1. Gorman, Geraldine PhD, RN

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This is one pregnant piece of writing. Narrative labor spans 18 months but conception occurred somewhere toward the end of nursing school, more than a decade past. In my mid-thirties with 2 small children and another due shortly, for reasons imperfectly understood, I entered one of the few extant diploma programs. Despite a master's degree in English literature and 10 years of direct social service, I regressed before tyrannical clinical instructors within a milieu reminiscent of the Catholic girls' high school from which I fled 18 years ago. Consider that period the "first trimester."


Gestation continued throughout bachelor of science in nursing (BSN) completion to the culmination of my doctoral program in 2000-second trimester. Hard labor advanced when I switched positions in the classroom, standing at the front as faculty.


My students' stories echoed my own. Their experiences were often painful to hear, mired in shaming and squelching of confidence. A desire to attest to this took root-to witness their disillusionment, to acknowledge my own, and, most importantly, to affirm my love of, and belief in, the profession I both teach and practice. I wanted a revolution in nursing education. Our students comprise a rainbow coalition belying neat categories and unwilling to abide old fashioned, mean-spirited ways. They deserve and demand more. So, I did some deep breathing, practiced a few Kegels, wrote an article, and sent it off to Nurse Educator. No go; it was reviewed and rejected. Insufficient dilation. Not yet ready to be brought forth into the light of day. I began again. I was told that what was too opinionated and research scanty for an article might work as an editorial. But it required paring. In its first version, replete with personal anecdotes of educational hazing, editor Suzanne Smith commented that "we all have our horror stories." She is right; I know you have yours and so, in this version, I will spare readers mine. But because she is right, we need to keep the issue of educational abuse on the table and in the airwaves until it becomes obsolete, a past embarrassment.


Throughout this process, Suzanne played midwife to my moans: 2000 words, maximum. No exceptions, no reprieves: just bear down. I take a cleansing breath and transition. I offer what follows to educators who incubate our future practitioners. I do so as a nurse awed by the sanctity of practice, as a faculty mindful of the myriad complexities of teaching and as an instructor humbled by the trust of courageous students. We need an educational paradigm shift of seismic proportion and we need it now. Let us open our eyes and hearts, borrow from other traditions, deepen our compassion, and expand our educational horizons. Let us acknowledge past mistakes, instances when we wielded power and humiliation as pedagogical weapons. Finally, let us not flinch from pain suffered in our own passage through nursing education but forgive the perpetrators, vowing that our actions will not perpetuate such hazing behavior. From Buddhist practice I extend a meditative technique and invite your consideration. It is termed Tonglen and so we begin. Time is of the essence. This baby needs to get born.



From Tibetan, tonglen translates "sending and taking." According to an American Buddhist nun Pema Chodron, tonglen represents the exchange of oneself for others, a "practice for activating loving-kindness and compassion".1(p55) In meditation, it involves breathing in of another's unwanted pain, holding it in deep compassion, and exhaling the intention that all who suffer will find relief. Breath becomes a bridge connecting us with one another, a gentle whisper of shared humanity.


Nurses confront the physical pain, anxiety, and grief that consumes our patients. Tonglen allows sustained witness even when physically separate. Infusing the essential philosophy of tonglen into nursing curriculum may assist us to guide our students, sending forth consummate practitioners of compassionate mind. Through it, we model behavior and attitudes to shape their practice. In a profession still shackled by its quasi-military history, reevaluation is imperative. Humiliation, intimidation, and deprecation do not belong in nursing education. They cripple the mind, distort the spirit, and, ultimately, harden the heart. Equilibrium is lost, our breathing grows shallow.



One goal of Buddhist meditation is to accept ourselves as we are. We let go of crippling insecurities, still the chatter of our internal censor, and relax into ourselves. "This complete acceptance of ourselve[horizontal ellipsis]," according to Chodron, "is called maitri, a simple direct relationship with the way we are. Trying to fix ourselves is not helpful. It implies struggle and self-denigration. Denigrating ourselves is probably the major way we cover over bodhichitta."1(p24)


Nursing education strives for rigorous evaluation. "Competency" is current gold standard, true measure of performance adequacy and authenticity. Respectfully, I dissent. We achieve success with our students in incremental uncovering of bodhichitta, "the soft spot, a place as vulnerable and tender as an open wound. It is equated, in part, with our ability to lov[horizontal ellipsis]it is also equated, in part, with compassion-our ability to feel the pain we share with others."1(p4)


Students come with very tender hearts indeed. Their motivation spans a vast spectrum of altruistic impulses. "Because I want to help," they tell us, "because I care about people." Many are inspired by nurses who have touched their lives-mothers, aunts, individuals who cared for them or for loved ones. Exceptions exist, of course; some view nursing as a pragmatic stepping stone, while others measure only economic potential. Generally, however, students arrive in openness and trust, pure in intention, vulnerable of heart.


While idealism often frays when confronted with reality, the severity and rapidity of student disillusionment should shock us into reevaluation. In clinical practice settings, they confront nurses who view them as a burden or, worse, as a threat. They witness encounters between practitioners and patients characterized by indifference or disdain and observe the pervasive demoralization found within medical caste systems. When they turn to their teachers for clarification, we are not always forthcoming. Instead of applauding their questioning and modeling the empathy they find lacking, we sometimes resort to platitudes. "It's just the way it is," we tell them, "just more hoops to jump through. We all have to go through it[horizontal ellipsis]"


More disturbing is what can unfold within academic settings. From faculty they deserve idealism and support, embodiment of compassion and empathy. If our hearts harden with bitterness and disappointment, we send forth distorted practitioners and the cycle repeats itself endlessly-like bad karma, like hazing rituals.


The attitudes, behavior, and pedagogical strategies reflected in our curriculum testify to our ethic. Nursing claims that caring grounds its identity and serves as a professional mandate. Our educational programs must reflect this commitment. Anything less is flagrant hypocrisy.


Web of Care

While the scholarship of those promoting an ethic of care, such as Benner2,3 and Watson,4,5 receives acknowledgment, it is regarded as rather passe by many. Caring appears a bit fuzzy, sentimental, inadequately "rigorous" in this era of competencies and evidence-based practice. Quantitative measurement coaxes lucrative grants from the National Institutes of Health and the National Institute of Nursing Research, tempting us to demean what we do best. We require gentle prods, reminders not to devalue what is central to our profession. Nel Noddings, Professor Emerita at Stanford University, advances the cause of care-based education. Her treatise, Starting at Home: Caring and Social Policy,6 makes bold claims for the humble practice of caring. She asserts that a moral education with a central ethic of care has potential to shape social framework: "If caring-for is basic in moral life, then an education that develops this capacity is essential."6(p24) Pivotal to this development is the teacher. Education necessitates relationship:


[horizontal ellipsis]we are formed by teachers. Yet in so many of our encounter[horizontal ellipsis]we are guided by purposive-rational thinking: we plan, strategize, instruct, correct, monitor and control. There is something deeply wrong in all of this and, paradoxically, when we see that something is wrong, we are inclined to use the same procedures more rigorously. We find it hard to give up the tendency to use prescriptive technologies. In education, as in parenting, the key must be relation, not control.6(p25-26)


Noddings' argument has particular relevance for nursing education. We demand critical thinking and we often come down hard when students do not meet our expectations of how we think they should think. Relationship falls by the wayside.


One of my more humbling moments as an educator came at the conclusion of spring semester. Graduating seniors sat in a circle discussing strengths and weaknesses of the education they received. While many shared tales of supportive faculty, inspirational clinicians, too many offered heart-wrenching stories, bloated with ill-digested frustration. In addition to complaints about indifferent preceptors, the group unleashed a flood of disappointment and hurt over instructors' comments. Men shared incidents suggestive of gender bias, pervasive perceptions of anti-male sentiment. Timid women spoke of bullying and intimidation endured and witnessed. One young woman of Hispanic descent described how she was told on several occasions that she "did not have what it takes, would never make it as a nurse." Quivering with emotion, she declared, "When they told me that, I knew I would make it. I would do it just to show them they were wrong."


Such negative and potentially damaging "instruction" infects nursing education, poisoning across all levels and institutions. While not every student arrives with success guaranteed, respectful and compassionate ways abound to assist individuals to discover their true path. We have no right to denigrate others because they do not conform to our conception of nursing identity. Most certainly, there is no place for shame or needless guilt within an educational system that molds practitioners of care. The imperious imposition of character analysis is not only wrong, it is counterproductive also.


Breathing and Weaving

We are-as the well-worn syllogism declared of Socrates, all mortal and thus we are all flawed and struggling-practitioners, educators, students, and patients. We get hurt; we pass on the hurt. Ditto for humiliation. We don't mean to haze; sometimes it just comes naturally in our frail humanity. Through the better part of a decade, like a contemporary ancient mariner, I hauled around a former professor's scathing criticism. I clung to the fear that perhaps she was right, perhaps I am a charlatan and "will never make it as a nurse." How I may have foisted upon others the albatross of my anxiety and sense of victimization I cannot know. A time comes, however, when one must drop the burden and break free of the painful karmic circle.


Tonglen suggests a different perspective from which to view our lives, our work, our relationships. What my professor passed on to me she received from another. And so I can inhale the pain that arises from indictment, hold it in compassion for all who feel inadequate, and exhale desire that we find comfort. When our students' gentle hearts begin to calcify, let us help them rediscover that soft spot, that essential bodhichitta that is their truest identity. If they can recognize it in themselves, they will discern it in those for whom they care and with whom they work. Chodron attests to this connection when she equates bodhichitta with the rawness of a broken heart:


Sometimes this broken heart gives birth to anxiety and panic, sometimes to anger, resentment and blame. But under the hardness of that armor there is the tenderness of genuine sadness. This is our link with all those who have ever loved. This genuine heart of sadness can teach us great compassion. It can humble us when we are arrogant and soften us when we are unkind. It awakens us when we prefer to sleep and pierces through our indifference. This continual ache of the heart is a blessing that when accepted fully can be shared by all.1(p4)


A musician of tender heart, Pablo Casals devoted a lifetime to coaxing forth authentic beauty from the instrument in his hands. We who are midwives of nursing practitioners would be well advised to heed his advice. He exhorted those blessed with the trust of the innocent to reassure them daily: "Do you know what you are? You are a marvel. In all the world there is no other exactly like you." Let us reject all rituals of hazing and intimidation, the perpetuation of bad karma that shrivels the spirit. Instead, let us welcome and celebrate our nursing students in all their rainbow manifestations. Our profession is richer for their varied hues and budding gifts and we must protect those vulnerable hearts, send them forth with confidence rather than bitterness. We must not only teach them but care for them.


We have languished too long in hard labor. It is time for rebirth in the full light of day.




1. Chodron P. The Places That Scare You. Boston: Shambala Press; 2002. [Context Link]


2. Benner P. From Novice to Expert: Promoting Excellence and Power in Clinical Nursing Practice. Menlo Park: Addison-Wesley; 1984. [Context Link]


3. Benner P. The Primacy of Caring. Menlo Park, Calif: Addison-Wesley; 1988. [Context Link]


4. Watson J. Nursing: Human Science and Human Care. Norwalk, Conn: Appleton-Century Press; 1985. [Context Link]


5. Watson J, ed. Applying the Art and Science of Human Caring. New York: NLN; 1994. [Context Link]


6. Noddings N. Starting at Home; Caring and Social Policy. Berkeley: University of California Press; 2002. [Context Link]