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  What is suffering? The meaning of suffering is rarely questioned, and when the attempt is made, it produces the dozens of definitions. The reason for this spectrum appears to be in the broadness of the concept of suffering. To complicate things, the suffering believed by the society to be the common knowledge; and yet the concept of suffering is entirety based on the individual"s perception, and the only common characteristic of suffering appears to be in its inevitability. This essay as an attempt to answer this question will be looking at the term suffering from the linguistic, psycho-social, physiological, theological and philosophical perspective. Consequently, this essay will establish the relevance of the concept of the suffering in the specific example from clinical practice, and to the nursing as a whole.
  According to the Merriam-Webster dictionary (2003) the word to suffer has originated from Latin sufferre, between thirteens" and fourteens" century, and it means "to submit to or be forced to endure" or "to put up with especially as inevitable or unavoidable". (Merriam Webster, 2003) The Union of International Associations (UIA), a non-profit psycho-social research institute that publishes the Yearbook of International Organizations, and the Encyclopaedia of World Problems and Human Potential; recognises the fact that all of languages have the pain, suffering and problem in their early vocabulary, as the part of societal learning process (UIA, 2011). In fact the concept of suffering universally transpires not only in language, but also in literature and art. There are multiple examples of the suffering, being the motivating force, the object or even in some cases, the consequence of art.
  Irrespective of the aforementioned definition, it appears that for the general majority of the population, the word suffering is almost synonymous to the word pain, and the experience of the pain. The Tortora (1996) defines pain as one of the somatic sense that specifically "provides information about noxious, tissue damaging stimuli and thus often enables us to protect ourselves from greater damage" (Tortora and Grabowski, 1996). But also, when someone is described as the suffering, it is usually implied that they not only experiencing the physical pain but also the psychological pain. Thus the assumption is made that in order to suffer the individual must possess the mental capacity to understand the consequences of a traumatic experience, which they are being subjected to.
  This is confirmed by the independent works of Cassell (2011) and the Wall (1999), who have found the direct correlation between, the suffering individuals" personal history and the perception of the world, and the individualised manifestation of their response to the traumatic experience. But the Wall (1999) in addition to more western, evidence based approach, of the Cassell, outlined the presence of pain without a cause and recognised the fact that there are a number of conditions that are not considered real by some members of the medical profession, although to the suffering individual their reality is unquestionable (Wall, 1999). Additionally, Wall (1999) distinguished the difference between individuals" private misery and the public display of the suffering, and pointed out that the private misery was often caused by the factors other than pain (Wall, 1999).
  Contrary to the aforementioned authors, the Dame Cecily Saunders followed the notion that the suffering is more of a complex socio-cultural, rather than individual experience; and not only incorporated the individual physical, psychological, but specifically social and spiritual elements (Clark, 1999). Saunders (1983), as the part of the concept of the total pain, was highlighting the body of factual evidence, which suggested the two way connection between the exacerbation or reduction of physical pain, and the spiritual needs of the individual (Saunders, 1983). She suggested that the understanding of the suffering of the individual could be the gateway to the understanding of their culturally defined needs. In her later work Saunders became an advocate of the pain being the illness in itself, and also emphasized the importance of the communication between the sufferer and the treating individual, as part of the pain relief (Clark, 1999). Interestingly, some of the work by Saunders received criticism for the use of the word pain in the social and spiritual context to which she replied that, it was the deliberate use in order to encourage the holistic approach to patients suffering (Saunders et al, 1993).
  The one, unifying feature, of all of the aforementioned definitions of the concept of suffering, is the fact that authors theorized from the perspective of healthcare. Whereas it is clear, even from these definitions that the concept of suffering is not limited to the field of medicine, health and illness. There is an evident strong role of the spiritual in the concept of suffering, regardless of what fulfils the need, the religion, philosophy or the individual search of meaning. Although, according to the David O. Moberg (1984), it appears that for the majority of the population their spiritual need is directly associated with the religious belief, even though the two are not synonymous (Moberg, 1984).
  This paradox is explained by the brief overlook of the number religions which will show that the suffering is often the key element of religious beliefs (Moberg, 1984). It is clearly seen in Buddhism were suffering is said to be equal to life, although the goal of life is to eliminate suffering through the elimination of attachment to the material and the achievement of nirvana (Woodhead et al, 2009). In Hinduism the suffering is the inevitable part of spiritual progression of the individual, through the rebirth, and the form of punishment for the mistakes of previous lives, which continues until the absolute freedom of suffering is, achieved (Woodhead et al, 2009). On the other end of theological spectrum lay the Christianity and Islam; they are surprisingly similar in their views on the suffering as part of their religion. In essence both religions preach the suffering of any form as the Gods plan and the way to test and strengthen the individual"s belief (Woodhead et al, 2009).
  In parallel to the religious beliefs there are a number of schools of philosophy that study the concept of suffering in the similar way. The school of philosophy which is probably the most integrated in the modern societies is the Humanitarianism, its aim is to elevate the suffering for all, rather than improve the wellbeing of a non-suffering individual (Walsh, 1985). Humanitarianism, in terms of popularity, is followed by Utilitarianism, this school of thought was described by Bentham as the greatest happiness of the greatest number, although the motivation mechanism in case of Utilitarianism is economical, rather than ethical (Walsh, 1985). This is not an exhaustive list of the philosophical theories that are based on the suffering, but due to constrain of this essay, only this two are covered.
  Now, that the concept of suffering has been holistically described, the attempt will be made to answer the questions of what is suffering. It appears, that although the nature of suffering has not been fully understood by the society, and it is incredibly variable, depending on the individual circumstances; for most of us the suffering is the basal experience of the sentient individual, which consists of the present or the potential displeasing effect or harm to that individual, and triggers the change in the individual"s actions or thought process (Morse et al, 1991).
  In conclusion it is necessary to identify the relevance of concept of suffering to the nursing. The specific clinical example that could show this relevance is the case of middle aged female patient, who in order to maintain confidentiality is going to assigned alias Jane. The Jane had to undergo the maxillofacial surgery that consisted of removal of part her lower jaw with the malignant tumour. The operation was successful and her physical pain appeared to be well controlled by the opiates, and the fact that she was well educated about her disease and the expected recovery time (Wall, 1999; Cassell, 2011). But she was still exhibiting such signs of suffering as low mood, irritability, agitation, sleep disturbance and even verbalising the meaningless of the surgery (Saunders, 1983).
  In order to address the Jane"s obviously present problem, the members of the nursing staff have done the assessment of the patient emotional needs, and investigated her psychosocial history (Saunders, 1983). During the assessment the Jane verbalised that she has been suffering from the awareness of facial disfigurement, and was worried about her ability to get back to normally active social life. In Jane"s case the coping strategy chosen by the nursing staff consisted of patient cantered communication and the empowerment of her social confidence through the continuous interaction with the members of staff and the available volunteers; who have had previously undergone the similar surgery (Saunders, 1983).This prevention of the alienation from normal social behaviour, allowed Jane to re-establish herself as the complete individual (Morse et al, 1991). Also, the understanding of the difference in the suffering and priorities of the patient and her relatives, allowed, for the nursing staff involved in Jane"s care, to become her communication median. Consequently, being informed about the state of their beloved one allowed the reduction of the anxiety of Jane"s family and prepared them for the better support in her recovery (Morse et al, 1991).
  As a final note it is important to mention. That although on her admission the Jane has registered her religion as the Church of England, during her stay in the hospital she has not expressed any desire to be seen by the chaplain or in any other way indicated that her spiritual needs were not met. It is possible to theoreticize that Jane would greatly benefit in her emotional comfort if more of the spirituality was addressed, but unfortunately most of the decisions regarding her care were based on the medical model of illness(Morse et al, 1991).
  In fact the nursing as a whole is, concentrated around the experience of illness of the sick individual and his significant others (Morse et al, 1991). Therefore the understanding of multidimensional nature of suffering of the patients and their family is the only way to make sure that the help they receive is holistic and humane (Morse et al, 1991).
  Reflection on Enquiry-based Learning (EBL)
  The aim of this part of the essay is to reflect on this EBL assessment, with the help of Graham Gibbs model of reflection (1988). During this module I as a part of my group was introduced to the EBL process. It is the format of learning in which the facilitator allocated to our group the task of exploration of the concept of suffering and asked us to prepare and demonstrate the presentation on it. The key element of this format of learning was the groups own enquiry in to the topic of research, based on our own perception and understanding of the subject (Barrett et al, 2005).
  The group was given the four week period during which we were self managing our learning process, with the minor guidance by the facilitator. We were encouraged by the facilitator to begin by electing two members of the group in to the roles of chair and scribe. The chair was intended to be the administrative leader regulating workflow and the scribe was the record keeper and the internal liaison. After the elections it was collegially decided to fragment in to the subgroups and develop the number of presentation plans, for the next session. In the following sessions the group unified the plan for the presentation and broke down the tasks amongst same subgroups. I as a participator in one of the subgroups was developing the visual presentation of the concept, in the form of short role-play movie. Within our subgroup we collegially developed the script for the role-play, which was based on the slide show from the main group session. Finally the presentation was combined, rehearsed by elected speakers and successfully presented on time.
  First thing I would like to emphasize is my surprise by the lack of the desire to be involved exhibited by the majority of the group, during the election stage. I would expect us to be more active, since we as a group have worked together before and new each other. Therefore the candidates for the elections were mostly self-announced. I felt that this desire to lead shown by our elected chairman and the fact that the group was already familiar with each other were the reason why the group as a whole was able to compromise real well, with only one account of conflict taking place during the debates on the presentation content. I think that because of the new, creative nature of the task of my subgroup, myself and other participants were well motivated and interested in the outcome. This motivation, combined with the good communication, allowed me to be confident and relaxed during the negotiation of the script and filming of the role-play. Retrospectively looking at the process I realise that I should be more confident in my group colleagues, as they have proven to be very skilful.
   Upon the evaluation of the process I can clearly see that the EBL allowed allot more personal look at the concept of suffering. This introduced some spiritual views of my colleagues, which I would not usually look at myself, consequently allowing me to connect theoretical aspects of concept of suffering to practise. I think that certain aspect of competitiveness inherent to this format of learning was the positive motivating force of the enquiry process (Barrett et al, 2005). Also we as a group were able to experiment with more creative formats of presentation. I think that another benefit of this format of learning was the reinforcement of the group working skills. I must admit that I initially considered this format of learning as the inefficient and somewhat conflict spawning. But after experiencing it myself, I agree that when the group development problems are under control, this format has the potential for the broader and more boundary crossing results (Barrett et al, 2005).
  In my opinion the more in-depth analysis of the EBL shows that although it has benefits as a learning method (Barrett et al, 2005). More interesting and possibly the key aspect of EBL is the understanding of the group development and the team working skills that it allows to develop. It is interesting that even though our group has existed prior to the participation in the EBL, and it would be fare to assume that we will be at the performing stage, we still had to exhibit all of the stages of Tuckman"s (1965) group development model. The forming stage of the group development is clearly visible during the election of chairman and scribe, and we have shown the signs of the storming and norming stages during the debates by whole group on the content of presentation (Tuckman, 1965). Finally the subgroup level shows the example of the Tuckman"s (1965) performing stage of the group development (Tuckman, 1965). This controversy was caused by the collision of the personal relationships and the task defined behaviours and complicated by some communication difficulties at the initial stages of group work (Tuckman, 1965). Therefore in my opinion the communication strategies would be something to look in to in order to improve the EBL results.
  In conclusion I would like to say that I believe the overall performance of group during this EBL assessment, was above what I have expected. Simultaneously the EBL highlighted to me the importance of communication in teamwork and especially, my own deficits in that regard. Therefore I will continue to work on my communication skills, and specifically my understanding of the task at hand.
  Barrett, T. Mac Labhrainn, I. Fallon, H. (ed.) (2005) Handbook of Enquiry & Problem Based Learning. Galway: CELT [Online] Available at: http://www.nuigalway.ie/celt/pblbook/ (Accessed: 23 February 2012).
  Cassell, E. J. (2011) "Suffering, whole person care, and the goals of medicine". In Hutchinson, T. A. (ed.) Whole person care: A new paradigm for the 21st century. New York: Springer Science + Business Media, pp. 9-22
  Clark, D. (1999). "Total Pain, disciplinary power and the body in the work of Cicely Saunders, 1958-1967". Social Science and Medicine, 49, pp 727-736. [Online] Available at: http://www.ingentaconnect.com/search/article?option1=tka&value1=Total+Pain%2c+disciplinary+power+and+the+body+in+the+work+of+Cicely+Saunders&pageSize=10&index=1 (Accessed: 18 December 2011).
  Merriam Webster (2003) Merriam Websters Collegiate Dictionary 11th ed. Credoreference. [Online] Available at: http://library.city.ac.uk/search (Accessed: 18 December 2011).
  Moberg, D. (1984) Subjective Measures of Spiritual Well Being. Review of Religious Research. New York: Religious Research Association.
  Morse, J. M. (ed.) and Johnson, J. L. (ed.) (1991) The Illness Experience: Dimensions of Suffering. London: Sage Publications, Inc.
  Saunders, C. (1983). Beyond all pain: A companion for the suffering and bereaved. London: SPCK.
  Saunders, C. (ed.) Sykes, N. (ed.) (1993). The Management of Terminal Malignant Disease. London: Edward Arnold.
  Tortora, G.J. Reynolds Grabowski, S. (1996) Principles of Anatomy and Physiology. 8th Edition. New York: Harper Collins
  Tuckman, B. W. (1965). "Developmental sequence in small groups". Psychological Bulletin, 63(6), pp 384-399. [Online] Available at: http://psycnet.apa.org/journals/bul/63/6/384/(Accessed: 24 February 2012).
  Union of International Associations (UIA) (2011) Encyclopedia of world problems and human potential project - commentaries, [Online] Available at: http://www.uia.be/encyclopedia-world-problems-and-human-potential-project-index-notes-and-commentaries (Accessed: 18 December 2011).
  Wall, P. (1999) Pain: The Science of Suffering. London: Weidenfeld & Nicholson
  Walsh, M. J. (1985) A history of philosophy. London: Geoffrey Chapman
  Woodhead, L. (ed.) Kawanami, H. (ed.) Partridge, C. (ed.) (2009) Religions in the modern world: traditions and transformations 2nd Ed. London: Routledge,
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