Private Prayer's Effect on Hospital Patients

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 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
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 patients 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
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: jmwalker@soton.ac.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
C Hollywell and J Walker
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); inadequate 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 introspection 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) proposed 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
638
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 psychoneuroimmunology has identified that religious conviction and
affiliation can boost the immune system and predict important 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$]
Prayer and health
Prayer and wellbeing
or wellbeing
Prayer and psychological
health
Personal prayer
Private prayer
Religious activity
Spirituality
Religiosity
Broad approach to the topic

Focused on prayer in context
To pick up intervention studies
To pick up intervention studies
Focused on research question
Focused on research question
May include prayer
May include prayer
May include prayer
Review
Critical review of private prayer
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.
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 published in a different language,
because of lack of translation facilities.
Non-Western studies were excluded
because of potential cultural difficulties
in generalisability to the majority
UK nursing context.
Studies where most participants are
aged under 18 years, because the study
focused specifically on applications
to adult care.
Mental health problems, because the
study was located in the context
of general adult nursing.
Studies of personal or
private prayer
Studies in English
Western studies
(predominantly UK,
USA and Australia)
Participants aged 18
years and over
Physical health and

wellbeing
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.
Table 3 Databases used in the literature
search, with rationale
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 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.
Spirituality and prayer are

often seen as alternative or
complementary therapies.
Includes grey health literature.
CINAHL
Covers literature relevant to

nursing including dissertations,
conference proceedings.
PsycINFO
Includes journals, book chapters
and dissertations from psychology.
Medline
Premier medical bibliographic
database of credible medical
journals in English.
BNI
Produced by RCN. Covers all
aspects of nursing.
Blackwell Synergy Holds content for most full-text
journals in medicine and social science.
Cochrane
Systematic reviews and meta-analyses.
Google Scholar
Academic search engine

with links to Pubmed.
The research question focuses

on wellbeing.
Includes US sources where
majority of research into
spirituality takes place.
The research was specific
to nursing.
Has cross-referencing options.
Provides best available evidence
for medical outcomes.
Ensures broad capture of more
obscure sources.
639
640
Koenig (1998)
Koenig et al. (1998)
Religious attitudes and

practices of hospitalised
medically ill older adults
Modelling the crosssectional relationships

between religion, physical
health, social support, and
depressive symptoms
Religious coping and health
status in medically ill
hospitalised older adults
Men of prayer: spirituality

of men with prostate
cancer
Walton and Sullivan (2004)
Cross-sectional surveys
Breast cancer survivors

give voice: a qualitative
analysis of spiritual factors
in long-term adjustment
Seeking comfort
through prayer
Neurocorrelates of
religious experience
Title
Gall and Cornblat (2002)
Qualitative research
Hawley and Irurita (1998)
Experimental designs
Azari et al. (2001)
Author/ Year
of publication
Table 4 Table of published studies identified to 14th November 2007
General medical (n = 542),

cardiology and neurology
patients aged over 60.
Study of 577 medical inpatients

age 55+ (73% response rate)
based on structured interview.
USA
USA
Survey of 4000 people aged 60+.

Private prayer/bible reading
measured separately.
USA
Grounded theory study of 11 male

prostate cancer inpatients, aged
5471.
Thirty-one women wrote in their

own words how religious and
spiritual factors played a part in
their understanding of and coping
with this illness.
Canada
USA
Qualitative interview study

(n = 13 post-CABG patients).
Compared neurological PET scan

effects of reading religious and
non-religious material on
religious and non-religious
students.
Overview of method
Australia
Germany
Location
of study
Private prayer/bible reading

negatively correlated with
physical health and positively
correlated with social support,
but unrelated to depression.
Negative impact of pleading for
direct intercession (Pleaded with
God to make things turn out OK;
Prayed for a miracle; Bargained
with God to make things better).
587% reported praying at least
daily. Prayer/bible reading more
prevalent in women, those with
lower levels of education and
stressful life events.
Beliefs that God listened to and

answered prayers for comfort
gave reassurance and strength to
face uncertainty.
Personal prayer was most common
religious coping activity and
consisted mainly of two types:
petitionary (call for help) and
colloquial (give thanks for
blessings).
Prayer was an important concept
in coping with cancer.
PET images showed a specific,

significant, activation of the right
dorsolateral prefrontal cortex
(indicative of a religious state) in
the religious subjects when
reading a psalm as compared
with non-religious subjects or
during a happy non-religious
reading.
Key findings
Religious orientation and

psychological wellbeing:
the role and frequency of
personal prayer
The prevalence of prayer as
a spiritual self-care
modality in elders
Maltby et al. (1999)
The relationship between

psychological wellbeing
and Christian faith and
practice in an Australian
population sample
Cancer and faith. Having
faith does it make a
difference among patients
and their informal carers?
Francis and Kaldor (2002)
Soothill et al. (2002)
The use of prayer by

coronary artery bypass
patients
Ai et al. (2000)
Dunn and Horgas (2000)
Patterns of positive and

negative religious coping
with major life stressors
Title
Pargament et al. (1998)
Author/ Year
of publication
Table 4 (Continued)
Students (n = 474). Questionnaires

measured religious orientation,
self-esteem and depressive
symptoms.
Descriptive study; convenience
community sample, n = 50 aged
6585, recruited from one church
and six senior centred in racially
diverse, large metropolitan city in
the Midwest.
UK
Retrospective analyses of longitu

dinal questionnaire data
(n = 151) are post-CABG
emotional health, religious
activities, social support and
non-cardiac chronic conditions.
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
Survey of college students designed

to construct and test 14-item
measure of positive and negative
patterns of religious coping methods (Brief RCOPE).
Overview of method
USA
Location
of study
Controlling for demographic and

clinical variables, patients with
expressed faith reported fewer psycho
social needs than those without faith
and greater need to engage in per
sonal prayer. Carers expressed
different needs to patients.
Positive pattern inc.: religious for

giveness, seeking spiritual support,
benevolent religious reappraisal.
Negative pattern: spiritual
discontent, punishing God
reappraisals, interpersonal
religious discontent.
Significant correlation between
religiosity and psychological
wellbeing. Personal prayer appears
to be an important variable.
Prayer was the most commonly
reported non-medical inter
vention, used by 84%. Prayer
may offer a spiritual cognitive
therapy to reappraise or
re-evaluate stressful life events,
minimise negative effects of stress
and maintain optimum health.
Use of prayer to cope was
associated with better post
operative emotional health.
Those aged >60 were more likely
to pray if religion was important
to them. Those aged <65 were
more likely to pray if lower
income, better preoperative
health and more education.
Overall, prayer was associated
with positive effect after control
ling for age and sex. No signifi
cant negative effect found.
Key findings
Review
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
The effects of spirituality on

wellbeing of people with
lung cancer
Prayers, spiritual support,
and positive attitudes in
coping with the September
11 national crisis
Religiosity/spirituality and
pain in patients with sickle
cell disease
Francis et al. (2003)
Ai et al. (2004)
Meraviglia (2004)
Ai et al. (2005)
Harrison et al. (2005)
Religiosity, stress and

psychological distress: no
evidence for an association
among undergraduate
students
Title
OConnor et al. (2003)
Author/ Year
of publication
Table 4 (Continued)
USA
USA
USA
USA
UK (Wales, N. Ireland)
UK (England/Scotland)
Location
of study
Data from longitudinal study of

the relationship of psychosocial
factor to pain. Hypothesis:
religious factors influence pain
perception in SCD patients
(n = 50). 700-item questionnaire
inc. demographics, pain,
religiosity and psychological
distress.
Survey of 453 students.
Interviews with cardiac patients

(n = 146, mostly Judeo-Christian)
two weeks prior to surgery
(CABG). 3-item Using Private
Prayer as a Means for Coping,
optimism and distress (CES-D)
measured.
Questionnaire study; n = 60;
age 3383.
Survey of 177 undergraduate

students included General Health
Questionnaire (distress) and
7-item Francis Scale of Attitude
Towards Christianity (FSAC)
(religiosity), including Prayer
helps me a lot.
Survey of 246 undergraduate
students using same question
naires as OConnor et al. also
assessed frequency of church
attendance and personal prayer.
Overview of method
Prayer mediated relationship between

health status and wellbeing and
explained 10% of the variance of
psychological wellbeing.
75% believed private prayer was
important in their lives. Prayer
indirectly associated with positive
attitude and emotions.
Daily prayer or Bible study occurred
in 39%, compared with 26% in the
general population. Frequency of
prayer and bible study did not
correlate with measures of pain or
mental health in this group.
Positive attitude to Christianity, but

not personal prayer, was positively
associated with health. Differences in
attitude toward religion are more
important than differences in
religious behaviour.
Private prayer mediator between faith
and optimism/agency which in turn
associated with lower distress
(anxiety and depression).
No correlation found between

religiosity and distress using these
measures.
Key findings
Private prayer and

optimism in middle-aged
and older patients
awaiting cardiac surgery
Religion, spirituality, and

acute care hospitalisation
and long-term care use by
older patients
The role of private prayer in

psychological recovery
among midlife and aged
patients following cardiac
surgery
Does private religious
activity prolong survival?
A six-year follow-up study
of 3,851 older adults
Religion and spirituality

among patients with
localised prostate cancer
Title
Ai et al. (2002)
Helm et al. (2000)
Prospective cohort studies

Ai et al. (1998)
Hamrick and Diefenbach (2006)
Author/ Year
of publication
Table 4 (Continued)
Community residents (n = 3851)

aged 65 and over. Private
religious activity assessed by:
How often do you spend time in
private religious activities, such as
prayer, meditation, or Bible
study?
Correlational study. Interviews
two weeks and one day prior to
surgery with 246 patients
awaiting cardiac surgery to test
effects of belief in the importance
of private prayer and intention to
use prayer to cope.
Study of medical admissions;
n = 811; age 50+; interviewed at
0, 3, 6, 9 and 12 months. 2-item
measure of frequency of private
prayer other than at mealtimes.
USA
USA
USA
Patients (n = 151) aged 4060.

Questionnaire administered
postop and six months and
one-year postdischarge.
Comparative study based on

questionnaire data from patients
(n = 254) diagnosed with
localised prostate cancer and a
random sample (n = 238) of
respondents to the national
general social survey.
Overview of method
USA
USA
Location
of study
Private prayer associated with

reduction of days spent in long-term
care, regardless of illness severity, but
not fewer days in acute care.
Majority intended to use prayer and

this predicted positive attitude prior
to surgery.
Private religious activities provided a

protective effect against mortality for
an elderly population free of
functional impairment, even after
controlling for numerous covariates.
Private prayer associated with

significant decrease in depression
and general distress one-year
postsurgery.
Positive benefits (inc. reduced worry)

of religious coping/practices
restricted to patients with higher
level of postdiagnosis increase in
religiosity; patients not reporting
postdiagnosis increases in religion
not engaging in religious coping/
practice adjusted equally well.
Key findings
Review
643
644
Depression, faith-based
coping, and short-term
postoperative global
functioning in adult and
older patients undergoing
cardiac surgery
The influence of prayer

coping on mental health
among cardiac surgery
patients: the role of opti
mism and acute distress
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
Private prayer had a negative indirect

effect on acute stress through
optimism, which appeared to
counteract its positive direct effect
on acute distress. Therefore, the total
effect of prayer on wellbeing was
insignificant.
Preoperative positive religious coping

was associated with better post
operative activities of living. Post
operatively, private prayer was
associated with poorer activities
of living.
Key findings
Review
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 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.
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 communicating back with them, whereas those who prayed regularly
listened for Gods 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 Gods 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, 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,
645
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 (08) and
church attendance (068). 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 assumptions 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 differentiate 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 attendance) 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 multicollinearity 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 between religiosity and wellbeing. The descriptive study by
Pargament et al. distinguished between two aspects of
religiosity, which may also have some bearing on discrepancies 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
Koenigs and Franciss were large-scale surveys. Dunn and
646
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 depression. 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 Gods
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 relationship between religious coping, religious practices and wellbeing. Their findings confirm that many people turn to
religion and prayer when faced with a potentially lifethreatening 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.
Review
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 depression. 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 (085):
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 oneyear 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 postoperative 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 patients religious tradition.
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
647
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 associated 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 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
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 interviewers 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 Sullivans 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 associated with passive coping (doing nothing) and faith-based
prayer, which is associated with active self-help coping
Review
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 patients 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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Private Prayer's Effect on Hospital Patients

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REVIEW

Private prayer as a suitable intervention for hospitalised patients: a

beneficial. Commenced as an undergraduate project, this

C Hollywell and J Walker

beliefs that sustain and support the individual through times

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

Table 1 Key words

All words based

Broad approach to the topic

Critical review of private prayer

Table 2 Inclusion/exclusion criteria

Exclusion and justification

Studies later than 1990

Studies prior to 1990 were not

Physical health and

include studies based on the general population including

These databases identified thousands of hits related to

Spirituality and prayer are

Covers literature relevant to

Academic search engine

The research question focuses

Koenig et al. (1998)

Religious attitudes and

Modelling the crosssectional relationships

Men of prayer: spirituality

Walton and Sullivan (2004)

Breast cancer survivors

Gall and Cornblat (2002)

Table 4 Table of published studies identified to 14th November 2007

General medical (n = 542),

Study of 577 medical inpatients

Survey of 4000 people aged 60+.

Grounded theory study of 11 male

Thirty-one women wrote in their

Qualitative interview study

Compared neurological PET scan

Private prayer/bible reading

Beliefs that God listened to and

PET images showed a specific,

C Hollywell and J Walker

Religious orientation and

Maltby et al. (1999)

The relationship between

Francis and Kaldor (2002)

Soothill et al. (2002)

The use of prayer by

Dunn and Horgas (2000)

Patterns of positive and

Pargament et al. (1998)

Students (n = 474). Questionnaires

Retrospective analyses of longitu

Survey of college students designed

Controlling for demographic and

Positive pattern inc.: religious for

The effects of spirituality on

Francis et al. (2003)

Harrison et al. (2005)

Religiosity, stress and

OConnor et al. (2003)

Data from longitudinal study of

Survey of 453 students.

Interviews with cardiac patients

Survey of 177 undergraduate