The diagnosis of cancer can initiate considerable distress for patients. The threat to physical health and life can challenge one’s previously held beliefs concerning life and well-being. Some people have found that their spirituality, particularly prayer, provides a resource to withstand the physical and psychologic crises brought on by the diagnosis and subsequent treatment of cancer. 1 An instrument assessing prayer in people with cancer can help to understand the importance of prayer activities and experiences in this group.
Prayer is defined in the literature in various ways. James’ definition provides a comprehensive understanding by describing prayer as “every kind of inward communion or conversation with the power recognized as divine.”2 The nature of prayer differs depending on one’s spiritual beliefs. Brown conducted a detailed study of the meaning of prayer, differentiating between the elements of prayer and the similarities and differences in previous understandings of prayer. He concluded from his concept analysis that there could not be only one definition of prayer. 3
Some authors have characterized prayer as an outcome of spirituality, whereas others view prayer as a quality of being spiritual. 4–6 For this study, prayer is defined as an activity and expression of the human spirit reflecting connectedness with God. Prayer influences and is affected by one’s spirituality. 7
Several studies indicated that prayer is important to people when they are ill. Patients preparing for liver transplantation described prayer by others as a supportive behavior. 8 Carson noted moderate correlations between hardiness and prayer in people who were HIV positive. 9 In a study of adults recovering from coronary artery bypass surgery, Ai and associates found prayer, along with exercise and lifestyle and diet modification, improved a person’s psychologic adjustment. 10
Two studies have confirmed that prayer activities and experiences were helpful to people with cancer. Sodestrom and Martinson reported that people with cancer described both praying personally and asking others to pray for them as spiritual coping strategies. 11 In addition, Swenson and associates described a positive relationship between the more complex stages of faith and increased frequency of prayer in adults with advanced cancer. 1
The research on the effects of prayer on physical responses to disease is striking. Several experimental studies showed that prayer had a positive effect on physical health for the people who were critically ill and for those experiencing chronic low back pain. 12–14 Descriptive studies have demonstrated that many people used prayer to manage their symptoms of aging and disease. 15,16 Interestingly, Meisenholder and Chandler found that those people who had more physical pain and less physical functioning prayed often. In addition, those with higher psychologic health reported praying often. 17
A review of the literature did not reveal an instrument for the measurement of prayer activities and experiences for people with cancer. Poloma and Pendleton’s Prayer Scale (PS) was the most acceptable tool because their operational definition was consistent with the previously chosen theoretical definition of prayer. 18
Poloma and Pendleton developed their scale to assess types of prayer activities and prayer experiences. The instrument included one item that asked participants about their relationship with God. They conducted telephone interviews of randomly selected adults (n = 560) in a midwestern community about prayer and sense of well-being. The researchers reported that the frequency of prayer was positively related to existential well-being and religious satisfaction. Experiences during prayer were also positively correlated to religious satisfaction and existential well-being. The authors assessed construct validity of the prayer activities subscale by factor analysis with items loading on 4 types of prayer. 16 Poloma reported a Cronbach’s alpha reliability coefficient of .85 for the instrument (personal communication, 1997).
Because the original instrument by Poloma and Pendleton was not sensitive enough to tap cancer illness, the scale was adapted by the author for use with people with cancer (Figure 1). First, the instructions were revised to direct the participant to focus on the period of time since being diagnosed with cancer. Second, 3 items were added to the instrument to assess the frequency of prayer (per day), focus of prayer (name), and length of prayer (in minutes). Third, an additional subscale on attitudes toward prayer during the cancer experience was developed to appraise the influence of prayer on the physical and psychologic responses to cancer and its treatment.
In addition, 3 open-ended questions were added to gather information about perception of prayer within the cancer experience. Questions asked if prayer helped during the treatment of cancer, if the person “heard” anything from God concerning his or her disease, and if anyone had been praying for him or her.
The initial draft of the adapted PS was distributed to measurement and content experts for review. Three measurement reviewers evaluated the scale for layout and completeness. Five content reviewers critiqued the items for accuracy and clarity of the content on prayer and/or cancer. Three of the experts were nurse researchers with extensive experience in oncology nursing. Also, 3 of the content experts were people known for their depth of experience and understanding of prayer. Content validity of the scale was assessed from the expert review of the questionnaire before pilot testing.
Recommendations from the reviewers were incorporated into a revision of the adapted PS. The adapted and revised PS has 39 items, which include 3 general items about prayer, 1 item on perceived relationship with God, 17 items on prayer activities, 9 items on prayer experiences, 6 items on attitudes toward prayer, and 3 open-ended questions. The 3 subscales had 7 Likert-type response categories ranging from 7 = strongly agree to 1 = strongly disagree. Total scores were computed for each subscale by adding the item scores. High scores reflected a high degree of prayer activity, prayer experience, or positive attitude toward prayer. Subscale scores could range from 17–119 for prayer activities, 9–63 for prayer experiences, and 6–42 for attitudes toward prayer.
The adapted PS was tested to determine whether the directions were clear and the scale items understandable. During testing, the reliability of the subscales for people experiencing cancer was also assessed. A correlational research design was used to examine the relationships between the elements of prayer, background information, disease characteristics, and perceptions of functional and physical health status. Such a design is especially useful in areas of investigation where there is limited research.
Participants were recruited from 3 urban oncology and 2 radiation clinics in central Texas. The inclusion criterion for participants in the study was any person aged 21 to 80 years with cancer. Criteria for exclusion included the inability to read or respond to the questionnaire.
After participants agreed to participate in the study, they completed a questionnaire that included the adapted prayer scale, along with a survey asking about personal background information, characteristics of their cancer, perceptions of their current functional and physical health status, and satisfaction with their current income.
A total of 32 people participated in the pilot study (24 women, 8 men), ranging in age from 31 to 74 years, with a mean age of 56. The majority of participants were caucasian (n = 27), with the remainder being African American (n = 5). Concerning religion, all the participants described themselves as Christian, primarily Protestant, with 9% Catholic and another 9% nondenominational. The majority of participants reported their relationship with God as close, with more than 40% responding to the highest option of “very close.” Participants had a variety of cancers, which included breast cancer (38%), lung cancer (16%), colon cancer (9%), uterine or ovarian cancer (9%), leukemia (6%), and other types of cancer (22%). Fifty-six percent of the sample reported that they were within the first 6 months of being diagnosed with cancer (Table 1).
Total scores on the 3 subscales varied. Prayer activity scores ranged from 58 to 108, with a mean of 87. The scores on the prayer experience subscale ranged from 18 to 52, with a mean of 36.8, whereas attitudes toward prayer scores ranged from 29 to 42, with a mean of 37.83. Scale total scores ranged from 117 to 201, with a mean of 161.80 (Table 2). Additionally, items from each subscale with the highest mean are listed in Table 3.
Reliability coefficients for the subscales were acceptable: prayer activity subscale (0.75), prayer experience subscale (0.78), and attitudes toward prayer subscale (0.72). The reliability coefficient for the entire scale was not accurate because the total number of scale items was greater than the size of the sample. 19
Correlations between elements of prayer and background and disease characteristics provided support for the validity of the adapted PS with patients. When analyzing the correlations, there were several significant relationships (P < .05) (Table 4). Frequency of prayer was negatively related to level of education (r = − 0.497) and functional status (r = − 0.384) and positively related to presence of metastasis at diagnosis (r = 0.332). The prayer activity subscale was negatively related to functional status (r = − 0.317). The prayer experience subscale was negatively correlated with physical health status (r = − 0.323).
In addition, there were significant positive correlations between participants’ perceived relationship to God and the 3 prayer subscales (P < .05): prayer activity (r = 0.394), prayer experience (r = 0.365), and attitudes toward prayer (r = 0.342). Similarly, the frequency of prayer was significantly correlated with the prayer activity subscale (r = 0.391) and attitudes toward prayer subscale (r = 0.374).
The findings from the pilot study supported the reliability and validity of the adapted scale for assessing aspects of prayer in people with cancer. The subscales of the instrument had adequate reliabilities, with alphas ranging from 0.75 to 0.78. The 3 subscales correlated well with one element of spirituality: scores on the relationship with God item. Furthermore, moderate associations between the subscales and elements of prayer provided support for the content validity of the instrument.
Elements of prayer were associated with background and disease characteristics in this sample of people with cancer. Interestingly, people with more education reported a lower frequency of prayer. As participants’ functional status decreased, their frequency of prayer increased. Moreover, participants with metastasis of cancer reported more frequency of prayer.
The negative correlations of aspects of prayer with functional status and physical health were expected from the review of the literature. Primarily as the participants’ degree of prayer experiences increased, their physical responses to cancer decreased. In addition, as their functional status declined their prayer activities increased.
The next step in developing this scale was to analyze the responses to the open-ended questions and compare them to the results on the subscales. Also, the instrument must be tested with a larger sample of people with various types of cancer.
Prayer, as one aspect of spirituality, is a valuable internal resource that can influence one’s perception of cancer. The findings from this pilot study demonstrate that prayer can lessen the effect of physical and psychologic responses to cancer. Participant responses on the attitudes toward prayer subscale demonstrated the importance of prayer as an expression of the human spirit in connection with God. Nurses must be aware of the spiritual benefits available to people through prayer.
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Keywords:© 2002 Lippincott Williams & Wilkins, Inc.
Prayer; Spirituality; Research; Pilot study