Validation of the spiritual screening tool ConnecTo

ABSTRACT

Understanding more about an older person’s spirituality is important when they begin engagement with organizations providing care. This research sought to determine the validity of the ConnecTo spirituality screening tool. This tool enables care providers to gain some understanding of the spirituality of older people entering residential aged care or receiving a home care package. A mixed-methods, triangulated approach was used in determining that the tool is valid. This included an analysis of both the quantitative and the qualitative data associated with the screening process. Some 56 older people and 15 interviewers participated in the research.

KEYWORDS:

• Aging
• Caregiver
• Quality of life
• Spirituality
• Tool use behavior

Introduction

ConnecTo (Meaningful Ageing Australia, 2017a) (Diagram 1) is a tool developed to enable care providers gain some understanding of the spirituality of older people entering residential aged care or receiving a home care package.

Diagram 1. ConnecTo – Concept Map. (Meaningful Ageing Australia, 2017b)

ConnecTo accepts as a basis for its function the definition of spirituality developed as an outcome of two conferences in the United States:

Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices (Puchalski et al., 2014, p. 646).

It is based on the principle that connectedness is an important aspect of spirituality (de Brito Sena et al., 2021). (In the above definition the concept of ‘relationship’ is synonymous with the that of ‘connectedness’.) The basis for ConnecTo was initially developed by Fletcher (2016) and later modified by Meaningful Ageing Australia. It recognises five domains that are integral to spirituality – connectedness with self, others, something or someone bigger or higher (including religion), nature and creativity.

The four domains developed by Fletcher (2016) were Self, Others, Mystery/Transcendence and World. The developers of ConnecTo renamed Mystery/Transcendence to the more vernacular term Something Bigger (that might include religion), and divided the World domain into Nature and Creativity. These last two domains, Nature and Creativity, are not always regarded as being spiritual. However, careful analysis will show that both are central to the inner being of many people. They come within the definition cited above. For example, Nature can be central to spirituality (Ferguson & Tamburello, 2015) and artists, in the broadest sense of the word, express their central being through their art (Prodan, 2014).

The tool is underpinned by a belief that spirituality is an important element of an older person’s life – it opens up understanding of the core of their being (Taylor, 2013) and provides information about what creates a sense of purpose and meaning in life (Cobb et al., 2012). It is premised on the concept that the development of spirituality will lead to a better quality of life and inner peace (Egan et al., 2017).

ConnecTo was developed and reviewed considerably when it was first introduced but it has never been formally validated, i.e. it has not been tested to determine that it measures what it purports to measure – an older person’s spirituality. The Australian National Guidelines for Spiritual Care in Aged Care (Meaningful Ageing Australia, 2017a) state that there is a need for an initial conversation with every older person entering aged care provision in order to understand their spiritual choices, needs and preferences. While there are many spiritual assessment and screening tools available, to the best of our knowledge no recent tools focusing on spirituality in older age have been produced for people who are accessing aged care services.

The validated tool used in this project (FACIT, 2010) makes no reference to older age. In addition, it is essentially a quantitative measure that does not promote discussion between a carer and an older person, the essence of spiritual care is conversation. FACIT-Sp-12 does not allow exploration of the person’s spirituality essential to understanding a person’s spirituality in greater detail. The use of statistics in this project is designed to assist in ConnecTo’s validation through converting responses that can be statistically compared and then analysed qualitatively with respect to verbal responses.

Method

The development of ConnecTo was predicated on a belief that an interview or conversation is conducive to understanding more about a person’s spirituality. This process has been used extensively in qualitative research and in spiritual care contexts (Naor & Mayseless, 2020; Walter et al., 2022; Wright, 2002).

Recruitment

In order to obtain participants in this study, Meaningful Ageing Australia, a nationally recognised association of aged care providers, was used to recruit participants. This association had about 100 member organisations at the time of the project. All were invited to participate. Fifteen member organisations accepted the invitation. The inability of some organisations to participate was due mostly to the circumstances of many organisations whose team members were affected adversely by the health and physical environment created through the COVID pandemic, floods and bushfires (wildfires). Those participating agreed to provide spiritual carers (team members trained to explore spirituality in older people) to undertake one-on-one, face-to-face interviews with people in their care. A sample target of over 50 participants was set for study to ensure that the number of participants enabled statistical analysis to be viable. At the same time, the qualitative component (recording verbal responses) suggested that the target should not be so high that analysis of these responses would become cumbersome.

Participants were all cognitive aware of the nature of the project. This was explained to them before data were collected. Older people clinically diagnosed with dementia were not included in the study. This criterion was applied to both people in aged care and those receiving home care packages.

The data collection process was time consuming (always an important element of qualitative research) in that each participant agreed to be interviewed, engage in the discussion and complete the ConnecTo questions. During the 30 to 45 minute interview, the interviewer explained the process and implemented the data collection. This included conveying the purpose of the study, seeking the participant’s consent to be involved, assuring confidentiality and recording (in writing) the subsequent conversation.

Participants

A total of 56 participants either in an aged care home or receiving a home-care package were interviewed by qualified and experienced spiritual carers. Spiritual carers were team members designated to assist in the spiritual development of clients of aged care providers and had significant experience in spiritual care.

Interviews were conducted in 15 different locations across Australia: Victoria, the Australian Capital Territory, New South Wales, Queensland and Western Australia. Data were collected over a period of 13 months due mostly to the understandable preoccupation of the interviewers with day to day aged care matters during the COVID pandemic.

Interviewers

The 15 interviewers (the spiritual carers) who collected data were trained specifically in the use of ConnecTo for the purposes of interviewing participants in this research.

The study was approved by a university human ethics committee and each organisation formally consented to be involved in a process overseen by the umbrella association.

Measures

ConnecTo. ConnecTo is available as three sub-tools that help in exploring the conversation on spirituality – the Visual Map (VM) (Diagram 2), Spectrum Version (Diagram 3) and the Likert Version (LV). In typical usage, one of these sub-tools is chosen by the organisation, or an older person, to use as the basis of their screening. With the sub-tool chosen, the interviewer asks for a verbal response to each domain after the tool questions were completed.

Diagram 2. ConnecTo Visual Map.

The basic question in relation to the domain is “What’s most important to you?” In this research, both SV and VM were used. The Likert Version was not used as it was seen by the developers, after publication of ConnecTo, as potentially less empowering of the older person. The scale ran from ‘hard to detect’ to ‘very strong’, suggesting that the aged care professional would be making a judgement about the person’s connections, rather than working with the person to use the tool to communicate how they were feeling. The developers’ concerns were confirmed by a Masters of Social Work student who undertook an evaluation of the ConnecTo sub-tools. He also worked with the framework to create a video with older people who are accessing aged care services.

The Visual Map (Diagram 2) asks older participants to indicate their connection visually through placing varied and appropriate lines between their ‘self’ and the domain to demonstrate their connection. The way responses were requested in the sub-tools meant that answers could be translated into quantitative data. (Refer to the response legend in Diagram 2). The range of scores was 14 to 30 with mean of 21.77, sd = 3.06.

The Spectrum Version sub-tool (Diagram 3) provides an opportunity for participants to express their spirituality in the five domains by estimating their position on the spectrum from their connection with the domain being ‘not at all connected’ to ‘strongly connected’. The range of scores was 15 to 30 with mean of 25, sd = 3.88.

Diagram 3. ConnecTo spectrum version (Sv).

FACIT-Sp-12 (FACIT, 2010). For this project, a validated spirituality assessment tool, was used as a cross-reference against the SV and VM tools. This was the FACIT-Sp-12 test, a measure developed in the UK, initially to evaluate the degree of spirituality in patients experiencing cancer. It was further developed to determine the relationship between the person’s spirituality and their quality of life. It is regarded as a reliable and valid measure (Munoz et al., 2015) and as being especially useful in assessing “the role of nonreligious spirituality in QOL and other health-related research” (Peterman et al., 2002). A limitation, however, is that it does not refer specifically to spirituality in older people and is illness centred. The Munoz et al. study referred to the increased value it had in older people receiving a higher score in a broad ranging age cohort. The FACIT-Sp-12 tool asks participants to respond to questions on a 1 to 4 scales where 0 = Not at all and 4 = Very much. The range was 15 to 47 with mean of 36.92, sd = 8.04.

Study design and data collection

A mixed methods approach was chosen for validation – quantitative, qualitative and triangulation (Noble & Heale, 2019; Santos et al., 2020). Initially, this involved using the statistical processes between the two sub-tools (VM and SV) and the validated spiritual test measure, FACIT-Sp-12.

The order of the presentation of the three tests (Diagrams 2, 3 and the FACIT-Sp-12 test) was changed in each location so that participant ‘tiredness’ was negated. All tests were completed in the same session for each individual. The completed forms were then de-identified by the interviewers and forwarded to the project coordinator for processing. Results are indicated in (Table 1).

Table 1. Relationship between “What’s important to you” statements and the Visual Map (VM) and Spectrum Version (SV) statistical scores.

Participant	Age	Domain	VM score	SV Score	Connectedness	Statement
Ada	84	Self	5/5	6/6	Strong	“Being true to myself; living honourably and honestly”
Pietr	71	Something bigger	1/5	1/6	No	“Nothing”.
Edie	90	Creativity	2/5	2/6	Little	“I don’t consider myself very creative really. I used to play a lot of sport. Now I watch it on TV.”
Kevin	80	Others	3/5	3/6	Just	“It depends on the person – to be kind, caring, good people.”
Molly	83	Nature	4/5	5/6	Fair	“I used to be very connected with nature but now I am confined to bed I am less able.”

Notes: 1. All names are pseudonyms.

2. Scores show the participant response first and the items in the scale second. The VM had five possible responses and the SV six. ‘Connectedness’ indicates a manual observation of the relationship between the participant score and the possible responses where 1 = not connected at all, and either 5(VM) or 6(SV) = strongly connected.

Secondly, the 15 spiritual carers who interviewed participants were asked to respond to four questions. These, and their responses, are provided in the Results (Table 2).

Table 2. Questions of interviewers and their responses.

Questions	No of responses	Mean	Standard Deviation
1 The participants were able to participate easily in the process	14	3.93	0.83
2 The ConnecTo questions covered most aspects of the participants’ spirituality	13	4.08	0.86
3 The overall screening process was valuable.	13	4.07	1.39
Question	No. of Responses	Responses	Standard Deviation
4 Which sub-tool do you think was more effective in understanding a person’s spirituality (VM or SV)?	12	VM = 7 SV = 5	0.52

Notes: The occasional difference in the number of responses in this Table occurred because some declined to respond, for whatever reason.

The correspondence between the test scores and the participants’ statements supports the validity of the screening tool and the process.

Finally, the relationship between the quantitative data and conversational information provided by the participants in the “What’s important to you?” question was analysed by the authors of this paper who also considered the responses to specific questions by the 15 interviewers. All these data were then cross-referenced and considered by the authors.

Results

The 56 participants numbered 18 males and 38 females, the average age was 84 years, and the median age was 80.5 years (ranging from 64 to 97). Information concerning ethnicity was collected but the numbers of people of different ethnic origin were insufficient to determine any differences in their spirituality.

The reliabilities of the ConnecTo scales were marginal. For SV Cronbach’s α = .50 and for VM Cronbach’s α = .57. The FACIT was higher at α = .82.The ConnecTo scales are different in structure than the typical Likert ratings and with only 5 items are likely to have lower internal consistency than longer scales.

The Pearson correlation between the SV and FACIT-Sp-12 totals was .66. The Pearson correlation between the VM and FACIT-Sp-12 totals was .53. The Pearson correlation between the VM total and SV total was .70. Thus, there are strong correlations between the two ConnecTo tests and between each ConnecTo test and the validated FACIT-Sp-12.

There was no statistically significant correlation with age or gender (coded 1 for females and 2 for males) of the participants. In a one-way ANOVA there were no statistically significant differences in means by order of presentation of the three tests with order of presentation coded 1 to 4. All three values of F were no larger than 1.00 and all p values were .40 or higher.

The statements made in the ‘What’s important to you’ question asked at the end of either the VM or SV questions showed that there was a close correspondence with the responses on the test questions. Table 1 (above) is indicative of the statements in relation to the scores on each of the VM (Diagram 2) and SV (Diagram 3) tests.

Table 2 (below) indicates the questions asked of the interviewers and the mean of the responses on a five-point scale, with responses in items 1, 2 and 3 being 1 ‘Not at all’, to 5 being ‘Very much’. In item 4 there was a simple response required of a preference for VM or SV.

Discussion

Any tool that purports to measure spirituality needs to be valid (Monod et al., 2011). The ConnecTo screening tool uses a description of spirituality that includes five domains based on connectedness that have been accepted as being useful; this provides the foundation from which the screening tool can be validated.

ConnecTo provides the opportunity for participants to focus their feelings in either of the VM or SV sub-tools and also to expand on them in the ‘importance’ question.

The results suggest ConnecTo is a valid tool in screening an older person’s spirituality based on three analyses of the data. One, the statistical analysis showed that there was a correlation between the two tests and the validated FACIT-Sp-12 test. Two, the qualitative analyses highlighted the consistency between these and the quantitative data. Three, the interviewer results affirmed the value of the screening tool in a practical way. Cumulatively, these results suggest the validity of ConnecTo.

Limitations of this process included a relatively small sample size for the quantitative analysis. A larger and more ethnically diverse sample would be useful to replicate this validation process. The interviewers were all experienced spiritual carers trained in the use of ConnecTo. If other aged care professionals were to use the tool, they would need to be fully trained in both understanding spirituality in older people and use of ConnecTo.

Conclusions

The findings of this study support the validity of ConnecTo as a screening tool that assists aged care providers to understand more about the spirituality of the people entering into their care. Its purpose as a screening tool is to provide an opportunity for organizations to understand the basic spirituality of their clients to ensure supportive actions are taken early in the care relationship and to create a pathway for more in-depth exploration at a later stage. ConnecTo can be used for later exploration, however, another tool, Connect-Explore, has been developed and validated that enables more in-depth carer and older person conversation on the older person’s spirituality.

Ethics approval

Ethics approval for this study was provided by the University of Southern Queensland. Reference No. H20REA215, approved on 26 February, 2020.

Acknowledgments

The authors wish to acknowledge the excellent cooperation extended by the organisations and aged care providers whose clients or residents participated in the project. Of specific mention are the 15 spiritual carers who interviewed the participants. They overcame the many obstacles of floods, bushfires and the COVID-19 pandemic to ensure they had time to further the challenges of assisting in the spiritual development of the people in their care.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This project received no direct funding from any organisation.