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The Relationship of Spirituality and Self-Health Assessment in Predicting Postoperative Pain and Analgesic Use

Material Information

Title:
The Relationship of Spirituality and Self-Health Assessment in Predicting Postoperative Pain and Analgesic Use
Creator:
MCNALLY, PATRICIA A.
Copyright Date:
2008

Subjects

Subjects / Keywords:
Analgesics ( jstor )
Arthroplasty ( jstor )
Chronic pain ( jstor )
Medications ( jstor )
Older adults ( jstor )
Osteoarthritis ( jstor )
Pain ( jstor )
Questionnaires ( jstor )
Spiritual belief systems ( jstor )
Surgical specialties ( jstor )
City of Indian Rocks Beach ( local )

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Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
Copyright Patricia A. Mcnally. Permission granted to University of Florida to digitize and display this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Embargo Date:
12/18/2004
Resource Identifier:
71667283 ( OCLC )

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Full Text












THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESSMENT IN
PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE















By

PATRICIA A. MCNALLY


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2004

































Copyright 2004

by

Patricia A. McNally

































To my family.















ACKNOWLEDGMENTS

There is no adequate way to thank my children, Jimmy, Meghan and Kerry. for all

of their support and love during my doctoral studies. I could not have completed this

work without their belief in me, the frequent phone calls, visits, and words of

encouragement. Lastly, I hope my grandchildren may you love and appreciate the

educational process with the wonder that I have experienced throughout my lifetime.

I would also like to thank my supervisory committee for their knowledge, guidance

and encouragement in supporting me. Especially, I would like to thank Sharleen

Simpson, my chair. Her constant patience and guidance and belief that "you can do this"

gave me such support throughout this doctoral process. Additionally, thanks go to

Hossein Yarandi for his valuable assistance in analyzing data, and to Dr. Donald Caton, a

teacher and friend, who has been a leader in relieving pain. Through his example, he

brings out the best in all of us. Finally, thanks go to Dr. Monika Ardelt who has pursued

research that includes the study of spirituality and geriatrics. I will always be indebted to

all of them for their direction.

I am grateful to Dr. Peter Gearen, Chairman, Orthopaedic Department, and Dr. Nik

Gravenstein, Chairman, Anesthesia Department, for their support in designing and

implementing this research. Additionally, I want to thank the Pre-Surgical Center

administration for supporting the importance of this research and providing access to

patients.
















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ................................................................................................. iv

L IST O F TA B LE S ........ .................... ...... .................... ........ .............. viii

ABSTRACT .............. .......................................... ix

CHAPTER

1 IN TR OD U CTION ............................................... .. ......................... ..

Background and Significance ......................................................... .............. 3
Chronic Pain in the Older Adult ................................ ....... ...............3
Osteoarthritis and Chronic Joint Pain in the Older Adult...................................4
Total Joint A rthroplasty in the Older A dult ........................................ ...............5
Spirituality in Older A dults ............................................................................5
Sum m ary ...................................... ................................... .................... 7
Specific A im s........................................................ 7
T erm inology ................................................................. 8

2 REV IEW OF TH E LITERA TU RE ...........................................................................10

Presence of Musculoskeletal Chronic Pain and Arthritis Among Older Adults ........10
The Relationship of Background Contextual Stimuli and Pain...............................11
A ge, Pain, and O steoarthritis..................................... ................... ...... ......... .. 11
Gender, Pain and Osteoarthritis..................... ..... ........................... 12
Age, Gender, and O steoarthritis ...................................................................... 12
R ace, Pain and O steoarthritis ........................................ ......................... 13
Total Joint A rthroplasty ......................................................................... .. 14
P re v a le n c e .................................................................................. 14
Gender and Arthroplasty .................................. .....................................15
R ace an d A rthroplasty ........................................... ........................................ 16
S p iritu al C o p in g ............ ....... ........................................................ .. .... .. .. .. .. 16
Spiritual C oping and H health ........................................................... .................. 18
Relationships between Spiritual Beliefs, Gender and Race .............................21
Roy Adaptation Model-Based Research .................................. ...............22
Roy Adaptation Model Gerontologic Research ...............................................23
S u m m a ry ......................................................................................................2 4



v









3 M E T H O D S ....................................................... 25

R e se arch D e sig n ................................................................................................... 2 5
Controls ................................ ..... ................25
Pow er Analysis and Sam ple Size ............................................. ............... 26
Procedures ............................ ................ 26
Protection of Human Subjects .......................... .................. ........ 27
Method .......................... ..............................27
Measures .......... ... ..... ......... .. ...............28
Preoperative Questionnaire M measures ...................................... ............... 28
Indicator of spirituality .......................................... .............................. ... 28
Indicator of self-health assessm ent ................................... ............... ..28
Indicator of ethnicity .............................................. ........ .......... .. ..29
Postoperative Data Collection Procedures .................................. ............... 29
D ata A n aly sis ............................................................. ..................... .. 1
S u m m a ry ................................ ....................................................3 2

4 R E S U L T S .............................................................................3 3

Sam ple Characteristics ........................................ ............................... 33
R regional A nesthesia ................... .............. ............ .. ...... ... ........ .... 34
Anesthesia Technique During Surgery ............. .................... .................34
Analysis of Data in Relation to the Hypotheses............................. ..............35
H y p oth esis 1 ........................................................................3 5
H hypothesis 2 .......................................................................35
H hypothesis 3 .......................................................................36
A additional Findings .......................................... ... .... ........ ......... 36
The Short Form -36 H health Survey ........................................ ......... ............... 37

5 D ISCU SSIO N ............. ........... .... ......... .. ........... ............ ... 45

R research F in ding s........... .................................................................... ........ .. ...... .. 4 5
Sample Characteristics ................................ ........ .. ...................45
Impact of Health Assessment and Spirituality on Pain Reports and Analgesic
M education U se ...................................... ........................... .... ........ ......48
C onclu sion s .................................................... ........................ 4 8
Strengths and Limitations....................................... ................... 49
Implications for Nursing Practice and Future Study .......................................50

APPENDIX

A LETTER OF AGREEMENT................................................ ............... 53

B INFORMED CONSENT 08-19-03 TO 07-15-04 ................................................55

C INFORMED CONSENT 01-29-04 TO 07-15-04 ............................................... 63









D INFORMED CONSENT 07-16-04 TO 07-15-05 ............... ................... ............71

E THE SHORT FORM-36 HEALTH SURVEY-SPIRITUAL INVOLVEMENT
A N D B E L IE F S SC A L E ..................................................................... ..................78

LIST OF REFEREN CES ........ ......................................................... ............... 87

B IO G R A PH IC A L SK E TCH ..................................................................... ..................92
















LIST OF TABLES


Table page

1 Frequency and Percent of Variables...................................................................... 38

2 Summary Measures of Variables ................................................... ................39

3 Pearson Correlation Coefficients-Spirituality and Variables with No
A dju stm en ts ...................................... ............................... ................ 3 9

4 Pearson Partial Coefficients-Controlling for Health Assessment ..........................39

5 Pearson Correlation Coefficients-Health Self-Assessment and Variables with No
A dju stm ents ...................................... ............................... ................. 4 0

6 Pearson Partial Coefficients-Health Self-Assessment and Variables Controlling
for Spiritu ality ........................................................................40

7 Frequencies and Percentages for Self- Reported SIBS Questionnaire (N=115). ....41

8 Frequencies and Percentages Questions that Indicated Ratings for General
Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey
questionnaire (N =1 15) .................. ..................................... .. ........ .. 43















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESSMENT IN
PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE

By

Patricia A. McNally

December 2004

Chair: Sharleen Simpson
Major Department: Nursing

The purpose of this descriptive study was to investigate relationships between

spirituality and self-heath with three postoperative outcomes after total hip or knee

arthroplasty in the older adult.

A total of 115 subjects between the ages of 55 and 86 years of age (M = 67.8) who

met the inclusion criteria were enrolled in this study. Forty-one were male and seventy-

four were female. One question from the Spiritual Involvement and Beliefs Scale and

one question from the Short Form-36 Health Survey were used to measure spirituality

and self-health assessment. Operative site, average daily pain scores, median daily pain

scores and analgesic medication use data were obtained from the patient's medical record

for three days postoperatively.

Bivariate analysis found that those participants with a high degree of spirituality

did not report less pain on days one (r = 0.01, p = 0.92), day two (r = 0.02, p = 0.84) or

day three (r = 0.03, p = 0.78). They also did not use less analgesic medication during the









three postoperative days (r = -0.04, p = 0.69). However, those participants who self-

assessed their health as good to excellent did have less pain on day one (r = 0.31, p =

0.00), day two (r = -0.29, p= 0.00) and day three (r = -0.22, p = 0.02). There was no

reduction in analgesic medication use (r = -0.11, p = 0.25). An ANOVA regression

found there was no relationship for a high degree of spirituality, a high self-health

assessment and the use of less pain medication (F = 1.04, p = 0.38).

The study supported the hypothesis that older adults who rate their self-health as

good, very good or excellent experienced less postoperative pain but this study did not

support less pain medication use. Second, this research did not support the hypothesis

that a participant's spirituality influences pain or analgesic medication use after

arthroplasty surgery. Third, a high degree of spirituality and good health together did not

make a difference in the amount of analgesic medication used for pain control.

The majority (81.7%) of the participants felt their health was good, very good or

excellent. Second, most (67%) indicated they were highly spiritual and 70% felt that

spiritual health contributes to physical health. Finally, the majority of the respondents

believe in spiritual coping behaviors such as prayer, belief in an afterlife and a personal

relationship with a greater power.

This research found that an individual who rates their self-health as good, very

good or excellent has less pain after arthroplasty surgery, but this self-health assessment

does not influence the use of pain medication. Although participants considered

themselves "highly spiritual", their spirituality did not influence postoperative pain or

pain medication use.














CHAPTER 1
INTRODUCTION

The increased number of aging persons has stimulated researchers to define the

concept of aging as viewed by older adults in our society. Rowe & Kahn, (1998) define

successful aging as the avoidance of disease and disability, social involvement and high

level of cognitive and physical function. Success, according to their definition, includes

few physical limitations, health, and the absence of chronic pain. Most adults over 55 yrs

of age do not report problems with daily activities such as: walking, bending and

stooping without assistance. In this age group, however, chronic pain can limit the level

of functional activity. A chief cause of chronic pain and disability among adults over 55

is osteoarthritis

The experience of chronic pain in the elderly is both a physiologic and emotional

experience. Although rooted in sensory stimuli, pain also has an important overlay from

an individual's culture and experience (Porter, et al. 1996). Among all age groups pain

can be defined as an experience with both a sensory and emotional component, but for

the elderly adult, pain may signify a chronic condition that is not always managed

effectively with drug treatment. The most frequent cause of chronic pain and total

disability reported by the older adult is arthritis (Affleck, et al. 1999; Felson, 1988;

Mobily, Herr, Clark, & Wallace, 1994; Praemer, Fumer & Rice, 1999; Schlesinger,

2001).

The American Geriatrics Society suggests using both pharmocologic and non-

pharmocologic methods to achieve a greater degree of pain relief (American Geriatrics









Society, 1998; Gagliese & Melzak, 1997). Non-pharmocologic methods of pain control

include massage, acupuncture, and behavioral therapy. Keefe, et al. (2000) in a study of

rheumatoid arthritis and joint replacement, found that effective coping strategies included

praying, hoping and calming self-statements.

Research on the relationship of spirituality and health has gained increasing interest

in the academic and popular press over the past 15 years. Most early research used

retrospective data analysis to study the effects of religious affiliation, and hypertension,

depression, mortality, and anxiety (Clark, Friedman, & Martin, 1999; Husaini, Blasi, &

Miller, 1999; Koenig, George, Blazer, Pritchett, & Meador, 1993; Koenig, George,

Meador, Blazer, & Dyck, 1994). They observed a positive correlation between church

attendance and various correlates, such as hypertension, depression, anxiety, hospital

length of stay, and mortality (Koenig, et al. 1993; Koenig & Larson, 1998; Meador, et

al. 1992).

Levin and Chatters (1998) suggest future quantitative studies to evaluate

relationships between spirituality and health. Although older people may rely more on

defensive coping strategies, the possibility that spiritual coping mechanisms may have a

therapeutic effect has not been explored. Such spiritual coping mechanisms might

include prayer, religious service attendance, and seeking a spiritual connection (Ellison &

Levin, 1998; Koenig & Larson, 1998; Pargament, Smith, Koenig, & Perez, 1998). These

studies suggest that older adults who use spiritual coping methods during stressful

medical conditions have a more positive health outcome.

I wished to explore the effect of spiritual belief, spiritual behavior and health self-

assessment on the response to postoperative pain. Towards this end I examined the









relationship between specific assessments of spiritual behavior, health self-assessment, to

reports of pain report and the use of analgesic medications among a group of older adults

recovering from hip replacements surgery.

Background and Significance

Chronic Pain in the Older Adult

Pain is defined as a noxious physical and emotional experience. Although similar

for all age groups, elderly adults appear to have a higher incidence of chronic pain. The

only measure of the presence and intensity of pain is the report of the person

experiencing the pain (Ferrell, 2000). Nociceptor pain, including chronic pain, begins

with the activation of special receptors and afferent fibers by peripheral stimuli usually

associated with processes involving tissue damage and inflammation (Ekblom & Rydh-

Rinder, 1998). Such pain may include musculoskeletal pain, ischemic pain, visceral pain,

and myofascial pain. There is little empirical evidence that biological or physiological

measurements correlates to the degree of pain expressed by the elderly individual

(Gagliese & Melzack, 1997). In other words, to a large extent the 'experience' of pain is

subjective.

Among the elderly, research indicates that more than 90% of the elderly experience

pain in the musculoskeletal system (Anderson, Ejlertsson, Lenden & Rosenberg, 1993).

Chronic arthritic joint pain begins in the upper extremities such as shoulders and then

progresses to the lower extremity as an individual ages (Anderson, et al. 1993; Mobily ,

et al. 1994). This site of the pain can greatly affect severity of chronic pain as well as the

degree of functional impairment.









Osteoarthritis and Chronic Joint Pain in the Older Adult

Osteoarthritis is the most frequent cause of end stage joint deterioration and chronic

pain in the elder adult. In the early stage, there is only a pathologic loss of cartilage. As

the disease advances joint cartilage and underlying bone are affected, with a total loss of

cartilage and joint space. Joint cartilage serves two functions: 1) smooth frictionless

surface movement of articulating bones, and 2) transmission of the weight bearing load.

Additionally, extensive tissue inflammatory changes surround the affected joint and

contribute to the limitation of joint range of motion and severe chronic pain (Schlesinger,

2001). Visible osteophytes or lateral outgrowths of bone in the joint margins add to an

increased sclerosis of underlying bone that contributes to an additional increase in

functional impairment (Felson, 1988; Schlesinger, 2001). This loss of the articular

cartilage can be demonstrated radiographically as a joint space narrowing and

occasionally, osteophyte formation. The most frequently affected joint locations are

knees, hips, fingers, and spine (Praemer, et al. 1999).

Measurement of the impact of arthritis includes two parameters: disability or

functional impairment and economic health care system impact. The adult person 65

years of age with arthritis may have more limitations of activity than those afflicted with

other chronic disease states such as cardiac disease, diabetes, and cancer. It has been

estimated that 50% of those persons 65 years of age and older experience activity

limitation from the chronic pain of osteoarthritis (Mobily, et al. 1994). The failure of

conservative medical management, such as medications and physical therapy, in the

treatment of end stage joint osteoarthritis, has increased the demand for surgical total

joint replacement.









Total Joint Arthroplasty in the Older Adult

The early 21st century has been declared the "Bone and Joint Decade" by 35 nations

and 44 states. Currently, more than 425,000 total joint replacements are performed each

year in the United States, and this number is expected to reach 702,000 by the year 2030

as the baby boomer generation ages (Praemer, et al. 1999). The increase in the number of

aging Americans, the increase in the prevalence of arthritis for this age group, and the

desire to remain active have added to the increase in demand for total joint replacement

surgery (Healy, Iorio, & Lemos, 2001). Joint replacement surgery has been documented

to improve pain, functional ability, social function, and quality of life for the recipient

(Aarons, Hall, Hughes, & Salmon, 1996; McGuigan, Hozack, Moriarty, Eng, &

Rothman, 1995; Norman-Taylor, Palmer, & Villar, 1996; Ritter, Albohm, Keating, Faris,

& Meading, 1995).

These findings demonstrate that osteoarthritis among older adults is a major cause

of chronic pain and functional impairment. Total joint replacement offers the older adult

pain relief and improved functional ability, particularly when there is failure with

conservative therapies.

Spirituality in Older Adults

Behavioral management of pain includes the strategy of active coping. Spiritual

coping behaviors that include praying and church attendance have been recognized as

active coping behavioral strategies used often by older adults (Koenig, et al. 1998).

Burkhardt, (1989) defines the "spirituality" as the individual's belief in God or a higher

power that is concerned with his or her striving to achieve a sense of harmony with self

and others. Spirituality often involves a relationship with an organized religion,

interrelationships with others, and the search for the meaning of life. Affiliation and/or









participation in organized religion, however, are not necessary to be considered spiritual

(Burkhardt, 1989; Principe, 1983). Different authors have defined 'spirituality' in

various ways. For the purpose of this discussion, I will use the "spirituality" to describe

the way of life an individual chooses that involves a belief in God or a higher power, a

belief in an after life, and a belief that a higher power influences life's events. I did not

limit this study to 'spirituality' associated with any specific religion or sect.

There has been an increasing interest in the interrelationship of spiritual

involvement, spiritual activity, and health outcomes among the elderly. Koenig,

McCullough, and Larson (2001) give three reasons for this current interest. First,

spirituality and religious affiliation continues to be a central part of people's lives despite

advances in technology, education, and medicine. Second, the United States and other

worldwide populations are aging due to a declining birth rate and greater longevity. In

the future, social programs will have severe financial hardships in providing services for

this population and religious groups may assist in providing some of these services.

There is the possibility that spiritual coping may aid in the prevention of health problems

and thereby assist in health care cost containment. Finally, there is a depersonalization in

the health care delivery system. Individuals seeking medical care and treatment expect

compassion with attention to their social, psychological, and spiritual needs. McFadden

and Levin (1996) summarize recent gerontologic spiritual research as focusing on four

areas of interest: "(a) multidimensional measures, (b) patterns, (c) predictors, and (d)

psychosocial and health related outcomes of religious involvement in older adults and

across the life course" (p. 350).









Summary

Many disciplines including medicine, psychology, and sociology have examined

the relationship of coping and religious affiliation; coping and spiritual beliefs; religious

attendance, and health outcomes like pain, depression, quality of life, mortality, and

morbidity. This investigator believes that the degree of spirituality in the post-surgical

older adult patient has not been considered in evaluating pain report and analgesic

medication use. Achieving adequate pain control is a major goal of professional nursing

care and utilizing spiritual coping may be an important addition in providing non-

pharmocologic pain management.

Specific Aims

The purpose of this study is to explore whether a high degree of spirituality, and

high scores for self-health assessment are correlated with postoperative pain and

analgesic medication use in the acute hospital recovery phase. Currently, there is no

evidence in literature that has examined these variables and their relationship with the use

of postoperative pain medication after total joint arthroplasty. Prior research focused on

relationships of long-term functional rehabilitation, quality of life and spiritual coping.

Using two multidimensional instruments, I propose to address three important aims that

will contribute to the relationship of spirituality, self-health assessment, pain report and

analgesic medication use in the postoperative older adult joint arthroplasty patient.

First, using a multidimensional instrument, this study will investigate whether a

high degree of spirituality is associated with less pain report and medication use in older

individuals receiving primary hip or knee arthroplasty for osteoarthritis. It is the aim of

this research to determine whether older adults receiving a hip or knee arthroplasty with a









high score for spirituality on the Spiritual Involvement and Beliefs Scale (SIBS) will use

less analgesic medication postoperatively.

Second, the Short Form-36 Health Survey that measures general health assessment

will be used to measure self-health in this research. It is the aim of this research to

determine whether older adults with a high score for health self-assessment will use less

analgesic medication after controlling for spirituality.

Finally, the responses for both spirituality and self-health together will be

correlated with analgesic medication.

Hypothesis 1. Older adults with a higher degree of spirituality receiving a hip or

knee arthroplasty for primary osteoarthritis will report less pain and receive less analgesic

medication than those participants with a lower degree of spirituality after controlling for

health self-assessment.

Hypothesis 2. Older adults with high scores on the self-health assessment tool will

report less pain and receive less analgesic medication than those participants with low

scores on the self-health assessment tool after controlling for spirituality.

Hypothesis 3. There will be significantly less analgesic medication used by those

older adults receiving hip or knee arthroplasty who have a high degree of spirituality, and

a high degree of self-health assessment.

Terminology

* Older adult: Age 55 or older

* Epidural: Medications administered to the epidural space surrounding the spinal
cord.

* Extrinsic religious orientation: The pursuit of religious beliefs and religious
practice to feel protected or gaining social status and approval.









* Femoral Nerve Sheath: Medication administered within the femoral nerve sheath
by means of a catheter to anesthetize the femoral nerve.

* Intrinsic religious orientation: The motivation to live the goals set forth by
religious tradition. The way of life often described as "living one's religion" and
using religious practices. The person who has an intrinsic religious orientation may
not be affiliated with a particular religious group.

* Medication Administration Record (MARS): Individual record of medication
administered to a patient during inpatient hospitalization. Each dose of medication
is recorded with the following data: medication name, dosage, time administered,
name of staff administering medication.

* Opioid equi-analgesic conversion: All narcotic medication was converted to
Morphine Sulfate IV equivalents.

* Patient controlled analgesia: Self-administered narcotic analgesia through an
intravenous infusion.

* Religious affiliation: Participating in an organized religious group

* Spirituality: The way of life an individual chooses to live that internalizes a belief
in a higher power. These life thoughts are separate from the body and may involve
God, a belief in an afterlife, and belief that this higher power influences life's
events.

* Spiritual behaviors: Praying, meditation and/or self-reflection, reading spiritual
writings

* Visual Analog Scale (VAS): A pain rating scale adopted by Shands at the
University of Florida to provide accuracy in a patient's pain. The scale is numeric,
one = no pain and

* 10 = the worst pain of life. Patients are asked to rate their pain using numeric
increments 0 to 10.














CHAPTER 2
REVIEW OF THE LITERATURE

This section deals with pertinent papers published during the past 20 years that

address chronic pain, osteoarthritis, lower extremity arthroplasty, and spirituality coping

among the elderly. The first section examines the prevalence of the chronic pain of

osteoarthritis and arthroplasty (focal stimuli), age, gender, and race (contextual stimuli).

The second reviews the relationship of spiritual coping to gender, race, age, and pain.

Presence of Musculoskeletal Chronic Pain and Arthritis Among Older Adults

Pain in the aged adult has become a focus of current gerontologic research. The

elderly have more painful diseases that require more medical visits. The impact of

musculoskeletal conditions on the elderly can be divided into two categories: 1) the

physical and social impact of physical pain (limitations in mobility and social interaction

imposed by these limitations), and 2) the monetary cost involved in the diagnosis and

treatment of these disorders (Praemer, Fumer, & Rice, 1992). Musculoskeletal disorders

after age 65, regardless of gender or racial group, are the most frequently reported

physical impairments, exceeded only by hearing disorders. Surgical intervention,

following failed medical management, is expected to increase dramatically in the next

twenty years (Praemer, et al. 1999). Musculoskeletal functional limitation has a

significant impact on the elderly.

Back and spine disorders are the most frequently reported category of dysfunction,

followed by lower extremity disorders of the hip or knee. Although there are many forms

of arthritis among the elderly, the two most common forms, those with the greatest public









health implications, are osteoarthritis and rheumatoid arthritis. The more prevalent of the

two forms, osteoarthritis, is estimated to affect 20 million people in the United States

(Praemer, et al.1999).

The Relationship of Background Contextual Stimuli and Pain

Age, Pain, and Osteoarthritis

Anderson, et al. (1993) found that 90% of individuals surveyed experienced

chronic musculoskeletal pain. Chronic pain symptoms increased between ages 50-64 and

then gradually declined. After age 60, however, the incidence of lower extremity pain

increased. Compared to younger adults, lower joint pain doubled after age 65 (Anderson,

et al. 1993; Gibson & Helme, 1995). In the Iowa study, Mobily, et al. (1994) observed a

lower incidence of overall pain (p< .0001) among those over 85 years compared to

younger age groups. They also found more than 86% of those surveyed experienced pain

longer than 12 months. Their research is felt to be particularly accurate because of their

large sample size and the longitudinal study design.

Several studies have examined the influence of age on pain sensitivity. Gibson and

Helme ((1995) examined sensitivity to several different forms of experimental pain using

a meta-analysis. Their data suggest a decline in thermal sensitivity after age 60, but do

not show a conclusive difference, or change, in pain sensitivity or pain tolerance. An

earlier study by Helme and Allen (1992) had found that the majority of those surveyed

(79%) agreed that pain was a consequence of the aging process. However, less than half

of these older adults reported pain. The authors concluded that older adults expected to

experience pain as they aged and they did.









Additional research is needed to evaluate both the physiologic and psychological

basis for pain among older adults. More effective management of pain in the older adult

originates in a better understanding of differences and similarities in the pain response.

Gender, Pain and Osteoarthritis

Experimental research has not demonstrated a conclusive difference in pain

perception related to gender. Using heat as a noxious stimulus in humans Paulson,

Minoshima, Morrow, and Casey (1998) concluded there was a gender similarity in the

cerebral and cerebellar activation, but anticipation of the stimulus was more intense in

females.

Keefe, et al. (2000) measured pain, disability, and pain behavior among men and

women with a mean age of 61.1 yrs. They reported significant gender differences in pain

intensity, pain behavior, and physical disability associated with osteoarthritis. Women

had significantly elevated levels (F (1,166)= 4.41, P <0.05) of osteoarthritis pain. They

measured pain behavior, which included stiff movement, rubbing affected joint, and

flexing the joint, in relation to gender. In their analysis women exhibited more pain

behavior than men (F (1,162) = 5.54, P < 0.05). In a recent study of pain and coping,

Affleck et al. (1999) observed that women reported daily osteoarthritis pain and pain

levels 73% greater than males with a similar arthritis diagnosis. Results of these studies

have suggested that among the elderly, there is a difference in pain intensity related to

gender. Further research is necessary to compare noxious pain stimuli, pain thresholds

and intensity studied in younger populations to the older adult.

Age, Gender, and Osteoarthritis

Compared to males, females have twice the incidence of osteoarthritis. Until age

65, however, men report a greater occurrence of osteoarthritis. While men are more









likely to have shoulder, elbow and foot joint pain; women have finger, hip, ankle and

wrist joint pain (Davis, Ettinger, Newhaus & Hauck, 1987). Although specific affected

joint patterns have been identified as following a gender pattern, gender differences do

not contribute to risk factors for the development of osteoarthritis (Davis, et al.

1987;Keefe, et al. 2000; Lawrence, et al. 1998).

Race, Pain and Osteoarthritis

Differences in cultural response to pain have been studied using two methods, non-

experimental using observational methods, and laboratory experimental using painful

stimuli and measuring the response. Zatzick and Dimsdale (1990) were unable to

correlate cultural variations in pain response in their meta-analysis of pain stimuli and of

pain response. They concluded, "there is no evidence suggesting that the

neurophysiology detection of pain varies across cultural boundaries" (p.554). However,

Bates, Edwards, and Anderson (1993) using observational methods to evaluate the

differences in reported chronic pain intensity among seven diverse ethnic groups, found

significant correlations. Additionally, they investigated specific sociodemographic,

medical, and psychological variables that may predict an intra-ethnic group variation in

pain intensity. Bates, et al. (1993) found that pain intensity did not vary among various

ethnic groups because of differences in neurophysiology but was a result of the

biocultural model of pain perception.

European whites have a greater incidence of osteoarthritis than Jamaicans, Blacks,

South African Blacks, Chinese, and Indians (Felson, 1988). Rates for American Indians

are intermediate. There is speculation that individuals of European white descent have a

genetic developmental defect in both the knee and hip joints that facilitates the









development of osteoarthritis. This is supported by greater reporting of joint pain in

whites when compared to blacks or other races (Praemer, et al. 1992).

Total Joint Arthroplasty

Prevalence

The first decade 21st century has been declared the "Bone and Joint Decade" by 35

nations and 44 U.S. states. The number of lower extremity joint procedures has

increased; total knee replacements increased 40.2% during the years 1990 and 1996,

while total hip replacements increased 15.5% for the same years (Praemer, et al. 1999).

Currently more than 425,000 total joint replacements are performed in the United States,

and this number is expected to reach 702,000 by the year 2030 as the baby boomer

generation ages (Praemer, et al. 1999).

The leading reason for joint replacement surgery in the elderly is failure of

conservative medical treatment for end stage arthritic joints. The increase in the number

of aging Americans, and the increase in prevalence of arthritis for this age group along

with a strong desire to remain active have continued to increase the demand for total joint

arthroplasty (Healy, Iorio, & Lemos, 2001). Joint replacement surgery has been shown to

improve pain, functional ability, social function, and quality of life (Aarons, et al. 1996;

McGuigan, et al. 1995; Norman-Taylor, et al. 1996; Ritter, et al. 1995).

The goal of total joint arthroplasty is to recreate the motion of flexion, extension,

adduction, and rotation of the joint that has lost range of motion. This surgical

intervention demonstrates a ten-year success rate for 98 % of elderly individuals while

relieving joint pain and correcting the joint deformity. For patients with bilateral knee

joint end stage arthritis, bilateral joint replacements are often performed at the same time

(Pellino, Preston, Bell, Newton, & Hansen, 2002).









Total hip arthroplasty (THA) is a surgical procedure that replaces a diseased joint

with a synthetic joint using a synthetic acetabulum, femur, and polyethylene liner that are

fixed to bone by cement or bone ingrowths. Total knee arthroplasty (TKA) involves

replacing the femoral and tibia sides of the joint using a long or short stem fixated by

cement. The goal of joint arthroplasty is to improve function with an artificial joint that

improves range of motion and provides pain relief with few surgical complications

(Brander, Mullarkey, & Stulberg, 2001). The decision making process in considering a

candidate for total joint replacement is the degree of radiographic changes and the degree

of functional impairment.

Gender and Arthroplasty

Although women have 1.5-2.0 higher incidence of osteoarthritis, men have more

total knee arthroplasty than women. Katz, et al. (1994) suggests that gender differences

in joint arthroplasty are difficult to evaluate because procedure rates are not reported by

severity of disease. The authors evaluated functional status using a daily living scale that

evaluates the ability to walk several blocks, climb stairs, or take part in vigorous activity.

Greater functional impairment and the use of walking support were reported for most of

the females. The authors suggest that males have earlier surgical intervention for

functional impairment and pain. Praemer, et al. (1999) do report that the number of total

knee replacements for men in 1996 was 1318/100,000 while for women in the same year

it was 928/ 100,000. There is some evidence that suggests women delay surgical

intervention out of fear of surgical failure, death or loss of function postoperatively.

Postponing surgical intervention can also be because of distrust of physicians and

hospitals, a reluctance to take risks and concern about caregiving responsibilities.









Conversely, males most reported concern is the length of rehabilitation time necessary for

the return of joint function (Ritter, et al. 1995).

Race and Arthroplasty

The relationship between race and arthroplasty has been poorly studied. A recent

study in a large county in Texas reported that Hispanics were under represented as

recipients for hip replacement surgery (Escalante, Espinosa-Morales, Del Rincon,

Arroyo, & Older, 2000). In their research, African Americans were also less likely than

Caucasians to receive arthroplasty surgery. Extensive review of research literature on

race and arthroplasty, however, revealed no evidence to suggest a disparity in race and

arthroplasty.

In summary, the number of total joint replacements increases dramatically for both

sexes after age 65 (Praemer, et al. 1999). The effect of this increase can be directly

attributed to the incidence of joint osteoarthritis, chronic pain and functional impairment

(Felson, 1988; Schlesinger, 2001). Women report greater functional impairment for all

activities of daily living and delay arthroplasty for a longer period of time. It is unclear

from previous research reasons for gender differences in osteoarthritis incidence or the

delay for surgical intervention. Previous research only verifies the age related changes of

osteoarthritis, functional impairment and the increase in total joint replacement surgery

for the relief of pain and improvement in physical function.

Spiritual Coping

According to Lazarus, DeLongis, Folkman, and Gruen, (1985), "efficacy

expectations and appraisals refer to cognitions: fear and distress refer to emotional states

that includes cognitions" (p. 776). Stress is regarded as a complex variable and the

individual in his/her personal environment reflects the processing of these variables.









Good health and the absence of chronic pain represent a person's stable environment. An

individual's inability to maintain these environmental variables creates stress and fear.

Through evaluating the stressors and using defense strategies, a coping process will be

used to overcome the disruption in a person's environment (Lazarus et al, 1985). The

older adult uses cognitive interpretation to identify stressful health changes and uses more

defense strategies to cope. Diehl, Coyle, and Labouvie-Vief, (1996) found that compared

to younger people; there was a difference in the use of self-restraint by older adults rather

than aggression to cope with environmental stressors.

Religious behaviors such as prayer, religious service attendance and seeking

spiritual connection, are part of the individual's practice of spiritual or religious coping

(Ellison & Levin, 1998; Koenig & Larson, 1998; Pargament, et al. 1998). Researchers

have studied the various spirituality concepts: 1) Religious doctrine; 2) Religious

attendance; and 3) Religious affiliation.

Spirituality includes both the world of experience and the way of life a person lives

that is guided by religious doctrine (Principe, 1983). It is the continuous process of

integrating oneself in current and past experience and the effort of relating to others with

trust and understanding. Spirituality links self with a power greater than the individual.

It is most often associated with a religion that defines the divine and offers ways to relate

to the sacred (McFadden & Gerl, 1990). Fowler describes the persons life spiritual

development as a developmental psychological process that uses cognitive and emotional

synthesis of a sense of meaning and purpose in the life journey (Shulik, 1988).

Interest in research involving the relationship of spirituality and health has been

increasing over the past 15 years. Most existing research has focused on religious









affiliation and health status in hypertension, depression, mortality, and anxiety (Clark,

Friedman, Martin, 1999; Husaini, Blasi & Miller, 1999; Koenig, et al. 1993, 1994). The

examination of a possible therapeutic effect of spirituality in the postoperative joint

replacement patient has not been explored. Levin and Chatters (1998) suggest that in

order to establish a relationship between spirituality and health, research must use

evaluate a measurable medical effect of spirituality or religion and aging. This research

will hypothesize that a positive relationship does exist between the older adult's degree of

spirituality and self-health assessment.

Spiritual Coping and Health

There has been no published research demonstrating a relationship between

spiritual coping, health assessment, and post-surgical pain. Most empirical research has

focused on the relationships of spiritual coping, spiritual beliefs, spiritual involvement

and health outcomes in mental health, hypertension, depression, and anxiety. Matthews,

et al. (1998) reviewed the relationships of religious factors that included religious

attendance and mental health status. The focal areas of mental health status were coping

and recovery from illness. The authors concluded in their review there was strong

support for religious commitment and positive medical outcomes following serious

illnesses e.g. heart disease, cancer. Pargament, et al. (1998) using a spiritual well being

scale found there was a relationship between positive and negative patterns of religious

coping in young and elderly age groups. They measured three diverse sample groups

experiencing stressful life events. The first sample represented Oklahoma City residents

who were evaluated for religious coping after the federal building bombing. The second

sample involved college students who had experienced a significant negative event, such

as a death of a friend or family problems. The third sample group was hospitalized









patients over the age of 55 with moderately severe medical illness. Although, the

participants were of different ages and diverse life event stressors, a positive pattern of

religious coping was found among the three groups. Those participants with positive

religious coping patterns had less psychological anxiety and distress. Those individuals

with negative religious coping were associated with greater emotional distress, e.g.

depression, and reported poorer quality of life. Pargament and colleagues (1990),

extended their religious coping research to more clearly identify the kinds of religious

beliefs, and behaviors that are helpful to individuals as they cope with negative life

events like death, illness, divorce and work related problems. Four separate themes of

religious beliefs and behaviors emerged to further define spiritual beliefs and practice: 1)

belief in a fair and loving God; 2) partnership with God is supportive; 3) positive

outcomes come from using of religious rituals; and 4) search for spiritual and personal

support through religious affiliation. Pargament, et al. (1990) explains nonreligious

avoidance with descriptor items from personal narratives such as "tried not to think about

it," "wished the situation would go away" (p. 818).

Using retrospective demographic data collection, early research that focused on

religious affiliation and health status demonstrated positive relationships between

religious affiliation and various health correlates, such as hypertension control,

depression, anxiety, length of hospital stay and mortality (Koenig, et al. 1993; 1998;

Koenig & Larson, 1998; Meador, et al. 1992). In a review of 20 empirical studies, Levin

& Vanderpool (1990) concluded that religion is therapeutically beneficial in the control

of hypertension. Koenig, et al. (1998) investigated the relationship of religious activities

and blood pressure control among older adults dwelling in communities. They concluded









that religiously active adults displayed lower blood pressures and were more compliant

with prescribed medication. Additionally, they observed a racial difference. The authors

found that although black religious males had higher blood pressures than white religious

males, they were more compliant with medication use for blood pressure control.

Recent research has examined spirituality and functional ability during

rehabilitation. Kim, Heinemann, Bode, Sliwa, & King (2000) examined spirituality using

an intrinsic Judeo-Christian scale of well-being and functional variables among patients

in a rehabilitation hospital. Intrinsic religiousness is defined as the individual's

internalizing a religious belief and living the belief. Individual spirituality scores though

high were not associated with variables of functional recovery such as mobility, and self-

care. Fitchett, Rybarcyk, DeMarco, and Nicholas (1999) found similar results in

postoperative rehabilitation. There was a high degree of spirituality among their patients

who rated their health as poor or very poor. Using a questionnaire that measures church

affiliation, attendance, and spiritual behaviors, the authors were unable to confirm a

relationship between self-health assessment, spirituality, and church activities. Pressman,

Lyons, Larson, and Strain (1990) in a small study of postoperative female orthopedic

patients found significant correlation between church attendance, personal importance of

religion, degree of spirituality, and functional meters walked (r=0.45, df = 27, p<0.05).

This research found that postoperative orthopedic subjects with strong religious beliefs

and practices, and less depression had better ambulatory function at discharge. The

spirituality score was not significantly correlated with ambulatory status independent of

depression. The authors suggest that subjects who are spiritual respond more favorably

to physical therapy because they are less depressed. Hodges, Humphreys, and Eck









(2002) investigated the effects of spirituality on spinal surgery recovery. Using a

spirituality tool that evaluates intrinsic spirituality, they found these subjects to be highly

spiritual (79%). The authors then compared preoperative and postoperative pain scores

with postoperative functional ability. They found no correlation between a high degree

of spirituality and pain scores or functional outcomes.

Spiritual research has investigated the possible relationships of pain, health and

functional recovery. In each study, older adults have a high degree of spirituality on

various measurement tools, but only one study reported a significant correlation that

included a finding of less depression. The investigation of spirituality and health has not

been evaluated using consistent measures of spirituality scales and postoperative

population groups. Most current research has observed possible religious affiliation,

spiritual beliefs and functional status.

Relationships between Spiritual Beliefs, Gender and Race

Few empirical studies have examined pain, gender, and racial relationships

(Affleck, et al. 1999). Research regarding utilization of health services demonstrated a

positive correlation between utilization and religious attendance in elderly male patients

60+ years of age. Increased attendance at religious services prior to hospitalization

correlated with a shorter hospital stay and fewer hospital admissions (Koenig & Larson,

1998).

Past research concentrated on religious coping behaviors, including religious

affiliation, beliefs and involvement. Research findings suggest that many older adults use

spiritual coping in various stressful health situations and that this coping has had a

beneficial effect. Further investigation is needed using spiritual measures to examine if









there is a spiritual coping adaptive effect in the management of older adult postoperative

pain.

Roy Adaptation Model-Based Research

In 1976, Sister Callista Roy's theory of an adaptation model for nursing was

presented to guide nursing education in the United States. The theory was later revised to

address the middle range or practice level theory relevant to patient care in nursing. In

1999, a new model of the Human Adaptive system was introduced to clarify the

understanding of the various components of the theory and to extend it into clinical

practice (Roy & Andrews, 1999). Roy defines the purpose of nursing practice as the

promotion of the ability of human adaptive systems to adjust effectively to changes in the

environment and to the individual's ability to modify their environment (Roy &

Andrews, 1999). Roy's theory contains scientific and philosophical assumptions that

describe successful human coping in changing environments. According to Roy, the

adaptation of the human system is based on scientific assumptions that include: 1)

meaning is necessary for person and environment integration; 2) thinking and feeling is

necessary for awareness; 3) people have a commonality of patterns and relationships; 4)

adaptation results from the integration people and their environment. Further, the

adaptation concept includes Roy's philosophical assumptions: 1) relationships include a

higher power and the world; 2) people use the ability of faith; 3) God is observed in

diversity of creation, and is the destiny of creation.











MODEL DIAGRAM OF RESEARCH QUESTIONS USING ADAPTATION MODEL
(ONTF..TTI Al. FOC L. COMPENSATORY ADAPTIVE
STIMULI STIMULUS LIFE PRO(_ ESiar MOUDES





DECREE OFIN PI
/E / I _SPIRITUALITY


TOTAL JOINT
RACE / ARTHaOPLASTY
FOR
OSTFOARTHMlTIS
AND CHRONIC
PAIN











Figure 2-1. Model Diagram of Research Questions
SELF-
ASS3E9SMNE .-ANALESIC
II I_ EALT H MEDICAW-nO USE *-
STATUS
COPING






Figure 2-1. Model Diagram of Research Questions

Roy Adaptation Model Gerontologic Research

Roy describes the adaptive process as adjusting effectively to environmental

changes using cognitive interpretation and coping processes to maintain an integrated

life. In this model, compensatory life processes are spiritual coping and health self-

assessment. These regulatory processes provide an adaptive response for less pain.

Roy's adaptation model has been used mainly with children and adults in a hospital

environment. One gerontologic study has used the Roy adaptation model to evaluate a

coping process and the concept of self-consistency. Roy believes the concept of personal

self is a combination of self-consistency, the moral-ethical spiritual self and the self-ideal

(Roy & Andrews, 1999). Zhan (2000) used the Roy Adaptation Model to study

adaptation and coping with severe hearing loss in 130 elderly adults. Health status and

coping data were analyzed for positive relationships between cognitive coping and self-









consistency. There was a positive correlation between those who rated their health as

good or excellent and self-consistency. The variance in self-consistency was the result of

cognitive coping processes. Three cognitive processes; clear focus and method, knowing

awareness, and self-perception were most significant (36.97 (p< .001, df =5).

There is support for the use of the Roy Adaptation Model in gerontological

research to evaluate spiritual coping and adaptation to pain. Successful adaptation to

environmental changes is necessary to return to good health and well being as people age.

Summary

Chronic pain in the aged adult is both a physical and emotional experience.

Current research suggests that the use of pharmocologic and non-pharmocologic methods

in the elderly may reduce chronic pain. However, some research findings suggest that the

use of specific non-pharmocologic interventions such as spiritual behavior, religious

attendance, and spiritual beliefs are inconclusive in providing relief from the negative

effects of chronic illness and pain. This research study will evaluate relationships

between spirituality and analgesic medication use after total joint arthroplasty in older

adults.

Measurement of the degree of spirituality and health will evaluate the effectiveness

of coping with postoperative pain in the older adult. This research will provide

quantitative data to provide a framework for evaluating older adult's spirituality as an

alternative non-pharmocologic intervention in postoperative pain management.














CHAPTER 3
METHODS

Research Design

This research examines the relationship of older adults' spiritual beliefs, and self-

health assessment and analgesic medication use during the first three days after total joint

replacement surgery. A correlational convenience design was used to investigate the

questions in a sample of surgical candidates scheduled for hip and knee joint arthroplasty.

Using the Roy Adaptation Model, this study examined relationships between total joint

arthroplasty for osteoarthritis, chronic pain, the degree of spiritual beliefs, spiritual

involvement, self-health assessment and the health outcome of postoperative analgesic

medication use. Participants for this research came from a socially diverse area in North

Florida.

Controls

Three orthopedic surgeons from the University of Florida College of Medicine,

Department of Orthopedics performed all of the total joint arthroplasty. To control

variations in general anesthesia technique, one supervising anesthesiologist planned each

participant's anesthetic care. Participants chose his/her preferred method of

postoperative pain control prior to surgery. Choices included regional anesthesia, Patient

Control Analgesia (PCA), or PRN dosing. Preoperative patient education and anesthesia

evaluation was done according to the standard of care established by the University of

Florida College of Medicine.









Inclusion criteria:

1. 55 years of age or older

2. Primary hip or knee joint arthroplasty

3. Osteoarthritis of the hip or knee joint as demonstrated by radiographic exam and
orthopedic surgeon's diagnosis as documented in the medical record

4. Failed medical management of chronic joint pain

5. Inclusion regardless of comorbidity status

6. Candidates for hip or knee arthroplasty

Power Analysis and Sample Size

An estimate of statistical power was determined using the G power computer

software to calculate the required sample size. A total of 115 participants were consented

and completed the study. The sample size was based on a formulation of 80% power, at

least six independent variables, an effect size of 0.15 (R-squared= 0.13) with a

significance of 0.05 for a two-tailed test. The G power computer software was used to

calculate the required sample size (Erdfelder, Faul, & Buchner, 1996).

Procedures

The Principle investigator of this study contacted the chairman of the Orthopedic

Department and presented a description of the study. The chairman then provided a

signed letter of agreement acknowledging awareness of this study (See Appendix A).

In the original protocol, I planned control variation in surgical technique using only

patients scheduled with one orthopedic surgeon. A total of 27 patients were enrolled

from July, 2003 until January, 2004. During this enrollment period, however, the

identified surgeon reduced the number of total joint surgeries he performed per month in

order to fulfill administrative duties. In January, 2004, the investigator met with

committee members to explore adding two additional surgeons in order to attain within a









reasonable length of time a number of subjects months adequate for a power analysis.

After appropriated discussions, two additional orthopedic surgeons agreed to help. They

were each provided a copy of the protocol and informed consent. A revision that

included the two additional orthopedic surgeons was submitted and approved by the IRB

in January, 2004.

Protection of Human Subjects

University of Florida Institutional Review Board (IRB) approval was obtained prior

to participant enrollment or data collection (See Appendix B for final approval, revised

approval and extension approval forms). A revision to include the additional orthopedic

surgeons was submitted and approved in January, 2004. A final IRB extension was

submitted June, 2004 to extend the research study from July, 2004 until July, 2005.

Method

Patients scheduled for surgery are scheduled in the pre-surgical center for an

examination by an ARNP to determine their suitability for anesthesia. From this group

the principal investigator identified potential subjects for study. Subjects who met the

inclusion criteria and agreed to participate in the study were given a verbal description of

the study, confidentiality assurance, and possible risks of their participation. Those

patients who expressed willingness to participate completed two questionnaires. The

questionnaires took approximately 20 minutes to complete during their pre-operative

visit. The principal investigator and each subject signed a copy of the informed consent.

A copy of the signed informed consent was given to the participant for their individual

records. The principal investigator verbally asked each subject if they had additional

questions regarding their participation in this research study prior to their discharge from

the pre-surgical center.









A key containing the participant's name, and confidential code was developed.

Informed consents and questionnaires were coded with the participant's confidential code

and are kept in a locked file cabinet in the principal investigator's office.

Measures

Demographic data. Age, gender and ethnicity were coded using a coding key

(see Appendix G). Demographic data was entered on an Excel spreadsheet after

enrollment. There was no missing demographic data.

Preoperative Questionnaire Measures

Indicator of spirituality

The Spiritual Involvement and Belief Scale- (Revised (SIBS-R) Hatch, Burg,

Naberhaus, & Hellmich (1998) evaluates a broad range of intrinsic spiritual content from

ability to find meaning in life to spiritual writings. Designed for use with individuals of

all religious and non-religious traditions that include Christian, Judeo, Hindu, Islam and

Atheist. This instrument differs from other spiritual measurement tools in that it is not

limited to individuals with a Judeo-Christian tradition.

For the purpose of this study one question was selected to evaluate participants'

spirituality. Two groups were created using the response to the question, "How spiritual

a person do you consider yourself?" Subjects were asked to rate themselves on a scale of

1 to 7 with 7 meaning "the most spiritual". Those groups who rated themselves 5, 6, or 7

were considered highly spiritual and coded as 1. Those who rated their spirituality as

1,2,3, or 4 were considered less spiritual and coded as 0

Indicator of self-health assessment

The Rand SF-36 Health Status Questionnaire measures physical functioning, social

functioning, role functioning (physical problems) and role functioning (emotional









problems). Additionally, the instrument measures mental health, fatigue, pain, and

general health.

One question, "In general would you say your health is", was used to create two

groups for the analysis. If a participant answered good, very good or excellent, their

response was considered as a high self-health assessment and coded as 1. If their

response was fair or poor, their self-health assessment was considered a low score and

coded as 0

Questionnaire data. Using the patient's confidential code all questionnaire data

was entered using an excel spreadsheet. Missing data on questionnaires was entered as a

dot.

Indicator of diagnosed osteoarthritis. A diagnosis of osteoarthritis was recorded by

the orthopedic surgeon and is available in each individual participant's medical record.

The diagnosis was verified with the individual's pre-surgical history and physical

assessment.

Indicator of ethnicity

Ethnicity was obtained from the patient's admission record. The admissions

department routinely obtains ethnicity information during a patient's initial interview

prior to entering the hospital.

Postoperative Data Collection Procedures

Indicator of pain scores. Individual postoperative pain scores were obtained from

the individual's medical record. Daily pain scores were recorded and averaged for three

days postoperatively. Additionally, a daily median pain score was recorded for this same

interval. Pain was evaluated using the Visual Analog Scale (VAS) that evaluates pain

intensity numerically using a 0 to 10 measurement (0= no pain, 10= worst pain). The









VAS instrument is used with all age groups and is the approved pain scale for use at

Shands Hospital at the University of Florida.

Analgesic medication use. Medications dispensed during a patient's hospitalization

are records in the Medication Administration Record (MARS). The MARS documents

each dose of medicine administered by nursing personnel. This medication record

contains the medication name, date, time, dosage and initials of hospital personnel

administering the medication. Individual Medication Administration Records (MARS)

were evaluated for the use of narcotic analgesic medication for every participant. An

Opioid equi-analgesic conversion table was used and all opiates were standardized to

morphine sulfate equivalents. For example, 1.5 mg IV Hydromorphone = 100 mcg

IV/SC Fentanyl = 20 mg P.O. Oxycodone = 10 mg IV Morphine (Pasero, Portenoy &

McCaffery, 1999). Total IV Morphine Sulfate equi-analgesic conversion was recorded

for each postoperative day for three days.

Regional anesthesia use. Regional anesthesia techniques such as epidural, Femoral

Nerve Sheath Catheters, and Psoais Compartment Catheters provide postoperative pain

relief by blocking nerve conduction with local anesthetics, thereby blocking the

transmission of pain (Pasero, Portenoy, & McCaffery, 1999). The use of a local

anesthestic provides a sensory and motor blockage. The epidural regional anesthesia

technique occasionally requires the use of an opioid agent in addition to a blocking agent.

The use of an opioid agent is recorded on a separate analgesic document in the patient's

medical record. The placement location of regional anesthesia is recorded on a separate

document located within the patient's medical record.









Medical record data. Medical record data collected included surgical site,

anesthesia data, pain scores and analgesic medication used. A form was developed (see

appendix) to collect data from the participant's medical record after discharge. Medical

records were requested using a Request for Records review and Shands at the UF

Research Chart Request forms. An average of 4-20 charts were requested each time;

medical records usually required two weeks to be assembled. Several delays were

experienced in obtaining medical records that included research medical records

personnel vacation days, sick days, and incomplete delivery of records. One medical

record has been lost. Two records are incomplete with medication records missing.

The Medical Record Department requires that all data and chart review must be

preformed in the records department. Using the coding key, data was recorded on the

case coding form. Pain scores were documented as average scores and median pain

scores. All opioid medications were converted to Morphine Sulfate IV equi-analgesics

and recorded. Surgical site, anesthesia type, regional anesthesia, general anesthesia were

coded using the coding key.

Data Analysis

Data obtained in the postoperative period were entered on an Excel spreadsheet.

Analysis used SPSS statistical software, Version 11 for Windows. Demographic data for

spirituality, self-health assessment, age, gender, pain scores, and analgesic medication

use were analyzed to generate descriptive statistics using mean scores and frequencies

The hypotheses were tested with analysis procedures using Pearson's correlation

coefficient, T-Test and ANOVA with significance levels of 0.05. Correlations measure

how variables are related and measure their linear association. Frequencies and mean

scores were analyzed for all demographic data, age, gender, operative site, physician,






32


regional anesthesia and analgesic medication use. Individual survey questionnaire items

were analyzed using frequency and percentage of individual participant response.

Summary

This chapter presented research design, sample inclusion, power analysis,

methodology, and data collection procedures for this study. Data analysis methodology

for research hypotheses was discussed.














CHAPTER 4
RESULTS

A description of the participants and the results of this descriptive study are

presented in this chapter. The results are examined in relation to the three hypotheses.

This study took place at Shands at the University of Florida. Subjects were recruited as a

convenience sample that included only persons that met the inclusion criteria. Informed

Consent and questionnaire data were collected in the pre-surgical anesthesia clinic.

Demographic data, pain scores and medication use were obtained from the subject's

medical record after hospital discharge. All data was computed using the SPSS statistical

software, version 11 for Windows. Statistical significance was set at p < 0.05.

Sample Characteristics

A total of 126 potential subjects who met the inclusion criteria were approached to

participate in the study. Eleven potential participants declined to participate. Three

stated they were "tired of filling out paperwork", two did not want to participate in any

research and one did not believe in spirituality. Five did not express a reason for refusing

participation. None of the potential research participants expressed any fear of an

adverse event by participating in this study. All subjects who agreed to participate signed

an informed consent and completed the two questionnaires in the pre-operative anesthesia

center. At the end of the study one subject's medical record was missing from the

Medical Records Department and after a detailed search was considered lost. One

subject's Medication Administration Record was missing from the medical record and









presumed lost. All other participants' medical records were complete at the end of the

data collection period.

One hundred and fifteen subjects who met the inclusion criteria were consented.

The mean age of the sample was 67.70 (SD = 8.23). Seventy- four (64.3 %) of the

participants were female and 41 (35.7%) were males. The majority of the participants

were Caucasian (n = 111), followed by Hispanic (n = 2) and African American (n = 1).

All participants were diagnosed with severe osteoarthritis and had failed

conservative medical management. Right total knee arthroplasty was the joint

replacement most frequently performed at 35% (n = 35), followed by left total knee

arthroplasty at 27.8% (n = 32), right total hip arthroplasty 18% (n=18), left total hip

arthroplasty at 13.9% (n =16), and bilateral total knee arthroplasty at 10.4% (n = 12).

Regional Anesthesia

Forty-six percent (n = 56) of the participants chose a femoral nerve sheath for post-

operative pain control, while 25.2% (n = 29) chose an epidural, 3.5% (n = 4) chose a

psoas compartment sheath, and 1.7% chose a continuous spinal. Patient controlled

analgesia (PCA) was used by 67% (n = 77) of subjects. The PCA group includes some of

the subjects who received a femoral nerve sheath. All other participants selected "as

needed" analgesia for postoperative pain control.

Anesthesia Technique During Surgery

General anesthesia was administered to 100 participants (87%) followed by

continuous spinal at 4.3% (n = 5), followed by managed anesthesia care at 2.6% (n=3).









Analysis of Data in Relation to the Hypotheses

Hypothesis 1

Hypothesis 1 stated that older adults with a high degree of spirituality receiving hip

or knee arthroplasty for primary osteoarthritis would report less pain and receive less

analgesic medication than those participants with a lower degree of spirituality after

controlling for health self-assessment.

The Pearson Correlational analysis as shown in Table 3, demonstrated there was no

significant correlation between spirituality response, self-health questionnaire response

and the following variables: age (r = -0.02, p = 0.84), average pain scores day one (r=

0.01, p = 0.92), average pain scores day two (r = 0.02, p = 0.84), average pain scores day

three (r = 0.03, p = 0.78) and analgesic medication use (r = -0.04, p = 0.69). A partial

correlation coefficient controlling for the self-health assessment score was then analyzed

(See Table 4) and there were no significant correlations between spirituality, and the

variables: age (r = -0.05, p = 0.60), pain day one (r = 0.53, p = 0.59), pain day two (r =

0.06, p = 0.53), pain day three (r = 0.06, p = 0.56) and pain medication (r = -0.02, p =

0.81). Hence, Hypothesis 1 was rejected.

Hypothesis 2

Hypothesis 2 stated that older adults with a high score on the high self-health

assessment tool would report less pain and receive less analgesic medication than those

participants with a low score on the self-health assessment tool after controlling for

spirituality.

The Pearson Correlation found there was a significant correlation as shown in

Table 5 between the variable for health on the Short Form-36 Health Survey and age (r =

0.23, p = 0.02), average pain scores day one (r = -0.31, p = 0.00), day two (r= -0.29, p =









0.00) and day three (r = -0.22, p = 0.03). There were similar results for days one, two,

and three and median pain scores. However, there was no significant correlation between

the variables, analgesic medication use (r = -0.11, p = 0.23) or high spirituality (r = 0.13,

p = 0.17) as shown in Table 5.

A Pearson Partial correlation for health assessment while controlling for spirituality

was analyzed. There was a statistically significant correlation for the following variables:

age (r = 0.23, p = 0.02), pain scores on day one (r = -0.31, p = 0.00), day two (r = 0.29,

p = 0.00), day three (r = -0.22, p = 0.02). There was no significance for less analgesic

medication use (r = -0.11, p = 0.26) as shown in Table 6. The results confirmed

Hypothesis 2 for pain, but rejected it for analgesic medication use.

Hypothesis 3

Hypothesis 3 stated that there would be less analgesic medication used in those

older adults receiving hip or knee arthroplasty who had a high degree of spirituality

involvement and beliefs and a high score on the self-health assessment tool.

An ANOVA regression was used to determine if there was an interaction between

good to excellent health and a high degree of spirituality. The relationship was not

significant (F = 1.04, p = 0.38). Further analysis a T-Test was used to determine if there

was a difference in the average analgesic medication use between the high spirituality

group and the good to excellent self-assessed health group (Ms = 7.63 and 8.49

respectively). Hypothesis 3 was rejected.

Additional Findings

For the purpose of this research, one question rating degree of spirituality was used

from this scale. The SIBS tool was satisfactory and demonstrated a Cronbach Coefficient

Alpha 0.94 Raw Score. Each participant completed the 39-item questionnaire and there









were a many positive responses to specific questions on the spirituality and beliefs scale.

For example, on the item "spiritual health contributes to physical health," 70.4% agreed

or strongly agreed. Most participants considered themselves spiritual when asked to rate

their spirituality on a scale of 1 to 7 (with "7" being the most spiritual). Participants used

religious coping such as hope, personal relationship with a greater power than self, and a

belief that prayer changes things. A high number of participants (77%) wanted others to

pray for them during their illness. More than 70% of the respondents felt that spiritual

health contributes to physical health. Additionally, 95 or 82.6% of the participants

always or almost always make an effort to apologize when they do wrong to someone.

Overall scores on the SIBS instrument reflected a positive relationship with a higher

power, prayer, a belief in an after life, and continued spiritual growth (see Table 7).

Participants expressed difficulty with the SIBS questionnaire and often said, "this is

too hard to answer" or, I have to think a lot". However, no participant asked for

clarification of a SIBS question.

The Short Form-36 Health Survey

For the purposes of this research participant response to the question "In general

would you say your health is: excellent, very good, good, fair, poor" was used for

analysis. Participants answered the 11-item self-assessment tool that queried physical

and emotional function. It is of interest that most were "limited a lot" for vigorous and

moderate activities. Daily activities such as walking, bending, kneeling and stooping had

the highest response for "limited a lot". Simple activities such as dressing and bathing

were least limited. The tool seemed easier than the SIBS for participants to complete and

there were no missed questions.









Table 1. Frequency and Percent of Variables
Variable Frequency Percentage
Sex
Male 41 35.7
Female 74 64.3

Ethnicity
White 111 96.5
African American 1 .9
Hispanic 2 1.8

Operative Site
No response 2 1.7
Left Total Hip Arthroplasty 16 13.9
Right Total Hip Arthroplasty 18 15.7
Left Total Knee Arthroplasty 32 27.8
Right Total Knee Arthroplasty 35 30.4
Bilateral Total Knee Arthroplasty 12 10.4

Orthopedic Surgeon
Surgeon #1 81 70.4
Surgeon #2 23 20.0
Surgeon #3 11 9.6

Regional Anesthesia
No Regional 22 19.1
No Response 1 .9
Epidural 29 25.2
Femoral Nerve Sheath 56 48.7
Psoas Compartment Sheath 4 3.5
Continuous Spinal 2 1.7
Spinal 1 .9

Patient Controlled Analgesia
No Response 3 2.6
NoPCA 35 30.4
PCA 77 67.0

Anesthesia Type
No Response 2 1.7
GETA 100 87.0
Spinal 5 4.3
MAC 3 2.6
Continuous Spinal 5 4.3









Table 2. Summary Measures of Variables


Variable
Age
Av. Pain
Scores day 1
Av. Pain
Scores day 2
Av Pain
Scores day 3

Median Pain
Scores day 1

Median Pain
Scores day 2
Median Pain
Scores day 3
Health Self-
Assessment
Spirituality


Mean
67.70
3.34

2.28

2.24


2.97


2.01

2.11

0.82

0.69


Std. Dev
8.23
1.99

2.04

2.15


2.67


2.31

2.38

0.39

0.46


Minimum
55.00
0


Maximum
86.00
9.13


7.20

9.20


9.75


9.00

9.00

1.00

1.00


Table 3. Pearson Correlation Coefficients-Spirituality and Variables with No
Adjustments
Variables r value p value n
Age -0.02 0.84 111
Pain Day 1 (average) 0.01 0.92 109
Pain Day 2 (average) 0.02 0.84 108
Pain Day 3 (average) 0.03 0.78 103
Pain Day 1 (median) 0.01 0.91 109
Pain Day 2 (median) -0.03 0.75 108
Pain Day 3 (median) 0.10 0.30 102
Analgesic Medication Use Day 1-3 -0.04 0.69 109




Table 4. Pearson Partial Coefficients-Controlling for Health Assessment


Variables
Age
Pain Day 1 (average)
Pain Day 2 (average)
Pain Day 3 (average)
Pain Day 1 (median)
Pain Day 2 (median)
Pain Day 3 (median)
Analgesic Medication Use Day 1-3


r value
-0.05
0.05
0.06
0.06
0.05
0.01
0.13
-0.02


p value
0.60
0.59
0.53
0.56
0.63
0.92
0.18
0.81









Table 5. Pearson Correlation Coefficients-Health Self-Assessment and
No Adjustments


Variables
Age
Pain Day 1 (average)
Pain Day 2 (average)
Pain Day 3 (average)
Pain Day 1 (median)
Pain Day 2 (median)
Pain Day 3 (median)
Analgesic Medication Use Day 1-3
Spirituality


r value
0.23
-0.31
-0.29
-0.22
-0.26
-0.30
-0.21
-0.11
0.13


Variables with


p value
0.02
0.00
0.00
0.03
0.01
0.00
0.04
0.23
0.17


Table 6. Pearson Partial Coefficients-Health Self-Assessment and Variables Controlling
for Spirituality
Variables r value p value n
Age 0.23 0.02 108
Pain Day 1 (average) -0.31 0.00 106
Pain Day 2 (average) -0.29 0.00 105
Pain Day 3 (average) -0.22 0.02 100
Pain Day 1 (median) -0.26 0.01 106
Pain Day 2 (median) -0.30 0.00 105
Pain Day 3 (median) -0.22 0.03 99
Analgesic Medication Use Day 1-3 -0.11 0.26 106









Table 7. Frequencies and Percentages for Self- Reported SIBS Questionnaire (N=115).
Answers reflect Agree or Strongly Agree scores only Frequency Percentage
except for questions that are reverse score negatively
worded items. These items were scored disagree or
strongly agree.
(1) I set aside time for meditation and/or self- 51 44.3
reflection.
(2) I can find meaning in times of hardship. 67 58.3
(3) A person can be fulfilled without pursuing active 43 37.4
spiritual life. (disagree/strongly disagree)
(4) I find serenity by accepting things as they are. 53 45.0
(5) Some experiences can be understood only through 64 55.6
one's spiritual beliefs
(6) I do not believe in an afterlife. 70 60.9
(disagree/strongly disagree)
(7) A spiritual force influences the events in my life. 70 60.9
(8) I have a relationship with someone I can turn to 69 60
for spiritual guidance.
(9) Prayers do not really change what happens. 79 68.7
(disagree/strongly disagree)
(10) Participating in spiritual activities helps me 70 60.9
forgive other people.
(11) I find inner peace when I am in harmony with 68 59.2
nature.
(12) Everything happens for a greater purpose 70 60.9
(13) I use contemplation to get in touch with my true 43 37.4
self.
(14) My spiritual life fulfills me in ways that material 62 53.9
possessions do not. (This question is missed by 25
or 21.7% do to its position in the questionnaire)
(15) I rarely feel connected to something greater than 62 53.9
myself. (disagree/strongly disagree)
(16) In times of despair, I can find little reason to hope. 80 69.6
(disagree/strongly disagree)
(17) When I am sick, I would like others to pray for 89 77.4
me.









Table 7. Continued
Answers reflect Agree or Strongly Agree scores only Frequency Percentage
except for questions that are reverse score negatively
worded items. These items were scored disagree or
strongly agree.
(18) I have a personal relationship with a power greater 81 70.4
than myself
(19) I have had a spiritual experience that greatly 57 49.6
changed my life
(20) When I help others, I expect nothing in return. 98 84.2
(21) I don't take time to appreciate nature. 70 60.9
(disagree/strongly disagree)
(22) I depend on a higher power. 70 60.9
(23) I have joy in my life because of my spirituality 74 64.3
(24) My relationship with a higher power helps me 69 60.0
love others more completely.
(25) Spiritual writings enrich my life. 61 52.1
(26) I have experienced healing after prayer. 47 40.9
(27) My spiritual understanding continues to grow. 74 64.3
(28) I am right more often than most people. 34 28.0
(disagree/strongly disagree)
(29) Many spiritual approaches have little value. 62 53.9
(30) Spiritual health contributes to physical health. 81 70.4
(31) I regularly interact with others for spiritual 52 45.2
purposes.
(32) I focus on what needs to be changed in me, not 75 65.2
what needs to be changed in others.
(33) In difficult times, I am still grateful. 91 79.1
(34) I have through a time of great suffering that led to 51 44.3
spiritual growth.
The following questions were scored using only the response always or almost always
(35) When I wrong someone, I make an effort to 95 82.6
apologize.
(36) I accept others as they are. 75 65.2
(37) I solve my problems without using spiritual 25 21.7
resources.









Table 7. Continued.
Answers reflect Agree or Strongly Agree scores only Frequency Percentage
except for questions that are reverse score negatively
worded items. These items were scored disagree or
strongly agree.
The following questions were scored using only the response always or almost always
(38) I examine my actions to see if they reflect my 49 42.6
values.
The following question was scored 1-7 with "7" being the most spiritual. Scoring for this
question used response 5,6,7.
(39) How spiritual a person do you consider yourself? 50 66.9


Table 8. Frequencies and Percentages Questions that Indicated Ratings for General
Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey
questionnaire (N=115).
Questions Frequency Percentage
(1) In general would you say your health is: 94 81.73
response: excellent, very good, good

(2) Compared to one year ago how would you rate
your health in general now?
Much better 9 7.83
Somewhat better 18 15.65
About the same 61 53.04
Somewhat worse now 23 20.00
Much worse now 4 3.48

(7) How much bodily pain have you had during
the past 4 weeks?
No response 2 1.74
None 0 0
Very Mild 14 12.17
Moderate 36 31.30
Severe 46 40.00
Very Severe 17 14.78

Additional findings included the increased use of regional analgesic techniques

during the last six months of this research. Concurrent research by another investigator

enrolled some of these same participants receiving total knee arthroplasty in a study using

femoral nerve sheath technique to treat postoperative pain. This investigator examined









the pain report outcomes for two of the most frequently used regional analgesia methods

of postoperative pain control: epidurals and femoral nerve sheath catheters. Analysis of

these two methods compared the mean pain scores on postoperative days one, two and

three. Both techniques had lower mean scores for pain scores on days one, two and three

when compared to no regional technique. The epidural provided the lowest mean score

day one (M= 2.74) compared to the femoral nerve sheath on day one (M= 3.17). Those

participants using PRN analgesia and no regional technique had the highest mean pain

score on day one (M=4.25). On day two, the femoral nerve sheath provided the lowest

mean pain score (M==1.82). On day three all of the regional analgesia had been

removed, but the mean pain scores for those persons who received regional analgesia

remained similar to days one and two. On all three days the PRN analgesia group had the

highest mean pain score (Ms= 4.25, 2.90, and 2.94, respectively).

In summary, these findings demonstrated that participants in this study were in

moderate to severe pain and had functional limitations preoperatively, but described

themselves as in good to excellent health and very spiritual. The use of regional

analgesia for postoperative pain control did lower pain scores for all days when compared

to those who did not receive a regional technique.














CHAPTER 5
DISCUSSION

The purpose of this study was to examine the relationships between the degree of

spirituality and high scores on a self-health assessment questionnaire with three

postoperative outcomes after hip or knee joint arthroplasty. Specifically, this study

examined the relationships between a high degree of spirituality, a high score for

individual self-health assessment and pain report and analgesic medication use for three

days after total joint replacement surgery. The hypothesized relational statements were

based on the need for quantitative data collection measuring the relationships between

spirituality, health assessment, pain report and analgesic medication use. There is no

previous empirical research that has examined these relationships in the postoperative

arthroplasty patient. The study sample consisted of 115 participants scheduled for hip or

knee arthroplasty in a large Southeastern teaching hospital. This chapter will present a

discussion of (1) research findings, (2) conclusions, (3) research strengths and

weaknesses, and (4) implications for nursing practice.

Research Findings

This section will discuss sample characteristics, followed by study of findings as

they related to the research questions.

Sample Characteristics

One hundred and fifteen older adults who were scheduled for hip or knee total joint

arthroscopy consented to participate in this study. All of the participants were recruited

from the pre-surgical anesthesia center of a large teaching hospital. In this convenience









sample, the participant ages ranged from 55 to 86. The average age was 67.70. There

were 41 males and 74 females enrolled in this study. This finding is somewhat less than

the 2:1 ratio females to males in osteoarthritis prevalence as reported by other researchers

(Davis, Ellinger, Newhaus, & Hauck, 1987). Participants described their generalized

body pain as severe or very severe (55%) during the four weeks prior to their scheduled

surgery, but self-assessed their health as excellent, very good or good (81.73%).

Anderson, et al. (1993) and Mobily, et al. (1994) reported similar pain report among older

adults. This research found that functional abilities were severely limited for vigorous

activity such as participating in strenuous sports, lifting heavy objects, vacuuming,

playing golf walking several blocks, bending, stooping and climbing stairs while more

moderate activities such as lifting groceries, bathing and dressing were "limited a little".

Praemer, Furner, & Rice, (1992) and Salmon, et al. (2001) found similar functional

limitations in osteoarthritis patients.

Ethnicity could not be examined due to the low numbers of African Americans and

Hispanics enrolled in this research. Felson (1988) similarly found that greater numbers

of European whites have osteoarthritis than other ethnicities and this may account for the

differences observed in this study. Only one African American and two Hispanics were

enrolled in this research. Socioeconomic status may have been a factor in the low

number of other ethnic groups seeking joint replacement. However, socioeconomic

status was not considered in this research.

Spirituality, Pain Report and Analgesic Medication.

The first research question examined the relationship of a high degree of

spirituality, postoperative pain scores and analgesic medication use. One research









question was used from the SIBS questionnaire. Two groups of participants were created

using one research question from the SIBS questionnaire. Those with high scores for

spirituality were considered highly spiritual. The majority (69.4%) of the respondents

were highly spiritual. A partial correlational analysis was used to identify a relationship

between a participants' high spirituality and the variables, age, pain report for three days

and analgesic medication use postoperatively, controlling for self-assessed health. There

was no relationship for spirituality and the variables. Therefore, hypothesis 1 was

rejected. Participants who have a high degree of spirituality did not tend to have less pain

and did not tend to use less analgesic medication postoperatively. Although there was a

high participant response to spirituality, the possibility of spiritual coping did not tend to

influence pain or pain medicine use after joint replacement surgery.

Health Self-Assessment, Pain Report and Analgesic Medication Use

It was hypothesized that participants who consider themselves healthy will report

less pain and use less analgesic medication postoperatively. The health variable "In

general would you say your health is: excellent, very good, good" was used to identify

those participants with a high score on health assessment. Of the participants, 81.7%

rated their health in this positive way. Correlation analysis found that persons who

considered themselves healthy tended to have less pain on each day postoperatively but

they did not tend to use less pain medication. Therefore, there was no association

between high health scores and less pain medication use. Further analysis using a partial

correlation controlling for the spirituality variable, found similar results; a healthy

assessment was related to less pain for the three days postoperatively and had no

relationship with the amount of pain medication.









In summary, participants who rated self-health as good, very good or excellent

tended to experience less pain during the first three days postoperatively. However, these

same participants did not tend to use less pain medication. Research question 2 was

accepted for less pain, but rejected for less pain medication use.

Impact of Health Assessment and Spirituality on Pain Reports and Analgesic Medication
Use

Lastly, it was hypothesized that participants who considered themselves to be very

spiritual and healthy would use less analgesic medication during their postoperative

recovery. A regression analysis was used to determine possible interactions between

health assessment and spirituality and analgesic medication use. There was no

relationship between the variables and pain medication. A further T-Test was used to

determine if there was a difference between the high spirituality and the high self health

assessment groups in analgesic medication use. The T-Test found no mean difference

between the two groups.

Therefore, Hypothesis 3 was not accepted. Those participants who self-rated their

health as good, very good or excellent and considered their spirituality as high did not

tend to experience less pain or use less pain medication than did the other research

participants.

Conclusions

Although participants reported moderate to severe bodily pain and a decrease in

functional activity on a health questionnaire, they considered themselves to be healthy.

There was a relationship between self-health and pain for the first three days after

surgery. It demonstrated that how a person views their health contributes to the amount

of pain they experience after joint replacement. Additionally, less pain experienced did









not mean less pain medication used. There has been no previous research evaluating

relationships between how healthy an individual feels and the amount of pain medication

used after surgery. Previous research that has evaluated health status has been with

individuals who were in "poor health" with long-term disability after surgery.

Most participants considered themselves to be highly spiritual and used spiritual

coping methods such as hoping, praying and dependence on a higher power. There is no

previous research that has examined the spirituality and postoperative pain or pain

medication use afterjoint replacement surgery. Previous research that evaluated

spirituality, health assessment and functional recovery used a very different patient

population. The only similarity was a high degree of spirituality among the older adult

rehabilitation patients (Fitchett, et al. 1999; Kim, et al. 2000; Pressman, et al. 1990). In

my research, most reported that they used spiritual coping methods and behaviors such as

participation in spiritual activities, spiritual writings and prayer. They also believe their

spiritual health contributes to their physical health. The majority of the participants in

this research used these spiritual coping methods. However, there was no evidence that

high self-evaluation for spirituality influenced pain or pain medication use after total joint

replacement surgery.

Strengths and Limitations

Although this research had strengths, it was limited in its methodology. Primarily

it was a convenience sample of pre-operative total joint arthroscopy patients. This

research was impaired by the use of regional anesthesia by the majority of the

participants. These patients received more regional anesthesia techniques for pain control

postoperatively than most other surgical patients. Regional analgesia is an effective

technique in the treatment of post-operative arthroplasty pain. Pain report and









medication use for this group of patients were affected by the use of the regional

anesthesia techniques. It was not possible to control for the increase in regional analgesia

techniques during this investigation.

There was an uneven distribution of males and females. This was to be expected,

but did not approach the 2:1 ratio for osteoarthritis found in previous research. There was

no ethnic diversity found in this research and this finding does not represent the ethnic

distribution in the geographic region.

Implications for Nursing Practice and Future Study

There is evidence from this study that these patients requiring total joint

replacement for osteoarthritis have a high degree of spirituality and perceive their health

as good to excellent. They use spiritual coping and behaviors such as prayer, spiritual

activities, and belief that spiritual health influences physical health.

Second, they feel their health is good to excellent regardless of their functional

limitations or pain. This self-assessment of good health contributed to less pain after total

joint surgery, but did not lessen the need for pain medication.

It is important that the clinician recognize that the postoperative patient is

multidimensional in their self-health and their spirituality. This quantitative study did not

support the hypothesis that spirituality decreases pain or pain medication use. This

research did find a relationship between self-assessed good health and decreased pain, but

did not find a relationship in less pain medicine use. This research contributes to the body

of literature evaluating spirituality and health in the older adult.

Future research should include postoperative function and pain using longitudinal

data collection. Assessing joint arthroplasty subjects pre-operatively, one month

postoperatively and at the end of the one-year recovery period would provide long-term









data on the relationships between spirituality, self-health assessment, pain and physical

function. Correlating functional longitudinal data with spirituality and health assessment

would provide more pertinent information without interference from postoperative

regional analgesia.

The implications of this study for nursing practice are that the findings of this study

support the use of spirituality and spiritual behaviors by the majority of the participants.

Good to excellent self-health assessment did change the amount of pain these participants

reported after surgery. Nurses should be more at ease in assessing a patient's spirituality

and self-health. Nurses do have to recognize that how a patient evaluates self-health may

be important in reducing postoperative joint arthroplasty pain.

In summary, evaluating the participants' spirituality and self-health assessment

found interesting relationships between postoperative pain and analgesic medication use.

Second, these research findings have implications for further future nursing research.















APPENDIX A
LETTER OF AGREEMENT
















1 UNIVERSITY OF
FLORIDA


,tlcr.- oni Mdedrp,.
eputment of Drthopedics and Rehabilitation



July 25. 2003


R. Petr lafate, PharmiD.
Chairman IRB 01
Box 100173


PO Box 100246
ainewsil FL 326~04)24
Plr.e i3t1392-L51
Fa.. 352i 3r2-afb37


Re: Poject 259-2003 "EBfecs of Spiral Belies and Involvement and a Positive Self-Halth
sicssmnenl Lri PredLr;n POSt-Operati Analgesic Medicaion Use in Total oint
Arhroplasly in the Older Adult"

Dear Peter,

I am aware of Pau riia McNaily',s audy on Lh, eAliecu of spiriiWIa bdicfs and its relationship on
pr1-opje)[alc analgcic imTdicadtir in lotl joint arthroplasty. She and I have had multiple
convenwrsaions about the study and the implementation of iL


1 appreciate the work and diligence of your group

All rhc hWi,

Sincerely.



Peter F. Gemren, M.D.
Associate I'roi'es~r and I[ntim Chairman
Dcpnirmnci ofOrhopaedics an] Rtehailliison

PFG/M

CC: Ms. LLrLId Kephan FI iln
Coordinmolr Rie~arUh Programs
Box 100173















APPENDIX B
INFORMED CONSENT 08-19-03 TO 07-15-04















Infonneconstl 0 Pakw re har kan k Sr
ond .whOraauetonfor Collecrion; Use, and
Disclosure of Protecled Heallh 14(onnfaton


University at fiorna
Heath Center
Instllional Review Board
APPROVED FOR USE
fea~8i9.m ffjt~fo -i~agi


IRB# 2S92003


You r being asked to take par in a research slid. This form provides you with Infomlion
about ite srud and sleks your auhonzation for the collkln, use and disclosure of your
proclead hcaltlih fomnnion necessay forthe study. Te Principal invewigaior (le pcrsn in
carge ofthis research) or a representatiw" offh Principal Investiglor v-il adLo dscnibe Ihis nsudy
to you tn ansHer aLi of your questions. BcfoI)ou decide whether or noi to tke pan, read ihe
information below and ask quesiorm about anything you do not undcstm d. Your participation is
entirely voluntary.

1. Nime or P lartpnpal ("Sludy Subject")



2. Tilk of Rearch Study

Effects ofSpiritual Befeis and rnvolvenwy t end a Positive Self-Healh As5csmer t in
Predicing Posoperative Analgesic Medication Use in Total Jont Athroplasty n the Older
Aduh

3. Principal lanvestgar and Tclkphone Numberis)

Patricia Anne McNalt
352-281-7452


4. Somrce orFundlag or Other Material Spport

University of Firida


S. What l the purpose of thi research study?

You are being asked if you are itereed in parric~patiinn his tidy because )ou are


259-2003 07-10-03 / Page 1 of 7












scheduled fr joint repllacinent surgery. This study is being done to ser if thre is a
relationship between your spiritual belef h and your health evaluation and your nted fr pain
medicine. T11 purpose o ihis study is to measure the amount of ain medication you use for .
the first three days after )our surgery.

6. What wWl be done if ou take part l (hias research study?

You will be asked to participate in this sIudy after >ou haFe been scheduled with Dr. P.
Gearen for hip or knee replacenmnI surgery. Through your panicipalon -i this study you will
be asked to complex Iwo survey questionnaires. These survey queslionrA~res ul l dke
approxin~tely 20 minutes io complete. You do not lave to answer ahl ofth questions if you
do not want to answer lL The purp~bc orthis study is to explore reltionshps between
sprtual beliefs, spiritual involvcneni, a personal health evaluation and the amount of pain
indication use after joint replaemen surgery. Your medical record wil be eaminied for
three days after surgery to determine the amount orpain ou report nr surgery and the
amount of pain meication you use. Other info nm oron e'mincd froim your medical record
Aill include your age, sex, diagnosis, location orjorum replacerncni and anesthesia given 10
you during your surgery. The Prncrpal Investigalor will code Oil ofyour infor nnion wilh
confidential code numbers. All ofyour data will kep in a locked secure fie.
All of your care wa be normal procedures ihat arc part of he ireaL-erm for all patients
haT-irng otial joint replacernent surgery. There will be no differences in your treatment while
you are part ofthis study.


7. Whma ar e heposible discomforts and riss?

There will be no possible risks for you as a participant in this study. You may experience
discnmfort in aswering qulestons regarding .3ou spirilualil)
Throughoi the study, the researcher will norify yu of new infomaliaon that nay become
available that irna) aff et .or dJcsion 10 reniain in the sudy.

If you wish to discuss the information above or anr discomforts you nmay e, ask queiorns nrow or call ihe Principal Inlrigator or co cun person listed on the front page of
this form.


sa, What are the possible baenelts to you?

There are no benefits to you as part of hi study.


8b.What are the possible benefits to others?

If this lsudy should show a relationship between spiritual b]ie l spiritual participation
person health evaluation and pain medication use, other studies may be done to develop
alternaiWve ways to treat patients in the future.


-;9.-03 / 07-10-03/ Page 2 of 7













9. If you oose to take part in this retarch study, will It ct you anything?

Thre wig be no change to you for being part of this study.


10. Willyou receive tompenIallin for asking prt in this reserch study?

You will not be paid for taking par in ths study.


11. What If you are Injured because of Ihbe b hl.?

[rfou cip.cricen an injury that is dircy caused by this slidy. only professional consulllive
care thai you receive at the University of Florida Health Science Center will be provided
without charge. However, bespiial cxpensi will have to be paid by you or .!Fw i,-ksurancw
provider. No other compensation is offered.


12. What olher options or treatments are atailjble if yu do not want lo be in this sudy?

You ar free 10 choose no to take pa in this study. Ifyou chose not to take part n this
study. your joint replacement surgery will continue and you wil receive the same level of
care. f you do not want to take part in this study, tell the Principal Investigaor or her
assistant and do not sign is Ii nforned Conseni Form.


13a. Can you wilhdraw from this reuear study?

You am free to willdraw your consent and to slop partkipalr' in his research study at any
time. If you do withdraw your consent, there w~II be no prally, and you will not lose any
benefits you are nlitled to.

f you decide to withdraw your consent to panricpaie -i il research sudy for any rJson, you
should contact Patricia Anne icNalty n (3 5 ) 2!1-7452.

Ifyou Iha e any questions regarding iour right s a rescich submi. you may phone the
Institutional Review Boad (IRD) oflte at (352) 846-1494.


13b. If you witlhdrw, can inlormatloa about you still be used sad/or collected?

f you withdraw fronm the study. the principal inveslator would like to mrninue io keep end
use bhe infonnation that you conpleed using the questionnairs, pain scores, pain medicine
and other information obtaied from your medical record If ou refuse to le the Principal
Invesigator continue to keep and use this information, it will not be used.


259-2003 07-0-D3 Page 3 of 7













13c. Can Ihe Principal investigator nihdraw you from hbis research stud)?

You may be withdrawn firn the sLudy without your consent for the following reasons;
You did not quality to be in ait study because you do not meet the Sudy reqLirimnnts Ask
the PiLnipal Investijiiorr if you woltd like more information obos this.


14. How nlIyour privacy and the confidentitUl) of hour prorreld health informarion be
protected?

Data will be gearered and maintained using confidential codes io proltiu o'Lur identify. Patricia
McNally, the Principal Invstigator, will gather medical data obtained from your medical
cord. All data and inirmtion will be kept in a locked file in the office of Palrlci McNally,
the Principal Invcsigalor. Patricia McNally wi a.sgn aU confidenLal code numbers Access
to your file w be restricted to the principle investigator.

li)ou participale in ths research, your proiccied h dilh infonrm ion will be coUlcc.-d used, and
disclosed under the terms specified in seclio 15 23 b-low.


15, ItIou agree to pardcipate in Ibis rtwarch arudy, what prtected health nforl action
about you may be colleci d, used d disclosed to other?

To dvlennine your cligibly rb r Ihe study and as part of your participation in the study, your
protected health Infornn;ton that is obtained from you, from review cf your pst. curmiil or
Ifture health record~ from procedures such as physical examntions, xrys, blood or urine
tests or other procedures. forn your response to any study trealnm ts you receive, from your
study visit and phone calls and "a other sludy relitd hrthh inlbrmntion, may be collected,
used and disclosed to others. More specifically, the fllowig information may be collected,
used, and disclosed to others:
Complete past medical history to determine rig iihi y criteria listed in informed consent
Quest ;onnires that you have comptl8ed
Medical records about yourjoinl replacement surgery
Medical records about pain nmdiialion us after surgery
Medical records about pain reported
Mkedial reords about ancsiF ia used during surgery


16, For whal srudl-relled purposes sill )our p roecled health lnformati a he coll0Eed, used
and dbclosed to others?

'atrr protlcid health information may be collected, used and disclosed to others to find out
your eligibility for, to carry out, and to !e auaic the results of the research study. More
specifically. your proectred heJath information may be colkleted, used and disclosed or the
Iblloling sthudy-reiued purpose): to determine if our slf-hrclsh assesrineri and spiritual
beliefs and spiritual parlicpalLori are related I. your pain afler surgery.


2 9- 2uU1 /07-10-03 F Pae 4 of 7














17. Who will be authorized to collect, use and disclose to otfbrs your protected health
iiformalion?

Your prolecled health r-formation may be collected, used, and disclosed to others by

the study Principal Investigator. Patricia A. McNalty
Dr. Peer Gearan, ChairnmuL Depanmenl of Onhopedii Shands at UF
ohir professionals oa the University of Florida or Shands Hospital thai provide study-
related ratment or procedures
The Univesity of Forida Institutional Review Boad



I1 Once collected or used, who may your projected health information be disclou-d lo?


SUS and foreign goviermenual aSencs who are responsible for overseeing reach,
such as the Food ad Drug Adrmnistration. the Department of Heakh and Human
Services, and the Oilice ojF Huan Research Prolcclbons
Government agencies who are responsible for overseeing public health cones such
as the Centers for Disease Cotrol and Federal, State ad local health departments


19. Ifyou agree to partlcipale ln bis research, bow lo will your protected health
information be collected, used and disclmed?

Your projected heallh inbrnmaion will be used and disclosed forever.



20. Why are you being lasdt roe turhorhz Ihe collection, use mad disclosure to orher afyour
protected health inornmalion?

Under a new Federal Law, researches cannot collect, u.e or djsclor any ofyoa prolclicd
heacih [nifmu ion for research unless you allow them to by signing this canse arJ
authorizarion.

21. Are you required to sign this content and authorizatin and allw the researchen to
collect, use and discose (give) to others ofyour protected health information?

No. and voLr reiual ro sign wilm nt alffcl yor Ircalnmeni, payment, oero1Mb nl, or eliibilty
for any benefits outside this research study. fHoiver, you cannot participate In tis research
unless you allow rhe collection, use ard dtscairir'e iftyrir protected he lth mrobrowaion bi
signing shis cwfasendmfrkorlaftio


259-2003 / 07-10-03 / Page 5 of 7













22. Can you review or copy your protected health infomatioR collNcted, used or disclosed
under iis aulboratlion?

You hanw the righ to review and copy your projected health infonnrion Howvr, you will
not be allowed to do so until after the study is finished.


23. is there a risk tht your prorwled health Ina rma ion could be given to others beyond
your authDrinzlioB?

Yes. There is a nmk Lhat injornuiCOn received by owlhorized psernS couDJ be given to others
beyond your aufthrizalion and rit covered by the law.


24. Can you revoke (cancel) your nuthortbtion for colectiona use and disclosure ofyour
protected health Information?

Yes. You fcn ca-.el your aLuLhrizaion a1 iny time before, during or aflnr you pnnicipaiion in
the rcscuch. Ifyou cancl, n nnew inform ationr wil be collected about you. However,
infornation tht wnas ready collected may be sVM be used and disclosed to others if the
researchers have crlied on it to complete and project the vraLidny ofrie research You can
cancel by giving a wrInLn reqicsi whih 3our signature n hi to the l'rinipal lnuesiigioor


25. How t ll rhe researchers) benefit from your being In this study?

In gcr erdi. prcscninfl research results helps carmLr uo scientli Tlhrcrore, ihe Principal
invesialor may beneEf if lhe result orfhis trudy are prCesnted t siehulrIC nrcing or in
scientific; journals.


259-2003 / 07-10-03 / Page 6 of 7







61




26. Signatures

As a representative of this study, I hav explained to the participant th purposL4 the
procedures, the possie benets, and ihe risks of his search study; the alternatives to being
in ihe study, and how the pnrticipdan's proicled hr lrh inrormnilon wil be collected used and
disclosed:




Signacl of Person Obnining Consern and Authcriarmon Date



You have been informed about thi study's purpose, pocedres, possible benefits, and risks;
the alternatives to beirg n he study. and how your protected hcnhh infomnlion wifl be
covected. used and disclosed. You hImc recc. cd a copy of his Form. You have been given
the opportunity to ask quer ians before you sign, and you have been told that you cn ask other
questions at any tmne.

You olunrilyarn agree co parikipate in this sudy You herchy aulhorize he colBection, use and
Lisclosure ofyaur proiecied thelrh unformalian us d-cribcd ir setIonm. 14-24 above, By
signing this f you are not tiiving any of your legal rngrh;




Signature ofPerson Consening and Aulhorizing Date


259-2003 07-10.03 / Page 7 of7















APPENDIX C
INFORMED CONSENT 01-29-04 TO 07-15-04














Informed Conset to Paricipae in Research
and Autkhorriaon for Collecion, Use, and
Dicrlosure of Protected Health Itnformamion


IRBiB# 259-2


University of lorida
Health Center
Inslitutional Review Board
APPROVED FOR USE
From I J/ o./ Through 7, /^/0


Yolu ar being asked to take pIt in a research study. This form provides you with information
about die study and sees your aulhorizalion for the collection, us and dis lI run:r L your
proteclcd health information necessary for the study. The Principal l i ics;I lc.r ( Lh person in
charge of this research) era representat ivofthe Principal Lrivemigaior will nlio Jdcs:nbe thi- ijuly
to you end answer all ofyour questions. Before you decide whether or not to lake par, read the
inmfonaionn below and ask cqucstrion abCtui an.U lliring )jo dJo njiot understand. Your particIpaliaLo L
entirely voluntary.


L. Name or Pn.ariipint ("Study Subject")




2. TIle of Resenrch Study

Effects ofSpiritual Beliefs and Involvement and a Posiltve Self-HelLh Assessment in
Prdliclng Postoperative Analgesic Medication Use in Total Joint Arhroplasty in Ihc Older
Adult


3. Principal Tn% esaiglor and Telephone Number(s)

Patricia Anne Mc N.ll)
352-281-7452


4. Source of Funding or Other Material Support

University of Florida


259-120031 Rv Ol7.27-04/ ~ge 1 of 7







64





5. Whal is the purpose of this research study?

You are being asked if you are inicrcscdj in p.aicip.liing in this study because you are
scheduled forjoin replacement ,urer Tins srudy i b ing do~ to scc if there is a
rcliaionship bctwcn your spiritual beliefs ain your: ellc evaluation and your need for pain
medicine. Tie purpose ofthis sludy is to measure the amount oCpain medication you use for
the first tree days Ailr your surgery.


6. What will be done if you take par in this research study?

You will be asked to puriAipaic in Ihs study allcr you have been scheduled with Dr. Gc;rc~i.
Dr. Myers, or Dr. Vlasak for hip or kne replaccaernt surgery. Through your participation in
ihis study you will be asked to complcle two survey questionnaires. These survey
qliisl;onnoircs will Inta uipron\ila[cI 20 minutes to complex,. You do not have to answer
all of the questions if you do not wanl I ans.cr all The purpose oflthis sludy is Io explore
reltioinships between spiritual dclicf1, spirilital involvement, a personal hall evaluation
and the amount of pain nudicariin use aRlr joinil rcplacmoncl surgery. Your medical record
will be cxainned for three days after surgery to determine the amount of pain you report after
surgery and the amount of pain medication you use. Other information examined from your
medical record will include your age. sex, diagnosis, location ofjoint eplaoen nl atnd
ansllhesia given to you during yo surgery. ThS Principal Invcstigator will code all of yrur
information wilh confidential code numbers. All ofyour daa will kepl in a locked secure
file.

All o your care will be normal procedures that re part of thc treatment for all patients
having, lotal joint replacement surgery. There will be n iliu n uiiccrin your Irealmcnl while
you ire part IrFlh; s.1mily


7. What are the possible discomforts and risks?

Ilcre w ill be no po:sibli ri.l,. for you as a pw;ric;pinl in ihis study. You nmayexperince
discomfort in answering qiuJerionr rc~grdi;ng your spiritualiy.

Throughout the study, the rzcserclier %..i]l IdcIul'y yu of ew informaltion that may bcornue
available that may ufacct your decision to remain in the study.

iryou wish to discuss Ihe information above or any discomforts you may experience, you may
ask questions now or call he Principal [nvesigatror contact person listed on the front page of
this form.


8a. What are the pouiblre lirnerli tn ou?

There are no bencils to you as part ofthis study.


259-2003D Rev 01,27-04 /pTa ",c- 'i













8b. What are the possible benefits to others?

[ this study should show a rclaionship between spiritual beliefs, tpiri mal p.ir;icipaiion,
personal health evaluation and pain medication use, oLther sudies nay I e incrin 1i develop
allcrnalive ways to treat patients in Ihe future.


9. ir you choose to take part In this riearch urud., will it cost omu anything?

There will be no charge to you For being part of Ihs study.


10. Will you receive compensallon for taking part in this research study?

You will not be paid for taking part in this study.


i What if you are injured because of the study?

If you experience n injury ih,[ is dircvcly caisid by thLs iuJy. oily prlf5ssioal consullative
care Ihat you receive at the University of Florida Healit Science Center will be provided
without charge. However, hospital expenses will have to be paid by you or your insurance
provider No ontiir coripcnniicin is offierd


IL2 What olhrr option or trrat m(a rire a c ailahcl if you do not want lo be In Lhis stud)?

You are Free to choose not to take part in [his study. If you chose not to take part in this
study, yourjoint replacement surgery will continue and you will receive the same level of
care If you do not want to take part in LhI i ~udy. tell the Principal Invcsligalor or her
assistant and do not sign this Informed Consent Formi


13n. Can you wlllhdraw from this research olud) .

You are fre to withdraw your consent and to slap panicip ling in this search study at any
rime. If ou Jo 'viilhdr o )or con.wnr. there will be no penally, and you will nol lose any
benefits you are entitled to.

II you dec, ide no wulniri-w your consent to participate in this research study for any reason, you
should contact Patricia Arne McNally at *3'52, 21 -7452.

If you have any questions regarling your righ as a research subject, you nay phone the
Institutional Rc-lew Ejrd (iRBi oicc F l (.1521 46-.194.-


13b. If you withdraw, can Information about you still be used and/or collected?

If you withdraw from the study, the Principal Investigator would like lo continue to keep and


2 9-2003 t/ r 0v L-214 / Page 3 or7













use the information ih.at yoi corr1pFl)cd using ihe qluisiornaires, pain scores, pain medicine -
and oilier information oblained from your medical record. If you refuse to let ihe Principal
Invesligalor continue to keep and use this inirmialion, it will not be used.


13e. Can the Principal In cstnigitor withdraw you from this research srudy?

You may be u ihdrain from the study without your consent for the following reasons:

SYou did not qualify to be in dIe study because you do not meet the study
requirements. Ask the Principal Invesligaor i you would like more infonnmaion
about this.


14. How will your privacy and the confdenlela.lly of your prrretrld health infnrmalWnh be
prot ictd?

Data will be gathered and maintained using confidential codes to protect your identity. Patricia
McNally. the Principal Ir' scligpor. will gather medical data obtained from your medical
record. All dala and information will be kepl in a locked rile in the police ofPaTui ciE McNlly,
I|Lu Pnricipal [vestigator, Patiicia TlMcNall dill assign all confidential code numbers. Access
to your Fle will be restricted Io ihe Principal Investigator,

if you participate in this research, your protected health information will he co lkl.-d. used, and
disclosed under the te=s specified in secions 15 24 below.


15. If you agree o participate in Ib s research slud). bhat proiLert-d hea lh idfornArian
about you may be coUeted, used and disclosed to others?

To dLirreir Lc ui c! igibili Ly if the sIudy and as paIr oI your participation in the study, your
prolected heallh infrmnalion that is obtained from you, fro review of your past, cuarcn or
future health rcconls, from procedures such as physical examinalions, x--nys, blood or urine
less or other procedures, rom your response to any study treatments you receive, from your
study visits and phone calls, and any oLliier asudy rriar-d IL akh information, maybe collected,
used and disclosed to others. More specifically, tie following in frunritiion ma y bK collecled,
used, and disclosed to others:

Complete past medicaL history to dalerninc eligibility criteria listed in informed
consent
Questioniaires that you have completed
SIMcdical rc-rd 1 aboful yourjoint replacement surgery
SMedical records about pain niedcalion use after surgery
SMedical records about pain reporlcd
Medical records about anesthesia used during surgery


259-2003 / RcV 01-21-.4 I'Pac 4 of 7







67





16. For what slud%-relaied purposes will your proteclod health information hb IclleclCd, used .
and disclosed to olbers?

Your protected health inrfomation may be collccled, used and disclosed to others to lind out
)ouc cligibilily for, lo carry o' aani is ievalu.ai1,Is il-resuh of [he rec sarn study. More
S .' Fticall. your prOLcMLCd health informJltioi nmay bccciL cct used and disclosed fo r he
following study-relaed purpose(s):

Sto dclcrminc '1 your selF-illalll i rsncmrnt and spinliual bliefs ad rpJ ninal
participation arc related to your pain after surgery.


17. Who wll be authllorized o collect, use and distrlse to others orur protected benlll.
information?

Your projected health inrbormnion may be collected, used, and disclosed Io otherC by:

Ihe sluJy Principal Investigalor. Patricia A. McNally
SDr. Per Gearen, Chainnan, Department of Orthopedics Shnds :i UF
oljer pro fisionals ai Ihe Uniln rsily of Fori da or Shands Hospital tha! proi; siuJv-
related irealmeni or pmledures
The University of Florida Instilutional Review Board


I. Once collected or used, wiso may your proie~tcd health information be disclosed le?

Your proteled health information may be given to:

United States and foreign oriimniernal 3agenc js -.FW iac responsible for overseeing
research, such as the Food and Drug Administralion. lhe D'p rrFmnrlt ofEcallh and
Human Services, and the Olfice ofrHuman Research Protections
Government agencies who are responsible for oVers~r ing public hc aih conc rrn i ch ~s
the Centers for Disease Control and Federal, Stale and local health departments


19. If you ngree to pnrliclpate in Ibis research, how long will your proteetrd health
information be colleled, used and disclosed?

Your protected health information will he colleled until the end of ihe srudy, This
information will be used and disclosed forever sine it will be stored for an indeinile period
of time in a secure dainbas.


259-20031Revo01,27-04: l'iL,c ?













20. Why are you being asked to authorize the colleclion, use and disclosure to oihrs ofyour _
protected health information? -- .

Inder a new Federal Law, tesearhecs cannot collect, use or disclose ry oar~iour priorlece
heallll inflorr'ion for research unless you allow them to by signing Ihis crnsnt and
authorization.


21, Are you required to sign this consent and authorlzallon and allow the researchers to
colIect, use and disclose (gisc) lo others of jour proiecled health information?

No, and your refusal to sign will nol afei'i your treatcnt, payment, cirollnrenti, Lreligibiilty
for any benlils outside tUis research study. However, you carJemo puirtr epa e in ld rfearclh
less you allow ite colleactri, ufenr orVl lisclosure of iiur prit;ectelhearih information by
sigdng this consentauthoriztion.


22. Can you review or copy your protected health Informalion collected, used or disclosed
under Ibis authorization?

You have the righi to review and copy your protected health infonntmion. Htlow. e. you will
not be allowed to do so unlil after ihe study is finished.


23. Is there a risl that your protected hbeth information could be given to others beyond
your authorizatlonu'

Yes. There isa risk that information received b) -unihori/ed persons could be given to others
beyond your authorization and not covered by i e law.


24. Can you rn uke (cancel) our aulbnorization for Ltoltion. useand dlsclosureor your
proleeied hralih information?

Yes. You .cincancel your auiuhoriil'(rt at any time before, during or oafer your participalion in
rie research. Ifyou cancel, no new information will be colJecied ambui you. However,
information Ila iass already collet rd im..y be slll be used and disclosed to oth s ifthe
researchers have relied on it wo currpleie and pruicci tihe ;dciill of ite rLse3arch You can
cancel bygiving a "vnhin rcquei u IC )t your sipnalurc on it to Ihe IPnrnip:I hIliiigator.


25. How will lte rsen reheril-s benefit from your bring in this study?

In general, presenting research results helps the career or a scienlis. Therefore, the Prinipal
]i ts Lnig. t. ma~ bcnefi if the results oflhis study are presented at scientific meetings or in
scientific joumnts.


259-2003 / Rev 01.27.41 ligc of 7













26. Signatures

As a representative of Uis study, I hIve explained to the participant the pLurpse, the
procedures, Ihe possible bir fisL. and Ihe risks of this research study; Ihi alternatives to being
ini the 51udy. and how the participant's protected health infoTmaton will be collected, usel, and
disclosed:




Si griauur of Peron ObLt ning CoInsIe ani Aulhon-alon Dale



You have been informed about this study'spurposc procedures. poaible benefit, anr nskst.
theallcnalivcs [o being in Lh2 sNudy. and howv your potected health information will be
collocietd. used and disclosed. You have received a copy of this Fonm You have been given
lthe opportunity lo ask questions bclirc you sign. and you have been told that you can ask other
questions ai any line.

'ou volunU~rily agree to palicipalt in this study. You hrreb" .uuLhori.h the .lkction, use and
disclosure oryour prolecled health information as described in sections 15-24 above. By
signing this ronrm you are not waiving any o your legal rights.


Signature ofPcrson Consenting and Aullhorizing


Dale


25900W IRcrv o1-27-04 / Pag 7 of 7















APPENDIX D
INFORMED CONSENT 07-16-04 TO 07-15-05















hIfon irm Consent to Paniidpnte in Research
and Authofriation for ColteeioMn, r, an d
Disclosure ofPrateced Health lifororaton


University of Florida
Health Center
lnstltutional Redew Board
APPROVED FOR USE
_Fr -4om__ Through V14.47.r
cS4


IR# 259-2003


You are being asked to lake part in a rsarcmh study. This form provides you wi h inlbrri lion
about ie study and seeks tour auithorin.aion for the collection usc nd disclosure aof yu
proecrid hea in irlbfor-minion nccLssarl for Ihe sludy. The Principal Inc si~aigor (die peron in
ichw;a oflhis rcA&erch) or a rcprcrsnlaiie of lIhe Principal Investigalor will also describe Ihis sludy
lo )ou arid jiriswLTr all ofyour questions. Your pilricipallr n is entirely voluntary. Before you
decide wlielher or not to take pan. ri.jl he iniomrrniaLn below irid ad. quiesiiont abcul ma)hin
you do nol understand. 1i you choose notr 1 participate in II~s s5Idy )ou will not be peniialcd or
laic lrny baiclils thai you woUld thterwAise be eirirEllnj l.

1. Nameof Participint ("Study Subject")




2. T'ileof RfslarchSludy

Eff is of Spiri;ual Beliefs and Involvement and a Positilc Seir-l lealdi A.-l5sin-iFci in
Prrdiciing Postoperative Analgesic Medicaion Use in Tolal Joint Artiroplasty in Ihe Older
Adult


3. Princpnl InTieslgalor and Telcphoae NunmbP~is)

Pairicia Anne McNally
352-281-7452


4. Source of Funding or Other Mncerril Support

University orFlorida


259-2003/Rev 6 4.4 /P Fc I of 7














5, Whal is the purpose of this research study!

You .ce being asked if you are interested in participating in this study because you are
scheduled for joint replacement surgery. This study is being done to sea if there is a
relationship belween yoLir spiri ual beliefs and your health evaluation and your need for pain
medicine, "Te pu-jpos of ih atludy is to measure the amount of pain inediehiiOn you use for
the frsi three dayi after your surgery,


6. Whnt will be done If you take part In this research sludy?

You will be asked to participate in this sludy after you have been scheduled wilh Dr. Gearen.
Dr. Myers, or Dr, Vlasak for hip or knee replacement surgery. Through your participation in
this study you will be asked to conrpile Iwo sure queslionnaires. These survey
questionnaires will take approximately 20 minutes to comptele. You do not have o answer
all of the questions if you do not want lo answer all. The purpose of this study is ln cmprincE
relationships between spiritual beliefs, spiritual involvement, a personal health evaluation
and the amount oflpaiin irdicalaion use after join replicirnini surgery. Your medical record
will be examined fcr there days ailer surgery to determine the amount of pain you report after
surgery and the amount ofpain medication you use. Oitlr inormiaiion etrnirncd from your
niedical record will includuc iour age, sex, dl.gnosis. loCAlIon ol'joint replacement and
anesthesia given to you during your surgery. The Principal Invesligalor will code all of your
informnlion wiih confidential code numbers, All orfyour data will kept in a locked secure
file.

All of your care will be normal procedures that are part of the ircatment for all patients
having tolal joint replacement surgery. ThLre Iill be no diTerences in your treatment white
you are part of this study.


7. What nre she possible discomforts and risks.

'Thee % il1 be no poNssibl nsks for yci as a pa ticiprnl in this study. You may experience
discomfort in answering queinions regardriin, our spintiulal').

Thrlouia1uii ihc sirdy. the researcher will nolify you of new information Ihait rmy become
available that may affect your decision to remain in the study.

If you wish to discuss the information above or any disconforts you may experience, you may
ask questions now or call the Principal Investigalor or contact person listed on the front page of
this form.


SaB What are the possible benefits to you?

There are no benefils Io you as par of Lhis study.


259-2003 / Rv 06-144 / Page 2 of 7







73





81. What are the possible benefits to others?

If Ihis iudry should show a relationship between spiritual beliefs, spiritual paiicip.Ilion.
personal hcallh evaluation and pain medication use, olher studies may be done to develop
allemative ways to Ircat patients in the future.


9. If you choose to take part in this research itud will it cost you anything?

There will be no charge to you for being part ofthis sludy.


10. WIl you receive compensation for taking part in this research study?

You will not be paid irr Ik in g part in this study.


11. What [fyou are Injured because or the studio ?

IFyou experience an injury that is directly caused by thii& study, only prifie.'iunal consultative
care that you res; c iiL the Uri crsily ofFlorida Health Science Center will be provide
.-irhoul chirgc. I Ich. o .-r. hospiinl expenses will have I be paid by you or your insurance
provider. No olh-r compeisilion is oflTfr Please contact the Principal Investialor listed in
Item 3 of this fImOi I yoLL \pc ricnce an injury or have any questions about any discomforts
that you experience while participating in this study.


12. What other oplioni or Irenrments nre aiallable If you do not want to be in ihis ludy?

You are free to choose not to take pan in this study. If you chose not to take part in this
study, yourjoiint replacceninc surgIery will continue mad you will receive Uth suam level of
are. if you do no want to take part in this study, tell the Principal Investigato or her
assistant and do not sign this Informed Consent Form.


3an. Can you nwitdraw from this research study?

You ar free to withdraw your consent and to stop participating in Lhis research sludy at any
time. if you do v6ilJhdiraw our conscri, there will be no penalty. and you will not lose any
benefits you are entitled to.

If you decide to widldraw your consent to participate in this eearh study fbr any reason, you
should contact Patricia Anne McNally at (352)28 1-7452.

If you hav an) q actions regarding your rihl as a research subject you may phone the
Instilulional Review Board (RB) office al 1352p 846-1 49-4.


259.2M00 3 Rev 06-1-041 Page 3 of 7














13b. If you "%ilhdran. can information about you still he used undinr collected?

If you withdraw from tie study, the Principnl Investigulor would like to continue to keep and
use the information ilat you complete using Ihe questionnaires, pain scores, pain medicine
and olher infornaiion obtained from sour iili~al record. If you refuse to let the Principal
Irn ctigsator corlinuc to keep and use this inf rmniiori, it will not be used.


13e. Can the Principal Investigator withdraw you from this research study?

You may be withdrawn from hde sludy without your consent for the following reasons:

You did not qu.ilif) Ho 'c- in the study because you do not meet the study
requireonentis Ask the Principal Investigator if you would like more infbormalion
about (his.


14. How will your privacy and the conflidencialir of )our prolected health informnaila be
protcoed?

D)la will be 4i.hcl.iLd a-ld nriinlaincJd using conldential codes to protect your identity. Patricia
McNally, the Pnicipal Investigator, will gather medical daa obtained from your medical
record. All data and infonnalion ill bI kept ni a lxked ile in WUiL ofITe:c of Patricia McNally,
the Principal nvcstigator. Patricia McNally will assign all confidential code rnwbers. Access
to your file will be restricled to the Principal Investigator.

If you participate in tlis research, your projected health information will be collected, used, and
disclosed under the iiens specified in sections 15- 24 below.


15. Ifyou agree to parllcipale in hiis research siudy. what protected health information
nhout you may be collected, used and disclosed to others?

To determine your eligibility for die study and as part of our panicipr lion n the study, your
protected health ifornalion tant is obtained from you, from review of your past, cu ren or
JurLUic hc iJLh rccords, from procedures such as pl.) i-c examinations, x-rays, blood or urine
tesis or other procedures, from your response to any study trealmenis you receive, from your
study hisii5 and phone calls. nnd aniy other slud) relat-d hcalih ini m.ilcior. rniy be collected,
used and disclosed to others More spec icnll., the following infonnalion may be collected
used, and disclosed to others:

Complete past medical history a delerin eligiili c rcrineia lisrd in informed
consent
SQuestionnaires thai you have comptcled
SMedical records about yourjoint replacement surgery
Medical records about pain medication use after surgery
Medical records aboul pain reported
Medical records about anesthesia used during surgery


-259*003 I ev 06Rc 4.- Pa 4 of7
















16. For wbat sludy-related purposes %ill your prolecLed hnlllh in ormation be collected, used
and discloIed to others?

Your proTecile hcj.ih i nforiaiori may be collected, used and disclosed l otlirs to ind oul
)our c I ig]hil] I f'Tr. to carry ou, and to evaluate the results oflhc research study. More
spiT.ilkla ly. your prlolcted health inlrcmiarion maybe collected, used and disclosed for te
Iollo.ing nudy-r.laiqd purpoae(s)

to dlcrrnie i'your s-lf-halil]i ;ssisn l enr and spntual beliefs and spiritual
pan;cip.j ion are rcialed to your pain after surgery,


17, Who will be auirlorlzed to sijlitcl. use and diclos lto others your protected health
Information?

Youw prolecced Ilealll infoermition maybe collecied, used, and disc.ors d to others by:

tlic sudy Principal invesigator. Patricia A MciNaJl
Dr. Peter Cearen, Chairman, Department or'Onhopediii. Sliar s at UF
oihcr professorilsl at rhe Univerity of Flonda arSh~nds Ho1lsilhi hal prio' mlC saidy-
rclated treatment or procedures
Th University of Forida Instituional Review Board


18. Once rollectrd or used, who may your protected health information be disclosed to?

Your protlcled health information may be given to:

SUniled Slates and foreign governmental agencies who are responsible for ovrseeing
tresarh. such as the Food iirsi Drug Adminiriinior.u Ihe Department of leallh and
Human Services, and the OiTicc of Hinan Research Proteclions
9 Govemment agencies who are responsible for ovcrsceiri public Iheith conccns such la
the cntlers for Disease Control and Federal, Stame uid ]ccal healIh depatnients


19. If you or9et to pnrlicipale In this rcsnerch, how long will your protected hellth
information be collcilcd, used nnd dlL.closed?

Your protected health infoamaion will be collected until the end oflhe study This
information will be used and disclosed forever since it will be scored for an indefinte period
of time in a secure database.


259-S03 I Revy0&1.4W I/Pftt ~ of 7














20. Why are you being asked to aultoriz the collccrion, use and dicTrourt ro oiheri uf your
projected health information?

Under j nc". FodcraJ Law, rrcfrcher crulrnnr ol [Ml. s or disclose any oryour protected
eallth information for research unless vwo allow dlnlrn o b.y signing this consent and
auftiorization.


21. Are you required to sign this consent and iullorization and allow the researchers to
collect, use and disclose (give) lo others of your protected benllh Informatloit?

No, and your refusal lo sign will not arect your treatimen, payment, enrollment, or eligibiyII
j;r an l b~ienefiP oLIIsrLJc ibh rcsairch slud). Hoi'.'ver '%u canxI t pjanicipate in this research
,.iMrss, aliathi ir. cotlcorrrf, ,tiF er'd Sio.rlrre 0j' rifr proSectd heakh infonrmatmo hNi
signing this consest/lauthorizotion,


12. Can you reticn or copyyour protected healJt tnformaorinu collcchid, used or dllosed
under this authlorizatlon?

You har thc ri ghr to review and copy your protected health inforrntion. However, you' ill
not be allowed lo do so until altr the study is 1rishei.,


23, Is there a risk Ihnt Nour proleried heaolh Information could be given In ohenrs beyond
your authorizaRton?

Yes. There is a risk thjl iiifoBmacion received by auhorizcd persons could be given to others
beyond yotr authorization and not covered by the law,


24. Can you rccie (cancell) yur nauhortzallon for collection, use and disclosure of your
projected health information?

Yes. You can cancel your authorization .11 any itim before, during cr .iaTr yoLo p;ricip.illor jn
the research. If you cancel, no new information will be collected about y However,
infonnation ihat was already collected may still be used and disclosed to others ifthe
researchers have relied on it locomplete and proi i Vt i.V.LdiI) ol'hc icicarch. You can
cancel by giin5 a writer rcques- with your signalureon [i io the Priinipal In,%clIgatr.


25. How %1ll Ilhe rtesorchLr(sj henefit rrom 3our being In ibis study?

In scrwirl. prcscrninI rIMesearci r culls help dime career ol a scientist. Therefore, the Pricipal
[tIiwesigior mra' bcnclii irthe resulls ofthis study are prtenltd at scientific meetings or in
Sl iellfic jCiumr js.


259-20031 /Rev 0614-04 / Pa6 of 7







77





26. SIgnalares

As a representative of ihis sudy, have explained lo ihe participant the pupose. Ihe
procedures, the possible bent fit, and Ihe risks or ihis rcarch sludy. ihe all'm.nitcs to being
in iliSe tuil, and how Ihc parieipail's protected health information will be collected, used, and
disclosed:




Signaiiun or Person Obtaining Consent and Authorizaion Date



You have been infonned about this sludy's ptupse, procedures, possibLo bmeielt, and risks;
ihe attemntves to being in the sludy, and ihow vyor prniecied ]i llh informilion will be
;oll]ccid, used and disclosed. You have received a copy ofthis Form. You have been given
ilt; opponuilly l Io ak qurslionrs be re[ n siln. and you hjae been iold imwr you can ask other
questions at ant iime

You voluntarily agr i io pirniCipai in ihis study. You liheby auiuhorir c Lhc icolcciion. us aid
disclosuir of your protected halth inromalion as described in sections 15-24 above. By
signing dl.s, J rin, you are nol waiving any afPaur Icgl nJghtl,




Signalure of Person Consenling and Authorizing Dale


250M2003 Rev 06-14-1 f Pa 7 of7
















APPENDIX E
THE SHORT FORM-36 HEALTH SURVEY-SPIRITUAL INVOLVEMENT AND
BELIEFS SCALE


The Short-Form-36 Health Survey



Instructions: This survey asks for your views about your health.

Answer every question by circling your response. If you are unsure about how to
answer a question, please give the best answer you can.




Question I Very
Excellent Good Good Fair Poor

In general would you say you health is: 1 2 3 4 5




Question 2 Much Somewhat About the Somewhat Much
Beter Now' Better Now Same Now WorseNow Worse Now

Compared to one year ago, how would 1 2 3 4 5
you rate your health in general now?












Question 3 The followmg items are about activities you might do during a typical day- Does your heaibh now limit
you in these activities? If so, how much?


Activities Yes, Yes, No, Not
Limited A Lt Limited A Little Limited At All

a. Vigorous activities, such as running, lifting heavy 1 2 3
objects, iFtidcip;tirng in strenuous sports


b. Moderate activities, such as moving a table, pushing a 1 2 3
vacuum clear, bowling, or playing golf


c. Lifting or carrying groceries 1 2 3

d. Climbing several flights of stairs 1 2 3

e. Climbing one flight of stairs 1 2 3

f. Bending, kneeling, or stooping 1 2 3

g. Walking more than a mile 1 2 3

h. Walking several blocks 1 2 3

i. Walking one block I 2 3

j. Bathing or dressing yourself 1 2 3













Question 4

During the past 4 weeks, have you had any of the following; problems with your work or
other regular daily activities as a resrdr of yonr physical health? Yes No


a. Cut down on the amount of time you spent on work or other activities 1 2

b. Accomplished less than you would like 1 2

c. Were limited in the kind of work or other activities 1 2

d. Had difficulty performing the work or other activities (for example, it took 1 2
extra effort)



Question 5
During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of any emolonal problems (such as feeling
depressed or anxious)? Yes No


a. Cut down on the amount of time you spent on work or other activities 1 2

b. Accomplished less than you would like 1 2

c. Didn't do work or other activities as carefully as usual 1 2














Question 6
Not at All Slightly Moderately Quite a Bit Extremely

During the past 4 weeks, to what extent has
your physical health or emotional problems 1 2 3 4 5
interfered with your normal social activities
with family, friends, neighbors, or groups?



Question 7 Very Very
None Mild Mild Moderate Severe Severe

How much bodily pain have you had during 1 2 3 4 5 6
the past 4 weeks




Question 8 A Little Quite
Not at All Bit Moderately a Bit Extremely

During the past 4 weeks, how much did pain
interfere with your normal work including 1 2 3 4 5
both work outside the home and housework)?












Question 9 These questions are about how you feel and how things have been with you during the past 4 weeks. For
each question, please give the one answer that comes closest to the way you have been feeling. How much of the time
during the past 4 weeks --

ALL of Most of A Good Bit Some of A Little of None of
the Time the Time of the Time the Time Time the Time

a. Did you feel full of pep? 1 2 3 4 5 6


b, Have you been a very 1 2 3 4 5 6
nervous person?

c. Have you felt so down in the dumps 1 2 3 4 5 6
that nothing could cheer you up?

d. Have you fll calm and peaceful? 1 2 3 4 5 6


e. Did you have a lot of energy? 1 2 3 4 5 6


f. Have you felt downhearted and I 2 3 4 5 6
blue?

g. Did you feel worn out? 1 2 3 4 5 6


h. Have you been a happy person? 1 2 3 4 5 6


i. Did you feel fired' 1 2 3 4 5 6














Question 10 All of Most of Some of A Litt of None of
the Time the Time the Time the Time the Time

During the past 4 weeks, how much' of the
time has your physical health or emotional
problems interfered with your social 1 2 3 4 5
activities (like visiting with friends,
relatives, etc.)?



Queiion 11

How TRUE or FALSE is each of the Definitely Mostly Don't Mostly Definitely
following srirnements for you? True True Know False False


a. I seem to get sick a little easier than 1 2 3 4 5
other people


b. I am as healthy as anybody I know 1 2 3 4 5


c. I expect my health to get worse 1 2 3 4 5


d. My health is excellent 1 2 3 4 5







84




2) Spiritual Involvement and Beliefs Scale (39 item version) Hatchet atl
Unhraity of Florida)

How strongly do you agi with the fomlowig stalemew.? Plcasmcirdcyour rtspose..

-Srog Mai3y Mi diy sbng
Agm Agc Arr e M NtrMl DBm Disp Dfa Ie


I. I s aside t ea for nredhaLion andloi
sel-rflecOion

2. I n find meaning in times of
hardship.

3.A prsoo can be fuiLled witlbh
pursuing an active spiritual life.

4-1 find isaerilyby accepting hihgs as
they are.

S Som rcxpriencs can be understood
only through ones spirile beliefs.

61do not believe in an afterlife.

7.A spiritual force influnccs Ihe events
in my life.

8. kLuwI n iclIonsl-up wlht ScmnWDe I
can turn lc for spiritual guidance-

9.Pmyrrs do not really change whale
happen.

1 OPatcipating pi spiilual activities
helps me forgive other people.

1 l. fl inner peace when I am in
harmony with nature

12. Ewrylhing happens for eaer
purpose.

131 use contemplation to ge in touch
with rmytru self.


7 6 5 4 3 2 1


7 6 5 4 3 2 1


7 6 5 4 3 2


7 6 5 4 3 2 1


6 5 4 3 2 1


7 6 5 4 3 2 I


7 6 5 4 3 2 i


7 6 5 4 3 2


7 6 5 4 3 '2 I


7 6 5 4 3 2


7 6 5 4 3 2 1














14. My spirual Ie i fills me i ways
ltar maria pcviwssiosr do not.



153 rarely feel connected 1o something
gpear ail anmyself

16.1n i e of despair I can find itle
reason 10 hope.

17t.'W I am sick, I would li~ olber
to pry for mr.

18J 4avc a pcrwOl reblaondhip with a
power greala than myself

19.1 hae had i spiritual cxpaeriene Ith
nitaily lunged mry if

20. Wte I hlp olbe s, I expect nothing
in rcturIn

211 don'l take time to appreiate nature

22.1 depend on a higher power.

231 have joy in my life because of my
iritualiy.

24My reh ionshipwith a hiltr povrcr
hlps me love others moreclmqplktey.

25.SpLilald writings rm-ich mry li~.

26.1 have eperinced hearing after
prayer.

27. My spiritual ustrstandding
coninues to gow.

2&. I am rigl t mre ofin iAnu moM
people.

?9 Maei s;piJriu approaches have linle


7 6 5 4 3 2 t


Strangly MBd Mdly Stronq
Agree Ari Agree et"nl Disagre DisBgr Disa
.7 6 5 4 3 2 1


7 6 5


7 6 5


7 6 5


7 6 5


7 6 5


4 3 2


4 3 2 [


4 3 2 1


4 3 2 I


4 3 2 I


6 5

6 5

6 5


7 6 5


4 3 2 I


6 5

6 5


7 6 5


7 6 5


7 6 :5


4 3 2 3


4 3 2


4 3 2


VMlue.I


__ ~











-vokI.


30. SpiriL halth contibutes to
gphysicl bealhb.

31.1 regularly inertct with others lor
spiinial purpoa.S

32.1 frac on vhar nreds to be chmgvcd
in Ie, no~ on what needs o be cdaged
in other

33. In dillicoU tdrcs, I am still graktcL

341 Ihav been through a tBim ofgreal
sunHring thoal d o spmruia growth.


Srangly Mityl Mi~tly Slroa
Agr Ag re Agre e Dnrgc grec Diagr
7 6 5 4 3 2 t


7 6 5 4 3 _2 1


7 6 5 4 3 2 1


6 5 4 3 2 I


7 6 $


4 3 2 1


Please indicate bow often you do the following:


Atwabs A


35.Wbn I wron sonoItne I make an
effort to npoogizc

36.1 acccpi oaer asthey are.

37.1 sole 4y problem without using
spiritual ssoets.

381 examine my a~ions to see if ty
racl myvahes.


mt Some- Nor AlmI N
wrys uy ims BsaBy w 3 N
6 5 4 3 2 i


7 6 5 4 3 2 1

7 6 5 4 3 2 1


7 6 5 4 3 2 I


39. Iow spiritual a person do you insider yourself? (With "7" being the nIm


1 2 3 4 5 6 7

Searin instmoiaar.
Rvrm sccrme all mplctiy w~mrdW ieasu (3.6A5l.162l2.E9-iTi
i.e. Slitg~ AAgrfte 1. Ag e 2, ..... SuagLy Disagr 7
or Albys L. Albu Alwa 2, ....New. 7















LIST OF REFERENCES


Aarons, H, Hall, G., Hughes, S., & Salmon, P. (1996). Short-term recovery from hip and
knee arthroplasty. The Journal of Bone and Joint Surgery, 8, 555-558.

Affleck, G., Tennen, H., Keefe, F.J., Lefebvre, J.C., Kashukar-Zuck, S., Wright, K.,
Starr, K., & Caldwell, D.S. (1999). Everyday life with osteoarthritis or rheumatoid
arthritis: independent effects of disease and gender on daily pain, mood, and
coping. Pain, 83, 601-609.

American Geriatrics Society. (1998). The management of chronic pain in older persons.
Journal of the American Geriatrics Society, 46, 174-192.

Anderson, H.I., Ejlertsson, G., Leden, I., & Rosenberg, C. (1993). Chronic pain in a
geographically defined general population: Studies of difference in age, gender,
social class, and pain localization. The Clinical Journal ofPain, 9, 174-192.

Bates, M.S., Edwards, W.T., & Anderson, K.O. (1993). Ethnocultural influences on
variation in chronic pain perception. Pain, 52, 101-112.

Brander, V.A., Mullarkey, C.F., & Stulberg, S.D. (2001). Rehabilitation after total joint
replacement for osteoarthritis: An evidence based approach. Physicial Medicine
and Rehabilitation, 15, 175-197.

Burkhardt, M.A., (1989). Spirituality: An analysis of the concept. Holistic Nursing
Practice, 3, 69-77.

Clark, K.M., Friedman, H.S., & Martin, L.R. (1999). A longitudinal study of religiosity
and mortality risk. Journal of Health Psychology, 4, 381-391.

Davis, M.A., Ettinger, W.H., Newhaus, J.M., & Hauck, W.W. (1987). Sex difference in
osteoarthritis of the knee: the role of obesity. Journal of Epidemiology, 127, 1019-
1029.

Diehl, M., Coyle, N., & Labouvie-Vief, G. (1996). Age and sex difference in strategies of
coping and defense across the life span. Psychology and Aging. 11, 127-139.

Ekblom, A., & Rydh-Rinder, M. (1998). Pain mechanisms: anatomy and physiology. In
N. Rawal, (Eds). Management of acute and chronic pain (pp. 1-22). London: BMJ.

Ellison, C.G., & Levin, J.S. (1998). The religion-health connection: evidence, theory, and
future directions. Health Education & Behavior, 25, 700-720.









Erdfelder, E., Faul, F., & Buchner, A. (1996). GPOWER: A general power analysis
program. Behavior Research Methods, Instruments, and Computers, 28:1, 1-11.

Escalante, A., Espinosa-Morales,R., Del Rincon, I., Arroyo, R.A., & Older, S.A.(2000).
Recipients of hip replacement for arthritis are less likely to be Hispanic,
independent of access to health care and socioeconomic status. Arthritis &
Rheumatism, 43, 390-399.

Felson, D.T., (1988). Epidemiology of hip and knee osteoarthritis. Epidemiologic
Reviews, 10, 1-24.

Ferrell, B.A., (2000). Pain management. Clinics in Geriatric Medicine, 16, 853-871.

Fitchett, G., Rybarczyk, B.D., & DeMarco, G.A.(1999). The role of religion in medical
rehabilitation outcomes: a longitudinal study. Rehabilitation Psychology, 44, 333-
351.

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Full Text

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THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESMENT IN PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE By PATRICIA A. MCNALLY A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2004

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Copyright 2004 by Patricia A. McNally

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To my family.

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iv ACKNOWLEDGMENTS There is no adequate way to thank my children, Jimmy, Meghan and Kerry. for all of their support and love duri ng my doctoral studies. I c ould not have completed this work without their belief in me, the fre quent phone calls, visits, and words of encouragement. Lastly, I hope my grandc hildren may you love and appreciate the educational process with the wonder that I have experien ced throughout my lifetime. I would also like to than k my supervisory committee for their knowledge, guidance and encouragement in supporting me. Esp ecially, I would like to thank Sharleen Simpson, my chair. Her constant patience and guidance and belief that you can do this gave me such support throughout this doctora l process. Additi onally, thanks go to Hossein Yarandi for his valuable assistance in analyzing data, and to Dr. Donald Caton, a teacher and friend, who has been a leader in relieving pain. Through his example, he brings out the best in all of us. Finally, thanks go to Dr. Monika Ardelt who has pursued research that includes the study of spirituality a nd geriatrics. I will al ways be indebted to all of them for their direction. I am grateful to Dr. Peter Gearen, Chai rman, Orthopaedic Department, and Dr. Nik Gravenstein, Chairman, Anesthesia Depa rtment, for their support in designing and implementing this research. Additionally, I want to thank the Pre-Surgical Center administration for supporting the importance of this research and providing access to patients.

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v TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES...........................................................................................................viii ABSTRACT....................................................................................................................... ix CHAPTER 1 INTRODUCTION........................................................................................................1 Background and Significance.......................................................................................3 Chronic Pain in the Older Adult............................................................................3 Osteoarthritis and Chronic Join t Pain in the Older Adult......................................4 Total Joint Arthroplasty in the Older Adult..........................................................5 Spirituality in Older Adults...................................................................................5 Summary.......................................................................................................................7 Specific Aims................................................................................................................7 Terminology.................................................................................................................8 2 REVIEW OF THE LITERATURE............................................................................10 Presence of Musculoskeletal Chronic Pa in and Arthritis Among Older Adults........10 The Relationship of Background Contextual Stimuli and Pain..................................11 Age, Pain, and Osteoarthritis...............................................................................11 Gender, Pain and Osteoarthritis...........................................................................12 Age, Gender, and Osteoarthritis..........................................................................12 Race, Pain and Osteoarthritis..............................................................................13 Total Joint Arthroplasty..............................................................................................14 Prevalence............................................................................................................14 Gender and Arthroplasty.....................................................................................15 Race and Arthroplasty.........................................................................................16 Spiritual Coping...................................................................................................16 Spiritual Coping and Health................................................................................18 Relationships between Spiritual Beliefs, Gender and Race................................21 Roy Adaptation Model-Based Research.............................................................22 Roy Adaptation Model Gerontologic Research..................................................23 Summary.....................................................................................................................24

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vi 3 METHODS.................................................................................................................25 Research Design.........................................................................................................25 Controls...............................................................................................................25 Power Analysis and Sample Size........................................................................26 Procedures...........................................................................................................26 Protection of Hu man Subjects.............................................................................27 Method.................................................................................................................27 Measures..............................................................................................................28 Preoperative Questionnaire Measures.................................................................28 Indicator of spirituality.................................................................................28 Indicator of self-h ealth assessment..............................................................28 Indicator of ethnicity....................................................................................29 Postoperative Data Co llection Procedures..........................................................29 Data Analysis..............................................................................................................31 Summary.....................................................................................................................32 4 RESULTS...................................................................................................................33 Sample Characteristics........................................................................................33 Regional Anesthesia............................................................................................34 Anesthesia Technique During Surgery................................................................34 Analysis of Data in Relation to the Hypotheses.........................................................35 Hypothesis 1........................................................................................................35 Hypothesis 2........................................................................................................35 Hypothesis 3........................................................................................................36 Additional Findings....................................................................................................36 The Short Form-36 Health Survey .............................................................................37 5 DISCUSSION.............................................................................................................45 Research Findings.......................................................................................................45 Sample Characteristics........................................................................................45 Impact of Health Assessment and Spir ituality on Pain Reports and Analgesic Medication Use................................................................................................48 Conclusions.................................................................................................................48 Strengths and Limitations....................................................................................49 Implications for Nursing Practice and Future Study...........................................50 APPENDIX A LETTER OF AGREEMENT......................................................................................53 B INFORMED CONSENT 08-19-03 TO 07-15-04......................................................55 C INFORMED CONSENT 01-29-04 TO 07-15-04......................................................63

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vii D INFORMED CONSENT 07-16-04 TO 07-15-05......................................................71 E THE SHORT FORM-36 HEALTH SURVEYSPIRITUAL INVOLVEMENT AND BELIEFS SCALE.............................................................................................78 LIST OF REFERENCES...................................................................................................87 BIOGRAPHICAL SKETCH.............................................................................................92

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viii LIST OF TABLES Table page 1 Frequency and Percent of Variables.........................................................................38 2 Summary Measures of Variables.............................................................................39 3 Pearson Correlation Coefficients-Spi rituality and Variables with No Adjustments..............................................................................................................39 4 Pearson Partial Coefficients-Controlling for Health Assessment............................39 5 Pearson Correlation Coefficients-Health Self-Assessment and Variables with No Adjustments..............................................................................................................40 6 Pearson Partial Coefficients-Health Se lf-Assessment and Vari ables Controlling for Spirituality..........................................................................................................40 7 Frequencies and Percentages for Self Reported SIBS Questionnaire (N=115)......41 8 Frequencies and Percentages Questions that Indicated Ratings for General Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey questionnaire (N=115)..............................................................................................43

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ix Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE RELATIONSHIP OF SPIRITUALITY AND SELF-HEALTH ASSESSMENT IN PREDICTING POSTOPERATIVE PAIN AND ANALGESIC USE By Patricia A. McNally December 2004 Chair: Sharleen Simpson Major Department: Nursing The purpose of this descriptive study wa s to investigate relationships between spirituality and self-heath with three postoperative outcomes after total hip or knee arthroplasty in the older adult. A total of 115 subjects between the ages of 55 and 86 years of age (M = 67.8) who met the inclusion criteria were enrolled in this study. Forty-one were male and seventyfour were female. One question from the Spiritual Involvement and Beliefs Scale and one question from the Short Form-36 Health Survey were used to measure spirituality and self-health assessment. Operative site, av erage daily pain scores, median daily pain scores and analgesic medication use data were obtained from the patientÂ’s medical record for three days postoperatively. Bivariate analysis found that those participants with a high degree of spirituality did not report less pain on days one (r = 0.01, p = 0.92), day two (r = 0.02, p = 0.84) or day three (r = 0.03, p = 0.78). They also did no t use less analgesic medication during the

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x three postoperative days (r = -0.04, p = 0.69). However, those participants who selfassessed their health as good to excellent did have less pain on day one (r = 0.31, p = 0.00), day two (r = -0.29, p= 0.00) and day three (r = -0.22, p = 0.02). There was no reduction in analgesic medication use (r = -0.11, p = 0.25). An ANOVA regression found there was no relationship for a high de gree of spiritualit y, a high self-health assessment and the use of less pain medication (F = 1.04, p = 0.38). The study supported the hypothesis that older adults who rate th eir self-health as good, very good or excellent experienced less postoperative pain but this study did not support less pain medication use. Second, th is research did no t support the hypothesis that a participant’s spirituality influen ces pain or analgesic medication use after arthroplasty surgery. Third, a high degree of spirituality and good health together did not make a difference in the amount of analge sic medication used for pain control. The majority (81.7%) of the participants felt their health was good, very good or excellent. Second, most (67%) indicated they were highly spiritu al and 70% felt that spiritual health contributes to physical hea lth. Finally, the major ity of the respondents believe in spiritual coping behaviors such as prayer, belief in an afterlife and a personal relationship with a greater power. This research found that an individual who rates their self -health as good, very good or excellent has less pain after arthroplasty surgery, bu t this self-health assessment does not influence the use of pain medi cation. Although participants considered themselves “highly spiritual”, their spiritua lity did not influence postoperative pain or pain medication use.

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1 CHAPTER 1 INTRODUCTION The increased number of aging persons ha s stimulated researchers to define the concept of aging as viewed by older adults in our society. Rowe & Kahn, (1998) define successful aging as the avoida nce of disease and disabilit y, social involvement and high level of cognitive and physical function. Succe ss, according to their definition, includes few physical limitations, health, and the absence of chronic pain. Most adults over 55 yrs of age do not report problems with daily activities such as: walking, bending and stooping without assistance. In this age gr oup, however, chronic pain can limit the level of functional activity. A chief cause of chroni c pain and disability among adults over 55 is osteoarthritis The experience of chronic pain in the el derly is both a physiologic and emotional experience. Although rooted in sensory stimu li, pain also has an important overlay from an individualÂ’s culture and e xperience (Porter, et al. 1996). Among all age groups pain can be defined as an experience with both a sensory and emotional component, but for the elderly adult, pain may signify a chr onic condition that is not always managed effectively with drug treatment. The most frequent cause of chronic pain and total disability reported by the ol der adult is arthritis (Aff leck, et al. 1999; Felson, 1988; Mobily, Herr, Clark, & Wallace, 1994; Praem er, Furner & Rice, 1999; Schlesinger, 2001). The American Geriatrics Society su ggests using both pharmocologic and nonpharmocologic methods to achieve a greater de gree of pain relief (American Geriatrics

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2 Society, 1998; Gagliese & Me lzak, 1997). Non-pharmocologic methods of pain control include massage, acupuncture, and behavioral ther apy. Keefe, et al. (2000) in a study of rheumatoid arthritis and joint replacement, f ound that effective coping strategies included praying, hoping and calming self-statements. Research on the relationship of spiritualit y and health has gained increasing interest in the academic and popular press over the pa st 15 years. Most early research used retrospective data analysis to study the eff ects of religious affili ation, and hypertension, depression, mortality, and anxi ety (Clark, Friedman, & Mart in, 1999; Husaini, Blasi, & Miller, 1999; Koenig, George, Blazer, Prit chett, & Meador, 1993; Koenig, George, Meador, Blazer, & Dyck, 1994). They obser ved a positive correlation between church attendance and various correlates, such as hypertension, depression, anxiety, hospital length of stay, and mortality (Koenig, et al. 1993; Koenig & Larson, 1998; Meador, et al.1992). Levin and Chatters (1998) suggest fu ture quantitative studies to evaluate relationships between spiritu ality and health. Although older people may rely more on defensive coping strategies, the possibility th at spiritual coping mechanisms may have a therapeutic effect has not been explored. Such spiritual coping mechanisms might include prayer, religious serv ice attendance, and seeking a spiritual connection (Ellison & Levin, 1998; Koenig & Larson, 1998; Pargament, Smith, Koenig, & Perez, 1998). These studies suggest that older adults who use spiritual c oping methods during stressful medical conditions have a more positive health outcome. I wished to explore the effect of spiritual belief, spiritual behavior and health selfassessment on the response to postoperative pain. Towards this end I examined the

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3 relationship between specific as sessments of spiritual behavior health self-assessment, to reports of pain report and the use of analge sic medications among a group of older adults recovering from hip replacements surgery. Background and Significance Chronic Pain in the Older Adult Pain is defined as a noxious physical and emotional experience. Although similar for all age groups, elderly adults appear to have a higher incidence of chronic pain. The only measure of the presence and intensity of pain is the re port of the person experiencing the pain (Ferrell, 2000). Noci ceptor pain, including chronic pain, begins with the activation of special receptors and afferent fibers by peri pheral stimuli usually associated with processes involving tissu e damage and inflammation (Ekblom & RydhRinder, 1998). Such pain may include musculos keletal pain, ischemic pain, visceral pain, and myofascial pain. There is little empirical evidence that biological or physiological measurements correlates to the degree of pain expressed by th e elderly individual (Gagliese & Melzack, 1997). In other words, to a large extent the ‘exp erience’ of pain is subjective. Among the elderly, research indicates that mo re than 90% of the elderly experience pain in the musculoskeletal system (Ande rson, Ejlertsson, Lenden & Rosenberg, 1993). Chronic arthritic joint pain begins in the upper extremities such as shoulders and then progresses to the lower extremity as an indi vidual ages (Anderson, et al. 1993; Mobily et al. 1994). This site of the pain can greatly affect severity of chr onic pain as well as the degree of functional impairment.

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4 Osteoarthritis and Chronic Jo int Pain in the Older Adult Osteoarthritis is the most frequent cause of end stage joint dete rioration and chronic pain in the elder adult. In the early stage, there is only a pathologic loss of cartilage. As the disease advances jo int cartilage and underlying bone are affected, with a total loss of cartilage and joint space. Joint cartilage serves two functions: 1) smooth frictionless surface movement of articulating bones, and 2) transmission of the weight bearing load. Additionally, extensive tissue inflammatory changes surround the affected joint and contribute to the limitation of joint range of motion and severe chronic pain (Schlesinger, 2001). Visible osteophytes or la teral outgrowths of bone in th e joint margins add to an increased sclerosis of underlying bone that contributes to an additional increase in functional impairment (Felson, 1988; Schlesinger, 2001). This loss of the articular cartilage can be demonstrated radiogra phically as a joint space narrowing and occasionally, osteophyte formation. The most frequently affected joint locations are knees, hips, fingers, and sp ine (Praemer, et al. 1999). Measurement of the impact of arthritis includes two parameters: disability or functional impairment and economic health car e system impact. The adult person 65 years of age with arth ritis may have more limitations of activity than those afflicted with other chronic disease states such as cardiac disease, diabetes, and cancer. It has been estimated that 50% of those persons 65 y ears of age and older experience activity limitation from the chronic pain of osteoarthr itis (Mobily, et al. 1994). The failure of conservative medical management, such as medications and physical therapy, in the treatment of end stage joint osteoarthritis, has increased the demand for surgical total joint replacement.

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5 Total Joint Arthroplasty in the Older Adult The early 21st century has been declared the “Bone and Joint Decade” by 35 nations and 44 states. Currently, more than 425,000 to tal joint replacements are performed each year in the United States, and this number is expected to reach 702,000 by the year 2030 as the baby boomer generation ages (Praemer, et al. 1999). The increase in the number of aging Americans, the increase in the prevalen ce of arthritis for this age group, and the desire to remain active have added to the increase in demand for total joint replacement surgery (Healy, Iorio, & Lemos, 2001). Join t replacement surgery has been documented to improve pain, functional ability, social f unction, and quality of life for the recipient (Aarons, Hall, Hughes, & Salmon, 1996; McGuigan, Hozack, Moriarty, Eng, & Rothman, 1995; Norman-Taylor, Palmer, & V illar, 1996; Ritter, Albohm, Keating, Faris, & Meading, 1995). These findings demonstrate that osteoarthr itis among older adults is a major cause of chronic pain and functional impairment. To tal joint replacement offers the older adult pain relief and improved functional ability, pa rticularly when there is failure with conservative therapies. Spirituality in Older Adults Behavioral management of pain includes the strategy of active coping. Spiritual coping behaviors that include praying and church attendance have been recognized as active coping behavioral strategies used often by older adults (Koenig, et al. 1998). Burkhardt, (1989) defines the “spirituality” as the individual’s belie f in God or a higher power that is concerned with his or her stri ving to achieve a sense of harmony with self and others. Spirituality often involves a re lationship with an organized religion, interrelationships with others, and the search for the meaning of life. Affiliation and/or

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6 participation in organized religion, however, ar e not necessary to be considered spiritual (Burkhardt, 1989; Principe, 1983) Different authors have defined ‘spirituality’ in various ways. For the purpose of this discussion, I will use the “spirituality” to describe the way of life an individual chooses that involves a belief in G od or a higher power, a belief in an after life, and a belief that a hi gher power influences life’s events. I did not limit this study to ‘spirituality’ associat ed with any specific religion or sect. There has been an increasing interest in the interrelationship of spiritual involvement, spiritual activity, and health outcomes among the elderly. Koenig, McCullough, and Larson (2001) give three reas ons for this current interest. First, spirituality and religious affiliation continues to be a central part of people’s lives despite advances in technology, education, and medici ne. Second, the United States and other worldwide populations are aging due to a dec lining birth rate and gr eater longevity. In the future, social programs will have severe financial hardships in providing services for this population and religious groups may assist in providing some of these services. There is the possibility that spiritual coping may aid in the prevention of health problems and thereby assist in health car e cost containment. Finally, there is a depe rsonalization in the health care delivery system. Individua ls seeking medical care and treatment expect compassion with attention to their social, psychological, and spirit ual needs. McFadden and Levin (1996) summarize recent gerontologi c spiritual research as focusing on four areas of interest: “(a) multidimensional measures, (b) patterns, (c) predictors, and (d) psychosocial and health relate d outcomes of religious involv ement in older adults and across the life course” (p. 350).

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7 Summary Many disciplines including medicine, psychology, and sociology have examined the relationship of coping and religious affiliation; coping and spiritual beliefs; religious attendance, and health outcomes like pain, depression, quality of life, mortality, and morbidity. This investigator believes that th e degree of spirituality in the post-surgical older adult patient has not been considered in evaluating pain report and analgesic medication use. Achieving adequate pain cont rol is a major goal of professional nursing care and utilizing spiritual coping may be an important addition in providing nonpharmocologic pain management. Specific Aims The purpose of this study is to explore whether a high degree of spirituality, and high scores for self-health assessment are correlated with postoperative pain and analgesic medication use in the acute hospita l recovery phase. Currently, there is no evidence in literature that has examined thes e variables and their relationship with the use of postoperative pain medication after total joint arthroplasty. Prior research focused on relationships of long-term f unctional rehabilitation, quality of life and spiritual coping. Using two multidimensional instruments, I propos e to address three important aims that will contribute to the relationship of spirituality, self-health assessment, pain report and analgesic medication use in the postoperative older adult joint ar throplasty patient. First, using a multidimensional instrument this study will investigate whether a high degree of spirituality is associated with less pain report and medication use in older individuals receiving primary hip or knee arthropl asty for osteoarthritis. It is the aim of this research to determine whether older adul ts receiving a hip or knee arthroplasty with a

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8 high score for spirituality on the Spiritual I nvolvement and Beliefs Scale (SIBS) will use less analgesic medication postoperatively. Second, the Short Form-36 Health Survey th at measures general health assessment will be used to measure self-health in this re search. It is the aim of this research to determine whether older adults with a high sc ore for health self-assessment will use less analgesic medication after c ontrolling for spirituality. Finally, the responses for both spiritual ity and self-health together will be correlated with analgesic medication. Hypothesis 1. Older adults with a higher degree of spirituality receiving a hip or knee arthroplasty for primary osteoarthritis wi ll report less pain and receive less analgesic medication than those participants with a lower degree of spirituality after controlling for health self-assessment. Hypothesis 2. Older adults with high scores on the self-health assessment tool will report less pain and receive less analgesic me dication than those pa rticipants with low scores on the self-health assessment t ool after controlli ng for spirituality. Hypothesis 3. There will be significantly le ss analgesic medication used by those older adults receiving hip or knee arthroplas ty who have a high degree of spirituality, and a high degree of self-health assessment. Terminology Older adult : Age 55 or older Epidural : Medications administered to the epidural space su rrounding the spinal cord. Extrinsic religious orientation : The pursuit of religious beliefs and religious practice to feel protected or gain ing social status and approval.

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9 Femoral Nerve Sheath : Medication administered within the femoral nerve sheath by means of a catheter to anes thetize the femoral nerve. Intrinsic religious orientation : The motivation to live the goals set forth by religious tradition. The way of life often described as “living one’s religion” and using religious practices. Th e person who has an intrinsi c religious orientation may not be affiliated with a pa rticular religious group. Medication Administration Record (MARS) : Individual record of medication administered to a patient during inpatient hospitalization. Each dose of medication is recorded with the following data: me dication name, dosage, time administered, name of staff administering medication. Opioid equi-analgesic conversion : All narcotic medication was converted to Morphine Sulfate IV equivalents. Patient controlled analgesia : Self-administered narcotic analgesia through an intravenous infusion. Religious affiliation : Participating in an organized religious group Spirituality : The way of life an individual chooses to live that inte rnalizes a belief in a higher power. These life thoughts ar e separate from the body and may involve God, a belief in an afterlife, and belief that this highe r power influences life’s events. Spiritual behaviors : Praying, meditation and/or self-reflection, reading spiritual writings Visual Analog Scale (VAS) : A pain rating scale adopted by Shands at the University of Florida to provide accuracy in a patient’s pain. The scale is numeric, one = no pain and 10 = the worst pain of life. Patients are asked to rate their pain using numeric increments 0 to 10.

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10 CHAPTER 2 REVIEW OF THE LITERATURE This section deals with pertinent papers published during the past 20 years that address chronic pain, osteoarthritis, lower ex tremity arthroplasty, and spirituality coping among the elderly. The first section examines the prevalence of the chronic pain of osteoarthritis and arthroplasty (focal stimuli) age, gender, and race (contextual stimuli). The second reviews the relations hip of spiritual coping to ge nder, race, age, and pain. Presence of Musculoskeletal Chronic Pa in and Arthritis Among Older Adults Pain in the aged adult has become a fo cus of current gerontologic research. The elderly have more painful diseases that re quire more medical visits. The impact of musculoskeletal conditions on th e elderly can be divided in to two categories: 1) the physical and social impact of physical pain (lim itations in mobility and social interaction imposed by these limitations), and 2) the mone tary cost involved in the diagnosis and treatment of these disorders (Praemer, Furner, & Rice, 1992). Musculoskeletal disorders after age 65, regardless of gender or racial group, are th e most frequently reported physical impairments, exceeded only by hearing disorders. Surgical intervention, following failed medical management, is expect ed to increase dramatically in the next twenty years (Praemer, et al.1999). Mu sculoskeletal functional limitation has a significant impact on the elderly. Back and spine disorders are the most fr equently reported category of dysfunction, followed by lower extremity disorders of th e hip or knee. Although there are many forms of arthritis among the elderly, th e two most common forms, thos e with the greatest public

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11 health implications, are osteoarthritis and rheu matoid arthritis. The more prevalent of the two forms, osteoarthritis, is estimated to affect 20 million people in the United States (Praemer, et al.1999). The Relationship of Background Contextual Stimuli and Pain Age, Pain, and Osteoarthritis Anderson, et al. (1993) found that 90% of individuals surveyed experienced chronic musculoskeletal pain. Chronic pain symptoms increased between ages 50-64 and then gradually declined. After age 60, howev er, the incidence of lower extremity pain increased. Compared to younger adults, lowe r joint pain doubled after age 65 (Anderson, et al. 1993; Gibson & Helme, 1995). In the Io wa study, Mobily, et al. (1994) observed a lower incidence of overall pa in (p< .0001) among those over 85 years compared to younger age groups. They also found more than 86% of those surveyed experienced pain longer than 12 months. Their research is felt to be particularly accurate because of their large sample size and the longitudinal study design. Several studies have examined the influe nce of age on pain sensitivity. Gibson and Helme ((1995) examined sensitivity to several different forms of experimental pain using a meta-analysis. Their data suggest a decl ine in thermal sensitiv ity after age 60, but do not show a conclusive difference, or change, in pain sensitivity or pain tolerance. An earlier study by Helme and Allen (1992) had f ound that the majority of those surveyed (79%) agreed that pain was a consequence of the aging proce ss. However, less than half of these older adults reported pain. The authors concluded th at older adults expected to experience pain as they aged and they did.

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12 Additional research is needed to evalua te both the physiologic and psychological basis for pain among older adults. More effec tive management of pain in the older adult originates in a better understanding of differences and si milarities in the pain response. Gender, Pain and Osteoarthritis Experimental research has not demonstr ated a conclusive difference in pain perception related to gender. Using heat as a noxious stimulus in humans Paulson, Minoshima, Morrow, and Casey (1998) conclu ded there was a gender similarity in the cerebral and cerebellar activati on, but anticipation of the stim ulus was more intense in females. Keefe, et al. (2000) measured pain, disa bility, and pain behavior among men and women with a mean age of 61.1 yrs. They re ported significant gender differences in pain intensity, pain behavior, and phys ical disability associated wi th osteoarthritis. Women had significantly elevated levels (F (1,166) = 4.41, P <0.05) of osteoarthritis pain. They measured pain behavior, which included s tiff movement, rubbing affected joint, and flexing the joint, in relation to gender. In their analysis women exhibited more pain behavior than men (F (1,162) = 5.54, P < 0.05). In a recent study of pain and coping, Affleck et al. (1999) observed that women re ported daily osteoarthritis pain and pain levels 73% greater than males with a similar arthritis diagnosis. Re sults of these studies have suggested that among the elderly, there is a difference in pain intensity related to gender. Further research is n ecessary to compare noxious pain stimuli, pain thresholds and intensity studied in younger pop ulations to the older adult. Age, Gender, and Osteoarthritis Compared to males, females have twice th e incidence of osteoarthritis. Until age 65, however, men report a greater occurrence of osteoarthritis. While men are more

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13 likely to have shoulder, elbow and foot join t pain; women have finger, hip, ankle and wrist joint pain (Davis, E ttinger, Newhaus & Hauck, 1987). Although specific affected joint patterns have been identified as following a gender pattern, gender differences do not contribute to risk factors for the deve lopment of osteoarthr itis (Davis, et al. 1987;Keefe, et al. 2000; La wrence, et al. 1998). Race, Pain and Osteoarthritis Differences in cultural response to pain have been studied using two methods, nonexperimental using observational methods, a nd laboratory experimental using painful stimuli and measuring the response. Zatz ick and Dimsdale (1990) were unable to correlate cultural variations in pain response in their meta-ana lysis of pain stimuli and of pain response. They concluded, “there is no evidence suggesting that the neurophysiology detection of pain varies acr oss cultural bou ndaries” (p.554). However, Bates, Edwards, and Anderson (1993) usi ng observational methods to evaluate the differences in reported chronic pain inte nsity among seven diverse ethnic groups, found significant correlations. Add itionally, they investigated specific sociodemographic, medical, and psychological variables that may predict an intra-ethni c group variation in pain intensity. Bates, et al. (1993) found th at pain intensity did not vary among various ethnic groups because of differences in neurophysiology but was a result of the biocultural model of pain perception. European whites have a greater incidence of osteoarthritis than Jamaicans, Blacks, South African Blacks, Chinese, and Indians (Felson, 1988). Rates for American Indians are intermediate. There is speculation that individuals of European white descent have a genetic developmental defect in both the knee and hip joints that facilitates the

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14 development of osteoarthritis. This is s upported by greater reporti ng of joint pain in whites when compared to blacks or other races (Praemer, et al. 1992). Total Joint Arthroplasty Prevalence The first decade 21st century has been declared the “Bone and Joint Decade” by 35 nations and 44 U.S. states. The number of lower extremity joint procedures has increased; total knee replacements incr eased 40.2% during the years 1990 and 1996, while total hip replacements increased 15.5% for the same years (Praemer, et al. 1999). Currently more than 425,000 total joint replacem ents are performed in the United States, and this number is expected to reach 702,000 by the year 2030 as the baby boomer generation ages (Praemer, et al. 1999). The leading reason for joint replacement surgery in the elderly is failure of conservative medical treatment for end stage arthritic joints. The increase in the number of aging Americans, and the increase in prevalence of ar thritis for this age group along with a strong desire to remain active have c ontinued to increase the demand for total joint arthroplasty (Healy, Iorio, & Le mos, 2001). Joint replacement surgery has been shown to improve pain, functional ability, social functi on, and quality of life (A arons, et al. 1996; McGuigan, et al. 1995; Norman-Taylor, et al. 1996; Ritt er, et al. 1995). The goal of total joint arthr oplasty is to recreate the motion of flexion, extension, adduction, and rotation of the joint that has lost range of motion. This surgical intervention demonstrates a ten-year success rate for 98 % of elderly individuals while relieving joint pain and correcting the joint deformity. For patients with bilateral knee joint end stage arthritis, bilate ral joint replacements are often performed at the same time (Pellino, Preston, Bell, Newton, & Hansen, 2002).

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15 Total hip arthroplasty (THA) is a surgical procedure that replaces a diseased joint with a synthetic joint using a synthetic acetabulum, femur, an d polyethylene liner that are fixed to bone by cement or bone ingrowths. Total knee arthroplasty (TKA) involves replacing the femoral and tibia sides of the joint using a l ong or short stem fixated by cement. The goal of joint arthroplasty is to improve function with an artificial joint that improves range of motion and provides pain relief with few surgical complications (Brander, Mullarkey, & Stulberg, 2001). Th e decision making process in considering a candidate for total joint replacement is the degree of radiographic changes and the degree of functional impairment. Gender and Arthroplasty Although women have 1.5-2.0 higher inciden ce of osteoarthritis, men have more total knee arthroplasty than wo men. Katz, et al. (1994) sugge sts that gender differences in joint arthroplasty are difficult to evaluate because procedure rates are not reported by severity of disease. The aut hors evaluated functional status using a daily living scale that evaluates the ability to walk several blocks, climb stairs, or take part in vigorous activity. Greater functional impairment and the use of walking support were reported for most of the females. The authors suggest that ma les have earlier surg ical intervention for functional impairment and pain. Praemer, et al. (1999) do report that the number of total knee replacements for men in 1996 was 1318/100,000 while for women in the same year it was 928/ 100,000. There is some evidence that suggests women delay surgical intervention out of fear of surgical failure, death or loss of function postoperatively. Postponing surgical intervention can also be because of distrust of physicians and hospitals, a reluctance to take risks and concern about caregivi ng responsibilities.

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16 Conversely, males most reported concern is th e length of rehabilitation time necessary for the return of joint function (Ritter, et al. 1995). Race and Arthroplasty The relationship between race and arthroplas ty has been poorly studied. A recent study in a large county in Texas reported that Hispanics were under represented as recipients for hip replacement surgery (Escalante, Espinosa-Morales, Del Rincon, Arroyo, & Older, 2000). In their research, Afri can Americans were also less likely than Caucasians to receive arthroplasty surgery. Extensive review of re search literature on race and arthroplasty, however, revealed no evidence to suggest a disparity in race and arthroplasty. In summary, the number of total joint repl acements increases dramatically for both sexes after age 65 (Praemer, et al. 1999). The effect of this increase can be directly attributed to the incidence of joint osteoart hritis, chronic pain and functional impairment (Felson, 1988; Schlesinger, 2001). Women repor t greater functional impairment for all activities of daily living and de lay arthroplasty for a longer pe riod of time. It is unclear from previous research reasons for gender diffe rences in osteoarthrit is incidence or the delay for surgical intervention. Previous rese arch only verifies the age related changes of osteoarthritis, functional impairment and the increase in total joint replacement surgery for the relief of pain and improvement in physical function. Spiritual Coping According to Lazarus, DeLongis, Folkman, and Gruen, (1985), “efficacy expectations and appraisals refer to cognitions : fear and distress refe r to emotional states that includes cognitions” (p. 776). Stress is regarded as a complex variable and the individual in his/her persona l environment reflects the proc essing of these variables.

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17 Good health and the absence of chronic pain represent a personÂ’ s stable environment. An individualÂ’s inability to maintain these e nvironmental variables creates stress and fear. Through evaluating the stressors and using defense strategies a coping process will be used to overcome the disruption in a pers onÂ’s environment (Lazarus et al, 1985). The older adult uses cognitive interp retation to identify stressful h ealth changes and uses more defense strategies to cope. Diehl, Coyle, and Labouvie-Vi ef, (1996) found that compared to younger people; there was a difference in the use of self-restraint by older adults rather than aggression to cope with environmental stressors. Religious behaviors such as prayer, re ligious service atte ndance and seeking spiritual connection, are part of the individualÂ’s practice of sp iritual or religious coping (Ellison & Levin, 1998; Koenig & Larson, 1998; Pargament, et al. 1998). Researchers have studied the various spirituality concep ts: 1) Religious doctrine; 2) Religious attendance; and 3) Religious affiliation. Spirituality includes both the world of experience and the way of life a person lives that is guided by religious doc trine (Principe, 1983). It is the continuous process of integrating oneself in current and past experien ce and the effort of re lating to others with trust and understanding. Spirituality links self with a pow er greater than the individual. It is most often associated with a religion that defines the divine and offers ways to relate to the sacred (McFadden & Ge rl, 1990). Fowler describe s the persons life spiritual development as a developmental psychological process that uses cognitive and emotional synthesis of a sense of meaning and pu rpose in the life jo urney (Shulik, 1988). Interest in research involving the relations hip of spirituality and health has been increasing over the past 15 years. Most existing research has focused on religious

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18 affiliation and health status in hypertension, depression, mortality, and anxiety (Clark, Friedman, Martin, 1999; Husaini, Blasi & Miller, 1999; Koenig, et al. 1993, 1994). The examination of a possible therapeutic effect of spirituality in the postoperative joint replacement patient has not been explored. Levin and Chatters ( 1998) suggest that in order to establish a relationship between sp irituality and health, research must use evaluate a measurable medical effect of spirituality or relig ion and aging. This research will hypothesize that a positive relationship does exist between the older adultÂ’s degree of spirituality and self-health assessment. Spiritual Coping and Health There has been no published research demonstrating a relationship between spiritual coping, health assessment, and post-su rgical pain. Most empirical research has focused on the relationships of spiritual copi ng, spiritual beliefs, spiritual involvement and health outcomes in mental health, hypertension, depression, and anxiety. Matthews, et al. (1998) reviewed the re lationships of religious fact ors that included religious attendance and mental health status. The focal areas of mental health status were coping and recovery from illness. The authors c oncluded in their review there was strong support for religious commitment and positive medical outcomes following serious illnesses e.g. heart disease, cancer. Pargamen t, et al. (1998) using a spiritual well being scale found there was a relationship between positive and negative patterns of religious coping in young and elderly age groups. Th ey measured three di verse sample groups experiencing stressful life events. The firs t sample represented Oklahoma City residents who were evaluated for religious coping afte r the federal building bombing. The second sample involved college students who had experi enced a significant negative event, such as a death of a friend or family problems. The third sample group was hospitalized

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19 patients over the age of 55 with moderately severe medical illness. Although, the participants were of differen t ages and diverse life event stressors, a posi tive pattern of religious coping was found among the three gr oups. Those particip ants with positive religious coping patterns had less psychological anxiety and di stress. Those individuals with negative religious copi ng were associated with great er emotional distress, e.g. depression, and reported poorer quality of life. Pargament and colleagues (1990), extended their religious coping re search to more clearly identify the kinds of religious beliefs, and behaviors that ar e helpful to individuals as they cope with negative life events like death, illness, divor ce and work related problems. Four separate themes of religious beliefs and behaviors emerged to furthe r define spiritual beliefs and practice: 1) belief in a fair and loving God; 2) part nership with God is supportive; 3) positive outcomes come from using of re ligious rituals; and 4) sear ch for spiritual and personal support through religious affiliation. Pargamen t, et al. (1990) explains nonreligious avoidance with descriptor items from personal narratives such as “tri ed not to think about it,” “wished the situation would go away” (p. 818). Using retrospective demographic data coll ection, early research that focused on religious affiliation and hea lth status demonstrated pos itive relationships between religious affiliation and various health co rrelates, such as hypertension control, depression, anxiety, length of hospital stay and mortality (Koe nig, et al. 1993; 1998; Koenig & Larson, 1998; Meador, et al. 1992). In a review of 20 empirical studies, Levin & Vanderpool (1990) concluded that religion is therapeutically beneficial in the control of hypertension. Koenig, et al. (1998) investigat ed the relationship of religious activities and blood pressure control among older adults dwelling in communities. They concluded

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20 that religiously active adults displayed lower blood pressures and were more compliant with prescribed medication. Additionally, they observed a racial difference. The authors found that although black religious males had higher blood pressures than white religious males, they were more compliant with me dication use for blood pressure control. Recent research has examined spirit uality and functional ability during rehabilitation. Kim, Heinemann, Bode, Sliwa, & King (2000) examined spirituality using an intrinsic Judeo-Christian scale of wellbeing and functional va riables among patients in a rehabilitation hospital. Intrinsic re ligiousness is define d as the individualÂ’s internalizing a religious belief and living the belief. Individual spir ituality scores though high were not associated with variables of f unctional recovery such as mobility, and selfcare. Fitchett, Rybarcyk, DeMarco, and Ni cholas (1999) found similar results in postoperative rehabilita tion. There was a high degree of spir ituality among their patients who rated their health as poor or very poor. Using a questionn aire that measures church affiliation, attendance, and spir itual behaviors, the author s were unable to confirm a relationship between self-health assessment, spirituality, and church activities. Pressman, Lyons, Larson, and Strain (1990) in a small study of postoperative female orthopedic patients found significant correl ation between church attendance, person al importance of religion, degree of spirituality, and functiona l meters walked (r=0.45, df = 27, p<0.05). This research found that post operative orthopedic subjects wi th strong religious beliefs and practices, and less depression had better ambulatory function at discharge. The spirituality score was not significantly correla ted with ambulatory status independent of depression. The authors suggest that subjects who are spir itual respond more favorably to physical therapy because they are less depressed. Hodges, Humphreys, and Eck

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21 (2002) investigated the effects of spiritua lity on spinal surgery recovery. Using a spirituality tool that evaluate s intrinsic spirituality, they found these subjects to be highly spiritual (79%). The authors then compared preoperative and postoperative pain scores with postoperative functional ability. They found no correlation between a high degree of spirituality and pain scor es or functional outcomes. Spiritual research has investigated the po ssible relationships of pain, health and functional recovery. In each study, older adults have a hi gh degree of spirituality on various measurement tools, but only one st udy reported a significant correlation that included a finding of less depres sion. The investigation of sp irituality and health has not been evaluated using consistent measures of spirituality scales and postoperative population groups. Most current research has observed possible religious affiliation, spiritual beliefs and functional status. Relationships between Spiritual Beliefs, Gender and Race Few empirical studies have examined pa in, gender, and racial relationships (Affleck, et al.1999). Research regarding utiliz ation of health services demonstrated a positive correlation between utilization and religious attendance in elderly male patients 60+ years of age. Increased attendance at religious services prior to hospitalization correlated with a shorter hospital stay and fewer hospital admissions (Koenig & Larson, 1998). Past research concentrated on religiou s coping behaviors, including religious affiliation, beliefs and involvement. Research fi ndings suggest that many older adults use spiritual coping in various st ressful health situ ations and that this coping has had a beneficial effect. Further investigation is n eeded using spiritual measures to examine if

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22 there is a spiritual coping adaptive effect in the management of older adult postoperative pain. Roy Adaptation Model-Based Research In 1976, Sister Callista RoyÂ’s theory of an adaptation model for nursing was presented to guide nursing edu cation in the United States. The theory was later revised to address the middle range or practice level theo ry relevant to patient care in nursing. In 1999, a new model of the Human Adaptive sy stem was introduced to clarify the understanding of the various components of th e theory and to extend it into clinical practice (Roy & Andrews, 1999). Roy define s the purpose of nursing practice as the promotion of the ability of hu man adaptive systems to adjust effectively to changes in the environment and to the individualÂ’s abil ity to modify their environment (Roy & Andrews, 1999). RoyÂ’s theory contains scie ntific and philosophical assumptions that describe successful human coping in cha nging environments. According to Roy, the adaptation of the human system is based on scientific assumptions that include: 1) meaning is necessary for person and environmen t integration; 2) thinking and feeling is necessary for awareness; 3) people have a co mmonality of patterns and relationships; 4) adaptation results from the integration pe ople and their environment. Further, the adaptation concept includes RoyÂ’s philosophical assumptions: 1) relationships include a higher power and the world; 2) people use the ability of faith; 3) God is observed in diversity of crea tion, and is the destiny of creation.

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23 Figure 2-1. Model Diagram of Research Questions Roy Adaptation Model Gerontologic Research Roy describes the adaptive process as adjusting effectively to environmental changes using cognitive interpretation and c oping processes to maintain an integrated life. In this model, compensatory life pr ocesses are spiritual coping and health selfassessment. These regulatory processes pr ovide an adaptive re sponse for less pain. RoyÂ’s adaptation model has been used mainly with children and adults in a hospital environment. One gerontologic study has us ed the Roy adaptation model to evaluate a coping process and the concept of self-consistency. Roy belie ves the concept of personal self is a combination of self-consistency, the moral-ethical spiritual self and the self-ideal (Roy & Andrews, 1999). Zhan (2000) us ed the Roy Adaptation Model to study adaptation and coping with severe hearing lo ss in 130 elderly adults Health status and coping data were analyzed for positive rela tionships between cogni tive coping and self-

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24 consistency. There was a positive correlati on between those who ra ted their health as good or excellent and self-consistency. The va riance in self-consiste ncy was the result of cognitive coping processes. Three cognitive processes; clear focus and method, knowing awareness, and self-perception were mo st significant (36.97 (p< .001, df =5). There is support for the use of the Roy Adaptation Model in gerontological research to evaluate spirit ual coping and adaptation to pa in. Successful adaptation to environmental changes is necessary to return to good health and well being as people age. Summary Chronic pain in the aged adult is both a physical and emotional experience. Current research suggests that the use of pharmocologic and non-pharmocologic methods in the elderly may reduce chronic pain. Howeve r, some research findings suggest that the use of specific non-pharmocologic interventions such as spiritual behavior, religious attendance, and spiritual beliefs are inconclusi ve in providing relief from the negative effects of chronic illness and pain. This research study will evaluate relationships between spirituality and analgesic medication us e after total joint arthroplasty in older adults. Measurement of the degree of spirituality a nd health will evaluate the effectiveness of coping with postoperative pa in in the older adult. Th is research will provide quantitative data to provide a framework for evaluating older adultÂ’ s spirituality as an alternative non-pharmocologi c intervention in postopera tive pain management.

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25 CHAPTER 3 METHODS Research Design This research examines the relationship of older adultsÂ’ spiritual beliefs, and selfhealth assessment and analgesic medication use during the first three days after total joint replacement surgery. A correlational conveni ence design was used to investigate the questions in a sample of surg ical candidates scheduled for hi p and knee joint arthroplasty. Using the Roy Adaptation Model, this study ex amined relationships between total joint arthroplasty for osteoarthritis chronic pain, the degree of spiritual beliefs, spiritual involvement, self-health assessment and the health outcome of postoperative analgesic medication use. Participants for this research came from a socially diverse area in North Florida. Controls Three orthopedic surgeons from the Univ ersity of Florida College of Medicine, Department of Orthopedics performed all of the total joint arthr oplasty. To control variations in general anesthes ia technique, one supervising an esthesiologist planned each participantÂ’s anesthetic ca re. Participants chose hi s/her preferred method of postoperative pain control prior to surgery. Choices included regional anesthesia, Patient Control Analgesia (PCA), or PRN dosing. Preo perative patient education and anesthesia evaluation was done according to the standard of care establ ished by the University of Florida College of Medicine.

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26 Inclusion criteria: 1. 55 years of age or older 2. Primary hip or knee joint arthroplasty 3. Osteoarthritis of the hip or knee joint as demonstrated by radiographic exam and orthopedic surgeonÂ’s diagnosis as documented in the medical record 4. Failed medical management of chronic joint pain 5. Inclusion regardless of comorbidity status 6. Candidates for hip or knee arthroplasty Power Analysis and Sample Size An estimate of statistical power was determined using the G power computer software to calculate the required sample size. A total of 115 participants were consented and completed the study. The sample size wa s based on a formulation of 80% power, at least six independent variables, an e ffect size of 0.15 (R-s quared= 0.13) with a significance of 0.05 for a two-ta iled test. The G power comput er software was used to calculate the required sample size (Erdfelder, Faul, & Buchner, 1996). Procedures The Principle investigator of this study contacted the chairman of the Orthopedic Department and presented a description of the study. The chairman then provided a signed letter of agreement acknowledging aw areness of this study (See Appendix A). In the original protocol, I planned control variation in surgical technique using only patients scheduled with one orthopedic surgeon. A total of 27 patients were enrolled from July, 2003 until January, 2004. During this enrollment period, however, the identified surgeon reduced the number of tota l joint surgeries he performed per month in order to fulfill administrative duties. In January, 2004, the investigator met with committee members to explore adding two additiona l surgeons in order to attain within a

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27 reasonable length of time a number of subject s months adequate fo r a power analysis. After appropriated discussions, two additional orthopedic surge ons agreed to help. They were each provided a copy of the protocol and informed consent. A revision that included the two additional orthopedic surg eons was submitted and approved by the IRB in January, 2004. Protection of Human Subjects University of Florida Institutional Review Board (IRB) approval was obtained prior to participant enrollment or data collecti on (See Appendix B for final approval, revised approval and extension approval forms). A re vision to include the additional orthopedic surgeons was submitted and approved in January, 2004. A final IRB extension was submitted June, 2004 to extend the research study from July, 2004 until July, 2005. Method Patients scheduled for surgery are scheduled in the pre-surgical center for an examination by an ARNP to determine their su itability for anesthesia. From this group the principal investigator identified pote ntial subjects for stud y. Subjects who met the inclusion criteria and agreed to participate in the study were given a verbal description of the study, confidentiality assura nce, and possible risks of their participation. Those patients who expressed willingness to participate completed two questionnaires. The questionnaires took approximately 20 minutes to complete during their pre-operative visit. The principal inve stigator and each subject signed a copy of the informed consent. A copy of the signed informed consent was gi ven to the participant for their individual records. The principal investigator verbal ly asked each subject if they had additional questions regarding their particip ation in this research study prior to their discharge from the pre-surgical center.

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28 A key containing the participant’s name, and confidential code was developed. Informed consents and questionnaires were c oded with the participant’s confidential code and are kept in a locked file cabinet in the principal investigator’s office. Measures Demographic data Age, gender and ethnicity we re coded using a coding key (see Appendix G). Demographic data was entered on an Excel spreadsheet after enrollment. There was no missing demographic data. Preoperative Questionnaire Measures Indicator of spirituality The Spiritual Involvement and Belief S cale(Revised (SIBS-R) Hatch, Burg, Naberhaus, & Hellmich (1998) evaluates a broa d range of intrinsic spiritual content from ability to find meaning in life to spiritual writings. Designed for us e with individuals of all religious and non-religious traditions that include Ch ristian, Judeo, Hindu, Islam and Atheist. This instrument differs from other spiritual measurement tools in that it is not limited to individuals with a Judeo-Christian tradition. For the purpose of this study one question was selected to eval uate participants’ spirituality. Two groups were created using the response to the question, “How spiritual a person do you consider yourself?” Subjects were asked to rate themselves on a scale of 1 to 7 with 7 meaning “the most spiritual”. Those groups who rated themselves 5, 6, or 7 were considered highly spiritual and coded as 1. Those who rated th eir spirituality as 1,2,3, or 4 were considered le ss spiritual and coded as 0 Indicator of self -health assessment The Rand SF-36 Health Status Questionnair e measures physical functioning, social functioning, role functioning (physical pr oblems) and role functioning (emotional

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29 problems). Additionally, the instrument me asures mental health, fatigue, pain, and general health. One question, “In general would you say your health is”, was used to create two groups for the analysis. If a participant an swered good, very good or excellent, their response was considered as a high self-heal th assessment and coded as 1. If their response was fair or poor, their self-health assessment was considered a low score and coded as 0 Questionnaire data Using the patient’s confidentia l code all questionnaire data was entered using an excel spreadsheet. Miss ing data on questionnair es was entered as a dot. Indicator of diagnosed osteoarthritis A diagnosis of osteoarthritis was recorded by the orthopedic surgeon and is available in e ach individual participan t’s medical record. The diagnosis was verified with the indi vidual’s pre-surgical history and physical assessment. Indicator of ethnicity Ethnicity was obtained from the patient ’s admission record. The admissions department routinely obtains ethnicity info rmation during a patient’s initial interview prior to entering the hospital. Postoperative Data Collection Procedures Indicator of pain scores Individual postoperative pain scores were obtained from the individual’s medical record. Daily pain scores were recorded and averaged for three days postoperatively. Additionally, a daily median pain score was recorded for this same interval. Pain was evaluated using the Visu al Analog Scale (VAS) that evaluates pain intensity numerically using a 0 to 10 measurement (0= no pain, 10= worst pain). The

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30 VAS instrument is used with all age groups and is the approved pain scale for use at Shands Hospital at the University of Florida. Analgesic medication use Medications dispensed during a patientÂ’s hospitalization are records in the Medication Administrati on Record (MARS). The MARS documents each dose of medicine administered by nursing personnel. This medication record contains the medication name, date, time, dosage and initials of hospital personnel administering the medication. Individual Medication Administration Records (MARS) were evaluated for the use of narcotic analge sic medication for every participant. An Opioid equi-analgesic conversion table was us ed and all opiates we re standardized to morphine sulfate equivalents. For example, 1.5 mg IV Hydromorphone = 100 mcg IV/SC Fentanyl = 20 mg P.O. Oxycodone = 10 mg IV Morphine (Pasero, Portenoy & McCaffery, 1999). Total IV Morphine Sulfate equi-analgesic conversion was recorded for each postoperative day for three days. Regional anesthesia use Regional anesthesia techniques such as epidural, Femoral Nerve Sheath Catheters, and Psoais Compartm ent Catheters provide postoperative pain relief by blocking nerve conduction with lo cal anesthetics, thereby blocking the transmission of pain (Pasero, Porteno y, & McCaffery, 1999). The use of a local anesthestic provides a sensory and motor bloc kage. The epidural regional anesthesia technique occasionally re quires the use of an opioid agent in addition to a blocking agent. The use of an opioid agent is recorded on a separate analgesic document in the patientÂ’s medical record. The placement location of regi onal anesthesia is recorded on a separate document located within the patientÂ’s medical record.

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31 Medical record data Medical record data collected included surgical site, anesthesia data, pain scores and analgesic medication used. A form was developed (see appendix) to collect data from the participantÂ’s medical record after discharge. Medical records were requested using a Request fo r Records review and Shands at the UF Research Chart Request forms. An average of 4-20 charts were requested each time; medical records usually required two weeks to be assembled. Several delays were experienced in obtaining medical records that included research medical records personnel vacation days, sick days, and incomp lete delivery of records. One medical record has been lost. Two records are in complete with medication records missing. The Medical Record Department requires th at all data and chart review must be preformed in the records department. Usi ng the coding key, data was recorded on the case coding form. Pain scores were documented as average scores and median pain scores. All opioid medications were converted to Morphine Sulfat e IV equi-analgesics and recorded. Surgical site, anesthesia type, regional anesthesia, general anesthesia were coded using the coding key. Data Analysis Data obtained in the postoperative period were entered on an Excel spreadsheet. Analysis used SPSS statistical software, Vers ion 11 for Windows. Demographic data for spirituality, self-health assessment, age, ge nder, pain scores, a nd analgesic medication use were analyzed to generate descriptive st atistics using mean scores and frequencies The hypotheses were tested with analysis procedures using PearsonÂ’s correlation coefficient, T-Test and ANO VA with significance levels of 0.05. Correlations measure how variables are related and measure their linear association. Frequencies and mean scores were analyzed for all demographic data, age, gender, operative site, physician,

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32 regional anesthesia and analgesic medication use. Individual survey questionnaire items were analyzed using frequency and percen tage of individual participant response. Summary This chapter presented research desi gn, sample inclusion, power analysis, methodology, and data collection procedures for this study. Data analysis methodology for research hypotheses was discussed.

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33 CHAPTER 4 RESULTS A description of the partic ipants and the results of this descriptive study are presented in this chapter. The results are examined in relation to the three hypotheses. This study took place at Shands at the University of Florida. Subject s were recruited as a convenience sample that included only persons that met the inclusion criteria. Informed Consent and questionnaire data were collected in the pre-surgical anesthesia clinic. Demographic data, pain scores and medica tion use were obtained from the subject’s medical record after hospital discharge. A ll data was computed using the SPSS statistical software, version 11 for Windows. Sta tistical significance was set at p < 0.05. Sample Characteristics A total of 126 potential subjects who met th e inclusion criteria were approached to participate in the study. Eleven potential par ticipants declined to participate. Three stated they were “tired of filling out paperw ork”, two did not want to participate in any research and one did not believe in spirituality. Five did not express a reason for refusing participation. None of the potential resear ch participants expressed any fear of an adverse event by participating in this study. A ll subjects who agreed to participate signed an informed consent and completed the two que stionnaires in the pre-operative anesthesia center. At the end of the study one subjec t’s medical record wa s missing from the Medical Records Department and after a deta iled search was considered lost. One subject’s Medication Administration Record was missing from the medical record and

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34 presumed lost. All other part icipants’ medical records were complete at the end of the data collection period. One hundred and fifteen subjects who met th e inclusion criteria were consented. The mean age of the sample was 67.70 (SD = 8.23). Seventyfour (64.3 %) of the participants were female and 41 (35.7%) were males. The majority of the participants were Caucasian (n = 111), followed by Hispanic (n = 2) and African American (n = 1). All participants were diagnosed with severe osteoarthritis and had failed conservative medical management. Right total knee arthroplasty was the joint replacement most frequently performed at 35% (n = 35), followed by left total knee arthroplasty at 27.8% (n = 32) right total hip arthroplasty 18% (n=18), left total hip arthroplasty at 13.9% (n =16), and bilateral total knee arthroplasty at 10.4% (n = 12). Regional Anesthesia Forty-six percent (n = 56) of the participants chose a femoral nerve sheath for postoperative pain control, while 25.2% (n = 29) chose an epidural, 3.5% (n = 4) chose a psoas compartment sheath, and 1.7% chose a continuous spinal. Patient controlled analgesia (PCA) was used by 67% (n = 77) of subjects. The PCA group includes some of the subjects who received a femoral nerve shea th. All other participants selected “as needed” analgesia for post operative pain control. Anesthesia Technique During Surgery General anesthesia was administered to 100 participants (87%) followed by continuous spinal at 4.3% (n = 5), followed by managed anesthesia care at 2.6% (n=3).

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35 Analysis of Data in Relation to the Hypotheses Hypothesis 1 Hypothesis 1 stated that olde r adults with a high degree of spirituality receiving hip or knee arthroplasty for primary osteoarthrit is would report less pain and receive less analgesic medication than those participants with a lower degree of spirituality after controlling for health self-assessment. The Pearson Correlational analysis as show n in Table 3, demonstrated there was no significant correlation between spirituality re sponse, self-health questionnaire response and the following variables: age (r = -0.02, p = 0.84), average pain scores day one (r= 0.01, p = 0.92), average pain scores day two (r = 0.02, p = 0.84), average pain scores day three (r = 0.03, p = 0.78) and analgesic medi cation use (r = -0.04, p = 0.69). A partial correlation coefficient controlling for the self -health assessment score was then analyzed (See Table 4) and there were no significan t correlations between spirituality, and the variables: age (r = -0.05, p = 0.60), pain day one (r = 0.53, p = 0.59), pain day two (r = 0.06, p = 0.53), pain day three (r = 0.06, p = 0.56) and pain medication (r = -0.02, p = 0.81). Hence, Hypothesis 1 was rejected. Hypothesis 2 Hypothesis 2 stated that older adults with a high score on the high self-health assessment tool would report less pain and r eceive less analgesic medication than those participants with a low score on the self-h ealth assessment tool after controlling for spirituality. The Pearson Correlation found there was a significant correlation as shown in Table 5 between the variable for health on th e Short Form-36 Health Survey and age (r = 0.23, p = 0.02), average pain scores day one (r = -0.31, p = 0.00), day two (r= -0.29, p =

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36 0.00) and day three (r = -0.22, p = 0.03). There were similar results for days one, two, and three and median pain scores. However, there was no significant correlation between the variables, analgesic medication use (r = 0.11, p = 0.23) or high spirituality (r = 0.13, p = 0.17) as shown in Table 5. A Pearson Partial correlation for health assessment while controlling for spirituality was analyzed. There was a sta tistically significant correlation for the following variables: age (r = 0.23, p = 0.02), pain scores on day one (r = -0.31, p = 0.00), day two (r = 0.29, p = 0.00), day three (r = -0.22, p = 0.02). Ther e was no significance for less analgesic medication use (r = -0.11, p = 0.26) as show n in Table 6. The results confirmed Hypothesis 2 for pain, but rejected it for analgesic medication use. Hypothesis 3 Hypothesis 3 stated that th ere would be less analgesic medication used in those older adults receiving hip or knee arthropl asty who had a high degree of spirituality involvement and beliefs and a high scor e on the self-health assessment tool. An ANOVA regression was used to determin e if there was an interaction between good to excellent health and a high degree of spirituality. The relationship was not significant (F = 1.04, p = 0.38). Fu rther analysis a T-Test was used to determine if there was a difference in the average analgesic medication use between the high spirituality group and the good to excellent self-a ssessed health group (Ms = 7.63 and 8.49 respectively). Hypothesis 3 was rejected. Additional Findings For the purpose of this research, one ques tion rating degree of spirituality was used from this scale. The SIBS tool was satisfa ctory and demonstrated a Cronbach Coefficient Alpha 0.94 Raw Score. Each participant comp leted the 39-item questionnaire and there

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37 were a many positive responses to specific questi ons on the spirituality and beliefs scale. For example, on the item spiritual health contributes to physical health, 70.4% agreed or strongly agreed. Most part icipants considered themselves spiritual when asked to rate their spirituality on a scale of 1 to 7 (with being the most spiritual). Participants used religious coping such as hope, personal relati onship with a greater pow er than self, and a belief that prayer changes things. A high num ber of participants (77%) wanted others to pray for them during their illness. More th an 70% of the respondents felt that spiritual health contributes to physica l health. Additionally, 95 or 82.6% of the participants always or almost always make an effort to apologize when they do wrong to someone. Overall scores on the SIBS instrument refl ected a positive relationship with a higher power, prayer, a belief in an after life, and continued spiritual growth (see Table 7). Participants expressed difficulty with the SI BS questionnaire and often said, this is too hard to answer or, I have to think a lot. However, no participant asked for clarification of a SIBS question. The Short Form-36 Health Survey For the purposes of this research particip ant response to the question In general would you say your health is: excellent, very good, good, fair, poor was used for analysis. Participants answ ered the 11-item self-assessment tool that queried physical and emotional function. It is of interest th at most were limited a lot for vigorous and moderate activities. Daily ac tivities such as walking, be nding, kneeling and stooping had the highest response for limited a lot. Simp le activities such as dressing and bathing were least limited. The tool seemed easier than the SIBS for participants to complete and there were no missed questions.

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38 Table 1. Frequency and Percent of Variables Variable Frequency Percentage Sex Male 41 35.7 Female 74 64.3 Ethnicity White 111 96.5 African American 1 .9 Hispanic 2 1.8 Operative Site No response 2 1.7 Left Total Hip Arthroplasty 16 13.9 Right Total Hip Arthroplasty 18 15.7 Left Total Knee Arthroplasty 32 27.8 Right Total Knee Arthroplasty 35 30.4 Bilateral Total Knee Arthroplasty 12 10.4 Orthopedic Surgeon Surgeon #1 81 70.4 Surgeon #2 23 20.0 Surgeon #3 11 9.6 Regional Anesthesia No Regional 22 19.1 No Response 1 .9 Epidural 29 25.2 Femoral Nerve Sheath 56 48.7 Psoas Compartment Sheath 4 3.5 Continuous Spinal 2 1.7 Spinal 1 .9 Patient Controlled Analgesia No Response 3 2.6 No PCA 35 30.4 PCA 77 67.0 Anesthesia Type No Response 2 1.7 GETA 100 87.0 Spinal 5 4.3 MAC 3 2.6 Continuous Spinal 5 4.3

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39 Table 2. Summary Measures of Variables Variable N Mean Std. Dev Minimum Maximum Age 115 67.70 8.23 55.00 86.00 Av. Pain Scores day 1 113 3.34 1.99 0 9.13 Av. Pain Scores day 2 111 2.28 2.04 0 7.20 Av Pain Scores day 3 106 2.24 2.15 0 9.20 Median Pain Scores day 1 113 2.97 2.67 0 9.75 Median Pain Scores day 2 111 2.01 2.31 0 9.00 Median Pain Scores day 3 105 2.11 2.38 0 9.00 Health Self115 0.82 0.39 0 1.00 Assessment Spirituality 111 0.69 0.46 0 1.00 Table 3. Pearson Correlation Coefficients -Spirituality and Variables with No Adjustments Variables r value p value n Age -0.02 0.84 111 Pain Day 1 (average) 0.01 0.92 109 Pain Day 2 (average) 0.02 0.84 108 Pain Day 3 (average) 0.03 0.78 103 Pain Day 1 (median) 0.01 0.91 109 Pain Day 2 (median) -0.03 0.75 108 Pain Day 3 (median) 0.10 0.30 102 Analgesic Medication Use Day 1-3 -0.04 0.69 109 Table 4. Pearson Partial Coefficien ts-Controlling for Health Assessment Variables r value p value n Age -0.05 0.60 108 Pain Day 1 (average) 0.05 0.59 106 Pain Day 2 (average) 0.06 0.53 105 Pain Day 3 (average) 0.06 0.56 100 Pain Day 1 (median) 0.05 0.63 106 Pain Day 2 (median) 0.01 0.92 105 Pain Day 3 (median) 0.13 0.18 99 Analgesic Medication Use Day 1-3 -0.02 0.81 106

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40 Table 5. Pearson Correlation Coefficients-H ealth Self-Assessment and Variables with No Adjustments Variables r value p value n Age 0.23 0.02 115 Pain Day 1 (average) -0.31 0.00 113 Pain Day 2 (average) -0.29 0.00 111 Pain Day 3 (average) -0.22 0.03 106 Pain Day 1 (median) -0.26 0.01 113 Pain Day 2 (median) -0.30 0.00 111 Pain Day 3 (median) -0.21 0.04 105 Analgesic Medication Use Day 1-3 -0.11 0.23 113 Spirituality 0.13 0.17 111 Table 6. Pearson Partial Coefficients-Health Self-Assessment and Va riables Controlling for Spirituality Variables r value p value n Age 0.23 0.02 108 Pain Day 1 (average) -0.31 0.00 106 Pain Day 2 (average) -0.29 0.00 105 Pain Day 3 (average) -0.22 0.02 100 Pain Day 1 (median) -0.26 0.01 106 Pain Day 2 (median) -0.30 0.00 105 Pain Day 3 (median) -0.22 0.03 99 Analgesic Medication Use Da y 1-3 -0.11 0.26 106

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41 Table 7. Frequencies and Percentages for SelfReported SIBS Questionnaire (N=115). Answers reflect Agree or Strongly Agree scores only except for questions that are reverse score negatively worded items. These items were scored disagree or strongly agree. Frequency Percentage (1) I set aside time for meditation and/or selfreflection. 51 44.3 (2) I can find meaning in times of hardship. 67 58.3 (3) A person can be fulfilled without pursuing active spiritual life. (disag ree/strongly disagree) 43 37.4 (4) I find serenity by accepting things as they are. 53 45.0 (5) Some experiences can be understood only through oneÂ’s spiritual beliefs 64 55.6 (6) I do not believe in an afterlife. (disagree/strongly disagree) 70 60.9 (7) A spiritual force influences the events in my life. 70 60.9 (8) I have a relationship with someone I can turn to for spiritual guidance. 69 60 (9) Prayers do not really change what happens. (disagree/strongly disagree) 79 68.7 (10) Participating in spiritual activities helps me forgive other people. 70 60.9 (11) I find inner peace when I am in harmony with nature. 68 59.2 (12) Everything happens for a greater purpose 70 60.9 (13) I use contemplation to get in touch with my true self. 43 37.4 (14) My spiritual life fulfills me in ways that material possessions do not. (This question is missed by 25 or 21.7% do to its positi on in the questionnaire) 62 53.9 (15) I rarely feel connected to something greater than myself. (disagree/strongly disagree) 62 53.9 (16) In times of despair, I can find little reason to hope. (disagree/strongly disagree) 80 69.6 (17) When I am sick, I would like others to pray for me. 89 77.4

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42 Table 7. Continued Answers reflect Agree or Strongly Agree scores only except for questions that are reverse score negatively worded items. These items were scored disagree or strongly agree. Frequency Percentage (18) I have a personal relationsh ip with a power greater than myself 81 70.4 (19) I have had a spiritual experience that greatly changed my life 57 49.6 (20) When I help others, I exp ect nothing in return. 98 84.2 (21) I donÂ’t take time to appreciate nature. (disagree/strongly disagree) 70 60.9 (22) I depend on a higher power. 70 60.9 (23) I have joy in my life because of my spirituality 74 64.3 (24) My relationship with a higher power helps me love others more completely. 69 60.0 (25) Spiritual writings en rich my life. 61 52.1 (26) I have experienced healing after prayer. 47 40.9 (27) My spiritual understanding continues to grow. 74 64.3 (28) I am right more often than most people. (disagree/strongly disagree) 34 28.0 (29) Many spiritual approaches have little value. 62 53.9 (30) Spiritual health contribute s to physical health. 81 70.4 (31) I regularly interact with others for spiritual purposes. 52 45.2 (32) I focus on what needs to be changed in me, not what needs to be changed in others. 75 65.2 (33) In difficult times, I am still grateful. 91 79.1 (34) I have through a time of gr eat suffering that led to spiritual growth. 51 44.3 The following questions were scored using onl y the response always or almost always (35) When I wrong someone, I make an effort to apologize. 95 82.6 (36) I accept others as they are. 75 65.2 (37) I solve my problems without using spiritual resources. 25 21.7

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43 Table 7. Continued. Answers reflect Agree or Strongly Agree scores only except for questions that are reverse score negatively worded items. These items were scored disagree or strongly agree. Frequency Percentage The following questions were scored using onl y the response always or almost always (38) I examine my actions to see if they reflect my values. 49 42.6 The following question was scored 1-7 with “7” being the most spiritual. Scoring for this question used response 5,6,7. (39) How spiritual a person do you consider yourself? 50 66.9 Table 8. Frequencies and Percentages Ques tions that Indicated Ratings for General Health, and Bodily Pain as Self-reported on the Short Form-36 Health Survey questionnaire (N=115). Questions Frequency Percentage (1) In general would you say your health is: response: excellent, very good, good 94 81.73 (2) Compared to one year ago how would you rate your health in general now? Much better 9 7.83 Somewhat better 18 15.65 About the same 61 53.04 Somewhat worse now 23 20.00 Much worse now 4 3.48 (7) How much bodily pain have you had during the past 4 weeks? No response 2 1.74 None 0 0 Very Mild 14 12.17 Moderate 36 31.30 Severe 46 40.00 Very Severe 17 14.78 Additional findings included the increased use of regional analgesic techniques during the last six months of this research. Concurrent research by another investigator enrolled some of these same participants re ceiving total knee arthropl asty in a study using femoral nerve sheath technique to treat postope rative pain. This investigator examined

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44 the pain report outcomes for two of the most frequently used regional analgesia methods of postoperative pain control: epidurals and fe moral nerve sheath catheters. Analysis of these two methods compared the mean pain scores on postoperative days one, two and three. Both techniques had lower mean scores for pain scores on days one, two and three when compared to no regional technique. The epidural provided the lowest mean score day one (M= 2.74) compared to the femoral nerve sheath on day one (M= 3.17). Those participants using PRN analgesia and no regi onal technique had the highest mean pain score on day one (M=4.25). On day two, the femoral nerve sheath provided the lowest mean pain score (M==1.82). On day three all of the regional analgesia had been removed, but the mean pain scores for those persons who received regional analgesia remained similar to days one and two. On a ll three days the PRN analgesia group had the highest mean pain score ( Ms= 4.25, 2.90, and 2.94, respectively). In summary, these findings demonstrated th at participants in this study were in moderate to severe pain and had functiona l limitations preoperatively, but described themselves as in good to excellent health and very spiritual. The use of regional analgesia for postoperative pain control did lowe r pain scores for all days when compared to those who did not receive a regional technique.

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45 CHAPTER 5 DISCUSSION The purpose of this study was to examine the relationships between the degree of spirituality and high scores on a self-hea lth assessment questionnaire with three postoperative outcomes after hip or knee join t arthroplasty. Specifically, this study examined the relationships between a high degree of spirituality, a high score for individual self-health assessment and pain re port and analgesic me dication use for three days after total joint replacem ent surgery. The hypothesized relational statements were based on the need for quantitative data coll ection measuring the relationships between spirituality, health assessment, pain report a nd analgesic medication use. There is no previous empirical research that has examin ed these relationships in the postoperative arthroplasty patient. The study sample consiste d of 115 participants scheduled for hip or knee arthroplasty in a large Southeastern te aching hospital. This chapter will present a discussion of (1) research findings, (2) conclusions, (3) research strengths and weaknesses, and (4) implica tions for nursing practice. Research Findings This section will discuss sample charact eristics, followed by study of findings as they related to the research questions. Sample Characteristics One hundred and fifteen older adults who we re scheduled for hip or knee total joint arthroscopy consented to particip ate in this study. All of the participants were recruited from the pre-surgical anesthesia center of a large teaching hospital. In this convenience

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46 sample, the participant ages ranged from 55 to 86. The average age was 67.70. There were 41 males and 74 females enrolled in this study. This finding is somewhat less than the 2:1 ratio females to males in osteoarthritis prevalence as reported by other researchers (Davis, Ellinger, Newhaus, & Hauck, 1987). Pa rticipants described their generalized body pain as severe or very severe (55%) dur ing the four weeks prior to their scheduled surgery, but self-asse ssed their health as excelle nt, very good or good (81.73%). Anderson, et al. (1993) and Mob ily, et al. (1994) reported sim ilar pain report among older adults. This research found that functional abilities were severe ly limited for vigorous activity such as part icipating in strenuous sports, lifting heavy objects, vacuuming, playing golf walking several blocks, bendi ng, stooping and climbing stairs while more moderate activities such as lifting groceries, bathing and dressing were “limited a little”. Praemer, Furner, & Rice, (1992) and Salmon, et al. (2001) found similar functional limitations in osteoarthritis patients. Ethnicity could not be examined due to the low numbers of African Americans and Hispanics enrolled in this re search. Felson (1988) simila rly found that greater numbers of European whites have osteoarthritis than other ethnicities and this may account for the differences observed in this study. Only one African Ameri can and two Hispanics were enrolled in this research. Socioeconomic status may have been a factor in the low number of other ethnic groups seeking join t replacement. However, socioeconomic status was not considered in this research. Spirituality, Pain Report and Analgesic Medication The first research question examined th e relationship of a high degree of spirituality, postoperative pain scores and analgesic medication use. One research

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47 question was used from the SIBS questionnaire Two groups of participants were created using one research question from the SIBS que stionnaire. Those with high scores for spirituality were considered highly spiritua l. The majority (69.4%) of the respondents were highly spiritual. A part ial correlational analysis was used to identify a relationship between a participants’ high spirituality and the variables, age, pain report for three days and analgesic medication use postoperatively, controlling for self-a ssessed health. There was no relationship for spirituality and th e variables. Therefore, hypothesis 1 was rejected. Participants who have a high degree of spirituality did not tend to have less pain and did not tend to use less analgesic medi cation postoperatively. Although there was a high participant response to spirituality, the possibility of spiritual coping did not tend to influence pain or pain medicine use after joint replacement surgery. Health Self-Assessment, Pain Report and Analgesic Medication Use It was hypothesized that participants who consider themselves healthy will report less pain and use less analgesic medication po stoperatively. The health variable “In general would you say your h ealth is: excellent, very good, good” was used to identify those participants with a high score on hea lth assessment. Of the participants, 81.7% rated their health in this positive way. Correlation analysis found that persons who considered themselves healthy tended to have less pain on each day postoperatively but they did not tend to use less pain medicat ion. Therefore, there was no association between high health scores and less pain medi cation use. Further analysis using a partial correlation controlling for th e spirituality variable, found similar results; a healthy assessment was related to less pain for th e three days postoperatively and had no relationship with the amount of pain medication.

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48 In summary, participants who rated se lf-health as good, very good or excellent tended to experience less pain during the first three days pos toperatively. However, these same participants did not tend to use less pain medication. Research question 2 was accepted for less pain, but rejected for less pain medication use. Impact of Health Assessment and Spiritual ity on Pain Reports a nd Analgesic Medication Use Lastly, it was hypothesized that participants who considered themselves to be very spiritual and healthy would use less anal gesic medication duri ng their postoperative recovery. A regression analysis was used to determine possible interactions between health assessment and spirituality and analgesic medication use. There was no relationship between the variab les and pain medication. A further T-Test was used to determine if there was a difference between th e high spirituality and the high self health assessment groups in analgesic medication use. The T-Test found no mean difference between the two groups. Therefore, Hypothesis 3 was not accepted. Those participants w ho self-rated their health as good, very good or excellent and considered their spirituality as high did not tend to experience less pain or use less pa in medication than did the other research participants. Conclusions Although participants reported moderate to severe bodily pain and a decrease in functional activity on a health questionnaire, they considered themselves to be healthy. There was a relationship between self-health and pain for the first three days after surgery. It demonstrated that how a person vi ews their health contributes to the amount of pain they experience after joint replacemen t. Additionally, less pain experienced did

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49 not mean less pain medication used. There has been no previous research evaluating relationships between how hea lthy an individual feels and the amount of pain medication used after surgery. Previous research that has evaluated h ealth status has been with individuals who were in “poor health” w ith long-term disab ility after surgery. Most participants considered themselves to be highly spiritual and used spiritual coping methods such as hoping, praying and dependence on a higher power. There is no previous research that has examined the sp irituality and postoperative pain or pain medication use after joint replacement surger y. Previous research that evaluated spirituality, health assessment and functiona l recovery used a very different patient population. The only similarity was a high degr ee of spirituality among the older adult rehabilitation patients (Fitchett, et al. 1999; Kim, et al. 2000; Pressman, et al. 1990). In my research, most reported that they used spiritual coping me thods and behaviors such as participation in spiritual activities, spiritual writings and prayer. They also believe their spiritual health contributes to their physical health. The majority of the participants in this research used these spiritual coping me thods. However, there was no evidence that high self-evaluation for spirituality influenced pain or pain medication use after total joint replacement surgery. Strengths and Limitations Although this research had strengths, it was limited in its methodology. Primarily it was a convenience sample of pre-operative total joint arthroscopy patients. This research was impaired by the use of regi onal anesthesia by the majority of the participants. These patients received more re gional anesthesia techni ques for pain control postoperatively than most othe r surgical patients. Regiona l analgesia is an effective technique in the treatment of post-operat ive arthroplasty pain. Pain report and

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50 medication use for this group of patients we re affected by the use of the regional anesthesia techniques. It was not possible to control for the increase in regional analgesia techniques during th is investigation. There was an uneven distribution of males a nd females. This was to be expected, but did not approach the 2:1 ra tio for osteoarthritis found in previous research. There was no ethnic diversity found in this research a nd this finding does not represent the ethnic distribution in the geographic region. Implications for Nursing Practice and Future Study There is evidence from this study that these patients requ iring total joint replacement for osteoarthritis have a high degr ee of spirituality and perceive their health as good to excellent. They use spiritual copi ng and behaviors such as prayer, spiritual activities, and belief that spiritual health influe nces physical health. Second, they feel their hea lth is good to excellent re gardless of their functional limitations or pain. This self-assessment of good h ealth contributed to le ss pain after total joint surgery, but did not lessen the need for pain medication. It is important that the clinician reco gnize that the postoperative patient is multidimensional in their self-h ealth and their spirituality. This quantitative study did not support the hypothesis that spirit uality decreases pain or pa in medication use. This research did find a relationship between self -assessed good health and decreased pain, but did not find a relationship in less pain medicine use. This research contributes to the body of literature evaluating spirituality and health in the older adult. Future research should include postoperati ve function and pain using longitudinal data collection. Assessing jo int arthroplasty subjects pre-operatively, one month postoperatively and at the end of the one-year recovery peri od would provide long-term

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51 data on the relationships between spiritualit y, self-health assessment, pain and physical function. Correlating functional longitudinal da ta with spirituality and health assessment would provide more pertinent information without interference from postoperative regional analgesia. The implications of this study for nursing pr actice are that the findings of this study support the use of spirituality and spiritual beha viors by the majority of the participants. Good to excellent self-health assessment did ch ange the amount of pain these participants reported after surgery. Nurses should be more at ease in assessing a patientÂ’s spirituality and self-health. Nurses do have to recognize that how a patient eval uates self-health may be important in reducing postope rative joint arthroplasty pain. In summary, evaluating the participantsÂ’ spirituality and self-health assessment found interesting relationships between postope rative pain and analgesic medication use. Second, these research findings have implicati ons for further future nursing research.

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APPENDIX A LETTER OF AGREEMENT

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78 APPENDIX E THE SHORT FORM-36 HEALTH SURVEY —SPIRITUAL INVOLVEMENT AND BELIEFS SCALE

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87 LIST OF REFERENCES Aarons, H, Hall, G., Hughes, S., & Salmon, P. (1996). Short-term recovery from hip and knee arthroplasty. The Journal of Bone and Joint Surgery, 8, 555-558. Affleck, G., Tennen, H., Keefe, F.J., Lefe bvre, J.C., Kashukar-Zuck, S., Wright, K., Starr, K., & Caldwell, D.S. (1999). Everyday life with osteoarthritis or rheumatoid arthritis: independent e ffects of disease and gender on daily pain, mood, and coping. Pain, 83, 601-609. American Geriatrics Society. (1998). The management of chr onic pain in older persons. Journal of the American Geriatrics Society, 46, 174-192. Anderson, H.I., Ejlertsson, G., Leden, I., & Rosenberg, C. (1993). Chronic pain in a geographically defined general population: Studies of difference in age, gender, social class, and pain localization. The Clinical Journal of Pain, 9, 174-192. Bates, M.S., Edwards, W.T., & Anderson, K.O. (1993). Ethnocultural influences on variation in chronic pain perception. Pain, 52, 101-112. Brander, V.A., Mullarkey, C.F., & Stulberg, S.D. (2001). Rehabilita tion after total joint replacement for osteoarthritis : An evidence based approach. Physicial Medicine and Rehabilitation, 15, 175-197. Burkhardt, M.A., (1989). Spirituality: An analysis of the concept. Holistic Nursing Practice, 3, 69-77. Clark, K.M., Friedman, H.S., & Martin, L.R. (1999). A longitudinal study of religiosity and mortality risk. Journal of Health Psychology, 4, 381-391. Davis, M.A., Ettinger, W.H., Newhaus, J. M., & Hauck, W.W. (1987). Sex difference in osteoarthritis of the kne e: the role of obesity. Journal of Epidemiology, 127, 10191029. Diehl, M., Coyle, N., & Labouvie-Vief, G. (1996) Age and sex difference in strategies of coping and defense across the life span. Psychology and Aging, 11, 127-139. Ekblom, A., & Rydh-Rinder, M. (1998). Pa in mechanisms: anatomy and physiology. In N. Rawal, (Eds). Management of acute and chronic pain (pp. 1-22). London: BMJ. Ellison, C.G., & Levin, J.S. (1998). The religion -health connection: evidence, theory, and future directions. Health Education & Behavior, 25, 700-720.

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92 BIOGRAPHICAL SKETCH Patricia Anne McNally was born in Wate rloo, New York. She graduated from St. Mary’s Hospital, School of Nursing, Rocheste r, New York. Pat attended the University of Florida and received a Bach elor of Science in Nursing in 1981. A Master of Science in Nursing degree with a specialization in adult and women’s health was received from the University of Florida in 1999. Ms. McNa lly’s current nursing specialty area is the pre-surgical center at the University of Florid a. She is a member of Sigma Theta Tau, the International Honor Society for Nursing. Ms. McNally’s nursing career has included emergency department staff nursing, charge nursing, nursing and business admini stration, and currently advanced nurse practitioner. She resides in Gain esville, Florida. Pat is the mother of three adult children and the “Mamasita” to th ree young grandchildren.