INTEGRATING SPIRITUALITY INTO NURSE PRACTITIONER PRACTICE:

THE IMPORTANCE OF FINDING THE TIME

Mary A. Helming
ABSTRACT Is it possible to find the time to incorporate spirituality into nurse practitioner (NP) practice in time-driven managed care? This article reviews how medical schools are increasingly adding spirituality into their curricula, although NP programs and literature may be deficient in the area of spirituality. Caring concepts and books on nursing and spirituality are reviewed. Stranahan cites that less than 50% of NPs interviewed incorporate spirituality into practice. Practical suggestions are given to NPs to add spirituality care into their practice and recognize how they can enhance spiritual care by the use of spiritual assessment scales. Keywords: caring, curricula, medicine, nurse practitioner practice, presence, spirituality

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n this age of increasingly fast-paced health care practice, We must ask ourselves the question: Are we fulfilling with insufficient time to provide such essentials as these spiritual competencies in our work as NPs? Infusing patient education, is it realistic to expect nurse practispirituality into health care involves inquiring whether tioners (NPs) to incorporate spirituality into everyday prachealth care providers should be encouraging it in their clintice? Many providers might agree that spirituality in health ical practices. Interestingly, even praying with patients may care is a wonderful idea, but too impractical in this era of be included in spiritual care. It is estimated that over 40% business-driven managed care.Yet it now appears that spiriof American physicians pray for their patients.3 A survey tuality is making a resurgence in the Western world. It must sponsored by Cable News Network (CNN) revealed that be reiterated that being spiritual may not imply the same 64% of respondents believed physicians should pray with thing as being religious. Spirituality is defined by Burkhardt their patients, if this is the wish of the patient.4 These statisand Nagai-Jacobson as the essence of our being. It permetics may be applicable to NPs, as well. How well are we ates our living in relationships and infuses our unfolding preparing future NPs to provide spiritual care? awareness of who we are, our purpose in being, and our inner resources...spirituality is expressed and experienced MEDICAL SCHOOLS OUTPACE NP PROGRAMS IN through living our connectedness with the Sacred Source, INTEGRATING SPIRITUALITY 1(p167) Religion, however, sets a the self, others, and nature. NP preparation programs could be doing a better job of structure through which groups of people share beliefs and preparing their students to discuss spiritual issues with values, and it may be associated with culture and birth. their patients. Outpacing NP programs, medical schools Centuries ago, spirituality and across the nation are increashealth care were intimately coningly incorporating spirituality nected, as described historically by into their curricula. Much of many authors. this emphasis was begun by Spirituality is common Our national practice guideDrs. Puchalski and Larson.5 In to all peoples, and lines suggest that spirituality 1994, only 17 medical schools prayer is considered a should be a vital component of required spirituality education, 2 In Domain 7, universal language. NP practice. but in 2009, the American Cultural Competence of the Medical Association has identiNational Organization of Nurse fied 100 of 150 national medPractitioner Faculty (NONPF) guidelines for NP ical schools that incorporate spirituality curricula, and 75 practice, spiritual competency is included. The 6 spiriof these 100 require a full course in spirituality.6,7 The tual competencies required of nurse practitioners in American Association of Medical Colleges has a policy this domain are: statement that physicians must understand a patients cul1. Respects the inherent worth and dignity of each ture, spirituality, and end-of-life needs. Further, the properson and the right to express spiritual beliefs as vision of spiritual care has been linked with many part of his/her humanity. positive benefits, including fewer hospital days, less sub2. Assists patients and families to meet their spiritual stance abuse, lower blood pressure, less depression, faster needs in the context of health and illness experirecoveries, and an enhanced sense of well-being.8 ences, including referral for pastoral services. In an attempt to determine if national nursing organi3. Assesses the influence of patients spirituality on zations are following suit in encouraging spirituality educahis/her health care behaviors and practices. tion, this author made telephone and e-mail queries to the 4. Incorporates patients spiritual beliefs in the plan of major nursing and NP organizations, and learned that not care appropriately. one of them maintains records on the number of NP pro5. Provides appropriate information and opportunity grams that incorporate spirituality curricula. However, the Health Ministries Association branch of the American for patients and families to discuss their wishes for Nurses Association remains involved in spirituality in nursend-of-life decision-making and care. ing, and Parish/Faith Community Nursing, and the 6. Respects wishes of patients and families regarding American Association of Colleges of Nursing (AACN) has expression of spiritual needs. 2(p4)

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pared to provide spiritual care.16 She concluded that NPs are in ideal positions to incorporate spirituality into practice and to model this behavior for other SPIRITUALITY IN NP PRACTICE health care professionals, especially as they often proThe published work on spirituality in NP practice is very vide continuing primary or end-of-life care. Many NPs sparse. This section reviews most of the studies specific to are now working in tertiary care settings such as skilled NPs and spirituality that are available in the literature. nursing and rehabilitation facilities, where patients may Much more has been published about nursing and spirituespecially be in need of spiritual care. Also, NPs workality in inpatient care, not outpatient or primary care where ing in emergency settings are frequently faced with so many NPs practice. patients in physical and spiritual crises. Stranahan discovered that more than 50% of NP Maddox advised that all NPs need to become respondents in a survey said they rarely or never procomfortable with providing some type of spiritual care vided spiritual care.10 Mesnikoff and fulfilling their professional identified that research is responsibilities when providing needed to discern spiritual care quality care to clients.17( p139) Advanced practice nurses interventions that are most benShe cited time constraints, eficial and least intrusive to inadequate resources for the need to develop community 11 She concluded that patients. provision of spiritual care, and contacts to improve their advanced practice nurses need discomfort with being open spiritual triage skills and to develop community contacts about spirituality, as barriers enhance their ability to to improve their spiritual triage to effective spirituality care. skills and enhance their ability Farneti, in describing how to manage spiritual distress. to manage spiritual distress in incorporate spirituality into the outpatient clinical setting or the role of the NP, wrote that through appropriate referral to spiritual leaders. Brush care that does not consider patients spirituality is and Daly questioned whether there was adequate time neither comprehensive nor wellness oriented.18(online) 12 Their to assess spirituality in primary care practice. She further explained that the growth of alternative findings indicated that lack of time, lack of spirituality medicine, including such spiritual practices as meditaeducation, and potential issues with spiritual selftion and prayer, was influential in raising the imporawareness were the primary reasons why spiritual tance of spirituality care. assessment and care was underdeveloped in NP pracThomas and colleagues wrote that NPs must hold fast tice. Graham et al wrote about Adult NPs working to the concept of caring as part of their identity. Caring along with a minister at a transitional shelter for males is highlighted through speaking and listening carefully to in substance abuse recovery, as spiritual care is often so the patient and modifying treatment to the patients pivotal in recovery.13 lifestyle and preferences; attention to spirituality was Hubbell et al performed a study of the spirituality noted to be a vital factor in caring.19 Heiferty described practices of NPs in nonmetropolitan areas of North how the pediatric nurse practitioner (PNP) is well-suited Carolina.14 Their results showed that although most to manage the spiritual care of the dying child, as he/she NPs surveyed felt spirituality was important, 73% did is aware of family dynamics and many resources. not routinely provide spirituality care. When they did, However, Heiferty cautioned that the PNP must own a the 3 primary examples of care were: referring the strong sense of his/her own spirituality to provide spiripatient to a religious leader, encouraging prayer, and tual care sufficiently.20 discussing spiritual topics. Another author, Healy, examBecause the articles mentioned above comprise the ined the use of the SPIRITual assessment tool by NPs.15 majority of NP spirituality articles currently available, it is Treolar cited many studies that promote the benefit evident that literature in this area is limited. In the followof integrating spirituality into practice models, but also ing section, selected historical literature on religion/ acknowledged that many NPs feel inadequately prespirituality in health care will be reviewed. incorporated spirituality into its Essentials for Baccalaureate Education just revised in October 2008.9
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CLASSICAL LITERATURE ON RELIGION/SPIRITUALITY PRACTICAL WAYS TO INCORPORATE SPIRITUALITY AND HEALTH Some NPs may avoid the topic of spirituality because of A number of physicians have published in the area of discomfort with potential issues raised, lack of time, or religion/spirituality and health, a growing field. fear of imposing ones own beliefs. Sherwood identified Whether physicians should prescribe prayer for health that the nursing professions moral ideal of helping others was discussed by Marwick in the renowned Journal of is not being consistently supported by the contemporary the American Medical Association.21 King wrote the business climate in health care.31 Therefore, nurses focus important book Faith, spirituality, and medicine: Toward the more on doing activities, rather than being activities, which making of the healing practitioner.22 The best-selling books may involve simply being present for a suffering patient, an Prayer is good medicine and Healing words: The power of essential aspect of providing spiritual care. However, there prayer and the practice of medicine, which describe a myrare some relatively simple ways to incorporate touches of iad of studies detailing healing and prayer research, were spirituality without spending large amounts of time. In 3 Koenig has prolifically researched written by L. Dossey. fact, many NPs may be practicing in this way without the health benefits of religious practice.8 recognizing that they are providing spiritual care. Numerous nurse-authors have penned books Attentive, non-judgmental listening makes the patient describing spirituality in nursing. Many nurses enter feel as though you are there just for him or her even this profession due to a sense of though you may have many love and caring for others, a other patients waiting, and this is sense of compassion, the need tending to spiritual needs. to alleviate human suffering, Asking open-ended questions, in Spiritual care often takes and a calling to do spiritual an attempt to elicit the patients work. Florence Nightingale, a true concerns and the personal little extra time, and it can mystic in the Western religious meaning of his or her suffering, make a monumental tradition according to B.M. is vital. Allowing time for difference in patient healing, Dossey, felt these sentiments.23 silence, collecting of thoughts, cooperation, and satisfaction. Nightingale, as evidenced and crying is equally significant. through her letters, believed she A simple act of touch, whether could find God within herself it is a hand on the shoulder or in an intimate prayer relationholding of hands, is capable of ship, and she also felt called by God to promote social creating a spiritual, person-to-person connection. NPs can action through nursing. Burkhardt and Nagaiteach patients self-care measures such as centering meditaJacobson, who describe the connections between healtion using a holy word, the relaxation response, or deep ing, spirituality, and nursing, reviewed how nurses can breathing. These concepts are relatively easy to teach and 24 Taylor incorporate spirituality into their own lives. can assist in promoting stress reduction, in addition to mitidescribed the history of spirituality in nursing, and the gating disease processes. NPs can prepare handouts for betprofessional mandates for spiritual care.25 Mauk and ter patient recall of these techniques and for Schmidt wrote about nursing research in spirituality time-efficiency. Guided imagery is a very useful process to and health, as well as the nurses own spiritual wellachieve pain control, promote relaxation, and stimulate the being.26 Numerous other books describing the relaimmune system. NPs can easily describe the practice of tionship between nursing and spirituality have also active guided imagery, by having the patient imagine being been written by such authors as Barnum, Macrae, in his or her favorite spot (eg, a beach at sunset, listening to 27-30 Suggestions on Carson and Koenig, and OBrien. the waves crash, or a cool lake at the base of a mountain) integrating spiritual care into general nursing are and returning to this mental image when undergoing radifound in many of these resources, but little has been ologic, laboratory, or invasive procedures. written about integrating spirituality into NP care. In Perhaps the simplest spiritual gift an NP can give is that the following section, some suggestions for improving of his or her presence. Burkhardt and Nagai-Jacobson define spirituality in NP practice will be offered. therapeutic presence as a spirit-to-spirit connection using
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to achieve healing and the greatest good for the patient.32 Further, NPs can use their personal life experiences or their F Faith and Belief experiences with other patients, to assist in understanding Do you consider yourself spiritual or religious? or Do and healing patients. The concept of the nurse as wounded you have spiritual beliefs that help you cope with stress? If the patient responds No, the health care healer implies that many nurses have been wounded or sufprovider might ask, What gives your life meaning? fered in some ways in their lives, and this may allow greater Sometimes patients respond with answers such as sensitivity to what the patient is going through. family, career, or nature. For some NPs and other medical providers, providing I Importance spiritual care extends to offering to pray with patients. For What importance does your faith or belief have in your some, this is crossing an uncomfortable boundary, but if the life? Have your beliefs influenced how you take care of NP is comfortable with offering to pray either there with yourself in this illness? What role do your beliefs play in the patient, aloud or in silence, or instead, in his or her own regaining your health? personal prayers, this may be offered. It is a great gift, but C Community both patient and NP must achieve a sense of comfort with Are you part of a spiritual or religious community? Is the topic of prayer. Winslow and Winslow discussed the eththis of support to you and how? Is there a group of people you really love or who are important to you? ical aspect of praying with patients.33 In certain regional Communities such as churches, temples, and mosques, areas of this country, where the topics of religion and spirior a group of like-minded friends can serve as strong tuality are more public and commonplace, patients and support systems for some patients. providers may have greater comfort levels in discussing or A Address in Care offering prayer. How would you like me, your health care provider, to Finally, another means to incorporate spirituality address these issues in your health care? into nursing comes with the increasing popularity of Source: Christina Puchalski, MD, Executive Director, The George the Parish or Faith Community Nursing model. Washington Institute for Spirituality and Health (GWISH), Associate According to Solari-Twadell and McDermott, the role Professor of Medicine and Health Sciences, George Washington of Parish Nursing is based in the health promotion University School of Medicine. Used with permission. and disease prevention care of the whole person.34 24 It is, in essence, the gift of mind, body, spirit, and emotion. Seven distinct functions are included in this model: self. It is being present with the patient mindfully, fully conintegrator of faith and health, health educator, personal centrating on that patients needs without being distracted health counselor, referral agent, health advocate, trainer by who is waiting in the next of volunteers, and developer room or how many phone calls of support groups. This relathere are to answer. Patients can tively new role, with educaPerhaps the simplest spiritual sense this deep caring, and perhaps tional preparation varying gift an NP can give is that of this is why NP care has been from several weekends to 2 lauded over the years. Over the years, utilizes nurses with varihis or her presence. years, it has been said that many ous backgrounds and levels of patients believe NPs really seem to expertise to attend to the listen and give them the time they need. Even if we are health and wellness care needs of members of religious pressured in this managed-care world to improve productivcongregations. It is an ideal role for the NP, as well. ity and enhance efficiency, what has been termed good bedside manner is that which NPs can truly offer, blending USE OF SPIRITUAL ASSESSMENT SCALES nursing backgrounds with practitioner roles. Good bedside What can be used to help NPs identify spiritual needs? A manner speaks to that often indescribable quality of sensing number of spiritual assessment scales have been developed, ones provider truly cares, listens attentively to their needs, primarily by nurses and physicians. These range from simple, 4-question scales to complex, lengthy open-ended question and does not act rushed (even if they are). surveys. These scales have been tested and validated and may Thornton and Mariano further described the concept provide the historical information that NPs can utilize to of intentionality, implying the NP will set his or her mind
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Table 1. FICA Spiritual History Tool

Table 2. Spirituality Scale

Please indicate your level of agreement to the following statements by circling the appropriate number that corresponds with the answer key. Key: 1. Strongly disagree 2. Disagree 3. Mostly disagree 4. Mostly agree 5. Agree 6. Strongly agree
1. I find meaning in my life experiences. 2. I have a sense of purpose. 3. I am happy about the person I have become. 4. I see the sacredness in everyday life. 5. I meditate to gain access to my inner spirit. 6. I live in harmony with nature. 7. I believe there is a connection between all things that I cannot see but can sense. 8. My life is a process of becoming. 9. I believe in a Higher Power/Universal Intelligence. 10. I believe that all living creatures deserve respect. 11. The earth is sacred. 12. I value maintaining and nurturing my relationships with others. 13. I use silence to get in touch with myself. 14. I believe that nature should be respected. 15. I have a relationship with a Higher Power/Universal Intelligence. 16. My spirituality gives me inner strength. 17. I am able to receive love from others. 18. My faith in a Higher Power/Universal Intelligence helps me cope during challenges in my life. 19. I strive to correct the excesses in my own lifestyle patterns/practices. 20. I respect the diversity of people. 21. Prayer is an integral part of my spiritual nature. 22. At times, I feel at one with the universe. 23. I often take time to assess my life choices as a way of living my spirituality. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

Copyright 2003 by C. Delaney. Note: Those interested in using the SS for clinical or research purposes are asked to contact Dr. Colleen Delaney, RN, PhD, AHN-BC, Associate Professor, University of Connecticut, 231 Glenbrook Road, Storrs, CT 06269-2026. Colleen.Delaney@uconn.edu. Used with permission.

provide strong spiritual care. Particularly for patients suffering with chronic diseases, pain management issues, and emotional burdens such as depression and anxiety, completing a spiritual assessment scale may help to identify issues that, if discussed, would promote patient healing. Examples of published spiritual assessment scales include those of the following authors: Dossey and Keegan (based on Burkhardts work), Howden, Hatch, Barker, and Delaney.1,35-38 NPs may also utilize only selected portions of spiritual assessment scales to ask specific questions to patients. Assessment scales vary in length and comprehensiveness, and some utilize acronyms to assist the health care provider in remembering the content. Examples of such scales include the SPIRITual Scale, the HOPE scale, and the FICA Spiritual History Tool.15,39,40 The FICA Tool created by Puchalski, who founded the educational and
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clinical organization George Washington Institute for Spirituality and Health (GWISH), can be seen in Table 1,40 and the Spirituality Scale (SS) created by Delaney can be seen in Table 2.38 To maximize efficiency, patients can be given a scale to complete either in the waiting room or at home, and the review of its contents might lead to another scheduled visit. Spirituality scales can even be included in the historical paperwork patients are asked to complete prior to health care visits, particularly for complete physical examinations. THE IMPORTANCE OF KNOWLEDGE ABOUT RELIGIONS AND CULTURAL VARIANTS Additionally, it is vital for NPs to augment their foundational knowledge in the basic principles of various world religions and cultures. Because many religions are associated
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with specific cultures and ethnicities, it is incumbent upon NPs to be knowledgeable about health practices or restrictions that may have a religious and/or cultural basis. Spirituality is common to all peoples, and prayer is considered a universal language. To provide competent and spiritually-sensitive care, it is essential to gain greater understanding of religious and cultural distinctions and needs. There are many useful resources now available in transcultural care that include religious and spiritual practices. THE IMPORTANCE OF FINDING THE TIME TO PROVIDE SPIRITUAL CARE In summary, it is vital for NPs to take progressive steps toward enhancing the spiritual care they provide. As the Joint Commission has mandated spirituality assessments, it is evident that all levels of health care providers can participate in spirituality care, but nurses and NPs have a special role to play in this level of care due to their education and the holistic essence of nursing. In too many instances, the Joint Commissions revised 2008 mandate is being inadequately met by providing data on religious and dietary preferences only.41 NPs need to be asking vital questions about the meaning of their patients suffering; their sense of purpose in life, which helps them counter illness and pain; their sense of hope, which may impact compliance, and their religious or spiritual support systems. Inner healing through spiritual comfort and management of spiritual distress can be as essential as physical healing, especially when patients are faced with chronic or terminal illnesses. The medical profession has taken a significant leap forward with the incorporation of spirituality education in the majority of medical schools. It is time for NP organizations to provide the same type of leadership in mandating spirituality education in NP curricula, as well as in undergraduate nursing curricula. A growing number of physicians have written about the importance of spirituality in medical care, but few NP researchers and authors have done the same. NPs with strong interests in spiritual and integrative care might find that the American Holistic Nurses Association provides the education and resources they need to learn and grow. Dossey and Keegans Holistic nursing: A handbook for practice (5th ed) is exemplary in providing knowledge and tools for spiritual and holistic education.1 Many NPs are members of this important organization. NPs in acute, long-term care settings, and hospice especially, may need to arrange meetings with pastoral care providers to collaborate with them in meeting patients spir604 The Journal for Nurse Practitioners - JNP

itual needs. NPs in Faith Community Nursing roles may be providing much of the inpatient and outpatient spiritual care themselves. Spiritual distress is designated as a nursing diagnosis. Patients in spiritual distress may be very angry at God or may have confusion regarding the meaning of suffering, pain, and death.20 Patients who are faced with chronic or terminal diseases and long-suffering may be most at risk for spiritual distress. It may be essential for them to seek forgiveness from others to obtain peace and to develop trust in health care providers and family members as their life control lessens.15 Spirituality can be considered an active way to deal with the problems of life, returning hope and perhaps increasing compliance as patients seek ways to recover from or manage their illnesses.20 Spiritual care often takes little extra time, and it can make a monumental difference in patient healing, cooperation, and satisfaction. Perhaps with the advent of the doctor of nursing practice degree, NPs may specialize in spirituality care within their education. Because spiritual care has historically been considered within the province of nursing, it is clearly essential that NPs, whose autonomous roles often include long-term care of patients and families, as well as proximity to patients and families in crisis, enhance their spiritual caregiving, and that NP educational programs better incorporate spirituality education.
References 1. Burkhardt MA, Nagai-Jacobson MG. In: Dossey BM, Keegan L, eds. Holistic nursing: a handbook for practice, 5th ed. Sudbury, MA: Jones and Bartlett; 2009. NONPF Competencies. Available at: www.nonpf.org/finalaug2002.pdf. Accessed February 28, 2009. Dossey L. Prayer is good medicine. New York: HarperSanFrancisco; 1996. Wallis C. Faith and healing: can prayer, faith and spirituality really improve your physical health; a growing and surprising body of scientific evidence says they can. Time. 1996;147:19. Puchalski C, Larson, DB. Developing curricula in spirituality and medicine. Acad Med. 1998;73;970-974. Fortin AH, Barnett KG. Medical school curricula in spirituality and medicine. JAMA. 2004;291:2883. Booth B. More schools teaching spirituality in medicine. Available at: http://www.ama-assn.org/amednews/2008/03/10/prsc0310.htm. Accessed March 2, 2009. Koenig H. Medicine, religion & health: where science and spirituality meet. West Conshohocken, PA: Templeton Foundation Press; 2008. American Association of Colleges of Nursing. Available at: http://www.aacn.nche.edu?Education/pdf/BVaccEssentials08.pdf. Accessed April 14, 2009. Stranahan S. Spiritual perception, attitudes about spiritual care, and spiritual care practices among nurse practitioners. West J Nurs Res. 2001;23(1):90-104. Mesnikoff JG. Practical responses to spiritual distress by nurse practitioners. Clin Excell Nurse Pract. 2002;6(3):39-43. Brush BL, Daly PR. Assessing spirituality in primary care practice: Is there the time? Clin Excell Nurse Pract. 2000;4(2):67-71. Graham JB, Brush BL, Andrew M. Spiritual care process and content: lessons learned from the ECHO projectexpanded care for healthy outcomes. J Am Acad Nurse Pract. 2003;15(10):473-481. Hubbell SL, Woodard EK, Barksdale-Brown DJ, Parker JS. Spiritual care practice of nurse practitioners in federally designated nonmetropolitan areas of North Carolina. J Am Acad Nurse Pract. 2006;18(8):379-385.

2. 3. 4.

5. 6. 7.

8. 9.

10.

11. 12. 13.

14.

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15. Healy H. Educational innovation for nurse practitioners: utilization of the SPIRITual scale. Comm Nurs Res. 2006;39:358. 16. Treolar LL. Integration of spirituality into health care practice of nurse practitioners. J Am Acad Nurse Pract. 2000;12(7):280-285. 17. Maddox M. Teaching spirituality to nurse practitioner students: the importance of the interconnection of mind, body, and spirit. J Am Acad Nurse Pract. 2001;13(3):134-139. 18. Farneti SK. Incorporating spirituality into the NP role. 2006. Available at: http://nursepractitioners.advanceweb.com/Editorial/Content/Editorial.aspx?C C578917. Accessed February 27, 2009. 19. Thomas JD, Finch LP, Schoenhofer S, Green A. The caring relationships created by nurse practitioners and the ones nursed: implications for practice. Topic Adv Nurs. 2004:4(4). 20. Heiferty CM. Spiritual development and the dying child: the pediatric nurse practitioners role. J Pediatr Health Care. 2004;18:271-275. 21. Marwick C. Should physicians prescribe prayer for health? Spiritual aspects of well-being considered. JAMA. 1995;273(20):1561-1562. 22. King DE. Faith, spirituality, and medicine: toward the making of the healing practitioner. Binghamton, NY: Haworth Pastoral Press; 2000. 23. Dossey BM. Florence Nightingale: mystic, visionary, healer. Springhouse, PA: Springhouse; 2000. 24. Burkhardt M, Nagai-Jacobson M. Spirituality: living our connectedness. Albany: Delmar Publishers; 2002. 25. Taylor E. Spiritual care: nursing theory, research and practice. Upper Saddle River, New Jersey: Pearson Education, Inc; 2002. 26. Mauk K, Schmidt N. Spiritual care in nursing practice. Philadelphia: Lippincott Williams & Wilkins; 2004. 27. Barnum BS. Spirituality in nursing: from traditional to new age. New York: Springer Publishing Company; 2003. 28. Macrae JA. Nursing as a spiritual practice. New York: Springer; 2001. 29. Carson VB, Koenig HG. Spiritual dimensions of nursing practice. Philadephia: Templeton Foundation Press; 2008. 30. OBrien ME. A sacred covenant: the spiritual ministry of nursing. Sudbury, MA: Jones and Bartlett; 2009. 31. Sherwood GD. The power of nurse-client encounters: interpreting spiritual themes. J Holist Nurs. 2000;18(2);159-175. 32. Thornton L, Mariano C. Evolving from therapeutic to holistic communication. In: Dossey BM, Keegan L, eds. Holistic nursing: a handbook for practice, 5th ed. Sudbury, MA: Jones & Bartlett; 2009:533-546. 33. Winslow GR, Winslow BW. Examining the ethics of praying with patients. Holist Nurs Pract. 2003;170(9):169-219. 34. Solari-Twadell P, McDermott M, eds. Parish nursing. Thousand Oaks, CA: Sage Publishing; 1999. 35. Howden WJ. Development and psychometric characteristics of the Spirituality Assessment Scale. Dissertation Abstracts Int. 1993;54(1):166. 36. Hatch RL, Burg, MA, Naberhaus DS, Hellmich LK. The Spiritual Involvement and Belief Scale. J Fam Pract. 1998;46:476-486. 37. Barker ER. Spiritual well being in Appalachian women: an instrument evaluation. J Holist Nurs. 1989;7(1):12-18. 38. Delaney C. The spirituality scale: development and psychometric testing of a holistic instrument to assess the human spiritual dimension. J Holist Nurs. 2005;23(2):145-167. 39. Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician. 2001;63(1):81-89. 40. Puchalski C. Spiritual assessment in clinical practice. Psych Annals. 2006;36(3):150-155. 41. Joint Commission. Revised 2008. Available at: http://www.jointcommission.org/AccreditationPrograms/HomeCare/Standards /09_FAQs/PC/Spiritual_Assessment.htm. Accessed April 14, 2009.

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Mary A. Blaszko Helming, PhD, APRN, FNP-BC, AHN-BC, is an associate professor of nursing and the family NP track coordinator at Quinnipiac University in Hamden, CT. She can be reached at Mary.Helming@quinnipiac.edu. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest.
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