Introduction
Spirituality is one of the fundamental factors affecting the physical and psychological health of a human being (Hvidt and Hvidt, Reference Hvidt, Hvidt, Lucchetti, Prieto Peres and Damiano Translates2019). It is a source of strength and hope for individuals and improves wellbeing (Batstone et al., Reference Batstone, Bailey and Hallett2020). Spiritual health reduces an individual's anxiety, stress, and depression, while enhancing positive health behaviors (Snider and McPhedran, Reference Snider and McPhedran2014).
The concept of spirituality is generally accepted as synonymous with the belief and cultural systems that connect human beings with spirituality and represent the whole of their world views in the context of the concept of religion. The concepts of spirituality and religion have differences between them, however. Religion is an organized system of beliefs and worship that provides the individual with the opportunity to derive meaning and value from life (Sadat Hoseini et al., Reference Sadat Hoseini, Razaghi and Khosro Panah2019; Batstone et al., Reference Batstone, Bailey and Hallett2020). Spirituality, on the other hand, is a more expansive concept that goes beyond the faith of an individual. Besides the search of an individual for a connection to a divine spirit, spirituality encompasses elements that delineate the purpose of life (Jaberi et al., Reference Jaberi, Momennasab and Yektatalab2019; Sadat Hoseini et al., Reference Sadat Hoseini, Razaghi and Khosro Panah2019).
Although “spirituality” and “spiritual health” are used in similar contexts, there are differences between the two terms. For example, faith, connectedness, transcendence, the search for meaning and purpose, and a unifying and integrating force are to be found in both concepts, but seeking balance between the aspects of a person's health is directly concerned with the concept of spiritual health (Jaberi et al., Reference Jaberi, Momennasab and Yektatalab2019). Individuals that enjoy spiritual health are healthy in the physical, emotional, and social sense. Study results have shown that individuals who enjoy spiritual health have a high level of self-esteem and wellbeing. They are better able to cope with stress and have a high level of quality of life. Consequently, such individuals are in the habit of leading a healthy lifestyle, eating healthily, and adopting a planned and scheduled life (Yonker et al., Reference Yonker, Schnabelrauch and DeHaan2012). It is reported that people who are spiritually healthy are better able to help those around them by providing care and spiritual support (Chiang et al., Reference Chiang, Lee and Chu2016).
Nurses make up one of the largest professional groups that care for individuals and provide spiritual support (ICN, 2012). Since nurses provide long-term patient care, the likelihood of their treating and caring for a patient with a spiritual need is high (Chiang et al., Reference Chiang, Lee and Chu2016; Atarhim et al., Reference Atarhim, Lee and Copnell2019). Spiritual care is defined as the nursing initiatives taken to meet the spiritual needs of patients (Timmins and Caldeira, Reference Timmins and Caldeira2017; Hvidt and Hvidt, Reference Hvidt, Hvidt, Lucchetti, Prieto Peres and Damiano Translates2019). Ensuring patients’ spiritual care is one of the fundamental professional roles of a nurse. Spiritual interventions provided to patients by nurses can be categorized in various ways. For example, these interventions can include providing patients with religious materials, supporting them in their moral/religious activities (such as prayer), referring patients to spiritual counselors or helping them contact persons that the patient values or holds in esteem. At the same time, nurses can help patients by listening, validating, respecting, giving hope, or assisting them to determine the meaning of their lives (Timmins and Caldeira, Reference Timmins and Caldeira2017; Hvidt and Hvidt, Reference Hvidt, Hvidt, Lucchetti, Prieto Peres and Damiano Translates2019; Batstone et al., Reference Batstone, Bailey and Hallett2020).
Nurses with greater levels of spiritual health have a more positive attitude toward spiritual care, nursing care, and professional commitment. In addition, nurses and nursing students who have better spiritual health may be more sensitive to patients’ spiritual problems and/or needs because they understand the meaning of spirituality and may be able to relate to the specific spiritual problems with which their patients are dealing (Chiang et al., Reference Chiang, Lee and Chu2016, Reference Chiang, Lee and Chu2020a; Atashzadeh-Shoorideh et al., Reference Atashzadeh-Shoorideh, Abdoljabbar and Karamkhani2017; Yari et al., Reference Yari, Siyasari and Shirani2018; Hu et al., Reference Hu, Jiao and Li2019). Identifying the spiritual health levels of nurses and nursing students is therefore important.
Turkey is a secular country where diverse ethnic groups subscribing to various religions live. However, Islam is the predominant religion in Turkish society. As in many societies, spirituality is associated with religion in Turkey (Aksoy and Coban, Reference Aksoy and Coban2017). The increase in migrations in recent years has produced the result that nurses must care for individuals of many different religious and ethnic backgrounds. Nurses may find it difficult to answer the spiritual needs of their patients when their religious beliefs differ from their own (Chiang et al., Reference Chiang, Lee and Chu2016). In previous studies conducted in Turkey, it was found that nurses did not have adequate awareness of the matter of spirituality and largely ignored their patients’ spiritual needs (Khorshid and Arslan, Reference Khorshid and Arslan2006; Yılmaz and Okyay, Reference Yılmaz and Okyay2009; Kavak et al., Reference Kavak, Mankan and Polat2014). Moreover, it has been seen that the studies carried out with nursing students in Turkey have only dealt with students’ spiritual perceptions (Daghan, Reference Daghan2018; Kalkim et al., Reference Kalkim, Midilli and Daghan2018; Karadağ, Reference Karadağ2020; Aslan and Unsal, Reference Aslan and Unsal2021; Dalcali and Melikoğlu, Reference Dalcali and Melikoğlu2021; Karaman et al., Reference Karaman, Kasar and Yıldırım2021). In our scan of the research, we did not come across any study that evaluated the status of spiritual health among nursing students in Turkey. Identifying levels of spiritual health is an essential step in planning interventions that will raise the level of spiritual health of Turkey's nurses and nursing students.
The measures related to spirituality in the Turkish literature have generally been developed to evaluate the behaviors of nurses/nursing students in the context of providing spiritual care (Ergül and Bayık, Reference Ergül and Bayık2007; Daghan et al., Reference Daghan, Kalkim and Midilli2019). However, there is no valid and reliable instrument that assesses the spiritual health of nurses/nursing students in Turkey, and therefore, it is important to develop a valid and reliable instrument to measure spiritual health and assess the status of spiritual health of a nurse or nursing student.
A look into the literature shows that many of the instruments that evaluate spiritual health do not provide a comprehensive assessment because most are based on an evaluation of patients with a particular chronic disease, or because they are not specific to nurses and are founded on religious concepts (Ellison, Reference Ellison1983; Hungelmann et al., Reference Hungelmann, Kenkel-Rossi and Klassen1996; Peterman et al., Reference Peterman, Fitchett and Brady2002). The Spiritual Health Scale-Short Form (SHS-SF) developed by Hsiao et al. (Reference Hsiao, Chiang and Lee2013) is a clearly comprehensible measuring tool that measures and assesses the spiritual health of nursing students. Additionally, the SHS-SF addresses all dimensions of spiritual health (connection to others, meaning derived from living, transcendence, religious attachment, and self-understanding) (Hsiao et al., Reference Hsiao, Chiang and Lee2013). With its inclusion of all dimensions of spiritual health, the scale is capable of making a more complete evaluation of the spiritual health of nurses and nursing students. At the same time, it has been reported that the SHS-SF is a simply phrased instrument that students can easily implement (Hsiao et al., Reference Hsiao, Chiang and Lee2013). Besides being a predominantly Muslim country, Turkey's geographical position lends itself to a familiarity with both European and Asian cultures. Consequently, it was our belief that the SHS-SF developed by Hsiao et al. (Reference Hsiao, Chiang and Lee2013) in Taiwan would be easily comprehensible and conducive to implementation in Turkey. It was for this reason that our aim in this research was to study the validity and reliability of the Turkish version of the SHS-SF in assessing the spiritual health of nurses and nursing students.
Method
Study design, setting, and sample
The study is of methodological design. The study was carried out in a Faculty of Health Sciences in western Turkey. This school provides a 4-year undergraduate program in nursing education. The school where the study was conducted was chosen using the convenience sampling method because the nursing students were easily accessible to the researchers. The population of the study was composed of 2nd, 3rd, and 4th-year Turkish nursing students (N = 520). In determining the inclusion criteria, students without religious beliefs were excluded due to the “religious attachment” sub-dimension of the SHS-SF. First-year nursing students were also excluded because they had not yet taken basic nursing and clinical practice courses. Foreign students were additionally excluded from the study because its aim was to adapt SHS-SF to the Turkish language and culture. The inclusion criteria were (a) speaking Turkish, (b) having clinical experience, and (c) willingness to participate in the study. The exclusion criteria were (a) being a foreign national nursing student and (b) not having a religious attachment.
Validity and reliability studies have indicated that participants that numbered 5 to 10 times the number of items should serve as a sufficient sample size (Grove et al., Reference Grove, Burns and Gray2013; Wolf et al., Reference Wolf, Harrington and Clark2013). These criteria were met by the number of participants enrolled in the study (n = 310), as this sample size was greater than 10 times the 24 items in a scale. The response rate of the study was 59.61%.
The approach used to obtain data from the participants
The study data were collected in January and February 2020. The data for the research were collected in the classroom setting. The questionnaire was distributed by the researchers, who explained the method to be used in administering the questionnaire. All the participants provided informed consent. It was ensured that the researchers were in the classroom with the students to clarify questions they did not understand. All the forms were submitted to the researchers after being filled by self-reporting. The collection of data took place under observation and lasted approximately 20 min; necessary explanations were made to the students who had problems at this stage.
Instruments
The sociodemographic questionnaire and the SHS-SF were used as data collection instruments. The questions regarded the participants’ age, gender, duration of clinical experience (hospital-based internship to learn the knowledge and skills required by the nursing profession), the status of living with family, and engaging in religious activities.
The SHS-SF was developed by Hsiao et al. (Reference Hsiao, Chiang and Lee2013) and is used to measure the spiritual health of nursing students. The scale is composed of 24 items and 5 subscales. The subscales are connection to others (items 1–4), meaning derived from living (items 5–10), transcendence (items 11–16), religious attachment (items 17–20), and self-understanding (items 21–24). Individuals were asked to answer an item by selecting from a range of “completely disagree (1)” to “completely agree (5)” on a Likert-type scale. All items in the scale are positive; that is, as the score of each item in the scale increases, the spiritual health status of the students increases. The scores on the SHS-SF range from 24 to 120, with higher scores indicating better spiritual health. The alpha coefficient reliability value of the scale was 0.93 (range = 0.88–0.93) (Hsiao et al., Reference Hsiao, Chiang and Lee2013).
Research procedure
Linguistic validity
Translation and back-translation were used to achieve linguistic validity of the scale (Esin, Reference Esin, Erdoğan, Nahcivan and Esin2015). The SHS-SF was translated from English into Turkish separately by two independent individuals who were English-language experts, and a Turkish nursing academic. These two translations were incorporated in a single document by three nursing academicians with English-language expertise. After that, the Turkish version was translated back into English by one of the English language linguists who had not seen the original scale and had a background in both English and Turkish language and culture. Since the Turkish version of the SHS-SF was obtained when it was found that the back-translated version and the Turkish version were similar.
Content validity
The content validity of the Turkish version of the SHS-SF was verified by 10 nursing academicians. The experts were consulted for their opinions after the language adaptation for assessing the scale's content validity. The experts were specialized faculty members in the departments of psychiatric nursing (three academics), public health nursing (three academics), pediatric nursing (two academics), and surgical nursing (two academicians). The Davis technique was used to evaluate the opinions obtained with the CVI. In this technique, the experts were asked to assess each item for clarity on a scale. As per the Davis technique, the experts reported each item as “inappropriate (1),” “requires critical revision (2),” “should be reviewed (3),” or “appropriate (4).” The items scoring lower than 3 points in the SHS-SF were modified in line with the expert opinions, and various additions and omissions were made to ensure coherence. In accordance with the expert opinions, CVI = 0.96 was calculated. Changes were made in the statements based on the recommendations, and the scale was given its final form. The concepts “Buddha, or Bodhisattva” in the 17th and 20th items in the Religious Attachment subscale were removed because these terms are not a part of Turkish culture and religion. The words “Allah, and heavenly God” were used instead of these concepts.
Pilot study
A pilot study was carried out to test the clarity of content, ease of understanding, time required for responses, and potential problems. The Turkish version of the translated SHS-SF was piloted on 20 nursing students meeting the inclusion and exclusion criteria. Feedbacks from the students showed that the items of the scale were easy to understand and respond to. The students participating in the pilot study were not included in the analysis of this study.
Ethical considerations
Before starting the research, permission was obtained via e-mail from the lead author and co-author of the scale, Ya-Chu Hsiao, for the testing of the Turkish validity and reliability of SHS-SF. Ethical approval was obtained from the University Non-Invasive Clinical Research Ethics Committee (Approval date: 26/12/2019; Ethics approval number: 60116787-020/1719). The researchers applied for permission to perform the study and provided information to the Faculty of Health Sciences regarding the study purpose, procedures, methods, and questionnaire content. The students were clearly informed of the research. All procedures were performed in accordance with the Declaration of Helsinki.
Data analysis
The data were analyzed using IBM SPSS Statistics (Chicago, IL, USA) Version 22.0 and AMOS 26.0 (IBM Inc., Armonk, NY, USA). Questionnaires with missing data (n = 6) were excluded from the analysis, so that 310 questionnaires were analyzed. The participants’ demographic characteristics were evaluated using descriptive statistics. Skewness and Kurtosis were utilized to determine whether SHS-SF was normally distributed. Because the data had a normal distribution (skewness: −0.69, kurtosis: 1.24), statistical analyses were performed by factor analysis (Pituch and Stevens, Reference Pituch, Stevens, Pituch and Stevens2016).
The Content Validity Index (CVI) (>0.80) was calculated to assess the content validity of the instrument. Construct validity of the instrument was ensured through Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA). In the EFA, the results of the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy (>0.50) and Bartlett's sphericity test (p < 0.05), eigenvalue line graph (≥1.0), and the “varimax” rotation technique were examined (Büyüköztürk, Reference Büyüköztürk2014; Esin, Reference Esin, Erdoğan, Nahcivan and Esin2015; Field, Reference Field2018). The lower cut-off point for the factor loading value was stated as 0.30 (Tabachnick and Fidell, Reference Tabachnick and Fidell2013; Esin, Reference Esin, Erdoğan, Nahcivan and Esin2015). Explained total variance (>50%) was used for determining the factor structures (Grove and Cipher, Reference Grove and Cipher2017).
In the CFA, statistical methods including the chi-square test (χ 2), degree of freedom (df), the ratio of df to χ 2 (χ2/df), root mean square error of approximation (RMSEA < 0.08), standardized root mean square residual (SRMR ≤ 0.08), Tucker–Lewis index (TLI ≥ 0.90), comparative fit index (CFI ≥ 0.90), and the incremental fit index (IFI ≥ 0.90) were used to analyze and evaluate the accuracy of the model (Teo, Reference Teo2013; Brown, Reference Brown2015).
In determining the reliability levels of the instrument, item-total correlation (>0.20) was used for internal consistency reliability and Cronbach's α (>0.60), reliability coefficient was used to calculate homogeneity (Everitt and Skrondal, Reference Everitt and Skrondal2010).
Results
Participant characteristics
The mean age of the study participants was 21.23 ± 1.32 years. The mean durations of the clinical experience of the participants were 2.18 ± 0.79 years. Of the participants, 83.9% were female, 95.5% were engaging in religious activities, and 60.0% were living with the family (Table 1).
Table 1. Demographic characteristics of the participants (n = 310)
SD, Standard Deviation.
Validity analysis
Construct validity
The EFA and CFA were used to analyze the construct validity of the SHS-SF. The KMO value and Bartlett's sphericity test were used for sampling adequacy before the factor analyses. According to the EFA for construct validity, the KMO value was 0.88, which was shown to be significant at an advanced level on Bartlett's sphericity test (χ 2 = 4325.52, p = 0.000). In the five-factor model of the SHS-SF based on the EFA, factor loadings ranged from 0.38 to 0.91, and the total variance was 66.49% (Table 2).
Table 2. Rotated factor loadings of the SHS-SF
CFA was used to evaluate how the factor structure of the Turkish form fit the original scale. According to the CFA performed for the construct validity of a five-factor model, the factor loadings for the 24-item scale ranged from 0.40 to 0.91 (Figure 1). Goodness-of-fit indices were used to investigate model fitness. The most widely accepted global fit indices are the chi-square, chi-square value/df, RMSEA, CFI, TLI, IFI, and RMR (Esin, Reference Esin, Erdoğan, Nahcivan and Esin2015; Teo, Reference Teo2013; Brown, Reference Brown2015). Based on the result of the CFA, goodness-of-fit indices of the scale were found as follows: chi-square value = 576.19 (df = 241, p = 0.000), chi-square value/df = 2.39, RMSEA = 0.06, CFI = 0.92, TLI = 0.91, IFI = 0.92, and SRMR = 0.061 (Table 3).
Fig. 1. Confirmatory factor analysis of the SHS-SF.
Table 3. Goodness-of-fit indices of the SHS-SF
Abbreviations: RMSEA, root mean square error of approximation; CFI, comparative fit index; TLI, Tucker–Lewis index; IFI, incremental fit index; RMR, root mean square residual.
Reliability analysis
Internal consistency reliability and Cronbach's alpha reliability coefficient
Item analysis was performed on the SHS-SF, and the results are presented in Table 4. The item-total correlation coefficients for the scale items ranged from 0.37 to 0.65. Cronbach's α value derived from the internal consistency analyses of the total scale was 0.91. The total scale had a high internal consistency, with alpha coefficient values for the five subscales ranging from 0.77 to 0.92 (Table 5).
Table 4. Item-total correlations of SHS-SF
Table 5. Cronbach's alpha for subscales and total scale
Discussion
The spiritual health of nurses is important for providing spiritual care to patients (Atashzadeh-Shoorideh et al., Reference Atashzadeh-Shoorideh, Abdoljabbar and Karamkhani2017; Yari et al., Reference Yari, Siyasari and Shirani2018; Hu et al., Reference Hu, Jiao and Li2019). Nurses and nursing students who have better spiritual health may be more sensitive to patients’ spiritual problems and/or needs (Chiang et al., Reference Chiang, Lee and Chu2016, Reference Chiang, Hsiang-Chun and Tsung-Lan2020b; Atashzadeh-Shoorideh et al., Reference Atashzadeh-Shoorideh, Abdoljabbar and Karamkhani2017; Yari et al., Reference Yari, Siyasari and Shirani2018; Hu et al., Reference Hu, Jiao and Li2019). It is important in this context to have a valid and reliable instrument with which to measure spiritual health and to be able to assess the status of the spiritual health of a nurse or nursing student. Previous studies have shown that the SHS-SF is an appropriate instrument to use in measuring the spiritual health of nurses and nursing students (Chiang et al., Reference Chiang, Lee and Chu2016, Reference Chiang, Lee and Chu2020a, Reference Chiang, Hsiang-Chun and Tsung-Lan2020b; Wang et al., Reference Wang, Wang and Wang2021). In this study, our findings for the scale, which we believed to be appropriate for the Turkish culture, confirmed the validity and reliability of the Turkish version.
In line with the experts’ opinions, various revisions were made in some of the statements to achieve content validity in the Turkish version of the SHS-SF. The concepts “Buddha, or Bodhisattva” in the 17th and 20th items of the Religious Attachment subscale were removed because they do not pertain to Turkish culture and religion. Turkey is a secular country with diverse ethnic groups from various religions. Islam is, however, the widespread religion in Turkish society (Aksoy and Coban, Reference Aksoy and Coban2017). The words “Allah, and heavenly God” were used in place of the mentioned concepts. The instrument's CVI was evaluated in line with the experts’ opinions. In the literature, the CVI value is recommended to be higher than 0.80 (Grove et al., Reference Grove, Burns and Gray2013; Field, Reference Field2018). In the present study, the CVI value was higher than 0.80, which suggests that the items in the scale sufficiently represent the characteristic to be measured in terms of quantity and quality (Büyüköztürk, Reference Büyüköztürk2014). These results indicate that the Turkish SHS-SF details all the concepts related to spiritual health and that the instrument is compatible with the Turkish language and culture.
The construct validity of the scale factors was evaluated with EFA and CFA. The EFA was used to explore the relationship between variables and the CFA to examine the factor structure of the scale (Esin, Reference Esin, Erdoğan, Nahcivan and Esin2015). The KMO analysis was used to determine the sampling adequacy for factor analysis. Sample size is not acceptable when the KMO value is below 0.50 (Büyüköztürk, Reference Büyüköztürk2014; Esin, Reference Esin, Erdoğan, Nahcivan and Esin2015; Field, Reference Field2018). In the present study, the KMO value was 0.88 and the Bartlett's test of significance value was p < 0.001, which showed that the sample size was adequate, and the data set was suitable for the factor analysis (Büyüköztürk, Reference Büyüköztürk2014; Esin, Reference Esin, Erdoğan, Nahcivan and Esin2015; Field, Reference Field2018).
The EFA was used to assess whether the scale items were clustered into distinct subcategories or remained equally independent. The eigenvalue achieved by the EFA is calculated by the sum of the squares of factor loadings, and the eigenvalues are utilized to calculate the factors. In general, it is appropriate to interpret the number of factors with an eigenvalue of 1 or higher (Esin, Reference Esin, Erdoğan, Nahcivan and Esin2015; Field, Reference Field2018). This analysis provided an eigenvalue of 15.94 for the five-factor construct in question. As in the original instrument, the Turkish version revealed a five-factor construct and the scale items were distributed into the same factors as in the original. This indicated that all the scale items were related to spiritual health in the Turkish language and culture. This finding is important in that it shows that religious and cultural differences did not distort the meaningfulness of the statements.
Factor load value is a coefficient that explains the relationship between the items and the factors. According to the EFA, factor loadings of the five-factor scale ranged from 0.38 to 0.91. In the literature, the lower cut-off point for the factor loading value was set at 0.30 (Tabachnick and Fidell, Reference Tabachnick and Fidell2013; Esin, Reference Esin, Erdoğan, Nahcivan and Esin2015) and the items in the scale remained as in the original scale. Factor loadings of the original scale ranged from 0.60 to 0.89 (Hsiao et al., Reference Hsiao, Chiang and Lee2013). Factor loadings obtained in our study were similar to the data of the original scale, and additionally, they were above the recommended reference values. Since factor loadings were higher than cut-off points, no statement was removed from the scale, meaning that all the new items were found to be appropriate for measuring spiritual health levels in the Turkish language and culture. The items with the highest factor loadings were found to be in the Religious attachment subscale. The reason for this may have been due to the close association of spirituality with religion in Turkey. Aksoy and Coban (Reference Aksoy and Coban2017) have, in fact, reported that spirituality is related to the concept of spirituality in Turkey (Aksoy and Coban, Reference Aksoy and Coban2017). Religion plays an important role in the lives of much of the population.
In our study, the five-factor construct explained 66.49% of the total variance. As the percentage of variance increases (it should be 50% or above), the factor structure of the scale is strengthened in the literature. According to studies in social sciences, a percentage of variance of between 40% and 60% is considered sufficient (Grove and Cipher, Reference Grove and Cipher2017). The variance in this study, therefore, showed a strong factor construct on the scale. In terms of spiritual health concepts, the Turkish instrument is equivalent to the instrument used for the Taiwanese language and culture. Moreover, the subscale with the highest explained variance was connection to others, which might be interpreted to represent the importance given to family and family relations in the Turkish population (Aydın et al., Reference Aydın, Kahraman and Hiçdurmaz2017). Family relations constitute one of the significant factors that influence spiritual health (Hanssen et al., Reference Hanssen and Pedersen2013). The students in our study scored highest in the statement, “I feel that a harmonious relationship with family is very important.” This and the fact that 60% of the students lived with their parents supports this finding.
CFA was used to evaluate whether the factor structure of the Turkish form fit the original scale. The classical goodness-of-fit model index is chi-square (χ 2). The fit value, which was determined by dividing chi-square coefficient by df, was found to be 2.39, reflecting a good fit. The most widely accepted global fit indices are RMSEA, CFI, TLI, IFI, and SRMR (Teo, Reference Teo2013; Brown, Reference Brown2015). If the RMSEA value is less than 0.08, this represents an acceptable fit; if it is less than 0.05, it represents a good fit (Browne and Cudeck, Reference Browne, Cudeck, Bollen and Long1992). In the original instrument, RMSEA was 0.065 and SRMR was 0.045’tir (Hsiao et al., Reference Hsiao, Chiang and Lee2013). The EFA resulted in an RMSEA value of 0.067, which is indicative of acceptable fit. It has been suggested that an SRMR value that is equal to or smaller than 0.08 indicates good fit. The SRMR value was 0.061, which is indicative of acceptable fit (Brown, Reference Brown2015). The CFI, IFI, and TLI values of 0.90 or higher correspond to a good fit (Teo, Reference Teo2013). The CFI on the original instrument was 0.93 (Hsiao et al., Reference Hsiao, Chiang and Lee2013). Accordingly, the CFI, IFI, and TLI values obtained in our study were >0.90, confirming goodness of fit. According to the goodness-of-fit indices obtained in this current study, the structure of the factors was confirmed, and the model was determined to have a good fit (Brown, Reference Brown2015). All the factors in the Turkish version conform to the factors in the original instrument, showing that the scale is applicable to the Turkish population. We consequently found in the present study that the five-factor model of the SHS-SF is appropriately applicable to the Turkish population.
The corrected item-total correlation coefficients indicate the correlation of an item with the total scale when that item is omitted. In this study, the corrected item-total score correlation ranged from 0.37 to 0.65. In item-total correlation, items below 0.20 should be excluded from the scale and not included in the total scoring (Everitt and Skrondal, Reference Everitt and Skrondal2010). Based on the literature data, we can state that item-total correlation coefficients of all items were at a good level in our study.
Our study, which sought to describe the development and validation of the original scale, showed that the total scale had a high internal consistency (α = 0.93), with alpha coefficients for the five subscales ranging from 0.88 to 0.93 (Hsiao et al., Reference Hsiao, Chiang and Lee2013). The total Cronbach alpha coefficient of the Turkish version of the SHS-SF was found to be 0.91. The Cronbach alpha coefficient values for all the subscales ranged from 0.77 to 0.92. Cronbach alpha values in our study were found to be similar to the Cronbach alpha values of the original scale. These results indicate a high level of reliability for the Turkish version of the SHS-SF. The literature points to values of 0.80–1.00 as high-level reliability (Grove and Cipher, Reference Grove and Cipher2017). At the same time, similar to the original instrument, the subscales Religious attachment, Transcendence, and Meaning derived from living displayed higher reliability. The similarity between the high levels of reliability in these subscales in the Taiwanese and Turkish cultures suggests that the concepts defining spiritual health are similar in both populations. These results point to the high reliability of the Turkish version of the SHS-SF (Grove and Cipher, Reference Grove and Cipher2017).
Limitations
There are certain limitations to this study. The participants’ years of clinical experience represent a short duration as the study was applied to nursing students. This may have resulted in higher levels of spiritual health among the participants. One of the factors on the scale is religion. Because of this, students with no religious beliefs were not included in the research since they could not respond to this factor.
Conclusion
This study confirmed the reliability, content, and construct validity of the scale in this sample of Turkish nursing students. The Turkish version of the SHS-SF was found to be appropriate for use in the Turkish language and culture. The scale can be used for evaluating spiritual health levels among Turkish nurses and nursing students. It is important to identify the level of spiritual health of nursing students with a valid and reliable instrument. This will provide an opportunity for planning appropriate interventions to improve the spiritual health level of nurses and nursing students. It is known that nurses and nursing students with higher levels of spiritual health can better identify the spiritual needs of their patients. This instrument can also be used as a reference in later studies to be conducted on spirituality in Turkey. We recommend the use of the SHS-SF for future studies that may be conducted to evaluate spiritual health status among Turkish nurses and nursing students.
Acknowledgments
This study was presented as an oral presentation (abstract) at the 2nd International 3rd National Public Health Nursing Congress between 7 and 9 January 2021.
Author contributions
Study conception and design: EK and AK designed the study. Data collection: EK. Data analysis and interpretation: EK, GKA, and AK. Drafting of the article: EK, AK, and GKA. Critical revision of the article: EK, AK, and GKA. All listed authors meet the authorship criteria, and all authors agree with the content of the manuscript.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Conflicts of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval
Ethics committee approval (Ethics approval number: 60116787-020/1719) for the study was received from the University Non-Invasive Clinical Research Ethics Committee.
