The first Catholic Healthcare Ethics Innovation Forum (CHEIF), held on December 16-17, 2019, provided an opportunity for those in Catholic health care to explore, present, and discuss innovative and novel ideas in health care ethics. The "lightning-round" format allowed participants to share the work they are doing to embed and integrate ethics into their health systems, to receive critical feedback from colleagues, and contribute to evolving the way Catholic health care thinks about and implements bioethics. The goal was to develop a forum where participants can present innovative ideas and enhance them together.

One of the key focus areas of the forum was on the competencies, development, management and self-care of those involved in the work of ethics, from the bedside to the boardroom. Caregivers (and I include ethicists within this term) are often very good at taking care of others, but neglect taking care of themselves. However, unless caregivers (including ethicists) are able to practice self-care, they run the risk of compassion fatigue, decreased work satisfaction, and burnout.¹ As Egan, et al state, "The stance that HCPs [Health Care Professionals] adopt of 'you before me' should not be 'you instead of me.'"² Yet, this is often the case. Mills, Wand and Fraser define self-care as "a proactive, holistic, and personalized approach to the promotion of health and well-being through a variety of strategies, in both personal and professional settings, to enhance capacity for compassionate care of patients and their families."³ What follows is an outline of some of the self-care practices, resources and tools which might be of use to those within the field of ethics and ethics leadership in caring for themselves, as they seek to care for others, both professionally and personally.

The nature of clinical ethics work requires that the ethicist be called into some of the most difficult conversations in health care. She or he must enter into situations with often complex medical, interpersonal, social and cultural dynamics, sometimes with little institutional or collegial support, and without the benefit of a consistent interprofessional team. A growing trend towards a more "proactive" model of ethics where ethical dimensions of care are addressed further upstream as part of the obligation to care for the whole person means that sometimes ethical concerns can be addressed before there is a conflict or before interpersonal dynamics become so strained, and that the ethicist is viewed as a valued member of an interdisciplinary care team. However, this is still not the prevailing norm. As such, many ethicists find themselves being called into an ethical conflict much too late, when tensions are already high, as well as the stakes (such as end-of-life cases), and the lines have already been drawn between the patient and the care team, or the patient and family, or between members of the care team. The ethicist must step into these settings, listen to often heart-wrenching stories from patients and families and moral distress of care providers, and then try to work with both to chart a path forward which respects the goals, values and beliefs of all involved, but most especially the patient. If one were to describe the job of clinical ethicist to prospective candidates in this manner, who would apply?

Yet, within such a vocation also lies the opportunity for meaning, purpose, fulfillment, collegiality and job satisfaction, as well as the opportunity for significant "compassion satisfaction" (CS).⁴ One of the keys to preventing compassion fatigue and promoting compassion satisfaction lies in balancing caring for ourselves so that we can care for others. We must keep our spiritual, emotional and physical "buckets" full so that we can then draw from the wellspring of our reserves to help and care for others.

When I decided to prepare a presentation for the CHEIF conference on this topic, it was not because of any expertise on this topic on my part. It was because I sensed a great need, both personally and professionally, for such a resource; to invite further conversation, and to raise awareness of this need. It may also stem, perhaps to the most significant degree, from my experience as the primary caregiver for my first wife, who struggled valiantly with chronic illness for twelve years, and passed away from cancer. In part, these lessons stem from failings on my part to utilize such resources, and the subtle (or not so subtle) reminders from her, even in the midst of tremendous existential suffering, that I needed to take care of myself or I could not hope to take care of her.

What follows stems originally from a presentation I gave to a group of case managers and social workers at St. Francis Medical Center in Hartford, Conn., on the occasion of their annual "appreciation day." I realized, as a clinical ethicist and vice president of mission at the time, that I failed to take my own advice; my spiritual toolbox was almost empty. I have modified and adapted it to apply more fully to the role of the ethicist, although I hope others within the health care field and otherwise also find some of these ideas meaningful.

"Self-Care Toolkit"

A Flashlight: A flashlight is used to guide the way when it is dark. It shines a light on places that are hidden, and on perhaps places where we'd rather not go. For the ethicist, a flashlight is a trusted mentor. Someone working within the field whose experience and wisdom we can rely on to guide us, especially when our path seems dark and uncertain. Someone we look up to, and who inspires us in the role we have chosen.

A Critical Friend: This term may seem contradictory at first but, upon reflection, I'm sure many of us can name a person in our lives who cares enough about us to be compassionately honest; someone who knows what we are capable of, and who holds us to account when we fall short of our true potential. A critical friend does not just agree with us to avoid conflict or because it is easier. They check our blind spots, challenge our assumptions and call us out when we either get to full of ourselves or wallow in self-pity. A "critical friend" can be either personal or professional, or both. The key to this relationship is trust.

A Warm Blanket: The image that immediately comes to mind for me with this reference is the Peanuts character, Linus, who always carries a blanket with him. In one Peanuts episode, he lends his blanket to Charlie Brown, who is in a national spelling contest. However, Linus becomes so lost and traumatized without his blanket that he has to travel to the spelling bee to get it back. Charlie Brown's dog, Snoopy, is always trying to steal Linus' blanket. In one of my favorite cartoons, Snoopy is actually wrapped in Linus' blanket, and Linus is holding on to Snoopy' s ear instead. Both are snuggled on a beanbag chair. To me, this is how a warm blanket feels. When we feel lost and traumatized, our warm blanket is our safe place. It is a person (or pet), place or activity where we feel wrapped in warmth, love, and safety. When we are enfolded in our warm blanket, we don't have to explain ourselves, or talk about what is bothering us (although we can if we need to), or do anything in particular except just "be."

A Pressure Release Valve: When the stress of balancing work and life, of a particularly bad day or a challenging encounter builds up within us, we need to find a pressure release valve. The image that comes to mind here is that of a pressure cooker. If the pressure cooker did not have a valve to release steam, it would explode. It is the same with us. We either find a positive valve to release pressure, or we explode at our colleagues, our loved ones, or the patients and families entrusted to our care. This pressure release could be a reflective exercise such as prayer or journaling, or meditation. It could be physical exercise such as running, walking the dog, or weightlifting, or a combination of reflection and physical exercise like yoga. Sometimes, when we don't find a positive pressure release valve, we turn to a negative one like alcohol or drugs. These are not authentic pressure release valves, but only serve in the long run to increase the pressure inside of us and decrease our ability to deal with it effectively. It is important, even in the midst of a busy workday, to integrate even a minute or two of pressure release. These might include a few minutes of deep breathing exercises, or keeping a prayer next to my computer so that, rather than getting frustrated as I wait for it to start up, I use this time as a moment of intentional reflection (one of my personal favorites). When I am on a conference call or webinar, I use exercise bands and a standing desk to stretch and move around, or a mini pedal-bike attached to my chair so I can pedal during webinars. Whatever strategies you employ, the important thing is to find a positive pressure release valve, so that we don't take our frustrations out in negative ways.

Duct Tape: As the legend goes, duct tape can fix almost anything (except maybe ducts). It is a very versatile product, and an essential element in our self-care toolbox. What is the one tactic, approach, or resource that you utilize in your professional life that almost always works, either to clarify a concept, de-escalate a situation, provide perspective, or help others become invested in what you are saying or doing? What one thing or practice can you turn to that almost always works? This is your spiritual duct tape that holds life and work together. Of course, if we watch any gangster or crime shows, we know that duct tape is also often used as a gag. It is placed over people's mouths so they can't talk. Sometimes, we may need to use our metaphorical duct tape (not real duct tape) to remember to listen more than we talk. This is how we learn the patient or family member's values, hopes, fears and concerns, or those of the care team. Sometimes as the ethicist, we are quick to jump in to solve the problem, when what we really need to do is listen. Sometimes when we provide space for silence, problems solve themselves.

WD-40: Much like duct tape, WD-40 is purported to be the cure-all for many things. If the wheel squeaks, add some WD-40. If the door is jammed, add some WD-40. The blue and yellow can has magical properties. When we are confronted with the "squeaky wheel" family member who, although having no legal or ethical right to do so, demands treatments or interventions clearly at odds with the patient's values and the standard of care, or threatens to sue us at every turn, the proper tool is not duct tape, but WD-40. What do we use to grease the wheel and get things moving again? What is our spiritual WD-40 to open doors that have been closed to us, or that have become stuck? Often, it is seeking to approach difficult situations with compassion and empathy. Is the "squeaky wheel" family member feeling scared, or guilty, or angry, or all three? Seeking to understand first rather than to react is often the best "WD- 40" we can use.

A Balancing Scale: It has become somewhat normal parlance to avoid the term "work/ life balance" in favor of the term "work/life integration." This is due in part to the fact that there are times when the nature of the work we do as ethicists requires that we sprint for a while before we can rest; the intense care team or family meeting, the impending publication deadline, the quarterly report that is due, or the continuous cycles of ethics committee meetings, consults, policies needing review, church relations work, travel and community engagement, all seem to clamor for our immediate attention. This may mean that we work extremely hard (sprint) for a defined amount of time. The question is, how do we integrate life within the mix? How do we avoid sprinting all the time? This is work/life integration. The reason I still posit a balancing scale as an essential tool in our self-care toolbox is because the image takes into account the "weight" of the work we do. Some aspects of our work carry heavier weight or meaning than do others, and some weigh more heavily on us. When we evaluate both our "energy grid" and our vocation, we need to honestly weigh those things that give us meaning and purpose, and those things which pull us away from our meaning and purpose. We cannot avoid all of the latter, just as much as we cannot only do the things that fit into the former category. We need to balance both of these things, and also rely on our "flashlight" and our "critical friend" as well as our family and those closest to us to tell us when we are off-balance.

Ritual: The last tool in our self-care toolbox is ritual. Although I could not find a way to cleverly (at least in my own mind) connect ritual to a tool in a toolbox, ritual may be more about how we use these tools. I do think it is an essential aspect of self-care. Rituals can help anchor our day, connect us to community, mark the passage of time, and honor significant moments. They can be elaborate or simple. Elizabeth Gilbert writes, "This is what rituals are for. We do spiritual ceremonies as human beings in order to create a safe resting place for our most complicated feelings of joy or trauma, so that we don't have to haul those feelings around with us forever, weighing us down. We all need such places of ritual safekeeping."⁵ This is, in part, the sense in which I view rituals as an essential tool for our spiritual tool-box. They help us process the feelings of grief, loss, joy and hope that are part of both our vocation and of the human condition. They can be more formal such as weddings or funerals, blessings and prayer services, employee recognition celebrations or values recognition awards, or quite simple like prayer before meetings or meals, or touching the picture of our spouse, children or pet before we begin our day. Rituals mark life's moments and life's passage. Here are a few suggestions of rituals I have encountered in my life and work. I also invite you to reflect upon those that you have experienced.

• When "foaming in" to a patient's room, set distractions aside and focus on this unique patient, with all the gifts and challenges she or he may present. Breathe deeply and be entirely present to the face of the Other before you.
• When you change out of your scrubs, lab coat or business attire into your "leisure wear," try to focus on shedding the negative energy of the day and clothing yourself with positive energy. If you can't do this, consider the pressure-release valve suggestions above.
• If you have a long commute home, do something that relaxes you (but not too much if you are driving!) or reinvigorates you. This might be quiet time for reflection, listening to music, audiobooks, or podcasts, or reading a good book (if you are on a train or bus or plane, etc.)
• Find a way to acknowledge, memorialize and honor loss, but don't be paralyzed by it. If you are, seek out support. I had a former student who became an occupational therapist. As such, she developed strong relationships with some of her clients. I remember her calling me in tears one day because she had her first patient die, and she didn't know how to process it. I suggested that she write his initials in her prayer book or journal, and go back to it as often as needed until she felt she had honored his passing. This ritual worked for her. I encourage you to find your own ways to ritualize loss; to honor it, but to still move forward to do the essential work of healing. Institutionally, we need to find ways to support care teams in doing the same. How do we create space and rituals that promote healing?

Not all of the tools in this spiritual toolbox may be applicable or helpful to every reader. I encourage and invite the reader to reflect upon what essential tools are in their spiritual toolbox, and whether or not they are helpful. I also invite us, as an ethics community, to continue to share our tools and resources with one another in support of the vocation to which we have been called.

Many of us who were trained as clinical or bedside ethicists and have since moved to system-level or leadership/administrative roles within ethics experience the void that comes from no longer (at least primarily) interacting with patients, families, and caregivers on a daily basis. Personally, this has proven to be both a blessing and a trial. The day-to-day work with patients, families and care providers is, in my opinion, where the "real work" of ethics resides. It is when we look into the eyes of a dying patient, or a struggling family member or a concerned physician or nurse and can provide some comfort, solace or direction to them through our shared learnings, listening and expertise that we find meaning and purpose. It is also when we can become the most exhausted, frustrated, fragile and jaded. These experiences can both lift us up and drag us down. It is the work that many of us were trained to do, and why we got into the field of ethics in the first place. It is where our sense of vocation, meaning and purpose lies. Yet, for some of us, this is no longer the world in which we live. We have moved from the bedside to the boardroom and from the critical care unit to the corporate office. Where do we find meaning and purpose, and what keeps our spiritual "bucket" full?

I started out my professional career as a high school teacher. My first love has always been the classroom and the interaction with students, especially those that others had written off or declared "unteachable." Yet, after several years of teaching, I became a high school principal. I spent most of my time outside the classroom, hiring and mentoring teachers, meeting with parents, attending school board meetings, or revising curricula. I still managed to teach one class per semester, but the dynamics and focus of my job had changed. That which gave me the greatest fulfillment, joy, sense of purpose and stress (teaching students) was no longer my primary focus. I grieved the loss of this part of my life and my vocation, and struggled to find meaning in my role as a leader and administrator. As a teacher, I built relationships with and directly impacted over 100 students each day. As a principal, I worked with, supported and mentored (or they mentored me) over 100 teachers. They, in turn, were better equipped to teach, support and inspire their students. While my impact might not be as deep with individual students, my reach and ability to effect change for the good was much broader.

As leaders in ethics, we have the opportunity to effect broad and systematic change within the field of ethics. We can find meaning and purpose in the development of new approaches and frameworks in ethics which move ethics further upstream and closer to the persons being served, and which support and empower others (especially caregivers) to identify and address the ethical dimensions of care in the work that they do and the care they provide every day. While we may not be at the bedside, we support those who are, and our breadth and reach can extend much further. We may not be at the forefront of patient care, and people may not even know the role we play in supporting those who are. In many ways, we are called to embody the type of leader Lao Tzu brings to mind when he writes, "a leader is best when people barely know he exists, when his work is done, his aim fulfilled, they will say: we did it ourselves." As system leaders in ethics, we may find ourselves fulfilling the roles of mentor and critical friend outlined above. This, along with recognizing the opportunity we have to effect lasting and meaningful change in the field of Catholic health care ethics, can help keep our spiritual bucket full.

Although this work has focused on self-care for ethicists and ethics leaders, I would be remiss if I did not comment briefly on the tremendous need for self-care and support of our direct care providers, including physicians, nurses, social workers and chaplains. There is significant evidence of moral distress, compassion fatigue, and burnout amongst those most responsible for caring for our patients. It is my hope that some of these strategies may be of help to them in easing moral distress and compassion fatigue, and in promoting moral resiliency and compassion satisfaction, and that the role of ethics and of the clinical ethicist can also prove to be a valuable "tool" in their self-care toolbox.

MATTHEW R. KENNEY, PH.D., HEC-C
Vice President
Ethics Integration and Education Ascension
St. Louis
matthew.kenne[email protected]

ENDNOTES

1. The term "compassion fatigue" (CF), is sometimes used to describe burnout among nurses, which defines a state of chronic worry and tension produced by the effect of the continuing impact of caregiving, which is related to secondary vicarious traumatic stress disorder. CF has been described as a negative effect in the professional caused by working with traumatized people, resulting in an inability to provide compassionate care. See Charles Figley, Treating Compassion Fatigue (New York: Brunner-Routledge, 2002), and Carla Joinson, "Coping with Compassion Fatigue," Nursing 22.11 (April 1992): 116-120.
2. Helen Egan et al., "'You Before Me': A Qualitative Study of Health Care Professionals and Students Understanding and Experiences of Compassion in the Workplace, Self-compassion, Self-care and Health Behaviours," Health Professions Education 5 (2019): 225-236.
3. Jason Mills, Timothy Wand and Jennifer Fraser, "Exploring the Meaning and Practice of Selfcare Among Palliative Care Nurses and Doctors: A Qualitative Study," BMC Palliative Care 17:63 (2018): 1-12.
4.  Compassion satisfaction (CS) is defined as the ability to receive gratification from caregiving. Stamm describes CS as the degree of joy resulting from the clinical experience of helping others. See Beth Stamm, "Helping the Helpers: Compassion Satisfaction and Compassion Fatigue in Self-care, Management, and Policy," in Kirkwood AD, Stamm BH, eds., Resources for Community Suicide Prevention [CD] (Meridian and Pocatello, ID: Idaho State University, 2012).
5. Elizabeth Gilbert, Eat, Pray, Love (New York: Riverhead Books, 2007).