JONA
Volume 48, Number 12, pp 615-621
Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION
Implementing a Peer Support Network to
Promote Compassion Without Fatigue
Carol Wahl, DNP, RN, NEA-BC, FACHE
Teresa Barry Hultquist, PhD, RN, PHCNS-BC, NE-BC
OBJECTIVE: The aims of this study were to imple-
ment a Peer Support Network (PSN) pilot project
including education/training, peer support, and resil-
iency training and to explore how interventions impact
compassion satisfaction (CS) and compassion fatigue
(CF) in a community hospital.
BACKGROUND: CF has been reported to negatively
affect nurse retention. The PSN provides a 3-tiered team
approach to enhance CS and support nurses experienc-
ing CF symptoms.
METHODS: Twenty nurses participated in PSN
training and completed preimplementation and 6-week
postimplementation surveys: Professional Quality of
Life, Compassion Practice Instrument, and self-care
resource utilization.
RESULTS: Statistically significant improvements in
CS and nonstatistical improvements in CF were found.
CONCLUSION: Promoting a PSN may increase
CS and potentially prevent work-related physical,
emotional, social, and intellectual CF sequelae.
Compassionate caring is a foundation of nursing
practice. An increasing focus on efficiency, productivity,
financial performance, standardization, outcomes, and
technology can minimize the priority and time for
compassionate caring and decrease compassion satisfac-
tion (CS) among nurses.1 Inattention to the foundations
Author Affiliation: Assistant Professor (Dr Wahl), University of
Nebraska Medical Center College of Nursing, Kearney; Associate
Professor (Dr Hultquist), University of Nebraska Medical Center
College of Nursing, Omaha; and Assistant Professor (Dr Struwe),
University of Nebraska Medical Center College of Nursing, Lincoln;
Clinical Educator (Ms Moore), CHI Health Good Samaritan,
Kearney, Nebraska.
The authors declare no conflicts of interest.
Correspondence: Dr Wahl, HSEC-CON, 2402 University Dr,
Kearney, NE 68849 (carol.wahl@unmc.edu).
DOI: 10.1097/NNA.0000000000000691
JONA  Vol. 48, No. 12  December 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Leeza Struwe, PhD, MSN, RN
Judy Moore, MSN, RN-BC
of nursing practice can lead to a decreased professional
quality of life (disengagement, dissatisfaction, compas-
sion fatigue [CF], and burnout [BO]).2,3 A decreased
quality of life can contribute to unintended outcomes
of lower patient satisfaction, inappropriate use of
resources, patient safety risks, BO, and turnover.4
The prevalence of CF among nurses ranges from
16% to 39%, with lifetime occurrence rates among
helping professions between 40% and 85%.5,6
Thirty-four percent of hospital nurses report BO,
and 37% of nurses employed in nonnursing occu-
pations indicated the main reasons for leaving the
profession were BO and/or stressful work environ-
ments.4 The Bureau of Labor Statistics projects 1.09
million RN job openings by 2024 due to job growth
and replacement needs.7 Retaining and recruiting
nurses within a supportive work environment are
critical to achieving the Institute of Healthcare
Improvement’s triple aim of improved population
health, improved patient experience, and reduced
costsVexpanded to include improved work life.4,8
Nurses must be aware of the potential for CF
and familiar with the range of symptoms and effects
in self and others so that timely interventions can
occur. Nurse leaders can examine organizational
scenarios that negatively impact compassion prac-
tices and design and/or adapt interventions to
support the clinical team. Organizations can pro-
mote the health and well-being of employees through
a supportive culture and access to resources and
support systems. A Peer Support Network (PSN) is
an example of an organizational system that supports
peer identification of symptoms and a formalized
team-based structure for intervention. Potentially the
existence of a hospital PSN can prevent the work-
related sequelae of CF, promote CS, and ultimately
contribute to nurse retention through support of a
professional quality of life.
615
 The author’s hospital leadership and shared gover-
nance members had invested in various initiatives that
focused on a supportive culture, evidence-based change,
innovation, and a positive work environment (eg,
Planetree certification, Magnet designation, safety
A
initiatives, Daisy awards, wellness/fitness center).9-11
Opportunities continued to exist to further engage
staff and enhance the culture. Specific to this project,
there had not been any formal education/training that
acknowledged the value of CS or provision of speci-
fic resources (eg, activities to promote well-being) to
mitigate CF occurrence. Only 5% of nurses were mem-
bers of the hospital wellness/fitness center.
The purposes of this project were to (1) increase
organizational awareness of the value of CS and
potential for CF, (2) develop a baseline of self-care
practices, and (3) provide a structured PSN within a
Midwestern community hospital to enhance the culture
of caring for self and others. PSN formation included
interventions of education/training, identification of
self-care practices, and a system of team-based support.
The specific aim was to determine if these focused
interventions improved CS and/or reduced CF for the
targeted group of PSN participants by comparing
preintervention and postintervention survey results using
Professional Quality of LifeYRevised v.5 (ProQOL-5)3
and Compassion Practice Instrument (CPI).12
Review of Literature
Compassion Satisfaction and Compassion Fatigue
Nursing embodies empathy and compassion. With
compassion, the nurse is aware of another’s suffering,
has an emotional connection with that experience, desires
to see relief of the suffering, and responds to relieve suffer-
ing.13 Compassion conveys action, whereas a related
term, empathy, provides the skill set that makes compas-
sion visible.14 Empathy includes self-awareness and com-
munication skills: an ability to listen, recognize and
respond to nonverbal cues, be present in the moment,
and suspend judgment.14,15 Empathetic communica-
tion skills can increase clinician satisfaction, improve
compliance, decrease errors, decrease BO, and increase
well-being.15 Research shows supportive interpersonal
relationships influence job-related satisfaction, emotional
well-being, resiliency to care delivery pressures, and in-
tent to remain in a position.16,17 Compassion satisfaction
allows nurses to feel a sense of joy and fulfillment in
their professional choices as they connect with patients
and their suffering and allows the nurse to fulfill his/her
professional and/or personal covenant to find meaning
through the work of nursing.18
The term Bcompassion fatigue[ was 1st used in the
literature in 1992 by nurse Carla Joinson to describe a
specific kind of BO that affects those in the caring
616
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
professions.19 Since then, the term has been used widely
by healthcare professionals to describe an entire range
of stress outcomes.20 In 2010, Stamm3 developed the
professional quality of life model, which introduced the
term CS to describe the positive outcome of helping
others versus the negative outcome of CF (subscales
defined as BO or secondary traumatic stress [STS]).3,20
Coetzee and Klopper18 identified that CF is progressive
and cumulative, with compassion discomfort and com-
passion stress as precursors. In 2018, Coetzee and
Laschinger20 developed a theoretical CF model using
conservation of resources theory and social neuroscience
of empathy research to attribute the etiology of CF to a
lack of internal/external resources, inadequate positive
feedback, and the nurse’s response to personal distress.
Using this knowledge, the nurse leader can develop
interventions and support systems to promote CS,
reduce the potential for CF, and build resilience within
a workplace culture that values employee well-being.
Within this context, resilience is defined as Ban ability to
recover from or adjust easily to misfortune or change.[21
A positive workplace culture provides a founda-
tion for employee engagement and compassionate
caring to flourish.8 A positive culture emphasizes: 1)
support and trust; 2) empathy and compassion; 3)
value-centered leadership; 4) innovation; and 5) learn-
ing. Meeting external standards such as Planetree
certification and Magnet recognition and providing
professional recognition/feedback such as the DAISY
Award demonstrate supportive workplace cultures.9-11
A culture that supports engagement requires structures
and skill-building opportunities to channel education,
practice, collaboration, and partnership.8 A PSN struc-
ture creates connections, reinforces an organizational
culture of supporting clinical practice, and provides inter-
ventions when symptoms leading to CF are present.22
Implementation of a PSN highlights mutual respect and
effective communication to facilitate nurse well-being.17
Description of PSN
The PSN consists of 3 tiersVdepartment peer supporters,
a peer support team, and expert clinical professionalsV
who provide support through alleviation of CF for
colleagues experiencing normal and/or cumulative
stress reactions (Figure 1). The PSN was implemented
with permission using a successful framework devel-
oped in a university system.22 The 1st 2 tiers provide
a form of emotional first aid specifically designed to
provide support when emotionally challenging and
stressful healthcare events occur. Tiers 1 and 2 con-
sist of individual/team support; tier 3 is a referral net-
work of individuals clinically trained in high-level
interventions. The system of responses/referrals lets
the affected person(s) know they are not alone and
allows individual-appropriate interventions. Services
JONA  Vol. 48, No. 12  December 2018
Figure 1. Framework for PSN. Adapted from Scott 3-tiered Interventional Model (21).
are available 24/7 and are voluntary, and conversations
are confidential.
Project Summary
Three months before PSN project implementation, the
hospital provided mandatory CF education for hospital
clinicians (N = 684). A 20-minute online module focused
on descriptions, causes, indicators, and appropriate
actions for compassion discomfort/distress, stress, and
fatigue. BIn the moment[ resiliency concepts were intro-
duced, including the following:
1. mindful momentsVgiving attention to a focus
word or phrase, saying a prayer, concentrating
on the breath
2. breath awarenessVfocusing on the breath by
breathing slowly and deeply
3. daily gratitudeVusing positive words, thanking
individuals, paying it forward
The resulting clinician interest in CF affirmed the
need for a formalized support system in the organi-
zation and informed the subsequent development of
the PSN. Nursing leaders shared the concept of PSN
with shared governance councils, unit-based coun-
cils, and other hospital senior-level/midlevel leaders.
Nurses were asked to communicate their interest of
participating in the PSN, and because the design of
the PSN included plans for staff deployment when a
need arose within the hospital, director permission
was obtained for staff volunteers. Attributes of the
preferred nurse participant included credibility with
peers, history of compassionate interactions, interest/
availability, ability to problem solve and access resources.
Interested nurses were supported by directors and were
invited to participate in targeted training. House supervi-
sors and key interprofessional clinicians were specifically
recruited because they embodied the preferred attributes
and were accessible when needed.
JONA  Vol. 48, No. 12  December 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Each clinician was sent a letter explaining parti-
cipant expectations, the institutional review boardY
approved narrative consent, and the survey instruments
administered through SurveyMonkey.23 Participants
completed an additional 20-minute online module
focused specifically on development of a PSN. Topics
included identifying at-risk colleagues, using therapeutic
communications, and using key words/phrases.24 Partic-
ipants then attended a 3-hour face-to-face session includ-
ing a 2-hour resiliency workshop facilitated by a PhD
organizational psychologist and a 1-hour PSN team
roles, activation process, and scenario review. Refer-
ence materials were distributed. Participants were
compensated by paid work hours for survey comple-
tion, online education, resiliency workshop, and PSN
implementation training.
Six weeks after training, participants again com-
pleted the ProQOL-53 and CPI.12 The repeat surveys
were scheduled to evaluate the effect of the PSN on
participant CS and/or CF and determine needed pro-
gram changes. The 6-week interval was intentionally
selected to reduce the impact of distractions occurring in
the organization (unit closing/consolidations, staff turn-
over, leader exits).
Methods
Design
This project was developed and implemented using a
nonexperimental purposive sample pre-post compar-
ison design with an integrated approach to impacting
CS/CF through the development of a PSN. Institu-
tional review board approval was obtained from the
hospital and the university where authors were associ-
ated as students or faculty. To determine a sufficient
sample size, an a priori power analysis was conducted
using a Cohen d of 0.50, a 2-tailed ! = .05, and power =
0.95, for a paired t test.25 A sample size of 54 was
needed to answer the aim of this project. Using pilot
617
study guidelines of at least 10% of a fully-powered with higher scores indicating higher levels of CS and
study,26 the current project sample size of 20 meets the CF (BO/STS). The tool has established content and
requirements while remaining realistic with time and cost. construct validity; scale reliabilities include CS, 0.88
to 0.91; BO, 0.71 to 0.75; and CF, 0.77 to 0.81.2,3 Cut
Setting and Subjects scores at the 25th, 50th, and 75th percentiles include
The setting was a 256-bed Midwestern regional level II CS (44, 50, 57), BO (43, 50, 56), and STS (42, 50, 56).
trauma center with 1200 employees. The hospital was Concerns have been raised about the ability of
part of a 14-hospital regional system. The majority of ProQOL-53 to adequately discern CF in nursing11,27;
PSN participants were nurses (n = 33); 8 nonnurses also therefore, authors also used a recently developed tool
participated (eg, chaplaincy, social work) in the to discriminate between various levels of CF. CPI is a
education/training and data collection. The focus of 19-item tool measuring levels of CS, discomfort/distress,
the data analyses was nursing. Thirty-three nurses stress, and fatigue on a 6-point Likert-type scale ranging
completed the preintervention surveys; postinterven- from Bnever[ to Balways.[12 CF consists of 3 CF con-
tion participation was 61% with 20 matched sets of structs: disengagement, impotence, and unfulfilled. Tool
surveys completed. reliability was established at CS, 0.839; CF-disengaged,
0.742; CF-impotent, 0.840; CF-unfulfilled, 0.633; and
Measures CF-total, 0.695. Content validity and construct validity
The measures used in this project were the ProQOL-5,3 were established.12,28 Mean scores for CS include low
CPI,12 and Self-care Resource Utilization Question- 0 to 2, moderate 2.1 to 4, and high 4.1 to 6. Mean
naire (SCRU) (C. Wahl, RN, unpublished tool, 2016). scores for CF subscales include compassion distress,
Participant demographic information was gathered 0 to 2; compassion stress, 2.1 to 4; and CF, 4.1 to 6.
at baseline (Table 1). The ProQOL-5 survey remains the The SCRU questionnaire (C. Wahl, RN, unpub-
most widely used tool in CF literature.3 The 30-question lished tool, 2016) provided baseline information about
tool measures CS and CF using a 5-point Likert-type self-reported use and perception of barriers to engaging
scale ranging from Bnever[ to Bvery often.[ The tool in health-promoting behaviors (healthy eating choices,
contains scales for CS and CF (measured by subscales nutrition counseling, exercise/fitness activities, athletic
for BO and STS). Domains assessed include traumatic training, spiritual activities, emotional support, hobbies).2,6
stress, anxiety/mood, and psychosocial functioning, A frequency scale was usedVcategories included
Brarely/never,[ [sometimes,[ and Boften/very often.[
Respondents could choose multiple answers in the
Table 1. Descriptive Statistics for Nurse barriers section (none, time, money, energy, access,
Participant Demographics knowledge, motivation).
% or
n (n = 20) Mean (SD)
Data Analysis
Gender
Male 1 5%
Data were imported from SurveyMonkey to SPSS 24.0.
Female 19 95% (Armonk, New York). Data were cleaned, and the
Age (range, 31-61 y) 45.7 (10.4) assumption of a normal distribution and homosce-
Positions
Nonmanagement 7 35%
dasticity were verified through graphing. All summary
Supervisor/coordinator 11 55% scales fell within the range of T1.4 for skewness and
Director/manager 2 10% kurtosis, with most scales below 1. An a priori ! = .05
Highest level of education
Diploma/associate degree 2 10%
was selected for inferential testing. Variables were sum-
Baccalaureate degree 11 55% marized using descriptive statistics. The demographic
Higher degree 7 35% survey was summarized with descriptive statistics and
(MSN, DNP)
Primary shift worked
frequencies; the SCRU was summarized with frequencies.
Days 18 90% The ProQOL-53 and the CPI12 were scored according
Nights/rotate 2 10% to researchers’ instrument manuals. Paired t tests were
Length of time at hospital
G2 y 1 5%
conducted for each of the summary scales of interest.
2-5 y 0 0%
6-10 y 4 20%
11-15 y 6 30% Results
915 y 9 45%
Shift length worked Table 1 details demographic characteristics. Table 2
e8 h 13 65% details ProQOL-5 and CPI results of nurse participants
10 or 12 h 7 35%
who completed surveys during both time points. Of
the 20 participants who completed the ProQOL-5 and

618 JONA  Vol. 48, No. 12  December 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 (BO, score 22.1 to 21.2; STS, score 23.1 to 21.8).
Table 2. ProQOL-5 and CPI Results of Although the actual low scores and direction of CF
Nurse Participants (Time 1/Time 2) change were encouraging, one might anticipate a cor-
responding increased CS score from T1 to T2.
ProQOL-5VCS
T1 41.2 (3.84) The CPI measured a statistically significant increase
T2 40.8 (4.70) in CS from T1 to T2, from 4.06 (moderate) to 4.58
ProQOL-5VCS T2-T1 paired t test: t19 = j0.818, P = .42 (high). One might have expected a higher preinterven-
ProQOL-5Vburnout
T1 22.1 (4.81) tion CS score because of the profile of nurses participat-
T2 21.2 (4.70) ing in PSN and the organization’s established person-
ProQOL-5Vburnout T2-T1 paired t test: centered culture. The postintervention measures
t19 = j1.630, P = .12
ProQOL-5VSTS showed a higher level of CS, perhaps suggesting that
T1 23.1 (4.94) education/training, PSN implementation, and personal
T2 21.8 (4.14) resiliency training impacted results in the short term.
ProQOL-5VSTS T2-T1 paired t test: t19 = j1.870, P = .08
CPIVCS CF-total and CF-impotent had decreases in the mean
T1 4.06 (0.508) but remained in the Bcompassion stress[ level. While
T2 4.58 (0.728) CF-disengaged had a slight increase, the mean remained
CPI CS T2-T1 paired t test: t18 = 3.991, P = .001
CPIVCF-disengaged in the Bcompassion stress[ level. For CF-unfulfilled, a
T1 2.17 (0.423) slight decrease was noted with the mean dropping to
T2 2.22 (0.425) the Bcompassion distress[ level. No CF results achieved
CPI CF-disengaged T2-T1 paired t test: t18 = 1.046, P = .31
CPIVCF-impotent statistical significance.
T1 2.50 (0.697) When comparing the overall results from both
T2 2.45 (0.577) surveys, it is notable that ProQOL-5 shows low CS and
CPI CF-impotent T2-T1 paired t test: t18 = j0.089, P = .93
CPIVCF-unfulfilled CF below the 25th percentiles, whereas CPI shows high
T1 2.08 (0.518) CS and moderate CF (compassion stress). While using
T2 1.94 (0.595) the same terminology, there are researcher differences
CPI CF-unfulfilled T2-T1 paired t test:
t18 = j0.925, P = .37 in definitions of both CS and CF; therefore, it is not
CPIVCF-total surprising that results are dissimilar. CPI may be able to
T1 2.23 (0.405) discern more subtle differences in CS/CF to guide
T2 2.19 (0.473)
CPI CF-total T2-T1 paired t test: t18 = j0.221, P = .83 nursing leaders in appropriate interventions.
The SCRU questionnaire provided a baseline of
ProQOL-5,3 CPI.12
actual utilization of health-promoting behaviors and
identified barriers as noted previously. Nurses often
CPI during both time points, all had complete data on exhibit poor health-promoting behaviors and miss
the ProQOL-5, and 19 had complete data on the CPI. opportunities to reduce the effects of work-life stress.2
These pairs were used for the paired t tests compar- Using PSN communication strategies (listening, debrief-
ing time 1 (T1) and time 2 (T2) results. Table 2 shows ing) and self-care strategies can strengthen a nurse’s
the results of the paired t tests on the subscales of ability to cope when stressful events occur.29 While the
ProQOL-5 and CPI. Although all scales showed impro- PSN had access to hospital wellness/fitness resources,
vements in decreasing fatigue or increasing satisfaction, additional resiliency training was provided to engage
only the CPI CS subscale was statistically significant and the individual in personal health promotion and
increased from a mean of 4.06 (0.508) to 4.58 (0.728) provide support options during PSN-nurse interactions.
after participation in the project, t18 = 4.0, P = .001. Table 3 details the highest frequency of utilization with
hobbies followed by healthy eating choices. The lowest
frequency activity was wellness activities. The most
Discussion
frequent barriers were time, money, energy, and moti-
The ProQOL-5 measures quality of lifeVboth the posi- vation. With organizational attention to productivity and
tive (CS) and negative (CF).3 Standardized cut scores, financial performance, minimal (or no) time is available
based on a database of responses from all professions, for self-care, which challenges nurse leaders to develop
may not accurately measure CF in nursing.11,27 Project innovative solutions. One way to reduce barriers is to
cut scores were compared with published norms, with provide in the moment self-care/resiliency options.
scores below the 25th percentile for both CS and CF.
Paired-sample statistics showed that ProQOL-5 CS
scores decreased between T1 and T2 (41.2, 40.8), but
Limitations
the change was not significant. The CF scores also Participation in the project was voluntary and con-
decreased, but neither change demonstrated significance ducted at 1 community hospital; thus, results may

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 not included in this analysis. Because of financial and
Table 3. SCRU Nurse Participants productivity constraints, some of the education was
Completing T1 and T2 Surveys (n = 20) offered through an online platform; there can be varying
Nurses Barriers Nurses
levels of participant attention, concentration, and
retention.
(All That
Frequency n (%) Apply) n (%)
Implications for Future Projects
Healthy eating choices
Never/rarely 3 (15) No barriers 3 (15) This project highlights the importance of preparing
Sometimes 6 (30) Time 14 (70)
Often/very often 11 (55) Money 2 (10)
nurses for a normal response of CF within an increas-
Energy 7 (35) ingly challenging care environment. Practice and edu-
Easy access 6 (30) cation have an opportunity to work collaboratively to
Knowledge 1 (5)
Motivation 11 (55)
develop education to recognize symptoms at student,
Exercise and fitness activities new-graduate, and experienced nurse levels and provide
Never/rarely 4 (20) No barriers 3 (15) early interventions. A number of questions invite future
Sometimes 9 (45) Time 17 (85)
Often/very often 7 (35) Money 1 (5)
projects. Is there a sequence of improvement, that is,
Energy 9 (45) does CS improve before CF is reduced? What are the
Easy access 4 (20) correlations between tools that measure CS/CF and
Knowledge 0 (0)
Motivation 8 (40)
which ones most accurately measure the experience of
Wellness activities (such as yoga and tai-chi) nursing? Because many nurse executives now manage
Never/rarely 12 (60) No barriers 4 (20) other clinical departments, do other clinical professionals
Sometimes 8 (40) Time 13 (65)
Often/very often 0 (0) Money 1 (5)
experience CF similarly to nurses, and are the actions the
Energy 3 (15) same? Work to further describe and understand CS/CF
Easy access 1 (5) development with tools such as CPI in various settings
Knowledge 3 (15)
Motivation 8 (40)
will contribute to ongoing knowledge transfer and
Spiritual activities (such as prayer, breathing/meditation, workplace support for staff.
and/or other contemplative practices)
Never/rarely 3 (15) No barriers 17 (85)
Sometimes 6 (30) Time 3 (15) Conclusions
Often/very often 11 (55) Money 0 (0)
Energy 0 (0) The presence and progression of CF symptoms are
Easy access 1 (5) real in today’s environment. With the forecast of a
Knowledge 2 (10)
Motivation 1 (5)
nursing workforce demand that exceeds supply, there
Emotional support is a call to support a healthy team that can deliver excep-
Never/rarely 2 (10) No barriers 12 (60) tional care in a constrained environment. Interventions
Sometimes 7 (35) Time 2 (0)
Often/very often 11 (55) Money 2 (10)
that educate nurses on those situations that cause stress
Energy 1 (5) and the creation of a supportive environment that
Easy access 5 (25) promotes seeking and/or receiving help can help to
Knowledge 0 (0)
Motivation 3 (15)
promote CS and alleviate the consequences of CF. The
Hobbies I enjoy results of this project suggest that educating nurses on
Never/rarely 1 (5) No barriers 5 (25) the experience of CF and training a team of knowl-
Sometimes 6 (30) Time 13 (65)
Often/very often 13 (65) edgeable peer responders can contribute to improved
Money 3 (15)
Energy 5 (25) CS. The same interventions may also contribute to
Easy access 2 (10) decreased CF, although measurement at 6 weeks
Knowledge 0 (0) postintervention may not have allowed sufficient time
Motivation 2 (10)
to demonstrate statistically significant results. Devel-
opment of effective professional support systems for
promoting CS and addressing CF may ultimately
not be transferrable to other hospital nurses. The par- contribute to retention of nursing within the organi-
ticipants exhibited characteristics of positive and com- zation and profession.
passionate interactions and a willingness to connect
with others; results may not be a true reflection of the Acknowledgment
whole of nursing. Nonnursing professionals were en- The authors thank Erick Hill, PhD; Kristine Hughbanks,
couraged to participate in the project because of similar DNP; Hospital Peer Support Network; Susan Scott,
challenges in care delivery; however, because of the PhD; and the University of Missouri Health Care’s
uneven distribution of nonnurse participants, they were forYOU Team.

620 JONA  Vol. 48, No. 12  December 2018

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