May I be the Nurse, the Doctor and Great Medicine – Working the Dharma in Nursing

Those of you familiar with Buddhist scripture, might recognize that the topic of this writing is derived from a text The Way of the Bodhisattva. A part of it is also recited during sesshins in the Finnish Tavallinen Mieli Zendo association that I practice with. This essay that is before your eyes aims not to be a scholarly analysis of the text. Rather, it is based on my experience of waking up to the ongoing embodiment of the view presented in it, of which my Zen teacher Karen asked me to write about, probably not so much to produce a publishable text, but to use it as a tool to structure these experiences within myself. This became a process of several months. The result is before you.

If the Way of the Bodhisattva is new to you, you can find an English translation of it online, just google it. To give the text some background in a nutshell I’ll just state that the text is a part of a wider whole which was written in the 8th century by an Indian monk called Shantideva. Shantideva lived and practiced at, the now long in ruins, Buddhist university of Nalanda. The tradition holds that at the university Shantideva was considered to be a lazy monk who had no interest in formal practice and study. According to a joke, his three awakenings were eating, sleeping and defecating. But the tale also tells that one day, the other monks bullied him into giving a talk before the entire student body. And on that day Shantideva dropped the jaws of his audience by lecturing on the Way of the Bodhisattva. 

To me, the most outrageous thing about the text is, what appears to be, a certain kind of high-flying naivety. As we recite the text we hope to be, among other things, a bed where a tired person can rest, a bridge, medicine, a nurse and a doctor for those who need them. We also hope to be cows and a miraculous wishing jewel. Without a shadow of modesty, a miles away from the brink of burnout, it is also our hope – according to The Way – that should we meet a random person whose wish it would be for a boulder to fall upon and crush us, we ought to willingly fulfill this insane wish of theirs by effectively becoming a puddle of blood. In accordance with the spirit of the text, we hope that the aforementioned person would not dirty their legs in the puddle, but would go on instead to attain complete enlightenment.

As the topic tells us, I will close in on the text and the view suggested by it from the perspective of nursing, as several of Shantideva’s verses refer to nurses and doctors specifically. As I’m writing this, I work as a registered nurse at a closed psychiatric safety ward for the care and research of especially hard to care for and dangerous adolescents. As a safety ward it has a long list of detailed rules and policies to prevent self-destructive and violent behavior. The patients should comprise 13 to 17 year-olds (the youngest I have encountered was a ten year old) who cannot be treated at a normal closed psychiatric ward due to their especially “hard to care for” state. Usually, this means that the adolescent is especially violent, psychotic and/or self-destructive or all of the above. In addition to this, the ward conducts psychiatric evaluations for adolescents who have committed a serious criminal offense such as homicide. In short, the ward collects the hardest to treat patients nation-wide, who have no other place to go to. It is the terminus point of psychiatric care. Nothing lies below – or above. This profile ensures that any person working there gets the opportunity to practice limitless compassion for people who have killed, raped or both, and who will verbally abuse you, kick you, hit you, claw you, spit at you and bite you. In short, they mean all kinds of bad things to you.

To return to the eloquent text by Shantideva, I awoke one day to the fact that without consciously realizing it, I had lived and embodied this view, rather completely, to the letter. Probably the life pictured in the text is usually lived in a more metaphorical way in Buddhist universities, but without coloring the truth at all, I realized I have, for some time now, concretely been a nurse, medicine, bed and a bridge for sick beings. I have evened out the psychotic chaos of a patient by my steady and calm presence; prevented constant self-destructiveness; held a patient’s head in my lap (an especially risky and often undesirable form of nursing). And while doing it I have been bit, verbally abused, kicked and spat at, and all this for the benefit of the patient. On top of this, I have not gotten exhausted or cynical, but have awoken every morning at 5.10 am (morning shifts) bursting with excitement and joy. I have been like a fish finding water, in a place I could never have believed that I would be able to set my roots in. Simply put, I have felt I just needed to do this. What else is there to do?

To tell a bit about my background: as a nurse, I’m rather a newbie. I did my first career as a visual artist, and have been transitioning more to the field of nursing for the past couple of years. In the meantime I have been practicing Zen for 20 years. I have been led, in a sense, to nursing for the last decade, slowly feeling my way into it, guided by experiences significant to me. So, my way into nursing could not be described as the most usual one. I have felt that nursing is a possibility, or rather a baptism by fire, to practice in the core of the things that all Mahayana Buddhist teaching tells us about, and to live true the insights a practitioner might experience on their path in meditation. This view is very idealistic and it is often challenged by the everyday care work at the previously mentioned ward.

A nursing relationship at the ward can last for years. All my patients have taught me something. It is a shame that because of the ethics of nursing and confidentiality I cannot open the matter any more than in a roundabout fashion. However, I can say that my most current work in nursing has not resembled the detached and cool practice of Zen. Rather, it has been more of a Tantric left hand path led by a dakini – a female demon goddess of a sort. One can imagine Tibetan mountain horns blowing in the background (the ward alarm sirens) as Mahakala (a wrathful protective deity) rocks the crust of the earth beneath him, maiming the creation.

Nursing is bound to awaken a lot of emotions in a nurse. The everyday experience contains such feelings as tiredness, anger, fear, disgust, caring, happiness, joy, sorrow, hope and desperation. When one tries to work in accordance with the ideals of nursing one can experience quite the opposite feelings of what you imagine it would take to uphold the principles of care. Still, you uphold them. You do not have to like your patient to be able to help them, but in my view it is good for the effectiveness of care if the nurse is able to empathically feel for the patient at any level. Many are able to maintain their balance by trying not to care, to shut out this side of them completely. Caring is hard. As an example I will offer a description of intensive psychiatric care where the nurse does not leave the patient for even a second, but stands at an arms length from them, or remains at a gazing distance, ready to intervene if necessary. This is a mode of nursing I frequently practice, often for a very self-destructive and psychotic patient. The description is general, illustrating the treatment of a patient type.

Usually you sit by the patient. In adult psychiatric care the nursing team assembles an hourly list where all of the nurses take shifts with the patient to ease the stress of the individual nurse. In adolescent psychiatry where I work, the list is usually not used and you will spend your working day mostly alone with the patient. It is a form of psychiatric care where you get to sit where you are for extended periods of time as long as your patient is not outrageously self-destructive. At the same time, according to the nature of the ward, you need to maintain awareness of your surroundings: where each of your colleagues are, what was that funny noise you just heard, how the emotional atmosphere of the place just somehow intensified, and the silence just got weird. A patient might be somewhere they are not supposed to be, doing something they are not supposed to do. It is also crucial you are aware of what is happening within yourself in the midst of the work.

In practice, during the most intensive point of this intensive care, this means you will be spending your days with your patient, even following them into the toilet and shower, and eating together. When the patient becomes self-destructive, or you see the signs that precede that, you close in to intervene in the situation, first verbally, and if that does not work, then physically restraining them in some form. During the day, you try to support the patient in different ways: by offering medication, holding their hand, talking, being present and so forth. One must constantly evaluate what is the best way to intervene at any given point, when one limit of behavior is crossed and when you need to come up with another way to respond. A patient may claw and bite at their own hands, a raw manipulative act and a cry for help that ensures adult attention and connection. You hold their hands for a while and when you release them, they go at it again. The patient will test the nurse's endurance, this is how trust is built. In a way you allow them to use you, you play the game, but the nurse's long term aim has to be a more durable solution. It is impossible to hold somebody's hand for the rest of their lives. On a good day you get through it by offering the patient support by holding them in a kind, caring manner. Sometimes harshness is called for and you need to confront the patient about their behavior. On other days anything you do is ineffective, their condition further deteriorates and you will need to hold down the patient by force. At that point you need, if you haven’t done it already, to call your colleagues to help you. It may be that by the time they arrive, you and the patient are wrestling on the floor as the patient, by all means possible, tries to continue their self-destructive behavior and that impulse turns into violence towards the nurse. Maybe you even remember to press the alarm button you have with you and other nurses from multiple wards are already on their way, running to help out.

The next phase in the course of treatment is restraining the patient by walking or carrying them to the restraining room and tying them down to a bed. It is fairly common that at this point the nurse experiences the most violence from the patient: kicking, hitting, spitting, biting and clawing. I’ve been part of a situation where it took seven male nurses to tie a person down. The tying down form of restraining lasts as long as it takes for the patient to calm down and you have together, with the patient, made up a plan to end the restraining procedure. In the meantime, you sit next to your patient and document on a computer how your patient is doing every 15 minutes. A doctor comes and evaluates whether restraints are necessary, while it is fairly common that the patient is involuntary medicated at this point. At worst, this can happen several times a day. For the nurse, this means that you are face to face entangling your eyebrows with your patient for the entirety of your working day, and by the end you will probably have the scent of your patient on you. Sometimes you will be patching up your wounds. If you have received a blow to your head you get to go home, but first you need to visit the ER and have a check up. Usually you get to cut the queue. All in all, if you cut out the supernatural element out of The Exorcist, this is a very similar experience to treating little Reagan.

In the midst of all of this, you will try to form a relationship of trust and collaboration with the patient. As you slowly get to know each other through shared experiences (the likes of which I just recounted) the patient will begin to share more about themselves. Maybe you end up talking about deep stuff together in a dark room. The patient, who has significant pathologies in their psyche, begins to open up, trust you and direct all the neglect, anger, hopes and so forth that they have experienced and dump it all on you. It’s at this point, at the very latest, that you need to be aware of the things that are being awakened in you and in the patient. The situation can be entangled into a magic circle of care, or to use Zen term, a “devil’s womb” – a place you don’t want to leave. One can become enchanted by the relationship. However, this spell can and does get broken thanks to the nurse's work experience, emotional maturity and a natural sense of boundaries. Supervision is also available, but one needs to seek it. After all, you need to take care of yourself and your own needs.

The aforementioned surroundings and situations can make it hard to maintain a wise and compassionate ability to function. However, every day I witness the manifestation of these qualities in the actions of co-workers who have never formally practiced them, at least not within any spiritual traditions or contexts. And yet I also witness the failure of fellow nurses to function with wisdom and compassion and the fact that they seem not to have the will, ability or the tools to practice and work with them.

And when I lose the ability to function wisely and compassionately it feels like I’m drowning. The things sore to me activate and my ability to process them is surpassed. My thinking narrows, my views towards different phenomena narrow and I begin to reject the experiences I have. The avoidance and judgment towards things is lack of mental space, narrowness of view, in fancy terms, lack of dialectics – simply put, the lack of freedom. When I notice this I must increase the space in my mind, to transcend the narrow borders of self.

The first step in all of this is observing the situation. I’m attentive with the eye of my mind, directing my attention to my bodily experience that arises with the phenomena. A difficult experience for me manifests in varying degrees of feeling like I’m being smothered, my breathing is blocked and I feel angry and afraid. I begin to breathe mindfully through my nose and I feel how my body and the bottom of my belly feels. Breathing in such a way allows me to include these intensive feelings into a greater whole, and I ground myself again, bringing awareness to the fact that there are also other things manifesting in this situation, some more silent things. The center of a hurricane is a peaceful place, if you can hold the situation in attention.

I often name the feelings I’m experiencing, feel the position of my feet on the ground, listen to the sounds or silence of the space around me. Equanimity is ever present. Through practice I move to a more open space which has more alternatives. I’m openly present to what is happening in the moment, in and around me, adjusting the field of awareness according to the situation. These actions are not only mental. And when I get caught by the enchantment of a nursing relationship, I find a way to ground myself with the company of other nurses. When I have noticed my own transference, anger, fear and the need to be adored to name a few, nothing grounds me better than the company of other nurses that have gone beyond, sometimes to the other side of cynicism. Caution is needed, though. A collapsed star of nursing has its charm, their event horizon radiates sarcastic vibes nearly lethal to nascent sparks of bodhicitta, and the gravitational field can suck you right in. However, this interaction can sap the energy from a dawning savior hybris. Working with people who are experiencing extreme mental states is a raw and energetic environment for practice. If one is able to hold all of it in awareness the energy flows back into attention. Spiritually this can be extremely expedient. One can feel like travelling in a spaceship that suddenly activates faster than light speed and plunges into the depths of space.  

If I’m present by the patient, and there is nothing particularly challenging in the situation, I’ll just be present and feel the moment. I aim to be open to what the moment seems to require. The moment is in a way heavy… and I don’t mean difficult, but rather full, laden, fully laden with possibilities. The situation is, at the same time both still and dynamic, where anything can arise. As before, I’m present, especially in my body, noticing my thoughts and feelings. Next, I do my best to act in accordance with the situation. It might be intentional or highly intuitive, not reacting to the situation but responding to it. A synthesis of reason, feelings and intuition is formed. Sometimes the process requires a degree of striving, on other times it’s effortless and spontaneous. Sometimes I might direct my compassionate awareness to myself asking ‘what would a compassionate being do in a situation like this?’.

Earlier, I have regarded compassion as being something special, even a magical phenomena which has to be separately created, removed from the everyday experience. As I’ve practiced with the matter I’ve begun to experience compassion as a universal feature that arises in conditions favorable to it, or that which is actually ever present. If this part of our experience is lost it should not be forced to emerge. If it feels artificial, what is produced instead is a varying degree of exhaustion. It is more commendable to make the surroundings more favorable for compassion to naturally grow, so that we can simply notice it again.

In the absolute sense, compassion has no limit. In the ideal situation, when we function with no-mind, compassion flows naturally and the person's conduct sets itself into appropriate ways. Appropriate is a challenging term, because the sense of right and wrong is relative. I like to believe that when functioning with true no-mind, behavior naturally emerges from the person's individual sense of “appropriateness”, which is probably conditioned by the cultural surroundings of the person’s origin. However, Buddhist philosophy maintains that the source of this action, the Buddha Mind, is unconditioned. My own experience in this is, that when functioning with true no-mind, compassion flows so concretely that we naturally appreciate and respect another person's boundaries. Breaking them in a harmful way would bring us pain. We see these boundaries as guarding something delicate and frail that needs to be protected. This frailty is our own frailty and beauty, for in this experience we know no limits. Actually, limits simultaneously are and are not. This is manifested through experience and action. I don’t know if anybody lives in this view all the time. I believe not. What remains of this is a memory, a comparable mental image which works as a reference point in the dialectics of our mind, the opposite being our usual narrow view of the world. The synthesis of this is that you recognize emptiness and compassion in everyday life.

For me compassion is no longer just a feeling. Rather, it is a lived or embodied view of working, principle, actions and ordinary life. At times my work is rather dramatic and exceptional, I tend to need a hard pressured situation to get the point. In our everyday life, acts like consoling a crying child and setting limits to an angry child are both acts of compassion. When we do them from our hearts we can not fail to embody compassion. It can be done despite the current feeling you are experiencing. However, it springs most clearly when our own innermost self is in balance. If the ability feels weak, we should turn the compassionate gaze upon ourselves. Sometimes compassion is like an oath, or a vow, which we feel is of the utmost importance to abide by, not because of the feeling of duty, but because experience has shown us that this is how the world truly lies. In its most dramatic manifestations this can be like, in metaphor, a light suddenly illuminating a previously dark space: you see, from another perspective, how things simply are. The significance of this experience is not the experience itself, but the thing it leads you to do. If you truly comprehend, one wakes up to what must be done. What remains is the question of how to live and embody this in our own life – a task for the rest of our lives.