TRANSFORMING DESOLATION INTO CONSOLATION: THE MEANING OF

BEING IN SITUATIONS OF ETHICAL DIFFICULTY IN INTENSIVE CARE

Anna Sderberg, Fredricka Gilje and Astrid Norberg
Key words: at-homeness; consolation; desolation; enrolled nurses; ethics; intensive care; narratives; phenomenological hermeneutics; presence The purpose of this phenomenologicalhermeneutic study was to illuminate the meaning of being in ethically difficult care situations. The participants were 20 enrolled nurses employed in six intensive care units in Sweden. The results reveal a complex human process manifested in relation to ones inner self and the other person, which transforms desolation into consolation through becoming present to the suffering other when perceiving fragility rather than tragedy. The main point of significance here is for all health professionals to create an ethical work environment and strive for praxis that fosters athomeness, which renders us free to transform desolation into consolation. Consolation is of significance in ethics because it makes us available and helps us to fulfil the demands of life, while desolation makes us unavailable to others.

Introduction
Intensive care units (ICUs) are challenging, technologically advanced environments, laden with ethically difficult care situations.1 Previous research reports have shown that: registered nurses (RNs) and physicians identify different ethical problems when caring for the same patients2; enrolled nurses (ENs), RNs and physicians ways of reasoning in ethical matters differ36; and a majority of identified conflicts among RNs and physicians in ICUs concern disagreements over ethical issues.7 Differences and disagreements in ethical matters, however, do not have to be seen as problems. When carers from various professional groups view situations differently, it makes it more probable that important aspects of care will not be neglected if they are communicated interprofessionally.6,8 Results from previous
Address for correspondence: Anna Sderberg, Doctoral Student, Department of Nursing, Ume University, S-901 87 Ume, Sweden.

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research on Swedish ENs experiences in situations of ethical difficulty in geriatric and surgical care, however, reveal a lack of such communication. While being at the lowest level of a professional hierarchy and closest to patients, ENs describe feelings of inadequacy, isolation, powerlessness, and a desire for communication and co-operation with physicians and RNs about ethical matters.4,6 A need for communication was also expressed among ENs working in ICUs.9 Even though they regretted that their confidential knowledge about patients was not included in decision making, these ENs seldom expressed their opinions to physicians. The main differences among professional groups in medical and oncological care in Norway,8 and in surgical,4,5 geriatric5,6 and intensive care9,10 in Sweden, concerned differences in perspectives. Physicians focused on the level of care from the perspective of difficulties in decision making, the RNs focused on realizing the physicians decisions in an executive and outcome perspective, while ENs focused on the suffering of patients and families in a relationship perspective. In tragic situations, dissimilarities in ethical perspectives pointed to prevailing differences in the foci of individuals: physicians struggled with realism in ethical decision making; ENs struggled with consolation as an outcome; RNs stories concerned dignity.9,10 A prerequisite for effective communication among professional groups is sharing a common moral language. Understanding the moral language of each professional group presupposes knowledge about what it means for them to be in situations of ethical difficulty. The aim of this study was to elucidate the meaning of being in ethically difficult care situations in intensive care, as narrated by ENs.

Method
With the purpose being to illuminate the meaning of the ENs experiences of being in situations of ethical difficulty in an ICU, a phenomenologicalhermeneutic approach, inspired by the philosophy of Ricoeur,11,12 developed further at Ume University, Sweden and the University of Troms, Norway, and previously employed by, for example, Lindseth et al.13 and Rasmussen et al.,14 was used. The phenomenologicalhermeneutic interpretation of text involves three phases that constitute a dialectic movement between the whole and the parts, and between understanding and explanation. A naive reading is the first surface interpretation of the text as a whole, which provides direction for further analysis. A structural analysis includes various examinations of the parts of the text in order to explain what and how it is expressed. An interpreted whole is a critical in-depth interpretation based on the pre-understanding of the authors, the naive reading and the structural analyses, viewed in the light of a conceptual framework for the purpose of revealing a deeper understanding of what the text conveys.15

Research context and participants

The setting for this study was general intensive care units of six hospitals located in northern Sweden. The context was that of high technology, patients having to travel long distances for intensive care, and open visiting hours. In these units,

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Transforming desolation into consolation 359 nursing was organized by a head nurse. An EN cared for one or more patients, while an RN was responsible for one to four patients and supervised up to four ENs. The chief physician, an anaesthetist, was, at the time of this study, legally responsible for the nursing care as well as the medical care. The convenience sample was composed of 20 ENs who were employed in intensive care units and chosen by the nurse manager at each hospital. The criteria for selection included gender distribution, length of professional experience, willingness to participate, and being a well-functioning EN as defined by the nurse manager. Ten ENs were female and ten were male. Their mean age was 33 years (range 2259) and the average employment in intensive care was 6 years (range 0.425). Probable gender differences5 and contrasts in levels of expertise16 will be addressed in another publication.

Narrative interviews
Data collection involved 2070 (mode = 30)-minute narrative interviews17 conducted between October 1991 and September 1992. Each participant was asked to narrate his or her experiences of being in a situation when it was difficult to know what was the good and/or right thing to do. Questions that clarified and explored their experiences were asked as needed. The interviews were audiotaped and transcribed verbatim. The study was approved by the Research Ethics Committee of the Medical Faculty, Ume University (181/91).

Interpretation process and results

Naive reading
The 90 ENs stories were characterized by physical closeness to the patients suffering, the patients families outbursts of feelings, and their own strong conflicting emotions that were aroused in situations of ethical difficulty. Examples of these situations include: caring for immobilized patients who were left in the care of ENs who had difficulty in interpreting their vague signs; caring for adolescents severely injured bodies while they were waiting to donate organs, without the family being present; preventing older patients from dying but subjecting them to hopeless and grotesque treatments without the ENs understanding the rationale; changing the level of treatment without informing ENs of the motive; the inability to resuscitate young people who had the will to live, while patients who had attempted suicide survived; dealing with the anxieties of patients and their families, when these are expressed through mistrust and aggression; and complex patient care that forced the focus towards high technology rather than the patient as a human being. In these situations, the ENs were consoled by the following: seeing patients progress towards recovery; good relationships with the patient, family and/or professionals; effective communication with others; experiencing personal growth in patients, patients families and themselves when in demanding situations; conquering ones own dread of death; and receiving strength from their experience.

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Structural analyses
The results of each of four structural analyses gave a preliminary interpretation of the whole, which took the form of a guess that needed validation, rejection or concept clarification15 through another structural analysis. The structural analyses, therefore, involved several movements back and forth between the small entities of the text, visions of the meaning of the whole, and readings in the works of the French philosophers Gabriel Marcel,1825 Jean Nabert,26 Paul Ricoeur2729 and Simone Weil.30,31 A common factor in all these writings is that the starting point for ethical reflections is the lived experience, which points to the basis of existence. Quotes from these readings are integrated into the text to facilitate an unfolding understanding of various interpretations. In order to condense this presentation, the results of the four structural analyses are intertwined with quotes, summaries of preliminary interpretations, and results. First structural analysis: narrative categories First, an analysis was conducted using narrative categories: the plot, the principal character, the author of the story, co-actors, the course of events, the narrator, and a style analysis.10,32 This analysis showed that the most frequent plots were those of relation to the patient and relation to the patients family.3 The most frequent principal character was the patient. The anaesthetist and the EN were most frequently the authors of the stories, and, as co-actors, ENs, RNs and the patients families were almost as frequently mentioned. The course of events showed a negative outcome for two-thirds of the stories. The narrators told about themselves, that the importance of their work was not officially valued or respected in the unit. They perceived their role as awakening the vital power among patients and their families (i.e. a will to survive, to recover, to struggle, to co-operate, to endure or to cope). Their narratives conveyed a conflict between their personal and professional responsibilities, which revealed vulnerability and powerlessness when caring for people who are innocently affected by suffering (e.g. taking personal responsibility in being close to patients and their families, but dealing with the consequences of others decisions and the injustice of life). The ENs seldom revealed their personal opinions to anyone, especially the physicians. The style analysis33 showed that the ENs primarily narrated from the perspective of being involved and engaged in the event. Second structural analysis: thematic analysis Secondly, the text was divided into meaning units, based on one or more sentences related by content and then condensed and abstracted as closely as possible to the text. The first thematic analysis resulted in 62 first-level subthemes with two forms. The negative subthemes conveyed a downward feeling, characterized by not knowing how to be or act in response to an ethical problem. The result was described as an experience of dread, or of being fettered, imprisoned and indecisive, which caused despair and an experience of desolation. The positive subthemes conveyed an upward, relieving feeling that generated an experience of meaning, significance, communion34 and decisiveness that consoled. As envisioned, from the naive reading, the core themes constructed were the end-points of the same

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Transforming desolation into consolation 361 dimension, desolation and consolation, which embraced the implied meaning of all the subthemes. To grasp further the intersubjective aspects of the realm between the end-points of consolation and desolation, the first-level subthemes were contrasted. According to Webb and Sells, it is only through the tension between two often paradoxically related propositions that a glimpse of the real can be gained (p. 247).35 Normal language functions according to the single proposition which can stand on its own. The language of the unsaying uses double propositions no single proposition on its own can be true or false, can be a meaningful utterance (p. 53).36 When contrasting the first-level subthemes of the end-points of consolation and desolation, the only difference revealed was a kind of motion (i.e. something dynamic), an understanding, a certainty, a courage and a creation, from which the second-level subthemes were constructed. Further condensation of the subthemes into third and fourth levels was conducted, resulting in a total of four themes, viewed from the opposite poles of consolation and desolation (Table 1). The theme common to both groups was perception. The other themes were: being confident/uncertain; being present/distanced; and experiencing meaning/meaninglessness. Third structural analysis: comparing and contrasting stories of desolation and consolation Thirdly, the 90 stories were categorized into two groups, with regard to outcome from the ENs point of view: (1) stories about desolation (n = 57; 63%); and (2) stories about consolation (n = 33; 37%). When comparing the groups of stories, the two similarities identified were: the apprehension of an ethical appeal of what to do; and the structure of all narratives (i.e. a polarity in events and, at the core of each situation, a threatened vision of the good life):
A young man rapidly became brain dead after a motorbike accident. Even though I dreaded meeting with his grieving family, the absence of the family was worse. I had to take care of his young, lacerated body and accompany him to organ donation without any family saying farewell.

In narratives about desolation, the threatened vision of the good life was further offended because the sufferers fragility was neither respected nor safeguarded:
I cared for a man suffering from legionnaires disease, week after week without any signs of recovery, just getting worse. He was my age and I knew him as well. He was on a respirator with 100% oxygen and six(!) pulmonary suction tubes. He became swollen like a Michelin-man, the nose was not visible in his swollen face and his scrotum was the size of a football. From the beginning it was all right to invest in all kinds of treatment but, later, when everyone knew he wouldnt survive, I experienced it as an unethical experiment to carry on the treatment. I was ordered to prick his swollen scrotum with cannulae and I wouldnt like anyone to do that to my husband. We all felt awful subjecting him to such treatment. He died after 3 months and I dont want me, or my family, to die that way!

In narratives about consolation, a turning point of certainty of what to do or how to think surprisingly changed the apprehension of the situation as a whole:

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It was so sad [starts crying] to have this body contact when caring for the deceased after the organ donation. The cuts were burned by laser beam, which looked negligent. It was trying to know that the organs were taken away, that no family was present and it was so sad to be alone when making the body look nice. Suddenly, I realized that someone out there was very happy just now, receiving one of these organs; someone out there was receiving a chance to live . . . like a gift.

Uniting all turning points in the transformation of desolation into consolation was the occurrence of a presence (i.e. becoming mentally and physically present and available to respond to the appeal in a situation of ethical difficulty). The decisive contrast, however, was that, in stories about desolation, the ENs felt pre vented from responding to the appeal, and the turning point was absent owing to barriers to becoming present. Barriers to becoming present In stories about desolation (n = 57), the ENs felt that they could not respond to the appeal because they were frightened or paralysed by experiences of horror, dishonesty and/or inadequacy. Examples of these experiences from the ENs descriptions as well as quotes from the literature follow. Horror was experienced in unintelligible tragic events, which forced the ENs to step back (e.g. a car accident involving a young boy):
I never got to know him because I had no contact with him before he was declared brain dead and I had no relationship with his parents when they arrived at the unit and cried out their unhappiness . . . it touched me so and frightened me so . . . and I did not dare to meet with them!

Weil says:
At the stark sight of death, the flesh recoils. It arouses horror. When affliction is seen vaguely from a distance, either physical or mental, so that it can be confused with simple suffering, it inspires in generous souls a tender feeling of pity. But if by chance it is suddenly revealed to them in all its nakedness as a corrosive force, a mutilation or leprosy of the soul, then people shiver and recoil. The afflicted themselves feel the same shock of horror at their own condition (p. 91).31

Dishonesty was experienced when the ENs were not able to be frank in their communication with patients, families or other professionals. This dishonesty concerned doubting the motive for treatment or not being allowed to question or discuss treatment approaches and options. This restraining of truth oppressed motivation, caused a feeling of imprisonment, interfered with becoming present, and also prevented ENs from giving support in a tragic situation, thus adding to the tragedy by treachery:
A young patient appeared to suffer from an incurable tumour that was not accessible to surgery or other kinds of treatment. The patient rapidly became critically ill and she questioned all the time what this was about. It was a very trying experience to me because I wasnt yet allowed to tell her anything until all the examinations were finished. It is easier to meet with patients who know the truth, even if it is a sad truth, because then you can be honest and dont need to go behind their back.

Marcel says, A morally healthy person is horrified by lying because he regards it as a defilement (p. 83).23 The one who betrays the truth is not a free man . . .

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he is without-a-home and without an at homeness there cannot be any freedom worthy of the name (p. 15051).19 Inadequacy was experienced in tragic situations never before encountered by inexperienced ENs. These ENs were very uncertain and, without sufficient knowledge and co-operation, they lacked ideas, vision and tools to transform the events. One example concerning a patient who is totally dependent on the ENs care is:
The tetraplegic patient was on a respirator and could do absolutely nothing by himself. The patient was eager to say something and I could not grasp what he was trying to tell. The patient got more and more upset, frustrated and angry. I tried and tried to understand but had the humiliating experience of being exposed as incapable.

Ricoeur says, The inability to respond to an expectation from someone who is counting on me means a violation of self-integrity and a destruction of selfconstancy (p. 190).29 As a first summary of the interpretation and results, it can be seen that, in each of these situations of horror, dishonesty and inadequacy the ENs inhibited disclosure of the real , which prevented them from being true (i.e. they suppressed their honest reactions, their weaknesses and their desired response to the appeal). This absence of honesty prevented the ENs from communion with professionals, patients and/or their families, and from acting congruently with their values and beliefs. From this experience, a sense of imprisonment emerged and their response became rejection, a protection of self. The barrier to presence was protection of self . The origin of protection of self is nonavailability (i.e. a nonpresence and a preoccupation with self, which mediates egoism).21,37 Egoism is a kind of revenge, which, in turn, mediates pessimism21; hence, the more nonavailable a person is, the less room there is in that person for hope. Protection of self creates a nonpresence:
If another person is not present to us, something essential is lacking. Communication without communion means that the other understands what I say to him, but he does not understand me. This stranger interposes himself between me and myself; I am not really myself while I am with him (pp. 2056).18

That is, the other alienates me from myself25 and from my own reality,22 and one who is alienated from himself cannot act (p. 101).38 To be alienated means to be morally or spiritually homeless.23 Meeting a very trying situation when being spiritually homeless, imprisoned and unable to act, awakes a need for emotional protection. In the stories about desolation, this protection was created by hiding the real through a spatial as well as an emotional distance from the tragedy. Ways of becoming present In stories about consoling situations (n = 33), the ENs revealed vulnerability, as in the desolation group. The ethical appeal from the other, however, awoke a conviction of what ought to be done. This certainty infused the confidence to dare to expose themselves to the trying event instead of protecting themselves. Ways of becoming present were described as welcoming participation, reflecting on self , readiness, struggling for the others freedom, honesty and creating beauty. Welcoming participation was an initial response to the appeal, which invited

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Transforming desolation into consolation 365 connection in the midst of professionals or families outbursts of mistrust and aggression, and which was the most demanding situation for these ENs:
A little girl suffering from severe asthma was put on a respirator and her parents were so despairing that they tried aggressively to prevent me from caring for her. I firmly told them what was my responsibility and what was theirs, and I talked to them in the tone of commanding a dog. When the girl safely co-operated with the respirator, I started to instruct and practice with the parents for our joint mission, but they protested aggressively. After 1 week of fighting, the parents surprisingly welcomed me with the words: Oh, we wished you would show up today!

Marcel says that to expect is in some way to give (pp. 4950).20 To welcome presupposes an at homeness (p. 89).25 Ricoeur says that value is at home within me and I see myself in light of what it offers (p. 79).27 Reflecting on self was a way of meeting destructive emotions through imagining ones self in the situation at hand:
My patients boyfriend made me furious because he was so aggressive and mistrusting. Suddenly I started to think, what would it be like to have my boyfriend lying here as a patient . . . and then I realized I would have been even worse, and my anger just disappeared!

According to Marcel, the presence of another person forces me to see things through his eyes (p. 51).25 To enter into the depths of ones self means here fundamentally to get out of oneself (p. 131).18 Presence is an encounter between two subjects, and there can be no encounter . . . except between beings endowed with a certain inwardness (p. 169).18 Readiness was described as an attitude of attentiveness and preparedness towards difficult situations. One example of this was narrated after a chaotic effort at resuscitating a baby:
When the little baby died, I realized I was the one who had to take care of the mother, because the physician had lost a baby in the same way not long ago and the RN had small children at home. It was a very trying experience for them and therefore I realized I was the one who had to be strong. One grows stronger throughout the years. Situations are never alike but one learns how to behave and that you will manage.

Marcel says that a real encounter . . . is something which does not happen accidentally, and one can ready oneself for it (p. 12).25 The being who is ready for anything is the opposite of him who is occupied or cluttered up with himself (pp. 2425).20 Struggling for the others freedom was about awakening the joy of living by respecting the patients wishes in spite of poor communication:
I cared for this severely injured and unconscious patient for a long time and I learned to know his smallest signs. When he started to wake up I found out he wanted a special soft drink and to get the news from the papers. Three weeks after departure he found out my name and phoned me at home just to say, Thank you.

Ricoeur asserts that we will arrive at ethics by introducing the idea of the second person, the idea of freedom in the second person (p. 178).28 This recognition of the freedom of the other person which seeks incarnation is the recognition of an ethical situation (p. 183).28 The meaning of being is revealed only to the free self.39

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Honesty was a very important prerequisite for creating an encounter of presence. An example was narrated by an EN who cared for a dying teenager who had been brain dead for several days, while the family gathered in the unit. The outcome was apparent and the EN experienced the event as emotional torture:
When the teenager died, I could not find anything consoling to say. After the familys farewell to their deceased daughter, I turned towards the mother and said, I would have said so much, but I have no words. The mother gave me a hug and said, I know, but you have done your best and you have been so nice and gentle to us and that is what warms me.

Nabert writes that the confession changes everything: the relation of the being with itself and its relationship to truth as well as its relation to other minds and to their inner being (p. 153).26 In the light of truth, in the presence of truth, it is just . . . as if this truth possessed a stimulating power, as if it were able to purify me, as a seawind can or the piney tang of the forest (p. 69).18 Creating beauty was fundamental in transforming horrifying situations into something that it was possible to grasp, to become involved and present in. One example was narrated by an EN who always wept uncontrollably when a patient died:
It was the same even this time. I couldnt console anyone because I could not stop crying when the patient died. But I made the deceased body, her bed and unit, as nice as possible and I trust this will console the family in the future when they think of this sad moment of parting and they remember, yet how nice it was.

Ricoeur states that creating beauty is engagement and engagement can be seen as the emotional response to the others suffering (pp. 19192).29 Justice, truth and beauty are the image in our world of this impersonal and divine order of universe (p. 34).30 As a second summary of the interpretation and results, it can be seen that common to all these ways of becoming present was breaking out of self to encounter others. Breaking out of self meant exposing oneself to the event, disclosing the real and becoming available to the other, in spite of ones emotional response to the tragic event (i.e. in spite of ones fear, violation, dislike, overwhelming sympathy and/or inadequacy). The ENs confessed their emotions and inadequacy to meet such trying events and admitted there was no other choice but to embrace the others fragility. When effectively responding to the appeal, the ENs experienced communion, confidence and helpfulness, which consoled. Disclosure of the real meant acting congruently with ones own convictions. This response involved a sacrifice of ones own protection40 to embrace the others fragility. Marcel writes that:
it is characteristic of the person to expose himself, to commit himself, to engage in confrontation. Courage is above all looking at things as they are; it is opposed to fakery and cheating of all kinds. And it appears also that what he is called on to confront is precisely truth (p. 87).23

The origin of sacrifice is the ultimate availability, which ceases to be sacrifice because it leads beyond differences between for self and for others (p. 77).25 Marcel explains sacrifice as a way of giving-of-oneself and to give is to expand

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Transforming desolation into consolation 367 oneself (pp. 11620).24 The soul of a gift is its generosity, and generosity is a virtue that must be distinguished from prodigality; hence, generosity is a light whose joy is in giving light, in being light. This light goes beyond the boundaries between the for self and the for the other. Like fire, generosity feeds on itself, because joy is not self-satisfaction but an exaltation, comparable with participating in an orchestra or a choir . . . bound up with a consciousness of being all together. A gift is not a result; it arises spontaneously and, availability, therefore, in a broader context, points to hope.39 There is not, and cannot be any sacrifice without hope (p. 96).21 Fourth structural analysis: concept clarification of presence In order further to understand the importance to ENs of becoming present to the suffering other, a conceptual clarification of presence was conducted,15 based on a concept analysis of presence41 and on the philosophical works of MacIntyre and Ricoeur42 and Marcel.18,20,22,25 The references to Marcel also include interpretations made by Randall,37 Schilpp and Hahn39 and Gallagher.43 The experience of presence The ENs responses to the appeal of sacrificing ones own protection opened the possibility for entrance into presence. As stated above, sacrifice is the ultimate availability. Availability as a human virtue does not involve being passively and instrumentally used by another person, rather it involves responding in complete freedom to a direct appeal (p. 183).39 Availability is an unconditional readiness that transforms circumstances into opportunities.20 To make oneself available means to receive the other person. Receiving does not consist of filling up some empty space with an alien presence but of having the other person participate in a certain reality, in a certain plenitude (p. 91).25 To receive, in this context, means to welcome an outsider into ones home,25 and to make room for the other in oneself.25 To welcome the other also presupposes a certain readiness, because a person does not receive anyone on unknown ground, rather in a room or in a garden where one experiences a being-at-home (p. 89).25 To provide hospitality is truly to communicate something of oneself to the other, the gift of self (p. 91).25 The response to a person who opens him or herself to receive is presence. Presence cannot be demanded, claimed or forced to occur, but it is received as a free gift.22,37 Presence is mysterious because the presence of persons spreads out beyond what they actually say and what they actually do, because it is a surplus, a beyond.18 Those who are ready for anything are the opposite of those who are occupied with themselves. They reach out, on the contrary, beyond their narrow selves, prepared to consecrate their being to a cause that is greater than they are, but which they, at the same time, make their own.25 The gift of self, therefore, mediates much more than I actually am, because it mediates what I believe in.20 Presence is the mystery of communion; hence, at the root of presence is a being who takes me into account.22 A bond of feelings is created between me and the other person. One discovers an experience that both have shared and a unity is established in which the other person and myself become we (i.e. he or she ceases to be him or her and becomes a thou and he or she ceases to intervene between me and myself). In communion, the other allows me to discover myself; my outer defences fall at the same time as the walls separating me from the other person

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fall.25 My response to the others appeal gives me my personality, makes me what I am.20 My personality is born and grows out of the intersubjective interaction between my inner self and others who become present to me. When somebodys presence really makes itself felt, it can refresh my inner being; it reveals me to myself; it makes me more fully myself.18 The others consciousness places me on the path of my being,26 and the miraculous happens, that the other gives me to myself43 (i.e. a revelation and renewal of self37 that recaptures the affirmative power of existing).42 The third summary of the interpretation and results shows that the defining differences between the responses to the appeal were as follows: the creation of a nonpresence that mediated pessimism; alienation from self; an experience of being homeless, imprisoned and prevented from acting, or the creation of a presence that mediated hope, availability, communion and the gift of self (i.e. being more fully oneself and having the ability to act congruently with ones conviction). Together, this is interpreted as experiencing at homeness in contrast to being homeless. Meeting tragic events when being homeless required the protection of self, while within the refuge of at homeness44 there was no need for such protection.
What is relevant rather, is the act by which I expose myself to the other person instead of protecting myself from him, which makes him penetrable for me at the same time as I become penetrable for him (p. 36).25

Interpreted whole and reflections

According to Ricoeur,11 to understand a text means to follow its movement from what it says, to what it talks about. These narratives of being in situations of ethical difficulty in ICUs describe the importance of transforming situations of desolation into consolation (i.e. becoming available and free to respond to the appeal perceived in the situation). This is accomplished by presence, and presence is the turning point for transforming desolation into consolation. To understand, in an ethical sense, what presence is pointing towards, further clarification is needed.

Perceiving the appeal

According to Marcel, 20 it depends on me whether or not the call is recognized as a call, hence the call comes both from me and from outside of me at the same time. Outside of the call: shifting perspective from tragedy to fragility According to MacIntyre and Ricoeur42 the only way to think ethically is first to think nonethically. Active listening is a pre-ethical mode of being, but not yet a mode of doing. MacIntyre and Ricoeur show how listening is a way of being open, being with and being available. Listening to one another can occur by following and going along with, or, in the negative modes, by not hearing, resisting, defying and turning away. In the light of this knowledge, an interpretation is that hearing, as listening to

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Transforming desolation into consolation 369 the appeal, made ENs in the desolation stories focus on tragedy (similar to the results of a study on tragedy in ICUs9), while ENs in the consolation stories moved beyond tragedy and focused on fragility. Ricoeur explains this difference: The tragic evokes a situation where a human awakens painfully to the consciousness of a destiny or fatality which weighs on his or her life, nature or very condition (p. 15).45 The conflict of fatality or destiny consists in its irremediability, because it refers to the past, to something that already happened, which we cannot change. The appeal coming from fragility, however, enjoins us to do something, to help, but moreover, to foster growth, to allow for accomplishment and to flourish. We are directed to the future of a human being in need of help in order to survive. We are rendered responsible by the fragile, because the fragile relies on us and trusts that we fulfil our obligations. In the light of Ricoeurs45 thoughts, an interpretation is that, when the appeal is apprehended as coming from tragedy, it is natural to ward off disaster. On the contrary, when the appeal is apprehended as coming from fragility, we are rendered responsible to help the other. There is no choice because the other, by relying on me, renders me accountable for my acts. Inside of the call: creating an at homeness What made the ENs focus on tragedy or fragility? The source of sacrifice was said to be availability 25 and, to be available and welcome the other presupposes an at homeness within me. Welcoming the other into ones home is a kind of receptivity that is truly a giving, and the response to such receptivity is human freedom and creativity, which constitute the cornerstones of at homeness. This freedom does not mean an alienation from but rather a communion with other human beings.39,25 Marcel25 says, that there is only a feeling-at-home with respect to a self, which moreover can be the self of another person, who is capable of asserting an I, who can impregnate its environment with its own quality, recognizing itself in its surroundings, entering into an intimate relationship with it and welcome the other to participate in it. This means that there is a vital connection between me and what I do, because a free act helps to make me what I am, as a sculptor might carve me.24 These cornerstones of at homeness, are consistent with what was disclosed in the stories of the consolation group and what was inhibited in the stories of the desolation group. The meaning of these cornerstones can be exemplified as follows. Freedom is the free act of welcoming the other as he or she is, without manipulating or degrading the other, which in turn conveys to the other the freedom of being oneself. To be free means that I am I.24 Creativity is the gift of self, which gives me my personality at the same time as the other is placed on the path of his or her own being, which means a revelation of self and the affirmative power of existing. An interpretation here is that the significance of at homeness is twofold. First, it facilitates hearing an appeal that makes us focus on the others fragility, enjoining us to do something for the future of a human being in need of help. Secondly, it constitutes a shelter into which the other is welcomed to take refuge.44 The response of being received in such a way creates the foundation of at homeness, within which disclosure of the real is made possible.

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Transforming desolation into consolation

Consolation, according to Jnsson,
is not the same as eliminating suffering or escaping grief. Consolation is rather to stay in the midst of the suffering and grieving without experiencing being threatened. When a trying event is counterbalanced, not by its contrast but by an experience of closeness, the sting is removed; hence the most trying experience is the loneliness. When in the midst of darkness you find something or someone to turn to to take refuge in then you no longer dread the darkness, because the only darkness is abandonment (book blurb, back cover).46

Jnssons thoughts led to a deeper understanding of the differences between the groups. In the group where a nonpresence was created between the sufferer and the EN, the fragility was not recognized but offended by being alienated from self (i.e. by experiencing homelessness). In the group where a presence was created between the sufferer and the EN, the fragility was recognized and embraced through being welcomed to take refuge in someones home, where the sufferers own feeling of at homeness found a response. In presence, the desolating experience of being homeless is transformed into a relieving experience of being at home. The true consolation tells me that I am a free human being, an inviolable individual, within my bounds a sovereign person (p. 288).47

Conclusion
The ENs stories about transforming situations of desolation into consolation point, in an ethical sense, to the significant connection between fragility and at homeness. To manage working in the closeness of patients and families suffering, there is a need for experiencing at homeness, which relieves the need of emotional protection and moves us beyond tragedy to human fragility. By the fragile, we are rendered responsible, because the fragile relies on us and trusts that we fulfil our obligations.45 Of significance here is that the ENs ethical reasoning in these situations deals with a deep human experience to which all professionals need to attend, regardless of their position. This requires dissolving professional barriers and emphasizing the importance of ethical praxis, which requires congruence of thinking, feeling, acting and being, and points to virtues. According to virtue ethics, doing the right and good thing calls for being the right person rather than following a particular set of rules.48,49 From this perspective, the ethical environment in a work setting is extremely significant for ethical praxis, because it contributes to creating the experience of at homeness, through becoming aware of and respecting each others values. Consolation is of significance for ethics, because desolation makes us unavailable to others and thus fosters pessimism and alienates the power to be, while consolation makes us available to others and helps us to fulfil the demands of life, which inspires hope and regains the power to be. As Marcel asserts: the only temptation against which we must guard ourselves, is that of despair (p. 10).22

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Transforming desolation into consolation 371

Critical considerations
This phenomenologicalhermeneutic study presents an interpretation that is one of several that are possible.11 The results of these analyses should be judged taking into account the authors pre-understandings. The first author is an RN with long experience in intensive care; the second author is an American nurse educator and specialist in the narrative method; and the third is a Swedish scholar of this research method. To these authors, the results represent the most useful understanding of the meaning of these ENs experiences of situations of ethical difficulty. The transference of the findings to other contexts presupposes a recontextualization of the results to the actual context.12

Acknowledgements
The authors are grateful to the participants in the study. This project was supported by Forskningsrdsnmnden, Sweden; the Faculty of Medicine at Ume University, Sweden; and Vrdalstiftelsen, Sweden. Anna Sderberg, Doctoral Student, Ume University, Ume, Sweden. Fredricka Gilje, Associate Professor, University of North Dakota, Grand Forks, ND, USA. Astrid Norberg, Professor, Ume University, Ume, Sweden.

References
1 2 3 4

6 7 8 9 10 11 12 13

Kendrick K, Cubbin B. Ethics in the intensive care unit: a need for research. Nurs Ethics 1996; 3: 15764. Walker RM, Miles SH, Stocking CB, Siegler M. Physicians and nurses perceptions of ethics problems on general medical service. J Gen Intern Med 1991; 6: 42429. Sderberg A, Norberg A. Intensive care: situations of ethical difficulties. J Adv Nurs 1993; 18: 200814. Udn G, Norberg A, Norberg S. The stories of physicians, registered nurses and enrolled nurses about ethically difficult care episodes in surgical care. Scand J Caring Sci 1995; 9: 24553. Norberg A, Udn G. Gender differences in moral reasoning among physicians, registered nurses and enrolled nurses engaged in geriatric and surgical care. Nurs Ethics 1995; 2: 23342. Norberg A, Udn G, Andrn S. Physicians, registered nurses and enrolled nurses stories about ethically difficult episodes in the care of older patients. Eur Nurs 1998; 3: 313. Nelson RM. Ethics in the intensive care unit. Creating an ethical environment. Crit Care Clin 1997; 13: 691701. Udn G, Norberg A, Lindseth A, Marhaug V. Ethical reasoning within nurses and physicians stories about care episodes. J Adv Nurs 1992; 17: 102834. Sderberg A, Norberg A, Gilje F. Meeting tragedy. Interviews about situations of ethical difficulty. Intensive Crit Care Nurs 1996; 12: 20717. Sderberg A, Gilje F, Norberg A. Dignity in situations of ethical difficulty in intensive care. Intensive Crit Care Nurs 1997; 13: 13544. Ricoeur P. Interpretation theory: discourse and the surplus of meaning. Fort Worth, TX: Texas Christian University Press, 1976. Ricoeur P. From text to action. Essays in hermeneutics 2 (French original published 1986). Evanston, IL: Northwestern University Press, 1991. Lindseth A, Marhaug V, Norberg A, Udn G. Registered nurses and physicians reflections on their narratives about ethically difficult care episodes. J Adv Nurs 1994; 20: 24550.

Nursing Ethics 1999 6 (5)

372
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

A Sderberg et al.

38 39 40 41 42 43 44 45 46

Rasmussen B, Sandman PO, Norberg A. Stories of being a hospice nurse: a journey towards finding ones footing. Cancer Nurs 1997; 20: 33041. Ricoeur P. Main trends in philosophy. New York: Holmes and Meier, 1997. Corley M, Selig P. Nurse moral reasoning using the nursing dilemma test. West J Nurs Res 1992; 14: 38088. Mishler E. Research interviewing: context and narrative. London: Harvard University Press, 1986. Marcel G. The mystery of being I. Reflection and mystery. London: Harvill Press, 1950. Marcel G. The existential background of human dignity. Cambridge, MA: Harvard University Press, 1963. Marcel G. Homo viator. Introduction to a metaphysic of hope (French original published 1951). New York: Harper and Row, 1965. Marcel G. Being and having (French original published 1935). London: Collins, 1965. Marcel G. Presence and immortality. Pittsburg, KA: Duquesne University Press, 1967. Marcel G. Tragic wisdom and beyond (French original published 1968). Evanston, IL: Northwestern University Press, 1973. Marcel G. The mystery of being II. Reflection and reality, Vol. II (French original published 1951). New York: University Press of America, 1979. Marcel G. Creative fidelity (French original published 1964). New York: Crossroad Publishing, 1982. Nabert J. Elements for an ethic. Evanston, IL: Northwestern University Press, 1969. Ricoeur P. Freedom and nature. The voluntary and the involuntary (French original published 1950). Evanston, IL: Northwestern University Press, 1966. Ricoeur P. The problem of the foundation of moral philosophy. Philos Today 1978; 22: 17593. Ricoeur P. Oneself as another (French original published 1990). Chicago, IL: University of Chicago Press, 1992. Weil S. Selected essays 19341943. Chosen and translated by R Rees. London: Oxford University Press, 1962. Miles S ed. Simone Weil: an anthology. London: Virago, 1986. Polkinghorne D. Narrative knowing and the human science. New York: State University of New York Press, 1988. Carr D. Time, narrative and history. Indianapolis, IN: Indiana University Press, 1986. Stern DN. The interpersonal world of the infant. A view from psychoanalysis and developmental psychology. New York: Basic Books, 1985. Webb RE, Sells MA. Lacan and Bion: psychoanalysis and the mystical language of unsaying. J Melanie Klein Object Relat 1997; 15: 24364. Sells MA. Apophasis in Plotinus: a critical approach. Harvard Theol Rev 1985; 78: 4765. Randall AB. The mystery of hope in the philosophy of Gabriel Marcel 18881973. Hope and homo viator (Problems in contemporary philosophy, vol.33). Lewiston, NY: Edvin Mellen Press, 1992. Cain S. Gabriel Marcels theory of religious experience (American university studies, series VII; theology and religion, vol. 182). New York: Peter Lang, 1995. Schilpp PA, Hahn LE. The philosophy of Gabriel Marcel. La Salle, IL: Southern Illinois University, 1984. Norton DL, Kille MF. Philosophies of love. Totowa, NJ: Rowman and Littlefield, 1988. Gilje F. Being there. An analysis of the concept of presence. In: Gaut DA ed. The presence of caring in nursing. New York: National League for Nursing, 1992: 5367. MacIntyre A, Ricoeur P. The religious significance of atheism. New York: Colombia University Press, 1970. Gallagher KT. The philosophy of Gabriel Marcel. New York: Fordham University Press, 1962. Zingmark K, Norberg A, Sandman PO. The experience of being at home throughout the life span. Investigation of persons aged from 2 to 102. Int J Aging and Human Dev 1995; 41: 4762. Ricoeur P. The hermeneutic of action. Kearney R ed. New York: Sage, 1996. Jnsson L. The Bibles word about consolation (in Swedish). Stockholm: Bokfrtaget Piccolo, 1962.

Nursing Ethics 1999 6 (5)

Transforming desolation into consolation 373

47 48 49

Dagerman S. Our need for consolation (in Swedish). Lagercrantz O ed. Stockholm: Nordstedts Frlag, 1955. Aristotle. Nicomachean ethics . Allmark P. Is caring a virtue? J Adv Nurs 1998; 28: 46672.

Nursing Ethics 1999 6 (5)