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Aim. This critical review seeks to identify if there is evidence that private (personal) prayer is capable of improving wellbeing for
adult patients in hospital.
Background. The review was conducted in the belief that the spiritual needs of hospitalised patients may be enhanced by
encouragement and support to engage in prayer.
Design. Systematic review.
Method. A systematic approach was used to gather evidence from published studies. In the absence of experimental research
involving this type of population, evidence from qualitative and correlational studies was critically reviewed.
Results. The findings indicate that private prayer, when measured by frequency, is usually associated with lower levels of
depression and anxiety. Most of the studies that show positive associations between prayer and wellbeing were located in areas
that have strong Christian traditions and samples reported a relatively high level of religiosity, church attendance and use of
prayer. Church attenders, older people, women, those who are poor, less well educated and have chronic health problems
appear to make more frequent use of prayer. Prayer appears to be a coping action that mediates between religious faith and
wellbeing and can take different forms. Devotional prayers involving an intimate dialogue with a supportive God appear to be
associated with improved optimism, wellbeing and function. In contrast, prayers that involve pleas for help may, in the absence
of a pre-existing faith, be associated with increased distress and possibly poorer function.
Conclusion. Future research needs to differentiate the effects of different types of prayer.
Relevance to clinical practice. Encouragement to engage in prayer should be offered only following assessment of the patients
faith and likely content and form of prayer to be used. Hospitalised patients who lack faith and whose prayers involve desperate
pleas for help are likely to need additional support from competent nursing and chaplaincy staff.
Key words: adult nursing, nurses, nursing, review, spirituality
Accepted for publication: 11 May 2008
Introduction
This literature-based study set out to identify if encouragement to engage in private (personal) prayer could potentially
improve wellbeing for adult patients in hospital. It was
prompted by the commitment of one of the authors to the
power of religious prayer and her belief that nurses can and
should support patients for whom prayer might prove
Authors: Claire Hollywell, BN, RN, Staff Nurse and Missionary
Nurse, Faculty of Medicine, Health and Life Sciences, University of
Southampton, Southampton, UK; Jan Walker, BSC, PhD, RN, RHV,
C. Psychol, FHEA, Visiting Senior Research Fellow, Faculty of
Medicine, Health and Life Sciences, University of Southampton,
Southampton, UK
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
doi: 10.1111/j.1365-2702.2008.02510.x
637
Method
A systematic approach was adopted to the identification of
relevant research-based evidence, although the study falls
short of a systematic review because no attempt was made to
include unpublished material. A list of key words is given in
Table 1. The original inclusion and exclusion criteria are
given in Table 2. In the light of our subsequent reading of the
literature and because of their apparent relevance to a critical
review, the inclusion criteria were subsequently broadened to
Rationale
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
Review
Studies of personal or
private prayer
Studies in English
Western studies
(predominantly UK,
USA and Australia)
Participants aged 18
years and over
Critical appraisal
It appears that interest in the role of spirituality in health
and wellbeing has increased substantially during the last
10 years, with many of the studies emanating from the
so-called bible belt of the USA. A total of 26 studies was
identified that specifically examined the active involvement of
people in private or personal prayer, as opposed to intercessional prayer, attendance at religious meetings, or private
beliefs.
Drawing on the hierarchy of evidence (Guyatt et al. 1995),
no randomised controlled trials to test the effectiveness of
private prayer were found, meaning that no meta-analysis of
its effects is currently possible. One matched subjects experimental study (Azari et al. 2001) examined the effects of
asking students to engage in reading religious material. From
the location of brain imaging responses, the authors argued
that religious reading acts as a cognitive prompt to religious
schema. This implies that activities such as private prayer may
be effective only for those with a pre-existing religious
affiliation. However, although prayer and bible reading are
commonly combined into a single religious coping variable,
Database
Description
Rationale
AHMED
Includes journals in
complementary medicine.
CINAHL
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
639
640
Koenig (1998)
Cross-sectional surveys
Koenig et al. (1997)
Seeking comfort
through prayer
Neurocorrelates of
religious experience
Title
Qualitative research
Hawley and Irurita (1998)
Experimental designs
Azari et al. (2001)
Author/ Year
of publication
USA
USA
USA
Canada
USA
Overview of method
Australia
Germany
Location
of study
Key findings
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
Ai et al. (2000)
Title
Author/ Year
of publication
Table 4 (Continued)
UK
Subsample of Australian
Community Survey (n = 989,
aged 15+). Single item on
frequency of personal prayer.
Questionnaire survey of cancer
patients (n = 402) focused on
association between faith and
psychosocial needs.
USA
Australia
UK
USA
Overview of method
USA
Location
of study
Key findings
Review
Critical review of private prayer
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
641
642
Religiosity and general
health among under
graduate students: a
response to OConnor
et al. (2003)
Faith-based and secular
pathways to hope and
optimism subconstructs in
middle-aged and older
cardiac patients
Ai et al. (2004)
Meraviglia (2004)
Ai et al. (2005)
Title
Author/ Year
of publication
Table 4 (Continued)
USA
USA
USA
USA
UK (Wales, N. Ireland)
UK (England/Scotland)
Location
of study
Overview of method
Key findings
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
Title
Ai et al. (2002)
Author/ Year
of publication
Table 4 (Continued)
USA
USA
USA
Overview of method
USA
USA
Location
of study
Key findings
Review
Critical review of private prayer
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
643
644
Depression, faith-based
coping, and short-term
postoperative global
functioning in adult and
older patients undergoing
cardiac surgery
Ai et al. (2007)
Title
Ai et al. (2006)
Author/ Year
of publication
Table 4 (Continued)
USA
USA
Location
of study
Cardiac non-emergency surgery
patients (n = 335) aged 3589.
Preop/postop cohort design.
Measures included: 14-item brief
religious coping scale (BRCS)
containing seven items each for
positive and negative coping; and
3-item using private prayer for
coping (UPPC).
Re-analysis of above data to in
clude structural equation model
ling to identify causal associations
within the data.
Overview of method
Key findings
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
Review
Qualitative studies
Qualitative research is often placed at the bottom of the
hierarchy of evidence along with case reports; however, this
overlooks its power to address research questions which are
not based on prior assumptions. Three qualitative studies
were found: Hawley and Irurita (1998) sought to establish
how people use prayer following surgery, Gall and Cornblat
(2002) studied the role of spiritual factors in understanding
and coping with breast cancer and Walton and Sullivan
(2004) studied the part played by prayer in how men cope
with prostate cancer.
These studies involved disparate samples, locations and
methodologies. Our review has raised concerns about sampling bias and other methodological flaws. Gall and
Cornblats phenomenological study of written accounts was
the largest. Their sample of 52 women with breast cancer
reported a high percentage of regular church attenders
(almost 60%), possibly because it was based predominantly
in Catholic Ottawa and involved only women [for comparison, Tearfund data indicate that in 2006 only 10% of British
people attend church at least once a week (Ashworth &
Farthing 2007)]. Hawley and Iruritas Australian study
involved 13 postsurgical adults from mainline Christian
churches, although it is not clear how this was ascertained.
The gender of their participants is not stated. The methodology was based on ethnographic type interviews and
grounded theory analysis, ignoring the fact that data
collection and analysis did not proceed in parallel as is usual
in grounded theory. In contrast, the Walton and Sullivan
grounded theory study of 11 men in the US Midwest with
prostate cancer used constant comparison to ensure that
saturation of the data was achieved. All of the studies appear
to have been presented to potential participants as focused on
spirituality, which may have biased recruitment. Neither the
Walton nor the Hawley study make it clear what participants
were asked at interview; therefore, it is possible that biases
may have been introduced by the interviewer. The instruction
in the Gall study to tell in your own words how religious and
spiritual factors played a part in your understanding of and
coping with this illness would appear to invite a positive
response and may have excluded those for whom spiritual
issues were not important or had played a negative role in
coping.
Cross-sectional designs
Fourteen cross-sectional studies were identified, falling into
three main types of sample: students, community residents
and patients. All were based on either the administration of
questionnaires or, in most cases involving inpatients, structured interviews. The relationship between private prayer and
wellbeing was assessed using various measures and included a
variety of additional independent and dependent variables.
Five surveys involved students, a convenience sample
commonly used by academics. They are included here
because of the interesting methodological issues raised. In
2003, studies by OConnor et al. and Francis et al. reported
on surveys of students in different parts of the UK using
identical measures of religiosity (the seven item, short form,
of the Francis Scale of Attitude Towards Christianity, FSAC)
and wellbeing/distress (the General Health Questionnaire,
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2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
Review
The fourth study (2006) focused on postoperative functional outcomes showing that, after controlling for age,
preoperative function and depression, together with allergies
and balance problems, neither prayer nor religious coping
made a significant contribution to postoperative function.
However, a second regression model showed a positive
influence on activities of living of preoperative religious
coping and a negative influence of postoperative prayer
possibly because those who had no established religious faith
turned to prayer in desperation to deal with postoperative
difficulties. Because allergies and balance problems were
included, it is not clear why other distressing symptoms such
as pain were not. This may be because the investigators
focused on medical conditions rather than symptoms. If the
symptoms of allergy and balance (itch and dizziness) are the
problem, pain and other distressing symptoms deserve to be
included in future studies.
A more recent analysis of their dataset (Ai et al. 2007)
focused on the role of optimism in explaining the relationship
between prayer and wellbeing (anxiety and depression). The
authors report that prior to surgery, 88% of respondents
expressed a belief in the importance of prayer and intended to
use personal prayer to cope with difficulties related to
surgery. The strong protestant tradition in Michigan might
account for this because in view of the high percentage who
claimed that their prayer would consist of a conversation
with God (74%). In the absence of faith, superstition might
play some part for those who claimed that they would pray
for the accomplishment of needs (50%) or other types of
prayer (15%). In support of this explanation, use of prayer
was found to be associated with a lower level of education
and increased level of chronic conditions (the last two closely
related), which may suggest that the poor have more health
problems and a greater imperative to pray. Simple correlations showed no relationship between the use of preoperative
prayer coping strategies and anxiety or depression. However,
a more detailed analysis showed that there were in fact two
competing pathways. Prayer was directly associated with an
increase in the symptoms of acute stress, which may indicate
that people under stress make more use of prayer. However,
this negative relationship was cancelled out by a decrease in
acute stress symptoms mediated by optimism. This suggests
that those whose prayers lead to increased optimism experience less symptoms of acute stress. The authors failed to
distinguish between different types of prayer although it is
possible that the types of prayer associated with optimistic
appraisals and lowering of post-traumatic stress are different
from those associated with an increase in post-traumatic
stress. Prayers prompted by desperation in response to pain,
poor prognosis or postoperative trauma may serve to increase
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
647
Discussion
The first points to emerge from this review relate to
methodological issues, notably sample bias, theoretical
confusion about the nature of causal relationships and
measurement distortions. Although several studies have
identified a positive association between prayer and wellbeing, this appears to hold for those who have a religious
faith, but not necessarily for others. Many of the studies
have taken place in areas of the world where there are
strong Christian traditions and where church attendance
and use of prayer are relatively high. Our review supports
observations of Speck et al. (2004) that active participation
in religious coping strategies including prayer seem to lead
to better health and wellbeing. However, sampling bias is
likely to be increased during recruitment to a study
explicitly about spirituality because this could deter those
who find the subject embarrassing or irrelevant. It is also
possible that compliant patients might confess to spurious
religious beliefs and activities during structured or semi648
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
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Conclusions
The original question was: Has personal prayer been shown
to be associated with positive health outcomes and, if so,
under what circumstances? The answer is that a positive
association has been found between prayer and wellbeing,
although evidence for this appears to be limited to those who
have a religious faith and engage in devotional pray on a
regular basis. There is no evidence that praying is likely to be
beneficial in the absence of any kind of faith and some
evidence that certain types of prayer based on desperate pleas
for help in the absence of faith are associated with poorer
wellbeing and function. However, these findings are based
predominantly on correlational findings. To reduce response
bias, we suggest that future research should focus on a range
of coping strategies that include prayer and other religious
coping strategies, rather than focusing specifically on these. At
the same time, studies need to distinguish between the effects
of different types of prayer. However, it should be noted that
our study was based on published data only and this may be
regarded as an important limitation of a systematic review.
Contributions
Study design: CH; data collection and analysis: CH, JW and
manuscript preparation: JW.
References
Ai AL, Dunkle RE, Peterson C & Bolling SF (1998) The role of
private prayer in psychological recovery among midlife and aged
patients following cardiac surgery. The Gerontologist 38,
591601.
Ai AL, Bolling SF & Peterson C (2000) The use of prayer by coronary
artery bypass patients. The International Journal for the Psychology of Religion 10, 205220.
Ai AL, Peterson C, Bolling SF & Koenig H (2002) Private prayer and
optimism in middle-aged and older patients awaiting cardiac
surgery. The Gerontologist 42, 7081.
Ai AL, Peterson C, Tice TN, Bolling SF & Koenig HG (2004) Faithbased and secular pathways to hope and optimism subconstructs in
middle-aged and older cardiac patients. Journal of Health
Psychology 9, 435450.
Ai AL, Tice TN, Peterson C & Huang B (2005) Prayers, spiritual
support and positive attitudes in coping with the September 11
national crisis. Journal of Personality 73, 763791.
Ai AL, Peterson C, Bolling SF & Rodgers W (2006) Depression, faithbased coping and short-term postoperative global functioning in
adult and older patients undergoing cardiac surgery. Journal of
Psychosomatic Research 60, 2128.
Ai AL, Peterson C, Tice TN, Huang B, Rodgers W & Bolling SF
(2007) The influence of prayer coping on mental health among
cardiac surgery patients: the fole of optimism and acute distress.
Journal of Health Psychology 12, 580596.
Ashworth J & Farthing I (2007) Churchgoing in the UK. Teddington,
Tearfund.
Azari NP, Nickel J, Wunderlich G, Niedeggen M, Hefter H, Tellman
L, Herzog J, Stoerig P, Birnbacher D & Seitz RJ (2001) Neurocorrelates of religious experience. The European Journal of
Neuroscience 13, 16491652.
Baldacchino DR (2006) Nursing competencies for spiritual care.
Journal of Clinical Nursing 15, 885896.
Department of Health (1998) A First Class Service: quality in the new
NHS. Available at: http://www.dh.gov.uk (accessed 17 November
2007).
Department of Health (2001) National Service Framework for Older
People. Available at: http://www.dh.gov.uk (accessed 17 November 2007).
Department of Health (2003) NHS chaplaincy: meeting the religious
and spiritual needs of patients and staff. Guidence for managers
and those involved in the provision of chaplaincy-spiritual care.
Available at: http://www.dh.gov.uk/en/publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_4073108 (accessed 22 November 2007).
Dunn KS & Horgas AL (2000) The prevalence of prayer as a spiritual
self-care modality in elders. Journal of Holistic Nursing 18,
337351.
Francis LJ & Kaldor P (2002) The relationship between psychological well-being and Christian faith and practice in an Australian
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
649
650
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
Review
Walker J (1989) The Management of elderly patients with pain:
a community nursing. perspective. PhD Thesis. CNAA/Dorset
Institute (Bournemouth University, UK).
Walker J (2001) Control and the Psychology of Health. Open
University Press, Milton Keynes.
Wallston KA, Wallston BS & DeVellis R (1978) Development of the
multidimensional health locus of control (MHLC) scales. Health
Education Monographs 6, 160170.
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637651
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