A Nurse’s Perspective on Janice Morse’s Praxis Theory of Suffering
Nancy L. Swezey
Hunter Bellevue School of Nursing
Janice Morse’s praxis theory of suffering was developed after decades of qualitative research to guide nurses in responding to the complexities of patients’ illness experience. It has proven to be valuable when taking into account context, cultural competence, and applying nursing intuition and evidence-based expertise. Its value as a true praxis model remains questionable. Greater exploration is warranted in specialized care, such as trauma and hospice.
A Nurse’s Perspective on Janice Morse’s Praxis Theory of Suffering
In 2001, after decades of qualitative research, Janice Morse published the praxis theory of suffering in order to guide dynamic and holistic nursing interventions. The theory was designed to give nurses the tools that they may aid in diminishing the suffering of their patients through interacting intelligently with them. (Butts, 2015) Morse’s theory described two states of suffering and how the nurse can best observe and respond by using specific behavioral cues unique to each state. The theory has been applied and critiqued in multiple specialties and settings, all suggesting an area of concern rich with potential. One such study in 2005 does so in regard to the care and treatment of sexual assault trauma victims, showing great utility in categorizing behavior but a deficit in terms of actual nursing practice. There is certainly great utility for nurses who are new and may lack either inherent intuition, or that which comes with experience, but one can safely assume that most nurses choose their career based on humane intuitiveness unique to a nurse’s professional character.
As nurses, it is clear that there are certain quantitative measures we use to account for our patients’ suffering. The most obvious of these is what we have come to know as the “fifth vital sign”, or pain. Pain becomes suffering when the meaning of one’s experience is perceived as a threat to personal integrity, or wholeness. (Sacks & Nelson, 2007) It is the meaning of pain that creates suffering, not the pain itself. Thus, pain can exist without suffering, and vice versa. (Mount, Boston & Cohen, 2007) One can transcend suffering by making new meaning out of the experience of suffering which leads to greater compassion, a revision of priorities and a new set of values. (Foss & Dagfinn, 2009) Therefore, suffering is paradoxically created by, and recovered from through meaning.
There are two states of suffering according to Morse: enduring and emotional suffering. They are mutually exclusive and oscillated between by the suffering individual. An enduring person’s main priority is the suppression of feelings and maintenance of control. Outwardly, they stand erect and move robotically while their faces contain blank stares. An enduring person speaks matter-of-factly in short sentences and without intonation. They may engage in small minute tasks like washing dishes or doing puzzles to escape. They may even release themselves from enduring temporarily by hysterical laughing, yelling or throwing inanimate objects. An emotionally suffering person’s behavior is the antithesis of one enduring. They are visibly emotional: sobbing, weeping, hunched over. Emotional suffering occurs when a person is ready to feel the sense of loss they may have been repressing. (Foss & Dagfinn, 2009; Morse 2015)
As one may expect, the appropriate responses to cues of suffering by the nurse are very different for the two states of suffering. An enduring person is to be given space. Emotionally charged conversation is to be omitted in order to avoid reminding the sufferer of that which they perceive as intolerable in that state. The nurse is to speak to the endurer minimally and when necessary, and in only a factual manner. On the other hand, with the emotionally suffering person, it is best for the nurse to soothe, comfort and express condolences. The nurse may put an arm on the emotional sufferer’s shoulder, or the nurse may even wrap his or her arm around them. In short, the nurse’s role is to enable the endurer and soothe the emotional sufferer. (Butts, 2015)
In 2005, using Morse’s praxis theory of suffering as a framework, Esposito recruited 43 sexual assault victims for open-ended interviews about their experience, both in terms of the assault itself and their medical and nursing care afterward. Among the 43, there were a total of 76 sexual assault experiences, for 20 of which victims sought treatment for afterward. All of the participants were women. The range of time that had elapsed between the assault and the interview was one and fifteen years prior. (p. 919)
Esposito used Morse’s praxis theory of suffering for inductive analysis of participants’ behavior. Using Morse’s theory, interviews were structured so that participants were interviewed first about their social history to establish rapport and create a safe space for sharing, while collecting important foundational data. Victims were then asked about the assault itself, any help-seeking they had undertaken, and post-assault care. (2005) Nursing care for sexual assault victims is a delicate undertaking for many obvious reasons. Further compounding the role of the nurse in post assault care is the possibility of being called to witness if the assault case goes to court. If the nurse, or any provider, is perceived as biased and advocating for the victim, their testimony is weakened and possibly invalidated by the defense. (p. 923)
Responses and outward emotional demonstrations were found to fall within the framework of Morse’s praxis theory of suffering. The praxis aspect of Morse’s work as it contributes to nursing however, revealed an area that is currently lacking in understanding but rich with potential. Participants in Esposito’s study clearly illustrated expressions that fell neatly within the two states of suffering according to Morse. Responses to trauma, both descriptions of feelings during immediate post-trauma care and emotional character during interviews themselves, were not consistent. (2005) While some of the women were repulsed by comforting touch during post-assault care, others expressed appreciation for a nursing approach that suggested familiarity and intimacy, such as pet names and colloquialism. (pp. 921-922) The study concluded that Morse’s praxis theory of suffering may be a valuable tool for organizing our understanding of trauma victim’s outward behavior in emergency care. Beyond that, Esposito called for more research to garner better insight into the provider’s best approach to supporting such exceptionally vulnerable individuals. (2005)
Morse’s theory is a valuable tool for efficiently categorizing the outward behaviors of patients and their families. In fact, there is seemingly few human expressions that do not fit the models of either enduring or emotional suffering. The theory implies that suffering is a temporary state that one experiences only during periods in which a sense of threat or loss exists. Even the laughing person is potentially only experiencing a brief release from enduring. (Morse, 2015) That said, perhaps suffering is not something we enter and exit periodically but a part of our lives continuously. In that sense, reformulation is not so much a matter of exiting the suffering state as simply having a new appreciation for, and acceptance of suffering. From the nursing perspective, this could lend itself to a better understanding of patients not just a person suffering due to illness or injury, but a person suffering because people suffer. Both nurse and patient are equally human, having equally complex experience and such recognition may lend itself to more healing, trusting rapport. (Georges, 2002; Sacks & Nelson, 2007)
As with Esposito’s work with women who had experienced sexual assault, a clear delineation of the appropriate role of nurse or provider is not yet achieved using Morse’s theory alone. (2005) Although Morse does make caveats for individual context (Butts, 2015), the theory may oversimplify the relationship between a patient and provider if relied too heavily upon. Nurses witness the complexities of, and wildly varying responses to, acute health crises, living and working through the intricacies of their own dispositions within and outside of professional work. Esposito’s work demonstrates that interactions between providers and patients seems not so much representative of a phenomenon neatly contained within theory, but a variety of memories as diverse as the individuals who shared them. Questions as to the validity of memory for trauma victims were not addressed. (2005)
According, to Georges (2002), praxis is more than just the practical application of theory. It is a phenomenon characterized by context, both highly individualized and reflective. Thus, Morse’s central thesis is rendered incongruous with current understandings of praxis, as well as the great emphasis in healthcare training today on cultural competence. Cultural competence has become a buzzword in healthcare and is emphasized greatly during clinical training and education. For nurses, cultural competence is the ability to interact effectively with patients by honoring the fluid nature of cultural identity, and the nuances of individuality for each person. The goal of cultural competence is to improve the quality of care, suggesting a need for contextual assessment and response in order to achieve best practice. (Dana & Allen, 2008) For nurses, a contextual praxis of suffering would take into account individual disposition, issues of social justice and oppression that play out in healthcare, as well as the state of the nurse, him or herself. Comforting is a matter of being with patient, simply expressing presence to them, rather than engaging in a prescribed power dynamic or relying only on outward behavioral cues. (Georges, 2002)
A provider’s greatest training for alleviating suffering is attunement to their own intuition (Green, 2012), which achieves its most poignant refinement through clinical experience. (Dana & Allen, 2008) Trust is the unifying theme which helps to create meaning for sufferers and thus move toward reformulation and solution. Nurse/patient is often a relationship through which trust can be established and thus suffering eased. (Sacks & Nelson, 2007) Implicit in the nursing skills and knowledge is nursing intuition, which is an embodied awareness, similar to riding a bicycle, that informs our technical skills, decision-making and is attuned to the subtleties of individualized and complex caregiving. We can use our nursing intuition as practical knowledge by engaging with our patients, and making clinical decisions that support our unified goal of best outcome for the patient. (Green, 2012)
Morse’s praxis theory of suffering is a beneficial tool in guiding providers to pay attention to the nuances of interactions with patients. It is valuable to the extent that it reminds nurses and other caregivers to be led by the deportment of patients, rather than focusing on symptom management and task-completion. Suffering, as a phenomenon which encompasses an individual’s selfhood in many dimensions—spiritual, physical, emotional—cannot be alleviated by pain control or any other somatic treatment alone. (Mount et. al, 2007) The praxis theory of suffering may be valuable in categorizing the behavioral cues of patients, if individual context is accounted for as well. The nurse’s role in the suffering experience is best guided by a combination of nursing intuition, established theory, and evidence-based clinical expertise. (Green, 2012) A response to suffering which takes into account specialty and cultural competence, such as trauma or hospice nursing, is rich with potential and an area of great import to nurses and their patients. (Esposito, 2005; Sacks & Nelson, 2007)
Butts, J.L., Rich, K.L. (Eds.). (2015).Philosophies and theories for advanced nursing practice.
Burlington, MA: Jones & Bartlett Learning.
Dana, R.H., Allen, J. (2008). Cultural competency training in a global society. https://doi-
Esposito, N. (2005) Manifestations of enduring during interviews with sexual assault victims.
Qualitative Health Research, 15(7), pp. 916-927.
Foss, B. & Dagfinn, N. (2009) Janice Morse’ theory of suffering–a discussion in a caring
science perspective. Vard/Norden 29(1)
Georges, J.M. (2002). Suffering: Toward a contextual practice. Advances in Nursing Science,
Green, C. (2012). Nursing intuition: a valid form of knowledge. Nursing Philosophy, 13(2).
Pp.98-111. http://dx.doi.org/ 10.1111/j.1466-769X.2011.00507.x
Mount, B.N., Boston, P.H., Cohen, R. (2007). Healing connections: On moving from suffering to
a sense of well-being. Journal of Pain and Symptom Management, 33(4). 372-388.
Sacks, J.L., & Nelson, J.P. (2007) A theory of nonphysical suffering and trust in hospice
patients. Qualitative Health Research, 17(5) pp. 675-689.