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Journal of Health Policy and Management

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Ortega-Jimenez Mayra del Carmen*, Villagomez-Razo Andrea, Garcia-Campos Maria de Lourdes, Padilla-Raygoza Nicolas, Ortega-Jiménez Marcela, Ramirez-Gomez Xochitl Sofia and Jimenez-Garcia Sandra Neli
North American Nursing Diagnosis Association (NANDA), Guanajuato University, Guanajuato, Mexico, Email: [email protected]
*Correspondence: Ortega-Jimenez Mayra del Carmen, North American Nursing Diagnosis Association (NANDA), Guanajuato University, Guanajuato, Mexico, Email: [email protected]

Received: 30-May-2020 Accepted Date: Jun 16, 2020; Published: 23-Jun-2020

Citation: Ortega-Jiménez Mayra del Carmen, Villagómez-Razo Andrea, García- Campos María de Lourdes, et al. Instrument to identify spiritual suffering in relatives of mechanically ventilated patients. Health Pol 2020;3(1):8-12.

This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact [email protected]


Objective: To determine the validity and reliability of the Instrument to Identify Spiritual Suffering in Family Members of Patients with Mechanical Ventilation (IISEPVM). Method: Descriptive, methodological, this instrument evaluates the spiritual suffering of primary caregivers of mechanically ventilated patients based on the latest update of NANDA 2018-2020. The instrument is a modification of the "Questionnaire to Identify Spiritual Suffering" designed by Villagomez-Razo, Jordan-Jinez and Garcia-Campos in 2004. It was carried out with the participation of 15 primary caregivers and measurements were made with internal validity and reliability. Results: The age of the participants was 19 to 93 years (range 74 years). 93% female sex, 93% professed Catholic religion, 46% secondary schooling, 73% married and 60% have a monthly income of 0 to 1000 Mexican pesos. Level of spiritual suffering was mild. A Cronbach alpha of 0. 93 internal consistencies and an average covariance of 0. 18 were obtained. Conclusion: The application of IISEPVM is applicable to the primary caregiver context with mechanical ventilation patients, showing a safe validity and reliability. Key Words: Spirituality; Spiritual;


Spirituality; Spiritual; Pain; Patients; Family relationships


Spirituality is a part that helps well-being, in conditions such as state anxiety [1,2] which is also related to the level of strength in the presence of the disease [3]. When this part is altered, the spiritual suffering (SE) of the person arises, in especially during the imbalance that lowers the illness of a family member hospitalized in a critical stage. Hence the importance of knowing what SE is, as a problem that alters the psychological health of these caregivers.

The primary caregiver becomes essential to provide delegated care to the patient with mechanical ventilation, and for providing comprehensive care, he even neglects his physical, emotional and spiritual health, which often causes the presence of spiritual suffering, the latter being so marked that should be attended by health personnel, in the North American Nursing Diagnosis Association (NANDA) [1] taxonomy the label called spiritual suffering is mentioned, where nursing should focus their attention to provide care to the family member who is facing this situation.

Defining spiritual suffering as "impaired ability to experience and integrate the meaning and purpose of life through connection with self, others, art, music, literature, nature, and/or a power greater than self. ” one.

The questionnaire that is presented is the continuity of the "Questionnaire to identify Spiritual suffering" designed by Villagómez et al. [4] currently reviewed, modified and updated by Ortega-Jiménez MC , Villagómez-Razo A, García-Campos ML, Padilla-Raygoza N, Ortega-Jiménez M, Ramírez- Gómez XS, Jiménez-García SN, professors from the University of Guanajuato, Mexico.

Spiritual suffering has such importance within nursing that it is considered part of its nursing diagnoses, since 1978 the North American Association of Nursing Diagnoses (NANDA) [1] incorporates it as part of nursing practice which remains in force until the last edition, the questionnaire on which it was based measures the dimensions of NANDA 2004-2006 [5] focused on measuring SE in hospitalized patients. That is why the questionnaire presented has the modification of the current edition NANDA 2018-2020 [1] but focused on the relatives of hospitalized patients with mechanical ventilation.


To develop an evaluation instrument to measure spiritual suffering in relatives of hospitalized patients who have mechanical ventilation.


The present investigation is a study that developed tests in four phases

First phase: A review of different bibliographic sources of the SE measurement scales was carried out such as: instrument “Scale of spiritual Well-being ” (EBE) prepared by Paloutzian et al. [6] Numerical scale to evaluate spiritual symptoms in care palliatives designed by Reyes et al . [7], Classification of Nursing Interventions (NIC) [8] 6th edition, Classification of Nursing Outcomes (NOC) [9] 5th edition, as well as the comparison between the editions of NANDA 2004-2006 [5] until the NANDA 2018- 2020 [1] based on the label spiritual suffering.

According to this revision, the scale modification was constructed. The dimensions of the instrument considering the diagnostic label of NANDA 2018-2020, [1] can be presented by different factors such as anxiety, questions about the meaning of life, suffering, identity, describes fatigue, insomnia, crying, fear as well as connections with art, music, literature, nature, connections with the self, connections with others and connections with a power greater than self.

In the connection with the self it involves expressions of lack of hope, peace or serenity, acceptance, love and forgiveness for himself.

In connection with others he manages rejection with interactions with spiritual leaders, rejection with interactions with friends, family [1,5].

In connections with art, music, literature, nature involves an inability to manifest a prior state of creativity, a lack of interest in spiritual literature. In connection with a power greater than one's own, it integrates an inability to pray, a request to see a religious leader, sudden changes in spiritual practices, manifestation of suffering and lack of hope [10-14].

With the aforementioned dimensions, the scale "Questionnaire to identify Spiritual suffering" designed by Villagómez-Razo et al. in 2004, for hospitalized patients, made up of 49 items, was modified with a scale of intensity with options nape=0, sometimes=1, frequently=2, and always=3 [4].

The IISEPVM questionnaire was made up of two parts, the first, with identification data such as the date of application of the questionnaire, diagnosis of the patient, age and date of hospital admission; socio demographic data: sex, religion, schooling, marital status, role played in your family, occupation and monthly income, the second part is made up of the modified questionnaire itself, which contains 58 items with an intensity scale, which gives options Always (S)=5 points, Almost always (CS)=4 points, Sometimes (AV)=3 points, Almost never (CN)=2 points and Never (N)=1 point.

It is important to emphasize that questions 56, 57 and 58 have the grade reversed, that is, Always=1 point to Never=5 points. To elaborate the items, the dimensions of the NANDA label “spiritual suffering” of the last edition until the moment of piloting the instrument, that is, NANDA 2018-2020, were considered [1].

Second phase: Some new modifications were made, among them the wording of items 56, 57, 58 which are reverse-rated, 8 new questions based on the current NANDA and a global review of the instrument adapted to the primary caregiver.

At the end of this second phase, piloting of the second version of the instrument was carried out. For this, the following steps are mentioned:

a) Approval of the instrument: experts in the field, full-time research professors from the University of Guanajuato were given the opportunity to evaluate the instrument. Submitted and approved by the Research Committee with registration number CIDSC-3430810 and the Bioethics Committee with registration CBCCSS-00610092018 from the same university since this instrument is part of the design of a research protocol.

b) Authorization: an official letter was made for the Secretary of Health of the state of Guanajuato, Mexico, to the Teaching area for authorization of piloting the instrument in its facilities.

a) Instrument piloting: When identifying the primary caregiver, the general questionnaire was delivered, 15 primary caregivers were surveyed with critically ill patients in the internal medicine area of a General Hospital in Guanajuato, Mexico. The data obtained through the questionnaire were integrated, assigning a rating to the dimensions of the questionnaires and later for the analysis of results [15-19].

Third phase: A database was prepared in the statistical package SPSS version 21 and Epidat 3. 1, and then the information was statistically analyzed.

Fourth Phase: With the analysis of the results obtained, the validity and reliability tests of the scale were performed.

The instrument is shown below in its different sections.

Part I

University of Guanajuato Celaya Salvatierra Campus

Division of Health Sciences and Engineering

Sociodemographic data questionnaire

Identification data

No of the questionnaire:______________ Date ______________

Diagnosis of your patient: ____________Age ___________

Date of your patient's admission to the hospital: ___________

Objective: The present questionnaire is used to know sociodemographic aspects of health of primary caregivers/family members of hospitalized patients.

Sociodemographic data

Instructions: Answer what is asked of you by placing an X in the space that corresponds to your answer.

1. Sex:

( ) Male Female

2. Religion:

() Catholic () Jehovah's Witness () Others Mention Which ?:


3. Schooling:

() None () Primary () Secondary () Preparatory () Technical career () Bachelor () Postgraduate

4. Marital status:

() Single () Married () Divorced () Widowed () Free union

5. Role in your family: () Mother () Father () Sister (0) () grandfather ()

() Other Mention which one? ________________

6. Occupation: () Alone () Spouse () Couple () Mother () Children () Close family () others Mention which?: ______________

7. Monthly Income

() 0 to 1000 pesos () 1001 to 3000 () 3001 to 6000 () 6001 to 9000 () Greater than 9001.

II. Spiritual needs

Instructions: Write an X in the box that corresponds to your current situation regarding the illness of your sick family member. Considering the following scale of answers (Table 1):

Items S CS AV CN N
I have tried to read motivational books 5 4 3 2 1
I like listening to music 5 4 3 2 1
I like the nature 5 4 3 2 1
I take care of the environment 5 4 3 2 1
I go for a walk in the countryside or recreational places 5 4 3 2 1
I think I can get out of difficult situations well 5 4 3 2 1
I am satisfied with my moral conduct 5 4 3 2 1
I consider myself a respectable person 5 4 3 2 1
Life is very important to me 5 4 3 2 1
My life makes sense 5 4 3 2 1
I consider that I am a useful person for others 5 4 3 2 1
I accept the opportunities that life gives me 5 4 3 2 1
I think life is easy 5 4 3 2 1
I am satisfied with my life 5 4 3 2 1
I have something that drives me to live 5 4 3 2 1
I want to continue living 5 4 3 2 1
I'm in the mood to get ahead 5 4 3 2 1
I want to improve myself 5 4 3 2 1
I set goals 5 4 3 2 1
I think the problems that arise in my life can be solved 5 4 3 2 1
I get ahead of the difficult situations that come my way 5 4 3 2 1
I have hope 5 4 3 2 1
I feel calm 5 4 3 2 1
I am patient with the illness of my family member (sick) 5 4 3 2 1
I feel happy 5 4 3 2 1
I hardly get angry 5 4 3 2 1
I hardly feel anxious 5 4 3 2 1
I think life has treated me well 5 4 3 2 1
I love me 5 4 3 2 1
I feel good as I am 5 4 3 2 1
I am satisfied with what I have done in life 5 4 3 2 1
I feel enough courage to face the illness of my patient 5 4 3 2 1
I trust the people around me 5 4 3 2 1
I feel that there are people who support me in the difficult moments of my life 5 4 3 2 1
I am spiritually well 5 4 3 2 1
I trust the people around me 5 4 3 2 1
I feel loved by other people 5 4 3 2 1
I like to live with other people 5 4 3 2 1
I show affection to the other people I love 5 4 3 2 1
I have believed in god in the course of my life 5 4 3 2 1
When I have difficult moments in my life I have the confidence that God is with me 5 4 3 2 1
I think god loves me 5 4 3 2 1
I have faith in god 5 4 3 2 1
I am satisfied with the religion that I profess 5 4 3 2 1
I think what my religion says is true 5 4 3 2 1
The religious practices that I carry out leave me satisfied 5 4 3 2 1
I feel hope 5 4 3 2 1
I can do religious activities that I used to do before my family member will get sick 5 4 3 2 1
I feel the need for a spiritual advisor to visit me 5 4 3 2 1
I think spirituality is important in my life 5 4 3 2 1
I have tried to visit the church or my religious institution 5 4 3 2 1
I want to go to spiritual retreats 5 4 3 2 1
I want to pray 5 4 3 2 1
When I have had hospitalized relatives, they ask what religion they are from before administering the treatment. 5 4 3 2 1
They respect my religious beliefs when applying the treatment to my patient (mechanical ventilation or even a medical device) 5 4 3 2 1
At this point in my life I wonder why this is happening to me? 1 2 3 4 5
At this point in my life I wonder what will happen to my patient for his treatment (mechanical ventilation)? 1 2 3 4 5
I am prepared for the death of my patient 1 2 3 4 5

Table 1: Questionnaire modified to identify spiritual suffering.

S: Always; CS: Almost Always; AV: Sometimes; CN: Almost Never; N: Never

Four levels of spiritual suffering have been differentiated based on the scores obtained absent, mild, moderate and severe (Table 2).

Level of spiritual suffering
Absent 58
Mild 59-136
Moderate 137-213
Severe 214-290

Table 2: Scoring levels of the modified questionnaire to identify suffering.


Validation of the questionnaire to identify spiritual suffering

The scale was administered to 15 patients in the internal medicine area of a General Hospital of Guanajuato, Mexico with an age range of 19 to 93 years (range=74 years). 93% female predominated, 93% professed Catholic religion, 46% secondary school, 73% married, 20% single and 7% divorced, 60% had a monthly income of 0 to 1000 Mexican pesos. The statistical package SPSS version 21 and Epidat 3. 1 were used.

Level of spiritual suffering was slight, this may be due to the family member having an adaptation to the place where their patient is hospitalized and the assimilation of their illness, thus a connection with the spiritual dimensions of NANDA 2018-2020 [1].

For the reliability analysis of the scale, Cronbach's alpha was used, satisfied 5 4 3 2 1 obtaining 0. 9321 of internal consistency and a mean covariance of 0. 1897, in the 58 items presented by the scale.

Cronbach's Alpha was applied to each of the items and the coefficients obtained are shown in Table 3.

Question number Cronbach's Alpha Question number Cronbach's Alpha Question number Cronbach's Alpha Question number Cronbach's Alpha
1 0.9253 16 0.9324 31 0.9283 46 0.9283
2 0.9324 17 0.9324 32 0.9436 47 0.9324
3 0.9324 18 0.9324 33 0.9283 48 0.9283
4 0.9283 19 0.9283 34 0.9283 49 0.9283
5 0.9283 20 0.9283 35 0.9283 50 0.9324
6 0.9283 21 0.9283 36 0.9283 51 0.9245
7 0.9283 22 0.9283 37 0.9283 52 0.9253
8 0.9283 23 0.9283 38 0.9324 53 0.9245
9 0.9324 24 0.9283 39 0.9324 54 0.9324
10 0.9324 25 0.9283 40 0.9324 55 0.9253
11 0.9579 26 0.9375 41 0.9324 56 0.9375
12 0.9283 27 0.9324 42 0.9324 57 0.9324
13 0.9283 28 0.9283 43 0.9324 58 0.9324
14 0.9283 29 0.9284 44 0.9324
15 0.9324 30 0.9283 45 0.9283

Table 3: Instrument to identify spiritual suffering in relatives of patients with mechanical ventilation (IISEPVM).

It was observed that the consistency of this last version of the instrument increased, since the "Questionnaire to identify Spiritual suffering" designed by Villagómez-Razo, Jordán-Jinez and García-Campos in 2004. 4 composed of 49 items, had a Cronbach's alpha result of 0. 85, versus the current version of the instrument, which was 0. 9321.


With this adaptation of the instrument to the main or family caregiver of the hospitalized patient, we can obtain a measure that allows us to analyze the level of spiritual suffering that this type of population experiences and also be able to intervene based on the results obtained, with an improvement plan to avoid future spiritual complications in the health support network that these family members represent.


The family is a decisive factor during the whole process of illness, recovery and mental and emotional maintenance of the patient, providing wellbeing, affection and quality of life. However, it is rarely taken into account 5, manifesting emotional and spiritual alterations.

Primary caregivers within the hospital setting must learn a high adaptive management to the circumstances that arise, assimilating the illness of their loved one and facing the challenges of treatment and the uncertainty of what will happen with the state of health of their patient.

When there is no balance to experience and integrate the meaning and purpose of life, that spirituality is altered, taking it from well-being to spiritual suffering. "Spiritual suffering is an impairment of the ability to experience and integrate the meaning and purpose of life through connection with self, others, art, music, literature, nature, or a power greater than self”.

Nursing after a specialized development in skills, can assess, diagnose and treat the spiritual suffering of the human being. Thus, he will be able to favor the coping of pain or suffering by identifying emotions. Recalling that an effective diagnosis and intervention would lead to an improvement in the quality of life of individuals who are affected by this feeling. It is necessary to complete the training of primary caregivers in some aspects such as the identification of spiritual and religious needs, the use of techniques to help the individual clarify their beliefs and values, their areas and reasons for hope in life.

Spiritual practices are associated with better states of health, less depression, better habits and less mortality, thus trying to detect this spiritual suffering in time for the primary caregiver, allowing to provide a better quality of non-specialized care to their patient. The problem with these needs is the difficulty in recognizing and detecting them. Health professionals, due to lack of tools and misinformation, do not manage to get inside people. Based on the above, an instrument was required to measure the spiritual suffering of the hospitalized relatives with an objectivity of the data; that is why it becomes essential to show valid reliability and reliability for your application.

By observing the changes in the family in spirituality, the task of having an instrument that evaluates the spiritual suffering of the family is given. The questionnaire in which the modifications were made was structured with NANDA 2004-2006, 4 which is why it decides to update to the latest edition and have an instrument based on NANDA 2018-2020. In NANDA's label “ spiritual suffering ” based on its definition, we find that family members present an imbalance in their spiritual well-being, altering their role as caregiver.

The instrument designed by Villagómez-Razo, Jordán-Jinez and García- Campos in 2004, 4 was modified, called “questionnaire to identify spiritual suffering”, which is focused on patients in the hospitalization area, the modification is adapted to the population of relatives with hospitalized patients. This instrument consists of a number of 58 items, with the dimensions of the current NANDA 2018-2020.

On the other hand, this modified instrument presented a Cronbach's alpha of 0. 9321 in its total score, higher than that obtained by the questionnaire prepared by the original author of the instrument designed by Villagómez- Razo, Jordán-Jinez and García-Campos in 2004 cronbach alpha 0. 86.


In the period of data collection, the needs of family members with hospitalized patients require different types of supports, such as the use of green areas, chapels, cafeterias, sites that serve as distractors of the hospital environment.

It is a wide field of qualitative research, where nursing as a professional discipline can explore and improve care against basic family requirements and manage with hospital authorities the importance of spiritual health in primary caregivers.


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