A pandemic has overtaken the world...our grief is great...as ever is the case,  nurses lead the charge of caregiving in a health crisis. A pandemic has overtaken the world. Only a few countries, mostly small island states, seem to have escaped: notably Comoros, Kiribati, Lesotho, Marshall Islands, Micronesia, Nauru, North Korea, Palau, Samoa, Solomon Islands, Tajikistan, Tonga, Turkmenistan, Tuvalu, and Vanuatu. However, it is likely that some of these larger states have simply not reported cases (World Health Organization, 2020). Many countries that have been stricken have had devastating health and economic consequences, and have taxed their healthcare systems in the extreme (Carlsson-Szlezak, Reeves, & Swartz, 2020). Some nations have emerged from the pandemic with SARS CoV2 under control, but without a guarantee that it will not coil and strike again in the future.

Our grief is great. At the time of this writing, the United States (US) is approaching an unthinkable 5 million persons infected, and now over 150,000 persons who have died. The numbers march unrelentingly upward. Some of those whom we have lost have been our own nursing colleagues and other healthcare providers (Johns Hopkins, 2020). As is ever the case, nurses lead the charge of caregiving in a health crisis. On April 17, the Los Angeles Times published a wrenching photo essay “Nurses are the coronavirus heroes.” The photos are of nurses around the world. The article notes,

The coronavirus is taking a serious toll on the doctors and nurses risking their lives while treating infected patients. Moving in and out of negative-pressure rooms, putting on protective equipment and taking it off again, nurses are caring for patients who are severely ill and sometimes dying. They spend the greatest amount of time with the patients. These nurses draw blood, obtain samples, provide oxygen, and devotedly tend to their patients’ needs. When a patient is placed in intensive care, it’s the nurses who do the mundane and the heroic to help the patient recover or die with a little more comfort. Nurses are the underappreciated heroes of this crisis. Though they are usually the coolest of head in the room, they are now feeling the tremendous pressure of their situation (McKoy, LA Times, paras 1-4).

To be sidelined unwillingly at such an hour of acute need brings its own frustration, regret, and grief. Some nurses, by reason of age or infirmity, are mandated to the sidelines, and yet still possess a deep-rooted sense of duty that calls them to respond to the enormity of human need visible in a constant stream of television news. To be sidelined unwillingly at such an hour of acute need brings its own frustration, regret, and grief. Nursing education, and career-long nursing camaraderie, ill-prepares us for being benched when there is patient need, and when we see our nurse colleagues overwhelmed, grieving, and suffering in the trenches as we watch. We can sew masks, pray, donate to the American Nurses Foundation Coronavirus Response Fund for Nurses (ANF, 2020), and more, none of which draw upon a nursing education and clinical experience. Perhaps providing a means to strengthen nurse resilience is a better way to enter the fray and link arms with those who are there in our stead.

The purpose of this piece is to provide a tangible and durable means of expression for suffering colleagues who find themselves wounded and drained by the demands, insecurities, and compassion fatigue of pandemic care. My hope is that this may help nurses find a measure of strength and healing that will sustain them amidst the crushing demands of these darkest of days. In this time of raging pandemic, we turn to science in the aching hope of uncovering the workings of the virus, and discovering a vaccine or drugs to treat this scourge.

A formal lament is a 2,500-year-old literary form that has passed to us; it offers us a largely forgotten yet structured way to respond to acute and overwhelming grief and suffering... In this time of global suffering we also turn to one another, and to music, art, literature, stories, and poetry. In short, in the midst of suffering, we turn to the arts and humanities - disciplines that reflect upon human experience - to ameliorate suffering. A formal lament is a 2,500-year-old literary form that has passed to us; it offers us a largely forgotten yet structured way to respond to acute and overwhelming grief and suffering, both individual and national. The literature of lament sees suffering, not as a problem, but as an experience, and as an inescapable part of the human condition. It offers us an established, literary, and deeply personal, structure for lament as an expression of grief and suffering.

Conceptual Footing in the Humanities: Poetry, Lament, and Nursing Work

The humanities are those non-scientific domains of human knowledge, exploration, and inquiry that reflect upon human experience and its environment using humanistic methods (National Endowment for the Humanities, 2020). The humanities include history, philosophy, ethics, languages, literature, art, music, and more. To treat SARS CoV2, or cancer, or malaria, or any range of diseases, we necessarily turn to science. But, to ameliorate the suffering that attends these diseases, we turn, in good measure, to the humanities. For example, in March the United Nations began a campaign that invited artists to submit their art dealing with the coronavirus pandemic (National Public Radio [NPR], 2020b).

...in the midst of suffering, we turn to the arts and humanities - disciplines that reflect upon human experience - to ameliorate suffering.A simple search of the internet, for pandemic, plus humanities, or poetry, or music, or stories, or song, produces thousands of “hits.” Audrey Azoulay, the head of the United Nations Educational, Scientific and Cultural Organization (UNESCO) stated that “art has the power to unite and connect in times of crisis...Bringing people together, inspiring, soothing and sharing: these are the powers of art, the importance of which has been made emphatically obvious during the COVID-19” (UN News, 2020), paras 1, 2). Gary Rolfe, in his study of the narrowness or nursing research writes that “in order to gain a fuller and deeper understanding of the human condition and human suffering necessary for compassionate care, nurse researchers, practitioners and academics need to develop the ‘nursing imagination’ through reflective writing, collaborative inquiry, the arts, humanities, novels and poetry” (Rolfe, 2020, pg. 517). He ends his study thusly: “Conclusion: more poetry is needed.” (Rolfe, 2020, pg. 525). In a recent interview poet Jane Hirschfield noted that "In a way, a poet is quite prepared for a pandemic, because we're always trying to look into the most difficult things and find a way to navigate to a deeper relationship to those events." (NPR, 2020a, para 3).

There is a small but significant literature on poetry in nursing, both as a means of expression by patients as well as by nurses, and as a pedagogical tool (Hahessy, 2016; Siles, 2020; Silva, 2020). Citing a number of studies, Kimberly Schoonover and colleagues write that “poetry provides an instrument for patients and health-care professionals through which to find meaning in illness and grief, and as a mechanism to develop compassion and empathy for oneself and others” (Schoonover, 2020, pg. 128).

We have received, from every known culture, ancient and modern, an immeasurable fund of poetry, in ancient times virtually always set to music and called hymns or psalms. Historically, they served many purposes such as expressions of praise, thanksgiving, celebration, sorrow, lament, a cry for help, and more. The ancient Hebrew psalms, written over a period of 500 years, are poems, of several genera, including psalms of thanksgiving, praise, national lament, and personal lament. As the death toll of the pandemic mounts we are sorely in need of a national lament, but the focus here is on personal lament as a means of self-care, and as one means of engaging in duties to self, called for by the ANA Code of Ethics for Nurses with Interpretive Statements (ANA, 2015).

Why Lament?

One means of self-care in these pandemic days is to formulate and record one’s lament.A formal lament provides a structured means of helping others, whether individuals, families, communities, or nations, to express suffering and grief. Because a lament is not free-form poetry, the structure itself is useful especially for those of us who might not know how to start. It offers nurses and other healthcare providers a means of expressing their personal anguish as they go about caring for those stricken with COVID-19 as they become an intermediary for families who cannot be with a loved one in their dying moments; as they worry about triage and clinical decisions that must be made; as they fear the very act of nursing itself with inadequate personal protective gear; or as they worry about carrying a virus to their own loved ones. Nurses have a moral obligation to care for others; nurses have a moral obligation to care for themselves as well. One means of self-care in these pandemic days is to formulate and record one’s lament.

A lament requires the courage to name one’s fears and vulnerabilities, to unmask social ills and concerns, and to do so within a society or culture that does not support this. A lament is a means of expressing one’s suffering, whatever its cause. A lament requires the courage to name one’s fears and vulnerabilities, to unmask social ills and concerns, and to do so within a society or culture that does not support this. A lament is a form of protest that enables the naming of what is tragic, fearful, damaging, wrong, unjust, angering, and more. A lament requires a movement from denial and avoidance to a place of acknowledgement and naming of one’s troubles and woundedness. The person who laments moves from “not me, not here, not now” to a place of acknowledgement, “yes me, yes here, and yes now,” giving voice to what is frightening, wrong, and unjust.

A lament opens one to the acknowledgement, reality, and presence of one’s own suffering, and the limits of our control - our finitude. In the process, it creates a space for coming to terms with the very real circumstances that are a cause for lament. Suffering can lead to us to become confused and overwhelmed and perhaps wrongly identify the curtailment of freedom, or unfair or unwanted external controls, as the source of suffering. It can be clarifying to write one’s laments. We protest our finitude, our vulnerabilities to sickness and death, and our limits to effectively prevent the spread of contagion, or to treat the virus, or perhaps to halt the inevitable march of untimely death despite our intensive interventions.

We are not alone, and naming our suffering, and lament can comfort others as well as ourselvesWithin our immediate situation, the limits of the possible can only become visible and actionable once we acknowledge and express our lament. Crying out our lament, our suffering and pain, opens us to seek help, healing, and commiseration. We can experience solidarity in our lament, we can recognize that our suffering is shared, that it is common among us, and that it need not isolate us in our anguish. We are not alone, and naming our suffering, and lament can comfort others as well as ourselves (Fowler, 1989, 2008, in press).

A lament can be formulated or written as narrative, or lyrics, or as poetry depending upon one’s particular gift of expression. The poet Ann Weems was encouraged to write her own psalms of lament when her son was murdered an hour after his twenty-first family birthday party. She did so in a poignant, heart-rending, series of fifty psalms published as Psalms of Lament (Weems, 1995). A few of her words from the beginning of her “Lament Psalm Seven” (p. 12) will indicate both the power and the freedom of this exercise:

O God, you’ve allowed death to take him away

Leaving me alone

In the chill dawn of unfinished love.

What could you have been thinking?

In only 25 words she exposes her grief, her anger, her aloneness, her emptiness, her desolation and her betrayal. That is the power of lament. Not all have Weems’ gift of poetic expression but what we share with her is experiences of profound suffering, whatever the cause, and the need to express the suffering that flays our lives and souls.

An Individual Lament and its Structure

The seven-fold structure can be expressed in both religious or non-religious terms, and either orally or in writing Varying means of addressing suffering are found in the global literature. But these are pandemic days, where nurses are little able to read and reflect at leisure, thus I provide a basic introduction to the structure of an individual lament. A concrete, practical, immediate means to address suffering can be found in the structure of the ancient psalms of individual lament in the Hebrew Bible. These psalms provide a formal literary means for the expression of personal lament and a separate structure for a national lament. The seven-fold structure can be expressed in either religious or non-religious terms, and either orally or in writing (Brueggemann, 1985; Westermann, 1961). When written, they can provide a chronicle of one’s daily journey in suffering.

It is important to note several points. First, the form demands that a full and complete lament be expressed, leaving nothing buried. If that means taking two or three turns through the three-fold expression of lament, so be it. Second, a personal psalm of lament may be impolite, impolitic, uncivil, or express untoward feelings or desires. There is no normative judgment; one’s lament is one’s lament however impolitic it might be. In addition, a psalm of lament is more than catharsis, specifically because it internalizes affirmations and ends on a rising note.

The three-fold lament portion takes you to the bottom of the pit...but it always helps you to begin to climb out. The three-fold lament portion takes you to the bottom of the pit, and may even require several turns around the bottom of the pit, but it always helps you to begin to climb out. Most laments are phrased in religious language, but that is not essential. Laments can be created with no religious content and can be used as a template for the expression of suffering, or as a mental template for the nurse working with one who suffers, who needs to express suffering and lament.

The elements of an individual psalm of lament are given in this table (Westermann, 1961). The examples are entirely too brief, but are intended to guide the general direction of reflection. I hesitated to make separate religious and non-religious columns but I have used this as a template for patients and nurses, many of whom are religious, and thus decided to include some religious expressions as well.

Table. The Structure of an Individual Psalm of Lament

Conclusion

There will be more pandemics in our future. Michael Lu, Dean of the School of Public Health at University of California, Berkeley writes,

An estimated 650,000 to 840,000 unknown viral species capable of infecting humans lurk in wildlife. At the same time, population growth, urbanization, globalization, climate change, the relentless destruction of wildlife habitats and the harvesting of wild species have brought these viruses in closer contact with humans than ever before...Pandemics may become the new normal” (Lu, 2020, paras 2, 3).

Lu observes that averting pandemic disaster will require an unprecedented global willingness to collaborate and to work together, something that unraveled in this pandemic. We must prepare for the future, for the possibility of unexpected and episodic pandemics. This preparation must be international, national, professional, and personal.

Ann Weems (1995) begins her “Lament Psalm Three” (pg. 5) with these words:

How large a cup of tears must I drink, O God?

How much is enough?

Must my cup grow and overflow

Even as I drink from it

Until it becomes

As deep as a well

And I can’t swallow anymore?

The individual psalm of lament is an invitation to express one’s grief and suffering in a way that is tangible, and forceful...This pandemic is a cup that grows and overflows and has become a deep well beyond what the world’s nurses can themselves swallow. It is overwhelming both individuals and nations. It is wounding and the source of untold, grief, suffering, and despair for nations, families, and nurses. We have not yet seen this pandemic’s end, and there will be more pandemics in our future.

The individual psalm of lament is an invitation to express one’s grief and suffering in a way that is tangible, and forceful so that we nurses can be strengthened-within-suffering to persevere in the amelioration of anguish and despair, and the mitigation of the harm of this contagion. It is offered here in the hope that through it nurses may find, for themselves and others, a measure of strength, healing, and resilience, both here and now and for the uncertain future.

Author

Marsha D. Fowler, PhD, MDiv, MS, RN, FAAN, RSA
Email: mfowler@apu.edu

Dr. Fowler holds a PhD in Social Ethics and has researched the history and development of US nursing ethics for 40 years. She held a Joseph P. Kennedy Jr. Fellowship in Medical Ethics at Harvard University, and is the recipient of the ANA Honorary Human Rights Award. Her recent Fulbright Research Award supported her research in the UK on the history and development of British and Irish nursing ethics. Dr. Fowler has served the ANA as Committee on Ethics chair, and as a member of the Steering Committee for the revision of the Code of Ethics for Nursing with Interpretive Statements, for which she was designated committee Historian and Code Scholar, 2013-2014. She has published extensively in the field of ethics, focusing on the history and development of nursing ethics, ethics and the social location of nurses, and the intersections of religion, ethics, and nursing. Dr. Fowler is currently serving on the writing subgroup for the revision of the code of ethics of the International Council of Nurses, 2019-2020.