How family practice physicians, nurse practitioners, and physician assistants incorporate spiritual care in practice

R E S E A R C H

How family practice physicians, nurse practitioners, andphysician assistants incorporate spiritual care in practiceRuth A. Tanyi, DrPH, Preventive Care Specialist, RN, MSN, FNP-C, APRN-BC, Certified Nutrition Specialist, ACSMCertified Health Fitness Specialist (Family Nurse Practitioner)1,2, Monica McKenzie, DrPH, Health Education andPromotion, RN, MPH, CHES, CLE Health Educator)2, & Cynthia Chapek, RN, MSN, FNP, APRN-BC (Family NursePractitioner)3

1 Prevention & Wellness Services, Loma Linda, California 923542 Loma Linda University School of Public Health, Loma Linda, California 923543 Luther Midelfort–Mayo Clinic, Rochester, Minnesota

KeywordsSpirituality; family practice; qualitative study;

primary care providers; barriers to spiritual

care.

CorrespondenceRuth A. Tanyi, DrPH, RN, MSN, FNP-C, APRN-BC

(ACSM), P.O. Box 1185,

Loma Linda, CA 92354.

Tel: 909-557-7269; Fax: 909-799-9093;

E-mail: [email protected]

Received: April 2008; accepted: August 2008

doi:10.1111/j.1745-7599.2009.00459.x

Abstract

Purpose: To investigate how primary care family practice providers incorpo-rate spirituality into their practices in spite of documented barriers.Data Sources: A phenomenological qualitative design was used. Semi-structured interviews were conducted with three physicians, five nursepractitioners, and two physician assistants.Conclusions: Five major theme clusters emerged: (1) discerning instancesfor overt spiritual assessment; (2) displaying a genuine and caring atti-tude; (3) encouraging the use of existing spiritual practices; (4) documentingspiritual care for continuity of care; (5) managing perceived barriers to spiri-tual care.Implications for Practice: Findings support that patients’ spiritual needs canbe addressed in spite of documented barriers. Techniques to assist providersin providing spiritual care are discussed and directions for future research aresuggested.

Introduction

A plethora of studies support that patients’ spirituality

plays a vital role in their healing and overall health,

and strong evidence supports primary care providers

incorporating patients’ spirituality into their care (Cotton

et al., 2006; Koenig, 2004; Krupski et al., 2006; Tanyi &

Werner, 2003). Growing interest is due in part to

the positive effects of spirituality on health outcomes

(Ellis, Campbell, Detwiler-Breidenbach, & Hubbard, 2002;

MacLean et al., 2003; Stranahan, 2001; Tanyi & Werner),

and results of national surveys showing that a large

portion of the population rely on their spirituality to

deal with illness (Carballo, 2007).

In addition, studies support that patients want their

physicians to address their spiritual needs (e.g., Krupski

et al., 2006; Tanyi & Werner, 2003). Additionally, current

educational oversight bodies for medicine and advanced

nursing practice advocate the inclusion of spiritual carein educational curricula (Association of Medical CollegesReport III, 1999; National Organization of Nurse Practi-tioner Faculties [NONPF], 2006). Based on these findings,not supporting patients’ spirituality would be neglectingan essential aspect of their care. Nonetheless, the lit-erature documents a multitude of barriers to spiritualcare experienced by primary care providers, such as alack of time, energy, education, fear of rejection, anddiscomfort about the topic (Stranahan, 2001; Craigie &Hobbs, 1999; Koenig, 2004; Chibnall, Bennett, Videen,Duckro, & Miller, 2004; Ellis et al., 2002; Hubbell, Wood-ward, Barksdale-Brown, & Parker, 2006; Olson, Sandor,Sierpina, Vanderpool, & Dayao, 2006).

Spirituality is an ambiguous concept, because it issubjective, multidimensional, personal, and different fromreligion, although it may be manifested through religiouspractices (Tanyi, 2002). In spite of its ambiguous nature,

690 Journal of the American Academy of Nurse Practitioners 21 (2009) 690–697 © 2009 The Author(s)Journal compilation © 2009 American Academy of Nurse Practitioners

R.A. Tanyi et al. Incorporating of spiritual care by medical practitioners

the spiritual dimension of a patient is an invaluablepart of his/her being (Johnson, Elbert-Avila, & Tulsky,2005; Udermann, 2000). Although there is an expandingbody of evidence supporting spiritual care, there aresparse qualitative studies in this area. The few relatedqualitative studies have been limited to examiningmedical doctors’ (MDs) and nurse practitioners’ (NPs)preferences for spiritual care (Craigie & Hobbs, 1999;Ellis & Campbell, 2005; Stranahan, 2001), and havenot included physician assistants’ (PAs’) perspectives.Furthermore, no qualitative study to our knowledge hasinvestigated how MDs, NPs, and PAs address barriers tospiritual care. Because NPs and PAs increasingly provideprimary care, it is important to include their perspectivesin relevant research.

The present study used a qualitative design to investi-gate how family practice MDs, NPs, and PAs incorporatespirituality into their patients’ care in spite of perceivedbarriers. Descriptive phenomenological methodology wasused because this type of research aims to describe phe-nomena as experienced from the perspectives of thosewho live it (Spiegelberg, 1975). Qualitative methodologycan yield additional direction and hypotheses that mayprovide insights to this under-researched area.

Methodology

Data collection procedure

Prior to initiation of the study, the InstitutionalReview Board (IRB) of each respective clinic gave itsapproval. Each participant also gave formal written con-sent before the interview sessions began. Face-to-facesemi-structured interviews were conducted with the goalof attaining rich narratives about the phenomena underinvestigation. Before the interviews, participants wereinformed there were no wrong or right answers; rather,their perceptions were most significant (Colaizzi, 1978).Participants were first asked about demographics andpractice characteristics. Thereafter, they were asked todescribe how they incorporate spirituality into their prac-tices when caring for patients. Participants were instructedto use specific examples to describe their experiences,thoughts, perceptions, and feelings about the topic.

The interview format was flexible, conversational,and relaxing, allowing time for probing questions andclarifications. Eight of the interviews took place inproviders’ offices; two took place outside the work settingper the providers’ requests. Interviews lasted from 45 to90 min and were audio-taped, ceasing when participantswere no longer revealing new information.

To minimize potential bias, the principal investigatorwho conducted the interviews set aside prior knowl-edge about the phenomena, and kept field notes about

presuppositions that arose during the interviews (Guba,1981). Additionally, credibility, dependability, confirma-bility, and transferability, supportive of rigor in qual-itative research, were strictly adhered to (Guba). Forexample, the principal investigator continually validatedand verified meanings of participants’ statements andexplored alternative interpretations so as to enhanceunderstanding.

As is appropriate in descriptive phenomenologicalresearch, participants (key informants) were selected ina nonrandom fashion to insure inclusion of those whoselived experiences provided them with valuable insightsinto the phenomena under investigation (Colaizzi, 1978).Subjects for this study were recruited by word of mouthamong personnel at the selected clinics.

Ten primary care family practice providers, three MDs,five NPs, two PAs, were approached and agreed toparticipate. All were family practice board certified intheir respective disciplines. Participants were employed atthree large clinics in the Minneapolis/St. Paul area. Therewere five men and five women.

The three male physicians aged 46–58 worked full-time,with 21–33 years of experience. Their religious affiliationswere Lutheran, Jewish, and Orthodox Christian. Twowere Caucasians and one was an Egyptian. Five femaleNPs, aged 39–47, participated, with years of experienceranging from nine months to 10 years. Three worked part-time and two worked full-time. One identified herselfas Muslim and the rest were Christians. The final twoparticipants, both males, were full-time PAs with 8 and33 years of experience, ages 33 and 58, respectively. Bothidentified themselves as Christians.

Data management and analysis

All of the audio-taped interviews were transcribed ver-batim by a professional transcriptionist and scrutinized bythe principal investigator to verify correctness. Thereafter,data management and analysis began based on Colaizzi’s(1978) phenomenological methodology. The three inves-tigators were involved in managing the data, althougheach carried out the process independently. Each inves-tigator read the original manuscript repeatedly, extractedsignificant statements, and formulated meanings, whichyielded clusters of themes.

Data analysis was also based on the phenomeno-logical methodology described by Colaizzi (1978). Thismethodology was chosen because of its well-delineatedsteps, ease in demonstrating a clear audit trail of theanalysis, and its wide usage in similar research investi-gating family physicians’ perspectives and spiritual care(Craigie & Hobbs, 1999), how dialysis nurses incorpo-rate spirituality into their patient care (Tanyi, Werner,

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Incorporating of spiritual care by medical practitioners R.A. Tanyi et al.

Recine, & Sperstad, 2006), and transcendence in gay menwith AIDS (Coward & Lewis, 1993). Colazzi’s method-ology of data analysis and interpretation involves sevensteps, which the investigators in this study adhered to(Table S1).

Results

Five major theme clusters were identified sup-porting how family practice MDs, NPs, and PAsincorporate spirituality into their patients’ care. Thefive themes are: (a) discerning instances of overt spiri-

tual assessment; (b) displaying a genuine and caring atti-

tude; (c) encouraging the use of existing spiritual practices;

(d) documenting spiritual care for continuity of care; and(e) managing perceived barriers to spiritual care. Althoughintertwined in actual experience, themes are pre-sented here in a linear fashion to enhance clarity(Table 1).

Discerning instances for spiritual overt assessment

All participants shared that the initial step in incor-porating spiritual care into their practices was to masterhow to discern and assess patients’ spiritual needs. Par-ticipants relayed that overt spiritual issues are salientwhen working with patients suffering from chronic dis-eases. One participant commented, ‘‘. . . certainly chronicconditions. . .. when it gets to these potentially mortal,

morbid sorts of situations in health care, you do see a lot

more of ‘Why me? Why is this happening? What have

I done?’’’ Another participant explained, ‘‘. . . if there is

particularly a grief issue, I think, are probably when I’m

most aware of the need for a spiritual or faith connection.

I will specifically ask ‘Do you have a church affiliation or

a spiritual connection?’’’

Waiting for the patient to bring up the topic was

another cue that providers said paved the way for them

to address spirituality in their practice. One participant

noted, ‘‘I mean if they kind of lead you towards that

thought process, that’s part of patient care too. . . ’’

Another added, ‘‘It would probably be a leading question

from the patient. It’s not part of my routine questions,

but if they bring it up or if they are struggling, oftentimes

that’s when it comes up.’’

All participants agreed that perceiving the patient’s

comfort level with the topic and treating patients who

frequently visited their practice facilitated the provision

of spiritual care. Relatedly, a participant stated ‘‘You have

to gauge the patient,. . . you feel it out a little bit.’’ Another

summed it up this way:

I try to be very discerning with my patients and try tofeel them out . . . we have limited time, 10–15 minutesper patient, but if I sense that something else is goingon and am not getting to the real problem why they’rehaving headaches and why they are depressed, I willoftentimes ask about some spiritual things. . .

Table 1 Selected examples of significant statements, formulated meanings, clusters of themes, and emerging themes

Significant Statements Formulated Meanings Clusters of Themes Emergent Themes

‘‘. . . Certainly chronic conditions. . .

when it gets to this potentially

mortal, morbid sorts of

situations. . . you do see a lot more

of that ‘‘why me?. . . ’’

The need to discuss spiritual issues is

obvious in the presence of a chronic

disease or grief process.

Patients’ presentation with chronic

diseases enabled providers to

readily discern the need for spiritual

assessment.

Discerning instances

for overt spiritual

assessment.

‘‘I do this by trying to remain

nonjudgmental and open to

whatever their concerns are.’’

Remaining nonjudgmental, treating

patients fairly, honestly, and

listening to their concerns are

integral in providing spiritual care.

Providers can meet patients’ spiritual

needs by being good listeners,

honest, remaining nonjudgmental,

and treating patients fairly.

Displaying genuine

and caring attitude.

‘‘If they are talking about prayer,

meditation, and going to church I

think that is fine.’’

Providers often encourage patients to

incorporate spiritual practices that

are helpful to them.


needs by encouraging them to use

existing spiritual practices.

Encouraging use of

existing spiritual

practices.‘‘I may comment that I have

encouraged the patient to seek

connection with the church or other

faith connection or spiritual

connection.’’

By indirectly documenting spiritual

care, providers can convey to their

colleagues what patients’ spiritual

beliefs and values are.


care by communicating to their

colleagues patients’ spiritual beliefs

and values.

Documenting the

spiritual care.

‘‘. . . it’s only the decision that I am

going to make spiritual care as part

of my practice has to get made and

the rest just comes naturally.’’

Making a decision to incorporate

spirituality into practice will

advance spiritual care.

Providers who recognize the

importance of spiritual care in their

patients’ health and healing will find

time to incorporate it.

Managing perceived

barriers to spiritual

care.

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Displaying a genuine and caring attitude

All of the participants emphasized that they providedspiritual care to their patients by exhibiting a positivecaring demeanor that was genuine and nonjudgmental.One participant stated, ‘‘Maybe the patient does nothave any religious background, and you have to givehim examples of other successes by creating a positiveattitude and believing that things will get better. . . manypatients have good success.’’ Another provider describedhis perspective:

I try to treat them fairly and honestly, and I think it’simportant to be a good listener. My patients really latchonto that with me, and they say that I do take thetime to listen to their whole story and not to makejudgments.

Another participant described his view on genuinecaring, ‘‘I try and take care of the patients according to theGolden Rule, meaning if you want to be treated nicely,you treat other people nicely. . . whatever goes around,comes around. . . ’’ Another perspective was offered byone provider who stated: ‘‘I think I try to do it by keepinghigh moral standards with my interactions with patientsand ethical standards. . . I do this by trying to remain. . . nonjudgmental . . . and open to whatever it is theirconcerns are. I think I imply this with body language andgood eye contact.’’

One participant poignantly summarized caring bystating, ‘‘The patient needs some of us to listen. . . there isno medication to be given but our support. Spiritualsupport, sometimes is positive attitude, which helpsdramatically for improvement.’’

Encouraging the use of existing spiritual practicesand beliefs

All of the participants noted that encouraging patientsto use spiritual practices that have helped them in the pastto manage difficult circumstances is another method bywhich they provide spiritual care. One participant related,‘‘I have had patients that truly believe spirituality and thebelief in a higher power and praying to that higher powersomehow has a positive influence in their life. If theybelieve it, I encourage it. . . ’’ Another stated, ‘‘If theyhave mentioned that they have talked to their pastor,I might encourage them along those lines to talk to aspiritual person in their lives.’’ This provider articulatedanother view:

If the patient says. . . ‘I don’t go to church, I don’t pray;’then I will encourage them to look at, and to thinkabout what gives them strength and hope because weall have that spiritual aspect of ourselves. . .

In general, however, participants noted that they wouldonly encourage what they personally judged to be positivespirituality. One participant commented, ‘‘If it’s someritual and I think there’s something bizarre about it,then I am not going to encourage that. . .. Don’t stopyour Lisinopril and don’t stop your Prozac.’’ Anotherprovider described how encouragement of patients’spiritual practices occurs when they are not religiouslybased, ‘‘. . . We could use exercise, yoga technique, getinvolved with helping other sick people so he will feelother people are ill and maybe they have even worse painthan himself so he will accept what he has. . . Stayingwithin what she believed in, you direct them further.’’

Documenting spiritual care for continuity of care

Providing spiritual care was more important than docu-menting it according to most of the participants. However,most of them conveyed that documenting spiritual carewas a way of fostering continuity of care in their absence,thereby meeting patients’ spiritual needs. One participantreported, ‘‘I would say something like. . . I also encour-aged them to seek support from their minister or theirchurch regarding their fear . . . I think that would bea great ending of the dictation. . . ’’ Another participantexpressed this view on documentation: ‘‘Maybe once in agreat while I have just [said] that their faith is importantto them.’’ Finally, another provider has this to say aboutdictation:

. . . in my dictations . . . I will say ‘feelings ofworthlessness or hopelessness’ or things like that thatkind of convey where that patient is at that time. If Iwere to leave the clinic and someone would be takingcare of my patients, I would hope they would take thetime to look back.

Managing perceived barriers to spiritual care

All participants reported perceived barriers to spiritualcare (see Table 2), although none mentioned havingexperienced overt opposition of spiritual discussionsfrom their patients. Notwithstanding the barriers, allparticipants reported they indirectly provided spiritualcare by actively listening to their patients’ needs andbeing present with them. One participant conveyed hisview in the following manner:

. . . I feel like you can give good care and if you’re thereand connected with that patient . . . So time is an issue,yes, and some days I admit I’m not as . . . energeticabout listening as I am other days, but time would notstop me from going in that direction if that’s where thepatient wanted to go. It just wouldn’t stop me fromdoing that.

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Another participant reported:

I do not set apart separate time for it. I think it is builtinto my care in such a way as I mentioned before,the caring and trying to be emotionally there for thepatient and connect with them and listen. Huge powerin listening, huge power.. . .

According to one participant, perceived barriers to

spiritual care can become a ‘‘mental block’’ to providers,

she said, ‘‘I think it’s your own mental block. If you feel

that this is something important in your practice you’ll

do it, you know.’’

Most participants reported a lack of time as one of

the perceived barriers to spiritual care, although some

of them admitted that time was not a major problem

compared to the perceived importance of spiritual care to

the providers’ practice. One participant commented:

We have to. . . rush through our patients so quickly, butI think you can get to the point very quickly. . . youcan do a lot in a very short period of time. If you feelthat you have not addressed everything, you can alwayshave the patient come back and finish. . .

Two other participants poignantly expressed their

perspectives: ‘‘I think if it’s something that’s important to

them [patients] and. . . their treatment, I will find time for

it.’’ The other stated: ‘‘Well, time shouldn’t be a barrier,

ideally, but in practicality sometimes, we have to. . . I think

we can give good care from a spirituality perspective in

the time allotted. I really do. It can be done.’’

Summary

Providers in this study perceived spiritual care to be

an important aspect of patient care. Most of them

expressed that it was their responsibility to identify

and assess patients’ spiritual needs, although some

insisted that patients also bear the responsibility to

report their spiritual distress. In spite of barriers, all

participants, including one participant who was reticent

about overtly broaching the topic with patients, reported

addressing spiritual needs indirectly via active listening

and presence. The participants who overtly discussed

spiritual issues in spite of perceived barriers did so because

of its relevance to their patients. As part of providing

spiritual care, the participants made a conscious effort to

continually maintain a positive and caring attitude in their

interactions, and encouraged patients to utilize spiritual

resources and practices that had been helpful in the past.

They sometimes documented spiritual care in order to

foster continuity of care.

Discussion

We sought to understand how family practice providersincorporate spirituality into their practice. Our findingsshow that in spite of documented barriers (Ellis et al.,2002; Ellis & Campbell, 2005; Koenig, 2004; McCauleyet al., 2005) the providers in our study incorporatedspiritual care on a regular basis. Similar studies havefocused on how physicians incorporate spirituality inpractice (Ellis et al.; Ellis & Campbell; Craigie & Hobbs,1999), but our study is unique because it investigatedspiritual care across an array of primary care providers(MDs, NPs, and PAs). With the abundance of literaturesupporting the need to address patients’ spiritual needs(Cotton et al., 2006; Ellis et al.; Koenig; Krupski et al.,2006; Tanyi & Werner, 2003), and more NA and PAproviders expected to provide primary care in the future,understanding how all types of providers incorporatespirituality is warranted.

With the exception of one participant who viewedspiritual care to be as important as medical care only ifthe patient perceives it to be, nine participants affirmedspiritual care as being important as medical care, hencesupporting the movement toward including patients’spirituality as part of their care (Boudreaux, O’Hea, &Chasuk, 2002; Tordes, Catlin, & Thiel, 2005). Techniquesthat paved the way for these providers to address spiritualneeds include gauging the patients’ comfort level withthe topic, openly asking patients questions about theirspiritual practices in the presence of chronic diseases,watching for clues from the patients, such as ‘‘Whyme. . . What have I done?,’’ actively listening to patients,documenting spiritual care, and managing perceivedbarriers. Unlike the physicians in Ellis et al.’s (2002)study, who reported that spiritual questions arose frompatients’ responses to chronic diseases, the providers inour study assumed that patients would have spiritualquestions as a result of their chronic disease states; hence,they seized the opportunity to address spiritual needs.Our findings support, and augment techniques that arehelping primary care providers to incorporate spiritualityinto primary care (Ellis et al.; Stranahan, 2001).

Our results further clarify simple but effective waysprimary care providers can incorporate spirituality. All ofthe participants stated that they approached every patientencounter with a genuine, positive, and caring attitude.They maintained friendly body language and eye contactwhile listening to their concerns with an open mind.Providers stated that they observed improved healthoutcomes, as they noticed less anxiety and fear from theirpatients in subsequent encounters. These findings supportresearch that suggests spiritual practices can amelioratefear and feelings of doom about one’s health and disease

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(Bussema & Bussema, 2007; Tsuang et al., 2007). The

10 participants in this study, like the 12 physicians

in Ellis et al.’s (2002) study, affirmed that encouraging

patients to use spiritual resources that helped them in

the past was another means of incorporating spirituality

into practice. However, unlike in Ellis et al.’s study, the

present providers articulated that these spiritual practices

must be positive and health engendering. Some examples

of positive practices include: ‘‘talking to the minister,’’

‘‘going to church,’’ and ‘‘helping other patients with their

circumstances.’’ The practice of encouraging patients who

are in the midst of health crises to help others in order to

gain a different perspective has not been salient in other

studies. Hence, this finding adds a new method by which

primary care providers can meet patients’ spiritual needs.

Documenting spiritual care was also a new theme not

well documented in previous studies. All participants saw

value in documenting spiritual care to foster continuity

of care, and agreed that documentation can encourage

other providers to address spiritual needs and care given.

However, for a few, the main reason for not documenting

spiritual care was cutting back on dictation time to save

money.

With regard to barriers to spiritual care, our study

supports other documented findings (Chibnall et al.,

2004; Ellis et al., 2002; Ellis & Campbell, 2005; Hubbell

et al., 2006). In spite of the perceived barriers (Table 2),

participants in our study continued to provide spiritual

care overtly and indirectly and offered some suggestions to

managing these barriers (Table 2). Our findings add to and

support other studies that have highlighted the essential

role of education in managing barriers to spiritual care

(Hubbell et al.; McCauley et al., 2005). Participants agreed

that educating primary care providers about the relevance

of spiritual care is key to managing barriers, although a

lack of comprehensive training in the area should not

preclude the initiation of spiritual care (McBride, 1999).

Surprisingly, participants in this study believed that

educating each other about techniques that are effective

in managing barriers can be more effective than attending

conferences and relying on management to arrange

seminars. An interesting perspective from the providers

in our study was their concern about management’s lack

of support for spiritual care because of reimbursement

issues. Amazingly, physicians in a related study cited ‘‘fear

of response from administration’’ (Hubbell et al., p. 144)

as the least important barrier to spiritual care. Some

participants in our study expressed that perceived barriers

to spiritual care can be manageable, if providers perceive

spiritual care to be important to their patients. This finding

is similar to the finding conveyed by physicians in another

relevant study who reported that personal barriers, such

Table 2 Barriers to spiritual care

Perceived Barriers to Spiritual Care

Reticence to approach the subject directly, because of fear that patients

will reject the discussionUncomfortable with discussion of spirituality with patients because of

lack of formal training and personal beliefs, which inhibits discussion of

the topicLack of discussion on the role of spirituality among care providersFear that patients would misinterpret discussion of spirituality as pushing

religionNot wishing to intrude on patients’ personal spiritualityPerception that spirituality is a private topic for discussionFear that patients do not expect spiritual discussions from providersFear of time requirements to pursue topic if patients are interested

Managing Perceived Barriers

Make a conscious effortUse active listeningBe present with the patientGet education on spirituality via seminars, journal articles, colleague to

colleaguePerceive spiritual care as importantAddress the topic overtly during chronic illness

as their beliefs about spirituality, are contributing barriersto the provision of spiritual care (Olson et al., 2006).

Limitations

This study aimed to uncover new perspectives onhow primary care providers incorporate spiritual careinto their care in spite of perceived barriers. Hence, theintent was to acquire new knowledge from the variousproviders typically practicing in family practice, ratherthan making generalizations, reaching conclusions, orjustifying perspectives. We do not espouse to representthe wide range and scope of primary care providers’perspectives and hence cannot generalize the findings.

Implications for practice and future research

A multitude of barriers exists in providing spiritual care;notwithstanding, the providers in our study were still ableto manage these barriers. This suggests that the clinicians’decision to incorporate spiritual care into their practiceis pertinent in managing perceived barriers. Addressingspiritual matters can also prove to be beneficial as it maydecrease interventions required for care (Lawrence &Smith, 2004). While time constraints in primary caresetting are acknowledged, providers can continuallymaintain a positive demeanor and display a caringattitude, thus supporting spiritual care. For providers whoperceive time constraints and overt discussion of spiritual

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issues as barriers, the mere act of being with the patient

for a few minutes can be a powerful spiritual intervention

as expressed by participants in our study.

For those who might be reluctant to attend seminars on

spiritual issues, being open to learning from colleagues

offers a viable educational option. As suggested by

participants in our study, one way to do this is to ask

other colleagues what they think of the topic, and what

is helping them to incorporate spiritual care.

The simple but effective techniques described by the

participants can be adopted by other providers, and

should be examined for their effectiveness (Koenig, 2004;

Luckhaupt et al., 2005). Drawing from examples offered

in this study, other providers can be alert to situations in

their patients’ lives that can facilitate spiritual dialogue.

Reminding patients to rely on existing spiritual practices

that are positive is another helpful technique. A few

documented sentences about patients’ spiritual beliefs

might help to promote spiritual care as well.

Future qualitative phenomenological studies could

focus on examining characteristics of primary care

providers and educational content that facilitate the

provision of spiritual care, in addition to elucidating

possible differences among providers in regard to spiritual

assessment. Current grounded theory research has

focused on spiritual care by Christian Parish Nurses

(Van Dover & Bacon Pfeiffer, 2006) and spiritual care

in nursing (Burkhart & Hogan, 2008). The results of this

and other qualitative research could be built upon to

create a grounded theory framework for the provision of

spiritual care and support for primary care providers.

Qualitative researchers could also investigate the types

of management milieu in family practice settings that

can facilitate the provision of spiritual care. Additionally,

it would be beneficial to investigate measures that

can enhance communication about spirituality between

management and providers. Researchers could also

investigate whether documenting spiritual care can

foster the provision of such care by providers who

are otherwise reticent. Lastly, further research could

investigate the type of educational setting, seminars,

published studies, colleague to colleague, that would be

most effective in educating providers about spiritual care

and managing barriers. The current findings also provide

direction for quantitative research in family practice. A

possible direction could be to investigate the relationship

between the provision of spiritual care by family practice

practitioners and health outcomes evidenced in their

patients, a much needed area of research for primary care.

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Table S1. Colaizzi’s seven steps of data analysis andinterpretation

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