Spirituality and Recovery from Cardiac Surgery: A Review

Spirituality and Recovery from Cardiac Surgery:A Review

Charles Adam Mouch • Amanda J. Sonnega

Published online: 17 May 2012� Springer Science+Business Media, LLC 2012

Abstract A large research literature attests to the positive influence of spirituality on a

range of health outcomes. Recently, a growing literature links spirituality to improved

recovery from cardiac surgery. Cardiac surgery has become an increasingly common pro-

cedure in the United States, so these results may provide a promising indication for improved

treatment of patients undergoing surgery. To our knowledge, a comprehensive review of the

literature in this area does not exist. Therefore, this paper reviews the literature relevant to the

influence of spirituality on recovery from cardiac surgery. In addition, it proposes a con-

ceptual model that attempts to explicate relationships among the variables studied in the

research on this topic. Finally, it discusses limitations, suggests directions for future research,

and discusses implications for the treatment of patients undergoing cardiac surgery.

Keywords Spirituality � Religion � Cardiac surgery � Faith � Prayer � Surgery �Recovery � Spirituality and health � Religion and health

Introduction

Spirituality and religion act as powerful guiding forces in a person’s life. Gallup polls show

that more than 90 % of all Americans believe in God or some form of higher power (Ikedo

et al. 2007; Thoresen 1999). It is estimated that between 75 and 90 % of Americans pray

regularly (Ai et al. 2009a; Thoresen 1999) and that 67 % of Americans belong to some

religious organization. Sixty-seven percent of Americans also reported that religion was

‘‘very important in their lives’’ (Thoresen 1999). Clearly, religion and the spiritual exercises

that accompany belief in God play a significant role in the lives of a majority of Americans.

C. A. MouchMedical School, University of Michigan, Ann Arbor, MI, USAe-mail: [email protected]

A. J. Sonnega (&)Survey Research Center, Institute for Social Research, University of Michigan, 4217 MISQ ISR Bldg,Ann Arbor, MI 48109-1248, USAe-mail: [email protected]

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J Relig Health (2012) 51:1042–1060DOI 10.1007/s10943-012-9612-y

Although patients often use the terms ‘‘religion’’ and ‘‘spirituality’’ interchangeably, the

health literature generally concludes that the terms ‘‘religion’’ and ‘‘spirituality’’ refer to

separate concepts (Idler et al. 2009). Religion is typically described as an organizational or

institutional structure established to maintain a set of core beliefs. Religion also describes

the social interaction of members within the institutional community (Chang et al. 2010;

Idler et al. 2009; Thoresen 1999). In contrast, spirituality generally refers to the subjective

experience of each person as they search for meaning in their lives and in their personal

relationship with the sacred. In this respect, spirituality implies a more individual concept

than religion (Chang et al. 2010; Idler et al. 2009).

Spirituality has been positively linked to improved physical health in a variety of

conditions. Various studies have suggested that spirituality may correlate with lower risks

of all-cause mortality, hypertension, stroke, and most cancers (for a review, see Levin

1994). Research demonstrating a connection between the mind and body can suggest the

existence of possible physiological mechanisms that may explain these results (Thompson

et al. 2009; Thoresen 1999). In addition to physical health, many studies have also linked

spirituality to improved mental health. Specifically, individuals with higher levels of

spiritual involvement report lower rates of depression, alcohol and other drug abuse, and

divorce, and higher rates of overall well-being (Thoresen 1999).Research showing positive effects of spirituality on overall health has heightened interest

in the influence of spirituality on more specific medical outcomes. Cardiac surgery is one area

in which the effect of spirituality on health has garnered increased, though limited, research

attention. A major motivation for this focus on cardiac surgery is its high prevalence in the

United States, particularly among the elderly. By 2005, the incidence of coronary artery

bypass graft surgery (CABG) had increased to nearly five times the incidence in 1979 (Ai

et al. 2009b), while an estimated 709,000 open-heart surgeries were performed in 2002.

Several studies have suggested that spirituality may have positive effects on physical

and psychological recovery from cardiac surgery (for a review, see Thoresen 1999). These

results could suggest additional treatment considerations that may lead to improved sur-

gical outcomes. These improved outcomes could significantly influence post-operative

quality of life and could reduce the financial burden placed on the healthcare system.

However, a comprehensive review of the published literature in this topic does not exist.

This paper reviews the research literature on the intersection of spirituality and recovery

from cardiac surgery, focusing first on physical outcomes and then on psychological

outcomes. We begin with research demonstrating the prevalence of spirituality as a way to

cope with the stress of cardiac surgery and go on to propose a heuristic conceptual model

of the relationship between spirituality and recovery from cardiac surgery. It is not a

theoretical model; rather, it attempts to portray the relationships investigated in the studies

reviewed here. The purpose of the model is to attempt to lend conceptual clarity to this area

of study and to serve as a guide for further investigations and, perhaps, as the basis for

future hypothesis generation. Our hope is that researchers will continue to build on and

improve this model as measurement issues are addressed and as our store of knowledge

about the link between spirituality and recovery from cardiac surgery grows.

Spirituality as a Coping Mechanism

Spirituality appears to be an important coping method used by cardiac patients during their

recovery from surgery (Ai et al. 2010a; Kaba et al. 2000). One study reported that 96 %

of cardiac patients used prayer as a means of coping with the stress they experienced

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post-operatively. Of these respondents, 97 % believed that their prayer helped them cope

more effectively (Saudia et al. 1991). Other studies provide similar evidence to suggest

frequent use of spirituality as a coping method following cardiac surgery. Ai et al. (1997)

found that prayer ranked second only to vitamins as the most common complementary

therapy used by patients in their study on the use of complementary therapies during

recovery from coronary arterial bypass graft (CABG) surgery. A different study also found

that prayer was one of the most popular alternative treatment options in patients undergoing

cardiac surgery (Liu et al. 2000). These results suggest that a high percentage of cardiac

patients use their spirituality as a coping method during their recovery from surgery.

Research in this area often implicitly utilizes the influential Transactional Model of

Coping and Stress that was first proposed by Lazarus and Folkman (1984). In this model,

individuals are faced with a stressor, evaluate its stressfulness (primary appraisal), and then

make an assessment of their resources for coping with the stressor (secondary appraisal).

Figure 1 articulates this model in the context of recovery from cardiac surgery. In our model,

the stress associated with cardiac surgery acts as the primary stressor that leads patients to turn

to their spirituality as a way to cope. Although cardiac surgery has become a relatively

common procedure in the United States, many patients view the procedure as a life-threat-

ening event (Ai et al. 2006a). The decision to have surgery, uncertainty about the future, and

sense of a loss of control are all factors that contribute to these feelings of stress (Camp 1996).

In the second stage of coping, individuals make an assessment of the coping resources

available to them. As noted, patients often turn to their spirituality as a source of emotional

comfort and stability. As Ai et al. (2010a) suggest, using prayer may allow the patient to

‘‘find comfort from a sacred interconnectedness in one’s faith or a sense of meaning in the

midst of distress’’ (p. 799). Other researchers echo these sentiments and suggest that

spirituality, expressed through religious coping, may allow cardiac patients to confront

their overwhelming feeling of stress with a renewed sense of strength (Ai et al. 2006a). In

this way, many cardiac patients use prayer as a source of emotional support that enables

them to continue their journey toward recovery.

The box labeled religious coping in Fig. 1 lists the range of terms used in studies of

spirituality and cardiac surgery to describe this phenomenon. The box serves to highlight

the wide range of terms used to describe spiritual experiences. However, Idler et al. (2009)

note that research in this area has relied heavily on this conceptualization and has given

less attention to what they call ‘‘extrinsic’’ religion, which is the social rituals, such as

Proximal Outcomes Infections Complications Length of Stay in Hospital Subjective Health Status Fatigue Psychological Distress

Distal Outcomes Morbidity Mortality Psychological Distress

Cardiac Surgery Primary appraisal Is it a threat?

Secondary Appraisal How can I cope?

Coping Resources Hope Optimism Social Support Sense of Control

Religious Coping Spirituality Religiousness Prayer

Sense of reverence Religious Involvement Religious service attendance Religious/spiritual beliefs Religious Strength and Comfort Spiritual Struggle

Physiological Mechanism

?????

Psychological Distress

Fig. 1 Conceptual model of spirituality and recovery from cardiac surgery

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church attendance, of religious life. As a result, the social support function of religious

experience may be underestimated. A large literature attests to the significant impact of

social relationships on health (House et al. 1988), and we include social support in a set of

coping resources that may be activated—and may interact with religious coping—when

facing a major stressor.

Lastly, the model enumerates the proximal and distal outcomes considered in the studies

included in this review. It is important to note that psychological distress is conceptualized as

a background factor as well as an outcome. It may also interact in meaningful ways with other

variables in the model and may influence ways of using religion and spiritual coping. For

example, one study reviewed here suggests that spiritual struggle as part of using religion to

cope with the stress of cardiac surgery was found to be associated with increased post-

operative distress (Ai et al. 2010b, c). Another study found that prayer appears to have similar

physiological effects as the relaxation response (Chang et al. 2010). We propose that this may

be an important mediator to the outcomes. Finally, our model indicates that the physiological

mechanism linking religious coping to physical outcomes remains unclear.

Overall, the studies reviewed suggest that patients perceive cardiac surgery as a major

life stressor, but coping resources like hope and optimism may mitigate the stress even at

the earliest stage. Our conceptual model suggests that coping resources may influence

primary appraisal of cardiac surgery as a threat. As patients marshal their resources for

coping with the stressor, the research indicates that many will turn to religion to help them

cope with this stress. In turn, a range of measures utilized in these studies show a positive

effect of religious coping on proximal outcomes such as post-operative complications,

fatigue, and distress (Ai et al. 2006b, 2007, 2009b; Contrada et al. 2004). A smaller number

of studies show lower long-term morbidity and even lower mortality among patients who

use religious coping (Ai et al. 2006a; Karademas 2010; Oxman et al. 1995). As we will

show, however, findings are mixed, and use of religious coping is surely even more

complicated than studies to date have reported.

Methods

A thorough search of the electronic literature was conducted to locate appropriate studies

to be reviewed in this paper. The search was performed using the PubMed (MEDLINE)

and PsychINFO online databases. Search terms relating to spirituality (i.e., spirituality,

religion, faith, prayer, spirituality and health, religion and health) were combined with

search terms relating to cardiac surgery (i.e., cardiac surgery, CABG, heart disease, heart

attack, surgery, recovery, heart surgery) to narrow the search to relevant studies. To be

included in this review, all studies were required to (a) be written in the English language,

(b) be published in a peer-reviewed journal, (c) be original research, and (d) examine the

relationship between spirituality and recovery from cardiac surgery. Of all the studies

considered, a total of 16 met these inclusion criteria.

Results

Effect on Physical Recovery

Aspects of physical recovery examined in the literature include post-operative length of

stay, post-operative complications, post-operative infections, short-term post-operative

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physical functioning, and short-term post-operative mortality. Studies addressing each of

these aspects of physical recovery will be reviewed in this section.

A recent study examined the influence of religious factors such as prayer and reverence

on physical recovery from CABG (Ai et al. 2009b). The authors recruited a convenience

sample (n = 177, mean age = 65) of patients aged 35 years or older who were scheduled

to undergo CABG at the University of Michigan Medical Center. Study participants

underwent a pre-operative interview, at which time psychosocial measures of religious

attendance, spiritual experiences, sense of reverence, and depression were assessed. The

results suggest that prayer (a form of religious reverence, a feeling of wonder associated

with an experience of the sacred) was inversely related to the number of post-operative

complications. The authors also report a similar relationship between secular reverence (a

feeling of wonder experienced during everyday observations of art, excellence, or nature)

and post-operative complications. A reduction in complications was also shown to reduce

the post-operative length of stay in the hospital. The authors suggest that the effects of

spirituality on health are complicated and that multiple measures of spirituality may play a

mediating role in recovery from cardiac surgery.

A different study also examined the influence of religious involvement and other

psychosocial influences on post-operative complications following CABG (Contrada et al.

2004). A convenience sample of 142 cardiac patients was recruited from the Robert Wood

Johnson University Hospital and interviewed pre-operatively. The interview assessed

religious and psychosocial factors such as religious involvement, depressive symptoms,

perceived social support, and dispositional optimism. Similar to the findings of Ai et al.

(2009b), Contrada et al. (2004) found that patients with stronger religious beliefs had fewer

post-operative complications and shorter length of stay (LOS) at the hospital. In this study,

fewer complications were found to mediate LOS. Unlike in Ai et al.’s (2009b) study, there

was no observed effect of prayer on complications or LOS. The authors also found that

attendance at religious services was inversely related to LOS. This result was surprising,

and Contrada et al. (2004) suggest that the negative effect may be present only in indi-

viduals who attend services regularly but do not have strong religious beliefs. Also

interesting was that prayer had no effect on physical recovery. The authors suggest that the

study design may have influenced this result. Specifically, participants were asked only

about their normal frequency of prayer, not the frequency of prayer as a coping method.

Therefore, this study only assessed the participant’s ‘‘baseline’’ prayer frequencies.

Ikedo et al. (2007) conducted another study that examined the effect of prayer and

relaxation techniques on physical recovery from cardiac surgery. Unlike previous studies,

this study examined the use of prayer during surgery (via headphones) and its effects on

post-operative recovery. It is also one of the only studies to use a randomized, controlled,

double-blind methodology. Patients (n = 105) completed a pre-operative questionnaire

and survey to assess their mood and spiritual beliefs. During surgery, patients were ran-

domly assigned to one of three groups: prayer, relaxation, or placebo. The prayer group

listened to a generic prayer during surgery, while the relaxation group listened to relaxation

therapy during surgery. The placebo group had no sound, but still wore the headphones

during surgery. The study did not record any statistically significant differences between

groups, but several non-significant trends did appear. Specifically, it seems that mean LOS

was shorter in the prayer and relaxation groups compared to the placebo group. Like Ai

et al.’s (2009b) study, this result suggests that prayer may have a positive effect on

reduction of post-operative LOS, possibly mediated by the incidence of post-operative

complications. Another notable result was decreased rates of sternal wound infection in the

prayer and relaxation groups compared to the placebo group.

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A different study analyzed the effect of spirituality, mediated by illness cognitions, on

post-operative physical functioning in a group of Greek cardiac patients (Karademas

2010). Illness cognitions are representations of a patient’s feeling of personal control over

their illness. This study recruited patients from the cardiology clinic in a Greek public

hospital (n = 135), many of whom (45.18 %) had undergone cardiac surgery in the past.

Study participants were interviewed to assess intrinsic religiousness, church service

attendance, illness-related cognitions, and patient perceptions of physical health func-

tioning. Karademas (2010) found that subjective physical functioning was indirectly

associated with religiousness and that illness cognitions mediated this relationship. The

author suggests that using illness cognitions as a pathway between religiousness and health

may help the patients accept their condition and minimize their focus on the negative

aspects of their condition. Additionally, unlike the findings of Contrada et al. (2004),

Karademas reported that attendance at religious services had no effect on subjective health.

A recent study performed by Ai et al. (2006a) reported similar findings related to short-

term post-operative functioning (SPGF) in middle-aged and older patients undergoing

cardiac surgery. The researchers recruited 335 patients who were scheduled for cardiac

surgery at the University of Michigan Medical Center. The patients each completed a

series of three interviews. The first interview, completed 2 weeks pre-operatively, assessed

sociodemographics, psychological distress, overall function, and cardiac condition. The

second interview, completed 2 days pre-operatively, assessed religious coping and social

support, and the third interview, completed 1 month post-operatively, assessed SPGF and

the use of prayer as a coping mechanism. The results suggest that positive religious coping

mechanisms may predict improved SPGF in post-operative cardiac patients. Surprisingly,

the use of prayer as a coping mechanism was correlated with poorer SPGF. This is in

contrast to the results of Ai et al. (2009a), which indicated a positive association between

prayer and post-operative physical recovery. To explain this result, Ai et al. (2006a)

suggest that patients in a greater amount of post-operative distress may more frequently use

prayer as a coping method.

In a related study, Ai et al. (2006b) reported that pre-operative positive religious coping

was shown to be associated with lower rates of post-operative physical fatigue. The authors

suggest that this study may provide the first evidence that directly relates measures of pre-

operative spirituality to short-term post-operative physical fatigue. A follow-up study

extended these findings to evaluate the influence of social support and cognitive coping

strategies on recovery (Ai et al. 2009a). It may be that prayer, through improvements in

cognitive strategies and social support, can have a positive influence on short-term post-

operative fatigue. The authors note that it will be important for future research to inves-

tigate whether long-term effects mirror the improvements in short-term post-operative

fatigue observed in this study.

Cardiac surgery has been shown to significantly reduce the incidence of death in

patients with cardiac disease, but researchers are still seeking new ways to improve post-

operative survival (Ai et al. 2009b). In the only reviewed study measuring mortality as an

outcome, Oxman et al. (1995) examined the influence of social support and religious

strength and comfort on risk of death after cardiac surgery. This prospective study recruited

232 elderly subjects (older than 55 years, mean age = 71.4 years) from a cardiovascular

unit at the Dartmouth-Hitchcock Medical Center. All patients included in the study had

undergone either CABG or valve replacement. Psychosocial mediators on immediate post-

operative mortality were measured through three interviews occurring at the pre-operative

appointment, 1-month post-operative visit, and 6-months post-operative visit. Psycholog-

ical and social factors that might influence post-operative mortality were assessed. The

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authors considered only death occurring within 6 months after surgery in their analysis,

since deaths occurring during this time period were more likely to be linked to the cardiac

surgery. Their results help to paint a clearer picture of the influence of religious factors on

mortality in the cardiac population. About 9 % (21/232) of the patients enrolled in the

study died within 6 months of surgery. Of these 21 patients, all but one died of cardio-

vascular complications that may have stemmed from the surgery. This mortality rate is

relatively high by current standards, as significant improvements have been made in

mortality following cardiac surgery in recent years (Fink et al. 2011). In addition, it is

difficult to interpret this mortality statistic because the authors reported on 6-month

mortality. Specifically, we were unable to find another study analyzing 6-month mortality

following cardiac surgery: all other studies examined in-hospital, 30-day, or long-term

mortality following cardiac surgery. Nonetheless, the authors reported that subjects were

three times more likely to die following cardiac surgery if they did not participate in an

organized group. Participation was measured as a subcomponent of social support in which

both the proximity to and frequency of attendance at social organizations was considered.

Frequency of attendance at religious functions was also measured in this study. Even more

striking, the authors noted a threefold increase in post-operative mortality among subjects

who lacked strength and comfort from religion. The authors suggest that these two results

may be linked, since religious organizations provide elderly individuals with a social group

that may offset the normal decline in social participation that occurs with age. Despite a

small sample size with limited generalizability, this study does seem to show that psy-

chosocial variables, specifically social group participation and a sense of strength and

comfort from religion, are associated with a significantly lower risk of death in patients

recovering from cardiac surgery.

To summarize, it seems that spirituality may have a positive effect on short-term

physical recovery from cardiac surgery. Prayer was the most common measure of spiri-

tuality included in the studies reviewed in this section, although some studies did evaluate

multiple measures of spirituality. Spirituality was shown to influence improvements in

many aspects of short-term physical recovery from cardiac surgery. Specifically, spiritu-

ality was shown to have a positive influence on complications, LOS, physical functioning,

and mortality. However, the interaction of spirituality with these physical outcomes is

highly complex and may be influenced by multiple factors, including social support and

cognitive strategies. Future research in this area should focus on investigation of both the

short- and long-term effects that spirituality may have on physical recovery from cardiac

surgery.

Effect on Psychological Recovery

In addition to physical and social factors, psychological factors play a vital role in

determining a patient’s post-operative QOL. Previous research has identified depression as

a major risk factor following cardiac surgery. The problem is prevalent, with estimates of

post-operative depression in cardiac patients ranging from 7.5 to 47 % (Ai et al. 2006a).

Other psychological factors may also influence post-operative QOL. Spirituality is known

to have significant positive effects on overall mental health (Thoresen 1999). As a result,

there has been an increasing amount of research undertaken to assess whether spirituality

may have an influence on post-operative emotional well-being. Studies in this section of

the paper will address the effect of spirituality on pre-operative optimism, post-operative

depression, and post-operative psychological distress.

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Ai et al. (2002, 2004) examined the relationship between private prayer and pre-

operative optimism in patients scheduled to undergo cardiac surgery. Patients (n = 226)

awaiting cardiac surgery at the University of Michigan Medical Center were recruited for a

series of two pre-operative interviews. The first face-to-face interview was conducted

2 weeks before surgery and assessed demographics, religiousness, and general health. The

second interview was conducted by telephone about 1 day prior to surgery and assessed

optimism. The authors found that 88.2 % of the study participants planned to use private

prayer as a coping mechanism. More importantly, the study suggests that the use of private

prayer predicts pre-operative optimism in patients awaiting cardiac surgery. However, no

specific types of prayer were found to be significantly correlated with optimism. As the

authors suggest, this relationship may indicate that private prayer may influence pre-

operative attitude, which may in turn predict better coping with the stress associated with

cardiac surgery.

A different study described patients’ methods of coping after heart transplantation

surgery (Kaba et al. 2000). Patients (n = 42) recruited for the study participated in

unstructured, in-depth interviews in which they discussed the methods they used to cope

after their surgery. The authors identified several themes when analyzing the data. The

themes most relevant to this review included the themes of ‘‘acceptance/optimism’’ and

‘‘having faith.’’ In particular, it seems as if optimism was associated with positive psy-

chological recovery from surgery. According to Kaba et al. (2000, p. 934), ‘‘participants

who tended to have a general positive outlook appeared to be satisfied and to make the

most of their circumstances, accepting problems as part of their treatment.’’ This finding

provides additional support for the assertion proposed by Ai et al. (2002) that pre-operative

optimism may be linked to improved post-operative psychological recovery.

A recent study by Chang et al. (2010) focused on the relationship between spirituality

and post-operative depression. Many studies have reported that depressive symptoms are

common among patients recovering from cardiac surgery. One report found that three of

four patients interviewed had experienced post-operative depression following CABG

(Eckhardt and Swanlund 2008). Chang et al. (2010) performed an observational study to

examine the influence of relaxation response (RR) training on psychological recovery

during cardiac rehabilitation. The authors hypothesized that participation in RR training

would improve spiritual well-being, which in turn would lead to more positive psycho-

logical outcomes following cardiac surgery. Study participants (n = 845) were divided

into groups of 12 and attended weekly classes for 13 weeks to learn how to elicit a

relaxation response. RR training promotes a mind–body strategy for coping with stress and

can be elicited by prayer, meditation, or other forms of spiritual contemplation. Patients

were encouraged to practice RR at home between sessions and to keep a daily log of these

experiences. Study participants also completed pre- and post-training questionnaires that

assessed self-reported health and psychological distress. The results suggest that patients

experienced both significant increases (12 %) in spiritual well-being and significant

decreases (18 %) in levels of depression after completing the RR training. As was true in

other studies, this study found a positive association between RR and improved spiritual

well-being. The authors therefore suggest that participation in RR is positively related to

lower levels of depression, with spiritual well-being acting as the primary mediator

between the two variables. A unique feature of this study is the methodology, which

allowed the authors to examine a dose–response relationship between RR and psycho-

logical outcomes. The results of this study suggest that RR provides a mechanism for the

improvement of spiritual well-being, which in turn may have a positive influence on the

psychological outcomes of patients in cardiac rehabilitation.

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Ai et al. (2010a) studied the relationship between pre-operative spirituality and long-

term depression in a group of patients who had undergone cardiac surgery. Data on

depression, anxiety, perceived social support, prayer coping, and sense of reverence were

collected pre-operatively and approximately 30 months after their surgery. The results

indicate that, controlling for pre-operative distress, patients who used prayer as a coping

mechanism reported fewer symptoms of depression. Interestingly, patients with high

reverence reported higher levels of depression after 30 weeks. This result contradicts the

results of other studies, but the authors suggest that the observed difference may be due to

differences in initial health of the study population. Overall, these results build on those of

Chang et al. (2010) by suggesting that pre-operative spirituality may have long-term effects

on psychological recovery.

In an earlier study, Ai et al. (1998) investigated the influence of private prayer on

psychological recovery 1 year after CABG. Study participants (n = 151) were selected

from the cardiac patient registry at the University of Michigan Medical Center and were

asked to complete two questionnaires at 6 and 12 months post-operatively. These ques-

tionnaires assessed cardiac health, social support, religious coping, and psychological

adjustment. The authors found that private prayer was the most frequently used coping

mechanism among the study participants. They also report that private prayer was asso-

ciated with both reduced depression and reduced psychological stress at the 12 months

post-operative interview.

Another study examined the relationship between religious coping styles and short-term

psychological distress in patients recovering from cardiac surgery (Ai et al. 2007). Study

participants (n = 309) scheduled to undergo cardiac surgery were interviewed three times:

once 2 weeks before surgery, once 2 days before surgery, and once 36 days after surgery.

The pre-operative interviews assessed demographics, religiousness, pre-operative distress,

and social support, while the post-operative interview assessed post-operative depression

and anxiety. The findings of this study indicate that positive religious coping was indirectly

associated with lower post-operative distress. It seems that positive religious coping pro-

motes both hope and social support, psychosocial factors which were directly correlated

with lower post-operative distress. The authors therefore conclude that both positive

religious coping and the psychosocial constructs hope and social support play protective

roles against short-term post-operative distress.

Two recent studies investigated the relationship between spirituality and psychological

recovery through a different perspective. Specifically, these studies focused on the effect of

spiritual struggle on psychological distress following cardiac surgery (Ai et al. 2010b, c).

Both studies used the same methods and study sample as that reported on in Ai et al. (2009a,

b), described above. The study participants (n = 162) were interviewed three times. The first

interview, which was conducted 2 weeks before surgery, assessed pre-operative anxiety,

medical condition, pain, and religiousness. The second interview, conducted 2 days before

surgery, assessed pre-operative hope and coping strategies, while the third interview, con-

ducted 36 days after surgery, assessed post-operative depression and adjustment. Blood

samples were also collected from the patients, and levels of interleukin-6 (IL-6) (an

inflammatory cytokines believed to act as a physiological marker for spiritual struggle) were

determined. The results suggest that spiritual struggle was associated with increased IL-6,

which in turn was associated with increases in post-operative depression symptoms. How-

ever, the authors also report that positive religious coping styles were attributed to reduced

post-operative depression, an effect that was possibly mediated by hope. As the authors stated

in an earlier study, spirituality may act as ‘‘motivational springboards in some contexts but as

crisis-related struggles in others’’ (Ai et al. 2007, p. 880). This second result also supports the

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findings of Ai et al. (2007) and suggests that positive religious coping mechanisms may be

important when considering an individual’s recovery from cardiac surgery.

The majority of studies reviewed in this section suggest a clear association between

spirituality and improved psychological recovery from cardiac surgery. Specifically,

aspects of spirituality have been linked to improved pre-operative optimism, less post-

operative depression, and less post-operative distress. However, as the two studies by Ai

et al. (2010b, c) suggest, spirituality may also contribute to negative psychological

recovery, particularly in the instance of spiritual struggle. In general, though, it appears that

spirituality, when used as a positive coping mechanism, is associated with improved

psychological recovery from cardiac surgery. Future studies in this area should focus on

the long-term effects of spirituality on psychological recovery.

Limitations

One of several limitations common to this area of study is the need for more precise

measurements of spirituality (Ai et al. 2007). As the conceptual model (Fig. 1) illustrates,

studies in this area refer to multiple dimensions of spirituality and use various terms to

reference them. There is a large literature related to the development of scales to measure

spirituality. However, researchers and statisticians have not yet agreed on the best method

for assessing spiritual factors and their influence on health (Idler et al. 2009). One main

focus of research in this area is the development of scales that assess measures of spiri-

tuality and religion, as opposed to the single-measure scales that have been used in the past

(Ai et al. 2010a; Idler et al. 2009). Another issue confronting those developing scales for

this purpose is the separation of spirituality and religion into unique concepts. It is rela-

tively easy to measure the aspects of religion, which is a social and organized process.

However, measuring spirituality is more difficult because of the highly individual and

subjective nature of the concept (Chang et al. 2010). Nonetheless, spirituality is the most

common measure used in studies investigating the influence of faith on health. Therefore,

the current trend in the measurement of spirituality is to focus the analysis on a specific

aspect of spirituality (i.e., religious coping) for which there is a validated scale (Idler et al.

2009). Thoresen (1999) also suggests that, given the newness of the field, a variety of

measures should be used to provide ‘‘methodological pluralism.’’ As these new methods

for measuring spirituality are developed, perhaps more meaningful results that encompass

wider dimensions of spirituality may be obtained.

In addition to measurement issues, other methodological problems are present in the

published literature on the relationship between spirituality and recovery from cardiac

surgery. Specifically, small sample size is often cited as an important limitation for studies

in this field (Ai et al. 2006b). Generalizability is also a common concern (Chang et al.

2010; Contrada et al. 2004). It should be noted that many of the studies reviewed in this

paper were conducted using similar or identical patient populations from the same area of

the United States. The use of different (and larger) patient populations should lead to more

generalizable results. In addition, many of the studies performed in this area of research use

interviews or questionnaires to assess self-reported health, which is known to be suscep-

tible to patient bias (Ai et al. 2006b).

Another major limitation of research on the relationship between spirituality and

recovery from cardiac surgery is the absence of a clear mechanism that explains the

observed results (Ai et al. 2007, 2010a; Maselko et al. 2007). The absence of concrete

mechanisms of action also extends to the broader field of spirituality and health. This is a

particularly important limitation because causation cannot be implied without a reasonable

J Relig Health (2012) 51:1042–1060 1051

123

mechanism. Several authors have suggested possible ‘‘pathways’’ through which spiritu-

ality might act to influence surgical recovery (Thoresen 1999). For example, Contrada

et al. (2004) suggest that the social support offered by religion may mediate the rela-

tionship between spirituality and recovery. Others suggest that psychosocial factors such as

empowerment, inner strength, or ‘‘deep interconnectedness’’ may be responsible for the

observed results (Ai et al. 2009b; Oman and Thoresen 2003; Oxman et al. 1995). However,

plausible explanations for the physiological processes connecting spirituality and health

are not clearly understood (Maselko et al. 2007). This is likely to be a major focus of

research as the literature on spirituality and health continues to expand. This paper has

proposed a heuristic conceptual model that incorporates the variables and concepts

investigated in studies to date and which may prove useful to researchers going forward.

Conclusion

Spirituality and religion are an important part of American life, and many Americans use

their spirituality as a coping method when confronted with a health crisis. Recently, a large

number of studies have reported positive effects of spirituality on general health. The wide-

ranging benefits of spirituality on health prompted investigation of more specific influences

of spirituality on individual conditions. Accordingly, a smaller, somewhat limited field of

study has emerged to examine the specific influence of spirituality on recovery from

cardiac surgery. The purpose of this paper was to review the current state of knowledge in

this growing field. Research in this field has focused on physical and psychological

recovery, the two main determinants of QOL in individuals recovering from cardiac sur-

gery. Aspects of spirituality have been shown to have positive influences on both physical

and psychological post-operative recovery from cardiac surgery. Regarding physical

recovery, measures of spirituality were associated with fewer complications, shorter LOS,

improved physical functioning, and reduced short-term mortality. With regard to psy-

chological recovery, spirituality was linked to improved pre-operative optimism, less post-

operative depression, and less post-operative distress.

As these results indicate, the influence of spirituality on recovery is generally positive

and may therefore provide patients with an additional method to help them cope with the

considerable stress associated with cardiac surgery. These results also suggest that phy-

sicians and medical professionals should be aware of their patient’s spiritual needs (Kaba

et al. 2000) and be willing to help patients incorporate their spirituality into their recovery

process. Ai et al. (2004) found that 87 % of their study participants used prayer as a coping

mechanism for pre-operative stress. Additionally, a different study reported that only 17 %

of patients had discussed complementary treatment options (this study considered prayer as

a form of complementary medicine) with their physician, although many participants stated

that they would have liked to discuss this matter with their physician (Liu et al. 2000).

Most of the studies reviewed in this paper emphasized the importance of physician

awareness of the positive relationship between spirituality and recovery from cardiac

surgery. Therefore, it seems reasonable to suggest that physicians begin to incorporate

discussions about spirituality into their normal interactions with patients. This effort will

facilitate the use of spirituality as a coping method and may also improve the patient’s

recovery from cardiac surgery.

Although the current research has reported a number of positive associations between

spirituality and recovery from cardiac surgery, some studies report that spirituality can

have either positive, negative, or no effect on recovery (Ai et al. 2006a; 2010a, b, c;

1052 J Relig Health (2012) 51:1042–1060

123

Contrada et al. 2004). The mixed results reported in these studies suggest that the effect of

spirituality on recovery is complex and cannot be determined by a single measure of

religiousness. Although findings on the influence of spirituality on health must be viewed

cautiously (Thoresen 1999), the preliminary results from studies in this area do provide a

promising indication for continued research. Perhaps most relevant is the need for studies

of long-term effects of spirituality on recovery from cardiac surgery. It would be partic-

ularly interesting to determine whether the short-term improvements in recovery translate

into longer-term improvements in QOL. Similarly, we found only one study that investi-

gated a potential effect of spirituality on mortality. Going forward, it would be important

for researchers to evaluate the effect of spirituality on this outcome. Another gap that

future research might fill is a lack of knowledge of the effects of spirituality on recovery

from cardiac surgery outside the United States. With the exception of one study published

in Greece, this review included only studies performed in the United States. It would be

interesting to investigate the effects of spirituality relating to different religions (i.e.,

Christianity, Judaism, Islam, Buddhism, Hinduism, Zulu) on recovery from cardiac sur-

gery. Similar studies could also be performed using ‘‘non-religious’’ forms of spirituality

such as meditation or yoga. Finally, there is a need for additional studies using prospective,

longitudinal designs and large sample sizes to validate the preliminary findings reported in

this review.

Appendix

See Table 1.

Table 1 Summary of main findings from each study reviewed in this paper

Authors

(Year)

Study participants Methodology Major findings

Ai et al.

(2009a)

294 patients undergoing

cardiac surgery at the

University of Michigan

Medical Center between

1999 and 2002

Three sequential interviews.

First interview (2 weeks pre-

operative) assessed the use

of prayer for coping. Second

interview (2 day pre-

operative) assessed coping

strategies and social support.

Third interview (36 day

post-operative) assessed

short-term post-operative

quality of life

Prayer is a common coping

strategy in the United States.

Private prayer was indirectly

associated with short-term

post-operative fatigue.

Cognitive strategies and

social support acted as

mediators between private

prayer and short-term post-

operative fatigue

Ai et al.

(1998)

151 patients selected from the

cardiac data registry at the


Medical Center

Participants completed a

6-month post-operative

follow-up questionnaire that

assessed their post-operative

cardiac health. Participants

also completed a 1-year

post-operative questionnaire

that assessed post-operative

health, perceived social

support, post-operative

religious practices, and post-

operative depression

Prayer was the most frequently

used non-medical coping

mechanism used after surgery

(67.5 % of participants used

prayer as coping mechanism).

The use of private prayer

predicted more favorable

psychological outcomes in

patients 1 year after surgery

J Relig Health (2012) 51:1042–1060 1053

123

Table 1 continued

Authors

(Year)


Ai et al.

(2010a)

Convenience sample of 262

patients who had survived

open-heart surgery at the


Medical Center

Survey mailed 30 months after

the date of cardiac surgery.

Survey assessed depression,

anxiety, social support,

optimism, hope,

religiousness, prayer/

religious coping, and sense

of reverence

Using prayer may provide

comfort for individuals

during stressful times.

Patients using prayer as a

coping mechanism reported

fewer depressive symptoms

at 30 months post-operative.

Suggests that pre-operative

spirituality may have long-

term effects on psychological

recovery. Absence of clear

mechanism to explain effect

of spirituality on health

Ai et al.

(2010b)

156 patients scheduled to

undergo bypass surgery at

the University of Michigan

Medical Center

Three sequential interviews

assessing pre-operative

anxiety and religiousness

(2 weeks pre-operative),

hope and coping factors

(2 day pre-operative), and

post-operative adjustment

(36 day post-operative).

Blood samples were obtained

and tested for IL-6 levels

Higher IL-6 levels were

associated with spiritual

struggle. Positive religious

coping serves a protective

function against spiritual

struggle. The results may

suggest a possible

physiological mechanism to

link psychological and spiritual

to physical response to stress

Ai et al.

(2010c)




Medical Center



anxiety and religiousness


hope and coping factors


post-operative depression

(36 day post-operative).

Blood samples were obtained

and tested for IL-6 levels

IL-6 (an inflammatory

cytokines) was associated

with spiritual struggle, which

was associated with greater

post-operative depression

symptoms. Positive religious

coping styles were attributed

to reduced post-operative

depression

Ai et al.

2007





1999 and 2002



stress (2 wks pre-operative),

social support and religious

coping (2 day pre-

operative), and post-

operative distress (36 day

post-operative)

Positive religious coping was

associated with less post-

operative distress. This

relationship may be mediated

by hope and social support,

two psychosocial factors

promoted by spirituality

Ai et al.

(1997)

151 patients recruited from the

cardiac data registry at the


Medical Center

Two questionnaires were

mailed to study participants.

The first questionnaire was

completed at 6 months after

surgery and assessed post-

operative cardiac condition.

The second questionnaire

was completed at 1 year after

surgery and assessed

depression, psychological

adjustment, and the use of

complementary medicine.

Data were also obtained from

a computerized database

85 % of patients reported using

complementary medicine

during recovery. Prayer was

the most common form of


used by participants(67.5 %).

Prayer was negatively

correlated with current

depression and general

distress. Exercise was the

second most common form of


used by participants (45.7 %)

1054 J Relig Health (2012) 51:1042–1060

123

Table 1 continued

Authors

(Year)


Ai et al.

(2002)


undergo cardiac surgery at


Medical Center

Two face-to-face interviews

were conducted. The first

interview took place about

2 weeks prior to surgery and

assessed religiousness, the

use of private prayer, and

mental health. The second

interview took place 1 day

prior to surgery and assessed

pre-operative optimism

88.2 % of patients planned to

use private prayer as a coping

mechanism for the stress

associated with their surgery.

87.8 % of patients considered

private prayer to be an

important part of their lives.

The intention to use private

prayer as a coping

mechanism was correlated

with higher levels of pre-

operative optimism. Different

prayer types were not

associated with different

levels of optimism

Ai et al.

(2006a)





1999 and 2002



depression and anxiety


religious coping and social

support (2 day pre-

operative), and short-term

post-operative global

functioning (1 month post-

operative)

Positive religious coping may

predict improved short-term

post-operative global

functioning (SPGF) in post-

operative cardiac patients.

The use of prayer as

a coping mechanism was

associated with poorer SPGF.

This may have occurred

because patients who

were in worse condition

prayed more frequently

during recovery than

healthier patients

Ai et al.

(2004)





May 1999 and December

2000

Series of two interviews

conducted by trained

interviewer. First interview

(2 weeks pre-operative)

assessed pre-operative

distress and spirituality.

Second interview (1 day

pre-operative) assessed hope

and optimism

88.2 % of study participants

planned to use prayer as

coping mechanism during

recovery from surgery.

Private prayer may predict

pre-operative optimism in

patients awaiting cardiac

surgery. No specific prayer

types were found to be

significantly correlated with

optimism

Aiet al.

(2006b)





1999 and 2000


assessing general and mental

health (2 weeks pre-

operative), religious coping

styles, perceived social

support, and optimism


prayer coping and fatigue

(36 day post-operative)

Positive religious coping

mechanisms associated with

lower rates of post-operative

fatigue. May be first study

to directly relate measures

of pre-operative spirituality

to short-term post-operative

physical fatigue. Unclear

whether long-term

fatigue is influenced

in same way

J Relig Health (2012) 51:1042–1060 1055

123

Table 1 continued

Authors

(Year)


Ai et al.

(2009b)




Medical Center

Face-to-face interview

conducted 2 weeks pre-

operative by trained

interviewers. Interview

assessed religious affiliation,

faith factors, and depression

Prayer was inversely

proportional to the number of

post-operative complications.

Secular reverence associated

with fewer post-operative

complications. Shorter

length-of-stay in hospital

associated with fewer post-

operative complications.

Effects of spirituality on

health are more complicated

than previously thought

Camp

(1996)

17 patients who had

undergone CABG surgery at

a large medical center in the

southern United States

Open-ended interviews were

conducted 4-7 days post-

operatively. Interviews

followed grounded theory

methodology. Interviews

were tape-recorded and

analyzed for common trends

Participants felt that their

greatest spiritual need was

having faith. Depending on

God was a common spiritual

need. Social support from

family and friends was a key

component in recovery. The

decision to have surgery,

uncertainty about the future,

and a feeling of losing control

were all factors that

contributed to stress for the

patients

Chang et al.

(2010)

845 outpatients with various

cardiac conditions

13-week program w/weekly

3 h sessions to teach

relaxation response. Pre- and

post-training surveys to

assess psychological

outcome, spiritual well-

being, and RR practice time

RR practice time associated

with improvements in

psychological outcomes.

Spiritual well-being might act

as mediator for this

relationship

Contrada

et al.

(2004)

Convenience sample

(n = 142) of patients

scheduled for cardiac

surgery at RWJU Hospital,

NJ

Pre-operative interview (avg

6.5 day pre-operative)

Assessed religious

involvement, depressive

symptoms, social support,

optimism, and hospital chart

data

Stronger religious beliefs

associated with fewer

complications, shorter LOS.

More frequent religious

attendance predicted longer

LOS. Prayer frequency had

no effect on recovery

Eckhardt

and

Swanlund

(2008)

4 men aged 56–72 years

recruited from Midwestern

cardiac surgeon’s office. All

study participants had

undergone both on-pump

and off-pump CABG

surgery

Subjects participated in a

single, qualitative,

semistructured interview in

which they were asked open-

ended questions to compare

their experiences with on-

pump and off-pump CABG

surgery

Consistent trends were

observed in each of the

participant’s answers. Three

of the four patients had

experienced post-operative

depression following their

CABG surgery. Patients felt

like they had lost control of

their health when making the

decision to undergo surgery.

Each patient felt that faith

and trust were important

aspects of their surgical

experience

1056 J Relig Health (2012) 51:1042–1060

123

Table 1 continued

Authors

(Year)


Idler et al.

(2009)

576 patients enrolled in other

cardiac surgery studies

Participants were interviewed

5.7 days prior to surgery and

then 3, 6, and 12 months

after surgery. Interviews

assessed self-reported health

status, physical functioning,

and religiousness (measured

using new scale developed

by researchers)

Distinction between spirituality

and religion: spirituality is

individual experience of the

sacred, while religion is

institution surrounding a set

of beliefs. Researcher and

statisticians have not agreed

on the best way to measure

religiousness or spirituality.

New research has focused on

developing scales to assess

religion and spirituality,

rather than focus on a

single measure such as

attendance

Ikedo et al.

(2007)


cardiac surgery at Nebraska

Medical Center

Three groups: prayer,

relaxation, placebo. Pre-

operative interview to assess

religion, mood state. Patient

administered one of three

conditions during surgery

(via headphone)

No significant results. Prayer,

relaxation groups had shorter

LOS and fewer sternal wound

infections

Kaba et al.

(2000)

42 patients who had received

heart transplants from a

Scottish medical center

Unstructured, in-depth

interviews were performed

by trained interviewers

during normal outpatient

post-operative visits

Spirituality is an important

coping mechanism for

patients undergoing cardiac

surgery. Themes of

‘‘optimism’’ and ‘‘having

faith’’ were common among

participants. Optimism was

anecdotally associated

with improved

psychological recovery from

surgery

Karademas

2010

135 outpatients with chronic

cardiac disease who were

seen at public hospital in

Crete, Greece

20-minute interview was

conducted by research

assistant. Interview assessed

intrinsic religiousness,

church service attendance,

illness-related cognitions,

and subjective health

Physical functioning was

indirectly associated with

religiousness. Illness

cognitions act as pathway

between religiousness and

health by minimizing focus

on negative aspects of

medical condition.

Attendance at religious

services had no

effect on subjective

health

Levin

(1994)

Review Review Review of positive effects

of spirituality on various

aspects of physical

health

J Relig Health (2012) 51:1042–1060 1057

123

Table 1 continued

Authors

(Year)


Liu et al.

(2000)


cardiac surgery at Columbia-

Presbyterian Medical Center

in New York City

Patients were surveyed in

waiting area of the

Cardiothoracic Surgery unit.

Survey took 10 min to

complete and assessed

demographic information,

attitudes toward healing, use

of alternative medicine, and

willingness to discuss

alternative medicine with

physician

75 % of patients reported using

at least one form of

alternative medicine during

the previous year. Vitamins

were the most commonly

used form of alternative

medicine (54 %).Prayer was

the second most commonly

used form of alternative

medicine (36 %). Only 17 %

of patients had discussed

alternative medicine with

their physician. Physicians

and healthcare staff

should be open to

discussion with their patients

about the use of alternative

medicine

Maselko

et al.

(2007)

853 patients obtained from

1988 wave of the MacArthur

Successful Aging Study

Questionnaire assessing

allostatic load and

attendance at religious

services

Physiological processes to

explain the relationship

between spirituality and

health are poorly understood.

At least weekly attendance at

religious services was linked

to lower levels of allostatic

load among women

Oman and

Thoresen

(2003)

Review Review Many studies suggest a

correlation between

spirituality and various

measures of health. Not all

forms of spirituality are

beneficial to health: some

may be harmful. Spirituality

may benefit health by acting

as a form of empowerment

for participants

Oxman et al.

(1995)


cardiac surgery at

Dartmouth Med Center

Pre-operative interview to

assess cardiac condition,

social networks,

religiousness. Post-operative

interviews at 1 mo, 6 mo.

Mortality within 6 mo was

measured variable

Lack of participation in

organized groups predicted

39 greater likelihood of

mortality. Lack of

comfort/strength from

religion associated with

39 greater likelihood of

mortality

Saudia et al.

(1991)

96 % of cardiac patients used

prayer as a means of coping

with post-operative stress.

Of these patients, 97 %

believed that their prayer

helped them to cope more

effectively during their

recovery from cardiac

surgery

1058 J Relig Health (2012) 51:1042–1060

123

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Documents

Spirituality and Recovery from Cardiac Surgery: A Review