Suffering and response: Directions in empirical research

Flourishing at the end of life

Flourishing is an increasingly common construct employed in the study of human wellbeing. But its appropriateness as a framework of wellbeing at certain stages of life is contested. In this paper, we consider to what extent it is possible for someone to flourish at the end of life. People with terminal illness often experience significant and protracted pain and suffering especially when they opt for treatments that prolong life. Certain aspects of human goods, however, that are plausibly constitutive of flourishing-such as meaning and purpose, deep personal relationships, and character and virtue-can be uniquely realised when life is ending. We argue that there is a qualified sense in which one can flourish at the end of life but that one must make important modifications to the criteria implicit in conventional conceptions of flourishing. We close with a discussion of the empirical assessment of wellbeing at the end of life and explore the possibility of introducing a flourishing measure in palliative care practice.

Global Assessment of Palliative Care Need: Serious Health-Related Suffering Measurement Methodology

CONTEXT

Inequities and gaps in palliative care access are a serious impediment to health systems especially in low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions.

OBJECTIVES

In this paper, an updated methodology - SHS 2.0 - is presented building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions.

METHODS AND RESULTS

The updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. Detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, is also shared, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS.

CONCLUSIONS

The methodology encompasses opportunities for applying SHS to future policy making assessment of future research priorities particularly in light of the dearth of data from low- and middle-income countries, and sharing of directions for future work to develop SHS 3.0.

Associations of self-forgiveness processes with distress and well-being outcomes: Evidence from a longitudinal study of Indonesian adults

To date, few empirical studies have examined the benefits of the processes involved in self-forgiveness-value reorientation and esteem restoration-for individual well-being using longitudinal data from non-Western samples. In this study, we take a step toward addressing this gap by analysing three waves of data collected among 595 Indonesians (Mage  = 21.95, SD = 4.39). Applying the analytic templates for lagged exposure-wide and outcome-wide longitudinal designs, we performed a series of linear regressions to estimate associations of value reorientation and esteem restoration in Wave 2 with three indicators of distress and 10 indicators of well-being in Wave 3, adjusting for Wave 1 covariates. Value reorientation and esteem restoration were each associated with improvements in several well-being outcomes (six for value reorientation and three for esteem restoration), but both showed little evidence of associations with the distress outcomes. In a secondary analysis, those who scored higher on both value reorientation and esteem restoration (i.e., self-forgiveness group) in Wave 2 reported higher well-being on five outcomes in Wave 3 compared to those who scored lower on value reorientation, esteem restoration, or both (i.e., no or partial self-forgiveness group). We discuss some implications of the findings for conceptualising self-forgiveness and promoting well-being.

Distant suffering: A concept analysis

BACKGROUND

Patients who are suffering may be commonly encountered in health care. The growing use of telehealth implies that encounters with patients who are suffering may increasingly take place at a distance. "Distant suffering" is a concept coined within sociology to describe the suffering of far-away others. It is conceptualized as a paradox, as distance changes the relation between the witness of suffering and the suffering encountered. Impacts may include a potential detriment to the sufferer and ethical implications for the witness.

OBJECTIVE

To explore the concept of distant suffering and any relevance, implications, or important avenues for potential research within the healthcare sciences.

DESIGN

Rodgers' evolutionary concept analysis.

DATA SOURCES

Databases of Web of Science, Medline, CINAHL and PsycInfo were searched for the terms "distant suffering" or "mediated suffering".

REVIEW METHOD

Attributes, surrogate or related terms, antecedents, consequences, and uses of the concept were extracted and synthesized.

RESULTS

Thirty articles published within the past ten years were selected for review from the search results. "Distant suffering" was characterized as comprising 1) mediated far-away suffering, 2) a "recognizer" or witness, and 3) a potential role of a moderator. Antecedents include shared understandings and socially-influenced responses. Consequences include responses like empathy, compassion, pity, also indifference, cynicism and compassion fatigue.

CONCLUSIONS

Further research to explore distant suffering from healthcare sciences' perspective could uncover valuable insights for those suffering, for healthcare workers, and any who are exposed to it. An improved understanding of how distant suffering is conveyed and moderated could enable targeted reduction of exposure or improve response to distant suffering. Such knowledge could help diminish negative consequences for those suffering, for healthcare workers who are caring at a distance for those suffering, or for others who encounter distant suffering in their occupations or in daily life via media, social media, or digital communications.

TWEETABLE ABSTRACT

New analysis finds that exposure to distant suffering may have important implications for health and health care.

Supporting elderly patients in strengthening their personal and spiritual health resources

Care for the sick, including spiritual support is sometimes called holistic medicine. The term bio-psycho-social-spiritual model is sometimes used to describe this type of therapeutic approach patient-oriented medicine. This report indicates the importance of taking into account the spiritual aspect of life due to its beneficial impact on the coping resources activated and the patient's well-being. Existential and spiritual issues are on the verge of new clinical and research interest in medicine, especially in gerontology, oncology, and palliative care. Clinicians focus not only on symptom control but also on spiritual and existential issues such as spirituality, hope, and meaning. This paper reviews the topic of spirituality in the context of illness and end-of-life care trying to define spirituality within the context of health resources of the subject. Spirituality is perceived in two of its main components: faith/religious beliefs and spiritual well-being. Especially this second construct is reviewed and described as a health resource.

Existential spectrum of suffering: concepts and moral valuations for assessing intensity and tolerability

This paper has two aims. The first is to defend a recent critique of the leading medical theory of suffering, which alleges too narrow a focus on violent experiences of suffering. Although sympathetic to this critique, I claim that it lacks a counterexample of the kinds of experiences the leading theory is said to neglect. Drawing on recent clinical cases and the longer intellectual history of suffering, my paper provides this missing counterexample. I then answer some possible objections to my defence, before turning to my second aim: an expansion of my counterexample into a spectrum of suffering that varies according to the selves and purposes that suffering affects. Next, I connect this spectrum to the tolerability of suffering, which I distinguish from its affective intensity. I conclude by outlining some applications of this distinction for the psychometric reliability of assessment instruments that measure suffering in clinical contexts.

Transcending the self to transcend suffering

Suffering is inevitable in human life. Our perspective paper theorizes on precise mechanisms for how self-transcendence-the state in which an individual looks beyond the self and adopts a larger perspective including concern for others and the world-may help people endure the experience of suffering. From an examination of empirical literature ranging from social psychology to clinical research, we propose that self-transcendence may aid the endurance of suffering along three psychological levels: (1) On the level of affect, the unique profundity and positivity of self-transcendent experiences (e.g., awe, flow, compassion) may supersede and reduce the salience of negative affect arising from suffering (e.g., fear, despair, depressive mood). (2) On the level of cognition, the larger frame of reference provided by self-transcendent thinking may contextualize one's suffering as something comprehendible, thereby helping to resolve the challenges of making meaning from suffering (e.g., that one's existing meaning systems are unable to explain the suffering event). (3) On the level of motivation, the drive to fulfill one's need for self-transcendence may counterbalance the more hedonically-oriented motivations that can promote negative coping strategies in response to suffering (e.g., avoidance, substance abuse). All three mechanisms may also provoke downstream prosocial behaviors that help embed the individual into networks of social support. Altogether, by synthesizing specific mechanisms from affective, cognitive, and motivational self-transcendent processes, our paper establishes a theoretical framework for how self-transcendence may help people endure and transcend suffering, thereby elevating the conditions and experiences of our existence.

When suffering contradicts belief: measuring theodical struggling

Global meaning systems help people make sense of their experiences, but suffering can violate global meaning and create distress. One type of potential violation is conflict between one's experience of suffering and one's deeply-held beliefs about God as loving, powerful, and just. The problem of theodicy-why an all-powerful and all-loving God would allow suffering-has long been an important theological and philosophical concern, but little is known about how theodicy plays out psychologically for religious individuals facing serious life difficulties. To address this issue within a specific religious tradition, Christianity, we drew upon philosophy, Christian theology, and psychology to develop the construct of theodical struggling. Through theological and philosophical input, we generated a 28-item pool and conducted 10 cognitive interviews with a diverse sample of Christian adults. In three consecutive online studies of Christian adult samples, we reduced the scale to 11 items through PCA, found a strong one-factor solution using EFA, and found support for the one-factor solution along with preliminary reliability and validity. This newly-developed Theodical Struggling Scale represents an important advance in understanding individuals' experiences of ruptures in their beliefs regarding God's goodness and paves the way for future research on this topic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-023-04642-w.

Development and Initial Validation of the Persevering Hope Scale: Measuring Wait-Power in Four Independent Samples

Hope has been conceptualized as agency and pathways to achieve goals. However, this goal-directed conceptualization does not encapsulate all situations in which hope may be beneficial. To address the dispositional motivation to endure when a desired goal seems unattainable, unlikely, or even impossible (i.e., goal-transcendent hope), we provide initial psychometric evidence for the new Persevering Hope Scale (PHS). We developed and refined the PHS with undergraduates at a public college (Study 1) and replicated our findings in a community adult sample (Study 2). We replicated and extended these findings using longitudinal data with undergraduates at a faith-based college (Study 3) and a community sample of chronically ill adults (Study 4), and examined measurement invariance (Study 5). Scores on the PHS demonstrated robust evidence of estimated internal consistency and of criterion-related, convergent/discriminant, and incremental validity. Estimated temporal stability was modest. Partial scalar invariance was evidenced across samples, and full scalar invariance was evidenced across gender, race/ethnicity, and time. These preliminary findings suggest that the PHS is a psychometrically sound measure of persevering hope. Its use can broaden the current body of literature on trait hope to include goal-transcendent hope and advance research on the nature and benefits of this important construct.

Suffering, psychological distress, and well-being in Indonesia: A prospective cohort study

Research on the subjective experience of suffering has typically focussed on older clinical samples living in Western, educated, industrialised, rich, and democratic (WEIRD) countries. To further extend the existing body of empirical research on suffering to less WEIRD contexts, we use three waves of data (Wave 1: December 2020; Wave 2: January 2021; Wave 3: February 2021) from a sample of nonclinical Indonesian adults (n = 594) to examine associations between suffering, two indices of psychological distress, and 10 facets of well-being. In our primary analysis, we estimated a series of multiple regression models that adjusted for a range of sociodemographic characteristics, financial and material stability, religious/spiritual factors, prior values of overall suffering, and prior values of each outcome assessed in Wave 1. Results indicated that overall suffering assessed in Wave 2 was associated with an increase in both indices of psychological distress and a decrease in eight facets of well-being assessed in Wave 3. Using a similar analytic approach, results from a secondary analysis indicated that higher scores on both indices of psychological distress and lower scores on seven of the well-being facets assessed in Wave 2 were associated with worse subsequent overall suffering assessed in Wave 3. These findings contribute to empirical literature on the implications of suffering for well-being.

Associations of suffering with facets of health and well-being among working adults: longitudinal evidence from two samples

Suffering is an experiential state that every person encounters at one time or another, yet little is known about suffering and its consequences for the health and well-being of nonclinical adult populations. In a pair of longitudinal studies, we used two waves of data from garment factory workers (Study 1 [T1: 2017, T2: 2019]: n = 344) and flight attendants (Study 2 [T1: 2017/2018, T2: 2020]: n = 1402) to examine the prospective associations of suffering with 16 outcomes across different domains of health and well-being: physical health, health behavior, mental health, psychological well-being, character strengths, and social well-being. The primary analysis involved a series of regression analyses in which each T2 outcome was regressed on overall suffering assessed at T1, adjusting for relevant sociodemographic characteristics and the baseline value (or close proxy) of the outcome assessed at T1. In Study 1, associations of overall suffering with worse subsequent health and well-being were limited to a single outcome on each of the domains of physical health and mental health. Overall suffering was more consistently related to worse subsequent health and well-being in Study 2, with associations emerging for all but two outcomes. The pattern of findings for each study was largely similar when aspects of suffering were modeled individually, although associations for some aspects of suffering differed from those that emerged for overall suffering. Our findings suggest that suffering may have important implications for the health and well-being of worker populations.

Passing through end-of-life suffering: Possible or not? Results from a qualitative inquiry

The objective of this study was to understand the factors associated with "passing through suffering" in terminal illness. We interviewed 19 adults diagnosed with terminal disease in palliative stage. Interviews were analyzed using thematic analysis. Four axes of understanding were generated. In the first, participants discussed the will to "feel alive" despite the disease. The second, the process of acceptance, is based on lucidity and on letting go. The third highlights the importance of relationships with others. The fourth axis describes the consequences of this passage through suffering. This study highlights a phenomenon of adapting to suffering.

The Garden and the Orchestra: Generative Metaphors for Conceptualizing the Complexities of Well-Being

Our understanding of well-being, and related concepts such as health and flourishing, is shaped by the metaphors through which we think about such ideas. Current dominant metaphors-including a pyramid, ladder, and continuum-all have various issues. As such, this paper offers two other metaphors which can better do justice to the nuanced complexities of these notions, namely, a garden and an orchestra. Through these metaphors, this paper articulates a comprehensive framework for conceptualizing and appreciating the nature of well-being (and associated concepts), which it is hoped will generate further insights and research into these valued and sought-after phenomena.

Perceived posttraumatic growth after interpersonal trauma and subsequent well-being among young Colombian adults: A longitudinal analysis

Research has shown that people sometimes report self-perceived growth as a result of dealing with a potentially traumatic event, but relatively few methodologically rigorous studies have examined whether perceived posttraumatic growth is associated with improved subsequent well-being across a wide range of outcomes. In this three-wave longitudinal study of Colombian emerging adults (n = 636), we examined the associations of perceived posttraumatic growth with 17 well-being outcomes across domains of psychological well-being (i.e., self-rated mental health, meaning in life, sense of purpose, happiness, life satisfaction), psychological distress (i.e., anxiety symptoms, depression symptoms, subjective suffering), social well-being (i.e., content with relationships, satisfying relationships, loneliness), physical well-being (i.e., self-rated physical health, sleep quality), and character strengths (i.e., state hope, trait forgivingness, orientation to promote good, delayed gratification). Using an outcome-wide analytic design that adjusted for a range of covariates assessed in Wave 1, we found that overall perceived posttraumatic growth assessed in Wave 2 was robustly associated with improvements in one or more facet of each well-being domain (15/17 outcomes in total) assessed approximately six months later in Wave 3. Our findings suggest that perceived posttraumatic growth may contribute to individual well-being over the longer-term.

EL, Cowden RG. Differential effects of decisional and emotional forgiveness on distress and well-being: A three-wave study of Indonesian adults

Research suggests that interpersonal forgiveness is beneficial to individual functioning, but few longitudinal studies have explored the independent contributions of decisional and emotional forgiveness to reducing different forms of distress and improving multidimensional well-being. In this three-wave (T1: December 2020; T2: January 2021; T3: February 2021) prospective study of predominantly young Indonesian adults (n = 595), we examined the associations of decisional and emotional forgiveness with three indicators of distress and 10 components of well-being. Applying the outcome-wide analytic template for longitudinal designs, our primary analysis involved estimating two sets of linear regression models (one set for decisional forgiveness and one set for emotional forgiveness) in which the outcomes were regressed on each interpersonal forgiveness process (one outcome at a time). Adjusting for a range of covariates (including prior values of decisional forgiveness, emotional forgiveness, and all 13 outcomes) assessed at T1, decisional forgiveness assessed at T2 was associated with an increase in seven components of well-being (i.e., life satisfaction, physical health, sense of purpose, promote good, delayed gratification, content with relationships, satisfying relationships) approximately 1 month later at T3. In contrast, emotional forgiveness assessed at T2 was associated with an increase in a single component of well-being (i.e., satisfying relationships) assessed at T3. Neither decisional nor emotional forgiveness assessed at T2 showed evidence of associations with any of the subsequent indicators of distress assessed at T3. Our findings suggest that, at least within a principally collectivistic cultural context such as Indonesia, decisional forgiveness in the aftermath of a transgression may have greater short-term benefits for well-being compared to emotional forgiveness. Implications of the findings for research and interventions are discussed.

Non-somatic Suffering in Palliative Care: A Qualitative Study on Patients' Perspectives

Objectives: Suffering is intimately linked to the experience of illness, and its relief is a mandate of medicine. Advances in knowledge around terminal illness have enabled better management of the somatic dimension. Nevertheless, there is what can be called "non-somatic" suffering which in some cases may take precedence. Inspired by Paul Ricoeur's thinking on human suffering, our aim in this qualitative study was to better understand the experience of non-somatic suffering. Methods: Semi-structured interviews were conducted with 19 patients. The results were qualitatively analyzed following a continuous comparative analysis approach inspired by grounded theory. Results: Three key themes synthesize the phenomenon: "the being enduring the suffering", "the being whose agency is constrained", and "the being in relationship with others." The first describes what patients endure, the shock and fears associated with their own finitude, and the limits of what can be tolerated. The second refers to the experience of being restricted and of mourning the loss of their capacity to act. The last describes a residual suffering related to their interactions with others, that of loneliness and of abandoning their loved ones, two dimensions that persist even when they have accepted their own death. Conclusions: Non-somatic suffering can be multifarious, even when minimized by the patient. When evaluating suffering, we must keep in mind that patients can reach a "breaking point" that signals the state of unbearable suffering. In managing it, we probably need to make more room for family and friends, as well as a posture of caring based more on presence and listening.

Are depression and suffering distinct? An empirical analysis

Depression and the subjective experience of suffering are distinct forms of distress, but they are sometimes commingled with one another. Using a cross-sectional sample of flight attendants (n = 4,652), we tested for further empirical evidence distinguishing depression and suffering. Correlations with 15 indices covering several dimensions of well-being (i.e., physical health, emotional well-being, psychological well-being, character strengths, social well-being, financial/material well-being) indicated that associations with worse well-being were mostly stronger for depression than suffering. There was a large positive correlation between depression and suffering, but we also found evidence of notable non-concurrent depression and suffering in the sample. After dividing participants into four groups that varied based on severity of depression and suffering, regression analyses showed higher levels of well-being among those with both none-mild depression and none-mild suffering compared to those with moderate-severe depression, moderate-severe suffering, or both. All indices of well-being were lowest among the group of participants with moderate-severe depression and moderate-severe suffering. In addition to providing further evidence supporting a distinction between depression and suffering, our findings suggest that concurrent depression and suffering may be more disruptive to well-being than when either is present alone.

A Scoping Review on the Concept of Physician Caring

BACKGROUND

Physicians' interest in the health and well-being of their patients is a tenet of medical practice. Physicians' ability to act upon this interest by caring for and about their patients is central to high-quality clinical medicine and may affect burnout. To date, a strong theoretical and empirical understanding of physician caring does not exist. To establish a practical, evidence-based approach to improve health care delivery and potentially address physician burnout, we sought to identify and synthesize existing conceptual models, frameworks, and definitions of physician caring.

METHODS

We performed a scoping review on physician caring. In November 2019 and September 2020, we searched PubMed MEDLINE, Embase, PsycINFO, CINAHL, and CENTRAL Register of Controlled Trials to identify conceptual models, frameworks, and definitions of physician caring. Eligible articles involved discussion or study of care or caring among medical practitioners. We created a content summary and performed thematic analysis of extracted data.

RESULTS

Of 11,776 articles, we reviewed the full text of 297 articles; 61 articles met inclusion criteria. Commonly identified concepts referenced Peabody's "secret of care" and the ethics of care. In bioethics, caring is described as a virtue. Contradictions exist among concepts of caring, such as whether caring is an attitude, emotion, or behavior, and the role of relationship development. Thematic analysis of all concepts and definitions identified six aspects of physician caring: (1) relational aspects, (2) technical aspects, (3) physician attitudes and characteristics, (4) agency, (5) reciprocity, and (6) physician self-care.

DISCUSSION

Caring is instrumental to clinical medicine. However, scientific understanding of what constitutes caring from physicians is limited by contradictions across concepts. A unifying concept of physician caring does not yet exist. This review proposes six aspects of physician caring which can be used to develop evidence-based approaches to improve health care delivery and potentially mitigate physician burnout.

What is Pain-Related Suffering? Conceptual Critiques, Key Attributes, and Outstanding Questions

Suffering holds a central place within pain research, theory, and practice. However, the construct of pain-related suffering has yet to be operationalized by the International Association for the Study of Pain and is largely underdeveloped. Eric Cassell's seminal work on suffering serves as a conceptual anchor for the limited pain research that specifically addresses this construct. Yet, important critiques of Cassell's work have not been integrated within the pain literature. This Focus Article aims to take a preliminary step towards an updated operationalization of pain-related suffering by 1) presenting key attributes of pain-related suffering derived from a synthesis of the literature and 2) highlighting key challenges associated with Cassell's conceptualization of suffering. We present 4 key attributes: 1) pain and suffering are inter-related, but distinct experiences, 2) suffering is a subjective experience, 3) the experience of suffering is characterized by a negative affective valence, and 4) disruption to one's sense of self is an integral part of suffering. A key outstanding challenge is that suffering is commonly viewed as a self-reflective and future-oriented process, which fails to validate many forms of suffering and marginalizes certain populations. Future research addressing different modes of suffering - with and without self-reflection - are discussed. PERSPECTIVE: This article offers a preliminary step toward operationalizing the construct of pain-related suffering and proposes priorities for future research. A robust operationalization of this construct is essential to developing clinical strategies that aim to better recognize and alleviate suffering among people living with pain.

Content Validation of a Semi-Structured Interview to Analyze the Management of Suffering

This work involves the content validation of a semi-structured interview, whose objective is to learn about the management of suffering in people. The interview items have been classified into several categories that define the suffering construct. For the content validation of the instrument, in addition to initially conducting a scientific review on the subject, the procedure known as expert judgement has been used. The results obtained in terms of the content validity achieved in the dimensions and areas assessed are, in general, satisfactory. However, some of these dimensions and certain areas have not exceeded the required minimum values for content validity. Therefore, it is necessary to modify the items comprising these dimensions in the areas evaluated with the additional incorporation of the qualitative suggestions for improvement indicated by the experts. As for agreement among experts, the results point to moderate agreement, which, moreover, is not due to chance.

Addressing Suffering in Patients With Psychiatric Disorders

BACKGROUND

Patients with psychiatric disorders (as well as general medical conditions) often describe their lives in terms of suffering. Although suffering is honored as a central focus of physicians' concerns, it is not even indexed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Generally connoting severe, prolonged distress, suffering can be distinguished from pain, depression, and anxiety. The aims of this article are to consider whether attending to suffering per se in psychiatric patients merits attention independent of other commonly assessed psychiatric symptoms such as anxiety, depression, and conventional distress, and how targeting suffering per se might add value to psychiatric patient care.

METHODS

Sources for this article were obtained via a selective literature search in PubMed using the terms "suffering" in the title and the terms "psychiatric disorder," "mental illness," "assessment," "measurement," "scale," "existential suffering," and "unbearable suffering." Articles of interest were followed up using a snowball technique to examine "similar articles" and "cited by" titles to find additional pertinent articles.

RESULTS

Definitions of suffering in the medical literature stress its subjectivity, particularity, complexity, and connection to a wide variety of noxious sensations, as well as real and anticipated deficits, losses, and thwarted motivations. These can affect the entire spectrum of universal human needs, from basic biological issues through intrapsychic, interpersonal, and social issues, encompassing existential concerns of meaning, purpose, and transcendence. Based on these factors, a definition of suffering in patients with psychiatric disorders is proposed. Although efforts to measure suffering have been limited and numerous gaps in the literature are evident, several scales may offer suitable bases for the study of suffering in patients with psychiatric disorders.

CONCLUSIONS AND IMPLICATIONS

Ascertaining sources of suffering may require new types of inquiry and additional time. Well-described, evidence-informed strategies and time-honored psychotherapy techniques are available for addressing the numerous concerns that contribute to suffering. Patients with psychiatric disorders whose distinct, multidimensional sources of suffering are identified, acknowledged, and addressed may experience better treatment quality, greater treatment satisfaction, and possibly better outcomes than those whose clinicians' attention is limited to conventional psychiatric signs and symptoms.

Suffering, Mental Health, and Psychological Well-being During the COVID-19 Pandemic: A Longitudinal Study of U.S. Adults With Chronic Health Conditions

Suffering has been a topic of considerable discussion in the fields of medicine and palliative care, yet few studies have reported causal evidence linking the experience of suffering to health and well-being. In this three-wave prospective cohort study, we explore the potential psychological implications of suffering during the COVID-19 pandemic by examining relations among suffering, mental health, and psychological well-being in a sample of U.S. adults living with chronic health conditions. We analyzed data from n = 184 participants who completed assessments one month before the SARS-CoV-2 outbreak was declared a pandemic by the World Health Organization (February 2020) and then two months (April 2020) and four months later (May/June 2020). Analyses controlled for a range of factors, including sociodemographic characteristics, physical health, religious/spiritual factors, psychological characteristics, and prior values of the predictor and each of the outcomes assessed one month before the COVID-19 pandemic. Results of the primary analysis indicated that greater overall suffering assessed one month into the COVID-19 pandemic was associated with lower psychological well-being (β = -.17, 95% CI: -.29, -.05) and higher levels of anxiety (β = .27, 95% CI: .13, .41) and depression (β = .16, 95% CI: .03, .29) two months later. In a secondary analysis that explored anxiety, depression, and psychological well-being as candidate antecedents of suffering, depression assessed one month into the COVID-19 pandemic was most strongly associated with worse overall suffering two months later. We highlight the implications of the findings for high-risk populations who are suffering amidst the challenges of the COVID-19 pandemic. Potential benefits of both integrating assessments of suffering into screening procedures and addressing experiences of suffering in mental health service settings are discussed.

Why Suffering Matters!

Despite Peter Frost’s (1999, p. 128) call for organizational scholars and practitioners to “find suffering as a significant aspect of organizational life,” both have largely remained silent about it. This silence misrepresents the fact that suffering is a pervasive, inescapable, and costly organizational reality. Suffering matters, and a recognition of our general inattention to it exposes an under-appreciated shortcoming of established theories and approaches to management. We must acknowledge, account for, and explicitly investigate suffering if we are to truly understand the full humanity of organizational life. Accordingly, this paper outlines promising areas for future research on suffering in organizations.

Relational inquiry approach for developing deeper awareness of patient suffering

To practice compassion, the recognition, understanding, and alleviation of patient suffering are of utmost importance. Nursing literature provides ample guidance about the nature and meaning and patients' views about compassion and physical and psychological suffering. However, missing is the discussion about how nurses can achieve a deeper awareness of patients' suffering to practice compassion. This paper aims to describe the relational inquiry nursing approach and illustrate how this approach can enable nurses to develop a deeper awareness of patient suffering. The relational inquiry approach encompasses two components: a relational consciousness and inquiry as a form of action. Relational consciousness requires the nurses to focus on the concrete situations and relationships as well as recognize the intrapersonal, interpersonal, and contextual factors affecting the situations. The interpersonal factors are among and between the individuals, intrapersonal factors are within the individuals, and contextual factors are the hidden factors influencing the individuals and situations. Inquiry as an action requires a critical analysis of the experiences of individuals, situational contexts, and knowledge to inform the nursing care modalities and actions. This approach encourages nurses to use the philosophies of hermeneutic phenomenology, critical theory, and pragmatism. The phenomenological worldview allows nurses to interpret their own and patients' experiences, the critical theory worldview allows nurses to examine the influence of social and cultural factors, and pragmatism allows nurses to question their prior knowledge and develop new knowledge in each situation. The relational inquiry approach allows nurses to develop a deeper understanding of patient suffering through building a therapeutic and trustworthy relationship, active listening, focusing on the details, and engaging in broad and situations specific inquiries to understand the patient narrative of suffering. Two case exemplars are shared to demonstrate how relational inquiry allowed nurses to move beyond recognizing physical suffering and understand patients' emotional and psychological suffering.