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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

by Toby Krell RN, BScN - chac.ca · Care with Compassion A study of nursing perception on how to enhance “Care with Compassion” by Toby Krell RN, BScN submitted in partial fulfillment

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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.

Care with Compassion…71

Appendices

Care with Compassion…72

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.