communicate. In a moment of frustration, a moment of aggression, they don’t use language as a way to communicate, the kinds of tools we use. They use other means of expression, through behaviour. The nurses stated that forensic patients seldom cried; rather, they became angry and acted out their agony. Patients who had difficulty enduring suffering were described as lacking competence to deal with problems. Instead, the nurses believed, patients tried to escape painful situations by taking drugs, or by ‘making themselves big’ through violent behaviours. However, when a nurse understood this problem, he/she was able to see behind the façade. This enabled nurses to detect patients’ conception of themselves and focus further interventions in order to alleviate suffering. Being present in suffering This theme was identified on the basis of nurses’ descriptions of being engaged in a caring relationship with the patient as a person. Thus nurses also related suffering to the patient’s lifeworld, and not only to the context. This was a challenge for nurses, as it required them to be present with the suffering patient. In those situations, nurses also encountered their own shortcomings when their capacity to alleviate suffering was insufficient due to the circumstances as well as to the severity of the patients’ poor psychiatric health. The basis for this presence is to never abandon the patient, no matter what happens. This also meant that nurses gave up their own assumptions about patients’ problems and the best thing to do, and endured being in a ‘not-knowing’ position. To never abandon the patient was also described in the context of advocating for the patient’s perspective in discussions with peers. When the nurse was genuinely interested in the patient as a person, the patient was invited to a communion rather than forced into conversations about the crime. Within the safe frame of this caring communion, nurses allowed the patient to set the pace for the development of a safe and functional relationship. To Lisa, this may look like the following: For some, this is a fast process, while it appears that others are stuck. But you can’t change patients and try to form them into your own preferences. You must start where they are. Letting the patient set the pace was considered a way to comprehend the patient as a unique person and described as a means to promote patients’ active participation rather than ‘fostering’ adjustment to a common approach. Thus the caring encounter to a great extent is formed by the patient’s needs. The nurses also claimed that the intensity of a patient’s suffering sometimes required that the nurse take a step backwards, not in order to abandon, but rather in order to come closer. Emma experiences this as: It is also a question of acceptance. Sometimes the patient doesn’t want to talk about it. If the patient has expressed that, I believe it is better to let it be, and hopefully you can pick up again after an hour or so. By acknowledging the patient as a suffering human being, nurses also facilitated the patient’s narration of suffering. When nurses were available and responsive to the patient’s needs, they established foundations for approaching the suffering patient in a way that they experienced as creating possibilities for growth, and thereby for the alleviation of suffering. Critical reflection In this final step, findings from previous steps are further explored in relation to relevant literature. The literature was chosen on the basis of the findings in the previous steps. The naïve interpretation concluded that different understandings about patients’ suffering and how to approach it contributed to conflicts among staff, as they gave rise to different opinions about how nursing care should be delivered. The structural analysis contributed a more explanatory view by highlighting that differences were manifested not only in different opinions but also in different ways of relating to the suffering person. Therefore, literature focusing on a common staff approach (Enarsson et al. 2007, 2008), different forms of presence (Fredriksson 1999) and caring conversations as a means to alleviate suffering (Fredriksson & Eriksson 2001, 2003) provides the theoretical basis for critical reflection. Further references are used to elaborate on the interpretations in regard to different aspects of the alleviation of suffering. As the critical reflection aims at generalizing by abstraction, the focus is not on the specific participants. Instead, the findings are re-contextualized on a general level (Ricoeur 1991, 1995). This change as regards the level of abstraction is also visible in the change of tense from past to present. That nurses sometimes ignore suffering is interpreted as a lack of understanding of the patient’s perspective. Explaining expressions of suffering as manipulation and disruptive behaviour enables nurses to keep their view of professionalism intact. Furthermore, they can side with their peers, avoiding both being alienated from them and becoming overwhelmed by patients’ suffering. As a consequence, patients are met with different strategies aiming at fostering an acceptable behaviour that fits the cultural demands of the unit (Enarsson et al. 2007). By overlooking suffering rather than approaching and alleviating it, nurses can avoid becoming personally involved in and touched by patients’ suffering. According to Knobloch, Coetzee