RESEARCH

Development of a conceptual nursing model for the implementation of spiritual care in adult primary healthcare settings by nurse practitioners
Rebecca Carron, MS, RN, NP-C (Family Nurse Practitioner, Doctoral Student)1 & Sharon Ann Cumbie, PhD, RN, CS (Faculty Associate, Associate Professor)2
College of Nursing, University of Colorado Denver, Centennial, Wyoming Watson Caring Science Institute, Boulder, Colorado, and Department of Nursing, College of Health Sciences, Appalachian State University, Boone, North Carolina
2 1

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: Rebecca.Carron@ucdenver.edu

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 experience 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 NPpatient relationship develops, the opportunity is often present for the NP to explore the adults spiritual system. The NP and adult may develop an interspiritual relationship with the potential to use the adults spirituality as a support resource. Implications for practice: The nursing model reects a spiritual-relational view. As the NP and older adult grow in relationship, they can grow into knowledge and use of spirit. The NP can use the adults 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.

Received: November 2009; Accepted: March 2010 doi: 10.1111/j.1745-7599.2011.00633.x

Spiritual care is an integral, but often neglected and poorly understood, component of holistic nursing practice for adults in primary healthcare settings. As the connection between spirituality and health is manifested more and more in the literature, a compelling need exists for nurse practitioners (NPs) to address the spiritual care needs of adult patients. However, in order to provide spiritual care, NPs need to understand the meaning and interpretation of spiritual care from an adult patients perspective. The patient perspective then needs to be integrated with the spiritual perceptions that NPs have about spiritual care. The relationship between spirituality and religion also needs clarication. NPs often establish 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 was to develop and propose a conceptual nursing model, based on evidence-based patient and NP perceptions of spiritual care, which provides the framework for the delivery of spiritual care to adults in primary healthcare settings.

Background
A persons spirituality can be helpful when coping with difcult healthcare problems (Meraviglia, 2004; Walton,

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1999; Walton & Sullivan, 2004). NPs and nurses, however, 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 & Bushwick, 1994). Additionally, NPs need to be aware of their own spiritual base and comfort level in providing spiritual care (Cavendish, Luise, Konecny, & Lanza, 2004; Nagai-Jacobson & Burkhardt, 1989; Treolar, 2000). Authentic, transpersonal, caringhealing NPpatient relationships are important in the provision of spiritual care (Cumbie, 2001; Watson, 2002, 2001). Spirituality is important to older people (Bauer & Barron, 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). Demographic statistics from the U.S. Census Bureau (2004) demonstrate that the population of the United States is increasing 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 provide spiritual care. Research with Roman Catholic nuns indicates that spirituality 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 between 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 ones own health (43.0%), followed by being prayed for by another person for ones health (24.4%), use of natural products (18.9%), deep breathing exercises (11.6%), and participation in a prayer group for ones 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 practice. While NP students helped perform an initial patient spiritual assessment for 18 men recovering from substance addiction, the actual spiritual care interaction occurred between the clients and a minister. The study ndings 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 meaningful self-reection (p. 476). It was important to help the client reconnect with a sense of self. A nonjudgmental attitude on the part of the minister was crucial to create a safe environment for the client. The authors acknowledged that barriers such as time restraints or lack of knowledge regarding spiritual care may make the implementation of spiritual care difcult 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 care in 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 Perspective Survey questionnaire. The study found that 73% of NPs did not routinely provide spiritual care. The most common spiritual practices were referral to clergy, encouraging patients to pray, and talking with patients on spiritual topics. However, the tool did not measure other spiritual care practices that NP participants identied as comprising spiritual care, for example, listening, touch, use of music, or caring. Treolar (2000) reported on the importance of spirituality in healthcare practice by NPs, but the report was limited to personal examples of spiritual care and a description of the importance of spiritual care in NP practice. Stranahan (2001) investigated spiritual perception, attitudes, spiritual care, and spiritual care practices in a sample of 102 NPs. Measurement tools were Reeds Spiritual Perspective Scale and the Nurses Spiritual Care Perspectives Scale developed by Taylor, Higheld, and Amenta. The results indicated that 57% rarely or never provided spiritual care. The most common spiritual interventions were praying privately or clergy referral. However, participants 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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incorporated into NP practice, particularly as an adjunct supportive or empowering healthcare strategy. The meaning and denition of spiritual care needs further clarication. It is essential that the discipline of nursing develop a method for providing effective spiritual nursing care to respond to the spirit residing in all people.

This connection brings faith, hope, peace and empowerment. The results are joy, forgiveness of oneself and others, awareness and acceptance of hardship and mortality, a heightened sense of physical and emotional well-being, and the ability to transcend beyond the inrmities of existence. (p. 506)

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 (18201910) believed that nursing was a sacred science grounded in spiritual beliefs that involved caringhealing nursepatient relationships based on Gods laws of nature (Calabria & Macrae, 1994; Dunphy, 2001; Nightingale, 1969). Watson (1940-) believes that identifying and connecting with a persons spirit can promote caringhealing transpersonal relationships between patient and nurse (Watson, 2002, 2001). Watson (2008) also noted the importance of acknowledging a persons inner belief system and the role of faith and hope in mediating health and illness. Cumbie (1950-) believes that caring nursepatient relationships can promote the health of both patient and nurse (Cumbie, 2001). St. Benedict of Nursia, (d. 545 A.D.) believed in the connection of each person to God and to each other (Chittister, 1990). Nightingale, Watson, Cumbie, and St. Benedict of Nursia developed and promoted the theoretical concept of authentic, spiritual, transpersonal caringhealing NPpatient relationships. Spirituality permeates and infuses the development of caringhealing NPpatient relationships. 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 spiritual base and touch the spiritual base of others to promote health and well-being for patient, the patients circle of family/friends, and the NP.

This denition is in accord with the theoretical framework for the study. Spirituality involves nding purpose and meaning in life, connectedness, relationships, honoring 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 incorporating grounded theory and phenomenological overtones. The aim of the study was to gain an understanding of spiritual care perceptions by adults and the role of the NP in response to these identied needs so that we could propose a conceptual nursing model for the implementation of spiritual care in adult primary healthcare settings. Spiritual care perceptions were explored in the study with four groups of individuals: adult primary care patients, family NPs (FNPs), community spiritual 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 qualitative descriptive design, which is an appropriate methodology when straight descriptions of phenomena are desired (Sandelowski, 2000, p. 334). Qualitative descriptive design incorporates elements of naturalistic design such as no manipulation of variables, but rather allows the phenomenon to present itself in its most natural state (Sandelowski, 2000). This methodology is especially suited for this study, which is seeking descriptive responses of perceptions of spiritual care. The study was cross-sectional in design in that data collection interviews were conducted with participants at one point in time, rather than at several points on a timeline as would occur with a longitudinal study. Qualitative descriptive research can include overtones from qualitative approaches such as phenomenology 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 participants (Creswell, 2007, pp. 5758). In this study, it was crucial to an understanding of spiritual care to hear the stories of lived experiences of spiritual care in primary healthcare settings in the lives of adults. Through

Denition of spirituality
The spirituality denition that guided this study was from a concept analysis of spirituality by Tanyi (2002). The following was her proposed denition:
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. 554

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these shared stories, the participants described the meaning and importance of spiritual care in primary care so that a nursing model could be developed from the common emerging themes. The grounded theory tradition was also important in the design of this research study. Grounded theory, developed 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 generated 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 focused on emerging themes and concepts important to perceptions of spiritual care in primary healthcare settings. As the interviews became more focused on emerging themes, areas of lesser importance were not aggressively 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 diverse perspective of spirituality. There were 14 participants in the study sample. The sample consisted of ve adult patients, three FNPs, four community spiritual leaders/educators, and two Benedictine nuns. The age range was 2884 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.

saturation was achieved and no new themes or categories were identied. Challenges to the validity of a qualitative study, as noted by Polit and Beck (2004), include the authors 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 description based on verbatim participant remarks that allowed for potential transferability. Triangulation of results among and between the four groups of participants (patients, FNPs, spiritual leaders/educators, and nuns) allowed for the validation of common themes that emerged from the study. As to personal bias, the principle author/researcher spent approximately a year prior to the study reading and reecting about the nature of spirituality and the authors own perceptions of spirituality while engaging in academic writing and other course work that involved spirituality. During the study, the principle author/researcher was then able to acknowledge and bracket her own biases and suppositions regarding spirituality, to allow the participant views to emerge. Finally, rich, verbatim description of the participants 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 participant audiotapes, and intercoder agreement between the two study authors on the common themes and conceptual model.

Results
The results indicated that spiritual care for adults included 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 youre glad to see us instead of, You, again.

Data collection and analysis

Data were collected with participant interviews, ranging in length from 3090 min. The participant interviews were audio-taped and professionally transcribed. The transcripts were then analyzed for content themes according to Van Manen (1990). Verication of data was accomplished through a systematic coding procedure. The interviews were analyzed for common spiritual care concepts and ideas. All thematic categories and concepts were grounded in participant interviews. Through the constant comparative method, common participant themes were identied and collected. Data collection and analysis was halted when theoretical

The previous statement was reiterated by other adult participants and became an important emerging theme of spiritual care in primary care settings. One participant stated, If youre kind and considerate and helping a person, what more spiritual could you be? Another remarked, Spirituality is a very caring person. This participant provided a summary of older adult spiritual care needs:
Its the sense of caring and sense of being welcome and what that does is cause a patient to feel better about the 555

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environment, feel better about himself, and help with the potential practices that are going to take place. Now all of that . . . will nd into the spirit and improve spiritual well being, I believe. And I believe that a smile costs nothing.

patients 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 example, one FNP remarked:
I ask them, if they have any support group, thats how I bring it (spirituality) up, do you have a support group? . . . Are you interested in any form of religion or spirituality? So, Ill bring it up then and if they say no, I dont really know where to go after that.

The adult participants described spiritual care as being welcomed, respected, and recognized as a person. They also viewed spiritual care as receiving kindness, support, and caring from the NP. Spiritual care for adult patients is viewed as occurring within the context of the nursepatient relationship, which Watson (2001) noted was important to help the person access the healer within (p. 348). The rst stage of the proposed nursing model for spiritual care emphasizes the importance of establishing a meaningful, interpersonal nursepatient relationship before advancing further with a nursing assessment and spiritual care interventions. The FNPs focused on several aspects of spiritual care in the interviews. The rst aspect was the role of religion in spiritual care. NPs expressed concern about offending patients 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. Its tough in this world where you want to be politically correct, you dont want to offend somebody, you dont want people to think that maybe youre a holy roller, and you need to respect that people come from different traditions from you and you certainly dont want to offend, you know, anybody.

The FNPs also believed that listening, providing support, talking, and being present with patients were spiritual care interventions. A caring attitude perceived by the adult patient as spiritual care appeared to be interpreted by the FNP as providing necessary spiritual support 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. Thats just me. Im kind of a touchy person. But, uhm, especially if theyre having a hard time, thats important. And Ill also listen to them as long as they want to. I dont care how long that appointment is. Ill sit there and listen to what they have to say. And some people dont want to go to a counselor or dont want to go to church. They just want to talk to someone, you know and so Ill have them come back and well just talk again.

Spiritual care perceptions differed in some areas between the patient and the FNP. One FNP when told that patients regarded spiritual care as kindness and compassion remarked, See, to me, thats 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 persons spirituality or source of inner support may be based on an organized religion such as Christianity, Judaism, or Buddhism. However, a persons 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 aspects of nature, for example. Spiritual care does not have to involve religious practices, although it could, depending on the source of the patients and NPs spiritual base. It is also important for the NP to be aware of different spiritual traditions, especially those in the local community. The proposed nursing model considers the importance of the patients and NPs 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
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These NP statements further develop the proposed nursing model for spiritual care. The importance of the nursepatient 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 persons spiritual belief or support systems which is here indicated by the NPs inquiring about a persons 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 rst step in providing spiritual care was establishing a comfortable NPpatient relationship. As the NPpatient relationship developed, the conversation could then address the spiritual sources of support for the patient, as suggested in the proposed model. All of the elements of the proposed nursing model for spiritual care including the nursepatient relationship, a spiritual assessment of a persons spiritual belief system, knowledge of the NPs own spiritual base, and interventions 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 youre concerned about that condition, whether its a cold or its a lifetime thing or whether it is terminal, that person is going to feel it {Relationship}. When that person feels it, its awfully easy then, that person becomes open to you. You view the opening to, you cant just come across bluntly, but you can maybe, at sometime or the other, ask them if they believe in God or if you dont want to say God, you might say a higher being to open the door {Assessment, Knowledge of own spiritual base}. A lot of times thats all it takes and then they will usually come back with Yes, I believe. But then also, you can go further and say, There is hope, no matter in what youre dealing with theres hope. {Intervention based on relationship and assessment}.

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 participant remarked:
If you have a rm 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 youre not even comfortable with your own concept of a higher power . . . I think that would be more difcult to relate with anyone else.

This example of the proposed nursing model is based on the Christian belief system, but could easily be transposed and applied to other spiritual belief systems. All of the participants were in agreement that healthcare 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 participant remarked that if a person did not want to discuss spiritual support, there was still a possibility that the person 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 selected those or others that supported their spiritual life. The study participants agreed that the demographic tool developed for this study would be useful in identifying spiritual support systems. Most participants suggested that the tool would assist NPs to structure questions regarding the adults spiritual life, supportive activities or people, and how these were or were not supporting the person. One participant remarked, Ive never been asked by anybody in health care how my creative life was. But for me, its an absolute index to the health of my total being. Participants noted that the NP needed to assess interventions that helped alleviate the adults stress and assess the adults support systems. The participants acknowledged that numerous people and activities supported their spiritual well-being. Spiritual supports identied included being in nature, personal prayer life, family and friends, spiritual/religious reading, general reading, music, exercise/walking/hiking. A Benedictine participant noted that Benedictine spirituality supported their well-being through the belief that God was present and to be found in all circum-

A study participant remarked that if an NPs spiritual life was not important to the NP, then it was probably not going to be an important part of the NPs practice. Assessment of the NPs 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 order to discuss spirituality with another person. The proposed model may help people who feel they do not have a spiritual base to rethink their concept of spirituality and their own sources of inner support. All of the study participants believed in a spiritual presence or higher being. Many of the participants dened spirituality in terms of the Christian God. Other participants dened 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 patient and the NP. Dynamic, interpersonal caring, healing NPpatient moments could occur as a result of the NPpatient relationship. These moments could provide the foundation for potentially exploring and assessing the patients spiritual base. As the NP and patient developed 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 patients spiritual base, in conjunction with the NPs acknowledgment of his or her own spirituality (intraspiritual relationship), could be drawn into the NPpatient relationship as spiritual 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 primary 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 patient, 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 interventions can be performed in an easy conversational style that most nurses already use so well in their practices. Use of spirit as an intervention should then ow 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, nding 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 persons physical and emotional resources and prevents one from remembering to maintain a balanced life that also includes spiritual and/or creative support. The NP can reintroduce 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.

from the participant conversations (Figure 1). The model consists of three interconnected circles. These circles represent the NP (as the APN), patient, and spirit. The rst stage of spiritual care is the development of the interpersonal relationship between the NP and patient. During this developmental phase, the NP can conduct either a written or oral spiritual assessment to determine the spiritual 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 occur between the NP and patient. At the same time, the NP and the patient each has his or her own unique spirituality 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 NPpatient relationship to enter into the spirit dynamic. The NP can use the spirit dynamic as a support system for both the patient and the NP. The model becomes an evolving dynamic relationship between the NP/patient/spirit. The proposed nursing model for spiritual care can assist NPs to begin to implement spiritual care in their practices. The model can help decrease barriers to spiritual care such as anxiety and lack of direction. The model demonstrates the importance of the initial NPpatient relationship and spiritual assessment rather than immediate implementation of specic 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 number was small at n = 14. While only ve older adults and three FNPs were interviewed, purposive sampling allowed for the diverse perspective provided by the smaller sample number of FNPs and older adults. All of the participants were Caucasian; no minorities were represented in the sample. Although the study did not focus on religion, most of the participants were Christians of either Episcopalian or Roman Catholic background. The study author knew many of the participants, which can be either an asset or a weakness of the study. While the nursing 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 nursing 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.

Nursing model
The nursing model for the implementation of spiritual care in adult primary healthcare settings evolved
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Implications for future research

This study needs to be replicated in other communities 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 healthcare settings. Additionally, the model needs to be tested by registered nurses (RNs) and other APNs such as clinical nurse specialists (CNS), and certied nurse midwives (CNMs) to see if the model is applicable to their practices. The model could be tested by conducting spiritual assessments within the nursepatient relationship and developing 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 need spiritual care interventions from NPs and other healthcare providers in primary care settings to assist in effective management of their healthcare problems. Spiritual care is often viewed by adults as receiving kindness and care from the NP. As the NPpatient relationship develops, the NP can conduct a spiritual assessment in order to incorporate the patients support systems as supportive adjunct therapy interventions to help the patient effectively manage challenging health or life situations. The NP and patient also have the opportunity to recognize and develop their own intraspiritual relationship for use in the NP/patient/spirit relationship. The nursing model provides spiritual care implementation guidance for NPs through caring relationships, spiritual assessment, language suggestions for spiritual care, and evidencebased concepts for providing spiritual care to adults. Spiritual care is based in the evolving, caring, transpersonal NPpatient relationship. It is essential that NPs acknowledge and use this wonderful component of holistic nursing care in their practices to benet 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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