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9 Articles in Volume 17, Issue #9
Can Physiological Profiles Affect Pain Treatment?
Editorial: Moving Forward from Trump's Opioid Declaration
How Might Pain Practitioners Best Offer Patients Relief Without Pharmacology?
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients
Lumbar Lordosis and Back Pain
Oxytocin, an Opioid Alternative, Ready for Regular Clinical Use to Manage Chronic Pain
Pain, Sleep & Suicide: The Core Role of Interventional Care
Spiritual Factors Impacting a Patient’s Ability to Cope with Uncertainty (Part 3)
The Inter-Connection between Smoking and Opioid Misuse

Spiritual Factors Impacting a Patient’s Ability to Cope with Uncertainty (Part 3)

A pilot study examines the impact of religion and social support on patients and caregivers facing death and dying.

To address how patients and caregivers manage uncertainty when facing death and dying, the authors examined the role of spirituality through a series of research papers. Part 1 focused on clear practitioner-patient communication as a means of offering patients who are dying the best chance of achieving a “good death.”1 Part 2 discussed coping efficacy and its relation to the Theory of Motivated Information Management (TMIM).2 In this third and final paper, the authors share the results of a pilot study seeking to identify correlations between religiosity/spirituality, social support, coping efficacy, and information-seeking among patients facing the end of life and the impact on their family caregivers.

As presented in Part 2, information stimulates an individual’s environment in order to add to his/her knowledge base.2-4 Information-seeking is a strategy used to evaluate the outcome and efficacy of a certain situation.3 Obtaining information that increases or decreases uncertainty, for example, may offer hope.3-5 In times of uncertainty, such as when facing dying or death, a person may choose to seek information after positively assessing the outcome of receiving information and after believing he/she can effectively attain the information actively, passively, or interpersonally.3

Active information-seeking is defined as researching or manipulating the environment to obtain a target response.3 Interpersonal information-seeking is the most effective of the three types and involves communicating directly with the target.3 This type can be especially useful when the patient is able to ask specific questions of a doctor or family member. This study examined active and interpersonal direct information-seeking.  

Following TMIM’s framework, the more a patient or caregiver thinks he/she can cope with talking about death, the more willing the patient or caregiver may be to seek information about death and dying, which can decrease uncertainty discrepancy and any associated emotion.6 Uncertainty discrepancy is the difference between the actual amount of uncertainty that surrounds a topic and the desired amount of uncertainty. A large discrepancy can lead to feelings of anxiety, fear, or even relief.

Discussing difficult topics with one another and with a pain practitioner, in the context of religion, may also decrease distress levels by creating stronger relationships.7 For example, a Swedish research group asked nursing students about their perceptions and feelings of death. Some used religion to view death as a natural part of life and to help them talk about death and their feelings about an afterlife, which made them feel more comfortable with the idea of dying.8 According to TMIM, if coping efficacy is high, a person is more likely to seek out information (eg, communicate with others).3,9

The authors sought to prove multiple hypotheses:

  • Hypothesis 1 predicted that religion/spirituality and coping efficacy would be positively correlated for both patients and informal caregivers.
  • Hypothesis 2 declared that the same relationship would exist between social support and coping efficacy for both patients and informal caregivers.
  • Hypothesis 3 asserted that a higher coping efficacy for dying patients would be positively related to information-seeking behaviors around death and dying, and, in turn, that the higher the coping efficacy, the more an informal family caregiver would be able to discuss the topics of death and dying with the patient.

Study Methods

Patients and caregivers of Stage III or IV cancer were initially enrolled in the study. However, due to difficulty in accessing this target population, the study was expanded to include those who had or cared for those with any stage of cancer, including those in remission. Patients and caregivers included in the study were over age 18. Caregivers were family members with no formal caregiving training. There was no request for verification of the patient’s cancer diagnosis; instead, patients were given a survey to list their diagnosis as well as to assess their religiosity, spirituality, social support, coping efficacy, and information-seeking behaviors. (See Appendices A-D.)

Participants were recruited by the authors via social media and email. In the first round of data collection, the survey link and standardized script were posted on social media sites (eg, Facebook, Instagram, and LinkedIn), encouraging readers to pass the survey along to others. In the second phase, student investigators called and emailed leaders of cancer and caregiver support groups in the Orange County, California area. Those who thought the research was appropriate for their group sent the survey to their respective groups via email.

In total, 75 subjects took the survey. However, because of missing answers or ineligibility, 34 surveys were inapplicable, resulting in 41 valid participants. About 87.8% of participants identified as female (9.8% male) and reported an age range of 18 to 79 years old, with the mean ranging from 30-39 years old. The largest ethnicity reported was Caucasian/White (68.3%). Asian/Pacific Islander made up 17.1% and approximately 9.8% of participants identified as Latino/Hispanic. One person reported as Native American.

There was a range of reported religion/spirituality beliefs. A majority identified with a Christian denomination (65.9%), including 22% percent identifying as Roman Catholic. Also, 7.3% of the participants identified as Jewish; 4.9% as Buddhist; 2.4% as atheist; and 12.2% as being spiritual but not religious. Another 4.9% stated they were neither spiritual nor religious.



To determine the relationship between religion/spirituality and TMIM’s coping efficacy, a cancer patient’s or informal caregiver’s level of religiosity/spirituality was measured. This was achieved by asking participants to complete an online survey, which included 31 items from the reliable (Cronbach’s alpha = 0.943) and valid Brief Multidimensional Measure of Religiousness and Spirituality (BMMRS).10,11

On the BMMRS scale, the word, “God” was replaced with “higher power” to represent multiple religions.12 Sample items from BMMRS included: “I feel a higher power’s presence,” and “In general, how close do you feel to a higher power’s presence?”12 Other items measured daily spiritual exercises, forgiveness, cultural practices, congregational support, and spiritual experience (see Appendix A).12 Responses were measured on a 5-point Likert-type scale (eg, 1=strongly disagree to 5=strongly agree). Some items were measured with the following categories: not at all/never, rarely, sometimes, very often and always, when applicable. A higher score indicated that the participant was more religious.

Social Support

The second survey measure used the valid and reliable (Cronbach’s alpha = .904) Multi-dimensional Scale of Perceived Social Support (MSPSS).13,14 In MSPSS, social support was originally measured as support a person receives from three sources: family, friends, and a significant other. Since this study focused on family caregivers, the survey only included family and the significant other dimensions. Participants were permitted to choose among five items for a maximum score of 40.

The higher the score, the more perceived social support the participant had. Sample questions were: “Can you talk about your problems with your family?” and “Is there a special person in your life who cares about your feelings?” (see Appendix B). 13 Likert-type options ranged from 1=strongly disagree to 5=strongly agree.

Coping Efficacy

The third measure was quantitative and addressed how well a participant believed he/she could handle particular information or a situation. To measure coping efficacy, the authors used the three-item coping efficacy scale (Cronbach’s alpha = 0.931) trialed by other researchers with regard to organ donation.15 The scale was modified to pertain to death and dying and made sensitive to the scope of cancer patients and their informal caregivers. For caregivers, the scale measured how able the caregiver felt in coping with the patient’s death and dying, but the word “patient” was replaced with “family member,” for instance. A sample question for a cancer patient was: “I am certain that I could handle whatever my thoughts are about death and dying, whether it be positive or negative” (see Appendix C).15 These survey questions used a Likert-type scale ranging from 1=strongly disagree to 5=strongly agree.

Seeking Information

Information-seeking was the final quantitative measure in the survey, which sought levels of information-seeking behavior about death and dying. A study crafted by researchers on organ donation was adapted.16 The terms on this three-item scale (Cronbach’s alpha = .641) were modified to pertain to death and dying

Sample items were: “I probed for more insight into my attitudes regarding my own death and dying” and “I was very direct in asking my patient about death and dying” (see Appendix D). Points ranged from 1=not at all to 5=all the time. It was deemed that, the higher the score, the more effort the participant put into seeking information on death and dying.

Data Analysis

Pilot data was run through MSPSS Next, a t-test, which assessed whether two groups are statistically different from each other, was conducted for each measure to compare differences between patient religiosity/spirituality and caregiver religiosity/spirituality, as well as between patient social support and caregiver social support. The next test looked at internal reliabilities by calculating the Cronbach’s alphas for each measure. Alpha values over 0.7 were considered reliable. Finally, the authors performed a correlation analysis. Correlations ranging from 0-0.3 were interpreted as weak. Scales with correlations from 0.3-0.5 were considered to be moderately correlated to each other, and those between 0.5-0.7 were considered strong. Correlations above 0.7 indicated that the two scales were isomorphic (ie, the two scales measured the same variable).

To address Hypothesis 1, religion/spirituality scores from the BMMRS and coping efficacy scores were correlated. A positive correlation would support the hypothesis, which predicted religion/spirituality and coping efficacy to be positively correlated. The same relationship was predicted to exist between social support and coping efficacy in Hypothesis 2. For Hypotheses 3, coping efficacy scores were correlated to information-seeking behavior scores. A positive correlation would support the hypothesis.


Surveys showed that religiosity and spirituality levels, as predicted in Hypothesis 1, were significantly correlated with coping efficacy for caregivers (r (27) = 0.506, p < 0.001). The mean religiosity/spirituality score was 104.28 (maximum = 155, minimum = 31), with a standard deviation of 24.34. For coping efficacy, out of a maximum score of 15, the mean was 9.98 with a standard deviation of 3.31. On the other hand, a significant correlation was not found in the patient group (r (10) = -0.224, p > 0.10).

Social support and coping efficacy (Hypothesis 2) were not shown to be correlated for either group (r (14) = -0.055, p > 0.10, r (27) = 0.125, p > 0.10). However, patient coping efficacy did have a significant positive correlation to information-seeking behaviors (Hypothesis 3) (r (14) = 0.641, v < 0.05).For caregivers, no significant correlation was found (r (27) = -0.011, p > 0.10). Table 1 shows these correlations and others.

The t-test revealed that patients and caregivers were similar in religiosity/spirituality, social support, coping efficacy, and information-seeking behaviors. There were no significant differences found (p = 0.286, 0.219, 0.059, 0.938, respectively). Therefore, in another round of data analysis, the two samples were combined (see Table 2).

Discussion and Study Limitations

The purpose of this study was to determine whether religion/spirituality could be applied to TMIM and whether TMIM applied to the death and dying context in cancer patients. The results suggested that religiosity/spirituality were positively correlated to coping efficacy in informal caregivers when dealing with the idea of a loved one dying. However, the same did not apply to patients. This result is most likely due to the small sample size (n = 41) and recruitment method, which is further explained below. Hypotheses 2 and 3 were not supported. While Hypothesis 3 showed some significant results for the patient, overall sample size was too small to make any concrete conclusions.

Moreover, although coping efficacy and information-seeking behaviors were strongly correlated in patients, the same relationship may not have existed in caregivers due to the complexity surrounding the topic of death. One study correlated distance to death with emotional complexity, suggesting that individuals closer to death experienced less emotional complexity.17 Applying this finding to caregivers in the cancer context, they may experience more emotional complexity.

Measuring only coping efficacy may not be sufficient when looking at information-seeking behaviors for caregivers. While coping efficacy had the strongest influence in a separate study, this correlation may not be relevant in the death and dying context.15 Other factors, such as outcome assessment, communication efficacy, and target efficacy, would be useful to measure in future research.

The t-test revealed that patients and caregivers did not differ significantly in religiosity/spirituality scores, social support scores, coping efficacy scores, or information-seeking scores. Results were anticipated considering patients and their informal caregivers (ie, family) care for one another and share the same religion. The context created by death and dying may have created emotional distance between patients and informal caregivers.

However, non-significant t-test results suggested that religion played a role in information-seeking behaviors and social support, a concept further supported by the literature. Results also suggested that the two groups had similar coping efficacy and information-seeking behaviors, which could lead to a negative coping environment if both groups avoided the topic. Similarities demonstrated in social support were not surprising, as the caregiver is often a core source of social support for the patient.

Future Research

Due to sample size, the authors were unable to make any solid conclusions. As a result, the trial was deemed a pilot study with plans to pursue additional research more representative of the population’s race, gender, religion, and stage of cancer. A more personal platform, beyond posting the survey on social media, was also recommended to expand the study group size and to reach a population that may not use social media or are skeptical of surveys from social media sites.

The authors found that the information-seeking scale used (Cronbach’s alpha = 0.641) did not have a strong reliability in comparison to other scales. The null hypothesis may have resulted from the unreliability of the scale. When performing correlation tests between the three items on the scale, data suggested the first item in the information-seeking scale was not correlated to the second or third items. Further consideration of dropping or modifying the first item would be advised. In addition, measures should be broadened to review all aspects of TMIM beyond spirituality and dying.

Applied Research: A Strategic Intervention Proposal

Because of the non-significant data, a concrete intervention could not be proposed. However, the long-term goal of this study was to create a health campaign to help physicians facilitate discussion between patients and caregivers about the uncomfortable topic of dying. Preparing for “a good death” may be presented as an important way to promote coping with death, as well as to reduce patient suffering and anxiety at the end of life.18,19 According to Minke Goldsteen, MD, et al, “a good death” is one in which the patient is aware and accepts the impending death, has open communication, lives life until the end, takes care of final responsibilities, and adequately deals with emotions.18

The authors propose enhanced curriculum development for medical students that could allow for this type of conversation facilitation. Physicians and nurses are involved in the decision-making process for patients and caregivers in terms of treatment plans. However, for some healthcare providers, the idea of letting someone die may be interpreted as “giving up.” As a result, ending treatment may not be an option that is considered, even when it may be the preferred option. An updated curriculum could help medical students become more comfortable with the idea of death and communication surrounding dying.

When speaking to a patient or family caregiver, for instance, medical students who were trained to incorporate social support and religion as coping mechanisms would be better able to assist patients at the end of life. Assuming TMIM’s applicability to the death and dying context, this action may increase a patient’s willingness to speak about dying and thereby open an opportunity for awareness (ie, information-seeking) and acceptance. Incorporating religion into social support messages, whether emotional or instrumental, could be an easy and effective way of achieving this goal.20

Looking ahead, it would be beneficial to carry out this pilot study on a larger scale to potentially impact the patient population being treated at the end of life. Healthcare decisions and attitudes about death and dying, as noted in the literature, may also be enhanced.21-23


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Last updated on: November 14, 2017
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The Effects of Religion and Spirituality on Coping Efficacy for Death and Dying
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