Got spirit? The spiritual climate scale, psychometric properties, benchmarking data and future directions

Our brief, 4-item measure of spiritual climate in healthcare appears to be a reliable measure that shows significant variability by healthcare worker role, hospital, and clinical area. The phrase “in this clinical area” provides a clear spiritual climate referent for each item, so it is interesting to note that the small-to-modest effect size for the ANOVA by clinical area translate into moderate to large effect sizes when comparing clinical areas in the top and bottom quartiles of spiritual climate. Clinical areas high on spiritual climate had respondents that reported lower burnout, lower intentions to leave, and lower rates of disruptive behaviors. Respondents reporting positive spiritual climate varied most by clinical area, ranging from 14 to 100%, suggesting that the clinical area environment is largely responsible for determining spiritual climate. Practically speaking, this means that the appropriate level for intervention aimed at affecting spiritual climate may be at the clinical area. Higher scores on spiritual climate were associated with better teamwork and safety climates (and relatively large effect sizes as well). Perhaps the relationships to teamwork and safety are associated with the overall theme of “respect for my views,” found in each of the scales, suggesting convergent validity of our novel spiritual climate scale. In particular, the item “My spiritual views are respected in this clinical area,” is central to the internal consistency of the spiritual climate scale as the reliability would be significantly lower if deleted. The items “In this clinical area, it is difficult to speak up if I perceive a problem with patient care” and “My suggestions about safety would be acted upon if I expressed them to management” from the teamwork climate and safety climate scales, respectively, echo the theme of “respect for my views.” If managers and administrators are able to foster an environment where healthcare workers feel that their spiritual views, an intimate and often taboo topic, are respected and understood, it is easy to imagine that this environment would also enable open conversations about problems with patient care delivery and medical errors. Though we could not test for the effects of type of clinical area, there appeared to be an overrepresentation of emergency departments and pharmacies in the low spiritual climate range, while high spiritual climate scores were common among rehabilitation, home health, and pediatric units. Still there were exceptions to each of these patterns and this should not be over-interpreted.

Furthermore, the ability of this brief measure of spiritual climate to predict some of the variability in intention to leave is encouraging, and is consistent with previous studies [6, 7]. This may be good news for managers and directors working in healthcare, who are struggling to find new and better ways to improve engagement and meaning for their staff. Promoting a respectful spiritual climate may open new doors for them. The link between spiritual climate and participation in executive rounding (Fig. 3), which is a quality improvement initiative, suggests that spiritual climate is sensitive to intervention and that other interventions more targeted at spiritual climate may be effective [12]. Even more than frequency of participating in executive rounding, it was those respondents who reported receiving feedback about actions taken as a result of executive rounding that reported the highest spiritual climate. If receiving feedback about the progress of quality improvement initiatives is associated with stronger spiritual climate scores, then perhaps future interventions could target spiritual climate improvements and discussions (feedback) with healthcare workers. While specific interventions to augment spiritual climate in healthcare workers have not been reported in the literature to date, Grant et al. reported that nurses who attended meetings where spirituality was frequently discussed were much more cognizant of their colleagues’ desire to express and talk openly about spirituality [4]. Spiritual climate was related to teamwork climate in our study. However, unlike teamwork climate, where physicians report higher levels of satisfaction with collaboration norms than nurses, [13, 14] the spiritual climate results showed that managers and nurse managers were more positive than nurses, who in turn reported better spiritual climate than physicians. If the theme of feeling respected and deeply understood undergirds spiritual climate, then our results could be interpreted as managers feeling more understood than nurses, who feel more understood than physicians.

Our study has to be interpreted within the context of its design. We analyzed data from only one health system, which was faith-based, and located largely on the west coast of the U.S. It is unknown whether our findings are generalizable to other regions or to secular health care delivery settings. There is potential for spiritual climate to be useful in the large number of extant faith-based hospitals, but it is not clear how these results would be different in non-faith-based hospitals. Previous investigations in safety culture suggest that teamwork and safety climate mean scores are not significantly different in faith based settings relative to non-faith-based settings [15]. Given the moderate associations between spiritual climate and teamwork and safety climate reported here, this would suggest that spiritual climate scores in secular settings would be comparable to these faith-based settings. Also, we relied upon self-report data from healthcare workers, without any independently observable behaviors or outcomes. However, this is standard practice for culture assessments in health care. Moreover, due to the length and nature of the survey administration, our novel scale to assess spiritual climate was introduced without incorporating previously reported workplace spirituality scales to test for convergent validity. Nevertheless, the psychometric and exploratory results from this large sample are encouraging for a brief scale to be used in subsequent research. For a more comprehensive exploration of spirituality as a scientific construct, please see MacDonald et al. [16]. Despite the abundance of research which has been done to improve our ability to assess and address the spiritual needs of our patients, [17–20] little work has been done to define and intervene on the spiritual needs of healthcare workers. Future research should explore how spiritual climate relates to personal well-being, depression, and burnout and test the responsiveness of spiritual climate to interventions designed to improve it. Our tired, busy, and often overwhelmed healthcare workforce deserves to feel “understood” during their working hours.