IHTP, 2(2), 129-133, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 129 Pleasure and suffering in the work of palliative oncology nurses: A reflective discursive presentation Ana Dulce Santana dos Santos1, Silvio Arcanjo Matos Filho2, Ricardo Souza Evangelista Sant’Ana3, Norma Valéria Dantas de Oliveira Souza4, Zulmerinda Meira Oliveira2, Simone Godoy3, Octávio Muniz da Costa Vargens4 1Faculty Santa Casa of Bahia, Salvador, Bahia, Brazil; 2University State of Southwest Bahia, Jequié, Bahia, Brazil; 3University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil; 4University State of Rio de Janeiro. Rio de Janeiro, Brazil Corresponding author: A. D. Santana dos Santos (anadulcesantana@yahoo.com.br) ABSTRACT In palliative care, nursing work is characterized by the concept of suffering as nurses cope with not only the death of patients, but also challenges with interacting with families. This suffering however, if offset by the concept of pleasure, as patients find meaning in illness, pain, and in the acceptance of death as a natural process, which generates pleasure. This reflective discursive presentation is based on the theoretical framework of Dejours’ psychodynamics of work and highlights the area of palliative oncology nursing as a source of suffering and pleasure. The daily life of palliative oncology nurses, subjectivity at work, and constant interactions between psychic, social, individual, and collective factors are discussed. In their clinical practice, palliative oncology nurses break with the prescribed way of engaging in care while building on various meanings of work that transforms and is also transformed. Considerations related to the need for teaching and research activities to examine pleasure and suffering in palliative oncology nursing is presented. KEYWORDS Job satisfaction; Nursing; Palliative oncology; Pleasure; Suffering BACKGROUND The concept of work is presented as the process between humans and nature whereby humans, through their own actions, mediate, regulate, and control their metabolism with nature; that is, humans transform the environment with their work and according to their needs, they are also transformed by this environment, which is a place of continuous interaction (Marx, 1996). Work is an ancient activity inherent to humans, occupies a considerable part of life, comprises the subjectivity of the subject, and can be a source of suffering and fatigue for some and pleasure for others (Kessler et al., 2012). In this context, “Work is the coordinated activity deployed by men and women in order to face that which, in a utilitarian task, cannot be obtained through the strict application of the prescribed organisation” (Dejours, 2011). Work is an activity aimed at meeting human needs, not only immediately but also through mediation, whether through a work instrument, which humans insert between themselves and the object they need, or through more complex, socially organized processes. Work, therefore, involves two dimensions, moving beyond the mere material production of goods and services to form the very subject who performs the work (Oro et al., 2019). Instilling any activity performed by individual workers with some meaning in their life, beyond simply the material, intellectual and practical investment in its completion, also requires an affective investment in this activity (Dejours, 2011). IHTP, 2(2), 129-133, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 130 In the nursing context, this activity is care, which is the essence of the profession and belongs to two distinct spheres: one objective, which refers to developing techniques and procedures, and the other subjective, based on sensitivity, creativity, and intuition in caring for another being. Care, therefore, requires in its relationship, the subjectivity of the nurse (Souza et al., 2005). The subjectivity of nursing work is based on several essential elements, such as the way in which care was taught, the appreciation of sensitivity, intuition, “doing with”, cooperation, availability, participation, love, interaction, scientific, authenticity, involvement, shared bond, spontaneity, respect, presence, human warmth, and smiling. This collection of values/ characteristics/ details that make a difference in care is learned as prescribed work (Souza et al., 2005). The work that, in its fragmented, hierarchical structure, is focused on the production of services, leads to suffering while being done. However, subjectivity is also influenced by empathy, respect for silence, receptivity, observation, and communication. Nurses reveal subjectivity, changes, and renormalizations in their activities, most of them by their own initiative, and break with the prescribed organization, seeking work aimed at creativity and pleasure. As a result, actual work is generated, that is, work significantly different from the prescribed organization (Kessler et al., 2012), (Dejours, 2011). Care is, therefore, not only an instrumental and operational work issue, but also the recognition of its purpose for human life and that this this work is not neutral, but instead supported by a set of theoretical- philosophical ideas that guide the choices made by those who provide care (Oro et al., 2019). This work involves suffering because nurses must cope with the death of patients, the difficulties of their families, and with end of life in their own daily lives. However, the paradox lies in the satisfaction gained from helping families of patients in palliative oncology, even during their suffering, find meaning in illness, pain, and in the acceptance of death as a natural process, which generates pleasure and new meanings in caring. This reflective discursive presentation is based on the theoretical framework of Dejours’ psychodynamics of work. To organize the construction of the reader’s critical thinking, this paper is divided into two sections: the nursing work setting as a source of suffering and pleasure, and the proximity to the process of human finitude imposed in the nursing work setting of oncology and palliative care (Dejours et al., 2011). REFLECTIVE DISCUSSION Setting as a Source of Suffering and Pleasure Professional practice in the hospital setting is marked by multiple requirements, including coping with pain, suffering, death, and losses, as well as unfavorable working conditions and low pay. In addition, the organization of work requires nurses to show initiative and be agile and creative, with insufficient material and structural conditions, thereby straining them and contributing to stress and burnout (Oro et al., 2019). The suffering and death of a patient are difficult factors to cope with in nursing work. However, this is the setting in which nurses live daily; they fight for life, against death, and take responsibility for saving, curing, or even relieving pain, and because death is most often regarded as a failure, it is therefore difficult to accept. The work of healthcare professionals, even in places such as intensive care and basic healthcare units, does not only involve suffering. The possibility of relieving pain, saving lives, feeling useful, and working collectively, among other factors, can be a source of comfort and satisfaction, which provides pleasure and favors the psychic balance of workers (Kessler et al., 2012). Maintaining good relationships with colleagues is also a source of pleasure in the workplace. However, in practice, nursing teams face some difficulties in which interpersonal relationships may generate dissatisfaction. This complexity of work relationships entails several factors that allow workers to share, skillfully, the workplace with their peers. The demands imposed by the organization of work in real situations determine that nurses working in hospitals must have excellent technical-scientific knowledge and be able to cope with loss, pain, suffering and all the stress resulting from their work. Such situations can trigger the burnout syndrome, which is linked to work and is caused by repetitive emotional pressures associated with being involved IHTP, 2(2), 129-133, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 131 with people for a long period of time. The characteristics of such an occurrence in the work of nurses are linked to an organizational process influenced by fragmentation, that is, a process that follows Frederick Taylor’s principles of scientific management theory, with the patient as the object of work (Hercos et al., 2014). Several situations generate pleasure and suffering in nursing work. In the hospital, among the aspects that cause exhaustion in nurses, two factors stand out: the lack of equipment and human resources, and the suffering and death of patients (Kessler et al., 2012), (Oro et al., 2019), (Souza et al, 2005), (Hercos et al., 2014).Although nurses experience suffering in this process, some researchers have indicated that their work is a source of pleasure, as job satisfaction can be found by alleviating patients’ suffering and by improving their health. In other words, despite living with situations of suffering and death, the nursing team lives through moments of success, which become gratifying and bring full satisfaction (Kessler et al., 2012). The psychodynamics of work enable the contemporary understanding of subjectivity at work. Studies on the psychodynamics of work support the analysis of this dialectic of feelings by emphasizing that work is never neutral in relation to health and that some elements in the organization of work trigger psychic suffering. As a result, workers may become ill (Dejours et al., 2011). Approaching the psychodynamics of work requires breaking with Frederick Taylor’s principles of scientific management theory and seeking new paradigms of work organization aimed at the integration between process and outcome, and at the decentralization of decisions, autonomy, flexibility, hierarchy, creativity, encouragement, participation, appreciation, and exercise of qualification, and, lastly, the history and accumulated experience of everyone (Martins el al., 2009). Impact of Occupation on Suffering and Pleasure Work in oncology, as a medical specialty spanning medium-to-high complexity healthcare levels, is stressful. Workers face situations ranging from a high technological density to imminent contact with death (requiring specialized and palliative oncology care, as well as family care), which present major challenges for these professionals (Hercos et al., 2014). Death is linked to a professional’s feeling of failure. Living with the condition of illness and death generates anxiety, which causes exhaustion in family members and professionals who live with end-of-life patients, such as those with advanced cancer, whose pain and worsening and degradation of general conditions affect everyone in contact with them (Kubler-Ross, 1996). When faced with the situation of death, professionals question the quality of care and sometimes feel useless for being unable to “cure” an individual. However, from this experience, a new paradigm in health has emerged; the adoption of explicitly humanitarian measures in end-of-life care whereby care is provided to not only heal but also to alleviate the symptoms and suffering of patients and their families in palliative oncology. From this perspective, all efforts are directed to enabling the understanding and acceptance of the process of dying with dignity. The perspective of the philosophy of palliative oncology, as disseminated in several countries and more recently (from the 1970s) in Brazil, emphasizes quality of life and professional performance aimed at “being by their side”, providing patients with better conditions of life, facilitating the process experienced by family members and patients, “and staying together when inevitably death comes” (Matos el al., 2010). Several studies consider that nurses have limited knowledge in working with death because their training is focused on technical and practical actions, with little attention to the real needs of end- of-life patients and their families (Hercos et al., 2014), (Martins et al., 2009). In addition to nurses, other healthcare professionals lack this training because this topic is rarely or almost never addressed in higher education courses (Hercos et al., 2014). To face psychological suffering and avoid occupational diseases, we must ensure professional recognition of end-of-life care and promote an institutional space of discussion between the various professionals involved in such care. As a result, knowledge about the work and the evaluation of outcomes (Hercos et al., 2014). will be enhanced. The method proposed by Dejours uses clinical listening, which enables speaking and listening to workers’ subjective experiences in their work environment. Such a process can empower workers, stimulating the work collective by changing the organization (Dejours, 2011). Palliative oncology nurses must find ways of coping with difficulties and find resources to IHTP, 2(2), 129-133, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 132 minimize or solve them, although working conditions have been improving (organizations with decreased bureaucracy, service dynamics, financial recognition with wage increase and adequate workload). Concomitantly, the inclusion of physical and leisure activities in the daily life of these professionals is encouraged, alongside a policy of continuing education and systematic psychological support to help them face difficulties in their daily work and invest in interpersonal relationships within healthcare institutions (Hercos et al., 2014). Spiritual needs, in the healthcare context, must also be considered as one of the human dimensions that directly influence how nurses tackle life and limit situations to help relieve their suffering and that of those under their care. One of the main goals of palliative oncology is to prioritize the value of the dignity of a person. This means recognizing that all persons are unique to themselves, to their families, and to their connections with the divine. Therefore, we must develop strategies for promoting care to relieve the physical, mental, emotional, and spiritual symptoms of these end-of-life patients (Bertachini et al., 2004). The philosophy of palliative oncology aims at providing patients and their families with the best possible quality of life. As a subjective concept, quality necessarily involves the ways in which nurses develop their actions in the context of work. Although work can be a source of suffering, it can also provide experiences of pleasure whereby humans build their life and enter the world of work not only for survival, but also for personal and professional fulfillment. Thus, work enables the process of individual training in its technical, political, cultural, esthetic, and artistic productivity, by involving subjectivity. We must advance the discussion on the complexity of the approach to end-of-life patients in healthcare services. This can be achieved by fostering support among professionals, promoting their participation in decision-making, and by welcoming others with positive effects on workers, who can express their subjectivity and share experiences in their relationships with others. From a Dejourian perspective this essay contributes to critical-reflective thinking about palliative oncology nursing. Suffering and pleasure are closely related in the daily life of palliative oncology as they result from relatively independent and complex logics, due to work subjectivity. Such subjectivity lies in the interaction between psychic and social and between individual and collective factors in the production of real work, breaking with the prescribed way of doing and building a meaning of work that transforms and is also transformed (Dejours et al., 2011). FINAL CONSIDERATIONS Working with end-of-life patients brings both pleasure and suffering to the nurses who provide them with care, given the demands of the organization of their work with these patients. The health paradigm underlying caring for life indicates the need to look in another direction, caring for death, and helping patients and their families as they experience the process of death and grief. With this movement, a new concept of caring, not just healing, emerged in clinical practice, focused on the entire existence of the individual until the end of life. Therefore, the work of nurses in the philosophy of palliative oncology involves the subjectivity that they learned as the prescribed work, with care seeking to provide comfort, relief from physical and emotional symptoms, and spiritual support, not only to patients but also to their families. Although real work brings suffering (from working with death, and its limitations), in this approach, the focus of the health paradigm shifts from healing to caring, giving dignity to the lives of those who die; this approach also enables professionals to find pleasure in real work, from a humanistic and holistic approach, favoring professional satisfaction. This Dejourian perspective confirms that suffering and pleasure are imbricated in the daily relationship with this work as the result of relatively independent and complex logics given the subjectivity of palliative oncology. The collective defense strategies adopted by workers to break with prescribed work contribute to the connection of the work team in experiencing pressure, facing the resistance to reality, and building a meaning of work that transforms and is also transformed. One of the solutions, in the field of psychodynamics of work, is teaching and research activities in healthcare settings, including undergraduate and graduate health courses aimed at the continuing education of professionals on palliative oncology. 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