Professional Development

Suffering and spirituality


In April 2007, two leading nurse ethicists at Creighton University’s Center for Health Policy and Ethics, Winifred Ellenchild Pinch, RN, EdD, FAAN, and Amy Haddad, BSN, MSN, PhD, assembled a group of premier nurse ethicists and asked each of them to reflect on her contributions to nursing ethics in a preconference essay. These essays eventually became chapters of Nursing and Health Care Ethics: A Legacy and a Vision, published in 2008 by the American Nurses Association and winner of the 2008 Society for Technical Communications Award of Excellence.

The book is organized into themes, including advocacy, care and caring in nursing, diversity and disparity, relationship issues, and vulnerability. The following excerpts are from Chapter 24, which discusses suffering and spirituality within the framework of nursing ethics and religion. Written by Marsha Fowler, PhD, MDiv, MS, RN, FAAN, this chapter is one of several that focus on the ethical dimensions of pain and suffering. Dr. Fowler is a senior fellow and professor of ethics, spirituality, and faith integration at Azusa Pacific University in Azusa, California. She is also a minister of the Word and Sacrament in the Presbyterian Church (USA).

The nursing literature has struggled with suffering and…has paid it disproportionately little attention….The Western theological literature…brings dimensions to the understanding of suffering…not resident in the nursing or medical literature.…This [theological] literature emphasizes both the inescapability of suffering—that it is part of the human condition—and that it is universal.…The power of suffering to isolate is concurrently the power to cause distortions or disruptions in one’s understanding of the world and of God. Fragmentation, even disintegration, may result.

In the midst of suffering there is in some cultures a human tendency to seek understanding, self-understanding, and perhaps meaning or simply sense-making of the suffering.…Suffering can make us acutely aware of our mortality and impotence, dashing our illusions of control and power, and yet it can move us to develop in new ways, ways that joy does not.…Theology also recognizes that some suffering may have redemptive qualities—not that the person is redeemed by or in suffering, but that the suffering is redeemed; theology also recognizes some suffering has no redemptive quality whatsoever.…More importantly and perhaps more practically for nursing and the patients who suffer, the theological literature emphasizes the necessity of lament and presence with one another in the midst of suffering.

Suffering has a cry and that cry is: be. Be with me. Be, not do. Be, even in silence. Just be. Nurses, however, are good at doing, doing, doing, speaking, speaking, speaking. Here, suffering brings us back to the necessity of…relationship.…[I]t is in being-with-another and in hearing that person’s lament…that the person who suffers comes to…[totality or completeness].…While most laments are phrased in the language of faith…this need not…be the case. Laments can be created with no religious content and can be used as a template for the expression of suffering, or as a mental template for the nurse working with one who suffers, who needs to express his lament.

Millennia of observation of human suffering are reflected upon in ancient scripture in many traditions. Western sacred writ reflects theologically upon causes [and other aspects] of suffering.…However, in the use of lament, one finds movement beyond the “problem” of suffering to the “experience” of suffering, beyond the “definitional” to the “practical.” …As suffering is a part of life, so is lament, whether individual or communal. While we would very much like to do otherwise, we must stick around for those moments when the patient [in the words of the biblical Job] does not restrain his mouth, speaks in the anguish of his spirit, and complains in the bitterness of his soul. In those moments, nurses whose impulse is toward doing, doing, doing, need not scramble to “find the words to say.” There are no words to say: just be.

There is, of course, more to this “being” than silence and physical presence. The recognition that suffering is not under our control; however much we might try to control it—through medications, interventions, and more—it remains beyond our control. When I am present for the suffering and lament of a patient, truly present, I am reminded that suffering is also my lot, even if not right here, right now. As I share in the patient’s suffering and lament and am present to the patient, I allow the terror and darkness that cannot be controlled to confront me in my own frailty; I too have a lament within. This presence is not the “therapeutic use of self” as nursing discusses. This presence is a presence in vulnerability—the vulnerability of the shared human condition—that, while it still retains identity boundaries, is open to an ontological change in both persons by virtue of human connectedness.

We have all had patients with whom we “fell in love”: patients with whom we have had a deep connectedness, often inexplicable. To share in the lament of another is to be open, truly open, to that connection in which one experiences the…gift element of humanity while being open to a change in the very nature of one’s being in response to the immediacy of that sharing and connectedness.

While…there is an important role for nurses to engage in spiritual care, and…all nurses should at least be able to recognize spiritual care needs, …the deeper reaches of spiritual care [do not] fall within the…purview of nursing. For the most part, nurses are neither prepared, nor skilled, nor called to dive into the deeper waters of the spirit. Like the person who is not the lifeguard who dives into the water to help the drowning swimmer, more likely both will drown. These deep waters, where silences are named, are not nursing’s domain. By silences I do not mean the immediate or underlying causes of grief or suffering, but rather the monsters that live down deep in the human soul—often feeding upon one’s spiritual theme—that must be ridden and broken to be tamed. It is the domain of the ineffable, and of the core of the person, and it is dangerous; it does not belong to nursing.

The nursing literature on religion is morbidly anemic, and its attention to the intersections of religion and ethics is nonexistent. For the most part, the nursing literature is attempting to craft a generic spirituality with which it can interact. I have found this vacuous and deeply unsatisfying, and have become more interested in religion per se. I have encountered few patients whose spirituality was not shaped by either a religious faith or by exposure to the “culture of a religion” that has long since ceased to be embraced by the present or preceding generation of his or her family. It is increasingly the case that we will see patients whose genetic memory of a religious tradition will have receded, but that is infrequently the case at present…

There are a number of ways in which the academic study of religion is important to nursing, more specifically to a study of ethics and nursing….It is essential that nursing engage in research and scholarship [on ethics, religion, and spiritual nursing care], if nursing is to understand itself, if nurses are to understand themselves, and if we are to understand our patients and the world in which we live—and presume to declare that we are interested in the whole person, or for our purposes here, whole-person ethics.

This text is excerpted from Nursing and Health Care Ethics: A Legacy and a Vision. Copyright © 2008 American Nurses Association. All rights reserved. For more information, go to or call 1-800-637-0323.

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