Validation of the Well-Being Picture Scale (WPS) as a measure of mood.
Abstract: This paper reports the extension of the psychometric properties of the Well-Being Picture Scale (WPS) developed by Gueldner and colleagues (2005). A convenience sample (N=220) of generally healthy registered nurses as well as nursing and psychology students in two Mid-Atlantic academic settings completed the WPS and the Profile of Mood States (POMS). The Rogerian energy field concepts of frequency, action, awareness, and power were found to correlate significantly with age (p=.027). Correlations between the scores and education, ethnicity, and gender were not found to be significant. An inverse association was found between the WPS and POMS Standard scores (r= -.343; p<.001), as might be expected. Confirmatory factor analysis revealed that the "eyes open" and "shoes tied" items accounted for 62.7 % of the variance in this sample. The overall Chronbach alpha was .838, which is consistent with the findings of previously reported work. This inaugural comparison demonstrating an inverse relationship between the WPS and the POMS suggests that the WPS composite score holds considerable promise for clinical usage to assess mood state.

Keywords: Well-Being Picture Scale, Sarah H. Gueldner, psychometric evaluation, mood state, Martha E. Rogers, Profile of Mood States, clinical assessment
Article Type: Report
Subject: Nursing students (Psychological aspects)
Nursing (Methods)
Authors: Johnston, Nancy
Guadron, Mary
Verchot, Christeen
Gueldner, Sarah
Pub Date: 01/01/2011
Publication: Name: Visions: The Journal of Rogerian Nursing Science Publisher: Society of Rogerian Scholars Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Society of Rogerian Scholars ISSN: 1072-4532
Issue: Date: Jan, 2011 Source Volume: 18 Source Issue: 1
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 272167864
Full Text: Rogers (1992) stated that the purpose of nursing is to "foster the well-being of humans in our care wherever they are in the environment" (p. 28). Well-being was not defined by Rogers, but is typically understood to mean a state of being healthy. In order to foster the well-being of another, one must come to understand the other's health. But health can be difficult to assess, especially the aspect of mood of another human being. A number of measures to screen for disturbed mood states exist for nurses to use; however, most use a negatively worded scale.

The Well-Being Picture Scale (WPS) developed by Gueldner et al. (2005) approaches the assessment of human well-being from a positive energy perspective. This scale attempts to capture a sense of well-being using black and white line drawings depicting the concepts of frequency, awareness, action, and power of the individual at a specific point in time. The purpose of this paper is to report the findings of a study using quantitative methods to further examine the psychometric properties of the WPS in a sample of generally healthy individuals. The research questions are 1) Is there a relationship between scores on the WPS and the Standard Profile of Mood States (POMS), 2) Is the WPS sensitive to assess mood state in the general population, and 3) Is there a significant difference of the factor analysis between previously reported findings in a sample from the United States, Taiwan, Japan, and Africa (n= 1027) (Gueldner et al., 2005), and the sample from the United States who participated in this study.

Well-Being in the Context of Rogerian Theory

Rogerian science posits that humans are always in the process of "becoming" rather than just "being" (Parse, 1997), and that the focus of nursing is on humans within their mutual human-environmental field. Rogers uses the term in her definition of nursing, "the purpose of nurses is to promote health and well-being for all persons wherever they are" (Rogers, 1992, p. 28). So central to the purpose of nursing is well-being.

Well-being is defined by Hills (1998) as a sense of relative harmony and satisfaction in one's life. Connections between well-being and health have emerged, including a movement toward self-fulfillment or realization of one's potential (Smith, 1981; Todaro-Franceschi, 1999) and personal commitment (Parse, 1997). Newman (2008) proposes that well-being cannot be distinguished from health, but rather is a manifestation of expanding consciousness not separate from the illness experience. Morris (1991) and Hills (1998) link well-being with awareness based on integrality, resonancy, and helicy. An understanding of these homeodynamic principles is essential to the definition of well-being. Helicy refers to "the continuous, innovative process within the human-environmental field pattern, manifested as movement toward one's potential, and is positively associated with a sense of well-being even in the presence of illness or other challenging life experiences" (Rogers, 1992, p. 31). Resonancy, described by Capra (1975, p. 226) as the "continual cosmic dance," characterizes the human-environmental energy field. Resonancy describes energy patterns from lower to higher frequencies, and is postulated to be associated with a heightened sense of well-being (Gueldner et al., 2005). Integrality is defined as the "continuous mutual human field and environmental interchange" (Rogers, 1992, p. 31). Malinski (1994) summarizes the relationships among these three important concepts by stating that helicy is the nature of change, resonancy is the process of change, and integrality is the context of change.

Well-Being Picture Scale (WPS)

Gueldner, Bramlett, Johnston, and Guillory (1996) revised the 18-item Index of Field Energy (IFE) to a shorter and simpler scale of ten picture pairs known as the Well-Being Picture Scale (WPS). It is postulated that the principles of helicy, resonancy, and integrality are embedded in the experience of well-being. Like its precursor the IFE, the WPS is designed to measure general well-being in an individual integral with his or her unique human-environmental field process, and is designed to be easily administered in the broadest possible range of adult populations. Like the longer IFE scale, the WPS measures well-being according to the four constructs of power, frequency, awareness, and action, as described below. It should be noted that a children's version of the WPS (Terwilliger, Gueldner, & Bronstein, in press) has recently been developed and tested for use with fourth grade and older elementary school children.

Power derives from the principle of helicy and is defined as the capacity of an individual to engage consciously (i.e., knowingly) in change (Barrett, 1990). Within the WPS, the lion-mouse item represents power. Frequency refers to the motion within human-environmental energy field(s), and is related to resonancy, as described by Capra (1975). Changes across a continuum ranging from lower to higher frequencies are portrayed in simple line drawn pairs of eyes open and closed, a lighted and unlit candle, a faucet running full or dripping, and a butterfly paired with a turtle. Awareness is derived from helicy and integrality. Awareness refers to an individual's potential or readiness for change within the environmental field, and is positively associated with a sense of well-being. This concept is reflected in the drawing of a sharp pencil opposite a dull pencil, and in puzzle pieces scattered and puzzle pieces together, balloons inflated or drooping, and sun in full view or behind clouds. Action derives from the principle of integrality as an emergent of the continuous mutual human field process (Rogers, 1992), but also reflects resonancy. Activities of daily living are included in actions such as eating, preparing food, personal grooming, engaging in social events, or doing chores. A single item reflecting action is the sneakers with laces untied opposite sneakers with laces tied and running. The WPS has been administered to over one thousand individuals around the world, including the United States of America (USA), Taiwan, Korea, Japan, Arabic speaking countries, and Africa. Confirmatory factor analysis and internal consistency measures reveal strength (Cronbach [alpha] = .8795) (Gueldner et al., 2005).

Mood Defined

Mood is defined as a relatively long lasting emotional state and reflects the health status. Moods differ from simple emotions in that they are less specific, less intense, and less likely to be triggered by a particular stimulus. Moods are viewed as having either positive or negative valence, and are often expressed as being in a good mood or a bad mood (Thayer, 2001). Unlike sudden fear or surprise, or other acute emotional feelings, moods often last for hours or days. Mood is an internal, subjective state with potential for long term disturbances such as depression, and can often be inferred from posture, behavior, or other body language. Thayer (2001) goes on to describe mood as a product of two dimensions: energy and tension. The reference to energy as a component of mood supports the tenets of the Science of Unitary Human Being. These authors postulate that a person in a state of well-being would be in a good mood. Conversely, it is postulated that a person with a mood disturbance would experience a decreased sense of well-being. Rogers's concept of resonancy appears to most closely embrace mood state within the human environmental field, in that it describes energy patterns from lower to higher frequencies, and sense of one's self as energy is a key aspect of mood state.

A commonly utilized instrument to measure mood is the Profile of Mood States (POMS) (Lorr, McNair, Heuchert, and Droppleman, 1971). A review of the literature for the use of the Profile of Mood States in clinical research revealed numerous studies. The POMS is used in nursing and biomedical research with both healthy and patient samples to measure mood state. Reliability and validity of the POMS have been well established. In reviewing only studies since 2004, research in four different specialties, including cancer (Knois, Aaronson, Uebelhart, Fransen, & Aufdemkampe, 2005), chronic pain (Dworkin, et al., 2008), psychology (Andersen, Farrar, & Golden-Kreutz, 2004), and hypothyroidism (Grozinsky-Glasberg, Fraser, Nahshoni, Weizman, & Leibovici, 2006) all utilized the POMS to evaluate baseline and subsequent change in mood across the respective clinical trials. In this study both the POMS and WPS were compared.

Methods

Design

This descriptive correlational study contributes to the understanding of the validity of the WPS by correlating a composite score on the WPS with the score on the POMS.

Sample

The convenience sample was comprised of 220 nurses as well as nursing and psychology students in two academic settings from different Mid Atlantic states. Age ranged from 18-67 years with a mean age of 35.45 (+/-12.98) and included participants for a range of 49 years. Eighty-two percent (82%) of the sample were born in the United States (U.S.) and the remaining 17% were born in Bosnia, England, Germany, Haiti, India, Japan, Kenya, St. Maarten, and Ukraine, representing every continent except Antarctica. The minimum education was "in college now" (70%) and the maximum was "graduate education" (30%). This homogeneous sample consisted of 94% females and 6% males. Table 1 provides demographic characteristics of the sample.

Procedure

After obtaining human subjects research approvals from the State University of New York at Binghamton, New York and Cedar Crest College in Allentown, Pennsylvania, nursing faculty in a rural upstate New York setting and a suburban midlevel region in Pennsylvania recruited a convenience sample of nurses, nursing students, and psychology students as part of class activities to experience research methods first hand. After informed consent was obtained, participants completed a one-page demographic sheet and the two instruments, WPS and POMS.

Instruments

Well-Being Picture Scale.

The Well-Being Picture Scale (WPS) is a 10-item non-language based pictorial scale that measures general well-being (see Figure 1) and was based on Martha Rogers' view of human beings as energy fields in continual mutual process with their environment. The Well-Being Picture Scale was designed for use with the broadest possible range of adult populations, including persons who are unable to respond to English-based text or complete a more lengthy or complex measurement instrument. The overall Cronbach's alpha is .8795 (Gueldner et al., 2005).

Profile of Mood States Instrument (POMS).

The Profile of Mood States (POMS) developed in 1971 by Lorr, McNair, Heuchert, and Droppleman consists of 65 items taking approximately 10 minutes to complete, and is concerned with the phenomenology of feelings and emotions. Each subscore is derived from the sum of ratings for 7 to 15 adjectives. Reliability estimates using the Kuder Richardson 20 statistic (KR-20) ranged from 0.84 to 0.95. Test/retest correlations ranged from 0.65 to 0.74 with a median of 0.69 (McNair, Lorr, & Droppelman, 1981). The respondent rates items on a 5-point scale ranging from "Not at all" to "Extremely." The items fall into six identified mood factors (five negative pairs and one positive pair): Tension-Anxiety, Depression-Dejection; Anger-Hostility: Fatigue-Inertia, Confusion-Bewilderment, and Vigor-Activity. Examples of feelings that respondents mark include "worn out," "grouchy," "energetic," or "listless." Sub scores for Tension, Depression, Anger, Fatigue, and Confusion are summed and then the subscore for Vigor-Activity is subtracted, resulting in either a negative score for mood stable participants or a positive score for those with mood disturbance. Norming of a sample of college students revealed a range of scores from 168 to -3 (mean = 55) (Lorr, McNair, Heuchert, & Droppleman, 2003).

[FIGURE 1 OMITTED]

Statistical Analysis

Data was analyzed using the Statistical Package for the Social Sciences (SPSS) Version 16.0 2007). Correlations between composite WPS, POMS, and demographic variables were conducted using Spearman's rho. Additional analyses of the WPS calculated factor loadings on individual items contributing to instrument validity. A calculation of missing data revealed .01% missing data or 37 items omitted by participants, out of 3,280 possible data pieces.

Results

WPS and Demographics

A composite WPS score was calculated by summing the Likert rating for each item and dividing by 10 (the total number of items in the instrument). Using this method WPS scores ranged from 10-70. The mean WPS score was 4.831 A positive correlation was discovered between the WPS composite score and the demographic variable of participant age (r=.408, p <.001).

Correlations were calculated for each item of the scale based on the demographic variables of age, education, and gender. Education and gender did not reveal significant associations. However, as was seen in the previous finding with age and the total WPS score, age was significant for every item. There was a positive association with age.

Differences in WPS scores also emerged between the Pennsylvania and New York participants. Even though the sample size was skewed toward Pennsylvania, the POMS scores for the New York participants were significantly higher (r=.192; p=.011). However, comparisons of WPS composite scores between Pennsylvania and New York participants were not significant (r=-.056; p=.223).

Item Analysis of WPS With Age

Power. The mean lion-mouse score was 4.74 (+/-1.5). For the age variable r=.198, p=.027.

Frequency. The concept of frequency was measured by four items: eyes, turtle, candle, and faucet.

* Eyes. The mean eyes score was 4.81 (+/-1.648). For age the r=.466, p<.001.

* Turtle. The mean turtle score was 4.93 (+/-1.62). For age

the r=.290, p=.001.

* Candle. The mean candle score was 5.09 (+/-1.47). For age the r=.239, p=.007.

* Faucet. The mean faucet score was 4.67 (+/-1.52). For age the r=.383. p<.001. Awareness. The concept of

awareness was assessed by four items: puzzle pieces, pencil, sun, and balloon.

* Puzzle. The mean puzzle score was 4.63 (+/-1.66). For age the r=.293, p=.001

* Pencil. The mean pencil score was 4.89 (+/- 1.45). For age

the r=.299, p=.001

* Sun. The mean sun score was 4.74 (+/-1.71). For age the r=.234, p=.009.

* Balloon. The mean score for balloon was 4.76 (+/- 11.71). The r score was .246, p=.006.

Action. The concept of action was measured by the sneakers; the mean sneakers score was 4.50 (+/- 1.56). For age the r=.204, p=.022.

POMS Findings

The POMS scores ranged from -8.2 to 94. The mean composite score was 26.84 (+/-8.53), with a positive score indicating that some participants (N=10; POMS score >83) were experiencing disturbed mood.

Correlation of WPS to POMS

The correlation revealed an inverse association between the WPS scores and the POMS scores (r= -.343; p<.001), as would be expected, given that mood was measured as a negative trait and well-being was measured as a positive trait. Internal Consistency

The Cronbach alpha (a=.838) was somewhat lower than reported by Gueldner et al. (2005) (a=.8795), but is still considered to be a strong indicator.

Factor Analysis

A factor analysis was performed using Principle Component Analysis with Varimax rotation, as was also performed in a sample from the United States, Taiwan, Japan, and Africa (Gueldner et al., 2005). A four-factor structure of the WPS was evident, consistent with previous results (Gueldner et al, 2005). As shown in Table 2, current results reveal that all 10 items were consistent with the proposed structure. Across all four samples, five of the ten items were completely consistent with the proposed structure (puzzle, balloon, sun, eyes, and lion). The remaining items (pencil, candle, faucet, butterfly, and shoes) were consistent across three samples.

Discussion

The data collection phase for this study lasted from June 2006 until September 2009, or 3 years and 2 months. The sample for this study was mostly female, predominantly U.S. citizens, all nurses or nursing and psychology students, which limits the generalizability of the findings. Every item in the WPS correlated with age in a positive direction; namely, the older the person the higher the WPS score. One possible explanation applying Rogers's theory could be that most of the older participants were registered nurses, older, and perhaps more evolved toward self-awareness, in contrast with the younger nursing and psychology students who were perhaps in an earlier stage of "becoming".

The candle item achieved the highest mean score (5.09) and was also highly significant (p = .007), bringing to question the possibility that the metaphor of the lighted candle may have prompted a special connection with the traditional icon of the lighted lamp as a professional symbol in this sample that included nurses and student nurses. The principle of frequency is at work in this item and represents the state of pattern in the "cosmic dance." However, it should be noted that in the confirmatory factor analysis "candle" accounted for only 1.75% of the variance.

The correlation between the WPS mean score and the POMS demonstrated an inverse relationship. As the WPS score increased (representing a state of well-being), the POMS score decreased (representing the absence of mood disturbance) in this generally healthy sample, suggesting that a high sense of well-being can exist only in the presence of a balanced mood.

The frequency (i.e., eyes, candle, faucet, and butterfly) and action (i.e., shoes) items account for more than 60% of the items on the scale, and it seems possible that items such as the open eyes and shoes in movement could foster special interpretations among this sample of nurses. For instance, nurses and nursing students may see themselves as the "eyes" for sick patients and their families. Likewise, nurses and nursing students may see themselves as "on the move," and today many nurses wear sneakers as they provide care to patients and families; therefore it seems possible that nurses and nursing students might respond in a different way than others to the frequency and action items. This question could be examined more specifically in future studies.

The factor analysis results demonstrate strong support for the proposed factor structure in addition to general consistency across this sample and three previous samples (Gueldner et al., 2005). Five of the ten items were completely consistent with the proposed structure (puzzle, balloon, sun, eyes, and lion) and the remaining items were consistent across three samples. Overall, participants in this study and in previous samples (Gueldner et al., 2005) show a similar interpretation of the items on the WPS scale, demonstrating that the items produce an acceptable degree of consistency across languages, cultures, education levels, and cognitive abilities.

Conclusion

It was found in this study that the WPS score and POMS score are associated in a significant inverse relationship, indicating that they represent related but opposite constructs. Based on the strength of internal consistency, the researchers calculated a WPS composite score, allowing for a comparison with the composite POMS score; both scales were previously analyzed using confirmatory factor analysis, both utilize a Likert scale, and the findings of both result in ordinal data. This inaugural comparison demonstrating an inverse relationship between the WPS and the POMS suggests that the WPS composite score holds considerable promise for clinical usage as a more simple measure to assess mood state. The findings of this study also confirmed that age and WPS composite scores are highly correlated, which has implications for future applications.

In future studies it is important to include participants with a variety of demographic characteristics such as urban or rural setting, religious affiliation, occupational category and income, marital status, and level of education. The investigators also suggest that it might be informative to include a general short answer question at the beginning of the testing session, asking them to indicate how they feel, such as, "How are you feeling today?" It is also important to extend testing of the WPS to other vulnerable or underrepresented populations, including frail elders, individuals with mental health problems such as depression and dementia, minority segments of the general population, individuals who are incarcerated in prisons, and other individuals with special needs. Finally, it is important to continue to test the recently developed children's form of the WPS, to provide a simple yet reliable measure of well-being in children.

The findings of this study are offered in support of an instrument based on Rogers's theory that uses "imaginative and creative use of knowledge" (Rogers, 1988, p. 100) in human service. It represents an exemplar of the promise that the Science of Unitary Human Beings can provide a foundation for expanding the quality of the nursing product by assessing "those who are otherwise too sick or weak" to have a voice (Gueldner, Britton, & Terwilliger, 2008, p. 122).

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Nancy Johnston PhD, CRNP, Assistant Professor, Nursing Department Cedar Crest College, Allentown, Pennsylvania

Mary Guadron, PhD, MSIS, RN, FNP, CNE Assistant Professor, Nursing Program State University of New York--Empire State College Saratoga Springs, New York

Christeen Verchot, PhD, RN, CWHNP, FNP, GNP Adjunct Professor, School of Health Professions and Education Utica College, Utica, New York

Sarah Gueldner DSN, FAAN, FGSA Arline H. and Curtis F. Garvin Professor of Nursing Frances Payne Bolton School of Nursing Case Western Reserve University, Cleveland, Ohio Professor in Nursing, State University of New York Binghamton, NY
Table 1
Demographic Characteristics of Sample

Country                             USA

Sample size (N)                     220
  NY                                (80) 36%
  PA                                (140) 64%
Ethnicity
  Caucasian                         (182) 82.7%
  African-American                  (20) 9.1%
  Latina/Latino                     (10) 4.5%
  Asian/Pacific Islander            (8) 3.6%
  American Indian/Alaska native     0
  Other                             0
Gender
  Female                            206 (94%)
  Male                              14 (6%)
Education
          
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