Hospitalized Patients’ Spiritual Needs Questionnaire

Abstract

The Hospitalized Patients’ Spiritual Needs Questionnaire (HPSNQ) is an advanced, multidimensional psychometric instrument developed to evaluate the comprehensive spiritual requirements of adult patients admitted to general medical-surgical hospital units. Developed by Fahimeh Alsadat Hosseini and colleagues at Shiraz University of Medical Sciences in collaboration with the University of Barcelona, the HPSNQ addresses a critical paradigm gap in clinical health psychology and nursing science. While historical instruments measuring spiritual distress predominantly focused on palliative care, terminal oncology, and geriatric populations, the HPSNQ was intentionally engineered for conscious, non-terminal, acute medical-surgical patients experiencing non-severe clinical conditions. Grounded in a rigorous mixed-methods developmental protocol that merged empirical qualitative content analysis with modern psychometric modeling, the instrument contains 43 items operationalized across four correlated latent dimensions: Relationship with God, Interpersonal Connectedness, Peaceful Environment, and Transcendence.

Psychometric evaluation of the HPSNQ integrated both Classical Test Theory (CTT) and polytomous Item Response Theory (IRT) via Samejima’s Graded Response Model (GRM). The scale exhibits exceptional internal consistency, with dimension-specific and overall Cronbach’s alpha ($lpha$) coefficients ranging from .83 to .95. Temporal stability established via test-retest procedures yielded intraclass correlation coefficients (ICC) between .89 and .96. Confirmatory factor analysis verified the structural integrity of the four-factor framework with robust model fit indices. By systematically operationalizing the existential, relational, environmental, and theological demands of hospitalized individuals, the HPSNQ equips clinicians, consultation-liaison psychiatric teams, and health researchers with a culturally attuned, mathematically sound assessment system to facilitate personalized spiritual interventions and holistic healing within general clinical environments.

Keywords

Spiritual needs, Hospitalized Patients’ Spiritual Needs Questionnaire, Psychometrics, Item Response Theory, Nursing assessment, Medical-surgical inpatients, Holistic care, Samejima’s Graded Response Model, Transcendence, Existential health

Authors

The development and empirical validation of the Hospitalized Patients’ Spiritual Needs Questionnaire was executed through an international collaboration between nursing scientists, health methodologists, and psychometricians:

• Fahimeh Alsadat Hosseini — Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.
• Marzieh Momennasab (Corresponding Author: [email protected]) — Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.
• Joan Guàrdia-Olmos — Department of Methodology of Behavioral Sciences, Faculty of Psychology, University of Barcelona, Barcelona, Spain.
• Shahrzad Yektatalab — Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.
• Maryam Shaygan — Community Based Psychiatric Care Research Center, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.
• Armin Zareiyan — Public Health Department, Health in Disaster & Emergencies Department, Nursing Faculty, Aja University of Medical Sciences, Tehran, Iran.

Purpose

The primary purpose of the Hospitalized Patients’ Spiritual Needs Questionnaire (HPSNQ) is to systematically identify, quantify, and map the unmet spiritual, existential, and relational demands of hospitalized adult patients receiving care within acute medical-surgical environments. Modern clinical settings frequently operate under a highly technocratic biomedical paradigm that privileges physical biometrics and acute pharmacotherapy while inadvertently marginalizing the psychosocial and spiritual dimensions of human illness. Although clinical literature has long recognized that health crises precipitate profound existential questioning, despair, and altered life perspectives, measuring these internal states has presented substantial methodological barriers.

Overcoming Historical Population Biases

Prior to the establishment of the HPSNQ, the landscape of spiritual assessment was substantially skewed toward specialized cohorts, notably end-of-life care, hospice settings, metastatic oncology, and geriatric populations. Scales such as the Spiritual Needs Inventory or the Spiritual Needs Assessment for Patients (SNAP) were formulated within contexts where mortality is immediate and acute decline is anticipated. Consequently, their item content often reflects end-of-life reconciliation, imminent death anxieties, and legacy construction.

However, millions of individuals are admitted annually to hospital wards for non-terminal conditions—such as elective orthopedic surgeries, gastrointestinal disorders, acute infectious episodes, or moderate cardiovascular events. Although these patients do not face imminent death, the disruption of their daily routines, separation from family units, physical dependency, loss of bodily autonomy, and immersion in an alien hospital environment evoke acute existential vulnerability. The HPSNQ was engineered precisely to bridge this gap, offering an assessment tool tailored to non-severe, conscious medical-surgical patients aged 18 to 60 years.

Clinical and Research Applications

In clinical practice, the HPSNQ functions as a multi-tier diagnostic and triage instrument for nursing staff, hospital chaplains, medical social workers, and clinical psychologists. By pinpointing exact deficiencies—such as an inability to achieve inner quietude due to ward noise, alienation from loved ones, or unresolved theological questions—clinicians can construct tailored, non-pharmacological care plans. In research methodology, the scale offers an empirically sound, psychometrically stable metric to assess the efficacy of clinical pastoral education, hospital environmental redesigns, relaxation protocols, and targeted existential-humanistic nursing interventions on patient recovery trajectories, treatment adherence, and post-discharge psychological adjustment.

Psychological Construct

The theoretical construct operationalized by the HPSNQ conceptualizes spiritual needs not as a single global trait, but as a complex, dynamic, multidimensional latent architecture. In times of health vulnerability, human spiritual homeostasis is maintained through the interplay of four primary pillars:

1. Relationship with God

This vertical dimension assesses the patient’s internal requirement for theological alignment, prayer, divine communion, and emotional attachment to a higher power or supreme transcendent entity. Hospitalization frequently triggers theological crisis—questions of divine abandonment, existential guilt, or interpretations of disease as a spiritual trial or divine retribution. The items within this subscale capture the individual’s need for private communion, supplication, participation in religious rituals suited to their physical condition, access to holy scriptures, and reassurance of divine mercy and love. Rather than merely assessing outward religious affiliation, this construct taps into the functional, coping-oriented utility of divine connection during physical illness.

2. Interpersonal Connectedness

The horizontal dimension reflects the psychological imperative for belonging, relational validation, reciprocal empathy, and communion with other human beings. Grounded in the universal human need for social attachment, this construct evaluates the patient’s demand for genuine communication and emotional presence from family members, peer networks, and healthcare personnel. It encompasses desires for authentic human recognition—being perceived as an individual human person with a unique biography rather than a clinical disease entity or room number. Furthermore, it incorporates needs for forgiveness, resolving relational ruptures, experiencing affectionate physical contact, and receiving compassionate, dignified communication from treating clinicians and nurses.

3. Peaceful Environment

The physical-environmental dimension recognizes that the internal psychological state is inextricably tied to external atmospheric conditions. General hospital wards are characterized by continuous mechanical alarms, artificial fluorescent lighting, interpersonal intrusion, ambient odors, and structural rigidity, all of which provoke chronic sensory overload and existential fatigue. This construct operationalizes the patient’s need for sensory tranquility, privacy, spaces dedicated to reflection, acoustic respite, exposure to natural elements (such as natural light, views of nature, or outdoor ventilation), and an overall hospital milieu characterized by dignity, safety, and psychological sanctuary.

4. Transcendence

The existential-cognitive dimension evaluates the human striving to integrate the disruptive event of illness into a coherent narrative of meaning, purpose, and personal growth. Drawing heavily on existential psychology, this dimension measures the patient’s quest to make sense of suffering, identify enduring values beyond physical functioning, articulate hope, reevaluate life priorities, and maintain internal dignity. It addresses the fundamental human capacity to transcend the limitations of somatic pathology by anchoring the self in philosophical, artistic, ethical, or spiritual aspirations.

Theoretical Framework

The architectural configuration of the HPSNQ is anchored at the intersection of several influential theoretical paradigms across psychology, nursing, and philosophy:

Frankl’s Logotherapy and Existential Analysis

The primary philosophical underpinning of the scale is Viktor Frankl‘s logotherapy, which asserts that the search for meaning (the “will to meaning”) is the fundamental motivational force in human beings. Frankl argued that human suffering can become meaningful if it elicits personal transformation, inner courage, and existential realignment. Within the HPSNQ, the Transcendence domain directly mirrors Frankl’s thesis: hospitalized patients, abruptly confronted by bodily vulnerability and existential crisis, must find purpose in their present condition to avoid despair and existential vacuum.

Watson’s Philosophy and Science of Human Caring

From nursing science, Jean Watson’s Theory of Human Caring provides the clinical framework for the scale. Watson posits that healing cannot be achieved through curative biomedical regimes alone; it requires a transpersonal caring relationship that honors the mind-body-spirit unity of the human being. The HPSNQ operationalizes Watson’s “caritas processes,” specifically those emphasizing the cultivation of spiritual practices, deep relational listening, and the creation of a healing environment at all levels (physical, non-physical, ecological), which correspond directly with the scale’s Interpersonal Connectedness and Peaceful Environment domains.

Biopsychosocial-Spiritual Model

Building on George Engel’s classic model, Sulmasy and colleagues expanded the framework into a comprehensive biopsychosocial-spiritual model of healthcare. This model conceptualizes the human organism as an integrated whole embedded within a web of dynamic relationships: biological integrity, psychological processing, social systems, and spiritual orientation. When acute medical pathology destabilizes biological equilibrium, it reverberates across the psychological, social, and spiritual subsystems. The HPSNQ provides an empirical operationalization of the spiritual subsystem within this holistic medical matrix.

Validity

The validation protocol designed by Hosseini and colleagues utilized an exploratory sequential mixed-methods design, progressing through content, face, and construct validation phases.

Content and Face Validity

The initial item pool was derived inductively from extensive qualitative, semi-structured interviews with hospitalized medical-surgical patients, clinical nurses, and clinical experts. Following item generation, content validity was quantitatively calibrated through an expert panel consisting of specialists in nursing, clinical psychology, psychometrics, and medical theology:

• Content Validity Ratio (CVR): Evaluated according to Lawshe’s criteria. Items failing to achieve the minimum critical cutoff value for panel consensus regarding essentiality were modified or discarded.
• Content Validity Index (CVI): Evaluated at both the individual item level (I-CVI) and the overall scale level (S-CVI/Ave). Retained items demonstrated I-CVI values exceeding .80, and the overall scale yielded an S-CVI well above the standard acceptable threshold of .90, confirming strong representativeness of the spiritual construct.
• Face Validity: Verified through cognitive interviews with hospitalized patients to assess syntactic clarity, reading ease, cultural appropriateness, and emotional resonance.

Construct Validity: Classical and Modern Test Theory

Construct validity was established via advanced multivariate statistical methodologies, pairing structural equation modeling with modern polytomous Item Response Theory:

• Exploratory Factor Analysis (EFA): Performed using Mplus with robust weighted least squares estimation (WLSMV) suited for ordinal categorical responses. The EFA extracted a clean four-factor latent structure comprising 43 items that accounted for substantial variance and demonstrated clear conceptual separation without problematic cross-loadings.
• Confirmatory Factor Analysis (CFA): Executed on an independent calibration sample. The four-factor oblique model exhibited excellent fit to the empirical data, confirming that the items load strongly and exclusively onto their designated theoretical latent domains.
• Samejima’s Graded Response Model (GRM): To assess item functioning at a granular psychometric level, Samejima’s IRT model was fitted. Item discrimination parameters ($a$) and category threshold parameters ($b_k$) confirmed that all 43 items exhibited high to very high discrimination capacity, effectively separating patients with lower spiritual needs from those with elevated spiritual distress across varying trait levels ($ heta$).

Reliability

The HPSNQ has demonstrated robust psychometric reliability across multiple evaluation criteria, reflecting high internal homogeneity and temporal stability.

Internal Consistency

The internal consistency of the HPSNQ was calculated using Cronbach’s alpha coefficient ($lpha$) across the complete instrument and its respective subscales. The total instrument exhibited high internal consistency ($lpha = .83$), with subscale coefficients ranging from .83 to .95:

• Relationship with God: Demonstrates high internal reliability ($lpha > .90$), indicating strong consistency among theological coping items.
• Interpersonal Connectedness: Exhibits solid homogeneity ($lpha = .85 – .91$), reflecting the unified nature of human attachment items.
• Peaceful Environment: Demonstrates robust internal consistency ($lpha = .83 – .88$), showing stable covariance among items addressing ward atmosphere and quietude.
• Transcendence: Reflects strong internal consistency ($lpha = .86 – .93$), confirming the reliability of items measuring meaning, purpose, and hope.

Temporal Stability

The test-retest reliability was evaluated by re-administering the questionnaire to a subset of clinically stable hospitalized patients across a pre-determined two-to-three-week interval. The resulting Intraclass Correlation Coefficients (ICC) ranged between .89 and .96 across all dimensions. These coefficients confirm that the HPSNQ yields highly reproducible results when the clinical and psychological condition of the patient remains stationary, ensuring that observed variations in longitudinal administration represent genuine shifts in spiritual need rather than stochastic measurement error.

Factor Analysis

The structural properties of the HPSNQ were analyzed using Mplus software, utilizing advanced categorical estimation methods appropriate for polytomous Likert-scale data.

Exploratory Factor Analysis (EFA)

An initial EFA was implemented to extract the latent dimensions from the expanded preliminary item pool. Principal axis factoring with oblique Geomin rotation was selected under the theoretical assumption that spiritual sub-dimensions are intrinsically interrelated. The extraction identified four distinct factors with eigenvalues greater than 1.0, corroborated by Cattell’s scree plot analysis and parallel analysis. Items loading below .40 or exhibiting severe cross-loadings (> .30 on secondary factors) were systematically culled, resulting in the refined 43-item matrix.

Confirmatory Factor Analysis (CFA)

The structural validity of the 43-item four-factor configuration was subsequently confirmed using CFA with the robust Diagonally Weighted Least Squares (DWLS / WLSMV) estimator. The empirical data demonstrated robust fit with the theoretical model, meeting standard psychometric benchmark criteria:

• Comparative Fit Index (CFI): > .95, confirming that the hypothesized multidimensional model is superior to the baseline null model.
• Tucker-Lewis Index (TLI): > .95, confirming excellent penalized fit accounting for model complexity.
• Root Mean Square Error of Approximation (RMSEA): < .06 (with 90% confidence intervals within acceptable boundaries), indicating minimal residual error between the hypothesized covariance matrix and the sample covariance matrix.
• Standardized Root Mean Square Residual (SRMR): < .08, corroborating excellent absolute fit.

Standardized factor loadings across all 43 items were positive, statistically significant ($p < .001$), and ranged from moderate to exceptionally high (.55 to .89), confirming that each item functions as an accurate empirical indicator of its respective latent construct.

Instrument / Measurement Tool

The technical characteristics, administration parameters, and scoring framework of the HPSNQ are structured as follows:

• Test Type: Standardized patient-reported outcome measure (PROM); multidimensional self-report psychological questionnaire.
• Target Population: Hospitalized adult inpatients (aged 18–60 years) admitted to general medical and surgical wards who are conscious, oriented, and experiencing non-severe, non-terminal conditions.
• Exclusion Criteria: Patients in terminal stages of illness, those admitted to intensive care units (ICU), individuals diagnosed with active severe psychotic or cognitive disorders, and patients with acute advanced oncological or end-stage infectious diseases (e.g., advanced HIV/AIDS).
• Item Count: 43 items distributed across four latent subscales:
• Relationship with God
• Interpersonal Connectedness
• Peaceful Environment
• Transcendence
• Response Scale: Polytomous graded Likert-type response format designed to evaluate the degree, frequency, or perceived importance of each specified spiritual need during the hospitalization period.
• Administration Mode: Self-administered paper-and-pencil or clinician-assisted bedside administration for patients with temporary physical fatigue or mild visual impairments.
• Administration Duration: Approximately 15 to 25 minutes depending on patient fatigue and reading speed.
• Scoring Protocol: Items within each domain are scored and summed to yield distinct subscale totals, alongside a global composite spiritual needs score. Higher scores reflect greater intensity of unmet spiritual needs, indicating elevated existential distress or a pressing demand for clinical spiritual care interventions.

Permissions & Fee and Test Year

The Hospitalized Patients’ Spiritual Needs Questionnaire was finalized and published in 2023 (with preliminary psychometric Item Response Theory analyses appearing in preprint form in 2020). The scientific development and psychometric validation were published in the peer-reviewed journal BMC Palliative Care under an open-access attribution model (Creative Commons Attribution 4.0 International License, CC-BY).

While the validation research is openly accessible, the full, standardized Persian test manual and any officially translated derivatives remain proprietary to the original investigative team. The scale is made available free of charge for non-commercial academic, psychological, and clinical research purposes. However, formal permission and authorization must be requested directly from the corresponding author, Dr. Marzieh Momennasab ([email protected]), prior to clinical institutional deployment, full item utilization, translation into other languages, or commercial adaptation.

References

Below is a curated academic reference list reflecting the theoretical, clinical, and methodological literature underpinning the development and validation of the HPSNQ:

• Boateng, G. O., Neilands, T. B., Frongillo, E. A., Melgar-Quiñonez, H. R., & Young, S. L. (2018). Best practices for developing and validating scales for health, social, and behavioral research: A primer. Frontiers in Public Health, 6, 149. https://doi.org/10.3389/fpubh.2018.00149
• Büssing, A. (2021). Spiritual needs in research and practice: The Spiritual Needs Questionnaire as a global resource for health and social care. Springer Nature. https://doi.org/10.1007/978-3-030-70139-0
• Büssing, A., Balzat, H.-J., & Heusser, P. (2010). Spiritual needs of patients with chronic pain diseases and cancer—validation of the Spiritual Needs Questionnaire. European Journal of Medical Research, 15(6), 266–273. https://doi.org/10.1186/2047-783X-15-6-266
• Edelen, M. O., & Reeve, B. B. (2007). Applying item response theory (IRT) modeling to questionnaire development, evaluation, and refinement. Quality of Life Research, 16(1), 5–18. https://doi.org/10.1007/s11136-007-9198-0
• Galek, K., Flannelly, K. J., Vane, A., & Galek, R. M. (2005). Assessing a patient’s spiritual needs: A comprehensive instrument. Holistic Nursing Practice, 19(2), 62–69. https://doi.org/10.1097/00004650-200503000-00006
• Hosseini, F. A., Momennasab, M., Guàrdia-Olmos, J., Yektatalab, S., Shaygan, M., & Zareiyan, A. (2023). Hospitalized Patients’ Spiritual Needs Questionnaire. BMC Palliative Care, 22(1), 121. https://doi.org/10.1186/s12904-023-01213-5
• Lawshe, C. H. (1975). A quantitative approach to content validity. Personnel Psychology, 28(4), 563–575. https://doi.org/10.1111/j.1744-6570.1975.tb01393.x
• Murgia, C., Notarnicola, I., Rocco, G., & Stievano, A. (2020). Spirituality in nursing: A concept analysis. Nursing Ethics, 27(5), 1327–1343. https://doi.org/10.1177/0969733020909534
• Samejima, F. (1970). Estimation of latent ability using a response pattern of graded scores. Psychometrika, 35(1), 139. https://doi.org/10.1007/BF02290599
• Sharma, R. K., Astrow, A. B., Texeira, K., & Sulmasy, D. P. (2012). The Spiritual Needs Assessment for Patients (SNAP): Development and validation of a comprehensive instrument to assess unmet spiritual needs. Journal of Pain and Symptom Management, 44(1), 44–51. https://doi.org/10.1016/j.jpainsymman.2011.07.008
• Timmins, F., & Caldeira, S. (2017). Assessing the spiritual needs of patients. Nursing Standard, 31(29), 47–53. https://doi.org/10.7748/ns.2017.e10312

Items of the Scale