private prayer as a suitable intervention for hospitalised patients: a critical review of the...

REVIEW

Private prayer as a suitable intervention for hospitalised patients: a

critical review of the literature

Claire Hollywell and Jan Walker

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 patient’s

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 encourage-

ment 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

beneficial. Commenced as an undergraduate project, this

has demanded a critical stance which, as observed by van

Loon (2005) and Swinton (2006), may be challenging for

someone with strong personal beliefs.

Nurses are often invited into the most private and intimate

areas of patient’s lives and this provides them with good

opportunities to recognise and address spiritual needs (Sellers

& Haag 1998). Spirituality in this context refers to a set of

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

Correspondence: Jan Walker, Visiting Senior Research Fellow, Forest

Hill Lodge West, Rushall Lane, Corfe Mullen, Wimborne, Dorset,

BH21 3RT, UK. Telephone: +44 1202 624 916.

E-mail: [email protected]

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637–651 637

doi: 10.1111/j.1365-2702.2008.02510.x

beliefs that sustain and support the individual through times

of difficulty, including illness, but does not necessarily require

religious affiliation. The nursing profession was founded on a

spiritual and religious heritage in which spirituality was

regarded as integral to nursing practice (Whitehead 2003).

It is accepted that spiritual care is an important element

of therapeutic care (Department of Health 1998, 2001).

However, at a time when intrinsic religious beliefs in a

transcendent being are reported to have increased (Hay

2001), patients’ spiritual needs commonly remain overlooked

(Koenig 2004). Possible reasons include cultural taboos

surrounding religious expression (Sloan 2001); lack of secure

beliefs and values among nurses and embarrassment about

sharing these with others (Taylor & Mamier 1995); inade-

quate focus on spiritual issues during professional training,

leading to lack of confidence in addressing spiritual issues

(McSherry 2002, Mesnikoff 2002, Baldacchino 2006); lack of

time (van Leeuwen et al. 2006); a belief reinforced by advice

from the Department of Health (2003) that spiritual care is

the remit of the chaplaincy; and the medicalisation of nursing.

Private or personal prayer needs to be distinguished from

intercessory (distant) prayer in which the individual is prayed

for by an external agent, with or without the knowledge and

approval of the recipient. A meta-analysis by Masters and

Spielmans (2007) has recently cast doubt on the latter as an

effective intervention. Prayer (from the Hebrew ‘le-hitpallel’,

literally ‘to examine oneself’) can be a vehicle for introspec-

tion and a bridge between oneself and a higher power

(Sherwin 2001). Important components of spiritual care from

the perspectives of patients include engagement in religious

practices, seeking guidance, finding meaning, maintaining

hope, achieving a state of forgiveness, peace and a sense

of ‘connectedness’ (Narayanasamy 2003, Pargament et al.

2005, Miner-Williams 2006, Ross 2006), all of which may be

addressed through prayer. Rossiter-Thornton (2002) pro-

posed that it is possible to separate prayer from religion in the

same way that activities such as meditation have been

extracted from their religious context. It is well recognised

that people of all persuasions tend to pray to ‘God’ for help

or mercy at times of great threat, although researchers in

the field of health psychology have included ‘wishing, hoping

and praying’ as passive coping strategies, generally associated

with poorer health outcomes (Wallston et al. 1978, Walker

2001). Therefore, it should not be assumed that private

prayer is necessarily beneficial and a central question for

this review is: ‘Has personal prayer been shown to be

associated with positive health outcomes and, if so, under

what circumstances?’

Harold Koenig, a former nurse, is currently the most

prolific theorist and researcher to test the hypothesis that

religious affiliation can result in a range of health benefits (Ai

et al. 1998). For example, Koenig et al. (1997) found that

increased religious attendance was associated with a lower

incidence of cancer, myocardial infarctions and hypertension.

Research from the relatively new discipline of psychoneu-

roimmunology has identified that religious conviction and

affiliation can boost the immune system and predict impor-

tant health benefits (Sephton et al. 2001). A meta-analysis by

McCullough et al. (2000) confirmed that religious attendance

was significantly associated with reduced mortality, although

it remains unclear what is responsible for this. For example,

while it might be due directly to religious beliefs and practices

such as prayer, it is also likely that those who attend church

have greater access to a social network on a regular basis.

Further, because those who are sick or disabled are less likely

to be able to attend religious services, there is likely to be a

bias in favour of better health status and lower mortality

among church, temple or mosque attendees. In contrast,

patients in hospital face a range of stressors at a time when

the availability of physical, social and environmental coping

resources is severely restricted. The purpose of this paper is to

find out if there is evidence that private (personal) prayer

affords any therapeutic physical or psychological benefits for

patients while they are in hospital.

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

Table 1 Key words

Key words Rationale

All words based

on pray [pray$]

Broad approach to the topic

Prayer and health Focused on prayer in context

Prayer and wellbeing

or wellbeing

To pick up intervention studies

Prayer and psychological

health

To pick up intervention studies

‘Personal prayer’ Focused on research question

‘Private prayer’ Focused on research question

‘Religious activity’ May include prayer

Spirituality May include prayer

Religiosity May include prayer

C Hollywell and J Walker

638 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 637–651

include studies based on the general population including

students and those where a small proportion of the sample is

aged under 18. The databases used are given in Table 3.

Following a preliminary search of these databases, searches

were regularly updated to identify relevant additions to the

literature.

These databases identified thousands of hits related to

prayer, although these were quickly reduced by focusing

specifically on original research related to personal or private

prayer. This produced a short list of key authors and studies,

which were cross-referenced using the reference list provided.

From this, a list of studies were extracted, details of which are

presented in Table 4.

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 interces-

sional 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 exper-

imental 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,

Table 2 Inclusion/exclusion criteria

Inclusion Exclusion and justification

Studies later than 1990 Studies prior to 1990 were not

automatically excluded, but were

reviewed to ensure that the context

remained relevant and had not been

superseded by contemporary research.

Studies of personal or

private prayer

Intercessory prayer (prayer on behalf

of the patient by others), church

attendance and other aspects of

religiosity, because these do not

address the research question.

Studies in English Studies published in a different language,

because of lack of translation facilities.

Western studies

(predominantly UK,

USA and Australia)

Non-Western studies were excluded

because of potential cultural difficulties

in generalisability to the majority

UK nursing context.

Participants aged 18

years and over

Studies where most participants are

aged under 18 years, because the study

focused specifically on applications

to adult care.

Physical health and

wellbeing

Mental health problems, because the

study was located in the context

of general adult nursing.

Table 3 Databases used in the literature

search, with rationaleDatabase Description Rationale

AHMED Includes journals in

complementary medicine.

Spirituality and prayer are

often seen as ‘alternative’ or

‘complementary’ therapies.

CINAHL Covers literature relevant to

nursing including dissertations,

conference proceedings.

Includes ‘grey’ health literature.

PsycINFO Includes journals, book chapters

and dissertations from psychology.

The research question focuses

on wellbeing.

Medline Premier medical bibliographic

database of credible medical

journals in English.

Includes US sources where

majority of research into

spirituality takes place.

BNI Produced by RCN. Covers all

aspects of nursing.

The research was specific

to nursing.

Blackwell Synergy Holds content for most full-text

journals in medicine and social science.

Has cross-referencing options.

Cochrane Systematic reviews and meta-analyses. Provides best available evidence

for medical outcomes.

Google Scholar Academic search engine

with links to Pubmed.

Ensures broad capture of more

obscure sources.

Review Critical review of private prayer


Table

4T

able

of

publi

shed

studie

sid

enti

fied

to14th

Nove

mber

2007

Auth

or/

Yea

r

of

publi

cati

on

Tit

le

Loca

tion

of

study

Over

vie

wof

met

hod

Key

findin

gs

Exper

imen

tal

des

igns

Aza

riet

al.

(2001)

Neu

roco

rrel

ates

of

reli

gio

us

exper

ience

Ger

many

Com

pare

dneu

rolo

gic

alPE

Tsc

an

effe

cts

of

readin

gre

ligio

us

and

non-r

elig

ious

mate

rial

on

religio

us

and

non-r

elig

ious

studen

ts.

PE

Tim

ages

show

eda

spec

ific,

signifi

cant,

act

ivati

on

of

the

right

dors

ola

tera

lpre

fronta

lco

rtex

(indic

ati

ve

of

a‘r

elig

ious

state

’)in

the

reli

gio

us

subje

cts

when

readin

ga

psa

lmas

com

pare

d

wit

hnon-r

elig

ious

subje

cts

or

duri

ng

ahappy

non-r

elig

ious

readin

g.

Quali

tati

ve

rese

arc

h

Haw

ley

and

Iruri

ta(1

998)

See

kin

gco

mfo

rt

thro

ugh

pra

yer

Aust

rali

aQ

uali

tati

ve

inte

rvie

wst

udy

(n=

13

post

-CA

BG

pati

ents

).

Bel

iefs

that

God

list

ened

toand

answ

ered

pra

yer

sfo

rco

mfo

rt

gave

reass

ura

nce

and

stre

ngt

hto

face

unce

rtain

ty.

Gal

land

Corn

bla

t(2

002)

Bre

ast

cance

rsu

rviv

ors

giv

evoic

e:a

quali

tati

ve

anal

ysi

sof

spir

itual

fact

ors

inlo

ng-

term

adju

stm

ent

Canada

Thir

ty-o

ne

wom

enw

rote

inth

eir

ow

nw

ord

show

reli

gio

us

and

spir

itual

fact

ors

pla

yed

apart

in

thei

runder

standin

gof

and

copin

g

wit

hth

isil

lnes

s.

Per

sonal

pra

yer

was

most

com

mon

reli

gio

us

copin

gact

ivit

yand

consi

sted

main

lyof

two

types

:

pet

itio

nary

(cal

lfo

rhel

p)

and

coll

oquia

l(g

ive

thanks

for

ble

ssin

gs)

.

Walt

on

and

Sull

ivan

(2004)

Men

of

pra

yer

:sp

irit

uality

of

men

wit

hpro

state

cance

r

USA

Gro

unded

theo

ryst

udy

of

11

male

pro

state

cance

rin

pati

ents

,aged

54–71.

Pra

yer

was

an

import

ant

conce

pt

inco

pin

gw

ith

cance

r.

Cro

ss-s

ecti

onal

surv

eys

Koen

iget

al.

(1997)

Model

ling

the

cross

-

sect

ional

rela

tionsh

ips

bet

wee

nre

ligio

n,

physi

cal

hea

lth,

soci

al

support

,and

dep

ress

ive

sym

pto

ms

USA

Surv

eyof

4000

peo

ple

aged

60+.

Pri

vate

pra

yer

/bib

lere

adin

g

mea

sure

dse

par

ate

ly.

Pri

vate

pra

yer

/bib

lere

adin

g

neg

ati

vel

yco

rrel

ate

dw

ith

physi

cal

hea

lth

and

posi

tivel

y

corr

elate

dw

ith

soci

al

support

,

but

unre

late

dto

dep

ress

ion.

Koen

iget

al.

(1998)

Rel

igio

us

copin

gand

hea

lth

statu

sin

med

icall

yil

l

hosp

italise

dold

eradult

s

USA

Stu

dy

of

577

med

ical

inpat

ients

age

55+

(73%

resp

onse

rate

)

base

don

stru

cture

din

terv

iew

.

Neg

ati

ve

impact

of

ple

adin

gfo

r

dir

ect

inte

rces

sion

(‘Ple

aded

wit

h

God

tom

ake

thin

gs

turn

out

OK

’;

‘Pra

yed

for

am

iracl

e’;

‘Barg

ained

wit

hG

od

tom

ake

thin

gs

bet

ter’

).

Koen

ig(1

998)

Rel

igio

us

att

itudes

and

pra

ctic

esof

hosp

italise

d

med

icall

yill

old

eradult

s

USA

Gen

eral

med

ical

(n=

542),

card

iolo

gy

and

neu

rolo

gy

pati

ents

aged

over

60.

58Æ7

%re

port

edpra

yin

gat

least

dail

y.

Pra

yer

/bib

lere

adin

gm

ore

pre

vale

nt

inw

om

en,

those

wit

h

low

erle

vel

sof

educa

tion

and

stre

ssfu

llife

even

ts.



Table

4(C

onti

nued

)

Auth

or/

Yea

r

of

publi

cati

on

Tit

le

Loca

tion

of

study

Over

vie

wof

met

hod

Key

findin

gs

Parg

am

ent

etal

.(1

998)

Patt

erns

of

posi

tive

and

neg

ativ

ere

ligio

us

copin

g

wit

hm

ajo

rlife

stre

ssors

USA

Surv

eyof

colleg

est

uden

tsdes

igned

toco

nst

ruct

and

test

14-i

tem

mea

sure

of

posi

tive

and

neg

ati

ve

patt

erns

of

reli

gio

us

copin

gm

ethods

(Bri

efR

CO

PE

).

Posi

tive

patt

ern

inc.

:re

ligio

us

for

giv

enes

s,se

ekin

gsp

irit

ual

support

,

ben

evole

nt

reli

gio

us

reappra

isal

.

Neg

ati

ve

patt

ern:

spir

itual

dis

conte

nt,

punis

hin

gG

od

reappra

isal

s,in

terp

erso

nal

reli

gio

us

dis

conte

nt.

Malt

by

etal

.(1

999)

Rel

igio

us

ori

enta

tion

and

psy

cholo

gic

al

wel

lbei

ng:

the

role

and

freq

uen

cyof

per

sonal

pra

yer

UK

Stu

den

ts(n

=474).

Ques

tionnai

res

mea

sure

dre

ligio

us

ori

enta

tion,

self

-est

eem

and

dep

ress

ive

sym

pto

ms.

Sig

nifi

cant

corr

elati

on

bet

wee

n

reli

gio

sity

and

psy

cholo

gic

al

wel

lbei

ng.

Per

sonal

pra

yer

appea

rs

tobe

an

import

ant

vari

able

.

Dunn

and

Horg

as

(2000)

The

pre

vale

nce

of

pra

yer

as

asp

irit

ual

self

-care

modality

inel

der

s

USA

Des

crip

tive

study;

conven

ience

com

munit

ysa

mple

,n

=50

aged

65–85,

recr

uit

edfr

om

one

churc

h

and

six

senio

rce

ntr

edin

raci

all

y

div

erse

,la

rge

met

ropoli

tan

city

in

the

Mid

wes

t.

Pra

yer

was

the

most

com

monly

report

ednon-m

edic

al

inte

r

ven

tion,

use

dby

84%

.Pra

yer

may

off

era

spir

itual

cognit

ive

ther

apy

tore

appra

ise

or

re-e

valu

ate

stre

ssfu

lli

feev

ents

,

min

imis

eneg

ativ

eef

fect

sof

stre

ss

and

main

tain

opti

mum

hea

lth.

Ai

etal

.(2

000)

The

use

of

pra

yer

by

coro

nar

yart

ery

bypass

pati

ents

USA

Ret

rosp

ecti

ve

analy

ses

of

longi

tu

din

al

ques

tionnair

edata

(n=

151)

are

post

-CA

BG

emoti

onal

hea

lth,

reli

gio

us

act

ivit

ies,

soci

al

support

and

non-c

ard

iac

chro

nic

condit

ions.

Use

of

pra

yer

toco

pe

was

ass

oci

ate

dw

ith

bet

ter

post

oper

ati

ve

emoti

onal

hea

lth.

Those

aged

>60

wer

em

ore

likel

y

topra

yif

reli

gio

nw

as

import

ant

toth

em.

Those

aged

<65

wer

e

more

likel

yto

pra

yif

low

er

inco

me,

bet

ter

pre

oper

ati

ve

hea

lth

and

more

educa

tion.

Fra

nci

sand

Kald

or

(2002)

The

rela

tionsh

ipbet

wee

n

psy

cholo

gic

al

wel

lbei

ng

and

Chri

stia

nfa

ith

and

pra

ctic

ein

an

Aust

rali

an

popula

tion

sam

ple

Aust

rali

aSubsa

mple

of

Aust

rali

an

Com

munit

ySurv

ey(n

=989,

aged

15+).

Sin

gle

item

on

freq

uen

cyof

per

sonal

pra

yer

.

Over

all,

pra

yer

was

ass

oci

ate

d

wit

hposi

tive

effe

ctaft

erco

ntr

ol

ling

for

age

and

sex.

No

signifi

cant

neg

ativ

eef

fect

found.

Sooth

ill

etal

.(2

002)

Cance

rand

fait

h.

Havin

g

fait

h–

does

itm

ake

a

dif

fere

nce

am

ong

pati

ents

and

thei

rin

form

alca

rers

?

UK

Ques

tionnair

esu

rvey

of

cance

r

pati

ents

(n=

402)

focu

sed

on

ass

oci

ati

on

bet

wee

nfa

ith

and

psy

choso

cial

nee

ds.

Contr

oll

ing

for

dem

ogra

phic

and

clin

ical

vari

able

s,pati

ents

wit

h

expre

ssed

fait

hre

port

edfe

wer

psy

cho

soci

al

nee

ds

than

those

wit

hout

fait

h

and

gre

ate

rnee

dto

engage

inper

sonal

pra

yer

.C

are

rsex

pre

ssed

dif

fere

nt

nee

ds

topati

ents

.



Table

4(C

onti

nued

)

Auth

or/

Yea

r

of

publi

cati

on

Tit

le

Loca

tion

of

study

Over

vie

wof

met

hod

Key

findin

gs

O’C

onnor

etal

.(2

003)

Rel

igio

sity

,st

ress

and

psy

cholo

gic

al

dis

tres

s:no

evid

ence

for

an

ass

oci

ati

on

am

ong

under

graduate

studen

ts

UK

(Engl

and/S

cotl

and)

Surv

eyof

177

under

gra

duate

studen

tsin

cluded

Gen

eral

Hea

lth

Ques

tionnair

e(d

istr

ess)

and

7-i

tem

Fra

nci

sSca

leof

Att

itude

Tow

ard

sC

hri

stia

nit

y(F

SA

C)

(rel

igio

sity

),in

cludin

g‘P

rayer

hel

ps

me

alo

t’.

No

corr

elati

on

found

bet

wee

n

reli

gio

sity

and

dis

tres

susi

ng

thes

e

mea

sure

s.

Fra

nci

set

al.

(2003)

Rel

igio

sity

and

gen

eral

hea

lth

am

ong

under

gra

duat

est

uden

ts:

a

resp

onse

toO

’Connor

etal

.(2

003)

UK

(Wale

s,N

.Ir

eland)

Surv

eyof

246

under

gra

duate

studen

tsusi

ng

sam

eques

tion

nair

esas

O’C

onnor

etal

.als

o

ass

esse

dfr

equen

cyof

churc

h

att

endance

and

per

sonal

pra

yer

.

Posi

tive

att

itude

toC

hri

stia

nit

y,

but

not

per

sonal

pra

yer

,w

as

posi

tivel

y

ass

oci

ate

dw

ith

hea

lth.

Dif

fere

nce

sin

att

itude

tow

ard

reli

gio

nare

more

import

ant

than

dif

fere

nce

sin

reli

gio

us

beh

avio

ur.

Ai

etal

.(2

004)

Fait

h-b

ase

dand

secu

lar

path

ways

tohope

and

opti

mis

msu

bco

nst

ruct

sin

mid

dle

-aged

and

old

er

card

iac

pati

ents

USA

Inte

rvie

ws

wit

hca

rdia

cpati

ents

(n=

146,

most

lyJu

deo

-Chri

stia

n)

two

wee

ks

pri

or

tosu

rger

y

(CA

BG

).3-i

tem

‘Usi

ng

Pri

vate

Pra

yer

as

aM

eans

for

Copin

g’,

opti

mis

mand

dis

tres

s(C

ES-D

)

mea

sure

d.

Pri

vate

pra

yer

med

iato

rbet

wee

nfa

ith

and

opti

mis

m/a

gen

cyw

hic

hin

turn

ass

oci

ate

dw

ith

low

erdis

tres

s

(anxie

tyand

dep

ress

ion).

Mer

avig

lia

(2004)

The

effe

cts

of

spir

ituali

tyon

wel

lbei

ng

of

peo

ple

wit

h

lung

cance

r

USA

Ques

tionnair

est

udy;

n=

60;

age

33–83.

Pra

yer

med

iate

dre

lati

onsh

ipbet

wee

n

hea

lth

statu

sand

wel

lbei

ng

and

expla

ined

10%

of

the

vari

ance

of

psy

cholo

gic

al

wel

lbei

ng.

Ai

etal

.(2

005)

Pra

yer

s,sp

irit

ual

support

,

and

posi

tive

att

itudes

in

copin

gw

ith

the

Sep

tem

ber

11

nati

onal

cris

is

USA

Surv

eyof

453

studen

ts.

75%

bel

ieved

pri

vate

pra

yer

was

import

ant

inth

eir

lives

.Pra

yer

indir

ectl

yass

oci

ated

wit

hposi

tive

att

itude

and

emoti

ons.

Harr

ison

etal

.(2

005)

Rel

igio

sity

/spir

ituali

tyand

pain

inpati

ents

wit

hsi

ckle

cell

dis

ease

USA

Data

from

longit

udin

al

study

of

the

rela

tionsh

ipof

psy

choso

cial

fact

or

topain

.H

ypoth

esis

:

reli

gio

us

fact

ors

influen

cepain

per

cepti

on

inSC

Dpati

ents

(n=

50).

700-i

tem

ques

tionnair

e

inc.

dem

ogra

phic

s,pain

,

reli

gio

sity

and

psy

cholo

gic

al

dis

tres

s.

Dai

lypra

yer

or

Bib

lest

udy

occ

urr

ed

in39%

,co

mpare

dw

ith

26%

inth

e

gen

eral

popula

tion.

Fre

quen

cyof

pra

yer

and

bib

lest

udy

did

not

corr

elate

wit

hm

easu

res

of

pain

or

men

tal

hea

lth

inth

isgro

up.



Table

4(C

onti

nued

)

Auth

or/

Yea

r

of

publi

cati

on

Tit

le

Loca

tion

of

study

Over

vie

wof

met

hod

Key

findin

gs

Ham

rick

and

Die

fenbach

(2006)

Rel

igio

nand

spir

ituali

ty

am

ong

pati

ents

wit

h

loca

lise

dpro

state

cance

r

USA

Com

para

tive

study

base

don

ques

tionnair

edata

from

pati

ents

(n=

254)

dia

gnose

dw

ith

loca

lise

dpro

state

cance

rand

a

random

sam

ple

(n=

238)

of

resp

onden

tsto

the

nati

onal

gen

eral

soci

al

surv

ey.

Posi

tive

ben

efits

(inc.

reduce

dw

orr

y)

of

religio

us

copin

g/p

ract

ices

rest

rict

edto

pati

ents

wit

hhig

her

level

of

post

dia

gnosi

sin

crea

sein

religio

sity

;pati

ents

not

report

ing

post

dia

gnosi

sin

crea

ses

inre

ligio

n

not

engag

ing

inre

ligio

us

copin

g/

pra

ctic

eadju

sted

equall

yw

ell.

Pro

spec

tive

cohort

studie

s

Ai

etal

.(1

998)

The

role

of

pri

vate

pra

yer

in

psy

cholo

gic

al

reco

ver

y

am

ong

mid

life

and

aged

pati

ents

foll

ow

ing

card

iac

surg

ery

USA

Pati

ents

(n=

151)

aged

40–60.

Ques

tionnai

readm

inis

tere

d

post

op

and

six

month

sand

one-

yea

rpost

dis

charg

e.

Pri

vate

pra

yer

ass

oci

ated

wit

h

sign

ifica

nt

dec

rease

indep

ress

ion

and

gen

eral

dis

tres

sone-

yea

r

post

surg

ery.

Hel

met

al.

(2000)

Does

pri

vate

religio

us

act

ivit

ypro

long

surv

ival?

Asi

x-y

ear

follow

-up

study

of

3,8

51

old

eradult

s

USA

Com

munit

yre

siden

ts(n

=3851)

aged

65

and

over

.Pri

vate

reli

gio

us

act

ivit

yass

esse

dby:

‘‘H

ow

oft

endo

you

spen

dti

me

in

pri

vate

reli

gio

us

act

ivit

ies,

such

as

pra

yer

,m

edit

ati

on,

or

Bib

le

study?’

’

Pri

vate

reli

gio

us

act

ivit

ies

pro

vid

eda

pro

tect

ive

effe

ctagain

stm

ort

alit

yfo

r

an

elder

lypopula

tion

free

of

funct

ional

impair

men

t,ev

enaft

er

contr

oll

ing

for

num

erous

covar

iate

s.

Ai

etal

.(2

002)

Pri

vate

pra

yer

and

opti

mis

min

mid

dle

-aged

and

old

erpati

ents

aw

ait

ing

card

iac

surg

ery

USA

Corr

elati

onal

study.

Inte

rvie

ws

two

wee

ks

and

one

day

pri

or

to

surg

ery

wit

h246

pati

ents

aw

ait

ing

card

iac

surg

ery

tote

st

effe

cts

of

bel

ief

inth

eim

port

ance

of

pri

vate

pra

yer

and

inte

nti

on

to

use

pra

yer

toco

pe.

Majo

rity

inte

nded

touse

pra

yer

and

this

pre

dic

ted

posi

tive

att

itude

pri

or

tosu

rger

y.

Koen

iget

al.

(2004)

Rel

igio

n,

spir

ituali

ty,

and

acu

teca

rehosp

itali

sati

on

and

long-t

erm

care

use

by

old

erpati

ents

USA

Stu

dy

of

med

ical

adm

issi

ons;

n=

811;

age

50+;

inte

rvie

wed

at

0,

3,

6,

9and

12

month

s.2-i

tem

mea

sure

of

freq

uen

cyof

pri

vate

pra

yer

oth

erth

an

at

mea

ltim

es.

Pri

vate

pra

yer

ass

oci

ated

wit

h

reduct

ion

of

days

spen

tin

long-

term

care

,re

gard

less

of

illn

ess

sever

ity,

but

not

few

erdays

inacu

teca

re.



Table

4(C

onti

nued

)

Auth

or/

Yea

r

of

publi

cati

on

Tit

le

Loca

tion

of

study

Over

vie

wof

met

hod

Key

findin

gs

Ai

etal

.(2

006)

Dep

ress

ion,

fait

h-b

ase

d

copin

g,

and

short

-ter

m

post

oper

ati

ve

glo

bal

funct

ionin

gin

adult

and

old

erpati

ents

under

goin

g

card

iac

surg

ery

USA

Card

iac

non-e

mer

gency

surg

ery

pati

ents

(n=

335)

aged

35–89.

Pre

op/p

ost

op

cohort

des

ign.

Mea

sure

sin

cluded

:14-i

tem

bri

ef

reli

gio

us

copin

gsc

ale

(BR

CS)

conta

inin

gse

ven

item

sea

chfo

r

posi

tive

and

neg

ativ

eco

pin

g;

and

3-i

tem

usi

ng

pri

vate

pra

yer

for

copin

g(U

PPC

).

Pre

oper

ativ

eposi

tive

reli

gio

us

copin

g

was

ass

oci

ate

dw

ith

bet

ter

post

oper

ati

ve

act

ivit

ies

of

livin

g.

Post

oper

ati

vel

y,

pri

vate

pra

yer

was

ass

oci

ate

dw

ith

poore

ract

ivit

ies

of

livin

g.

Ai

etal

.(2

007)

The

influen

ceof

pra

yer

copin

gon

men

tal

hea

lth

am

ong

card

iac

surg

ery

pati

ents

:th

ero

leof

opti

mis

mand

acu

tedis

tres

s

USA

Re-

analy

sis

of

above

data

toin

clude

stru

ctura

leq

uati

on

model

ling

toid

enti

fyca

usa

lass

oci

ati

ons

wit

hin

the

data

.

Pri

vate

pra

yer

had

aneg

ativ

ein

dir

ect

effe

cton

acu

test

ress

thro

ugh

opti

mis

m,

whic

happea

red

to

counte

ract

its

posi

tive

dir

ect

effe

ct

on

acu

tedis

tres

s.T

her

efore

,th

eto

tal

effe

ctof

pra

yer

on

wel

lbei

ng

was

insi

gnifi

cant.



it is possible that prayer is unique in terms of its effects. The

remainder of the evidence considered in this review relies on

qualitative, cross-sectional and prospective cohort studies. For

the purpose of the critique, we have grouped the studies

according to the methodological approach used.

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 sam-

pling bias and other methodological flaws. Gall and

Cornblat’s 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 compar-

ison, Tearfund data indicate that in 2006 only 10% of British

people attend church at least once a week (Ashworth &

Farthing 2007)]. Hawley and Irurita’s 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 method-

ology 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.

Given these limitations, it is perhaps not surprising that all

three studies focus on positive aspects of spirituality and

prayer. The Walton study identified prayer as of central

importance in providing each participant with comfort and

inner strength. They did, however, note that participants who

prayed in time of need said they did not feel God commu-

nicating back with them, whereas those who prayed regularly

listened for God’s voice. In the Gall study, almost all the

participants reported using active religious or spiritual coping

activities and relied on prayer as a way of constructing

meaning out of their cancer experience. The Hawley findings

identified six different types of prayer: for those with a formal

religious belief, prayer was more disciplined, focused on

asking God to be with them and seeking God’s will

(honouring prayer). For all, prayer might be directed at

personal needs (survival prayer) or to the needs of others such

as family, friends or other patients (confiding prayer). For

some, it simply reflected a general cry for help (instinctive

prayer). Others made no attempt at personal prayer, but

relied on the prayers of others for support (acquiescent

prayer).

Despite methodological limitations, these studies offer

some interesting insights into the ways that people of

Christian faith use prayer in a positive way to help find

meaning and gain support in the face of life-threatening and

life-changing illnesses. But they tell us nothing about any

negative consequences of using prayer, nor how people of

little or no faith use prayer, or how people of non-Christian

faiths use prayer. Only the Hawley study differentiates

between types of prayer, inviting the possibility that different

types of prayer are associated with different outcomes (see

Koenig et al. 1998).

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, struc-

tured 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 O’Connor 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,



GHQ). Francis introduced additional single items to measure

frequency of church attendance and prayer (although values

given for the sample are difficult to interpret). Possibly

because of religious cultural differences, attitudes towards

Christianity were very much more positive among the Welsh/

Irish than in the English/Scottish students, particularly among

males, which may have some bearing on the discrepant

findings. Francis reported very strong correlations between

frequency of prayer and both religious attitude (0Æ8) and

church attendance (0Æ68). One of the most important

problems with cross-sectional studies is the difficulty in

distinguishing cause from effect: correlation does not imply

causation, whereas regression is based on theoretical assump-

tions about causal relationships which may or may not be

true. Using regression, Francis reported that 8% of the

variance associated with health and wellbeing was predicted

by attitude towards Christianity and virtually none by church

attendance or prayer. However, the GHQ fails to differen-

tiate between health and wellbeing, making the findings

difficult to interpret. Moreover, in multiple regression,

predictors of the dependent variable (in this case health/

wellbeing) are influenced by the order in which the

independent variables (religiosity, prayer and church atten-

dance) are entered into the regression equation. In the

Francis study, the measurement of prayer was already

subsumed within the measure of religious attitude, as

demonstrated by the high correlation. By entering religious

attitude into the regression equation first, all of the variance

for prayer was already included, giving rise to multicollin-

earity and eliminating prayer as a significant predictor of

health and wellbeing. In contrast, in the UK Maltby study

(Maltby et al. 1999), prayer was entered first into the

regression equation, enabling the authors to demonstrate

that personal prayer alone explained as much as 6% of the

variance associated with reduction in depression. Their

findings concur with the findings of Ai et al. (2005) that

among university students, personal prayer mediates bet-

ween religiosity and wellbeing. The descriptive study by

Pargament et al. distinguished between two aspects of

religiosity, which may also have some bearing on discrep-

ancies in the literature on prayer. They studied patterns of

religious coping in students and distinguished between

positive and negative coping appraisals (see Table 4). Their

findings lend support to the hypothesis that different

patterns of prayer may be associated with different ways

of coping and different coping outcomes.

Three studies have focused on community-based samples:

Koenig et al. (1997) and Dunn and Horgas (2000) in the

USA; and Francis and Kaldor (2002) in Australia. Both

Koenig’s and Francis’s were large-scale surveys. Dunn and

Horgas recruited older church attenders and reported that

prayer was associated with positive wellbeing. In contrast,

the Koenig survey of those aged over 60 found no

association between private prayer/bible reading and depres-

sion. Reasons for this discrepancy include differences in

faith-based coping between church attenders and the general

population, differences in measures of wellbeing (which is

not necessarily the same as the absence of depression) and

failure to control for differences in sex and age during the

analysis (Dunn). Overall, the Francis and Kaldor study

emerges as strongest in terms of sampling, measures used

and analytical procedures. Their findings indicate that

prayer is associated with positive wellbeing after controlling

for age and sex, but there may be differences in the use and

response to prayer between men and women and between

different age groups.

Cross-sectional data from studies involving patients have

focused mainly on people with chronic conditions and

cancer. Koenig (1998) surveyed older medical patients in

the ‘bible belt’ (a large area in the Southeast USA) and found

that 59% reported praying every day. This compares with

39% of sickle cell African-American patients whose average

age was 36 years (also in North Carolina) and 26% in a

general population (Harrison et al. 2005). Koenig et al.

(1998) went on to report differences in the effects of different

types of prayer. Prayer that involved pleading for God’s

intercession was associated with increased depression. This

supports the findings of Pargament et al. (1998) that religious

coping may be negative as well as positive and indications

from Walton and Sullivan (2004) that petitionary prayer is

less likely to be associated with wellbeing than intimate

devotional types of prayer in men. This is important because

many quantitative studies continue to measure prayer

frequency but not prayer content.

Soothill et al. (2002) found that cancer patients who

reported a religious faith expressed fewer psychosocial needs

and a greater need for prayer. Faith appeared to change the

cancer experience for these patients, compared to those with

no faith. The comparison study by Hamrick and Diefenbach

(2006) also offers important insights into potential relation-

ship between religious coping, religious practices and well-

being. Their findings confirm that many people turn to

religion and prayer when faced with a potentially life-

threatening illness. Men in this type of situation appear to

benefit from religious practices, including prayer, only if their

religious convictions increase, whereas those with no change

in religious conviction or prayer do just as well. Soothill et al.

conclude that the development of spiritual interventions, such

as encouraging private prayer among those with no religious

conviction, is premature.



Prospective cohort studies

Unlike cross-sectional studies, prospective studies of a single

cohort provide an opportunity to test cause-and-effect

relationships over time, provided the sample is sufficiently

large to allow for attrition. Our review has identified seven

published studies that have focused on the effects of private

prayer over time: one community-based study (Helm et al.

2000); five of cardiac surgery patients by members of the

same research team including Koenig, Peterson and Ai; and

one of older medical patients (Koenig et al. 2004). Helm et al.

used data from a very large interview survey of community

residents aged 65+, part of a multicentre collaborative, to

conduct a six-year follow-up of just over 4000 people living

in the American ‘bible belt’. This part of the study was

designed specifically to analyse the effects of private religious

activities including prayer and bible reading on reliable

measures of physical health, activities of living and depres-

sion. For those who were relatively fit and active, engagement

in private religious activities was associated with increased

survival. However, this study leaves unanswered the question

‘which aspect of religious activity is most beneficial?’

Important studies of hospitalised cardiac surgery patients

(Ai et al. 1998, 2000, 2002, 2006, 2007) have focused

specifically on private prayer. This has enabled the research

team to follow up and test emergent issues over time and

develop a context-specific measure of prayer: ‘Using Private

Prayer as a Means for Coping’ scale (UPPC; Ai et al. 2002),

based on the following three items, each scored using a 4-point

Likert scale and achieving very good internal reliability (0Æ85):

• ‘Prayer is important in my life.’

• ‘Prayer does not help me to cope with difficulties and stress

in my life’ (reverse scored).

• ‘I will use private prayer to cope with difficulties and stress

associated with my cardiac surgery.’

At first glance, the findings from these studies appear

somewhat contradictory. The first (1998) appeared to confirm

a positive association between prayer and wellbeing at one-

year postsurgery. The second (2000) indicated that prayer was

associated with increased wellbeing (reduction in depression),

although there were age-related differences in reasons for

using prayer. The third (2002) focused on pre- to postoper-

ative changes and showed only that prayer was associated with

preoperative positive attitude to surgery. In their discussion,

the authors speculated that patients use prayer as a spiritual

means to self-empowerment, discovering practical solutions

for dealing with medical crises and distancing themselves from

distress and worry. They concluded that nurses and doctors

should give attention to encouraging patients’ spiritual coping,

regardless of the patient’s religious tradition.

The fourth study (2006) focused on postoperative func-

tional 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 correla-

tions 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 expe-

rience 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



distress by focusing introspectively on their distress and its

causes.

Summary of key findings

• Prayer, measured by frequency, is usually associated with

lower levels of depression and anxiety.

(a) But most of the studies that show positive associations

between prayer and wellbeing were located in areas

that have strong Christian traditions and involved

samples that report relatively high levels 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

make more frequent use of prayer.

(a) It may be that the weak and vulnerable in society are

more likely to turn to the church and to prayer in times

of difficulty.

• Prayer is a coping action that mediates between religious

faith and wellbeing.

• Prayer takes different forms, some beneficial, others

possibly not:

(a) Devotional prayers that take the form of an intimate

dialogue with a supportive God are associated with

improved optimism, wellbeing and function.

(b) Prayers that involve only pleas for help in extremis

may, in the absence of a pre-existing faith, be associ-

ated with increased distress and possibly poorer

function.

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 well-

being, 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 semi-

structured interview. Walker (1989) noted that older

patients who did not subscribe to a particular religious

belief appeared reluctant to express this until they had

checked the interviewer’s views and tested her reaction.

Therefore, the reader needs to know if the researchers

exhibited tangible signs of their own religious affiliation.

Most of the studies appear to have included questions that

might have signalled to participants that religious coping

was seen as a desirable response. Only the study of sickle

cell patients (Harrison et al. 2005) measured social response

bias and it is reassuring that this showed no association

with prayer or other religious variables (although it neared

significance for intrinsic religiosity). Nevertheless, it might

be better in future research to omit overt references to

spirituality and prayer in the title or aim and focus instead

on coping strategies.

Various measures of prayer have been used in the studies

reviewed. Measures that combine prayer with bible reading

appear to assume that prayer is devotional in nature, which is

clearly not the case for all those threatened by illness. Single

item measures of prayer frequency assume that all prayer is

equally effective. The UPPC measures prayer as a means of

coping and focuses on its importance and use, but fails to

differentiate aspects of prayer that could lead to different

outcomes, as suggested by Walton and Sullivan’s qualitative

study. One student study not included in our review (Ladd &

Spilka 2006) attempted to address some of these issues by

producing a multidimensional prayer scale. Unfortunately,

the descriptors (‘radical approaching’ and ‘seeking to be

revolutionary’) are clearly inappropriate for use in a hospital

context, but the studies of Pargament et al. (1998) and Gall

and Cornblatt (2002) do appear to provide the basis for the

development of an appropriate measure for use with ill

people. Even among those with an expressed religious faith,

Pargament et al. (1998) found negative patterns of religious

coping and prayer associated with distress, whereas Koenig

et al. (1998) found that pleading and bargaining prayers are

associated with negative outcomes among medical patients.

Such people are clearly in need of additional spiritual care

and social support. In their discussion of spiritual support, Ai

et al. (2007) referred to the concept of locus of control. The

literature on this indicates that those with external (chance)

locus of control, whose coping depends solely on wishing,

hoping and praying, show a higher level of catastrophic

thoughts and poorer emotional and functional outcomes

(Walker 2001). This is supported by the findings of Ai et al.

(2006) and suggests that future researchers need to

differentiate between the effects of petitionary prayer asso-

ciated with passive coping (doing nothing) and faith-based

prayer, which is associated with active self-help coping



strategies exemplified by the common saying: ‘God helps

those who help themselves’.

Finally, the use of depression scales as a measure of

wellbeing is based on the assumption that wellbeing is the

same as an absence of depression. Spiritual aspects of

wellbeing might be expected to include feelings of serenity,

peace and even joyfulness that are simply not captured by the

depression measures used in these studies. This could cause

type 2 error (failure to find an effect when there really is one)

when analysing the relationship between faith, prayer and

wellbeing.

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.

Relevance to clinical practice

The research question was framed in the belief that nurses

could and should help hospitalised patients to achieve

spiritual peace through prayer. Based on the evidence

available, our review indicates that encouragement to engage

in prayer should be given only after a proper assessment of

the patient’s religious faith and the nature of prayer likely to

be used. Those wishing to engage in devotional prayer should

be given the encouragement and privacy to do so. Those

whose prayers take the form of desperate pleas for help are

likely to be in need of help to identify and alleviate the causes

of their distress. These issues need to be taken into account

when designing educational strategies to improve nurses’

knowledge and competencies to assess and provide spiritual

care.

Contributions

Study design: CH; data collection and analysis: CH, JW and

manuscript preparation: JW.

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