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January 2003 Article of the Month
This month's article selection is by Chaplain John Ehman, Presbyterian Medical Center, Philadelphia PA


Ai, A. L., Peterson, C., Bolling, S. F. and Koenig, H. [University of Washington, Seattle, WA;]. "Private prayer and optimism in middle-aged and older patients awaiting cardiac surgery." The Gerontologist 42, no. 1 (February 2002): 70-81. 


SUMMARY: This study of 246 cardiac surgery patients at the University of Michigan Medical Center investigated the use of private prayer and its relationship to optimism, in light of empirical evidence linking optimism to enhanced physical well-being and improved health outcomes. Measures were employed for optimism, prayer, religious affiliation and religiousness, health status and health impact, and mental health. The authors argue against measuring private religiosity in terms of the frequency of personal religious behaviors, and they have developed a new three-item measure of private prayer for clinical use that focuses on psychological processes underlying the patient's decision to pray. "The results showed that the vast majority of...patients intended to use prayer and that this means of coping...predicted a positive attitude immediately before a major medical event." However, "optimism was not linked with any particular type of prayer"--a finding that "implies that spiritually rooted active coping along with a patient's intention to survive may be more important than any content or type of prayer in sustaining their positive attitudes under the circumstances of a life crisis" (p. 77). Other factors influencing optimism were older age, better socioeconomic resources and healthier affect; thus indicating that the relationship between spirituality and optimism may be part of a complex set of relationships. Moreover, the study found no evidence of a commonly assumed connection between religiosity or religious affiliation and optimism (though the authors address limitations of the study that may explain this). Clinical implications are considered, including: physicians should pay attention to patients' spirituality or religious coping, nurses should accommodate the schedule of a patient's spiritual practices, social workers should assess spiritual needs that may affect the coordination of resources for a patient, and chaplains should accommodate cultural and religious diversity according to individual patient and family needs.

COMMENT: This is a well-presented study, offering a thorough sense of the authors' thinking and a detailed account of their method, analysis and results. It also provides a good overview of the literature in this area, supported by a bibliography of 63 articles and books. A major strength of the article is its explication of the subtle dynamics of measuring religious practice and the potentially indirect path by which spirituality may be connected to health: e.g., a private religious activity may bear upon a general attitude that in turn may bear upon health outcomes. If, to this reader, the article seems to be lacking, it is with regard to the absence of any delineation of the concept of optimism from the closely related concept of hope.* In addition, some treatment of the concept of intrinsic religiosity would seem to have been in order. Also, this reader, being a chaplain, notes that the authors seem unaware that professional chaplaincy is typically marked by competency in patient-centered pastoral care that attends to cultural and religious diversity and individual needs. Nevertheless, the study is a solid contribution, particularly regarding cardiac patients, and a good follow-up to a 1998 study by Ai, et al., "The role of private prayer in psychological recovery among midlife and aged patients following cardiac surgery" [The Gerontologist 38: 591-601]. The findings are intriguing, and, along the way, important concerns about operable concepts and methodology are raised.

*Note: In addition to hope, other concepts that may be closely tied to (or perhaps confused with) that of optimism include benefit-finding, wishing, and grateful disposition. [The concept of hope and its connection to spirituality will be the topic of a future Article-of-the-Month.]  

Suggestions for the Use of the Article for Discussion in CPE: 

Students not used to reading research may get bogged down in the treatment of measures and statistics in the Methods and the Results sections of the article (pp. 73-77) and may need to be advised to read the introductory and the Discussion sections first. Students might be asked to contemplate the relationship between religiosity and outlook-on-life. The study shows some evidence that private prayer may drive optimism, but in the Limitations section the authors address the argument that perhaps optimism drives prayer. Students may also want to discuss the characterization of prayer as a "coping strategy" and how it may be an expression of underlying psychological processes. On this last point, research-inclined students may be interested in the new the three-item measure of private prayer and the discounting of long-used frequency measures of private religious activity [see esp. p. 72]. In light of the article, students might discuss further implications for their own chaplaincy work, such as how to support patients' practice of private prayer. Finally, the article may serve as an entree to discussion of the predicament of cardiac patients as a clinical group. Other recent articles about cardiology patients published in the health-care literature are listed below.  

Other Recent Articles about Spirituality and Heart Patients in the Health Care Literature:  

Beery, T. A., Baas, L. S., Fowler, C. and Allen, G. "Spirituality in persons with heart failure." Journal of Holistic Nursing 20, no. 1 (March 2002): 5-30. [This study of 58 patients with heart failure used the Medical Outcome Survey Short Form 36 and Index of Well-Being measures of quality of life, the Spiritual Well-Being Scale, and the Relative Importance Scale. Combined spirituality scores predicted 24% of the variance in global quality of life. Pp. 26-30 contain a continuing education quiz on the article.] 

Desai, P. P., Ng, J. B. and Bryant, S. G. "Care of children and families in the CICU: a focus on their developmental, psychosocial, and spiritual needs." Critical Care Nursing Quarterly 25, no. 3 (November 2002): 88-97. [The focus on children in this review article is relatively unusual in the literature. It describes the roles of members of the care team, including the chaplain, and discipline-specific assessment and interventions. There are 24 references.] 

Kennedy, J. E., Abbott, R. A. and Rosenberg, B. S. "Changes in spirituality and well-being in a retreat program for cardiac patients." Alternative Therapies 8, no. 4 (July-August 2002): 64-66, 68-70 and 72-73. [An intervention of a 2.5 day educational retreat was designed to see if spirituality might be affected and might in turn indicate health benefits. Spirituality is here construed broadly, and retreat activities included yoga, meditation, visualization, and prayer. Seventy-eight percent of the 72 participants reported an increase in spirituality, associated with increased well-being, meaning of life, and confidence in handling problems, and a decreased tendency to become angry.] 

Koenig, H. G. "Religion, congestive heart failure, and chronic pulmonary disease." Journal of Religion and Health 41, no. 2 (2002): 263-78. [See the summary of the article in the November 2002 Article-of-the-Month.] 

Morris, E. L. "The relationship of spirituality to coronary heart disease." Alternative Therapies in Health and Medicine 7, no. 5 (September-October 2001): 96-8. [Participants from Dr. Dean Ornish's Lifestyle Heart Trial completed the Spiritual Orientation Inventory. Significant differences emerged in the scores of members of the research group and a control group. Spirituality scores were significantly correlated with progression and regression of coronary artery obstruction over four years.] 

Peterson, J., Atwood, J.R. and Yates, B. "Key elements for church-based health promotion programs: outcome-based literature review." Public Health Nursing 19, no. 6 (November-December 2002): 401-11. [This review article illustrates key elements in the success of church-based health promotion programs by looking at a church-based program intended to increase physical activity in middle-age women to reduce their risk of heart disease. It implies the potential for research in such faith-based community programs. There are 57 references.] 

Reyes-Ortiz, C. A. "The mind-heart connection in coronary artery disease." Comprehensive Therapy 25, no. 3 (March 1999): 169-73. [This review article discusses "neurocardiologic pathways" by which spirituality, among other factors, may be a resource against coronary artery disease. Spirituality is construed broadly here. There are 55 references.] 

Salyer, J., Sneed, G. and Corley, M. C. "Lifestyle and health status in long-term cardiac transplant recipients." Heart and Lung 30, no. 6 (November-December 2001): 445-57. [This empirical study of 47 patients found, among other things, that spiritual growth was the most frequently reported lifestyle characteristic. Women showed greater spiritual growth than men.] 

Walton, J. "Discovering meaning and purpose during recovery from acute myocardial infarction." Dimensions of Critical Care Nursing 21, no. 1 (January-February 2002): 36-43. [This qualitative study of 13 patients uses grounded theory analysis to draw out five phases of patients' experience: facing mortality, letting go of fear and turmoil, identifying and making lifestyle changes, seeking God's purpose, and finding meaning and purpose in everyday life. "Participants explained that spirituality was part of their every moment, decision, relationship, and process from the onset of their AMI through recovery" (p. 36).] 

Westlake, C. and Dracup, K. "Role of spirituality in adjustment of patients with advanced heart failure." Progress in Cardiovascular Nursing 16, no. 3 (Summer 2001): 119-25. [This qualitative study of 87 cardiac outpatients describes a three-step process whereby spirituality contributed to the patents' adjustment to advanced heart failure: development of regret regarding past behaviors and lifestyles, the search for meaning within the present experience of heart failure, and the search for hope for the future and reclaiming of optimism.] 

Westlake, C., Dracup, K., Creaser, J., Livingston, N., Heywood, J. T., Huiskes, B. L., Fonarow, G. and Hamilton, M. "Correlates of health-related quality of life in patients with heart failure." Heart and Lung 31, no. 2 (March-April 2002): 85-93. [This study of HRQOL in 61 outpatients with advanced heart failure undergoing transplantation evaluation assessed spirituality with the Spiritual Perspective Scale, a 10-item measure focusing on the extent to which spirituality permeates one's life and one engages in spiritually related interactions. Spirituality was defined as "the human capacity for transcendence in terms of personal views and behaviors that express a sense of relatedness to a transcendent dimension or to something greater than the self" (p. 87). No significant relationship was found between level of spirituality and components of HRQOL, contrary to other published investigations (see pp. 91-2).] 


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