437 .516* .855** .303 .132 .499* .424 .490*

a. Could not be computed because of one or more variables being constant. *p < .05. **p < .01.

Table 3 Means, Standard Deviations, and Ranges of Independent and Dependent Variables
Variable PSS Time 1 PSS Time 2 PSS Time 3 PSS Time 4 PSS Time 5 SpS Time 1 SpS Time 2 SpS Time 3 SpS Time 4 SpS Time 5 SWBS Time 1 SWBS Time 2 SWBS Time 3 SWBS Time 4 SWBS Time 5 N 27 21 20 11 9 27 21 20 13 9 27 21 20 17 10 Mean *25.52 21.05 *21.10 22.73 21.22 *5.32 5.51 *5.51 5.49 5.52 95.56 100.28 99.65 100.82 90.40 SD 8.54 7.91 8.45 4.86 6.05 .517 .405 .496 .457 .602 14.75 13.83 16.48 14.09 10.83 Sample Range 10-41 8-37 8-37 12-28 12-33 4-64 5-6 2-4 4-6 4-6 71-118 71-120 65-120 69-119 69-105

Note: PSS = Perceived Stress Scale; SpS = Spiritual Perspectives Scale; SWBS = Spiritual Well-Being Scale. *p < .05, denotes a significant change in the measure over time.

decreases in participants levels of perceived stress from Time 1 to Time 3, F(2, 34) = 4.21, p < .05, suggesting a significant effect for the intervention. The second analysis also indicated a significant effect for the intervention. The sphericity assumption was not met, and the Huynh-Feldt correction was applied. There was a significant increase in participants levels of spirituality from Time 1 to Time 3, as measured by the SpS, F(2, 34) = 3.60, p < .05. However, the results of the third analysis did not reveal significant differences in spiritual well-being across the three time

periods, F(2, 34) = 1.17, p > .05. Thus, the results of this analysis did not support the proposed effects of the intervention on spiritual well-being over time or the findings may be explained by the lack of sufficient power or effect size. There were no relationships found between the demographic variables (age, race, gender, and education level) and the study variables of perceived stress and spirituality. The absence of any gender differences is likely attributable to the small number of male participants enrolled in the study. The convenience sample was primarily middle-aged adults (median age of 52) who were highly educated and who were all members of faith communities. As indicated by the pretest data, participants entered the study with moderately high scores for SpS and SWBS, possibly explained by the age of participants and the source of the sample. Although the sample in the pilot study is homogenous in many respects, there are significant findings. The data indicated that the change in scores for SpS was significant from Time 1 to Time 3, indicating an increase in spiritual perspective denoting greater awareness and interactions. One of the benefits of the intervention might be a heightened sense of ones spirituality. Spiritual well-being did not change significantly over time, but the level of spiritual well-being was high at baseline and the level of SWBS did inversely influence perceived stress in the desired direction. It is also noteworthy that there was a significant decline in perceived stress in the 12-week period. It would be helpful to know whether the decline continued at 6 and 12 months. A larger sample would answer the question of long-term effects of

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Table 4 Qualitative Description of Spiritual Responses

Categories A belief in a personal relationship with God Exemplars of Participants Responses It is my relationship with God. My relationship with God is a part of it. Sometimes I get angry with God and impatient for answers. I question Him. Spirituality is the extent to which I permit or am able to permit my relationship to God to be a guiding force in the totality of my life. Connection with people, nature and birds. Spirituality is the connection with self, others, nature, art, and music. I struggle with what I am supposed to do. Spiritual life is a process/a journey; still evolving spiritually. Guiding force in the totality of my life. I have seen some very tough times in my life; it was my spirituality that got me through those times. Spirituality is the essence of who I am. Spirituality as a deep understanding about life. It is self-growth; time for self. I think about at this moment and do the best thing as much as I can. Praying daily. Meditating in the office and when working with others. It is the most important thing in my life! Especially right now when Im out of work; it is what gets me through each day.

A connection and relationship with others Spiritual journey, guide, or struggle

Spiritual essence of self

Spiritual express in actions

Integral spirituality

the intervention and the additive effects of monthly booster sessions. The intervention was viewed as feasible by the facilitators. Participants, as evidenced by the evaluative and complimentary comments offered, viewed the intervention as acceptable. Nearly 80% of the original sample completed the 6-week intervention. The difficulty of retaining members of the group during the 12-month period was directly related to participants availability to attend the groups. Another explanation for the attrition rate may be credited to the fact that this healthy population was not experiencing any health crises nor were there incentives provided for their continuation in the study. The booster sessions, although more difficult to coordinate because of the lack of contact with participants over time, were thought to be beneficial, and most participants liked the idea of having a reunion affirming the connections or bonds that were established while in the group.

Qualitative Findings
The responses from the participants were content analyzed and yielded six disparate categories that are briefly described below with exemplars. The categories are a belief in a personal relationship with

God; a connection and relationship with others; spiritual journey, guide, or struggle; spiritual essence of self; spirituality expressed in actions; and integral spirituality (see Table 4). The first category was a belief in a personal relationship with God. The category included statements that described the nature and intimate quality of this relationship. The relationship was sometimes viewed as a partnership and at other times a subordinate relationship with a deity or higher power. Participants sought guidance from God, often challenged Him, or questioned His will. One participant stated, Sometimes I get angry with God and impatient for answers. I question Him. Another stated, Spirituality is the extent to which I permit or am able to permit my relationship to God to be a guiding force in the totality of my life. Participants described another type of relationship in the second category that focused on other persons and nature. This relationship differed from the relationship with God in that it was an acknowledgment of a connection or association with others, but the relationship itself was more even tempered, factual, and impersonal. The third category involved a spiritual journey, guide, or struggle. Participants described spirituality as an evolving process that often resulted in a struggle and/or journey: I have seen some very tough

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times in my life; it was my spirituality that got me through those times. Another participant shared, I have always been somewhat aware of my spirituality; I believed in God and prayed; but as I have gotten older, it has become so much more important. I ask myself, What have I been doing all my life? Look how I have wasted it. Yet another stated, It is how we relate to the unknown. How we formulate guiding principles in our life. Category 4 included the spiritual essence of self or that which gives meaning to life. It is striving for a deeper understanding of oneself and recognition of ones soul. It is what allows one to be humble and respectful of others, [to seek] self growth and time for self. The fifth category reported how participants expressed their spirituality through a range of activities such as reading, meditating, bird watching, and the most frequent action of praying. One participant remarked, I pray every day; sometimes I meditate by walking meditation. And another comment was I went to church and participated in contemplative prayer every day. The final category was named integral spirituality. Participants stated that spirituality was an integral part of their livesit was everything. One member said, Its a part of my daily life and later stated, I use spirituality both in daily life and in difficulty. In conclusion, the meaning of spirituality for this group of healthy adults included a strong sense of God and of self. Spirituality was a growth-oriented action process, powerful in its effect and presence. In conclusion, SPIRIT-6 had positive direct effects on perceived stress and spiritual perspective (awareness and interactions) in this convenience sample of community-dwelling adults. Spiritual well-being was moderately high at baseline and experienced slight changes during the intervention, but these changes were not significant. Although changes in spiritual well-being were not significant, the awareness and engagement in spirituality did increase. The correlations between perceived stress and spiritual well-being were significant at several time intervals, indicating the positive effect of the intervention. SPIRIT-6 intervention might serve as an effective stress management activity for healthy adults. The search for meaning that occurs as a part of spiritual development appears to influence stress-coping responses. One can hypothesize that if positive experiences such as SPIRIT-6 can help persons while healthy, there may be greater likelihood that these strategies may also benefit individuals during periods of illness or crisis.

Nursing Implications
The intervention proved effective in reducing stress in this healthy adult sample. The results of the study make it clear that spirituality has a significant influence on the health of individuals. The findings of the study support a holistic view of health promotion and maintenance while recognizing the impact of spirituality on healing approaches on persons with acute, chronic, or terminal illnesses. Implications of the findings will assist nurses in recognizing the spiritual needs and valuing the role of spirituality in promoting health and well-being among all persons. The activities included in the intervention are within the scope of nursing practice. Efforts to increase the awareness of spirituality and promote spiritual growth and well-being have potentially powerful implications for stress reduction and, therefore, are a significant factor for consideration for inclusion in nursing practice.

References
Ano, G. G., & Vasconcelles, E. B. (2004). Religious coping and psychological adjustment to stress: A meta-analysis. Journal of Clinical Psychology, 61(4), 461-480. Auerbach, S. M., & Gramling, S. E. (1998). Stress management: Psychological foundations. Upper Saddle River, NJ: Prentice Hall. Baldacchino, D., & Draper, P. (2001). Spiritual coping strategies: A review of the nursing research literature. Journal of Advanced Nursing, 34(6), 833-841. Benson, H. (1997). Timeless healing. New York: Simon & Schuster. Benzein, E., Norberg, A., & Saveman, B. I. (1998). Hope: Future imagined reality. The meaning of hope is described by a group of health pentecostilists. Journal of Advanced Nursing, 28(5), 1063-1070. Buford, R. K., Paloutzian, R. F., & Ellison, C. W. (1991). Norms for the Spiritual Well-Being Scale. Journal of Psychology and Theology, 19(1), 56-70. Carson, V. B., & Green, H. (1992). Spiritual well-being: A predictor of hardiness in patients with acquired immunodeficiency syndrome. Journal of Professional Nursing, 8(4), 209-220. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385-396. Dunn, K. S., & Horgas, A. L. (2000). The prevalence of prayer as a spiritual self-care modality in elders. Journal of Holistic Nursing, 18(2), 337-351. Friedman, I. A. (1991). High- and low-burnout schools: School culture aspects of teacher burnout. Journal of Educational Research, 84(6), 325-334. Goddard, N. C. (1995). Spirituality as integrative energy: A philosophical analysis as requisite precursor to holistic nursing practice. Journal of Advanced Nursing, 22(4), 808-815.

Downloaded from jhn.sagepub.com by jarupapha wasi on September 16, 2010

Tuck et al. / Spirituality in Healthy Adults

253

Graham, S., Furr, S., Flowers, C., & Burke, M. T. (2001). Religion and spirituality in coping with stress. Counseling and Values, 46, 2-13. Hebert, R. S., Jenckes, M. W., Ford, D. E., OConnor, D. R., & Cooper, L. A. (2001). Patient perspectives on spirituality and the patient-physician relationship. Journal of General Internal Medicine, 16(10), 685-692. Isaia, D., Parker, V., & Murrow, E. (1999). Spiritual well-being among older adults. Journal of Gerontological Nursing, 25, 15-21. Jackson, C. (2004). Healing ourselves, healing others: First in a series. Holistic Nursing Practice, 18(2), 67-81. Joseph, M. (1998). The effect of strong religious beliefs on coping with stress. Stress Medicine, 14, 219-224. Kim, Y., & Seidlitz, L. (2002). Spirituality moderates the effect of stress on emotional and physical adjustment. Personality and Individual Differences, 32, 1377-1390. Koenig, H. G. (2004). Religion, spirituality, and medicine: Research findings and implications for clinical practice. Southern Medical Journal, 97(12), 1194-1200. Koenig, H. G., Pargament, K., & Nielsen, J. (1998). Religious coping and health status in medically hospitalized older adults. Journal of Nervous and Mental Disease, 186, 513-521. Lazarus, R. S. (1996). The role of coping in the emotions and how coping changes over the life course. In C. Magai & S. H. McFadden (Eds.), Handbook of emotions, adult development, and aging (pp. 289-306). New York: Academic Press. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Levin, J. S. (1994). Religion and health: Is there an association, is it causal? Social Science in Medicine, 38, 1475-1482. Levin, J. S., & Taylor, R. J. (1997). Age differences in patterns and correlates of the frequency of prayer. The Gerontologist, 37(1), 75-88. Mackenzie, E. R., Rajagopal, D. E., Meilbohm, M., & LavizzoMourey, R. (2000). Spiritual support and psychological wellbeing: Older adults perceptions of religion and health connection. Alternative Therapies in Health and Medicine, 6(6), 37-45. Narayanasamy, A. (1999). ASSET: A model for actioning spirituality and spiritual care education and training in nursing. Nurse Education Today, 13, 274-285. Paloutzian, R. F., & Ellison, C. W. (1982). Loneliness, spiritual well-being and the quality of life. In L. A. Peplau & D. Perlman (Eds.), Loneliness: A sourcebook of current theory, research and therapy (pp. 224-237). New York: John Wiley. Pargament, K. I. (1997). The psychology of religion and coping: Theory, research, practice. New York: Guilford. Reed, P. G. (1987). Spirituality and well-being in terminally ill hospitalized adults. Research in Nursing and Health, 10(5), 335-344.

Reed, P. G. (1992). An emerging paradigm for the investigation of spirituality in nursing. Research in Nursing and Health, 15(5), 349-357. Rose, E. M., Westefeld, J. S., & Ansley, T. N. (2001). Spiritual issues in counseling: Clients beliefs and preferences. Journal of Counseling Psychology, 48(1), 61-71. Sherwood, G. D. (2000). The power of nurse-client encounters. Interpreting spiritual themes. Journal of Holistic Nursing, 18(2), 159-175. Tabachnick, B., & Fidell, L. (2001). Using multivariate statistics (4th ed.). Needham Heights, MA: Allyn & Bacon. Targ, E. F., & Levine, E. G. (2002). The efficacy of a mindbody-spirit group for women with breast cancer: A randomized controlled trial. General Hospital Psychiatry, 24(4), 238-248. Torosian, M. H., & Biddle, V. R. (2005). Spirituality and healing. Seminars in Oncology, 32(2), 232-236. Tuck, I. (2004). Development of a spirituality intervention to promote healing. Journal of Theory Construction & Testing, 8(2), 67-70. Tuck, I., McCain, N. L., & Elswick, R. K. (2001). Spirituality and psychosocial factors in persons living with HIV. Journal of Advanced Nursing, 33, 776-783. Walton, J., & Sullivan, N. (2004). Men of prayer: Spirituality of men with prostate cancer: A grounded theory study. Journal of Holistic Nursing, 22(2), 133-151. Inez Tuck, RN, PhD, is a professor and chair of the Department of Integrative Systems in the School of Nursing at Virginia Commonwealth University. Her research interests are in the areas of spirituality and healing in populations of persons living with chronic or terminal illnesses and experiencing devastating life events. She has conducted studies implementing a group spiritual intervention that she developed with persons living with HIV disease and with women newly diagnosed with breast cancer. She has published on the topics of spirituality, mental health, and parish nursing. Renee Alleyne, MS, is a doctoral candidate in psychology at Virginia Commonwealth University and has served as a research assistant implementing the spiritual group intervention with persons living with HIV disease and breast cancer. Her research is on the topic of cancer risk reduction in adolescence. Wantana Thinganjana, MS, RN, is a doctoral candidate in nursing at Virginia Commonwealth University and, on completion of her degree, she will return to her faculty position in Thailand. Her research focus area is spirituality and healing. In her research, she examines the relationship of spirituality and diabetes in adult Thai immigrants living in the United States.

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