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Feature: NCPD Connection: practice

Dedication in a Difficult Context

Faith-Based Nursing in Haiti

Roberts, Lisa R.; Georges, Marie; Nick, Jan M.; Taylor, Elizabeth Johnston

Author Information
doi: 10.1097/CNJ.0000000000000816

Abstract

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Most nurses work in challenging environments as they care for complex patients. Nurses in developing countries, however, often face huge obstacles such as significant politico-social-economic disparities, deleterious infrastructure, and lack of needed supplies and training. Yet they maintain dedication and demonstrate resilience. Such is the work of nurses in Haiti.

Haiti, a country in the Caribbean Sea, shares the island of Hispaniola with the Dominican Republic. Due to Haiti's location, 90% of the population is at risk due to natural disasters such as fierce storms, extensive flooding, and massive earthquakes (Central Intelligence Agency [CIA], 2017; Kang, 2016). Health problems following natural disasters include infectious outbreaks—diarrheal diseases, fatal cholera, and acute respiratory infections—as well as skin and wound infections. Loss of shelter contributes to vector-borne diseases and infections associated with human and animal waste (Pan American Health Organization, 2015).

Haiti is the poorest country in the western hemisphere (CIA, 2017), contributing to poor health indicators such as high maternal and infant mortality rates. For a population of 11 million, there are approximately 1,400 qualified nurses for the entire country (Garfield & Berryman, 2012), and 70% of these nurses work in Haiti's capital, Port-au-Prince (Chen, 2010). Differing nursing educational practices, nurse migration, high turnover rates, and other variables contribute to this nursing shortage and maldistribution.

Nursing education in Haiti comprises a combination of five public schools, five major private nursing schools, and 400 small private nursing schools (Garfield & Berryman, 2012; Greene & Meline, 2014). The public schools provide a 3-year diploma program, training nurses for hospital service. Graduates sit for a national exam before becoming registered as professional generalist nurses. Some private schools provide a 4-year program and offer specializations in midwifery and HIV care (Garfield & Berryman, 2012). However, the explosion of small private schools makes regulation of curricula and standardization of educational levels difficult, although steps have been taken to strengthen reconnaissance, which is similar to accreditation (Greene & Meline, 2014).

Variations in practice environments such as resources and role expectations directly affect nurse staffing turnover rates in most Western countries. This effect may also be an important consideration in Haiti's nursing shortage. Environments that support professional nursing practice generally improve staffing ratios and thus, patient safety. Assorted factors influence work outcomes, including commitment to the organization's mission, self-confidence, optimism, hope (nurses' positive psychological capital), and intent to stay, which is influenced by the ability to balance workplace and personal life demands (Luthans & Jensen, 2005). Low job satisfaction, lack of respectful work relationships, low pay, lack of autonomy, and poor employee engagement can result in high staff turnover. Staff turnover is expensive for the organization and results in a lack of organizational memory (e.g., policy, mentoring, institutional norms), which jeopardizes patient outcomes. Organizational mission fulfillment is also threatened (Collini et al., 2015; Inoue et al., 2017).

Conversely, among resilient nurses who experience positive job satisfaction, burnout and turnover decrease and ability to cope with difficult situations is increased (Harker et al., 2016; Laschinger & Leiter, 2006). Traditionally, nurses in Haiti are not included in planning sessions for patient treatment or developing health system policies. However, nursing is undergoing a transformation in some key organizations, such as Zanmi Lasante, which have employed and developed strong nurse leaders (Partners in Health, 2016).

The nurse-to-patient ratio is 1.1:10,000 qualified nurses for the population in Haiti, whereas in the United States there are 94:10,000 nurses (Lev et al., 2013). Additionally, there are high rates of nurse migration to higher resource settings (Clark et al., 2015; Floyd & Brunk, 2016). Countries such as Haiti with low per capita income are particularly prone to nurse migration to higher-income countries. The conditions experienced in Haiti are like other low-resource countries, and therefore, their nursing populations are also strained (Walani, 2015). A phenomenon experienced by high- and low-resource countries alike is that faith-based hospitals often compete with urban hospitals for high-quality nursing staff, as urban hospitals typically offer attractive high resource opportunities; this competition causes a maldistribution of the nursing workforce (Chen, 2010; Garfield & Berryman, 2012). Understanding how to attract and retain qualified nurses while staying true to the organizational mission is of great importance to limited resource faith-based hospitals, with the goal of patient safety and positive outcomes, factors that are directly linked to the quality of nursing staff.

The nursing shortage in Haiti potentially compromises patient care, particularly at faith-based hospitals that typically operate with fewer resources, including fewer nurses; therefore, retention is paramount. This study's purpose was to describe perspectives of Haitian nurses employed at faith-based hospitals, and specifically to identify these nurses' responses to perceived challenges.

STUDY METHODS

The researchers used a qualitative descriptive study design to generate thick descriptions of Haitian nurses' perspectives of their work environment, emotions, and attitudes about being a nurse in a faith-based institution and their work experiences. This design is well-suited to the context of limited time and resources, and in which only the nurses directly involved are appropriate to provide relevant information to further understanding and describing the phenomenon of interest (Bradshaw et al., 2017).

Administrators and nursing leadership at two faith-based hospitals in the Ouest Department of Haiti facilitated initial scheduling and contact with the nursing staff. One investigator provided study information verbally in French and Haitian Creole to recruit nursing staff. Participants who volunteered as key informants (KI) received an informed consent form in either French or Creole (according to preference). Investigators reviewed the informed consent form and answered questions before proceeding. Snowball sampling was primarily utilized; however, additional purposive sampling also was used to ensure representation from both day- and night-shift nurses of varied experience.

Permission to conduct the study was obtained from each site, with key stakeholders providing initial introductions to nursing staff leadership. Informed consent was obtained prior to each interview. This study received ethical approval from the Institutional Review Board at the authors' institution. All interviews were conducted in a private room to safeguard participants' confidentiality.

The researchers also acknowledged their participation in the research process, as the first and second authors spoke directly to the nurses and observed their environment and behaviors. All the authors tried to take an emic stance (starting the analysis from the participants' perspectives as their words portrayed), but acknowledge that the authors' subjectivity influences the interpretation of findings (Bradshaw et al., 2017).

To gather demographic data and serve as a conversation starter and icebreaker, the interviewers verbally administered a brief demographic questionnaire. The KI interviews were then conducted using a semi-structured interview guide with open-ended questions. The second author, being culturally and linguistically matched and also trained in qualitative methods, conducted the interviews under the guidance of the first author. The semi-structured interview guide had been piloted with English-speaking, nonparticipant nurses before the interviews conducted at the two sites. The KI interview questions were designed to elicit nurses' perspectives and experiences with questions such as, “What do you think are the best aspects of working here?” and “What are the challenging aspects of working here?”

Interviews were typically 60 minutes and were audio-recorded, transcribed verbatim, and translated to English. Transcripts were redacted for identifying information. Field notes and memos were written to capture contextual data and researchers' thoughts and impressions concerning the interviews. The first and second authors conducting the interviews deemed that saturation was reached when no new ideas, experiences, or situations were identified. Nine KI interviews were conducted at a hospital in the southern mountains, and eight interviews were conducted at the second hospital on Haiti's southwest coast.

DATA ANALYSIS

The data were analyzed using constant comparative analysis (Denzin & Lincoln, 2011) retrospectively, allowing codes and themes to emerge from the data, but without revising interview questions as the data were collected (Olson et al., 2016). The transcripts were divided so that two independent researchers read and re-read four transcripts of the English translation, each individually coding phrases. Initial coding involved highlighting particularly vivid portrayals of perceptions and experiences, strongly expressed opinions and emotions, or well-developed ideas.

This process was repeated until data congruency was demonstrated and the codebook was developed. Reliability of the coding was assessed by determining intercoder agreement, dividing the number of agreed-upon codes with all possible codes, then multiplying the result by 100 (Kelsey et al., 1996). Overall agreement was 96.4%. Coding proceeded with all researchers coding the remaining transcripts while employing additional strategies as follows: searching for repeated words, phrases, or concepts; identifying typical expressions such as nursing lingo or colloquial terms; illustrative analogies or representations; and comparative statements made by participants. Researchers noted similarities and differences within and across transcripts. Coding and emerging themes were discussed and agreed upon, re-evaluating as analysis continued. Throughout the process, researchers referred to the original transcripts, checking that conclusions were grounded in the data and closely represented participants' expressions. Sample size was adequate as code saturation was reached (no new themes identified) after the 14th interview, and the remaining three interviews functioned as validating data (Hennink et al., 2017).

Trustworthiness in qualitative research entails demonstration of credibility, dependability, confirmability, and transferability by maintaining rigor and methodological consistency (Bradshaw et al., 2017). For credibility, the investigators developed rapport with participants prior to conducting the interviews, expressed empathy appropriately, and utilized member checking to support credibility. To establish dependability, careful recordkeeping by two researchers provided an audit trail supporting dependability. Field notes and memos, demographic information from participants, and inclusion of direct quotes to represent findings supported confirmability. Purposeful sampling, in addition to convenience sampling, memoing, and detailed description, support transferability.

FINDINGS

The 17 interviewees were all female nurses, ranging in age from 27 to 71; their years of nursing experience ranged from 5 months to over 30 years. One participant preferred to interact in French, seven participants preferred to interact in Creole, and nine stated they had no preference. Three nurses self-identified as Catholic, 13 as Protestant, and one declared no religious affiliation. Eight nurses held a 4-year degree, six had graduated with a 3-year diploma, and three were auxiliary nurses (nurse assistants). Eleven participants worked the day shift, and six the night shift. Participants' commute time to work by bus or moto ranged from 30 minutes to 3 hours, and those who walked to work reported walking from 5 minutes to an hour.

In total, 17 participants were interviewed individually. Five themes emerged: a) the state of nursing in Haiti; b) the public's view of nursing in Haiti; c) organizational culture and environment; d) professional development; and e) the divine calling of nursing.

State of Nursing in Haiti

Participants often described work-related challenges as stressors inherent to the healthcare system in Haiti, irrespective of their place of employment, and sometimes summed this up as, “This is Haiti.” Stressors included long shifts, exhaustion, a long walk/time to commute, working extra jobs due to the low pay, irregular schedules, being hungry while at work without access to suitable food, emotional pain, lack of autonomy, and lack of respect from other healthcare providers. The nurses also acknowledged that nursing is in a state of transition in Haiti in terms of education, professional standards, and accreditation. Nursing competency was also discussed regarding the need for continuing education for current knowledge, developing/maintaining skills, critical thinking, professionalism, and advocacy.

“. . . We have to bring our food; and if we come to work and we don't have any food, we will remain like that, all day with nothing.”

“When I come to work the night shift, I will leave my house at 1:00 p.m., and I come here around 5:00 p.m.”

“Before that, I used to teach nursing fundamentals in a school, but that did not work because the school did not follow the rules although they were accredited, but for me, the students were not competent enough, so I quit.... We are living this situation here in Haiti with the nursing profession—we are revamping our education system, because if we are not sure of the education/formation of the nurses how can we place our confidence in the professionals that we are forming.”

Although nurses acknowledged many challenges, these were taken in stride with an attitude of perseverance. Their willingness to make the best of their situation and strive for improvement underscores their resilience.

Public View of Nursing

Most nurse participants described experiences of positive interactions with community members and enjoying the public trust, honor, and thanks bestowed on nurses, as well as small gifts and recognition received.

“When you meet them in the street, they call you: ‘Miss [Name]’. It's a great encouragement. Some of them have their little garden and when they harvest, they gather some of the produce, and stand up to wait when the Miss is passing by to give to me.”

“After they saw that you spent a lot of time with them, caring for them, before they leave, they come to thank you.”

“My family is very happy because I am a nurse and it is their pride.”

A few nurses felt that the public used to esteem nurses, but felt that public perception had recently shifted. Some felt as though they were seen as physicians' handmaidens rather than professionals, and some had heard derogatory terms used to describe nurses or perceived a lack of respect.

Respect for nursing was reflected as the nurses reiterated their predominantly positive interactions with the public. Participants' faces lit up with pride as they shared positive encounters despite occasional negative messages.

Organizational Culture and Environment

Nurses' personal alignment with organizational mission and values was noted on a continuum from positive (description of personal fit with mission and values, positive attitude toward hierarchical structure, and intent to stay) to negative (lacking alignment with mission and values, negative attitude toward hierarchical structure, and/or intent to leave). Figure 1 depicts a word cloud result of the participants' words in this overarching theme.

Figure 1.
Figure 1.:
Word Cloud of Participants' Words Describing Organizational Culture and Environment

For most, strong personal alignment resulted in their ability to focus on their duties, resulting in patient-centered care.

“I feel very well because there is a church right here on campus, and everyone is preaching God's love, and while caring for the patients, I feel happy, and I like it because I am also a Christian.”

“I don't have any problem working here because I always like the mission, and my signature is Baptist, and the mission is Baptist.”

“This is my way of living. When I am at the hospital, I am happy.”

Subthemes involved comparing faith-based and government hospitals as well as discussion about pay and benefits and emotional and physical safety. Field notes provided context supporting participants' sentiments regarding differences in work environments.

During the interviews, participants made comparisons between faith-based and government hospitals. Even those who had not been employed in a government hospital had done some practicum hours there and expressed strong opinions about the differences. Positive aspects of faith-based hospitals included availability of supplies; positive interactions with colleagues, patients, and families; the structure of insurance, fees, and payment (or providing care even for patients who cannot pay); and the quality of care. Negative comments pertained to aggressive behavior by patients or family members which they perceived as being tolerated by administration, and low pay.

“...Here [faith-based hospital] the nurses give their all and work with all their souls.”

“...If someone comes at the urgent care, and the person does not have the money to pay for the fees or anything, we will not return this patient home without the care. This person remains, the care is provided and after they discharge the person, they can pay the hospital.”

Positive comments regarding government hospitals were related to higher pay and job security; however, most comments about the environment in government hospitals were negative—particularly related to the irregularity of pay, lack of supplies, and fear or mistrust.

“All Haitians would like to have a government job. So that would be a General Hospital or government hospital.... You can have insurance.... When you find a state hospital to work, the job is for life (or) until you leave the country.”

“This is not like the General Hospital [government]. They don't have many supplies for the work—gauzes—and they have nothing. But here it's much better. We have syringes and although the people buy them, we can find a little of everything.”

Participants repeatedly mentioned low pay at faith-based hospitals, but also noted that the paycheck was dependable. Many also reported doing private duty nursing in addition to their hospital job in order to subsidize their low salary.

“. . .The salary can't answer to my responsibilities really.... The money is too small... The salary is really not satisfying.”

“...If I can find another job that can help me [with better pay] I would not need to do two jobs.”

Although government hospitals reportedly paid much better, participants also confided that government pay was unreliable, with some employees going without pay for months. Although participants expressed that if they were to leave their faith-based hospital jobs, it would be for better pay, they expressed reluctance to do so due to their overall negative impression of government hospitals.

Professional Development

Nurses described their efforts to move forward in their nursing career and do whatever it takes to reach professional development goals. They described future goals: “I would like to become part of the administration,” seeking English classes to pursue higher education such as an advanced nursing degree or work abroad and the desire for in-service/continuing education opportunities.

“I want to advance with my studies and have a doctorate in Public Health. ... Now I am learning English because I would love to continue with the master and reach the doctorate level.”

“Because this is our situation in Haiti, I chose the night shift, so I can go four days a week at the [name] to learn only English.”

The cost of these goals was noted at great personal expense and/or use of personal resources (e.g., “But I, myself, spend my own money to learn more about other aspects of nursing.”). For some, the lack of opportunity created a feeling of being trapped.

“I can't go and learn something else; the money is not enough. So, if you say that you are quitting, it's going to be very difficult to find another place to work.”

Barriers to professional development were described as a lack of access to advanced education and resources such as up-to-date information, professional journals, reliable Internet, and professional organizations. Participants often perceived these barriers as insurmountable.

“I have seen one journal that came from Canada—one nurse has shown it to me—but this does not happen a lot.”

“Now we could try to do this online, but we don't have the means to have the Internet although we could pay $80 to have it. If we want to have high-speed, it costs a lot, and a nurse does not have this means.”

Some participants noted gaining experience as important for increased competency and as a stepping stone toward future goals: “My aspiration, for now, is having a lot of experience. When it's time to go to another place, you already have enough experience to move on.” The participants also noted the importance of supporting each other in these pursuits or lifting others up: “Because we are all human beings, we try to help each other, and encourage one another.” Participants did not express a competitive spirit or wanting to get ahead at the expense of colleagues.

Resilience was noted through memoing as an important subtheme within professional development, as participants described overcoming challenges/barriers and maintaining hope or a positive attitude while pursuing goals. Supporting each other also fostered resilience: “I really have some collaboration in this sense.”

The Divine Calling of Nursing

Positive attributions were noted in expressions of nursing as a calling rather than strictly a means to an end—a fulfilling of God's will—and some participants expressed having their position or the ability to receive a nursing education as divine intervention.

“...Whatever you do, do it with love. It doesn't matter what the problems are; if you do it with love, you can survive. But if you come to this hospital because you are going to be well paid, or well treated, no, no. Nurses who work in this hospital are like missionaries.”

Conscientiousness was expressed frequently, noting the nursing code of ethics and carrying out nursing as an ethical duty; nursing can be described as caring and an expression of one's Christian walk or Christian service.

“Well, since you made a vow, you need to respect the vow and always do your duty.”

“. . . the code of ethics for the nurses ‘to forget self, and to serve’.”

“. . . Just work with all your heart.”

“Care with love and all that you have learned, do it well.”

“When we give a service, we don't do it for ourselves, but we do it directly for God.”

The nurses also indicated a sense of professional pride:

“It is a work which is noble because we can help save someone's life.”

“I love my profession; nursing is a noble profession. When a patient comes here, and you take good care of him/her, the patient has a good time here, and you feel good as well. You feel proud because you did a good job and it makes you feel good.”

However, angst was noted when the nurses perceived a threat to their self-image caused by detrimental events or negative interactions that threatened their ability to maintain a Christian demeanor or have a godly attitude.

“Even myself in my good mind, it's true that we are Christian, but sometimes, they excite you even though we can't talk to them, they make you angry. And this is not good!”

“. . . I don't like for my patients to leave unhappy.”

Burnout, expressed as when “...that compassion starts to fade,” was not mentioned frequently, but was an important observation of the result of encountering situations causing a sense of hopelessness.

The nurses described observing spiritual care or faith-related activities (Bibles provided, pastors praying with patients, and sometimes healing), but few stated they participated in providing spiritual care or felt that they had overt spiritual care to offer. Some shared expressions of faith with patients (such as saying, “God bless you”), but most saw nursing as synonymous with missionary work when carried out with a Christian demeanor.

“Everyone is trying to deal with issues in a Christian manner.”

“This place helps the people come closer to God, and I find great pleasure in the morning when I go to the unit; you can find the patient with the Bible that they received as a gift, reading it.”

DISCUSSION

In this qualitative study, five themes emerged: a) the state of nursing in Haiti; b) the public's view of nursing; c) organizational culture and environment; d) professional development; and e) the divine calling of nursing. Each theme highlights the experiences of Haitian nurses working in faith-based hospitals. The participants are dedicated nurses working in a difficult context, demonstrating coping and resilience. They saw themselves as missionaries and enjoyed the personal and public regard for their profession. They expressed professional aspirations, alignment with the organization's mission, and a sense of divine calling to nursing.

The State of Nursing

The challenging state of nursing in the healthcare system of Haiti was difficult to separate from the general state of Haiti, which is fraught with poverty and the frequent aftermath of natural disasters. Stressors that the nurses experienced were both personal and environmental. Environments supportive of professional nursing practice also support patient safety. When nurses feel positive about their work, they are less likely to experience burnout and turnover. In turn, this results in higher patient satisfaction scores and health outcomes (Laschinger & Leiter, 2006) as well as financial savings for healthcare institutions (Waldman et al., 2010).

Contributors to a positive environment include administration and leaders' commitment to and investment in nursing. These factors are demonstrated through tangible and intangible provisions such as continuing education, development of nurse leaders, appropriate pay, and supporting autonomy (Laschinger & Leiter, 2006). Some participants noted coping by working several jobs. This finding is not surprising given Haiti's economic and political instability and is consistent with findings reported by previous researchers (Chiang-Hanisko et al., 2006). A supportive work environment is especially important in areas with so many challenges (AbuAlRub et al., 2016).

The nurses expressed many individual factors contributing to a professional nursing environment, including a commitment to the organization's mission, self-confidence or efficacy, optimism and hope, work-life balance, and viewing nursing as a divine calling rather than merely a means to an end. Nursing is a caring profession and experiencing joy and job satisfaction are documented essential ingredients in employee retention. A failure of supervisors to address work-related stress can lead to increased employee turnover (Kelly & Lefton, 2017). Therefore, supervisors' efforts to reduce work-related stress and support positive work environments are important considerations for employee retention.

Public View of Nursing

Most nurses perceived that the public experienced nursing positively; however, some expressed a negative shift in public perception. Academic preparation of nurses is correlated with improved patient care and health outcomes in the United States and low-resource settings (Street et al., 2019). The inconsistent preparation of nurses in Haiti (Garfield & Berryman, 2012; Greene & Meline, 2014) may be affecting public opinion of nursing. However, the overall finding of positive public perception and interaction with nurses is supported by efforts to uphold and improve nursing education in Haiti (Baird et al., 2019; Baumann & Alexandre, 2016; Mason & James-Burga, 2019). For example, a recent study indicated higher respect for professional nursing responsibility and leadership skills, as well as teaching praxis as a result of a program to increase Haitian faculty capacity (Street et al., 2019). Consistent quality of nursing education has important implications for nursing practice both directly and indirectly. Quality nursing care increases patient satisfaction and improves outcomes, which in turn enhances public perception of nursing. Nurses imbued with a sense of professional pride are likely to be resilient.

Organizational Culture and Environment

The authors were struck by the pronounced patient-centered findings in both the transcripts and the word cloud, which speaks for itself. The participants' strong commitment to nursing and to patients contributes to their overall resilience due to close alignment with the organizational culture (Zander et al., 2013). The nurses' alignment also was evidenced by their choice to work in faith-based hospitals over higher-paying government hospitals. Although faith-based hospitals may not be able to compete with other institutions' pay structures, it is important for administrators and managers to enhance less tangible yet valuable aspects of working in faith-based institutions.

Professional Development

The nurses' desire to continue learning, gain experience, pursue higher education, and move up the career ladder is noteworthy for the personal sacrifice and determination required to pursue professional development. Consistent with the literature, these nurses indicate professional engagement demonstrated by their commitment to the professional role through expanding their knowledge and stewarding the profession (Berg et al., 2017).

Unfortunately, some of the nurses indicated that their best opportunities for professional development and advancement required learning English in preparation to work abroad, potentially contributing to the nursing shortage in Haiti (Clark et al., 2015; Floyd & Brunk, 2016). Additionally, those who expressed feeling trapped by the lack of opportunity and resources may be disappointed with their personal accomplishment and, thus, be at higher risk for burnout (Ramirez-Baena et al., 2019).

Resilience was noted as the nurses described overcoming challenges and pursuing professional development despite many barriers. Their hope, positive attitudes, and supportiveness of each other are characteristics of resilience (Williams & Shepherd, 2016). Resilience is also an important quality in the prevention of burnout (Harker et al., 2016). Supporting professional development has important implications for nurses' resilience and creative solutions in low-resource settings should be considered.

The Divine Calling of Nursing

Overall, the positive regard for nursing was infused with expressions of nursing as a divine calling, enacting faithful service to God, in a profession and sometimes even employment ordained by God, consistent with the historical roots of nursing (Egenes, 2017; McCaffrey, 2019). The authors believe this commonality has a unifying effect and supports resilience. Resilience has been found to be both an individual and a group characteristic (Zander et al., 2013).

Perceived threats to their identity as Christian nurses was distressing, and perhaps both a contributing factor to, and a result of symptoms of, burnout. A sense of hopelessness and waning compassion, tantamount to emotional exhaustion, are symptoms of burnout (Maslach et al., 1996). However, surprisingly little evidence of burnout exists in this study population, and perhaps may be attributable to the nurses' sense of purpose, serving the greater good for God, and resilience.

Although the nurses linked their faith inextricably to their profession, seeing themselves as missionaries, for the most part they perceived that they did not explicitly provide spiritual care. Nurses' religious view of their work as a ministry or spiritual calling is not unique to this sample. Christian and Muslim nurses in other countries (Bakibinga et al., 2014 [Uganda]; Taylor et al., 2014 [United States]; Tirgari et al., 2013 [Iran]) have done likewise, and report personal religion giving meaning to their work and helping them to cope with its stresses.

What is intriguing about these study findings is that the nurses were unable to identify specifically how they provided spiritual care. The spiritual care therapeutics frequently discussed in Western nursing literature of screening and assessment, being present, and deeply listening (e.g., Taylor, 2020) were not described by the nurses in this sample. Perhaps they are unable or unskilled to do so; like many, they may not receive instruction about spiritual care (White & Hand, 2017).

Spiritual care is part of whole person care and can be fulfilling for the nurse and simultaneously therapeutic for the patient (Connerton & Moe, 2018). Perhaps the nurses in this study could increase their resilience by offering spiritual care, which aligns with their belief regarding the nature of nursing as a divine calling and might lessen the sense of hopelessness experienced when there is little else to offer. Nursing educators and administrators in similar settings may find it worthwhile to offer spiritual care training.

Although we collected data in the setting of the participants who experience the phenomenon of interest, our presence as researchers may have influenced the phenomenon itself. Using a diverse team of researchers, including a Haitian nurse, increased our cultural sensitivity and provided greater understanding of context and responses. Although code saturation indicated an adequate sample size, the number of participants from each institution required combining responses to help protect confidentiality. Comparing responses of participants between the two sites may have provided a more nuanced understanding of organizational differences and the nurses' experiences in each setting, thus possibly enhancing meaning saturation (Hennink et al., 2017). Diversifying the sample could help minimize bias. Additional strategies to demonstrate trustworthiness could have been employed, such as triangulation.

CONCLUSION

This study represents a preliminary exploration into the experiences of Haitian nurses in faith-based hospitals. The findings may be particularly relevant, as knowledge and understanding of how nurses perceive and experience nursing in a difficult environment may spur further research. Understanding current issues at faith-based hospitals will be useful to guide future recommendations and interventions not only for the study area, but also has implications for other countries experiencing similar challenges.

Web Resources

CIA: The World Factbook Haiti:https://www.cia.gov/library/publications/the-world-factbook/geos/ha.html

Haiti National School of Nursinghttps://sigma.nursingrepository.org/bitstream/handle/10755/17371/Baird_96633_B13.pdf?sequence=1&isAllowed=y

Haiti Nursing Foundationhttps://www.haitinursing.org/

Pan American Organizationhttps://www.paho.org/salud-en-las-americas-2017/?page_id=131

USAID:Haiti https://www.usaid.gov/haiti

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Keywords:

calling; Christian service; Haiti; nursing; powerlessness; psychological resilience; self-care

InterVarsity Christian Fellowship