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1.1 Introduction

The word spirit has its root in the Latin word spiritus, meaning breath, and most often refers to a noncorporeal substance differentiated from the material body. Throughout human history, spiritual pursuits have been an essential and integral part of human life at both individual and societal level. From a psychological point of view, Erikson’s eight stages of development suggest that every individual will at some stage of their lives ask questions like “what is the meaning of my life?” and “how do I feel about my life?” Searching for ego integrity thus becomes a key aspect of healthy psychological development (Hearn et al. 2012). From a social development perspective, the gerotranscendence theory suggests that during the aging process, individuals shift their focus from a materialistic to a more cosmic and transcendent worldview (Tornstam 2005). One of the routes to achieving such a worldview is spirituality, which can be argued to be a part of normal aging that contributes to positive developments in later life. Over the past few decades, health- and social care professionals, particularly nurses and social workers, have started to pay much more attention to spirituality and spiritual care, which is now believed to contribute significantly to an optimal holistic care system (Bullis 2013; Idler 2014; Koenig 2013; O’Brien 2013). At the macro level, public health specialists have also started to focus on spirituality and health outcomes. In 2003, the World Health Organization (WHO) proposed including spiritual health in their health impact assessment (Chuengsatiansup 2003).

Regardless of the fact that spirituality has attracted increasing interest from health- and social care professionals, there is still no consensus on how to define and measure it. Almost 20 years ago, a group of nursing faculties opened a discussion on how to define spirituality and concluded that its definition was complex and diverse in nature and seemed to depend upon individuals’ own worldview and interpretation (Cawley 1997; Martsolf and Mickley 1998; McSherry and Draper 1998). Later, two new directions on spirituality were advocated, from the nursing and social work profession, respectively. Within a dialogue about spirituality and nursing, some scholars advocated for a broad definition that went beyond religion-based meaning-making and practice. One such proposal referred to the concept proposed by Buck based on an analysis of nursing research on spirituality, defining spirituality as a human experience that “seeks to transcend self and find meaning and purpose through connection with others, nature, and/or a supreme being, which may or may not involve religious structures or traditions” (Buck 2006). Another direction came from the social work profession, suggesting that studies on spirituality should pay attention to the cultural context within which individuals make sense of their lives and form their worldview. After reviewing the assessment of spirituality, Hodge argues that this must take into consideration the sociocultural context in which people are embedded (Hodge 2001; Hodge and McGrew 2006; Hodge and Williams 2002). It is clearly understandable that social work scholars have been not only interested in defining and assessing spirituality in theory, but also translating such an assessment into interventions that will be effective within a particular cultural and/or subcultural context.

Chinese older adults account for one-fifth of the world’s aging population (United Nations 2010). Throughout the history of China, the majority of its population have eschewed formal religious affiliation (Morton and Lewis 2005). On the contrary, many emperors developed strong alliances with a Confucian worldview, with parallel influences from formal and informal religious beliefs including Buddhism, Daoism, traditional Chinese worship, Catholicism, Christianity, and Islam. In the past few decades, healthcare professionals in Hong Kong have begun to make an effort to provide spiritual care to Chinese people with life-threatening illness such as cancer and those reaching the end of their lives (Chan et al. 2002; Liu et al. 2008). Somewhat regrettably, a recent critical review on spirituality in Chinese society shows that (1) there is limited literature available on Chinese spirituality as compared with Western studies, even though a broad definition has been adopted and (2) Chinese measurement tools are most often translated from Western measures, with few indigenously developed measures in use (Shek 2010). The review argues that future research should be conducted “to examine the convergence and nonconvergence of Western and Chinese concepts of spirituality,” to construct “theoretical models on Chinese spirituality,” and to “validate indigenous measures of Chinese spirituality” (Shek 2010).

1.2 Defining Spiritual Well-Being

Among healthcare professionals, nursing scholars are at the front line in terms of critically analyzing how to define spirituality. As summarized in Table 1.1, spirituality can be conceptualized as having the following features:

Table 1.1 A summary of themes identified in defining spiritual Well-Being
Full size table
  1. 1.

    A sense of meaning and purpose together with corresponding emotions including peace and hope. It denotes a state of human existence independent of individual consciousness and personal/cultural background, including religion;

  2. 2.

    Transcendence, which refers to a sense of being that goes beyond time and space. It can be regarded as a unique and distinguished manifestation of spirituality;

  3. 3.

    Connectedness with self, others, the world, and a higher power, making the human being an integrated self with meaning, purpose, and hope; and

  4. 4.

    Spiritual pursuits as a dynamic growth process leading toward an optimal sense of being and meaningfulness.

1.3 Measuring Spiritual Well-Being

As Pesut et al. (2008) point out, spirituality seems to be defined as a broad construct that contains multiple elements, both religious and nonreligious. When an operational definition is developed as a basis for designing measurement tools, such comprehensiveness challenges what to measure and how to measure it. A review of the literature suggests three observations in regard to operationalizing and measuring spiritual Well-Being.

Firstly, spiritual Well-Being can be measured as a spiritual or existential component within the quality of life construct. Such scales tend to assess spirituality as a general construct without probing its differentiated components. The Spiritual Well-Being Scale (SWBS), the most widely adopted measure to assess spiritual quality of life, was developed in the early 1980s (Paloutzian and Ellison 1982) in response to a call to expand measures of quality of life to encompass the spiritual aspect. The SWBS is a 20-item scale that measures religious and existential Well-Being in general, without differentiating subthemes. An item-by-item review shows that item contents are associated with a sense of meaning of life and transcendence, but the instrument does not address the emotional aspect of spiritual Well-Being. Moreover, it measures connectedness with God, but not self, others, and the world. Subsequent studies have suggested there is a ceiling effect when using the SWBS with respondents who adhere to a religion (Ledbetter et al. 1991) and that its factor structure is inconclusive when differentiating existential and religious Well-Being (Musa and Pevalin 2012). In the Chinese context, the Chinese Spirituality Scale (CSC) was developed as part of a body–mind–spirit Well-Being scale (Ng et al. 2005). The 13-item CSC measures three components: tranquility, resistance to disorientation, and resilience (Wang et al. 2008).

Secondly, aside from treating the spirituality measure as part of a quality of life assessment, standalone measures have also been developed by scholars from different backgrounds. The Spirituality Assessment Scale (SAS) was developed from a nursing perspective, guided by a four-component spirituality framework including unifying interconnectedness, innerness or inner resources, purpose and meaning in life, and transcendence (Howden 1992). The 28-item SAS collects responses using a 5-point Likert-type scale ranging from strongly disagree to strongly agree. However, the interconnectedness and innerness components have been found to be more prominent empirically. The spiritual belief section of the Royal Free Interview for Religious and Spiritual Beliefs is another example (King et al. 1995, 2001). As indicated by its title, it tries to capture both religion and spiritual forces. Questions that aim to measure spiritual power focus on whether the respondent believes “in a spiritual power or force that influences what happens to you…” and “a spiritual power or force that enables you to cope personally with events in your life.” As such, the scale seems to be based on a strong assumption that spiritual power or force follows a similar route of influence as religion. The Spiritual Well-Being Questionnaire (SWBQ) was developed by a group of scholars who were concerned more with faith among the adult population with or without religious affiliation (Gomez and Fisher 2003). The 20-item scale is made up of 4 subscales examining personal, communal, environmental, and transcendental Well-Being. The structural validity of SWBQ has been tested and shown to be stable (Gomez and Fisher 2003, 2005).

Thirdly, some work has focused on measuring spirituality among people suffering from life-threatening illnesses such as cancer or who are in exigent circumstances, such as the end-of-life stage. Such measures can be part of quality of life or Well-Being assessments. The Spiritual Well-Being Scale of the Functional Assessment of Chronic Illness Therapy (FACIT-Sp-12) is one of the measures included in the Functional Assessment of Chronic Illness Therapy (Brady et al. 1999). This 12-item scale was developed with input from cancer patients, psychotherapists, and religious officiants. It comprises two subscales on meaning/peace and faith and has been translated into other languages (Peterman et al. 2002). Along with a general approach to quality of life assessment for people experiencing life challenges such as cancer, the McGill Quality of Life Questionnaire (McQoL) fills a gap by including existential Well-Being as an important ingredient (Cohen et al. 1996). It contains 16 items, 6 of which measure this component. Item-by-item content analysis shows that the instrument measures a general sense of life’s meaning, worth, control, and sense of being connected with self. The McQoL has been popularly used to assess quality of life among cancer and end-of-life patients in clinical settings (Balboni et al. 2010; Jones et al. 2011; Vallurupalli et al. 2012). It has been validated using Chinese samples of palliative care patients in Hong Kong (Lo et al. 2001) and Mainland China (Hu et al. 2014).

As you may be able to tell from this discussion, measures that take a more religious approach have not been included in this review. The research team fully respects the contribution to be made by religiously oriented spiritual measures. However, in this work, I intend to focus more on measuring spirituality as a universal human experience instead of as an aspect of religious practice. As pointed out by Meezenbroek and colleagues in their critical review of 10 spiritual Well-Being measures, selecting or using such instruments must firstly consider the purposes for which they are to be used (de Jager Meezenbroek et al. 2012). As discussed in the preface, my purpose is to develop a measure of spiritual Well-Being that can guide intervention. It is then more desirable to generate a measure that assesses different components of spirituality, as reflected in this conceptual review, than to carry out a general assessment of existential Well-Being and/or transcendence. Moreover, so far, not a single measure that aims to assess the multidimensionality of spiritual Well-Being has been developed outside a Western cultural context. I do not deny that there may be a cross-cultural universal human spirituality; however, culturally specific manifestations of spiritual energy and pursuits may be much more relevant if the ultimate goal is to develop practical interventions for enhancing Well-Being.

1.4 Factors Associated with Spiritual Well-Being

It is generally agreed that spiritual Well-Being is associated with physical, psychological, and social Well-Being. Taking a broad definition of spirituality that includes religious practices, spiritual beliefs or practices have been shown to have moderate links with physical and mental Well-Being. In particular, they are associated with the reduced onset of, and favorable recovery from, physical and mental illness (George et al. 2000). Biological pathways have been identified linking spirituality to cardiovascular, neuroendocrine, and immune functions (Seeman et al. 2003). In particular, spiritual coping has been identified to be a powerful life force that helps people endure tremendous uncertainty and achieve transformation after ill-health or disastrous life events (Faigin and Pargament 2011; Koenig et al. 2004; Tuck and Anderson 2014).

Spiritual practices differ across cultures, communities, and individuals. The literature indicates that individual factors (such as gender, age, and level of education); family factors (structure and relationships); and community factors (social norms and peer influences) could confound the relationship between spiritual and other aspects of Well-Being (Maselko and Kubzansky 2006; Shahabi et al. 2002). In theory, the motivation to pursue spiritual Well-Being could increase during the aging process (Reed 1991, 2003). Along the life course of human development, individuals go through various psychosocial developmental stages that eventually aim for a state of integrity (Ardelt et al. 2013).

1.5 Spiritual Pursuits in a Chinese Context

The health, psychological, and social work research on spirituality is embedded in Western countries within a Christian theology, which views spirituality as denoting a personal relationship with God and surrendering to his will (Ardelt et al. 2013; Bullis 2013; Faigin and Pargament 2011). Investigating spirituality in a Chinese context must take into account the Chinese cultural context in relation to its four core features: (1) being dynamic and developmental across the life course; (2) embodying a relationship to the ways in which individuals engage in spiritual pursuits while interconnecting with the self, others, and the world; (3) achievement through a transcendence that can go beyond time and space; and (4) having the ultimate aim of achieving a sense of meaningfulness with corresponding emotions.

During more than five thousand years of history, China has been influenced by multiple cultural traditions including Christianity, Buddhism, Daoism, Islam, and traditional worship. Confucianism is recognized as having a dominant role with a profound impact on people’s worldviews and life experiences. Confucius believed that human development is a process of self-transformation and self-cultivation. Although there are individual differences, everyone goes through the same developmental stages. Each stage brings its own task to be achieved. For example, the Master said that “at fifty, I knew the decrees of Heaven. At sixty, my ear was an obedient organ for the reception of truth” (Legge 2009). During the development process, emphasis is placed on the remaking and reforming of the moral self in the hope of realizing the ethical ideal of “ultimate goodness” (zhi shan) (Yan 2013).

Another important aspect of sociocultural context that might can differentiate Chinese cultures from others is collectivism vs. individualism (Oyserman et al. 2002; Triandis 1995). The collective tradition emphasizes a relational and/or socially oriented life that influences identity development, self-esteem, relationship rules, family dynamics, volunteering, health beliefs, and organizational behavior (Becker et al. 2012; Cross et al. 2002; Finkelstein 2011, 2012; Lam et al. 2010; Zhang 2005). Chinese people tend to express the meaning and purpose of their lives in terms of developing and maintaining harmonious relationships with oneself, others, the natural environment, and religion. The Chinese word guanxi refers to these relationships with self, others, and the world. In the Chinese context, guanxi is a complicated mechanism that basically defines the social web of a Chinese society and dictates the features of one’s support network, the source and resolution of conflict, and the rules of interpersonal exchange (Chan 2006; Chen et al. 2013; Hwang 1998; Lam 2001; Lou 1999).

Collectivist cultures tend to socialize the interdependent self, reflecting the significant role of relationships in the construction of the self (Hwang 1987; Markus and Kitayama 1991). In particular, interdependence is shaped by a common Confucian heritage. Central to Confucianism is the value placed on the maintenance of interpersonal harmony with one’s five cardinal relationships (wu lun): father–son, husband–wife, elder–younger, emperor–subject, and friend–friend (Su et al. 1999). The roles associated with these relationships are relatively fixed and each bears specific obligations. For harmony to be achieved within any hierarchical unit, it is essential for individuals’ actions to correspond with their roles. Individuals are socialized to know their place and to act accordingly. Sometimes, people are expected to perceive the self as a “little me” in the sense that the individual is extinguished from different relationships. Moreover, Confucius argues that it is important for an individual to become a perfect gentleman, behave according to perfect standards, and strive for the right conduct; that is, Ren (humanism), Yi (faithfulness), Li (propriety), and Zhi (wisdom or a liberal education). In doing so, people can achieve harmonious relationships with themselves.

In a collective culture, social relationships are much more important than personality traits. Bond and Hwang identify three essential aspects of Confucianism in constructing a Chinese social psychology (Bond and Hwang 1986): (1) humanity exists through, and is defined by, our relationships to others; (2) these relationships are structured hierarchically; and (3) the social order is ensured by each party honoring the requirements of their role-based relationships. Interpersonal relationships lie at the centre of a Chinese society ruled by the wu lun principle (Yang 1995). Both parties to the relationship, however, are circumscribed by the rules of correct behavior (Li), which entails both rights and responsibilities. Harmony will be realized if each member of the unit is conscientious in following the requirements of his/her role. Moreover, the rules of interpersonal relationships distinguish between in- (Zi Ji Ren) and out-group members (Wai Ren) (Hwang 1987; Leung and Chan 2003). For in-group members, unconditional support but not social exchange is emphasized. For out-group members, the focus is on reciprocity and social exchange. Throughout the life course, Chinese people are encouraged to establish interpersonal relationships with both in- and out-group people so as to enhance the chances of exchange and mutual benefit (Chan 2006).

Confucian thinkers consider heaven to be the same as nature and to behave according to its own principles (Legge 2009). Confucius said that “Heaven does not speak, yet the four seasons run their course and all things come into being.” Heaven in this context refers to living nature which is independent of human will. Confucian thought does not give human beings dominion over nature, nor does it sacrifice human development at the altar of a pristine nature. Confucians argue that humans and nature could be integrated and aim to achieve a harmony and unity between the two. The Doctrine of Mean prescribes that “attaining equilibrium, heaven and earth will be in their right places and all things will come into being.” In handling the relationship between human beings and the natural world, people need to observe the principle of equilibrium and behave accordingly, so that the vitality and harmony of nature and the ecological balance of the natural environment can be properly maintained. Confucian thinkers suggest that participating in the cultivation of heaven and earth is a way to achieve self-realization.

Through continuous consciousness and practice of the moral teachings including Ren (仁), Yi (義), Li (禮), Zhi (智), Zhong (忠), Shu (恕), Xiao (孝), and Ti (悌), individuals’ inner strength will be enhanced. This engages the self morally in developing harmonious relationships with other people and with nature. Eventually, individuals will find the meaning and purpose of their lives in moments of unity with heaven (Tianyenheyi).

1.6 Conclusion

In summary, spirituality is a universal human experience that deserves attention from both a health- and social care perspective. A nonreligious perspective on the concept of spiritual Well-Being and its measurement and intervention has so far been neglected in the literature. However, China provides a perfect research context for such exploration.

Spirituality in a Chinese context should be understood from a more social-relational point of view. In Chinese society, the core aim of spirituality is to achieve unity with the universe/heaven through maintaining a harmonious or balanced relationship with all beings. To have a good and wholesome life, it is important to maintain harmony with all spiritual forces, including those operating in the natural process of the cosmos, the various Gods, Goddesses, and spiritual beings of the cosmos and community, and the ancestral souls that influence the ongoing life of the family.