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30.1,.) LIBRARY 302048 8825
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This is to certify that the

dissertation entitled

Families Use of Religion/Spirituality as
a Psychosocial Resource

presented by

Vicki Hendrix Kloosterhouse

has been accepted towards fulfillment
of the requirements for

 

Ph.D. degree in Family & Child Ecology

ideal/“9&9

Major professor

Date June 27, 2000

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11/00 chIRCDatoDuepfiS—p 14

 

FAMILIES’ USE OF RELIGION/SPIRITUALITY
AS A PSYCHOSOCIAL RESOURCE

By

Vicki Hendrix Kloosterhouse

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Department of Family and Child Ecology

2000

ABSTRACT

FAMILIES’ USE OF RELIGION/SPIRITUALITY
AS A PSYCHOSOCIAL RESOURCE

By

Vicki Hendrix Kloosterhouse

The purpose of the study was to determine if there was a relationship between the
use of religion/spirituality as a resource, and the ability of families to cope with the stress
of having a child in the hospital. The data also were used to test an a priori model to
determine if there was a relationship between the model’s predictive variables and
families choosing to use religion/spirituality as a coping mechanism. The predictive
variables used in the a priori model were religious/spiritual (R/S) practices, R/S beliefs,
R/S affiliation, interaction with spiritual caregiver, race, income, education and gender
and age of the family respondent.

The Pearson product moment coefficient was used to analyze hypothesis one,
which looked at the relationship between the families’ use of religion/spirituality and the
ability to cope with the stress of having a child in the hospital. To test this hypothesis, the
respondents were asked if their families used religion/spirituality as a coping mechanism
and how stressful and difficult it was to cope with having a hospitalized child. No
significant relationship was found between the use of religion/spirituality as a resource
and a decrease in the families’ stress level and difficulty in coping.

The a priori model, upon which hypothesis two was based, was first tested using a

path analysis. The analysis determined that the data were not consistent with this model.

The model then was modified to include only three predictive variables, R/S practices,
beliefs and affiliation and the dependent variable, the use of religion/spirituality as a
coping resource. Multiple regression was used to analyze the modified model. The
model demonstrated a high level of explanatory power with an R2 of 81.80 percent and an
adjusted R2 of 65.3 percent. The ratio of explained to unexplained variance was
statistically significant at .000, with an F value of 43.472. The magnitude of the R2 and
the adjusted R2 indicated a good fit with the modified model.

When family members were asked if their immediate family’s R/S beliefs were
important in helping them to cope with having a child in the hospital, a majority of the
family members agreed. These responses appeared to be contradictory to the findings of
hypothesis one. This may be due to the fact that completion of the surveys occurred when
respondents’ families were at the initial stage of the coping process in which a stressor is
defined and meaning is attached to the situation. Respondents did indicate that their R/S
beliefs provided meaning and purpose to life, were a source of strength, and offered hope.
However, religion/spirituality did not appear to help families during the later stages of
coping where it is more common to see a reduction of stress and difficulty in coping. In
this study, families may not have been at this stage of coping, thus leading to inaccurate
measurements of hypothesis one. Or, religion/spirituality may have helped in the initial
stages of coping but was not influential in the rest of the coping process.

Further research needs to be conducted on how and if families use
religion/spirituality to cope with stress. Nonetheless, it would be beneficial for both
health care and family science professionals to begin to consider whether they are giving

adequate consideration to the use of religion/spirituality as a resource.

DEDICATION

To my husband who is so secure in who he is
that he has always encouraged and supported who I am.

To my mother, who is a remarkable woman, and has
taught me the joy and importance of learning.

ACKNOWLEDGEMENTS

I wish to acknowledge by sincere thanks and appreciation to all the individuals
who helped me to complete this work. First, I wish to thank Barbara Ames who has been
my advisor and the chairperson of my dissertation committee. I have appreciated her
support and patience during this experience. She has been an excellent role model, and I
value the professional standards that she has set for her students.

I also would like to thank Linda Keilman and Kristen Salomonson who patiently
worked with me and taught me the basics of path analysis. It was quite a learning curve,
but I truly have learned a great deal about this statistical technique. Additional
acknowledgement needs to go to Marsha Carolan and Anne Soderman who were willing
to serve on my committee. I appreciated your critiques and suggestions.

I want to thank Reverend Diane Morgan, Ellen Sneider, and Sister Helen
Huemantel for their support and encouragement. The research would not have happened
without your help.

Jumping through all of the hoops to make it through graduate school can at times
be quite challenging. I would like to give a special thanks to all of the secretaries in the
Family and Child Ecology Department who have helped make this process an easier task.
A special thank you goes to Ruth Sedelmaier who always had a smile and helped me in
anyway she could.

Finally, I want to acknowledge my family. Jon and Kristen you always have been
there for me. I cannot begin to express how I have valued your love, support, and

encouragement. It would have been a difficult task to accomplish without you.

V

TABLE OF CONTENTS

LIST OF TABLES ........................................................................................... viii
LIST OF FIGURES ............................................................................................ ix
CHAPTER I
INTRODUCTION ............................................................................................... 1
Scope of the Problem ..................................................................................... 1
Significance of the Study ............................................................................... 5
Purpose of the Study ....................................................................................... 8
Theoretical Framework .................................................................................. 9
Antonovsky’s Generalized Resistance Resources .................................... 9
Human Ecology Theory .......................................................................... 15
A Blending of the Concepts .................................................................... 19
Blending the Concepts into a Model ....................................................... 26
Research Objectives .................................................................................... 33
Conceptual and Operational Definitions ..................................................... 34
Assumptions ................................................................................................ 37
An Overview of the Following Chapters .................................................... 40
CHAPTER 11
REVIEW OF THE LITERATURE .................................................................. 41
Family Science Perspective on Stress and Coping ...................................... 42
The Use of Religion/Spirituality as a Conceptual Term ............................. 48
Religion and Family from a Historical Perspective ............................... 50
Religion/Spirituality and the Generalized Resistance Resources .......... 51
Neutral/Negative Influence of Religion/Spirituality on Health ............. 61
Building a Predictive Model ....................................................................... 63
Building a Path Diagram ............................................................................. 75
CHAPTER III
METHODOLOGY ............................................................................................ 81
Research Design ........................................................................................... 81
Research Hypotheses .................................................................................... 82
Data Collection ............................................................................................ 83
The Sample .............................................................................................. 83
County Demographics ............................................................................. 84
Distributing and Collecting the Surveys ................................................. 85
The Instrument ......................................................................................... 85

Confidentiality ......................................................................................... 88

Approval for Research ............................................................................ 89
Reliability and Validity ........................................................................... 89
Pilot Testing ............................................................................................. 91
Data Analysis ................................................................................................ 92
Research Limitations .................................................................................... 94
CHAPTER IV
RESULTS .......................................................................................................... 97
Description of the Sample .......................................................................... 100
Description of the Scaled Variables ..................................................... 103
Test of Hypothesis ...................................................................................... 105
CHAPTER V
DISCUSSION .................................................................................................. 1 15
Findings ...................................................................................................... 116
Hypothesis One ..................................................................................... 117
Hypothesis Two ..................................................................................... 120
Predicted Variables in the Modified Model ......................................... 123
Additional Analysis: Responses to Questions about Good
Spiritual Care ......................................................................................... 125
Generalizability of the Findings ............................................................ 126
Discussion of Findings ............................................................................... 127
Implications for Health Care Professionals ............................................... 133
Implications for Family Science Professionals ......................................... 134
Recommendations for Future Research ..................................................... 136
APPENDIX A ................................................................................................. 139
APPENDIX B .................................................................................................. 144
APPENDIX C .................................................................................................. 147
REFERENCES ................................................................................................ 149

LIST OF TABLES

Table 1: Antonovsky’s Generalized Resistance Resources ............................ 11

Table 2: The Blending of Antonovsky’s Generalized Resistance Resource
and Concepts fi'om the Human Ecology Theory .............................................. 18

Table3: Religion/Spirituality Viewed as a System that Can Provide
Generalized Resistance Resources .................................................................... 31

Table 4: Descriptive Statistics of Children’s Age, Days Stayed in Hospital,
and Gender ....................................................................................................... 100

Table 5: Respondent’s Mean Age, Frequency of Family Member’s Race,
Gender, Relationship to Child, R/S Affiliation, Family’s Income and Highest
Education Level ............................................................................................... 101

Table 6: Descriptive Statistics of Immediate Family’s Stress Level, Difficulty
of Coping, and the Use of R/S Beliefs to Help Cope with Having a Child in the

Hospital ............................................................................................................ 103
Table 7: Descriptive Statistics of the Scaled Variables ................................. 104
Table 8: Variables and Their Measures for Path Analysis ............................ 107
Table 9: Correlations for Path Analysis ......................................................... 108
Table 10: Residuals from Path Analysis ........................................................ 111

Table 11: The Beta Coefficients of the Predictive Variables Used in the
Multiple Regression Model ............................................................................. 113

LIST OF FIGURES

Figure 1: The Family Is Viewed as an Important Part of Health Care, because
the Family Has the Capability to Recognize Outside Systems, which Can
Provide Resistance Resources to Help Cope with Daily Hassles and Traumatic
Events ................................................................................................................. 27

Figure 2: A Path Diagram Predicting How Various Constructs Influence the
Family’s Use of Religion/Spirituality as a Psychosocial Resource to Help
Cope with the Stress of Having a Child in the Hospital ................................... 76

Figure 3: Modified Path Diagram of How Various Constructs Influence the
Family’s Use of Religion/Spirituality as a Psychosocial Resource to Help
Cope with the Stress of Having a Child in the Hospital ................................... 99

Figure 4: The Path Model As Estimated by Path Coefficients ..................... 110

CHAPTER 1
INTRODUCTION

Scope of the Problem

Many health care professionals are concerned that the United States is facing a
health care crisis because of escalating medical costs (Beadle, 2000; Friedman, 1998).
The US. Department of Health and Human Services has estimated that by 2008 health-
care costs will increase to 1.7 trillion dollars per year, which means that 17 percent of the
gross domestic product will be spent on health care (Beadle, 2000). It is projected that by
2020 one out of every four dollars will be expended for medical costs. Beadle suggests
that these increases threaten the counu'y’s personal and economic health, and individuals
need to consider other cost-effective resources beyond use of technology.

Friedman (1998) also writes about the poor use of medical resources and laments
that today’s health care system is taking a high tech and crisis management approach. In
many cases, this comes too late to successfully manage the disease. She writes,

In the case of chronic illness — our prevailing cause of morbidity
and mortality - we are not treating and eradicating disease, but only
minimizing its impact, repairing the damage as much as possible,
and treating its complications. We are spending most of our money
treating the end result of self-destructive lifestyles rather than

focusing on the causative factors of ill health, such as lifestyle and
environmental hazards. (Friedman, 1998, p. 38)

As Friedman points out, many of the factors related to ill health could be eradicated
through preventive medicine, which would be both beneficial and cost effective. The
lack of attention paid to prevention can be summed up by US. Secretary of Health and
Human Services, Donna Shalala. She approximates that only four percent of the United
States’ health care budget is spent on preventive services (Whitmer, 1999). Whitmer
capsulizes the significance of this statistic by calculating that money spent on preventive
medicine “adds up to less than a nickel from each health care dollar. The other 95
percent goes directly toward diagnosis and treatment of diseases, half of which are
preventable.” (p. 21).

Even though prevention may be one of the most important and cost-effective
means of fighting disease, it still does not seem to be a primary focus of many health care
providers nor the American public. For example, depending on which research one
reads, it is reported that between 60 to 90 percent of all primary-care physician office
visits are due to symptoms that are related to stress and lifestyle practices (Benson &
Stuart, 1992). These findings are troubling because realigning behavior and/or the
environment may be one of the most effective factors in‘ helping to control many health
problems.

Not only have many health care providers chosen to ignore the importance of
practicing prevention, they also have disregarded the use of complementary therapies that
may help in the prevention of diseases, rehabilitation and/or palliative care. However,
their patients have not ignored the use of complementary health therapies. In 1990, one-
third of Americans were using complementary therapy outside of mainstream medicine

such as massage, acupuncture, mind/body connection, and prayer to enhance their health

(Cerrato, 1998). David Eisnberg, as cited in McDonagh (1999), found that from 1990 to
1997 the use of complementary therapy increased by 25 percent. In 1997, it is estimated
that 62.9 million Americans paid visits to alternative therapy practitioners and spent over
27 billion dollars for the therapists’ services. Research conducted by Stanford University
discovered that 39 percent of the patients who were satisfied with their conventional
physician were still using complementary therapy to enhance their health (Comarow,
1998). Perhaps this new trend is a clarion call to the medical profession that changes
need to be made in the approaches used to deal with illness and disease. The United
States is well known for its ability to provide excellent medical care in treating illness.
However, it needs to be acknowledged that the medical system has not been as effective
in preventing diseases and promoting beneficial complementary therapy. Like any
organizational unit, the health care system has limited resources to provide health care to
the American people. The health care profession has been handicapped in reaching these
goals by the cost of advanced medical treatments, the loss of human resources due to
downsizing, and perhaps the failure to look for preventive and complementary health care
resources outside of the walls of the mainstream Western medical profession. It is an
impossible task for the healthcare community to take full responsibility for our nation’s
health. Therefore, health care professionals need to consider other resources and

therapies that can be used to complement the current medical care in the United States.

Religion/Spirituality as a PswhosocMesource
It is beyond the scope and purpose of this research to look at all complementary

resources that could be useful in preventive and rehabilitative health care. Instead, the

focus will be limited to investigating the effects of religion/spirituality on health.
Specifically, this study will focus on the use of religion/spirituality as a psychosocial
resource to cope with stress. Addressing the Conference of the Psychology of Health,
Immunity and Disease, Bruno Cortis (1993), a practicing cardiologist in both the United
States and Europe, spoke to the importance of spirituality when he stated, “Health is not
simply the absence of disease. In terms of the total human being, health implies our
physical, mental and spiritual dimensions” (p. 67). Antonovsky (1985) also has
suggested that religion/spirituality is a viable resource in helping an individual gain a
“sense of coherence” to adapt to daily stressors. After 30 years of research, Herbert
Benson, MD. (1996), an Associate Professor of Medicine at Harvard Medical School,
has become convinced that belief in a higher power provides a critical contribution to an
individual’s well-being. In the book, Timeless Heaflg, Benson (1996) suggests that
human beings are “wired for God.” He is convinced that each individual is genetically
encoded with a need for nourishment from faith. Benson postulates that when
individuals use their faith, they activate a neurological pathway that helps with healing.
Citing research, Benson notes that religious people have better general health, lower
blood pressure, fewer psychological symptoms, and a longer survival rate. Benson also
projects that religious people have greater life satisfaction, marital satisfaction, well-
being, altruism, fellowship, coping skills and self-esteem as compared to non-religious
people. These characteristics lead to decreased stress and anger and improved
psychoneuroimmunological pathways, which help fight disease within the body.

Many researchers believe that teaching people how to use effective coping

resources to deal with stress not only will help to maintain or improve health but also is

cost-effective (Greenberg, 1993; Benson & Stuart, 1992; Antonovsky, 1985).
Researchers have identified an association between stress, the lack of psychosocial
resources to deal with stressors, and immunological disturbances (Benson & Stuart, 1992;
McCubbin & Patterson, 1983). It has been found that a depressed immune system may
occur in people who are bombarded by daily hassles and/or are confronted by profound
life changing events (Irwin & Strausbaugh, 1991). McCubbin and Patterson (1983) have
submitted that the effect of stress depends on how individuals perceive an event and then
how they cope with it. One of the factors that will influence individuals’ perception of
the event is whether they have adequate physical and psychosocial resources. Studies
have found that religion/spirituality is a system that can provide coping resources

(McIntosh & Spilka, 1991; Pargament & Hahn, 1986).

Significance of the Study
Health care costs are increasing yearly and will continue to do so if the main focus

continues to be on rehabilitation and high-tech treatments. Over the next eight years,
health care costs are expected to grow from one trillion to 1.7 trillion dollars (Beadle,
2000). This means that 17 percent of the gross domestic product will be spent on health
care cost. Therefore, it is important that professionals begin to look for preventive and
rehabilitative resources that are not only beneficial but also cost-effective and readily
available. The researcher is proposing that religion and/or spirituality can act as such a

resource.

More Resegch Is Needed in the Arc; of Religion/Spirituality

The National Institute for Healthcare Research (N IHR) has taken an in-depth look
at research that has intentionally as well as inadvertently looked at the influence of
religion and spirituality on health (Larson, Swyers, & McCullough, 1997). When
reviewing past studies, the NIHR’s researchers frequently found that studies did show
that there was a positive relationship between religion/spirituality and health. However,
due to the political climate, findings, if reported at all, were basically ignored. Larson
and colleagues write, “findings pertaining to religious/spiritual-health linkages were often
buried in tables, often without comment in either text or abstract, and usually without
references to similar findings from other studies” (Larson, Swyers, & McCullough, 1997,
p. 4). Times are changing, and in the last decade there has been an increase in the number
of studies focusing on the beneficial effects of religion and spirituality. However,
according to the NIHR, research in this field needs to be expanded.

It should be noted that for this study, the researcher has used research
recommendations that have been established by the NIHR. In 1998, the NIHR published
an extensive report entitled Scientific Research on Spiritujalitv and Health: A Cow
M (Larson, Swyers, & McCullough, 1998). The report was based on the Scientific
Progress in Spirituality Conference. The conference participants consisted of scholars
and researchers in the field of medicine, psychology, sociology, education, health policy
management, public health and religion. The report recommended that special attention
be given to improvement in quality of methodology, statistical techniques and
commonality in the conceptualization of religion and spirituality. Based on the

suggestion of the NIHR report, the researcher has used religion/spirituality as a

conceptual term for this study. Further discussion about the use of religion/spirituality as
a conceptual term will be found in Chapter II.

The NIHR has recommended a number of domains that need further study in
regards to the relationship between religion/spirituality and health. One of the areas cited
for further research is the influence of religion/spirituality on coping with stressful life
events. Therefore, it is hoped that this research, which has focused on the relationship
between religion/spirituality and a family’s ability to cope with stress, will contribute to

the literature on religion/spirituality and health.

Few Studies mm Focused on the Farlily

Past research mainly has investigated the influence of religion/spirituality on the
patient’s health and/or well-being, while little research has looked at the family of the
patient. In this study, the researcher will be focusing on the ability of the family to cope
with having a child on the pediatric unit in the hospital. The ability of the family to
successfully cope with the stress of having a child in the hospital is of great importance
for a number of reasons. First, when a child is in the hospital several changes can occur
that have the potential to transform the family from a functional to a dysfunctional unit.
A discussion of these changes occurs later in Chapter I. To successfully adapt, the family
needs to have adequate resources available to help with the coping process.
Religion/spirituality may be one of the resources, which can help the family adapt to these
changes so they can continue to adequately function (Friedman, 1998; Danielson, Hamel-
Bissell, & Winstead-Fry, 1993; Hanson & Boyd, 1996). Second, it is important that the

family successfully cope with the stress of having a child in the hospital, because family

members are key players in helping to influence the course of the child’s medical
problems. According to a 1985 national Gallup survey, families provided more help in
health matters than any other source, including doctors (cited in Friedman, 1998). Third,
family members, especially parents, are role models for others in the family unit. As
members observe other individuals in their families using appropriate psychosocial
resources such as religion/spirituality to cope with stress, they may experience and learn
that religion/spirituality can be used as an effective coping tool. Fourth, if additional
studies continue to indicate that religion/spirituality is an important tool in coping, then
health care professionals needs to validate that a family’s religious and spiritual practices
and beliefs can enhance a family’s well-being. This is especially important, because in
the realm of health care, religion/spirituality is a resource that is cost-effective and readily

accessible to most people.

Purpose of the Study

The purpose of this study was to determine if there was a relationship between
families’ ability to cope with the stress of having a child in the hospital, and the use of
religion/spirituality as a system to help decrease the families’ stress. The data also were
used to test an a priori model constructed to determine if there was a causal relationship
between predictive variables, and families choosing to use religion/spirituality as a
psychosocial resource to cope with the stress of having a child in the hospital. The
predictive variables included in the model were religious/spiritual (R/S) practices, R/S
beliefs, interaction with spiritual caregivers during the child’s stay in the hospital, R/S

affiliation, race, income, education, and gender and age of the family respondent.

Theoretical Framework
Antonovsky/’8 Generalized Resistance Resources
Aaron Antonovsky (1985), a former professor of medical sociology at the Ben

Gurion University in Israel, proposed that stress, combined with the lack of resources to
deal with it, are major players in health related issues. He criticized the medical
community for only using the pathogenic model to look at health care concerns. The
pathogenic model focuses on disease without considering other psychosocial factors that
might contribute to illness. Antonovsky believed that this approach limited health care
professionals in determining the root cause of the problem. He believed that if underlying
causes, such as psychosocial issues, were not addressed, then patients were more likely to
stay ill and manifest additional disease symptoms. To address this problem, Antonovsky
developed the “salutogenic model of health.” In his model, Antonovsky looked beyond
the disease and posited that stress by definition places a burden on people. He referred to
stress as strain tension, and he was convinced that if tension was not dealt with, it would
cause the body to break down. He visualized this concept by describing a health
continuum that ranged from an ease end of health to the opposite end being described as
dis-ease. Antonovsky wrote:

To ask about a specific disease is to narrow one’s search to specific,

disease-relevant factors. To ask about ease and dis-ease is to ask

about generalized factors that are relevant to all diseases. And to ask

about health case, that is, to seek to explain what facilitates our

movement toward the most salutary end of the breakdown continuum,

is to search for weapons that may be far more potent in decreasing

human suffering than is any specific disease-preventing or
disease-curing factor (p. 56).

Antonovsky (1985) perceived stress as a disequilibrium of homeostasis, which is
caused by internal and/or external environments of an individual. How well an individual
dealt with stress was dependent upon life experiences and available resources, which he
referred to as generalized resistance resources (GRRs) [see Table l]. Antonovsky
proposed that both life experiences and the availability of resistant resources influenced
an individual’s sense of coherence. He defined a sense of coherence as:

A global orientation that expresses the extent to which one has a

pervasive, enduring though dynamic feeling of confidence that

one’s internal and external environments are predictable and

that there is a high probability that things will work out as can

reasonably be expected (p. 184).
A person with a sense of coherence usually views the world as predictable and
comprehensible. This type of individual understands that life brings failure and
frustration, but because he or she has a sense of coherence, there is a confidence that
in the end things would work out. It does not mean that the person is in total control, but

the person does affirm that he or she has the opportunity to participate in the process of

shaping one’s destiny as well as one’s daily experience.

10

Table l: Antonovsky’s (1985) Generalized Resistance Resources (GRRs)

 

 

 

 

 

 

 

 

Resource Definition

Physical/Biochemical Health of the body and of the immune system

Artifactual Material possessions including money, shelter,
clothing, power, status, availability of services

Cognitive The ability to obtain knowledge and information
about the real world and skills

Emotional A lifelong forming of ego identity, a picture of
one’s self in the world which one lives

Valuative/Attitudinal One’s coping strategies, the individual’s perception
of the availability of resources he or she has to use

Interpersonal/Relational Social support and ties a person has to others, a
sense of commitment to a group and the group is
committed to the person

Macrosociocultural Gives cultural stability (a language, a role set, a

 

larger world in which to fit) and a philosophy of life

 

ll

Antonovsky’s (1985) model offers an intriguing perspective on the importance of using
resources to help reduce stress and move an individual or group of individuals toward the
ease end of the continuum. He suggested that using the GRRs would improve one’s
sense of coherence, which in turn helps one react more constructively to stress. Not only
would a person have the confidence that stressors could be dealt with, but the individual
also would know how to draw upon the GRRs to dissipate or resolve the stressful
situation. Consequently, as individuals have more GRRs available to deal with stress,
they also have a greater chance of staying closer or moving toward the ease end of the

continuum, with the outcome being stabilized or improved health.

Limitations of Antonovsky’s Model

Antonovsky’s “salutogenic model of health” is both insightful and helpful in
identifying non-medical resources (GRRs) that individuals can use to successfully deal
with stress, creating a greater potential to stay healthy. However, the researcher would
suggest that Antonovsky has lefi out one of the most important resources in our society,
which can be very effective in promoting and maintaining health — the family. Peterson
(1995) noted that no other system affects an individual’s daily life as much as the family.
He emphasizes that the family is intertwined in many diverse areas of an individual’s life,
even down to how members “squeeze the toothpaste tube” (p. 23). For instance, families
are usually the primary care givers when an individual goes through a crisis, especially
health emergencies. To meet health care concerns, family members often alter their roles,
reallocate resources, and utilize new coping strategies to meet a loved one’s medical

needs (Friedman, 1998; Hanson & Boyd, 1996; Danielson, et a1, 1993). As a primary

12

source of care giving, the family also provides physical, social and emotional support
during the crisis.

The family not only is supportive during an emergency, but also helps in the
process of shaping family members’ health care habits. Troost and F ilsinger (1993)
identify a number of important roles the family plays in this arena. They propose that
lifestyles, whether positive or negative, are learned within the family setting. Since
family members share some of the same biological risk factors, the family also can play
an important role in helping members identify and successfully deal with those risks.
Vaughan-Cole, Johnson, Malone & Walker (1998) emphasize the importance of making
the family feel like an “insider” when focusing on health promotion and disease
prevention, because it is the family who builds the environment that contributes to a
healthy lifestyle. Friedman (1998) cites a number of reasons why the family plays an
important role in health care. She notes that parents in the family are the “primary
teachers” who help children learn how to deal with health care issues. Furthermore, the
family is a critical resource for the actual delivery of many health care services. In
addition, working with one family member may help the health care professional
recognize and connect to other members who need help. The family also may be able to
share invaluable information about a patient that a health care provider would not be able
to find elsewhere. Boise, Heagerty, and Eskenazi (1996) point out that the health care
system is dependent on the family in helping individuals to achieve optimum health. It
would be too costly for the health care community to do this on its own; therefore, it must

rely on valuable resources such as the family unit.

13

One might contend that the family is already recognized in Antonovsky’s (1985)
salutary model under social support. However, the researcher would argue that listing the
family under social support puts it in a secondary position. In essence, one could then say
that other people or organizations that offer social support have as powerful an influence
over an individual’s life as the family unit. Peterson (1995) points out that one of the
distinct characteristics of the family, as compared to other social groups, is its
permanence and importance in an individual’s life. Even though friends and social
organizations can contribute to a person’s well being, they normally do not have as
intimate contact with or provide as many services to the individual as a person’s family,
nor do they usually sustain a relationship with an individual over time.

It also could be argued that families do not necessarily make positive contributions to
a family member’s well-being. For example, an individual may learn inappropriate
communication patterns or coping skills from the family unit, which eventually
contributes to increased stress in the person’s life. Likewise, a family member may
acquire an undesirable health habit. It cannot be denied that a family can have a negative
effect on a family member’s psychological and physiological health. However,
Antonovsky (1985) acknowledged that any of the GRRs have the potential to have a
positive or negative influence on an individual’s sense of coherence. The fact that the
family can play either a positive or negative role in health care should be an even greater
incentive for the health care community to educate families about the importance of being
positive role models. If the family is identified as a unique and important resource, then
there is a greater likelihood that more attention will be given to educating and equipping

the family with other resources to promote health. However, the family should not be

14

viewed as just another GRR, but should be recognized as a vital co-partner with the
health care community. The family also should be seen as a system that has the ability to
integrate a wide variety of resources to use for preventive and rehabilitative strategies.
The researcher proposes that Antonovsky’s (1985) GRRs can be successfully
blended with concepts from the human ecology theory that emphasizes the importance of
the family. The intent of this blending is to build a model that would advance the
concepts of the GRRs, while at the same time highlighting the importance of the family
as an essential resource partner in health care. The family is viewed as such because of

its major role in educating members in identifying and using a variety of resources to stay

healthy.

Human Ecology Theog

The human ecology theory views the family as a dynamic system, which has a
significant influence over its individual members as well as society. As will be
demonstrated later, the concepts on which this theory is based are very compatible with
GRRs described in Antonovsky’s (1985) salutogenic model of health. The theory focuses
on the interaction and interdependence of families within their environment. The
environment can act as a stressor to the family as well as provide resources to promote
well being (Bubolz & Sontag, 1993). The family is viewed as a microunit of society that
interacts with the natural, physical, social-cultural, and behavioral milieu (Bubolz &
Whiren, 1984). Bubolz and Sontag point out that the human ecology theory emphasizes
the family’s ability to create, use, and manage resources “for creative adaptation, human

development, and sustainability of environments” (p. 419). The family also is seen as an

15

energy transformation system that is cyclic in nature. It can be pictured as a continuous
cycle, which begins with the family receiving input from its enviromnent via information
or through resources. The family then integrates the information and resources into its
own microunit and makes any needed adjustments. The cycle comes full circle when the
family transmits original and learned information and resources back into society.
Resources of various kinds are viewed as an important part of the family system, because
the resources or lack thereof, have the potential to have a positive or negative influence
on the family’s ability to transform and use energy.

One of the key words used in the human ecology theory is “adaptation.”
Adaptation indicates that a change or behavior modification occurs to fit the structure of
the environment (Bubolz & Sontag, 1993; Bubolz, Eicher, & Sontag, 1979). This is a
crucial concept, because it intimates that resources can act as change agents in helping
family members make important lifestyle improvements in their health. This process of
adaptation stems from the cyclic, energy transformation system. For example, if family
members have appropriate resources to help cope with stress, they are more likely to have
an increased sense of coherence, which leads to positive adaptations and sufficient energy
to move them toward the ease end of the health continuum. This in turn will have a
significant influence on family members’ productivity, and the amount of resources that
they will be able to feedback into their environmental settings such as work, school,
and/or the community. Over a period of time, the family’s usage of a wide variety of
resources may decrease the amount of health care resources the family will need to use to

maintain members’ health.

16

Throughout most of history, the family has been the primary provider of health
care. Before the 20’h century, the family home had been the main site of care ranging from
births to deaths. However, in the 20th century, births, doctor visits, care for ill family
members and even deaths were moved from the home into an institutional setting
(Howell, 1988). As family care moved out of the home, the concept of health care shifted
from viewing the family as an important resource in promoting and preserving health to
turning this task over to the health care system. Unfortunately, this practice has placed
too large a burden on the medical community and has diminished the importance of one
of the most valuable and economical resources in health care, the family.

Viewing the family as a vital resource in transmitting and integrating information
about health and the use of GRRs is beneficial both to the family unit and society. The
following section will depict how Antonovsky’s GRRs can be compatibly blended with
the concepts advanced by the human ecology theory. While Antonovsky’s (1985) model
mainly focused on resources to improve a sense of coherence, and therefore health, the
human ecology theory adds the special dimension of the family as an important resource
in helping individuals to successfully interact with their environment (Bubolz & Sontag,
1993). Table 2 gives a brief overview of the close association between Antonovsky’s
GRRs and concepts from the human ecology theory, while the next section will give a

more in-depth explanation.

17

Table 2: The Blending of Antonovsky’s Generalized Resistance Resources and

Concepts from the Human Ecology Theory

 

Antonovsky’s Generalized Resistance

Resources (Antonovsky, 1985)

HumanjEcology Concepts
(Bubolz & Sontag, 1993)

 

Thysical/Biochemical

o lntemal environment to support life

Carrying Capacity

0 Ability of an environment to support life

 

 

0 Knowledge

0 lnforrnation

Artifactual Artifacts
a Material 0 Physical objects
Cognitive Communications

0 Information and meaning created and

transmitted

 

Emotional

0 Ego identity

Human Development
0 Ability to perceive and act in relation to the

environment

 

ValuativelAttitudinal
o Coping strategies

Decision Making and Management
0 Goal setting/planning

0 Problem solving

 

Interpersonal/Relational
0 Social Support

0 Commitment

Needs and Values
0 Needs for having, relating and being
0 Commit to a group that is good, right, and

worthwhile

 

Macrosocioculture
0 Cultural Stability
0 Philosophy of Life

 

 

SFcial-Culture

0 Societal blueprint

0 Rituals, beliefs, values of the family
(McAdoo, 1993)

 

l8

 

A Blending of Com

Physical-Biochemical/Cagying Capacig

Physical and biochemical resources are the first two GRRs mentioned by
Antonovsky (1985). Even though the human ecology model does not include a concept
that addresses the physical and biochemical needs, Sutton and Harmon do talk about the
carrying capacity of an environment (cited in Bubolz & Sontag, 1993). It is the
“capability of a particular environment to support life” (p. 433). Theoretically, this also
could be used to describe every individual’s physiological health, because each person
has his or her own internal environment, which must physically and biochemically be
able to support life. Likewise, every individual’s health should be considered an
important resource, because it has the potential to influence interaction with the person’s
immediate family as well as with others in the external environment. A person’s physical
health also will be a factor in the amount of resources needed to sustain his or her life.
While it is true that genetically some individuals are healthier than others, the availability
and use of material as well as psychosocial resources may have as great an influence on a
person’s health. Both Antonovsky’s (1985) model and the human ecology theory (Bubolz
& Sontag, 1993) include material and psychosocial resources as important components of

adaptability and coping.

Artifactual-Material/Artifacts
One of the most prominent material resources in the Western culture is money,
and this falls under the artifactual GRR (Antonovsky, 1985). With money comes the

ability to purchase needed resources, which in turn has the potential to decrease stress and

19

give access to health care services. Money also tends to increase one’s power base. In
this category of GRR, Antonovsky also included other material resources such as shelter,
clothing, and adequate food. The human ecology theory’s (Bubolz & Sontag, 1993)
description of artifacts would be similar to Antonovsky’s model when referring to
resources needed to maintain well-being. Families can be encouraged to identify material
resources that they have available to meet their needs. However, if a family believes that
their basic needs such as food, clothing and shelter are not being met, it becomes difficult
for them to consider other ways of coping. It also should be noted that families with
wealth, power and knowledge will be more likely to take advantage of available resources
(Antonovsky, 1985). Families who come from lower socioeconomic backgrounds may
need additional encouragement to seek preventive or intervening health care. Once basic

needs are addressed, other GRRs such as cognitive resources can be promoted.

Cogm’tive/Communication

Cognitive refers to knowledge and information exchange (Antonovsky, 1985),
which is expressed as communication in the human ecology theory (Bubolz & Sontag,
1993). This exchange takes place at every level of the ecosystem, whether it is in the
family setting or with an external system. The exchange begins with sharing knowledge
and information within the family. It then expands outside of the home where
information and knowledge is directly shared between an individual and the community
at large. Cultural beliefs, values, and norms of society influence the knowledge and
information received by the family. As stated earlier, individuals with fewer resources

tend to have less accessibility to medical information and intervention. Health care

20

professionals should recognize that knowledge and information exchange is a source of
power that opens up the door to family options and choices. When family members have
more options and choices, they generally feel that they have more control over a situation,

and this in turn may decrease stress (Benson & Stuart, 1992).

Emotiongl/Humgn Development

The emotional GR is based upon how an individual views self. Antonovsky
(1985) referred to this as ego identity. He described it as the way a person pictures self in
relationship to his or her environment. It encompasses a sense of the inner person
relating to social and cultural reality, but at the same time being able to keep a sense of
independence. The human ecology theory labels this concept as human development.
Similar to Antonovsky’s definition, Bubolz and Sontag (1993) define it as a “process of
ongoing and interrelated changes in an individual’s ability to perceive, conceptualize, and
act in relation to his or her environment” (p. 43 7). Both Antonovsky and the proponents
of the human ecology theory would agree that this is a life long process and that all levels
of the ecosystem have the potential to influence the way an individual views self. How
families view themselves usually affects how family members perceive themselves as
individuals and as a family unit. Various levels of the cultural strata can have either a
negative or positive influence on the ego identity (human development) of the family and

individual members.

21

Mative-Attitudingl/Decision Making-Management

The next GR is labeled as valuative-attitudinal. This resource has to do with an
individual’s coping style. Antonovsky (1985) postulated that the valuative-attitudinal
resource could have a great influence over all the other resources, because its main focus
is on the individual’s or family’s cognitive appraisal of a stressor. Otherwise, how does
the family cope with stress? Do just some of the family members perceive a situation as
stressful? Do they feel that there are enough resources available so that they can
successfully deal with the problem? The response that members have to these questions
will determine the effect and scope of the stressor on the family unit. The ecological
perspective would define this GRR as the ability of the family to make decisions and then
manage the resources needed to resolve the problem or reach the goal. Bubolz and
Sontag (1993) would label this process as “integrative decision making” (p. 437).

As Antonovsky (1985) pointed out, maybe one of the best ways to empower a
family is to help them recognize the resources that they already have available to cope
with their stressors. When a family is aware that they have a number of resources, which
in turn broadens their options, it often gives them a sense of control over their own
destiny. This realization widens the family’s horizons and helps them understand the

importance of looking for and managing their resources when making a decision.

Integagrsonal-Relational/Needs-Values

The interpersonal-relational GR is the next resource that Antonovsky (1985)
listed. This resistance resource is usually referred to as an individual’s social support

system. In the book, Health, Stress, and Coping, Antonovsky gave several examples of

22

studies, which demonstrate that social support has illness-reducing power. Kantern’s (as
cited in Antonovsky, 1985) theoretical concept of commitment states that three types of
social commitments are necessary. The first is continuance commitment, which is the
process of judging whether it is worthwhile for the individual to stay connected to a
group. The second type is a cohesion commitment in which the individual senses a feeling
of unity with the group and feels he or she could fit in as a member. Third, control
commitment is when the individual buys into the moral rightness of the group and the way
the group operates.

In addressing this resource, the human ecology theory would speak to the
individual’s needs and values. Bubolz and Sontag (1993) write about the microunit's
need to relate to others. In any microsystem, individuals need to feel a sense of being
loved and loving someone. They need to have a sense of being accepted and well thought
of by others. Individuals also need to value the group(s) to which they belong and feel
that the group is good, right, and worthwhile.

In the last decade, a number of studies have supported the importance of social
support and connection to other human beings as critical to an individual’s well being
(Benson & Stuart, 1992). There are a number of ways that the family can connect to
others, and the family unit should be encouraged to reach out to their extended family,
friends, a religious/spiritual group, and/or other community groups to gain social support.
Connections with someone outside of the immediate family unit may help give the

additional support that is needed for the family to make it through a stressful situation.

23

Marcosocioculture/Socigl-Culture

Antonovsky’s (1985) last GR is the macrosocioculture. The essence of this
GR is that the culture gives individuals their place in the world. It is a mechanism that
provides a place to get answers about what is going on in life and how the social structure
is defined. The human ecology theory uses a similar label called the social-cultural
environment (Bubolz & Sontag, 1993), and sees this environment as having a powerful
influence on the family. For example, there are a number of ways that the surrounding
social and cultural environment may influence a family’s health. One of the best
examples is the medical community, which has had a profound effect on how our culture
views the family’s role in relation to health care.

Over the past century, scientifically-based medical knowledge has been touted by
our society as the mainstay to well-being. Families and individuals readily bought into
this notion and often viewed health care as out of their realm of expertise. It is true that
medical technology has advanced at an amazing speed over the last 100 years and has
been of great benefit to society. However, removing families as the gatekeeper of family
members’ health has not served society well. Matocha (1995) asserts that when the
family is not encouraged to share helpful, in-depth insight about a client, additional stress
is placed on the health care team to provide all of the answers. Not using all accessible
information boxes the health care worker into the “test tube” mentality. Instead of
looking at psychosocial factors that might cause or contribute to a family member’s
disease, the health practitioner often looks only for answers that are based on traditional

Western medicine. This does not negate the use of medical technology, but instead it

24

opens the door for society to value the use of a variety of resources to help maintain
health.

Health care providers also need to be aware of cultural diversity and identify how
these differences can influence families’ perspectives on health. Professionals need to
work within a family’s cultural belief system when attempting to assess the best
techniques to use to promote health care practices. It also would be beneficial to begin by
focusing on the positive practices that are already taking place within a particular family
and/or community. For example, health care practitioners should be congratulating
families who have developed strong decision making and management skills, are
participating in community health screening programs and/or participating in their
religious/spiritual organizations. Recognition of a family’s positive practices not only
reinforces their behavior, but also provides a springboard for the professional to discuss

other health-related practices.

Using GRRs to Save Famin Energy

‘ Most of the resources cited by Antonovsky (1985) and the human ecology theory
(Bubolz and Sontag, 1993) are inexpensive and accessible to families. This is important,
because it means that the well-being of family members can be improved without
spending a great deal of money and/or energy to secure the resources. Available energy is
a crucial commodity for the family as well as society. From a human ecological
perspective, Bubolz and Whiren (1984) write that “. . . higher levels of energy or more

efficient use of energy are needed for adaptive, creative behavior to enable a system to

cope with changing environments, internal stresses, and unusual demands on the

25

system” (p. 6). The wider the variety of resources available for the family, the greater the
chance the family has of establishing enough energy reserves to cope with life’s stressors.
Also, adequate resources enable a family to become more efficient in dealing with
problems, so they do not expend as much energy. This is important for two reasons.
First, the less emotional and physical energy used by the family to deal with stressors, the
greater the likelihood that family members will move closer to the ease end of the health
continuum. Second, the less energy a family uses to cope with stress, the more energy
they have to transmit back into the environment (e.g. saving health care dollars,
increasing productivity, participating in community service).

Bubolz and Whiren (1984) refer to the loss of energy within the family system as
an “energy sink.” They define an energy sink as a period in a family’s life when they are
so drained that the family can no longer think of methods of adaptation or creative
behavior to deal with the stress. This leads to costly consequences, because there is little
or no energy reserve left to deal with additional daily hassles or traumatic events. It also
increases the chances that there will be a greater toll on the family members’ emotional
and physical stamina, causing them to move toward the dis-ease end of the health

continuum.

Blending the Concepts into a Model

Following is a conceptual model that blends Antonovsky’s (1985) GRRs with
concepts from the human ecology theory. Figure 1 depicts the family as an important part
of health care, because the family has the ability to recognize and use systems outside of

the microunit to provide GRRs. This philosophy promotes the concept of

26

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educating and encouraging the family to use a variety of systems that can provide
resistance resources to help family members stay healthy. As a family deals with daily
hassles and/or traumatic stressors, the family will be required to move into a state of
adaptation and adjustment that can either lead to “growth and integration” or “disorder
and disintegration” (Bubolz & Whiren, 1984, p. 6). During the process of adaptation and
adjustment, if the family looks for and uses an appropriate system(s) to help provide
GRRs, they are more likely to reach a period of balance and stability that leads to grth
and integration, which Antonovsky refers to as a sense of coherence (Antonovsky, 1985;
Bubolz & Whiren, 1984). This balance or sense of coherence helps to move the family
closer to the ease end of the health continuum. As the family becomes more aware of and
skilled at using a variety of resources, they expend less energy to deal with life’s
stressors, thus saving energy. The conservation of energy leads to improved stewardship
and sustainability of resources and the decreased use of medical resources. This in turn
increases the family’s potential to build an energy reserve and transmit additional energy
back to society via sustained resources and productivity. The successful use of GRRs
also increases the flow of energy that feeds back into the family (Bubolz & Whiren,
1984). The family is then able to use this energy to deal with additional stressors or meet
other demands. The feedback loop also generates information about how well the family
was able to cope with the stressors. If a family has successfully used GRRs to help deal
with a stressful situation(s), the family learns that it is important and beneficial to use
available resources to help resolve and dissipate stress.

The recognition and use of GRRs can be viewed as a preventive health measure.

For example, if a family is able to recognize and use the appropriate resources to adapt

28

and adjust to life stressors, the family has a greater chance of increasing their sense of
coherence, which helps the family move closer to ease end of the health continuum.
These actions have the potential to improve family members’ psychological health, which
according to research in psychoneuroimmunology, can help prevent an onset of an illness
or decrease the negative effects that stress can have on exacerbating an existing health
problem (Antonovsky, 1985; Irwin & Strausbaugh, 1991; Benson & Stuart, 1992).

The lower, right-hand quadrant of the model in Figure 1 depicts a family who has
limited use of GRRs. The model suggests that families who do not know about, have
limited availability, or choose not to use systems that offer a variety of resources to deal
with stressors may have a more difficult time in adapting to stress, thus decreasing the
family’s sense of coherence. Consequently, the family may move closer to the dis-ease
end of the health continuum. The limited use of GRRs also may lead to an energy sink.
The energy sink not only affects the family, but all of society, because it has the potential
to create poor stewardship of resources, increase the use of medical resources and lead to
a decreased flow of energy back to the family. As stated earlier, the decreased energy
flow and information fed back to the family can be factors that contribute to the
disruption and/or breakdown of family functions (Bubolz & Whiren, 1984).

The spiral notation on both feedback loops in Figure 1 depicts that a family’s
pattern of adjustment and adaptation is not necessarily a direct linear process, but can
follow a circuitous route. McCubbin and Patterson (1983) point out that many families
take a circuitous route that requires extra time and resources to adapt and adjust to
stressful situations. Some families may move in and out of the crisis mode and eventually

make the needed adjustments to adapt to a stressful situation, while other families may

29

never adapt. The inability or the slow process of adapting to a stressful situation may be
due to a number of factors, including the family not using available GRRs (Antonovsky,
1985; McCubbin & Patterson, 1983). For example, when first trying to cope with a
stressful event, a family may choose not to take advantage of outside systems that offer
GRRs, and they may have a difficult time adapting and adjusting to the stressor(s). As
the family begins to move towards an energy sink, family members may reevaluate the
situation and make needed adjustments by seeking the use of GRRs, which in turn
changes the dynamics of dealing with the problem. The ultimate goal is to provide
families with a number of resistance resources to help them move as efficiently as
possible into a state of adaptation and adjustment, which helps the family to either grow

and/or integrate the necessary changes into their lives (Bubolz & Whiren, 1984).

Viewing Religion/Siliritualm fl System to Provide GRRs

As stated earlier, the purpose of blending Antonovsky’s GRRs with the human
ecology theory is to promote two important concepts. First, the family should be viewed
as an important partner in dealing with health care. Second, the family should be
educated to recognize and use psychosocial resources to improve the family unit’s sense
of coherence, decrease strain tension and move them closer to the ease end of the health
continuum. The theoretical framework for this research is based on the conceptual
model just described, and the premise that one of the systems that has the potential
to provide GRRs to the family is religion/spirituality (see Table 3). For example,
most religious/spiritual (R/S) organizations promote the importance of taking care of

one’s body and provide guidelines that reduce illness-causing behavior. These

30

Table 3: Religion/Spirituality Viewed as a System that Can Provide Generalized

Resistance Resources

 

Antonovsky’s GRRs

(Antonovsky, 1985)

Human Ecology
Concepts

(Bubolz & Sontag, 1993)

Religion/Spirituality

 

 

 

Physical/Biochemical Carrying Capacity Provides guidelines for healthy
living and reduces illness
causing practices

Artifactual Artifacts Often provides material

0 Material 0 Physical Objects resources to members and
others in need

Cognitive Communication Communicates information,

0 Knowledge 0 Information and such as values, beliefs, and

0 Information

meaning created and
transmitted

knowledge about life and death

 

Emotional
o Ego identity

Human Development
0 Ability to perceive

Gives a person a sense of who
he or she is in relation to

 

and act in relation to religious/spiritual beliefs and
the environment offers a purpose for beg;
Valuative/Attitudinal Decision Making and Gives spiritual guidelines for
Management decision making and

o Coping strategies

0 Goal setting/planning
0 Problem solving

management and offers tools
for coping

 

 

 

Interpersonal! Needs and Values Provides social support, a
Relational 0 Needs for having, sense of connectedness,
0 Social Support relating and being teaches that people are
0 Commitment 0 Committed to a group valuable and needed.
that is good, right,
and worthwhile
Macrosocioculture Social-Culture Gives a philosophy of life, a

0 Cultural stability
0 Philosophy of life

 

o Societal blueprint
o Rituals, beliefs, and
values of the family

 

purpose for being and a
cultural identity (McAdoo,
1993)

 

3l

 

organizations often provide food, clothing, and shelter to members and others who are in
need. R/S teachings also provide a source of knowledge, such as information about
values and beliefs that can help people cope with stressors and solve problems. In most
cases, religion/spirituality provides individuals with a sense of connectedness and teaches
that human beings are valuable because they have been created by a higher power.
Furthermore, research has shown that R/S organizations provide individuals a place
where they can find social support and give members a sense that they are needed and
valued (Levin, 1994; Albrecht-Jenson, 1991; Maton, 1989). Finally, R/S beliefs provide
a blueprint for living and offer individuals a philosophy of life and a sense of cultural
identity. Through an in—depth review of the literature, Chapter II will look at the potential
of religion/spirituality being a system that can provide GRRs. The chapter also will
contain a discussion about the limitations and negative influences that religion/spirituality
may have on a family.

Based on the theoretical framework and the premise that religion/spirituality can be
viewed as a system that provides GRRs, two questions were raised that have helped to
shape this research project. First, do families use religion/spirituality as a psychosocial
resource to help cope with stressful events? Second, if families do use
religion/spirituality to help cope with stress, what factors influence families to use
religion/spirituality as a coping mechanism? The following research objectives were

derived fi'om these questions.

32

Research Objectives

One of the purposes of this study was to determine if families used
religion/spirituality as a psychosocial resource to help cope with the stress of having a
child on the pediatric unit of a hospital. In addition, a recursive path (a priori) model was
constructed that included the following nine variables: income, education, race,
respondent’s age and gender, R/S beliefs, R/S practices, R/S affiliation, and interaction
with a spiritual caregiver(s). The researcher investigated if the nine variables were factors
in influencing families to use religion/spirituality as a psychosocial resource to cope with
the stress of having a child in the hospital. Toward this aim, the research was based on
two objectives:

1. To conduct a survey of families who have a child on the pediatric unit of a major
metropolitan hospital and to determine if the families used religion/spirituality as a
psychosocial resource to help cope with the stress of having a child in the hospital.

2. To construct a recursive path model and to determine if there is a causal

relationship between the nine variables in the model, and families choosing to use
religion/spiritualityI as a psychosocial resource to help cope with the stress of having a
child in the hospital. Specifically, the researcher will be attempting to ascertain if each of
the nine variables contribute to the predictive and explanatory power of the causal model.
A discussion of the variables included in the a priori model will be covered in the review

of literature in Chapter II.

33

Conceptual and Operational Definitions
Immediate Family
Conceptual Definition: “A family consists of a householder and one or more other
persons living in the same household who are related to the householder by birth,
marriage, or adoption. (US. Department of Commerce, 1990 p. 8-9).
Operational Definition: Individuals who are related to the child biologically, by

adoption, or guardianship and live in the same household.

Child on the Pediatric Unit of the Hospital

Conceptual Definition: An individual who is 21 years of age or younger and is currently
a patient on the pediatric unit of the hospital who is ready for discharge (as defined by the
hospital’s definition of age of child admitted to the pediatric unit).

Operational Definition: Age will be verified by a child’s adult family member (see

Appendix A, question 4).

Religion/Spiritualig

Conceptual Definition: The feelings, thoughts, experiences, and behaviors that arise from
a search for the sacred, and the means and methods (e.g. rituals or prescribed behaviors)
of the search that receive validation and support from within an identifiable group of
people. The search also can include non-sacred goals such as searching for identity,

belongingness, meaning, health or wellness. (as adapted from the Scientific Research On

 

34

Wit}! a_ng Health: A Consensus Remrt; Larson, Swyers, & McCullough, 1997, p.
21).

Operational Definition: The respondents will be asked to reply to questions on a survey
about RIS practices (repeated, systematic religious/spiritual activities such as prayer,
worship, religious attendance and social support), RIS beliefs (acceptance or confidence
in religious/spiritual presuppositions) and RIS affiliation (a religious/spiritual
organization a family is associated with or connected to) [see Appendix A, questions 10-

11, 12d-h].

Abilig to C0p_e

Conceptual Definition: A process, based on perception of the situation and the use of
existing and new resources, used by individuals and/or families to attempt to

deal with significant personal or situational demands in their lives. (Folkman & Lazarus,
1984; McCubbin, Hamilton, & Patterson, 1983).

Operational Definition: The respondent will be asked to reply to a question on a survey

about coping (see Appendix A, question 12b).

m

Conceptual Definition: “The negative effects of life pressures and events” (Benson &
Stuart, 1992, p. 177).

Operational Definition: The respondent will be asked to reply to questions on a survey

about his/her perception of the level of stress the family encountered when their child was

35

in the hospital, the medical reason for the child’s hospitalization, and the number of days

the child spent in the hospital (see Appendix A, questions 1-3).

Interaction with the Spiritual Caregiver

Conceptual Definition: During the child’s stay in the hospital, communication with an
individual who is viewed by the family as a conduit of RB beliefs and practices.
Operational Definition: The respondent will be asked to reply to questions on the survey
about their interaction with the spiritual caregiver and the effects of that interaction (see

Appendix A, questions 6-9).

The following section will only give operational terms, because the conceptual definitions
are commonly understood.

Agg

Operational Definition: Age will be measured by asking the family respondent to list
his/her birth date (see Appendix A, question 16).

Education

Operational Definition: Educational status will be measured by asking the respondent to
check the appropriate educational category that indicates the highest education level
reached by a member in the immediate family (see Appendix A, question 17) .

BM

Operational Definition: Race will be measured by asking the respondent to check the

appropriate category that specifies his/her race (see Appendix A, question 13).

36

Income
Operational Definition: Income will be measured by asking the respondent to check the

appropriate annual income of the immediate family (see Appendix A, question 18).

Gender
Operational Definition: Gender will be measured by asking the respondent to check

either the male or female category (see Appendix A, question 15).

Assumptions

The research is based on the following five assumptions.

Assumption 1: Religious beliefs and practices are important to most Americans.
The Wallstreet Journal (Holt, 1994) identifies that 90 percent of Americans say they
believe in God. A Newsweek article, “In Search of the Sacred,” noted that words such as
soul, sacred, spiritual, and sin are becoming “chic” again (Kantrowitz, King, Rosenberg,
Springen, Wingert, Namuth, & Gregax, 1994). A 1999 survey conducted by Brand
Futures Group studied the importance of religion in a person’s life (“God Back,” 1999).
Trendsetters (motivated people, oriented toward the future) in the United States, Italy,
Britain, France, Germany and Netherlands were surveyed. Of the 15,580 people
questioned, researchers found that there was an increasing number of people throughout
the world and especially in the United States (59.4%) who identified that
religion/spirituality was an important aspect of their lives. Stuart Harris, assistant director

of Brand Futures Eurpoa stated, “Presently there is clear evidence that the wave of

37

religious interest is turning, and above all, among the world’s trendsetters — people
generally not associated with such a view” (p. 2A).

Assumption 2: Resources other than conventional Western medicine can be
complementary in helping to improve an individual ’s emotional and physical well-being.
Many professionals are now recognizing that psychosocial influences and behavior can

have as profound an effect on individual health as can physiological behavior (Pearsall,
1994; Greenberg, 1993; Benson, 1996). Emmet E. Miller, MD. (1993) suggests that
health is the expression of the whole person, and health care professionals should look at
the aspects of an individual’s whole being, including all communications and
relationships with others and with the environment. Therefore, Miller posits that, when
dealing with emotional and physical health issues, it is important to draw from resources
that can help address a client’s psychosocial needs as well as his or her physical needs.
In addition, Americans are increasingly looking for and consistently using alternative
therapies in conjunction with their current health care modalities (Alternative Medicine,
1999).

Assumption 3: Having a child in the hospital is a stressful event for the family.
There is an abundance of evidence that having a family member in the hospital is a
stressful event for the family (Friedman, 1998, Lynn-McHale & Smith, 1991; Danielson,
et al., 1993; Molter, 1979). When a family member enters the hospital there are a number
of stressful concerns that occur, such as family members having to take on new tasks and
roles, dealing with the treatment and diagnosis of the family member and negotiating the
health care system (Hanson & Boyd, 1996; Lynn-McI-Iale & Smith, 1991; Hodovanic,

Reardon, Reese, & Hedges, 1984). Problems often become magnified for families who

38

have children in the hospital, because the family also has to deal with issues such as
separation anxiety, 3 sense of helplessness in caring for the child, modifications in family
activities and goals, and the strain placed on other family relationships (Patterson &
McCubbin, 1983; Vaughan-Cole, Johnson, Malone, & Walker, 1998). Furthermore,
Bood (1996) submits that the parents or guardians are under a great deal of stress, because
“the child relies on his parents to interpret reality” (p. 222). Bood also concludes that the
family must be careful in how they treat and react to the child, because if the family’s
behavior changes toward the child due to the illness, it will increase the child’s stress
level.

Assumption 4: Religion/spirituality should be measured using a
multidimensional approach.
Before 1970, researchers usually examined only the relationship between age and formal
church participation, but now they have determined that to measure religiosity, one must
use a multidimensional approach (Levin, 1994; Ainlay, Singleton,& Swigert, 1992).
Davidson and Knudsen (1977) emphasize the importance of looking at both the
subjective and behavioral dimensions of religious involvement. Many researchers believe
that parameters of measurement should include frequency of participation in R/S
activities (e. g. attending religious service, prayer, meditation and scripture reading) and
the meaning/beliefs that religion/spirituality brings to a person’s life. (Poloma, 1993;
Willits & Crider, 1988; Levin & Markides, 1986; Witter, Stock, Okun & Haring, 1985;
Pargament, Kennell, Hathaway, Grevengoed, Newman, & Jones, 1998; Koenig, Kvale, &

Ferrel, 1988).

39

Assumption 5: The survey will be completed by a member of the immediate
family.
The unit of analysis is a family member who will be asked to represent his or her
immediate family’s R/S beliefs and practices. Therefore, to diminish error, it is
imperative that a member from the immediate family (as defined in the conceptual terms)
completes the survey. To help assure that a member of the immediate family completes
the survey, the beginning of the survey states who should fill it out and gives a definition

for the immediate family.

An Overview of the Following Chapters

Chapter II will present a review of the literature, which will look at a family
science perspective on stress and coping, and the relationship between religion/spirituality
and health. The chapter then will conclude with a description of the operational map
showing the path diagram (a priori model) that depicts how various constructs may
influence the family to use religion/spirituality as a psychosocial resource to help cope.
Chapter III deals with the methodology used for the study and will cover the topics of
research design, data collection, data analysis, and research limitations. The fourth
chapter will discuss the findings in regard to the proposed research questions and whether
the hypotheses were supported. Chapter V will conclude with a discussion of the

findings and recommendations for further study.

40

CHAPTER 11

REVIEW OF THE LITERATURE

The review of the literature will cover three general topics: 1) a family science
perspective on stress and coping, 2) the relationship between religion/spirituality and
health, and 3) predicative variables that may influence a family to use religion/spirituality
as a psychosocial resource. The section focusing on the family science perspective on
stress and coping will specifically look at the Double ABCX Model with the intent to
give a broader perspective on the family and stress. Even though the Double ABCX
Model is not being used as a part of the theoretical fi'amework for this research, it
substantiates the idea that availability of adequate resources is an essential element in
helping a family to successfully cope with stress (McCubbin & Patterson, 1983). The
portion of this chapter’s literature review that covers the relationship between
religion/spirituality and health is divided into the following four sections: a discussion of
the term religion/spirituality, religion’s historical perspective on the family,
religion/spirituality as a provider of all the generalized resistant resources, and the

negative influence of religion/spirituality on health.

41

A Family Science Perspective on Stress and Coping

Families who have successfully survived the rigors of life have had to adjust and
adapt to change. As the 19003 progressed, social scientists, especially family science
professionals, became interested in this process of adaptation that occurred when a family
coped with stressful events. In 1949, Ruben Hill presented one of the earliest family
science models that attempted to conceptualize the effects of stress on the family
(McCubbin & Patterson, 1983). Hill’s model was labeled the ABCX Family Crisis
Model. The letters in the model symbolized a specific progression that a family would go
through when confronted with a stressor. Hill did make a distinction between a stressful
situation and a crisis. He defined stress as an event that caused disruption in the natural
flow of the family, which required a family to make adaptive changes so the family unit
could manage the stressful event. However, if the stressor was not dissipated or
controlled, the family would then move into a crisis situation and reach a state of
imbalance.

The first letter in Hill’s model was “A,” which represented an actual stressful
event that had the potential to place a hardship on the family unit (McCubbin &
Patterson, 1983). Letter “B” signified the beginning of the interaction phase where a
family would begin to use resistance resources to deal with the problem. At this point, a
family might actually be able to dissipate or control the stressor without a major
disruption to the family unit. Hill chose letter “C” to indicate the next step in the process,
which was appraisal. This step looked at how the family viewed a particular event and to
what degree they defined the event as a stressor or hardship. The last step in the process,

symbolized by the letter “X,” stood for crisis. If a family had been unable to dissipate or

42

control the event during steps “A”, “ B”, or “ C”, Hill projected that a crisis would occur
within the family system.

McCubbin and Patterson (1983) concurred that Hill’s model ofi‘ered a beginning
foundation to study the effects of stress on a family. However, when it was used as a
theoretical model for other longitudinal studies, it did not adequately explain the process
of adjustments and adaptations that a family had to go through when dealing with a
stressful event. To compensate for the missing links, McCubbin and Patterson developed
a new model called the Double ABCX Model of Adjustment and Adaptation. Following

is a brief overview of the model and how it ties into this research project.

aA Factor

Change is a natural process that occurs in a family. Some families will go through
more significant changes than others, but all changes have the potential to create stress in
a family’s life. McCubbin and Patterson (1983) propose that families rarely deal with one
change or stressor at a time, but rather “experience a pile-up of stressors and strains
particularly in the aftermath of a major stressor” (p. 11). These stressors may come from
a number of sources, including individual family members, the family as a unit and/or the
community. In the Double ABCX Model of Adjustment and Adaptation this pile-up is
labeled as the “aA” factor. During the pile-up, what appears to be the initial stressor or
hardship can trigger a number of other types of changes (stressors). McCubbin and
Patterson describe four additional types. 1) Normative transitions are changes that
usually are required to deal with a stressor or hardship. As mentioned earlier, a family

system is seldom stagnant but is required to change over time. In order for a family to

43

adapt to a stressor, transition is required. 2) Not only will a family need to adapt to the
current change(s), but they also may be required to deal with prior strain. In most
situations, families have prior issues which have not been completely resolved. When a
stressful situation occurs, these unresolved issues usually surface and place additional
stress on the family unit. 3) Another type of stressor that can occur is triggered by the
methods and resources used to cope with the initial hardship. For example, an additional
stressor may surface if a chosen manner of or resource for coping is unacceptable to one
or more family members. 4) The last type of stressor is the ambiguity that can transpire
during a stressful situation. Being uncertain about the future or the consequences of an
event can heighten the sense of stress that is already being generated in the family system.
A prime example of how a pile-up could occur is when a family has a child in the
hospital. Initially, the stress of having a child in the hospital may cause some family
members to experience physiological and/or psychological changes as they attempt to
deal with the situation. In addition, the initial stressor will cause most families to begin
to make normative transitions within the family system. For instance, decisions must be
made such as to who will stay with the hospitalized child and who will watch the other
children at home, what will the parent do about work commitments, and/or how will
other family roles need to shift to meet the challenge. Prior strains such as financial
concerns and/or marital conflict may be exacerbated, adding additional stress to the
situation. Family conflict also may occur as a family attempts to decide what resources
should be used to cope with the situation. Last, and perhaps creating the highest degree
of stress, is the ambiguity about the child’s health. Will the child get well? How long

will it take? Will the family be able to successfully care for the child and/or pay the bills

44

generated by the illness? As depicted by the model, it is inevitable that stressors will

begin to pile-up, requiring even more changes and adaptation within the family system.

bB Factor

The “bB factor,” as depicted by the Double ABCX Model, is categorized as the
family’s adaptive resources. McCubbin and Patterson (1983) identify existing resources
and expanded family resources as the two general types of resources used when dealing
with a stressful situation. Existing resources would be classified as resources that already
are in place and being used by the family. The natural reaction of the family would be to
immediately use these resources to help deal with and buffer the effect of the stressor.
Expanded resources are resources that the family is able to identify and learn to use when
dealing with hardships.

The underlying basis of this research study is that if families can identify and use
existing generalized resistance resources (GRRs), then they will be better equipped to
cope with and adapt to stressful events. The ability to recognize and employ the use of a
number of GRRs has the potential to help families dissipate or diminish the effect of the
stressor(s). In this study, the family’s stressful event is having a child in the hospital.

The researcher is proposing that religion/spirituality can be an important resource system
that can offer a number of GRRs, which in turn can help a family cope with the stress of
having a hospitalized child. McCubbin and colleagues have identified in the discussion
of the Double ABCX Model that religion/spirituality can be an important resource in
helping a family cope (McCubbin and Patterson, 1983; McCubbin, McCubbin, &

Thompson, 1993). They also posit that one of the most important resources available to

45

the family is social slipport, because it helps the family deal effectively with a crisis and
regain stability. As will be discussed later in this chapter, social support is a key

resistance resource that is offered by religion/spirituality.

cC Factor

The “cC” factor signifies the appraisal and the meaning that the family attaches to
the situation. McCubbin and Patterson (1983) suggest that when a family is able to
redefine a situation in a more positive light, the family is usually able to cope more
effectively. This redefining process includes the process of elucidating the issues,
realigning the emotional concerns so that they are placed in the proper perspective, and
encouraging the family to continue to live life as normally as possible. As will be
highlighted later in this chapter, religion/spirituality offers GRRs that allows a family to
redefine a stressful situation and refrarne it from a more positive or understandable
viewpoint. For example, families may refrarne issues by agreeing that God will not
allow them to go through more than they can endure, and/or that God is in control and
will help them cope with the problem no matter what the outcome may be. McCubbin,
McCubbin, and Thompson (1993) suggest that the “cC” factor may be one of the most

critical steps in helping a family to cope and adapt to a stressful situation.

xX Factor
The “xX” factor indicates how well the family was able to adapt to the stressful
situation (McCubbin & Patterson, 1983). Two terms are used to describe the adaptation

process: bonadaptation and maladaptation. Bonadaptation is defined as the ability to

46

achieve a “balanced fit.” It does not mean that there is a perfect solution, but that the
family is able to maintain or strengthen its integrity, to continue to develop both
individually as well as a unit, and to maintain a sense of control (a sense of coherence).
Maladaptation occurs when the family is out of balance, which in turn causes the
family’s integrity, developmental process and well-being to be affected. The family
begins to experience a decline in its stability, and negative consequences usually begin to

affect family members.

Family Adjustment and Adaptation Respon_se — FAAR
Observations made by McCubbin and colleagues (McCubbin & Patterson, 1983)

have led them to suggest that a family’s adjustment and adaptation response (FAAR) to a
stressful situation takes place in three phases. Each phase basically incorporates all the
steps (letters) of the Double ABCX Model . The first phase is the family adjustment
phase. The family becomes aware of the stressor, defines it, and begins to appraise the
situation. At this point, the family may use one of three techniques to cope with the
situation - avoidance, elimination or assimilation. McCubbin and Patterson point out that
the availability of resistance resources will be one of the determining factors in how the
family deals with this phase of adjustment. How well the family is able to adjust,
theoretically, will fall at some point on the bonadaptation-maladaptation continuum.

The second phase, family adaptation, is divided into Level I (restructuring) and
Level II (consolidation) [McCubbin & Patterson, 1983]. During the restructuring phase
the family acknowledges the stressor(s), constructs a shared definition of the problem,

works out a solution and begins to implement a plan to deal with the problem.

47

McCubbin and Patterson suggest that the availability of resources, including support, are
crucial to the success of adapting to this phase. Consolidation is the last phase of family
adaptation. This phase is very important to the adaptation process, because it is when the
family begins to consolidate into a coherent unit. To move through this phase, the family
starts to develop solutions that enable all members to make appropriate changes to deal
with the stressor(s). Once the changes have been negotiated and identified, the family
begins to implement the changes.

As discussed in Chapter I, adjustment and adaptation is not necessarily a linear
process. Instead, a family may take a circuitous route that involves extra time and
resources to make it to the final destination of bonadaptation. In other cases, families
may not be able to adapt and will move toward maladaptation. Based on this perspective,
one of the questions that should be asked is how can a family science and/or health
professional help a family successfully work through a stressful situation and move
towards bonadaptation? Though there may be a number of valid suggestions, one of the
primary premises upon which this research is built is the importance of educating the
family about GRRs, which can be used to help families adjust and adapt to stressful
situations. The next section of this chapter will identify and discuss the importance of

using religion/spirituality as a system that has the potential to offer the GRRs.

The Use of Religion/Spirituality as a Conceptual Term
The National Institute for Healthcare Research published an extensive report
entitled Scientific Research on Spirituality and Health: A Consensus Remrt (Larson,

Swyers, & McCullough, 1998). The report was based on the Scientific Progress in

48

Spirituality Conference. One of the tasks of the conference was the establishment of a
panel charged to write a conceptual definition(s) for religion and spirituality, which was
neither too broad nor too narrow and that could consistently be used in research. The
significance of this task was highlighted in the conference report, because without a clear
definition, it becomes difficult for both researchers and the general public to understand
what is meant when others talk about religion or spirituality. The conference report also
stated that without a clear definition it becomes troublesome for disciplines, such as
social science, to compare and draw “general conclusions” from studies. The panel
designed two separate definitions, one for religion and the other for spirituality.
Conceptually, the definitions were written so that they could be blended together to create
one definition or used independently. The panel defined spirituality as “the feelings,
thoughts, experiences, and behaviors that arise from a search for the sacred” (Larson,
Swyers, & McCullough, 1997, p. 21). “Search” was defined to mean someone who
“attempts to identify, articulate, maintain or transform” (p. 21), while “sacred” was based
on each individual’s perception of a “divine being, ultimate reality, or ultimate truth” (p.
21). The panel developed the definition for religion by first acknowledging that religion
often begins with a spiritual dimension, because it usually entails a search for the sacred
and/or non-sacred (such as finding meaning or identity in life, having a sense of
belonging, health, or wellness). However, religion also includes “the means and the
methods of the search that receive validation and support from within an identifiable
group of people” (p. 21).

Even though the panel recognized that a person could be spiritual and not be

religious, they found that in most cases religion and spirituality “co-occur” (Larson,

49

Swyers, & McCullough, 1997). The panel also determined that it is very diffith “to
measure spirituality as a separate construct from religion” (p. 24). They asserted that a
common step that occurs in most religious beliefs and experiences is the search for the
sacred, which in fact could be labeled spirituality. Therefore, the panel recommended
that the construct measured in most research should be referred to as “religious/spiritual
measures” (p. 24). The panel also concluded that the general public sees very little
difference in the meaning between religion and spirituality, and that most “believers”
integrate both into their lives. Based on this reasoning, the researcher will use the
designation “religious/spiritual” as the conceptual term in this study. The definition for
the religious/spiritual measure is:

The feelings, thoughts, experiences, and behaviors that arise from a

search for the sacred, and the means and methods (e.g. rituals or

prescribed behaviors) of the search that receive validation and support

fiom within an identifiable group of people. The search also can

include non-sacred goals such as searching for identity, belongingness,

meaning, health, or wellness. (as adapted from the S_c__ientific

Research On Spirituality and Health: A Consensus Repgrt; Larson,
Swyers, & McCullough, 1997, p. 21).

Religion and Family from a Historical Pers_pective

 

Through out history most religions have placed an important emphasis on the
family as a fundamental unit of society. Families have been viewed as providers and
caregivers, as well as important facilitators who teach and model the basic tenets of the
family’s religious beliefs to the children. In the Judeo-Christian tradition, the family is a
vital element in religious teaching. In the book of Genesis in the Bible, the first family is

established through the joining together of Adam and Eve, and they are charged to

50

procreate and care for the earth. Genesis 11 continues to depict the importance of family
by giving a long running list of the genealogies of families, while the rest of the Old
Testament vividly portrays various family units, showing both the positive and negative
of family life (Johnston, 1979). Johnston notes that in ancient Israel the family was
considered such an important unit of the Jewish community that severe punishment was
metered out to anyone who committed a serious offense against a family.

Likewise, other religions attach a great deal of importance to the family. In the
Mormon faith, the family is seen as a fundamental unit of society as well as heaven
(Adleman, 1999). The Islamic faith also views the family as an essential element of its
faith and strongly encourages believers to marry. Daneshpour (1998) writes that there are
two main objectives of marriage in the Islamic community. The first objective is to
provide a place of comfort and security for the husband and wife, and second, to
procreate and bring forth a new generation of healthy, moral and faithful children. In
addition, Friedman (1998) points out that the predominant beliefs of the Asian culture are
based on a blending of Eastern religions and philosophies. One of the core values taught
in this culture is to focus on the family more than the individual. The family is viewed as
very important, and family members are encouraged to have a strong sense of duty and

responsibility toward one another.

Religion/Spirituality an_d the Gen_eLalized Resistance Resources
There is a body of research that has examined the positive relationship between
religion/spirituality and mental and physical health. David and Susan Larson (1994) of

the National Institute of Healthcare Research compiled an annotated bibliography of

51

systematic reviews and clinical research on religious and spiritual topics. Based on their
extensive review, they concluded that there was sufficient research to demonstrate the
beneficial effects of religion/spirituality on health. Goodloe and Arreola (1992) also
reviewed the literature, which looked at the relationship between religion/spirituality and
health. In their article, “Spiritual Health: Out of the Closet,” Goodloe and Arreola cite a
number of ways that fellow researchers suggest that religion/spirituality can influence
health. 1) Human spirituality is a core dimension of an individual and plays a significant
role in giving meaning and purpose to life and in helping to determine an individual’s
well-being. 2) Religion/spirituality helps an individual move beyond self, so the
individual can more readily share warmth, love and compassion with others. 3)
Religion/spirituality provides meaning and purpose to life, which is an important
dimension of health. 4) Religion/spirituality engenders a sense of well-being that is
particularly essential in today’s culture, because Americans are living in a society where
they do not feel “connected,” but instead feel a sense of self-alienation, loneliness,
despair, fear, boredom and lack of meaning or purpose in life. 5) Optimum health must
take into consideration spiritual values, because many of our health issues such as sex
education, euthanasia and healthy lifestyles have spiritual overtones.

Other studies have consistently shown that religion/spirituality has a positive
influence on an individual’s psychosocial health (Matthew, Larson, & Barry, 1993; D.
Larson & S. Larson, 1994). One such study, which measured religiousness and its
relation to the parent’s and child’s mental health, was conducted by Strayhom, Weidman,
& Larson (1990). The researchers found that the group of parents who were more

religious demonstrated an increased number of positive parenting practices and a lower

52

sense of hostility. Studies also have shown that in the general population religiously
committed people had significantly less psychological distress than the less committed
(D. Larson & S. Larson, 1994).

Hadaway and Roof (1978) reported that faith was one of the strongest predictors
of an individual’s feeling that life was worthwhile. Saudia, Kinney, Brown, & Young-
Ward (1991) concluded that religion had a positive influence on adults who were coping
with difficult illness. A 12 year review of quantitative articles from the American Journal
of Psychiatry and the Archives of General Psychiatry found that 72 percent of the
variables used for religious commitment were beneficial to mental health (Larson,
Sherrill, et al., 1992). As will be demonstrated later, religion/spiritualtiy also seems to
have a positive influence on an individual’s physical health (Benson, 1996; Benson &
Stuart, 1992). This may be due to the effect that religion/spirituality has on the psyche,
which in turn can affect the nervous and immune system, and the body’s ability to heal
itself.

Religion/spirituality can be viewed a system which offers multiple resources to its
members to help deal with life events and cope with daily stressors. Research has found
that religion/spirituality can help in improving the carrying capacity of a believer’s body,
providing material goods, communicating knowledge and information, shaping one’s ego
identity, teaching coping skills, offering a place for social support and commitment, and
providing a philosophy of life and blueprint by which to live (Benson, 1996; D. Larson &
S. Larson, 1994). Even though it cannot be measured, it also must be mentioned that
most religions believe that an individual can be emotionally and physically healed

through the direct auspice of a supernatural power. Levin (1994) has coined the phrase

53

“psychodynamics of faith,” which means that one’s belief in religion or a higher power
may be a factor that stands by itself in producing health enhancing, salutary effects.
Levin also acknowledges that researchers are not able to measure the supernatural, but
this does not mean that the touch of a higher power does not happen. Therefore,
researchers should not deny that this can happen, but neither do researchers have
sufficient methods to measure and prove that it does occur. The following section will
review the measurable resources that religion/spirituality has to offer. These resources

will be discussed within the framework of the GRRs as cited in Chapter I.

Physical-Biochemical/nging Capacig

There has been a great deal of research that positively associates
religion/spirituality with improved health. Religious faith has been found to improve
recovery from surgery, lower blood pressure, and decrease the negative effects of chronic
disease (D. Larson & S. Larson, 1998). One study has shown that elderly people who
attended church, as compared to those who did not, had a healthier immune system
(Cerrato,1998). Studies from both the Dartmouth Medical School and the University of
Pittsburgh have found that patients who had a strong religious commitment were
physically and emotionally healthier after undergoing heart surgery or heart transplants
than their counterparts who were not religiously committed (D. Larson & S. Larson,
1998). Schiller and Levin (1988) reviewed 250 studies that had investigated the

association between religious affiliation and commitment and morbidity and mortality.
They discovered a direct association between religion/spirituality and positive clinical

effects regardless of age, sex, race, ethnicity, nationality or study design. In a follow-up

54

review of the literature, Levin and Vanderpool (1987) concluded that frequent religious
attendance was a factor in longer life expectancy. Similarly, McKee and Chappel (1992)
discovered that there was less chance of men dying from arteriosclerotic disease when
they attended church at least once a week as compared to men who did not. Jenkins’ and
Pargament’s (1995) study of 62-cancer patients, found that the patients who had a
stronger perception of God were able to make a more positive adjustment.

Most religions also have guidelines within their belief structure that teach
moderation and promotes lifestyles that are less conducive to creating certain health
problems. For example, various religious organizations discourage the use of alcohol,
tobacco and other drugs; some religions, such as the Mormon and Jewish faith, promote a
restrictive diet; and others promote exercise and care of the body (Levin, 1994; Levin &
Vanderpool, 1991; Vaux, 1976). Many religions also have specific hygiene criteria,
allow expressive display of human emotions and have specific codes on how human
sexuality should be expressed. McIntosh and Spilka (1990) found that individuals who
practiced their religious beliefs on a daily basis also felt more obligated to live a healthy
lifestyle.

The practice of preventive health behavior by religious groups has been very
apparent in epidemiological studies. Gardner and Lyon (1982) discovered Mormon
women who were active in their denomination had a lower rate of cancer, probably due to
their dietary and hygienic practices. The Seventh Day Adventist have long been known
for being one of the healthiest subpopulations in the United States due to lifestyle

behavior (Levin, 1994). Levin’s review of the literature also showed that groups such as

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Sephardic Jews, Benediticine Monks, Mormons, Baptist clergy, and Zen Buddhist priests

had lower blood pressure.

Artifactual

As discussed in Chapter 1, people with wealth, power, and knowledge are more
likely to take advantage of the health care system's resources. For the most part, they also
are more likely to deny the benefit of using religious/spiritual (R/S) resources or not use
them as frequently (Antonovsky, 1985; Levin, 1994). Inversely, poorer people with
negligible resources often use religion/spirituality as one of their main resources to help
them cope. One of the ways that many religious institutions interact with individuals is
by helping to provide material resources. Often religious groups offer shelter, clothing,

food and even health care services such as blood pressure screening and mammograms.

Cogaitive/Communication

R/S organizations share knowledge and information in a number of ways. For
instance, religious organizations may share knowledge about a number of topics, which
helps its members deal with the essentials of everyday living. A case in point is an
organization of churches known as F.A.C.E.D (Faith Access to Community Economic
Development) [1999] in Flint, Michigan. Individuals in the organization are working
with the county’s public health department and the local community college to train
members to provide health care information and health services to their churches. Their
philosophy is if they can have healthier church members, they will be able to have a

healthier community, which leads to improved human and economic development. Other

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religious organizations are offering information and knowledge via such vehicles as
parenting workshops, marriage seminars and financial planning.

Some might argue that most importantly, R/S organizations offer knowledge that
educates members about religious beliefs, values, and knowledge of life and death. Kaye
and Robinson (1994) found that religious teachings on life and death are very important,
because these teachings help to decrease the fear of death and often help people to
become more comfortable with the dying process. Pollner (1989) posits that information
taught about forgiveness and how to release or resolve shame and anger are very
important functions of religious teachings, because without the process of forgiveness or

the release of shame and anger, individuals have a greater chance of becoming ill.

Emotional/Humfl Development

A part of emotional/human development is how individuals view themselves (ego
identity) in relation to their environment (Antonovsky, 1985; Bubolz & Sontag, 1993). It
encompasses individuals feeling comfortable with who they are in their social and
cultural environment, but at the same time being able to picture themselves as
individuals. Religion/spirituality, when used positively, can contribute to a sense of
connectedness to others and can make a person feel a part of something important
(Antonovsky, 1985; Benson, 1996). It also can impart a reason and purpose for being - a
knowing of “who I am” and “why I am here.” Religion/spirituality also can provide a
sense of integration and stability and grant a person a view of who they are based on a
life-span perspective. Hadaway and Roof (1978) directed some of the first research that

looked at how religion/spirituality could influence an individual’s self-worth. They

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conducted a secondary investigation of the data from 1971 Quality of American Life
Survey. The researchers found that people of religious faith felt that their lives were more
worthwhile, had a greater sense of well-being and life satisfaction as compared to those
who did not share the same commitment to R/S beliefs. Since that time, other researchers
have drawn similar conclusions. Maton (1989) believes that emotional support is one of
the great gifts of religion, because it projects the concept that God values, loves and cares
for the individual, which in turn increases a person’s sense of self-esteem. Pollner (1989)
is convinced that religion/spirituality provides an individual with a greater sense of self
and contributes to meaning in life, which helps the person build a stronger sense of

personal identity.

Valuative-Attitudinal/Decision Making-Management

The ability to be able to cope with and manage a stressful situation may be one of
the most important tools an individual or family can have. Researchers continue to
propose that religion can provide a number of resources to help cope with stress
(Pargament, Ensing, et. a1, 1990). Resources such as participating in prayer and/or
worship, reading spiritual material, sharing in times of joy and sadness, and seeking
spiritual guidance have all been deemed as helpful with the coping process (Kay &
Robinson, 1994). Kay and Robinson also found that religion/spirituality is beneficial,
because it offers hope, neutralizes stressful situations and gives guidelines for decision
making and management. Pollner (1989) and Maton (1989) suggest that

religion/spirituality gives a perspective on how to appraise a situation, as well as gives an

58

orderliness and predictability to life’s occurrences. This is important, because it offers an
explanation of why certain things happen and helps in the management of the events.
Pargament and Hahn (1986) project that religion/spirituality is important in the
coping process, because it allows individuals to attach a meaning to a situation and give
them a sense of control. Rothbaum and colleagues generalize that religion/spirituality
offers three types of control: interpretive, predictive and vicarious control (McIntosh &
Spilka, 1991). An individual uses interpretative control to say that there must be a reason
why an event has happened even though it may take a period of time before God shows
me why. Predictive control allows the individual to apply a direct religious explanation
to why a certain life event happened. An individual who believes that God is in control
of a situation and will be able to help him or her through the event is practicing vicarious
control. Like Pargament and Hahn (1986), the researchers concluded that using these
types of controls offer individuals a sense of meaning in life, especially when they feel
they have no control over the situation. Having a sense of meaning in life, and a feeling
that ultimately a greater power is in control, helps individuals and families decrease their

sense of dis-ease and promotes the feeling that they will be able to deal with the situation.

Integxrsonal-Relational/Needs-Values

There has been a great deal of research that has demonstrated that the association
between religion/spirituality and health may be partly due to social support, fellowship
and the sense of belonging and cohesiveness that is created by a religious community
(Levin, 1994; Hadaway & Roof, I978; Willitis & Crider, 1988; Ferraro & Albrecht-

Jensen, 1991). A study by Oxman, Freeman and Manheimer (1995) examined the

59

relationship of social support and religion on the mortality rate of 233 older patients (55-
years and older) who had had elective open-heart surgery. The researchers discovered
that the patients who participated on a regular basis in a social group possessed a unique
quality, which acted as a life protective mechanism. They also found that the patients’
religious beliefs gave them strength and comfort as they recovered. According to the
researchers, there was a three times greater risk of death for individuals who did not
participate in social or community groups and who did not gain any sense of strength or
comfort from religion. It also has been suggested that when it comes to
religion/spirituality, social support should not be viewed as limited to other individuals,
but also should be seen as the connection or relationship that an individual has with God
or a higher power (Pargament & Hahn, 1986). This may be especially important for
people who do not feel that they are in control of a situation. Instead, to deal with the
problem, they commune directly with God or a higher power and receive a source of

support, encouragement and reassurance.

Macrosociocultuyral/Social-Cultural

 

Religious organizations have long been known as systems that offer blueprints for
living. They give believers a culture or a place in which they can find a set of rules by
which to live. Witter, Stock, Okun and Harding (1985) conducted a meta analysis of
quantitative research that studied the relationship between religion and subjective well-
being. They found that religion/spirituality provided individuals with a sense of social
integration and helped them to connect to a larger cultural group with like views. Shuler,

Gelberg and Brown (1994) concluded that belonging to a religious community offered

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people cultural stability and gave meaning to life. Lazarus and Folkman (1984) stated
that “humans are meaning-oriented, meaning-building creatures who are evaluating
everything that happens” (p. 171). Perhaps this is why people are drawn toward religious
faith, because one of the purposes of religion is to fulfill the individual’s need for finding
meaning in life (Ferraro & Albrecht-Jenson, 1991). Levin and Vanderpool (1991) posit
that religion negates a sense of helplessness, confusion and insignificance. Instead, it
provides a sense of tradition, a guide from birth to death and a sense of memory — all of

which offer meaning.

The Neufial/Negative Influence of Religion/Spirituality on Health

As Antonovsky (1985) noted, any of the GRRs that can be used to benefit a
person also can be used as a negative influence. Religion/spirituality is no different. As
the review of the literature has demonstrated there is a preponderance of evidence that
establishes the positive relationship between health and religion/spirituality. However,
Ferraro’s and Albrecht-Jenson’s (1991) review of the literature concluded that not all
studies have found the same positive results. For example, Markides (1983) studied the
strict religious practices of older Mexican Americans. He found that they had increased
blood pressure due to their guilt because of their inability to adhere to strict religious
norms. The Duke Longitudinal Study conducted by Blazer and Palmore (1976)
concluded that there was no association between older adult’s religious activities and
longevity. Ferraro’s and Albrecht-Jenson’s (1991) study found that members of
conservative denominations had poorer health. However, they proposed that this might

be due to the fact that conservative denominations tend to draw more individuals from a

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lower socioeconomic level. People in this social stratum are less likely to practice
preventive health care, often will not seek out medical treatment and have a more
fatalistic attitude about illness. Dein & Stygall (1997) reviewed several cancer studies
and discovered no significant relationship between religion/spirituality and coping.
Maton (1989) cited research that found that prayer and religious interpretations were not
related to individual’s ability to cope successfully. It also should be recognized that
individuals could become involved in unhealthy R/S practices. For example, some R/S
affiliations promote the handling of poisonous snakes, prohibit a member from seeking
appropriate medical treatment and/or set guidelines so rigid that members are loaded
down with a sense of guilt and/or shame.

Another factor that should be considered is that a family’s R/S conviction may be
negatively affected when the family is enmeshed in a stressful situation, such as having a
child in the hospital. For example, instead of turning to religion/spirituality for strength,
the family’s stress level may be increased because of their R/S beliefs. For instance, the
family may see their child’s illness as punishment from a higher power, and this belief
makes it more difficult for the family to adapt or adjust to the situation (Castiglia &
Harbin, 1992). Whaley and Wong (1991) found that as some families move through the
shock and denial of learning that their child has a chronic illness, disability or is dying
that the family may reject their R/S beliefs. The family may feel angry and resent any
mention of religion/spirituality and/or interaction with a spiritual caregiver (Castiglia &

Harbin, 1992).

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Building a Predictive Model

As indicated earlier, one of the objectives for this study is to estimate the
interrelationship between variables and to specify an a priori model that will predict what
factors influence a family to use religion/spirituality as a psychosocial resource. Based on
this objective, the question then becomes what are the independent variables that should
be used in the model? The variables that will initially be tested to build the model are
income, race, education level, the respondent’s gender and age, and the family’s R/S
practices, beliefs, affiliation and interaction with a spiritual caregiver(s). Following is a

discussion of the variables.

Religious Practices and Beliefs

Researchers have determined that religion/spirituality is multidimensional, and its
effects cannot be measured by using only one dimension such as church attendance
(Levin, 1994; Pargament, Ensing et al., 1990). Instead, to measure the effects of
religion/spirituality, a researcher must look at several factors such as values, beliefs,
attitudes, religious attendance and social support received from the R/S community.
Levin (1994) believed that how frequently one was involved in R/S activities and the
depth of that involvement influenced one’s psychosocial and physical health. Two of the
categories he used as a measure for religion/spirituality were the “psychodynamics of
belief systems” and the “psychodynamics of religious rites.” He noted that the
psychodynamics of the belief system gave meaning and purpose to life and made one feel
peaceful and self-confident. The psychodynamics of religious rites included participation

in R/S practices such as worship, rituals, and fellowship. Levin concluded that these

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effects of religion/spirituality could help individuals by replacing such emotions as
anxiety and loneliness with a feeling of being cared for and loved.

Rutledge, Larson, Levin, and Lyons (1995) used a similar division when
determining the pattern of how R/S coping manifested itself in believers. The researchers
presented the idea that individuals used religion/spirituality to cope “intrapsychically” as
well as “institutionally.” Intrapsychical coping is defined as someone’s R/S values,
beliefs and attitudes. On the other hand, institutional coping has to do with the practice
of religion such as attending religious services and fellowship. In a similar fashion,
Witter, Stock, Okun and Haring (1985) discussed the importance of operationalizing
religion by measuring both religious activity and religiosity (meaning and importance that
religion has to the person).

Pargament, Ensing et al. (1990) also found that individuals’ beliefs in God and the
frequency that they practiced their faith influenced their health. The researchers studied
586 members of Protestant churches and looked at what religious variables individuals
used to cope with negative events. They found four key themes that were associated with
positive outcomes in coping. The first was the belief in a just and loving God. This
belief helped individuals appraise the event in a more positive light, as opposed to
someone who felt that the negative event was a punishment from God. Second, was the
tenet that God was a supportive partner in the process, and even if the person felt he/she
did not have much control, God did. The third theme was the importance of participating
in religious practices such as scripture reading, attending religious services and prayer.

The fourth benefit was that people who did attend church coped more effectively if they

also endeavored to gain closeness to God and used their religious/spiritual beliefs as
guidelines to deal with the negative events.

A number of studies have found that religious beliefs can positively influence an
individual’s coping skills. Willits and Crider (1988) reported that individuals who
believed in the existence and divine character of a higher power were usually healthier.
Ferraro & Albrecht-Jenson (1991) also found that how close one feels to God would
influence health. Johnson & Larson (1998) discovered that when people gained a sense
of meaning, optimism and safety from their R/S beliefs, they had an increased sense of
well-being, which in turn helped them to cope. Also, individuals who demonstrated an
intrinsic pattern of R/S beliefs were healthier and more likely to use these beliefs to cope
(Larson & Larson, 1994).

Some of the first studies that discovered that religion/spirituality might have a
positive influence on health occurred when researchers included church attendance as a
measurement in health studies (Levin, 1987). Since then, investigators have progressed
by looking at a variety of R/S practices that might influence one’s health. A number of
studies have found that a variety of activities such as worship, prayer, participating in
sacraments and rituals were beneficial in coping and/or improving health (Willits &
Crider, 1988; Levin, 1994; Ferraro & Albrecht-Jenson, 1991). Levin, Larson, and
Puchalski (1997) concurred that spiritual practices were beneficial in helping to promote
health-related behavior, and because these practices provided social support, they also
helped individuals cope. In much of the researcher, prayer seemed to be a very important
factor in helping individuals cope with negative events (McIntosh & Spilka, 1990; Willits

& Crider, 1988).

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Strawbridge, Cohen, Shema & Kaplan (1995) concluded in their study that
frequent religious attendance was associated with less depression, lower blood pressure
and increased perception of health and life satisfaction. The researchers conducted a
28-year study that tracked the association between religious attendance and mortality.
They found that mortality rates were lower for frequent religious attendees. They
postulated that this occurred because of the increased social contact, greater stability in
marriages and a tendency for religious individuals to practice better health habits.

Hathaway and Pargament (1991) suggest that one of the conditions that must be in
place for an individual to use religion/spirituality as a means of coping is availability.
They argue that without a R/S background, an individual is less likely to think of or use
religion/spirituality as a resource. Conversely, if individuals have experienced a greater
involvement in R/S activities, they are more likely to perceive religion/spirituality as an
important means of coping. One might then question, if a spiritual caregiver is available
to the family, when they have a child in the hospital, would this be a factor in influencing

the family to choose to use religion/spirituality as a coping resource?

Interaction with a Spiritual Caregivegs)

The researcher is defining the term, “spiritual caregiver” as an individual who is
viewed by the family as a conduit of religious and spiritual beliefs and practices. This
could include such people as the hospital chaplain, parish nurse, priest, nun, pastor, rabbi
and imam. Spiritual caregivers who participate in hospital visitations have the potential
to fulfill a number of roles to help patients and families cope (McKee & Chappel, 1992;

Widerquist & Davidhizar, 1994 ; Handzo, 1996; Hanson & Boyd, 1996). For example,

66

the spiritual caregiver often offers comfort and social support to the family. Spiritual
caregivers can help families and patients find hope, attach meaning to a stressful situation
and value the importance of the family working together to make it through the crisis.
The spiritual caregiver also can facilitate the expression of feelings and act as a conduit to
help families deal with guilt, shame, forgiveness and anger. In addition, they act as
counselors for dying patients, help families deal with grief, and make funeral and burial
arrangements (Wilson, 1989).

In studying the role of hospital chaplains, McKee and Chappel (1992) have
suggested that chaplains may be of tremendous help in the healing process, because they,
along with other spiritual caregivers, are often viewed as “physicians of the soul” (p.
201). Maton (1989) concluded that chaplains offer spiritual support and a more positive
appraisal of an event, this in turn helps individuals to reduce the negative effects of a
traumatic situation. Widerquist & Davidhizar (1994) state that chaplains “bring
transcendence to the individual in distress, pain and crisis, inviting persons to respond in
their spirit” (p. 648). Handzo (1996) sees chaplains as individuals who offer hope and
help a patient or family gain a new perspective and way of thinking about God during a
time of crisis.

Whether a hospital chaplain or a visiting spiritual caregiver, one of the most
important contribution either one can make is to act as catalyst to remind people that
religion/spirituality can be used as a coping mechanism. As mentioned earlier, Hathaway
and Pargament (1991) stated that one of the conditions that increases the possibility of
using religion/spirituality to cope is that individuals find themselves in a compelling

situation. Spiritual caregivers who are ministering to individuals in the hospital are often

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surrounded by compelling situations where patients and families are not able to explain or
resolve the traumatic event by the use of secular resources. Therefore, the patient and
families may be looking for another available resource to help them cope with the
negative circumstance. The availability of spiritual caregivers to serve as symbols and
providers of religion/spirituality offers a new resource for the patients and their families
to use in the coping process. The essence of concern, comfort, hope and support that
spiritual caregivers bring with them into the hospital room is indeed a very compelling
resource that many often reach for in a time of crisis.

Three factors that may influence a family’s receptiveness and interaction with a
spiritual caregiver are the family’s R/S practices, beliefs, and affiliation (Levin, 1994;
Rutledge, Larson, Levin & Lyons,.1995; Levin & Vanderpool, 1987). If a family is
actively involved in R/S practices and beliefs, they may see the interaction with a spiritual
caregiver as a positive extension of their faith (Jenkins & Pargament, 1995). However, if
the family has a different R/S affiliation than the visiting spiritual caregiver (e.g. hospital
chaplain), the farme may view the interaction as obtrusive. For example, an orthodox
Jewish family may be very uncomfortable with a spiritual caregiver from another faith.
The family may feel that the spiritual caregiver does not understand their needs and/or

may be fearful that they are being proselytized.

Religious/Spiritual Affiliation

A review of the literature has shown that there has been a statistically significant
association between religion/spirituality and health across a variety of religious

affiliations, including studies on Catholics, Protestants, Jews, Hindus, Buddhists, Parsis

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and Muslims (Levin, Larson & Puchalski, 1997). However, individual research does
show there may be some difference in specific religions, and a religion’s influence on
well-being and health. Levin and Vanderpool (1987) suggest that how a R/S affiliation
affects one’s health may be dependent upon how the culture in which one lives views that
religion. In example, they cite religious groups such as the Christian Scientists and
Holiness sects who have viewpoints that are often at odds with the philosophy of
mainstream society. This conflict of viewpoint may in fact create enough stress in a
religious member’s life that it has a negative effect on the person. However, Levin and
Vanderpool (1987) suggest that groups such as Orthodox Jews, Mormons and the Amish
may actually be promoters of positive health, because they “foster psychological peace
and a sense of social integration even though they value beliefs and practices not shared
by the dominant culture” (p. 597). Hadaway and Roofs (1978) data from the 1971
Quality of American Life Survey found that the importance of faith negatively affected
“life’s worthwhileness” among Jews. They also sight McCready’s 1976 study that
showed that overall Judaism is a more pessimistic faith as compared to Christianity. In a
study that looked at religious activity, denominations, membership and life satisfaction,
McClure and Loden (1982) found a mixed result among various religious groups. The
researchers discovered that Catholics and fringe Christian groups had a stronger sense of
worthlessness as compared to Protestant groups. Mormons and Baptists spent more time
in R/S activities and responsibilities as compared to Catholic and Jews. Baptists and
Jews had a greater sense of satisfaction with their religious activities than Mormons.
Jews and Mormons had less overall life satisfaction, and Baptists and Mormons were the

happiest with their religious affiliation. There is not a great deal of research that

69

pinpoints the effects of specific religion on health; more investigation needs to be done in

this area.

Bag;

In the book, Family Nursing: Research, Theory, and Practice, Friedman (1998)
acknowledges that religion is very intertwined with race. She writes that for many
cultural groups religion/spirituality is a key construct that shapes families’ health values,
beliefs and practices. From her observation and research, she noted that Hispanic-
American families readily reach out for spiritual support when a family member is going
through a health crisis. In comparing Latinos to Anglos, she found that the Latinos were
more likely to accept that God, prayer and faith were important methods of coping with
their child’s cancer. Between 85 to 95 percent of Hispanic-Americans are Catholic
(Jackson & Saunders, 1993; Friedman, 1998). Most Hispanic’s R/S beliefs are based on
the Catholic precepts that a higher power guides an individual’s life and is in control of
when that life will end (Friedman, 1998; Edelman & Mandle, 1998; Jackson & Saunders,
1993).

Afi'ican-American families are very dedicated to their religious community and
beliefs, and a majority of Afi'ican-Americans are Protestant (Friedman, 1998; Jackson &
Saunders, 1993). A central system in the African-American community is the church,
and it provides a place for expression, socialization and spiritual growth. In this
community, religion/spirituality plays a significant role in many families’ lives, and
pastors within the community are viewed as very influential people (Edelman & Mandel,

1998; Ashwill & Droske, 1997). When comparing black middle-class to white middle-

70

class families, Friedman (1998) concluded that the black families placed a higher priority
on their R/S beliefs. Jenkin’s and Pargament’s review of the literature also found that
African Americans used religious coping more often than Caucasians. Levin, Chatters
and Taylor (1995) investigated the effects of religion on health status and life

satisfaction among Black Americans. They found that Black adults attend church
frequently; many are church members and are often engaged in religious practices such as
prayer and reading devotional material. Levin and colleagues also stated that one of the
reasons religion/spirituality has an influence on the well-being of African-Americans is
because the Black church has done an excellent job in attempting to buffer and change
conditions within society that are harmful to the Black community’s health.

It becomes more difficult to pinpoint the effects of R/S beliefs for Asian-
Americans. Friedman (1998) writes that, “the influence of the philosophies/religions of
Confucianism, Taoism, and Buddhism are deeply ingrained in the Asian culture. Thus
whether or not an Asian overtly identifies with these systems of thoughts/beliefs, he or
she inadvertently follows their prescriptions, which are often synonymous with cultural
norms/values” (p. 54). Friedman identifies a number of core values of this ethnic group,
none of which are related directly to belief in a higher power. Jackson and Saunders
(1993) point out that the philosophical and religious roots of Asian Americans often
create a sense of fatalism. This group’s philosophical/religious beliefs tend to promote
the concept that one should move with the natural rhythm of life and accept one’s fate,
instead of challenging and resisting the situation.

Many individuals from the Middle East practice the Islamic faith. Daneshpour,

(1998) points out that Islamic culture values the strong traditions and rituals that tie

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families and religious beliefs closely together. Ghazizadeh (1992) states that, “Islam
prescribes a set of spiritual, social, economic, political, sexual, dietary, and military
guidelines that make the daily life of Moslems inseparable from their religion” (p. 227).
During family distress, Daneshpour explains that Muslim families are more likely to deal
with their stress by staying close to other family members and “making a strong
connection to God (Allah)” [p. 363]. The Muslim family makes this strong connection
through prayer and believes by sitting quietly and praying, they can get in touch with their
true self and Allah. This in turn helps them to accept self and the pain that comes from a
stressful situation.

In the past, Caucasians have been found to have a higher life satisfaction in
relation to their religious beliefs as compared to non-whites (Hadaway & Roof, 1978).
However, as Friedman (1998) points out, many families in today’s society have become
more secular, and thus religion/spirituality has less influence on these families. Studies
have shown that as Americans receive a higher level of education and are upwardly
mobile they tend to become more secular and less religious (Ferraro & Albrecht-Jensen,
1991). These findings may be most applicable to Caucasians, because they are more

likely to fit this socioeconomic profile.

Income and Education

Relatively little research has investigated the relationship between income and
education levels as related to the use of religion/spirituality as a coping mechanism.
Zuckerman, Kasal, and Ostfeld’s (1984) study of the poor showed that religiousness had a

protective effect on their health. In past research, Hadaway and Roof (1978) cited two

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studies that concluded that the level of income had very little influence on religion’s
relationship to the quality of life. Comstock and Partridge (1972) found that middle-class
people attended church more frequently than those in a lower social class. However,
more current studies have shown that people with wealth, power, and knowledge are
more likely to take advantage of health care resources, and for the most part, deny or do
not use religious resources as frequently (Antonovsky, 1985; Levin, 1994). Ferraro and
Albrecht-Jenson (1991) noted that people with a higher social status were less
conservative and less involved in R/S activities. Jenkins and Pargament (1995) noted the
same pattern in the use of religious coping. Adults with a higher socioeconomic level
used religion less as a coping resource as compared to adults with a lower socioeconomic

status.

we;

Mixed reviews seem to prevail on the issue of whether or not gender is related to
R/S and health. Zuckerrnan, Kasal, and Ostfeld (1984) studied the psychosocial
predictors of mortality among the elderly poor and found evidence that religiousness had
a protective effect on both elderly males and females. Hadaway and Roof (1987) came to
similar conclusions when they examined whether religious meaning and religious
belonging were positively associated with life satisfaction. They found no difference
between males and females in respect to the importance of faith, but they did find a
slightly stronger male relationship to religious membership, participation and the feeling
of life satisfaction. A look at religiousness and personality characteristics among college

students by Mayo and colleagues concluded that there was a positive correlation between

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religiousness and mental health for male students but not for female students (as cited in
Matthew, Larson, & Barry, 1993).

Koenig (1990) found that women mentioned religious behavior as being a positive
benefit to their mental health almost twice as often as did men. Likewise, a 1987 study
by Brown on stress, social support and health in urban blacks indicated that religion
seemed to appear less important for black men than it did for black women. Levin,
Chatters and Taylor’s (1995) research found that African American and Caucasian
women participated more in religious activities than their male counterparts. Likewise,
J enkin and Pargament’s (1995) review of the literature concluded that women, as
compared to men, were more likely to use religion as a coping resource. Though studies
differ in their findings when studying the influence of religion/spirituality on gender, the
more current studies tend to lean toward females being more actively involved in

religion/spirituality than their male counterparts.

Studies have delineated that R/S activities tend to change over the life cycle, but
not necessarily R/S beliefs. Albrecht and Cornwall (1989) cited research that showed that
R/S activities tend to decrease during the teens and early twenties. As individuals reach
the late twenties and thirties, they begin to increase their activity levels. According to
Albrecht and Cornwall this may be due to the fact that they are reaching child-bearing
ages, taking on an adult status and beginning to deal with more serious problems that
come as one ages. Moody (1998) also suggests that parents with younger children are

more likely to attend R/S services, but participation drops off after middle age. Cox and

74

Hammond’s (1988) review of the literature found a consistent pattern in adult church
attendance. They state “that church attendance hits a low between18 and 24, remains
relatively stable between 25 and 54, rises slightly after 54 and drops slightly after
80” (p. 3).

Moody (1998) reports that adults over 65 are more likely to attend church on a
regular basis as compared to those who are under 30. Levin’s (1993) research found that
50 percent of older adults attended religious service a minimum of once a week. He also
found an older individual is more likely to express a belief in God. A meta analysis of
the literature supports that the relationship between religion and subjective well-being
was strongest in older people in comparison to the younger generations (Witter, Stock,
Okun & Harding, 1985). However, other research points out that even though
religion/spirituality appears to be an important part of an older adult’s life, there is little
evidence that as one ages they become more religious (Johnson, 1995; Ainlay, Singleton,
& Swigert, 1992; Chatters & Taylor, 1994). Consequently, individuals may be more
active in practicing and expressing their R/S beliefs as they age, but this does not mean

that they become more religious/spiritual.

Building a Path Diagram
One of the objectives of this research project was to build a recursive path model
that would identify variables which influence a family to use religion/spirituality as a
psychosocial resource to cope with the stress of having a child in the hospital. Figure 2 is
an a priori model in the form of a path diagram that gives an overview of the nine

variables involved in this process. As depicted on the map, the variables are classified

75

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into the subgroups of exogenous and endogenous variables. The exogenous variables
consist of the respondent’s age and gender and the family income, education and race.
The variables included in the endogenous subgroup are the family’s R/S practices and
beliefs, interaction with spiritual caregiver(s), and W8 afiiliation.

Based on the review of the literature, the researcher began to construct the
diagram by hypothesizing whether the exogenous and endogenous variables would have a
positive or negative causal effect on the dependent variable. In this path diagram, age is
designated as having a positive (+) relationship, because past studies have shown that as
persons age they tend to become more actively involved in their faith (Moody, 1998;
Albrecht & Cornwall, 1989; Cox & Hammond, 1989). However, these findings may be
due to a cohort effect. The relationship between religion/spirituality and age may change
as new cohorts are studied. Gender also is characterized as having a positive causal
relationship. This designation was made because the researcher assigned the female
gender a positive (+) sign. This is based on the review of literature, which shows that the
female gender is more likely to be positively related to R/S practices and belief (Jenkin &
Pargament, 1995; Koenig, 1990; Levin, Chatters & Taylor, 1987).

Individuals with higher education and income levels tend to be more secular and
are not as likely to use religion/spirituality as a resource to cope (Levin, 1994; Albrecht-
Jenson, 1991; Antonovsky, 1985). Therefore, a negative (-) causal relationship was
designated in the path diagram based on the assumption that the higher a family’s
education or income levels, the less likely the family is to be actively involved in MS

practices and beliefs.

77

The review of the literature has shown that a large number of people in each racial
group practice some form of WS beliefs. However, it should be noted that income and
education might be an important factor when attempting to determine if some racial
groups are more R/S than others. Groups in the United States such as Hispanics-
Americans and African-Americans have less education and lower income levels than their
Caucasian counterparts (Edelman & Mandel, 1998; Friedman, 1998). Research has
shown that individuals with lower levels of education and income may more likely view
religion/spirituality as an important resource in their lives (Levin, 1994; Antonovsky,
1985). The researcher has assigned a positive (+) notation to subjects who identify
themselves as a member of a minority race in the United States such as Hispanics-
Americans, Afi'ican-Americans, and Arabic-Americans. A negative (-) notation was
assigned to individuals from the Caucasian race. Thus, the path diagram, which shows
race as a positive exogenous variable, is based on the premise that minority races in the
United States will have a more positive (+) causal relationship with religious/spiritual
practices and beliefs as compared to Caucasians.

The exogenous variable, race, also is shown in the path diagram as having a
positive (+) causal relationship with a family’s religious/spiritual affiliation (Friedman,
1998; Elelman & Mandel, 1998; Daneshpour, 1998; Jackson & Saunders, 1993). For
example, many, but certainly not all, Hispanic Americans associate with the Catholic
faith, Arabic-Americans with the Islamic faith, African-Americans with a Protestant faith,
and Caucasians with either a form of Christian or Jewish affiliations.

Just as the path diagram illustrates that the exogenous variables have a causal

relationship with religious/spiritual practices, beliefs and affiliations, the diagram also

78

projects that the endogenous variables, R/S practices, beliefs and affiliation, have a
positive (+) causal relationship with the family’s interaction with a spiritual caregiver(s).
As cited earlier, families that actively participate and/or acknowledge their R/S beliefs
may view a spiritual caregiver as a positive extension of their religion/spirituality, and
thus be more willing to interact with a spiritual caregiver (Levin, 1994; Rutledge, Larson,
Levin & Lyons, 1995; Levin & Vanderpool, 1987). This may especially hold true, if the
spiritual caregiver is of the same R/S persuasion as the family.

As indicated on the path diagram, R/S affiliation is proposed to have a positive
causal relationship with a family choosing to use religion/spirituality as a resource. The
literature differs on which R/S affiliation is most likely to foster the idea that a person’s
faith can act as resource to help one cope. Even though the literature is unclear, R/S
affiliations must be ranked to test the path diagram. Kline (1998) states, “The literature
for relatively new research areas can be very limited, so decisions about what to include
in the model sometimes need to be guided more by the researcher’s experience and
intuition than by published works” (p. 99). Intuitively, the researcher ranked the R/S
affiliations from high to low as follows: Catholic/Islam ranked equally, Protestant,
Jewish, spiritual but no religious affiliation, and no religious/spiritual affiliation.

The final phase of the path diagram indicates that all of the endogenous variables
have a positive (+) causal relationship with the family choosing to use religion/spirituality
as a resource to help cope with the stress of having a child in the hospital. As discussed
earlier in the review of the literature, individuals with R/S backgrounds are more likely to
use religion/spirituality as a means of coping than individuals who have no association

with religion/spirituality (Hathaway and Pargament,1991). In addition, Hathaway and

79

Pargament note that the availability of religion/spirituality is a factor in individuals
choosing to use religion/spirituality as a resource to cope. Therefore, the researcher has
hypothesized that a family’s R/S practices, beliefs, and affiliation and the family’s
interaction with a spiritual caregiver(s) at the hospital is causally related to the family
choosing to use religion/spirituality as a resistant resource to cope with the stress of
having a child in the hospital.

Chapter III will discuss the statistical technique that was used to test the proposed
a priori model. Other methodological procedures used in the research project also will be

discussed.

80

CHAPTER III

METHODOLOGY

The methodology used in this research is described in this chapter. Four main
sections covering research design, data collection, data analysis and research limitations
are included.

Research Design

This research study used a descriptive, cross-sectional design. The aim of this
study was to survey families who have a child on a pediatric unit of a large metropolitan
hospital. The study was conducted under the auspices of the Pastoral Services
Department, the Customer Relations Department, and the Pediatric Unit Nurse Manager.
A pediatric inpatient survey was used as the instrument to study the relationship between
the use of religion/spirituality as a psychosocial resource and the ability of a family to
cope with the stress of having a child in the hospital. The primary use of the research
data was to estimate the causal relationships between exogenous and endogenous
variables that are included in the recursive path model (see Figure 2), and to evaluate the

model’s goodness-of-fit.

81

Research Hypotheses

As discussed in Chapter 1, the research is based on two objectives: 1) to conduct
a survey of families who have a child on the pediatric unit of a major metropolitan
hospital to investigate the use of religion/spirituality as a psychosocial resource to help
cope with the stress of having a child in the hospital, and 2) to construct a recursive path
model to determine if there is a causal relationship between the path diagram’s nine
observable variables and families’ choosing to use religion/spirituality as a psychosocial
resource to help cope with the stress of having a child in the hospital. Based upon these

two objectives, two hypotheses were formed.

Hypothesis One: Using R/S as_a C(mirflesource

 

Hypothesis one refers to the relationship between the family’s perceived ability to
cope with having a child in the hospital (dependent variable), and the family using
religion/spirituality as a coping resource (independent variable).

Hypothesis 1: There is a positive relationship between the use of religion/spirituality as a
resource, and the ability of the family to cope with the stress of having a child in the
hospital.

Hypothesis two expresses that there is a causal relationship between the
variables in the path diagram (see Figure 2).
Hypothesis 2: As depicted in the a priori model, there is a causal relationship between

the predictive variables and the family’s use of religion/spirituality as a resource to help
cope with the stress of having a child in the hospital.

82

Data Collection
The Sample

The sample for the study was drawn from immediate family members who had a
child on the pediatric unit of a major metropolitan hospital. A description of the sample
can be found in Chapter IV. During a six-week period, surveys were distributed each day
to a family member who had a child being discharged from the pediatric unit. Pediatric
unit daytime volunteers distributed the survey to the family member. The subject was
asked to complete the survey, place it in an attached envelope, seal the envelope, affix an
enclosed seal across the flap of the envelope, and return it to the volunteer before he or
she exited the hospital. The volunteers deposited the sealed envelopes in a file box in the
office of the Nurse Manager of the Pediatric Unit. Approximately 225 patients are
discharged per month (Pediatric Nurse Manager, personal communication, September 2,
1999)

The researcher set the minimum sample size of 100 surveys to be collected. There
is no absolute standard set for sample size in the structural equation modeling procedure
of path analysis. However, if the model is not complex, then a medium sample size of
100 to 200 is acceptable (Kline, 1998; Hair, Anderson, Tatham & Black, 1995).

Statistical stability is lost in the procedure if the subject/pathway is less than five to one
(Kline, 1998). The researcher used a total of 16 pathways in developing the path analysis,

which means that at a minimum of 90 completed surveys should be collected.

83

County Demogpaphics (Based on Hospital’s Location)

 

The 929 bed teaching hospital is located in a metropolitan area in southeast
Michigan. The hospital is located in a county that has a Planning and Economic
Development Department. The following demographic information, unless otherwise
specified, was provided by a technical assistant from this department ( Technical
Assistant, personal communication, September 19, 1999). The July 1, 1996 US. Census
population estimates for the county where the hospital is located was 1,162,098. Of this
number, three percent are Hispanics, 86.8 percent White Non-Hispanics, 8.4 percent
African Americans, .003 percent American Indians and .03 percent Asian Pacific
Islanders. The median family income in 1997 was 57,360 dollars and the average
housing cost was 177,997 dollars. The number of females living in the county in the year
2000 is expected to be 593,488 with the median age of 36.4 years. The projected number
of males living in the county in the year 2000 is 625,396 with the median age of 38.4
years. The 1990 educational attainment for persons 18 years and over was as follows:
32.8 percent had less than a high school diploma, 20.5 were high school graduates, 18.7
percent some college, no degree, 5.1 percent an associate degree, 14.2 percent a
bachelor’s degree, and 8.7 percent had a graduate or professional degree [1990 US
Census Data]. According to the 1990 Census there are 369 Protestant churches, 52
Catholic churches, and 32 Jewish synagogues located in the county (County Profile,

1993).

Distributing and Collecting the Surveys

Permanent day volunteers on the pediatric unit, who help to service the family and
patient during the child’s stay in the hospital, distributed and collected the surveys. The
volunteers were chosen for the following reasons. 1) There was an increased likelihood
that surveys would be completed and collected if the parent or guardian is personally
asked to complete it on the day of discharge. 2) The volunteers have the ability to
distribute the survey early enough on discharge day to allow adequate time for the survey
to be completed. 3) The volunteers already are recognized by the patient and families.
Thus it was felt that the survey, which asked questions about the sensitive topic of
religion/spirituality, would be less threatening coming from a recognizied individual. To
ensure a consistent procedure in distributing and collecting the surveys, all volunteers
participated in a training session conducted by the researcher. The training session
included a description of the research, review of the survey, general guidelines and
procedures to be used in distributing and collecting the survey. See Appendix B for the

specification sheet that was used during the training session.

The Instrument
The instrument (see Appendix A) used in the study was a survey developed by the
researcher. Survey development involved a number of steps. First, several meetings
were held with the Director of the Pastoral Services Department and the chaplains. These
meetings involved discussions about the type of interaction chaplains and/or other
spiritual caregivers have with families and patients, and the type of questions needed to

be included in the survey. Next, to gain a better understanding of the type of interaction

85

the chaplains and or visiting spiritual caregivers might have with patients, the researcher
spent a lZ-hour day shadowing six of the chaplains. As reflected in Chapter I], review of
the literature also was an important source in developing questions that would be
appropriate to help measure the multidimensionality of religion/spirituality. The next
step was writing the initial survey and having it reviewed by the Director of the Pastoral
Services Department, the Director of Customer Relations Department, and the Nurse
Manager of the Pediatric Unit.

The Pastoral Services Department, the Customer Relations Department, and the
Nurse Manager of the Pediatric Unit requested that the survey not be more than two pages
in length. On the day of discharge, families are anxious to leave the hospital, and the
hospital staff felt that a family member would be more willing to accurately complete a
short survey. Also, on the same day or immediately after discharge, each family is asked
to fill out an additional one-page pediatric unit survey.

The questions in the survey were used to gather the following information fi'om
the respondent.
o The level of perceived stress the immediate family experienced while having a child in

the hospital.

1. Using a ranking from 0 to 4 (with 0 = no stress and 4 = very high stress) how stressful
was it for your immediate family to have a child in the hospital?

2. What is the medical reason (or diagnosis if you know it) for your child’s hospital
stay?

3. During this specific hospital stay, how many days has your child been in the hospital?

86

How well the family thinks they are coping.

. My immediate family has a difficult time coping with having a child in the hospital.
1) completely disagree 2) somewhat disagree 3) neither agree/nor disagree
4) somewhat disagree 5) completely agree

The importance of religion/spirituality as a resource in helping the immediate family
cope with having a child in the hospital.

. My immediate family’s religious/spiritual beliefs were important in helping to cope
with having a child in the hospital.

1) completely disagree 2) somewhat disagree 3) neither agree/nor disagree
4) somewhat agree 5) completely agree

The immediate family ’s participation in religious/spiritual practices.

. Participation in religious/spiritual activities (e.g. prayer, scripture reading) plays an
important role in my immediate family’s life?

1) completely disagree 2) somewhat disagree 3) neither agree/nor disagree
4) somewhat agree 5) completely agree

. My immediate family seeks out people from our religious/spiritual community, when
we need help or support?
1) completely disagree 2) somewhat disagree 3) neither agree/nor disagree

4) somewhat agree 5) completely agree
. How often does your immediate family attend religious/spiritual services?
times per (weeks ~ months ~ years) —- Please circle the correct time
period

The immediate family ’3 religious/spiritual beliefs.

. My immediate family’s religious/spiritual beliefs gives us a sense of meaning and
purpose in life.

1) completely disagree 2) somewhat disagree 3) neither agree/nor disagree
4) somewhat agree 5) completely agree

. Religious/spiritual beliefs are a source of strength for my immediate family in
everyday living.

1) completely disagree 2) somewhat disagree 3) neither agree/nor disagree
4) somewhat agree 5) completely agree

87

3. My immediate family’s religious/spiritual beliefs give us a sense of hope.
1) completely disagree 2) somewhat disagree 3) neither agree/nor disagree
4) somewhat agree 5) completely agree

0 The types and the importance of the interaction the immediate family had with a
spiritual caregiver(s) while the child was in the hospital?

1. During your child’s stay in the hospital how many times did you interact with a
spiritual caregiver(s)? times during my child’s stay in the hospital

2. During this hospital stay, please identify the spiritual caregiver(s) with whom your
family interacted? (Check as many as applies)
_ hospital chaplain _ imam _ pastor _ parish nurse _ priest
_ rabbi _ other (please specify)

3. In the hospital, what type of interaction did your immediate family have with a
spiritual caregiver? (Check as many as applies)

_ prayer __ explored spiritual/emotional issues
__ other religious/spiritual activities __ general conversation
(please specify)

4. While in the hospital, how did your immediate family’s interaction with a spiritual
caregiver(s) help? (Check as many as applies)
_ provided comfort _ provided hope _ an outlet for expression of feelings
_ was not helpful _ other (please specify)

o The immediate family ’s religious/spiritual afliliation?

1. What is your immediate family’s religious/spiritual affiliation?
_ Catholic _ Islam _ Jewish _ Protestant
_ Spiritual but not religious affiliation _Other (please specify) _ None

0 Additional demographic information about the immediate family (race, annual

income, education level, child ’s age, and respondent ’s age and gender).

Confidentiality

No questions on the pediatric inpatient survey asked for the respondents’ names,

addresses or telephone numbers. The respondent was asked to seal the completed surveys

in an attached envelope and affix a seal across the flap of the envelope so that the
volunteers who collected the surveys did not have access to the answers. Volunteers
deposited the surveys in a file box in the Pediatric Unit Nurse Manager’s office. The
original pediatric inpatient surveys are secured in the researcher’s home with all other
dissertation-related records. In addition, the hospital required the researcher to sign a
policy form stating that all information, other than for the purpose of the research, will be

kept confidential.

Approval for Research

Both the hospital and Michigan State University’s institutional research
committees gave approval for this research. Michigan State’s University Committee on
Research Involving Human Subjects reviewed and approved the research on November
22, 1999 (IRB# 99-690, Category l-C). The hospital’s Human Investigation Committee
approved the research on December 22, 1999. The research was exempt under paragraph

one of the Department of Human Health and Services Federal register [45 CFR, 46.101

0’) (2)]-

Reliabilitv and Validity
To increase the reliability of the study, the researcher wrote questions that were
simple and easy to understand and that were directed at immediate family members who
should have found the questions relevant to their experience of having a child in the
hospital. A five-point Likert scale was used in a number of questions when the

respondents were given categories from which to choose. Research shows that Likert

89

scales of five or more categories are more reliable (SPSS, 1998). There were two other
factors that added to the survey’s reliability. The first is that having a child in the
hospital generally will leave a marked impression on the family. It has been shown that if
an event has had a great influence on an individual, that a person will have a higher recall
of the event (SPSS, 1998). The surveys also were distributed and collected on the day of
the child’s discharge, which provided a greater chance for the family to have accurate
rather than retrospective recall. In addition, three questions were used as indicators for
both religious/spiritual practices and beliefs, and four questions have been identified as
measurements for the construct, interaction with the spiritual caregiver. According to the
SPSS Manual on Survey Writig (1998), when three or more questions are used to
measure a construct, tests can be run to determine the question’s internal consistency
reliability. Hair et al. (1995) denote that as few as two indicators per construct can be
used to measure reliability. Rubin and Babbie (1997) project that in most cases survey
research has strong reliability. The reason for this is that the questions and statements are
exactly the same in each survey completed by the respondents.

Even though Rubin and Babbie (1997) believe that surveys are high on the
reliability scale, they note that they are weak in validity. They posit that weak validity is
due to the artificiality of survey format. Few people would normally answer a question
using the wording that occurs on a Likert scale. Keeping this in mind, Rubin and Babbie
suggest that when assessing the data gathered from a survey, a researcher should regard it
only “as approximate indicators of what we have in mind initially in framing the
questions” (p. 365). Face validity has been used to assess the questions in the survey. As

already indicated, the survey was based on a review of the literature and was assessed by

90

the Pastoral Services Department, the Customer Relations Department, and the Nurse

Manager of the Pediatric Unit.

mm

A pilot test was conducted to investigate the effectiveness of the survey. During a
ten-day period, pediatric unit, day volunteers were asked to distribute and collect the
surveys. Before the distribution, the researcher trained the volunteers on the appropriate
procedures to be used. The pilot test survey also included a cover letter (see Appendix C)
that the volunteers gave to the family member. The letter asked the respondents to
complete the survey and to highlight or circle any unclear terms or phrases. The
respondents also were encouraged to write any comments on the survey or the comment
sheet to identify any problems or concerns. The family members were then instructed to
place the survey in an envelope, seal it, and place a seal across the flap of the envelope.

Fifteen surveys were collected over a ten-day period. Of the 15 surveys collected,
13 were completed. The respondents seemed to be able to fill out the surveys without a
problem, and there were no written comments from the respondents about any problems
they encountered filling out the survey. Based on the completion of the survey, no
changes were made in the wording of the survey questions. However, the researcher
made a few cosmetic changes to the survey so that it would be easier for respondents to
read and complete.

During the pilot test, the pediatric unit, day volunteers who had worked on the
weekends were no longer serving at the hospital. It was determined during the pilot test

that a great number of discharges from the pediatric unit occurred over the weekend.

91

Therefore, many families did not receive the opportunity to fill out a survey, because their
child had been discharged on Saturday or Sunday. The problem was corrected before the
final research phase began. Through the help of the hospital, a pediatric unit volunteer
for the weekend was secured and trained in how to distribute and collect the surveys. It
also should be noted that although physicians discharge patients in the evening hours,
there were no volunteers who worked during the evening. Therefore, collection only took

place during the hours from 9 am. to 4 pm.

Data Analysis

The data analysis incorporated the use of descriptive statistics to summarize the
central tendency and variability of the data. The level of measurement of each question
dictated the format in which the summary of data is presented. Following is a discussion
of how the specific hypotheses were analyzed.

Hypothesis One: There is a positive relationship between the use of
religion/spirituality as a resource, and the ability of the family to cope with the stress of
having a child in the hospital.

A scattergram was used to identify and present a pattern of a possible linear
relationship between the family members’ use of religion/spirituality as a resource, and
their perceived ability to cope with the stress of having a child in the hospital. A
Spearrnan’s rho test was utilized to look at the strength and direction of the relationship
between the ranks of the independent variable and the dependent variable. This

nonparametric statistical test was chosen because of the use of ordinal level variables.

92

Hypothesis Two: As depicted by the a priori model, there is a causal
relationship between the predictive variables, and the family ’s use of religion/spirituality
as a resource to help cope with the stress of having a child in the hospital.

The statistical method used to analyze the data was path analysis, which is a
statistical technique of structural equation modeling. The purpose of path analysis is to
study causal relationships between a set of predictive variables by analyzing the structure
of the data. The process is similar to multiple regression. However, instead of
regressing a dependent variable on one independent variable at a time, the dependent
variable is regressed on every independent variable that is predicted to affect it. The
statistical procedure then weighs the strength and direction of the relationships among the
hypothesized variables (Leong & Austin, 1996).

Hair et al. (1995) outline procedures to be used in this statistical process. The
path diagram, as depicted in the operational map, is translated into structural equations
and then specified in a measurement model. The purpose of the measurement model is to
specify what indicators will be used for each construct and to measure each construct’s
reliability for estimating causal relationships.

The data then are entered into a correlation matrix for estimation, and Pearson
product moment correlation is used to measure the relationship between variables.
Structural equation modeling is a very robust statistical technique that can be used to
measure different levels of data. A structural model is then employed to a) determine if
there is an adequate number of equations used in the model, b) evaluate goodness-of-fit,

c) evaluate any potential problems within the model, and d) make needed model changes.

93

Path analysis is the means for testing a hypothetical a priori model (path
diagram), which has been formulated using theory and review of the literature. Through
the statistical procedures mentioned above, the data are analyzed to see if there is a “cause
and effect” among the variables. If it is determined that the data are consistent with the

model, one can only state that the model is not “disconfirmed” by the path analysis.

Research Limitations

There are a number of limitations that occur when one is using a cross-sectional
study to survey families. Cross-sectional surveys are a snapshot of only one timefi‘arne
and do not show any relationships that might exist over a period of time. This becomes a
problem, because as Albrecht and Cornwall (1989) point out, religion/spirituality is
dynamic in nature. It is not uncommon to see a family’s or individual’s faith pattern ebb
and flow over a lifetime. For instance, a family may go through a period of increased
faith, followed by a period of decreased faith or vice versa. Therefore, the question
becomes, if the subjects had been surveyed at a later point in time, would they have
responded in the same way?

Even though a great deal of effort and research was put into writing the survey,
there are always inherent problems when using such an instrument. Rubin and Babbie
(1997) have determined that surveys, especially those used in cross-sectional studies,
work well for external validity but offer limited internal validity. They write that surveys

. . .represent the least common denominator in assessing people’s
attitudes, orientations, circumstances, and experiences. By designing

questions, that will be at least minimally appropriate to all respondents,
you may miss what is most appropriate to many respondents. In this

94

sense surveys often appear superficial in their coverage of complex
topics (p. 364).

As discussed in the review of literature and assumption four, religion/spirituality
is multidimensional and can be a very complex measure. A more thorough job of
measuring the multidimensional aspect of religion/spirituality could occur if the
researcher had not been limited to a two page survey. This also limits the richness of
data that can be gleaned, because it is not possible to use additional assessments that more
accurately measure the family’s level of stress and the family’s perceived coping skills.

The families that choose to complete the pediatric inpatient surveys may do so
because of selection bias. Therefore, how families truly feel about using
religion/spirituality as a coping resource may be skewed. Another bias that may occur is
the identifiable connection of the pediatric inpatient survey with a spiritual caregiver(s).
The recipient of the survey may give a biased response if he/she equates the spiritual
caregiver(s) as a direct representative of religion/spirituality. The family member’s
response also may be affected by the contact that he or she had with a particular spiritual
caregiver. For example, even though all hospital chaplains have been trained to serve on
the pediatric unit, only one person is assigned as the primary chaplain for this unit
(Department Head of Pastoral Services, personal communication, September 14, 1999).
This can pose a problem if a family has had or perceives a conflict in any interaction they
may have had with this particular chaplain and/or any other visiting spiritual caregiver. In
addition, a family’s opinion may be skewed if the spiritual caregiver with whom they

interact is of a different religious/spiritual (R/S) persuasion than the family.

95

Choosing only one family member to represent the immediate family can skew the
findings, because the family member’s responses may not be representative of the rest of
the family. However, as Copeland and White (1991) point out, questions generally are
asked only of one member of the family. The reason for this is that most statistical
methods require that data come from individuals who are independent from other
individuals in the study. Consequently, it should be remembered when using only one
family member to complete the survey that the data could be given from a perspective
that differs from the rest of the immediate family.

It also is important to understand that the definition for immediate family in this
study may be different from other studies. Therefore, one must be careful in generalizing
findings from this study to other areas of family research, because the conceptual
definitions may be different.

Last, it must be remembered that an important element of most R/S groups is a
higher power, a supernatural being. When measuring the effects of religion/spirituality
on psychological and physical health, a definitive analysis would include a measurement
on the supernatural effects of a higher power. However, as Levin (1994) notes, science is
about measuring the natural, therefore we cannot measure the supernatural because it is
outside of nature. Therefore, researchers do not have the ability to measure or control for

every aspect of religion/spirituality, especially the effects of the supernatural.

96

CHAPTER IV

RESULTS

This chapter presents the results of the data analyses used to describe the sample
and test the two hypotheses posed for this study. First an analysis was conducted to
determine if there was a relationship between families’ ability to cope with the stress of
having a child in the hospital and the use of religion/spirituality as a psychosocial
resource. A path analysis then was implemented to investigate if the data collected were
consistent with the a priori model, which looked at characteristics of families who would
choose to use religion/spirituality as a coping resource. Modifications were made to the
model and multiple regression analysis was conducted to determine the model’s fit.

The results of the data analysis are divided into two sections. The first section
uses descriptive statistics to give an overview of the sample. The second section
addresses hypothesis one and two by presenting the results of the statistical analysis used
to assess each hypothesis.

Surveys were collected from immediate family members who had children on
the pediatric unit of a hospital. On the day of a child’s discharge, pediatric daytime
volunteers passed out and collected the surveys. During the six-week period, 306

children were discharged from the hospital during the day. Thirty-five percent (n = 107)

97

of the immediate families (one member per family) who had children being discharged
completed a survey. Further discussion about the collection procedure and implications
of the finding can be found in Chapter V.

Upon review of the collected surveys, two problems were identified. The first
problem was the lack of interaction between the respondents and spiritual caregivers. Of
the 107 family members surveyed, only 25 indicated that their immediate families had
interacted with a spiritual caregiver. This provided inadequate observations to measure
the effect of this construct in the path analysis. It was therefore decided to modify the
path diagram by removing this construct (see Figure 3). Further discussion about removal
of this construct will be covered in Chapter V.

In addition, there was a large number of surveys that contained missing responses.
One of the debates that is occurring in the use of path analysis relates to the assumption
that numbers of observations among variables in the path diagram need to be equal
(personal communication with statisticians, March, 2000). This is being questioned
because more advanced models deal with less restrictive sets of assumptions. However,
after carefirl consideration of the data, a more conservative approach was used. Surveys
only were included if the questions to be used for measurement in the path analysis were

completed. Sixty-nine out of the 107 surveys met this criterion.

98

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99

Description of the Sample
Demographic information was gathered about the child, the respondent and the
immediate family. The data were summarized using descriptive statistics. Table 4 shows
that the mean age of the children was 5.03 years (sd=5.63), with the mean of 3.30
(sd=1.97) days spent in the hospital. Thirty-nine (56.5%) of the children were male, with
30 (43.5%) female.

Table 4: Descriptive Statistics of Children’s Age, Days Stayed in Hospital, and
Gender

 

Number Mean §l_)_ Range

Minimum Maximum

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age of Child 69 5.03 5.63 .01 22
Days Child in 68* 3.30 1.97 l 13
Hospital

Freguengy Percentage 1“ f i 7 4
Gender of Child Total = 69
Male 39 56.5
Female 30 43.5 A
‘Missing data = l

The respondents also were asked to provide demographic information about
themselves and their immediate families. Table 5 presents the results of the analysis.
The mean age of the respondents was 33.96 years (sd = 7.44). It was decided to collapse
the variable, race, into the categories of white and non-white, because of the lack of racial
diversity in the sample. Fifty-eight (84.1%) of the respondents were white, while 11
(15.9 percent) were non-white. Of the non-white, nine of the respondents were African

American. Of the family members who completed the survey, 54 (78.3%) were

100

Table 5: Respondents’ Mean Age; Frequency of Family Members’ Race, Gender,

to RIS

  

Member’s

Race
White
Non-white
Total
Gender
Male
Female
Total
Family Member’s Relationship
to Child
Mother
Father
Grandmother
Guardian/Other F
Other
Total
RIS Affiliation
Catholic
lslam
Jewish
Protestant
Not
No R/S Beliefs
Total
F Education
Graduate/Professional

2

Some Col No
School

Total

F ’3 Annual Income

75 or More

50 — 74 999

30 - 49 999

29 or Less

Total

‘Missing data = 1

   

Nu

F

101

Mm;

’s Income &

s2

 

Education Level
Range

Militant—Mum
17 51

  

female, with 52 (75.4%) of whom were the child’s mother. The other family members
who completed the survey were as follows: 12 (17.6%) fathers, one grandmother (1.5%),
one (1.5%) guardian/other family member, and two (2.9%) other. As Table 5 indicates, 34
families (49.3%) had a Protestant affiliation. Twenty-one of the respondents (30.4%)
were Catholic, three (4.3%) were Jewish, one (1.4%) was Islamic, five (7.2%) said their
family was spiritual but had no religious affiliation, and five (7.2%) had no R/S
affiliation.

The respondents were asked to specify the highest educational level reached in
their immediate family. It should be noted that this is not necessarily the respondents’
education level. As specified in Table 5, 17 of the subjects (24.6%) marked that the
highest educational level in their family was graduate/professional, 19 (27.5%) a four-
year college degree, 6 (8.7%) a two-year college degree, 17 (24.6%) some college but not
completed, and 10 (14.5%) indicated a high school degree. As presented in Table 5, 31
(44.9%) of the families had an annual income of $75,000 or more, 19 (27.5%) 850-
74,999, nine (13%) $30-49,999, and 10 (14.5%) of the respondents’ families had an
annual income of $29,999 or less.

The respondents were asked to identify their immediate family’s stress level
related to having a child in the hospital, the difficulty in coping with having a child in the
hospital, and if the family’s religious/spiritual (R/S) beliefs helped them to cope. All of
the measurements were based on a five-point Likert scale. The question that asked
respondents to rank the family’s level of stress used a range from 0 for no stress to 4 for
very high stress. The other two questions used a range from 1 for completely disagree to

5 for completely agree. Table 6 summarizes the findings. The mean for the immediate

102

family’s stress level was 2.81 (sd = 1.15), a mean of 3.38 (1.34) for the difficulty of
coping, and a mean of 3.97 (sd = 1.32) for the use of R/S beliefs in helping

the immediate family cope.

Table 6: Descriptive Statistics of Immediate Families’ Stress Level, Difficulty of

Coping, and the Use of R/S Beliefs to Help Cope With Having a Child in the
Hospital

 

 

 

 

 

 

 

 

 

Number Mean S_D Range
Minimum Maximum

Stress Level of 69 2.81 1.15 0 4
Having Child in
Hospital
Difficulty of 69 3.38 1.34 1 5
Coping
R/S Beliefs 69 3.97 1.32 l 5

. Helping to Cope

 

 

 

Description of the Scaled Variables

Descriptive statistics were obtained for the two-scaled variables used in the path
analysis. The scaled constructs included R/S practices (attending R/S services,
participating in R/S activities, seeking out support from MS community), and W8 beliefs
(a source of strength, gives a sense of meaning and purpose, gives a sense of hope). Table
7 lists the scaled constructs and the mean score for each of the construct’s subscales.

Three questions (subscales) were used to measure R/S practices. The subscales,
participating in R/S spiritual activities and seeking out support from the W8 community,
were rated using a 5-point Likert scale ranging from 1 for completely disagree to 5 for
completely agree. The mean score for participating in R/S activities was 3.91 (sd = 1.3),

and for seeking out support from R/S community was 3.64 (sd = 1.27). The third

103

subscale measured the number of times per year the immediate family attended R/S

services with a mean of 44.13 (sd = 54.42).

Table 7: Descriptive Statistics of the Scaled Variables

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number Mean @ Range
Minimum Maximum
R/S Practices
Participation in 69 3.91 1.30 5
W8 Activities
Seeks Support 69 3.64 1.27 5
from R/S
Community
Number of times 69 44.13 54.42 360
per year
R/S Beliefs
Source of 69 4.17 1.15 5
Strength
Sense of Meaning 69 4.13 1.19 5
and Purpose
Gives Hope 69 4.19 1.14 5

 

 

Three subscales measured the construct, R/S beliefs: R/S beliefs as a source of

strength, gives a sense of meaning and purpose, and gives a sense of hope. The three

questions were rated using a 5-point Likert scale ranging from 1 for completely disagree

to 5 for completely agree. As indicated in Table 7, the mean for a source of strength was

4.17 (sd =1.15), the mean for a sense ofmeaning and purpose was 4.13 (sd =1.19), and

the mean for gives hope was 4.19 (sd = 1.14).

104

 

Test of Hypotheses
Two hypotheses were proposed for this study. Each of these hypotheses was
evaluated by using inferential statistical analyses with an alpha level of .05 as the decision

criterion for determining the statistical significance of the findings.

Hypothesis One

Hypothesis one looked at the relationship between the families’ perceived ability
to cope with the stress of having a child in the hospital, and the families choosing to use
religion/spirituality as a coping resource. Using a five-point Likert scale, the subjects
were asked to respond to a question about their family’s stress level, and a second
question about how difficult it was for their family to cope with having a child in the
hospital. The second question was built into the survey to be used as a reliability check to
see if the family member gave similar responses to the two questions. This was based on
the premise that if individuals perceive a situation to be very stressful, they also will
indicate that it is more difficult to cope. Pearson product moment correlation was used,
and there was a significant relationship (r = .588; P < .00) between the two constructs.

To assess the degree of relationship between the families’ use of
religion/spirituality as a resource and the ability of the families to cope with the stress, the
Pearson product moment correlation was used instead of Spearman rho as indicated in the
methodology section. This decision was made because of the robustness of the Pearson
product moment correlation to analyze data measured by a five-point Likert scale (SPSS,
1998). To assess this hypothesis, the researcher correlated both the perceived stress level

of the families and the families’ difficulty of coping with the use of religion/spirituality as

105

a coping resource. The results indicated that while the families’ child was in the hospital,
neither the farnilies’ stress level (r = .035; p > .05) nor the family’s difficulty in coping
(r = .065; p>.05) were decreased by the use of religion/spirituality as a coping resource.

Hypothesis one was rejected.

Hypothesis Two

It was stated in hypothesis two that the data would be consistent with the a priori
model. As indicated earlier, the construct, interaction with spiritual caregiver, was
removed from the original path diagram (a priori model) due to inadequate number of
observations (see Figure 3). Path analysis, a form of structural equation modeling, was
used to analyze the hypothesis. Path analysis is based on the theoretical framework and
review of the literature, and its purpose is to show the causal relationship between
variables. This type of statistical procedure assumes that “strong theoretical support can
make estimation of causation possible” (Hair, et al., 1995, p. 618). In the model, some
questions were scaled to build the constructs, R/S practices and R/S beliefs. Table 8
contains a list of variables and specifies how they were used in the path diagram. The
statistical program that was used to assess the path diagram analyzed the contribution of
each scale item and also measured and corrected the scales for reliability.

Path analysis requires an estimation of the proposed model, which is

accomplished through the use of bivariate correlations. All of the variables to be used in

106

Table 8: Variables and Their Measures for Path Analysis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variable Type Measurement
Name

Survey Questions

Race Categorical What is your immediate family’s race?

Education Categorical What is the highest educational level reached in your
immediate family?

Income Categorical What is the approximate annual income of your combined
immediate family?

Age Actual What is your birth date?

Number

Gender Categorical What is your gender?

R/S Scale 1. How often does your immediate family attend

Practices religious/spiritual services?
2. Participation in religious/spiritual activities (e.g. prayer,
scripture reading) plays an important role in my immediate
family’s life.
3. My immediate family seeks out people from our
religious/spiritual commqu when we need help or support.

R/S Beliefs Scale 1. Religious/spiritual beliefs are a source of strength for my
immediate family in everyday living.
2. My immediate family’s religious/spiritual beliefs give us a
sense of meaning and purpose in life.
3. My immediate family religious/spiritual beliefs give us a
sense of hope.

Affiliation Scale What is your immediate family’s religious/spiritual
affiliation?

R/S Single Item My immediate family’s religious/spiritual beliefs were

Support important in helping to cope with having a child in the

to Com hosLital.

 

the path analysis were reviewed, and if necessary were recoded for use in the statistical

package. Correlations among the variables age, gender, income, education, race, R/S

practices, beliefs, affiliation, and support were computed. The correlation matrix in Table

9 was then used as the input data for the path analysis.

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PACKAGE was the statistical program used to conduct the path analysis. The
program employs three criteria to assess the fit of the model (path diagram). First, path
coefficients are assessed to examine the relationships among the variables and the
consistency with the theoretical rationales. Second, the residual matrices are examined
for statistically significant deviations, and confidence intervals are drawn around the
obtained correlations to examine whether the predicted correlations fall within their
range. Last, a global test of the overall fit of the model was conducted using a Chi square
test.

Figure 4 shows the path coefficients calculated for the model. The path
coefficients in relation to age and R/S practices and beliefs were 0.04 and 0.02,
respectively. The paths between gender and R/S practices and beliefs were 0.08 and 0.14,
respectively. The path coefficients for income and R/S practices were 0.10, and 0.02 for
income and R/S beliefs. The paths between race and R/S practices and beliefs were 0.17
and 0.27, respectively. All of these paths move in a positive direction, though some of
the paths showed a negligible relationship. Two of the endogenous variables presented a
negative relationship. As predicted, education had a negative relationship with R/S
practices and beliefs, -0. 14 and —0.15, respectively. In addition, race showed a negative
relationship with R/S affiliation (-0.04).

The path coefficients indicated that there was a positive path between R/S
practices and the family choosing to use religion/spirituality as a coping resource (0.34).
A positive path also occurred between R/S beliefs and religion/spirituality as a coping
resource (0.50). The construct, R/S affiliation, had a negligible path relation with

religion/spirituality as a coping resource (0.05). The residual matrix in Table 10

109

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shows that several of the residuals were 0.20 or higher, indicating that the model was
problematic because of the large degree of unidentified relationships.

The measurements of higher income and education level were positively
skewed, however, the PACKAGE program used ordinary least squares, which has the_
capability of adjusting for violations of nonnormal data (Hair, et al., 1995). The global
Chi square (Chi-square = 35.18; df = 12; p<.000) indicated that the observed data and the
expected (model) observations were significantly different. Thus, the data were not
consistent with the model.

Further analysis of the residuals and the path coefficients indicated that none of
the exogenous variables had significant path coefficients and did not contribute to the
model’s overall strength, while two of the endogenous variables had stronger path
coefficients. Due to these factors and the homogeneity of the exogenous variables, the
decision was made to drop the exogenous variables from the predictive model and look
only at the contributions of the endogenous variables.

Multiple regression was used to analyze the modified model. To assess the
explanatory power of the predictive variables (R/S practice, belief and affiliation), the
variables were simultaneously regressed with the dependent variable, the families’ use of
religion/spirituality as a coping resource. This approach was chosen because it was
consistent with simultaneous regression in path analysis.

As depicted in Table 11, the measurements of the variables were standardized so
that they could be compared. Following is the formula for the standardized model.

Y = .342 (R/S practice) + .502 (R/S beliefs) + .044 (RIS affiliation) + e

112

The standardized estimate for the model showed that a one standard deviation change in
the construct, R/S practices, on an average is associated with a .342 standard deviation
change in the use of religion/spirituality as a psychosocial resource when all other
independent variables are being held constant. The construct, R/S beliefs, had a .502
standard deviation change and R/S affiliation had a .044. Focusing on the standardized
estimations, R/S beliefs had the largest positive relationship with the families’ use of
religion/spirituality as a psychosocial resource to help cope with the stress of having a
child in the hospital. R/S practice had a moderate positive relationship, and R/S
affiliation had a negligible relationship.

Table 11: The Beta Coefficients of the Predictive Variables Used in the Multiple
Regression Model

 

 

 

 

Beta Coefficients Significance
R/S Practices .342 .006
R/S Beliefs .502 .000
R18 Affiliation .044 .583

 

 

 

 

 

The model demonstrates a high level of explanatory power with an R2 of 81.80
percent and an adjusted R2 of 65.3 percent. The ratio of explained to unexplained
variance is statistically significant at .000, with at F value of 43.742. The magnitude of
the R2 as well as the adjusted R2 indicate a good fit with the modified model.

In summary, hypothesis one was rejected. The data did not indicate that there was
a positive relationship between the use of religion/spirituality as a resource and the ability
of the family to cope with the stress of having a child in the hospital. As a result of the

modification of the predictive model, hypothesis two was partially supported. The data

113

did show that a majority of families (50.7 % completely agreed, 18.8% somewhat agreed)
believed that religion/spirituality was important in helping them to cope with the stress of
having a hospitalized child, and that the families’ R/S practices and beliefs had a
significant influence on the family choosing to use religion/spirituality as a psychosocial

resource.

114

CHAPTER V

DISCUSSION

The results of the research are discussed in the first section of this chapter,
including a brief summary of the respondent’s comments about what good spiritual
caregiving includes. Even though this question was not a measure of either hypothesis,
the information is included in the chapter because of the richness of the data. The
generalizability of the findings is then reviewed, followed by a discussion of the findings.
Implications for health care and family science professionals are covered in the third
section, with the final portion of the chapter providing recommendations for future
research.

The purpose of the study was to ascertain if there was an association between the
use of religion/spirituality as a resource, and the ability of families to cope with the stress
of having a child in the hospital. Analyses also were used to investigate the
characteristics of families who used religion/spirituality as a resource.

Data were collected for a six-week period, covering mid-January through the
third week of February. The surveys were collected during this time frame to avoid

encountering any major religious holidays that might have influenced a family member’s

115

response. As discussed in Chapter IV, only 69 out of the 107 surveys were used,
because a large number of surveys contained missing responses.

Pearson product moment correlation was used to assess the association between
religion/spirituality and the family’s ability to cope with the stress of having a child in the
hospital. The a priori model, upon which hypothesis two was based (see Figure 4), was
first tested by using path analysis. The statistical program used to conduct the path
analysis was PACKAGE. The program employed three criteria to assess the fit of the
path diagram. First path coefficients were assessed to examine the relationships among
the variables and to see if they were consistent with the theoretical rationales. Second,
the residual matrices were examined for statistically significant deviations, and
confidence intervals were drawn around the obtained correlations to examine whether the
predicted correlations fall within their range. Last, a global test of the overall fit of the
model was conducted using a Chi square test.

Subsequently, the a priori model was modified and multiple regression was used
as the mode of analysis. Multiple regression can be use to build a predictive model by
analyzing the relationship between a dependent variable and two or more predictor
variables (Hair, et al., 1995). Each predictor variable is weighted to determine how much
it helps to explain the dependent variable. From the results of an analysis, predictor

variables can be combined to form a model that best predicts the dependent variable.

Findings
As discussed in Chapter IV, hypothesis one was rejected, and based on the

modifications of the a priori model, hypothesis two was partially supported. The results

116

showed that families’ religious/spiritual (R/S) practices and beliefs had a significant
influence on whether they chose to use religion/spirituality as a coping resource. There
were contradictory findings regarding the families’ use of religion/spirituality as a

psychosocial resource to help them cope.

Hypothesis One

Hypothesis one was rejected because there was no positive correlation between
the use of religion/spirituality as a resource, and the ability of the family to cope with the
stress of having a child in the hospital. Four questions were initially used as subscales to
measure families’ ability to cope with the stress of a hospitalized child. Respondents
were asked to: a) identify their stress levels on a zero (no stress) to four (very high stress)
scale, b) list their child’s medical diagnosis, c) indicate the number of days the child was
in the hospital, and d) identify if their family had a difficult time coping with having a
child in the hospital (on a 5-pt. Likert scale from completely disagree to completely
agree).

The respondents were asked to identify the medical reason for their child’s
hospitalization. Of the 69 surveys collected, forty-four different medical diagnoses were
identified. To use this question in the statistical analysis, each medical diagnoses needed
to be ranked according to the potential level of stress it might generate within a family.
The pediatric unit nurse manager indicated that it was impossible to rank the diagnoses,
because of uncontrolled factors, no two families would react the same way to a medical
diagnosis (Pediatric Unit Nurse Manager, personal communication, January, 2000). It

became clear that it was impractical to use a medical diagnosis in helping to determine

117

families’ stress levels. For example, the level of stress of the family does not necessarily
depend on the seriousness of the illness, but how many times the child has been admitted
to the hospital and how familiar the family members are with the procedure. One father,
whose son had cancer, wrote “These answers may not be relevant, as we have been in
treatment [with our son] for 3 V2 years — with monthly overnight stays — as a result we are
very familiar with the hospital. On previous visits, at higher stressed times, [my] answers
may have been different.” It was decided that this question was an invalid measurement,
and it was eliminated from the analysis.

Neither was the number of days a child was in the hospital a good indicator of a
family’s stress level. For instance, a child who had surgery for a broken arm may have
been in the hospital longer than a child with a life threatening illness. Further, when a
child is hospitalized for several days, it may become easier for the family to cope as they
learn the hospital routine and make adjustments at home. Therefore, the time a child
spent in the hospital was not an accurate measurement of the family’s stress level.

To examine this assumption, the Pearson moment product correlation was used to
assess the relationship between the number of days the child spent in the hospital and the
family’s stress level (r = .233, p>.05). The number of days the child spent in the hospital
also was correlated with the family’s ability to cope (r = .133; p>.05, respectively).
Neither of the findings was significant. It was decided to use this measurement only as a
descriptive statistic.

The questions regarding the families’ stress level and how difficult it was to cope

also were correlated to determine if there was a relationship between the two

118

measurements. Pearson product moment correlation was used, and there was a
significant relationship (r = .588; P < .00) between the two constructs.

Consequently, only two measurements, the family’s stress level and the difficulty
in coping, were used to determine if there was a positive relationship between the
families’ use of religion/spirituality as a resource, and the ability of the family to cope
with the stress of having a hospitalized child. The results indicated that while the child
was in the hospital, neither the families’ stress level (r = .035; p > .05) nor the families’
difficulty in coping (r = .065; p>. 05) were decreased by the use of religion/spirituality as
a coping resource. Hypothesis one was rejected.

Even though hypothesis one was rejected, the families did indicate that they used
religion/spirituality to help them cope. Of the respondents, 50.7 percent “completely
agreed” that their families’ religious/spiritual (R/S) beliefs were important in helping to
cope with the stress of having a hospitalized child, and 18.8 percent “somewhat agreed.”
This raises the question of why the findings were inconsistent. One of the reasons may
have been the brevity of the survey (additional discussion will occur later in the chapter).

The hospital personnel had requested that the survey be two-pages in length. They
felt that at discharge, a family member would more likely complete a short survey.
However, a longer survey with each construct measured with several questions would
have been preferable. It also would have been beneficial to use separate instruments,
which had been tested for reliability and validity, to independently measure the
respondents’ stress level, coping ability, and stage of coping. The survey contained only
one question each about the families’ level of stress and the difficult time the family had

coping with a child in the hospital. Using a standardized instrument to more accurately

119

measure the families’ stress level and another to measure the families’ ability to cope and

the stage of coping would have enhanced the study.

Hymthesis Two

The a priori model as depicted in Figure 3 was rejected, because the fit of the path
model was not consistent with the data. However, the path coefficients of the a priori
model indicated that there was a positive relationship between the family’s R/S practices
(0.34) and beliefs (0.50) and the family choosing to use religion/spirituality as a
psychosocial resource to cope. Based upon these finding and the homogeneity of the
exogenous variables, it was decided to modify the model and include only the three
endogenous variables (R/S practices, beliefs & affiliation). Multiple regression analysis
was used to look at the explanatory power of the modified model. The next section will

discuss the findings as related to the path analysis and the exogenous variables found in

the path model.

Exogenous Variables

The exogenous variable, age, had little effect on R/S practices and beliefs (see
Figure 4). Age was coded for the path analysis to indicate that as individuals age, the
more likely (positive) they are to participate in their faith. The mean age of the
respondents was 33.96 years (sd = 7.44), with the respondents’ age ranging from 17 to 51
years. Of the respondents completing the survey, 94.1 percent indicated that they were

the child’s parents. Albrecht and Cornwall (1989) posit that adults ofien begin to view

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religion/spirituality as an important part of their life as they begin to have children. In
addition, Benson (1996) has found in his research and medical practice that it is not
unusual for hospitalized patients and/or their families to turn to “the faith factor” as a
means of coping and healing. Therefore, being a parent with a child in the hospital may
override any effect that age would have on participation in R/S beliefs and practices.

As specified in the path diagram in Figure 4, gender had a very small effect on
R/S practices (.08) and a somewhat larger effect (.14) on R/S beliefs. The exogenous
variable, gender, was coded to show a more positive relationship between females and
R/S practices and beliefs as compared to males. Though the path coefficients were small,
the findings are consistent with current research that shows that females, as opposed to
males, tend to be more actively involved in religion/spirituality and are more likely to use
it as a coping resource (Levin, Chatters, & Taylor, 1995; Jenkin & Pargament, 1995).
When interpreting this data, it should be remembered that 78.3 percent of the respondents
were female. The results may have been different if there had been a greater number of
males participating in the study.

It was designated in the path diagram that families with higher income levels
would have a negative association with R/S practices and beliefs as compared to their
counterparts with lower income levels. However, as illustrated in Figure 4, the path
analysis generated a positive path between income and R/S practices (.10) and income
and R/S beliefs (0.2). Even though these are very small path coefficients, they do indicate
a change in direction from that specified.

The average income level of this sample was positively skewed as compared to

the county where the hospital was located and in the entire United States. Of the 69

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respondents, 44.9 percent indicated an annual family income of 75,000 dollars or more,
and 27.5 percent had an annual family income of 50,000 to 74,999 dollars (see Table 5).
In 1997, the median income for families in the county was 57,360 dollars (County Profile,
1993). In addition, the 1997 annual median income for the United States was 37,005
dollars (US Census Bureau, 1999), which is significantly lower than the sample for this
particular research. Therefore, one cannot generalize these findings to other populations.
It was specified in the path diagram (Figure 4) that there was a negative

relationship between education and R/S practices and beliefs. The statistical analysis did
indicate a negative path (-.14) between education and R/S practices and R/S beliefs
(-.15). These findings were consistent with the review of the literature.

The final exogenous variable, race (minority status would have a more positive
effect), did have a mediating effect on R/S practices (.17) and R/S beliefs (.27).
However, race showed a very small but negative effect (-.04) on R/S affiliation, which
was inconsistent with the model. Eighty-four percent of the respondents were white and
16 percent were non-white. Due to this lack of diversity among the respondents, the
variable, race, was collapsed into the two categories of white and non-white. The small
number of non-white respondents (n = 9 out of 11 in the non-white category were African
Americans), skewed the data, because there was not enough variation to accurately assess
this path.

The homogeneity of the exogenous variables and the lack of significant path
coefficients indicated that these variables did not contribute to the a priori model. As

discussed earlier, the model was changed to include only three predictive variables, with

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multiple regression being used to explore the power of the modified model. The next

section will discuss the findings of this analysis.

Predictive Variables in the Modified Model

The predictive variables in the modified model were R/S practices, beliefs and
affiliation. The magnitude of the R2 (.818) and the adjusted R2 (.653) indicated a good fit
with the modified model.

A small beta coefficient (.044) was found between R/S affiliation and the family
choosing to use religion/spirituality as a psychosocial resource. In this sample, there
seemed to be little relationship between a particular R/S affiliation and a family choosing
to use religion/spirituality as a coping mechanism. Again, these findings may be due to
the lack of diversity within the sample. As Table 5 presents, 49.3 percent of the families
were Protestant and 30.4 percent were Catholic, with only a small percentage of the
sample representing the other five categories. A larger number of respondents may have
garnered a more diverse sample, which in turn may have generated different findings.

The most positive effects that occurred in the modified model were between R/S
practices and beliefs and the dependent variable, families choosing to use
religion/spirituality as a psychosocial resource to cope with the stress of having a child in
the hospital. A moderate effect was found between R/S practices (.342) and the
dependent variable, and an even stronger relationship was expressed between R/S beliefs
and the families’ use of religion/spirituality as a resource to cope with stress (.502).

These findings are consistent with other research.

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Hathaway and Pargament (1991) proposed that it is unlikely that individuals with
little or no R/S background would use religion/spirituality as a resource. Conversely, if
individuals have a greater involvement in religion/spirituality, there is an increased
probability that they will perceive it as an important means of coping. It also is more
likely that families who have stronger R/S beliefs will have stronger R/S practices (Levin,
1994), and in turn will be more inclined to choose religion/spirituality as a resource for
coping.

As compared to R/8 beliefs, R/S practices had a smaller mediating effect on
families choosing to use religion/spirituality as a coping mechanism. The difference in
the two constructs may be due to the type of effect the construct has upon a family. Many
researchers use Gordon Allport’s concept that individuals will have either an intrinsic
religious orientation or an extrinsic religious orientation (Pargament et al., 1990; Larson
& Larson, 1994). Individuals with an intrinsic religious orientation tend to live their R/S
beliefs day by day and are more likely to use their R/S beliefs to cope (Larson & Larson,
1994). Individuals with extrinsic religiosity may be actively involved in R/S practices,
but may not have internalized or live out the beliefs that are a part of their particular R/S
affiliation. Instead, they use religion/spirituality as a means of status or obtaining
security. People with either orientation will usually call upon their religion/spirituality
during a stressful event (Larson & Larson, 1994). Of the two religious orientations,
researchers have found that people who internalize R/S beliefs tend to be more active and
successful in using religion/spirituality as a coping mechanism, (Pargament, Ensing, et a1,
1990). The findings in this study are consistent with Allport’s theory. RIS beliefs, which

is intrinsically oriented, had a stronger mediating effect on the family choosing to use

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religion/spirituality as a coping resource as compared to the extrinsic orientation of NS
practices.

The data showed that a majority of family members viewed religion/spirituality as
an important psychosocial resource to cope with the stress of having a child in the
hospital. However, it must be remembered that this is inconsistent with the findings of
hypothesis one. Further consideration of these contradictory findings will be covered in
the discussion section. It also was concluded that prior R/S beliefs and practices

influenced the families’ use of religion/spirituality as a resource.

Additional Analysis: Responses to the Question about Good Spiritual Care

Of the 69 surveys used in the research, 26 of the respondents (3 8%) replied to the
question, “In your opinion, what kind of things would good spiritual care include when a
patient is in the hospital?” The responses were varied and included such items as the
importance of the spiritual caregiver offering hope and comfort, consoling and listening
to the family, and being friendly and respectful to family members. However, the two
most common comments about good spiritual care were related to visitation and prayer.
Thirty-eight percent of the respondents who answered the question cited that visiting the
family in the hospital at least once was an important aspect of spiritual caregiving. In
addition, 42 percent wrote that prayer with the family was very important. One of the
subjects stated, “. . .to have a spiritual caregiver see the family and child and pray
together. It is a comforting thought for parents to know that someone else cares and is

praying and thinking of your child.” Another subject reflected, “[I would like]. . .for each

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spiritual caregiver to be in contact with each patient whether very ill, or just a cold. I find

it really helps when a prayer is said.”

Generalizabilitv of the Findilgs

Rubin and Babbie (1997) point out that collection of data, even though carefully
planned, may generate issues that affect the generalizability of the research. This section
will discuss aspects of data collection that may have limited the findings. Though the
sample size was within the guidelines for path analysis, a larger sample may have offered
a greater diversity of race, income, education, R/S affiliations and a higher number of
male subjects. As discussed earlier, the sample size was diminished because of
incomplete surveys. This may have been due to the layout or wording of the survey,
and/or the personal nature of the questions. In addition, only 35 percent of the families
who had children in the hospital during the six-week research period consented to filling
out the survey. According to Rubin and Babbie (1997), a response rate of 50 percent or
higher is important, because it decreases the chance of obtaining data that is biased. One
of the factors that contributed to the low response rate was the number of surveys
collected during the weekdays. Based on weekly averages, a total of 30 children were
discharged during the week, but only four to five surveys were collected. An average of
19 children was discharged each weekend, with an average of 13 surveys collected. This
inconsistency in the survey collection may have been due to the hesitation of the weekday
volunteers to participate in the study. It should be noted that the volunteers were given
training, and no objections to collecting the surveys were voiced. The pediatric unit nurse

manager did remind the weekday volunteers about the importance of collecting the data.

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An exit interview of the pediatric volunteers also was helpful in identifying two
other problems. Though the volunteers did not keep a specific count, they indicated that
some of the family members declined to fill out the surveys because of language barriers,
and the family member did not want to use an interpreter. The surveys also were given
out on the day of the child’s discharge, and many of the family members did not want to
take the time to complete the survey.

Self-selection bias also may have determined if an individual was willing to
complete a survey. For instance, if family members had little interest in
religion/spirituality, they may have declined to complete the survey, while other family
members who were actively involved in religion/spirituality may have been more inclined
to do so. Also when filling out a survey, a respondent, because of his or her RIS
background, may have felt obligated to answer questions about religion/spirituality in a

positive manner.

Discussion of Findings
As discussed in Chapter 1, identifying and using psychosocial resources to cope

is important in helping family members deal with the stress of having a child in the
hospital. Bood (1996) states that family members are critical in every aspect of a child’s
hospital stay and return to health. Therefore, family members need to use available
resources to sustain their own emotional and physical health so they are better able to
help their child.

Bubolz and Whiren (1984) propose that higher levels of energy are essential for a

family to adapt to stressors in their lntemal and external environments. The more

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resources the family has available to help them cope, the more likely the family is to
sustain the energy level that is needed to deal with all of the consequences of having a
hospitalized child. Bubolz and Whiren refer to the lack of energy to deal with stressors as
an “energy sink,” where the family is so drained that they can no longer successfully deal
with their problems. Antonovsky (1985) would propose that this “energy sink” has a
negative effect on family members, and has the potential to move them toward the dis-
ease end of the health continuum. This negative transition may not only affect family
members’ health, but also has the potential to negatively affect the hospitalized child.
One way for families to help prevent an energy sink is to recognize and use generalized
resistant resources (GRRs) to cope with their stressors.

As depicted by the conceptual model (see Figure 1), families need to be aware of
and encouraged to use available GRRs to help them cope with a stressful event. This
research proposed that religion/spirituality can act as a system to provide GRRs and help
families cope with stressors. When family members were questioned about whether their
immediate family’s R/S beliefs were important in helping them to cope with having a
child in the hospital, 50.7 percent completely agreed, while 18.8 percent somewhat
agreed. This response appeared to contradict the findings of hypothesis one that indicated
that the use of religion/spirituality as a psychosocial resource neither decreased the
families’ stress level or the difficulty in coping with the stress of having a child in the
hospital. The inconsistencies of these findings may be due to the coping stage in which
families found themselves when the family members filled out the survey. McCubbin
and Patterson (1983) point out that a major family crisis is not usually instantaneously

resolved, but evolves and resolves itself over a period of time. They suggest that a family

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dealing with a major stressor goes through a process of coping, which includes
recognizing the stressor, identifying resources the family needs to adapt, assigning a
definition and meaning to the situation, and adapting to the situation. This process may
take a circuitous route, with the resolution of the stressor, if resolution occurs at all,
taking a period of time.

Hathaway and Pargament (1991) also agree that there are several elements that
are a part of the coping process. Like McCubbin and Patterson (1983), they posit that
after the recognition of the stressor, the next elements (phases) of coping include an
appraisal of the situation to see if there are adequate coping resources to deal with the
crisis and an attachment of meaning to the situation.

Hathaway’s and Pargament’s (1991) research on the religious dimensions of
coping found that religion/spirituality could positively contribute to the initial phases of
the coping process, because it offered a way to appraise and give meaning to a crisis.
The family members’ responses in this research were consistent with Hathaway’s and
Pargament’s findings. Of the respondents, 53.6 percent completely agreed that
religion/spirituality provided meaning and purpose, and 23.2 percent somewhat agreed. A
majority of the respondents (56.5 percent) completely agreed that religion/spirituality
gave their family hope, while 20.3 percent somewhat agreed. The observations were
similar when the respondents were asked if religion/spirituality was a source of strength
for their family (53.6% and 26.1%, respectively). McCubbin and Patterson (1983) point
out that families often use religion/spirituality to redefine a situation and give it meaning.

They believe the process of attaching meaning to a situation is a critical part of the coping

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process. In this research, it appeared that families used religion/spirituality to help them
appraise and give meaning to the stress of having a hospitalized child.

Hathaway and Pargament (1991) also suggest that religion/spirituality can be an
important part of the adjustment and adaptation phase where individuals begin to sense a
decrease in their stress level, and an increase in their ability to cope with and successfully
meet the demands brought about by the stressor. However, this research found that the
use of religion/spirituality as a coping resource did not decrease families’ stress level or
difficulty in coping. The incongruent findings within this study may be due to the coping
stage that families were at when respondents completed the survey. For example, the
families may have used their R/S beliefs as a resource to appraise and attach meaning to
the situation, but had not moved to the next stage in adjustment and adaptation. It also is
possible that religion/spirituality was used to appraise and attach meaning to the situation,
but was not influential in the rest of the coping process.

McCubbin, McCubbin and Thompson (1993) posit that an essential component of
a family’s appraisal process is the family schema. The family schema can be defined as a
composite of shared values, goals, beliefs, priorities and expectations that the family uses
to center and anchor them during a crisis. It is used in the appraisal of a stressful situation
and helps determine what resources the family will use to deal with a stressor. The
researchers suggest that a family’s R/S beliefs, or the lack thereof, are a component of the
family schema and therefore, can play a role in how a family chooses to deal with a
stressor. As found in this study, families’ R/S beliefs had a significant influence on

whether families chose to use religion/spirituality as a psychosocial resource.

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Dein and Stygnell (1997) highlight the importance of health care professionals
talking to patients and families and identifying if R/S beliefs are a part of the family
schema. They write that asking patients and families about R/S beliefs, “. . . may make
them feel that members of the treatment team are interested in him or her [sic] as a whole
person” (p. 295). Dein and Stygnell also posit that this type of interaction may not only
offer hope and support to the patient and family, but also may help to increase the
patient’s and family’s cognitive coping function. They suggest that the pastoral care staff
should be viewed as an important part of the hospital’s treatment team and when
appropriate, the pastoral care staff should be collaborating with the treatment team in
helping to provide resources and care.

Dein’s and Stygnell’s (1997) suggestion to use pastoral care staff as part of the
treatment team would mean that many medical care centers would need to reassess the
amount of resources they are allocating to their pastoral care services. In this particular
study, only 25 families had the opportunity to see a spiritual caregiver in the hospital. One
of the reasons for this minimal amount of interaction was the lack of finding for a full
time chaplain to work on the pediatric unit (Department Chair of Pastoral Care, personal
communication, March 2000).

As discussed earlier in the chapter, 26 of the 69 subjects responded to the
question about what should be included in good spiritual care. The two items most
consistently mentioned were prayer and a visit by a spiritual caregiver. Thirty-eight
percent of the 26 respondents said that visitation by a spiritual caregiver was important.
One family member commented that each patient should receive a visit from a spiritual

caregiver, whether the patient is very ill or just has a cold. Forty-two percent of the 26

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respondents wrote that prayer was a very important part of spiritual caregiving. One
respondent suggested that parents be asked if they would like a spiritual caregiver to pray
for their child as soon as the child is admitted. Another stated that she was flattered to
think that someone else was praying for her child to recover.

Previous research supports both prayer and visitation by a spiritual caregiver as
beneficial. In a hospital setting, spiritual caregivers often have a “right to access” that
other professionals are denied, because families are seeking out individuals they can trust
and with whom they can be open (Hathaway & Pargament, 1991; Wilson, 1989).
Research also has shown that families want to be given information about hospital
chaplains and their services (Lynn-McHale & Smith, 1991). Patients and families often
view spiritual caregivers as a conduit of hope, helping the family deal with the crisis of
having a loved one in the hospital (Widerquist & Davidhizar, 1994; Maton, 1989)

Research has established that prayer is beneficial to both patients and families
during a family member’s illness. Benson (1996) has found that when he teaches his
patients techniques to elicit relaxation, 80 percent of them choose prayer. Upon further
investigation, he discovered that prayer lowers anxiety and fear and increases the will to
live. Poloma (1993) reports that prayer contributes to an individual’s sense of well-being.
Prayer also was beneficial for individuals who were getting ready to undergo cardiac
surgery. The day before the surgery, the patients were asked if prayer was helpful
(Saudia, Kinney, Brown, &Ward, 1991). Ninety-six of the 100 patients indicated that
they used prayer as a coping mechanism, with 70 designating that it was very helpful.

Saudia and colleagues also cited that family caregivers used prayer to manage stress.

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Implications for Health Care Professionals

Despite the rejection of hypothesis one and only partial support of the modified a
priori model, other findings in the study corroborate that health care professionals should
consider religion/spirituality as a psychosocial resource. In this sample of family
members, religion/spirituality appeared to be an important part of the family schema. A
majority of the families indicated that their R/S beliefs were a source of strength, which
gave them a sense of meaning, purpose and hope in life. The families also actively
practiced their faith and on average attended R/S services 44.13 times per year.

As discussed earlier, the family schema is used in the initial appraisal of a
stressfill situation to deal with a stressor (McCubbin, McCubbin and Thompson, 1993).
It acts as an anchor to help center the family during a crisis. Based on this study, the
families’ R/S beliefs were an important part of their family schema. Taking this into
consideration, health care professionals need to become sensitive to families’ R/S needs.
This can be accomplished in a number of ways. For example, the health care professional
should ask a family if their R/S beliefs are important. If a family acknowledges the
importance of religion/spirituality in their lives, then they should be encouraged to use it
as a psychosocial resource. As Dein and Stygnell (1997) point out, just asking a patient
and family about their R/S beliefs, gives them a sense that the health care professional
cares about them as whole individuals. In addition, many health care sites, such as
hospitals, have a pastoral care staff that works with the medical personnel to meet the
patients’ and families’ R/S needs. The medical staff may find it beneficial to work more
closely with the pastoral care team and direct them toward families and patients who

would benefit from a spiritual caregiver.

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Managers of health care facilities also need to consider if they are giving adequate
consideration to the use of religion/spirituality as a resource. They need to determine if
sufficient funding is being given to the pastoral care department and if the facility makes
it easy for community-based spiritual caregivers to interact with patients and their
families. In this particular study, only 25 families had the opportunity to see a spiritual
caregiver in the hospital, but at the same time a majority of the respondents indicated that
religion/spirituality was an important resource.

The topic of religion/spirituality can be a very sensitive subject. Nonetheless, as
indicated in this study, it is often an important part of a family’s schema. Therefore,
health care personnel need to be trained regarding the implications of religion/spirituality

and health and ways to address the subject with patients and their families.

Implications for Family Science Professionals

A common theme in family science and related fields is helping families to adapt
and adjust to change (Olson, 1993). An important stage of the adjustment and adaptation
process is identifying the stressor(s) and determining available coping resources (Fischer
& Sollie, 1993). Families generally will appraise a situation and identify needed
resources based on their family schema (McCubbin, McCubbin & Thompson, 1993). As
previously cited, religion/spirituality is ofien an important component of the family
schema. As research continues to verify that religion/spirituality can contribute to
physical and mental health (Benson, 1996; Larson & Larson, 1994; Larson, Sherrill, et
al., 1992; Levin & Vanderpool, 1991) family science professionals need to consider if

they are addressing the use of this resource.

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In the past, family scholars have basically ignored the importance of
religion/spirituality in the family (Doherty, Boss, LaRossa, Schumm & Steinmetz, 1993).
Doherty and colleagues suggest that this is an oversight, because the family is “one of the
main agents for the transmission of ethics, values, and religious traditions...” (p. 17).
They believe that the issues concerning ethics, values and religion need to become an
important topic of study in family theory and research.

There are a number of questions about religion/spirituality and the family that
can act as a catalyst for family science research and practice. One question that arises
from this study - does religion/spirituality contribute to all stages of the adjustment and
adaptation process? The findings in this research demonstrated that families used
religion/spirituality in the initial phases of coping by offering a way to appraise and give
meaning to the crisis. A majority of the families indicated that their R/S beliefs were a
source of strength, which gave them a sense of meaning, purpose and hope in life.
However, the use of religion/spirituality did not decrease families’ stress level or
difficulty in coping with the crisis. It would be beneficial to determine if
religion/spirituality has an influence on different stages of coping.

It also is important to determine if the use of religion/spirituality as a resource
varies according to age, race and socio-economics. Even though this question was
addressed in the study, the small sample size and the lack of diversity within the sample
did not allow accurate measurement.

Family educators have the important role of helping to strengthen and enrich
families’ lives. This is done in a number of venues from parenting classes to classes on

aging. These programs are based on the premise that families have the strength and

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resources to grow and develop (Hermon & Arcus, 1993). One of the challenges of the

family educator is to recognize and encourage the use of a variety of resources, one of

which is religion/spirituality. As found in this study, many families viewed
religion/spirituality as a resource that provided meaning and purpose to life and was a /
source of strength and hope. Family educators need to become familiar with the current
research on the benefits of religion/spirituality as a resource and share it with their clients.
When discussing this topic, an approach can be used that recognizes the sensitivity of the

subject and the diversity of R/S beliefs within a community.

Recommendations for Future Research
As in the case of most research, the results of this study raised further questions.

While some of the findings of the study were consistent with past research, others had

mixed results. For example, more research needs to be conducted to determine the

influence of age, education, income, gender, and race on the use of religion/spirituality as

a psychosocial resource. Based on this study the following is recommended:

0 If a similar study was conducted, it needs to take place in a more diverse hospital
setting or at several diverse hospitals concurrently (e. g. rural, suburban, and urban
hospitals). This would offer a broader range when investigating race, R/S affiliations,
income, and education levels. In addition, most of the relatives who completed the
surveys were mothers. There might be greater variance in this finding when looking
at a more diverse population. A study also could be conducted that used only mothers

as the unit of analysis and controlled for the diversity within the sample.

136

In addition, a similar study should investigate the distinction between the families’
use of religion/spirituality to deal with stress and the use of religion/spirituality to
help cope. The use of standardized instruments to measure stress and coping would
provide a more reliable investigation of the relationship between religion/spirituality
and the two constructs.

As stated earlier, religion/spirituality is dynamic in nature. A longitudinal study could
investigate the families of chronically ill children to determine if the families use
religion/spirituality as a resource over time.

Research needs to take place on different types of hospital units. This would help
give a broader perspective to see if families in similar but yet different circumstances,
use religion/spirituality as an important coping resource. The study could be
conducted to examine the families’ use of religion/spirituality while controlling for
the effects of the family members’ medical diagnoses.

Additional research, with a larger sample, needs to study the effects of interaction
with a spiritual caregiver on the emotional and/or physical well-being of patients and
families.

In many studies, including this one, the Protestant faith is recognized as one group.
However, there is a great deal of diversity within this category. In future studies, it
would be interesting to investigate how different Protestant faiths view and use
religion/spirituality as a psychosocial resource.

It is recommended that researchers study community-based spiritual caregivers to

determine how actively involved they are in hospital visitation, the importance they

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place on hospital visitation, and if they feel their presence is beneficial to the
hospitalized patient or family.

It also is suggested that a qualitative approach be used to observe families, their stress
levels, and the use of religion/spirituality to cope with the stress of having a child or
other family member in the hospital. This approach would offer a richness of data
and could possibly open up new avenues for research. A qualitative study also might
offer more tangible results that hospitals and spiritual caregivers could immediately
implement.

The question still remains, can a model be built that will predict the characteristics of
immediate families who choose to use religion/spirituality as a psychosocial resource
to cope with the stress of having a child in the hospital? Therefore, a logical
extension of this research is to continue to explore variables that could be included in
such a model.

It would be interesting to investigate family scholars’ and family educators’ attitude
about incorporating religion/spirituality into family research and theory. Conducting
a meta-analysis of the literature would give an overview of past use of
religion/spirituality in family theory and methods.

Another interesting study would be to look at the fluctuation of the use of

religion/spirituality as a coping mechanism throughout the family life cycle.

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APPENDIX A

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Survey Cover Letter

Date xxxxxxx

Dear Family Member,

You are invited to participate in a study. Vicki Kloosterhouse, a Ph.D. candidate at
Michigan State University, in conjunction with XXXX hospital, is conducting research to
see if families use religion/spirituality to cope with the stress of having a child in the
hospital.

We would appreciate if you would take a few minutes to honestly respond to this
short two-page survey. All responses are confidential. You are under no obligation to
participate. There are no known risks, beyond those of everyday life, involved in
participating in this study. Your privacy will be protected to the maximum extent
allowable by law.

We appreciate your consent and willingness to help us by filling out this survey.
After you have completed the survey please place it in the attached envelope, seal the
envelope, and place the enclosed “thank you” seal across the flap. Please return it to the
pediatric unit volunteer before your child is discharged from the hospital.

Thank you for filling out this survey, your input is invaluable. The ultimate goal of
this research is to build a more effective program to service XXXX’s pediatric patients
and families. If you have any questions please contact Vicki Kloosterhouse at (248) 360-
3018. In addition, you can contact Dr. David Wright, the Chair of Michigan State
University Committee on Research Involving Human Subjects, at (517) 355-2180.

Thank You,

Vicki Kloosterhouse, PhD. Candidate
Department of Family and Child Ecology
Michigan State University

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Pediatric Unit Survey

Thank you for taking time out of your busy schedule to answer these questions.
When you have completed the survey, please place it in the attached envelope, seal
the envelope and place the seal across the closed flap. This will ensure your
confidentiality. Return the envelope to the pediatric unit volunteer.

Answer the questions in the survey according to your immediate family’s viewpoint.
Immediate family is defined as individuals who are related to the hospitalized child
biologically, by adoption or guardianship and live in the same household. Please circle
your responses or fill in the blank.

1.

6.

Using a ranking from 0 to 4 (with 0 = no stress and 4 = very high stress) how stressful
was it for your immediate family to have a child in the hospital?
0 1 2 3 4

What is the medical reason (or diagnosis if you know it) for your child’s hospital
stay?

 

. During this specific hospital stay, how many days has your child been in the hospital?

 

What is the age of your hospitalized child? If you know the exact birth date
please write here

 

. What is the gender of your child? Male Female

During you child’s stay in the hospital how many times did you interact with a
spiritual caregiver? times during my child’s stay in the hospital
If you answered “0” skip to question 10

During this hospital stay, please identify the spiritual caregiver with whom your
family interacted. (Check as many as applies)

_ Hospital Chaplain _ Imam _ Pastor _ Parish Nurse _ Nun
_ Priest _ Rabbi _ Other (please specify)

 

In the hospital, what type of interaction did your immediate family have with the
spiritual caregiver? (Check as many as applies)

_ prayer _ explored spiritual/emotional issues __ general conversation
_ other religious/spiritual activities (e.g. communion, scripture reading) — please
specify)

 

141

9. While in the hospital, how did your immediate family’s interaction with a spiritual
caregiver(s) help? (Check as many as applies)
_ provided comfort __ provided hope _an outlet for expression of feelings
_ was not helpful _ other (please specify)

 

The next section is important, because it will give us a better understanding and
sensitivity to patients’ and families’ needs. Please circle, check or fill in the most
appropriate answer.

10. How often does you immediate family attend religious/spiritual services?
times per week (week ~ month ~ year)— Please circle the correct time period

11. What is your immediate family’s religious/spiritual affiliation?
Catholic Islam Spiritual but no religious affiliation _ None
Jewish Protestant Other (please specify)

12. Beside each statement please check whether you completely disagree (CD), somewhat
disagree (SD), neither agree/nor disagree (N), somewhat agree (SA), or completely
agree (CA).

CD SD N SA CA

 

a. Interaction with a spiritual caregiver(s) was
beneficial in helping my immediate family
cope with the stress of having a child in the
hospital.

 

b. My immediate family has a difficult time coping
with having a child in the hospital.

 

c. My immediate family’s religious/spiritual beliefs
were important in helping to cope with having
a child in the hospital.

 

d. Religious/spiritual beliefs are a source of strength
for my immediate familyin everyday livijng.

 

e. My immediate family’s religious/spiritual beliefs
give us a sense of meaning and purpose in life.

 

f. My immediate family’s religious/spiritual beliefs
give us a sense of hope.

 

g. Participation in religious/spiritual activities (e.g.
prayer, scripture reading) plays an important role in
my immediate family’s life.

 

 

h. My immediate family seeks out people from our
religious/spiritual community when we need help
or support.

 

 

 

 

 

 

13. What is your immediate family’s race?
African American Hispanic White/Caucasian
Asian Middle Eastern Other (pleas specify)

142

 

14. What is your relationship to the child who was the patient?

 

Mother Father Guardian/Other Family Member
Grandmother Grandfather Other (please specify)
15. What is your gender? Male Female
16. What is your birth date? (month/day/year)
17. What is the highest educational level reached in your immediate family?
_Did Not _High _Some College _2-year _4-year _Graduate/
Complete School But Not College College Professional
High School Completed (e.g. MD, JD)

18. (Optional) What is approximate annual income of your combined immediate family?
_ $29,999 or less _ $30 — 49,999 $50-74,999 _ $75,000 or more

19. In your opinion, what kind of things would good spiritual care include when a patient
is in the hospital? For this question, please write any thoughts or ideas that you may
have. If you need more room for your comments, please write them on the back of
the survey.

143

APPENDIX B

144

Pediatric Unit Volunteer’s Specification Sheet

Thank you for your willingness to help with this research project. One of the

characteristics of a successful research study is that consistent procedures are used

throughout each phase of the study. Since you have the important task of distributing and
collecting the surveys, it is critical that each volunteer consistently follows the same
procedures. Listed below are guidelines to help you successfully accomplish this task.

0 On the day of a child’s discharge please distribute the survey and the attached
envelope to an immediate family member of the child. An immediate family member
is defined as an individual who is related to the hospitalized child biologically, by
adoption, or guardianship and lives in the same household.

0 When distributing or collecting the surveys you need to have a neutral demeanor
about the contents of the survey. This means that you should not express or engage in
a conversation about how you personally feel about religion/spirituality, or its
influence on helping a family to cope with a stressful event. If you are asked your
opinion, you can make a noncommittal statement such as, “It will be interesting to see
the results of the study.”

0 When you distribute the survey please do the following:

1. Hand the survey to an immediate family member of the child. Explain to the
individual that the hospital is conducting research in conjunction with the
pediatric unit.

2. Inform the family member that the survey should only take 10 to 15 minutes to

complete and that you will be back later to pick up the completed survey.

145

3.

If the family member cannot speak or cannot read English, please inform the
nurse’s station. The family will be connected to an interpreter via a telephone

line.

0 When you collect the survey please do the following:

4.

Make sure that the family member has placed the survey in the envelope,
sealed it and affixed a seal across the flap of the envelope. For the sake of
confidentiality, it is important that you do not see the respondent’s answers.
If the respondent chose not to fill-out the survey, please assure the family
member that it is all right. Ask the individual if he or she would be willing to
write on the survey why they chose not complete it. Tell the family member
that it is important for the researcher to know why someone may not want to
fill out the survey (e.g. the respondent felt the topic of religion/spirituality was
too personal). Please assure the person that his or her response will be
confidential. If the family member chooses not to respond all he or she needs
to do is to write the reason for not completing the survey at the bottom or the
side of the survey, place the survey in the envelope, seal it, affix the seal
across the flap of the envelope and give it to the volunteer.
After collecting the surveys please return them to the file drop box at the
nurse manager’s office.

Thank you for your help!

Vicki Kloosterhouse

146

APPENDIX C

147

Pilot Cover Letter

November, 1999
Dear Family Member,

XXXXX Pastoral Services Department, Customer Relations, the Pediatric Unit, and
Vicki Kloosterhouse, a Ph.D. candidate at Michigan State University are preparing to
conduct research to study how spiritual caregivers (e. g. chaplains and visiting clergy) can
more effectively serve pediatric patients and their families. An important part of the
research is a survey that we will be asking immediate family members of the children on
the pediatric unit to fill-out

Before we begin the study we need to conduct a pilot program to see if immediate
family members are able to fill out the survey without any problems or concerns.
Therefore, we are asking if you would be willing to consent to being a part of this pilot by
filling out the pediatric inpatient survey. All of your responses will be confidential and
none of your responses will be used in the actual study. However, comments or
suggestions that you make on the survey will be very beneficial in helping us to improve
the survey before the research actually begins. There are no known risks, beyond those of
everyday life, involved in participation in this study.

To participate in the pilot please do the following:

1. Read and fill out the enclosed pediatric inpatient survey.

2. Highlight or circle any unclear terms or phrases that are hard to understand.

3. Write any comments that you feel will help improve the survey directly on the survey
or on the attached comment sheet. You may wish to comment on such items as terms
being used and/or the length and space of the survey.

4. Once you have completed the survey please place it in the attached envelope, seal the
envelope, and return it to the pediatric unit volunteer.

Thank you for your help. The comments and notations you make will be helpful in
generating any needed changes. The ultimate goal of this research is to build more
effective programs to service XXXX Hospital’s pediatric patients and families. If you
have any questions please feel free to contact Vicki Kloosterhouse at (248) 360-3018.

Sincerely,

Vicki Kloosterhouse, PhD. Candidate
Department of Family and Child Ecology
Michigan State University

148

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