EXPLORING THE INTERPROFESSIONAL CONTRIBUTIONS OF SPIRITUAL HEALTH PRACTITIONERS TO PREVENT COMPASSION FATIGUE IN NURSES by AMY HILDEBRAND BSN, RN, Vancouver Island University, 2008 Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCE IN NURSING in the FACULTY OF GRADUATE STUDIES TRINITY WESTERN UNIVERSITY August 2021 © Amy Hildebrand, 2021 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE ii Table of Contents ABSTRACT vi ACKNOWLEDGMENTS vii CHAPTER ONE: INTRODUCTION AND BACKGROUND 1 Background 2 Thesis Description 7 Study Methods 11 Chapter Summary and Outline of Thesis 12 CHAPTER TWO: LITERATURE REVIEW 13 Introduction 13 Search and Retrieval Strategies for Literature Review 13 Search Terms 13 Inclusion and Exclusion Criteria 14 Extraction Questions 15 Summary of Selected Literature 16 Role of SHP Support for Nurses’ Well-being 17 Nature of the “Problem” 18 Definition of Spirituality 19 Organizationally-led Interventions 20 Nurses’ Individual Spirituality and Meaning Making 22 Summary of Themes 23 Chapter Summary CHAPTER THREE: RESEARCH METHODS 24 25 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE iii Introduction 25 Design 25 Purpose and Objectives 26 Sampling 27 Procedures 29 Ethics 31 Scientific Quality 31 Limitations 32 Chapter Summary 33 CHAPTER FOUR: FINDINGS 35 Introduction 35 Overarching Theme: Value of Connectedness 35 (De)Prioritization of the Spiritual in Health Care 38 Collective Definition of Spirituality and its Role in Health Care 39 Past and Present Factors Influencing Spirituality in Health Care 41 Exemplification of Spirituality in Health Care Leadership 44 SHPs’ Perception of Nurses’ Compassion Fatigue and Lack of Connection to Spirituality 46 Nurses’ Self-Awareness of Spiritual Well-being and SHP Support from the Perspective of SHPs 47 How Nurses Handle the “Norm” of Nursing and Factors Contributing to Compassion Fatigue 51 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE iv Lack of Language Connecting Spiritual Well-Being to Compassion Fatigue and Other Interrelated Concepts The Nature of SHP Support The Commission and Availability of SHPs 55 60 60 Variety of Support Approaches and Resistance or Reception from Nurses 63 Impact of SHP Support to Mitigate Compassion Fatigue, Related Interventions and a Link to the Aesthetic 69 Implications of the COVID-19 Pandemic 81 Chapter Summary 85 CHAPTER FIVE: DISCUSSION 87 Introduction 87 (De)Prioritization of the Spiritual in Health Care 88 The Shifting Tide of Spirituality 88 Setting the Tone 93 SHPs’ Perception of Nurses’ Compassion Fatigue and Lack of Connection to Spirituality 96 Spiritual Self-Awareness 96 A Lost Language 100 The Nature of SHP Support 104 In-situ Nurturing 104 Impact of SHP Support to Mitigate Compassion Fatigue 109 Chapter Summary CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS 114 117 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE v Introduction 117 Summary 117 Conclusions Recommendations 118 119 Education 119 Leadership 121 Policy 122 Practice 123 Research 124 Conclusion REFERENCES 125 127 Appendix A – Matrix for Included Articles 146 Appendix B – PRISMA Flowchart 150 Appendix C – HREB Approval Forms 151 Appendix D – Letter of Invitation 153 Appendix E – Consent Form 154 Appendix F – Demographic Form 157 Appendix G – Compassion Cart Study Demographics Table 158 Appendix H – Interview Guide 159 Appendix I – Codebook 161 Appendix J – Transcriptionist Confidentiality Form 164 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE vi Abstract The connections amidst compassion fatigue, the spiritual well-being of nurses, and the provision of support by spiritual health practitioners (SHPs) have not been well studied. The purpose of this qualitative thesis is to explore the perspectives of SHPs in their support for nurses to prevent compassion fatigue. This study was conducted using a qualitative interpretive description design. The methods utilized included a current literature review and thematic analysis of individual interviews with seven SHPs. A brief secondary analysis of data collected from a related research project informed the background and some findings of this study. One overarching theme, The Value of Connectedness, and three main themes were identified from the data: (De)Prioritization of the Spiritual in Health Care; SHPs’ Perception of Nurses’ Compassion Fatigue and Lack of Connection to Spirituality; and The Nature of SHP Support. Several conclusions and recommendations have been made from the completion of this research. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE vii Acknowledgements Thank you to my Father, the God of compassion, for sharing His heart with me, to know what it is like to walk alongside others in suffering and have the innate desire to alleviate that distress. Thank you that I do not walk this path of life alone, but am connected to the Source of life itself, giving sustenance for today and hope for tomorrow. Thank you to my thesis committee, Dr. Sheryl Reimer-Kirkham and Dr. Barry Quinn, who invested their own time and expertise and so graciously guided me as I navigated the research process. Both of you are the epitome of intelligence clothed in humility. Thank you to my husband who not only changed my surname in the middle of this journey, but also brought clarity to many of my murky moments, prayed with and loved me through my stints of despair, and provided non-stop encouragement and perspective. Sean, you are the human I love the most! Thanks to my ever-loving, prayerwarrior mama who thinks I am capable of anything. Thank you also to Marj D. who bluntly told me to do my masters now. You have been an ever-encouraging mentor to me. Finally, I would like to thank and honour every individual who put up with me, painstakingly listened to me, and believed in me during this thesis journey. You inspired, encouraged, and motivated me to press on to the end! May the words of my thesis cause us to look within, reach out, and seek the Truth. “Therefore, as God’s chosen people, holy and dearly loved, clothe yourselves with compassion, kindness, humility, gentleness and patience” (Colossians 3:12, NIV, emphasis added). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE Chapter One: Introduction and Background Spirituality is an intrinsic part of every human being1 (Puchalski et al., 2014). The environment in which a majority of nurses find themselves today is one where time and space have not been created for incorporating the spiritual aspect of their lives (Puyat et al., 2019). Critical incidents in health care, which can be defined as life-threatening emergencies in which health care responders must act in a timely and skilled manner, may elicit a significant stress response in nurses and other providers (Lane, 1994). This stress response can leave them in a state of unsettled emotion, compassion fatigue, and ultimately burnout. Spiritual health practitioners (SHPs) are positioned in a unique role that may be beneficial in guiding nurses through examining their thoughts and emotions, creating a buffer against compassion fatigue, and offering debriefing support after stressful situations. The nature of some critical incidents may overwhelm a nurse’s capacity to process and cope. Over time, due to lack of resources or self-awareness, this may cause the nurse to experience feelings of hopelessness, confusion, and lack of meaning, as aspects of spirituality in the workplace (Smiechowski et al., 2020). Related to this response, spiritual health practitioners have been trained in the provision of a variety of spiritual care practices, including religious and spiritual facilitation, counseling, emotional support, and advocacy (Ho et al., 2018). Unfortunately, current literature shows a lack of SHP interaction with nurses to explore spirituality within the workplace, thus ignoring a vital resource that could assist nurses in preventing compassion fatigue through the expression of residual distress. The purpose of this 1 Although the assumption that spirituality is an intrinsic part of every human being underpins this thesis, I acknowledge that there are some who do not hold to this assertion (Paley, 2008). 1 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 2 qualitative thesis is to explore the perspectives of SHPs in their support for nurses to prevent compassion fatigue. Background As defined by the Canadian Nurses Association (CNA, 2007), registered nurses are: self-regulated health-care professionals who work autonomously and in collaboration with others. [They] coordinate health care, deliver direct services and support clients in their self-care decisions and actions in situations of health, illness, injury and disability in all stages of life (p.6) Front-line nurses in the acute care setting face heightened modern-day stressors due to a variety of factors, such as higher patient acuity, inappropriate nurse to patient ratios, rigorous standards set by the latest research, occasional threats to personal safety, and increased life-saving measures (Cavendish et al., 2004; Eslami Akbar et al., 2015; Holland & Neimeyer, 2005; Ramya & Jose, 2013; Zhang et al., 2019). These factors, combined with a rapidly changing environment, can have an impact on the mental well-being of nurses. During unexpected medical emergencies, cardiopulmonary resuscitation (Code Blue) or some end-of-life situations, nurses may experience a variety of emotions due to the suffering or chaos they witness. Moral residue and distress, secondary or vicarious trauma, compassion fatigue and burnout are all negative outcomes that can result from prolonged exposure to stressful work environments or critical incidents (Adimando, 2018; Badger, 2001; Drake et al., 2020). Over time, nurses may lose their “human expressions of compassion” and be tempted “to turn in on themselves and shut out the sick for the sake of their own well-being” (Balboni & Balboni, 2019, p. 306). Furthermore, this can cause nurses to leave the profession or a high turnover rate within nursing positions, costing the health authorities a large amount of resources (Zhang et al., 2019). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 3 In my experience as a nurse, I have found that a critical incident such as a Code Blue to be occasionally traumatic in nature. For instance, when reflecting on particularly distressing situations with unfavorable outcomes, my palms began to sweat, my heart rate increased, and I felt nauseous, indicating a sympathetic nervous system response. Over time, I became anxious to go to work for fear of not meeting patient care standards due to inappropriate nurse to patient ratios and started becoming apathetic to situations that previously elicited a more compassionate response from myself. Futility of care and some end-of-life and Code Blue situations began to scar and harden my once sensitive and empathetic heart. Countertransference was something that I identified early on during my shifts in the ICU. It is described as “the totality of feelings experienced by the clinician toward the patient – whether conscious or unconscious, whether prompted by the client’s dynamics or by issues or events in the clinician’s own life (Katz, 2006, p. 4). I found that I was experiencing my own version of grief alongside the family members of the patients who died in the ICU and took these feelings of sorrow home with me. I resonated with the famous words John Donne penned in one of his sermons on human connectedness: “Any man’s death diminishes me, because I am involved in mankind.” Recognizing my physical and emotional symptoms as an unhealthy response to memories of critical incidents, I sought out a counsellor who provided a Christian perspective in her therapy. Through reflection on the situations, mental processing and prayer, I experienced significant healing which diminished the intensity of the trauma and suffering. This intervention considerably alleviated my level of emotional distress and allowed me to return to work with a more resilient approach. As a Christian nurse, my faith has helped me to contend with some of the difficult life events that I witness while caring for patients and their families. Wrestling through concepts such as suffering has pushed me to examine my own beliefs and seek solace in Biblical truths SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 4 and promises. The following quotes from Ann Voskamp (2021), an inspirational speaker and author, summarize how spirituality is integrated into my worldview: Jesus is not simply a belief to me; He is breath to me. Not some theory; He is gravity. Not a lens for my life; He is my life. He is not some sphere of a multi-dimensional life. He is atmosphere, terra, lung, and the only way not to suffocate in self. If you live in a universe where the sun revolves around you, eventually life as you want it will wither up and die. Only when our life revolves around the sun (Son), is there any hope of real life. His is the only real universe that will actually last forever, where those who accept that they are at the end of themselves get to accept the endless kindness of God. (Voskamp, 2021). To me, these words speak to the foundational source of life and strength that I have outside of myself and the significance of connectedness. Connectedness here pertains to the importance of looking within and knowing why you believe what you believe; establishing relationships with others in a life-giving community; and identifying and routinely pursuing a foundational source outside of oneself. These three forms of connectedness address the spiritual aspect of self and, for me, aid in meaning-making within my nursing practice. As I talked to other nursing colleagues regarding my experience, I discovered similar stories of what might well be moral distress and compassion fatigue. This prompted my interest and further research into the literature on health care ethics and compassion fatigue. Being able to actually place a term to or name what I was experiencing was significantly helpful in knowing that my experience was not an isolated one. I came to realize that every nurse needs to pay attention to the intersection of intellect, emotion, and spirit that will allow them to experience meaningful connections to themselves and others (Palmer, 2017). By ignoring the spiritual aspect of ourselves, we ignore the very purpose of why we have been placed here on earth and our SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 5 interconnectedness with “self, others, the world, or a higher being” (Smiechowski et al., 2020, p. 2). This creates a deficit in caring for our holistic self, resulting in an imbalance that may create dissatisfaction and disillusionment with ourselves and the work we engage in. The nature of most nurses’ work exposes them to varying degrees of others’ suffering. What I have noticed is that as nurses, we have been trained to problem-solve and do our best to alleviate others’ suffering. Yet while we encounter suffering on a regular basis, I have also noticed that there is a general aversion to examining how that suffering may be vicariously affecting ourselves. Reflecting on the impression that suffering leaves on us forces us to turn inward. This is an introspective process that many of us elude for fear of what we may find, need to face, or existential questions that will arise. Or maybe we lack frameworks that help us make sense of what we experience in the workplace. We as nurses need to recognize the uncertainty of death and suffering that our patients face, and not shy away from it, as this may also affect our ability to provide care (Quinn, 2020). Recognizing that we not only need to explore these existential questions for ourselves but also walk alongside our patients in their journey of meaning-making in suffering requires us to address the concept of suffering, as it impacts nurses’ levels of compassion fatigue (Frankl, 1959). Having identified compassion fatigue as a reality that many nurses face, my interest was then piqued to find practical solutions to this problem. While there is no single solution that is applicable to every nurse and every situation, I did discover a specialized group of individuals who, from personal experience and a review of literature, currently seem underutilized in the prevention of compassion fatigue in nurses. In British Columbia, spiritual health practitioners are defined as individuals who SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 6 provide comprehensive spiritual care and emotional support to patients, families and health care staff in a manner that is appropriate to belief system and cultural diversity. They act as a liaison during crisis intervention and participate in an organization’s clinical ethics discussions/reviews. (Ministry of Health, 2012) Spiritual health practitioners are skilled in the provision of spiritual care to others, often alleviating distress through simply engaging in conversation regarding what someone is currently experiencing or trying to process. When given the opportunity to informally or formally process and debrief what they are mentally carrying, nurses give themselves permission to connect their spirit, emotion, and intellect into more meaningful understanding of what they are experiencing. Spiritual health practitioners are able to help facilitate this conversation because of their training in emotional and spiritual care. The lack of visible SHPs within the health authority where I have been employed for the last 13 years prompted me to further explore the support of SHPs for nurses in other locations. British Columbia’s Ministry of Health published a framework in 2012 to guide SHPs practices, stating that “[s]piritual health care provides therapeutic interventions across the continuum of care to individuals, families and staff to support and increase their ability to better manage their needs based on their individual strengths, values, beliefs and culture” (p. 9). Their vision includes the statement to provide “[s]upport for spiritually healthy organizations and staff” (Ministry of Health, 2012, p. 26). Evidence of this framework in action was not apparent within the health authority where I was employed. Understandably, when the provision of spiritual care was observed, it was focused on the best interest of the patients, but rarely inclusive of the staff. Spiritual support provided within the Canadian health care context is commissioned by the government, as evidenced by the Ministry of Health statement above. Religion and SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 7 spirituality in Canada include a wide variety of beliefs, including major religions, Indigenous spiritualities, those who claim to be spiritual but not religious or do no identify as spiritual at all, amongst other beliefs (Beaman, 2017). In a 2011 survey conducted by Statistics Canada, 23.9% of Canadians claim to have no religious affiliation. The specific region that this study was conducted within reported that 36-41% of the population identified as not having a religious affiliation (Statistics Canada, 2011). Data was not found regarding those who identify as spiritual but not religious. Due to the diversified spiritual beliefs of those living within Canada’s borders, SHPs have been commissioned to “tend to the multicultural and multifaith needs of BC’s pluralistic population” (Ministry of Health, 2012, p. 3). Thesis Description While choosing a specific focus for this thesis, I decided to explore the specific concepts of compassion fatigue and support of SHPs for nurses. Issues that will not be addressed in this thesis are moral distress, trauma-based interventions or counselling, or post-traumatic stress disorder. While related to my thesis topic, these concepts hold distinct differences and would broaden the study too extensively. Compassion fatigue is not a new concept to nursing, but has been investigated more in depth over the more recent years. As defined by the Merriam-Webster dictionary, compassion fatigue is “the physical and mental exhaustion and emotional withdrawal experienced by those who care for sick or traumatized people over an extended period of time” (Merriam-Webster, n.d.). Originally coined by Figley in 1982, the term has been researched within different contexts, usually associated with an element of trauma. Not all nurses may identify as having been “traumatized” by critical incidents they have witnessed; however, the theme of trauma was often referenced in literature in conjunction with compassion fatigue (Adimando, 2018; Badger, 2001). A multitude of factors contribute to the causation of SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 8 compassion fatigue, including: “burnout and stress; heightened emotions of patients’ families; inability to maintain self-care; lack of social support; practitioners’ empathy levels; uncontrolled work stressors; lack of defined boundaries; degree of traumatic exposure; lack of experience; and patients’ stories” (Austin et al., 2013, p. 40). Compassion fatigue is negative in the sense that it breaks the connectedness between caregivers and patients, and within oneself and to others, and diminishes the energy required for attuned and caring acts (Austin et al., 2013). Caution should be taken when using the label "compassion fatigue," so as not to confuse it with interconnected terms such as burnout and moral distress (Sinclair et al., 2017). Figley tends to correlate these closely related terms such as PTSD and compassion fatigue, although others attempt to separate them out (Austin et al., 2013). Compassion fatigue has been used as a label for many different clinical and non-clinical situations, and the term can often be interchanged for situations that have different meanings. Compassion fatigue and burnout differ in that compassion fatigue results from the emotions nurses experience when being a witness to the suffering of others, whereas burnout “results from loss of control and low morale related to goals that cannot be fulfilled” (Taher, 2020, p. 392). Workplace stressors, such as increased workload or patient acuity without proportional nurse to patient ratios, are more to blame for the fatigue that nurses experience as opposed to a lack or draining of the nurse's compassion (Austin et al., 2013; Hodge & Lockwood, 2013). Austin et al. (2013) describe that in addition to the flaws within the health care system, loss of hope and disconnectedness from one’s vocation, or original calling to their profession, are major contributors to compassion fatigue. Sinclair et al. (2017) warn that when one is examining the concept of compassion fatigue, attention should not be focused on the individual nurse so much as it should be addressing the "other equally negative 'endpoints' associated with healthcare professions" (p. 21). This requires paying attention to SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 9 systemic or corporate practices that may not intend to be problematic but end up producing barriers to patient care and personal self-awareness. While not all individuals identify themselves as a “spiritual being”, it is important to look into the roots of the term itself and comprehend the definition of “spirituality”. The Latin origin of the word “spirit” is “spiritus”, meaning “breath” (New World Encyclopedia, n.d.). Every breath that we inhale and exhale sustains the very life within us, and points to the fact that we house “spirit” or “breath” within ourselves (Karakas, 2010). Because we are so inextricably linked or life-dependent with the spirit within us, it is crucial that we pay attention to the thoughts, emotions, feelings and facts that influence it (Cilliers & Terblanche, 2014). Viktor Frankl (1959), a survivor of the holocaust, provides an introspective standpoint that all individuals are indeed spiritual and are on an existential search to create meaning with their lives. Recognizing that our spirituality is ultimately connected with our holistic selves (mental, emotional, physical, social, spiritual), we must nurture its well-being to ensure it positively impacts or balances the other aspects of self (Grafton & Coyne, 2012; Ramya & Jose, 2013; Wu et al., 2020). The definition of spirituality that I chose for the purpose of this thesis was: Spirituality in a clinical context is defined as that aspect of the human self pertaining to those dimensions of human experience which a person relates to as providing meaning to life and connecting them to a transcendent or higher purpose. It is experienced both cognitively and emotionally. This aspect of the self has been recognized in ancient and modern times as important in mobilizing the internal healing mechanisms of the body and mind (Ministry of Health, 2012, p. 20). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 10 More specifically, Ho et al. (2018) describes spirituality as “a human characteristic that refers to the way individuals seek and express meaning and purpose and is often tied with the feeling of connectedness to the moment, self, others, nature, the significant, or the sacred” (p. 279). Both of these definitions describe the necessity of exploring one’s spirituality in order to determine meaning, purpose and connectedness. Although the premise is applicable to any person in any life situation, nurses in particular would benefit from understanding and embracing their own spirituality in order to provide compassionate care that is both purposeful and meaningful. Puchalski et al. (2014) recognized that “spirituality is intrinsically linked with compassion” (p. 643). Situations such as critical incidents may cause an interruption in a nurse’s normal ability to mentally process as they typically would, creating emotional distress and, over time, compassion fatigue. Nurses who increase their spiritual self-awareness to include “a sense of transcendence, meaning and purpose, call to service, connectedness to others, and transformation—are more able to be compassionate with their patients” and, in my opinion, to themselves (Puchalski et al., 2014, p. 643). Reflecting on critical incidents with a spiritual perspective may be useful in making sense of the experience and decreasing the risk of compassion fatigue. Finally, while spirituality has been identified as an important dimension in nursing, there is concern about the stagnation of its progress in being implemented in practice (Swinton, 2006). Swinton (2006) shared trepidation that: there is a concerning lack of movement and growth within some of the spirituality literature and little evidence of there being a positive movement towards a new phase of development. The conversations that occur around the role of spirituality in nursing tend to be rather static. (p. 917) SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 11 The tendency to view spirituality in health care as inert and ambiguous has perhaps contributed to its (de)prioritization and decreased importance on nurses’ radar. In this thesis, I explore the positionality of spirituality in health care today in order to further understand the experience of SHP support for nurses. Study Methods Preliminary data on the support for nurses by SHPs prompted the purpose of this qualitative thesis: to explore the perspectives of spiritual health professionals about their contributions for the prevention of compassion fatigue in nurses. The research questions I explored are as follows: 1. What is the current state of knowledge in regard to how SHPs can mitigate compassion fatigue for nurses? 2. What perspectives do SHPs hold on how self-aware nurses are of their own emotional/spiritual well-being after a critical incident such as Code Blue? Do SHPs think that nurses link their well-being to compassion fatigue? 3. How do SHPs describe the support they offer to nurses? What links do SHPs make between such support, bearing witness to suffering, and the mitigation of compassion fatigue? Has any change in support been noted since the start of the COVID-19 pandemic? 4. What recommendations can be made about best practices for the involvement of SHPs for the support of nurses? I conducted this study using a qualitative interpretive description design. This design is defined as “inductive analytic approaches designed to create ways of understanding clinical phenomena that yield applications implications” (Thorne et al., 2004, p.1). The methods I used SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 12 included a current literature review, individual interviews with seven SHPs, and a brief secondary analysis of a data set from a study of similar interest. Research question one was addressed by the literature review. Question two was partially answered by a research project of similar interest, the Compassion Cart study, the purpose of which was “to examine how post Code Blue debriefing on a telemetry-medical unit can provide emotional support to nurses, with the overarching intention of preventing compassion fatigue” (Drake et al., 2020). The one-onone interviews that I conducted with seven SHPs from local health authorities served to inform research questions three and four. Lastly, I uploaded the transcripts of the interviews and the focus groups to NVivo 12™, coded them, and performed a thematic analysis of the two data sets. Chapter Summary and Thesis Outline The concept of compassion fatigue has been investigated for the past four decades, yet many practical solutions for it remain unresearched. Its interwovenness amidst other similar issues demonstrates a connection to a larger problem. For the purpose of this interpretive description study, I focused on the key concepts of the perspectives of SHPs supporting nurses for the mitigation of compassion fatigue. In this chapter, I have introduced my thesis and have provided background on my topic of research. In Chapter Two, I describe the literature review that I performed which provided academic insight for this study. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 13 Chapter Two: Literature Review I conducted a thorough literature review to gain insight on the current research on SHP support of nurses for the prevention of compassion fatigue. Literature was also sought out specifically on influencing factors of compassion fatigue in nurses, such as the current COVID19 pandemic. While the combination of these searches revealed some academic and grey literature on these topics, very few studies were actually found pertaining to my specific thesis topic. Those that were found were analyzed with my inclusion/exclusion criteria and themes of spirituality, the role of SHPs, interventions administered by SHPs, personal meaning-making by nurses, and factors affecting compassion fatigue. An updated literature search was performed upon completion of this study to provide the most current summary of themes. Search and Retrieval Strategies for Literature Review Search Terms The following question was used to guide the search: What is the current state of knowledge in regard to how SHPs can mitigate compassion fatigue for nurses? From this question and in collaboration with a librarian and my thesis supervisor, the following search terms were decided upon (see Table 1). The headings under which the terms were listed were: compassion fatigue, spirit*, and health care providers. Terms were truncated and categorized under each heading with Boolean operators. Finally, the searches under the three headings were combined with the Boolean operator “AND.” A secondary search using the following terms was added to the original three categories: COVID* OR pandemic OR coronavirus OR “coronavirus 2019.” Medline, CINAHL, and ATLA religion databases were searched between a date range of 1985-2020, for a total result of 668 articles. After duplicates were removed, 579 articles remained. I reviewed the articles first by title, eliminating approximately 400. The remaining SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 14 articles were sorted by reading the abstracts and opening the articles for further perusal. Three articles matched my thesis topic precisely, while eight others strongly informed my research, and three others moderately corresponded with my specific focus. In total, 14 articles were included in the matrix for further analysis. An updated search between the years of 2020-2021 with the same keywords was performed upon completion of my research and resulted in an additional 64 articles. Of these, approximately 15 were used to inform my study, but none were added to my matrix as they did not precisely match inclusion criteria. See Appendix A for a matrix of the included articles and Appendix B for a PRISMA flowchart on the selection of articles. Table 1 Keyword search Compassion fatigue AND Spirit* (Chaplaincy) “compassion fatigue” spirit* OR “sacred OR burnout OR “ pause” OR chaplain* OR vicarious trauma*” “spiritual care” OR OR “Secondary “spiritual health trauma*” OR “postpractitioner” OR trauma*” OR PTSD “spiritual care OR “emotional practitioner” OR contagion” OR “pastor*” “moral residue” OR “stress of conscience” OR “stress reduc*” OR “critical inciden*” OR “code blue” AND Health Care Providers Nurs* OR “health care provider” Inclusion and Exclusion Criteria The inclusion and exclusion criteria for my literature search initially started out more specific but needed to broaden as the scope of my search was too narrow. Originally, I did not want to include nurses who worked in palliative, hospice, oncology, or pediatric departments as there is a general presumption that those areas may receive more spiritual health support (Ferrell SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 15 et al., 2020). I was more interested in spiritual support pertaining to areas such as general medicine or intensive care; however, my search results were too few. I focused instead on general SHP support for nurses in all departments. The final inclusion criteria were: must address all three of the main concepts (nursing, SHP support, and compassion fatigue); interventions must be directed towards nurses, although not exclusively; must make mention of spirituality alongside SHP-led support (from an organizational/unit facilitated perspective); and Englishonly articles. Exclusion criteria were: an intervention to mitigate compassion fatigue implemented by anyone other than SHPs; if the article did not target nurses, but rather other health care providers; or if the article focussed solely on moral distress, burnout, and secondary vicarious trauma and did not mention compassion fatigue. Of the 14 articles, 11 lead authors were based in the U. S. A. and three were in Canada. Four of the studies were quantitative, three were qualitative, four grey literature (non-peer reviewed), two mixed methods, and one systematic review. The settings they were performed in ranged from an oncology unit, to military nurses, to critical care areas, to chaplaincy departments to a medical-surgical unit. The four grey literature articles included in my research contributed significantly to understanding the concept of compassion fatigue and its link to spirituality, as well as practical interventions to prevent compassion fatigue suggested by SHPs. Extraction Questions I applied extraction questions to the final 14 articles selected for my literature review, focused on the individual concepts I researched. The first question asked the article what role SHPs had in supporting the well-being of nurses. This examined the presence and scope of practice of a SHP on a unit or organization. The next question asked the article to describe the nature of the “problem”, or more specifically to describe the degree of compassion fatigue that SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 16 nurses were experiencing. Connected to this definition of compassion fatigue was the definition of spirituality, which was the next concept I isolated. Then I asked how SHPs were involved in organizationally-led interventions that were currently used or proposed, with a focus on workplace spirituality. Following this, I studied the article to determine if nurses’ individual spirituality and meaning making were described. This pertained to independent self-care practices that were not associated with the support that SHPs provided. Summary of Selected Literature It is important to note that a considerable amount of the literature reviewed was not inclusive of SHP support as a contributing factor to reducing compassion fatigue. Several studies reported the benefit of mindfulness-based stress reduction (MBSR) strategies, leadership recognition of staff experiencing vicarious trauma, staff education for self-care strategies and identification of workplace stressors, but few actually identified incorporating spirituality into practice as a beneficial option (Adimando, 2018; Cho & Cho, 2021; Cohen-Katz et al., 2004; Collins & Long, 2003; Koren & Purohit, 2014; Oman et al., 2006). Moreover, Cavanagh et al. (2020) and Xie et al. (2021) recently published systematic reviews and meta-analyses on the prevalence of compassion fatigue in health care providers, with a specific focus on nurses. The results from their studies show increasing evidence of the need for health care organizations to provide compassion fatigue interventions for nurses, but still did not make the link to spiritual well-being. In Lying Down in the Ever-Falling Snow, Austin et al. (2013) provide an insightful perspective on the experience of compassion fatigue in health care providers from a Canadian perspective. The book examines the origins of compassion fatigue, various interpretations of what it is, and detailed description of individuals’ experiences. While this research contributes to understanding the lived experience and definition of compassion fatigue, it does not explore the SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 17 influence of spirituality on the mitigation of compassion fatigue. From what I observed, there is a significant lack of research focus on the contributions of spirituality within the workplace specifically related to nurses’ compassion fatigue. Role of SHPs Support for Nurses’ Well-being Often referred to as chaplains, clergy, or spiritual care providers in the literature, SHPs have had a varying role in supporting nurses. Pesut et al. (2012) report that “the role of the chaplain has diminished substantially, and in some hospitals, it has disappeared entirely, with the secularisation of society and the adoption of hospitals by government run health services” (p. 826). Some health authorities have shifted from the title of chaplain to spiritual care provider or practitioner as the former was correlated with Christianity. SHPs are committed to providing support to an array of diverse faiths, cultures, and religions (Pesut et al., 2012). Karakas (2010) states that while there are a number of challenges that SHPs encounter when providing support to nurses, these can be mitigated with the right strategies. For instance, "the danger of proselytism; the issue of compatibility; the risk of spirituality becoming a fad or a management tool to manipulate employees; and the legitimacy problem the field of spirituality at work faces in theory, research, and practice” can be moderated by “accommodation of spiritual requests; respect for diversity; openness and freedom of expression; and acknowledgment of employees as whole persons" respectively (Karakas, 2010, p. 99). In addition to this, a recent study has highlighted the barriers between nurses and SHPs, including lack of awareness of SHP roles, overlapping or underutilizing SHPs’ scope of practice, and allowing one’s own spiritual predisposition to interfere with SHP interaction (Johnston Taylor & Trippon, 2020). Resource allotment for SHPs is challenging because the services they provide do not closely align with the biopsychosocial medical model (Pesut et al., 2012; Taylor et al., 2015). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 18 There seems to be little room left for a spiritual component (Taylor et al., 2015). Health authorities may outweigh the known benefits of reduced pain, increased patient satisfaction, and shorter hospital stays from SHP intervention with more obvious resource issues such as a shortage of front-line care providers (Charlescraft et al., 2010; Pesut et al., 2012). As of 2018, out of 425 hospitals in the U.S., only 54.4% had the formal provision of spiritual support to patients in their adult palliative care programs, not including the provision of support to nurses (Ferrell et al., 2020). This identified lack of front-line SHP support makes it difficult to fulfill their role of meaning making, alleviating emotional distress, and contributing to the spiritual climate of the workplace (Guthrie, 2014). Nature of the “Problem” The problem of compassion fatigue has been well documented in more recent years. Nurses readily identify “physical, emotional, social, and spiritual adversity” resulting from prolonged exposure to the suffering of others (Aycock & Boyle, 2009, p. 183). Nurses with compassion fatigue report “anxiety, intrusive thoughts, apathy, depression, lessened enthusiasm, desensitization, diminished ability, irritability, emotionally feeling overwhelmed, hypervigilance, emotional disturbances, and disordered thinking” (Charlescraft et al., 2010; Guthrie, 2014; Melvin, 2015, p. 68). Professional side effects of compassion fatigue include "depersonalization, reduced output/endurance/diminished performance, loss of empathy and poor judgment” and could “have a global impact on a healthcare provider’s identity, self-understanding and existential well-being" (Sinclair et al., 2017, p. 13-14). Disenfranchised grief after exposure to critical incidents may result in a prolonged build-up of compassion fatigue and eventually burnout (Brosche, 2007). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 19 With the natural progression of chronic compassion fatigue to burnout, it is no surprise to see that absenteeism and retention of nurses has become a growing problem (Keogh et al., 2017). This can ultimately cost the organization a significant amount of resources to then replace nurses at straight- or over-time rates while also paying sick time to the nurse who is off. Organizational structure, culture and social environment are all contributing factors to compassion fatigue (Hodge & Lockwood, 2013). In fact, “[h]ealthcare organizations can be seen as both a cause and a victim of compassion fatigue” (Hodge & Lockwood, 2013, p. 82). Some studies suggest that workplace spirituality can decrease nursing turnover and increase the magnetism of nursing environments (Holland & Neimeyer, 2005; Pirkola et al., 2016). Fostering workplace spirituality can be challenging for nurse leaders or management if they are not well-versed in this area (Cruz et al., 2020; Pirkola et al., 2016; Wu et al., 2020). Nurses in positions of leadership are encouraged to educate themselves in how to promote workplace spirituality, but this particular aspect of nursing can also be supported by SHPs, as this is their area of specialty (Ferrell et al., 2020; Keogh et al., 2017; Pesut et al., 2012). While patient support seems like an obvious and natural source of attention from SHPs, the fact that staff satisfaction and retention can be positively correlated with increased spiritual intelligence should also not be ignored (Jarden et al., 2020; Keogh et al., 2017; Mesquita Garcia et al., 2021; Wu et al., 2020). Definition of Spirituality Spirituality has been identified by multiple studies as a resource that nurses utilize to cope with workplace stress (Ada et al., 2021; Alazmani-Noodeh et al., 2021; Ibrahim et al., 2020; Jarden et al., 2020; Rushton et al., 2015; Williams et al., 2018; Zhang et al., 2019). While few of the articles chosen for my thesis actually gave a definition for spirituality, two studies did SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 20 report descriptions, stating that spirituality is “a vital component of the holistic person” and “the journey to find a sustainable, authentic, meaningful, holistic, and profound understanding of the existential self and its relationship” (Campbell, 2013, p. 79; Karakas, 2010, p. 91). Spirituality influences attitudes, behaviors, and ability to critically think and make decisions (Kaur et al., 2013). Nurses can experience freedom to express emotions, feel valued as a human being, find meaning and purpose in their work, and make connections with their colleagues and work environment if workplace spirituality is encouraged (Cruz et al., 2020). Cruz et al. (2020) states that workplace spirituality, if influenced by organizational standards, fosters “the concept of compassion, flexibility, a sense of interconnectivity, meaning and appropriateness of mind” which can be “woven together to form personal values” (p. 2). Organizationally-led Interventions After examining the literature on SHP support for nurses in the prevention of compassion fatigue, multiple interventions were discovered. I refer to these as “organizationally-led” because nurses did not have to seek out the resources themselves; rather the interventions were provided by the organization utilizing interprofessional team members such as SHPs for nurses to voluntarily participate in. The interventions ranged from informal one on one SHP initiated support to formal education sessions to blessing of the nurses’ hands (Aycock & Boyle, 2009; Charlescraft et al., 2010; Keogh et al., 2017; Phillips, 2018). Other interventions included “Tea for the Soul”, lobbying for SHP support, post-Code Blue pause, allowing for silence, debriefing questions, and pamphlets given to staff to help identify symptoms of acute stress, suggestions for self-care, and resources for them to access. (Aycock & Boyle, 2009; Copeland, 2016; Kapoor et al., 2018). Campbell (2013) reports two SHP interventions in their study: “Nursing our Needs”, which was developed by nursing, but facilitated by chaplaincy; and huddles, with debriefing SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 21 after critical incidents to allow staff to process their emotions. Nursing our Needs was carried out one on one at the bedside due to patient acuity, and allowed the nurse to "process concerns related to professional, personal, or spiritual issues" (Campbell, 2013, p. 81). One fascinating study reports the implementation of three interventions to decrease the risk of burnout in critical care nurses (Roth, 2020). Two of the interventions included chaplains as co-facilitators: a formalized, three-day workshop focusing on renewal and unity and an informal “Reflection Round” held with an intensivist. During the “Reflection Round”, the chaplain would explore the emotional aspects of the patient scenario after the intensivist had reviewed the medical components of the case. Staff reported a decreased level of burnout after attending these voluntary sessions. Of note, this study was included as supportive literature as it did not actually address the component of compassion fatigue, but rather burnout, which is strongly linked. Phillips (2018) described how two hospitals in New York have recently implemented a Code Lavender response to staff who are experiencing distress after critical incidents such as Code Blues. A Code Lavender team is comprised of volunteer nurses, mental health specialists, and clergy members. This service is offered in a separate room away from the unit to allow nurses to de-stress, process, and debrief about the critical incident (Phillips, 2018). Keogh et al. (2017) report their success with implementing a “Chi Cart”, or mobile cart brought to the nurses by chaplains to facilitate an opportunity to help nurses de-stress. The cart contained items such as aromatherapy, calming music, tea and healthy snacks. The majority (93.5%) of staff reported feeling valued by management because of the intervention, 92.1% felt less stressed afterwards, and 86.3% experienced improved patient interactions after the intervention (Keogh et al. 2017). While there are multiple interventions provided by SHPs to support nurses, further research is SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 22 needed on institutional-based strategies for the identification and reduction of compassion fatigue (Alharbi et al., 2019; Drake et al., 2020). Nurses’ Individual Spirituality and Meaning Making Nurses report several strategies are helpful for processing through emotional distress: peer support, personal strategies such as compartmentalising, family support, and asking existential questions through spiritual worldview perspectives (Forester & Hafiz, 2015). The correlation of spirituality and psychological and physical health has been a growing area of interest over more recent years. Individuals who have a personal understanding of their own spiritual beliefs have been noted to report fewer incidences of anxiety and depression, alcohol and substance abuse, and overall fewer physical symptoms of stress (Ho et al., 2016). Ho et al. (2016) also states that “spirituality can provide a broader meaning structure, helping workers to understand their situation, gain a sense of meaning in their work, and regain cognitive mastery over their situation” (p. 70). One factor influencing resiliency in nurses is their own personal faith and beliefs; this involves them being aware of their own spirituality to ensure a “healthy sense of general well-being” (Ang et al., 2019, p. 420; Charlescraft et al., 2010). Calhoun and Tedeschi (2006) suggest that nurses can experience growth after exposure to a traumatic or critical incident by developing a more critical awareness and understanding of one’s own spirituality or philosophical assumptions. Kaur et al. (2013) states that “spiritual intelligence centers on inner resources of a person, and it manifests in various ways such as positive self-concepts, unselfish giving, higher moral character and personal transcendence” (p. 3199). This can translate into a healthier state of mind, decreasing the risk of compassion fatigue. Staff from a cross-sectional survey study of long-term care workers identified that faith and prayers, “giving time and space to reflect and grieve, and ensuring the availability of spiritual SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 23 care” were supportive to the distress and fatigue they were experiencing (Puyat et al., 2019, p. 718). With recognition of the pluralistic and secular nature of contemporary health care delivery, one must consider how a connection can be made with nurses who do not share or hold spiritual beliefs (Lacy, 2018). Spiritual support by SHPs encompasses connecting with individuals one on one or in small groups to cultivate a caring spiritual climate in the workplace, an opportunity to pause, reflect, debrief, and form healthy thought patterns to approach the work that nurses are engaged in. These are non-threatening, non-religious approaches to addressing nurses’ spiritual health and well-being. While some correlation has been made to an individual’s religiosity and levels of burnout, additional research is needed in this specific area (Ho et al., 2018; Hylton Rushton et al., 2013). Summary of Themes Themes that arose from the articles chosen for my thesis and supporting literature include: the need for SHP support for nurses (Aycock & Boyle, 2009; Charlescraft et al., 2010; Guthrie, 2014; Karakas, 2010; Phillips, 2018; Sinclair et al, 2017; Taylor et al, 2015); recognition of the lack of time to process emotions after critical incidents (Brosche, 2007; Copeland 2016); the lack of literature on SHP support for compassion fatigue prevention in nurses (Campbell, 2017; Copeland, 2016; Sinclair et al., 2017); recognition of compassion fatigue leading to burnout and increasing nursing turnover rates (Charlescraft et al., 2010; Hylton Rushton et al., 2015; Liberman et al., 2020; Sinclair et al., 2017); and establishment of the SHP role in relation to workplace spirituality (Charlescraft et al., 2010; Houck, 2014; Karakas, 2010; Pesut et al., 2012; Simmons, 2018; Taylor et al., 2015). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 24 Chapter Summary After a thorough literature review, several themes arose pertaining to the concepts of my thesis. One specific theme reiterates the need for research in this area: there is a substantial lack of literature available on the topic of SHP support for nurses in general, let alone associated with the concept of compassion fatigue. The information the SHPs shared with me on their understanding of compassion fatigue and experience of providing support to nurses contributed to this needed body of knowledge. The literature review I performed provided a foundation that guided the formation of my interview questions. It also served as a basis to compare and contrast my research findings with current literature. Chapter Three reviews the methods with which I conducted my study, as well as ethical considerations and pre-identified limitations. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 25 Chapter Three: Methods Although valid and reliable measurement tools exist to separately quantify spirituality and compassion fatigue, I chose to pursue a qualitative method to explore a phenomenon in nursing that may be more richly and uniquely described via interviews and focus groups. The specific qualitative method that lent itself to this task was interpretive description (Thorne, 2016). The particular population chosen to be interviewed was SHPs, with a brief secondary analysis performed on focus groups from the Compassion Cart study. Findings were studied via thematic analysis after the data was uploaded and coded with NVivo 12™ software. Design Interpretive description was chosen for its reach beyond mere description or theorizing of a concept into the “so what,” or meaning making, that could be translated into a potential action (Thorne, 2008). It was developed within the discipline of nursing to allow for research that did not fit methodology strictly defined by other disciplines, such as sociology or anthropology. Interpretive description acknowledges “the challenge of retaining the coherence and integrity of a theoretically driven approach to knowledge development while supporting defensible design variations according to the specific features of context, situation, and intent” (Thorne, 2008, p. 27). In other words, it allows for interpretation of data that may reflect individuality or uniqueness, while adhering to methods that ensure rigor. Interpretive description also lends itself towards a theoretical framework that aligns with this study. While my thesis is informed by intersecting literatures between workplace spirituality and compassion fatigue, Jean Watson’s Theory of Caring is also applicable (Watson, 2008). Watson’s Theory of Caring indicates that nursing practice “is enacted in transpersonal, intersubjective encounters. Spirituality is viewed as integral to human nature and therefore is SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 26 integral to all transpersonal encounters” (Richards, 2016, p. 231). Watson proposes that one must cultivate their own spiritual growth as a “necessary requirement” within the nursing discipline (Richards, 2016, p. 232). Linton and Koonmen (2020) use Watson’s Theory of Caring to suggest that spiritual self-care is actually an ethical obligation as a nurse for the provision of safe patient care and sustainability within the profession. Since this is a concept of caring that is not easily quantifiable, this theoretical framework is best examined using an interpretive description approach. This will guide the research for more than “mere description without purposeful direction” (Thorne, 2016, p. 39). Purpose and Objective Questions The purpose of this qualitative thesis using interpretive description and secondary analysis is to explore the perspectives of SHPs about their contributions to the prevention of compassion fatigue in nurses. The questions used to guide this research were: 1. What is the current state of knowledge in regard to how SHP can mitigate compassion fatigue for nurses? 2. What perspectives do SHPs hold on how self-aware nurses are of their own emotional/spiritual well-being after a critical incident such as Code Blue? Do SHPs think that nurses link their well-being to compassion fatigue? 3. How do SHPs describe the support they offer to nurses? What links do SHPs make between such support, bearing witness to suffering, and the mitigation of compassion fatigue? Has any change in support been noted since the start of the COVID-19 pandemic? 4. What recommendations can be made about best practices for the involvement of SHPs for the support of nurses? SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 27 Sampling The proposed participants were SHPs who had any length of experience providing support to nurses. Spiritual health practitioners were selected for their unique contributions to fostering workplace spirituality. Any SHP who had not previously interacted with nurses was excluded from the study. These SHPs were purposively chosen from local health authorities or positions with similar scope of practice. Participants were selected based off of local networking referrals. Snowball sampling occurred on two occasions resulting in the addition of two participants. I originally anticipated my sample size to be between five to seven SHPs, with the end result being seven SHPs. While Streubert and Carpenter (2011) state that saturation occurs when there is “repetition and confirmation of previously collected data”, this is not a concept that is claimed within interpretive description (p. 30). In order for my research to produce authentic results, I needed to consider the “infinite experiential variation” that may be expressed during the interviews of individual SHPs. Despite my smaller sample size, clinically significant data was still extracted based on the knowledge that a variety of responses were elicited, and further research will always be warranted. The regions that my SHP participants were currently employed in included southwest British Columbia and northwest Washington. The SHPs’ varying levels of experience and practice areas added to the diversity of the data. Three of the participants had been practicing as SHPs for 0-5 years, while the remaining four participants had the following levels of experience: 6-10 years (1), 11-15 years (1), 16-20 years (1), and 20+ years (1). Ages ranged from 31-40 (1), 41-50 (1), 51-60 (3), and 61-10 (2) (see Table 2). Practice areas encompassed large city and rural hospitals, both in general practice and specialty areas covering all ages of the lifespan, with the majority of participants working at multiple sites. Examples of their roles as full-time SHPs SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 28 included: certified supervision educator for clinical pastoral education; spiritual health clinical educator; and Critical Incident Stress Management team (CISM) and stress resiliency educator. Two of the SHPs were retired from their previous clinical positions. Table 2 Participant Demographics (Spiritual Health Practitioners) Name Age Category Years of Experience Ethnicity Faith Affiliation (years) as a SHP Emerson 31-40 6-10 Caucasian Full Gospel – Charismatic Peyton 41-50 0-5 Caucasian Protestant – Christian McKenzie 51-60 0-5 Caucasian Anglican Taylor 51-60 20+ “White” Baptist Avery 51-60 0-5 Caucasian “I drink from the nectar of all traditions” Brooke 61-70 11-15 Caucasian None Robin 61-70 16-20 “Canadian” Protestant – Salvation Army Note: n = 7 The participants were not diverse, however, in their personal religious affiliations, as the majority (5) identified as Christian, although from different denominations. One participant identified as having no religious affiliation and another stated that they “drink from the nectar of all traditions.” The highest levels of education that participants reported were: Master of Divinity; Master of Arts in Christian Studies – Chaplaincy; Pastoral Counselling Degree; Master’s Degree in Theology and Pastoral Leadership; Doctor of Ministry in Chaplaincy; Master’s Degree in Christian Studies; Master’s Degree in Public and Pastoral Leadership with specialization in spiritual care; Bachelor of Arts in Christian Ministry Counselling; and Master’s Degree in Theological Studies. The participants were anonymized for confidentiality purposes and renamed with the following non-gendered aliases: Emerson, Robin, Mckenzie, Taylor, Brooke, Avery and Peyton. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 29 The second group of participants were obtained from the Compassion Cart study and included two expert stakeholders in Employee Wellness and 19 nurses (Drake et al., 2020). As a graduate student research assistant on this project, I assisted in conducting four focus groups wherein clusters of four to six nurses at a time would share about their previous experience with Code Blues. The focus groups were facilitated by a panel of myself, my thesis supervisor and one or two SHPs and were organized by the unit manager and educator at a local urban hospital. The data collected from these focus groups informed the creation of a Compassion Cart, containing physical items useful for decompressing, and a psychological debriefing script, which was trialled on the unit being studied. The nurses from the focus groups all identified as female and ranged from 20-50+ years of age, with the most common age range being 25-29. The majority of the nurses (12) had been employed as a RN for one to three years. Of the 19 nurses, 15 had achieved a bachelor’s degree as their highest level of education. See Appendix G for a table of the demographics. The data set from this study was not used extensively to inform my thesis as I was focusing more specifically on the delivery of spiritual support by SHPs, but was included in the discussion to give perspective from nurses involved in critical incidents. Procedures Participants (SHPs) were contacted via email with an invitation letter and consent form to participate in this study (Appendices D & E). If a favourable response was returned within 14 days, I then contacted the SHP via email to set up a virtual interview utilizing an online platform or telephone (i.e. Zoom) due to social distancing requirements related to COVID-19. If no response was received within 14 days, a follow up email was sent to remind the participant of the invitation; after this, no further contact was made. Eight potential participants were contacted during the data collection period, seven of whom agreed to participate in the study. Confirmation SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 30 of a signed consent was made prior to conducting the interview and a reminder was given to participants that they may withdraw from the study at any time until completion of the thesis. A demographics form was also collected (Appendix F). Interviews were conducted over a period of 45-60 minutes, which was forestated in the invitation letter. An interview script guided the conversation while I remained adaptable to any emerging insights or contextual changes that might have arisen (Appendix H). The interviews were recorded via a portable recorder. After the interviews were completed, they were sent to a transcriptionist and then uploaded into NVivo 12™ and coded for thematic analysis. The codes from my interviews and the focus groups were then compared and contrasted. By performing a secondary analysis on the Compassion Cart study, I was hoping to utilize my pre-existing data set to ask new or additional research questions in order to explore concepts that may have been missed or not previously examined during the original study (Heaton, 2008). Unfortunately, after re-examining the transcripts from the Compassion Cart study, I found that the codes were not as relevant to my study because questions pertaining to spirituality were not directly asked during the focus groups. While this research project focused on compassion care for nurses after critical incidents such as a Code Blue, it did not have strong integration of a spiritual perspective. Because it did not have complete overlap with my particular topic, I was not able to utilize the study to specifically inform my thesis. I utilized the data that was coded under the following headings to generally inform my study: resilience or pre-existing coping mechanisms; emotions associated with Code Blues; self-awareness; psychological impact of Code Blue and the ability to provide patient safety thereafter; and assessment of staff well-being and readiness to debrief. Recommendations of how future research could be conducted to include a more accurate nursing perspective are included in Chapter Six. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 31 Ethics This study obtained Human Review Ethics Board (HREB) approval on November 24, 2020 from Trinity Western University, file no. 20ED11 (Appendix C). An amendment to my ethics board application was made in January 2021 as I discovered that one of my participants was actually located outside of local health authorities in British Columbia. A second HREB approval was granted on January 25, 2021 to accommodate this change (Appendix C). Confidentiality was maintained by anonymizing all participants, including the nurses from the focus groups. Non-gendered names were assigned to the seven SHP participants. Electronically signed consent and demographic forms were kept in a password protected online storage space; I did not receive any hard copies of consent forms. Recordings of the interviews will be erased five years after completion of the thesis, and transcriptions are currently stored in a password protected online storage space. Transcriptions have remained purely electronic; no hard copies have been made. The transcriptionist signed a confidentiality agreement for the transcription of the interviews (Appendix J). Transcriptions were only viewed by myself, the transcriptionist, and my committee members. No risks to participants were identified. Scientific Quality To ensure the credibility of this study, the following activities were undertaken, based on Thorne’s interpretive description principles to ensure scientific quality. Credibility has been demonstrated by epistemological integrity, which is shown by the descriptive methods of interpreting data related to the research question (Thorne, 2016). The findings were presented in detail, thematically analyzed, and correlated with the research purpose and questions. In addition to this, transparency of my analytic process and reference to my inferences as tentative deductions rather than conclusions enhances credibility (Thorne et al., 2004). Representative SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 32 credibility was employed with the use of triangulation from my two separate sources of data (a variety of SHPs and multiple focus groups) plus the literature review. This was performed to “confirm our inherently constructed perception of an event or process” (Thorne, 2016, p. 234). Analytic logic ensured that I was adhering to “an inductive reasoning process” by showing “evidence of that logic be made sufficiently visible throughout the report in such a manner as to allow us to confirm or reject its credibility,” as evident in my findings and discussion (Thorne, 2016, p. 234). Interpretive authority was demonstrated by my field notes and reflexive journaling after each interview and focus group to remain transparent about my preconceived notions or a personal bias. I recognized that my positionality as a researcher with previous experience in the field I was studying (nursing) would influence my interpretation of my findings while also providing the advantage of familiarity to my concepts. Throughout the research process, I was guided by the expertise of my thesis committee members, who are well-versed in conducting qualitative studies. This included attending weekly to bi-monthly thesis supervision meetings; repeatedly listening to and reading participant interviews; and seeking and incorporating feedback on the codebook, themes, and interpretation of the research findings. Cumulatively, these operational techniques support the rigour of my thesis. Limitations Several limitations were identified during this study. Participants were purposively selected from local health authorities, providing a perspective that was not representative of health care organizations elsewhere. Limiting the data collection to one geographic region allowed the results to be compared and contrasted without consideration of additional variables, such as different structuring or funding of a health authority, with the exception of one SHP. The purposive and snowball sampling techniques also resulted in participants of a similar SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 33 demographic background (Table 2). Five of the participants identified as having a Christian background and all SHPs were of Caucasian descent. Another major limitation of the study was the absence of nurses’ perspectives on the questions asked during the interviews, such as how they would measure their own level of spiritual self-awareness or ability to link spirituality to compassion fatigue. While nurses’ experiences of Code Blues were elicited, no specific questions were asked of them pertaining to spiritual well-being as the Compassion Cart study occurred prior to finalizing my research questions. My involvement as a graduate student research assistant on the Compassion Cart study served to inform the background for my thesis but did not specifically answer the questions pertaining to spirituality that I was asking. A limitation that extended from this was the potentially paternalistic viewpoint coming from the SHPs rather than the nurses speaking directly to their own perception of spirituality and compassion fatigue. The fact that the interviews needed to be conducted either via telephone or an online platform such as Zoom was another limitation. Influencing contextual factors were not as easily identified during the interviews and relational aspects or social cues were hampered by lack of face to face connection. Finally, my position as a neophyte researcher did not contribute to the rigor of this study; rather, trial and error and many return trips to qualitative research textbooks along with the guidance of a superior thesis committee allowed me to slowly and successfully complete my thesis research. I was highly aware of the influence of my own presumptions and worldview and frequently revisited the data to ensure I was accurately representing what was stated rather than what I wanted it to say. Chapter Summary The methodology chosen for this study allowed the concepts I was studying to be meaningfully described for the purpose of making recommendations for practice. Interviews with SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 34 SHPs provided rich dialogue, while the secondary analysis of focus groups provided a partial perspective on nurses’ level of compassion fatigue. Thematic analysis identified common themes that allowed data to be compared, contrasted, and compiled from both the data sets and literature review. Limitations included a non-representative sample of SHPs of various faith backgrounds, the absence of nurses’ perspectives specifically on compassion fatigue and spirituality, restricted geographic sampling, and my limited research experience. Chapter Four presents the research findings in the form of a thematic analysis. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 35 Chapter Four: Findings Thematic analysis of the interviews from my seven participants revealed one overarching theme, three main themes, and several sub-themes. The overarching theme interwoven into my three main themes was the Value of Connectedness, not simply human to human connection but human to a foundational source. The first main theme highlighted the underlying issue of how spirituality is ranked or viewed within the hierarchy of some health care systems. (De)Prioritization of the Spiritual in Health Care looked at how spirituality is collectively defined by SHPs and what role it plays in health care, its origins and metamorphosis over time, and the impact of leadership integrating spirituality in their practice. The second main theme titled SHPs’ Perception of Nurses’ Compassion Fatigue and Lack of Connection to Spirituality investigated factors contributing to compassion fatigue, SHPs’ perceptions of how self-aware nurses are of their holistic well-being, how they handle the “norm” of nursing, and the lack of language connecting spiritual well-being to compassion fatigue. The final main theme explored The Nature of SHP Support. This theme looked at SHP commission and availability, variety of approaches, including a link to aesthetics, and the impact of SHP support to mitigate compassion fatigue both outside of and during the COVID-19 pandemic. Overarching Theme: The Value of Connectedness Throughout the interviews, a common theme was discovered about the value, power, and importance of connectedness. This connectedness did not merely pertain to human to human connection, albeit this is one of the most obvious and prominent connections individuals have. The theme highlighted connection to the parts of self (physical, emotional, spiritual and further broken down into other psychological aspects); others – family, friends, our patients, our colleagues; and something greater than and outside of ourselves - a source of strength and/or SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 36 God. Peyton stated that part of what spirituality can be defined as is that connection or “relationship to self, family, and others, community, society, nature, and the significant or sacred”. The value of connectedness was revealed when examined through a spiritual perspective, according to the participants. Connection to a foundational source outside of oneself was seen as giving life, purpose, meaning, strength and a source of hope. In the view of the SHP participants, a break in that connectedness might result in disillusionment, lack of direction or fulfillment and weariness, to name a few negative outcomes. Simply stated by Taylor, there's usually a disconnect between your spirituality, what grounds you what, what gives you a foundation and what you're experiencing on a daily basis. That's where spiritual care can help re-connect people to what is foundational for them, because there's probably been a disconnect there somewhere. This observation about connection to one’s spirituality as a source of strength and hope, and conversely disconnection as a source of weariness and lack of direction, quickly emerged as consensus amongst the participants. In their view, one could not understand and address compassion fatigue without acknowledging its association with spirituality and the disconnect that had occurred. Connectedness to a foundational source could take on a variety of forms, such as social support or engaging in ritual or other activities of spirituality. Participants suggested that connectedness might include being present with another individual, listening, “checking-in,” acknowledging another’s value as a human being, or eating food together, to name a few examples. Robin spoke of how they intentionally chose to perform their SHP-related documentation on the unit rather than in their quiet office, in order to be a presence on the unit SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 37 and increase visibility and accessibility. This presence not only visually displayed their position on the health care team, but also provided informal opportunities for nurses to discuss patient concerns or engage in conversation. Taylor spoke about how social support from an individual who is highly trusted provided a valuable sense of connectedness. This person can assist with reconnection by understand[ing] where I come from, what motivates me, what centres me, what grounds me, and they'll be able to help me diagnose; whether it's just a buddy or a counselor, they'll be able to help me diagnose where's the disconnect. With this comment, the SHP reiterated the significance of having a confidant who is able to redirect or remind the person in distress of their connectedness to a grounding source. SHPs frequently relayed their ability to “read the room” or tendency to pick up on various feelings that nurses were emoting. This emotional intelligence would be used to connect with nurses on an informal basis, developing rapport, establishing relationships, and acknowledging the nurses themselves and their work. Avery stated how they would walk about a unit and inquire how individual nurses were. They stated that: a lot of nurses are absolutely astonished that someone stands right in from of them and asks “How are you doing?” because they don't often get that very direct personal attention. Some were actually taken off guard, but I also make a point of walking around, again informally, and saying to the nurses “I appreciate you. And I honour the job that you do.” And “thank you for the work that you do.” Approaching nurses and stating “I see you for who you are in this moment standing in front of me. You’re a human being” is an example of affirming and humanizing connectedness (Avery). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 38 Connectedness to another human being was described as irreplaceable. Peyton shared their opinion of the efficacy of online mental/emotional health initiatives that are sent via an email link or are gamified. While these interventions pertaining to the mental well-being of nurses could be useful, Peyton observed from feedback that: They (nurses) don't want another [link] where they're having to sit in front of a screen and go into these platforms and learn head knowledge. They want an in-situ nurturing, an insitu care for the caregiver and they want to feel presence just as they are presence to the patient. This level of human connectedness via “in-situ nurturing” and being present alongside another human being communicates intentionality and instills value and worth unlike the wellintentioned support that is offered virtually. The message of connectedness, whether implicitly or explicitly stated, will be found interwoven throughout the following three main themes, echoing the data shared here by the nurses and SHPs. (De)Prioritization of the Spiritual in Health Care The first main theme requires an examination of the hierarchical placement of spirituality in health care, which illuminates where it was derived from and how it has evolved over time. This was a surprising theme that arose from the data as it was not the original focus of my research question to explore the beginnings, importance and place of spirituality within health care itself. Rather, it became evident that the underlying theological and philosophical foundations of spirituality within health care were important for comprehending the role it has today. Careful data analysis revealed that the prioritization of the spiritual in health care served as a strong influencing factor or context to how SHPs responded to nurses and their compassion fatigue. The subthemes cover the collective definition of spirituality as told by SHPs, what role SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 39 spirituality plays in health care, how it has been affected by past and present influencers, and the effect of leadership exemplifying spirituality in health care. Collective Definition of Spirituality and its Role in Health Care Despite having chosen a specific definition of spirituality to inform my research, I also asked each SHP to provide a definition of spirituality. There seemed to be consensus that spirituality is “about connecting with people's sources of meaning, value and belief” (Emerson). This could be “to the divine, whatever you understand that to be” (Robin) or “beyond what they can define, understand, see, touch, feel, that gives meaning to their life” (Taylor). Avery further described spirituality as: the direction your life is going, your self-worth, your self-esteem, your confidence. Who you are in this world as an essence. Not just as a person, as in what do you do, who your family is, but what walks you forward, what gets you out of bed in the morning. Who are you? It was agreed upon that spirituality could have a “vast definition” and was “quite broad” (Avery & Peyton). Peyton summarized the definition of spirituality derived by the International Consensus Conference on Improving the Spiritual Dimension of Whole Person Care: The Transformational Role of Compassion, Love, and Forgiveness in Health Care held in 2013. They paraphrased: Spirituality is an intrinsic aspect of humanity, through which persons seek their own ultimate meaning, purpose and transcendence. People experience spirituality through their relationship to self, family, and others, community, society, nature, and the significant or sacred. And spirituality is expressed through beliefs, values, traditions, practices, and rituals and experiences. (Peyton) SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 40 The collective definition of spirituality also included religion but was not limited to those who identified as religious. Overall, the definitions that the SHPs shared aligned with the definition I chose to use for my research, reiterating a connection to the transcendent and providing personal meaning and purpose. One difference was that the definition of spirituality I used from the Ministry of Health (2012) openly stated that spirituality “has been recognized in ancient and modern times as important in mobilizing the internal healing mechanisms of the body and mind.” This was not overtly mentioned by my participants, although it was implied. Defined as the aspect of oneself that gives meaning and purpose to life itself, we must ask what role spirituality plays within the health care system. Emerson cautioned against viewing spirituality as something we simply “use.” It is not this thing that we can employ it and use it; it's a very modern mechanistic mentality - I'm going to take this thing and employ it for our own objectives. Spirituality moves back and forth; it’s narrative based; it’s in the stories and lives of people and how their lives interact, so you can't just relegate it to something that we use. (Emerson) Emerson summarized that spirituality is useful for meaning making, is an essential component in providing holistic care, and can enhance communication on challenging issues. We can engage with spirituality to “promote meaning, to utilize those things that are most beneficial for peoples’ coping,” along with “giving us an ethical principle to be holistic in our care” (Emerson). Finally, they also stated that ethics, character, virtue, morality - these are also part of what you see in spirituality. Where are we as staff members providing patience and kindness and compassionate care, and how are we cultivating that among ourselves and with the patient? (Emerson). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 41 Based off of my experience and informed by Emerson’s comments, nurses initially may not view these qualities as part of spirituality. This challenges nurses to consider from a spiritual perspective how these attributes, such as patience, kindness, and compassion, are being administered both to themselves and others. It is widely held that spirituality is an inherent aspect of every human being (Hall & Powell, 2021; Puchaslki et al., 2014; Wu et al., 2020). It is also recognized that spirituality has a broad definition and can be linked to a multitude of activities or concepts. Spirituality is useful for meaning making or identifying purpose in one’s life, and assists with coping, communication, and displaying characteristics such as compassion (Emerson). Paying attention to the spiritual aspect of one’s life is essential due to the interconnectedness it has with the holistic parts of oneself; hence, spirituality plays a significant role in health care as it affects the “internal healing mechanisms” and overall mental, emotional and physical well-being of both nurses and patients alike (Ministry of Health, 2012). Past and Present Factors Influencing Spirituality in Health Care From my readings in the field of nursing, I have learned that some individuals may not consider the purpose or meaning of life as part of spirituality (Paley, 2008); Peyton, however, claimed it is: “it’s existential philosophy.” This reference points to the roots or origins of spirituality within health care, and the shifting tide away from these roots, which was also identified by other participants. Participants alluded to spiritual care as rooted in specific traditions, particularly Christianity or Judeo-Christian within the Western culture (Avery). Avery noted that a shift, however, has occurred, as “many societies now across the world and globally are quite disconnected from soul, spirit. And it's just become our Western way since the Enlightenment, since we kind of bought into the whole line of rationality and reason.” Emerson SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 42 also spoke of nursing traditions originating within the Catholic church and how religion and spiritual practice was incorporated within the work of service or nursing. Since then, however, “we have kind of lost that sense of vocation in healthcare. We've lost the spirit, and we haven't been able to integrate it like it used to be. We are kind of falling to god of the gaps, where spirituality is getting smaller and smaller” (Emerson). One factor that may have also contributed to this shift is that “spirituality and health as an academic discipline and research discipline is primarily written by physicians and psychiatrists and not written very much by historians, philosophers and theologians” (Emerson). For example, physicians might place more focus on physical issues within “the hierarchy of their attention” (Emerson). Physicians and psychiatrists function primarily under the influence of the medical model and the need to measure health outcomes and may not be trained to delve further into the rich philosophic and theological traditions by which we can understand the meaning of illness and suffering (Balboni & Balboni, 2019). While this may be understandably and justifiably so, it shrinks the available space left for addressing spiritual aspects. Avery mentioned that spiritual care has become “really quite countercultural.” Several SHPs mentioned a negative connotation associated with spiritual care or “chaplains,” as “there is baggage and history of chaplains coming with an agenda” (Peyton). This may translate into hesitancy or resistance towards SHPs. For this reason, SHPs may find the need to “talk about ourselves in a way that perhaps we never have before” (Avery); however, this poses a problem as we lack a common vocabulary to speak to the issue. Brooke stated that we don't have language because the church no longer plays that major role that it used to…the church had played a major role in people’s lives, but now…the organized church has almost lost its voice and in our in our culture and the sad part about that is that we SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 43 don't have ritual anymore that we identify as common amongst us, and so there's no language. McKenzie also mentioned the loss of ritual and its associated meaning. Ritual can be used in spirituality as a form of recognition for what has occurred, for example ringing a bell or lighting a candle when a patient dies, but is used in very few settings (McKenzie). Another example was how mindfulness could be used in a ritualistic, intentional way, such as taking a moment to pause when entering a room and reaching for the door handle; this allows the nurse to center themselves and enter a new situation, leaving behind the old situation (Avery). Movement away from some of these ritualistic behaviours is reflective of the shift away from spirituality. Separation of religion and spirituality was mentioned by all of the participants. All seven of the SHPs shared how they originally viewed spirituality as steeped in religion, but over time, their definition of spirituality evolved to include those who identified as spiritual but not religious, which is a position that is increasingly accepted today. Varying views were held about this trend, such as Brooke talking about how they restructured the content of a spiritual care course they taught. Brooke stated: no, this is not what spirituality is about. It's not just based on a person's religious construct of a church, it’s much much deeper than that. So I got rid of all of that and in the end, when I would teach, especially to students who come in with their own ideas of religious formation or spiritual formation, I would say, you know, “What is spirituality about?” It’s about “How does that person in front of you identify their spirituality?” We need to put aside ourselves, and we need to listen closely to what has informed and formed this being in front of us. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 44 Others made more general statements, such as “a good way to start a conversation is with meaning and purpose - what makes your life? But religion - with what denomination are you? That can get you into trouble” (Robin). Although Robin did not explicate what this “trouble” might entail, my interpretation was that religion difference could be seen as a source of disagreement or even conflict. Yet another SHP mentioned that while they recognize the separation of religion and spirituality, for them and some of the individuals they work with, these two concepts are still linked (Taylor). These observations by Robin and Taylor point to the need to locate spirituality in health care within its historical roots in order to understand how it has been shaped today. Despite the fact that SHPs in this study provided support from a spirituality perspective, there was a degree to which they are still heavily informed by the historical and cultural context of religion and continue to utilize specific spiritual practices and ritual associated with religion (Paley, 2008). Collectively, they provided a picture of a pluralistic health care system, in which the tide of religion has seemingly gone out, yet the innate desire and need for connectedness remains, which some seek and find within spirituality and religion. Hence, as Emerson stated, “I think there is actually a movement to discover it (spirituality),” spirituality may be returning to a higher prioritized place within health care on the in-coming tide. Exemplification of Spirituality in Health Care Leadership As we examine the prioritization of spirituality in health care, it is natural to look at how spirituality is exemplified in those who provide guidance and leadership. Some SHPs reported informally “checking-in” with Patient Care Coordinators (PCCs) or managers to see if they knew of any nurses on their radar who may benefit from spiritual care. The majority of SHPs described how they might receive requests from managers or team leads to conduct a meditation or SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 45 mindfulness session, or a debrief alongside a Critical Incident Stress Management team, in order to support the staff spiritually. Managers or PCCs who noted emotional changes amongst their nurses and reached out for this type of support were viewed by the SHPs as “shepherding” their nurses or demonstrating “maternal or paternal care” (McKenzie). The same SHP described the varied reactions from a PCC or manager when they were offered a formal spiritual support session. Some of the nursing leaders would welcome the SHP and advertise the session while others would say, “‘well, yeah, you can come at two, that'll be fine’, but did not need to announce it”. Brief mention was made of spirituality exemplified at a level higher than management; Robin stated that “we had a professional practice director for a while who looked after all the professional practice leaders…and she always incorporated spirituality into every meeting; she included that component in it.” This SHP appreciated the inclusion of spirituality from the leadership level. The timing of when SHP support was provided was also reflective of how leadership exemplified and prioritized spirituality. In relation to providing staff wellness sessions, Peyton stated: we were trying not to do it as a Lunch and Learn. And the reason why is because we wanted staff to realize that their self-care was important enough to be doing it on work time. Ok, and that spoke loudly, because…when you need a break and you're tired and exhausted, you want your lunchtime as the break for you, to be able to have your lunch break. And also have something that is restorative and nurturing for you where you are doing it on work time, that speaks volumes. Peyton recognized that the message that is conveyed to nurses by offering support during a personal work break does not respect the mental/emotional/physical rest that the nurse needs SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 46 during their shift. Rather, they suggested that an intervention is offered during work time but not during a break so that nurses do not need to come into their workplace during their personal time, showing the nurses how they are valued as employees. Peyton stated that they have found it helpful “to have a connection…in the higher up areas of nursing, whether it's a clinical manager, or a nurse educator, that they are recognizing a need within their staff…they have reached out and invited me to come.” This builds trust, connection and rapport that both SHPs and leaders can rely upon in order to support nurses. From what the SHPs shared, little room has been left to incorporate spirituality within the day to day practice of health care. Ignoring the spiritual aspect of oneself results in disconnectedness to the parts of self, others, and a foundational source, and also overlooks the rich philosophic and theological roots that spirituality originated from (Emerson). As will be discussed in more depth in Chapter Five, my interpretation of this data is that the prioritization or de-prioritization of spirituality in health care must be acknowledged and recognized in order for SHPs to provide nurses with supportive links between spirituality and compassion fatigue. From the comments of my participants, it appears that organizational leaders who exemplify spiritual characteristics or value spirituality can help create a work environment that is conducive to incorporating spirituality, which ultimately demonstrates to nurses that they are valued and cared for, resulting in higher levels of job satisfaction and lower levels of compassion fatigue. SHPs’ Perception of Nurses’ Compassion Fatigue and Lack of Connection to Spirituality The second main theme describes the SHPs’ insight into the problem of compassion fatigue and of its occurrence amongst nurses. Subthemes will address how SHPs perceived nurses’ awareness of their own spiritual well-being and their knowledge of SHPs’ roles. The second subtheme will portray how SHPs perceive nurses handle the “norm” of nursing and what SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 47 factors contribute to compassion fatigue. The final subtheme will address a lack of terminology within nurses’ vocabulary pertaining to spirituality and compassion fatigue amongst other interrelated concepts. Nurses’ Self-Awareness of Spiritual Well-being and SHP Support from the Perspective of SHPs Participants offered mixed perspectives of nurses’ self-awareness of their own spiritual well-being. One must keep in mind that these observations are the SHPs’ perceptions and not solicited from nurses themselves. To set the stage, Emerson defined what it means to be aware of one’s spiritual well-being by stating that “spiritual awareness is when you are aware of your thoughts your feelings, and your sensations.” One participant stated that “nursing staff, I have found, are a little bit better at self-awareness” (Taylor) while another stated that “generally I'd say [nurses are] not very self-aware” (Avery). Emerson went on to say that they have “always found that nurses were attuned to their thoughts and feelings” but that “they might mix them up,” which requires assistance to “really help them to put a name to what they were experiencing so it wasn’t just a jumble of rubber bands.” Along a similar line of thought, Peyton stated that “I wouldn't necessarily think that they would naturally equate (compassion fatigue) with spiritual well-being. I think they look more at emotional and mental well-being.” Additionally, another SHP commented on what they originally thought was a correlation between length of work experience and self-awareness: There's still a huge variation from individuals. I used to think it was based on experience, that the more experience, the more self-aware they might be, but you know I don’t think that’s the case. I do find that if I interact with a nurse that has been a nurse for 15 or 20 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 48 years and still is really compassionate with patients…there's a passion about their work, they're the ones that are more self-aware. (Taylor) Brooke reflected that “I think that many nurses don't know themselves well enough and they take that suffering [on],” resulting in compassion fatigue. From these comments, SHPs seem to think that nurses have some degree of self-awareness, but it more frequently pertains to their emotional and mental well-being rather than spiritual well-being. Even within that awareness, nurses may struggle to make sense of what they are attuned to, making it difficult to know how to process the critical incidents or patient encounters they experience. Robin explained how having a personal spiritual framework may assist nurses to be more self-aware of their spiritual well-being: No, I think they will not go to the spiritual, unless they are people of deep faith or deep practice, they are not going to go to the spiritual unless they have had spirituality explained to them, as the things that give your life meaning and purpose, which is your caregiving. Previously developed mechanisms of resilience were seen as beneficial for checking-in with one’s own spiritual well-being. Taylor stated that if resilience has not been learned, “the selfawareness is too painful, but...um...you don’t want to admit that and so you do withdraw.” In other words, the emotional fatigue and withdrawal seen in compassion fatigue was directly linked to a disconnectedness of self, or lack of self-awareness. Peyton offered further insight into why nurses may be less self-aware of their spiritual well-being because of the paradigms they function within, stating that nurses: have very high expectations of themselves, and are quite self-judgmental and critical of self and don't give themselves a lot of room for error…they are under an understanding SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 49 that there isn't much room for mistakes or for self-compassion in the midst of it…they will look sort of analytically at what they have done or what they have not done and how they're responding or not responding. They’re focusing more on the task of the situation… they're not as willing to give themselves grace. In essence, nurses operate under high standards that are required to provide safe patient care; however, these standards might also create expectations that leave little room for nurses to selfcompassionately debrief after a critical incident. A personal spiritual framework or paradigm affected how suffering was viewed. According to Brooke, nurses must look within to determine how they typically approach and process issues like suffering. They encouraged nurses to ask the questions: What are your own intentions here? Who are you with this? How do you resolve your own pain and suffering when you see someone else suffer?...you can't do anything about it necessarily because not all suffering in this world can be managed by good nursing care. Nurses can gain spiritual awareness by questioning where they have situated themselves within their patient’s care and how this is affecting them. This can be challenging if nurses have not previously asked existential questions or further explored the concept of suffering. My analysis of these comments suggested a lack of connectedness that nurses have to their spiritual wellbeing. One must also examine how SHPs’ preconceptions of nurses and their levels of spiritual self-awareness could potentially act as a barrier in the provision of spiritual support. This will be further discussed in Chapter Five. Next, we examine how aware nurses are of a SHP’s scope of practice. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 50 According to SHPs, nurses were only partially aware of the SHP role. Emerson stated that “I don’t think nurses have at the top priority the safe and effective use of spirituality” while Brooke said, “often staff are not…fully educated in what spiritual care can do.” Peyton reflected about when they originally started offering staff wellness sessions, it was difficult to attract attendees as nurses expressed hesitancy about the content. They shared how the lead nurse: was just sort of trying to get people to come because they just didn’t know what exactly this meant or entailed…Some people were a little bit wary because of spiritual care and they equated spiritual care with religion, and they didn't want it to be that. But…when they realized what I was actually doing, word travelled and then there was a wait list. Overall, SHPs believed nurses had pre-conceived notions of SHPs and their roles based on previous life experience or hearsay. Robin recalled an instance when someone was surprised that a SHP was joining in on workplace humour. They shared how the nurses were doing something at the nurse’s station. Everybody was laughing and having fun and I was joining in and this person looked at me and said, “Are you sure you’re a minister?” because I was having fun! I think it’s important for them to realize I'm not there to preach and that I'm part of the same team that they are part of. This SHP reflected on their desire to be included as part of the health care team and correctly understood, not tainted by the previous misconceptions that some nurses held. A few participants mentioned strategies of how they could promote their services to nurses, such as speaking at a new staff orientation session or supporting managers or leadership to incorporate spirituality into the flow of the workday. While SHPs preferred to be invited or approached by nurses or leadership to provide support, they frequently spoke about being present or visible on a unit in order to engage in informal care or develop rapport with staff. McKenzie SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 51 mentioned that “the spiritual care person is just not seen as a team member,” while Taylor reported the opposite experience of working closely alongside nurses in the emergency room and intensive care unit and forming strong relationships. Another participant relayed that they “had lots of influence so that (spiritual care) wouldn't be the last thing that the nurses would think about” (Brooke). This resonated with other SHPs who mentioned that the nurses who had previously attended a spiritual care session or were made aware of SHP support made a higher number of patient care referrals. In summary, SHPs categorized the level of nurses’ self-awareness of their spiritual wellbeing as low. Not only was this aspect of introspection low, but nurses’ awareness of SHPs and their role on the health care team also seemed to be deficient. A possible link exists between this lack of awareness of personal and external resources and the development of compassion fatigue in nurses, as explored in the next subtheme. How Nurses Handle the “Norm” of Nursing and Factors Contributing to Compassion Fatigue When addressing the issue of how nurses respond to critical incidents, SHPs provided their perspective of what they thought was “normal” or expected for nurses to encounter within their average workday. In reference to the debriefing process required after a Code Blue, Robin responded with “now I wouldn’t call [a Code Blue] a critical incident cause that's kind of normal. That's the normal range of nursing.” Taylor provided more description of what they would consider a critical incident to be something that “involve(s) young children or multiple casualties or suicide or they're working on a co-worker or family member.” This forces us to ask the question: to what extent can bearing witness to another’s suffering be normalized or dealt with clinically? Depending on the context of care, I have found that health care professionals may be exposed to profound human suffering for the duration of their career, which can have caustic and SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 52 wearisome side effects. Incidents like these require focussed attention to ensure they are properly dealt with, as McKenzie stated: “they shouldn't just be par for the course, or part of the job folks, chin up, right? That’s a real error of thinking.” Brooke described how nurses handle the everyday “norm” of nursing this way: we have our level that is our normal functioning, but then we get into crisis and it creates this rise…then we plateau and will come down, but if it's not dealt with appropriately we never come back down to our norm… so then it goes up again…finally gets right to the top. From these excerpts, we see the SHPs had differing perspectives on what they considered the normal range of nursing, which is likely due to the fact that they are viewing nursing through an interprofessional lens. Their perspectives could also differ from what nurses consider is “normal” within their scope of practice, creating a barrier to the times when spiritual support is needed and how it is provided. Recommendations will be made in Chapter Six on how to minimize this gap in perspectives. Brooke mentioned that the way nurses have been trained to rely on frameworks may negatively affect their ability to manage situations that fall outside of the algorithms. They stated that: that's the essence of how you are trained as a nurse and so that when you do get into those situations where you can't, there is no algorithm that's going to resolve the suffering of this patient, that's when it hits the nurses right? That's when they don't know what to do with that because the algorithm isn't helping them. (Brooke) Essentially, nurses may struggle to know how to respond to a clinical situation where the unexpected has happened. Inability to process the unexpected can result in an accumulation of SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 53 confusion and distress. Another assumption that Brooke believed nurses operate under is the demeanor they are expected to display at all times despite what they are experiencing. Brooke explained that nurses are always expected to be “putting on a brave face and moving forward, I think that's always been the fabric of being a nurse and…this shouldn't affect me…because this is what I've been trained for, but it does, it affects very deeply their being.” This preconceived notion of how to respond during a “normal” day at work for nurses may actually be causing a hindrance to be self-aware of their own holistic well-being. Along with the intrinsic factor of how nurses viewed their work, numerous other extrinsic factors were identified by the SHPs as contributing to compassion fatigue. According to the SHPs, some of the identified factors are organizational structures, difficult patients, personal life stressors, and most recently, the COVID-19 pandemic. This ultimately ends in “job weariness,” “nursing tiredness” and feeling “bagged” (Robin). Robin went on to say, “I also think compassion fatigue happens when we have this perception that what we're doing isn't making a difference.” When a nurse experiences several patient deaths in a row, or frequently encounters aggravated family members, they may question “why am I doing what I am doing? It doesn’t seem to be making any difference. It just seems to be agitating people. So, the shutdown begins” (Robin). This “shutdown” or withdrawal is one of the main effects seen in someone experiencing compassion fatigue. Organizational factors, such as the structure of patient flow, do not accommodate moments when a nurse may need to process something upsetting they just experienced, such as a patient death. There are “other tasks to do now because they died; so I have to phone this person and I have to finish off these charts” etc. (McKenzie). Time and space are not naturally created to pause and process after a situation like loss of life. Emerson described how nurses’ exposure SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 54 to difficult situations may prompt existential questioning. They explained that depending on the unit nurses are on, they may “see so much death anxiety and total pain” and therefore incur thoughts of “helplessness and existential angst that you feel for yourself in confronting your own death” (Emerson). Unless a nurse has their own worldview that helps them work through these questions, they may be intimidated and avoid existential questioning altogether. The format of assistance for processing these difficult concepts typically requires the nurse to self-initiate support. Peyton mentioned that “a lot of [nurses] just don't do that (access support) because then they're having to organize something on their own time.” Other workplace dynamics such as culture may cause nurses to “withdraw from the team, and just be overloaded because it's just so negative, negative, negative” (Peyton). All of these organizational factors can collectively contribute to the formation of compassion fatigue. According to SHPs, compassion fatigue may abruptly occur due to an isolated incident when “things just go sideways…complications arise that might not be what was expected,” or cumulatively over time (Peyton). When compassion fatigue occurs suddenly, it may be due to how a critical incident was conducted. Brooke explained that “there was just so much distress over a specific incident…what is that? That is their compassion that, just can't let go of it, the compassion towards that particular situation and how it was handled or how it was not handled.” This speaks to the importance of conducting both a medical and psychological debrief, as evidenced by the Compassion Cart study (Drake et al., 2020). Brooke stated that on the other hand, a slow build of stress can result in distress: “all those things doesn't happen just with one patient. It becomes an accumulation of patients but then you have that one really really really difficult patient that puts you over the edge.” Taylor agreed by saying: SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 55 it's just the work in general because it usually comes up, not during a critical incident, but during a very regular day, where there's a heavy patient load and they are having to do…the mundane daily stuff and just aren’t feeling engaged with it…so most of the complaints that I hear are just the daily grind stuff, not the critical incidents. Whether it is the unavoidable nature of the everyday work assignments or a sudden unexpected event, compassion fatigue can develop from a range of abrasive circumstances. Spiritual health practitioners in this study recognized that nurses are exposed to a wide variety of human experiences along the continuum of life. Some of these situations are more difficult to witness and participate in, and unless a nurse has the ability to critically reflect on these incidents, they may experience an accumulating level of distress and compassion fatigue over time. Organizational factors such as these may further compound the level of compassion fatigue a nurse experiences. A combination of self-awareness and readily available support is required for a nurse to receive the assistance necessary to mentally process critical incidents. This connection to the spiritual aspect of oneself can create clarity and resilience to withstand the factors contributing to compassion fatigue. Lack of Language Connecting Spiritual Well-Being to Compassion Fatigue and Other Interrelated Concepts Over the course of the seven interviews, it became apparent that SHPs thought that there was a lack of standardized terminology used by nurses to speak about spirituality, let alone the ability to link spirituality to compassion fatigue and other interrelated concepts. The SHPs reported that nurses would use a variety of words to describe how they were feeling. Robin stated that “my job was to help them find the words” and “I remember this one (nurse) would say, I am so bagged!” to which the SHP would respond by asking “her to tell me what was in the SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 56 bag, like, start unpacking that bag; but she wasn’t unpacking it for me, she was unpacking it for her.” Emerson reported how they would group the nurses’ thoughts, feelings and emotions into either an affective, existential, or transcending category. This allowed the SHP to identify a framework, debriefing process, or grounding technique that may be useful for the nurse to identify what they were experiencing, to place a name to it. Prior to these interactions, Emerson noticed that “articulation wasn't there and now it was and they (the nurses) affirmed it and grabbed on to it.” Avery also mentioned that nurses may “struggle to…find the words in the moment” due to the fact that “our medical model that tends to discourage a show of emotions in any way, they are trained that way.” As mentioned earlier, nurses may feel restricted in their expression of emotion due to the composed, professional demeanour that is expected of them while on shift and therefore are unable to adequately verbalize what they are experiencing. Upon reflection of how compassion fatigue and spirituality are linked, Brooke stated that: I think that compassion fatigue is actually very deeply based in our spirituality but they (the nurses) just don't have the language to use it. So they would say, I have compassion fatigue, like I'm just done, you know I'm burned out…but it really does come with the fact that that they have carried so much of someone else’s burden and how do you release that? How do you let that go? From my perspective, the fact that nurses do not naturally link compassion fatigue and spirituality speaks to the afore mentioned theme of lack of self-awareness pertaining to spiritual well-being. Robin spoke about how concepts such as spirituality, spiritual care and well-being can’t be identified unless first comprehended. They said: SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 57 we can’t deal with something until we recognize it. We need someone who knows how to gently help us recognize what's happening, where feelings are coming from, helps us to verbalize what's happening, and then help us to take the steps to move forward. The facilitation that SHPs provide to help nurses process the feelings and emotions that they are holding or carrying is beneficial to the spiritual, mental, and emotional well-being of the nurse. Occasionally, nurses do self-identify as having compassion fatigue, but still may not make the link to their spiritual well-being. Taylor relayed how one nurse independently identified as having compassion fatigue after she described her symptoms to a SHP. Generally, however, SHPs don't necessarily think [nurses] even link compassion fatigue to spirituality…Once they understand the meaning and definition of what we're using as spirituality then they are a little bit more open to discussing it in that way, but (it doesn’t) come naturally. (Peyton) Linking back to the separation of religion and spiritual and preconceived opinions, Brooke stated nurses “didn’t have the language or didn't even know how to engage in the spiritual because they always identified spiritual as being uniquely…religious.” They would find themselves asking nurses the same questions they’d ask patients: “Do you believe in a higher power, in something bigger than you, whether that be God, whether that be nature, but is there something that is that you identify even though you don't have a language for it?” Peyton made a more existential observation by stating: The health care staff that have a problem or struggle a bit more with compassion fatigue, I believe anyway…are people who have not wrestled with their own mortality and come to terms with their own understanding of spirituality. And what happens in the process of death and after, if they even believe something happens after. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 58 This portrays the need for nurses to be able to explore what their thoughts, feelings and emotions alongside a SHP who can help provide meaning and organization to what nurses are experiencing. Concepts that are closely related to compassion fatigue can cause confusion amidst the terminology that nurses may be familiar with. On average, the SHPs conveyed that they “seldomly” interacted with nurses who specifically reported experiencing compassion fatigue. This was not only due to the lack of standardized language involving compassion fatigue and spirituality, but also due to the interrelatedness of other similar concepts, such as burnout, moral distress, vicarious trauma, and PTSD. When talking about the signs and symptoms of compassion fatigue, “the mind automatically goes to burnout” (Robin). This same SHP stated by the end of their career, compassion fatigue “would have been a term that was recognized; I think in the beginning everybody just called it burnout.” Emerson and Peyton stated that what they “have seen more is moral distress.” Taylor described how compassion fatigue should potentially be rebranded: So compassion fatigue has been around for as long as we've been doing nursing. A more modern term that's been coined is resilience, and I’m sure you have heard of that; it's all related. It all has to do with stress load, trauma experience, your capacity to be able to give of ourselves. How much we can absorb and bounce back to our base level and how quickly we can do that. This observation speaks to the cautious use of buzzwords or concepts which may have negative connotations (Taylor & Robin). For instance, Robin stated that they “stopped calling them compassion fatigue workshops and started calling them compassion satisfaction workshops…I don't want to promote compassion fatigue” (Robin). When SHPs are addressing issues pertaining SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 59 to spirituality, delineation needs to be made amongst the interrelated concepts so that issues can be clearly understood and the correct intervention can be applied. Subtheme three highlights the significance of missing terminology pertaining to spirituality in nurses’ vocabularies. Factors such as shifting away from religion and embracing a more ambiguous approach to spirituality and the disconnect between spiritual well-being and compassion fatigue all contribute to the problem of a lack of standardized language. In addition to this, closely related concepts such as burnout and moral distress make it unclear and difficult to pinpoint the actual issue being spoken about. To summarize theme two, SHPs believed there were several factors pertaining to compassion fatigue in nurses. One is the SHP view of a generally low-level of spiritual selfawareness while on shift and insufficient understanding of the support SHPs can offer. This once again speaks to the overarching theme of connectedness; if connectedness to the parts of self (spiritual aspect) and others is lost, an imbalance occurs, and the nurse will not be able to function holistically. Second, SHPs believed that nurses are expected to meticulously function under high standards and maintain a controlled, professional demeanour while doing so no matter what situation they find themselves in. Related to this are the organizational or personal factors that may compound stressful situations. Third, a major subtheme noted was what the SHPs perceived as the disconnect between compassion fatigue and spirituality. This could be attributed to an overall lack of standardized, universal language that nurses have to speak about spirituality, as well as the confusion that can occur when speaking about interrelated concepts. The third main theme addresses a SHP’s scope of practice, how they deliver spiritual care, and why they think it makes a difference. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 60 The Nature of SHP Support The nature of SHP support is dynamic and multi-faceted. From my observations, it encompasses a group of dedicated professionals who seek to provide spiritual care to patients, families and staff while navigating the plurality of a secular health care system. The first subtheme examines the current commission of SHPs to provide support to patients versus staff, along with their availability to meet the demands of their job. The second subtheme explores the informal and formal approaches of SHP support, as well as the resistance or reception SHPs have encountered from nurses. The third subtheme describes the impact of SHP support on the mitigation of compassion fatigue and addresses the interventions that SHPs use to mitigate compassion fatigue, along with the value of incorporating aesthetics. Finally, the fourth subtheme investigates the impact of the COVID-19 pandemic on the provision of SHP services. The Commission and Availability of SHPs The seven SHPs reported a general consensus that their commission to provide spiritual care to health care staff versus patients has increased over time. McKenzie stated, “the first few years it was all about the patients and sure enough with every year that went by, it's become more and more about staff.” Some health authorities had alternate resources to support staff, such as employee wellness, and therefore commissioned their SHPs to “very explicitly...serve the patients first. There's even…an actual resistance to ‘you're doing too much staff care’” (McKenzie). Despite this directive, Emerson stated that it requires a change of strategy in order for SHPs to have a more compounded affect: “if I can help staff in some way, then I'm helping the patients too.” Other health authorities operate under a different structure. Taylor stated that they are “employed by a non-profit organization…the hospitals then contract with the non-profit SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 61 to provide chaplain services.” Avery stated that they divvied out their time based on their own assessment of spiritual care need: I think of the hospital as my congregation. So I don't distinguish between patients and staff when it comes to where I lay my energies…in our job description, …you must spend, you know 80% of your time with patients and 20% staff…but I consider the staff and their well-being…equally as important. So I spend a lot of time with staff; that is my own personal decision…we are one of the very few departments who actually does have that mandate that we do. Similar to Avery, Peyton also stated that their job is carried out differently in reality versus the description that is written on paper, with more time being spent with staff than what is allotted. When addressing the importance of maintaining nurse well-being, Robin stated “it wasn't just spiritual care for the patients. It was also spiritual care for the team.” Robin also questioned who was responsible for nurses’ well-being and how it is prioritized. When providing support to nurses experiencing emotional withdrawal, they asked: Who does that for the staff? Nobody, because the social worker is looking at patients and it’s not their job to look after the nurses, but somehow our role has that dual side to it, to look at staff as well as the patient families and it gets lost and it's really important that we keep that up there. While other health care staff such as nurse managers and Employee Wellness teams provide informal or formal support to staff, Robin expressed how they felt the responsibility of nurses’ well-being. Robin also expanded that the benefit of “supporting the morale and the well-being of the team” in turn supports both the patients and the institution. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 62 As for SHP availability, participants reported having large portfolios, being involved in multiple projects at once, and sometimes having less than one SHP employed per hospital site. One SHP reported providing support for “the hospital…four extended care units…a group in the psych outpatient program and…a hospice on site, so I was totally pager controlled” (Robin). One health authority previously expunged the majority of SHPs from their positions during a time of restructuring, leaving staff and patients with limited spiritual support. Some SHPs reported being tired but highly satisfied by the nature of their work, such as Robin stating that “sometimes I went into the evening or stayed later or went in earlier but that is what made it my ministry.” With such demands on them, Emerson questioned why they personally never experienced compassion fatigue despite being exposed to a plethora of secondary trauma and suffering. On the opposite end of the spectrum, another SHP reported feeling “maxed out” in their job at times and would withdraw from personal relationships that resembled the nature of their work (Peyton). Brooke stated, “it was very busy…people would say, ‘How do you ever get to see patients?’ Well, it actually worked out very well, because I find that with spiritual health, it's always just in time care.” McKenzie stated that spiritual support for staff “is something they get to doing with what time is leftover.” Robin shared, “I had to make an effort to stop outside the door if I saw a nurse who looked weary…time wise it just meant you didn't stop the whole time you were there.” Overall, SHPs reported tension and satisfaction of working within their large portfolios. Previously, SHPs were commissioned primarily for the provision of spiritual support for patients, but their assignments have expanded beyond patient and family care to health care staff as well (McKenzie). All seven of the SHPs indicated that the balance between provision of support to both patients and staff is delicate and challenging due to time constraints. As we will SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 63 see in the next subtheme, the manner in which meaningful connections are formed between SHPs and staff take time, intuition, and adaptability. Variety of Support Approaches and Resistance or Reception from Nurses Throughout the course of the seven interviews, participants listed off a variety of ways in which they provide support to nurses. While there were several specific formal interventions mentioned, the majority of support provided was informal in nature. Formal interventions might look like scheduled sessions offered by SHPs exploring self-awareness or general staff wellness sessions. Robin relayed how they worked alongside social workers and the CISM team in order to provide more formalized debriefs for nurses who may have encountered more frequent patient deaths, such as in hospice or medical units. Other support was “formally informal”, or rather routinely scheduled but informal in nature. McKenzie described how “every Friday, I went into a different unit and brought them what we called Tea for the Soul…I went into units and just offered spiritual care…it was nourishment like tea, plus all those free beautiful…pastries and things.” This provided the opportunity to engage in conversations that may involve emotional processing or reflection on their vocational calling, which in turn could mitigate compassion fatigue. The SHPs described an instinctual awareness or ability to know which nurses are in need of spiritual care. Informal approaches included being a presence on the unit, trying to “read people's responses…if it looks like they are particularly stressed…sometimes you get kind of a glossy look like they’re just overwhelmed” (Emerson). This would then involve the SHP engaging in an “informal check in, you know just wanting to see how things are going. Today I just noticed that…or I was part of this patient care, there were a lot of challenges around their discharge and I just wanted to follow up with you about that” (Emerson). McKenzie succinctly SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 64 described their informal approach as “small, on-the-fly support. It’s really woven into the patient care that I do.” Several SHPs reported walking around nursing units, reading the facial expressions of nurses as they come out of rooms. Robin poignantly recalled: I remember once just outside of the room of a patient, I was there as the nurse came out and she leaned against the wall and just “aahhh.” So you know I stepped off and took my cue. What I learned is that if they can spend 5 minutes with me, whether it's in a hallway or a quiet room or wherever, it prevents them calling in sick the next day. Brooke shared a similar story: “with the nurses, I did exactly that same thing. I would just you know, So how's it going? What's up? I heard you had a really bad case last week…just being there for them, and being that listening ear.” Avery described that “I do something that I call hallway spiritual care, and so it's really impromptu.” They described this as taking “a snapshot of the ward as I walk in and I'm kind of looking for, you know energetically… sometimes I can feel some distress coming off of someone” (Avery). These informal encounters with nurses spoke of the awareness that SHPs have for the well-being of staff and their flexibility to provide “in the moment” care for the caregivers. Several SHPs shared how they are mindful to ensure they are not coming across as intrusive or with an agenda, which is reflective of their ability to contextualize their support according to the individual they are engaging with. Many of the participants mentioned that “active listening is a big part of what I do” (Taylor). Taylor went on to describe how they informally engaged with nurses and contextualized support: So a lot of times a nurse will say, that was a rough one; it generates a conversation or we pull aside and have a conversation about what was rough about it. What support is needed there, either for me personally or reconnecting that nurse with other resources for SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 65 support, whether that's family or other staff or EAP (employee assistance program) or whatever is going to be appropriate. A lot of time it’s just that conversation over a quick coffee, just being able to verbalize their story which allows them to get a better handle on it. I get a lot of nurses saying, “thank you so much for everything” and all I did was listen. One example of how a SHP was able to contextualize their care for the nurse was to facilitate a smudging ceremony with an Indigenous elder for a patient but include the nurse as well. This elder was present to care for the patient, but the “nurse and patient bonded over the deep…roots of heritage…just grounding herself with her own heritage that she had never experienced before” (Brooke). Brooke described how her ability to “not manipulate [support] but just participate in it, facilitate it and to acknowledge that there is deep spirituality in all of us, it's just that it looks different for each of us” was something that they loved about their position. Another way Peyton described the contextualization of care was that “it's very much coming underneath and supporting like a rose trellis rather than a cookie cutter coming over and above” (Peyton). Not only does this provide us with a visual of what provision of spiritual care should look like, but it also speaks to the movement away from a solitary religious approach. The next section will look at the receptiveness of nurses towards SHPs as well the negative associations some nurses have with SHPs, resulting in feelings of being unwelcome or resistance. Some SHPs reported forming deeper connections with nurses and experiencing increased receptiveness over time. Robin reported the importance of “building up that relationship so they can know your name when they need you.” One way this SHP did this was through bringing instant coffee to the units for staff to enjoy during spiritual care week to thank them for the care the nurses provided and increase their visibility as a SHP. These efforts by SHPs were useful for SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 66 building relationships with nurses. One SHP even told of their friend who was a chaplain who “became like the pastor to these people” and was asked to perform weddings and funerals of nurses or family members if they did not have their own officiant (Robin). Brooke also spoke of working closely alongside nurses and being asked for advice on personal life matters. The SHPs found these deeper relationships with nurses rewarding and meaningful. One of the interview questions that all participants were asked was if they had encountered resistance or a sense of being unwelcome during their offers to provide support to nurses. On the whole, the SHPs reported that they generally did not incur resistance or feel unwelcome, which appeared to mainly be due to their approach. Peyton explained that for them: I haven't had that situation with nurses specifically because I'm not approaching the nurses, I'm only coming on invitation…if nurses or health care staff they want me, I'm available to them, but I'm not going to force myself on them. I'm not going to push myself on them in that regard. And I think because spiritual care is such you know, a sensitive, very deep and internal part of each human being, to have someone come in on their own terms and start to mingle around without that invitation, I think it lends itself to arrogance maybe. But that's my own philosophy…I would rather be invited in and wanted. As Peyton waited for the invitation from nurses to connect, they naturally did not incur resistance as they did not impose themselves on others. Taylor described how their close working relationship with nurses decreased the likelihood of resistance when support is offered, or even increased the probability that nurses would reach out voluntarily. They explained how: SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 67 usually with nursing staff, they don't have that type of reaction as much because…they've observed what the chaplains do in the hospital. So normally if there's a negative connotation, it has more to do with their past experiences with the [SHP]. Instances when SHPs reported they did feel unwelcome or experience resistance included a lack of relationship with the nurses, previous negative exposures, trauma reactions, or in combination with other resources that nurses might view as unhelpful. McKenzie described how “it's really difficult to provide spiritual care to older, more experienced nurses until you have built a relationship.” When sensing hesitancy from a nurse who was referred to the SHP, Taylor asked: have you ever had another interaction with the Chaplain? And “Oh Yes”; and it had been with someone who was trying to force their own religious beliefs on her, and so I just kind of backed off a little bit and explained to her how I operate. They go on to say that “as a chaplain, I found out that trying to not force but even go to religion, if that nurse isn't the one bringing it up, it's going to be counterproductive.” Peyton agreed and associated resistance with the previous practice of some SHPs: “some of the chaplains or a priest, they are coming with a specific agenda right, and in our training now, as spiritual health practitioners, we’re not coming in with that agenda.” Taylor reflected on what they had learned over their multiple years of experience as a SHP and stated that it is essential to first value the nurse and their work, listen well, and always treat each interaction as “brand new,” rather than with a blanket, one-size-fits-all approach. Another barrier could be utilizing spirituality language that the nurses do not yet have in their vocabulary. Taylor described that “for me to try to bring in any language or ideas or beliefs into the conversation that they're not accustomed to simply separates us more.” SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 68 Taylor explained how the natural reaction of anger after experiencing a traumatic situation may be interpreted as resistance. For some individuals, Taylor described, their “trauma reaction often is going to involve anger, as one of the first places we tend to go as humans.” They go on to expound that: the chaplain's job is just to walk alongside the middle of that and try to support him through that anger, because the anger’s not going to stay there for most people. Once they work through that part of it, they'll be able to engage more deeply or sincerely, more honestly and seriously feel more better about being there. Another fascinating perspective on feeling unwelcome was the response of nurses to spiritual care offered in conjunction with other support, such as a CISM team. Robin reported that staff “would say they didn't have a need for it, but it wasn’t…spiritual care wasn’t wanted, it was this whole process, I'm not comfortable with it.” Brooke stated that nurses did not always demonstrate receptiveness as they would sometimes “roll their eyes and they would say no, that's not what we're looking for” when offered support from a CISM team. Their possible explanation for the nurses’ responses of “ah nah, that doesn't help any, you know, I didn't find that helpful” is “I think it's because there isn't that investigation of ‘What gives your life meaning?’. Isn't that the essence of spirituality?” By addressing existential or purpose of life questions, Brooke pondered that discussing spiritual matters would produce a greater depth of satisfaction and resolution than simply acknowledging feelings and emotions. The SHPs shared a variety of formal and informal approaches that they intuitively used while providing support to nurses. Their expertise guided their interactions, directing them to nurses who were in need of support and respecting the personal space of those who were not interested in spiritual care at the time. They also identified a potential need for an SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 69 interprofessional approach during interventions or debriefs to include SHPs to address spiritual matters, such as spiritual distress or existential questions. One concept that was unaddressed pertained to any potential barriers that may have been created by a more one-sided, paternalistic approach by SHPs rather than a collaborative approach alongside nurses. I return to this point in my Chapter Five discussion. The next section describes the impact of compassion fatigue interventions and the benefits of combining spiritual care with arts-based therapy. Impact of SHP Support to Mitigate Compassion Fatigue, Related Interventions and a Link to the Aesthetic The seven participants unanimously agreed that spiritual care is valuable for the mitigation of compassion fatigue. Caregiving, or the “giving of care,” is equated to the “giving of compassion” by Robin. Many nurses “don't understand that that is part of spirituality,” which can leave them in a compassion fatigued state if they do not view caregiving through a spiritual lens (Robin). McKenzie viewed spiritual care as beneficial in mitigating compassion fatigue because “it has the tools to provide support for the ways in which people become fatigued.” Spiritual care is useful for “pin-pointing what it is specifically…causing the depth of your angst here, the depths of your, you know, call it compassion fatigue” (Brooke). They went on to say that when providing spiritual support, valuing the spiritual in each individual “was the only way that they knew to get to the crux of the issue.” Addressing the spiritual aspect of one’s life allows for a depth of connectedness to the heart, mind and soul unlike anything else. It connects to and permeates the entire holistic being. Emerson described how “for spiritual care, our primary emphasis are three problems” which are affect (problems with feelings), existence (existential distress) and transcendence. Exploring these three areas with both patients and nurses allowed SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 70 SHPs to categorize what the individual was experiencing and apply the most appropriate intervention or guide them through a process that assisted them to make meaning of it. One way that SHPs provided support was in cases of spiritual distress, which nurses may not have even realized they were in as they did not have had the ability to name or articulate it. Spiritual distress is defined by Robin as “when everything we've always believed in doesn't seem to be working anymore, whether it's God, or the management team, or family, or it’s just not working.” Taylor agreed and stated that spiritual care can be useful for decreasing compassion fatigue as it can help explore “what worldviews have been violated.” In other words, where has the disconnect occurred between what someone believes and the reality that is happening in front of them? Spiritual health practitioners hold a unique position to be able to speak into that spiritual distress, provide frameworks that may help nurses articulate what they are experiencing, and offer further referrals if needed. Spiritual care is useful for enhancing self-awareness. Emerson equated spiritual awareness to one’s self-awareness of their thoughts, feelings, and sensations. Avery reminded nurses “what an honorable profession [nursing] is…extending your heart strings, your empathy, your compassion, your caring, your loving kindness to people,” and that this extension of care is from the spiritual aspect of themselves. Robin summed it up concisely: “it's like role of the spiritual practitioner is to remind them that what they do does make a difference.” Peyton also shared of how they remind nurses of their importance and significance both as an individual and within their profession: a lot of what I'm doing is helping people to remember who they are. What their own calling and vocation is, what their inherent value and worth is. Because it's easy as a caregiver to forget that, because you're so busy caring for the other. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 71 Peyton’s comments help remind nurses how to reconnect with their original passion for their profession and refresh their current perspective, decreasing their level of compassion fatigue. While the services of other interprofessional team members are crucial, McKenzie stated that SHPs are able to bring a different aspect of support to nurses. Although not always recipients of inclusivity, SHPs have formed closer professional working relationships with nurses over time. McKenzie reported that the SHP role has got the sense of trying to be a part of the team, so that is different to what these drop-in crisis management teams, to come into the critical incident things; the spiritual care person is on site; they are part of the team. (McKenzie) Familiarity with nursing staff forms a bridge that strengthens the sense of connectedness and allows them to get to the heart of matters that are not as freely spoken about. Providing spiritual care allows SHPs to “address the spirit in some way. That it covers all facets when we talk about the wholeness of the human body and spirit, energy fields or whatever we want to call it. I mean we're not just physical beings” (Avery). Spiritual health practitioners specialize in restoring the spiritual aspect of one’s holistic well-being. Spiritual health practitioners also view spiritual care as useful in helping nurses locate themselves within the larger health care organization as opposed to feeling insignificant. Peyton recognized how nurses may feel overwhelmed by the seeming lack of independence or influence they perceive they have: the reality is when you are a nurse in health care, you are a cog in a wheel. There's a much bigger system and you can feel undervalued or devalued, you can feel disempowered, can feel like you are, you know, being pulled in a variety of different SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 72 directions, be that by administration or physicians. You may not feel like you have a sense of autonomy. From my clinical experience, I have observed that nurses may frequently feel short of time and energy to advocate for themselves due to workplace tasks and stressors. For this reason, Peyton reiterated the importance of reminding nurses to maintain their holistic health: it’s sort of bringing it back to who they are. But also, in connecting to something larger than themselves. Ok, so when it comes to compassion fatigue,…it's recognizing that they can effectively come as an empty vessel and to gain power, to gain energy, to gain love, to gain compassion, to gain everything that they need from something beyond themselves. And so part of what I'm doing is teaching them to tap into that energy source, that endless resource…We try to do things on our own, and the whole the whole point is that when we constantly try to do everything on our own, we eventually get to the end of our rope ok. So, in my field, I'm constantly seeing people unravel and I constantly see them come to the very end of themselves. It's then when they recognize that they need spiritual care. From what the SHPs shared, the provision of spiritual care undoubtedly plays an invaluable role in the holistic well-being of nurses. As Peyton stated, it is when individuals “come to the very end of themselves” or are circumstantially overwhelmed that they recognize the need to nurture themselves spiritually. In summary, spiritual health practitioners have the skill, talent and dedication to minister to the spiritual aspect of every individual who identifies with spirituality. During times when one’s capacity has run low and resilience has all but left, SHPs have been trained to walk alongside those who are spiritually drained and help them re-establish a connection to SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 73 themselves, others and their foundational source. Though nurses may sometimes have difficulty identifying what is so burdensome, SHPs have the ability to help them articulate, make sense of, and grow through their experiences as health care providers, mitigating the impact of compassion fatigue on their everyday lives. My preliminary literature review revealed exceedingly few publications about spiritual care interventions to mitigate compassion fatigue in nurses; however, after speaking with my seven participants, it was evident that the occasional compassion fatigue intervention had been employed in local health authorities. Some of the SHPs had previously facilitated an education session specific to compassion fatigue or had incorporated the concept of compassion fatigue into a session on resilience. That being said, almost all of the SHPs had ideas of how these interventions could be further maximized or re-envisioned for the future to bring more attention to the concept of compassion fatigue and its link to spiritual health. These interventions ranged from informal meetings with nurses to retreats to formalized debriefs. Table 4 presents the interventions (i.e., support strategies) practiced or proposed by the SHPs (see Table 4). Table 4 List of Interventions for the Mitigation of Compassion Fatigue Intervention Formal (Scheduled) Compassion Cart Compassion Round Informal (Impromptu) x x Description A facilitated psychological debrief after a Code Blue using grounding techniques, guiding script, ritual, nutrition, arts-based therapy Performed as needed to provide a debrief session after a critical incident, such as a staff death; staff may verbalize thoughts/feelings Compassion Satisfaction Workshop x Workshop describing the concept of compassion fatigue and how compassion satisfaction can be obtained Formalized Debrief x In place of or alongside Employee Wellness; allows nurses to process distress after a critical SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 74 incident using grounding techniques, guiding script, or rituals Imagery x Pleasant/beautiful images of nature located on unit or in a quiet area where nurses can pause; helpful for mental “resetting” Lavender Alert (Code Lavender) x Similar to a Compassion Round; explores nurses’ emotional/mental/spiritual well-being after a critical incident Lunch and Learn x Education sessions during lunch break on the concept of compassion fatigue and link to spirituality Meditation x Similar to mindfulness, allows for mental clearing or “resetting”; improves sense of calm and focus Mindfulness Sessions x Short, facilitated sessions; helps with mental “resetting”, allowing for greater clarity and focus during work One on One Meetings x Re-Generativity x Nurses may interact with SHPs at any given time, or make an appointment, to discuss topics such as distress, empathy, compassion, resilience etc. 15-30 minute sessions, unscheduled, during a break; set up in a quiet space; self-guided art projects with existential prompts Resilience Training x Education sessions on developing resilience and increasing job performance and retainment of staff Retreats x A half-day retreat away from the workplace, focusing on nature (rock rituals, ponds, candlelight) and spiritual stories from different traditions Sanctuary Staff Orientation Tea for the Soul x x Lunch-break sessions inviting nurses to listen to soft music, and inspirational reading, and sit in solitude if desired SHP introducing self to nurses during new staff orientation in order to increase awareness of SHP scope of practice x A nutrition break while on shift (tea and baked goods); provides an opportunity for conversation on holistic (spiritual) well-being SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 75 Emerson shared how they are engaged in a variety of spiritual care initiatives, all of which could be useful for the mitigation of compassion fatigue. They mentioned running monthly mindfulness groups, which involved relaxation and allowed the nurses to “come out refreshed, they'd come out so happy.” Not only did this increase the positivity of their mood, but Emerson proposed it increased performance levels as the nurses would “come out more competent because…they switched off and they switched it back on again. It's like turning a computer on and you know, you’re rebooting.” Allowing the nurses to “reset” their minds purportedly increased patient safety along with improving job satisfaction. The purpose of mindfulness sessions, according to Avery, was “reminding us to be in the moment, nothing's permanent, just take deep breaths…know that what you're doing is of great worth and value, to not just those around you but yourself as well.” During this time, nurses were reconnected to their vocational purpose and how their role as a nurse was meaningful and invaluable to the themselves and others. The nature of the other work that Emerson was engaged in was also relevant to mitigating compassion fatigue, and included one on one support for nurses who were challenged about situations experienced in the workplace. Debriefing about complex subjects that could be ethically and morally distressing such as medical assistance in dying (MAiD) could be considered an indirect intervention for preventing compassion fatigue by mitigating the increasing levels of stress that accompany these situations. Robin offered “compassion satisfaction workshops,” which avoided promoting the negative concept of compassion fatigue. In these workshops, they would explain what compassion fatigue was and how to then obtain “compassion satisfaction.” Although not specifically targeting compassion fatigue, Robin also SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 76 orchestrated a weekly lunch-time session that they called “sanctuary.” Their inspiration for this intervention originated during their childhood: as a child we went to a bird sanctuary and my mom explained to me, it's a place where the birds came and rested and got nourished and then went back to what they had to do, which was fly south. So I had this sanctuary and there was soft music playing and people were free to come and sit and not say a word. I opened always with a very simple little era poem or reading or just some little thought. And then…if they wanted to talk to me they could, otherwise they could just sit in the solitude. Robin believed that if they could create an environment similar to the concept of how birds find rest, it could allow nurses to continue their shifts with an increased sense of being grounded and refreshed. For staff who have been involved in a critical incident, Taylor shared about a debriefing intervention that SHPs facilitated within the hospitals. In order for this to happen, they'll trigger the program that we set up. That means at the end of that shift,…one of the chaplains who's trained in the model can lead them through something we call a diffuser…takes 20-30 minutes; we usually arrange to have oncoming staffing in a few minutes early so we can get the staff onboarded a few minutes early and do it in that overlap time. And it's usually a small group; the invitation is put out to everyone who is working on that incident…but it's voluntary attendance…they are done fairly regularly, two to three times a month. Offering the intervention during the shift that the critical incident occurred on allowed for staff who were actually involved in the situation to participate and return home with a minimal level of residual distress. Taylor also provided training to those in hospital leadership. The teaching SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 77 involved “four-hour resilience training and it helps people identify what resilience is about…and stress response.” The benefit of this education is that it will ideally “translate into being able to do your job better or longer without personal impact as much. So avoiding compassion fatigue.” Another intervention that SHPs offered included “compassion rounds,” where nurses can speak about “their own thoughts and feelings in regards to” a traumatic incident, which is part of a “Lavender Alert” (Peyton). The Lavender Alert response involves a “reflective discussion” in response to an unexpected event, such as a staff death. The SHP facilitates a conversation with nurses to process their experience of the event. It involves asking “What was your interpretation of this? How are you feeling in the midst of this? How are you doing emotionally, mentally, etc.?” (Peyton). During this debriefing time, the SHP is “looking at the individual’s emotional and mental and spiritual response and perspective and well-being in the midst of it.” Sorting out the chaotic mess of emotions, thoughts and feelings allows the nurse to move beyond the distress that they experienced or witnessed. Peyton had also “just developed a curriculum that has to do with…spirituality and existential philosophy but…I'm trying to make it very nonthreatening to people who don't consider themselves spiritual. It is dealing with things with meaning and purpose and value and worth.” Working through one’s own existential beliefs equips nurses with a greater capacity to interact with the suffering of others. Other interventions that SHPs would like to have are: hire more spiritual care staff; time to speak to nurses during new staff orientations on the SHP role; greater emphasis on building resilience within the workplace culture; “a room in the hospital that when someone has experienced a trauma…that they can go sit in that room for just 15-20 minutes of quiet”; additional in-person guided mindfulness sessions; increased use of ritual, such as a “sacred pause”; incorporating items that are nutritious and hydrating into their support for nurses; more education sessions on what spirituality and SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 78 spiritual distress actually is; and exploration of an arts-based therapy approach (Robin, McKenzie, Avery, Peyton). An aesthetic or arts-based therapy approach may be a key method of encouraging nurses to assess and engage their spiritual health while at the workplace. Avery and Peyton incorporated the use of music therapy, which is inextricably linked to the aesthetic world. Peyton shared about their background of theatre and music, and how “art and spirituality naturally go together.” They talked about how “tapping into that creative self and creativity is generativity, and so it's sort of fuel, and it gets people out of maybe a mundane clinical setting and brings colour to what could be a very sterile environment” (Peyton). In response to this, Peyton reported their engagement in an initiative called Re-generativity. So it’s creating both staff open sessions and using creative elements in that, but it's hosting decompression rooms for staff breaks that will lead selfguided sessions. It's…self-guided art projects that staff can do as a decompression break, and all of them have existential prompts to them. So they’re creative projects that can be done in either 15 minutes or 30 minutes. And they are soul-care for staff in essence. And it gives a reflective prompt, something for the staff to think about but then they get to respond with a way to create. The word “regenerative” pertains to the ability “to regrow or be renewed or restored, especially after being damaged or lost” (Dictionary.com, n.d.). While nurses may not identify as being “damaged or lost”, there is an element of hurt and distress that develops with compassion fatigue. Because compassion fatigue results in an exhausted and potentially withdrawn individual, there is an identified need for restoration and reconnection, which regenerative interventions such as this arts-based one can be beneficial in facilitating. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 79 Robin described the use of pleasant imagery that may temporarily alleviate stress. They suggested that a staff bathroom be decorated with beautiful images, such as pictures of nature, and a sign be placed on the door that nurses could indicate that they needed a few minutes of alone time. This could provide temporary distraction from the current environment and allow the nurse to reconnect their distressed parts of self to their foundational source or simply reset their frame of mind. Avery explained how they routinely distribute a poem of blessings for nurses in order to encourage them and remind them of the greater significance of their work. They print up the poem “on pretty paper and tie in a ribbon and walk around and just hand it out to nurses” in order to reconnect them to their vocation. Other SHPs utilize metaphors or imagery that may assist nurses in processing what they are experiencing. One SHP stated they were taught that the crisis within a crisis is not having the words to explain it… my job was to help them find the words. That has always stuck with me so, “How can I help you find the words?”. That usually means I need a metaphor, or a picture, because you're not just going to sit down and tell me how bad it is (Robin). On one unit that had recently suffered several patient deaths, Robin attempted to alleviate their compassion fatigue by using the imagery and metaphor of a Pieta. They described how they got a bunch of pictures of Pieta…it’s Mary holding Jesus in death, the Roman sculpture. But “you are Pieta as a nurse when you're with someone, holding them in death.” And so I just showed…pictures of like a fireman carrying a child out of the building…then I would show them pictures of a nurse and say, “You're a Pieta…what does it feel like to be a Pieta? what does it feel like to hold someone, to have their life in your hands? And that's the shifting point…but before that it was just, the job was too much and that would SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 80 make them tired; then they would realize there was compassion there and that’s what was tired. By giving the nurses a parallel visual example to the work they were doing, the SHP renewed the nurses’ perspective on the nature of their work, reminding them of the sacredness of the actions they carry out. The SHP also reminded the nurses of their competent capability to carry out their duties, but how their caregiving can exact a significant amount of energy and compassion which must be regenerated by connection to a source both within and outside of themselves. Peyton provided a couple of metaphors to describe how nurses need to be aware of their own spiritual health, capacity or resiliency, and where their source of strength originates from. They explained that when nurses realize that they can't do it themselves, they open themselves up to being attached to a greater force, whatever that might be. You know, they talk about…guys in the military that get to what they feel is the end of their rope. And the training in that is to know that when you get to that point, it means that you actually have forty percent left. So it's sort of recognizing ok, you know you have resources that you're not accessing. You have power that you're not accessing, energy that you're not accessing. You’ve got respite and compassion, and grace and kindness and gentleness that is above and beyond you, that you need to attach yourself to and be in the flow and channel it out. And so it's sort of like a light bulb attaching to the light socket right? And being connected to that energy flow, so part of meditation and prayer and all of these things that…are combining spiritual care and sort of helping people to connect with those resources. By using a metaphor from another profession, Peyton gave clarity to the disconnect that can occur between one’s capacity for resilience and their regenerative foundational source. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 81 The list of compassion fatigue interventions is ever-growing as more attention is paid to this salient concept. The SHPs in my research study shared about the work they already engaged in to mitigate compassion fatigue, as well as the great potential for future implementation and maximization of these interventions. An arts-based therapy approach may assist nurses in understanding the connection between compassion fatigue and spiritual well-being and provide them with techniques to prevent compassion fatigue from becoming debilitating. Next, I will address how the COVID-19 pandemic has affected SHPs work. Implications of the COVID-19 Pandemic The COVID-19 pandemic has ostensibly exaggerated the need for spiritual care (Ferrell et al., 2020; Galang, 2021; Ribeiro et al., 2020; Roman et al., 2020). When the COVID-19 pandemic first began, Avery reported how SHPs’ attention was primarily focused on nursing staff: there was so much confusion, and fear, and panic…I realized very quickly that the spiritual care that was needed the most was with the staff, in particular the nurses. So about 90% of my time…for a couple months was focused on the nurses. Peyton explained that there was a heightened demand for spiritual care support in response to fear from the “what ifs”: So [workload] has increased. Immediately when we went into lockdown, there were a lot of team leaders that were reaching out to me asking me to do meditations for their team…because so many of them were watching the media and social media videos of what was happening in Italy and Spain…people were just getting freaked out, right? And we just didn't know what was coming towards us, and so it was more the anticipatory fear SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 82 of being overwhelmed and not being able to cope, and not knowing how it was actually going to land on our health system or what it was going to take. An increase in SHP utilization was also reiterated by Taylor, who reasoned that it was caused by the fact that “individually, folks that maybe a year ago, they had enough space to absorb this one and not have it could be troublesome in their life. Now immediately they’re hitting the ceiling and it's becoming troublesome.” In addition to fear and anxiety at the start of the pandemic, Emerson noted a trend in what nurses were saying about the “unknown.” They stated that “the theme kept coming up the most I just feel like I'm just at the edge of the unknown.” Emerson explained that “our CP (clinical pastoral) education primarily functions around that theme…we help people get close to the edge of the unknown in their relationships…and helping them just sit there and hold it with them.” From my perspective, nurses, or human beings in general, are not comfortable with the unknown as it tends to cultivate apprehension. Brooke talked about how the unpredictability of the pandemic disrupted the certainty of what nurses knew and could rely upon before. Nurses’ dependency on previous policies and procedures had been shaken because “it's new for everybody, you know everything is new, and yes, we know more now in the second wave than we knew in the first wave but there is still so much uncertainty of things.” Pertaining to the increased amount of stress and tension that was experienced, McKenzie found nurses “were burdened, they needed to talk, they wanted to talk, they would talk.” McKenzie shared a story about how they had “a community nurse tell me that they are so exhausted and she said, I just want somebody to ask me how I am.” The nurse also expressed a desire to leave their position when the pandemic is over due to the fact that they “are so exhausted of the fear, the risks that SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 83 community nurses have to go into the unknown COVID situations” (McKenzie). This extreme decision to leave one’s workplace reflected the amount of stress and pressure nurses were facing. Spiritual health practitioners shared additional perspectives on how the pandemic was personally affecting nurses. McKenzie described how “generally COVID shook everything up”; it was like a “cloud that descended over us all” and provoked “existential anxiety.” They observed that staff were “manically trying to move it then they were sitting in catatonic state of waiting; oh, there's no one here; we don't know what next week’s going to (bring).” The amount of preparation for an impending catastrophe left nurses in a hypervigilant state of defence. Taylor reported that they were contacted to provide support “because the nominal stress level, instead of being at a three is at seven, there's less room for people to absorb trauma.” After the initial first wave of the pandemic, McKenzie got the message that people were really not only tired, there was a sort of resigned grimness about it; oh, we all felt it. Oh no, this this thing is not just going to be here for months, this feeling like we are going to be in this for a long time and now the meals are gone, and the cheering is gone and then also you had some of the units incredibly understaffed. The overwhelming uncertainty of being on the front lines during a pandemic and the prolonged period of working in “crisis mode” has contributed to an increased level of compassion fatigue for many nurses. Adjustments that SHPs needed to make during the COVID-19 pandemic ranged from the mode of delivery of support to the content they provided. In one health authority, the pandemic actually brought SHPs closer to the bedside as they were required to wear hospital issued scrubs or the same uniform that nursing and other staff wear if they were working on units with SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 84 COVID-19 positive patients (McKenzie). Normally, SHPs’ attire consists of business-casual street clothes. The scrubs provided an increased sense of inclusion, while at the same time raised the question of who was “essential” to be at the bedside. McKenzie went on to say that despite having the training for donning and doffing personal protective equipment to adhere to infection control precautions, their presence was not always welcomed, as staff were functioning under the premise of “no clergy’s allowed, no family’s allowed, nobody's allowed in there.” Other SHPs reported restrictions on group size for support or mindfulness sessions, such as “one on ones” (Emerson) or “multiple small groups instead of one larger group” (Taylor). Mode of delivery was sometimes changed to online or via telephone instead of in-person, and previous support that involved food items or additional equipment stored on a unit was “shut down” and cleared away (Emerson). For their response to the pandemic, Peyton shared that they have been creating curriculum for support sessions pertaining to more “heart knowledge” and respite than “head knowledge.” This indicated that nurses’ minds were over-crowded with the ever-changing onslaught of information that was required for their jobs, but that they also needed to be cared for. They also increased the number of staff wellness sessions, available both via an online platform (Zoom) or in-person. The in-person sessions were a priority for Peyton, as they observed increased efficacy of spiritual support when it occurred face to face, reflecting once again on the value of connectedness. Overall, the SHPs observed that the COVID-19 pandemic exacerbated pre-existing levels of stress, created doubt, fear and chaos, and caused an overall increase in the need to address existential questions and spiritual well-being. The pandemic has actually created an opportunity and space to focus on spirituality where it previously may have been ignored. Despite limitations on resources and availability, the SHPs in my study reported how they were able to contribute to SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 85 this identified need and aspire to continue meeting the spiritual needs of health care staff in the future. Summary The content from these seven interviews provided rich data that informed the experience of SHP support for nurses for the mitigation of compassion fatigue. Thematic analysis revealed three broader themes over a series of subthemes. An overarching theme on the power of connectedness was intertwined throughout the three main themes. This spoke to the vital need to be connected to the parts of oneself, others, and a foundational source outside of oneself. Not only does connectedness contribute to a holistic balance of one’s well-being, it is also integral to possessing capacity, resilience, and self-awareness, all of which can affect one’s level of compassion fatigue. Spiritual health practitioners found that nurses were often in various states of compassion fatigue or spiritual distress when a “disconnect” had occurred within themselves or between another person or their foundational source. The participants’ responses to the interview questions prompted critical thought towards the actual place and role of spirituality in health care and how it has evolved from its historical roots. Cultural and societal factors, along with a strong embrace of the medical model, have shifted spirituality’s hierarchical place lower within health care. This shift has resulted in reduced time and space to incorporate the spiritual within both patient care and a nurse’s personal routine. Nurses may now be experiencing the tension of needing to provide more person-centered care while working within a system that does not create space for it. Spiritual health practitioners provided a collective definition for spirituality and illuminated how diverse spirituality is for all individuals, requiring contextualization of care depending on the person they are supporting. Attention was also briefly but consistently paid to the exemplification of SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 86 spirituality in leadership and how this either fosters or hinders the spiritual awareness of others depending on how it is carried out. Spiritual health practitioners provided further insight into the concept of compassion fatigue, how they believe it affects nurses, and what factors they identify contribute to it. They shared their perspective on how they don’t think nurses are very spiritually self-aware, or may actually be aware of their thoughts, feelings and emotions but do not have a framework to organize and process them with. A major recurring subtheme within this theme surrounded the lack of consistent, familiar language to speak about spiritual matters or make links between one’s spiritual well-being and compassion fatigue. Lastly, the SHPs gave greater understanding to their role, the types of support they provide, and why they perceive spiritual care as impactful for the mitigation of compassion fatigue, especially during the COVID-19 pandemic. Spiritual care was perceived as useful for the mitigation of compassion fatigue in nurses because SHPs have been equipped with the frameworks, theories and techniques that assist others to explore areas of spiritual distress, identify what they are experiencing, and acquire the skills needed to comprehend and maximize their spiritual health. The following chapter delves into discussion of these themes and how they contribute to current literature on the topic. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 87 Chapter Five – Discussion The perspectives shared by SHPs about the delivery of spiritual support in health care and how it relates to compassion fatigue among nurses was enlightening and thought-provoking. Conversation about the concept of compassion fatigue and the support that SHPs provide prompted further questions regarding spirituality within health care generally. While some of the data shed positive light on how spiritual care can mitigate compassion fatigue, other data stirred me to further investigate why spirituality in health care is in some ways overlooked and how this has affected nurses’ current state of well-being. In light of this, an additional analytic research question post-data collection was added to my original list of research questions: What are the contextual factors that shape spirituality within health care? This chapter answers the following research questions by discussing the three main themes that arose from the data. Question one, What are the contextual factors that shape spirituality within health care? will be answered by discussion of the theme (De)Prioritization of the Spiritual in Health Care. This looks at historical and current influences that have shaped the concept of spirituality in health care and provides background to inform the following research questions. The second set of research questions asked: What perspectives do SHPs hold on how self-aware nurses are of their own emotional/spiritual well-being after a critical incident such as Code Blue? Do SHPs think that nurses link their well-being to compassion fatigue? In response is the theme SHPs’ Perception of Nurses’ Compassion Fatigue and Lack of Connection to Spirituality. This describes the SHPs’ perspectives on why they believe nurses do not associate spirituality and compassion fatigue, and why nurses may find it challenging to be spiritually selfaware in the workplace. Finally, the third set of research questions were: How do SHPs describe the support they offer to nurses? What links do SHPs make between such support, bearing SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 88 witness to suffering, and the mitigation of compassion fatigue? Has any change in support been noted since the start of the COVID-19 pandemic? These are responded to by the third theme, The Nature of SHP Support, which describes the value of formal and informal provision of spiritual care for nurses and the exaggerated need for it during the COVID-19 pandemic. The overarching theme of The Value of Connectedness will be addressed throughout the discussion of the main themes, highlighting the deep-seated need for connectedness to oneself, others, and a foundational source. (De)Prioritization of the Spiritual in Health Care The comments made by SHPs on the philosophical and theological origins of spirituality in health care and their perceptions of how societal, cultural, and scientific influences have altered our sense of its belonging over time prompted me to ask how this shift has affected the spiritual well-being of nurses today. My curiosity extended even further as I questioned not only a nurse’s ability to be aware of their own spiritual needs but also their awareness of the spiritual needs of those around them. A few of the SHPs alluded to the notion that if they were able to minister to the spiritual needs of nurses, it would not only impact the nurses’ spiritual well-being but also ripple out to positively affect patient care, and even more broadly, the organization itself. This section discusses this notion, with an exploration of the question: What are the contextual factors that shape spirituality within health care? Historical and modern influences on spirituality in health care are examined along with the prioritization and exemplification of spiritual care by leadership. The Shifting Tide of Spirituality When one hearkens back to the historical beginnings of nursing, they will note, irrefutably, the religious foundations from which nurses established their practice. From SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 89 medieval times to the post-Reformation era through to World War II, nurses operated out of a sense of calling that was usually founded in a religious background, such as Christianity or Islam (Alshmemri & Ramaiah, 2021; O’Brien, 2018). During that time, it was considered “valid nursing work to read the Bible to a patient or to pray with him,” but since mid-20th century, what was considered permissible when providing spiritual care significantly changed (Barnum, 2006, p. 9). Spiritual care within nursing transformed with the shifting paradigm towards the scientific or medical model (Balboni & Peteet, 2017; Barnum, 2006; Richards et al., 2006; Taylor et al., 2015). Religion was replaced by a greater focus on “bodily health, cure, and physical comfort as chief love or ultimate concern” (Balboni & Balboni, 2019, p. 297). Anything not explained by science was presumed “illusory”, hence a general aversion developed towards openly addressing spiritual matters (Barnum, 2006). A decreased connection of health organizations to religious institutions ensued. An example of a concept that has been greatly impacted by the medical model is death. Harvard scholars, theologian Michael Balboni and palliative physician Tracy Balboni, observe that conceptualization of death, particularly in settings other than hospice, has evolved over the years, becoming increasingly institutionalized, depersonalized and marginalized by medicine (Balboni & Balboni, 2019). There has been a shift away from the expectation and reality of death, with focus now placed on cure and long life rather than care (Balboni & Balboni, 2019). The giving of compassion is synonymous with the giving of care, but if the focus of the institution is on curing rather than caring, nurses will find themselves in a state of contention when the cure does not work, contributing to compassion fatigue. Balboni and Balboni (2019) explain that religion, which was once closely tied to the provision of patient care, offered a sense of hope, moderation, and acceptance in the face of death. The “optimism that any disease can be overcome through the diligence of science” in today’s health care model and SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 90 separation from religious influences can result in feelings of angst, regret and distress when death is the result (Balboni & Balboni, 2019, p. 99). These negative feelings in response to endof-life situations or other critical incidents can then accumulate and contribute to the level of compassion fatigue that nurses experience. Alongside this divergence away from religion came the emergence of spirituality in health care. In Canada in particular, the focus or prioritization of religion changed as health care became government funded and was no longer closely influenced by religious organizations (Reimer-Kirkham et al., 2020). This change led to the implementation of chaplaincy, or provision of spiritual care by those trained in a more standardized approach to spirituality. Chaplains, or SHPs, have since adapted to provide a broad, non-specific form of spiritual care in order to diversify from the original connections to any one religion. In their book Prayer as Transgression?: The Social Relations of Prayer in Healthcare Settings, Reimer-Kirkham et. al (2020) provided a specific example of how changes in terminology are reflective of a shift within spiritual care away from the traditional roots of religion. Terms such as “ministry” or “pastoral” are no longer being encouraged, but rather “clinical” or “spiritual” are taking their places (p. 88). While these changes in vocabulary are not viewed negatively, they are indicative of the broadening chasm between religion and what is defined as spirituality and may have more implications than we recognize. This gap may have contributed to what my participants observed as the lack of common language used to speak about spirituality and also a decreased awareness amongst nurses of their spiritual well-being and that of their patients. The shift in prioritization of spirituality was commented on by the SHPs in my study. They spoke about the challenge of inserting themselves as a member of the health care team and having their scope of practice accurately recognized (McKenzie & Robin). Emerson, however, indicated that a rekindled SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 91 societal interest in spirituality may assist in increasing clarity and awareness (Bone et al., 2018; Pesut et al., 2012). As the concept emerged, spirituality was defined more along the lines of “a broadly inclusive concept that is concerned primarily with human meaning, purpose and connectedness” (Pesut & Sawatsky, 2005, p. 127). Although arguing from a drastically different reductionist perspective, Paley (2008) also drew attention to the loose definitions of spirituality that are presented without questioning or reference and used liberally within health care. If we detach spirituality from its “historical associations,” it becomes “transformed into a sort of giant conceptual sponge, absorbing a lavish and apparently inexhaustible range of items,” which he listed as ideologies borrowed from religion, art, connectedness and energy etc. (p. 5). The problem with spirituality becoming so ambiguous is that it is not “subject to anything more stringent than the requirements of personal preference” and results in “radical individualism” (Paley, 2008, p. 5). Pesut and Thorne (2007) provided another caution for how we use spirituality within health care, saying that “rather than recognizing a variety of worldview approaches to spirituality, which include religious approaches, there has been a tendency to adopt a generic, universal approach that paradoxically marginalizes difference” (p. 398). Balboni and Peteet (2017) suggested that the broad definition of spirituality is not meaningless but rather inclusive for the purpose of providing “compassionate, whole-person care” (p. 328). Statements like this cause us to question the ability to reach a consensus on the definition of spirituality and how it is being exemplified in health care today (Pesut et al., 2009). As the tide of religion and spirituality within health care ebbed and flowed over the centuries, and more recently within the past several decades, we must ask ourselves how spirituality is currently prioritized and utilized. Despite the commonly held belief that humans SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 92 are comprised of both body and spirit, a significantly greater percentage of time is focused on the physical rather than the spiritual within health care (Heidari et al., 2020). Physicians and nurses in general pay more attention to the physical presentation of their patients than the other aspects. Even when spirituality is addressed, other challenges may arise. Recognition that an individual may not identify as spiritual must be taken into consideration. Pesut et al. (2009) suggested that an appropriate place to start inquiring about personal spiritual beliefs is to ask if the individual holds spiritual beliefs and if they believe spirituality could influence their health status. Conversation could then be directed from this neutral starting place. Despite positive attributes of engaging with spirituality within the health care context, spiritual care seems to be prioritized much lower in the hierarchy of health care, as evidenced during the COVID-19 pandemic. A variety of opinion pieces and scholarly articles have recently been published on the need for spiritual care in light of the COVID-19 pandemic. Cones (2021) illuminated the contentious issue of what was actually considered to be an essential service during the pandemic. While understanding that the decision to refrain from in-person worship gatherings was based on an attempt to decrease transmission of the virus, churches questioned the label of being “nonessential” (Cones, 2021; Del Castillo et al., 2020). In the region where this study took place, one health authority assigned SHPs as an essential service and thus they provided face-to-face, bedside care, while the neighbouring health authority did not name SHPs as an essential service, resulting in the adaptation to virtual spiritual care provision. Such contextual factors impacted the sense of belonging that SHPs experienced working alongside health care workers who were considered “essential.” McKenzie shared about the tension experienced on the COVID-19 hospital wards, having received the infection control training to be present alongside nurses to work with patients yet being told by nurses that they were not welcome to enter the patients’ SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 93 rooms. Previous research has established a positive association between physical and mental health and one’s spirituality or religious affiliation, and therefore could be useful in mitigating the negative mental, emotional and spiritual effects of the pandemic (Bentzen, 2020; Cobb et al., 2012; Hall & Powell, 2021; Jim et al., 2015; Seybold & Hill, 2001). Not only does spirituality have a positive impact on aspects of health, it also has been shown to have cost-saving measures by shortening patients’ length of hospital stays and improved retainment of staff (Hall & Powell, 2021; Liberman et al., 2020). Although the need for spiritual care was vocalized during the pandemic, attention was focussed primarily on physical aspects of care, reinforcing the embrace of the medical model and suggesting that spirituality has been ranked lower in the hierarchy of health care priorities. The manner in which spirituality is modelled by those in leadership also speaks volumes to how it is prioritized and is discussed next. Setting the Tone Although spirituality in organizational leadership and its effect on workplace culture warrants its own thesis, it bears mentioning here as multiple participants in my study alluded to the importance of this connection. There is a significant and growing amount of literature on the exemplification of spirituality in leadership (Pirkola et al., 2016; Rushton et al., 2015; Williams et al., 2018; Zhang et al., 2019). Reimer-Kirkham et al. (2020) proposed that aspects of spirituality in health care are “fundamentally shaped by the core priorities and values of a healthcare institution” (p. 71). Leaders who demonstrate spiritual characteristics and qualities, such as humility, transparency, flexibility and self-awareness create an environment that fosters “belonging, motivation and commitment” (Ribeiro et al., 2021, p. 602). An article by Hooper et al. (2010) addressed ways in which management can exemplify and promote spiritual qualities such as connectedness amongst nurses who are at risk of experiencing compassion fatigue. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 94 Hooper et al. (2010) stated that those in leadership positions “should focus on strategies that emphasize relationship-centered values and promote a culture of caring that recognizes the extraordinary acts of staff with patients on a day-to-day basis” (p. 426). Exemplification of spirituality in leadership not only contributes positively to workplace culture, but also promotes a sense of “well-being, job satisfaction, personal motivation and quality of care” (Ribeiro et al., 2021, p. 603). It can also increase recruitment and retainment of nurses and improve magnetism of the workplace, which can have cost-saving benefits to the organization (Ada et al., 2021; Hall & Powell, 2021; Liberman et al., 2020; Pirkola et al., 2016). Other characteristics that spirituality promotes include creativity, intuition, honesty, trust and personal fulfillment, which positively shape workplace culture (Cruz et al., 2020; Houghton et al., 2016). Another way in which leaders demonstrate how they prioritize spirituality in the workplace is through the offering of supportive interventions. From what I have observed in the literature and from my interviews, the majority of these interventions are not specific to compassion fatigue, but rather address concepts like mindfulness or “emotional first-aid” for situations that are morally or ethically distressing (Corcoran, 2020). These interventions, however, have a role in mitigating compassion fatigue by assisting nurses to articulate what is burdensome to them. When these interventions are scheduled links to the value that organizational leaders have placed on their employees. From personal experience, if the interventions occur during a shift, an education leave may or may not be granted for the nurse to attend the intervention depending on the availability of staff on that shift. Nurses are sometimes able to have another nurse cover their assignment as they attend the education session but are frequently inattentive to the information provided as they are preoccupied by their patient assignments. Nurses from the Compassion Cart study (Drake et al., 2020) shared that while SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 95 having an intervention occur during their shift is helpful, they can only concentrate on what is being shared if they know that their patients are being cared for in a safe and timely manner; if not, they reported being distracted by the many nursing duties awaiting them when they returned to the bedside. If the intervention occurs on a day off, nurses are expected to attend on their own time, uncompensated. As Peyton described in the interviews, they think that nurses feel most valued when interventions occur within their scheduled shift and additional staff are brought in to cover their assignments. There is recognition that this investment in nurses comes at a financial cost to the organization, but allocating resources for this purpose does prevent nurse turnover by preventing compassion fatigue and increasing job satisfaction in the long-run (Aycock & Boyle, 2009; Hall & Powell, 2021). Exemplification of spirituality by organizational leaders, be it charge nurses, managers, senior leaders, or others, can promote satisfaction and meaning within the work that nurses do (Harris & Griffin, 2015; Wu et al., 2020). Nurses will ideally feel greater freedom to express their emotional thoughts, feel heard, and find purpose and community within their workplace (Wu et al., 2020). This type of workplace culture creates an increased number of outlets for nurses to decompress and prevent compassion fatigue. If possible, interventions pertaining to the spiritual well-being of staff will be offered during their shift in an environment that allows nurses to fully engage with the support being offered. An added benefit of establishing this supportive milieu is the reduced cost associated with nursing turnover. Based on this analysis of my findings, it seems spiritual health practitioners must also work in collaboration with nurses to offer support that is relevant and applicable to their identified needs, as opposed to providing subjective care. Next, I discuss how nurses can optimize their spiritual self-awareness and expand their vocabulary pertaining to spirituality. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 96 SHPs’ Perception of Nurses’ Compassion Fatigue and Lack of Connection to Spirituality This section examines the perspectives that SHPs shared regarding nurses’ spiritual selfawareness and their ability to link compassion fatigue with spirituality. The findings, based on my interview participants’ views and those of the nurses from the Compassion Cart study, answered the following original research questions: What perspectives do SHPs hold on how self-aware nurses are of their own emotional/spiritual well-being after a critical incident such as Code Blue? Do SHPs think that nurses link their well-being to compassion fatigue? I will also discuss these findings in light of the literature, specifically to offer deeper analysis of how the shifting tide of spirituality in health care has impacted nurses’ ability to identify and articulate their own thoughts, feelings and emotions and contributed to a loss of vocabulary used to speak about spirituality in health care. Spiritual Self-Awareness From the perspective of the seven SHPs in my study, along with the expert stakeholders from the Compassion Cart study, nurses demonstrated a general inability to make sense of their thoughts, feelings and emotions shortly after a critical incident or make a link to a larger concept like compassion fatigue. The SHPs interpreted this inability as indicative of a low level of spiritual self-awareness. In the discussion and interpretations that follow, I make every effort to account for the fact that these observations have been filtered through the lenses of the SHPs and not the nurses themselves. Recommendations for a more inclusive perspective on nurses’ spiritual self-awareness will be addressed in Chapter Six. Occasionally, nurses who sought support from SHPs would be able to articulate what they were experiencing, such as compassion fatigue, but the shared observations by SHPs and expert stakeholders indicated that most nurses were not naturally inclined to do this. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 97 Academic literature gives insight into the factors that might be influencing this lack of connection between nurses’ spiritual well-being and compassion fatigue, such as: decreased involvement of religious institutions in health care; (de)prioritization of the spiritual in health care; no prior personal engagement in existential questioning; unclear personal spiritual beliefs; lack of spiritual preparedness in nursing education; and vagueness of vocabulary used to speak about spirituality (Ali et al., 2018; Ang et al., 2019; Balboni & Balboni, 2019; Barnum, 2006; Cochran et al., 2020; Emerson, participant; Galek et al., 2007; Paley, 2008; Pesut et al., 2009). In my careful analysis of the findings, I see that these factors cumulatively contributed to a workplace milieu of general unfamiliarity or avoidance of spirituality, both at personal and organizational levels. From what the SHPs shared, ways in which spirituality can be fostered in the workplace include simple staff education sessions on what spirituality is, the support SHPs offer, and encouragement to question one’s own worldview. Establishing these basics of spirituality is necessary, as evidenced by the lack of a common language used to address spirituality. From what the nurses described during the focus groups of the Compassion Cart study, they do experience a variety of emotions from patient care situations, and report having a lingering negative impact from some critical incidents (Drake et al., 2020). Nurses reported experiencing emotions such as feeling numb, fearful, vulnerable, frozen, or anxious during a Code Blue scenario. They also described some situations as traumatic or chaotic or they blocked out certain stimuli during or after the incident because of their stress responses. This could potentially affect the delivery of safe patient care, as one nurse stated that sometimes there are “just too many things bothering you and then you can’t really focus on everything.” One nurse stated that she had long-lasting psychological side-effects of two traumatic Code Blue situations SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 98 that she would carry “to her grave.” Many other nurses recalled specific Code Blue situations that continue to stick with them or are vividly replayed in their minds. Some nurses reported experiencing physiological reactions more indicative of PTSD symptoms, such as nausea, sweaty palms, increased heart rate and distinct picturing of the faces of patients and their families, while recalling these critical incidents. These nurses collectively shared how the suffering they had witnessed had lingering psychological, emotional and spiritual effects, although not particularly named in this manner. One personal observation that I made while facilitating the focus groups was that the nurses initially focused on the clinical aspect of the critical incident and then as the conversation deepened, they would describe their mental or emotional reaction to the situation in a fragmented way. None of the nurses independently made a direct link to their spiritual wellbeing or compassion fatigue, similar to the findings from the SHPs. Considering these conversations were held prior to the COVID-19 pandemic, I would anticipate that nurses have since experienced increased stress levels due to the added complexity of nursing during such unpredictable and extraordinary times. Each nurse may vary in their timing and ability to be more spiritually self-aware, requiring a variety of spiritual care approaches in order to mitigate compassion fatigue. The nurses provided differing feedback on the timeliness and manner in which they process critical incidents, some preferring time and solitary space, while others desired a facilitated psychological debrief immediately following a critical incident. One nurse reported not having the time to think or feel during a critical incident, but reflected on the situation afterwards, when leaving their shift or while at home. Linking back to the timeliness of when SHP support interventions are offered, it is important that support is widely available to nurses depending on when they identify a disconnect within themselves or to others. While limited resources may be a SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 99 barrier to this approach, I believe that increased availability of intentional spiritual support may bring greater attention to the importance of spiritual self-awareness and decrease the stigma associated with “asking for help” (Austin et al., 2013). A healthy spiritual climate is one where nurses feel supported spiritually and also have the freedom to express themselves spiritually (Zhang et al., 2019). Nurses may decrease their level of compassion fatigue by correctly identifying what they are experiencing (i.e. being more spiritually self-aware) and consequently engaging in their job with increased efficiency, satisfaction, and commitment (Zhang et al., 2019). According to personal experience, feedback from the Compassion Cart project, and participant Peyton, nurses will also feel more valued from an organizational perspective if support interventions are easily accessible and routinely offered in an intentional manner. Ultimately, nurses’ spiritual self-awareness leads to a greater connectedness within oneself and to others, such as SHPs, which can help to alleviate the spiritual distress and compassion fatigue that nurses experience (Taylor et al., 2015). In summary, nurses may outwardly demonstrate a lack of spiritual self-awareness according to SHPs. They also do not naturally link their spiritual well-being to phenomenon such as compassion fatigue. From the perspective of SHPs, the benefit of becoming more spiritually self-aware includes being equipped to make sense of their thoughts, feelings and emotions and hence gaining a framework to mitigate compassion fatigue with. The analysis of the findings of my study suggest it is also beneficial to collaborate with supportive SHPs for the purpose of personal and professional growth. Spiritual health practitioners believe that increased visibility of their role and more frequent interactions with nurses may improve nurses’ level of spiritual selfawareness and ability to conceptualize compassion fatigue. Part of facilitating spiritual self- SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 100 awareness includes knowing how to speak about one’s experience using a common language that others understand. The next section discusses this major gap in health care vocabulary. A Lost Language By speaking directly to the nurses in the Compassion Cart study, it would appear that nurses do have the ability to articulate the mental, emotional or spiritual distress they are experiencing, but do not necessarily categorize it as such or link their distress to a greater, cumulative concept like compassion fatigue. The language surrounding spirituality in health care has become unclear and is currently evolving according to cultural and societal constructs (Peyton, participant; Swinton & Pattison, 2010). This change has seemingly produced confusion and avoidance of spirituality in health care, possibly due to lack of spiritual self-awareness, fear of causing offence or previous negative associations with religion (Meredith et al., 2012; Swinton & Pattison, 2010; Walton, 2012). It could also be due to the (de)prioritization of spirituality in health care as evidenced by a lack of resource allocation and the repurposing of sacred spaces (Ferrell et al., 2020; Reimer-Kirkham et al., 2020). Swinton and Pattison (2010) argue that rather than using the nebulous definitions of spirituality as an excuse to elude spirituality, one should instead embrace the opportunity that spirituality gives us to address the absences identified within health care. This provides the occasion to fill those absences with a connectedness, presence or in-situ nurturing that is longed for (Peyton, participant; Swinton & Pattison, 2010). So what do we do about an evolving language that is difficult to define? One obvious suggestion is to determine a base-line definition that is broadly understood, such as Puchalski et al. (2014) described in an attempt to reach “national and international consensus” and begin with SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 101 educating those who need to speak the language. Puchalski et al. (2014) shared that after much deliberation, international consensus was reached on a definition of spirituality: Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices. (p. 646) Definitions like this, when incorporated at an organizational level, provide staff with universal language to use and a common understanding of spirituality. Spiritual health practitioners reported that nurses make the connection between their spiritual self-awareness and compassion fatigue once they have received education on what constitutes spirituality, spiritual distress, and compassion fatigue (Emerson & Taylor). Several studies highlighted the significance of providing nurses with education to increase their spiritual self-awareness, although did not specifically link to the concept of compassion fatigue (Charlescraft et al., 2010; Pirkola et al., 2016; Richards et al., 2006). After receiving education, nurses can subsequently communicate more candidly about situations that may promote compassion fatigue and therefore mitigate residual negative thoughts, feelings or emotions (Emerson). The way in which nurses can be educated about spirituality in health care will be described under the theme of The Nature of SHP Support. From what I gathered in my interactions with SHPs and relevant literature, one must also question other causes of the ambiguity of spiritual language in health care, such as the level of preparedness nurses receive in their undergraduate training, previous misconceptions, lack of spirituality within an organization’s values, or confusion amongst other similar concepts (Austin et al., 2013). Attention has been increasing towards preparing nurses to interact with the SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 102 spirituality of their patients, with many studies concluding there is a general lack of “conceptual clarity and articulation” and a decreased understanding of the philosophic roots of spirituality in health care (Ali, 2018; Bone et al., 2018; Cilliers & Terblanche, 2014; Cochran et al., 2020; Lewinson et al., 2015; Ross 2014). One study reported a low-level of spiritual preparedness in nursing students as they transitioned into new graduate positions (Cilliers & Terblanche, 2014). The students demonstrated a beginning understanding of the importance of one’s spirituality, but lacked incorporation of spirituality into practice, especially related to stress management, which is linked with compassion fatigue. Student nurses may be educated primarily in advancing technological and scientific knowledge rather than self-awareness and emotional well-being (Austin et al., 2013). While not a focus of this thesis and in addition to preparedness of the nurse, thought must also be given to include the concepts of expertise and power imbalance when providing spiritual support to patients (Kim et al., 2017; Pesut & Thorne, 2007; Johnston Taylor & Trippon, 2020). As mentioned in the first theme (De)Prioritization of the Spiritual in Health Care, nurses hold pre-existing personal and experiential understandings of what spirituality is. Their understanding can be marked by positive or negative connotations that influence the likelihood of them accessing spiritual care resources. Taylor and Peyton shared that when sensing hesitancy or resistance from nurses, a simple discussion of the SHP scope of practice may be all that is needed to decrease animosity and provide clarity of the purpose of support. As discussed earlier under the exemplification of spirituality in leadership, the clarity of SHP services is also increased when spirituality is embedded within an organization’s values, not only for patients but also for staff. Reminding nurses of the organization’s value of spirituality during staff meetings and offering practical ways this can be carried out is one way this message can be reinforced SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 103 (Harris & Griffin, 2015). Finally, it can be unclear to nurses how spirituality and compassion fatigue are linked due to the vague language used to describe these and other interrelated concepts. Because of the closely related nature of compassion fatigue, moral and ethical distress, burnout and PTSD, nurses can often be confused as to what they are experiencing, but simply recognize that something is off or not right. Nurses may also have difficulty differentiating between terms such as “self-care” and spirituality, as many of the characteristics of self-care are included under the umbrella of spirituality but simply not named as such (Adimando, 2018; Cochran et al., 2020; Grafton & Coyne, 2012; Mesquita Garcia et al., 2021). Once nurses have been educated on the difference between these concepts and how spirituality pertains to each of them, they can seek out mental/emotional/spiritual resources that are specifically useful to what they are experiencing. Ultimately, greater clarity and implementation of spiritual education is required at both the student nurse level and on the job for nurses currently working in health care (Adimando, 2018; Cochran et al., 2020). From the analysis of my data, nurses demonstrate a fluctuating level of spiritual selfawareness, although generally described as low by external observers. They also do not naturally link compassion fatigue to their spiritual well-being. This is due to a variety of factors, including personal worldviews, prior education on the concept of spirituality, degree of exposure to SHPs, the exemplification of spirituality by organizational values or leaders, and unclear language used to describe spirituality and its philosophic underpinnings in health care. Spiritual self-awareness can be increased by encouraging nurses to engage in activities such as existential questioning, educational sessions on spiritual care, and utilizing language pertaining to spirituality that is clear and commonly understood. Next, I will discuss the scope of SHPs’ practice and its usefulness in mitigating compassion fatigue. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 104 The Nature of SHP Support Where resources are available, SHPs provide a range of spiritual care support approaches to nurses (Ferrell et al., 2020). The provision of these formal or informal interventions offer nurses a form of in-situ nurturing, or a compassionate presence, that allow nurses to feel seen, heard, appreciated and cared for. In this section, I will address the following research questions: How do SHPs describe the support they offer to nurses? What links do SHPs make between such support, bearing witness to suffering, and the mitigation of compassion fatigue? Has any change in support been noted since the start of the COVID-19 pandemic? I will discuss the impact that SHPs believe spiritual care has on mitigating compassion fatigue, while highlighting potential barriers to the safe delivery of spiritual care. In-situ Nurturing From my initial literature review, I noted that the majority of research conducted on spirituality in health care pertains to the provision of spiritual support to patients and not staff. Some studies focused on self-care strategies for nurses, but did not make a link between spiritual well-being and the incidence of concepts such as compassion fatigue (Adimando, 2018; Cho & Cho, 2021; Cohen-Katz et al., 2004; Collins & Long, 2003). This section of the discussion will therefore be primarily informed by the data collected from my study, my observations as a nurse and the few recent publications I have found on this specific topic. As described in the findings, SHPs offer a variety of support approaches to nurses. These approaches range from being informal, unexpected hallway conversations with nurses to scheduled educational sessions on topics like compassion fatigue. These “chance encounters” were predominant within my interviews with the SHPs as they described the nature of their interactions. During informal interactions or “chance encounters,” SHPs intuitively followed verbal or non-verbal cues given SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 105 by nurses. SHPs viewed these cues as triggers to initiate a conversation with any nurse who displayed a sense of exhaustion, exasperation, fatigue, or some other emotion. A sense of connectedness between SHPs and nurses was implied during these encounters as relationships were initiated or fostered. Through this connectedness, SHPs practiced active listening, offered encouragement and perspective and suggested strategies with which nurses could process or transcend the distress they were experiencing. The nurses from the Compassion Cart study expressed gratitude for the opportunity to speak about their previous experiences and be acknowledged. As Peyton previously described from their perspective as a SHP, nurses desire an in-situ nurturing or caregiving for themselves just as they provide for their patients. In-situ nurturing involves being a presence or demonstrating care towards nurses (Peyton). The opportunity, accessibility and awareness of spiritual care to support nurses requires intentionality, time and space. In my opinion, creating space for nurses to process their exposure to human suffering is vital in order to create meaning, reset one’s focus, provide safe patient care, and regenerate strength. Arshinoff (2020) surmised that the grief that nurses sometimes feel after losing a patient is significant and should not be discounted lest it result in “forgotten mourners” and disenfranchised grief. She reiterated the need for “health institutions [to] provide a safe space and process to support such grief for health professionals” (p. 393). Austin et al. (2013) described the necessity for health care staff to have a safe space to dwell in to be able to experience “restful contemplation” and gain a sense of connectedness outside of their current context (p. 134). Ferrell et al. (2020) boldly claimed that spiritual care is an inextricable part of both patient and staff care: “We have seen that spiritual care is not a luxury, it is a necessity for any system that claims to care for people whether the people are in the bed or draped in protective gear” (p. e8). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 106 Understandably, nurses self-identify differently how and when they prefer to debrief or receive spiritual care, hence a variety of formal and informal interventions need to be offered (Drake et al., 2020). One recent study acknowledged the benefit of having SHPs provide “informal, immediate debriefing…after challenging clinical situations” as well as routine, scheduled interventions for nurses (Bone et al., 2018, p. 217). This allows the staff who were affected by the event on shift to be included in the debrief, as well as subsequent opportunities for follow-up support. The workplace environments that Austin et al. (2013) described, which foster hope and mitigate compassion fatigue, are ones that provide opportunities and freedom for sharing and debriefing, such as routine coffee breaks or social excursions as a group of nurses, or an open office door to speak with someone in a leadership position. Other ways that Austin et al. (2013) suggested as useful to mitigating compassion fatigue are through re-establishing connectedness to oneself, others, and a source greater than oneself, aligning with the overarching theme of my study. Relationships with others, whether colleagues or within a broader community, can be an invaluable means of re-directing perspectives and cultivating hope. These connections to others, including SHPs, offer us a source of strength to accomplish things that we otherwise would not be able to do on our own. Connectedness with others is described in a Malawian context by Kaethe Weingarten (2003): One stick on its own is easily broken, but if you put sticks in a bundle, that bundle becomes very strong, so strong that you cannot break it. A spirit on its own can be easily broken. But bundled together we will not break. That is our power and strength. (p. 89) The strength found in collegiality enables us to accomplish more than we could in solitude. Nurses from another study reported feeling comforted while providing care to patients in the critical care setting knowing that SHPs were there to experience the patient’s death or difficult SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 107 situation alongside of them (Bone et al., 2018). This type of in-situ nurturing is precisely what nurses need in order to sustainably carry out their acts of compassion. Compassion fatigue interventions provide structured means of connection and in-situ nurturing between SHPs and nurses. As discussed in Chapter Four, interventions can be delivered in a variety of forms and levels of intentionality, such as prayer, a Code Lavender, a sacred pause, Tea for the Soul, or mindfulness-based stress reduction (Callis, 2020; Jacobsen & Stallwood, 2018; Kapoor et al, 2018; Koren & Purohit, 2014; Phillips, 2018). A few of the SHPs and Austin et al. (2013) mention art-based therapy as a useful means of reconnecting within oneself, or a way of regenerating strength and resilience (McKenzie, Avery & Peyton). Leaning into one’s aesthetic side of self may be useful for some nurses to mitigate compassion fatigue as it focusses on re-generativity and creativity. Phillips and Becker (2019) are amongst a growing number of researchers interested in the benefit of art-based therapy for health care providers. They performed a recent systematic review on art-based therapy for nurses and found this mode of support effective in decreasing stress levels and improving psychosocial well-being (Phillips & Becker, 2019). Art-based therapy interventions such as the one that Peyton described consisting of short, self-guided creative activities with existential prompts should be increasingly utilized as evidence emerges of its benefits to mitigate compassion fatigue. From my observations, SHPs function as brokers or liaisons for individuals who are experiencing spiritual distress (Pesut et al., 2012). As agents leading the way through the doorway of spirituality, SHPs are equipped with spiritual assessment skills, pastoral counselling, and psychotherapy techniques (Arshinoff, 2020). Based on what the SHPs shared in the interviews, a certain tension exists as SHPs assert themselves as members of the health care team, yet also wait for permission or an invitation to connect with nurses (Pesut et al., 2012; SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 108 Taher, 2020). In my opinion, part of this tension may be influenced by the general avoidance that some nurses have towards SHPs due to uncertainty regarding their scope of practice, uneasiness about the place of religion in publicly funded health care contexts, and ambiguity about spirituality itself. This tension could also be due to the fine balance between an authoritarian versus advocacy approach that SHPs have, similar to how nurses approach their patients. If nurses feel like they are being approached paternalistically, they may resist the support offered as opposed to seeking it out themselves. While the SHPs in my study did not identify a gap between the support they are able to offer and what nurses may actually need, further collaborative research is required in this area. Nurses may also hesitate to share their feelings in a group setting during a debrief (Taher, 2020). The danger with nurses experiencing compassion fatigue is that they may not intrinsically recognize the emotional withdrawal within themselves and therefore require an outside presence to provide insight and support. Spiritual health practitioners must then know how to be “brokers of diversity” or to contextualize their support for nurses, just as they do for patients of various spiritual beliefs (Lacy, 2018; Pesut et al., 2012; Taher, 2020). Nurses desire to be heard, acknowledged and supported (Aycock & Boyle, 2009; Ferrell et al., 2020). Whether or not nurses recognize compassion fatigue within themselves, SHPs can provide them with an in-situ presence that facilitates meaning-making, brings resolution or simply walks alongside nurses in solidarity. Time, space, and opportunity are essential for nurses to access spiritual care. Spiritual health practitioners must navigate their sense of belongingness on the health care team and are learning over time to become instinctual and invited brokers of diversity to meet the needs of both patients and staff. Next, I discuss how SHPs carry out this complexly sensitive yet innate service and are able to decrease the prevalence of compassion fatigue. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 109 Impact of SHP Support to Mitigate Compassion Fatigue The participants in my study shared the unanimous perspective that the provision of spiritual care is beneficial and effective in mitigating compassion fatigue for nurses. The reasons that influenced their perception included: • Spirituality provides a language for nurses to identify and express what they are experiencing (Robin & Emerson). • Spiritual care categorizes distressing issues into groups that can be deconstructed into more manageable concepts—affect (problems with feelings), existence (existential distress) and transcendence (Emerson). • Spirituality increases self-awareness by drawing focussed attention to thoughts, feelings and emotions that are troublesome (Avery, Emerson, Peyton & Robin) • Spiritual health practitioners remind nurses of their sacred positions within their vocation and the invaluableness and purpose of their work (Avery, Peyton & Robin). • Spiritual care restores connectedness to self, others and a foundational source (Peyton & Taylor). • Spiritual care addresses a vital aspect of the holistic self, restoring a balance between the physical, mental, emotional and spiritual (Avery). Collectively, these many advantages of spirituality can facilitate the prevention of compassion fatigue in nurses when employed routinely. The most recent literature on compassion fatigue and spirituality reiterates similar benefits of SHPs providing spiritual care to staff, including assisting nurses to cope with workplace stressors, increasing resilience, finding meaning and purpose within their vocation, and safely engaging with their profession (Arshinoff, 2020; Bone et al., 2018; Corcoran, 2020; Hall & Powell, 2021; Ho et al., 2016; Taher, 2020). These collective SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 110 benefits of addressing the spiritual needs of nurses and mitigating compassion fatigue cannot go unnoticed or else, as Peyton puts it, “we are going to be in a crisis.” The COVID-19 pandemic has exaggerated nurses’ current level of compassion fatigue and led us closer to a crisis-like state of unbalanced well-being (Callis, 2020; Ferrell et al., 2020; Meghani & Lalani, 2020). Nurses on units affected by the pandemic found themselves face to face with a greater threat to global health than few of them ever imagined encountering during their lifetimes. Previous experience with severe acute respiratory syndrome (SARS) has taught us that nurses can have long-lasting psychophysiological and post-traumatic stress symptoms after a health crisis like this has occurred (Kang et al., 2020). The risk of social isolation due to the COVID-19 pandemic affected the general public and health care workers alike. Nurses not only carried the responsibility of caring for patients with a highly transmissible virus in the context of potentially limited resources, but also lost a sense of connectedness to family and friends due to social distancing requirements. Ribeiro et al. (2020) acknowledged these detrimental effects and suggested that alternative means of connection, such as a phone number that health care workers can use to speak to a spiritual care provider, be in place to support nurses both professionally and personally. Roman et al. (2020) outlined how spiritual care can be used as a coping mechanism for both health care providers and patients alike, while Galang (2021) advocated for spiritual support for all those living in isolation. Galang (2021) petitioned for all those qualified in the delivery of spiritual care to potentially “extend their services” in order to decrease “stress and anxiety, increase in hope and calmness.” Galang (2021) stated the results would include both a grounded state of mind and an improved immune response. In light of the COVID-19 pandemic, Ferrell et al. (2020) called attention to health care workers as “a depleted group of clinicians, surrounded by the traumatic grief and post-traumatic stress of SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 111 frontline workers who likely have no pause button to recover and who need significant support” (p. e10). The recommendations from these articles echoed the increased requests for spiritual care that the SHPs in my study received from front-line leaders. Perhaps the COVID-19 pandemic has more visibly exposed our innate need for spirituality and will serve as a catalyst for increasing spiritual care services in health care. As Albert Einstein said, “In the midst of every crisis lies great opportunity.” In light of this knowledge, one must ask if the current health care milieu is one that is open and receptive to increasing the prioritization and delivery of spiritual care. Austin et al. (2013) suggested rather bleakly that compassion fatigue interventions, such as spiritual care, “cannot happen – or if they do, they will be unable to make a significant difference – until the corporate approach to health care is averted and its compassionate purpose reaffirmed” (p. 187). Instead, they made practical suggestions that awareness of compassion fatigue and the realities of health care be communicated, adequate breaks be taken, and support from those who understand the context and nature of work that nurses do be provided in order to mitigate compassion fatigue. Balboni and Balboni (2019) stated that connectedness between a health care provider and spiritual resources fosters “meaning, a transcendent calling, resilience in the face of suffering, and positive coping in the light of an impersonal health system” (p. 235). They describe the benefit that religious organizations can have to “counter the impersonal dimensions of medicine that have led to poor clinician well-being” and prevent the snowball effect of adverse outcomes and further inefficiencies within the health care system (Balboni & Balboni, 2019, p. 237). In light of the life-giving and career-sustaining necessity of spirituality, health care systems would be imprudent not to further integrate spiritual support for their employees. While I acknowledge the barriers of a “lack of systemic resources” and “a system prove[n] too SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 112 inflexible to adapt to the situation at hand”, my research adds to the current literature by suggesting that spiritual care can be a valuable tool for the mitigation of compassion fatigue (Austin et al., 2013, p. 148). Rather than simply concluding with the conceptualization of compassion fatigue, my research moves beyond to explore a correlation between SHPs, compassion fatigue, and nurses. Spiritual care does not have a “one-size-fits-all” approach but rather requires extensive contextualization within a secular health care system. Some ways that Balboni and Balboni (2019) suggest spirituality be universally employed in health care is with a non-compulsory, pluralistic approach, which embraces the traditions that spirituality is based upon and protects against spiritual coercion. Precautions must be taken to prevent a SHP from having “power over” or “imperialism of empathy” towards those they are supporting, as this could result in a toxic, opposite effect than intended (Mohrmann, 2008). Taher (2020) shared how those who experienced negative circumstances during their formative years (i.e. sexual abuse or dysfunction within the family unit) may have “a distorted belief system and negative image of God” (p. 328). The emotion that someone with this history may experience when receiving spiritual care could cause an unhealthy response instead of clarity, meaning, and mitigation of their distress related to compassion fatigue. Taher (2020) stated that SHPs can navigate the complexity of delivering spiritual care by being patient and observant and exhibit “diligence that is other-centered, without judgement and supportive” (p. 179). Adhering to these safeguards will enable SHPs to make healthy, constructive connections with nurses with the intent to decrease their compassion fatigue. The focus of this thesis pertains to the spiritual support of nurses rather than patients, but it is important to mention that spiritual care must not be solely allocated to SHPs. Spiritual care SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 113 allows the concept of personhood to be holistically incorporated (Bone et al., 2018; Sinclair et al., 2017). A SHP is one of the members involved in providing person-centered care which is defined as “an approach to practice that is established through the formation and fostering of therapeutic relationships between all care providers, patients and others significant to them” (McCormack et al., 2011, p.1). Whether provided by SHPs, nurses, colleagues or others, spiritual care is the collective responsibility of every individual, not simply siloed to SHPs. That being said, SHPs are viewed as experts within their field of study and should be consulted accordingly in order to avoid other clinicians working outside their scope of practice (Johnston Taylor & Trippon, 2020). An increase in spiritual self-awareness and education on spirituality in health care will assist with the safe provision of spiritual care and collaboration amongst team members. Informed by general observations and personal experience, humans rely upon an innate connectedness within themselves and to others and a foundational source for sustainability and fulfillment in life. Without it, negative effects like compassion fatigue can set in. As John Donne so famously penned during a time of personal illness, “No man is an island, entire of itself.” He recognized his reliance on and interconnectedness with others. This is particularly true in health care, as team members rely upon each other to provide cohesive, holistic patient care and require collegial support to press on in the nature of their work. In-situ nurturing offers this type of care for nurses through the provision of spiritual support. Spiritual health practitioners are in a unique position to assist with the mitigation of compassion fatigue in nurses, as their area of expertise focuses on person-centered care and brings restoration of the spiritual aspect of self (Balboni & Peteet, 2017; Koren & Purohit, 2014; Roth, 2020). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 114 Summary Spirituality is at the heart of providing care (Balboni & Balboni, 2019). If spirituality is separated from the delivery of health care, it becomes a mechanistic, depersonalized, systematic operation, devoid of compassion and focused on cure, science and technology (Balboni & Balboni, 2019; Richards et al., 2006). In the wake of decreased religious associations with hospitals, spirituality has developed to encompass a diversified, all-inclusive approach to providing support. Health care organizations have the responsibility to uphold spirituality within their missional values, in the provision of care for both patients and staff. A workplace culture that incorporates spiritual values generates an environment of honesty, appreciation, commitment and increased job satisfaction (Cruz et al., 2020). This, in turn, gives employees the freedom to communicate issues that they may identify as distressing, knowing that they will be heard and acknowledged. Current research concurs with the value of incorporating spirituality in health care practices in order to care holistically and strengthen institutions (Hall & Powell, 2021; Houghton et al., 2016; Hooper et al., 2010; Liberman et al., 2020; Pirkola et al., 2016; Ribeiro et al., 2021). Nurses may not always know how to “cope with their own feelings when they witness suffering,” which can arise suddenly or build up over time, contributing to compassion fatigue (Arshinoff, 2020, p. 397). Spiritual health practitioners report observing lower levels of spiritual self-awareness in nurses, which may be influenced by factors such as the (de)prioritization of spirituality in health care, lack of pre-existing existential questioning or personal belief systems, and a loss of common language to address spiritual matters (Ang et al., 2019). Having decreased spiritual self-awareness develops a reduced tendency in nurses being able to identify, articulate and make sense of the thoughts, feelings and emotions they are experiencing. Spiritual self- SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 115 awareness can be increased by education sessions on spirituality facilitated by a SHP along with resources that aid in identifying compassion fatigue and exploring personal worldviews. The enhancement of language pertaining to spirituality can be established through increased spiritual self-awareness and consistent communication of organizational spiritual values. Spiritual health practitioners are positioned in a unique role to be facilitators of connectedness. They are professionally trained to provide a type of in-situ nurturing for patients and health care staff through spiritual assessments, pastoral counselling, and psychotherapy (Arshinoff, 2020). Through a variety of formal and informal interventions for nurses, SHPs are able to mitigate compassion fatigue by helping nurses examine previously distressing situations, providing “broader meaning structures” and offering techniques that are spiritually restorative (Ho et al., 2016, p. 70). Spiritual health practitioners report advantages to delivering regular support sessions for staff and not merely after critical incidents, as this demonstrates that the organization values nurses’ spiritual well-being and establishes rapport for on-going support (Arshinoff, 2020). The COVID-19 pandemic has revealed an underlying desire for in-situ nurturing and connectedness in health care workers due to an increase in existential questioning, overwhelming uncertainty, unusual patient circumstances and social isolation leading to disconnectedness (Cones, 2021; Del Castillo et al., 2020; Ferrell et al., 2020; Galang, 2021; Meghani & Lalani, 2020; Ribeiro et al., 2020). Spiritual health practitioners need to ensure that they are administering non-judgemental, spiritual support to those of any faith in order to contextualize their care and navigate pre-existing triggers that some nurses may have with those in spiritual care positions (Balboni & Balboni, 2019; Karakas, 2010; Mohrmann, 2008; Taher, 2020). The provision of spiritual care is a collaborative effort. Future compassion fatigue interventions should be developed within a partnership between SHPs and nurses to increase the SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 116 relevancy, effectiveness, and receptivity of the interventions. The role of SHPs has great potential to be further maximized to equip nurses with spiritual resources to prophylactically prevent and intervene when compassion fatigue has been recognized (Houck, 2014; Liberman et al., 2020. The final chapter offers summative conclusions of the study, addresses limitations and proposes recommendations for the future. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 117 Chapter Six – Conclusions and Recommendations The journey of this thesis research has taken me from an idea inspired by my nursing practice to analyzing the rich data collected in my small-scale study to a clearer sense of SHPs experience of providing support to nurses. The last chapter of my thesis summarizes the research conducted, provides conclusions that contribute to current literature on the topic of SHP support and the mitigation of compassion fatigue, and offers recommendations under the nursing domains of education, leadership, policy, practice, and research. Summary of the Study Compassion fatigue in nurses is a topic that has garnered increasing attention over the past four decades since the concept was formalized. Little attention, however, has been focused on the link between spiritual well-being and compassion fatigue for nurses. The purpose of this qualitative thesis was to explore the perspectives of SHPs in their support for nurses to prevent compassion fatigue. I conducted this study using a qualitative interpretive description design, which involves inductive analysis of clinical concepts for the purpose of making recommendations and applications relevant to one’s discipline (Thorne et al., 2004). The methods utilized included a current literature review and thematic analysis of individual interviews with seven SHPs. Also included was a brief secondary analysis of a data set collected from a related research study. Three main themes were identified from the data: (De)Prioritization of the Spiritual in Health Care; SHPs’ Perception of Nurses’ Compassion Fatigue and Lack of Connection to Spirituality; and The Nature of SHP Support. The overarching theme, The Value of Connectedness, arose from the repeated SHPs’ observations of the need for connectedness to self, others and a foundational source in order to maintain spiritual SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 118 well-being and mitigate compassion fatigue. Several conclusions and recommendations have been made from the completion of this study, which are outlined next. Conclusions The following conclusions have been formed according to my interpretation of the research data. 1. Spiritual health practitioners have found that nurses can experience compassion fatigue due to a combination of workplace and personal stressors and require broader meaning structures to identify, prevent, and recover from compassion fatigue. 2. The literature and SHPs indicate that nurses’ spiritual self-awareness has been influenced negatively by health care’s lower prioritization of spirituality within its organizational values. This has contributed to a decreased connectedness within the self, to others and to a foundational source, all of which are buffers to compassion fatigue. 3. Spiritual health practitioners observed that nurses do not utilize a common language to address matters of spirituality, which may be due to nurses’ lack of awareness, preparedness, and minimal integration of spirituality in health care. 4. According to SHPs, few nurses naturally make a link between their spiritual well-being and compassion fatigue. 5. Spiritual health practitioners have a role in mitigating compassion fatigue by offering formal or informal spiritual support to nurses. Spiritual support is beneficial for developing awareness of thoughts, feelings and emotions; working through issues of existential angst; achieving transcendence of suffering; and providing meaning and purpose within one’s life. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 6. 119 Critical incidents should not be isolated as the only factor influencing compassion fatigue. Compassion fatigue may arise suddenly or develop slowly, impacted by a variety of workplace stressors and personal life issues. 7. Health care organizations have the responsibility to establish and exemplify spiritual values for the purpose of creating holistic, sustainable work environments. Such environments help to mitigate compassion fatigue. Recommendations Compassion fatigue has been and continues to be an on-going occurrence that nurses experience. The goal of this research was to further examine this phenomenon in relation to the provision of spiritual support by SHPs. Although the study was of small scale, the richness of the data and the interaction of the findings with extant evidence and theoretical knowledge allows for a degree of confidence in offering these recommendations. My study demonstrated inferential generalizability by providing contextual background information and thick description of each research step, particularly the findings. My desire is that this research will also hold naturalistic generalizability, or resonate with those who read this thesis (Hays & McKibben, 2021). Several recommendations for compassion fatigue mitigation can be made from the conclusions of this study due to its transferability. The interpretive description method used to execute this study lends itself to practical clinical applications within the discipline of nursing. The following recommendations will be categorized under five domains within nursing: education, leadership, policy, practice, and research. Education Nurses’ education begins at the undergraduate level and continues as a life-long commitment to learning throughout the rest of their career. Part of this education prepares nurses SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 120 to provide holistic patient care, which includes consideration of spiritual practices. Less emphasis is placed on the spiritual preparation of the nurse, as evidenced by predominantly lower levels of preparedness in new graduate nurses to incorporate spirituality into their practice (Ali et al., 2018; Attard et al., 2019; Cilliers & Terblanche, 2014; Cochran et al., 2020; Minton et al., 2018). Cochran et al. (2020) mentioned that faith-based curriculum pays more attention to holistic self-care, which is a useful suggestion for other schools of nursing to integrate similar curriculum for the spiritual preparation of nurses. The comprehension and use of spiritual practices in nursing would be enhanced by ensuring structured curriculum and standardized competencies are delivered to nursing students, which includes a focus on the philosophic underpinnings of spirituality in nursing in order to emphasize holistic care (Ali et al., 2018; Attard et al., 2019; Ross et al., 2018). Attention should also be paid to the preparedness and selfawareness of those who are providing the education (Ali et al., 2018). Undergraduate nursing education should incorporate curriculum on spiritual preparedness of the nurse for both patient care and personal spiritual self-awareness. Once nurses have begun their nursing career, it is essential that they are aware of the spiritual care services offered by their health care organization and have opportunity to receive in-situ support from SHPs when needed. Newly employed staff at health care organizations should be orientated to spiritual care services and the scope of practice of a SHP, including how and when to make a referral for patient care or personal support. This will enrich and inform the interprofessional relationship between nurses and SHPs. Collaboration between SHPs and nurses increases patient accessibility to spiritual care resources in addition to increasing nurses’ spiritual self-awareness (Johnston Taylor & Trippon, 2020). Spiritual health practitioners can assist nurses with re-establishing connectedness within themselves, to others, or to their identified SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 121 foundational source. Routinely offered educational sessions on understanding spirituality, recognizing spiritual distress, and accessing spiritual resources are beneficial for establishing a basic understanding of spiritual support, language, and self-awareness. These foundational aspects of spirituality in health care ultimately are useful for preventing compassion fatigue. Leadership The exemplification of spirituality by leadership in health care organizations positively influences workplace culture and dynamics (Karakas, 2010; Keogh et al., 2017; Pirkola et al., 2016; Wu et al., 2020). Leaders in health care first and foremost need to examine their organizational values and ensure the inclusivity of spirituality within their standards. If spirituality is not included within their organizational values, health care leaders should advocate for the recognition of the holistic self, within both patient and staff care. Second, spiritual values such as humility, transparency and self-awareness need to be visibly demonstrated by those in leadership positions. This contributes to developing healthy workplace cultures where staff experience the freedom to address workplace stressors and learn to speak a common language pertaining to spirituality (Hodge & Lockwood, 2013). The common language enables nurses to speak about their experiences in a universally understandable way, making links between concepts like compassion fatigue, personal or workplace stressors and their spiritual well-being. Workplace spirituality is an emerging field of research that is contributing to the formation of positive organizational practices and has great potential to minimize compassion fatigue levels (Cruz et al., 2020; Pirkola et al., 2016; Wu et al., 2020). Studies have revealed that organizations that enact spiritual values have improved magnetism, increased job-satisfaction and lower staff turnover, resulting in cost-saving measures (Charlescraft et al., 2010; Pirkola et al., 2016; Wu et al., 2020). SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 122 Policy Health care organizations need to increase resource allocation for the delivery of spiritual care to holistic human beings. Accreditation Canada regards the provision of holistic care, including addressing spiritual needs and preferences, as a high priority standard for patients, although recommendations for employees were not noted (Interfaith Health Care Association of Manitoba, 2017). The Canadian recommended ratio of SHPs to patients in the general acute care setting is 1:100; this number does not include the provision of support to health care professionals (Interfaith Health Care Association of Manitoba, 2017). Several of my participants mentioned the enormity of their portfolios of providing support for both patients and staff at multiple secondary and tertiary sites, which indicates the need for a higher ratio of SHPs to those they are caring for. As mentioned earlier, Ferrell et al. (2020) also points out the deficiency of spiritual care resources, stating that 54% or less of palliative care programs in the United States have a dedicated SHP assigned to them. Normally, these types of programs have a predominant spiritual care focus due to end-of-life needs. Recognition needs to be given to the fact that spiritual distress can occur during any disruption to one’s health or bearing witness to another individual’s health crisis, let alone at the end of life. This requires adequate availability of SHP services to ensure support is provided with timeliness and to patients and staff alike. When looking at the national level, the Canadian Association of Spiritual Care (CASC) competencies for SHPs contain one statement pertaining to building capacity “for the spiritual health and wellbeing among other professionals” (CASC, 2019, p. 8). While it is mentioned once on the long list of SHP proficiencies, the support of other professionals such as nurses would appear to have lower organizational priority. In the Spiritual Health Framework, British Columbian SHPs are commissioned with the provision of spiritual care to health care employees; SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 123 however, significant budget cuts to the spiritual care department at one large health authority in B.C. in the last decade has resulted in extremely limited support for both patients and staff (Ministry of Health, 2012). Spiritual care needs of staff are subsequently not being met in a visible manner. With the growing amount of research on the benefits of incorporating spirituality into the workplace, global, national, and provincial health bodies such as the World Health Organization and Canadian Nurses Association (CNA) would be prudent to update their position statements to include and promote the provision of spiritual support to nurses (CNA, 2010; Winiger & PengKeller, 2021). The only thin reference to spiritual self-awareness that the British Columbia College of Nurses and Midwives (BCCNM) has in their recently released new graduate nurse competencies is to “engage in self-reflection to interact from a place of cultural humility and create culturally safe environments” (BCCNM, 2020, p. 13). There is no direct mention of spirituality in the entirety of the document; therefore, as mentioned earlier, if there is no set expectation or competency to meet, it results in a low level of nurse preparedness to provide spiritual support aside from their 24/7 presence at the bedsides of patients, as well as personal decreased spiritual self-awareness. Nursing students, nurses, and SHPs need to collaboratively advocate to these governing bodies for the incorporation of spiritual care needs of patients and staff alike. Practice Compassion fatigue interventions or in-situ nurturing provided by SHPs should be routinely available to nurses. According to the SHPs in my study, informal chance encounters with nurses were a means to develop connectedness; remind and encourage nurses why they do what they do; and explore any thoughts, feelings, or emotions that they find burdensome. From SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 124 the perspective of the SHPs, providing nurses with broader meaning structures in moments of frustration or distress had an impact on mitigating compassion fatigue. Regularly offered compassion fatigue interventions, such as Tea for the Soul or Re-generativity breaks, acknowledge the challenging aspects of nursing and the accompanying reactions that nurses may have to these challenges. Acknowledgement destigmatizes the negativity, frustration and feelings of withdrawal that nurses may experience with compassion fatigue. Reaching out to nurses to offer support rather than nurses trying to independently conceptualize what they are experiencing conveys organizational value of the employee and care for the caregiver. Any support that is offered must be collegially delivered, voluntarily received, and relevant to nurses. One recommendation to increase relevancy and effectiveness of support for nurses would be a collaborative approach to designing and implementing compassion fatigue interventions between nurse champions who are knowledgeable or passionate about spirituality in health care and SHPs. Research From the conclusions and recommendations of this study, further research is recommended in several areas. For nursing education, additional research is needed to provide standardized spiritual care competencies for nursing students for adequate preparation and integration of spirituality within patient care and their personal practice (Ali et al., 2018; Attard et al., 2019; Ross et al., 2018). A growing amount of research is establishing the fact of the increasing prevalence of compassion fatigue amongst nurses and its causative factors (Cavanagh et al., 2020; Xie et al., 2021); therefore, attention now needs to be focused on what should be done about the problem of compassion fatigue. Spiritual care for health care staff needs to be emphasized in future studies. While smaller pilot studies have been performed on various SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 125 compassion fatigue interventions, institutional-based strategies for the identification and reduction of compassion fatigue are needed in collaboration with both nurses and SHPs to ensure the needs of the nurses are recognized and incorporated (Alharbi et al., 2019). Exploration of combined arts-based therapy and spiritual support for the mitigation of compassion fatigue should be pursued (Phillips & Becker, 2019). A representative sample in these studies would need to include the voices of nurses in addition to SHPs. For future research on the link between spiritual well-being and compassion fatigue, I would recommend the use of a mixed-methods approach, utilizing measurement tools such as the Spirituality and Spiritual Care Rating Scale, Professional Quality of Life Scale or the WHOQOL Spirituality, Religiousness and Personal Beliefs questionnaire for pre- and post-intervention evaluation, in addition to qualitative interviews or focus groups (McSherry et al., 2002; Stamm, 2009; WHO, 2012). Additional research could also be performed to develop valid and rigorous measurement tools specific to assessing health care providers’ spiritual well-being and their integration of spirituality into practice. This would aid in future research on the effectiveness of compassion fatigue interventions with a focus on spiritual well-being. Conclusion The conclusions and recommendations presented in Chapter Six caused me to reflect back on my thesis journey. Within the first decade of my career, I personally experienced compassion fatigue from bedside nursing in the intensive care unit. At the same time, I noticed a complete lack of visible SHP presence at my workplace. After participating in the Compassion Cart study, I was motivated to further investigate the impact of spiritual care on the level of compassion fatigue in nurses (Drake et al., 2020). The provision of spiritual care by SHPs for the mitigation of compassion fatigue in nurses has received minimal research focus. The objective of SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 126 this thesis was that it would aid in identifying recommendations and interventions that health care organizations could utilize for the prevention of compassion fatigue in nurses, informed by the experience of SHP support. As a person of Christian faith, I believe that the routine, transparent, carefully discerned provision of spiritual support can offer nurses a means of establishing connectedness within themselves, providing meaning and purpose, to others around them, and to a grounding, strength-giving, foundational source. The process of completing this thesis has revealed preliminary indicators that spiritual support for nurses can have a positive impact on decreasing compassion fatigue, but further research is required to ensure representative sampling, generalizability and effectiveness of potential interventions. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 127 References Ada, H. M., Dehom, S., D’Errico, E., Boyd, K., & Taylor, E. J. (2021). Sanctification of work and hospital nurse employment outcomes: An observational study. Journal of Nursing Management, 29(3), 442–450. https://doi.org/10.1111/jonm.13162 Adimando, A. (2018). 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Positive spiritual climate supports transformational leadership as means to reduce nursing burnout and intent to leave. Journal of Nursing Management, 28(4), 804– 813. https://doi.org/10.1111/jonm.12994 Xie, W., Chen, L., Feng, F., Okoli, C. T. C., Tang, P., Zeng, L., Jin, M., Zhang, Y., & Wang, J. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 145 (2021). The prevalence of compassion satisfaction and compassion fatigue among nurses: A systematic review and meta-analysis. International Journal of Nursing Studies, 120. https://doi.org/10.1016/j.ijnurstu.2021.103973 Zhang, Y., Wu, X., Wan, X., Hayter, M., Wu, J., Li, S., Hu, Y., Yuan, Y., Liu, Y., Cao, C., & Gong, W. (2019). Relationship between burnout and intention to leave amongst clinical nurses: The role of spiritual climate. Journal of Nursing Management, 27(6), 1285–1293. https://doi.org/10.1111/jonm.12810 Appendix A – Matrix for Included Articles SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 147 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 148 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 149 Appendix B Screening Screening Screening Screening Records excluded (n = 539) Eligibility Eligibility Eligibility Full-text articles excluded, with reasons (n = 36) Eligibility Screening Screening Eligibility Eligibility Eligibility Eligibility Eligibility Screening Screening Screening Screening Records screened (n = 579) Full-text articles assessed for eligibility (n = 50) Eligibility Screening Eligibility Screening Eligibility Screening Eligibility Screening Eligibility Screening Eligibility Eligibility Screening Records after duplicates removed (n = 579) Included Reasons for exclusion: Studies included in synthesis (n = 14) Qualitative (n = 3) Mixed Methods (n = 2) Quantitative (n= 4) Systematic Reviews (n = 1) Grey literature (n = 4) 1. Does not address all three concepts of SHPs, nurses, and compassion fatigue 2. Intervention implemented by someone other than a SHP Identification Identification Identification Identification Identification Identification Additional records identified through other sources (citation searching) (n = 48) Identification Identification Identification Identification Identification Records identified through database searching (n =668) Identification Identification PRISMA Flow Diagram- Hildebrand Thesis Screening Methodology SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE Appendix C 151 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 152 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 153 Appendix D Invitation to Participate Hello! If you have a moment, I would like to talk with you about the research I’m conducting on the experience of Spiritual Health Practitioners (SHPs) and the prevention of compassion fatigue in nurses. As a SHP, you are positioned in a unique role that may be beneficial in guiding nurses through examining their thoughts and emotions, and offering debriefing support after stressful situations. I am a graduate student researcher at Trinity Western University, and I am conducting research through the Master of Science in Nursing program to explore the perspectives of SHPs in their support for nurses to prevent compassion fatigue. I am looking for SHPs who have previously provided support or have interacted with nurses to participate in my research. The time commitment required will be approximately 45-60 minutes during an interview. Due to COVID-19 restrictions, interviews will be conducted virtually via the online platform Zoom, or by phone if you would prefer. Please contact me by (date two weeks from email being sent) via the contact info listed below if you are willing to be a participant or to learn more about my study. Following your agreement to participate, I will provide you with a Zoom link and we will arrange a mutual date and time for the interview. Thank you for your time and consideration, and I look forward to hearing from you! Sincerely, Amy Hildebrand RN, BScN - Principal Investigator Graduate Student, Master of Science in Nursing Trinity Western University, Langley, BC Phone: xxx-xxx-xxxx | Email: xxxxxxxxxx Thesis Supervisor: Dr. Sheryl Reimer-Kirkham, Ph.D., RN Dean and Professor | School of Nursing Trinity Western University, Langley, BC Email: Sheryl.kirkham@twu.ca SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 154 Appendix E Participant Consent Form EXPLORING THE INTERPROFESIONAL CONTRIBUTIONS OF SPIRITUAL HEALTH PROFESSIONALS TO PREVENT COMPASSION FATIGUE IN NURSES Principal Investigator Amy Hildebrand, RN, BScN, Graduate Student of the Masters of Science in Nursing program, TWU Phone: xxx-xxx-xxxx | Email: xxxxxxxx As a graduate student, I am required to conduct research as part of the requirements for a degree in Masters of Science in Nursing. This research is part of a thesis and will be made public following completion. It is being conducted under the supervision of Dr. Sheryl ReimerKirkham. You may contact my supervisor using the following information: Co-Investigator(s) Dr. Sheryl Reimer-Kirkham, PhD, RN, Dean and Professor of the School of Nursing, TWU Phone: 604-513-2121 (xxxx) | Email: sheryl.kirkham@twu.ca Purpose The purpose of this qualitative research study is to explore the perspectives of Spiritual Health Practitioners (SHPs) in their support for nurses to prevent compassion fatigue. The reason this topic is being studied is because of the increasing state of emotional distress, compassion fatigue, and subsequent burnout in nurses, which leads to high rates of nursing turnover or nurses leaving the profession. The aspect of spirituality is not routinely incorporated into nurses’ practice, which research has shown to be beneficial in decreasing levels of compassion fatigue/burnout and increasing resilience. This research will provide insight on the experience of SHPs in their support for nurses for the purpose of compassion fatigue mitigation. You are being asked to participate because you have been identified as a SHP who may have previously provided support to or interacted with nurses in a health care setting. What is involved If you voluntarily consent to participate in this research, your participation will consist of an interview which will take approximately 45-60 minutes. Due to COVID-19 restrictions, interviews will be conducted virtually via the online platform Zoom, or by phone if you would prefer. Following your agreement to participate, you will be provided with a Zoom link and we will arrange a mutual date and time for the interview. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 155 Interviews will be recorded for transcription purposes. The transcript of the interview will be deidentified so that you as a participant remain confidential. No compensation is offered for your participation; however, a summary of the study findings will be made available to you upon completion of the research study by the Principal Investigator. Potential Risks and Discomforts There are no known or anticipated risks associated with participating in this research. Potential Benefits to Participants and/or to Society There are no direct benefits to the participant as a result of participating in this research. That being said, there is potential for furthering awareness on a topic of which there is limited focused research and knowledge. This will ideally aid in identifying recommendations and interventions that health care organizations can utilize for the prevention of compassion fatigue in nurses. It will also enrich and inform the interprofessional relationship between nurses and SHPs. Confidentiality and Anonymity Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law. Confidentiality will be protected by assigning code identifiers to all research participants and documents and keeping the hard copies in a locked safe. Electronic copies will be kept in an online password-protected storage platform. Electronic data will be stored for a total of five years for use in potential publications or further investigation and then destroyed. Hard copies of data will be destroyed immediately after thesis defence. Research participants will not be identified by name in any reports of the completed study. Contact for information about the study If you have any questions or desire further information with respect to this study, you may contact Amy Hildebrand at xxx-xxx-xxxx or (email). Contact for concerns about the rights of research participants If you have any concerns about your treatment or rights as a research participant, you may contact Elizabeth Kreiter in the Office of Research, Trinity Western University at 604-513-2167 or researchethicsboard@twu.ca. Consent Your participation in this study is voluntary and you may refuse to participate or withdraw from the study at any time without explanation. If you do withdraw from the study, your data will only be used with your permission. If you do not want your data to be included in the study, it will be removed and destroyed. This may occur at any time up until the date of the research study completion (tentatively Spring 2021). Signatures Your signature below indicates that you have had your questions about the study answered to your satisfaction and have received a copy of this consent form for your own records. SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 156 Your signature indicates that you consent to participate in this study and that your responses may be put in anonymous form and kept for further use after the completion of this study. ___________________________________________ Research Participant Signature _______________________ Date _____________________________________________________________ Printed Name of the Research Participant signing above PLEASE SELECT STATEMENT: I consent to the use of my data in future research: ______________ (Participant to provide initials) I do not consent to the use of my data in future research: ______________ (Participant to provide initials) I consent to be contacted in the event my data is requested for future research: ______________ (Participant to provide initials) SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE Appendix F Demographics Form 1. What is your age range? 20-30 31-40 41-50 51-60 61-70 2. Please state your gender: _______________ 3. How many years of experience do you have as a spiritual health practitioner? 0-5 years 6-10 years 11-15 years 16-20 years 20+ years 4. What is your highest level of education (please describe)? Diploma in ___________________________________ Degree in ____________________________________ Master’s degree in _____________________________ Doctorate degree in_____________________________ Other: _______________________________________ 5. Personal religious affiliation, if any: ________________________________________________ 6. Ethnicity: ________________________________________________ 157 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE Appendix G Table 3 Compassion Cart Study Participant Demograhics Number of Participants Age: 20-24 25-29 30-34 35-39 40-44 45-49 50+ Sex: Male Female Prefer not to state Highest level of eduation: Bachelor’s degree Graduate/professional university degree Other (please specify) Years employed as a RN: 1-3 4-6 7-9 10-12 13-15 16+ Participated in a Code Blue in the past year: Yes No If yes to the above question, was a debreifing held after the code: Yes No Note: n = 19 Percentage of Participants 3 5 3 2 1 3 2 16% 26% 16% 11% 5% 16% 11% 19 100% - 15 1 79% 5% 3 16% 12 1 2 0 0 4 63% 5% 11% 21% 16 3 84% 16% 11 5 69% 31% 158 SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 159 Appendix H Interview Guide Ensure consent signed and returned. Remind participant of voluntary participation and may withdraw from the study at any point up until completion of the research study. 1) Please describe your current role. 2) How do you define spirituality? 3) What role does spirituality have in providing direct patient care? Role as a chaplain vs. nurses’ role or provision of spiritual care 4) What is the nature of the support you provided to nurses? Please explain (prompt: informal or formal interaction? Did you approach the nurse or did the nurse make an appointment? What issues did nurses identify when interacted with?) 5) Has the nature of your support for nurses changed since the beginning of the COVID-19 pandemic? If so, how? 6) Are there situations in which your support has been unwelcome or resisted? 7) Are there particular practices or approaches that you have found unhelpful or ineffective in your provision of support to nurses? 8) As you know, my research is focused specifically on compassion fatigue. This is the definition I am working with for my research study. (Prompt: give definition of compassion fatigue if needed - “the physical and mental exhaustion and emotional withdrawal experienced by those who care for sick or traumatized people over an extended period of time” (Merriam-Webster, n.d.). How does this definition resonate with your experience of providing support to nurses? SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 160 9) If you have interacted with a nurse after a critical incident such as Code Blue (cardiopulmonary resuscitation), how self-aware are nurses of their own emotional/spiritual well-being? Do they make a link to compassion fatigue and critical incidents? If so, please describe. (Do nurses link more to the concept of compassion fatigue than spirituality when speaking about their well-being?) 10) How often would you say you interact with nurses who report they are experiencing compassion fatigue? Very often, often, sometimes, rarely, never. 11) Do you perceive spiritual care as impactful in mitigating compassion fatigue? Why or why not? 12) Have you ever been involved in a specific planned intervention to mitigate compassion fatigue? If so, please describe. 13) If you could implement an ideal spiritual care program or intervention that would positively affect the workplace and decrease compassion fatigue, what would it look like? SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 161 Appendix I Hildebrand Thesis Codebook Name Description (Lack of) Language Connecting Spirituality and Compassion Fatigue Files References 6 30 Availability of SHP Resources FTE’s/workload/reporting structure 6 26 Biopsychosocialspiritual Well-being of Nurses Have they asked themselves the existential questions that their patients are facing? 6 15 Commission to Support Patients vs. Staff 6 12 Common Issues Identified by Nurses 6 16 Compassion Fatigue Interventions 7 34 Context of Care Practice area/clinical unit/society (secular) 6 13 Definition of Critical Incident According to SHPs 3 5 7 15 7 12 Description of SHP role 7 24 Effect of Critical Incidents 4 9 Factors Contributing to Compassion Fatigue 7 33 Formal Support for Nurses (Organized Intervention) 5 19 Frequency of Use of the Term - Compassion Fatigue 6 12 5 8 Definition of Spirituality Separation of religious and spiritual How Do We Handle the 'Norm' of Nursing Theological or philosophical framework that nurses approach their work with; what philosophic/existential skills do we educate nurses with? SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE Name Description Files 162 References Impact of COVID-19 on SHP Support 6 15 Informal Support for Nurses 7 36 Interdisciplinary Team Approach 5 20 Link Between Spirituality and Aesthetics 3 9 5 15 Nurses' Connection and Obligation to Patients 3 7 Nurses' Self-Awareness After a critical incident, or even when engaging of Well-being with nurses, how aware are they of their own emotional or mental or spiritual well-being? 7 20 Nursing Awareness of SHP Role or Support 7 17 Philosophical Underpinnings Influencing Spirituality in Health Care 6 19 Prioritization of the Spiritual in Health Care 1 2 Quotes I love! 6 24 6 14 Resistance Encountered Continuum of receptiveness of by SHPs SHPs/unwelcome/indifference 6 15 Role of Ritual in Spirituality 3 3 1 4 7 19 5 13 Metaphors or Imagery Used by SHPs to Support others Relatedness of Compassion Fatigue to Other Concepts Evocative phrases/aesthetic expressions i.e. vicarious trauma, moral distress, burnout, PTSD What role does ritual play? How is it beneficial to spiritual health? How does repetition of a word or act bring a sense of calm? Related to the expected? Role of Spirituality in Health Care Impact of Spiritual Care to Mitigate CF Spirituality in Leadership Workplace/organizational level; what organizational interventions allow nurses to feel SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE Name Description Files 163 References valued? The Value of Human Connection 6 16 6 28 Ability to Ability to provide care to individuals of different Contextualize Care or faiths/backgrounds; ability for SHPs to have a Support pluralistic approach 5 14 Incorporating SelfActualization Practices 3 5 6 26 Variety of SHP Support Approach Verbal or Non-Verbal Cues that SHPs Observe Based on years of experience, educational background, personality Picking up on a “vibe”; looking for tension or weariness; hearing a sigh; reading the “energy” of the unit SPIRITUAL HEALTH PRACTITIONERS AND NURSES’ COMPASSION FATIGUE 164 Appendix J CONFIDENTIALITY AGREEMENT FOR TRANSCRIPTIONIST for Research Study by Amy Hildebrand (Principal Investigator) I understand that: ∙ all confidential and/or personal information that I have access to, or learn from my affiliation with the principal investigator of this study, is confidential, ∙ as a condition of my affiliation with the principal investigator of this study, I must comply with the following: I agree that I will not access, use or disclose any confidential and/or personal information that I learn of, or possess because of my affiliation with the principal investigator of this study, unless it is necessary for me to do so in order to perform my responsibilities as transcriptionist. I also understand that under no circumstances may confidential and/or personal information be communicated except to the principal investigator. I agree that I will protect the confidentiality of any information that I access and that I will not alter, destroy, copy or interfere with this information, except with authorization and in accordance with the principal investigator I agree that I am accountable for the work I do in my role as transcriptionist for this study. I will ensure that while in my possession, I will keep all data pertaining to this study (i.e., interview audiotapes and transcriptions stored on password protected external USB drive) in a locked drawer. If I have reason to believe that any confidential information has been compromised or stolen, I will immediately notify the principal investigator. I agree to return all data pertaining to this study to the principal investigator as soon as I have completely transcribed the audiotapes of the interviews. __B.D._____Feb 23, 2021___________________ Signature of Transcriptionist / Date __A. Hildebrand______ Signature of Principal Investigator ___B.D._______ Name of Transcriptionist __Amy Hildebrand________ Name of Principal Investigator February 23, 2021________ (print) Date