Development of a Conceptual Nursing Model for The

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RESEARCH

Development of a conceptual nursing model for theimplementation of spiritual care in adult primary healthcare

settings by nurse practitionersRebecca Carron, MS, RN, NP-C (Family Nurse Practitioner, Doctoral Student)1

& Sharon Ann Cumbie, PhD, RN, CS (Faculty Associate, Associate Professor)2

1 College of Nursing, University of Colorado Denver, Centennial, Wyoming2 Watson Caring Science Institute, Boulder, Colorado, and Department of Nursing, College of Health Sciences, Appalachian State University, Boone,

North Carolina

Keywords

Spirituality; nurse practitioners; primary care;

stress and coping; qualitative research.

Correspondence

Rebecca Carron, MS, RN, NP-C, College of

Nursing, University of Colorado Denver, P.O.

Box 74, Centennial, WY 82055.

Tel: 307-760-1609;

Fax: 970-482-1411;

E-mail: [email protected]

Received: November 2009;

Accepted: March 2010

doi: 10.1111/j.1745-7599.2011.00633.x

Abstract

Purpose: The purpose of this research was to develop a conceptual nursing

model for the implementation of spiritual care in adult primary care by nurse

practitioners (NPs), with an emphasis on older adults.

Data sources: The study was a descriptive, qualitative design incorporating

a grounded theory and phenomenological approach. Purposive sampling was

used to recruit participants to obtain a broad perspective of the lived experi-

ence of spirituality in primary care. Fourteen interviews were conducted with

older adults, family NPs, community spiritual leaders/educators, and nuns.

Data were analyzed using a constant comparative approach to identify themes

of spiritual care.

Conclusions: The results demonstrated that as the NP–patient relationship

develops, the opportunity is often present for the NP to explore the adult’s

spiritual system. The NP and adult may develop an interspiritual relationship

with the potential to use the adult’s spirituality as a support resource.

Implications for practice: The nursing model reflects a spiritual-relationalview. As the NP and older adult grow in relationship, they can grow into

knowledge and use of spirit. The NP can use the adult’s spirituality as a

resource for helping the adult cope with ongoing and emerging problems.

The model provides spiritual care guidance for NPs through evidence-based

concepts.

Spiritual care is an integral, but often neglected and

poorly understood, component of holistic nursing prac-

tice for adults in primary healthcare settings. As the con-

nection between spirituality and health is manifestedmore and more in the literature, a compelling need ex-

ists for nurse practitioners (NPs) to address the spiritual

care needs of adult patients. However, in order to pro-

vide spiritual care, NPs need to understand the mean-

ing and interpretation of spiritual care from an adult pa-

tient’s perspective. The patient perspective then needs to

be integrated with the spiritual perceptions that NPs have

about spiritual care. The relationship between spiritual-

ity and religion also needs clarification. NPs often estab-

lish lasting relationships with their adult patients. Within

this relationship, the NP has the unique opportunity to

implement spiritual care interventions that can assist

adults to effectively manage the challenges of life. The

purpose of this descriptive qualitative research study wasto develop and propose a conceptual nursing model,

based on evidence-based patient and NP perceptions of

spiritual care, which provides the framework for the de-

livery of spiritual care to adults in primary healthcare

settings.

Background

A person’s spirituality can be helpful when coping with

difficult healthcare problems (Meraviglia, 2004; Walton,

552 Journal of the American Academy of Nurse Practitioners 23 (2011) 552–560 C2011 The Author(s)Journal compilation C2011 American Academy of Nurse Practitioners



R. Carron & S. Ann Cumbie Nurse practitioner model for spiritual care

1999; Walton & Sullivan, 2004). NPs and nurses, how-

ever, are often unsure how to implement spiritual care

(Grant, 2004; Sellers & Haag, 1998; Treolar, 2000). NPs

need to understand adults’ perceptions of spiritual care

needs (Bauer & Barron, 1995; Grant, 2004; King & Bush-

wick, 1994). Additionally, NPs need to be aware of theirown spiritual base and comfort level in providing spir-

itual care (Cavendish, Luise, Konecny, & Lanza, 2004;

Nagai-Jacobson & Burkhardt, 1989; Treolar, 2000). Au-

thentic, transpersonal, caring–healing NP–patient rela-

tionships are important in the provision of spiritual care

(Cumbie, 2001; Watson, 2002, 2001).

Spirituality is important to older people (Bauer & Bar-

ron, 1995; Dunn & Horgas, 2000; Touhy, 2001). It can

assist the elderly to cope with stress (Dunn & Horgas,

2000) and nurture feelings of hope (Touhy, 2001). De-

mographic statistics from the U.S. Census Bureau (2004)

demonstrate that the population of the United States isincreasing in age. According to the U.S. Census Bureau,

the percent of the population in 2000 aged 65 and above

was 12.4%. The U.S. Census Bureau predicts that in

2050, more than 20% of the population will be over 65.

As a result, NPs are likely to see an increased need to pro-

vide spiritual care.

Research with Roman Catholic nuns indicates that spir-

ituality is important to their perceptions of well-being as

they age (Brandthill et al., 2001; Huck & Armer, 1996;

Kvale, Koenig, Ferrel, & Moore, 1989). The knowledge

gained from an understanding of the relationship be-

tween the spirituality of older nuns and their well-being

may have applications to older adults.

A 2004 report by the National Center for Health

Statistics on the use of complementary and alternative

medicine (CAM) for health by adults in the United States

indicated that the most commonly used CAM therapies

were prayer for one’s own health (43.0%), followed

by being prayed for by another person for one’s health

(24.4%), use of natural products (18.9%), deep breathing

exercises (11.6%), and participation in a prayer group for

one’s health (9.6%; Barnes, Powell-Griner, McFann, &

Nahin, 2004). The most commonly cited reason (54.9%)

for using CAM was the belief that CAM and conventional

medicine can work together.There is limited information on the implementation of

spirituality or spiritual care by NPs in primary healthcare

settings. Graham, Brush, and Andrew (2003) addressed

the incorporation of spiritual care by NPs into their prac-

tice. While NP students helped perform an initial pa-

tient spiritual assessment for 18 men recovering from

substance addiction, the actual spiritual care interaction

occurred between the clients and a minister. The study

findings indicated that the problems of the men included

substance abuse in childhood and inadequate parenting,

anger at God, and seeking forgiveness and trust. The men

also experienced feelings of depression, despair, guilt, and

shame. The study minister described the spiritual-care

process as “providing companionship, offering blessings,

giving relevant gifts, and providing avenues for meaning-

ful self-reflection” (p. 476). It was important to help theclient reconnect with a sense of self. A nonjudgmental

attitude on the part of the minister was crucial to cre-

ate a safe environment for the client. The authors ac-

knowledged that barriers such as time restraints or lack

of knowledge regarding spiritual care may make the im-

plementation of spiritual care difficult for NPs.

Brush and Daly (2000) described the development of

an education/practice model to assist NP students with

implementing spiritual care. Spiritual care classes and

clinical experience helped students learn to implement

spiritual care in primary care settings. McEvoy (2000)

noted that a spiritual history can help NPs to provide carein a pediatric setting with information, for example, on

diet, contraception, or blood transfusions.

Hubbell, Woodard, Barksdale-Brown, and Parker

(2006) explored the use of spiritual care practices by NPs

in North Carolina. The authors measured spiritual care

practices with the Nurse Practitioner Spiritual Care Per-

spective Survey questionnaire. The study found that 73%

of NPs did not routinely provide spiritual care. The most

common spiritual practices were referral to clergy, en-

couraging patients to pray, and talking with patients on

spiritual topics. However, the tool did not measure other

spiritual care practices that NP participants identified as

comprising spiritual care, for example, listening, touch,

use of music, or caring.

Treolar (2000) reported on the importance of spiritual-

ity in healthcare practice by NPs, but the report was lim-

ited to personal examples of spiritual care and a descrip-

tion of the importance of spiritual care in NP practice.

Stranahan (2001) investigated spiritual perception, atti-

tudes, spiritual care, and spiritual care practices in a sam-

ple of 102 NPs. Measurement tools were Reed’s Spiritual

Perspective Scale and the Nurses Spiritual Care Perspec-

tives Scale developed by Taylor, Highfield, and Amenta.

The results indicated that 57% rarely or never provided

spiritual care. The most common spiritual interventionswere praying privately or clergy referral. However, partic-

ipants noted that touch, meditation, listening, presence,

music, and staff prayer were also important spiritual care

interventions that were not assessed by the measurement

tools.

In summary, the literature indicates that spirituality

is important to many adults as a coping and support

strategy, but more research is needed to understand the

role of spiritual care in NP practice. Research is needed

to indicate how spirituality and spiritual care should be

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Nurse practitioner model for spiritual care R. Carron & S. Ann Cumbie

incorporated into NP practice, particularly as an adjunct

supportive or empowering healthcare strategy. The

meaning and definition of spiritual care needs further

clarification. It is essential that the discipline of nursing

develop a method for providing effective spiritual nurs-

ing care to respond to the spirit residing in all people.

Theoretical framework

The theoretical framework for the study was based

on the theories and ideas of Florence Nightingale, Jean

Watson, Sharon Cumbie, and St. Benedict of Nursia.

Nightingale (1820–1910) believed that nursing was a

sacred science grounded in spiritual beliefs that in-

volved caring–healing nurse–patient relationships based

on God’s laws of nature (Calabria & Macrae, 1994; Dun-

phy, 2001; Nightingale, 1969). Watson (1940-) believes

that identifying and connecting with a person’s spirit canpromote caring–healing transpersonal relationships be-

tween patient and nurse (Watson, 2002, 2001). Watson

(2008) also noted the importance of acknowledging a

person’s inner belief system and the role of faith and hope

in mediating health and illness. Cumbie (1950-) believes

that caring nurse–patient relationships can promote the

health of both patient and nurse (Cumbie, 2001). St.

Benedict of Nursia, (d. 545 A.D.) believed in the connec-

tion of each person to God and to each other (Chittister,

1990).

Nightingale, Watson, Cumbie, and St. Benedict of

Nursia developed and promoted the theoretical con-

cept of authentic, spiritual, transpersonal caring–healing

NP–patient relationships. Spirituality permeates and in-

fuses the development of caring–healing NP–patient re-

lationships. NPs need to be aware of their own spiritual

base and how this base provides them with a philosophy

of nursing that guides their nursing practice. Kindness,

caring, and attention, grounded in nursing theory and

reinforced by concepts from Benedictine spirituality, can

empower and challenge NPs to reach out from their spiri-

tual base and touch the spiritual base of others to promote

health and well-being for patient, the patient’s circle of

family/friends, and the NP.

Definition of spirituality

The spirituality definition that guided this study was

from a concept analysis of spirituality by Tanyi (2002).

The following was her proposed definition:

Spirituality is a personal search for meaning and purpose in

life, which may or may not be related to religion. It entails

connection to self-chosen and or religious beliefs, values,

and practices that give meaning to life, thereby inspiring

and motivating individuals to achieve their optimal being.

This connection brings faith, hope, peace and empower-

ment. The results are joy, forgiveness of oneself and oth-

ers, awareness and acceptance of hardship and mortality,

a heightened sense of physical and emotional well-being,

and the ability to transcend beyond the infirmities of exis-

tence. (p. 506)

This definition is in accord with the theoretical frame-

work for the study. Spirituality involves finding purpose

and meaning in life, connectedness, relationships, honor-

ing inner belief systems, and the development of faith and

hope to inspire, transcend, and perhaps be transformed

by the experiences of health and illness as well.

Methods

Design and conceptual framework

The study was a qualitative descriptive design incor-

porating grounded theory and phenomenological over-tones. The aim of the study was to gain an understand-

ing of spiritual care perceptions by adults and the role of

the NP in response to these identified needs so that we

could propose a conceptual nursing model for the im-

plementation of spiritual care in adult primary health-

care settings. Spiritual care perceptions were explored

in the study with four groups of individuals: adult pri-

mary care patients, family NPs (FNPs), community spiri-

tual leaders/educators, and Benedictine nuns. The study

participants described their personal lived experiences of

spiritual care in primary healthcare settings and in their

individual lives. This goal was in accord with qualita-

tive descriptive design, which is an appropriate method-

ology when “straight descriptions of phenomena are

desired” (Sandelowski, 2000, p. 334). Qualitative de-

scriptive design incorporates elements of naturalistic

design such as no manipulation of variables, but rather

allows the phenomenon to present itself in its most nat-

ural state (Sandelowski, 2000). This methodology is es-

pecially suited for this study, which is seeking descriptive

responses of perceptions of spiritual care.

The study was cross-sectional in design in that data col-

lection interviews were conducted with participants at

one point in time, rather than at several points on a time-

line as would occur with a longitudinal study.Qualitative descriptive research can include “over-

tones” from qualitative approaches such as phe-

nomenology or grounded theory (Sandelowski, 2000).

Phenomenological research tries to understand the “lived

experience” of a phenomenon and then describe the

commonalities about a phenomenon shared by the par-

ticipants (Creswell, 2007, pp. 57–58). In this study, it

was crucial to an understanding of spiritual care to hear

the stories of lived experiences of spiritual care in pri-

mary healthcare settings in the lives of adults. Through

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these shared stories, the participants described the mean-

ing and importance of spiritual care in primary care so

that a nursing model could be developed from the com-

mon emerging themes.

The grounded theory tradition was also important in

the design of this research study. Grounded theory, de-veloped in the discipline of sociology, seeks to “generate

or discover a theory,” grounded in the data, that provides

an explanation or theory of processes or actions gener-

ated by the views of the participants (Creswell, 2007,

p. 63). Initial raw data are organized into categories. As

more data become available, new material is compared

to the existing categories through the process of constant

comparison. The categories then serve as the framework

to explain a model or describe a relationship (Creswell,

2007).

In this research study, the grounded theory overtones

allowed the participant interviews to become more fo-cused on emerging themes and concepts important to

perceptions of spiritual care in primary healthcare set-

tings. As the interviews became more focused on emerg-

ing themes, areas of lesser importance were not aggres-

sively pursued in the interviews.

Institutional Review Board approval for the study was

granted by the University of Wyoming. Participants and

facilities signed individual consent forms for the study.

Participants also completed a demographic form.

Sample

Purposive sampling was used to obtain a broad and di-

verse perspective of spirituality. There were 14 partici-

pants in the study sample. The sample consisted of five

adult patients, three FNPs, four community spiritual lead-

ers/educators, and two Benedictine nuns. The age range

was 28–84 years of age for all participants. There were 11

women and 3 men in the sample. There were three adult

women patients and two adult men patients.

Data collection and analysis

Data were collected with participant interviews, rang-

ing in length from 30–90 min. The participant inter-views were audio-taped and professionally transcribed.

The transcripts were then analyzed for content themes

according to Van Manen (1990). Verification of data

was accomplished through a systematic coding proce-

dure. The interviews were analyzed for common spir-

itual care concepts and ideas. All thematic categories

and concepts were grounded in participant interviews.

Through the constant comparative method, common

participant themes were identified and collected. Data

collection and analysis was halted when theoretical

saturation was achieved and no new themes or categories

were identified.

Challenges to the validity of a qualitative study, as

noted by Polit and Beck (2004), include the author’s own

biases, suppositions, and the personal nature of the data

collection and analysis. Validity of this study, as described by Creswell (2007), was achieved through triangulation,

clarifying personal biases by the researchers, and rich de-

scription based on verbatim participant remarks that al-

lowed for potential transferability. Triangulation of re-

sults among and between the four groups of participants

(patients, FNPs, spiritual leaders/educators, and nuns) al-

lowed for the validation of common themes that emerged

from the study. As to personal bias, the principle au-

thor/researcher spent approximately a year prior to the

study reading and reflecting about the nature of spiritual-

ity and the author’s own perceptions of spirituality while

engaging in academic writing and other course workthat involved spirituality. During the study, the princi-

ple author/researcher was then able to acknowledge and

bracket her own biases and suppositions regarding spiri-

tuality, to allow the participant views to emerge. Finally,

rich, verbatim description of the participant’s views of

spirituality in primary healthcare allows the readers to

make judgments about the validity of the results and their

potential transferability to other healthcare settings and

situations. Reliability of the study, as noted by Creswell

(2007), included professional transcription of the partic-

ipant audiotapes, and intercoder agreement between the

two study authors on the common themes and concep-

tual model.

Results

The results indicated that spiritual care for adults in-

cluded a need for kindness, compassion, and gentleness

from a caring, personal relationship with NPs as shown

by this statement from an older adult participant when

asked to describe spiritual care:

Your attitude when we come in there is really important to

me. You always treat us like you’re glad to see us instead

of, “You, again.”

The previous statement was reiterated by other adult

participants and became an important emerging theme

of spiritual care in primary care settings. One partici-

pant stated, “If you’re kind and considerate and helping

a person, what more spiritual could you be?” Another

remarked, “Spirituality is a very caring person.” This par-

ticipant provided a summary of older adult spiritual care

needs:

It’s the sense of caring and sense of being welcome and

what that does is cause a patient to feel better about the

555




environment, feel better about himself, and help with the

potential practices that are going to take place. Now all of

that . . .will find into the spirit and improve spiritual well

being, I believe. And I believe that a smile costs nothing.

The adult participants described spiritual care as be-

ing welcomed, respected, and recognized as a person.They also viewed spiritual care as receiving kindness, sup-

port, and caring from the NP. Spiritual care for adult pa-

tients is viewed as occurring within the context of the

nurse–patient relationship, which Watson (2001) noted

was important to help the person “access the healer

within” (p. 348). The first stage of the proposed nurs-

ing model for spiritual care emphasizes the importance

of establishing a meaningful, interpersonal nurse–patient

relationship before advancing further with a nursing as-

sessment and spiritual care interventions.

The FNPs focused on several aspects of spiritual care in

the interviews. The first aspect was the role of religion inspiritual care. NPs expressed concern about offending pa-

tients if they asked questions regarding religious support

systems. Sample statements by NPs included:

Spirituality is still an uncomfortable thing to bring up. And

I think if I was trained more or had a tool I would be more

comfortable bringing it up.

It’s tough in this world where you want to be politically

correct, you don’t want to offend somebody, you don’t

want people to think that maybe you’re a holy roller, and

you need to respect that people come from different tradi-

tions from you and you certainly don’t want to offend, you

know, anybody.

Spiritual care perceptions differed in some areas be-

tween the patient and the FNP. One FNP when told

that patients regarded spiritual care as kindness and com-

passion remarked, “See, to me, that’s nursing . . .I guess

it just depends on what your interpretation of spiritual

care is.” It is important for NPs to be able to distinguish

between spirituality and religion when thinking about

spiritual care. A person’s spirituality or source of inner

support may be based on an organized religion such as

Christianity, Judaism, or Buddhism. However, a person’s

source of inner support or meaning may have nothing to

do with organized religion and may instead be based in

receiving support from the creative and life-giving aspectsof nature, for example. Spiritual care does not have to in-

volve religious practices, although it could, depending on

the source of the patient’s and NP’s spiritual base. It is

also important for the NP to be aware of different spiri-

tual traditions, especially those in the local community.

The proposed nursing model considers the importance

of the patient’s and NP’s own spirituality and sources of

support.

The second aspect of spiritual care focused on by

the FNPs was the importance of an assessment of the

patient’s support systems that could include family,

friends, or spiritual base. The FNPs believed that support

systems could help a patient in a crisis situation. For ex-

ample, one FNP remarked:

I ask them, if they have any support group, that’s

how I bring it (spirituality) up, do you have a support

group? . . . Are you interested in any form of religion or

spirituality? So, I’ll bring it up then and if they say no, I

don’t really know where to go after that.

The FNPs also believed that listening, providing sup-

port, talking, and being present with patients were spir-

itual care interventions. A caring attitude perceived by

the adult patient as spiritual care appeared to be inter-

preted by the FNP as providing necessary spiritual sup-

port through listening, talking, and being present to the

person. The following is an example of the caring attitude

by the FNP as a spiritual intervention:

I touch people all the time. That’s just me. I’m kind of

a touchy person. But, uhm, especially if they’re having a

hard time, that’s important. And I’ll also listen to them as

long as they want to. I don’t care how long that appoint-

ment is. I’ll sit there and listen to what they have to say.

And some people don’t want to go to a counselor or don’t

want to go to church. They just want to talk to someone,

you know and so I’ll have them come back and we’ll just

talk again.

These NP statements further develop the proposed

nursing model for spiritual care. The importance of the

nurse–patient relationship is again emphasized with the

willingness to talk and listen to the patient. Then, the

next step of the model is a spiritual nursing assessment

of a person’s spiritual belief or support systems which

is here indicated by the NPs inquiring about a person’s

sources of support. The spiritual assessment could be as

simple as asking about sources of support and how these

are working for the person, or a more detailed assessment

of supportive activities.

The participants proposed methods for NPs to overcome

their anxiety in providing spiritual care. One community

leader/educator proposed that there was a need to meet

the spiritual care needs of the patients within the comfort

zone of the NP. The participant suggested that the firststep in providing spiritual care was establishing a com-

fortable NP–patient relationship. As the NP–patient rela-

tionship developed, the conversation could then address

the spiritual sources of support for the patient, as sug-

gested in the proposed model.

All of the elements of the proposed nursing model for

spiritual care including the nurse–patient relationship,

a spiritual assessment of a person’s spiritual belief sys-

tem, knowledge of the NPs own spiritual base, and in-

terventions based on the relationship and assessment are

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summarized and contained in the following statement by

an adult participant:

If you let that person really know you’re concerned about

that condition, whether it’s a cold or it’s a lifetime thing

or whether it is terminal, that person is going to feel it

{Relationship}. When that person feels it, it’s awfully easy

then, that person becomes open to you. You view the

opening to, you can’t just come across bluntly, but you

can maybe, at sometime or the other, ask them if they be-

lieve in God or if you don’t want to say God, you might

say a higher being to open the door {Assessment, Knowl-

edge of own spiritual base}. A lot of times that’s all it takes

and then they will usually come back with “Yes, I be-

lieve.” But then also, you can go further and say, “There is

hope, no matter in what you’re dealing with there’s hope.”

{Intervention based on relationship and assessment}.

This example of the proposed nursing model is based on

the Christian belief system, but could easily be transposedand applied to other spiritual belief systems.

All of the participants were in agreement that health-

care providers needed to be careful when asking a patient

about their religious views or spiritual support systems.

Some participants thought the NP should bring up the

subject, while others thought the NP should wait for the

patient to bring up religious or spiritual views. One par-

ticipant remarked that if a person did not want to discuss

spiritual support, there was still a possibility that the per-

son might want to discuss spiritual views at another time.

A demographic tool developed for this study included

questions on the participants’ spiritual support systems,

the importance of a spiritual life to the person, and a

selection of 40 activities from which the participants se-

lected those or others that supported their spiritual life.

The study participants agreed that the demographic tool

developed for this study would be useful in identify-

ing spiritual support systems. Most participants suggested

that the tool would assist NPs to structure questions re-

garding the adult’s spiritual life, supportive activities or

people, and how these were or were not supporting the

person. One participant remarked, “I’ve never been asked

by anybody in health care how my creative life was. But

for me, it’s an absolute index to the health of my total

being.” Participants noted that the NP needed to assessinterventions that helped alleviate the adult’s stress and

assess the adult’s support systems.

The participants acknowledged that numerous people

and activities supported their spiritual well-being. Spir-

itual supports identified included being in nature, per-

sonal prayer life, family and friends, spiritual/religious

reading, general reading, music, exercise/walking/hiking.

A Benedictine participant noted that Benedictine spir-

ituality supported their well-being through the belief

that God was present and to be found in all circum-

stances. God was there to love you and support you in all

circumstances.

The participants discussed the need for the NP to feel

comfortable with his or her own spiritual life in order to

discuss the spiritual support of other patients. One partic-

ipant remarked:

If you have a firm religious belief or you feel comfortable

with your own spirituality, then it is going to be easier for

you to bring that up to a patient, a friend, whoever. But

if you’re not even comfortable with your own concept of

a higher power . . . I think that would be more difficult to

relate with anyone else.

A study participant remarked that if an NP’s spiritual

life was not important to the NP, then it was probably not

going to be an important part of the NP’s practice. Assess-

ment of the NP’s spiritual belief system by the NP is also

an important part of the nursing model; the NP needs to

be comfortable with his or her own spirituality in orderto discuss spirituality with another person. The proposed

model may help people who feel they do not have a spir-

itual base to rethink their concept of spirituality and their

own sources of inner support.

All of the study participants believed in a spiritual pres-

ence or higher being. Many of the participants defined

spirituality in terms of the Christian God. Other partici-

pants defined spirituality in terms of a power or energy

force. Spirituality helped many participants to connect

with others. In general, spirituality to the participants

meant being connected to a spiritual power and being

connected to other people.

Discussion

Common themes

Several common themes emerged from this study.

One important theme was that spiritual care evolved

from the reciprocal, caring relationship between the pa-

tient and the NP. Dynamic, interpersonal caring, heal-

ing NP–patient moments could occur as a result of the

NP–patient relationship. These moments could provide

the foundation for potentially exploring and assessing

the patient’s spiritual base. As the NP and patient de-veloped their relationship, they could grow into spirit by

understanding the meaning of spirit and spiritual support

systems for both NP and patient. Then, an interspiritual

relationship between the NP, patient, and spirit could

evolve as a supportive strategy for managing current

and emerging healthcare problems. The patient’s spiri-

tual base, in conjunction with the NP’s acknowledgment

of his or her own spirituality (intraspiritual relationship),

could be drawn into the NP–patient relationship as spiri-

tual care interventions by the NP. These common themes

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Figure 1 Nursing Model for the Implementation of Spiritual Care by

APNs C

were merged in the creation of a nursing model for the

implementation of spiritual care for adult patients in pri-

mary healthcare settings (Figure 1). In the model, the

more generic term of advanced practice nurse (APN) is

used and includes NPs.

The intersection of the relationship between the pa-

tient, NP, and spirit looks and feels like a very comfortable

relationship, based on caring, and not based in anxiety or

fear of spirituality. The relationship, assessment, and in-

terventions can be performed in an easy conversational

style that most nurses already use so well in their prac-

tices. Use of spirit as an intervention should then flow

out of the conversation. One does not need to be able to

pray or read a religious book with a person to provide

spiritual care. The spiritual interventions can be simple as

indicated by the support systems used by the participants.

For example, getting out in nature for walks, listening to

music, finding out what works, what does not work to

support a person and supporting those activities that do

function as spiritual supports. As a participant remarked,

sometimes a healthcare problem overwhelms a person’s

physical and emotional resources and prevents one from

remembering to maintain a balanced life that also in-

cludes spiritual and/or creative support. The NP can rein-troduce a balanced perspective on life through the easy

conversational style of the nursing model that may help

a person maintain the balance of body-mind-spirit and

look at a healthcare challenge from a more positive and

balanced perspective.

Nursing model

The nursing model for the implementation of spiri-

tual care in adult primary healthcare settings evolved

from the participant conversations (Figure 1). The model

consists of three interconnected circles. These circles rep-

resent the NP (as the APN), patient, and spirit. The first

stage of spiritual care is the development of the interper-

sonal relationship between the NP and patient. During

this developmental phase, the NP can conduct either awritten or oral spiritual assessment to determine the spir-

itual support systems for the patient. In order to do this

assessment well, the NP must recognize and acknowledge

the role of his or her own spirituality. The dotted circles

represent the growth and evolving dynamic that can oc-

cur between the NP and patient. At the same time, the

NP and the patient each has his or her own unique spiri-

tuality that is developed as an intraspiritual relationship.

This again can be an evolving relationship as indicated

by the enlarging, dotted circles. As the NP and patient

each grow in their interpersonal spiritual relationship, the

potential occurs for the NP–patient relationship to enterinto the spirit dynamic. The NP can use the spirit dy-

namic as a support system for both the patient and the

NP. The model becomes an evolving dynamic relation-

ship between the NP/patient/spirit.

The proposed nursing model for spiritual care can assist

NPs to begin to implement spiritual care in their prac-

tices. The model can help decrease barriers to spiritual

care such as anxiety and lack of direction. The model

demonstrates the importance of the initial NP–patient re-

lationship and spiritual assessment rather than immediate

implementation of specific religious practices by the NP.

While the model is designed for NPs, it is applicable to all

APNs and other nurses practicing in healthcare settings.

Limitations of study

The study has limitations. The study was conducted

in one small western community. The participant num-

ber was small at n = 14. While only five older adults

and three FNPs were interviewed, purposive sampling al-

lowed for the diverse perspective provided by the smaller

sample number of FNPs and older adults. All of the par-

ticipants were Caucasian; no minorities were represented

in the sample. Although the study did not focus on re-

ligion, most of the participants were Christians of eitherEpiscopalian or Roman Catholic background. The study

author knew many of the participants, which can be ei-

ther an asset or a weakness of the study. While the nurs-

ing model is believed to be applicable to all nurses, the

study interviews were only conducted with FNPs.

If the NP or patient does not acknowledge, or refuses to

acknowledge, their spiritual support base, then the nurs-

ing model will have limited applicability. Conversely, the

greater the inner life of the NP or patient, the greater the

ease and applicability of the nursing model.

558




Implications for future research

This study needs to be replicated in other communi-

ties and among a more culturally diverse population to

see if the results are replicated or changed. The nursing

model also needs to be tested by NPs in primary health-

care settings. Additionally, the model needs to be tested

by registered nurses (RNs) and other APNs such as clini-

cal nurse specialists (CNS), and certified nurse midwives

(CNMs) to see if the model is applicable to their practices.

The model could be tested by conducting spiritual assess-

ments within the nurse–patient relationship and develop-

ing a spiritual intervention based on the assessment. The

usefulness of the intervention could be evaluated by NP

and patient.

Conclusion

This study demonstrated that adults desire and needspiritual care interventions from NPs and other health-

care providers in primary care settings to assist in effec-

tive management of their healthcare problems. Spiritual

care is often viewed by adults as receiving kindness and

care from the NP. As the NP–patient relationship devel-

ops, the NP can conduct a spiritual assessment in or-

der to incorporate the patient’s support systems as sup-

portive adjunct therapy interventions to help the patient

effectively manage challenging health or life situations.

The NP and patient also have the opportunity to rec-

ognize and develop their own intraspiritual relationship

for use in the NP/patient/spirit relationship. The nursingmodel provides spiritual care implementation guidance

for NPs through caring relationships, spiritual assessment,

language suggestions for spiritual care, and evidence-

based concepts for providing spiritual care to adults. Spir-

itual care is based in the evolving, caring, transpersonal

NP–patient relationship. It is essential that NPs acknowl-

edge and use this wonderful component of holistic nurs-

ing care in their practices to benefit both patient and NP.

Spirituality needs to be recognized, used, and valued.

Acknowledgments

The authors acknowledge the kind assistance of Ann

Marie Hart, PhD, RN, APRN, BC, Fay W. Whitney School

of Nursing, University of Wyoming, Laramie, Wyoming,

in the preparation of this manuscript.

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