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Rehabilitation Nursing Vol. 31, No. 6 November/December 2006 249
Spiritual care has long been recognized as an essential component in providing holistic care to patients. However, many
nurses have acknowledged that their education lacked practical guidelines on how to provide culturally competent spiri-
tual care. Although all nurses are required to provide spiritual care, rehabilitation nurses are particularly challenged to
be competent in this area, due to the lengthy recovery time and special needs often presented by rehabilitation patients.
This article provides practical guidelines for rehabilitation nurses, to assist patients in meeting their spiritual needs.
Spiritual Care: PracticalGuidelines for Rehabilitation NursesLinda S. Rieg, PhD RN Carolyn H. Mason, MS APRN BC Kelly Preston, MSN RN
From earliest documents to recent literature, there
has been an acceptance that all persons are spiritual
beings and that care of the spirit is an essential and in-
tegral part of healing and wholeness. Although most
would agree with this premise, it is of interest that the
volume and quality of nursing research and writings
related to spirituality and spiritual care is significantly
smaller than that related to the physical, mental, and
social aspects of nursing. However, within the last
20 years there has been increased interest in holistic
nursing, including a focus on spiritual care.
Although a need for spiritual care is recognized
in all healthcare settings, rehabilitation patients often
have significant spiritual care needs related to their
conditions. Due to the longer term relationship be-
tween rehabilitation patients and nurses, more situa-tions occur that are conducive to addressing spiritual
care needs, and that may warrant spiritual care.
Most nurses recognize that spiritual care is an es-
sential component of holistic care. However, many will
acknowledge that it is rarely given the same priority as
other dimensions of care. Not seeing spiritual care as a
top priority is cited as a reason for omitting it (Johnson,
2005). However, another significant barrier that nurses
identify is discomfort due to a perceived lack of com-
petence to provide spiritual care (Page, 2005).
This article provides an overview of the basic
knowledge needed to ensure patients receive cultur-
ally competent spiritual care for rehabilitation nurs-es. This article puts theory into practical guidelines
which can be used when providing spiritual care to
a diverse population of rehabilitation patients and
their families.
Relationship of Worldview to Spirituality
If nurses are expected to provide spiritual care,
they must first understand how a persons worldview
relates to his or her personal concept of spirituality.
Worldview is defined as a basic set of beliefs and
concepts that work together to provide a more-or-
less coherent frame of reference for all thought and
action. Out of ones worldview, a person evaluates,
makes decisions, and makes meaning and sense of
his or her life. Although worldviews may be catego-
rized in various ways, there are basically two major
divisions: theism and naturalism. In theism, God is
the infinite personal Creator and sustainer of the cos-
mos; in naturalism, it is the nature of the cosmos itself
which is primary, and God does not exist (Sire, 1997).
Depending on which worldview a person embraces
as the foundation for meaning and purpose in life, it
will determine many of the persons views and be-
liefs about spirituality, as well as his or her spiritual
care needs.
Nurses must understand that in a multifaith society,
definitions of spirituality differ, based on a variety ofworldviews and opinions (Carson, 1989, 1993; Cus-
veller, Sutton, & OMathuna, 2004; Doornbos, Groen-
hout, & Hotz, 2005; MacLaren, 2004). According to
Burkhart and Nagai-Jacobson (2002), spirituality is
a broad concept, transcending religious boundaries.
Other authors have written about spirituality, spiritual
care related to diagnosis or cultural backgrounds, and
the differences between spirituality and religious belief
(Burkhart & Solari-Twadell, 2001; Conner & Eller, 2004;
MacLaren; McSherry, & Draper, 1998; Reed, 1991; Stoll,
1979; Taylor & Mamier, 2005). Nurses need to recognize
that a persons religious affiliation is not necessarily the
same as a persons spirituality. By virtue of being hu-man, all people are spiritual, regardless of whether or
how they participate in religious observance. Spiritual-
ity is regarded as an essential part of peoples ultimate
concern and quest for meaning and purpose (Emmons,
1999; Frankl, 1984; Wong, 2000).
Rehabilitation Patients: The Need for Spiritual
Care
Because of the issues rehabilitation patients fre-
quently face, spiritual care is often a significant need.
Assisting patients to draw on their faith as a resource
Rehabilitation NURSING
CONT
INUING
EDUCA
TION
KEY WORDS
guidelines
rehabilitation
spiritual care
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250 Rehabilitation Nursing Vol. 31, No. 6 November/December 2006
can be an important way to help them strengthen
their spiritual beliefs and find hope during rehabili-
tation. Patients in rehabilitation are often ready to
learn, and the rehabilitation environment seeks to
maximize potential in every facet of a persons life(Derstine & Drayton-Hargove, 2001; Easton, 1999;
Mauk & Schmidt, 2004).
Schmidt (2004) identified that when faced with the
loss of physical and/or mental abilities, patients and their
families commonly had feelings of anger, bargaining,
and other forms of emotional response to grief. Depres-
sion was not uncommon among those with long-term
health problems; anxiety, frustration, and hopelessness
often loomed with progressive and degenerative health
concerns. In addition, patients expressed feelings of
chronic sorrow with each exacerbation or setback.
Feelings of loss may cause patients and families
to confront their spiritual nature, ask questions about
their spiritual beliefs, and turn toward their faith to
find comfort and hope. Hope is often what patients
say keeps them going through difficult times. Reha-
bilitation promotes hope because its goal is to maxi-
mize function to allow a patient to reach the highest
level of holistic independence possible. A necessary
part of successful rehabilitation is the development
of a different set of coping skillsskills that many
patients or families may not yet have developed, but
which are essential for satisfactory recovery.
During the process of healing from injury or dis-
ease, each patient must work toward integrating hisor her old selfinto a new selfand toward rediscovering
meaning and purpose in life with newfound hope.
In Frankls bookMans Search for Meaning (1984), he
describes tragic optimism as a state where hope and
despair can coexist and in which we can remain opti-
mistic, no matter how helpless and hopeless we feel.
Nurses often work closely with patients and fami-
lies during the rehabilitation process and as a result
establish close, long-term relationships. Due to the
rapport established in these relationships, nurses are
often instrumental in helping patients develop this
tragic optimism.
Wong (2004) identified five key ingredients nec-essary for the development of tragic optimism: ac-
ceptance of the reality of the situation, affirmation
of the value and meaning of life, courage to move
forward, faith in God or a higher power, and self-
transcendence (serving others or a cause larger than
oneself). A first step for rehabilitation patients is a
realistic understanding of their conditions and a rec-
ognition of their losses.
Patients in the contexts of suffering, disability, ter-
minal illnesses, and dying are often struggling with
the meaning of life and death (Puchalski, 2002; Wong,
2000; Wong & Stiller, 1999). This is especially true for
the rehabilitation patient who is struggling to integrate
old self into a new self. Understanding patients beliefs
about spirituality and their identified needs in this
area of life is essential to providing spiritual care.
Nurses Therapeutic Use of Self
Before providing appropriate spiritual care to
patients, a nurse needs to clearly identify his or her
own worldview, understand how that worldview is
foundational to their spiritual beliefs, and recognize
how those beliefs are integrated into their life. In or-
der to do this, several authors have suggested that
nurses need to appreciate the attributes that foster
ones spiritual sense, such as love, understanding,
wisdom, and faith (Cavendish et al., 2000; Fowler,
1981; Haase, Britt, Coward, Leidy, & Penn, 1992)
When a nurse does not understand his or her own
worldview and personal spiritual beliefs, it makes it
more difficult, although not impossible, to address
patients spiritual concerns. By discovering their own
spiritual foundations, nurses are better prepared to
distinguish the actual needs of their patients from
their own spiritual perspectives.
Guidelines for Providing Spiritual Care
Many authors have analyzed the complex issues
inherent in spirituality and how to provide spiritual
care (Barnum, 2003; Brillhart, 2005; Burkhart & So-
lari-Twadell, 2001; Cavendish et al., 2000; Cusveller1998; Goldberg, 1998; Grant, 2004; Gucwa, 2002; Kel-
ly, 2004; Krebs, 2001; MacLaren, 2004). How authors
have identified spiritual needs varies. In one study,
seven major constructsbelonging, meaning, hope,
the sacred, morality, beauty and acceptance of dy-
ingwere revealed in an analysis of the literature
pertaining to patient spiritual needs (Galek, Flannel-
ly, Vane, & Galek, 2005, p. 62). Others have discussed
best practices for approaching spiritual care, spiritua
well-being, spiritual assessment, and spiritual care
interventions (Cavendish et al.; Conner & Eller, 2004
Draper & McSherry, 2002; McGrath & Clarke, 2003;
Van Dover & Bacon, 2001; Walton, Craig, Derwinski-Robinson, & Weinert, 2004).
The essence of providing spiritual care is the
therapeutic use of self. Nurses must be willing to
engage self in this activity while recognizing that
spiritual care must be patient led, not nurse direct-
ed. Nurses need to clearly understand where their
own spiritual needs start and stop and where their
patients needs begin. Skills of listening, observing
and presence are inherent in nursing and support
spiritual care.
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Rehabilitation Nursing Vol. 31, No. 6 November/December 2006 251
Process for Spiritual Care
Spiritual care should be purposeful in the same
way as other nursing care. However, it does not al-
ways require formal planning; in fact, if a nurse is
present and sensitive to a patients cues, then spiri-
tual care often occurs spontaneously and purpose-
fully during that unique patient situation. As with allnursing care, a therapeutic use of the nursing process
is necessary to address spiritual care needs.
Assessment
Todays healthcare environment makes it chal-
lenging for the nurse, with a heavy patient load and
little time, to identify spiritual care needs. Therefore,
nurses need the ability to do a succinct spiritual as-
sessment by asking just a few questions. Not every
patient encounter will necessitate nor warrant a com-
plex, formal spiritual assessment with a detailed plan
of care. However, every patient deserves the nurses
willingness to be present and respond to spiritualneeds, whether expressed verbally or nonverbally.
Spiritual assessment, similar to physical assess-
ment, requires both baseline data and ongoing as-
sessments based on the changing status of the pa-
tient. There are many ways to approach spiritual care
assessment. However, we suggest these approaches
may be grouped into two basic categoriesinten-
tional and situational.Intentional spiritual assessments are completed us-
ing a deliberate, systematic method. These are gen-
erally completed at times of admission or transfer,
or during a crisis event that might trigger spiritual
distress. Several excellent approaches, using mne-
monics, for spiritual assessment are available (see
Figure 1). The most important ability for the nurse
to master is to become comfortable with the types of
questions that elicit spiritual assessment data. The
following key questions can be asked and answered
in a short period of time during the assessment:
Do you have spiritual beliefs that are impor-
tant to you and help you with lifes issuesand problems?
Figure 1. Mnemonic Devices for Intentional Spiritual Assessment
Maugans S.P.I.R.I.T.
S Spiritual belief systemP Personal spiritualityI Integration into a spiritual communityR Rituals and restrictionsI Implications for medical careT Terminal care (as required): How their beliefs impact the care they offer when
patients reach the end of their lives
Maugans, T. A. (1996). The SPIRITual history. Archives of Family Medicine, 5, 1116.
Anandarajah and Hights H.O.P.E.H Sources of hope, meaning, comfort, strength, peace, love and connectionO Organized religionP Personal spirituality/practicesE Effects on medical care, disability, end-of-life decisions
Anandarajah, G., & Hight, E. (2001). Spirituality and medical practice: Using the HOPE questions as a practical tool for
spiritual assessment. American Family Physician, 63(1), 8189.
Puchalski and Romer F.I.C.A.
F Faith or belief: Do you consider yourself spiritual or religious?I Importance / Influence: What importance does your faith or belief have in your life?C Community: Religious or spiritual: Are you part of a spiritual or religious community?
A Address: How would you like me, your healthcare provider, to address these issuesin your healthcare?
Puchalski, C. M., & Romer, A.L. (2000). Taking a spiritual history allows clinicians to understand patients more fully. Journal
of Palliative Medicine, 3, 129137.
Combination of Cultural and Spiritual: E.T.H.N.I.C.S.
E Explanation: Why do you think you have this?T Treatment: What have you tried for this?H Healers: Who have you sought help from for this?N Negotiate: How best do you think I can help you?I Intervention: This is what could be doneC Collaborate: How can we work together on this?S Spirituality: What role does faith/religion/spirituality play in helping you?
Kobylarz, F. A., Heath, J. M., & Like R. C. (2002). The ETHNIC(S) mnemonic: A clinical tool for ethnogeriatric education.
Journal of the American Geriatric Society, 50, 15821589.
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252 Rehabilitation Nursing Vol. 31, No. 6 November/December 2006
If so, what can we do to assist you in prac-
ticing your faith or receiving spiritual sup-
port?
If you are having a particularly difficult time,
is there someone, such as a spiritual leader,
clergy person, or friend whom you wouldlike us to contact?
If notwhat provides you with the most sup-
port in dealing with lifes issues or problems
and how would you like us to help you?
Situational spiritual assessments are not planned but
depend on the patients or familys behavior or ex-
pressed needs. In almost every rehabilitation setting,
nurses will see patients struggling with physical or
emotional setbacks and perhaps expressing strong
emotions. Many times during a crisis, patients or
families will not express their needs directly. Patients
may not be aware that what they are experiencing is
a spiritual need until they are helped to recognize the
nature of their need.
The nurses role is as a detective who discovers
what a patient believes his or her needs are, as well
as what interventions might be helpful. Nurses are
ideally situated to pick up on verbal and nonverbal
cues. Verbal cues may include expressions of anger or
frustration, requests for help, prayer, and requests for
support from family, friends, clergy, or nurses. Non-
verbal cues may include silence, withdrawing from
others, crying, or a sad appearance. Nurses should
see these as signs that a situational spiritual assess-
ment should be done. Nurses who are sensitive andwilling to listen to these cues and ask key questions
(Figure 2) can often help patients identify spiritual
needs and offer spiritual support. Sensitivity, insight,
and knowing when to ask strategic questions can be
enough to identify a spiritual need.
Diagnosis and Plan
As a nurse analyzes a spiritual assessment, it
leads to nursing diagnoses, which in turn should
determine the appropriate spiritual care interven-
tions. The nursing diagnoses of spiritual well-being
and spiritual distress are well established and have
recognized defining characteristics, related factors,suggested interventions, and evaluative client out-
comes (Burkhart & Solari-Twadell, 2006a, 2006b;
Solari-Twadell & Burkhart, 2006). Familiarity with
these diagnoses can increase a nurses comfort and
confidence in providing spiritual care.
Culturally Competent Spiritual Care
Interventions
The patient or family should set the direction
for spiritual care and should freely give permission
for any interventions. Patients need to feel safe in
expressing their spiritual concerns. Patients will gen-
erally reflect their worldviews and the corresponding
role of spirituality in their lives through information
gathered during assessments or requests for specific
spiritual care interventions.
It is important to determine who is best suited to
meet the patients spiritual needs. Ideally, the best care
can be provided when the nurse and the patient have
the same worldview, with like values and spiritual be-
liefs. Examples include a Christian nurse praying with
a Christian patient, a Buddhist nurse sharing sources
of hope with a Buddhist patient, or a Jewish nurse sup-porting the worship needs of a Jewish patient. How-
ever, in the real world that usually does not happen.
Nurses and patients come from all cultures and
have varied spiritual beliefs. Nurses must decide
upon the most ethical and culturally sensitive man-
ner to provide spiritual care when the patient and
nurse have differing worldviews or spiritual per-
spectives. Most important is that both the patient
and the nurse are treated respectfully and recognize
that each one has a right to embrace his or her own
individual spiritual beliefs.
All nurses have a responsibility to assess spiritual
needs and to help patients identify appropriate spiri-tual care resources. However, every nurse should not
be expected to participate in every type of spiritua
intervention. This is especially important when the
spiritual beliefs and worldviews of the nurse and
patient are different.
For example, many complementary and alternative
therapies are compatible with all worldviews, such as
literature, music, and meditation or quiet times of de-
votion, but other spiritual care interventions that a pa-
tient may desire may not be compatible with the nurses
worldview, or vice versa. Without understanding the
Figure 2. Situational Spiritual Care
Assessment Questions
Ask open ended questions that focus on what
the patient is feeling, such as questions abouttheir concerns, needs, or hurts. Examples of these
types of questions includeWhat is the hardest part of this or the situation?
What hurts the most?What angers you the most right now?
Then direct the conversation to what the patient
believes would help them, such as
What has helped you the most in the past when
you have felt this bad?Does your family, friends, or faith help you?
The patient at that time may express the desire forspiritual support.
Mason, C. H. (1995). Prayer as a nursing intervention.
Journal of Christian Nursing, 12(1), 48.
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Rehabilitation Nursing Vol. 31, No. 6 November/December 2006 253
Table1.SpiritualCareEngagem
entBasedonWorldviews
Pro
cedural/Instrumental
Cultu
ralistic/Instrumental
TherapeuticInteraction
Transformational
Description
Alogicalandtechnicalapproachto
addressingspiritualneedsisused;
thisisbasedonroutinessuchas
standardizedassessmentsforreli-
giousp
referencesandpractices.
Appropria
teculturallydefinedspiritual
practicesareincorporated,basedon
spiritualassessmentandhistory.
Thisappro
achcanbenonreligious.Thenurse
useslistening,empathy,andreflectivetech-
niquestoh
elpthepatientexplorepersonalfeel-
ingsabout
thesituation.
T
hisapproachisbasedonmore
s
piritualknowledgeandcom-
p
assionatecare;itdemandsa
p
ersonalspiritualexperience.
S
piritualcarebecomesnotjust
a
tool,butthesharingofones
o
wnspirituallifewiththepatient.
Itinvolvesahealingconnection
a
ndpresence(Wong,2004).
Typeofnurse-patient
engagement
Minima
lengagementisrequired.
Moderate
engagementisrequired.
Completeengagementisrequired.Thenurse
practicestherapeuticuseofself;nursepresence
isrequired
.
Intenseengagementisrequired.
Apatientmaybeuncomfortable
receivingspiritualcarefrom
anurse
withadifferentworldview.
Nursesmaynotbeabletoparticipate
incertainpracticesbasedonworld-
view.
Considerations
Strength:Anyonecandoitandlittle
timeis
required.
Comfortandrapportbetweennurse
andpatien
tareneededforthesharing
ofbeliefsandpractices.
Emotional
andspiritualneedsoftenoverlap.
M
utualunderstandingandshar-
ingisrequired.Nursesneed
tobeawarethathislevelof
e
ngagementcanleadtoprofes-
s
ionalboundaryconfusion.
Concer
n:Nurseswhousethis
approa
chmaytendtostereotype
patientsbasedonreligiouslabeling;
potenti
alexistsformakinginac-
curateassumptions;patientsreal
needsmaynotbeidentifiedormet.
Worldview
Differencesinworldviewsarenot
problem
atic.
Mostinter
ventionsarenon-worldview-
dependent.
Thisisnot
dependentonhavingsimilarworld-
views.
T
hisisdependentonsharing
s
imilarworldviews.
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254 Rehabilitation Nursing Vol. 31, No. 6 November/December 2006
patients worldview, a nurse would be intrusive to ap-
ply therapies or interventions without adequate assess-
ment and permission. For example, a nurse would not
expect a Jehovahs Witness to accept a blood transfu-
sion due to religious convictions. Likewise, evangelical
Christian patients should not be offered energy thera-
pies due to their conviction that these therapies are
tied to Eastern mysticism and are in conflict with their
belief that Christ is their source of healing (OMathuna
& Larimore, 2001).
Even if there are differences between a nurses and
patients worldviews and beliefs, it does not absolve
the nurse from the duty to address spiritual needs
Providing spiritual care may be simple or complex,
in addition to requiring different levels of nurse-pa-
tient engagement. Four levels of spiritual care are
described: procedural/instrumental, culturalistic/
instrumental, therapeutic interaction, and transforma-tional. Table 1 describes these four levels, explains the
types of nurse-patient engagement required for each
based on worldviews and certain considerations and
provides examples of spiritual care interventions. De-
pending on the circumstances and unique situations,
the nurse could use any or all of these interventions
In most circumstances, nurses offer care at the proce-
dural/instrumental level and use only the culturalis-
tic/instrumental level as needed. Because therapeutic
interaction requires a more intense use of therapeutic
self and presence, it will probably most often be used
with patients in times of distress. Some nurses may
never interact with a patient at the transformationallevel, because this requires intense nurse-patient en-
gagement, and similar worldviews, and it involves a
healing connection and presence. The nurse should
not feel compelled to provide this level of care; how-
ever, many nurses and patients find great satisfaction
when transformational spiritual care is provided.
Evaluation
Like all other aspects of nursing, spiritual care
should be focused to achieve the best possible out-
comes. Professional expectations for spiritual care
have been established in the Code of Ethics (Ameri-
can Nurses Association, 2001), dictated by patientsrights (American Hospital Association, 1992), and
required for accreditation (Joint Commission on Ac-
creditation of Healthcare Organizations, 2003; Com-
mission on Accreditation of Rehabilitation Facilities,
2004). However, the most important evaluation of
spiritual care should be determined by each patient,
based on that patients personally identified spiritua
needs and desired outcomes. When the patient and
family indicate that their cultural and spiritual needs
have been satisfiedthen spiritual outcomes have
been achieved.Table1.SpiritualCareEngagem
entBasedonWorldviews(Continu
ed)
Procedural/Instrumental
Culturalistic/Instrumental
T
herapeuticInteraction
Transformational
Interventionexample
Thenur
seasksapatientsreligion
andcall
sclergypeopleoffaithas
indicate
dbythepatientandfamily.
Exampleofnon-worldview-related
care:Then
urseincorporatescultural
sensitivity
intocarebyrearrangingthe
Islamicpat
ientsroom,asrequested,
sothatthe
bedfacesMecca.
Anurseuse
stherapeuticlisteningskillstohelp
apatientwhoisstrugglingwithangertoward
anotherperson(emotional)whilefeelingguilty
becausehis
orherfaithrequireshim
orherto
forgivethe
person(spiritual).
EvangelicalChristianpatients
an
dnursesfeelasenseofrela-
tionshipbecauseoftheirshared
beliefs.Prayer,presence,scrip-
tu
res,andmusicmaybeshared
fo
rcomfort.
Worldview-relatedconflict:AMuslim
manorwo
manmaynotwantaJewish
orChristiannursetoprovidespecific
spiritualca
re.
A
Buddhistnurseunderstands
th
eneedforacalm,peaceful
m
indatdeathandtheneedto
av
oidanalgesicsandsedatives
as
thepatientapproachesthe
en
doflife.Thisnursewould
lik
ewisebeabletoaidaBuddhist
patientbyusingappropriate
Buddhistritualsandwritings.
Worldview-relatedconflict:AChristian
nursemigh
thaveaconflictparticipat-
ingwithapatientinavoodooritualor
ceremony.
AdaptedfromKoening&Lewis,2000;Narayanasamy&Owens,2001;Schmidt,2004;andWong,2004.
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Rehabilitation Nursing Vol. 31, No. 6 November/December 2006 255
Summary
Spirituality is an essential dimension of all human
beings. Patients in rehabilitation settings are in need
of hope and support along with a desire for resources
to help them in recovery. Rehabilitation nurses are in
strategic positions to use appropriate and culturally
competent spiritual care as a resource of hope to helppatients construct a new self. This article provides
an overview of spiritual care and addresses some of
the issues nurses identified as barriers to giving ho-
listic, compassionate care to a diverse set of patients.
Practical guidelines were provided to assist nurses
as they provide spiritual care for culturally diverse
rehabilitation patients.
About the Authors
Linda S. Rieg, PhD RN, is an associate professor at XavierUniversity and can be contacted at 3800 Victory Parkway,Cincinnati, Ohio 45207-7351 or [email protected].
Carolyn Mason, MS BSN, has worked for three years as astaff member for Nurses Christian Fellowship in Michiganteaching nurses about integrating their faith in nursing.She is certified in community health nursing and has taughtnursing for over 23 years. She holds a masters degree fromthe University of Illinois, Chicago and bachelor of sciencein nursing from California State University.
Kelly Preston, MSN, attended the congregational health/parishnursing program at Samford University. The nursing programat Samford focused on whole person health promotion with thespiritual care of patients as the primary focus. After earning her
graduate degree, she coordinated a program within an integratedhealthcare delivery system whereby she and her colleagues workedwith faith communities to help them establish health ministries.
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