Teaching and learning how to care for patients who are suffering are far from the center of nursing education. However, students often speak of struggling with their feelings of helplessness, anger, and guilt as they bear witness to patients' suffering. Nurse educators strive to create a caring community conducive to learning in the presence of suffering. How are nursing students helped to keep their call to care alive and vibrant in the presence of suffering?
Reflecting on suffering brings to the forefront feelings of vulnerability. Sharing the lived experience of entering into situations of suffering helps nurses and students understand the phenomenon. This dialogue is essential to make visible the nursing profession's caring practices and visions for the future (Street, 1992). Suffering must be recognized, and a genuine pedagogy of suffering created by communicating that which is witnessed (Frank, 1992). A summary discussion related to the concept of suffering may be found elsewhere (Eifried, 1998a). This article addresses the inclusion of students in the circle of care involving suffering.
The research study reported in this article used interpretive phenomenology to answer the question, "What is it like for a student in nursing to care for a patient who is suffering?" (Eifried, 1998b). Interpretive phenomenology explicates meanings as they are lived in the lifeworld of everyday experience (van Manen, 1990).
The methodological structure of interpretive phenomenology is an interplay of the research activities of turning to the phenomenon, investigating the experience as it is lived, reflecting on essential themes, describing the phenomenon, maintaining a relationship to the phenomenon, and balancing the research context by examining parts and wholes (van Manen, 1990). The researcher does not follow a prescribed set of steps or procedures but instead uses a scholarly approach that provides an optimum account of the text generated in the study (Benner, 1994). Careful listening and hearing the participants' voices allows the researcher to provide an account that represents the participants' world and articulates the takenfor-granted meanings of the students' lived experiences of caring for patients who were suffering.
Participants for this study included 13 college seniors, ages 21 to 38, enrolled in a program preparing them for a baccalaureate degree in nursing. The participants were studying advanced medical-surgical nursing and were not in any of the researcher's classes at the time of the study. The students participated in individual and group conversational interviews conducted throughout the course of one semester. The researcher also visited students in their clinical settings to share more intimately the experiences referred to in conversations. In addition, the students shared journal entries that discussed their experiences of being with patients who were suffering. In this article, all names have been changed to protect the confidentiality of the participants and the patients in their care. Institutional Review Board approval was obtained, and the students signed consent forms. Students were free to withdraw from the study at any time.
The researcher began by asking the students to tell a story about a time they could not forget when they cared for a patient who was suffering. This was followed by a request for details of the experience and what it meant to the students. The conversations were audiotaped and transcribed verbatim to generate a text that was examined interpretively in an effort to understand the students' experiences. The text for this study includes transcripts of conversations with students and students' journal entries.
A selective, or highlighting, approach was used to uncover thematic aspects of the phenomenon in the text (van Manen, 1990). Martin, a computer software program (Diekelmann, Lam, & Schuster, 1991), was used to organize the interpretive process. Analysis of the text revealed many recurring ideas in statements or phrases. Interviewing continued until the data were saturated. After isolating and describing the themes that captured the nature and core of the experience, interpretation began.
During analysis of the text, an interpretive description of the lived experience was written and shared with the students. After isolating and describing themes that captured the nature and core of the experience, a deeper interpretation began. The participants verified the faithfulness of the descriptions and the interpretation of the experience. Nursing students who were not research participants also recognized the description of the lived experience and commented that the interpretation rang true for their experiences.
TESTTMONLES OF SUFFERDfG
The students in this study told many stories about what they perceive as suffering, beginning with their own life experiences at times when they suffered or witnessed suffering in people close to them. One student witnessed her aunt caring at home for her daughter who was brain damaged from a car accident. Another student needed to support her sister, nieces, and nephews when they were told their husband and father was killed suddenly in a tragic accident. Several students described caring for their fathers, grandmothers, or grandfathers as they cried out during their dying days. One student was the only person willing to hold the hand of her 18-year-old friend as she delivered a stillborn baby girl. Two students experienced life-threatening illnesses that required years of medical care and recovery time.
Past experiences influence the recognition of current suffering. Some examples of patient suffering encountered by the participants were:
* A man experiencing physical pain, the psychological pain of depression, HIV dementia, alcoholism, and suicidal thoughts.
* An 11-year-old boy with a pained face, swollen feet, encephalopathy, and wasting syndrome.
* A woman crying out in agonizing pain.
* A woman rendered breathless and voiceless due to respiratory failure.
* Many patients balanced between life and death.
* Patients restrained, so they could not pull out their tubes.
* Patients who were alone.
* Patients newly diagnosed with terminal illnesses.
BEARING WITNESS TO SUFFERLNG
Each student brought a rich history and a unique lived experience to the study. In analysis of the text, the researcher sought shared meanings and an understanding of the phenomenon of nursing students being with patients who were suffering. Bearing witness to suffering emerged as a metatheme that captured the students' experiences. Students see, hear, and feel suffering in their various clinical experiences and can bear witness to it. Bearing witness, providing testimony, and telling the story to others can be ways of understanding and learning about suffering. The following subthemes captured the essence of bearing witness to suffering:
* Grappling with suffering.
* Struggling with the ineffable.
* Getting through.
* Being with patients who are suffering.
* Embodying the experience of suffering.
* Seeing possibilities in suffering.
When students bear witness to suffering experiences, they become acutely aware of their vulnerability and struggle to be authentically present to patients. It is in being present to patients that students become aware of the embodiment of suffering and the meanings embedded in the experience.
Grappling With Suffering
Students' stories about their experiences of being with patients who were suffering call attention to many struggles. All students described trying to come to grips with the suffering experience and the many feelings suffering evoked. Many students expressed feeling nervous about the many tasks needing to be accomplished and the helpless feeling of being unable to relieve patients' pain. Students cannot stop the ravages of illness and feel powerless when helping is out of their reach. Kelly's story is one example of grappling with suffering.
Kelly described her first patient, who had her "eyes welling up with tears from the first moment I picked up the chart." During orientation to the unit, Kelly had seen Danny among the other children and had learned that he was being treated for AIDS. Later she found out he would be her patient. She was full of apprehension at the thought of caring for him. Being assigned to take care of a sweet little boy dying with AIDS was so threatening that Kelly found herself glued to the medication cart. Kelly said:
I kept putting it off for some reason, like going into his room... the morning I was with him, I looked at my meds [medications] 10 times before I'd go in there, and he had an eight o'clock med [medication]. I just kept putting it off and didn't want to go in. It was very tough, very tough.
Kelly struggled with taking the first step into the world of being a nurse for a little boy with AIDS. Kelly did not know how she was "going to hold it together." She was afraid she would become so upset that Danny would see she was hurting. She worried, "What would Danny say?" and "What would her instructor say?"
Taking care of little Danny was traumatic for everyone in Kelly's clinical group. Every week a different student cared for Danny. When Danny stopped hoarding his candy, the situation became even more difficult for the students. Kelly said:
Danny's such a hoarder. He has every kind of candy you can think of in his room. In his bed, he has cookies stuffed inside the mattress. Of course, he never eats hardly any of that stuff; it's just all there. He would not let anybody have it, but now since he's really sick, he's telling people to go ahead and take it, "?1 never be able to finish it." That's really tough too, oh, God, I didn't even recognize it, but he's gonna [sic] die; that's really sad. Now I kind of wish he had dementia... so it's less painful for him, less painful that I could handle it better. It's just sad. That was tough for even the people that didn't take care of him; everybody went in and saw him.
The students were part of Danny's last will and testament. He bequeathed his treasures to those he cared about and those who cared about him. Eventually the students overcame their fear of showing their emotions in front of Danny, but the hurt in their hearts did not seem to fade.
Even worse than the feeling of helplessness is the feeling of being alone in the struggle. The following story exemplifies being alone and overwhelmed. Jane stated:
Mrs. D. was my toughest patient. She was my first trach [tracheostomy] patient, and I was very nervous about that. I knew the only way we could communicate verbally was if I did [a] finger occlusion. Early in the day, she told me in her breathy voice that she had had enough. She couldn't take it anymore. Her watery eyes stared up at me. I was to call her husband because she wanted to die. I felt my eyes well up as my finger slid off her trach. This is how my day started. Throughout the day I was repeatedly challenged both emotionally and physically. She had 13 medications, suctioning, turning, tube feedings, bath.... I was overwhelmed. She kept telling me how much the bed sore on her head hurt. I tried to reposition her, and I gave her pain medication. Nothing I did seemed to help. I felt completely helpless, and even more, I felt alone. By 2:30 I had not even had time to go the bathroom or even get a drink of water. Mrs. D.'s tube feeding ran out, and no one knew where her type of food was. I saw my instructor, and she asked if I was OK I burst out crying and sobbed, "I can't find Mrs. D.'s food!" The day was very upsetting for me. What hurt the most was that I felt alone.
Jane felt alone while trying to do her best. This situation addresses the high acuity level of hospitalized patients and large clinical groups. A caring instructor unknowingly allowed a student to suffer. What do students need to be able to heal the suffering they endure as they reach out to comfort others? Jane said:
Suffering is a two-way street. I, as a student, suffer in some of the situations I am in, and my patients suffer because of the situations they are in. I feel like I suffer the most when I feel like I can't do anything for my patients. When I see patients suffering, I get an ache in my stomach. What can I do? - my patient is dying. They don't teach us this in nursing school. My first idea of death is terrifying. Is the patient scared? Is the family suffering? I think if I knew how to "prepare" terminally ill patients and their families for death, I would not suffer so much because I would not feel so helpless.
Dass and Gorman (1993) stated, "discomfort in the presence of suffering is usually less toxic and infectious when it's no longer denied" (p. 67). When one is aware of one's discomfort, one can enter into the experience of suffering more easily. "We're no longer running away, glancing over our shoulder. We can stop and face what's right before us" (Dass & Gorman, 1993, p. 67). What students often face is a feeling of vulnerability and a "call to woundedness" (Lashley, 1994, p. 41). When students are asked to enter into suffering, they experience "helplessness and vulnerability to isolation, illness, and loss and the fear of one's own destiny" (Lashley, 1994, p. 42).
Struggling With the Ineffable
Ineffable means "beyond expression, indescribable, or unspeakable," something "not to be uttered" (.American Heritage Dictionary, 1969, p. 672). When students encounter suffering, they often are compelled to ask unspeakable questions. Many of the questions have no answers, while others have answers that defy expression or are "not to be uttered."
Being so close to suffering caused Kate to ask, "Why do patients have to go through this?" This query begs for an answer and called Kate to question her moral beliefs. Kate also questioned the role of nursing in alleviating suffering, the role of suffering in patients' Uves, the role of suffering in her life, and the meaning of suffering. Are there answers to these questions? Faculty must find a way to help students pose the appropriate questions and accept that some questions have no answers.
Many students in this study were shocked at times by their patients' conditions and searched for explanations. Often, none were forthcoming. Kay's story provides an example of struggling with the ineffable:
I didn't get the information I should have gotten in the report. So, when I walked in there, into that room, I was totally taken aback by this patient's state. He was totally covered in blood, his face, dried blood, dripping blood from his nose, blood all over his hands, all over the sheets. I mean I just went into a state of shock. I almost wanted to cry. It was ridiculous. He was restrained, and he can't wipe the blood from hie face. Blood is all in bis mouth, in his lips. When he talks, it's like all in his gums cause it's just covering his face, and I'm just totally shocked. So, I start cleaning him up right away, and I'm like what's happening, how long has this been going on?
This story is about caring for patients in a state of unknowing. For Kay, the situation seemed surreal. This was not the picture painted by Kay's textbooks or her instructors.
For Kelly, questions emerged when she felt "in between" agreeing with the doctors who requested her patient be taken off the ventilator to die and wanting her patient to be given a chance to live. She said:
The doctors are talking to the daughter and finding out about taking her [the patient] off the vent [ventilator] because she has a dead brain. You know, I guess the CVA [cerebrovascular accident] damage is done; she's not really going to get any better. It really didn't matter what the daughter said.. .they're gonna [sic] suggest taking her off the vent. So I was like, you just have to deal with all the issues. I'm looking at her history, and she's 77, and she does have all this going on, and you're kind of in between. Would it be better for her to just take her off the vent so she's not going to be suffering? But, when I see the patient you're like [sic], even if I just say one thing to her, and her eyes open, and she looks at you, I'm like, wait a minute, does she know what's going on here. Doesn't she have a say? Does she know what's going on? Sometimes you say her name, and she looks right at you, and I'm like, wait a minute, did someone tell her? Does she want to get off the vent? She's gonna [sic] die. She might say yes, take her off the vent, but I don't know. It's kind of hard. I was flip-flopping [sic] back and forth all day. Is this a good thing or not?
What is it like to harbor all these feelings and questions inside while at the bedside? When Kelly touched the patient, was she hoping the patient would touch her back? What is it like to want to hold on to life at all costs? What is it like to not know where to turn with your questioning, tearful eyes? When Kelly went back the next week, her patient was not there. Kelly assumed the doctors had taken her off the vent and she had died, but she did not ask. She said, "I just feel strange because I was there... not that I'm responsible or running away from anything.. .. I don't feel like I want to know about it." Why is this? What are students giving up through such unknowing? Is it possible Kelly would have had to face the possibility that she lost the patient?
Students described finding many different ways of responding to their feelings of helplessness, sadness, and loneliness. Several students in this study reported confiding in each other and finding great comfort in doing so. It is a rare joy when students can turn to understanding mothers, fathers, siblings, or spouses for support. However, family members or significant others often cannot relate to students' experiences and may ask, "Could you please not tell that story now?" In the clinical setting, students seek each other for help and support and wonder what it will be like when their friends are not there to turn to. Students feel that having the presence and support of their peers, both within and outside the clinical setting, is important for their well-being. They form a sharing and supporting circle. It is a rare when faculty are included in this circle.
According to the participants, students may feel the need to hide (e.g., sipping juice in the cafeteria, looking for things in the utility room), especially when faculty are not around or do not seem to have the time to comfort them. One student, Tori, said she goes to the bathroom just to get away. One day she had to try several places to find a hideout. She first went to the conference room, and someone was there. Then, she went to the bathroom, and the janitor was cleaning it. She said, "No matter where I went someone was there." She thought, "Where am I gonna [sic] go now?" Tori desperately wanted a place to call her own, if only for a minute, to collect her thoughts and muster the fortitude to return to the bedside of her suffering patient.
While striving to be present to their suffering patients and trying to learn what needs to be done, students often feel overwhelmed and hopeless and seek a place to which they can escape. Jane explained that this is a place where she could "step back and clear [her] mind for a minute, just relax."
The space in which people find themselves (i.e., thenlived space) affects the way they feel (van Manen, 1990). For example, the space may make an individual feel small, free, trapped, safe, vulnerable, helpless, alone, or comfortable. Examining the lived space of the students' experiences of being with patients who are suffering helps uncover the meaning of the lived experience. Students experience feelings of vulnerability as they step into the presence of patients. If they are tenuous, it is partly because the place is not familiar to them.
In this study, through their stories, the students revealed other sources of strength. At times, an inner strength pulled them through. They described having a sense of responsibility and "maybe a little self-esteem" that let them know that, as Maddie said, "you can do this if you really try." The students sensed that their patients who were suffering needed them, and they did not want to let them down. On one particular day, Maddie took one look at her patient and knew that she was needed. Maddie related, "I wasn't going to let her [the patient] down; so I stayed, and it worked out really well. It's just getting over that hump, that fear, that anxiety that says, 'RUN.' If you can get over that, you'll be all right."
Diane found that praying helped her. When her patients were suffering, Diane turned to her faith and felt that "someone has control... there's something going on, and there may be a reason for it.... It's a security for me and whether it is [true] or it isn't, it's what I believe." Diane also prayed every day to God for strength. When individuals pray, they expose their fears, hopes, and need for help (Bolen, 1996). According to Bolen (1996), "Praying can heal our isolation, strengthen our ability to keep on keeping on, and nourish our spirit" (p. 129).
The stories students told about getting through revealed several tensions. Students wanted to share their feelings of helplessness, sadness, and loneliness with others but seldom risked telling faculty or shedding tears. The vulnerability felt in the presence of suffering can be compounded by the fear of appearing inadequate in the presence of the instructor. Therefore, the need to share often is sacrificed because students are unsure where it is appropriate to share their woundedness. In some situations, students need to leave for a while so they can return to be truly present to patients who are suffering. They seek a place where they can respond to their heartache and gather their thoughts.
Being With Patients Who Are Suffering
In being there for a patient in physical pain, when "every cell in his body was screaming," Jane felt she had to be a rock for Mr. M. She tried to "Just be there, like strong, and just sit next to him." Kelly said she did not think it was easy to just sit with a patient but that she was willing to do it for a patient. Kelly related:
Sometimes you don't say anything, just let them keep talking, so that you can just be a rock that way, just listening and letting them say whatever they want to say. [It's also hard when you try to] get out the words to tell them it's gonna [sic] be OK
When Kate cared for a patient with a spinal injury who was dependent on a ventilator, much of her care focused on "emotional support offered in touch and speech." She also became vigilant about maintaining his privacy because staff "tended to go in the room and perform tasks as if he was [sic] a mannequin in the skills lab." When Kate was trying to bathe the patient, and the doctors wanted to stand in the room and discuss the patient, Kate stopped the bath, covered the patient, and waited for the doctors to leave. The doctors were shocked. Kate said, "the concern was not for me but for the patient and his privacy. The entire experience was a learning one, and I think now I will make an extra effort to always recognize the patient."
At times it seems the students are the only people who recognize the patients. Faculty can learn, or relearn, much from students. Frank (1992) encouraged all caregivers to engage the "full scope of the patient's experience and suffering" (p. 469) and to allow this engagement to lead to recognition. Kate was able to engage her patient, to watch him, and to see the frustration on his face as he tried to communicate but could not form the words. She responded in touch and speech, treating him like a person, recognizing him.
When students face patients who are suffering, they are able to focus on what is needed. Students described providing physical comfort and emotional support. The students were present to their patients in word, song, laughter, and silence. When students are face to face with patients, they sense their responsibility and respond. In their woundedness, they may respond haltingly to suffering but savor opportunities to reach out and make a difference. According to Lévinas (1962/1996), students are put into question by the Other and are summoned to respond:
The I is not simply conscious of this necessity to respond, as if it were a matter of an obligation or a duty about which a decision could be made; rather the I is, by its "very position," responsibility through and through, and the structure of this responsibility will show the Other (Autrui), in the face, challenges us from the greatest depth and the highest height (p. 17).
Students respond to patients and each other. It is caring faculty who sense a responsibility and respond to students as they encounter patients face to face.
Embodying the Experience of Suffering
Students learn to recognize the embodiment of suffering in themselves and their patients. Jane said that when Mr. M. spoke, she "could almost feel his pain. It enveloped the small room like a dark cloud." Kate stated that at one time it was difficult for her to watch her patient because "frustration was evident on his face." Another student, Kelly, knew her patient could not take it anymore when his watery eyes stared up from the bed. Maddie knew when her patients needed to be turned and cleaned by the expressions on their faces. She knew it hurt when she turned them because she "[heard] them moan and groan and cry." Doris remembered when large doses of pain medication were not enough, and her patient was "screaming in agony" every time she had to be moved. Anita recognized suffering in her patient's "eyes; I could see it in her facial expression that she was scared and she didn't know what was going on and she was suffering." When one of Tori's patients had a tracheostomy, "she [the patient] couldn't cry or anything, so when she was upset you could see her face upset, but you couldn't hear anything."
Sometimes students hear no sounds but see tears running from their patients' eyes. Kay described caring for a 5-year-old boy, Michael, who had a number of chronic health problems that had created a need for a permanent gastrostomy tube and tracheostomy. When Kay cared for Michael, he was in isolation to prevent the spread of a viral disease. Kay told the following story about caring for Michael:
I can't know exactly what this small child was feeling the day I cared for him or on any other day, but he can't possibly feel the happiness and joy of a healthy child his age. My heart broke just looking at him. It's just so sad to see a child [who is] intubated, can't speak, and lying there helpless. Even though I woke Michael up gently and talked to him soothingly, I think he was scared upon seeing me, after all [everyone] entering his room had on masks, gowns, and gloves. How frightening that must seem to a child.
The one event of the day that made me actually think about suffering more than anything was when I was going to move Michael from his crib into his specialized wheelchair. I thought he would like to get out of bed and be able to look around. How can one really know, however, what a child in this stage does want, until maybe it's too late. I was picking him up to get ready to move him, and I was focused on making sure all his tubes, leads, ventilation tube, [and] gastrostomy [were] not caught on anything, and I looked at his face for a moment. And, although he is completely silent, I see these tears running from his eyes. He was either frightened to death of this stranger removing him from his bed, or he really just wanted to stay in the crib. The point that was made to me through this event was that this little guy was suffering, and I didn't know or have any idea what he was feeling. It's so different with children because you can't always know how they feel. You have to use your powers of observation much more efficiently.
This is a story of not sensing suffering until tears were shed. When Kay shared this story in the group meeting, she revealed how much it hurt her to not know what Michael was feeling. She stated, "There's a lot of body language involved with children that you have to read into." Kay also shared that it was not until after she wrote the story in her journal that she "realized probably it was me that was suffering more than him."
What happens when it is the students who are suffering? Kay suffered because she felt she missed knowing that Michael was hurting until she saw his tears. Then, she had to guess what was causing Michael to cry. Kay was uncertain about Michael's suffering but was painfully aware of her own. She may never have realized if she had not been asked to tell her story. According to Bolen (1996), "A story has emotional power: it brings meaning, hope, and vision together; it connects body and soul" (p. 95). Through her story, Kay, and the others in the group, felt cared for and connected. Michael's tears and Kay's hurt gathered meaning.
Jane wrote the following narrative about caring for children who are completely dependent:
These children break my heart. I can literally hear it crack when I look at them lying in bed, eyes fixed, staring. Can they hear me - do I want them to hear me? Why are they alive? What about quality of life? Who makes these decisions? Am I being cruel if I even think this stuff? Why are these children made to suffer? Why am I suffering? This hospital just fills my head with questions and hardly any answers. The floor I was on was very challenging. Of all the children I took care of for 6 weeks, only one smiled at me, and it took all day to get that smile.
Leder (1990) stated that "the gaze of another... initiates self-reflection. I apprehend myself as embodied and defined when I look into the eyes of another looking at me" (p. 23). Jane's eyes connected with her patient's eyes, and although she could not always read the patient's expressions, she felt a broken heart opening her heart. Jane was able to reach out with compassion to her patient and experience some peace.
The stories students tell about embodying the experience of suffering speak of the tears and heartbreak of their patients and themselves. Patients express their suffering through their bodies. The students sense their patients' suffering through their own bodies. The students physically experience their own hurt and learn through their embodiment of suffering.
Seeing Possibilities in Suffering
All the research participants saw "possibilities" amid the suffering they witnessed (e.g., the patients' courage and strength). As an example, Anita related the following story:
I had never seen anyone so sad. I wanted to do so much for her, to get rid of her suffering; however, this was not in my power. I did help her get her mind off her depression. We talked about her life, things she enjoyed, and we played cards. This didn't rid her of her depression, but it kept her from thinking about it for some time. To be able to do this for her meant a lot to me and, hopefully, to her, too.
The students accepted their limitations. They knew they could not "fix everything." However, as shown in Anita's story, they tried to be there for patients, to support them, and to let them know they are not alone. It is being present and connecting that is important.
Students are in touch with helping patients find peace and meaning. One of Sue's patients was dying of cancer, and on one occasion, he became short of breath and appeared scared. As Sue sat with him, she acknowledged that she was hearing his comments about having been good all his life. Sue said:
His eyes looked a little wiry [sic], kind of scared, and he was mumbling a lot more. He was mumbling out loud and staring ahead, kind of as if he was saying his prayers and making his peace within the world himself.... I think that made him feel better that somebody knew that he was at peace with himself and who he was. I think that made him feel a little more comfortable. He rested well the day that I was there and that made me feel better, and it made him feel better.
Students also find meaning in their own lives through the care they provide to patients who are suffering. Anita revealed how one of her patients touched her life. She said:
She was just so scared, and when I was caring for her, I made a difference, and that really meant a lot to me. You could see the fear in her eyes over little things, and when I would comfort her... or just hold her hand she would be so much better.
Through the experience of being with patients who were suffering, students also learned about love. One week Diane was caring for Mr. P., who had been diagnosed with cancer and pneumonia. Mr. P.'s wife was on the same unit with diagnoses of lung cancer, pneumonia, and chronic obstructive pulmonary disease. Mr. P. asked if Diane could take him to see his wife, and when Diane answered yes, Mr. P. "was absolutely beaming." Diane described the encounter:
As I wheeled him through the halls, he was saying hello to everyone he saw. His excitement was contagious. When we came through her door, I thought he was going to jump out of the wheelchair. His eyes rilled as he held tightly to her [his wife's] hands. "There she is, my beautiful Lizzie." I smiled and said hello as he introduced me, but I just wanted to cry. It turned out that Lizzie was leaving the next day to go to a nursing home, but Mr. P. was staying in the hospital. How could they do that? They should be together! [Later, back in Mr. P.'s room,] I sat with him, and he told me how much he missed his wife. He asked me about my Ufe, and I didn't mind sharing. I felt very close to him. He went on to tell me about how a man should act toward a woman and how to make a marriage successful. I listened. He should know.... Through this experience of suffering, I learned about love. I don't think that the loss is as great if there isn't a deep love first. I felt a sense of loss myself after getting so close. I also learned that there are different types of suffering. Almost all involve pain, but it isn't always physiological pain.
Diane saw how close a relationship can be. Mr. P. and Lizzie appeared to be soul mates. According to Moore (1994), a soul mate or soul partner is "someone to whom we feel profoundly connected, as though the communicating and communing that take place between us were not the product of intentional efforts, but rather a divine grace" (p. xvii). In responding to the grace of relationship, Moore indicated it is important to "give thanks, to honor, to celebrate, to tend, and to observe" (p. 256). Diane demonstrated what she learned about love and soul mates when she described observing these responses in Mr. P. and Lizzie. Soulful relationships have the possibility to lead us "into the mysteries that expand our hearts and transform our thoughts" and reveal to us "many of the pathways and openings that are the geography of our own destiny and potentiality" (Moore, 1994, p. 257).
LEARNING AMID SUFFERING
What prepares students as they set out on their journey with suffering? A concern for learning amid suffering was evidenced throughout the students' stories. Students said that sometimes they felt abandoned in the clinical setting. The two things students identified that would help them were having instructors who say it is OK to cry, make students feel important, foster closeness and accessibility to the clinical group as a support group, allow time in the clinical setting to talk about experiences and feelings surrounding the suffering experience, and are present to them, and knowing how to prepare patients with terminal illnesses for death.
Kate's experience exemplifies the importance of having supportive instructors. One day during the clinical experience, Kate was overwhelmed by the care her patient required. Her patient had just returned from having a radical neck dissection and had a tracheostomy and a gastrostomy tube (G-tube). The patient's G-tube became clogged, and Kate was unable to provide the pain medication that was to be administered through the tube. Due to respiratory depression, the patient could not have any narcotic pain medication. Kate told her story, and Anita responded.
Kate: They wouldn't let me give him any kind of pain medicine besides in the G-tube. I [told them], "He's in so much pain." He [the patient] was just so mad; he just wanted to strike out and hit someone. They [the staff] wanted to restrain him. I'm like [sic], they don't need to restrain him; we need to give him pain medicine. We [had to] wait for the doctor to come and declog the tube, and Fm like, can I just give him an LM. [intramuscular] shot? We could have given him a Toradol [ketorolac] shot. You know they're not going to do that. I felt so behind all day, and everything was overwhelming. Then we didn't have postconference, and I was like running around. I left there thinking I don't even know what happened today.
Anita: Yeah, sit down and gather your thoughts. Say what happened and get feedback.
Kate: What was going on? Was it me or was it just organization?
This story describes Kate's feelings of being disheartened. Kate was distressed about being unable to do what she perceived as essential to relieve her patient's pain. At the end of Kate's day, she felt there was nowhere to turn for comfort. In a way, she felt like a failure. Kate had not had time to discuss these feelings with her instructor, and most likely, her instructor was unaware Kate felt so alone.
The students defined a caring instructor as one who is open to hearing what they are going through and acknowledges their struggle. Anita indicated that the caring instructor "encourages us to talk about suffering and think about it... and by us talking about it and sharing experiences I think that helps us to understand." Students described needing feedback from instructors.
The students also stated that they would not feel so helpless and guilty in the face of suffering if they knew how to prepare patients for the inevitable. Jane explained:
If we knew how to prepare these terminal cancer patients for death, and it doesn't have to be this horribly frightening thing, and help their family understand it like their person will be at peace, then maybe we won't have all those feelings of helplessness, guilt that we can't save this patient. Well have some tools to go along with our personali ties... just listening and holding hands or hugging or crying with patients, but you know we will have something that we can offer them to help prepare for some of those things they might be going through.
Students remembered some classroom content related to death and dying, but it seemed inadequate in preparing them for real-life experiences with patients who were suffering. Is it because students spend so much time thinking about skill performance and so little time thinking and writing about suffering and death?
In general, the students described supporting each other in being with suffering patients and in their learn ing. Students are, according to Kay, "lifted up" by each others' supportive comments. Anita described what the students experience together as "a bond. Nobody else knows what we go through but us." The students formed a circle as they gathered around to hold each other up. Students described their clinical group as working well together. They considered themselves a team and did not hesitate to ask each other for help. Diane felt that, because suffering changes the nurse-patient relationship, it draws the students closer to each other.
Bolen (1996) pointed out that I-Thou relationships can be found within a circle of people who gather in a safe place to talk about important matters and are committed to listening compassionately. In I-Thou relationships, a trust exists among people. According to Bolen (1996), "IThou relationships matter, especially when one falters and is caught and kept from plummeting into despair by the heart and hand of another" (p. 112). Students in a circle of caring establish a trust and I-Thou relationships that keep each person from drowning in his or her struggle with suffering.
Tori said she was comfortable sharing with the clinical group because it was small. "If we had a whole class discussion like this, it wouldn't be the same. I wouldn't say a word." The stories students told about teaching and learning highlight the value of having a circle of support. Hearing and telling stories of their care of patients who were suffering and the feelings those encounters evoked helped the students understand themselves and the suffering experience. Students described needing to feel as if their experiences were within their capabilities. They reached out to those whom they know care. Their stories are about ways students seek to keep their call to care alive.
Considering the many ways students encounter suffering in their clinical experiences and their stories about learning amid suffering, it is imperative that a space be created to attend to a pedagogy of suffering. Within the space envisioned, students and faculty are attuned to each others' feelings of vulnerability and, together, gather courage to voice the concerns and struggles inherent in the suffering experience. The call to care is nurtured and sustained, and connections are made possible.
Students often care for suffering patients in an environment that is lonely and shrouded in silence. Is this the intent of faculty? Do faculty unknowingly "throw" students into situations of suffering, much like a baptism of fire? If nurse educators were asked how they care for patients who are suffering, they would most likely respond that they are gentle, caring, holistic, supportive, comforting, and vigilant. Is this not what faculty hope they are helping students to learn? When faculty place students in situations of suffering, the students also suffer. How can faculty address students' suffering with gentleness, caring, holism, support, comfort, and vigilance? Faculty know how to care for patients. It is through a pedagogy of suffering that faculty can extend this caring to students.
What would a curriculum that includes a pedagogy of suffering look like? A pedagogy of suffering espouses a caring pedagogy that would create a caring community. Nurse educators would be wise to reflect on Diekelmann's Concernful Practices of Teaching and Learning (Diekelmann & Ironside, 1998; Leobold & Douglas, 1998) These practices address welcoming students into an inviting atmosphere; knowing and connecting to others; presencing by being open and attending; creating a sacred space that sustains the primacy of caring; safeguarding the practices of reading, thinking, writing, and dialogue; and engendering community.
The following approaches are some ways of opening up the possibility of creating a caring community dedicated to teaching and learning related to the suffering experience. Faculty may begin by designing a clinical experience that provides support and activities devoted to teaching and learning about caring for patients who are suffering. Time for reflecting and dialogue about suffering is a primary concern of students. Ideally, this should be done on the day of the suffering experience (e.g., in clinical postconference). Asking students about their day and encouraging discussion related to the topic of suffering is essential. Asking students to write about suffering also is helpful. It is not enough to ask students to "write a reflection." Faculty must be explicit about the topic of the reflection. Students acknowledge that they would not introduce the topic or write about suffering unless specifically asked to by faculty. However, when students engage in these activities, they find it a turning point in their ability to cope with their feelings and respond to suffering with their healed broken hearts. The broken heart then is more present as a caring heart.
A second strategy is to create a sacred space for selfcare, connecting, and calling forth students' voices. In the clinical setting, a space must be designated for students to cry, regroup, save face, and relax. At times, students will want to be in this space alone. However, it also will be important to gather with others in this space, where it is safe to voice the anguish that accompanies facing suffering for the first time as a caregiver. Students need a place to acknowledge the embodiment of their suffering and to immerse themselves in their emotions. It is a space sacred enough for crying out and reaching out to others. It also is a space where faculty can make students feel cared for and special.
Third, faculty need to introduce students to narrative pedagogy. This means attending to the stories of instructors and students (Picard, 1991). At every opportunity, faculty can ask students to share their personal stories. This can be done in the classroom, seminars, clinical conferences, or advising sessions. Any time conversations occur, students and faculty can share stories. Using metaphor and writing and sharing poetry will help students tell their stories. Students may need help expressing their feelings and reflecting on their inner strengths. Faculty need to share their own stories and the stories of nursing's shared practices.
Finally, faculty can find ways to facilitate the peer bonding that is so important to students. Students confide in each other and depend on each other for caring. This connection needs to be encouraged, and the circle must not be broken. It is in this circle that students are most in touch with learning about their embodied knowing. It is an intuitive response students may be unaware of at the bedside but explore with each other after the suffering experience is over. When speaking of child development and learning, Vygotsky (1935/1979) stated that "learning awakens a variety of internal development processes that are able to operate only when the child is interacting with people in his environment and in cooperation with his peers" (p. 90). It is also true for nursing students who are learning to care for suffering patients.
Above all, faculty need to listen to Heidegger (1954/1968) who said that:
teaching is even more difficult than learning.... The teacher is ahead of his [sic] apprentices in this alone, that he [sic] has still far more to learn than they- he [sic] has to learn to let them learn. The teacher must be capable of being more teachable than the apprentices (p. 15).
Bearing witness to suffering opens the door to learning because it calls students to a relationship with the Other. Learning about suffering occurs as a result of the opportunity for students to reflect and discuss suffering and the ways to help patients who are suffering. Faculty must provide the forum for the reflection to occur, to allow the students to speak out loud, and to learn.
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