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BY: CAMILLA M. JAEKEL, MSN, PhD, RN

You are soon to enter into a special segment of your own pilgrimage in life — a pilgrimage to the holy places of Francis and Clare. … When you return from this small pilgrimage, it is our hope that your way will be clearer, you will know how to continue and with whom you are traveling in the greater pilgrimage of life.

— A Pilgrim's Companion to Franciscan Places¹

Pilgrimage, in the literal sense, is to travel to sacred places that hold high moral or spiritual significance for the pilgrim. In a metaphorical sense, pilgrimage means traveling within one's spiritual or belief system.

I have been a nurse at Mayo Clinic Health System-Franciscan Healthcare in La Crosse, Wisconsin, for 22 years. In 2016, I had the privilege of taking part in a short pilgrimage in Italy to walk in the footsteps of St. Francis of Assisi. I expected to gain a richer understanding of the Franciscan Sisters of Perpetual Adoration's heritage — the sisters are our sponsor — but I also wondered if a traditional pilgrimage would translate to a pathway for nurses that would renew their sense of the profession's purpose.

Both kinds of journey can be transformative experiences that leave lasting impressions, unique to the pilgrim. Both offer time for contemplation, an important aspect of the journey for a pilgrim seeking answers to complex questions. As nurses "travel" through their careers, patients come into their lives bringing experiences that permeate the soul and expand the understanding of what it means to provide care for those vulnerable to disease.

FRANCISCAN WAY OF LIFE
The ancient city of Assisi is nestled into the slopes of Mount Subasio in the Umbria region of Central Italy, about 90 miles north of Rome. Assisi is best known as the birthplace of St. Francis, in 1181 or 1182. His father was a wealthy merchant, and Francis not only enjoyed a privileged life, he was a young man known for his drinking and partying.

At 19, Francis took part in a war between Assisi and nearby Perugia. He was captured and, because his father was wealthy, Francis was held for ransom. During the year of waiting for release from his Perugian prison, God sent him visions, Francis later said.

Ransom paid, Francis returned home and, after a long illness, devoted himself to living God's will. He took a vow of poverty, others joined him and the pope eventually recognized them as a Catholic religious order, the Order of Friars Minor. Francis died in 1226 and was canonized two years later.²

PILGRIMAGE, NOT VACATION
When the Mayo Clinic Health System-Franciscan Healthcare leadership chose me for the Italian pilgrimage, my handbook quickly educated me about the great difference between being a tourist and being a pilgrim. Pilgrims, it said, perceive an internal dimension to the pilgrimage; invest themselves; are affected by the pilgrimage; consider the importance of each moment along the journey, as well as the arrival to the trip's destination; and form a sense of community with fellow pilgrims.³

The notion of being a pilgrim struck me as a metaphorical representation of a nurse caring for his or her patients. The journey of a nurse's career stretches from bringing new life into this world to the time when a life will leave it.

I wondered if a nurse can provide care while avoiding personal commitment or being untouched by the experience. What happens if a nurse doesn't feel the sense of community with colleagues or patients and their families? To merely travel through life providing nursing care based on a list of tasks would certainly have us be tourists with a heavy itinerary. To be a tourist, we would not be in awe of a patient's courage in times of despair, or stand amid a crisis with a sense of immense responsibility or truly experience the joyous miracle of a first-time mother holding her newly born child to her chest.

Maybe, I thought, the career of a nurse is a lifelong pilgrimage where the human connectedness through daily patient encounters holds deeper meaning for a nurse's inner being.

MESSAGES ALONG THE WAY
I intended to write about my pilgrimage, so I was going to prepare an outline ahead of time that would allow me to fill in notes about my experiences and interpret my thoughts along the way. Bad idea, advised past pilgrims — don't interrupt the experience to take notes. Remain in the moment as your journey unfolds. Thoughts and "messages" will follow.

I'm glad I was open to that advice. The messages became clear as we visited the holy places. To be freely open to each moment allowed me to realize I was a pilgrim — not a tourist — and the resounding messages from each experience pointed me to a clear pathway of spiritual sustenance for me, for all of us, in nursing.

There's no real knowing what my fellow pilgrims experienced. A pilgrimage touches each person differently. Two people can hear the same words, but interpret them in such different ways that each comes away with a unique experience. Here, though, are the three things the pilgrimage gave me to think about:

• Naming our original blessing
• Stripping away influences in order to claim our original blessing
• Recognizing solitude is necessary

NAMING OUR ORIGINAL BLESSING
We pilgrims took part in daily group sessions to contemplate what we had experienced earlier in the day and to prepare for the next day's outing. During one session, we delved into a deep discussion about the concept of original blessing. We talked about Thomas Merton, an influential monk and Catholic author who described the concept of a point deep within our soul that is of the utmost purity — what Merton termed Le Point Vierge.

Merton wrote of this "virgin point" as a starting place that is free of illusions or disillusions, allowing people to become who they were meant to be. Fr. André Cirino, OFM, one of the pilgrimage leaders, emphasized that regardless of who we believe our creator to be, we all were born with goodness as our starting point, our original blessing.

Fr. Cirino also emphasized that it is not our task in life to "find this blessing, but to name it and nurture it."

After I returned from the pilgrimage, I still struggled to understand what it meant to "name this blessing." If the concept of being born in goodness is already named as our original blessing, then how am I to name it for myself, and, most importantly, how am I to claim it?

I later spent time with Sr. Rhea Emmer, CSA, DMin, RN, co-creator and director of the RISEN (Re-Investing Spirituality and Ethics in our Networks) program for The Center To BE, an inclusive spirituality center in Fond du Lac, Wisconsin. Sr. Emmer helped me to clarify that naming our original blessing means to truly believe we are all, indeed, good. By believing we are innately good, natural behaviors follow that allow us to live a fulfilling and rewarding life. Sr. Emmer helped me to understand that it is through our personal preferences, which shape our behaviors, that we learn how to claim this blessing.

For me, the personal preference is simple: compassion towards those who struggle with illness. The act of compassion is the result of me naming and claiming my original blessing. I'm going to guess that many other nurses would also name compassion as the manifestation of their original blessing.

Nurses convey compassion to patients in even the smallest of actions. We have been referred to as "angels in comfortable shoes" through the profession's devotion to performing these acts of compassion. Writing in the Journal of Christian Nursing, authors Chelsea Harris and Mary T. Quinn Griffin describe a nurse's ability to conceptualize compassion through his or her innate capacity to nurture and embrace another person's suffering.⁴

Authors of an article in Clinical Psychology Review performed a systematic literature review on the concept of compassion and proposed a five-element definition: 1) recognizing suffering; 2) understanding the universality of suffering in human experience; 3) feeling empathy for the person suffering and connecting with the distress (emotional resonance); 4) tolerating uncomfortable feelings aroused in response to the suffering person; 5) motivation to act to alleviate suffering.⁵

What sets the act of compassion apart from the feeling of sympathy is that it combines the acknowledgement of pain and suffering with the desire to do something to alleviate that pain or suffering. Unfortunately, compassion does not come easy, and it can be inhibited by both internal and external influences that affect our ability to remember our original blessing.

STRIPPING AWAY INFLUENCES
Throughout his life, St. Francis demonstrated his ability to strip away societal influences to be closer to his original blessing and his devotion to God. One notable anecdote describes St. Francis removing his expensive clothing to stand naked in front of his prosperous father, the townspeople and the bishop, declaring his devotion to God and stating that God was his one true father.⁶

In a symbolic stripping, he went to a leper colony just outside of Assisi and washed a leper's sores. By doing so, St. Francis stripped his "bitter"⁷ feelings for a population that he once found repulsive. Through these actions, St. Francis was able to get closer to his original blessing and manifest his ability to treat all creatures as God's children.

While on pilgrimage, Fr. Cirino asked us to contemplate what we needed to strip from our lives in order to be closer to our original blessing. He asked us to step into the shoes of St. Francis and identify who or what were the figurative "lepers" in our daily practice.

As for me, I remembered those patients who always were on their call light, or those who, no matter how hard I tried, I could not satisfy with the care I provided.

So, who or what are the "lepers" in your life? If you prefer compassion, who or what inhibits you from being compassionate to those you care for?

Nurses are known for "being there" for their patients. However, the act of "being there," or being present, can occur at various levels, from physical presence to the ultimate practice of therapeutic presence. According to authors Maggie J. McKivergin and M. Jean Daubenmire, therapeutic presence is the ability to care for our patients by providing the technical care patients require while also simply being with them. Being with a patient is not just about physical presence, but being fully present through "mind, body, emotions & spirit."⁸

While discussing this concept with Sr. Emmer, she asked me, "How are you with your patients in a way that invites them to trust you to care for them?"

That question had me thinking about a few of the elements of compassion — feeling empathy for the person suffering and feeling motivated to act to alleviate suffering. Empathy is considered a key element of a therapeutic relationship, and McKivergin and Daubenmire wrote that to fully be with a patient, a nurse must "have a valid perception of the patient's experience and an ability to understand the patient's feelings at any given moment in time."⁹

We nurses pride ourselves on diagnosing and treating our patients' responses to their medical and physical diagnosis and treatment. Once we truly understand our patients and their suffering, however, we are better able to identify their responses to their medical care. By understanding our patients, we can empathize with their suffering, which then allows us to be compassionate and truly be with our patients through therapeutic presence.

Ask someone why he or she became a nurse, and chances are the response would be the desire to help alleviate another's suffering. The motivation is driven by the impact a nurse can have on a patient's comfort and well-being.

RECOGNIZING SOLITUDE AS NECESSARY
During the pilgrimage, the leaders defined "rest" as "reflection." They asked us to use inserting our room key into our door as a reminder to start a time of rest and reflection.

How often do nurses go throughout a shift without a break? What can we use to remind us to reflect throughout the day, to let our mind and spirit "rest"?

We find ourselves answering the needs of our patients at the expense of our own needs. This chronic self-sacrifice while caring for others and prolonged exposure to difficult situations leads to a high number of nurses who have experienced compassion fatigue.

Compassion fatigue is emotional and spiritual depletion that renders a person unable to empathize with another's suffering.¹⁰ Three out of four nurses report work-related stress and overwork leading to compassion fatigue as two of their top health concerns.¹¹ One study found that 17 percent of nurses reported suffering from depression, which is 8 percent higher than the national average.¹² Another longitudinal study reported that nurses who worked night shifts with high levels of self-reported job stress suffered from sleep deficiency and an increased cardiometabolic risk.¹³ Nurses must protect their own emotional, spiritual and physical health to continue to provide the best possible care for patients.

To determine what each of us needs personally, we must take time to look inward, to refresh and renew. We must recognize times of solitude or reprieve as necessary, not selfish. Nurses often write down the times for all the tasks for patient care throughout a shift to make sure that patients get what they need at the time they need it. At what point in that shift do we schedule time for what we need? We recognize, and even appreciate, our patients' vulnerability. Why can't we recognize and appreciate our own vulnerability?

Sr. Emmer told me, "Being alone with our feelings can be uncomfortable, but it doesn't have to be unsafe."

"Our original blessing can become buried, but it cannot be destroyed," she said. "It is through self-exploration that the consciousness of our spirit increases. And a commitment to ourselves is to not allow this consciousness to become suspended again."

CONCLUSION
Regardless of the pilgrimage we are on, it is not about reaching the destination, but, rather, the profound effect the journey can have on our lives. The journey is about getting to know ourselves and accepting our original blessing.

For most nurses, caring for others puts us at risk of depleting ourselves. We struggle to ask for permission from our colleagues and, most importantly, ourselves, to take the time we need to allow ourselves rest, reflection and renewal.

During our pilgrimage, Fr. Cirino talked about personal boundaries, boundaries that protect us from our own inner critic as well as people and situations that can deplete our spiritual energy. It is up to each of us to continue to care for ourselves so we can continue to manifest our original blessing.

St. Francis died on October 3, 1226. His last words to his fellow brothers before he died were, "I have done what is mine. May Christ teach you what is yours to do."¹⁴

May we all hear our calling, claim our blessing and let it guide us on our pilgrimage through life.

CAMILLA M. JAEKEL is a nursing practice enhancement specialist at Mayo Clinic Health System-Franciscan Healthcare in LaCrosse, Wisconsin.

NOTES

1. Franciscan Pilgrimage Programs, A Pilgrim's Companion to Franciscan Places (Assisi, Italy: Editrice Minerva Assisi, 2002).
2. Donald Spoto, Reluctant Saint: The Life of Francis of Assisi (New York: Penguin Press, 2002).
3. A Pilgrim's Companion to Franciscan Places.
4. Chelsea Harris and Mary T. Quinn Griffin, "Nursing on Empty: Compassion Fatigue Signs, Symptoms, and System Interventions," Journal of Christian Nursing, 32, no 2 (2015): 80-87.
5. Clara Strauss et al., "What Is Compassion and How Can We Measure It? A Review of Definitions and Measures," Clinical Psychology Review 47 ( 2016): 15-27.
6. Spoto, Reluctant Saint.
7. A Pilgrim's Companion to Franciscan Places.
8. Maggie J. McKivergin and M. Jean Daubenmire, "The Healing Process of Presence," Journal of Holistic Nursing 12, no. 1 (1994): 65-81.
9. Carl Koch, Leading like Francis: Building God's House (Hyde Park, NY: New City Press, 2014).
10. Harris and Griffin, "Nursing on Empty."
11. American Nurses Association, "2011 ANA Health and Safety Survey: Hazards of the RN Work Environment," news release. http://nursingworld.org/FunctionalMenuCategories/MediaResources/MediaBackgrounders/The-Nurse-Work-Environment-2011-Health-Safety-Survey.pdf.
12. Christine Kovner et al., "What Does Nurse Turnover Rate Mean and What Is the Rate?" Policy, Politics, and Nursing Practice, 15, no. 3-4 (2014): 64-71.
13. Henrik B. Jacobsen et al., "Work Stress, Sleep Deficiency, and Predicted 10-Year Cardiometabolic Risk in a Female Patient Care Worker Population," American Journal of Industrial Medicine, 57 no. 8 (2014): 940-49.
14. Spoto, Reluctant Saint.