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Care with Compassion
A study of nursing perception on how to enhance “Care with Compassion”
by
Toby Krell RN, BScN
submitted in partial fulfillment of the requirements for the Master’s Degree
City University August 2006
Professor Dr. Douglas Player
Care with Compassion…2
Table of Contents
Introduction 3
1. Discussion of the Problem 4
2. Literature Review 7
3. Methodology and Project Design 35
4. Findings of the Survey 40
5. Summary, Conclusions, and Recommendations 59 Appendix I 72 Appendix II 73 Appendix III 74 Appendix IV 75 Appendix V 76
Care with Compassion…3
Introduction
St. Joseph’s General Hospital in Comox is unique within the Vancouver Island
Health Authority as it is a denominational hospital retaining its own Board of Directors: it
has a mission statement which is summarized and spoken as “Health Care with
Compassion”.
….St. Joseph’s General Hospital embodies Christian principles of health care in
the Catholic tradition. For those we serve, and those providing the service, our
inspirations are the qualities of commitment, compassion, competence, human
dignity and social responsibility in caring for the whole person (St. Joseph’s
General Hospital, 2004).
Registered nurses are the largest group of health care providers within the
organization. They work 24 hours a day, seven days per week in a pattern of rotating
shifts. Concerns expressed by registered nurses’ groups are not necessarily separate from
the concerns of the health care organizations in our rapidly changing health environment.
The focus of this project is to find the common values and needs underlying seemingly
different approaches to quality health care. As St. Joseph’s General Hospital is a
Catholic facility with, therefore, a strong commitment to spiritual values, the Mission
Statement is held as a guiding light. As the Hospital employs registered nurses licensed
by the College of Registered Nurses of British Columbia (CRNBC1), the commitment to
best practice is expressed as Quality Practice Environments. The intention of this project
1 As of August 21, 2005 the Registered Nurses Association of British Columbia [RNABC] became the College of Registered Nurses of British Columbia [CRNBC].
Care with Compassion…4
is to seek common meanings between the Organization’s grounding in Mission
Integration, the CRNBC’s commitment to Quality Practice Environments and the voice
of the front-line nurse. What is learned will be shared with Hospital Administration. This
may then inform policy and assist continued strategic development of the organization.
The ultimate goal is a workplace that meets quality practice environment standards in
which Nursing feels supported as a profession and therefore can more effectively live the
mission statement and provide care with compassion.
Organization of the Paper
The first chapter is gives the background and scope of the Problem; Chapter Two
is a Review of the Literature; Chapter Three describes Project Design and Methodology;
Chapter Four iterates the Findings of the Project; Chapter Five contains the Summary,
Conclusions, and Recommendations of the Project.
Chapter 1: Discussion of the Problem
Background of the Problem
Nurses are the backbone of service to patients in a hospital. Nurses frequently do
not feel they have a direct voice in the governance and hence the creation of the system
they work in. Nurses are employees of the hospital, not private practitioners as most
physicians are. They struggle with the independence of their profession, with
independence from physician-driven care and with the hierarchies of their facilities.
Nurses may not have a voice in meetings of financial, technological and business
interests or at Board meetings. If they are present at these tables, nurses may not find
their voices to speak convincingly.
Care with Compassion…5
There are organizations in the United States designated as “magnet hospitals”
which retain nurses during this time when other facilities are experiencing nursing
shortages. What defines these institutions is a participatory governance structure and
decision making style. For other institutions to move in this direction, nursing staff and
management alike need support and education in how to approach problem solving
collegially.
Statement of the Problem
I am concerned about low nursing morale and their perception that nurses do not
have a voice in their organizations. Nursing theorists have developed an extensive
collection of nursing models; nursing programs are taught with inclusion of feminist
perspectives, personal empowerment, political awareness and yet nurses continue to feel
devalued. Since I first began this project, St. Joseph’s Hospital has instituted a
comprehensive Employee and Family Assistance Program. I have been personally
involved in providing a team debriefing following staff’s involvement in a significant
incident. Both program types have been identified as positive by staff. I continue
however to believe that no real change has occurred in nursing perception of
administrative or systemic support.
From my direct experience in the facility I hypothesize that specific issues are
affecting nursing morale. They include:
• Nurses do not perceive their influence in organization and desire a more
participatory style of decision making
• Nurses do not perceive that they are valued by the organization personally
Care with Compassion…6
• Nurses experience moral distress due to workload and lack of time to process
critical incidents
• Nurses are of different generations: the Mission of the nurses who started the
Hospital in 1912 was also their vocation. Nurses today value their personal needs
as highly as their professional needs.
• Rapid pace of organizational change including managerial and administrative
positions affect work life for all staff.
These issues are affecting the ability of nurses to provide care with the level of
compassion they would wish to express to their colleagues and patients and therefore
affect the quality of nursing care provided. I submit that the feelings and ideas of nurses
in this one organization would be parallel to those of nurses throughout North America as
explored in this project’s literature search.
Purpose of the Project
This project was designed to invite nurses to become more involved in
articulating their issues and offer their perspectives and ideas to the Organization. The
purpose in doing this was to enhance the ability of nurses to embrace the Mission
Statement of St. Joseph’s General Hospital and provision of Care with Compassion.
Scope of the Project
Work life quality models developed for nursing in Canada and the United States
were reviewed. A Quality Practice Environment guideline developed by the CRNBC was
used to develop a framework for nursing issues and definition of terms. These were used
as guides to begin developing questions to help St. Joseph’s nurses reflect on what would
make a difference in their ability to deliver highest quality patient care. It was further
Care with Compassion…7
hypothesized that themes would be found within the nurses’ responses that would offer
keys to change.
The project was designed as an ethnographic inquiry viewing the Hospital as a
field of study. A survey would be developed to administer to all registered nurses who
wished to respond. It would be developed by exploratory meetings with nurses to capture
their specific areas of concern or interest. Appreciative Inquiry was chosen as a
methodology for question development2. The responses would be tabulated seeking
themes and any patterns relative to length of practice or length of service with this
organization. The resulting information would be compared to the external inventory of
models of care to best offer suggestions to the Organization in support of nursing
engagement. Involving the nurses at the outset would be part of the Action intended to
foster a change process. The presumption was that staff will engage more passionately as
their issues are articulated heard and begin to trust that changes to the system will result.
Chapter 2: Literature Review
There is an almost infinite amount of literature on the changing world of healthcare
today: some of the phrases commonly used are: Magnet Hospitals in the United States,
Quality Practice Environments in Canada, Mission Effectiveness and Mission Integration
in religious organizations; ethical and moral distress, hospital restructuring, resource
allocation, cost containment, and many more. The scope of this project and this paper do
not allow for an in depth search of any one topic let alone all, yet all are very much part
2 Appreciative Inquiry is a method to explore the needs of an organization from the perspective of what is valued rather than what is lacking. Instead of focusing on problems as such, the problem-solving is found in recollections of what has worked well. See Literature Review below and References for further information.
Care with Compassion…8
of the experience of today’s nurses and all healthcare providers and consumers. Nursing
commitment to health care of the highest quality in Canada is referred to as Quality
Practice Environments. The American Nurses’ Association has a program of Magnet
Hospital recognition in which hospitals are given Magnet status when certain work life
quality indicators are met.
Because there is such a wealth of literature from different perspectives focused on
nursing morale today, I will touch on points from literature that reflect key themes. While
there is much literature reviewed on the issues of health provision today from the
perspective of magnet hospitals in the United States, or quality practice environments in
Canada, literature on the feelings of nurses from the perspective of mission effectiveness
or mission integration, i.e. care with compassion, is not as easily found.
Magnet Hospitals
Although it is of American origin, I started my search with Magnet Hospitals as
that concept has been much discussed by Canadian leaders. In the early 1980’s a study
was conducted by the American Nursing Academy to examine the hospitals which were
able to recruit and keep nurses most successfully and also delivered excellent care
(Kramer, 2004). The eight attributes according to Kramer are:
• Support for education
• Working with other nurse who are clinically competent
• Positive nurse/physician (RN/MD) relationships
• Autonomous nursing practice
• A culture that values concern for the patient
• Control of and over nursing practice
Care with Compassion…9
• Perceived adequacy of staffing
• Nurse manager support
(Kramer, 2004, p. 50).
With the publication of the study, “nursing leaders began to have a greater
understanding of factors that helped to attract and retain professional nurses…” according
to an American Association of Colleges of Nursing White Paper (2002, p. 3). The Texas
Nurses Association (2005) lists and describes in detail the “12 essential elements
identified as an ideal practice environment…” which impact on patient care as well as the
professional satisfaction of the nurses. They are:
• Control of nursing practice
• Safety of the work
• Systems exist to address patient care concerns
• Nurse orientation – competency based
• Chief nursing officer – activities supported by hospital administration
• Professional development
• Competitive wages
• Nurse recognition – incentives and acknowledgement
• Balanced lifestyle – needs of nurses at home and at work
(Texas Nurses Association, pp. 1-6).
There is a notable change from the 1980’s to this more recent list which includes
safety concerns, balanced lifestyle and competitive wages, all of which recognize the
needs of the nurse as well as those of the patient in fostering best nursing practice.
Havens and Johnston (2004) conducted a study consisting of focus group
Care with Compassion…10
discussions on “how to get there” (p. 580) referring to achieving the qualities of Magnet
status. They state that there is much information on what works well, but not on what is
needed to achieve the magnet attributes. Themes that emerged from their study were:
• Securing buy-in from key stakeholders
• Celebrating
• Using external consultants
• Putting the structure in place
• Communicating frequently
• Educating
• Mentoring by magnet hospital staff
• Telling the story
• Paying the costs – personnel and others
(Havens and Johnston, p. 581).
Havens and Johnston (2004) suggested ways of reaching the seemingly diverse
interests by appealing to the specific mindset of each stakeholder group: Board members
were generally aware of the magnet hospital studies: they encouraged nursing to venture
into what they perceived as an “innovative and creative” way to “validate” (p. 581) that
they already had a quality organization; physicians were drawn in by evidence-based
studies and educational events; nurses and particularly nurse-leaders were “the hardest
sell” (p. 581) due to workload concerns. Other departments and support staff needed to be
involved from the beginning to achieve success. The insight that “nursing…sits within a
larger culture” was essential to “energize” the entire organization (Havens and Johnston,
p. 581).
Care with Compassion…11
Laschinger, Almost, and Tuer-Hodes (2003) found that the combination of access
to empowering work conditions and magnet hospital characteristics was significantly
predictive of nurses’ satisfaction with their jobs. They discuss Aiken’s research that says,
“nurses in magnet hospitals have lower levels of burnout and greater job satisfaction….”
and, “hospitals with these characteristics have better patient outcomes, including lower
mortality rates” (Laschinger et al.., p. 410). They further say managers have a key role in
facilitating staff nurse satisfaction by how they perform their role. The old style of
control is unsupportable; rather managers need to focus on “coordination, integration, and
facilitation of nurses’ work” (Laschinger et al., p. 420). As well they need to be visible
and meet with staff regularly to encourage nurses to voice concerns and stay informed of
policy changes.
Ponte, Kruger, DeMarco, Hanley, and Conlin (2004) discuss the need of nurses to
carry out in practice what was learned in school. They define coherence as, “the feeling
of confidence that one’s internal and external environments are predictable” (Ponte et al.,
p. 174) and having confidence that things will work out reasonably well. Some of the
conditions that interfere with “coherence” are:
• Fiscal constraints
• Lack of teamwork and collaboration
• Deteriorating professional practice
• Lack of consistent supports to attain and maintain competency
• Understaffing
• Not enough time to complete work
• Communication issues with colleagues
Care with Compassion…12
• Lack of respect
• Lack of needed supplies
(Ponte et al., p. 174).
A significant issue with Ponte’s respondents was, “…self advocacy scores
suggested a tendency toward self-silencing behaviors, or an inclination to avoid
expressing thoughts and feelings” (Ponte et al., 2004, p. 174). Many conditions that
supported a feeling of coherence were about leadership development of staff nurses and a
collegial relationship with a visible manager. Ponte et al. (2004) state the manager is
perceived as supportive when the nurses feel that they know what is expected and when
she/he makes sure the equipment and supplies are there as needed. Phrases used to
describe good managerial skills were commitment, trust, and shared responsibility. The
importance of recognizing the role of staff team leaders and supporting this with
education time was discussed. Designing and implementing improved systems of care
using multidisciplinary teams, discharge planning as well as Patient Safety Leadership
teams and a Nursing –Pharmacy Liaison Program were all ideas brought forth to
improve nursing coherence. A strong case is made that creating best practice
environments requires the trust of nursing and other professional staff that they are
supported by administration. This trust is sustained by developing links for nursing to
bring concerns and issues directly to administration (Ponte et al., 2004).
Canadian perspectives on Quality Practice Environments
The Canadian Nurses Association (CNA) Position Statement on Quality
Professional Practice Environments for Registered Nurses states, “a quality nursing
professional environment is one in which the needs and goals of the individual nurse are
Care with Compassion…13
met at the same time as the patient or client is assisted to reach his or her individual
health goals, within the costs and quality framework mandated by the organization where
the care is provided (O’Brien-Pallas, Bauman, & Villeneuve, 1994)” (CNA, 2001).
The Position Statement includes a specific list of indicators with descriptors that
describe a quality environment which are summarized as follows:
• Staffing and staff mix:
o The employer respects and values the ability of the nurse to determine
what level and mix of staffing is required to meet the client needs.
• Nurses at all levels are involved in decision-making:
o this addresses nursing leadership, practice councils, communication,
standards of practice and ethics, “including issues of whistleblowing.”
• Policy setting:
o wide-ranging goals including equipment management, zero tolerance of
workplace violence, equipment availability and maintenance and space in
which to use it, flexible scheduling and control of overtime availability,
recognition of the unique role of nursing with opportunities for
professional development and “compensation…commensurate with
education, experience, responsibility and performance”.
• Support for “implementing evidence-based decision making” based on:
o continuing education, research, technological use, and data collection.
(CNA, 2001, pp. 1-3 of 5 retrieved).
British Columbia
Winslow, in 2001, discusses RNABC policy: The Registered Nurses Association
Care with Compassion…14
of British Columbia stated without prevarication the need for practice environments that
support staff work life to provide quality care. Citing “an extensive literature review” and
direct conversations with registered nurses in British Columbia, the Nurses’ Association
according to Winslow states, “the quality of nurses’ work life has a direct correlation
with job satisfaction, productivity, recruitment and retention and ultimately with the
quality of client care” (2001, p.13).
Winslow refers to the U.S. magnet hospital program success. She says:
The study found that nurses in magnet hospitals were less likely to feel
emotionally drained or frustrated by work and were more satisfied with their jobs.
They rated quality of care in their hospitals as higher. Although there were higher
nurse to patient ratios, the cost was more than significantly offset by shorter
lengths of stay and lower utilization of intensive care unit days (Winslow, 2001,
p. 13).
The mandate of the College of Registered Nurses of British Columbia [CRNBC]
is protection of the public. In 2003, the then RNABC developed a document entitled
Guidelines for a Quality Practice Environment for Registered Nurses in British Columbia
to aid organizations in developing a work environment and culture, “with the assumption
quality of care will improve” (RNABC, 2003, p. 3). The CRNBC reissued the document.
It states that Guidelines are not mandatory as Standards3 are, but are tools that may be
used to assess and make changes to the organization. The five guidelines are:
• Workload management
• Nursing leadership
3 CRNBC. (2005). Professional Standards for Registered Nurses and Nurse Practitioners. Pub. No. 128. Vancouver, B.C.
Care with Compassion…15
• Control over practice
• Support and recognition
• Professional development
• Organizational Support
(2005, p. 5).
Each guideline has a number of indicators to help those wishing to effect change.
They state emphatically, “creating quality practice environments is a shared
responsibility of government, employers and nursing organizations” (CRNBC, 2005, p.
4). Further to this, they give greater weight, and therefore responsibility, to the control
that employers have over “the environments in which nurses practice” (2005, p. 4). This
is then linked to the ability of organizations to attract and retain nurses and create healthy
working environments with better client outcomes. The indicators are of a general
enough nature to allow flexibility and discussion within a given worksite.
According to Winslow and Herman (2006), the CRNBC conducted a web-based
survey in 2005 asking nurses to compare their practice environments in 2002 prior to the
release of the Guidelines to that of their environment in 2004. The CRNBC identified 15
indicators out of 33 that were statistically significant in their ratings between the two
given years. 4 were improved but 11 worsened. “Practice environments that enable and
support nurses to meet CRNBC’s Standards of Practice are essential to client safety”
(Winslow & Herman, 2006, p.17). The authors conclude that investing funds to create a
care delivery system which will meet nurses needs will possibly be reclaimed in time
through reduced costs of overtime, sick leave and turnover. Winslow and Herman
additionally state quality of work life could be improved by cultural shifts which do not
Care with Compassion…16
require additional funding.
Alberta
The Alberta Association of Registered Nurses has similar standards to those of British
Columbia which also include the Canadian Nurses Association Code of Ethics. They
have added an Appendix C: Organizational Supports Needed in the Practice Setting. “A
professional practice environment is needed to enable nurses to meet the Nursing Practice
Standards and provide safe, competent, and ethical care.” The six areas of support are:
• Service delivery - including staffing and staff mix
• Health Records Management
• Communication - including information systems and conflict resolution
• Facilities and Equipment
• Nursing Leadership
• Professional Development
(Alberta Association of Registered Nurses, 1999, p. 7-8).
Saskatchewan
The Saskatchewan Registered Nurses Association [SRNA] (2004) has a specified
set of “Ends” policies for RNs and RN(NP)s4 which is reviewed annually. They are:
Vision and Mission; Competent, Ethical Practice; Professional self-regulation;
Comprehensive Primary Health Care; Professional Growth and Support; and Practice
Environments Conducive to Quality Care.
“This end is interpreted to include, but is not limited to”:
• sufficient nursing resources – includes financial support for education or other
4 Nurse Practitioners
Care with Compassion…17
means of retention
• transparent and accountable care delivery frameworks
• role definition within a collaborative practice setting
• organizational support for safe and autonomous practice
• strong links among nursing policy, practice and research
(SRNA, 2004, p. 3).
Ontario
Campbell and Mackay (2001) describe the Continuing Competence Program used
by nurses in Ontario. They state,
While nurses have an individual responsibility and accountability for maintaining
competence, and regulatory bodies have an accountability to the public to ensure
that nurses are competent, employers have a responsibility to create practice
environments that support competent practitioners to provide quality patient care
(Campbell & Mackay, 2001, p. 28).
The Canadian Nurses of Ontario [CNO] developed a set of “seven key system
attributes” (Campbell & Mackay, 2001, p. 28) that would pave the way for employers
and nurses to work constructively together. The main tenets of the program are described
in more detail below as they are a Canadian model for collaboration between healthcare
employers and nurses. The program is available to other provinces as a service for
purchase. It supports the assumption that healthcare agencies and its employees have the
same objectives. It offers a measurable system to assess progress and create a quality
environment from a collaborative perspective. Mackay and Risk (2001) state the Ontario
program, “is based on the assumption that a competent professional nurse, in a quality
Care with Compassion…18
setting will practice according to standards and engage in reflective practice and ongoing
learning to provide appropriate effective and ethical care that contributes to the best
possible health outcome for the client (CNO 1996)” (p. 19).
In contrast, they discuss that restructuring of health care systems in conjunction
with increased acuity has impacted nurses’ perceptions of their ability to offer quality
care due to “loss of autonomy, decreased nursing leadership, inconsistent care delivery
systems, diminishing resources and reduction of staff and support systems…” (Mackay &
Risk, 2001, p. 20). The results of another study “… indicate that as the proportion of
hours of care delivery by RNs decreased the rates of decubiti, medication errors and
client complaints increased” (Mackay & Risk, 2001, p. 20).
Focus groups held in 1996 preceded the development of the Quality Practice
Setting Attributes model. Mackay and Risk (2001) also reference many sources in their
descriptors of the 7 key attributes which are summarized below:
1. Care delivery process
• Planning and providing clinical care/services with other health professionals
• Unregulated care providers now as support roles – research is descriptive and
anecdotal: need more to evaluate the ability of regulated providers to effectively
implement quality practice with new mix
2. Communication systems
• Need to communicate with clients, families, professional colleagues; within and
between programs/services; use of conflict resolution: may adversely affect care if
not used
3. Facilities and equipment
Care with Compassion…19
• Supplies need be available when needed, up to date and in good working order
4. Leadership
• Vision of the organization, management style, staff participation in decision
making
• Giving recognition, guiding and being supportive of the team
• Creating a positive work environment
• Establishing standards for practice
• Being visionary
• Effects job satisfaction if not giving recognition, being critical of performance,
not following up on issues
• Staff able to act autonomously at level of knowledge
5. Organizational supports
• Mission, vision and philosophy statements
• Standards
• Policies and procedures that promote client safety
• Recruitment and retention
• Ethical standards that affirm obligation of health professionals to provide safe and
competent care: staff encouraged to identify ethical issues and be comfortable to
challenge standards or practices they find unethical
6. Professional development system
• Orientation
• Continuing education
• Reflective practice
Care with Compassion…20
• Staff development educator
7. Response to external demands
• Legislative, regulatory and health and safety requirements
• Client satisfaction
• Outreach to local communities
• Employee recognition programs
• Accreditation
• Shorter hospital stays
• Higher acuity
• Customer driven
(Mackay & Risk, 2001, pp. 21-24).
Nova Scotia
In 1999, in response to nurses’ expressions of difficulties in meeting the
Standards of Practice, and “recognizing that quality nursing care is the ultimate project of
quality work environments…” (College of Registered Nurses of Nova Scotia, 2003, p. 1).
the College of Registered Nurses of Nova Scotia piloted a project aimed at improving the
ability of RN’s and LPN’s to meet their standards of practice within the work
environment. As they developed and refined the program over time, they incorporated
some of the elements of the Ontario program through an agreement with the Nurses
Association in that province, “including a valid and reliable survey instrument” (College
of Registered Nurses of Nova Scotia, 2003, p. 1) designed at McMaster University in
collaboration with CNO. Nova Scotia continues to offer their quality improvement
program to organizations. The attributes being assessed are the same as those of the
Care with Compassion…21
Ontario model. They form “work teams” at the sites involved and bring in consultants to
support prioritizing and action-planning. It takes about a year to a year and a half to
complete the initial program steps. Because quality improvement is seen as a continuous
process reviews are done after this time period.
Nursing Leadership
The importance of nursing leadership emerged in the Literature as a strong theme
in creating and maintaining quality practice environments for Nurses.
McGirr and Bakker (2000) state, “the position of the chief nursing officer is being
eroded or in some instances has disappeared. The role of the nurse manager is becoming
more diffuse with a broader scope of services to administer and more managerial tasks to
accomplish” (McGirr & Bakker, p. 7). They point to research that says, “findings from
the Magnet Hospital studies drew attention to the effective impact of nursing executives
who were seen on nursing units and known to staff” (McGirr & Bakker, p. 11). They say
that research indicates in positive work environments, “norms such as communication
about mission, goals, feedback, rewards and support are used as evidence of this
satisfaction” (McGirr & Bakker, p. 7). Mackay and Risk in their section on leadership
state, “high visibility and accessibility to staff, as well as personifying and interpreting
the organization’s missions, values and strategic plans to staff are all pivotal in promoting
a positive work environment” (Mackay & Risk, p. 23).
As mentioned earlier in the magnet hospital discussion, the role of nurse leaders is
evolving. Cummings, Hayduk, and Estabrooks (2005) conducted a study based on Daniel
Goleman’s work on Emotional Intelligence. They quote him as saying that “…while
leadership attributes include analytic intelligence, task completion, and organizational
Care with Compassion…22
skills, the primary role must extend to effectively responding to their own and others’
emotions (Goleman, Boyatzis, and McKee, 2002)” (Cummings et al., p.2). Resonant
leadership is described as that which “reflects the art of hearing their workers’ negative
feelings yet responding empathically” (Cummings et al., p.2).
Their discussion was focused on the restructuring of hospitals as being intricately
woven into the practice concerns of nurses at this time. The characteristics of magnet
hospitals and quality practice environments are repeated in their findings which
“…suggest that nurses who reported characteristics of resonant leadership also reported
enhanced teamwork between physicians and nurses, nursing workgroup collaboration,
and the freedom to make important patient care decisions…”(Cummings et al., 2005,
p.11). In reference to a Health Canada model for organizational risk reduction, the
authors assert “…that resonant nursing leadership is a key-but missing-ingredient…for
achieving these goals in hospitals” (Cummings, 2005. p.11). Resonant leadership is
linked to less of a negative impact on nurses during restructuring. It does not “eliminate
the negative effects of …restructuring” but “did lessen some of the negative effects…”
(Cummings et al., p.11)
At a Future of Healthcare in Canada Forum healthcare stakeholders from across
Canada were interviewed regarding leading healthcare changes. Use of the word Leader
as opposed to Manager emerged as a theme. “They [employers] want a leader with a
visionary, strategic approach” (CHM staff, 2004, p.15). Managers who are
“transactional” as opposed to “transformational”… “don’t have the ability to engage
employees” (CHM staff, 2004, p.15).
Care with Compassion…23
Mission Effectiveness/Mission Integration
The Catholic Health Associations (CHA) of both the United States and Canada
have well-developed philosophies and supporting literature on Mission Effectiveness and
Mission Integration. Mission Effectiveness can be described as assessing how people are
living out the values of the organization; a measure of how good a job is being done.
(CHABC, 1995). CHA United States [no date] designed a manual directed toward elder
care but applicable to other institutions. It is a “how-to” manual to guide Mission
Integration for health care leaders, including Board members and administrators, drawing
on support from modern masters of Leadership as well as Scripture. It offers
methodology as well as reflective questions and actions. It states that the starting place
for understanding an organization is in its mission statement. The mission statement is the
heart of the healthcare organization. It “describes its purpose, why it exists” (CHA United
States, p.80). The role of leadership is crucial in Catholic Healthcare. Three roles of a
leader are described. The first essential role as a designer involves
…the integration of mission, values, and vision. It involves constantly checking
for alignment between mission elements and the various operations and activities
of the organization – seeing that there is congruity and consistency. It involves
pausing to ask, “If we’re not living up to our mission, how do we redesign our
structures so that we can be successful?” (CHA United States, p.18).
The leader’s role as a teacher is to educate staff about the history and continuing
purpose of the organization and giving staff the knowledge to understand the depth from
which decisions are made. As a steward, a leader is seen as being protective of the
mission by his/her depth of feeling which in turn is imparted to managers and staff (CHA
Care with Compassion…24
United States, p. 18). To help leaders bring back a state of excited involvement in the
organization, they draw on the roots of the organization as expressed in its beliefs,
mission, values, and vision. (CHA United States, pp. 23-29). The manual has a chapter
that describes ethics and ethical reflection stating, “…ethical reflection is nothing more
than reflecting how we should respond to the world around us while considering our (or
the organization’s) values” (CHA United States, p. 32).
Mission integration can be seen as “helping the organization to understand its
identity and purpose and to operate in accord with that…” or “It is the work of nurturing
the spiritual dimension of the organization” (CHA United States, p. 72). While it is the
responsibility of every staff member, the manual for Mission Integration for services to
the elderly suggests Mission Integration may more fully rest on the leadership of the
organization. A leadership team commitment to the Mission being realized in practice is
critical to others internalizing it. It is important to delegate a person to the responsibility
to keep the mission of the organization “in focus and nurtured” (CHA United States, p.
73). The ultimate responsibility however lies with the Chief Executive Officer to be fully
committed to Mission Integration and to act as a role model for its greatest success. The
manual further states that the Principles of Mission Integration contain elements of deep
reflection, visibility and mental presence on the part of the Mission Integration Manager,
be it the chief executive officer or someone appointed to that role, as well as a hands-on
presence in the planning and policy making for the organization (CHA United States, p.
73).
Haughian (no date) of the Catholic Health Association of Canada focuses on the
need for a distinct character if Catholic health agencies are to continue to exist in the
Care with Compassion…25
current health care climate. He discusses what is fundamental to such organizations.
Regarding staff relations, he links “…the professional growth and satisfaction of
employees and medical staff” as being “…consistent with a concern for social justice” (p.
12). Haughian states that a focus on ethical concerns has always been characteristic of
Catholic health care. He says that in today’s technologically advancing world and with
resource allocation issues, the need is greater and broader: “Medical-moral and social
justice issues in health care have become linked…and…a forum for ethical reflection is
needed (p. 36).
Clark and Olson (2000) make a connection between a positive self-image and
nursing’s ability to provide the full-complexity of health promotion it is capable of. They
state, “the self-image of nurses practicing in faith communities will affect how they carry
out their role within faith communities and, conversely, the role that they see themselves
carrying out will affect their self-image” (Clark & Olson, p.119).
Ethics
The common ground that links the language of magnet hospitals, quality practice
environments, and both religious and non-religious healthcare mission statements is
found in Ethics. Catholic facilities have a strong ethical grounding in the Health Ethics
Guide (Catholic Health Association of Canada, 2000). Non-religious healthcare
organizations have a different form of service than religious institutions according to
Dugan (2001). He states, “…committees in religiously based HCO’s [Health Care
Organizations] have wider “radar screens” than their nonreligious counterparts. The faith-
based mission and core values of religious organizations cause some issues to materialize
as “ethical,” presenting conundrums and calling for resolution” (Dugan, p.2). The
Care with Compassion…26
example used to illustrate this is contraceptive sterilization. Dugan sees a difference as
well in response to the norms of the day using the legal response of some States to
withholding treatment when further medical care is considered futile. He states,
…ethics committees in religiously based HCO’s must consider…whether
institutional policies or clinical responses to patient care conundrums are aligned
with the organization’s religious mission and core values….a fixed point of
reference, one that does not change as societal laws and professional customs do
(Dugan, 2001, p. 2).
His third point is that in religiously based organizations, Mission Integration is more than
the ethics of business and legalities. “It refers to the organization’s responsibility to
ensure that the foundational mission and core values of the organization influence
decision making from the bedside to the boardroom” (Dugan, 2001, p. 3) .
Marceau (2005) discusses the importance of spirituality in creating motivation in
the workplace whether secular or religious: “Spirituality is about the ways of the human
spirit in the world, for believers and nonbelievers alike” (p. 19). He points out that the
congruence of people’s values and beliefs with the mission of the organization they work
for creates a situation where employees will be involved beyond meeting their material
needs. If work is personally meaningful to employees it will be reflected in the outcomes.
He differentiates between spirituality in Catholic health care organizations from that
which he considers “generic” or “eclectic”. He points to the factors that constitute the
“healing ministry of Jesus” such as” respect, compassion, unconditional care, and
love…” (Marceau, 2005, p. 20). He also differentiates Catholic Health in that it is
influenced by the mission of the founders and this is carried forward to influence present
Care with Compassion…27
policy making (Marceau, p. 20). This has similarities to Dugan’s perspective above
regarding Mission Integration throughout the organization.
The Catholic Health Association of Canada (1997) published a document that
directly ties its teachings on social justice to fairness to employees in times of
restructuring. It gives some background into how the ethical values of Catholic social
teaching apply to the health care organization that may be facing restructuring. There are
suggestions given to meet the challenges of human resource planning relative to
contracting out and layoffs of staff. The focus is clearly on protection of the employees
through good relationships with unions and reflective decision making to minimize
disruption of the existing system.
Ethical and Moral Distress
Moral distress was first identified as a concept in nursing in 1984 by Jameton
according to Corley, Minick, Elswick, and Jacobs. It was defined then “as painful
feelings and/or the psychologic disequilibrium that occurs when nurses are conscious of
the morally appropriate action…but cannot carry out that action because of
institutionalized obstacles” (Corley et al., 2005, p. 382). According to Nathaniel (2002) a
U.S. government report cites nurses’ dissatisfaction with staffing, workload, increasing
overtime, and lack of support staff. She hypothesizes that these situations may be
contributing to moral distress which in turn may contribute to the nursing shortage
therefore negatively impacting patient care (Nathaniel, 2002, p. 5).
In her Table which illustrates the historical progression of moral distress in
nursing literature, she summarizes Penticuff and Waldren (2000) as having “found that
nurses’ ethical practice is influenced by the setting in which they practice including their
Care with Compassion…28
perceptions of their influence and value within the institution, administrative support,
views concerning quality of care, ethics resources, and satisfaction with practice
environment” (Nathaniel, 2002, p. 4).
According to the Canadian Nurses Association [CNA], “ethical or moral distress
arises when one is unable to act on one’s ethical choices, when constraints interfere with
acting in the way one believes to be right” (CNA, 2003, p. 2). Citing the CNA Code of
Ethics, it continues to elaborate on the definition of ethical distress as:
situations in which nurses cannot fulfill their ethical obligations and commitments
…or they fail to pursue what they believe to be the right course of action, or fail
to live up to their own expectation of ethical practice, for one or more of the
following reasons: error in judgment, insufficient personal resolve or other
circumstances truly beyond their control (Webster & Baylis, 2000). They may
feel guilt, concern or distaste as a result (CNA, 2003, p. 2).
Sources of Nurses’ ethical distress that the CNA has identified as most significant
from the literature are:
• Harm to patients (pain, suffering)
• Treatment of patients as objects
• Policy constraints
• Medical prolongation of dying without informed choice
• Definition of brain death
• Inadequate staffing
• Effects of cost containment (Corley, 2002)
(CNA, 2003, p. 4).
Care with Compassion…29
The Paper reports the effects of moral or ethical distress from different findings which
indicate physiological or psychological symptoms result and suggest they cause illness
and burnout.
Rodney and Varcoe (2001) take the perspective that an Ethical Inquiry into
nursing work requires recognition of that which nurses do which is not visible and
factoring such work into the economic valuation of nursing. Their goal is “to shed light
on some of the values inherent in health care that, if not critically examined, may distort
the economic evaluation of costs” (Rodney & Varcoe, 2001, p. 36). They refer to reforms
and restructuring in health care and the resulting outcomes of nurses working beyond
scheduled times without compensation to complete what is required but which may not
be visible or economically valued. Some of their examples include the emotional care of
people during unexpected admissions or deaths, care of confused patients without
resorting to the use of restraints, or when people are brought to hospitals when there was
no other place for them in the public system. The limited resource situation fosters
judgments around the value of individual needs and then emotional withdrawal of nurses
in order to complete the visible work of nursing. The outcome for nurses as described
correlates with the symptoms of moral distress and burnout. Rodney and Varcoe (2001)
conclude that greater nursing involvement in decision making about staffing ratios and
workload might effect the “quantitative and qualitative evaluation of resources” (p. 50)
and therefore the outcomes for those being cared for. They also make a reference to
feminist writers who suggest that unpaid caregivers at home, who are generally women,
are impacted by hospital cost containment.
A study done in Toronto from a feminist perspective brought forth the point that
Care with Compassion…30
nurses experience a moral burden and sense of powerlessness because the limits of the
profession are not clearly defined and they have “little opportunity to be relieved from
patient care in order to participate in the broader decision-making activities of their
organization” (Peter, Macfarlane, & OBrien-Pallas, 2004, p. 360).
In British Columbia, Storch, Rodney, Pauly, Brown, and Starzomski
undertook to analyze, describe and understand the enactment of ethical practice,
the opportunities for and barriers to such enactment, as well as the resources
nurses need for ethical practice….We identified practice realities that create a
climate for ethical or moral distress, and the way in which nurses attempt to
maintain their moral agency5 (Storch et al., 2002, p. 7).
The issues identified were similar to other studies, such as resource utilization, role of
nurse leaders, power structures, and policy development. “… Nurses’ discussions
conveyed their struggles to practice ethically in the midst of demands of an increased
workload, increased expectations, an increased volume of patients and a higher severity
of patient illness” (Storch et al., 2002, p. 9). Nurses expressed a distrust of using ethics
committees either for their being not well-understood or, “…they doubted the level of
support they might receive” (Storch et al., p. 10). The authors were “disturbed” at this
finding as they were to similar findings in a study reported by Storch and Griener in 1992
(Storch et al., p. 10).
Storch et al. (2002) identified resources needed by nurses in organizational
support. They state, “nurse leaders need to be the moral compass for nurses, using their
5 “In this article the terms ethical and moral are being used interchangeably. While Storch prefers to define moral in reference to ‘what’ action is taken, reserving ethical for ‘why’ such a choice of action would be made, there appears to be a trend in the literature to utilize the word moral more extensively and more synonymously with ethical. Given the various descriptors attached to the term moral throughout this article, readers should read moral as synonymous with ethical.” (Storch, 2002. endnote 1, p.15)
Care with Compassion…31
power as a positive force to promote, provide and sustain quality practice environments
for safe, competent and ethical practice” (Storch et al., p. 7). Nurse leaders too expressed
moral distress when they are unable to develop such environments where “nursing
practice can flourish” (Storch et al., p. 7) and “…spoke about ‘having their hands tied’,
that is, not being able to effect change to accomplish goals they believed to be for the
good” (p. 10). The authors state that nurse leaders must listen to staff nurses “rather than
insisting that they “cope”…and help break the silence of nurses” (Storch et al., p. 12).
Nurse leaders must place priority on “advancing models of care and nursing staff mix
which support safe and ethical practice to allow nursing and health team consultations to
become a norm of nursing practice” (Storch et al., p. 13). They continue on to suggest
“ethics rounds and/or workshops and continuing education course on ethics for staff
nurses” (Storch et al., p. 13).
As they conclude, Storch and colleagues offer a strong statement of why there is a
need to continue pursuing quality practice environments from a nursing perspective:
The freedom to be a moral agent, to be able to “do good” for clients, must
be seen as a priority reason for improving work environments. This does
not go without saying. It needs to be spoken and written: it needs to be
‘named’. Naming the value of the client’s well being is, after all, of high
priority in the Canadian Nurses Association Code of Ethics for Registered
Nurses….When nurses are not able to keep individual, family or
community needs in the foreground of their practice, their ability to be
moral agents is removed. (Storch et al., 2002, p. 13).
Care with Compassion…32
Generational Factors
Brief mention is made here of generational issues which too may affect
nurses’ sense of what constitutes a quality workplace. Greene (2005) points out
that organizations are not factoring in the differing expectations of the younger
nurses. Acknowledging that she is generalizing, she divides today’s workforce
into four generations each with its own set of expectations and priorities for
balancing work and personal lives. She points to research that indicates the
hierarchical systems model will not attract the young who “value a workplace that
is service-oriented, flexible, diverse, high-tech and has a sense of community
among employees, from executives to staff” (Greene, p. 38). She further separates
the issues by age related categories which cause dissatisfaction among nurses:
“High on the list for the over-32 age group is lack of teamwork; while the under-
32 group see a lack of work/personal life balances” (Greene, p. 38). Other
“sources of dissatisfaction” listed for the older group are support services, lack of
information sharing, security services and physical plant. For the younger group
the issues additionally are organizations not focused on patient needs, outdated
medical equipment, and insufficient development opportunities.
Appreciative Inquiry
Appreciative Inquiry (AI) is a means of approaching organizational
change from a positive rather than a problem-focused perspective. With
Appreciative Inquiry one seeks the strengths of an organization through asking
people what they value and building on those themes. As a means of
understanding the organization, AI seems to be compatible with the positivism
Care with Compassion…33
inherent in Mission Integration and Quality Practice Environments. Instead of
asking what was wrong in the past, AI seeks transformation through asking
people what works well within their organization. “It involves systematic
discovery of what gives life…when it is most effective and most capable in
economic, ecological, and human terms” (Cooperrider and Whitney, 2005, p. 8).
It suggests a means of surveying staff about organizational needs while
maintaining respect for the organization as it is. The use of AI fosters
inclusiveness and collective responsibility for a positive work environment.
Summary of Author
Magnet Hospital studies and criteria seem to form the baseline and strongest link
between all nursing perspectives. The Texas attributes are not dissimilar to Magnet
Hospital criteria and appear to build on them as do Canadian Quality Practice
Environment literature. Canadian literature refers to Magnet standards within its own
contexts. In all cases moral distress of nurses is today a foremost concern that requires
particular attention from many perspectives as the healthcare system evolves.
Nursing competence is influenced by the environment in which it is practiced
according to the literature. Restructuring, financial constraint and responsibility, nursing
shortages, and nursing struggling within itself to grow and find its professional self-
respect are accepted information. That the quality of the environment that nurses work in
directly affects their satisfaction and that this in turn has a direct effect on the quality of
patient care is agreed upon from many perspectives.
Much was said about leadership, and the need for leaders to be more visible. I was
surprised by how much the subtleties of leadership are considered to be vital to nursing
Care with Compassion…34
morale and competence: to involve managers and staff in stewardship requires their buy-
in, their commitment to the organization, and not simply compliance with policy. The
importance of visionary leadership was repeatedly emphasized as required to create
culture and climates in which the central core values of the organization can nurtured and
manifested concretely.
This elevates the responsibility of management in spearheading and supporting
change to an even greater responsibility: that of having a vision of the future and
inspiring others who have a narrower scope of practice to trust and follow. It also implies
seeing something which is not yet visible: taking the data, the statistics and surveys and
being able to see how they all fit together into a responsive system that meets the needs
of the client population of the next generations.
This directly suggests that nursing’s ability to practice to the highest of ethical
standards and therefore contribute to quality practice environments is inextricably linked
to the perceived support received by nurses from their management team. Nursing’s
ability to live the Mission Statement is directly related to the leadership style of their
managers. The word perceived was used frequently indicating the importance of
perception of staff as opposed to what others may claim is the organizational reality.
I find the regular mention of equipment that is accessible, stored properly, and in
good working order an interesting issue. The use of mechanical and sophisticated
electronic equipment is now part of every aspect of health care. There will undoubtedly
be more and more reliance on such systems and it will be essential to have the
infrastructure to support both the equipment and the staff who use it.
If one accepts that nurses are a marginalized group, as per Peter et al.. (2004),
Care with Compassion…35
then the Catholic Health Care concern for social justice becomes relevant to improving
the work life of this group. Nurse Managers need leadership development to enable the
support of staff nurses as they too have disempowerment issues and are the bridge
between staff and administrative teams.
Ethics committees are not well-known or seen as a safe forum to access by staff.
They are fundamental to Catholic organizations and provide a means for examining
ethical challenges and a venue for reflection. Greater publicity and developing grass-roots
access can be important to relieving moral/ethical distress for nurses.
Nursing quality issues and Catholic health ethics are clearly aiming for the same
outcomes. Quality Practice and Mission Effectiveness are not separate from each other.
Nursing is the part of the health care team which provides continuous care including
times and places when nurses are the sole presence. The responsibility therefore to seek
out the needs of nursing and align organizational values with this professional group is
fundamental to preserving the core of a religious healthcare organization. It is not an
issue of one hospital. There are common issues in North American healthcare systems
based on current political and social realities. By inquiring into how nurses in one’s own
organization perceive their situation in relation to those issues can lead an organization to
a higher standard of practice excellence as well as validation of what are its strengths.
Chapter 3: Methodology and Project Design
To the end of exploring the feelings and perceptions of nurses at St. Joseph’s
Hospital, I chose an Action Research approach that would combine elements of
phenomenology and survey methods. The research aspect was meant to evolve as the
Care with Compassion…36
project developed depending on who evidenced interest and what directions they pointed
to. Involving the nurses at the outset was conceptualized to foster integration of the
project with the change process. In aid of developing the survey, my concept was to hold
meetings with nurses to seek which areas they would find essential to include in the
survey. I planned to focus on Registered Nurses (RN’s) as the material in the literature
search was developed primarily from research of registered nursing experience. The
concept was taken to the Hospital Ethics Committee for approval. I wanted as much
involvement in the project as possible. I wanted members of the Administrative Team to
be aware of what conversations might be taking place in their organization. I received
permission to develop the survey (Appendix I).
I called a series of exploratory meetings during October and November of 2005
which were not attended by RN’s other than one colleague. I had extended the invitation
through the nurse-managers, the Union Stewards, by poster and word of mouth. People
expressed much enthusiasm and said they would attend but did not. I did however have
inquiries from Licensed Practical Nurses (LPN’s) through their shop steward asking if
they could be included and why they were not included originally. They represent
approximately ten per cent of the organization’s nursing population. In keeping with the
Action approach, I welcomed their participation. I had a series of questions prepared
(Appendix II) to invite their interest as well as snacks and literature to create a relaxed
professional environment.
Two LPN’s came both of who have had many years of experience within this
Organization. The nurses who came did not respond directly to any question I had
prepared. Crucial to them was that they were being asked their opinions about the
Care with Compassion…37
workplace. These meetings were not video taped as trust was a fragile issue. They began
to tell their stories in their personal styles (as opposed to my constructed style)
spontaneously and at length. I was unable to channel them into my agenda of survey
development through specific questions. I typed as they spoke asking a few clarifying
questions as they proceeded. Essentially, I recorded their vision of nursing, their passion,
what nursing means to them, what is missing in terms of recognition of their worth, and
sources from which they do perceive support and valuation. I had a similar experience
with one senior nurse who did not wish to attend a meeting.6 She wished to speak with
me privately. I met with her for about one hour. Her need to tell her story in her own
style and be heard was reminiscent of the practical nurses. Common themes evolved from
their narratives that helped focus development of my questions.
A survey was then developed to administer to LPN’s, RN’s and Registered
Psychiatric Nurses (RPN’s) 7 within St. Joseph’s Hospital. The survey consisted of nine
open-ended questions using an Appreciative Inquiry approach. Space was left for short
narrative personal responses. I chose this design as nurses had indicated the need to tell
their stories as I sought their involvement in the project. It became clear that a
quantitative survey with numerical ratings would not capture and express the passion and
emotion they feel about nursing. A pure phenomenological approach on the other hand
might have made it more difficult to capture a broader base of focal areas. The questions
as developed sought to address what nurses feel would add to their ability to feel more
compassionate to themselves and their patients within their culture of their worksites.
6 Nurse-managers are Registered Nurses within Contract who coordinate care on nursing units 7 RPN’s may or may not hold an RN designation as well. They are in either case part of the registered nursing population, generally working in the residential care and psychiatric areas of nursing.
Care with Compassion…38
The survey questions were submitted to Hospital Shop Stewards for any insight or
feedback. They were reviewed by the Director of Mission Integration from another
denominational health care system in Canada. As I received feedback I modified the
questions for clarity. I then brought the final survey to the Ethics Committee a second
time. Approval was received to administer the survey (Appendix III). I amended the
survey as per the Committee recommendation to include questions based on what
individuals do themselves to foster compassion in the workplace (Appendix IV).
The survey was distributed on February 6, 2006 with the final return date being
February 28, 2006. A cover letter (Appendix V) was stapled to it to explain the purpose
and use of the survey along with a self-addressed return envelope. Administrative support
staff was asked to put them in individual mailboxes if existent on the particular wards.
Casual8 staff was included. There were extra copies left in the cafeteria areas where
nurses congregate. Reminders were called to unit clerks to be sure surveys were available
and visible. The Hospital Chaplain took an interest in personally encouraging nurses to
complete the survey. The return date was ultimately extended by two weeks in the hope
of eliciting more respondents. It was also made clear that responding was entirely
voluntary.
The record of meetings and results of the survey were reviewed to identify themes
and focal areas of interest to nurses that arose from the data. The themes were compared
to the literature standards for quality practice environments. Conclusions and
recommendations were developed for the consideration of the Organization through
submission of the completed project paper to the Hospital. My hope is that administration
8 Regular staff are those who have permanent positions with a known schedule. Casual staff are those who are part of the staff mix but may be called when a regular staff member is ill or on vacation or for additional workload needs in general
Care with Compassion…39
will share these reflections with the Board and consider how they might further garner
nursing trust and goodwill. Nurses may perceive a greater voice within the organization
and some uplifting of nursing spirit could result.
Limitations of Project
• My first contacts are nurses who have already shown an interest in leadership and
may not be representative of all nurses.
• Those most unhappy may not feel there is any use in speaking out.
• Nurses may not voice their deepest concerns if they fall into some of the patterns
mentioned in the literature search, i.e. remaining silent when troubled by an issue.
• The sample may not be generalizable to other facilities since this is a hospital of
denominational status. There is little literature regarding nurses’ perceptions from
a mission integration perspective to use as a comparison.
• The respondent group was barely 10% of all possible nurses and may not be
representative of all nurses.
• The sample that responded may have been affected by survey fatigue as many are
circulated during any given year.
• Because interviews were not taped, I cannot ensure verification of precision of
what was said.
• Confidentiality is protected by the anonymous nature of the survey. I cannot
guarantee therefore that all responses are from single individuals employed by St.
Joseph’s General Hospital. I can see no reason however why anyone would falsify
a response.
• There were instabilities due to Organizational change specific to the time period
Care with Compassion…40
the survey was being developed and distributed. Contract negotiations were
imminent in British Columbia for collective agreements in health sectors when
the survey was administered. These issues may have affected respondent
perspectives.
• It is not the intention of this project to provide replicable or numerically graded
responses.
Chapter 4: Findings of the Survey
The meeting attendees talked for about one hour identifying issues that were of concern
to them. The themes they identified were as follows:
Validation from Management
• They mentioned the support of Pastoral Care whose role involves psychosocial
and spiritual care of staff, patients and families. He is frequently on the nursing
units by the nature of his work. Attendees stated they feel validated by this
individual, that he “knows what our work life is like here”. I asked what he does
that makes them feel validated. They responded:
• He sits down
• Always has a word
• Knows everyone’s name
• Tell us we’re angels and he appreciates us
• Always pleasant
• Comes as soon as you phone no matter what time of day
• Steady, reliable
Care with Compassion…41
• Can tell him your problems
• Comes to functions
Devaluation of Staff
They said that spiritual care and crisis support is provided if you seek it out but is
not a regular part of work life9. Personal needs are not supported by the Organization
according to these staff members. They cited a situation where a long time employee was
denied paid leave during a time of great need because it is not in the collective
agreement. They felt this extra help would have shown compassion to staff.
Workload issues
“Nurses know when they need help” they stated as opposed to calling in
workload based on a Tool. They feel that staff complains about little things due to the
heaviness of the workload. They called it a “vicious cycle” of stress and criticism. They
have been told to “prioritize” by their Nurse Manager. They say that they feel they are
not good enough to complete their work and go home feeling that they didn’t do their
jobs well if they are not actually given permission to let go of certain tasks. They said that
older nurses particularly have a higher standard and when overstressed and overloaded go
home feeling badly. The younger nurses however received training that is not realistic
and become angry that they cannot do the psychosocial work. They say they have been
lied to.
9 Since this interview, a comprehensive Employee Assistance program has been instituted with extensive cost-free counseling available.
Care with Compassion…42
Helpful Factors/Passion for Nursing
Taking students as preceptors helps rekindle energy and a fresh perspective. It
helps nurses keep their skills up to date and improves mental health said one staff
member. It also adds help to the ward. She said her reward is seeing how well the
students do under her supervision. They appreciate the letters and gift certificates from
the College as recognition of their help. Sharing their knowledge of bedside nursing care,
the ability to decrease pain and suffering by care and not only medication is satisfying in
showing the students nursing’s art. They felt that today’s more recently educated nurses
and doctors generally treat each other respectfully. Social events with all disciplines are
helpful. The main thing that would make the workplace “wonderful” would be “if there
was enough money for us to have enough staff”. The mix of acute care and long-term
care patients they feel is “not a good mix”. With the reduced resources they feel that
some care may get missed. When asked what helps maintain their passion, one said
vehemently, “I don’t need help maintaining my passion. I am passionate!” Kind words
from the patients and colleagues keep these nurses going. “If I knew my patients received
total care including spiritual care, I would go home feeling satisfied.”
Suggestions directly from LPN’s
• Job sharing, self scheduling
• More information and knowledge about decisions made at Ethics Committee
• A facilitated Support Group, drop in over lunchtime for people who feel
overwhelmed
• Newsletter of personal news, marriages, births, travel, department changes
Care with Compassion…43
• Administrative staff on nursing units and more in touch with staff
• Administrative staff on nursing units in morning to see the chaos and how busy
everyone is and in afternoon when we’re charting to say “you do an awesome
job”.
• Suggestion boxes
• We need to stick together and work together
Senior Registered Nurse
A senior registered nurse wished to speak with the researcher privately to express her
perceptions. Again, she did not offer any suggestions for survey questions, but had
frustrations that she felt were not being addressed. She said that staff are generally
frustrated, tired and burnt out. She noted that there is no staff for vacation relief thus
regular staff is asked to work on holidays. She said it is hard to be compassionate
when you’re in that situation and a patient is yelling at staff. She said that nurses need
to look after each other with compassion and use teamwork to support each other. She
said nurses need to feel valued. They need the physicians working with the Team
which she feels is of interest to the physicians as well. She feels the public is
“spoiled” in terms of their expectations. She too mentioned the same individual as
the LPN’s did as a model of what support looks like: she said this individual knows
people by name, talks to them, touches base regularly, reads people well and cares
about people. She too suggested more walk-through by Administrative staff.
Care with Compassion…44
Individually Written Response
One nurse submitted suggestions and observations based loosely on the final
survey questions:
• After a death allow staff member time to recoup, have coffee and reflect if only
for 20 minutes. Everyone to pitch in to support the time.
• Remember the we not the I for goal setting
• Financial sacrifices should be made when staff off on compassionate leave to care
for loved one. i.e. covering the cost of benefits when on extended leave in that
circumstance
• Acknowledge accomplishments – encourage and financially support mini “expert
on topic” staff individuals; create resources within working environment
• Acknowledge and thank people – be visible, create relationships
• Share goals and visions for organization with staff
• Management listening to front line workers when changes are to take place in the
areas that they work. Being validated and listened to by management facilitate a
smoother transition of change
These comments are parallel to the other respondents’ answers in terms of
teamwork, personal support during crisis beyond contractual basics, sharing between
different levels of the organization including validation of staff by administration,
education, and trust of decision making and use of time by staff.
The Survey
350 surveys were distributed to all units where practical or registered nurses are
Care with Compassion…45
part of the staff mix. 32 surveys were returned. The responses to each question were
tabulated (appendix VII) according to profession, RN or LPN, number of nursing years
and number of years with the present organization. No Registered Psychiatric Nurses
(RPN) responded as such. The Registered nursing range was from 8 months years of
nursing practice all within the present organization to 34 years of practice with 3 ½ years
at the present organization. Two LPN’s responded to the survey of whom one has10
years nursing practice. The other did not indicate any number of practice years. Five
respondents, one LPN and four RN’s, didn’t indicate their years of practice.
Questions 1 to 3 are in reference to this statement: recall a time when you felt
especially compassionate toward a patient or resident.
1. What in the environment helped?
29 RN/LPN respondents ranging from 2 years to 30 years of practice answered
this question including 4 RN’s who did not indicate their length of practice. 21of the 29
responses clearly related to having quality time with the patients or residents10. What
helped according to respondents was a less busy time such as night shift or when there
was less acuity on the ward and support of team members was given. Specific to the
environment were decreased noise, privacy and low lighting as things which enhanced
communication with patients. Interestingly, other staff members’ “seeming lack of
compassion” was cited as promoting one respondent’s own feelings of caring. Other
issues mentioned that helped were specific to the characteristics of the situations
themselves such as the death of a child, or patients receiving chemotherapy, and the
10 People requiring care are referred to as patients in acute care and as residents in residential care. Residential care is considered to be the home of the people who live there as opposed to acute care where cure and care of specific illness is given. Both environments provide care of the dying person or care for illnesses that have no cure but can be moderated for best quality of life, known as palliative care.
Care with Compassion…46
obvious support and love of a family member for a patient. One person said that the
environment was not a factor, but that compassion comes from within. This was an RN
with 30 years of practice, 18 at SJGH. Another RN of 25 years simply answered
“nothing”. An RN with 34 years of practice stated that “the profound feeling of
comradeship with the other staff involved in the situation” helped foster compassion.
In summary, three of the most senior practitioners in the respondent group seemed
to feel that compassion was generated by factors not dependent on the environment but
on inner resources, camaraderie and/or the profundity of what is happening to the
patients. This sentiment was not limited to those nurses however as the least practiced
nurse also said it is the team that supports her as did nurses of 14 and 15 years practice.
The overwhelming majority of respondents including some of the most senior spoke of
environmental factors, primarily quality psychosocial time with their clients. Nursing
education is grounded in caring. The responses to this question indicate nurses’ need and
ability to affect healing through physical and psychosocial interactions as opposed to
technical competency alone. One nurse said of a high point in nursing, “I was supposed
to spend time being with patients.” This touches on the moral distress nurses experience
when they see a need to be with patients rather than having to do something at all times.
They feel that they are taking the time from other priorities that they themselves have not
set. Significantly, the esthetics of the physical environment were cited numerous times as
having helped when there was privacy, quiet, lack of distraction and low lighting.
2. What did you learn or re-learn at that time?
29 RN/LPN respondents answered this question ranging from 8 months to 34
years of practice including 4 RN’s who did not indicate their length of practice. Many
Care with Compassion…47
responses again referred to time availability and team support being important. Many
other ideas were brought forth that are quite individualistic and touching. Points raised
are
• relearning the advocacy role of the nurse
• the satisfaction of expressed compassion, empathy, humanism
• how to be genuine when there is not enough time and how time need not
necessarily be a factor in expressing compassion
• how little it takes to show caring
• the complexity of each human being and how the fabric of their lives
impact on people’s experience of illness
• Understanding leads to empathy; compassion is sometimes forgotten even
though staff tells themselves they care.
• The uniqueness of each person’s response to a situation and to suffering
A nurse of 13 years experience said that “the ability and opportunity to connect
with patients and with their families is what keeps me at bedside nursing.” Another nurse
of 20 years experience said that she learned the “purpose and intent of our care.”
Listening and understanding were expressed as fundamental to nursing. One nurse wrote
more detail about protecting her physical well-being by not being too close to an
inebriated patient and also commented on how others might be “repulsed by a drunken
patient” and how “superficial trappings” are important to individuals. One nurse of 30
years experience expressed concern about the judgments and lack of compassion of other
staff and another with no stated years of experience also reinforced the need to avoid
judgments. The five most senior nurses, 28 – 24 years of experience, seemed to have a
Care with Compassion…48
greater commonality in their responses: they focused on listening, lack of judgment,
support for each other and the development of the therapeutic relationship through
constancy and safe relationships.
In summary, the responses expressed in this question exemplify the essence of
nursing. They point to the extent of the caring that is professional nursing. At a time of
greater compassion, each nurse was apparently reminded once again of what it is to be a
nurse. Anyone can learn the tasks of nursing but developing the compassion and
understanding the basis for that compassion is what distinguishes nursing as a profession.
Advocacy, empathy, humanism, lack of judgment, individuality and uniqueness of that
person’s experience underlie each interaction between a nurse and his/her clients.
Listening is fundamental as is establishing these keys to relationship in very small
amounts of time while other care is being given in a complex environment. The more
experienced nurses were more constant in their references to team support and
relationship building.
3. Describe what the workplace would be like if we were able to offer
compassion in this way all the time?
28 RN/LPN respondents ranging from 8 months to 34 years of practice replied to
this question including 3 RN’s who did not indicate their length of practice. Some
responded from the perspective of what pragmatically they would need within the
workplace to offer compassion more consistently. Some responded from the perspective
of how they would feel if the workplace had the previously mentioned qualities that had
enabled them to feel more compassionate. Nearly every response was different but there
were common elements as indicated by repetition of phrases including adequate staffing,
Care with Compassion…49
decreases frustration, and improved care for patients and residents.
Required elements to foster compassion were defined as:
• less busy, less hurried: decreased workload
• adequate staffing; beds, not nursing in hallways
• teamwork between nurses and physicians
• increased casual staff and available at discretion of regular staff
• less task orientation, more person-centered
• calmer happier co-workers; less frustrating, less demoralizing
• more client centered; able to know residents and families better; flexible
programming that focuses on purposeful daily life rather than care-focus
and entertainment
• cozy environment; private areas for patients and family
• expectation of dialogue about biases and for self-growth; support to help
all staff “feel something”
• group debriefing and one on one support following stressful situations
prevent burnout
How staff would feel if the conditions that would foster care as they would like to see
it were in place:
• healing would improve; better patient outcomes
• naturally would offer compassion to selves
• more satisfying; more fulfilling
• really make a difference
• inner self accomplishment at end of the day
Care with Compassion…50
• decrease burnout and sick time use
• decrease frustration and increase team sense
• morale would be high
• ability to respond to stressful situations more effective
Five RN’s with from 2 to 34 years of practice indicated that if they felt such
compassion in this way all the time it would be ideal, utopian, incredible, “a place
that I would look forward to coming to work” and ethereal as well as “healthy”. This
was defined as a “warm, connected and supportive atmosphere.” One RN with 25
years of experience in response to this question said this is not a realistic expectation
as all situations are different.
In summary, the responses reflect the nurses’ love of their chosen profession in its
purity. The frustrations nurses experience is about having enough time to show the
compassion that is naturally part of their experience. What is mainly being asked for
is sufficient staff to allow more time to practice fully in a person-centered
environment. Teamwork including debriefing after intense situations as well as,
again, the physical environment plays a part in creating an environment that is
conducive to best practice and therefore best outcomes for the clients. The
respondents feel that in this environment they too would be healthier and bring the
effects of that well-being to the workplace. This in turn would generate a more
positive workplace.
4. What would you need to be able to come to work feeling excited and energetic?
30 RN/LPN respondents answered this question ranging from 8 months to 30
years of practice. 4 RN’s and l LPN who did not indicate their length of practice are
Care with Compassion…51
included. In this instance, one practical nursing response diverged from the registered
nursing responses. An LPN stated higher wages expressed as their “correct wage” is
needed as well as giving out medications in all areas and more respect11. Some of the
responses from previous questions were reiterated. Some ideas were mentioned for the
first time.
• Ten respondents mentioned need for decreased workload or increased staff
numbers, including time to take scheduled meal breaks.
• Five respondents mentioned increased support and awareness of the ward
situations by Administrative staff: there is a need for direct acknowledgement of
how difficult the present work environment is in and of itself.
• Four nurses ranging from 2 years to 20 years of practice said they do come to
work excited and energetic, mentioning support of supervisor and co-workers,
feeling valued for work and opinions, having the ability to “effect change in
people’s lives” and having autonomy in decision making.
• Three respondents mentioned communication between staff, and staff and
administration as an issue of concern as well as “moral distress”. One said s/he
needed “the time to truly nurse, nurture, create esthetic for well-being, meet
needs.” Restructuring was included in this response as a means of aiding the
registered nurse to practice to her/his full-scope of practice which was described
as “non-task oriented roles”.
Other respondents mentioned a need for more educational opportunities for nurses, a
11 LPN’s are just beginning to work to the “full scope of practice” in that there have been limitations within certain facilities on skills that they are taught in training but are reserved only for registered nurses in practice. RN’s are educated with a 4 year degree granting university education while .LPN’s continue to have a 13 month compressed college program.
Care with Compassion…52
need for more sleep with the suggestion of a health nurse on site at all times. Teamwork,
mutual respect for opinions, and lack of negative talk were other issues. A mention was
made of having adequate physical space within which to work and less time spent on
“non-nursing” duties to make more time available to patients and families. The most
senior nurse commented that “…a greater feeling of self-confidence and ability….is
difficult in an ever-changing environment.”
In summary, the new ideas raised for the first time are the role of Administration
as a personal presence: their being aware of the situations on the wards. Some staff do
come to work in a positive frame of mind within the present environmental factors and
take their strength from collegial support, acknowledgment of a job well-done, the ability
to make decisions that affect their environment, and the changes they effect in their
client’s lives. On the other hand, being able to practice to full-scope of practice is
something other nurses do not feel they are able to do without a change in the way the
organization is structured. Moral distress was raised as a concept: the dissonance felt by a
caregiver when what is able to do is different than what is understood to be ethically
correct. The constantly changing nature of the healthcare environment itself was
mentioned as a challenge to best practice as was the need for more education to remain
current in knowledge. Lack of sleep was identified as a stressor that could be ameliorated
by having an industrial health nurse to help staff with their mental and physical health
concerns.
Question 5: what lets you know you are making a difference?
30 RN/LPN respondents ranging from 8 months to 34 years of practice answered
this question including one LPN and 4 RN respondents who did not indicate their length
Care with Compassion…53
of practice. The responses to this question are very consistent throughout the years of
service and for both nursing groups. Exceptionally, 24 respondents of both groups and all
levels of experience indicated that verbal or written responses from patients, families, co-
workers and pastoral care staff make a significant difference to the nurses. There were
comments that indicated the effect of nursing care as observed on the patients or residents
make that difference for Nurses. One nurse with 13 years of practice answered, “When
my patients get well, are calm and peaceful and tell me they feel better; when I can see
the fruit of my labor; when I’m told I made some difference”. One nurse, when s/he
reflects on the day, knows whether s/he has made a difference by her “gut” response.
Two RN’s stated “nothing from the Organization” in response to this question,
one with no stated length of service, and one with 8 years of practice, 5 at this
organization. An RN of 13 years practice, 11 at this organization said “Usually the
patients, and sometimes staff certainly not management.” A nurse of 25 years of
experience with 5 years at this organization said she doesn’t feel she is making a
difference.
Continuing education and being well-received by colleagues were seen as
indicators of making a difference by 2 senior nurses.
The profound need for acknowledgment of a job well done from both patients and
the organization is fundamental to the respondents’ sense of well-being and professional
satisfaction. The progression of the patients in itself gives intrinsic satisfaction to the
nurses. It is disturbing that someone who has nursed for 25 years does not have the
satisfaction of knowing she makes a difference.
Question 6: How can the organization show concern for staff in times of
Care with Compassion…54
personal need?
30 RN/LPN respondents ranging from 8 months to 34 years of practice answered
this question including one LPN and 4 RN respondents who did not indicate their length
of practice. Again, there is significant commonality in the responses in terms of issues,
but not necessarily in terms of concrete solutions. Nearly every response used the word
support, respect or acknowledgement. Expressions of verbal concern from management
or administration are considered appropriate; staff members want to be known as
individuals.
• Eleven respondents made some direct mention of their need for more time off, or
time off for mental health or stress reasons and times of grief. Trust was
mentioned: “trust in the staff member that they will take what they need without
taking advantage.” RN 13 years, 5 SJGH. Not making staff feel guilty when time
is important to respondents. “The organization can refrain from maintaining a
constant adversarial stance” was said by an RN with 18 years of nursing at SJGH.
• Provision of sufficient staff and resources were also seen as indicative of personal
support as, again, is visibility of administrative staff on the wards.
• Pastoral care was valued as a support, as is the newly initiated Employee and
Family Assistance Program.
• Listening, cards and gifts, and expressions of verbal support were all mentioned
as helpful to showing concern for staff whether by co-workers or administration.
A buddy system was queried as a possible means of further support.
In summary, although questions were framed to uncover the positives, the
answers implied the respondents’ sense that there is more administration could do to
Care with Compassion…55
acknowledge them directly. These responses are similar to the previous question. The
words support, respect and acknowledgement are telling. Trust, as evidenced by staff
being able to take time off when they deem necessary without justifying it, is a major
issue. Neither guilt nor any kind of organizational pressure is seen as promoting good
relationships between staff and the organization. When the issue for the staff member is
related to family grief of any kind it seems that more spaciousness around time usage
would be seen as supportive and appropriate. The supportive resources that are in place
were acknowledged particularly the pastoral care department and the newly instituted
Employee and Family Assistance Program (EFAP). Interestingly along with visibility of
administrative staff, having the unit running well in terms of sufficient staff and resources
are deemed evidence of support to staff.
Question 7: How do you imagine the leadership of the hospital further
cultivating a culture of compassion?
29 RN/LPN respondents ranging from 8 months to 34 years of practice answered
this question including one LPN and 4 RN respondents who did not indicate their length
of practice. The respondents varied in their answers, making them more difficult to
categorize. The general ideas of what can cultivate a culture of compassion are:
• Administration being more visible on the wards and listening seriously to the
voices of nursing, especially about workload issues
• Acknowledgement of work done including thanks and positive feedback
• Demonstrations of compassion toward staff by co-workers and by
administration
• Education of staff was mentioned a number of times as a concrete
Care with Compassion…56
demonstration of compassion to staff
• Some personal preferences were mentioned such as support for a short term
mission to a developing country
• Budgetary concerns were mentioned in a few instances as overriding people
concerns; the Human Resources department was cited by a senior nurse as being non-
responsive to the Hospital mission statement in that staff does not feel valued as
professional individuals who at times have personal needs.
• Mention was made of grass roots or bottom-up perspectives in decision
making as a positive step toward cultivating compassion.
The responses to this question themselves seem to summarize much of the
information in the previous responses. It is the personal touch to each staff member as an
individual that informs employees that the organization too is composed of individuals
who care about the staff members. This in turn fosters the ability of staff to practice
nursing more compassionately.
Question 8: How as an individual do you see yourself cultivating compassion
in the workplace?
29 RN/LPN respondents ranging from 8 months to 34 years of practice answered
this question including 4 RN respondents who did not indicate their length of practice. I
had thought that respondents might not find answers to this question but quite the
opposite occurred. The answers seemed to flow from the heart of each nurse who
answered. Each saw him/herself as a compassionate practitioner working as part of a
team. The most senior of the respondents simply said they would continue on as they
have been doing, hoping to be received as role models.
Care with Compassion…57
• Six respondents mentioned both support of co-workers and patients as
how they cultivate compassion in the workplace.
• Some respondents mentioned either their support of colleagues or of other
staff as how they cultivate compassion
• Being a role model for other staff or a mentor was mentioned in some
form by eight respondents
• Following or upholding the Code of Ethics and advocating for others was
mentioned more than once
• Different ways that staff cultivate compassion are “trying to exercise a
gentleness of spirit”; reducing judgment; maintaining the focus on the
individual patient/resident; and trying to transmit these behaviors to other
staff by example, teaching, sharing experiences and storytelling.
• Words that were used frequently but within different contexts were
patience, listening, leadership, respect, encouraging, and caring.
In summary, all the responses have some element of relationship within them.
Whether role-modeling or mentoring; listening or supporting, it is people taking care of
people that counts for nurses. The ethics and essence of nursing practice are evidenced
through caring behaviors including non-judgmental attitudes and sharing of oneself and
one’s knowledge and experience.
Question 9: Describe a time when you felt particularly compassionate
towards yourself. What was different about this situation?
25 RN/LPN respondents ranging from 8 months to 34 years of practice answered
this question including one LPN and 4 RN respondents who did not indicate their length
Care with Compassion…58
of practice. The responses to this question were the most difficult to categorize and the
most moving. Each was individualistic, often revealing a personal moment in the
respondent’s life or a moment of vulnerability and self-insight.
• Approximately 10 respondents referred to their realizing that they need to
put themselves first as an act of compassion toward themselves. Some
noted this was the first time they acknowledged it being valid to put their
own needs first. Others noted the understanding that stress was a normal
response and not to be hard on themselves when overwhelmed: “I knew
my frailty and how hard things can be. I loved myself”.
• Some respondents referred to a particularly difficult patient situation
where they cried with or for the patients.
• A few intimated that they took time off after illness or during a personally
stressful situation where they might not have in the past.
• Two referred to a change of perspective when they became the patient and
saw things from another perspective or had deaths in their own families.
• Five of twenty-five respondents had no answer to this question. They said
that they weren’t sure or that the question is difficult. One senior nurse
said “Never have”. Another said “strange concept at work”. The latter two
responses were from nurses with greater than 24 years of practice.
• A few mentions were made of focusing on caring for oneself and personal
strategies such as being at a spa or walking and being with family.
In summarizing this last question, it seems fair to say that the nurse respondents to
this survey evidence a degree of caring about others that has historically excluded their
Care with Compassion…59
own selves. It often takes a life-altering personal situation for the nurses to realize they
must care for themselves. Some continue to refrain from seeing this as a priority.
Chapter 5: Summary, Conclusions, and Recommendations
Summary
Nursing is grounded in caring as its core value in both education and
practice. It follows that the ability to give good nursing care would be seen as its
own reward. The nurses who responded to the survey evidenced their high
standard of care with compassion. Nurses have not lost their passion for nursing.
Nurses love nursing and vehemently desire the ability to care for their residents or
patients with both the science and the art of their profession. Even under duress of
workplace limitations and personal crises they indicated that their greatest reward
is the satisfaction of personal interactions and the received appreciation of their
client population. The respondents in this project evidence the conflicting need to
care for their clients no matter how challenging the environment. There weren’t
marked consistent differences between the respondents based on length of service
or practical nurse and registered nurse; however, there was an indication that the
senior nurses maintain an ethic closer to the historical value. In that model, the
needs of oneself are not reflected upon and factored in when giving care. Today’s
generation of nurses are educated to accept that self-care is essential to fitness to
practice. (CRNBC Professional Standards p. 16)
Themes
Workload
Care with Compassion…60
The most consistently mentioned issue is workload. Nurses are unable to
provide care to their own ethical standards no matter how much they try. The
outcome of this is moral distress. Moral distress can be mitigated with the effect
of altering the spirit and culture of the organization. Nursing input into best
patient/staff ratios would help return a sense of engagement and control of their
environment. When workload is particularly challenging, nursing would see
autonomy to determine staffing needs as evidence of trust.
Leadership
Much was said about leadership. Frequent mention was made of seeing
and being seen by senior administrators. Nurses want to have more direct
partnership in decision making and organizational development. They desire more
pathways for nurses to communicate directly with administration. Visibility is
particularly valued during times of crisis. It is not possible to know from this
study if staff would have this need if workload issues were not as prominent. It
seemed to be relevant that administrative staff see first-hand how very
challenging the environment is for nursing.
Resources
Nurses require resources to provide care. The resources are of differing
types. Education is important. Having equipment maintained and available is
necessary. The physical environment affects the ability to give compassionate
care. Hospitals are industrial environments with rare exceptions. There are alarms,
overhead pages, and less than esthetic surroundings with equipment stored
visibly. Nurses identified that being nurtured by their physical and human
Care with Compassion…61
environment enhance their ability and spirit to provide the holistic care. It is partly
from this that their inner satisfaction is derived.
Relationship
The nursing soul is nurtured by human interaction. Nurses retain their
passion and they need support for their own value system to practice to the best of
their abilities. Mentoring students and role modeling for others is inspirational.
Being validated by external evidence, whether it is the grateful words of their
patients/residents and families, or the encouragement and thanks of their
management team brings out the passion and willingness to do that much more.
Social events that are interdisciplinary are valued. Importantly, time that is
legitimized for the art of nursing, i.e. the psychosocial interactions and the act of
being with someone in their moment of need is essential. In turn, nurses require
emotional and spiritual replenishment themselves to maintain their equilibrium.
The challenge of recognition of personal issues as a valid concern is not
unimportant to the interests of the organization. Experiences of compassion as
experienced with clients or for themselves fostered greater awareness and
increased commitment to compassionate care.
Areas for Further Study
The magnet hospital criteria and models developed in Canada differ in
detail but are congruent in identifying how to help nurses find the satisfaction in
their practice once again. This in turn translates into organizations where staffing
is sufficient, costs related to absenteeism are reduced and care provision is
superior. As the sample in this study was small, further studies of a more
Care with Compassion…62
quantitative nature might be useful to more accurately pinpoint focus areas and
increase participation. A quantitative approach would appeal to different
populations or individuals within the organization to bring more stakeholders on
board with the change process. The use of consultants is something which might
be considered to bring in more objectivity. Some further areas of study that are
suggested by this project’s results are:
• how to best support the leadership abilities of managers
• generational diversity and needs within organization
• what promotes personal ability to sustain intrinsic satisfaction during difficult times
• how to demonstrate administrative support in a concrete way for staff
• how to improve physical space through sound mitigation and esthetics
• direct comments from family/clients being important to morale is significant enough to warrant further depth of study into how better to elicit responses
• how to further leadership within the nursing staff group
• how the Ethics Committee could develop into a known and safe venue of staff
support Conclusions
The issues raised by nurses are challenging from an organization perspective
based in a labor management style that must out of fairness and economy set standards
for the group rather than the individual. Yet, recognition of psychosocial needs both of
the client population and the staff will create rewards of its own. This has been
demonstrated in different models both within Canada and the United States. Individual
initiative and presence requires acknowledgement and possibly reward to further cultivate
compassionate care. This approach can take many forms with creativity and
Care with Compassion…63
organizational soul-searching. It is entirely mandated by the foundations of both Catholic
Health Care and Quality Practice tenets from within the nursing professional standards.
Differences can be made by even one individual as indicated by comments made about
pastoral care’s presence. The perception that decision making is lacking ongoing input
from staff groups is causing moral distress. Organizational articulation of the full-scope
of practice for RNs and LPN’s, as determined by their Colleges, would go a long way
toward maximizing staff use within the organization as well as staff satisfaction.
Leadership education to support nurses in role articulation and advocacy would benefit
both as well.
Suggestions of areas to explore to rekindle nursing engagement based in the
responses to this survey might be:
• Innovation in leave from work options • Flexible scheduling options
• Staff leadership roles for workload management
• Unifying policy manuals to make organizational information easily accessible to staff
• Administrative staff personally on nursing units and directly in touch with staff
especially at busiest times of day or during crises
• Wider scope for Ethics Committee with nursing staff
• Creative ways for staff to have input directly into administrative decisions
• Fostering staff as educational resources and team leaders
• Mission integration officer that is associated with Pastoral Care • Wider role for Pastoral Care in staff support. Consider a charitable fund for
personal crises.
Care with Compassion…64
• Employee Assistance Program positively received. Build on that strength to develop other programs.
• supports for personal needs
• Facilitated Support Group for times when people feel overwhelmed
• Newsletter that shares personal landmarks in staff lives
The more compassion can be expressed within the context of the complexity of each
day, the more nurses are satisfied and feel good about themselves and therefore provide
more compassionate care. In times of systemic reorganization within health care, it is
challenging how to best involve staff in understanding and supporting the organization to
prevent their feeling that the increased pressure is being downloaded within the
organization. Nurses have expressed their deep frustration that workload concerns have
moved beyond their ability to balance the needs of care with compassion and meet certain
tenets of nursing to their level of acceptable satisfaction. The lower satisfaction has
affected the work culture to the point where complaining has become a cultural response
that is affecting the peer group. When considering recruitment, it has become essential to
recognize that the nurse entering the workforce now will assert personal needs in a way
that was not traditional to nursing. If they cannot nurse to the same standard as their
educational model, they may become disaffected and leave nursing sooner than their
older colleagues.
Nurses have an intrinsic value of care and a high ethical standard. The challenge
for the organization is how to authentically convince its nurses that Board and
administrative employees, management and staff alike share the same priorities for Care
with Compassion. All the data supports the value of organizations supporting nurses: the
key is found in consulting with nurses at all levels of the organization and having their
Care with Compassion…65
spirited involvement during these times of change. The perception of nursing cannot be
refuted in deference to economy or other quantitative date that demonstrates nurses can
provide safe care. There is so much to be gained by hearing and heeding the passion of
nursing, the heart from which its compassion is sustained.
The following was submitted anonymously along with a respondent’s Survey:
To begin to speak about ethics is to ask ourselves, “What kind of world do
I want to live in?” If we want an environment in which there is
respect for others, honesty, compassion… we have already set a context
for our discussion. With those values as guides, we now think about how
to ensure that they endure by way of our actions.
Finally, of course it come down to courage – how to act when I know what
to do, but when I also know that what I should do will be very difficult for
me.
Dr. Abbyann Lynch
Toronto, Ontario
Abbyann Day Lynch is currently Director of Ethics in Health Care Associates (a
private consulting group)…. Professor Lynch is a Member of the Order of
Canada, and has been awarded the Order of Ontario.12
12 Biographical information retrieved June 18, 2006 from http://www.ohqc.ca/en/ourpeople.asp?name=Lynch
Care with Compassion…66
References
Alberta Association of Registered Nurses. (1999). Professional conduct: nursing practice
standards. Retrieved Aug. 28, 2005, from http://www.nurses.ab.ca/profconduct/npa.html.
American Association of Colleges of Nursing. (2002). Hallmarks of the professional nursing
practice environment. Retrieved Aug. 28, 2005, from
http://www.aacn.nche.edu/Publications/positions/hallmarks.htm
American Nurses Association. (2005). Organizational self-assessment for magnet readiness.
Retrieved Aug. 28, 2005, from
http://www.nursingworld.org/ancc/magnet/forms/orgready.pdf.
American Nurses Association. (2005). Staff nurse self-assessment to determine readiness to
pursue magnet recognition. Retrieved Aug. 28, 2005, from
http://www.nursingworld.org/ancc/magnet/forms/selfassess.pdf.
Campbell, B., & Mackay, G. (2001). Continuing competence: an Ontario nursing regulatory
program that supports nurses and employers. Nursing Administration Quarterly, 25(2),
22-30.
Canadian Nurses Association. (2001). Quality professional practice environments for registered
nurses. Retrieved Aug. 28, 2005, from http://www.cna-
nurses.ca/CNA/documents/pdf/publications/PS53_Quality_Prof_Practice_Env_RNs_Nov
_2001_e.pdf.
Canadian Nurses Association. (2003). Ethical distress in health care environments. Retrieved
Aug. 27, 2005, from http://cna-
aiic.ca/cna/documents/pdf/publications/Ethics_Pract_Ethical_Distress_Oct_2003_e.pdf
Care with Compassion…67
Catholic Health Association of British Columbia (CHABC), (1995) Living the mission through
health care reform. Video Archive
Catholic Health Association of Canada. (CHAC), (2000). Health ethics guide., Ottawa, Ontario
Catholic Health Association of Canada. (CHAC), (1997). Justice in the workplace. Ottawa,
Ontario
Catholic Health Association of the United States. (no date). Mission integration in long -term
care and other services for the aging. St. Louis, MO
CHM staff. (2004, December). Looking for an action hero: who will lead Canada's healthcare
transformation? Canadian Healthcare Manager, 14-20.
Clark, M., & Olson, J. (2000). Nursing within a faith community. Thousand Oaks, Cal: Sage
Publications, Inc.
College of Registered Nurses British Columbia. (2005). Guidelines for a quality practice
environment for registered nurses in British Columbia. Pub. No. 409. Vancouver, BC.
College of Registered Nurses British Columbia. (2005). Professional standards for registered
nurses and nurse practitioners. Pub. No. 128. Vancouver, BC.
College of Registered Nurses British Columbia. (2005). Guidelines for a quality practice
environment for registered nurses in British Columbia. Pub.No. 409. Vancouver, BC.
College of Registered Nurses of Nova Scotia, (2003). Practice environment collaboration
program. Retrieved Aug. 21, 2005, from
http://www.crnns.ca/default.asp?id=190&sfield=content.id&search=1159&mn=414.70.8
1.413.
Cooperrider, D, & Whitney, D (2005). Appreciative inquiry: a positive revolution in change. San
Francisco: Berrett-Koehler.
Care with Compassion…68
Corley, M. C., Minick P., Elswick R.K., and Jacobs, M. J. (2005). Nurse moral distress and
ethical work environment. Nursing Ethics, 12(4), 381-390.
Cummings, G., Hayduk, L., & Estabrooks C. (2005). Mitigating the impact of hospital
restructuring on nurses: the responsibility of emotionally intelligent leadership. Nursing
Research, 54(1), 2-12.
Dugan, D. (2001, August ). Ethics committees in religious hospitals: a different landscape. The
Parkridge Center Bulletin, 22. Retrieved Aug 27, 2005, from
http://www.parkridgecenter.org/Page1204.html.
Greene, J. (2005). Different generations different expectations. Hospitals and Health Networks.
79(3), 34-42.
Haughian, R. (no date). Mission education: a manual for catholic health care facilities. 1st ed.
Ottawa, ON: Catholic Health Association of Canada.
Havens, D.S., Johnston, M.A. (2004). Achieving magnet hospital recognition. Journal of
Nursing Administration, 34(12), 579-588.
Kramer, M., & Schmalenberg, C. (2004). Essentials of a magnetic work environment part 1.
Nursing 2004, 34(6), 50-54.
Laschinger, H. K., Almost, J., & Tuer-Hodes D. (2003). Workplace empowerment and magnet
hospital characteristics. Journal of Nursing Administration, 33(7/8), 410-22.
Mackay, G., & Risk, M. (2001). Building quality practice settings: an attributes model. Canadian
Journal of Nursing Leadership, 14(3), 19-27.
McGirr, M., & Bakker, D. (2000). Shaping positive work environments for nurses: the
contributions of nurses at various organizational levels. Canadian Journal of Nursing
Leadership, 13(1), 7-14.
Care with Compassion…69
Marceau, P. (2005, May-June). Spirituality in the Catholic Workplace. Health Progress, 18-21.
Nathaniel, A. (2002, winter ). Moral distress among nurses. Ethics and Human Rights Issues
Update, vol 1 no 3. Retrieved Aug 20, 2005, from
http://www.nursingworld.org/ethics/update/vol1no3a.htm#moral.
Peter, E.H, Macfarlane, A.V., & O'Brien-Pallas L.L. (2004). Analysis of the moral habitability of
the nursing work environment. Journal of Advanced Nursing, 47(4), 356-364.
Ponte, P.R., Kruger N., DeMarco, R., Hanley, D., and Conlin, G. (2004). Reshaping the practice
environment: the importance of coherence. Journal of Nursing Administration, 34(4),
173-179.
Roche, J. (no date). Justice in the workplace: principles and guidelines for health care
organizations in times of restructuring. Ottawa, ON: Catholic Health Association of
Canada.
Rodney, P., and Varcoe, C. (2001). Towards the ethical inquiry in the economic evaluation of
nursing practice. Canadian Journal of Nursing Research 33(1), 35-57.
Saskatchewan Registered Nurses Association (SRNA). (2004). Mission statement and council
policies. Retrieved Aug. 19, 2005, from http://www.srna.org/about/mission.php.
St. Joseph's General Hospital. (2004). Mission. Retrieved Aug. 28, 2005, from
http://www.stjosephs-comox.org/
Storch, J.L., Rodney P., Pauly, B., Brown, H., and Starzomski, R. (2002). Listening to nurses'
moral voices: building a quality health care environment. Canadian Journal of Nursing
Leadership, 15(4), 7-16.
Texas Nurses Association. (2005). Nurse-friendly hospital criteria. Retrieved Aug. 28, 2005,
from http://www.texasnurses.org/wkplaceadv/NF/nurse-friendly.htm
Care with Compassion…70
Winslow, W. (2001). Practice environments that attract and retain nurses. Nursing BC, 33(4), 13-
14.
Winslow, W., and Herman, C. (2006). Practice Environments: What’s Improving? What’s Not?
Nursingbc. 38(2), 17-18.
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Appendix I
Ethics Committee Meeting May 18, 2005 - Page 2 of 2
Toby is asking permission to go forward with this project and she will be compiling a questionnaire for nursing staff. Sheila Cruikshank has agreed to be her Nurse Advisor.
MOVED: Ron Philip/Lisa Murphy
That the Ethics Committee approves the project in principle and Toby will proceed with developing the questionnaire and bring back the survey to the Committee for review.
CARRIED DATE OF NEXT MEETING
The next meeting will be June 23, 2005 at 8:00 a.m. in Room A. 6 ADJOURNMENT
The meeting adjourned at 9:00 a.m.
C. Marles Recording Secretary J. James Chairperson
6.Carter Secretary
Care with Compassion…73
Appendix II
HOW CAN WE AS AN ORGANIZATION FURTHER SUPPORT STAFF TO FULFILL
OUR MISSION – CARE WITH COMPASSION? An Invitation to RN’s/RPN’s/LPN’s St. Joseph’s Hospital
Drop-in Meeting Wed. November 16 7:00-9:00 p.m.
Clinical Lecture Room METHOD: I would like you to tell me how I can best learn from you. Possibilities include a survey, or a record of nursing stories. Sample survey/interview questions are attached to give you the idea of “Appreciative Inquiry”. You are the ones who are passionate about nursing care and whose voices are not always perceived as heard. Please contact me by phone at local 1556 weekdays 7-3:30 or 890-0048 evenings and weekends or email [email protected] to let me know of your interest. All questions, ideas, and comments are welcome. I would also meet you individually or at other times in small groups of your choice. Sample Survey/Interview Questions What actions by your organization would demonstrate compassion to staff? If you came to work and you felt full of energy and excited to be working, what would be motivating you in the workplace? What would you and others be doing? What things would a manager be doing for you to feel really supported? Tell me about a time when you felt the satisfaction of being validated for your work. Tell me about a time when you felt appreciated by your organization for something special you did? Can you tell me about what was happening around you at a time when you were caring for someone and felt especially compassionate (felt you could express your compassion)? What did you learn or re-learn during this time? I wonder what the workplace would be like if we were able to offer compassion in this way all the time?
Care with Compassion…74
Appendix III
Ethics Committee Meeting December 13, 2005 - Page 2 of 2
4.2 Video Sharing Bad News" - Part Two. Tabled in order to allow Tabled Toby to present her Master's Survey.
NEW BUSINESS 5.1 Approval of Master's Survey |
Toby presented her "Care with Compassion Survey" for approval. The goal of the survey is to assist our organization in ensuring that "Care with Compassion" continues to flourish as part of our culture for patients/residents and staff. Toby advised she had looked at mission effectiveness in depth and she will distribute this survey to nursing units through the unit clerks and/or shop stewards.
It was recommended she develop a question based on the positive steps individuals have taken to influence the workplace.
MOVED: Ron Philip/Gordon Carter
That the Ethics Committee approves this survey for distribution to staff.
CARRIED
5 TOPIC FOR NEXT MEETING
Second Half of Video on "Sharing Bad News."
6 DATE OF NEXT MEETING
The next meeting will be Tuesday, January 17, ?006 at 8:00 a.m. in Cafeteria Conference Room "B."
7 ADJOURMENT
The meeting adjourned at 8:50 a.m.
________ J. James G. Carter C. Marles Chairperson Secretary Recording Secretary
Care with Compassion…75
Appendix IV Care with Compassion Survey
Profession RN RPN LPN Years of Practice Years at SJGH
Recall a time when you felt especially compassionate toward a patient or resident. 1. What in the environment helped? 2. What did you learn or re-learn at this time? 3. Describe what the workplace would be like if we were able to offer compassion in this way all the time? 4. What would you need to be able to come to work feeling excited and energetic? 5. What lets you know you are making a difference? 6. How can the organization show concern for staff in times of personal need? 7. How do you imagine the leadership of the hospital further cultivating a culture of compassion? 8. How as an individual do you see yourself cultivating compassion in the workplace? 9 . Describe a time when you felt particularly compassionate towards yourself. What was unique about this situation? Return in attached envelope via hospital mail by February 28, 2006. Thank you for helping ensure that “Care with Compassion” continues to flourish as part of our culture. Any comments are welcome [email protected] or 890-0048
Care with Compassion…76
Appendix V
HOW CAN WE AS AN ORGANIZATION FURTHER SUPPORT STAFF TO FULFILL
OUR MISSION – CARE WITH COMPASSION? An Invitation to RN’s/RPN’s/LPN’s St. Joseph’s Hospital
WHAT: I would like your collective help with a project which I hope will foster new spirit and nursing leadership at the “grass roots” level in nursing. The project is part of my Master’s schoolwork. GOAL: My goal is to assist our organization in ensuring that “Care with Compassion” continues to flourish as part of our culture for patients/residents and staff. OBJECTIVE: What I hope to do is to articulate the issues of Nurses for Administration in a positive forward-looking style and a language that matches the core values of this Hospital. PREMISE: I believe if nurses feel supported and valued we can better fulfill our Mission and create a “Quality Practice Environment”. METHOD: I have developed a survey with input from individual staff members including BCNU shop stewards and the approval of the Hospital Ethics committee. The survey asks for your professional role but not your name to protect the confidentiality of your replies. I will compile the information I receive and identify common themes. I encourage you to fill out the survey: You may answer as few or as many questions as you choose. Please return it by February 28. LOOKING FORWARD: I have started a Leadership section in the library in Room 10 (across from HR). They are available to browse and borrow now: look for the books with the red dots on their spines. I would be interested in helping develop a nursing leadership group as an outcome of this work. Please let me know if you are interested. Any questions or comments welcome: [email protected] or 890-0048 Toby Krell, RN, BscN.