The Spiritual Supporter Scale as a New Tool for Assessing Spiritual Care Competencies in Professionals: Design, Validation, and Psychometric Evaluation

This study aimed to design, validate and standardize the Spiritual Supporter (SpSup) Scale, a tool designed to assess competency to provide spiritual care including knowledge, sensitivity to spiritual needs and spiritual support skills. This instrument can be used by all those engaged in or training for caregiving roles. The study was conducted in Poland in the Polish language. The SpSup Scale demonstrates high overall reliability (Cronbach’s α = 0.88), a satisfactory diagnostic accuracy (0.79), and a satisfactory discriminatory power of the items. Given the psychometric properties of SpSup Scale demonstrated here, the scale is recommended for the assessment of the competency to provide spiritual care in both clinical and research settings in Poland.


Introduction
Spirituality has long been widely discussed in the caregiving professions as it relates to the provision of comprehensive care, and support for people in difficult situations (Bożek et al., 2020;Chow et al., 2021;Wells-Di et al., 2021;Younkin et al., 2021). While contemporary medical literature increasingly emphasises the need for a holistic approach to support patients and to recognise their somatic suffering in social, mental, and emotional terms (Muszala, 2017;Puchalski et al., 2013;Saunders, 1964), it is also important to consider the individual's spirituality (Sulmasy, 2002) by using the biopsychosocial-spiritual model of the human being (Balboni et al., 2014;. Patients report that they appreciate skill in spiritual care in, and the satisfaction of spiritual needs by, the professionals caring for them (Büssing et al., 2015;O'Callaghan et al., 2019). Spiritual care skills in healthcare professionals contribute to patients' satisfaction with treatment and care, well-being, and quality of life (Siddall et al., 2015) while reducing anxiety (Hughes et al., 2004) and depression (Bekelman et al., 2007). Patients are able to better cope with disease and have a more positive attitude despite deteriorating health (Brady et al., 1999;Whitford et al., 2008).
The relationships between quality of life, coping with disease and receiving spiritual support confirm that spirituality is an essential dimension of patient care (Vandenhoeck, 2013). The importance of spiritual care has been illustrated in diverse groups including: the elderly (Oz et al., 2021), disabled people (Kaye & Raghavan, 2002); as well as oncology (Ben-Arye et al., 2006), psychiatry (Galanter et al., 2011), cardiology (Ozdemir et al., 2021), thoracic (Chen et al., 2021) and HIV-positive patients (Chang et al., 2018;Dalmida et al., 2015). Furthermore, interest in spiritual competencies has also been expressed in the fields of teaching (Epstein, 2018;Harbinson & Bell, 2015), psychotherapy (Mutter et al., 2010;Ren, 2012) and in training for other healthcare professions such as nursing and midwifery (Deluga et al., 2021;McSherry et al., 2021). In summary, gaining competence in and providing spiritual care is important for all professionals who are dealing with people who suffer.

Need for a New Tool to Assess Competency in Spiritual Care
If spirituality is implicated within the diagnosis and treatment of those experiencing suffering, it is important to ensure that staff are appropriately educated (Lucchetti et al., 2012;. In order to ensure relevant competencies, a validated tool that allows us to assess and confirm the skill level is needed. A review of the literature reveals many scales for the assessment of spiritual needs (Anandarajah & Hight, 2001;Best et al., 2020;Büssing et al., 2010Büssing et al., , 2015Groves & Klauser, 2009;Maugans, 1996;Neely, 2009;Puchalski, 2002;Ross & McSherry, 2018), and spiritual care competencies, including the Spiritual Care Competency Scale (SCCS) for nurses (Frick et al., 2019;Pastrana et al., 2021), the Spiritual Care Competence Questionnaire (SCCQ) for various professions (Van Leeuwen et al., 2009), and the Servant Leadership and Spirituality Scales (Maglione & Neville, 2021). Tools that examine spirituality or religiousness as a phenomenon 2. Existential quest, especially with regard to: the meaning of life, suffering, and death; issues of personal dignity and personhood; a sense of individual freedom and responsibility, hope and despair, reconciliation and forgiveness, love and joy; 3. Values by which a person lives, especially in relation to oneself and others, work, nature, art and culture, ethical and moral choices, and life at large (PTODM, 2021).
Healthcare professionals should be aware of all these dimensions as a potential source of patients' coping in the face of death or spiritual suffering.

Study Objectives
In view of the broad potential application of spiritual care, we decided not to limit ourselves to medical professions but to design a tool that would be useful for all people engaged in or training for caregiving professions, for example medical and healthcare professionals, psychologists, and teachers.
Our objective was the construction and validation of a tool to study: 1. Respondents' opinions on spirituality and their understanding of their own spirituality; 2. Attitude to spirituality in a relationship with a person in need of care and support; 3. The level of skills necessary to diagnose the spiritual suffering in supported persons; 4. Respondents' readiness to provide spiritual support to those who suffer.
The proposed scale is intended for students and practitioners in the caregiving professions.

Study Design
The design, development and standardization of the SpSup Scale were carried out according to established standards for the development and psychometric validation of research scales and questionnaires (AERA APA, 2014; Boynton & Greenhalgh, 2004;Brzeziński, 1985;Dogan, 2016;Dufrene & Young, 2014;Koenig & Al Zaben, 2021;Rubacha, 2008;Sousa & Rojjanasrirat, 2011;Wild et al., 2005). Since we conducted our study, Koenig and Al Zaben (2021) have outlined the steps for the development and psychometric validation of a new scale in spirituality measurement and we have followed most of them.
The stages of scale development are described below in 4 phases: (1) Generation of items; (2) Cognitive debriefing of scale; (3) Validation and standardization-Study 1; and (4) Validation and standardization-Study 2. Methodology is summarised in Fig. 1, and each phase is explained in full below. All analyses were conducted in SPSS. The next stage of validation is currently underway and will be reported in a future paper. As recommended by Koenig and Al Zaben (2021), the authors will compare the SpSup Scale to existing scales to assess construct validation.

Participants and Data Collection
The project was approved by the Ethics Committee at Collegium Medicum in Medicum in Bydgoszcz of the Nicolaus Copernicus University in Toruń (number 736/2018) and conducted between 2017 and 2019.
For study I and II of validation and standardization, the questionnaire containing the SpSup Scale was distributed to university students by oral invitation, online or as a printed document. In the case of teachers who participated in study II of validation

Phase 1: Generation of Items
Potential items for the first draft version of the scale were based on the definitions of spirituality and its dimensions given above (theoretical and definition indicators) (Koenig & Al Zaben, 2021;Rubacha, 2008) and formulated by the research team. The researchers chose those items which corresponded most accurately to the definition of spirituality in medicine. This resulted in a provisional list of 104 items. The first draft of the scale was developed from this list, comprised of 51 items organized as 3 subscales: Me and my beliefs about spirituality (15 items); My spirituality (15 items); My idea of a relationship with a person (as such) experiencing spiritual pain (21 items). The scale included a Likert scale (4 response options from 'I strongly disagree with this statement', to 'I strongly agree') (Brzeziński, 2004), the instructions and the definition of spirituality.

Phase 2: Cognitive Debriefing of Scale with 51 Items
According to the literature, cognitive debriefing is used with the target group for whom the scale is prepared, or relevant experts (Sousa & Rojjanasrirat, 2011). The draft questionnaire was therefore assessed by an invited expert panel comprised of 14 members: psychologists (4), physicians (3), nurses (2) and students (5). They were asked to ensure the clarity of questions ("Are items clear and understandable for you?"), and to suggest possible paraphrasing where necessary. They were also asked to provide feedback on the tool regarding its length and usefulness, and the emotions experienced while completing it. During the study, experts were instructed to provide comments about the tool and to propose amendments ("Would you like to change anything in any item?") (Boynton & Greenhalgh, 2004;Dickie et al., 2018;Patrick et al., 2011;Sousa & Rojjanasrirat, 2011;Wild et al., 2005). Most of the questions were found to be clear and easy to understand. The structure of the questions was assessed positively. The definition of spirituality included in the scale was also evaluated positively and approved with no reservations. The inclusion of the PTODM's definition of spirituality in the instructions was vital as in Polish culture the term 'spirituality' is frequently perceived as synonymous with religiousness. Without this definition, the study could render inaccurate responses. The experts found four statements incomprehensible and proposed changes to make them clearer (Table 1).
The research team discussed differences in opinion and agreed on the most appropriate versions of the items and wording. As a result, the second draft of the scale The following statements were prepared based on the definition of spirituality The following statements were prepared based on the definition of spirituality In contact with another person, I assume that faith is not an essential element of support for this person In contact with a patient/person in need of support, I assume that faith is not an important element of this support I do not personally engage in a relationship with another person Faith is not a crucial factor in providing effective support to another person In a relationship with the patient/person in need of support, not only the body or somatic symptoms but also the actual spiritual suffering and dilemmas are important When someone complains to me about problems with forgiving, I can recognise it I can tell when someone in a conversation with me is complaining about problems with forgiving, I try to help them with it When someone says they find it hard to forgive, I can see it I can tell when someone is suffering on the spiritual level, for example, because they find it hard to forgive was constructed with 51 items and 3 subscales, similar to the first version but with corrected wording and the same Likert scale.

Phase 3: Study 1
The first study of the SpSup Scale was undertaken to establish scale reliability, internal consistency, and discriminatory power of items in a relatively homogenous population. From 2017 to 2018, participants were recruited from the medical faculties at 2 Polish universities. The sample contained 204 medical students, of whom 127 were female and 67 male (for 10 participants-no data). The median age was 22.99 years (range: 19-30) ( Table 2).

Psychometric Evaluation of Study I
The Internal Consistency of Items and the Initial Reliability of the Scale In the first step, the items' discriminatory power was verified to exclude those with a weak correlation with the overall scale score. The results of these calculations are presented in Table 3.

3
The initial reliability of the tool, based on Cronbach's alpha, was 0.929 (95% confidence interval: 0.914-0.942). Following analysis, the statements with Cronbach's alpha below 0.20 were removed. These questions were excluded from further analyses. Finally, the Cronbach's alpha was recalculated for all remaining items. The resulting values were satisfactory, with the tool reliability at this stage assessed at 0.940 (95% confidence interval: 0.927-0.951), indicating a very high and satisfactory outcome for our scale.

Exploratory Factor Analysis
In the next step, exploratory factor analysis was performed to determine the factor structure of the tool (Table 4). The optimal number of factors was established through parallel analysis (Green et al., 2012;Horn, 1965) to extract the number of factors for which eigenvalues were at least in the 95th percentile of the expected eigenvalue (Green et al., 2012). This method was selected because it is believed to produce the best results of all methods based on eigenvalues (Schmitt, 2011;Zwick & Velicer, 1986). In addition, factor analysis was further justified with the results of Bartlett's test of sphericity, with correlations between items significantly different from zero (χ 2 [465] = 2964,00; p < 0.001). The Kaiser-Meyer-Olkin test confirmed the adequate sample size for factor analysis (KMO = 0.865).
The analysis showed five factors that explained 48% of the variance in all items. Some items did not load on any of the corresponding factors or presented high factor loadings on more than one latent variable. The final factor solution is shown in Table 5. Given the expected (and existing) correlations between the factors, rotated factor loadings are presented (oblimin rotation).

Scale Reliability
In order to check the reliability of the scale, Cronbach's alpha (with 95% confidence interval) and McDonald's omega were calculated (AERA APA, 2014). The results are presented in Table 6.
The results for the scale points and the 95% confidence interval indicated a high level of internal consistency for the scale overall and individual subscales. Scales 4  Factor 5 -and 5 featured a slightly lower, albeit still acceptable, level of reliability. The discriminatory power of the items was re-estimated with regards to the overall score and individual subscales (Table 7). All indicators exceeded the value of 0.20 and can therefore be considered satisfactory.
The final outcome of the first standardisation performed as Study I was a questionnaire consisting of 31 questions organised into five subscales: 1. Attitude to prayer (5 items). 2. Beliefs regarding spirituality (10 items). 3. Spirituality in relation to one's own suffering and the suffering of others (9 items). 4. Sensitivity to the suffering of others (3 items). 5. Attitude to community (4 items).

Phase 4: Study II
The second study of the SpSup Scale was undertaken to establish the psychometric properties of the scale (e.g. scale reliability, internal consistency, discriminatory power of items, exploratory factor analysis) and was performed on a larger and more diverse population of respondents. In addition, the comparison of psychometric factors between different groups of participants was performed. At the end of scale standardisation, the final norms were defined, leading to the final version of SpSup Scale.

Characteristics of the Sample
The sample collected from 2018 to 2020 contained 527 participants who were working or preparing to work as professional caregivers: medical students, students of other healthcare faculties, students of non-healthcare faculties and teachers) of whom 416 (79%) were female and 96 (18.22%) male (no data: n = 15, 2.85%). The median age was 25.76 years, with age range 19-70 years.  Four comparative groups were distinguished based on occupational affiliations. As a result, the following groups were studied: teachers (n = 85; 16.13%), medical students (n = 189; 35.86%), students of other healthcare faculties (n = 109; 20.68%), and students of non-healthcare faculties (n = 144; 27.32%).
In the teacher group, most of the respondents were female (n = 54; 63.53%). The average age in this subgroup was 46.55 years (range 24-70 years) with average professional experience of 22.92 years (SD = 7.87; range 4-45 years). In the group of medical students, the mean age of the respondents was 24.28 years (range 22-28) with a majority of women (n = 125; 66.14%). At the time of the study, all students in this group were in the fifth year of study. In the group of students of other healthcare faculties, most students were in their third year of bachelor level study (n = 78; 71.56%), while the remainder were second year students of master level study. The group was dominated by women (n = 104; 95.41%). The average age in this subgroup was 22.34 years (range 21-29 years). The group of non-healthcare students was dominated by first-year and second year students of bachelor level study (n = 90; 62.50%; and n = 12; 8.33%, respectively), while the remainder were first year students of master level study. The average age in this subgroup was 20.77 years (range 19-25 years). More information about the demographic characteristics in Study II is presented in Table 8.

Psychometric Evaluation of Study II
Factor Structure The theoretical structure developed in Study 1 was tested using confirmatory factor analysis (CFA). It allowed us to verify the adequacy of the five-factor model. Given the ordinal measurement level of the scale and the significant skewness and kurtosis of some items (skewness above ± 2.0 was found in Item 1; kurtosis above ± 2.0 was found in items 1, 2, 4, 25), the diagonally weighted least squares (DWLS) method was used for the model estimation.
The results suggested that the identified latent factors represented a significant part of the 'shared' variance in many cases. In view of this, it was necessary to verify whether the variance was sufficiently significant to provide the basis for isolating the second-order factor to explain the covariance of the first-order factors. To this end, the CFA was performed again to test the fit of the hierarchical model with In both cases, factor loadings for individual items were generally satisfactory and statistically significant. Item 11 was an exception as its fully standardised factor loading was 0.08 and 0.09 for Models 1 and 2, respectively. Nevertheless, it was statistically significant. The exact values of the fully standardised factor loadings for both models are presented in Table 10. Given the results, the theoretical validity can be assumed to have been confirmed in terms of factor stability. Furthermore, the acceptable fit of the hierarchical model with the second-order factor also indicates that, next to five specific dimensions of spirituality, a primary dimension can be distinguished, being the overall spiritual awareness.

Scale Reliability and Discriminatory Power of Items
The mean scores, standard deviations, and other descriptive statistics for the dimensions of spirituality and overall test score are presented in Table 11. This table also shows the reliability levels for individual measurements. Reliability was assessed using Cronbach's alpha and McDonald's omega (AERA APA, 2014). The last of the measures was calculated due to the lack of strict unidimensionality in the analysed test.
Nearly all subscales demonstrated a satisfactory level of reliability, with the highest observed for Attitude to prayer. Reliability was also satisfactory for the overall spirituality level. Only the Spirituality in relation to one's own suffering and the Suffering of others subscales were characterised by a borderline reliability level (above 0.60), which was attributed to a lower mean correlation between items (0.19). Nevertheless, all subscales should be considered to be potentially useful.

Differences in Spirituality Between Groups According to Sex, Profession and Age
The dimensions of spirituality were tested for possible sex-specific differences. Given the considerable differences in the size of both groups and the lack of normal distributions for the tested variables, the groups were compared using the Mann-Whitney U test.
The analysis showed no statistically significant sex-specific differences for Attitude to prayer; Beliefs regarding spirituality; and Sensitivity to suffering. Minor differences (small effect size) between females and males were observed for

Spirituality in relation to one's own suffering; Suffering of others; and
Attitude to community. Women demonstrated higher scores on these scales. They also presented a higher level of overall spirituality, with a small effect size of differences for men.
The spirituality dimensions were also tested for possible differences among the four identified professional groups. To this end, a one-way analysis of variance (ANOVA) was used with ω 2 values to measure the effect size. The analysis showed no statistically significant differences for Attitude to prayer; Spirituality in relation to one's own suffering; and Suffering of others. However, minor differences (small effect size) among the groups were observed for Attitude to community; Sensitivity to the suffering of others; and overall spirituality level.
Tukey's test was used for pairwise post hoc testing. It revealed statistically significant differences for Attitude to community only in the comparison of students of other healthcare faculties with students of non-healthcare faculties: t = 3.22; d = 0.43; p = 0.007. Cohen's d showed a medium effect size for differences. The scores for Attitude to community were higher for students of other healthcare faculties compared with students of non-healthcare faculties (M = 9.09; SD = 2.12; and M = 8.15; SD = 2.27, respectively). No differences were observed between other groups for this dimension of spirituality.
The pairwise comparisons revealed no statistically significant differences for Sensitivity to the suffering of others. However, a comparison between future physicians (medical students) and students of non-healthcare faculties showed a trend towards statistical significance: t = 2.40; d = 0.25; p = 0.078. A similar trend was observed when comparing future physicians with teachers: t = − 2.39; d = − 0.31; p = 0.081. The effect size for both differences was medium. The scores for Sensitivity to the suffering of others were higher for medical students compared with students of non-healthcare faculties and teachers (M = 6.01; SD = 1.62 for future physicians; M = 5.59; SD = 1.72 for students of non-healthcare faculties; and M = 5.52; SD = 1.52 for teachers). No differences were observed between other groups for this dimension of spirituality.
Regarding the overall level of spirituality, statistically significant differences were observed only when comparing students of other healthcare faculties with students of non-healthcare faculties: t = 3.61; d = 0.48; p = 0.002. The effect size for the differences was moderate. The former group had higher scores for the overall level of spirituality compared with the latter group (M = 66.92; SD = 9.62; and M = 61.88; SD = 11.27, respectively). No differences were observed between other groups in this dimension of spirituality.
We investigated whether the respective dimensions of spirituality were related to respondents' age and seniority (in this case, correlations were calculated only for the group of teachers in which this variable was measured). Given the significant sample size, the Pearson correlation coefficient was used. The analysis showed no statistically significant relationships between spirituality and its dimensions and the demographic variables of age and seniority. In terms of the factors, the only (very weak) correlation was found between Attitude to prayer and seniority (r = 0.09; p = 0.047).

Diagnostic Accuracy
To estimate the diagnostic accuracy of a test, one needs to compare the results obtained in a tested group of respondents with an external criterion that allows us to assess the same variable as the one measured by that test. In our case, the external criterion was defined as the respondents' behaviour, for instance, their opinion regarding spiritual support and care in a specific situation (task). To this end, 43 subjects were asked to complete the scale, while the results were calculated using Yule's formula. The result was 0.79, with the estimated significance level ϰ 2 = 27.51.
The chi-square critical value was from 3.841, ∞, which means that the obtained result ϰ 2 falls within this range. The result can therefore be assumed to be statistically significant at p < 0.05. Consequently, the relationship between the respondents' perception of their ability to perform a given task and the SpSup Scale score was found to be true, with the type I error probability of 0.001 (one in 1000) or less.

Sten Scores and the Key for the Scale Calculations
The final step in the development of the proposed questionnaire was to establish a standardised scale for the calculation of the scale scores. Given that no significant differences were found among groups in terms of the dimensions of spirituality, common standards were adopted for all respondents using Sten scores. Scores within Sten 1-2 were defined as very low, 3-4 as low, 5-6 as medium, 7-8 as high, and 9-10 as very high.

Discussion
Training courses for people in caregiving professions, such as physicians, nurses, midwives, psychologists, pedagogists, teachers, chaplains and other helpers, focus on improvement in skills, an outcome which requires evaluation (Cortés-Rodríguez et al.,., 2022;Moore et al., 2018;Puchalski et al., 2021). As our university was the first in Poland to introduce spirituality into the medical curriculum, we wanted to develop a scale to assess the outcomes of this programme. A literature review showed that, despite the availability of several spiritual care tools, none of them captured the variables of interest to us (Deluga et al., 2020;Dobrowolska et al., 2016;Heszen-Niejodek & Gruszczyńska, 2004;Jarosz, 2011;Piotrowski et al., 2013). Furthermore, we wanted a scale that was relevant beyond healthcare. After methodological consultations, the target group of the SpSup Scale was extended, and the scale can now be used to test any adult working in or preparing for a caregiving profession. Results of the validation and standardization of our tool and the obtained psychometric values are highly satisfactory. It is worth highlighting the overall high reliability of the scale (Cronbach's α = 0.88) and subscales (1 = 0.65; 2 = 0.85; 3 = 0.84; 4 = 0.73; 5 = 0.73), a satisfactory diagnostic accuracy (0.79, with the estimated significance level ϰ 2 = 27.51), and a satisfactory discrimination index. Construct validation of the SpSup Scale is currently underway through correlation with similar scales, as recommended by Koenig and Al Zaben (2021, pp. 3475-3476).
As such, the SpSup Scale is recommended for the assessment of spiritual care, in both clinical and research settings, with regards to the following components: (1) Respondents' opinions on spirituality and their understanding of their own spirituality; (2) Attitude to spirituality in a relationship with a person in need of care and support; (3) The level of skills necessary to diagnose the spiritual suffering in supported persons; and (4) Respondents' readiness to provide spiritual support to those who suffer.

Study Limitations
This study has some limitations. The questionnaire's format as it stands may be too long for everyday use. Future studies should investigate whether a shorter version of the scale could be created. In addition, future research studies should replicate the present study using large cohorts to establish correlation between SpSup Scale and factors such as personality or emotional intelligence. We also believe that crosscomparing findings among multiple professional domains would reveal insightful and useful findings.

Conclusions
Supporting others requires many competencies and skills from professionals. In addition to knowledge, experience and technical skills directly related to the specific profession, people looking for support are increasingly expecting interpersonal competencies in their caregivers, including those related to spiritual support. Regardless of their belief system, a suffering person wants to be treated not only by a specialist qualified in a specific field, but also by a fellow human being capable of showing concern, recognising emotions, talking, and offering help.
Many universities are implementing programmes for the development of interpersonal attitudes and other qualifications necessary for specialists to show multilevel support suited to clients'/patients' needs. To evaluate the effect of such training courses, it is necessary to have appropriate measures. The Polish version of the SpSup Scale has been constructed as an instrument for measuring spiritual competencies among professionals. Considering the good psychometric properties of the tool, its use is recommended for the assessment of spiritual care and support, along with their components, in both clinical and research settings.

INSTRUCTIONS:
This questionnaire examines beliefs about spiritual care provided to a suffering person who needs spiritual support. The following statements were prepared based on the definition of spirituality presented below. Please read the definition and all statements carefully and try to respond to each statement using the following formula: 1. I strongly disagree with this statement 2. I disagree with this statement 3. I agree with this statement 4. I strongly agree with this statement Definition of spirituality proposed by Polskie Towarzystwo Opieki Duchowej w Medycynie/Polish Association for Spiritual Care in Medicine (PTODM). 2 Spirituality is a dimension of human life that relates to transcendence and other existentially important values.
Dimensions of spirituality: 1) Religiousness of a person, especially their relationship with God, personal beliefs, and religious practices, as well as community interaction; 2) Existential quest, especially regarding: -the meaning of life, suffering, and death, issues of own dignity, who one actually is as a person; -a sense of individual freedom and responsibility, hope and despair, reconciliation and forgiveness, love and joy.
3) Values by which a person lives, especially with regards to oneself and others, work, nature, art and culture, ethical and moral choices, and life at large. Author Contributions MF-K and MK contributed to the study conception and design. Material preparation, data collection and analysis were performed by MF-K. The first draft of the manuscript was written by MF-K. Megan Best was involved in critical analysis and interpretation of the study results. All authors read and approved the final manuscript.
Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.