Research Protocol of the Polish Adaptation and Validation of HOPE Scale: Qualitative Measurement of Patients' Spiritual Needs

Abstract

Background:

The HOPE Scale by Gowri Anandarajah is a qualitative tool for examining and assessing the spiritual needs of sick people, which can be used by health care professionals, but also other personnel whose purpose is to support the patient during illness.

Aim:

The aim of this study was the cultural adaptation and validation of a qualitative tool for examining the spiritual needs of patients.

Methods:

A six-step procedure was adopted with the inclusion of four independent forward and two backward translations and cognitive debriefing of the Polish version with experts (n = 11) and chronically ill patients (n = 15). These methods were used to verify a semantic validation and comprehensibility of the HOPE scale according to the standards of cultural measure validation and adaptation. Bioethics Committee approval No KE-0254/222/2020.

Results:

No major problems were encountered during the process of straightforward and backward translation, and the suggested minor linguistic corrections were made. The HOPE scale was found to be comprehensible and readable by experts and patients, and the instructions were clear and did not pose any difficulties for the respondents. Following the six steps of the validation, the final Polish version of the HOPE scale was obtained, adapted stylistically and culturally to Polish conditions.

Conclusions:

The Polish version of the HOPE scale is culturally and linguistically adapted and is ready to be used for assessing patients' spiritual needs. The scale can be used both for research and in practice when working with chronically ill people.

Introduction

In clinical practice, the importance of treating people and their experiences with integrity is of paramount importance to better understand the patient and provide adequate support.^1–3 In addition to diagnosing ailments and symptoms related to illness, attention is also drawn to the need to recognize spiritual needs. Although spirituality as human experience is difficult to understand and measure in terms of scientific analysis, there is ample evidence in the specialist literature to support its beneficial role in medical practice.⁴ The European Association for Palliative Care (EAPC) defines spirituality as “the dynamic dimension of human life that relates to the way persons (individual and community) experience, express and/or seek meaning, purpose and transcendence, and the way they connect to the moment, to self, to others, to nature, to the significant and/or the sacred.”⁵ Studies indicate positive effects of spiritual support and spiritual aspects on patient satisfaction with treatment and care, better well-being and quality of life as well as less anxiety and depression.^6–8 Patients are also more able to cope with a disease and exhibit more positive attitudes despite their difficult health situation.⁹ Furthermore, the results of several studies indicate that the provision of spiritual care is strongly correlated not only with improved mental well-being, but also affects the physical health of patients.^10,11 The presented relationships with quality of life, coping with the disease, and the received spiritual support confirm that spirituality is an essential part of human life and patient care.^12,13

The results of studies in the field of spiritual care show that patients and their families expect it to be carried out by medical staff.^14,15 Examples of spiritual care interventions include showing care and respect, providing patients with a sense of hope, listening, respecting religious beliefs, as well as praying together.¹⁶ Attending to the spiritual needs of patients is an important aspect of modern health care based on a holistic approach to the patient. At the same time, research findings show that patients report that their spiritual needs are inadequately met by health care personnel, both in inpatient and outpatient settings.^17,18

A search of the English-language literature indicates a number of scales and questionnaires for exploring spiritual needs from both a qualitative and quantitative perspective.^15,19 An example would be Richard Groves' Spiritual Health Assessment Tool to Assess Patient's Spiritual Pain,²⁰ FICA Tool by Christina Puchalski,²¹ or SPIRIT Model.²² Notable scales for diagnosing spiritual needs worldwide include Büssing's spiritual needs questionnaire,²³ FACIT-Sp,⁹ and SpIRIT.¹⁶

Compared with English-language literature, there are few tools in Polish for measuring the spiritual needs of patients. Despite the growing literature on the subject, not many attempts have been made to empirically describe and measure the spiritual needs of patients in Poland. Among the tools used there are scales to investigate the spiritual sphere, opinions about it or to investigate spirituality in the context of the Catholic denomination, such as the Self-Description Questionnaire,²⁴ the Sense of Holiness Scale,²⁵ the Spiritual Sphere Questionnaire,^26,27 or spirituality tools: The Centrality of Religious Attitude Scale by Prężyna²⁸ and The Intensity of Religious Attitude Scale by Prężyna.²⁹ However, these are not scales designed to explore the spiritual needs of patients. In the group of foreign methods adapted to Polish conditions, we should mention the Scale of religious relations—Lived Relations to God by D. Hutsebaut; Post-Critical Beliefs Scale by Hutsebaut; Huber's Religious Centrality Scale, or Questionnaire for studying religious strategies of coping with stress in youth RCOPE Pargamen,³⁰ while they also do not cover issues related to spiritual needs, especially in relation to medical care for the sick.

Therefore, the aim of this study was to adapt and validate a tool that would make it possible, in a concrete, comprehensive and systematic way, to identify, in a conversation with the patient, his or her spiritual needs and, consequently, to allow legitimate and precise interventions in this area.

Aim of the Study

The aim of this study was to culturally adapt and validate a qualitative tool to explore patients' spiritual needs—the HOPE scale by Gowri Anandarajah.

Materials and Methods

Study design

A validation study with qualitative approach was performed from June 2020 to May 2021.

HOPE scale description

The HOPE scale was created by Gowri Anandarajah. The HOPE scale questions were developed as a teaching tool to help professionals begin the process of incorporating spiritual assessment into their medical interviews. These questions have not been validated by research, but the strength of this particular approach results from the fact that it allows for an open-ended exploration of an individual's general spiritual resources and concerns, and serves as a natural follow-up to the discussion of other support systems. It does not immediately focus on the word “spirituality” or “religion.”⁴ In the scale, questions categorized into four subscales can be distinguished (Table 1):

Table 1.

The HOPE Scale in the Original and Polish Versions

The HOPE scale (original version)⁴	Skala HOPE (Polish version)
H: Sources of hope, meaning, comfort, strength, peace, love, and connection. We have been discussing your support systems. I was wondering, what is there in your life that gives you internal support? What do you hold on to during difficult times? What sustains you and keeps you going? For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with life's ups and downs; is this true for you? If the answer is “Yes,” go on to O and P questions. If the answer is “No,” consider asking: Was it ever? If the answer is “Yes,” ask: What changed?	H: Źródła nadziei, sensu, komfortu, siły, pokoju, miłości i więzi Porozmawiajmy o wsparciu. Zastanawia mnie, czy jest w Twoim wewnętrznym życiu coś, co podtrzymuje Cię na duchu. Co lub kto, Twoim zdaniem, jest dla Ciebie największym wsparciem w trudnych momentach? Co Cię mobilizuje i sprawia, że się nie poddajesz? Dla niektórych ludzi ich przekonania religijne lub duchowe są źródłem komfortu i siły w radzeniu sobie ze wzlotami i upadkami życiowymi. Jak to wygląda w Twoim przypadku? Jeśli odpowiedź brzmi “Tak,” przejdź do pytań O i P . Jeśli odpowiedź brzmi “Nie,” zastanów się, czy kiedykolwiek tak było? Jeśli w tym przypadku odpowiedź brzmi “Tak,” zadaj pytanie: Co się zmieniło?
O: Organized religion Do you consider yourself part of an organized religion? How important is this to you? What aspects of your religion are helpful and not so helpful to you? Are you part of a religious or spiritual community? Does it help you? How?	O: Religia zinstytucjonalizowana Czy jesteś wyznawcą określonej religii? Jakiej? Jak bardzo jest to (ta przynależność) dla Ciebie ważne? Jakie aspekty Twojej religii pomagają Ci a jakie nie (np. określone praktyki religijne)? Czy należysz do wspólnoty religijnej lub duchowej? Czy to Ci pomaga? W jaki sposób?
P: Personal spirituality/practices Do you have personal spiritual beliefs that are independent of organized religion? What are they? Do you believe in God? What kind of relationship do you have with God? What aspects of your spirituality or spiritual practices do you find most helpful to you personally? (e.g., prayer, meditation, reading scripture, attending religious services, listening to music, hiking, communing with nature)	P: Osobista duchowość/praktyki Czy masz osobiste przekonania duchowe, niezależne od wyznawanej religii, do której należysz? Jeśli tak to jakie? Czy wierzysz w Boga? Jaką masz relacje z Bogiem? Które aspekty duchowości lub praktyk duchowych pomagają Tobie najbardziej? (np. modlitwa, medytacja, czytanie świętych pism, udział w praktykach religijnych, słuchanie muzyki, wędrówki, obcowanie z naturą).
E: Effects on medical care and end-of-life issues Has being sick (or your current situation) affected your ability to do the things that usually help you spiritually? (Or affected your relationship with God?) As a doctor, is there anything that I can do to help you access the resources that usually help you? Are you worried about any conflicts between your beliefs and your medical situation/care/decisions? Would it be helpful for you to speak to a clinical chaplain/community spiritual leader? Are there any specific practices or restrictions I should know about in providing your medical care? (e.g., dietary restrictions, use of blood products) If the patient is dying: How do your beliefs affect the kind of medical care you would like me to provide over the next few days/weeks/months?	E: Wpływ na opiekę medyczną i problemy związane z końcem życia Czy bycie chorym (lub Twoja obecna sytuacja) wpłynęło na Twoją zdolność/Twoje możliwości realizacji praktyk, które zazwyczaj pomagają Ci duchowo? (lub wpłynęło to na Twoją relację z Bogiem)? Czy jest cokolwiek co mogę zrobić dla Ciebie jako pracownik opieki zdrowotnej, żeby pomóc Ci uświadomić sobie rzeczy (sięgnąć do Twoich osobistych zasobów), które zazwyczaj Ci pomagają w trudnych dla Ciebie sytuacjach? Czy obawiasz się sytuacji, że proponowane Tobie leczenie/opieka medyczna będzie niezgodne (lub w konflikcie) z Twoimi przekonaniami lub wiarą? Czy pomocna byłaby dla Ciebie rozmowa z kapelanem szpitalnym/przewodnikiem duchowym? Czy istnieją jakieś szczególne praktyki lub ograniczenia wynikające z Twoich przekonań religijnych lub światopoglądowych, o których powinnam/powinienem wiedzieć, realizując opiekę medyczną (np. ograniczenia żywieniowe, stosowanie produktów krwiopochodnych)? W sytuacji, gdy pacjent umiera zapytaj: Co chciałbyś, abym dla Ciebie zrobił/zrobiła w procesie opieki medycznej, abyś się poczuł lepiej i aby było to zgodne z Twoimi przekonaniami?

H: Sources of hope, meaning, comfort, strength, peace, love, and connection

O: Organized religion

P: Personal spirituality/practices

E: Effects on medical care and end-of-life issues

As recommended by the author, the HOPE scale can be used in practice by medical students, residents, and practicing physicians, and also by other health professionals.^4,31 HOPE assessment is also used by psychologists, social workers, chaplains, and physical therapists and serves as an aid when talking with the patient about their spiritual experiences and spiritual needs in the process of care and treatment.

Cultural adaptation and validation of the HOPE scale

The HOPE scale is a qualitative scale, which is a form of conversation between the professional and the respondent; therefore, the adaptation of the scale was prepared according to the standards of cultural validation typical for qualitative scales. Since the author of the test did not provide the validation steps required by her, with the author's consent, we have adopted the applicable validation adaptation principles specified as part of methodological standards in the international literature.^32–39

According to these standards, the process of adapting and validating the HOPE scale included six main stages (Table 2).

Table 2.

Steps of the Polish Adaptation and Validation of the HOPE Scale

Steps	Action undertaken
1. Preparation	Consent of the author of the test to adapt and validate the scale in Poland
	Obtaining consent of the Bioethics Committee to implement the project
	Literature review
2. Forward translation and reconciliation	Four independent forward translations Reconciliation of forward translation
3. Backward translation and reconciliation	Two independent back translations Reconciliation (review) of back translation Prefinal version
4. Cognitive debriefing with prefinal version	Assessment by experts Assessment by target group—patients
5. Harmonization of the prefinal version	Consultation with the author of the test to approve the final version of the scale
6. Finalization	Final Polish version of HOPE scale

Preparation

After obtaining permission from the author of the tool, Gowri Anandarajah, to adapt and validate the HOPE scale for use in Poland, the author was presented with the planned stages of adaptation, to which she agreed (a document confirming the author's consent is in the records of one of the team members). At the same time, the consent of the Bioethics Committee of the Medical University of Lublin (No. KE-0254/222/2020 dated November 5, 2020) was obtained to implement the research.

Before proceeding with the translation, an analysis of publications relating to the validated scale was carried out.³¹ Particular attention was paid to the definitions of spirituality, spiritual needs, and holistic treatment of a human being, in addition to crisis or spiritual anxiety and the need to provide spiritual care in clinical conditions. All the categories adopted by the author emphasize the multidimensionality of spiritual experiences and point to the possibility of experiencing diverse and individualized spiritual experiences and needs. The author consistently differentiates between religious practices or institutional religion and spirituality understood as “pertaining to people's understanding of and beliefs about the meaning of life and their sense of connection to the world around them. It is multidimensional and can encompass both secular and religious perspectives.”³¹ It is important to note the subjectivity of spiritual experiences which, through the HOPE scale, gives professionals the opportunity to focus on patients' experiences and provide them with adequate spiritual support. In addition, according to Gowri Anandarajah,³¹ the capacity for spiritual care developed by professionals allows them to explore and reflect on their own spirituality, beliefs, and values.^4,31

Forward translation and reconciliation

The next stage involved translating the scale into Polish. For this purpose, four independent translators were asked to translate the test, with their native language, as recommended, being the language of the country where the test was to be adapted^33,37,39—in this case Polish. The translators were expected to prepare the questions and scale instructions in Polish using simple terminology and words that would be understandable to every respondent. They were also asked whether any of the expressions were difficult to translate into Polish or seemed unacceptable in Polish culture.³⁹ No such expressions were reported by them. The four translated versions of the scale were then analyzed and compared in detail to produce a standardized version.³⁷ Each question was discussed by authors of this article separately, and in the case of differences in translation across scale items, the best and most accurate version was selected.

It should be noted that when standardizing the translation version, attention was paid to whether the scale included any ambiguous or emotionally charged sentences. Attention was also paid to the extent to which the translated sentences would be understood by potential respondents. Particular attention was paid to explaining the categories of spirituality, religiosity, spiritual beliefs, or religious practices present in the scale. In order for the scale to properly sound and be understood by potential recipients, the translation was applied in such a manner as to allow deviations from the original, especially with respect to terms, phrases, and expressions that are untranslatable or difficult to translate, and their replacement with Polish language equivalents.^37,40

Backward translation and reconciliation

At the backward translation and reconciliation stage, the central focus was placed on identifying any errors or ambiguities in the final version by comparing it with the source version.^37,39 To this end, two translators fluent in both languages were asked to translate back into the source language. The versions thus obtained were then reconciled. To obtain the best possible final version of the scale, the standardized version was sent for evaluation to the author of the test—she approved the agreed version of the back translation (email correspondence available with the authors of the article).

The scale was then drawn up in terms of facade equivalence, that is, the Polish HOPE scale was prepared in a manner that resembled the original version in appearance and structure.

Cognitive debriefing

This validation step involved two steps. In the first one, experts (n = 11), including psychologists, doctors, nurses, and patients' families were asked to evaluate the scale. The experts' task was to evaluate the tool in terms of the clarity and comprehensibility of the individual questions and to assess the clarity of the instructions accompanying the scale. The experts were asked to assess the comprehensibility of the individual questions on the scale and to write down any comments or suggestions if any statement seemed unclear, sounded wrong, or did not function in Polish culture.³⁷

Based on the analysis of the expert evaluation, a prefinal version of the HOPE scale was developed and submitted for evaluation by the target group, that is, the people for whom the research tool is intended.^34,37,41 In this case, these were 15 people with chronic illnesses, which is sufficient within the range of the recommended in the literature number of people surveyed at this stage of the study.³⁷ The aim was to obtain respondents' opinions on the validated tool, “to evaluate the instructions, response format and the items of the instrument for clarity.”³⁹ Semistructured interviews were conducted in which the respondents assessed the tool in terms of being able to understand all the questions^34,36 and gave their overall opinion on the scale, its length, its usefulness, and the emotions that accompanied its completion.⁴²

The evaluation was both in the form of open-ended as well as structured oral statements according to a preprepared evaluation sheet for each participant.³⁴ The respondents were asked to rate the scale using a 0 or 1 score, where 0 means that the question is unclear/incomprehensible and 1 denotes a question which is clear/understandable.³⁷ Discrepancies in respondents' opinions were discussed by the team to determine the most accurate version of those items, words, or sentences that were not clear for the patients.⁴⁰ During the survey, patients were also asked to provide any suggestions and comments about the tool and recommendations for changes.³⁴

Results

The 11 experts included 3 psychologists, 1 educational psycho-oncologist, 3 physicians, 1 nurse and 1 midwife, 1 priest and 1 carer—occupational therapist. The expert group comprised eight women and three men. The average age was M = 41.45, with the oldest expert being 57 years and the youngest 27 years. All the experts declared that they had been brought up in the Catholic faith, including eight people declaring themselves as church-going and three who stated to be nonbelievers. The vast majority of experts (n = 8) had experience of working with chronically ill people, either in inpatient units or in home-care settings. Experts were instructed to evaluate each item for understanding and clarity (“Is the question clear and understandable to you?”).

The respondents were asked to rate the scale using a 0 or 1 score, where 0 means that the question is unclear/incomprehensible and 1 denotes a question, which is clear/understandable.³⁷ Furthermore, they could write their own suggestions as to how selected questions could be worded when in doubt (“Do you have any suggestions for changing the question or its wording?”). It should be noted that, in accordance with the standards for cultural validation and cognitive debriefing, recurrent suggestions related to a specific question in the scale were considered in the analysis. Surveys were conducted in the form of cognitive face-to-face interviews (3), phone interviews (2) or by e-mail (7). The results of the expert assessments are provided in Table 3.

Table 3.

Evaluation and Expert Suggestions to the HOPE Scale Questions

Question	Positive assessment (n)	Negative assessment (n)	Suggestions for change
Are the individual scale questions understandable and clear to you?	9	2
Is there any question you think is unclear?	5	6	Question: “We have been discussing your support systems. I was wondering, what is there in your life that gives you internal support?”Suggestion: the statement “internal” may be puzzling and unclear (two jurors)Question: “Do you consider yourself part of an organized religion?”Suggestion: Not all patients may understand what the term “organized religion” means (three jurors)
Do you have any proposals or suggestions for changing any of the questions?	5	6	Question: “We have been discussing your support systems. I was wondering, what is there in your life that gives you internal support?”Suggestion: Would it be possible for the phrasing of the question to avoid an objective approach (“what”) by replacing it with an impersonal one (“where do you get your support from…”) or to complement it with a subjective one (“or who”) (two jurors)
			Question: “Do you consider yourself part of an organized religion?”Suggestion: Are you a believer? (three jurors)
			Question: “Do you consider yourself part of an organized religion? How important is this to you?”Suggestion: is religion/belief in God important to you? (clarify the question) (three jurors)
			Question: “As a doctor, is there anything that I can do to help you become aware the resources that usually help you?Suggestion: replace the phrase “become aware” with a more general expression (three jurors)
Your impressions following scale assessment			“That's a nice scale”“A useful tool”“An interesting test”

The analysis of the obtained data allows us to conclude that for the majority of the surveyed experts (n = 9) the questions in the scale were clear and understandable. The experts found individual questions to be clear and not likely to pose a difficulty to those being interviewed. Repeated suggestions for change appeared in relation to several questions as given in Table 3, and described hereunder. These suggestions did not affect the meaning of the questions, but their use when developing the scale allowed for the creation of a tool that would be more readable for the audience.

Following the corrections made, the questions became better adapted to Polish conditions. In the question, “We have been discussing your support systems. I was wondering, what is there in your life that gives you internal support?,” two experts suggested that the statement “internal” may be incomprehensible and that the word “what” be replaced with “who” to make the question more subjective. Next question: “Do you consider yourself part of an organized religion?,” to which experts (three people) pointed out when suggesting a change, referred to being a follower of a particular religion and the phrase “organized religion.” It was suggested that asking if the person is a believer would make it much easier to answer and understand this question. Another question that experts felt needed to be corrected was, “How important is this to you?.”

According to experts, in this version the question is unclear and may not be understood by the respondent, hence the suggestion to make it more specific. In the question of Polish translation of the HOPE scale “As a doctor, is there anything that I can do to help you become aware of the resources that usually help you?,” three experts suggested that the word “become aware” (Polish: “uświadomić sobie”) used in the Polish translation for the phrase “access the resources” should be replaced. The remaining questions about which there were doubts were analyzed and amended in such a way that the wording of the questions did not change and their meanings were consistent with the original version of the scale, and also to make the test better adapted to Polish audience.

Following a detailed analysis of the scale in terms of the jurors' suggestions, a decision was made not to change the words “internal” (“wewnętrznym”) and “become aware” (“uświadomić sobie”), but to give additional description in brackets of what is meant by these questioned phrases. The joint analysis of the questions by the research team resulted in the decision to retain the original translation, as in our opinion the questions as formulated seem clear and not objectionable. We also concluded that we want to see what the evaluation results would be from a study of patients who would be evaluated on the scale.

The scale was very well received among experts. By talking to the experts about their impressions of the tool, it was established that they found the scale useful, interesting, and very easy to use in a relationship with a patient.

Patients invited to participate in the study were being treated for chronic cardiovascular diseases in the Cardiac Intensive Care Unit of the Independent Public Clinical Hospital No. 4 in Lublin. The patient group consisted of 10 women and 5 men. The average age of the patients was 53 years, with the oldest patient being 73 and the youngest 32 years old. Nine patients were married, two were widowed, two remained in an informal relationship, and two were single. Most of the patients (n = 9) lived in urban areas, whereas the rest (n = 6) came from rural areas. Fourteen patients indicated that they had been brought up in the Catholic faith, one patient stated to be nonbeliever. Five patients had higher education, and the other 10 people had secondary education.

Referring to the medical condition of patients, all of them struggled with multiple diseases. In majority of cases, admission to hospital was the matter of urgency (n = 11) and most of the patients were in serious condition, required intensified medical/nursing care (bedridden patients) (n = 11). Most of the patients were diagnosed with different chronic cardiac arrhythmias (n = 10), arterial hypertension (n = 8; in addition, they had myocardial infarction (n = 3), and chronic circulatory failure (n = 3). One patient had cardiac arrest with successful resuscitation. Moreover, most of the patients had documented other diseases, for example, diabetes, epilepsy, chronic renal failure, condition after sigmoid resection, state after partial gastrectomy, and others. The results of the evaluations of the study patients are given in Table 4.

Table 4.

Cognitive Debriefing with Target Group (n = 15)

Question	Positive assessment (n)	Negative assessment (n)	Suggestions for change
1. Are the individual scale questions understandable to you?	15	0
2. Is any sentence in the scale incomprehensible to you and should be changed?	15	0
3. Are all the words in the scale used correctly for you?	14	1	Replace the word “comfort” with the word “calm”
4. Do you think the scale might be too long?	13	2
5. Do you think the scale is/will be useful in helping another person?	15	0
6. Did you experience any emotions while filling in this scale?	15	0	Stress, intimidation, embarrassment, sadness, reflection, discomfort, surprise (three patients), joy (two patients), curiosity

Questions about all four areas of the HOPE scale: Sources of hope, meaning, comfort, strength, peace, love, and connection; Organized religion; Personal spirituality/practice; and those regarding Impact on medical care and end-of-life issues were understood by all respondents (n = 15). Furthermore, respondents did not report difficulties in understanding individual sentences (n = 15) as well as individual words (n = 14). One respondent suggested replacing the word “comfort” with “calm.”

The analysis of the evaluations obtained among the patients surveyed, as well as the expert evaluations and the suggestions and comments provided, allowed for the assessment and evaluation of the scale in terms of language, grammar, and style, which ultimately resulted in a revised scale taking into account all suggestions and adapting the tool, both linguistically and culturally, to the needs of the patients surveyed, and in cultural terms also to Polish conditions (Table 1).

Discussion

Holistic medical care requires health care professionals to account for spiritual needs in the care and treatment plan. According to research reports, patients expect medical staff to deliver spiritual care.^43,44 Unfortunately, health professionals find it difficult to measure spiritual needs, mainly owing to confusing spirituality and religion.⁴⁵ This study aimed to apply cultural adaptation of the HOPE tool to Polish conditions. The tool is based on a comprehensive approach to spirituality, presenting in detail its relationship to medical care, with fewer aspects relating to religious needs, as opposed to tools such as the FICA Tool and SPIRITual.⁴⁶ The created scale and its theoretical foundations for the holistic care of a sick person are also in line with the increasingly common treatment and curing method, first proposed by Cicely Saunders.²

The results show that the HOPE scale can be effectively applied in clinical practice. It appears to be a helpful tool not only with respect to collecting information about the patient's spirituality, but also as the one that enables learning about their preferences and spiritual needs. Cultural adaptation has revealed that the tool can be used to draw up customized care plans for the spiritual care provided to patients afflicted by various disease entities and experiencing different elements of spirituality. Confirmation of this can be found in a study by Blaber et al.⁴⁶ who reviewed and analyzed available research tools for assessing patients' spiritual needs in a qualitative way.

Patients in the study (n = 15) found the HOPE scale to be a helpful tool in clinical practice and one that will likely be useful for providing aid to another person. Similar conclusions can be drawn from the study by Frick, who made assessments of patients' spiritual needs using the SPIR semistructured clinical interview⁴⁷ and a proprietary scale.⁴ In addition, according to the patients who participated in our study, a clinical assessment of spiritual needs may provide important information about the patient's ability to cope with stress, illness, social support, and search for meaning in life. It can lead to a stronger therapeutic relationship between the patient and the medical staff. Above all, however, incorporating the tool into clinical practice can contribute to helping patients identify their own inner spiritual resources⁴ and thus improve patients' physical domain and quality of life.^6–11

However, what is important, any conversation between medical staff and a patient about their spiritual needs should be conducted with sensitivity and in conditions ensuring intimacy as it relates to the intimate aspects of life. In our study, when asked if they had experienced any emotions while filling out the scale, patients indicated next to positive emotions, such as joy, curiosity, and reflection, and also negative ones, such as stress, intimidation, embarrassment, sadness, and discomfort. In Polish culture, a conversation about spirituality is usually conducted as part of pastoral care, rarely by medical personnel, which could have evoked the above-mentioned emotions. What is more, the results of the published studies indicate that also health care personnel feels discomfort when talking with patients about spiritual or religious needs.⁴⁸ This is usually the effect of lack of knowledge and skills to provide such a conversation. This indicates the need to include these issues in professional education to prepare physicians, nurses, and other specialists who work with patients, for example, psychologists, to provide spiritual care.

There were only few comments from patients and experts on the wording and meaning of individual questions of the scale. It should be noted that some words, for example, “comfort,” can be translated in this context into more than one Polish word (“komfort” or “spokój”). Bakker encountered similar difficulties in terms of linguistic detail, in the process of cultural adaptation to Dutch conditions of qualitative tools on spirituality.⁴⁹ The final Polish version of the tool evidences the accuracy of the translation and indicates that it is appropriate for Polish culture and language. The reliability and rigorous approach to the cognitive debriefing procedure allows us to conclude that they prepared an accurate form and the content of the questions was relevant to the respondents' assumed concept of spirituality. Another advantage stems from the fact that the experts applied additional evaluation.

The analysis of the results allows us to conclude that one of the main problems when using the HOPE scale in clinical practice may be that too much cognitive effort is required of respondents when answering the questionnaire. To the question, “Do you think the scale might be too long?” 13 respondents answered in the affirmative. Similar conclusions can be derived from cultural adaptations of other tools. However, this is usually the result of erroneous and underspecified wording of individual questions, which refer primarily to the subjective views and feelings of the respondent.⁵⁰ In addition, Lucchetti points out that an appropriate instrument for qualitative research in the field of spiritual care should not be elaborated to the point where it would be impossible for responses to be collected within 15 minutes.⁵¹ The HOPE tool is in line with these recommendations. It is important to remember that the pilot study was conducted in a cardiac intensive care unit, where patients requiring intensive care and therapy are hospitalized, usually in exacerbation of a chronic disease or owing to life-threatening conditions. The health status of the patient may influence the response to the HOPE scale questions. Therefore, it should be highlighted that our study has some limitations. The patients taking part in the study were relatively young and homogenous when it comes to their health condition. Although their condition was serious, they had a good prognosis and did not face death. Therefore, their perspective on spirituality may differ greatly from persons with a predictably poor prognosis measured in months. However, the emergency mode of patients' admission to hospital could affect their reflection on spirituality. This may be the issue for further exploration.

Conclusions

Spiritual care is a unique aspect of medical care that cannot be replaced by religious or psychological care. It is the foundation for the health and holistic well-being of every individual. Owing to the sensitive and personal nature of spirituality, qualitative samples are more appropriate for exploring its dimensions. Studies have shown that HOPE is a reliable and helpful tool for collecting information about patient's spirituality. Recommendations for future studies include performing larger group studies, with diversity of health status (particularly proximity to death) and diversity of health care setting (hospital vs. outpatient). This study showed that patients do have spiritual needs and expect them to be noticed by health care professionals. The analysis of the qualitative material will make it possible to look at the spiritual needs of patients and to develop standards for spiritual care, which should be incorporated into the therapeutic and care process for each patient. In addition, the HOPE tool should be able to assist in guiding the education of future health care professionals in the context of spiritual care by pointing out aspects to be enquired about and taken into consideration in the therapeutic-care process.

Footnotes

Authorship Confirmation Statement

All authors confirmed authorship of this article and agree for submission and publication.

Funding Information

No funding was received for this article.

Author Disclosure Statement

No competing financial interests exist.

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