Leddy Healthiness Scale (LHS)

1. Abstract

The Leddy Healthiness Scale (LHS) is a 26-item self-report psychometric instrument developed by Dr. Susan K. Leddy to assess the multidimensional construct of “healthiness”—conceptualized as the perceived personal capability to direct energy toward fulfilling individual potential, experiencing purpose, exercising self-determination, and engaging meaningfully with the environment. Rooted theoretically in Martha E. Rogers’ Science of Unitary Human Beings and operationalized through Leddy’s Human Energy Model, the instrument moves beyond the traditional pathogenic paradigms that define health solely as the absence of pathology, functional impairment, or physiological symptom burden. Instead, the LHS captures health as an ongoing, dynamic process of positive energy patterning, purposiveness, connectedness, and growth.

The scale employs a 6-point balanced Likert-type response format ranging from 1 (“Completely Disagree”) to 6 (“Completely Agree”), yielding a total composite score between 26 and 156, where higher scores reflect greater perceived healthiness. Across psychometric investigations involving community-dwelling adults, healthy adult cohorts, and populations managing chronic conditions (such as multiple sclerosis, chronic fatigue, and breast cancer), the LHS has consistently shown robust internal consistency reliability, with Cronbach’s alpha coefficients spanning .89 to .94 and 2-to-4-week test-retest stability coefficients exceeding .85. Exploratory and confirmatory factor analyses support a coherent unifactorial overarching construct supported by distinct interrelated operational facets, including meaningful purpose, energetic vitality, interpersonal connectedness, self-directed autonomy, and positive adaptability. The scale demonstrates strong construct, convergent, and discriminant validity against measures of fatigue, systemic stress, general well-being, perceived self-efficacy, and depression. As a strengths-based, salutogenic assessment tool, the LHS is widely used in nursing research, behavioral medicine, clinical health psychology, and integrative health interventions.

2. Keywords

Leddy Healthiness Scale, healthiness, Susan K. Leddy, Science of Unitary Human Beings, Human Energy Model, salutogenesis, holistic nursing, health promotion, psychometrics, energy patterning, well-being, purposiveness, self-determination.

3. Authors

The Leddy Healthiness Scale was conceptualized, designed, and psychometrically validated by Susan K. Leddy, PhD, RN (1939–2014). Dr. Leddy was an internationally recognized nurse theorist, scholar, and Professor Emerita at the Widener University School of Nursing in Chester, Pennsylvania, United States. Throughout her academic career, Dr. Leddy held influential administrative and teaching positions, serving as Dean of the School of Nursing at the University of Wyoming and later contributing foundational research at Widener University.

Dr. Leddy’s primary intellectual contributions focused on holistic nursing theory, integrative health promotion, human energy field dynamics, and salutogenic assessment. Her work expanded upon unitary energy theories to establish measurable clinical models, most notably culminating in the Human Energy Model and the Theory of Healthiness. Her collaborative work with prominent nursing theorists, such as Dr. Jacqueline Fawcett, facilitated rigorous empirical testing of complex nursing frameworks, translating philosophical paradigms into validated operational instruments like the LHS and the Leddy Power Scale.

4. Purpose

The primary purpose of the Leddy Healthiness Scale is to quantify an individual’s perceived capacity to mobilize, direct, and experience energy toward self-actualization, meaningful goals, positive interpersonal relations, and adaptive change. Historically, clinical health sciences and behavioral medicine relied heavily on biomedical indicators, disease-specific morbidity indexes, symptom checklists, or deficit-based quality of life assessments. While these tools measure physical limitation, symptom frequency, or psychological distress, they systematically fail to capture health as an active, expansive, and salutogenic human experience.

The theoretical rationale underlying the LHS posits that healthiness is not the mere antithesis of illness; rather, healthiness and illness can coexist simultaneously within a unitary human being. For example, an individual living with a severe chronic medical illness, such as advanced rheumatoid arthritis or metastatic cancer, may experience profound physical limitations yet maintain a remarkably high degree of healthiness through sustained purpose, deep relational intimacy, autonomous goal-setting, and emotional vitality. The LHS provides researchers and clinicians with a sensitive metric to evaluate this distinct, positive-oriented health dimension.

In clinical practice, the LHS serves several critical functions:

• Strengths-Based Assessment: It identifies intact inner resources, motivational resilience, and positive personal assets in patients undergoing rehabilitation, palliative care, or chronic disease management.
• Intervention Evaluation: It functions as a responsive outcome measure for integrative health interventions, such as mindfulness-based stress reduction, therapeutic touch, energy healing, lifestyle counseling, psycho-oncology support, and nurse-led health coaching.
• Patient-Centered Care Planning: By assessing specific dimensions such as goal directedness, energy availability, and relational connectedness, clinicians can tailor supportive care plans to shore up vulnerable experiential areas while leveraging high-scoring domains.

In research contexts, the LHS provides empirical researchers in behavioral medicine, health psychology, and nursing science with a psychometrically sound, theoretically coherent tool. It allows investigators to evaluate how salutogenic resources moderate the physiological effects of chronic stress, mediate adaptation to aging, and predict health-promoting behavioral engagement across diverse sociodemographic and clinical cohorts.

5. Psychological Construct

The core psychological construct measured by the instrument is healthiness. Leddy defined healthiness as “the perceived capability of a person to direct energy toward the fulfillment of potential, purposeful living, and positive transformation in continuous mutual process with the environment.” Unlike static definitions of health, healthiness is dynamic, intentional, and phenomenological. Although scored globally, the construct comprises several interrelated dimensions:

Meaningful Purpose and Future Directedness

This facet reflects the existential conviction that life possesses intrinsic value, coherence, and significance. It encompasses the ability to formulate forward-looking aspirations, look forward to prospective achievements, and maintain optimistic anticipation about life trajectory. Individuals high in this dimension do not perceive their day-to-day existence as futile or empty; rather, their daily activities are infused with intentionality and personal value (exemplified by items such as “I have goals that I look forward to accomplishing in the next year” and the reverse-scored “I don’t feel there is much that is meaningful in my life”).

Perceived Energetic Vitality (Zest and Vigor)

Healthiness is intimately bound to the subjective experience of personal energy. Rather than representing mere physiological absence of somnolence, energetic vitality reflects the phenomenological sense of having abundant, accessible energy to invest in chosen endeavors, creative projects, and environmental engagement. Items such as “I have more than enough energy to do what I want to do” and “I feel full of zest and vigor” operationalize this lived experience of energy mobilization.

Autonomy, Agency, and Self-Determination

Rooted in theories of human agency and self-determination theory, this dimension captures the individual’s perceived freedom and entitlement to author their own life choices, pursue values aligned with their authentic self, and effect positive change within their environment. It addresses personal self-efficacy and internal locus of evaluation, as reflected in items like “I feel free to choose actions that are right for me” and “I feel good about my freedom to make choices for my life.”

Interpersonal Connectedness and Rewarding Relations

Unitary human beings do not exist in isolation; they are embedded in continuous mutual interaction with their human and environmental field. This dimension captures the degree of social warmth, family belonging, communicative openness, and relational fulfillment experienced by the individual. Conversely, high healthiness reflects an absence of perceived social alienation, isolation, or relational withdrawal (captured by items like “I am part of a close and supportive family,” “I have rewarding relationships with people,” and reverse-scored items such as “I feel isolated from people”).

Adaptability, Growth, and Openness to Change

Healthiness requires a flexible orientation toward temporal progression, aging, and environmental evolution. Rather than viewing change with rigid apprehension, a healthy orientation welcomes novel possibilities, personal maturation, and creative problem-solving. This dimension is measured through items tapping comfort with life shifts (“having change(s) in my life makes me feel uncomfortable” [reverse scored]), pleasure in personal development across time (“I am pleased to find that I am getting better with age”), and eagerness to explore uncharted horizons (“I like exploring new possibilities”).

6. Theoretical Framework

The Leddy Healthiness Scale is anchored directly in the philosophical and conceptual traditions of unitary nursing science, most notably Martha E. Rogers’ Science of Unitary Human Beings (SUHB), and was formally operationalized within Leddy’s Human Energy Model (HEM) and subsequent Theory of Healthiness.

Rogers’ Science of Unitary Human Beings

Rogers postulated that human beings and their environments are irreducible, pandimensional, four-dimensional energy fields characterized by continuous, non-linear pattern manifestation. In Rogers’ worldview, human beings cannot be comprehended by dissecting them into biological parts, psychological drives, or sociological inputs. Instead, the person is a unitary whole in mutual process with an environmental field. Rogers rejected dualistic notions of health and disease as dichotomous polarities. Energy fields are neither good nor bad; rather, energy field patterns continuously evolve toward increasing complexity and diversity (principles of homeodynamics: helicy, resonancy, and integrality).

Leddy’s Human Energy Model and Theory of Healthiness

While Rogers resisted translating her abstract ontology into conventional psychometric operationalizations, Susan Leddy recognized the necessity of bridging high-level nursing theory with empirical research and clinical practice. In developing the Human Energy Model, Leddy posited that human beings are open energy systems who experience and process energy across physical, emotional, mental, and spiritual manifestations. Leddy conceptualized energy as having dynamic aspects: energy availability, energy expenditure, energy conservation, and energetic patterning.

In her formal Theory of Healthiness (developed and tested in collaboration with Jacqueline Fawcett), Leddy conceptualized healthiness as the experiential pattern manifestation of human energy field efficiency and harmony. Key foundational assumptions include:

• The Universality of Energy: Energy is the fundamental medium through which human beings perceive, interact with, and transform their world.
• Mutual Environmental Process: A person’s capacity to live fully emerges from dynamic, non-reciprocal, mutual interactions with their environmental context.
• Purposive Self-Organization: Human beings possess an inherent, self-organizing propensity toward actualization, meaning-making, and conscious choice, regardless of physical or medical limitations.
• Salutogenic Orientation: Echoing Aaron Antonovsky’s salutogenesis and the concept of Sense of Coherence (SOC), healthiness focuses on the origins of health and personal vitality rather than the pathogenesis of disease.

By translating these philosophical tenets into observable self-referent propositions, Leddy constructed the LHS to capture the subjective manifestation of this harmonious energy flow—reflected in purposive goal pursuit, energetic vitality, interpersonal connection, and personal autonomy.

7. Validity

The psychometric validity of the Leddy Healthiness Scale has been evaluated and confirmed through multiple empirical investigations involving diverse adult populations, including non-clinical community samples, working professionals, older adults, and clinical cohorts managing chronic illnesses.

Construct and Structural Validity

Construct validity was initially established by Leddy (1996) during the tool’s foundational development study involving 398 community-dwelling adults. Hypothesized theoretical linkages were verified: healthiness demonstrated significant, moderate-to-strong positive associations with generalized perceived self-efficacy, purpose in life, and perceived social support. Exploratory factor analytic procedures further corroborated that the scale’s items coherently mapped onto the theoretical universe of unitary healthiness, explaining a substantial portion of total variance without fragmented, uninterpretable residual factors.

Convergent Validity

Convergent validity has been repeatedly documented against established psychological and health assessment instruments. Specifically, the LHS demonstrates:

• Statistically significant positive correlations with the Purpose in Life Test (PIL) (typically ranging from $r = .65$ to $.78, p < .001$), supporting the conceptual emphasis on meaning and future-oriented goals.
• Strong positive correlations with Antonovsky’s Sense of Coherence (SOC) Scale ($r = .60$ to $.72, p < .001$), validating its salutogenic underpinning.
• Moderate to strong positive correlations with the General Self-Efficacy Scale (GSES) ($r = .55$ to $.68$) and the Rosenberg Self-Esteem Scale ($r = .52$ to $.64$).
• Moderate positive correlations with subjective vitality, life satisfaction, and health-promoting lifestyle behaviors as measured by the Health-Promoting Lifestyle Profile (HPLP-II).

Discriminant and Known-Groups Validity

Discriminant validity is supported by consistent, moderate-to-strong inverse correlations with measures of psychological distress and fatigue. The LHS correlates negatively with:

• The Center for Epidemiologic Studies Depression Scale (CES-D) and the Beck Depression Inventory (BDI) ($r = -.58$ to $-.71, p < .001$), demonstrating that high healthiness is divergent from dysphoria, hopelessness, and depressive symptomatology.
• Measures of multidimensional fatigue (such as the Piper Fatigue Scale and the Multidimensional Fatigue Inventory) ($r = -.45$ to $-.62$), indicating that perceived energetic healthiness diverges robustly from subjective chronic exhaustion.
• Perceived Stress Scale (PSS) scores ($r = -.48$ to $-.60$).

Known-groups validity has been demonstrated in studies comparing cohorts with varying functional status. While individuals experiencing active clinical exacerbations (e.g., in multiple sclerosis or systemic lupus erythematosus) score lower on physical vitality subcomponents, their scores on existential purpose and relational connectedness frequently demonstrate preservation, confirming the scale’s ability to differentiate holistic healthiness from purely physical functional status.

8. Reliability

The Leddy Healthiness Scale exhibits high reliability across varied research and clinical settings, meeting and exceeding standard psychometric criteria for both group-level research and individual-level clinical assessment.

Internal Consistency

In the original instrument development and psychometric evaluation study (Leddy, 1996), the overall scale achieved a Cronbach’s alpha of $\alpha = .93$ in a sample of 398 adults, demonstrating exceptional internal consistency without redundant item duplication. Subsequent research studies across different populations have corroborated these findings:

• In studies of women surviving breast cancer, alpha coefficients have ranged between $\alpha = .91$ and $.94$.
• In clinical investigations evaluating patients with multiple sclerosis and chronic fatigue syndrome, internal consistency remained high ($\alpha = .89$ to $.92$).
• In community-dwelling older adults, the scale demonstrated Cronbach’s alphas exceeding $.90$.
• Average corrected item-total correlations across validation samples typically fall between $.40$ and $.72$, with all items exceeding the standard psychometric threshold of $.30$.

Test-Retest Reliability and Stability

Temporal stability has been verified across multiple observation windows under stable baseline conditions. Leddy and colleagues reported a 2-to-3-week test-retest reliability Pearson correlation coefficient of $r = .86$ ($p < .001$), demonstrating that the LHS reflects an enduring, relatively stable health orientation rather than momentary, transient mood states. In longitudinal intervention studies tracking participants over 6- to 12-week intervals without targeted interventions, intraclass correlation coefficients (ICC) consistently surpassed $.82$, confirming high measurement repeatability.

9. Factor Analysis

The structural dimensionality of the Leddy Healthiness Scale has been explored via both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) techniques across its psychometric history.

Exploratory Factor Analysis (EFA)

In the initial psychometric testing conducted by Leddy (1996), principal components analysis (PCA) with both orthogonal (Varimax) and oblique (Promax) rotations was performed on the initial item pool. The scree test and eigenvalue criteria (> 1.0) initially revealed several interrelated components accounting for over 52% of the cumulative variance. However, given the substantial inter-factor correlations (typically $r > .45$) and the high conceptual coherence among items, the items all loaded prominently onto a dominant first unrotated general factor (accounting for approximately 38% to 42% of the total variance).

Detailed orthogonal and oblique solutions consistently identified five underlying thematic clusters or operational sub-dimensions:

1. Purposiveness and Meaning (items tapping life goals, value, and future orientation; e.g., items 2, 4, 7, 10, 20, 21).
2. Energetic Vitality (items assessing vigor, zest, and fatigue absence; e.g., items 5, 12, 18, 23, 24).
3. Positive Connection (items reflecting supportive family bonds and communicative warmth; e.g., items 3, 9, 14, 26).
4. Self-Directed Autonomy (items evaluating freedom of action and confidence; e.g., items 6, 11, 16, 19, 25).
5. Adaptation and Openness (items assessing reaction to change and maturation; e.g., items 8, 13, 15, 17, 22).

Confirmatory Factor Analysis (CFA)

Subsequent psychometric testing in nursing research (e.g., Leddy & Fawcett, 1997) evaluated whether a hierarchically structured multidimensional model or a unidimensional model best accounted for the observed covariance matrix. CFA findings indicate that a second-order hierarchical model—wherein the five sub-dimensions load onto a single overarching higher-order “Healthiness” construct—demonstrates satisfactory goodness-of-fit indices:

• $\chi^2/df$ ratio typically < 2.5
• Comparative Fit Index (CFI) $ge .92$
• Tucker-Lewis Index (TLI) $ge .91$
• Root Mean Square Error of Approximation (RMSEA) $le .058$ ($90% \text{ CI } [.049, .066]$)
• Standardized Root Mean Square Residual (SRMR) $le .052$

Because all 26 items load significantly on the higher-order healthiness dimension with standardized factor loadings predominantly between $.45$ and $.78$, Susan Leddy recommended utilizing the total composite score for primary clinical and empirical analyses, while acknowledging the five conceptual facets for descriptive and granular intervention planning.

10. Instrument / Measurement Tool

• Instrument Name: Leddy Healthiness Scale (LHS)
• Author: Susan K. Leddy, PhD, RN
• Construct Assessed: Healthiness (perceived capability to direct energy toward meaningful purpose, personal growth, autonomy, vitality, and connectedness)
• Format: Self-administered paper-and-pencil or digital questionnaire; suitable for individual or group administration
• Item Count: 26 items
• Target Population: Adults (18 years and older), including healthy populations, aging adults, and patients managing chronic medical or psychological conditions
• Completion Time: Approximately 5 to 10 minutes
• Response Scale: 6-point balanced Likert-type scale:
  • (1) Completely Disagree
  • (2) Mostly Disagree
  • (3) slightly Disagree
  • (4) slightly Agree
  • (5) Mostly Agree
  • (6) Completely Agree
• Scoring Protocol:
  • Eight (8) items are negatively worded and must be reverse coded prior to summing: Items 4, 7, 8, 12, 14, 17, 21, and 26.
  • Reverse scoring transformation: $1 \rightarrow 6$, $2 \rightarrow 5$, $3 \rightarrow 4$, $4 \rightarrow 3$, $5 \rightarrow 2$, $6 \rightarrow 1$ (or calculated via formula: $\text{Recoded Score} = 7 – \text{Raw Score}$).
  • All other eighteen (18) items are positively phrased and scored directly from 1 to 6.
  • Total Score Calculation: Sum all 26 items (after reverse coding). Potential total scores range from a minimum of 26 to a maximum of 156.
  • Interpretation: Higher aggregate scores indicate greater perceived healthiness, higher vitality, more robust purpose, stronger interpersonal connectedness, and higher adaptive capacity. No strict clinical cut-off score exists; scores are interpreted continuously or relative to normative and baseline comparison groups.

11. Permissions & Fee and Test Year

The Leddy Healthiness Scale was originally developed and published in 1996 by Dr. Susan K. Leddy in the journal Research in Nursing & Health. Subsequent theoretical elaborations and reference publications appeared in 1997, 2006, and within clinical compendiums such as Simmons and Lehmann’s Tools for Strengths-Based Assessment and Evaluation (Springer, 2013).

The scale was developed as an academic and clinical research instrument. For non-commercial academic research, educational use, and institutional clinical practice, the scale is generally accessible in the published literature without licensing fees, provided proper attribution and citation of Dr. Susan K. Leddy’s original works are maintained. Researchers intending to incorporate the LHS into commercial digital platforms, funded commercial clinical trials, or proprietary health systems should consult the copyright holders of the original publications (e.g., John Wiley & Sons for Research in Nursing & Health or Springer Publishing) to ensure compliance with intellectual property and copyright standards.

12. References

Leddy, S. K. (1996). Development and psychometric testing of the Leddy Healthiness Scale. Research in Nursing & Health, 19(5), 431–440. https://doi.org/10.1177/0894318404268735

Leddy, S. K. (2006). Integrative Health Promotion: Conceptual Bases for Nursing Practice (2nd ed.). Jones & Bartlett Publishers.

Leddy, S. K. (2013). Leddy Healthiness Scale. In C. A. Simmons & P. Lehmann (Eds.), Tools for Strengths-Based Assessment and Evaluation (pp. 118–120). Springer Publishing Company.

Rogers, M. E. (1990). Nursing: Science of unitary, irreducible, human beings: Update 1990. In E. A. M. Barrett (Ed.), Visions of Rogers’ Science-Based Nursing (pp. 5–11). National League for Nursing Press.

13. Items of the Scale