This article draws on research conducted for the author's doctoral thesis completed in 2019, which found that meaningful conversations about suicide are co-created in illuminating space in what is considered a human pivotal encounter (Rebair, 2019). In order to maximise a pivotal encounter, the co-construction of a meeting space and complex areas of negotiation is required. Relational exploration of the meaning of suicide is required in order to engage in conversations and to address personal vulnerabilities and fears.
From this research, the Meeting Space Framework was derived. It is a unique framework designed from the evidence to support students/nurses to engage in meaningful conversations about suicide. It adds to the available knowledge of suicide intervention and nursing care as it supports the student nurse to address personal fears and vulnerabilities and maximise meaningful engagement with an intention of meeting the whole person. The Meeting Space Framework can be used as a reflective tool to facilitate conversations about suicide in nurse education and in clinical practice and as part of lifelong learning. The core of the model is interhuman relations and the co-construction of meaning in meeting spaces.
Meaning and spirituality
Pesut and Thorne (2007) discussed the necessity of nurses adopting an orientation to spirituality in practice and a reciprocal role based on humanity. Noticing and responding to suicidal persons is now a proficiency for all nurses (Nursing and Midwifery Council (NMC), 2018) along with the assessment and review of spiritual needs. Respecting spiritual beliefs is referred to in the International Council of Nursing (2021) Code of Ethics regarding human rights, value and customs of individuals.
This is not a new concept. Spirituality occurs in many works by nurse theorists as implicit to the nursing role. Rogers (1970) considered understanding energy fields as implicit in nursing relations; positing that man and environment interchange energy mutually and simultaneously thereby affecting the other. Jean Watson advocated for nursing the spirit or the soul (Watson, 1985). She talked about the involvement and transcendence of the roles occupied by both nurse and patient, describing union at the level of the spirit giving access to greater energy for renewal and healing. Both Parse (1989) and Watson (1985) referred to the essential spiritual healing role of the nurse, where blurring of the personal and professional occur. It can be said that the nurse is facilitator and guide, reflecting humanity and supporting the exploration of meaningful conversation. Spirituality is realised through the interaction and created in the space in-between. It is here where understanding unfolds.
During the course of research for a doctorate in nursing (Rebair, 2019), the author drew on semi-structured interviews, focus groups and field notes involving both people who had thoughts of suicide or who had attempted suicide and had conversations with nurses and health professionals, and also student nurses enrolled in an undergraduate nursing degree programme. Students were fearful and vulnerable of stepping into this space, which impacted on their ability to provide an authentic response to suicidal people. On the other hand, people with suicidal thoughts wanted a meaningful human encounter, this was an experience sometimes beyond words.
For the author's research, an interpretive methodology of constructivist grounded theory was used, underpinned by the theoretical perspective of symbolic interactionism. There are many theories in nursing to help gain an understanding of how people interact and how self emerges through being and relating. Martin Buber's spiritual teachings became prominent in the development of the author's theory. Buber saw meeting and being met as a bi-directional, shared process, where each person is akin to the experience. He did not consider the meaning of the experience for the other as separate. Meaning is produced relationally:
‘We do not find meaning lying in things nor do we put it into things, but between us and things it can happen.’
Buber believed that human existence was about relationships, and the continued desire to meet and be met, hence ‘all real living is meeting’ (Buber, 1958: 24-25). If we apply this to conversations about suicide, the meaning of the experience in spiritual terms is not separate but a shared relational experience.
A category ‘emerging in illuminating spaces’ that emerged in the author's research demonstrated the point of the student nurse becoming less preoccupied with self, instead turning towards the other. The need to meet and be met was consistent with people with experience and students. Both parties were wanting to be ‘seen’. This establishes what Buber referred to as I-Thou—meeting the other in their entirety, as opposed to I-It (equivalent to us and them, objectification). In I-It, the I in me and the I in Thou (you) have distance, there is no connection; we do not share, we do not relate. This was reflected in the ‘unceremonious pivotal encounter’ in the author's research findings. This is of interest to nursing and conversations about conversations because it helps understand what is needed to engage, crucial for suicide intervention and prevention.
Working with suicidal people requires the nurse to be open and present to the unfolding situation and willing to engage and see the whole person. The dialogic spirituality is manifested through the common bond of spirit and spirit. For Buber this was ‘the between’, the meeting place where there is harmony between two voices (Kramer, 2012: xxi). This reflected the research finding of ‘human pivotal encounter’, where the person with experience had an authentic encounter with the nurse and the nurse stepped into a space as a human being to meet them. The Meeting Space Framework calls for reflection of where the student nurse is in relation to their personal philosophy and feelings about suicide.
The Meeting Space Framework—crafting conversations about suicide in nursing
The framework developed by the author represents a shift from psychiatric discourse into a spiritual domain as a starting point of co-creating meaningful conversations about suicide. It combines the doctoral research findings with Buber's philosophy on dialogical spirituality and the tenets of social constructionism, consistent with the research philosophy. It is developed from the grounded theory of Meeting Spaces developed by the author.
Underpinning principles
The theoretical framework supports adopting a way of being with those who are suicidal. The position proposed for adoption is based on Buber's six spiritual teachings (Box 1). This was extended by the author to create a nursing position, including the findings and the philosophical basis of the research project (Box 2). The categories that emerged from the research were considered in relation to Buber's principles and the Meeting Space Framework (Figure 1) was developed. It is to be used in conjunction with the underpinning principles in Box 1 and Box 2.
Box 1.Summary of Buber's spiritual teachings
- Heart searching Decisive heart searching—the beginning of the human way, responding to the question: Where am I [on this human way]? This is designed to deconstruct your system of hideouts and help you know from where you came, where you are going, and to whom you will have to render accounts
- Your way Every person's unique task is to get in touch with life-valuing relationships with others and that which connects you in your own way with your whole being
- Resolution Part of spiritual practice is the necessity of seeking resolution by refocusing on the goal and by remaining open to whatever addresses you
- Beginning with oneself To advance spiritually, you are required to begin with your deeper self, by taking full responsibility for any conflict situations by harmonising your thought, speech and action, and by saying what you mean and doing what you say
- Turning towards others Practising genuine turning, from self-orientation toward the orientation of otherness of the other. According to Buber, this renews you from within and deepens your connection with the world
- Standing here Fulfilment and discovering purpose, letting that which universally connects guide and maintain interaction with the world
Source: Adapted from Kramer, 2012: xxxvii
Box 2.Expanding on Buber's spiritual teachings: underpinning principles of the Meeting Space Framework
- Heart searching Nursing is an interhuman practice, multifaceted and complex, incorporating the whole spiritual being. In order to meet the other, the nurse is required to explore the meaning of spirituality for themselves, the space they occupy, the space they hide, the source of connection. The nurse needs to be aware of their own limitations and strengths in relation to responding to suicidal persons or asking about suicide—we act on the basis of the meaning things have to us
- Your own way Nursing addresses humanity in all of its guises. Relationships are living, and it is through social connectivity and co-construction of dialogue with others that we interpret the meaning of life. Utilising that which connects you creates the intention to interact with others, honouring them and what they bring to the shared space
- Seeking resolution Nursing requires self-awareness. Increasing self-awareness involves seeking resolve for what causes conflict and pain. Resolution is first and is part of spiritual practice. Resolution may be ongoing or reignited, given the contexts that arise, and symbolic interpretation of conversation constructed with others
- Beginning with yourself Nursing and interhuman relationships require transparency, honesty and trustworthiness both with self and with others. These in turn require acknowledging vulnerability. Recognising your own vulnerability is a strength in human connection and can mirror that of others. You are responsible for what you bring to the space, both verbally and energetically, therefore developing understanding of conflict areas and the meaning of this to practice is fundamental before you can turn to the other and engage in genuine conversation
- Turning towards the other Nursing requires accepting the other in their mere presence, as the ‘otherness of the other’. The nurse's intention is to seek shared humanness and to be open to renewal of meaning through what is co-constructed in the interactive context. The nurse's conflict or fear of suicide will be affected due to the co-construction of meaning and interaction with the other through the process of genuine dialogue
- Standing here Nursing requires the extension of hope. In the case of conversations about suicide, the nurse's authentic occupation of space and presence can provide illumination in interhuman relations
The intention is to move from object-relation conversation (I-It, expressed in the grey area of the triangle) to whole person dialogue (I-Thou, expressed in the yellow and orange areas of the triangle). This direction of travel is towards experiencing a human pivotal encounter, emerging in the meeting space. The meeting space is constructed through the qualities described as an ‘illuminating space’. In the author's research those with experience of suicide identified: being seen—presencing, time, sharing the story of why, experiencing authentic care and a sense of freedom. For student nurses, qualities included meeting the other (seeing beyond self), confidence and courage about engaging with a human in distress). From Buber's teachings came silence and being fully present as a way of being with another.
The circle encompassing the triangle represents the fluidity throughout meeting spaces and the construction of meaning. It is acknowledged that this changes and evolves continuously, the relational encounter will be universally different each time a conversation takes place. It also represents Buber's primary question of asking oneself: where am I (in relation to my thoughts and feelings of suicide)? It asks the student to continuously assess where they are in relation to addressing suicide through whole-person care. Life events, personal experiences and energies will impact on this.
Caveats
It is noted that the subject of suicide and areas for exploration and discussion may appear contentious in the first instance. It is imperative that honesty is encouraged, and a safe environment created, to allow student nurses time to acknowledge their authentic human response. The nature of personal inquiry can be illuminating and distorting.
The framework is not a prescriptive guide. It does not provide orderly questions to ask in a conversation about suicide. It is a framework conducive to reflection, self-discovery and supporting a positive direction of travel. It is complementary to suicide awareness and prevention principles.
It is worth explicitly stating that in any case of actual harm to self, stability of bodily systems and preservation of life is of course paramount and in the case of suicide, spiritual care should be considered an emergency alongside this.
Structure of the Meeting Space Framework
Unceremonious pivotal encounter
The underpinning principles for this are points 1, 2 and 3 in Box 2. Responding to suicidal persons in this domain reflects the I-It stance—the focus of the scientific and causal understanding of human beings in the world. The basis is one of objectifying, describing and measuring creating the potential for an unceremonious pivotal encounter. Here student nurses are navigating the line of process and procedure in the first instance as opposed to humanness and connection.
Limiting space
This relates to emotional limitations and limitations of knowledge and of the subject of suicide. They may present as harbouring fear of the unknown. Vulnerability is a key feature where exploration of the consequences of actions and consequences of ‘being me’ should take place.
One dominant approach is that of medicalising suicide, and establishing risk and intent in the first instance. Discussions are not to deny the medical construct of suicide or risk, but to understand the immediate focus of it as limiting and unrepresentative of the whole person. The story of ‘why’ is key alongside the suicidal person's perspective of what they think will happen if they implement their plan. This section merits critical debate about how the student ‘sees’ suicide by exploring family and cultural beliefs and ideas of romanticism/sensationalism.
Distorted space
This area warrants the exploration of:
- Professional self—expectations, role restriction and ethical and moral tensions regarding the right to live and die coupled with personal spiritual or religious views
- Personal self—acknowledging feelings of being with suicide and those who are suicidal. Exploring conflict between what the students are actually feeling and thinking versus what they are expected to think and feel in a professional context (for example, anger versus compassion). Explore the student nurse's need to be seen as a person.
Illuminating space, seeing shared humanness
The underpinning principles for this are points 4 and 5 in Box 2. Seeing shared humanness is seeing others as the same but different from ourselves. It is moving towards I-Thou and away from I-It. This is about embodying caring values and relaying them energetically, as opposed to undertaking assessment in a rote fashion that is unfelt and devoid of meaning. The starting point is accepting the presence of the person and understanding the ethical and moral foundations of the nursing role. The intention is to be open and truthful, sharing responses and seeking support when required. It requires consideration of the following areas.
Exploration and practice
Seeing shared humanness warrants discussion and exploration of will and courage to meet the other, to admit vulnerability in order to explore the place in between. Careful discussion of professional boundaries is warranted and the exploration of ‘who I am as a nurse’, and ‘who I am as a person’ as students declared they were fearful of being ‘me’.
Whole person space
This relates to the moral and ethical question of nurses embracing a spiritual dimension to caring or embracing the other as a spiritual being. In the case of the Framework, this is the essential focus for the interhuman relation. It includes the exploration of the spaces we inhabit, spatial presence, energy and where we share space. It considers the extension of self beyond the physical self and the student nurses' relationship with that. For Buber, wholeness is multidimensional. Buber's list (Kramer, 2012) can be used to guide exploration and discussion and construct meaning in this area:
- Our place in the cosmos
- Our connection with destiny
- Our relation to the world
- Our understanding of the other
- Our attitude towards the mystery of life's encounters, and
- Awareness of our own death.
Meeting space, human pivotal encounter
The underpinning principle for this is point 6 in Box 2. This encompasses practising presencing, being the light and connection to humanity. This encourages a human pivotal encounter. Meeting the other and seeing shared humanness is assumed within the nursing role and participating in conversations about suicide.
- Practising presencing: being with one's own pain and discomfort and that of others. For Buber, this begins with oneself and relates to the whole as discussed above. Turning towards the other, is the intention. For Buber the person seeks interrelation
- Meeting others: a space where one can see the other. Heart searching using Buber's principle (Box 1) features here to create heart-searching responses to the existential question: where am I? The emphasis is on finding your own way, relating to the life path and gaining resolution with self. Resolution is concerned with the commitment to address conflict within oneself. The conflict that suicide and human distress might bring in interhuman relatedness.
Implementing the Framework in education and clinical practice
The Meeting Space Framework can be introduced to nursing students throughout nurse education, ensuring time to sequentially embed learning and practice. Scaffolding learning and allowing students to return to the framework to reflect on knowledge and skill development is key to self-awareness and understanding.
The Meeting Space Framework is flexible to different learning styles (Kolb, 1984). It can be presented in detail or explored in seminars in parts (as expressed in the colour code key). It is conducive to a ‘flipped classroom’ approach. It can be presented in templates for interactive and systematic learning and students can work on the framework in private beyond the classroom discussions. It lends itself to independent discovery, prepared exercises and interactivity. It can also translate into clinical practice; linking theoretical, spiritual and practical perspectives to the clinical context and can be utilised by clinical educators. The Meeting Space Framework lends itself to the supervision processes, aligning with skill development in the practice arena along with enhancing ways of knowing by reflecting on experience (Carper, 1978; Johns, 1995) with students and registered nurses. Referring to the framework and reflecting ‘where am I?’ in relation to travelling towards a human pivotal encounter, may serve as a reminder of the intent to connect humanly with suicidal people. In the spirit of engagement with patients and transparency, the student could request feedback on performance via their assessor. The aim is to ascertain: how did you experience me? And, importantly, did I see you? Not only does this provide a basis for transparent discussion, it also challenges the archetypal hierarchal approach to relationships and embeds the human-to-human dynamic. Hubble et al (1999) identified that the most powerful indicator for successful outcomes for clients seeking help is the therapist adopting a change focus. They added that relationship factors are identified as the second greatest contributor to change. The Meeting Space Framework supports both of these observations, offering the development of a specific meeting space.
Conclusion
Sociopolitically, it is a fitting time to share the Meeting Space Framework, as the NMC (2018) has published proficiencies across all fields of nursing to recognise and respond to those who are suicidal. A framework for conversations about suicide could be a timely interjection. However, this stance is significantly different in expecting nurses to espouse a particular world view or ‘apply’ spiritual intervention. Nurses are part of the spiritual intervention by sharing their humanness, and understanding spaces in this way enables nurses to consider how humanness can be enacted. Inherent are ethical and moral considerations synonymous with adopting such a position.
The emerging evidence base combined with the voices of those who have been suicidal serve as an educational tool, reminding us that, first and foremost, we share humanity, and this is the point of meeting and connection. Nursing is traditionally associated with interhuman aspects of care provision, rightly so; however, the dominant discourse has little or no focus on spirituality or educating how to be with ourselves and others, and how to respond to suicidal persons in a human way. The Meeting Space Framework provides a space for this and adds to the debate of suicide intervention and prevention. It provides a framework for creating a genuine meeting space and maximising a human pivotal encounter between potentially fearful and vulnerable human beings.
KEY POINTS
- ‘Suicide’ is a limiting word that becomes synonymous with ‘risk’
- Conversations about suicide require the intention of genuinely ‘meeting’ the person
- Conversations about suicide can take place between potentially fearful, vulnerable human beings
- Suicidal persons and nurses share humanity; shared humanity is the seat of meeting and connection
- The Meeting Space Framework supports the co-construction of meaningful conversations about suicide
CPD reflective questions
- What are your honest thoughts and feelings regarding suicide?
- What are your thoughts about nursing as a spiritual activity?
- Relook at each of the 6 items in Box 2. Does this affect the answers you gave above?
- ‘Where are you’ in the Meeting Space Framework’? What does this mean for your practice and what is the first thing you can do to develop your practice?