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Southern Cross University
[email protected]
Theses
2007
The influences of Thai Buddhist culture on
cultivating compassionate relationships with
equanimity between nurses, patients and relatives :
a grounded theory approach
Tippamas Chinnawong
Southern Cross University
Publication details
Chinnawong, T 2007, 'The influences of Thai Buddhist culture on cultivating compassionate relationships with equanimity between
nurses, patients and relatives : a grounded theory approach', PhD thesis, Southern Cross University, Lismore, NSW.
Copyright T Chinnawong 2007
[email protected] is an electronic repository administered by Southern Cross University Library. Its goal is to capture and preserve the intellectual
output of Southern Cross University authors and researchers, and to increase visibility and impact through open access to researchers around the
world. For further information please contact [email protected]
The Influences of Thai Buddhist Culture
on Cultivating Compassionate Relationships with Equanimity
between Nurses, Patients and Relatives:
A Grounded Theory Approach
Tippamas Chinnawong
RN., B.N.S., M.N.S. (Adult Nursing)
A thesis submitted in total fulfilment of the requirements for the
degree of Doctor of Philosophy
May, 2007
Department of Nursing and Health Care Practices
School of Health and Human Sciences
Southern Cross University
Lismore, New South Wales, 2480
STATEMENT OF SOURCES
I, Tippamas Chinnawong, declare that the work presented in this thesis is, to the best
of my knowledge and belief, original, aspect as acknowledged in the text, and that
the material has not been submitted, either in whole or in part, for a degree at this or
any other university.
Signed
………………………………………………………Date…………………………
ii
Dedication
This study is dedicated to nurses, patients, and patients’ relatives
who are sharing the truth of life, facing both suffering and happiness
in the process of caring for illness, death and dying, who are cultivating
compassionate acts with equanimity and supporting each other
in alleviating suffering, promoting comfort
and preparing for a peaceful death.
iii
ACKNOWLEDGEMENTS
I am deeply honoured to have the chance to do grounded theory research in spirituality and
holistic nursing care, exploring the influences of the Thai Buddhist culture on nurses’, patients’
and relatives’ relationships in Thailand. This thesis could not be completely finished without
direct and indirect support from people and sacred power from all directions of my life. I believe
that other people, the universe, and I always relate to and support each other by the gentle flow
of breathing in and breathing out.
Thank you very much to Thai Government, the Ministry of Education (previously the Ministry
of University), and related staff who offered a scholarship, provided a chance to study in
Australia, and for their wonderful support. I give my thanks to the Office of the Civil Service
Commission, Office of Educational Affairs in Canberra, Australia, for their assistance while I
studied in Australia. Thanks to my supportive colleagues at the Faculty of Nursing, Prince of
Songkla University, Thailand, expecially Associate Professor Arphorn Churprapaisilp, who
introduced me to my supervisor. You all gave me the best chance in my life to study overseas, to
learn and absorb the best from the Australian people, the university and a multicultural setting.
I pay homage to the Buddha, the Dhamma, and the Sangha for cultivating my compassion and
guiding me to gain deep understanding about working and living with mindfulness, compassion
and equaminity while dealing with multiple suffering in my personal, work, and study life
especially in the four years of hard work during this PhD.
I am grateful to Barney G. Glaser, Anselm Strauss, Juliet Corbin, and the qualitative and
grounded theory researchers who opened new ways of thinking, provided methods and processes
for social and nursing research, and provided me with flexible guidelines to do grounded theory
research.
A respectful acknowledgement is for my participants: nurses, patients and relatives, my great
teachers, who shared their stories about compassionate and spiritual caring relationships.
iv
The greatest acknowledgement is to my superb supervisor, Professor Bev Taylor, who is my
teacher, sister, and spiritual supporter. She has become my spiritual friend who always
understands, helps, and supports.
Thank to all caring staff and PhD friends at the Department of Nursing and Health Care
Practices, especially Ms. Chris Game, Associate Professor Dr Nel Glass, Dr Kierrynn Davis, Jill
Barwick, Carmen Zammit, Susan Westwood, Linda, and Jane. Thanks to my critical friends: Dr
Neville Jennings, Dr Leonie Jennings, Dr Arphorn, Pe Sukulya, Pe Sawangpong and Pe Steven,
who shared the idea of doing qualitative research about Buddhist spirituality. To my wonderful
editors, Jude Belcher, Sue Cronen, Kim Luckman and Pe Pratin, my English has gradually
improved because of you.
Thanks to Tricia Freely and Chris Garlick, for being the best English teacher and moral
supporter. Chris Tricia and English teachers from English Language Centre thank you also.
Thanks to the friendly staff at the International Office, computer room, and library, at Southern
Cross University, especially at the document supply section, and the learning assistance unit.
Thanks to my wonderful homestay families, Peggy and Mark Predebon, their warm family and
friends: Cecily, Michel and Susie. Mark tried to teach me to drink wine, but I always failed this
subject. Peggy will always be with me whenever I am happy or sad. She is my beloved sister.
Bede, my brother, and Fabia, my dear sister, played with me and taught me to play with Barbie.
She also tried to teach me to speak English with her dolls. Lexie and Peter, and Uncle Ken are
my best friends in my homestay family, who took care of me as one of their daughters.
To my Thai friends and families, especially Pe Nee, Pa Su, Pe Rin, Pe Pa, Pe Tuk, Pe Wan.
Thank you for very yummy hot and spicy Papaya Salad, Thai Curry, chilli paste and fresh spring
rolls. You made my life comfortable and it felt like home. Also Pe Tin who always gave me some
herbs, cheered me up and encouraged me to improve my writing skills. Thank you Pe Pok, P
Boon, P Ta, Tony, Nong Jib, Leky, Noi, Goi, and nong Nan, who shared their happiness and
support with each other.
I’d also like to thank all my good friends at Sirius College and at SCU, expecially Aethea,
David, Judy, Alana, Nick, Belinda, Kim, Julia, Ankie, Vanessa, Diep, Vi, Bao, Sunny,
Ephraim, Phosai, Gloria, and Atsushi.
Thanks to many Thai sisters and friends, especially Pe Sa, Pe Nai, Pe Nom, P Taew, Pe Su, Pe
Ying, Pe Hong, Pe Aree, Nong O, Pe Peak, Pe Luay, Pe Ra, Ly, Tas, Jang, Maew, Lak, Cake,
Pui, Pure, Pla, Yui, and Nok, who were always ready to listen to my sad stories and be with me
when I needed help and suport. Thank you my spiritual friends for taking care of my sick parents
while I studied overseas.
I am also remember with gratitude the very supportive environment, the bus drivers and
friendly people from the very peaceful town of Lismore, a herd of cows in the farm near the
Sirius residence, chilli trees and herb gardens at the Sirius college, and all the sacred power
and sources of healing energy around us: the Australian blue sky, the sun, the moon, the rain,
wonderful weather, beautiful birds, flowers, trees, parks, beaches, and the peaceful field in
front of my unit which helped me calm my mind and get ready to keep writing my thesis.
Finally, I’d like to thank my parents, sisters, and brothers in Thailand for all their support. I am
deeply grateful to Pe Sukanda Chinnawong who, since I was born, has taken care of me as the
second mother and always nurtured my freedom and creativity with her kindness and
compassion, Pe Wanpimol Chinnawong who devotes herself to help me take care of our sick
parents while I am staying so far away from home.
Thank you, everybody and everything, for providing learning power and moral support so I could
complete my thesis. May good health, peace and happiness be with you all. Thank you very
much.
ABSTRACT
The Influences of Thai Buddhist Culture on Cultivating Compassionate
Relationships with Equanimity between Nurses, Patients and Relatives:
A Grounded Theory Approach
Thai Buddhist people, especially elderly patients, usually apply Buddhist
teachings to deal with illness and death. This grounded theory research was
developed to explore the influences of Buddhist culture on nurse-patient-relative
relationships in Thailand. The purposes were to highlight the importance of the
spiritual dimension in nursing care and examine ways in which nurses can use
Buddhist principles to improve nursing care. Seventeen registered nurses, 14
patients and 16 relatives were purposely selected. The semi-structured interviews
and audio tape recording took place in Thailand from October 2003 to March
2004. Three steps of analysis: open, axial and selective coding (Strauss &
Corbin,
1998)
were
conducted.
“The
Cultivation
of
Compassionate
Relationships with Equanimity between Nurses, Patients and Relatives” emerged
as the basic social process, which were composed of the three co-processes
including: 1) facing suffering/understanding the nature of suffering, 2) applying
Dhamma (Buddhist beliefs and practices), personal/local wisdom, and traditional
healing, and 3) embodying compassion with equanimity. Such relationships
showed influences of Buddhism and Thai culture, and highlighted patientrelative centred care. Personal, professional and organisational factors as well as
cultural and religious aspects that promote and inhibit compassionate
relationships are discussed. Implications are discussed for nursing practice,
education, management and research.
v
TABLE OF CONTENTS
Statement of sources
Page No.
ii
Dedication
iii
Acknowledgements
iv
Abstract
v
Chapter 1: Introduction
Introduction
1
The researcher’s background
6
Significance
7
Aim
8
Objectives
8
Research questions
8
Assumptions
9
Key terms
10
Glossary of Thai words
11
Thesis chapters overview
15
Chapter 2: Setting the Context
Introduction
18
Thailand: “The Golden Land” and “The Land of the Yellow Robes”
18
Thai Buddhist culture
19
Fundamentals of Buddhism
22
The Four Noble Truths and the Noble Eightfold Path
23
The Five Precepts
24
Buddhism and health
24
Issues and trends in the Thai health care system
25
Thai National Health Development Plan
25
Health services and health seeking behaviours
26
Thai nursing
27
Conclusion
30
vi
TABLE OF CONTENTS
Page No.
Chapter 3: Methodology
Introduction
31
Grounded theory and its position in qualitative research
31
Strengths and weaknesses of the grounded theory
36
Approaches of grounded theorists
38
Development of grounded theory methodology
38
The commonality of the four approaches
40
The distinguishing components of grounded theory
41
Glaser and Strauss’s approach: the original version
41
The Glaserian approach: the classic version
42
Strauss and Corbin’s approach
43
Charmaz’s approach: the constructivist version
43
Major differences between Glaser’s classical approach and Strauss and
46
Corbin’s approach
Strauss and Corbin’s grounded theory approach
Basic knowledge and procedures in Strauss and Corbin’s grounded
46
49
theory approach
Responses to Strauss and Corbin’s grounded theory approach
50
Grounded Theory in Nursing
52
Grounded theory, spirituality and the nurse-patient-relative relationship
53
Examples of grounded theory using Glaser’s classical approach
54
Examples of grounded theory using Strauss and Corbin’s approach
56
Computer-aided theory-generating analysis
60
Grounded theory research in the Thai Buddhist context
62
Selecting the methodology and the specific approach
63
Conclusion
65
Chapter 4: Methods and Processes
Introduction
66
Gaining ethical approval
66
TABLE OF CONTENTS
Considering ethical principles
Page No.
66
Beneficence
67
Respect for human dignity
67
Justice
68
Engaging multiple ethical approvals
Settings and participants
The settings
68
69
69
The elderly centre
70
The primary health care clinic
70
The community hospital
71
The provincial hospital
71
The regional hospital
72
The University hospital
72
The wards and the chaos
74
Recruiting participants
77
Applying theoretical sampling to maximise different groups of
79
participants
Recruiting participants from different Buddhist backgrounds
79
Recruiting participants from different patterns of nurse-patient-
79
relative relationships
Collecting data
80
Building the researcher-participant relationship
80
Interviewing, taking notes and memos, and asking specific questions
81
Restating and performing ethical principles
85
Applying informed consent
85
Performing confidentiality
86
Being concerned about potential risks of the research
87
Preventing imposing researcher ideas
89
Avoiding researcher’s power over participants
89
Appreciating positive responses and preventing harm for special
89
participants
TABLE OF CONTENTS
Dealing with some patients who had economic problems
Page No.
91
Preventing guilt and conflicts and dealing with conflicts
91
Maintaining some good deeds within the researcher role
91
Listening to cassettes and transcribing data
92
Validating data
93
Translating data
94
Analysing data: techniques and processes
96
Doing the formal analysis
99
Applying open coding
99
Applying axial coding
102
Section one of axial coding: developing categories from 15
103
selected cases (fives nurses, five patients and fives relatives)
Section two of axial coding: adding the rest of codes and sub-
104
categories from the remaining participants under the similar
categories
Applying selective coding
106
The emergence of the basic social process
106
Reaching theoretical saturation
107
Writing memos and theoretical notes, and sorting memos
107
Illustrating examples of memos and theoretical notes
108
Listing intuition and new ideas
108
Raising and answering some more questions
109
Drawing diagrams and seeing the links between data
110
Sorting memos and doing the final theory refinement
117
Sorting memos
117
Doing the final theory refinement
117
Ensuring trustworthiness and the quality of research
117
Summary the processes of doing the grounded theory research
121
Conclusion
124
TABLE OF CONTENTS
Page No.
Chapter 5: Nurses’ Experiences and Emerging Codes
Introduction
125
The nurses’ demographic data, experience, and emerging codes
126
Nurses’ demographic data
126
Nurses’ experiences and emerging codes
127
Pe Metta’s experience
Conclusion
128
154
Chapter 6: Patients’ Experiences and Emerging Codes
Introduction
155
The patients’ demographic data, experiences, and emerging codes
155
Patients’ demographic data
155
Patients’ experiences and emerging codes
157
Pe Da’s experience
Conclusion
157
171
Chapter 7: Relatives’ Experiences and Emerging Codes
Introduction
172
The relatives’ demographic data, experiences, and emerging codes
172
Relatives’ demographic data
172
Relatives’ experiences and emerging codes
175
Khun Damrong’s experience
Conclusion
175
193
Chapter 8: The Process of the Grounded Theory Development:
from Open Codings to the Substantive Theory
Introduction
194
The process of theory development from all perspectives
194
Core category 1: Facing suffering/understanding the nature of
200
suffering
Facing suffering
201
Understanding the nature of suffering
206
TABLE OF CONTENTS
Core category 2: Applying Dhamma (Buddhist beliefs and practices),
Page No.
207
personal/local wisdom, and traditional healing
Applying Dhamma
207
Approaching/learning Dhamma
208
Believing in Dhamma/considering Buddhist philosophy
209
Performing/Practising Dhamma
212
Applying Dhamma to nursing care
214
Appreciating outcomes
217
Concerning problems of applying Dhamma
218
Suggesting ways for applying Dhamma
220
Applying personal/local wisdom and traditional healing
221
Applying local wisdom and traditional healing
221
Applying personal wisdom (using other coping methods)
222
Core category 3: Embodying mutual compassion with equanimity
Describing characteristics of compassionate nurses from nurses’,
223
223
Patients’ and relatives’ perspectives
Good heart
224
Good experiences and skills
224
Good social support
225
Avoiding added suffering (dehumanising behaviours)
225
Acting with compassion and equanimity
225
Acting with compassion
226
Acting with equanimity
230
Being aware of relationship problems
231
Appreciating relationship outcomes
231
Being concerned about factors influencing relationships
232
Being concerned about factors promoting relationships
232
Personal factors
232
Professional factors
233
Organisational factors
233
TABLE OF CONTENTS
Being concerned about factors inhibiting relationships
Page No.
234
Personal factors
234
Professional factors
242
Organisational factors
244
Considering clients’ expectations and suggesting paths to cultivate 244
compassionate relationships
Considering clients’ expectations
244
Suggesting paths to cultivate compassionate relationships
246
Conclusion
251
Chapter 9: Buddhism and the Nurse-Patient-Relative Relationship
Introduction
252
Relationships: the Eastern worldviews
252
Buddhism and relationships
253
The Four Sublime States of Consciousness (Brahma-vihara)
254
The six directions of relationship
256
The path to accomplishment (The Four Iddhipada)
256
Issues from the Thai Buddhist culture that influence relationships
257
Buddhist paradigm on health and healing in Thai society
258
Buddhism and nursing
263
Rogers’ Theory and Buddhist teachings
264
Newman’s Theory and Buddhist teachings
265
Watson’s Theory and Buddhist teachings
265
Relationships in nursing
269
Relatives in the relationships
271
Caring relationships
274
Buddhist culture and the nurses-patient-relative relationship in Thailand
281
Conclusion
283
TABLE OF CONTENTS
Page No.
Chapter 10: Discussion and Conclusion
Introduction
284
The grounded theory of Cultivating Compassionate Relationships with
284
Equanimity
Suffering and understanding the nature of suffering
286
Cultivating compassion
289
Understanding suffering and wanting to help sufferers
289
The nature of compassionate acts is unselfish and non-violent
290
Promoting holistic care and healing
291
Promoting ethics and ethics of care
292
Balancing self-compassion and compassion for others
292
Focusing on compassion in the Christian perspective
293
Cultivating equanimity
294
Cultivating compassion with equanimity
296
Influence of Buddhist and traditional beliefs and practices
299
Influence of Buddhism on Thai caring characteristics
300
Factors influencing the nurse-patient-relative relationship
300
Insights
301
Reflections
303
Reflecting on the research participants
303
Reflecting on the grounded theory research
303
Reflecting on the qualitative research
304
Reflecting on the nursing theory
305
Strengths and limitations of the research
307
Strengths
Reaching a high level of theory development
Limitations
307
307
309
The complexity of the participants’ experiences
309
Managing the overlapping of data collection and analysis
309
processes
TABLE OF CONTENTS
Page No.
310
Implications
The right path for nursing care
310
The right path for nursing education
313
The right path for nursing management
314
The right path for future nursing researchers
315
The right path for Thai people and Buddhist organisations
317
The final thought
318
References
319
Appendices
Appendix A: Plain language statement for participants
1-3
Appendix B: Consent form
1-3
Appendix C: Counsellors contact list and research project supervisor
1-2
Appendix D: Southern Cross University memorandum: approval No.:
1-2
ECN-03-76, Human research Ethics Committee (HREC)
Appendix E: Nurses’ emerging codes
1-16
Appendix F: Patients’ emerging codes
1-7
Appendix G: Relatives’ emerging codes
1-8
Appendix H: Table 8.2: Illustrated all open coding which supported
1-69
related concepts, categories, core categories,
and the basic social process
Appendix I: Table 8.3: Summary of open coding and selective coding
which support related concepts, categories,
core categories, and the basic social process
1-20
FIGURES
Page No.
84
Figure 4.1
The folder for participants
Figure 8.1
The connection of each core-category
199
Figure 9.1
Wilber’s All-Quadrant Model
268
MEMOS
Memo 1
Page No.
The Thai context: Thai holistic way of life (operational 108-109
note)
Memo 2
Questions and answers (operational notes, and theoretical
109-110
notes)
Memo 3
Emergent issues, some cultural differences (operational
110
notes)
Memo 4
Diagram created after thinking of positive and negative
111
qualities of people including nurses
Memo 5
Diagram drawn after thinking of some factors in Thai
111
Buddhist culture which influence good nurse-patientrelative relationships
Memo 6
The conditional/consequences matrix of related concepts
112
which link to nurse-patient-relative relationships in the
Thai Buddhist Culture
Memo 7
Cultivating Compassionate Relationships between
113
Nurses, Patients and Relatives
Memo 8
Clarifying the meaning of compassion, equanimity, and
114
relationship from dictionaries, participants’ meaning and
literature
Memo 9
Seeing the interconnectedness of the nurse-patient-
115
relationship and the influences of Buddhism on
compassionate relationship with equanimity
Memo 10
The application of Buddhist teachings in the Thai context
116
TABLES
Table 2.1
Classification of Thai symbolic representations
Page No.
21
Table 2.2
Health care seeking behaviours of Thai people
27
Table 2.3
Summary turning points in the development of nursing in
29
Thailand
Table 3.1
Scientific and naturalistic terms appropriate to various
37
aspects of rigor
Table 3.2
Comparison of the procedural steps of two versions of
47-48
grounded theory method
Table 4.1
Nurse: Patient ratios and systems of nursing care in each
75
setting of the University hospital
Table 4.2
Nurse: Patient ratios and systems of nursing care in each
76
setting of the hospitals under the Ministry of Public Health
Table 4.3
Illustrated examples of different kinds of language
Table 4.4
Activities and processes of doing the grounded theory
96
122-123
research
Table 5.1
Nurses’ demographic data
127
Table 6.1
Patients’ demographic data
156
Table 7.1
Relatives’ demographic data
174
Table 8.1
Summary of selective coding, sub-categories (minor sub-
197
categories and major sub-categories), core categories, and
the basic social process from NPRs’ perspectives
Table 9.1
Summarised factors that influence “spiritual caring
271
relationships” between nurses, patients, and relatives when
focusing on nurses and nursing professional issues
Table 9.2
A preliminary model of effective clinician-patient
277
interactions
Table 9.3
Spirituality and relationships in the Western and the
280
Eastern worldviews
Table 10.1
Contrasts between Western and non-Western philosophical
world view influencing research paradigms
306
Chapter 1: Introduction
CHAPTER 1
INTRODUCTION
Introduction
Thailand is a Buddhist country in which 94.2 percent of the people are Buddhist
(Wibulpolprasert, 2005), therefore, nurses, patients and relatives are usually Buddhist.
Thai culture and Thai national etiquette, and the Thai way of life, have been strongly
influenced by Buddhism. Thai etiquette, a part of Thai culture, is influenced by the
Sekhiyavatta of the Buddhist teaching, which develops characteristics of loving
kindness, compassion, and polite humanity through spirituality (Tangkuptanon, 2001).
For instance, Tongprateep (2000) described the essential elements of spirituality among
rural Thai elders as related strongly to the religious practices of merit making,
observance of moral precepts, gratitude and caring in the family, and meditation. These
behaviours are influenced by spiritual beliefs including the law of kamma and life after
death, the consequences of coping with the vicissitudes of life, being hopeful, and
having a peaceful mind.
Pincharoen and Congdon (2003) described spirituality as experienced by older Thai
people living in the United States, focusing on how spirituality helps them maintain
health and what they value most as they age. Five major themes were identified by the
participants: connecting with spiritual resources to provide comfort and peace; finding
harmony through a healthy mind and body; living a valuable life; valuing tranquil
relationship with family and friends; and experiencing meaning and confidence in
death. These patterns also hold true in Thailand itself. Describing the spirituality of Thai
people is important because spirituality, based on religious and supernatural beliefs, is
part of Thai people’s daily lives. Older Thai people view later life as a time to visit the
temple, practise meditation and calm the mind.
Chapter 1: Introduction
In addition, Kongin (1998) in her grounded theory project on self-care of the rural Thai
elderly, found several examples of Buddhist influence on self care of the elderly. For
example, rural Thai elderly perceived self-care as natural or normal lifestyle practicesliving with an acceptance of their old age, taking care of their own health, working hard
and staying active, continuing involvement in religious practices and having a positive
perception of health. The elderly took care of their own health by self-treatment, getting
help from supportive persons, and getting treatment from a local healer and health care
professionals. Involvement in religious practices was crucial for emotional and spiritual
support.
Spirituality relates to health and well-being of humankind. Spirituality is described as “a
life-giving force nurtured by receiving the presence of the divine, family, friends, health
care providers, and creation” (Walton, 1999: 34). Increasing evidence indicates that
strong, well-based spirituality influences one’s health and well-being profoundly
(Bensen, 1996). Malinski (2002: 283) claims that “outcomes of spirituality include
physical, psychological, and spiritual well-being; self transcendence; health; and
meaning and purpose in life.” Health care often challenges, rather than reinforces, the
personal connections that fulfil spiritual needs so critical to the overall satisfaction of
both client and caregiver (Sherwood, 2000). For Buddhists faced with suffering in daily
life, even though spirituality is greater than the sum of the client’s religious preferences,
beliefs and practices (Malinski, 2002; Mohan, 2004; Schmidt & Mauk, 2004),
religiosity underpins spiritual harmony and well-being.
Spiritual research relevant to different cultures will help nurses to provide linkages
between health behaviour, culture, and spirituality (Miller, 1995). Moreover, to provide
care effectively and to achieve the goals of nursing care, nurses must recognize the
patients’ spiritual beliefs and use a holistic approach that will enhance patients’ well
being (Tongprateep, 1998, 2000; Tongprateep, Pitagsavaragon, & Panasakulkarn, 2001;
Tongprateep & Soowit, 2002). Furthermore, living in a Buddhist culture, Thai nurses
and nursing students can train their minds in order to be kind and compassionate to
2
Chapter 1: Introduction
patients and relatives and to provide good quality nursing care. For this reason
Chuaprapaisilp (1989, 2002) recommended nurses and nursing students practice
meditation, which is called “Satipatthana”-developing mindfulness-in order to raise
consciousness, self-awareness and wisdom in working and daily life.
There is little nursing research on the spiritual dimension in Thailand. Furthermore,
there is no prior research, which has explored how the Buddhist culture influences the
nurse-patient-relative relationship in Thailand. There has only been one research project
conducted on Buddhist culture in relation to Thai nursing students, which found that
Thai female final year undergraduate nursing students value compassion, competency,
comfort, communication, creation and courage in nursing care (Lundberg &
Boonprasabhai, 2001). In addition, Suginunkul (1998) found that the registered nurses
had more than five psychological and Buddhist characteristics including: a positive
attitude toward nursing performance, the belief in an internal locus of control, marital
adjustment, the Buddhist way of life, and working better than their counterparts. Also,
Phosrithong (1993) stated that positive nursing behaviours towards elderly patients were
significantly different for nurses, who had high scores on closeness in the Dhamma
questionnaire, than for nurses with lower scores.
There is some evidence that Buddhism influences nurses’ behaviour in Thailand, even
though Thai nurses seldom reflect on their culture and their wisdom about how
Buddhist culture influences them. Lundberg and Trichorb (2001), Northcott (2002),
Rodgers and Yen (2002) and Tongprateep et al (2001) highlight the significant aspects
and benefits for nurses if they apply Buddhist principles to care for Buddhist clients and
relatives. Furthermore, the trend is increasing towards studying the influence of
Buddhism on nursing care. During the years 2001-2005 while this project was
proceeding, articles were published on Buddhism and nursing, especially with regard to
moral
competence
(Jormsri,
Kunaviktikul,
Katefian
&
Chaowalit,
2005);
communication and education (Burnard, Claewplodtook & Pathanapong, 2000; Burnard
& Naiyapatana, 2004a,b; Hebden & Burnard, 2004); cultural care (Lundberg, 2000);
3
Chapter 1: Introduction
women’s health (Arpanantikul, 2004; Klunklin & Greenwood, 2005); mental health
(Suttharangsee, Chetchaovalit & Lerdpaiboon, 2002); living with illness, coping and
self-management (Aphichato & Tulathumkit, 2005; Chailangka, Chuaprapaisilp,
Triprakong & Wonnawong, 2005; Junda, 2004a,b; Lundberg & Trichorb, 2001;
Songwsthana, 1998, 2001); the role of family as caregiver (Limpanichkul & Magilvy,
2004; Rungreangkulkij & Chesla, 2001; Sethabouppha 2002; Sethabouppha & Kane,
2005), complementary therapies (Hatthakit, Parker & Niyomthai, 2004); spiritual health
promotion (Pulphatharachevin et al, 2003); spiritual beliefs and pain coping
(Lukkahatai, 2004); and the meaning of death (Wisesrith, Nuntaboot, Sangchart &
Tuennadee, 2003). All of these results support influences of Buddhism on the nurses’,
patients’ and relatives’ caring behaviour and relationships.
Buddhism is a key determinant of “Thai-ness” and illustrates ways in which some
Buddhist principles influence behaviours and relationships. The characteristics of Thainess tend to be elaborated as being quiet and polite, not expressing emotion in public,
being pleasing, rather than antagonistic, and being respectful and thoughtful of other
people’s needs (Burnard & Naiyapatana, 2004a). Komin (1990) argued that even
though Buddhism teaches non-self, avoidance of emotional extremes, detachment, and
so on, it is not possible to take a “Buddhism-explains-all” approach to Thai culture,
because it misses quite a bit of reality in Thai culture. Nowadays, there are several
social, cultural, economic, political and ethical issues that influence the nursing and
health care system in Thailand.
Modern Thai Buddhism tends towards more magical-animistic interpretations and
practices, than practising Buddhist wisdom (Klausner, 2002). Thai social structure
depends on repaying gratitude and respect to superiors as well as being conscious of
hierarchy and patronage. Thai people usually show kreng jai (care and consideration)
for others and prefer smooth relationships (Bechtel & Apakupakul, 1999; Komin, 1990;
Mulder, 2000; Wongtes, 2000; Terweil, 1995). People in modern Thai society,
especially the younger generation, tend to value the material world more than practising
4
Chapter 1: Introduction
religion (Paonil, 2003; Wibulpolprasert, 2005); and the Thai health care system has
been strongly influenced by American modern medicine (Boyd, Ratanakul &
Deepudong, 1998; Burnard & Naiyapatana, 2004a,b; Ekintumas, 1999; Muecke &
Srisuphan, 1989; Wibulpolprasert, 2005).
Thai culture is in transition and Thailand faces dramatic changes in its economic, social
and political systems (Klausner, 2000, 2002; Mulder, 2000), whilst also facing an
economic crisis. In the future, mainly because of economic constraints, Thai relatives
may take less time to care for patients. The structure of the Thai family will be smaller
and many young people will move from home to work in industrial area. Moreover, the
moral and ethical foundations of Thai people, especially of Thai health care personnel,
might change gradually. Ratanakul (1988, 1999a,b, 2004) has paid strong attention to
the cultivation of Buddhist ethics amongst Thai nurses and doctors for several decades.
In keeping with the Buddhist teaching about the law of cause and effect (karma) and the
concept of dependent origination (paticcasamuppada) (Bhikkhu 2002; Payutto, 2003;
Wasi, 2002), all the changes in Thai culture and in Buddhist beliefs and practices would
affect the health care system and nursing care in Thailand.
The conceptual framework of the National Health Development Plan under the 9th
National Economic and Social Development plan (2002-2006) continues to focus on the
concept of a “human-centred” development approach in a holistic manner adopted in
the 8th Plan. His Majesty the King’s Philosophy of “sufficiency economy” has been
adopted as a guide for the development of the Thai people’s health, including the
overall health system. Conceptually, under the 9th Plan, “health” is regarded as the state
of physical, mental, social and spiritual well being, that is interrelated holistically.
Therefore, to improve people’s health status, it is necessary to develop an entire system
that is linked to several other elements. These include both individual and
environmental aspects (economic, social, political, physical, and biological), as well as
the health services system, which includes active participation of all sectors of society
(Wibulpolprasert, 2005).
5
Chapter 1: Introduction
In summary, Buddhism and Thai culture influences the Thai way of life, as well as
health care beliefs and practices of Thai Buddhist people. Several researchers showed
that Thai people including nurses, patients, and patients' relatives apply Buddhist beliefs
and practices in their daily life, when they care for others or are being cared for by
nurses and their relatives. It seems that Thai Buddhist culture influences spiritual and
holistic care. However, in modern society there are several factors which have caused
changes to modern Thai life-styles, for example, modernisation, social change, political
and economic problems. Nevertheless, there are several issues that inhibit spiritual
caring relationships in the Thai nursing context and the health care system. This
includes the influence by Western medicine for more than 200 years, especially with
task-oriented work and the busy context of hospitals. In order to provide effective
spiritual care, nurses need to understand how Thai nurses, patients, and patients’
relatives apply Buddhism to spiritual support and how the Buddhist culture influences
the nurse-patient-relative relationship in Thailand.
The researcher's background
As a Buddhist lay person and a nursing teacher, I realise that Buddhism is a way of life
and also the most crucial way to deal with the suffering of most Thai people. I perceive
that some Buddhist principles are embedded in every worldly Buddhist, even when they
have never been ordained or have not studied the Dhamma in breadth and depth. Being
ordained means men over 20 years old have gone through spiritual training and
Dhamma principles. Even though women in Theravada Buddhism cannot be ordained
as monks, they can learn the Dhamma in both direct and indirect ways from society.
Thai lifestyles rely on Buddhism from birth until death and stretch from the ancestors to
new generations. I have been taught by my family, relatives, neighbours, teachers and
monks to be kind, compassionate, patient, generous and to help others in appropriate
ways. My Buddhist activities as a lay person include chanting, reading the Dhamma
books, making merit by helping others, providing food for monks and practising
Buddhist rituals.
6
Chapter 1: Introduction
Furthermore, I believe in the law of kamma followed by my family. In my life I always
receive good things from my good deeds. This belief helps me keep myself in virtuous
ways, that is: by being generous to others, not destroying the environment and
renouncing sin and the hurtful effects of being a cruel person and continuing to improve
myself for the benefit of humankind. I continue to apply Buddhist principles to provide
nursing care for critically ill patients and their families, by reminding them to practice
their religious and traditional beliefs in the end stage. I remind them about the nature of
life, and also suggest that AIDS, cancer and chronic patients apply Buddha-dhamma to
deal with their daily suffering, by developing mindfulness and practising good deeds. I
also remind myself to learn from patients and develop a generous mind. I believe that
the Buddha’s teaching is one of the very important ways that all Buddhist clients can
use holistic care for their health status. Therefore, this project will be very beneficial for
Buddhist clients and nursing professionals in using ancient wisdom and new knowledge
development to improve care.
Thai Buddhist people usually apply Buddhist Dhamma to deal with various kinds of
suffering especially life crises, illness and death. In contemporary Thai health care
contexts we do not know yet how Buddhist beliefs and practices among nurses, patients
and their relatives affect their collaborative relationship, health and spiritual well-being.
A grounded theory approach was used in this study to explore the influences of the
Buddhist culture on the nurse-patient-relative relationship in Thailand.
Significance
As indicated earlier, around 94.2 percent of Thai nurses and patients are Buddhist.
Moreover, there are so many factors in modern Thai Buddhist culture that affect the
nurse-patient-relative relationship, spirituality and holistic nursing care in Thailand. As
a lay Buddhist, a Thai nurse and a nursing teacher, I realised that more research was
needed in exploring the influences of Thai Buddhist culture on nursing care, especially
in nurse-patient-relative relationships, which highlight that spiritual care is needed. This
7
Chapter 1: Introduction
project is important in developing knowledge in this field. This research is also
important in order to understand the actual nursing situations in Thai Buddhist culture
and to find effective ways to promote spirituality or spiritual caring relationships, as the
heart of holistic nursing care suited to Thai culture. This is the first research project to
explore the influences of Buddhist culture on the nurse-patient-relative relationship in
Thailand using grounded theory. Grounded theory is the most rigorous method of
providing preliminary or exploratory research in an area in which little is known
(Annells, 2003; Glaser & Strauss, 1967; Strauss & Corbin, 1998). The findings illustrate
the impact on nurse-patient-relative relationship and on health care outcomes when
nurses, patients and relatives connect in nursing contexts within Thai culture.
Aim
This research project explored how Buddhist culture influences the nurse-patientrelative relationship in Thailand.
Objectives
The objectives of this research were to: generate a middle range theory of the nursepatient-relative relationship, highlight the importance of the spiritual dimension in
nursing care, and examine ways in which nurses can use Buddhist principles to improve
nursing care.
Research questions
Two main questions underpinned this research:
How do Thai nurses, patients, and patients’ relatives apply Buddhism to spiritual
support?
How does the Buddhist culture influence the nurse-patient-relative relationship in
Thailand?
8
Chapter 1: Introduction
Assumptions
There were several assumptions made in this research. The main assumption, which can
be both a strength and a limitation of this research, is that the researcher is not an expert
in Buddhism. The researcher has experienced Buddhism by living in the Buddhist
culture, being an intensive care nurse, a medical nursing teacher, a researcher in the area
of chronic illness, and taking care of dying patients, especially patients with AIDS and
cancer, for almost 10 years. The researcher is a lay Buddhist, who has never been
ordained and has never learnt Buddhism through formal education. This research was
conducted because the researcher realised the benefit of Buddhist beliefs and practices
in promoting good relationships between nurses, patients and relatives in providing
spiritual support to each other. The main research results come from experience of lay
nurses, lay patients and lay relatives, who mainly realised that they did not practice
religion actively. Apart from the actual experiences of participants, the main
information about Buddhism and Buddha’s teachings discussed in the literature reviews
and introduction mainly come from publications, not directly from the Tipitaka, the
Buddhist scriptures, because the researcher did not have sufficient knowledge to analyse
the original teachings. However, the strength of being a non-expert in Buddhism is the
analysis, results and the suggestions, which can be easily understood and applied by lay
people who are, in the main parts of Thai society, not expert in Buddhism.
Another assumption is about the context of language. Because Theravada is the main
school of Thai Buddhism, and Pali language is used to represent the original teachings
of the Buddha, the researcher decided to use the Pali language to follow the Theravada
school. For example: 1) the word Dharma (Sanskrit) means Dhamma (Pali); 2) the word
karma (Sanskrit) means kamma (Pali), and 3) the word Tripitaka (Sanskrit) means
Tipitaka (Pali). In addition, because Thailand has its own language, which is the Thai
language, and the participants recounted their experiences in Thai, some Thai words
have specific and authentic meaning. Therefore, the researcher utilised some Thai
words in order to show the main ideas of caring relationships and the application of
9
Chapter 1: Introduction
Buddhist teachings from participants’ perspectives. This approach is supported by the
“in vivo” coding styles employed as a grounded theory language. For example, Thai
people use the greeting “Sawasdee ka” (for women), and “Sawasdee khrab” (for men).
They use the word kreng jai which means “feeling considerate for another person, not
wanting to impose or cause another person trouble, or hurt his/her feelings”, and use
some other words, (details of which are given in the glossary).
Key terms
Compassion is a sincere wish and act for all sentient beings to be free from suffering
and the causes of suffering. It is a main teaching of the Buddha, an essential component
of holistic nursing care, a fundamental for natural ethics and for a positive relationship,
and a direct antidote to prejudice and bullying. It can heal suffering and promote health
and peace in oneself and others.
Dhamma or Buddha-dhamma or Buddhist Dhamma in general means the Buddha’s
teachings. In Thailand it also means: the nature itself; the law of nature; the duties that
must be performed according to that law of nature; and the fruits or benefits that arise
from the performance of that duty (Bhikkhu, 2001:2).
Equanimity from a Buddhist perspective means balance, a middle way, detachment,
non-judgment, freedom from bias and prejudice, self-reliance, and accepting limitation
due to one’s own kamma.
Relationship in this research means a spiritual caring relationship between nurses,
patients and their relatives, which promotes health, well being, healing, of both caregivers and care-receivers and/or to promote a patient’s peaceful death.
10
Chapter 1: Introduction
Relative in this research has two meanings. The first meaning is of the participants,
who play significant roles of informal caregivers and who have closely helped patients
for more than two months. The second meaning is relatives who help patients through
the process of living with illness, including the patients’ family members, their kin and
friends, neighbours, monks, and folk healers, who help, support and visit patients.
Suffering (dukkha), in the context of the First Noble Truth, suffering means
“imperfection”, “impermanence”, “emptiness”, “insubstantiality”. The Pali word
dukkha, in ordinary usage means “pain”, “sorrow” or “misery”.
Thai Buddhist culture means Buddhist and Thai traditional beliefs and practices of lay
Thai Buddhists people including nurses, patients and relatives performed in their daily
living, working, and dealing with crisis, illness, and death.
Thai traditional wisdom and healing means traditional beliefs and practices that Thai
people have applied to deal with health problems and life crises, such as using Thai
herbs, Thai massage, and performing traditional rituals or spiritual practices including
seeking help from folk healers, making and repaying a vow, making merit, and so on.
Glossary of Thai words
Ahosikamma (A-Ho-Si-Kam) means defunct kamma, and act or thought which has no
longer any potential force, and for Thai people, giving Ahosikamma means giving a
forgiveness.
Anapanasati means mindfulness with breathing.
Aniccata means impermanence, transience.
Bitter Mara is a kind of herb called Momordica
Bodhisatava Kuan Im or Kuan-yin refers to the Chinese goddess.
11
Chapter 1: Introduction
Bojjhanga means the Buddha’s teaching about Enlightenment factors, including:
mindfulness, truth investigation, effort, zest, tranquillity, concentration and equanimity
(Payutto, 2003: 205-6).
Boon (Bun means Punna) and kamma: Boon means righteousness, good deeds, good
kamma, merit, the power of merit. In this sense Boon means the effect of good deeds
and kamma means the effects of bad deeds.
Brahmavihara principles means the Four Noble Sentiments, the Highest conduct
including Metta (loving kindness, friendliness, goodwill), Karuna (compassion, pity),
Mudita (sympathetic or altruistic joy), and Upekkha (equanimity, neutral feeling).
Budd-Dho are words for prayer, Thai Buddhist people usually use when they realise the
Buddha’s kindness and ask for the Buddha’s protection. When people think of the
Buddha, Dhamma and the Sangha they usually say Bud-dho, Dharm-mo, Sang-kho.
Buddhadasa Bhikkhu (1906-1993) is the most influential Buddhist teacher in the history
of Thailand. He founded Wat Suan Mokkhablarama, one of the first forest monasteries
in Thailand in 1932.
Buddhavandana means paying homage to the Buddha.
Cankama means doing walking meditation, walking up and down a terraced walkway.
Chevachit means complementary therapies and strategies for bio-psychological support,
providing guidelines by Dr Satit Intharakamheang, a Thai nutritionist.
Chinabanchorn means The Pali verse, the sacred incantation, which Thai people usually
chant when they need to be protected and prevent any bad luck, as well as to ask for
good luck and moral support.
Dern Jong Klom (in Pali Cankama) see Cankama.
Dukkhata means the state of suffering or being oppressed.
Five Precepts (The) means rules of morality including abstaining from killing, stealing,
sexual misconduct, false speech and intoxicants that cause heedlessness.
Four Ariyasacca (The) means The Four Noble Truths, including: Dukkha (suffering),
Samudaya (the cause of suffering), Niroha (the cessation of suffering), and Magga (the
path leading to the cessation of suffering).
12
Chapter 1: Introduction
Iddhipada (The Four Iddhipada) means the path of accomplishment; basis for success
including Chanda (will, zeal, aspiration), Viriya (energy, effort, exertion, perseverance),
Citta (thoughtfulness, active though, dedication), and Vimamsa (investigation,
examination, reasoning, testing).
Ja, na ja, na ka refers to polite words Thai females use to end a conversation and to
show their politeness.
Jai khao means another’s mind , Jai rao means one’s own mind, Jai khao-jai rao means
thinking of another’s mind and one’s own mind.
Jai loy means loss of concentration.
Kalyanamit, Kalyanamittata means good friends, a spiritual friendship.
Kam lung jai means having a happy heart and good will power, from good moral
support.
Kamma means deed, action, and the justice by which a person has status in life,
according to actions in last lives.
Karuna means compassion.
Kathin ceremonies means Kathin offerings made to all the priests in a temple, usually in
November.
Kilesa means defilements.
Kreng jai means hesitation, consideration, concern others’ feelings.
Kuan-Im or Kuan Yin goddess is a Bodhisattava, an iconographic symbol of a
compassionate carer, who encompassed Dhamma as a medicine to heal the sick, never
tiring to help suffering people (Fuss, 2000).
Kusala means a meritorious act and wholesome action.
Kwarm metta means kindness.
Kwarm rug means love.
Loka-Dharma principles refers to the eight worldly vicissitudes.
Luang Pho Tuad is the sacred, well-known monk in the Southern part of Thailand.
People, especially in the south, respect his image, hold his amulet necklace and ask him
for luck, especially to travel safely.
13
Chapter 1: Introduction
Manohra means a form of votive ritual or entertainment, popular in the south of
Thailand.
Maranasati means mindfulness of death.
Metta means loving kindness.
Metta-dham means the Buddha’s teaching about loving-kindness and compassion.
Mokkhalana means a close follower of Buddha.
Mother Siri Karinchai means a Thai teacher, who teaches Vipassana meditation.
Na Ma Pa Ta are chanting words for Buddhist lay people.
Namo-tassa are chanting words in Buddhism.
Pamada means heedlessness.
Parami are the stages of spiritual perfection achieved by a Bodhisatta on his path to
Enlightenment.
Pen gun aeng means informal, friendly, feeling at home.
Piti means joy and zest.
Plong means letting go of negative feelings, accepting illness and problems.
Samatha means tranquility or concentration meditation practices.
Samsara means the Round of Rebirth, the process of Birth and Death.
Sangha are Buddhist monks.
Sanghadana means offering to the Order, a gift to the Sangha, a gift dedicated to the
community as a whole.
Sankhara means body, compounded things, all things which have been made up by preexisting causes, kamma formations (in the Five Aggregates and in the law of
Causation).
Sati means awareness, mindfulness, attentiveness, recollection, detached watching.
Songkran day is The Thai traditional New Year and water festival in Thai land, April 13
of each year.
Tak Bart (Pindadana) means to offer food to the monks on their alms rounds.
Than is a Thai word, which is normally used as a pronoun, to refer to a monk or a
person of higher status, for example, Than Buddhadasa Bhikkhu is a monk’s name.
14
Chapter 1: Introduction
Tilakkhana principles are The Three Characteristics or The Common Characteristics of
everybody and every thing, including Aniccata (impermanence, transiency), Dukkhata
(state of suffering or being oppressed), and Anattata (soullessness, state of being not
self).
Tot Pha-Pa, Tod Kathin, Magha Puja, Visakha Puja are Buddhist ceremonies in
Thailand.
Upekkha means neutral feeling, equanimity, detachment.
Vessondon means the Arrahant, who are the previous lives of the Buddha.
Vinnana means consciousness, an act of consciousness.
Vipassana means mindfulness meditation.
Wat Ampawan is a well-known temple located in Shingburi province, the central part of
Thailand. This temple runs many meditation courses
Thesis chapters overview
This chapter is the introduction to the researcher’s background, significance, aim and
objectives of the grounded theory of exploring the influences of the Thai Buddhist
culture on the nurse-patient-relative relationship. Research questions, assumptions, and
the main key terms were also explained.
Chapter two sets the context for the research by describing fundamental descriptions
relating to the Thai Buddhist culture, Buddhism, issues and trends in the Thai health
care system, and Thai nursing. However, these ideas were written after the analysis
process, therefore, they do not influence the analysis and interpretation of participants’
accounts.
Chapter three explains grounded theory methodology and its position in qualitative
research. Development of grounded theory methodology and the four approaches of
grounded theorists, their commonality as well as strengths and weaknesses of the
grounded theory are discussed. After comparing the major differences between Glaser’s
15
Chapter 1: Introduction
classical approach and Strauss and Corbin’s approach, the Strauss and Corbin’s
grounded theory approach was selected. Computer-aided theory-generating analysis, an
example of grounded theory in nursing, spirituality, and the nurse-patient-relative
relationship especially in the Thai Buddhist context are explained.
Chapter four explains the grounded theory methods and processes, applying Strauss and
Corbin’s approach. The important methods were: preparing a researcher as a qualified
research tool, writing the proposal, considering and performing ethical principles,
deciding settings and recruiting participants, and applying theoretical sampling. The
data collection included: preparing good equipment and having a non-biased attitude,
building the researcher-participant relationship, interviewing, taking notes and memos,
and asking specific questions. It then involved listening to cassettes and transcribing
data, validating data, translating data and analysing data using open coding, axial
coding, and selective coding. The importance of ensuring trustworthiness and quality of
research were highlighted throughout the research process.
Nurses’ experiences and emerging codes are described in Chapter five. Chapter six
describes patients’ experiences and emerging codes, while relatives’ experience and
emerging codes are described in Chapter seven. Each chapter presents one selected case
and the remainder of the participants’ experiences are in the Appendices.
Chapter eight explains the process of theory development. The influences of Thai
Buddhist culture on Cultivating Compassionate Relationships with Equanimity between
Nurses, Patients and Relatives” emerged as the basic social process; this chapter
explains the three core categories of the substantive theory as well as their related
factors which influenced the nurse-patient-relative relationship.
Because this is grounded theory research, the related literature about Buddhism and the
nurse-patient-relative relationship are discussed in Chapter nine. The main Buddhist
teachings about relationships, Buddhism and nursing theory, aspects of the nursepatient-relative relationship, Buddhist culture, the nurse-patient-relative relationship in
16
Chapter 1: Introduction
Thailand, and factors influencing relationships are explained and discussed extensively
in this chapter.
The last chapter contains the discussion and conclusion. The grounded theory of
cultivating compassionate relationship with equanimity is restated briefly. The
discussion section focuses on suffering, compassion and equanimity. The influence of
Buddhist/traditional beliefs and practices on complementary care, alternative self care
and coping, influences of Buddhism on Thai caring characteristics, and factors
influencing the nurse-patient-relative relationship are discussed. Insights and reflections
on strengths and limitations of the research are explained before suggesting the
implications of research for nursing care, education, management and future nursing
research.
17
Chapter 2: Setting the context
CHAPTER 2
SETTING THE CONTEXT
Introduction
This chapter sets the context for the research, by describing Thai Buddhist culture,
Buddhism, issues and trends in the Thai health care system, and Thai nursing. The main
sources of literature are books about Thai culture in transition and inside Thai society,
research articles related to Thai nursing and Thai nursing education, accessed through
OVID, CINAHL and Thailand Health Profile 2001-2004 of the Ministry of Public
Health, Thailand (http://www.moph.go.th/ops/health_48), and from the Nursing Council
Thailand (www.moph.go.th/ngo/nursec/webcom.htm). As this literature sets the context
for the research and does not influence the analysis and interpretation, it is appropriate
to place it here, to provide foundational descriptions.
Thailand: “The Golden Land” and “The Land of the Yellow Robes”
The history of Thailand and Thai people represents the characteristics of the Thai
Buddhist people. Thai people’s behaviours originate from various areas and subcultures,
but Buddhist people share common characteristics and lifestyles, values, beliefs,
relationships, self-care, coping and caring behaviours.
Five thousand years ago, there were human migrations from various directions of the
globe. People from north moved to the south, settled in the land and mixed with the
Indigenous people. The Chinese settlers from south China-Sichuan and Yunnan
Provinces moved to various parts of Thailand. Thailand in the past was named “The
Golden Land”, the land of prosperity, where people from the west and the east wanted
to trade (Wongtes, 2000). The name Thai means free and in the past the country was
called “Siam” by foreigners. To its citizens it used to carry the name of its capital,
Sukhothai, Ayurrhaya, Thonburi, and Rattanakosin (Lundberg, 2000; Payutto, 2001).
Chapter 2: Setting the context
Thailand had its own diverse civilization, a wide range of attractive geography, and an
area of 514,000 square kilometres. Thailand is located in the heart of Southeast Asia,
with a population of about 65 million. This country boasts people of multiple races,
ethnic groups, cultures and languages. Because of multi-ethnicity and geographical
differences, Thailand enjoys a rich multi-faceted culture. Food, language, and
traditional ceremonies for instance, differ from region to region and carry their own
identity (Wongtes, 2000).
Agriculture and the warm climate of Thailand affect Thai people’s way of lives. Thais
represent “peace-loving, comfort-loving, simple, unambitious, and satisfied with what
they have”. Things are cheap and easy to find, and Thai people, in general, often feel
that they do not lack for anything in life (Wongtes, 2000: 117).
According
to
Klausner
(2002),
Thailand
nowadays
has
dramatic
political
transformations, causing tensions and conflicts which have led to a crisis of personal
and national confidence. Change in values and life-styles are a result of changes in
society, both political and economic, and Thai people find it hard to cope and maintain
their dignity and pride. The changes also affect quality of life and cause spiritual
disharmony to Thai people.
Thai Buddhist culture
Thai society is Buddhist and that Buddhism is the national religion. Buddhism is
supported by the ruler or King (Wongtes, 2000). However, the society is open to other
religious faiths. Most Thai people are Buddhist (94.2%), followed by Muslim (4.6%).
Christians (0.8%), Hindus and Confucians (0.1%) others, and unidentified (0.3%)
(Wibulpolprasert, 2005). Buddhist culture in modern Thailand is mainly Theravada
Buddhism mixed harmoniously with Mahayana schools and supernatural beliefs.
Wongtes (2000) explained that before Thai people accepted Buddhism and Brahmanism
19
Chapter 2: Setting the context
from India, they had their own traditional beliefs, especially the belief in “phi” or
spirits. Many Thai people have believed in spirits and supernatural or magical power.
Mulder (2000) analysed the symbolic representations of two basic principles in Thai
culture which were, khuna (moral goodness) and decha (amoral power) (see Table 2.1),
which helped to explain Thai interaction. The decha dimension of perception and
behaviour were applied to public life, primarily perceived as holders of power and
hierarchical position. Behaviour in the public world was characterised by good looking
presentation, ordered along lines of hierarchy and relative power, associating a person
with his or her status position, and analytically characterised by relative social distance
and access to resources, unstable pattern of interaction, characterised by the laws of
amoral power, forceful social control, and a short time perspective. The decha affects
the use of power, protection and auspiciousness, both in public life and religious
practices. Right manners and a smile seem to smooth interaction and to induce kind and
pleasant mutuality in confrontation with strangers, while right presentation is used for
promoting kindness and protection in return from powerful persons. Animistic
expression of “magic” are popular in Thai Buddhist culture, which deal essentially with
the tenuous order of saksit, plus the chaotic realm of evil powers and these religious
expressions were influences by Brahmanic expressions (include state ritual, civic
religion, and khwan ceremonies). To understand Thai interaction, one should
understand power (Mulder, 2000), (see detail about khuna and decha in Table 2.1).
According to Wongtes (2000), Buddhism has taken root in Thai society for a long time.
As religion is a major factor in shaping society, Buddhism has influenced Thai attitudes
and social values. The Thai value system is inseparably tied to the Theravada sect of
Buddhism. For example, Thai people value individualism rather than group
cohesiveness or the collective interest. They do not give serious advice to others. All
this is in line with the teachings of Buddhism that one should help oneself and should
not interfere with other’s business. As a result, their capacity for teamwork leaves much
to be desired.
20
Chapter 2: Setting the context
Table 2.1: Classification of Thai symbolic representations (adapted from Mulder, 2000:
38-39)
Khuna (moral goodness)
Order
Pure order
Symbol
Interpretation
The Buddha
(Dhamma;
Sangha)
Order of
goodness
The mother
(parents;
teacher)
Order of
community
The “good”
leader (thammaracha; “father”
Quality
Pure virtue
Pure
compassion
Wisdom
Stillness
Stability
Moral
goodness
(pure
bunkhun)
Reliability
Forgiveness
Time
perspective
Religious
complex
Cycle of
rebirth
Doctrinal
Buddhism
Eight Fold
Path
Aim
Liberation,
better rebirth
Means
To make merit
as a moral
pursuit
Infraction
Sin
Direction
Ultimate
refuge
Decha (power)
Tenors order
Chaos
Bad spirits
(death)
Phra-khun and
phra-decha
Safety
Mutuality
Stability to be
defended
Saksit forces
(spirits (phi);
thewada
(gods)
Ambiguous;
potentially
protective;
benevolent yet
jealous; amoral
Instability
Continuity
Lifelong
Short time
To honour
parents, elders
and teachers
Cult of Mother
Rice (Mae
Phosop)
Moral
continuity;
identity;
fertility
To
acknowledge
khun; to be
grateful; to
return favours
Agriculture
ritual
Brahmanic
ritual; ancestor
cult; khwan
ceremonies
“Civic religion”
Animistic
ritual
(including
popular
Buddhism)
Auspiciousness;
continuity and
safety; peace
To ensure
protection and
good fortune
To be a
dependable and
reliable group
member
To respect
tradition
To show
respect; to vow
and redeem the
vow
To make merit
as a protective
pursuit
Stupidity, social
sanctions
Revenge; bad
fortune; loss
face
One has to
give/respect
first
Karmic
retribution;
feeling of guilt
One receives
first
Reciprocity
Entirely
dangerous:
whimsical;
threatening
Immoral
Capriciousness
Immediate
Magic
(mobilising
saksit power)
Awamonghkon
(death) ritual
To ward off
danger
Protective
amulets,
khatha
(incantation),
etc.
Powerful
magic
To make
merit for the
deceased
Activates
danger
One is
extorted
The present social structure reflects much of such religious teachings: for example, the
relationship between the younger and the senior, belief in reincarnation, the law of
causality (kamma), making merit (thambun), in the hope of a better life in the next
reincarnation, and lifelong monkhood as the greatest merit (Wongtes, 2000).
21
Chapter 2: Setting the context
Wat Thai capitalizes on the Buddhist belief of “making merit” “giving gifts” to the
monk and the temple, and “doing good thing” throughout one’s life. Merit making has
long been the most popular everyday practice among Thai Buddhists for accumulating
good kamma and positively influencing a person’s current and future lives (Bao, 2005).
In addition, merit making entails some simple actions such as giving alms, offering food
to the monks, and helping others. However, in many merit making events, Thai people
tend to be extravagant, physically and financially, because they believe the more they
do the better their next life will be (Wongtes, 2000). According to Bao (2005), he
referred Thai American’ capitalist activities at Wat Thai in California as “merit-making
capitalism”, in addition, Terweil (1995) concerned about the strength and complex of
the magico-animistic interpretation of Thai Buddhism which was underestimated in
western studies of the religion phenomena. The merit-making capitalism becomes the
main religious practices of Thai Buddhist people where they live.
Fundamentals of Buddhism
Buddhism was born in India where Brahmanism was dominant, after an Indian prince
known as Siddhartha Gautama, left his luxurious palace to seek the truth, and ways to
overcome suffering. He lived from approximately 563-483 BC (Silva, 1990; Bodhi,
2005). He achieved enlightenment (bodhi) while practising meditation, and thus was
known as the Buddha, the awakened one. Then he spent the rest of his life teaching the
Dhamma (truth). He gathered and ordained disciples, setting up an order of monks
(bhikkhus) and nuns (bhikkhunis). The Buddha also taught laymen and laywomen to
follow the Dhamma in their activities in society. Opposite to Hindu societal structure,
the Buddha accepted men and women equally and eradicated the traditional distinctions
between classes and castes (Ludwig, 2004). Later, Buddhism spread throughout South,
Southeast, and East Asia. People are interested in Buddhist teachings because of its
peaceful, non-dogmatic character, it has always adapted easily to the pre-existent
cultures and religious practices of people (Bodhi, 2005).
22
Chapter 2: Setting the context
There are three major divisions of Buddhsim: Theravada, Mahayana, and Vajrayana
(sometimes considered part of Mahayana). The Theravada (Hinnayana, way of the
elders) were considered as it closer to the original teaching of the Buddha, whereas
Mahayana (greater vehicle) modifies some new, broader teachings and practices, which
highlight compassion and kindness as a great act of the Bodhisattva. Vajrayana
(thunderbolt vehicle) included esoteric, Tantric practices into the basic Mahayana
framework (Bodhi, 2005). Today, generally, Theravada is dominant in the Buddhist
lands of South Asia and Southeast Asia such as Sri Lanka, Burma, and Thailand.
Mahayana predominates in East Asian countries such as China, Taiwan and so on; and
Vajrayana is strong in Tibet and also as Shingon, one of the Buddhist schools in Japan
(Ludwig, 2004).
The Four Noble Truths and the Noble Eightfold Path
The Four Noble Truths is the main teaching of the Buddha. The First Noble Truth is of
suffering (dukkha) all life is permeated with suffering, sorrow, anxiety, discontent, and
fear which underlie people’s lives. Even in moments of happiness, we know that they
will not last, and change, loss, sickness, and dying are experienced as suffering. The
Second Noble Truth reveals the cause of suffering, clinging or attachment. The Third
Noble Truth concerns the cessation of suffering. Suffering can be eliminated by not
clinging which leads to perfect health, wholeness, equanimity and the supreme state of
nibbana. The Fourth Noble Truth is the Noble Eightfold Path which consists of right
understanding, right intention, right speech, right action, right livelihood, right effort,
right mindfulness, and right concentration (Jumsai, 2000; Ludwig, 2004; Payutto,
2001).
These can be grouped as the three methods of moral training and ethical conduct
(comprising the right speech, right action, and right livelihood), concentration or mental
development (comprising right effort, right mindfulness, and right concentration), and
wisdom (consisting of right understanding and right intention). These practices are
23
Chapter 2: Setting the context
summed up by the three Fundamental Principles namely: not to do any evil, to cultivate
good, and to purify the mind. This is called the Middle Way. “Those who follow it
avoid the two extremes of sensual indulgence and self-mortification, and live a balanced
life in which material welfare and spiritual well-being go hand in hand, run parallel and
are complementary to each other” (Payutto, 2001: 9). “These disciplines are structured
to promote and reinforce wisdom, moral uprightness, and meditation. This way of life
combines mental, moral, and spiritual discipline holistically” (Ludwig, 2004: 153).
The Five Precepts
Lay Buddhists have been taught to cultivate good conduct by observing or undertaking
the training of the Five Precepts. The five precepts include: to avoid taking the life of
beings, to avoid taking things not given, to avoid sensual misconduct, to refrain from
false speech, and to abstain from substances which cause intoxication and heedlessness.
These are the basic precepts expected as a day to day training of any lay Buddhist
(Jumsai, 2000).
The Buddha teachings also value love, compassion and good friendship. “It is the
whole, not the half of the best life-this good friendship, this good companionship, this
association with good.” (Payutto, 2001: 10)
Buddhism and health
There is a widespread professional interest in Buddhist principles and benefits of
Buddhist practices. In the area of health care, the Buddha teachings are applied mainly
through psychology (Mcconnell 2004; Silva, 1990, 1991) and medicine especially in the
area of Buddhist ethics (Boyd, Ratanakul & Deepudong, 1998; Florida, 1994; Hughes
& Keown, 1999; Jormsri, Kunaviktikul, Katefian & Chaowalit, 2005; Ratanakul, 1986,
1988, 1999a,b, 2004). Nursing professionals have borrowed Buddhist health related
principles and applied them to the concepts of caring (Watson, 2005), spiritual care
24
Chapter 2: Setting the context
(McGrath, 1998; Tongprateep, 1998, 2000), palliative care (Bruce & Davies, 2005;
Johns, 2004; Ott, 2004), alternative care (Sohn & Loveland, 2002), nursing ethics
(Jormsri, Kunaviktikul, Katefian & Chaowalit, 2005; Tuckett, 1999), and stress
management (Cohen-Katz, 2004).
Mindfulness meditation (Bonadonna, 2003; Brown & Ryan, 2003; Cohen-Katz, 2004;
Krasner, 2004; Ott, 2004) and loving-kindness meditation (Carson, et al, 2005), have
became the mainstream healing methods. Mindfulness-based stress reduction (MBSR)
is popular among stress management techniques that can successfully reduce stress, and
increase empathy and well-being. As well as prayer, mindfulness and loving kindness
meditation and Buddhist healing techniques have become parts of holistic care, spiritual
healing, and alternative and complementary medicine (Fontaine, 2005; Sohn &
Loveland, 2002).
Issues and trends in the Thai health care system
Health care is becoming more complex due to its association with a range of social and
environment factors. Thailand’s health situation and trends require close inspection of
factors such as: genetics, behaviours, beliefs, and spirituality, also environmental factors
for example, physical, biological, economical, political, cultural, religious, educational,
technological, and other factors. These dimensions affect health problems as well as the
health service system. The Thai health care system is concerned with equity, quality,
and efficiency. The type and level of services cover public and private sectors
(Wibulpolprasert, 2005).
Thai National Health Development Plan
The conceptual framework of the National Health Development Plan under the 9th
National Economic and Social Development plan (2002-2006) continues to focus on the
concept of a “human-centred” development approach in the holistic manner adopted in
25
Chapter 2: Setting the context
the 8th Plan. His Majesty the King’s Philosophy of “sufficiency economy” has been
adopted as a guide for the development of the Thai people’s health including the overall
health system. Under the 9th Plan, “health” is regarded as the state of physical, mental,
social and spiritual well being, that is interrelated holistically. Therefore, to improve the
people’s health status, it is necessary to “develop the entire system that is linked to
several other elements”, that is, an individual and environmental (economic, social,
political, physical, and biological), the health service system, including active
participation of all sectors of society (Wibulpolprasert, 2005: 21). Developing primary
health facilities and healthy life-skills in a holistic manner, creates healthy lifestyles
based on self-reliance and self-care principles, using local wisdom and appropriate
technology, promoting the use of herbal medicines and Thai traditional medicine,
promoting good quality, accurate and up to date care, raising staff’s knowledge,
capability, skills, righteousness, morality, attitudes and values for health care services
(Wibulpolprasert, 2005).
Health services and health seeking behaviours
Health services in Thailand are classified into five levels according to the level of care
(Wibulpolprasert, 2005). Level 1 is the Self-Care at the Family Level. Level 2 is the
Primary Health Care Level related to health promotion and disease prevention in the
community. Level 3 is the Secondary Care Level, provided by health care personnel and
general practitioners (GPs). Level 4 is the Secondary Care Level, managed by medical
and health personnel with intermediate level of specialisation. Level 5 is the Tertiary
Care level including general hospitals, regional hospitals, University, large public
hospitals, and large private hospitals (Wibulpolprasert, 2005).
The health seeking behaviour of Thai people varies from using traditional care to
accessing public and private hospitals. The economic crisis in 1997 seemed to affect the
health seeking behaviour of Thai people. However, in 2004 there was an increase of use
in the private sector. Some people still depend on the traditional sector of care and some
26
Chapter 2: Setting the context
people prefer some treatment to deal with basic health problems, (see details in Table
2.2
Table 2.2: Health care seeking behaviours of Thai people (showed data in percentage)
(adapted from Wibulpolprasert, 2005: 165).
Behaviour
1991
1996
2001
2003
2004
No treatment
15.9
6.9
5.4
5.9
5.3
Traditional care/others
5.7
2.8
2.5
2.9
4.4
Self-medication
38.3
37.9
24.2
21.5
20.9
Health centres
14.8
20.8
17.4
23.9
24.6
Public hospitals
12.9
12.9
34.8
33.1
30.2
Private clinics/hospitals
12.4
18.7
15.0
19.4
22.7
The Ministry of Public Health (MoPH) is the core agency that implements the universal
coverage of health care or 30-baht health care scheme. It began with a pilot scheme in
six provinces in April 2001, later expanded to another 15 provinces on 1 June 2001, and
finally to all provinces in January 2002. As a result in Financial Year (FY) 2003, 47.7
million Thai citizens or 74.7% of all 63.8 million people nationwide were covered by
the universal healthcare scheme, leaving only 3.2 million people or 5% of total
population without any health insurance coverage, while the rest had already been
covered by other health insurance schemes (Wibulpolprasert, 2005).
Thai nursing
The development of Thai nursing shows the influences of Western nursing and medical
education and the health care system. However, nurses try to balance positive Thai
nursing characteristics influenced by Buddhist teachings, with the modern, Western
health care system.
27
Chapter 2: Setting the context
According to Muecke and Srisuphan (1989), in 1896 the first nursing school was
opened in Thailand. A succinct overview of the development of Thai nursing is
presented in Table 2.3. Muecke and Srisuphan (1989: 645) claimed that:
The strong royal interest in Western medicine has shaped not only the definition
of medical standards and practices in Thailand, but also the definition of
nursing. Nursing has followed medicines’ disease-oriented model … of hospital
based practices, where it remains subordinate to medicine both structurally and
in public opinion. By medicalising nursing practice in Thailand, medical control
over the profession has been continually reinforced. There is a close parallel
between the social constructs of imported biomedicine and the indigenous sociopolitical order that probably contributes to the easy transplantation of
biomedicine to Thai society: both structures are characterised by vertical
relationships with power concentrated at the top of social hierarchy.
28
Chapter 2: Setting the context
Table 2.3: Summary turning points in the development of nursing in Thailand (adapted
from Muecke & Srisuphan, 1989: 645)
Turning points
Year
1.
First hospital and medical school established
1888
2.
First nursing school established: The School of Medicine-Midwifery and Female
1896
Nurses, Bangkok
3.
Second nursing school founded: The Thai Red Cross Nursing School, in Bangkok
1921
4.
Third nursing school founded: McCormick Nursing School, in Chiang Mai
1923
5.
Government and Rockefeller Foundation fellowships for nurses to study abroad
1925-36
and for U.S.A. nurses to consult in Thailand
6.
Educational requirement for admission to nursing school raised to the tenth grade
1935
7.
Nursing Division established in the Ministry of Public Health
1952
8.
First Baccalaureate level nursing program established at Siriraj School of
1956
Nursing, Bangkok
9.
Public health added to curricula of Ministry of Public Health Nursing Schools
10. Educational requirement for admission to nursing school raised to the twelfth
1956
1959-73
grade
11. “Brain drain” of nurses to the west, particularly to the U.S.A., for work and study
1968-75
12. First university-level Faculty of Nursing established, at Khon Kaen University in
1971
northeast Thailand
13. Royal Thai Government and international organisation fellowships for doctoral
1971-88
study abroad, most in the U.S.A.
14. First master’s degree program in Nursing established the Faculty of Education,
1973
Chulalongkorn University
15. Four-year college-level or college-equivalent academic program required for all
1978
nursing schools in the country
16. Two-year post-secondary school program created by the MoPH to produce
1980
technical nurses
17. First doctoral program in Nursing established, at the faculty of Public Health,
1984
Mahidol University
18. Doctoral program in Nursing science established Faculty of Nursing at: Chiang
1990
Mai University, , Khon Kaen University, Mahidol University, and Prince of
Songkla University
29
Chapter 2: Setting the context
At present, Thailand has 64 nursing colleges under seven major agencies: 13 under the
Ministry of Education, 35 under the Ministry of Public Health (MoPH), three under the
Ministry of Defence, one under the Royal Thai Police, one under the Thai Red Cross
Society and 10 in the private sector. From 2005 state-run nursing colleges (except for
those under the Ministry of Education) will be educating more nurses. The MoPH
nursing colleges will be producing 1,000 more nurses each year, in addition to current
output of 15,000 nurses per annum as the current production output is insufficient.
In 2002, Thailand had 113,718 registered professional nurses, but only 76,578-91,602
nurses are actually practising for its population of about 63 million. It is estimated that
in 2015 there will be 120,197-173,321 professional nurses, whereas there will be a need
for 137,997-142,336 professional nurses. That is, in the future supply will be close to
demand. Most of the nurses are clustered in Bangkok and the central region. Their
distribution trends are close to those of medical doctors, dentists and pharmacists
(Wibulpolprasert, 2005).
Conclusion
This chapter sets the context for the research by describing foundational ideas relating
to Thai Buddhist culture, Buddhism, the Thai health care system, and Thai nursing. As
these ideas do not influence the analysis and interpretation of participants’ accounts, the
literature relating to these areas has been placed in this section of the thesis, to orientate
readers to fundamental Thai and Buddhist principles and way of life in Thailand.
Chapter three describes the grounded theory methodology used in this research.
30
Chapter 3: Methodology
CHAPTER 3
METHODOLOGY
Introduction
This research explored influences of Buddhist culture on the nurse-patient-relative
relationship in Thailand. The methodology of grounded theory provides practical
techniques and procedures to study social processes of interactions and relationships
among people. Moreover, grounded theory is also suitable to explore psycho-social
and spiritual care processes (Annells, 2003). This chapter illustrates grounded theory
and its position in qualitative research, the strengths and weaknesses of grounded
theory, approaches of grounded theorists and the development of grounded theory
methodology. The three main approaches of Glaser and Strauss, Glaser, Strauss and
Corbin in terms of components, major differences are discussed. Also described are
grounded theory studies in spirituality and the nurse-patient-relative relationship,
and grounded theory research in a Thai Buddhist context.
Grounded theory and its position in qualitative research
Qualitative research was originally established in sociology, from the work of the
Chicago School in the 1920s and 1930s. In the same period anthropologists also
used qualitative approaches to study the customs and behaviours of other cultures
and societies, and other disciplines, such as education, psychology, nursing,
medicine, social work and business utilised qualitative research to investigate the
body of knowledge of each discipline (Denzin & Lincoln, 2003a). There are many
phases of change in the area of research inquiry and Denzin and Lincoln (2000)
pointed out the seven moments of qualitative research, which were explained in five
phases. These include 1) the traditional phase (the early 1900s to World War II), 2)
the modernist phase (the postwar years to 1970s), 3) blurred genres (1970-1986), 4)
the crisis of presentation (the mid-1980s) 5) the triple crises and paradigm shift
especially of the meaning of knowledge, ways of knowing and quality of each kind
of research. Annells (1997) also contented that each changing moment also
influenced the development of grounded theory in nursing.
Chapter 3: Methodology
People ask questions and seek various ways to find new knowledge over time.
Communities subscribe to different paradigms or views of the world, and a
researcher’s choice of paradigm will influence their work, and how they think and
act during the research process (Norton, 1999). Qualitative research is a natural way
to understand human knowing and existing. For example, Taylor (2002a: 307)
explained that:
Whenever nurses raise questions about what they know, and how they know
it is trustworthy knowledge, they are asking about epistemological questions.
Whenever nurses are asking about the nature of the existence of something
or someone in nursing, they are asking ontological questions.
Qualitative research focuses on the naturalistic perspective and the interpretive
understanding of human experience (Denzin & Lincoln, 2003b). Generally, a
philosophy underpins ways to find knowledge, for example, “constructivism is the
basis for naturalistic (qualitative) research which include grounded theory approach,
while positivism and more recently post-positivism, is the basic of empirical
analytical (quantitative) research” (LoBiondo-Wood & Haber, 2006: 133). The basic
beliefs of constructivist paradigm include assumptions about epistemology. The
truth is determined by the individual or cultural group, subjectivist values, and
created findings. Ontology means relativism where local and specific constructed
realities and multiple realities exist, influenced by culture and environment. Context
is emphasised and value is placed on rich details of context in which phenomena
occur. Inquiry aims for description (narrative), understanding, reconstruction and
building middle range theory. Values are included and add to understanding the
phenomenon. The researcher is an active participant as facilitator of multi-voice
reconstruction. Methodology is hermeneutical and dialectical. Knowledge
accumulation is informed and by sophisticated reconstruction and vicarious
experience. Ethics is an intrinsic process and goodness or quality criteria, value
trustworthiness and authenticity (LoBiondo-Wood & Haber, 2006). Grounded
theory also shares commonality among these qualities while it has some degree of
positivist inquiry (McCann & Clark, 2003a).
32
Chapter 3: Methodology
There are many ways of categorising qualitative research. The most common
methodologies in qualitative interpretive forms are phenomenology, ethnography,
grounded theory and historical research; while action research, feminist research and
critical ethnography are critical qualitative methodologies (Taylor, 2002a). Although
there are many different approaches for qualitative research, grounded theory is the
most rigorous method for providing preliminary or exploratory research in an area in
which little is known (Glaser & Strauss, 1967; Taylor, 2002b; Schreiber & Stern,
2001; Strauss & Corbin, 1998), where existing theory offers no solutions to
problems, or for modifying existing theory (Bluff, 2005).
The methodology for this project is grounded theory. Originally, it was developed
by two American sociologists, Barney Glaser and Anselm Strauss in 1967 (Annells,
2003; Byrne, 2001; Cutcliffe, 2000; Dey, 2004; McCann & Clark, 2003a). Grounded
theory was designed “to discover theory rather than test hypotheses deduced from
prior knowledge” and was concerned “to generate theory rather than to generalise
from cases to wider populations” (Dey, 2004: 90). Strauss and Corbin (1998: 9)
stated that:
The reasons for the development of this methodology were (a) the need to get
out into the field to discover what is really going on; (b) the relevance of
theory, grounded in data, to the development of a discipline and as a basic for
social action; (c) the complexity and variability of phenomena and of human
action; (d) the belief that persons are actors, who take an active role in
responding to problematic situations; (e) the realization that persons act on the
basis of meaning; (f) the understanding that meaning is defined and redefined
through interaction; (g) a sensitivity to the evolving and unfolding nature of
events (process); and (h) an awareness of the interrelationships among
conditions (structure), action (process), and consequences.
Grounded theory is “a highly systematic research approach for the collection and
analysis of qualitative data for the purpose of generating explanatory theory that
furthers the understanding of social and psychological phenomena” (Chenitz &
Swanson, 1986: 3). Grounded theory is a mode of inductive analysis, and Glaser
33
Chapter 3: Methodology
(1978: 37) explained “the theory is induced or emerged after data collection starts.”
It can be thought of as a theory that is derived from the “ground” of everyday
experiences, such as nurse and patient interactions, discharge planning, physician
and nurse communication and management styles (Carpenter, 2003). The
foundations and epistemological assumptions of grounded theory are embedded in
symbolic interactionism (Chenitz & Swanson, 1986; Glaser, 1978), which assumes
that one’s communications and actions express meaning (Byrne, 2001), which
represent the process of interaction between peoples’ social roles and behaviours
(Denzin, 1989 cited in McCann & Clark, 2003a). Grounded theory has major
differences from other qualitative methodologies because its primary purpose is to
generate or develop explanatory models of human social processes, which are
grounded in the data (Eaves, 2001). While phenomenology researchers focus on
describing a particular phenomenon, grounded theory researchers develop a theory
from psychosocial process and specific events (Carpenter, 2003). Strauss & Corbin
(1998) stated that:
Grounded theory means theory derived from data, systematically gathered and
analysed through the research process. In this approach, data collection,
analysis, and eventual theory development are in close relationship to one
another. A researcher does not begin a project with a preconceived theory in
mind. Rather, the researcher begins with an area of study and allows the theory
to emerge from the data. Grounded theories, because “they are drawn from
data, are likely to offer insight, enhance understanding, and provide a
meaningful guide to action” (Strauss & Corbin, 1998: 12).
A central feature of grounded theory is its method of constant comparative analysis
(Glaser & Strauss, 1967, Morgan, 2001, Priest, Roberts & Woods, 2002; Strauss &
Corbin, 1998), in which data collection and analysis occur simultaneously. Each
item of data is compared with every other item; then similar items are grouped
together to form categories, focused on theoretical coding; more data are collected
by using theoretical sampling methods to gain different aspects to support each
category; and some irrelevant codes might eliminated before linking core categories
together to form a core basic process. The inductive form of theory is “conceptually
34
Chapter 3: Methodology
dense”, that is, it develops a theory with many conceptual relationships, and these
relationships are embedded in a context of descriptive and conceptual writing”
(Cutcliffe, 2000: 1477).
Field and Morse (1985: 4-7) divided theory development into three types which
were: deductive theory in the scope of a quantitative study, inductive theory in a
qualitative approach, and grounded theory which is “one approach to development
of inductive theory, although both inductive and deductive thinking are used in the
process.” Bluff (2005: 154) also supports this idea that “unlike other qualitative
approaches, grounded theory is therefore an inductive and deductive process.” Also,
“when placed on a continuum with other qualitative approaches, grounded theory
can be sited as close to the quantitative paradigm when compared with other
qualitative approaches” (Bluff, 2005: 149). McCann and Clark (2003a: 9) stated that
grounded theory applies “processes of induction, deduction, and verification”, and
they also explained:
Induction requires the researcher to use a ground-up (from practice to theory)
approach, to enter the field with no preconceived hypotheses from literature
or elsewhere, and to be open-minded and flexible, so that the theory emerges
from data. Only after initial data collection can provisional hypotheses be
formed. Empirical verification of the hypotheses is undertaken through
further data collection. The theory can then be tested, allowing predictions to
be developed deductively from general principles.
Glaser (1978:37-38) explained that:
deductive work in grounded theory is used to derive from induced codes
conceptual guides as to where to go next for which comparative group or
subgroups, in order to sample for more data to generate the theory … Suffice
as to say, deduction is in the service of further induction and the source of
derivations are the codes generated from comparing data, not deductions
from pre-existing theories in the extent literature … the focus of deduction is
35
Chapter 3: Methodology
on more comparisons for discovery, not on deriving an hypothesis for
verification.
Grounded theory was not initially intended as a pure qualitative method, however it
has become a favoured approach in qualitative studies (Bluff, 2005). The outcome of
theory development is substantive or formal middle range theory. This kind of
theory is derived from inductive approaches and shows the connection of related
concepts of one or more categories (Annells, 2003).
Strengths and weaknesses of the grounded theory
There are some critical points about the nature of the grounded theory which can be
explained as strengths and weaknesses. According to Annells (2003), the strength of
grounded theory is in providing systematic analysis methods and procedures, which
can attract many new researchers. The weakness of grounded theory is the complex
methods of developing theory. Often researchers “present their findings
thematically, based around the categories that have been developed following
grounded theory techniques, instead of developing a true grounded theory” (Priest,
Roberts & Woods, 2002: 4). Moreover, Lofland (1971) and Charmaz (2000) noted
that grounded theory researchers pay little attention to data collection methods.
However, researchers can amend this weak point by applying qualitative research
data collection methods, which mainly use semi-structured interviews, participant
observation, field notes, and documentary materials (McCann & Clark, 2003c).
Issues of “rigour” or quality of grounded theory have also been discussed. The main
issue is about research quality, or “meeting the test of rigor” (Guba & Lincoln, 1981:
104), which comes from the traditional image of qualitative research which was
labelled “soft” science (Denzin & Lincoln, 2003a). However, Glaser and Strauss
(1967) realised this issue when they developed grounded theory, providing
systematic data collecting and analysis methods including the constant comparative
method to generate theory from data, which can demonstrate fit, work and
relevance, and modifiability. Guba and Lincoln (1981: 104) proposed new terms to
assert the nature of qualitative criteria (Table 3.1). Sandelowski (1986, 1995) also
36
Chapter 3: Methodology
raised awareness that nurse researchers should be concerned about how qualitative
research can be made rigorous and trustworthy.
Table 3.1: Scientific and naturalistic terms appropriate to various aspects of rigor
(Guba & Lincoln, 1981: 104)
Aspect
Scientific terms
Naturalistic terms
Truth value
Internal validity
Credibility
Applicability
External validity/
Fittingness
generalisability
Consistency
Reliability
Audibility
Neutrality
Objectivity
Confirmability
Grounded theory researchers pay attention to research quality by adhering to
trustworthiness
criteria
such
as
credibility,
transferability,
dependability,
confirmability (Polit & Beck, 2004; Roberts & Taylor, 2002) or fairness and
authenticity (Chiovitti & Piran, 2003).
Grounded theory is an interpretive research approach, in the constructivist paradigm
of qualitative research, influenced by symbolic interactionist epistemology. It aims
to generate middle range theory based on specific social events or participants’
experiences. It is placed conceptually in between quantitative and qualitative
approaches because it uses inductive and deductive inquiry to build substantive or
formal theory. The strength of grounded theory is in providing systematic analysis
methods and procedures; the weakness of the grounded theory is the complex
methods of developing theory while paying little attention to data collection
methods. Grounded theory is a rigorous method for providing preliminary or
exploratory research findings in order to build middle range theory in an area which
is unclear or little is known.
37
Chapter 3: Methodology
Approaches of grounded theorists
Strauss and Corbin (1998) pointed out that their approach can help researchers
develop the main characteristics of grounded theorists such as: the ability to step
back and critically analyse situations, to recognise the tendency toward bias, to think
abstractly, to be flexible and open to helpful criticism, sensitive to the words and
action of participants, and a sense of absorption and devotion to the work process.
This section describes the development of grounded theory by key grounded
theorists.
Development of grounded theory methodology
Within 40 years, since two sociologists, Glaser and Strauss (1965) started the first
grounded theory study about death and dying process; grounded theory has been
developed and modified into two main approaches, of the classic approach and
Strauss and Corbin’s approach. These two versions have been used by many
researchers in many disciplines including nursing and business. Dey (2004: 80)
claimed that “we have different interpretations of grounded theory-the early version
or the late version, and the version according to Glaser (1978), or Strauss and Corbin
(1990), among others (e.g. Charmaz, 1990 and Kools et al., 1996 cited in Dey,
2004).” The development of grounded theory approaches reflects the flexibility of
the original purpose of the co-developers, Glaser and Strauss, who claimed that
grounded theory can be applied flexibly to any discipline in order to generate theory
from data (Glaser & Strauss, 1967).
The original version of grounded theory was published in 1967 in the book “The
Discovery of Grounded Theory” (Glaser & Strauss, 1967). The first development
occurred when Glaser (1978) launched his monograph “Theoretical Sensitivity,
Advances in the Methodology of Grounded Theory”, in order to support doctoral
students and colleagues. In 1987, Strauss published his book “Qualitative Analysis
for Social Scientists” to provide more formal guidelines to novice students and
researchers about different data analysis techniques and procedures. In 1990, Strauss
extended his work after working with Juliet Corbin, a nurse researcher, and
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Chapter 3: Methodology
published the Strauss and Corbin’s version of grounded theory in the book “Basics
of Qualitative Research: Grounded Theory Procedures and Techniques”. The second
edition of this book was republished in 1998, a year before Strauss died.
During that period, there were many debates and criticisms about the differences
between the two approaches. The main criticism was that Strauss and Corbin’s
approach tended to force the theory development (Annells, 1997; Duchscher &
Morgan, 2004; Glaser, 2005), by using several analytic tools and a paradigm model
to guide data analysis, as well as using personal experience and literature to enhance
sensitivity to data, thus paying more attention to using pre-existing theories through
deductive analysis. Strauss and Corbin’s approach was criticised as devaluing the
emerging nature of the classic version (Glaser, 1992, 2005). It was seen to “distort
and misconceive grounded theory” (Bluff, 2005: 148).
In 1992, Glaser maintained his emerging version of grounded theory, which focuses
on generating theory and using proper theoretical coding and spoke out against the
methods that force the analysis. In the beginning of the twenty-first century Kathy
Charmaz (2000), a Professor of Sociology, realised the flexibility of grounded
theory methods and the paradigm shift of the qualitative worldview, and criticised
the objectivist approach of the original version of Glaser and Strauss and Corbin’s
version. She presented a new short cut version of grounded theory called
“constructing grounded theory”. This approach shares all commons basic concepts
of grounded theory, however, in her latest book, Charmaz (2006) claims that the
researcher can use personal and professional experiences when analysing the data
and constructing a grounded theory, which clearly supports Strauss and Corbin’s
analysis methods. It is too early to make critical comments on this newest version of
grounded theory. However, for nurses and other researchers, any version of
grounded theory can be applied if it includes all basic principles and methods to
build a theory from the ground. Nurse researchers can apply whichever version fits
their inquiry, phenomenon and personal experiences.
This following section explains the brief development of the grounded theory
approach, which includes four versions of grounded theory which are the original
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Chapter 3: Methodology
version, Glaser’s classical grounded theory, Strauss and Corbin’s version, and
Charmaz’s constructing grounded theory. I will summarise the commonality of these
four approaches and the distinguishing components as well as discuss each version.
The commonality of the four approaches
The four versions of the grounded theory share basic assumptions of grounded
theory interpretative inquiry within the constructivist paradigm. Charmaz (2003:
249-250) stated that:
Essentially, grounded theory methods consist of systematic inductive
guidelines for collecting data and analysing data to build middle-range
theoretical frameworks that explain the collected data.
McCallin (2003: 205) asserted that “the main differences of each version are about
how the techniques and procedures are interpreted.” According to Dey (2004: 8081), firstly, all grounded theory “requires of the researcher a sensitivity to empirical
evidence, a deposition to ‘discover’ ideas in data without imposing preconceptions.”
Secondly, grounded theory involves a process of “theoretical sampling” of
successive sites and sources, selected to test or refine new ideas as these emerge
from data. Thirdly, grounded theory relies to some extent on qualitative data
acquired through a variety of methods, such as observation and unstructured
interviews in the initial stages, then more structured forms of data collection as the
study becomes more focused. Fourthly, the process of analysing data centres on
“coding” data into categories for the purpose of comparison. Constant comparison
identifies and redefines relations and properties. Finally, grounded theory provides
the methods to build theory.
Data collection is completed when categories reach “theoretical saturation”, that is,
when no new ideas emerge Also, data analysis stops when core categories emerge
and the researcher links connections of each core category and explains a basic
social process of the emerging theory. Annells (2003: 168) claimed that the
fundamental elements of grounded theory include: 1) theoretical sampling, 2)
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Chapter 3: Methodology
constant comparative data analysis, 3) theoretical sensitivity, 4) memo writing, 5)
identification of a core category and 6) a resultant explanatory theory. Similarly,
McCann and Clark (2003a), and Backman and Helvi (1999) concluded that
grounded theory has seven key characteristics which are: theoretical sensitivity,
theoretical sampling, constant comparison analysis, coding and categorising the
data, theoretical memos and diagrams, literature as a source of data, and integration
of theory. These elements are described in detail in Chapter 4.
The distinguishing components of grounded theory
Glaser and Strauss’s approach: the original version
Originally, grounded theory research responded to the criticism of traditional
qualitative research by empirical deductive research (Glaser & Strauss, 1965).
Barney Glaser and Anselm Strauss utilised the different strengths of qualitative and
quantitative approaches to study death and dying phenomena in the hospital context,
from which they gained new ways of theory development. Glaser and Strauss
(1965), then published the first grounded theory strategies for qualitative researchers
in the book “Discovery of Grounded Theory” in 1967. The name “grounded theory”
reflected that the discovery of theory from data. In order to show strong evidence
that the theory generating process was accurate and rigorous, Glaser and Strass
(1967: 3) claimed “the discovery of theory from data-systematically obtained and
analysed in social research.” In brief, the original version of grounded theory
explained techniques to generate theory by performing theoretical sampling, doing
comparative analysis forming substantive or formal theory, clarifying and accessing
comparative studies.
Glaser and Strauss (1967) also confirmed the flexible use of data as well as the
validity of grounded theory. They used the word “rigor” to convey the worth of the
research, for example, “more rigorous testing may be required to raise the level of
plausibility of some hypothesis” (Glaser & Strauss, 1967: 233). The focus on rigor
attracted critical comments from quantitative researchers that this word reflected
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Chapter 3: Methodology
scientific inquiry (Sandelowski, 1986) and that other forms of qualitative research
were just as rigorous as the grounded theory methods (Chiovitti & Piran, 2003).
The Glaserian approach: the classic version
The classic grounded theory method or Glaserian version was developed by Barney
Glaser. His book “Theoretical Sensitivity” illustrated advances in the methodology
of grounded theory (Glaser, 1978). (See the main characteristic of this version in
Table 3.2). He explained how to do theoretical sensitivity, theoretical sampling, and
theoretical coding in order to reach theoretical saturation (Glaser (1978). Glaser
(1978, 1992, 1998, 2005) values the idea of emerging data which happens when the
researcher becomes more sensitive to the data, by not letting any preconceptions
from literature and researcher experiences to bias data collecting and analysis. While
Glaser (1978) proposed an open and theoretical coding to generate theory, Strauss
and Corbin (1990) used open, axial and selective coding to develop theory (Annells,
2003; Dey, 2004). Glaser (1978) suggested techniques to analyse data by using
coding families, which included: causality: causes, contexts, contingencies,
consequences and conditions, process: stages, phases, progressions; classification:
type, form, kinds, styles, classes, etc.; strategy: strategies, tactics, mechanisms, and
so on. When Strauss and Corbin (1990, 1998) opened channels for researchers to use
their personal, professional experiences and some related literature in the theory
development process, they developed the paradigm model of analysing qualitative
data to enhance researcher sensitivity to data and thereby gain various dimensions of
data, whereupon Glaser (1992, 2002, 2005) commented that Strauss and Corbin
devalued the real meaning of the grounded theory.
Glaser’s approach is “the emerging version” because it values the naturally
emerging theory from the data without forcing data. This version was critiqued as a
more open and less structured approach (McCann & Clark, 2003c).
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Chapter 3: Methodology
Strauss and Corbin’s approach
According to Duchscher & Morgan (2004), this version can be called “Straussian’s
version”. Ten years after developing grounded theory with Glaser, in 1987 Anselm
Strauss published his own book “Qualitative Analysis for Social Scientists” (Strauss,
1987), which presented the development of new techniques and procedures for
doing grounded theory. In 1990 Strauss and his nursing research colleague, Juliet
Corbin developed the book “Basics of Qualitative Research” which has become the
main reference of the Strauss and Corbin’s version (Annells, 2003).
Strauss and Corbin’s approach highlights three levels of data analysis which include:
open, axial and selective coding, and some new analytic tools and ideas for using the
Paradigm Models to analyse data (Annells, 2003; Strauss & Corbin, 1998). Charmaz
(2000) contended that this version of grounded theory was similar to constructivist
methods, which later she applied in her constructivist grounded theory approach.
McCallin (2003) claims that Strauss and Corbin’s approach (1998) provides a clear,
explicit framework that assures the novice researcher, but its technical procedures
and methods may restrict a researcher’s creativity, in contrast to Glaser’s version
which provides more open methods and processes. However, Strauss and Corbin
(1990, 1998) suggested that researchers use the tools flexibly when necessary. Even
though this version was criticised by Glaser (1992, 2002) as “the forcing version”, it
provides various techniques and procedures for theory development and a more
structured approach to data collection and analysis (McCann & Clark, 2003c), which
assists novice researchers.
Charmaz’s approach: the constructivist version
Dey (2004: 80) claims that “like any cultural artefact, methodologies change and
evolve.” Charmaz (2006: 9) claims that some researchers including herself “have
moved grounded theory away from the positivism in both Glaser’s and Strauss and
Corbin’s version of the methods.” Glaser and Strauss encouraged other researchers
to use grounded theory strategies flexibly in their own way.
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Chapter 3: Methodology
Constructivist grounded theory is derived from the interpretive tradition and
objectivist grounded theory is derived from positivism. Constructivism “places
priority on the phenomena of study and sees both data and analysis as created from
shared experiences and relationship with participants and other sources of data”
(Charmaz, 2006: 184). Charmaz (2006: 130) also explained that:
A constructivist approach means more than looking at how individuals view
their situations. It not only theorises the interpretive work that research
participants do, but also acknowledges that the resulting theory is an
interpretation. The theory depends on the researcher’s view; it does not and
cannot stand outside of it.
Basically, this version employs basic grounded theory techniques and procedures
similar to Strauss’s version, such as coding, memo-writing, theoretical sampling and
saturation and integrating. However, it highlights different levels of coding which
include: 1) initial line-by line coding and 2) focus coding, including axial coding and
theoretical coding. Charmaz (2006) helps researchers by providing clear paths that
expand worldviews, quickening the pace and avoiding problems in the grounded
theory development. She claims that “the constructivist grounded theory provides a
methodological route to renewing and revitalising the pragmatist foundations of
classic grounded theory, it can also serve researchers from other traditions”
especially feminist theory, narrative analysis, cultural studies, critical realism, and
critical inquiry. The main standpoint of this version is influenced by the Chicago
school traditions with pragmatist underpinnings that “foster openness to the world
and curiosity about it; encourage an empathetic understanding of research
participants’ meanings, actions, and worlds; take temporality into account; and focus
on meaning and process at the subjective and social levels” (Charmaz, 2006: 184).
Similar to Strauss and Corbin’s version, the role of constructivist grounded theory is
for the researcher to use their personal and professional experiences to construct the
data that are derived from participants’ experiences and events. Charmaz (2003)
claimed that the Strauss and Corbin approach is close to the constructivist approach
and she intended to move grounded theory away from the logical-positivist tradition.
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Chapter 3: Methodology
In her view objectivist grounded theory, such as Glaser’s classic version is “a
grounded theory approach in which the researcher takes the role of dispassionate,
neutral observer who remains separate from the research participants”, to analyse as
an outside expert, and this treats research relationships and representation of
participants as unproblematic (Charmaz, 2006: 188). As a form of positivist
qualitative research Glaser’s grounded theory subscribes to many of the assumptions
and logic of the positivist tradition (Charmaz, 2006).
Charmaz (2006: 131) also asserts that
Thus, the constructivists attempt to become aware of theory presuppositions
and to grapple with how they affect the research. They realise that grounded
theorist can ironically import preconceived ideas into their work when they
remain unaware of their starting assumptions. Thus, constructivism fosters
researchers’ reflexivity about their own interpretations as well as those of
their research participants.
After reviewing several critiques from qualitative researchers especially sociologists
(Charmaz, 2000, 2006; Denzin & Lincoln, 2003a; Dey, 2004; Seale, Gobo, Gubrium
& Silverman, 2004), and nursing scholars (Annells, 2003; Benoliel, 1996; Bluff,
2005; Duchscher & Morgan, 2004; Field & Morse, 1985; McCallin, 2003; McCann
& Clark, 2003a,b; Schreiber & Stern, 2001) on each version of grounded theory,
there were three main reasons that promoted the changes of grounded theory
approach such as which were: the different background of Barney Glaser and
Anselm Strauss, the flexibility of grounded theory methods, and the influence of the
paradigm shift.
Firstly, the different background of Barney Glaser and Anselm Strauss later
influenced their different ideas about data collection and analysis processes. Glaser
had a background in quantitative research and Strauss had grounding in qualitative
research (Bluff, 2005). Dey (2004: 80) noted that “sadly, what started as a most
productive partnership between Glaser and Strauss ended in something akin to
acrimonious divorce”. Secondly, the flexibility of grounded theory methods
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Chapter 3: Methodology
enhances creativity of researchers (Charmaz, 2003; Strauss and Corbin, 1998). This
has assisted the paradigm shift of grounded theory from positivist paradigm to other
perspectives (Charmaz, 2006). Lastly, the influence of the paradigm shift has
encouraged new ways of seeking and validating knowledge (Annells, 1997; Denzin
& Lincoln, 2003a). McCann and Clark (2003c: 31) conclude that Strauss and
Corbin’s approach “reflected the contemporary shift towards social constructivist
ontology and poststructuralist paradigm”, while classic grounded theory was
established in “the critical realist ontology and postpositivist paradigm.”
Major differences between Glaser’s classical approach and Strauss and
Corbin’s approach
Among various approaches of grounded theory that concern human action and
interaction, Glaser’s classic grounded theory and Strauss and Corbin’s approach
have become the core methodologies for theory development. Annells (1997, 2003)
and McCann and Clark (2003b) distinguished several main differences between
these two versions and compared different procedural steps of two versions of
grounded theory (see Table 3.2).
The diversification of grounded theory approaches does not make one superior to
one another, rather, the changes represent the maturity and progression of theory
development (Annells, 1997; McCann & Clark, 2003b,c). This resembles Buddha’s
teaching about change; it is inevitable and everything is under the law of change.
We can learn from changes by being open to learn and being more flexible to deal
with any form of knowledge.
Strauss and Corbin’s grounded theory approach
Strauss and Corbin (1998) provided the basic knowledge and procedures for novice
grounded theory researchers who want to build substantive theory, which Corbin
said is “a way of life” of grounded theory researchers (Strauss and Corbin, 1998: ix).
Annells (2003) agreed that it suited the exploration psycho-social and spiritual care
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Chapter 3: Methodology
Table 3.2: Comparison of the procedural steps of two versions of grounded theory
method (adapted from Annells, 1997, 2003 and McCann & Clark, 2003b)
Glaser’s classic
Strauss and Corbin’s
Grounded theory method
Grounded theory method
Critical realist ontology and post
Social constructivist and post structuralist
positivist paradigm
or postmodern paradigm
More positivistic
Less positivistic
Researcher’s role
Independent
Dialectic and active
Theory
Emphasis on theory generation
Emphasis on verification and validation
Epistemology
of theory and hypotheses
Focus on the field
Literature review
Main emphasis on symbols,
Emphasis on structural, contextual,
interactions and context
symbolic and interactional influences
Emphasis on socially
Emphasis on describing cultural scene
constructed world of participants
(macro) and socially constructed world of
(micro)
participants (micro)
Main review to support
Primarily review to enhance theoretical
emerging theory
sensitivity
Main review to support emerging theory
Research problem
Emerges in study
Personal experience, suggest by others,
literature, Emerges in study
Emerging from data
Emerging from data
Data collection and
Principle and practices of
Rules and procedures
analysis
qualitative research
Paradigm model to provide structure
Theoretical
framework
Guided by participants and
socially constructed reality
Sampling
Theoretical sampling directed by
Theoretical sampling: open, relational/
emerging codes until categories
variational, and discriminative
are saturated
Sources of
Knowledge of coding families,
Professional and personal experience,
Theoretical
conceptual ability, and literature
literature and the analytic process
sensitivities
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Chapter 3: Methodology
Table 3.2: Comparison of the procedural steps of two versions of grounded theory
method (adapted from Annells, 1997, 2003 and McCann & Clark, 2003b) (cont.)
Glaser’s classic
Strauss and Corbin’s
Grounded theory method
Grounded theory method
Constant
comparative data
analysis:
Coding
Open and theoretical
Open, axial and selective
Coding framework
Choice from multiple
Specified coding framework named the
coding families depending
“Paradigm Model”
on best “fit” to data
Memos
Primarily for sorting to form
Code, theoretical, and operational notes
hypothesis
Focus on process
Movement over time with at
Linking of action/interaction sequences or
least two stages-a basic
non-progressive movements
social process
Category
Relevant categories and
In terms of properties which are then
development
relevant properties emerge
dimensionalised and the categories grouped.
by comparing incident to
Relationship validated against data. Gaps in
incident and/or incident to
categories are filled until theoretical saturation
concepts looking for the
is reached
relevance, the fit, and
emergent patterns until
theoretical saturation occurs
Core category
The basic social process
Expecting a story line about the central
emergence
emerges and is the core
phenomenon around which other categories
category that accounts for
are integrated using the Paradigm Model
most of the variation in the
problematic pattern
Conditional/
Nil-micro levels of analysis
Specified-moves between micro and macro
consequential
only
levels of analysis
Fit, work, relevance, and
Difference to canons of qualitative research
modifiability
outlines by other qualitative researchers,
matrix
Evaluation
within trustworthiness criteria such as
credibility, transferability, dependability,
conformability, fairness, authenticities, etc.
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Chapter 3: Methodology
processed. The merit of Strauss and Corbin’s grounded theory approach is that it
provides practical techniques and procedures to study social processes of interaction
and relationships among groups of people, and offers a set of useful tools for
analysing qualitative data in a flexible approach, not as commandments, but to allow
the researcher to use and adapt any method (Strauss and Corbin, 1990, 1998). This
version of grounded theory offers a methodology, “a way of thinking about and
studying social reality”, which was influenced by natural scientists, with strong
influences in qualitative research, such as Dewey (1922), Mead (1934), Thomas
(1966), Park (1967), Blumer (1969) and Hughes (1971) (Strauss & Corbin, 1998: 4,
9). The main characteristics of Strauss and Corbin’s approach are shown in Table
3.2. In the following section, descriptions are given of knowledge and procedures in
Strauss and Corbin’s grounded theory approach and the main characteristics of a
grounded theorist.
Basic knowledge and procedures in Strauss and Corbin’s grounded theory
approach
According to Strauss and Corbin (1990, 1998), Annells (1997, 2003), and McCann
and Clark (2003a), the epistemology of Strauss and Corbin’s grounded theory
approach is social constructivist and post structuralist, which is less positivistic and
closer to the postmodern paradigm. The researcher’s role is more active with
participants while collecting data, and researchers need to prevent any biases while
maintaining good relationships with participants. This approach emphasises
verification and validation of theory and hypotheses, which are originally derived
from data, by using literature or further data collection. The field of study includes
structural, contextual, symbolic and interactional influences on describing the
cultural scene (macro-level) and socially constructed world of participants (microlevel). The literature review consists of reviewing to enhance theoretical sensitivity,
and to support the emerging theory. The research problem is initially from personal
experience, suggested by others, literature, or it emerges during the study. There is
no theoretical framework before collecting data otherwise the preconceived ideas
can cause biases to block interpretation. The variety of concepts and categories of
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Chapter 3: Methodology
each complex phenomenon emerge naturally from data. Rules, procedures and the
paradigm model provide structure for collecting and analysing data.
Data
collection
and
analysis
focus
on
theoretical
sampling:
open,
relational/variational, and discriminative, in order to develop dense core-categories.
Strauss and Corbin (1990, 1998) pointed out that sources of theoretical sensitivities
come from professional and personal experience, literature and the analytic process.
Constant comparative data analysis highlights three levels of coding which are open,
axial and selective coding. The coding framework guides a specified coding
framework named the “Paradigm Model”. Memos which enhance systematic data
analysis include the code memo, theoretical memo, and operational notes. This
approach focusses on the process of the phenomenon by linking action/interaction
sequences or non-progressive movements. Category development in terms of
properties are then dimensionalised and the categories grouped and relationships
validated against data. Later, gaps in categories are filled until theoretical saturation
is reached. Finally, there is a core category emergence as story line about the central
phenomenon, around which other categories are integrated using the Paradigm
Model. This version of grounded theory does not clearly mention a basic social
process as a final outcome of theory, because it highlights categories and
relationship between categories. The matrix is of other techniques suggested by
Strauss and Corbin, to analyse the conditional/consequential phenomenon which
moves between micro and macro levels of analysis. Finally, Strauss and Corbin’s
version encourages the researcher to validate the grounded theory by trustworthiness
criteria, such as credibility, transferability, dependability, confirmability, fairness,
and authenticity.
Responses to Strauss and Corbin’s grounded theory approach
Strauss and Corbin (1998) contended that they did not intend to disrespect Glaser’s
work, but they learnt and modified ideas from teaching and working experiences.
According to Bluff (2005), this version allows researchers to integrate ideas from
the literature and undertake further sampling in order to expand the theory. Strauss
and Corbin claimed that they did not intend to force data, rather they provided
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Chapter 3: Methodology
practical techniques and procedures to develop a grounded theory derived from data.
They also valued researcher creativity and flexibility when they applied their
research tools and techniques, in using literature, personal, and professional
experience to enhance richness and various dimensions of theory (Strauss & Corbin,
1990, 1998).
Bluff (2005: 148-149) explained that Glaser (1992) claimed that “Strauss and
Corbin (1990, 1998) adopt a detailed, systematic and more prescriptive approach”,
which forces the development of theory and erodes the method by omitting some
original procedures such as the influences of symbolic interaction. However, Strauss
and Corbin (1990) debated that they have “adopted grounded theory to meet the
needs of phenomenon under study”, resulting in increased understanding and richer
theories using inductive processes.
Strauss’s version provides full conceptual description, which was later criticised by
Glaser (1992) as “a paradigm model that forces the data into a predetermined
structure” (Bluff, 2005: 154-155). Pidgeon (1996 cited in Bluff, 2005: 155) noted
that “this version is very structured; some researchers may follow it as prescriptions.
In contrast, the Glaserian approach could be perceived as being rather vague.” The
common issue is that Strauss and Corbin’s approach uses different phases of coding,
open coding, axial coding and selective coding.
When the researcher applies Strauss and Corbin’s approach, the outcome of
grounded theory development can be divided into three levels which are:
1) description-using language to convey ideas into abstract concepts and aspects of
the action and interaction, 2) conceptual ordering-organising ideas into abstract
concepts and grouping (classifying) these into like groups (categories) and possibly
sub-groups (sub-categories) in order to make sense of action and interaction, and 3)
an explanatory scheme-offers plausible but contextualised explanatory relationship
between the categories (and includes also levels of description and conceptual
ordering) (Annells, 2003: 166; Strauss & Corbin, 1998: 15).
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Chapter 3: Methodology
Because there are several differences between the two main grounded theory
approaches, Annells (1997) suggested that the grounded researcher should explain
their reasons for applying a particular version of grounded theory. In their grounded
theory research exploring how community mental nurses promote wellness with
clients who are experiencing an early episode of psychotic illness, McCann and
Clark (2003c) explained their reasons for selecting Strauss and Corbin’s approach.
These reasons were: firstly, Strauss and Corbin (1990, 1998) emphasised the
importance of identifying structural as well as contextual, symbolic and interaction
influences in micro and macro levels of analysis. Secondly, the paradigm model was
helpful in collecting data, structuring the analysis and developing categories while
they remained mindful about possibility of forcing data. Thirdly, this version
provided a more structured approach to data collection and analysis (McCann &
Clark, 2003c), which is useful for novice researchers.
Grounded Theory in Nursing
Nursing research links theory education and practice together, to achieve the goal of
providing quality bio-psycho-social outcomes in partnership with clients, their
families/significant others and the community in which they live (LoBiondo-Wood
& Haber, 2006). According to LoBiondo-Wood and Haber (2006), nursing research
has developed through many changes since the nineteenth century, when Florence
Nightingale highlighted prevention of disease by having concern for healing
environments while caring for the sick. Before 1950 nursing research focused
mainly on education, and task-orientation. After 1950 practice-oriented nursing
research became established. Nurses in this period also worked with other
disciplines such as psychology, sociology and education. Grounded theory was
developed in this period when Glaser and Strauss (1965, 1968) studied death and
dying (Strauss & Corbin, 1990), which contributed to deeper understanding for
nurses about death and dying. At that time nurse researchers applied this
methodology to explore unclear nursing contexts, for example, Quint’s (1967) report
on “The Nurses and the Dying Patient” (Field & Morse,1985: 23). In the 1970s,
grounded theory was applied to nursing research (Annells, 1997). Presently, there
are specific books about grounded theory for nurses (Chenitz & Swanson, 1986;
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Chapter 3: Methodology
Schreiber & Stern 2001), however, grounded theory methodology and methods are
published mainly in qualitative research textbooks and journal articles for nurses.
The first specific grounded theory book for nurses was “From Practice to Grounded
Theory” (Chenitz & Swanson, 1986). Later, another book was published for nurses,
“Using Grounded Theory in Nursing” (Schreiber & Stern 2001). These books
provide full descriptions of grounded theory development, methodology and method
and applications for nurses as well as examples of grounded theory research and
guidelines for writing dissertations and publications.
Grounded theory as “a methodology approach to research, has utility for nurseresearchers who are attempting to identify unknown or unclear phenomena” and
“nurses have been active in the use of grounded theory” (Field & Morse, 1985: 6,
23). These days, grounded theory research is “not necessarily just focused on social
processes but had also evolved to explain human action and interaction in social,
psycho-social or spiritual dimension of life” (Annells, 1997: 164). Grounded theory
is a useful methodology for studying interpersonal relationships between nurses and
patients and others (McCann & Clark, 2003a: 16).
Grounded theory has substantive and formal theory outcomes. Annells (2003)
showed that most grounded nursing theory outcomes are substantive theories. The
main weakness in research in nursing is that not every grounded theory reports to the
level of the theory or shows the links between concepts and categories.
Grounded theory, spirituality and the nurse-patient-relative relationship
Grounded theory methodology is popular because it provides practical methods
(techniques and procedures) and inductive, deductive and verification processes to
develop middle range theory. This kind of theory is derived from data and has the
level of abstraction among related concepts and categories which can be applied to
daily practice. A search of the nursing databases (CINAHL, Nursing fulltext, and
Ovid MEDLINE) found 10,123 journal articles in the 2001-2006 period that referred
to grounded theory in various ways. There were 3,637 nursing research projects that
have applied a grounded theory methodology. Among these studies there were 789
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Chapter 3: Methodology
projects related to caring, 92 projects to grounded theory in spirituality, 84 to the
nurse-patient relationship, and 16 projects were grounded theory projects undertaken
in Thailand. Classic grounded theory and Strauss and Corbin’s approach were
applied equally.
Quantitative and qualitative research explores nursing phenomena relating to
spirituality (Tongprateep, 2000), caring (Euswas, 1991, 1993), communication
(Burnard & Naiyapatana, 2004a,b) and relationship (Williams & Irurita, 2004).
Qualitative studies about spiritual caring and nurse, patient, and relative
relationships involving compassion, communication and power issues were
undertaken in various ways. Most projects used descriptive research and content
analysis, such as: “caring and uncaring encounters in nursing in an emergency
department” (Wiman, 2004), and story telling, such as: “views of nurses, patients,
and patients’ families regarding palliative nursing care” (Taylor, Glass, McFarlane
& Stirling, 2001).
Some grounded theory projects do not specify which version of grounded theory
was used. This may be because the nursing researchers have applied the grounded
theory methodology and methods from social science into nursing care, using
various unspecified concepts. Even though research has increased since 1990, some
nurse researchers may not have enough basic knowledge about grounded theory to
pay attention to specific approaches in order to develop good quality grounded
theory projects.
Examples of grounded theory using Glaser’s classical approach
This sections highlights grounded theory projects about relationships which
employed a Glaser and Strauss (1967) approach.
Shaw (2004) used semi-structured audiotaped interviews with 15 nursing home staff
(9 nursing assistants, three registered nurses, and three nursing home administrative
staff) from six facilities (three federal government and three for-profit facilities).
Data were transcribed and coded line by line. Additional data from one facility
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Chapter 3: Methodology
included incident reports, workers’ compensation applications and incident logs
detailing 138 episodes of physical assaults against staff during a 12-year period.
Developing immunity emerged as the basic social psychological process which
explained that staff protect themselves from the impact of abuse by residents in
ways that are not detrimental to themselves or residents. A self-protecting mind-set
allows them to continue to work in the nursing home. Conditions related to abuse
were resident fear and being overwhelmed by care, close proximity and invasion of
personal space. Conditions related to staff continuing to work were job-person fit
and valuing caring for elders. Phases of dealing with abuse included: becoming
socialised, developing an ideology of abuse, becoming proactive, practising
vigilance, intuiting, and strategising. There were different levels of developing
immunity which were 1) developing and sustaining immunity, 2) developing and
losing immunity, and 3) never developing immunity. Shaw suggested that to
effectively deal with resident aggression, staff must become proactive, which
involved three dynamic and interactive processes: practising vigilance, intuiting, and
strategising.
In a grounded theory study about therapeutic and non-therapeutic interpersonal
interactions from the patients’ perspectives, Williams and Irurita (2004) employed
the Glaser and Strauss (1967) version of grounded theory. This research aimed to
explore and describe the perceived therapeutic effects of interpersonal interactions
experienced during hospitalization. Forty participants were interviewed. Seventyeight hours of participant observation and informal interviews with nurses and
patients were conducted. Relevant documentation such as nursing care plans, and
patient notes were reviewed. Williams and Irurita (2004) identified “emotional
comfort” as a therapeutic state that patients perceived as enhancing their recovery.
Personal control was found to be a central feature of emotional comfort. The main
conditions that promoted and inhibited emotional comfort were the levels of
security, knowledge and personal value.
Henderson (2003) explored how the Patients’ Charter affects nursing care. She
aimed to explore and describe nurses’ and patients’ views regarding partnership in
care in hospital, gaining basic concepts about grounded theory from Glaser and
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Chapter 3: Methodology
Strauss (1967), and using the constant comparative method in her analysis.
Henderson (2003: 501) explained:
The finding showed that nurses viewed involving patients in care as
requiring them to give patients information and to share their decisionmaking powers with them. With the exception of a few, the majority of
nurses were unwilling to share their decision-making powers. This created a
situation of power imbalance with subsequent little patients lacked medical
knowledge and the perceived need for nurses to hold onto their power and
maintain control. If nurses and patients are to work as partners, it is
important that nurses make every effort to equalise the power imbalance.
One way to do this is for nurses to share and give information to patients
readily and to be open on their communication with them.
Examples of grounded theory using Strauss and Corbin’s approach
This section illustrates five grounded theory projects reflecting Strauss and Corbin’s
approach.
Carter, MacLeod, Brander and McPherson (2004) used grounded theory research to
explore what people living with a terminal illness considered to be areas of priority
in their life. The interviews were conducted with 10 people living with terminal
cancer then data were analysed by incorporating principles of narrative analysis with
grounded theory methods. More than 30 categories emerged and they were collated
into five inter-related themes which were personal/intrinsic factors, external/
extrinsic factors, future issues, perception of normality and taking charge. Practical
issues of daily living and the opportunity to address philosophical issues around the
meaning of life emerged as important areas. The central theme, “taking charge”,
concerned with people’s level of life engagement, was integrally connected to other
themes.
McCann and Clark (2003c), Australian researchers, used Strauss and Corbin’s
approach to explore how community mental health nurses promote wellness with
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Chapter 3: Methodology
clients who are experiencing an early episode of psychotic illness. They used Strauss
and Corbin’s approach because, firstly, it took account of both micro and macro
influences on a phenomenon. Secondly, the paradigm model was helpful in
collecting data, structuring the analysis and developing categories about not forcing
data. Thirdly, this approach reflected the shift towards a social constructivist
ontology and a post structural paradigm, and finally, Strauss and Corbin (1990,
1998) provided more structure approach to data collection.
The researchers used interviews and non-participant observation to create data
triangulation to enhance research rigour. Three different groups of participants
(clients, their relatives and nurses) were recruited; also participants came from three
districts (inland, urban and a coastal town). The researcher used theoretical
sensitivity and theoretical sampling to guide data collection and analysis. Manual
constant comparative method and open, axial and selective coding were performed
systematically. The substantive theory was “adopting care provider-facilitator roles”.
The core categories were clustered around three phases of care which were
engaging, advancing self-determination and developing linkages. The phases of care
had two domains, interacting with the client and interacting with others. The
supportive categories were being accessible, mutual relating, assessing, providing
support, educating, fostering self-control, uncovering hope, enhancing life style,
coordinating, collaborating, influencing and withdrawing.
Mok, Chan, Chan and Yeung (2003) studied family experiences of caring for
terminally ill patients with cancer in Hong Kong. Using the Strauss and Corbin
approach, they approached 31 caregivers, seven of whom refused to be interviewed.
In-depth semi-structured interviews with 24 families’ caregivers were conducted at
either the caregiver’s home or the hospital clinic. Each interview lasted from one
hour 15 minutes to two hours 15 minutes. All interviews were conducted in
Cantonese and transcribed verbatim into Chinese. Data were analysed by constant
comparison method. A coding paradigm model linked subcategories to a category in
a set of relations denoting phenomenon, context, and consequences. After analysis
all themes and significant statements were translated into English. The grounded
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Chapter 3: Methodology
theory reflected cultural aspects of caregivers’ commitment. The researchers
reported:
Commitment emerged as the precondition of the caregiving process. The
caregiver did not perceive the work of caring as a burden. Rather, they felt
that despite any personal hardships, what they were doing was important to
their loves ones and therefore meaningful to them as caregivers. The
components of commitment can be described as relational commitment, the
act of showing love, and determination. The process of caregiving includes
four phases: 1) holding onto hope for a miracle, 2) taking care, 3) preparing
for death, and 4) adjusting to another phase of life. A patient-caregiver
relationship, Confucian concepts of yi (appropriateness and rightness), and
filial duty are reflected in the process of caregiving. Consequences of the
process included finding meaning in life, and peace of heart and mind. The
emotional aspect of the caregiving experience can be describes as an intense
emotions experience filled with feelings of hope and hopelessness, guilt,
fear, and regret. As a result of the caregiving experience, most participants
found they have had a change of worldviews and treasure their lives (Mok,
Chan, Chan &Yeung, 2003: 267).
Maijala, Paavilainen and Astedt-Kurki (2003), Finnish researchers, employed
Strauss and Corbin’s approach to generate a substantive theory delineating the
interaction process between caregivers and families expecting an impaired child.
There were threes set of data. Firstly, the participants were 18 families who were
expecting or had been experiencing an impaired child. Some families were
interviewed two to four times. Paired interviews were conducted with 20 parents and
single interviews were conducted with nine parents. The audiotaped sessions ranged
from 10 to 113 minutes in length. Secondly, interviews were conducted with 22
caregivers, one nurse, 17 midwives and four doctors, at the women’s clinic working
with families expecting an impaired child. The interview questions included the
family’s need for psychological support, factors preceding interaction and the
beginning phase, central content, termination and consequences of interaction, from
general issues to specific themes. The data collection lasted one year and three
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Chapter 3: Methodology
months. The third data set consisted of essays written by five mothers and fathers
from four families who had expected an impaired child.
Data were manually analysed using the constant comparison method. Open, axial
and selective coding maintained the reliability of the research. The resulting
substantive theory showed the interaction process between the caregiver and family,
which included gaining and losing strength in relation to impairment issues.
Families expected moral support while trying to help. The families’ outcomes
included being helped and being left. Caregivers also realised that sometimes they
were unable to help families.
Williams (1998) explored the delivery of quality nursing care using a grounded
theory study of the nurses’ perspective. Her data included tape recorded interviews,
twelve additional transcripts from interviews conducted by postgraduate students,
published literature and some participant observation. Participants were ten nurses
from an acute-care public hospital in Perth, Western Australia, including novice,
competent and expert registered nurses with different academic degrees. Participants
were selected purposefully and theoretical sampling accessed further participants.
Data were interpreted using a systemic set of procedures to develop a substantive
theory of the phenomenon (Strauss & Corbin, 1990). Data were analysed by using
the constant comparative method in which collection, coding, and analysis occur
simultaneously. Some of data were returned to nurses for them to validate their
descriptions. The research reported:
Quality of nursing care was perceived to relate to the degree to which
patients’ physical, psychosocial, and extra care needs were met. The
consequences of quality care were interpreted as “therapeutic effectiveness”,
which the therapy provided by nurses was perceived to positively affect
patients’ healing. This was gauged by the patient’s psychosocial and physical
response to illness, safety, and satisfaction. Therapeutic effectiveness was
facilitated by the development of positive relationships between nurses and
patients, nurses’ positive attributes and competence practices, as well as a
functional nursing team. The problems of nurses’ inability to consistently
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Chapter 3: Methodology
provide quality nursing care to all patients was identified. Insufficient time
(caused by lack of human and physical resources) was perceived as the main
reason for this. Dissatisfaction and stress in nurses was related to this
problem. To deal with this, nurses used a process names “selective focusing”
Work was planned to most effectively utilise the time available, within the
parameters of safety (Williams, 1998: 808).
Computer-aided theory-generating analysis
After reviewing the main grounded theory articles from the nursing databases during
2000-2007, I found that grounded theory researchers used computer programs for
qualitative data analysis mainly NUD*IST and NVivo. These researchers applied
grounded theory research with quantitative approaches in a mixed-method approach
for large grounded theory projects including more than 30 participants and at a high
level of data analysis. Even though nurses can apply a specific version of grounded
theory approaches, especially for data analysis with computer programs, Oaksford,
Frude and Cuddihy (2005: 6) warn that “the task and responsibility of data
interpretation remains with the researcher.”
Mallinson et al (2005) published their research “Maintaining normalcy: A grounded
theory of engaging in HIV-oriented primary medical care”, as the first part of a
mixed-method (quantitative-qualitative) study of factors influencing how persons
with HIV engage and are retained in HIV-oriented primary medical care. The
researchers employed the theoretical sampling technique and constant comparative
method described by Strauss and Corbin (1998) for recruitment, data collection and
analysis. The main participants were regular and irregular users of HIV-oriented
primary medical care. Additional criteria were applied to maximise the diversity of
the sample in term of age, race/ethnicity, gender, and sexual orientation.
The researchers contacted clients by telephone and recruited them for individual
interviews to be conducted by doctorally prepared nurse researchers in private
rooms after the informed consent process was completed. They developed focused
questions after the first general interview. The interviews were recorded and
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Chapter 3: Methodology
transcribed for substantive analysis confidentially with NVivo computer textual
analysis software. The researchers did not give details about using the NVivo
program. Strauss and Corbin’s strategies were used to analyse the narrative data.
Research team members read each interview; and words, phases and concepts salient
to the process of engaging in regular HIV-oriented primary care were highlighted.
The formation and refinement of data categories were undertaken by group
discussion. The interviews were discontinued when no new insights emerged in the
process of engaging in care.
Maintaining normalcy emerged as a model of transition into regular HIV-oriented
primary medical care, from accounts of 27 participants, 17 males and nine females,
from various backgrounds, including homosexual, bisexual and transgender people,
ranging in age from 24 to 71 years from one urban and two suburban HIV clinics
during the summer of 2003. The theory of maintaining normalcy was described:
For each individual, the transition from sporadic engagement in care to
attending regular appointments involved confronting a variety of stigma and
obstacles, each of which contributed to personal perceptions about the
impact of HIV in normal life. One’s level of health literacy and ability to
develop connectedness with healthcare providers of other support systems
influences their perceptions of HIV disease and helped each balance
risks/benefits associated with accessing clinical services. As these clinic
clients transition into regular users of care, they develop life mastery skills to
integrate new knowledge, communication their needs, and use their
resources to the best of their ability (Mallinson et al, 2005: 4).
Oaksford, Frude and Cuddihy (2005: 6) applied grounded theory in the area of
rehabilitation psychology using Glaser and Strauss (1967) and Strauss and Corbin
(1990) approaches. They undertook a cross-sectional qualitative exploration of how
individuals cope with a lower limb amputation and examined the influence of
positive coping and stress related psychological growth adjustment. The participants
were 12 patients with a lower limb amputation, after surgery from six months, one
year and five years. There were 10 men and two women, age between of 51 and 83
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Chapter 3: Methodology
years. The primary causes of amputation were vascular changes, diabetes mellitus
and trauma. Data were collected by semi-structured interviews and analysed using
Strauss and Corbin’s approach (Strauss and Corbin, 1990). The researchers used
NUD*IST 4.0 computer software to facilitate the systemic structuring of the
interview data. The researchers explained that the software acts as a text base
manager, sorting the interview transcripts and facilitating a multitude of analytic
operations, such as coding and categorising of the data” (Oaksford, Frude &
Cuddihy, 2005: 6). The researchers did open coding, and an interim summary of the
first six interviews, so they could see the evolving themes and tentatively link
categories, before axial and selective coding, as suggested by Strauss and Corbin
(1990). The results of this qualitative study were: appraisal and individual difference
factors, coping with lower limb amputation, the process of coping overtime and
positive reframing, and psychological growth.
Grounded theory research in the Thai Buddhist context
The number of qualitative research projects in Thailand has gradually increased
because of the increased numbers of Doctoral students and staff. The main studies
are phenomenology, ethnography and grounded theory. Some qualitative research
projects found influences of Buddhist beliefs and practices on patients’ and
relatives’ self-care and coping (Klunklin, 2001; Kongin, 1998; Pincharoen &
Congdon, 2003; Sethabouppha & Kane, 2005; Songwathana, 1999, 2001;
Tongprateep,
2000)
and
caring
(Euswas,
1991;
Wannapornsiri,
Sindhu,
Phancharoenworakul & Gasemgitvatana, 2005). Studies on nurses’ perspectives of
applying Buddhist beliefs and practices to nursing care are few. Also there is no
previous systematic study on the process of caring relationship between Thai nurses,
patients, and relatives.
Grounded theory projects in Thailand were done mainly by Master and Doctoral
nursing students, nursing educators and few clinical nurses. The first grounded
theory project was presented in 1991 (Euswas, 1991), and now there are 20 research
projects including many areas of nursing concepts and practice, such as caring: “The
actualised caring moment: a grounded theory of caring in nursing practice” (Euswas,
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Chapter 3: Methodology
1991); health seeking behaviours: “Exploring the experiences and health care
seeking behaviours of commercial sex workers” (Ratinthorn, 2000); medical care:
“Self-care processes in adults with diabetes” (Sritanyarat, 1996), “Family adaptation
in caring for patients with HIV/AIDS” (Oumtanee, 2001), “Self-management in
patients with COPD” (Duangpaeng et al., 2002), “Everyday life for men with
paraplegia” (Singhakhumfu, 2002), “Self-care in people with hypertension”
(Panpakdee et al., 2003), “The struggling process in persons with HIV infection”
(Namjantra et al., 2003), “Thai mothers living with HIV infection in urban areas”
(Thampanichawat,
2000);
“Caregivers’
experiences
in
caring
at
home”
(Limpanichkul & Magilvy, 2004); elderly care: “Self-care of the rural Thai elderly”
(Kongin, 1998), “Caregivers’ processes in caring for elderly with stroke”
(Subgranon, 1999), “Caring for the elderly” (Choowattanapakorn, 2004); mental
health and psychiatric nursing: “Skill and role development in psychiatric
caregiving” (Tungpunkom, 2000), “The recovering process in women with
depression” (Seeherunwong, 2002), women’s health: “Role clarity and health
perceptions in Thai women with valvular heart disease” (Sindhu, 1992),
“Experiences of wife abuse” (Sripichayakan, 1999), “Thai Women’s experiences of
HIV/AIDS” (Klunklin, 2001); and paediatric nursing: “Children’s experiences with
postoperative acute abdominal surgical pain” (Fongkaeo, 2002), “Parents’
experiences in asthma attack prevention” (Santati, et al., 2003), and “Children’s
experiences in postoperative acute abdominal surgical pain” (Wiroonpanich &
Strickland, 2004).
Selecting the methodology and the specific approach
In exploring influences of Buddhist culture on the nurse-patient-relative relationship
in Thailand, I decided to do grounded theory because, firstly, my nature of thinking
is close to qualitative inquiry, which values learning from people’s experiences,
describing and explaining phenomena in a holistic way. Secondly, the nature of my
research problem related to action and interaction in human caring relationships and
also includes concepts (structures) and processes of performing spiritual care, and
thirdly, there was little systematic knowledge about this topic in Thailand.
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Chapter 3: Methodology
I decided not to use any computer program for qualitative analysis because this is
my first grounded theory research and I preferred to do a manual analysis so I can
develop research skills step by step. I maintained my theoretical sensitivity and
creativity while I stayed close to the data.
I knew that “we can use grounded theory methods as flexible, heuristic strategies
rather than as formulaic procedures” (Charmaz, 2003: 251). The most important
issue for doing the grounded theory is that the researcher gains a clear understanding
of their approach and can see appropriate ways of applying the theoretical concepts
in the research design (McCallin, 2003). In doing research about relationship and
spirituality, I cannot see a participant as an object, rather I realised the importance of
good relationship between researcher and participants, which promotes rich data and
prevents harmful side effects against bias when exploring nurses’, patients’ and
relatives’ experiences.
I decided to employ Strauss and Corbin’s approach because this version shares all
the important foundations and concepts of grounded theory research. This version
provides practical techniques and procedures of theory development methods which
are good for my first grounded theory project. Open, axial and coding analysis
provide flexible guidelines to develop theory from the various groups of data about
the nurse-patient-relative relationship. The analytic tools and the need to examine
conditions, action and interaction, some strategies, and consequences in the data was
a complex undertaking for 47 participants. The paradigm model guided me to look
at the data from many directions and enhance my theoretical sensitivity. I did not
intend to apply every analytic tool provided by Strauss and Corbin (1990, 1998) to
do my research, rather, I applied general ideas from the three levels of coding to
analyse the data. The important questions that I applied to the process of collecting
data were: What is happening?, Who did it?, With whom?, How many people were
involved (in helping the patient)?, When did that happen?, Why?, How? What were
the outcomes? and What made them believe and act like that?
The flexibility of the Strauss and Corbin grounded theory methodology, methods
and process inspired me throughout the research process. I was also pleased that this
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Chapter 3: Methodology
approach would nurture my creativity and help me as a researcher to become a more
flexible person. I kept in mind the idea that learning the process of grounded theory
research involves a bit of luck and courage, as well as hard work and persistence,
which is not always a pleasurable experience (Strauss, 1987).
Conclusion
This chapter explained the position of grounded theory among other qualitative
approaches, the development of grounded theory methodology from the founders of
objectivist grounded theory, Glaser and Strauss (1967), Strauss and Corbin (1990,
1998) and the later work of Charmaz (2000, 2006). Strauss and Corbin’s grounded
theory approach influenced this research. Examples of grounded theory in nursing
and studies of spirituality and the nurse-patient-relative relationship in Thailand
were also described. In the next chapter, I will describe and explain the research
methods and processes.
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Chapter 4: Methods and processes
CHAPTER 4
METHODS AND PROCESSES
Introduction
“While methodology provides a sense of vision, where it is that the analyst wants to
go with the research … the techniques and procedures (methods) furnish the means
for bringing that vision into reality” (Strauss & Corbin, 1998: 8). This chapter
explains the methods and processes of doing grounded theory in exploring the
influences of Buddhist culture on the nurse-patient-relative relationship in Thailand.
The research processes included preparing the researcher, writing the proposal and
gaining ethical approval, deciding on settings and recruiting participants, ethical
consideration of principles and practices, collecting and validating data, maintaining
trustworthiness and the quality of the research, analysing data, writing and sorting
memos, and planning for writing the grounded theory. This project was influenced
by Strauss and Corbin’s (1998) grounded theory methods and processes. This
chapter summarises the research activities throughout the four year, of this grounded
theory project.
Gaining ethical approval
Considering ethical principles
Respect for participants’ rights and guaranteeing the validation of the research
findings are the main ethical activities to which researchers must pay attention
throughout the research process (Roberts, 2002). According to Polit and Beck
(2004) and Roberts (2002), the three major ethical principles underpinning most
research standards are beneficence, respect for human dignity, and justice. As a
Buddhist I know the rule of “do good” and “avoid doing bad” plus “purify the mind”
by working with mindfulness, having good intention and a kind mind while relating
with research participants, as also the main teachings of the Buddha. I thereby could
perform Buddhist ethics and research ethics throughout my research process
simultaneously.
Chapter 4: Methods and processes
I was a novice grounded theory researcher, but I had have some experiences of
doing qualitative research, as I used in-depth semi-structured interviews and nonparticipant observation methods when I did my Master thesis of “Perception and
Coping of Lung Cancer Patients Receiving Chemotherapy: A Phenomenological
Study” (Chinnawong, 1999). I was always mindful that the researcher is an ethical
and qualified instrument for data collection. In the course of this research, a number
of processes and procedures were used to ensure the ethical standards of the projects
to safeguard human rights.
Beneficence
Beneficence is “doing good” and it incorporates “the principle of non-maleficence
or doing no harm” (Roberts, 2002: 99). It involves the protection of participants
from physical, psychological, emotional, social, and financial harm; protecting the
participants from exploitation; and performance of some good (Polit & Beck, 2004).
Qualitative research can cause emotional harm during the interview process when
the researcher seeks details of participants’ lives, which involves private and
confidential issues. Social and financial harm can happen when the researcher
interferes with the participant’s kinship and family relationship or the participant
loses employment as a result of participating in a research project (Roberts, 2002).
In risky situations, the risk/benefit ratio between participants and society could be
carefully assessed (Polit & Beck, 2004).
Respect for human dignity
According to Polit and Beck (2004: 159), respect for human dignity “involves the
participants’ right to self-determination, which means they have freedom to control
their own activities”. It also encompasses the right to full disclosure, so the
researcher needs to fully describe to participants their rights, and cannot collect
information without “the participants’ knowledge or consent”, nor can they provide
false information. Participants also have the right to refuse to participate and to
withdraw from a study at anytime without penalty. Using informed consent is
important especially for special participants such as the elderly with hearing or
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Chapter 4: Methods and processes
seeing impairment, children, disabled and mentally ill persons, or unconscious
persons (Roberts, 2002). As this study involved aged patients and relatives, respect
for human dignity was maintained at all times.
Justice
Justice includes the right to fair treatment and the right to privacy. Privacy can be
maintained through anonymity, or through formal confidential procedures that
protect the information derived from participants (Polit & Beck, 2004). Pseudonyms
or code numbers are usually used to protect participants’ identities (Roberts, 2002).
In this study pseudonyms were used for all participants and all other information
about settings was de-identified.
Engaging multiple ethical approvals
I submitted my proposal to the Human Research Ethics Committee of Southern
Cross University in June 2003. The proposal was approved in August 11, 2003
without any comments (see Appendix D).
The project was fully approved by four parties and organisations which were: 1) The
Human Research Ethics Committee of Southern Cross University, 2) the Thai
Government, Office of Educational Affairs, Canberra and Bangkok, 3) the research
settings which included every ward/unit selected from fours hospitals, one primary
health care clinic, and one elderly centre, and 4) the participants. I informed the Thai
government through the staff at Office of Educational Affairs, Canberra and
Bangkok, two months before starting the data collection. I sent them the application
translated into Thai. Similarly, all plain language statements and consent forms were
written in Thai for participants. Later, in August, 2003, the Thai Government
confirmed my research and signed the official document for ethical clearance. The
Government clearance was also shown to each participant.
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Chapter 4: Methods and processes
Settings and participants
The main criteria for selecting settings were to find locations where Buddhist nurses,
patients and relatives were applying Buddhist teachings when they are sick or care
for sick patients and were willing to be research participants. In order to gain many
aspects of data I needed to include both positive and negative cases of the
application of Buddhist teachings to spiritual care and influences of Buddhism on
the nurse-patient-relative relationship.
I decided to approach participants from more than one setting in order to see various
patterns of relationships, in different levels of care, such as home care, primary care,
secondary care, and critical care; in both acute and chronic settings. This decision
supported me when I performed “theoretical sampling”. It also helped me to manage
my time effectively, because I could interview patients who came to the elderly
centre while I was waiting to get the permission from the hospitals. Moreover, I also
could interview nurses, patients and relatives at the other hospitals while I waited for
the University hospital to approve my project, about three months later.
The settings
I did my data collection in Southern Thailand. I had to submit my proposal to all of
my selected settings. To do this, I translated the English version of my proposal into
the Thai language and waited for permission from each setting before accessing
participants. I applied purposive sampling to select the settings and snowballing
technique to select my participants. For better time management and in order to
maximise the participant’s experiences, to reflect all level of services of the Thai
health care services, I decided to approach six settings, which included one elderly
centre, one primary health care clinic, one community hospital, one provincial
hospital, one regional hospital, and one University hospital. All of these settings
were in the same province, which was in a central part of Southern Thailand.
Because my background was as an intensive care nurse, and I teach Bachelor degree
nursing students about adult nursing, elderly care, and critical care at the intensive
care units, medical wards, and the elderly centre; I recruited participants from the
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Chapter 4: Methods and processes
medical and surgical wards and the intensive care units. As I used to work with the
community nurses for the HIV/AIDS prevention and care project, I also decided to
approach some nurses, patients and relatives from the community hospital and the
primary care clinic where my friends worked.
The elderly centre
The elderly centre was a part of the social service activity of the Faculty of Nursing.
This centre is run by the nursing teachers and the committee, who are the members.
It provides health promotion and rehabilitation services for older people around the
province, three days per week. The members were older than 55 years old. The main
activities were physical check, doing Tai Chi and low-impact aerobic exercise and
various kinds of health promotion, health education, cultural and religious activities.
Each day 80-100 members join the activities from 7.30 a.m. to 11.00 a.m. The
members have several kinds of illness due to old age. However, their health status
has gradually been improved from doing regular exercise and having healthy
lifestyles. Sometimes a few members have severe symptoms which prohibit
exercise. After approaching the head of this centre, two members were
recommended as research participants, because they have applied Buddhist beliefs
and practices to deal with their illness and they were having good relationships with
other members and come from very warm family backgrounds. The first participant
was a man with remission colon cancer; another participant was a woman with
myocardial infarction and chronic cardiac myopathy.
The primary health care clinic
This clinic was a part of one community hospital, which was 100 kilometres from
the University hospital. It was a new service, which extended nurses’ roles to run
primary health care for people in the community, to promote health promotion and
prevent patients’ accessing hospital unnecessarily. Nurses provide medical and basic
treatments under the authority of doctors. Routinely, nurses work at the clinic from 8
a.m. to 12 p.m., then they do home visits from 1 p.m. to 4.30 p.m. Here, I
interviewed one senior nurse and she took me to visit four patients’ homes. They all
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Chapter 4: Methods and processes
were willing to be participants, however, I decided to interview one husband of a
patient after an accident, one daughter of an old age patient with diabetic mellitus
and one wife of a patient with stroke, as these participants had rich experiences of
the nurse-patient-relative relationship, from being the main caregivers of patients at
the provincial hospital for more than six months. I could not interview the patients
because all of them could not speak due to head injury and stroke. Another patient
was very old and had hearing problems, and at that time, so I needed to recruit more
patients who were admitted in the hospitals.
The community hospital
I asked for permission to access participants from the 30 bed community hospital,
associated with the HIV/AIDS prevention and care project. The head of the nursing
department at this hospital was my friend. After I explained my project to her and
gave her my proposal, she helped me to contact and recruit one nurse, one patient
with AIDS and his mother. A week later, I went to introduce myself and my project
and interviewed them in a peaceful private room. The nurse had five years nursing
experiences and worked in a general ward. The patient with AIDS had a mother who
was a very supportive caregiver.
The provincial hospital
This hospital was a 400 bed hospital, located 16 kilometres from the University
hospital. I selected this hospital because of trying to access male nurses, which are
very rare in the Thai nursing context. I was told there was one male nurse who
worked in this hospital. One of my friends told me that the nurse who graduated
from the Faculty of Nursing ran a psycho-spiritual support project in the intensive
care unit. Here, I recruited one intensive care unit nurse, one male nurse from a male
medical ward, one patient from a male medical ward and one relative, who was the
daughter of the critically ill mother with septic shock.
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The regional hospital
This was the largest hospital for the lower part of Southern Thailand, and it was very
busy hospital, because it was open to every patient who was referred from
community and district hospital from 14 provinces, within an unlimited hospital
beds policy. More nurses were called to do extra work when the ward was very busy
especially in periods of flooding, fever dengue virus spread, and accidents. I selected
the medical wards, where I used to work because I could build rapport and approach
nurses, patients and relatives easily. Finally, I recruited two nurses from the female
and male medical wards, three patients (two males and one female), and one relative
to be participants. All patients and relatives from this setting, recruited as
participants, had low and medium incomes, and some had financial problems.
The University hospital
This University hospital was the training place for medical, nursing students, and
health care professionals. It had about 1,000 hospital beds. It specialised in areas,
such as cancer care, cardiopulmonary care, and neurological care, for people in
Southern Thailand. This hospital was a leader in implementing the hospital
accreditation project and gave quality management and the best practice. The
discharge planing program and primary care unit were initially launched to improve
continuing care, holistic care with effective cost-benefits. The main weakness for the
nursing department was to show the evidence that they already provided holistic
care for clients. The palliative care team was established to provide better care for
incurable illnesses and reduce unnecessary treatments. Therefore, nurses and doctors
learned about and focused on roles of culture, religions, and families’ and patients’
values and beliefs by implementing the palliative care project. I approached key
persons who were the palliative care committee, registered nurses, head nurses and
clinical nurse specialists, who had rich experiences of applying Buddhist beliefs and
practices to care for patients in normal and critical situations, and in the death and
dying period. Ten nurses, five patients and five relatives from this hospital were the
participants. Some patients and relatives were admitted to the ward, and some of
them recovered and were at home. All participants reflected on different situations
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Chapter 4: Methods and processes
and conditions which affect nurses’, patients’ and relatives’ relationships. The main
participants came from the radiation clinic, the medical wards, the surgical ward, the
intensive care unit, the Radiation Clinic, the gynaecological ward and orthopaedic
wards, and one patient with chronic renal failure was in the hemo-dialysis unit.
In general situations Thai nurses were challenged to reflect on what they understand
about spirituality and how to provide nursing care to meet the holistic care mission
within very busy contexts and with limited financial support. Thai patients and
relatives applied many kinds of self-care and coping strategies to deal with their
health related problems, especially Buddhist beliefs and practices, local wisdom, and
Thai traditional healing. Thai families were the main caregivers who were involved
in helping nurses to care for patients in the hospitals and at home.
The University hospital and the other hospitals differed in their purposes and scope
of services. The University hospital was placed under the Ministry of Education,
having previously been under the Ministry of University Affairs. This hospital had
limited hospital beds and did not allow relatives to stay overnight with patients near
patients’ beds, except under exceptional circumstances such as in the first night of a
patient’s admission, or when patients were in crisis and reaching death. The other
hospitals were under the Ministry of Public Health, which helps people from every
walk of life, most of them with low incomes and not high educated. These hospitals
allow one or two relatives to stay with patients all day and all night in order to help
nurses to do some basic nursing care, such as bed baths, sponges, changing patients’
clothes and bed linen, feeding patients via mouth or nasogastric tube, turning
patients’ position, and so on. Relatives are told to move out of the ward when the
cleaner comes to clean the floor. When the doctors come to patients, relatives
usually stay with patients and tell doctors about patients’ symptoms and their main
concerns. Relatives seem to be the patients’ voice, especially for elderly patients
who depend on relatives and let relative talk with doctors for them. Many patients’
relatives watch nurses work all the time, some of them become like nurses’ external
auditors and sometimes they criticise and gossip about nurses’ personalities and
caring behaviours.
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Accessing participants from the different levels of hospitals, which had different
kinds of services and relatives’ participation was beneficial. I gained perspectives of
various patterns of relationships when different kinds of nurses met different kinds
of patients and relatives, in different kinds of hospitals.
In this study, I did not approach nurses, patients and relatives from the private room
of each hospital and from private hospitals, because these groups of participants had
been trained to provide nursing based on high expectations of quality care. These
groups of clients can access special services based on their ability to pay. They
usually prefer to pay for better services, and most of them have good economic
backgrounds.
The wards and the chaos
In this research, I did not intend to explore management issues of the setting; rather I
focused on approaching participants at a personal level, for personal experiences of
applying Buddhist teachings, and patterns and processes of nurse-patient-relative
relationships. In this section, I provide very brief pictures of the settings.
The wards at the University hospital provide functional care plus case management
in some areas, such as for patients with cardiovascular accident, acute myocardial
infarction, and diabetic mellitus. The wards at the hospital of the Ministry of Public
Health applied case management, but some areas still use the functional care team.
Both areas employed some care map and discharge planning projects.
In 2003, the University hospital was in a transition stage of using computer based
services, instead of paper work. The doctors ordered treatments and therapies via
computers, but the system was in the beginning stage. To make sure that nurses
completed every order, nurses still had to write all of orders on paper and recheck all
of the data to make sure that patients received complete care. The issues of busyness
then became obvious. Patient and relatives often complained about having too many
levels of doctors, nurses, nursing and medicals students taking care of them but they
usually had communication problems with understanding the doctor’s language. On
the other hand, nurses from the hospitals of Ministry of Public Health had to deal
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Chapter 4: Methods and processes
with unlimited admissions and a very fast turn-over rate of patients’ admissions and
discharges in the wards. They also had to deal with some problems from letting
relatives stay with patients all the time, such as when some relatives were too
worrying, demanding, and when they acted as nurses’ external auditors, sometimes
gossiping about nurses. The Nurse: Patient ratio and system of nursing care in each
setting is in Table 4.1 and 4.2.
Table 4.1: Nurse: Patient ratios and systems of nursing care in each setting of the
University hospital
The University hospital (1000 bed hospital)
Intensive
Male medical
Female medical
Surgical ward
Care Unit
ward
ward
8 beds for
28 normal beds, 2
40 beds
40 beds
medical ICU,
teams (1-14, 15-28)
3 teams (1-14,
3 teams (1-14,
8 beds for
plus 10 beds for
15-28, 29-40)
15-28, 29-40)
surgical ICU
respiratory care
Using functional
Using functional
Using functional
care team
care team plus
care team
plus case
case management
management in
in some diseases,
some diseases, such
such as CVA, MI
(ICU)
Hospital beds
unit
System of
Total care
nursing care
as CVA, MI
Nurse:
1 RN: 1-2
1 team leader, 1
1 team leader, 1
1 team leader, 1
Patient ratios
patients, and
medication nurse
medication nurse
medication nurse
2-3 pre-
and 1 treatment
and 1 treatment
and 1 treatment
registered
nurse and one pre-
nurse and one
nurse and one
nurses per
registered nurses
pre-registered
pre-registered
shift per team
per team per shift
nurses per team
nurses per team
per shift
per shift
I interviewed nurses from the Radiation Clinic, gynaecological ward and
orthopaedic wards of the University hospital and one patient at the dialysis unit,
which were under the similar management. A participant from the gynaecological
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Chapter 4: Methods and processes
ward ran a research project of applying religious belief to support cancer patients
and families to cope with their illness, which had a very positive impact on the
holistic care goals of the ward and the hospital. Nowadays, more nurses from other
wards in the University hospital and other hospitals in the country come to visit this
ward and some of them apply this service to their settings. The issues about spiritual
care, complementary care and holistic care have become very popular in the Thai
health care context, since the introduction of quality and evidence-base practice
within the best practice policy.
Table 4.2: Nurse: Patient ratios and systems of nursing care in each setting of the
hospitals under the Ministry of Public Health
The regional hospital (700 beds hospital)
Male medical ward
Female medical ward
System of nursing care
Using case manager
Using case manager
Nurse: patient ratios
1 RN: 8-15 patients plus 1-3 nurse assistants per team
(1:8 for day shift, 1: 10 for evening shit, 1:15 for night shift)
Extra conditions
one more registered nurses or nurse assistant would be called to
work when the number of severely ill patients were increased
The provincial hospital (400 beds hospital)
System of nursing care
Intensive care unit
Male medical ward
Total care
Functional care plus case management
in some disease such as TB, MI
Nurse: patient ratios
1 RN:2-4 patients,
1 RN: 8-15 patients plus 1-3 nurse
plus 1-3 nurse
assistant per team
assistant per team
(1:8 for day shift, 1: 10 for evening shit,
1:15 for night shift)
Extra conditions
one more registered nurses or nurse assistant would be called to
work when the number of severely ill patients were increased
The community hospital (30 beds hospital)
General ward
System of nursing care
Using case manager
Nurse: patient ratios
1 RN: 8-15 patients plus 1-2 nurse assistant per team
Extra conditions
one more registered nurses or nurse assistant would be called to
work when the number of severely ill patients were increased
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My observations and personal experience told me that nurses were very busy, but
some shifts when they were less busy they did not change their working styles; that
is, they did not improve their caring behaviours. In the same busy settings, some
nurses were very active and some nurses were very inactive. Some nurses tried to
spend time talking and providing information to patients and relatives while some
nurses just focused on their jobs. They did not even talk to patients and relatives.
This made me wonder whether there were some others factors, especially nurses’
backgrounds and attitudes to nursing care, and something about the quality of mind,
which could be influencing their personal values and beliefs. I needed to seek the
answers from nurses to explore the factors that made some nurses good and some
nurses not so good, in patients’, relatives’, and nurses’ view points. I realised that
nurses’ behaviours could affect the quality of the nurse-patient-relative relationship.
So, this research focused on micro-structures and processes of the nurse-patientrelative relationships rather than the macro-structures of the wards and management
in each organisation. However, I was mindful to consider every factor which nurses,
patients, and relatives perceived affected spiritual caring relationships.
Recruiting participants
The preliminary selection criteria of participants in this project were as follows:
Ten Buddhist nurses, at least two males and eight females (to reflect the ratio of
males to females in Thai nursing), more than 20 years old, self-perceived as
Buddhist, and working in areas related to chronic illness for more than 5 years,
speaking Thai, consenting to be a part of research and being willing to share
accounts of their experiences. Seventeen nurses (two men and 15 women) were
participants (see details in Chapter 5).
Ten Buddhist patients, at least five males and five females (not less than three in five
of male patients have been ordained), who have had a chronic illness more than two
years, more than 20 years old, self-perceived as Buddhist, in a rehabilitation or
recuperative stage and not having any emergency and critical problems, who can
speak Thai, consenting to be a part of research and being willing to share accounts
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Chapter 4: Methods and processes
of their experiences. However, I recruited 14 patients (seven men and seven women)
as participants (see details in Chapter 6).
Ten Buddhist relatives, at least: three males and seven females (not less than 1 in 3
of male relatives have been ordained), more than 20 years old, self-identified as a
relative, self-perceived as Buddhist, having closely helped patients more than two
months, consenting to be a part of research and being willing to share accounts of
their experiences. Finally, 16 relatives (five men and 11 women) became
participants (see details in Chapter 7).
Participants were accessed mainly by discussing recruitment with head nurses and
senior nurses working at university hospitals, provincial hospitals and community
hospitals, mostly in the Southern and central part of Thailand. A snowball technique
was used to find suitable participants. I decided to recruit participants from four
hospitals, one primary care clinic, and one elderly centre to participate in this
research. The snowball technique guided me to find suitable participants who were
recommended by my colleagues. Fortunately, my previous experience led me to
meet many participants who could share their experiences to meet my research
goals.
For nurses at Songklanakarind Hospital, Prince of Songkla University, where I
worked, I announced the project, aims and processes to potential participants to
nurses and head nurses, who attended conferences and workshops on spirituality and
palliative care. After initial contact, a snowball technique was performed. After I
obtained the names and addresses of participants from nurses, I approached them
directly by visiting and/or telephoning them at the hospital and/or at home and I
introduced them to the study. I explained the research project and how they could
be involved as participants. Finally, I invited nurses, patients and relatives to be
participants. I gave them 2-3 days to make a decision after my first approach, and all
of them were happy to participate, so I started the interviewing process. During the
data collecting period participants could contact me by visiting, telephoning or emailing me at the Department of Medical Nursing, Faculty of Nursing, Prince of
Songkla University. My telephone number was 074-286411, and e-mail address was
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[email protected] I also provided the list of counsellors who provided free
counselling services for people, and suggested the participants contact me, or nurses
at the wards, or call to consult counsellors if they needed help or emotional support.
No participant required professional counselling.
After explaining issues in the Consent Form to each participant, I gave them the
outline of questions in order to let them prepare themselves to share their
experiences of being a Buddhist nurse, patient or relative and how the Buddhist
culture influences the nurse-patient-relative relationship from their respective
viewpoints. For patients and relatives who could not read, I explained with simple
language to tell me if they used some part of religious beliefs and practices to deal
with their illness, how they perceived their relationship with nurses and asked them
to share their ideas about what kinds of nurses they wanted and that kinds of nursing
activities that they needed from nurses. Therefore, the principle of theoretical
sampling was applied throughout the recruiting and data collecting process.
Applying theoretical sampling to maximise different groups of participants
Recruiting participants from different Buddhist backgrounds
Apart from the initial flexible criteria that I developed in my proposal, as shown
above, there were a lot of Thai Buddhist people who were not religious persons and
could not explain about applying Buddhist teaching. Some of them were close to
Dhamma (the Buddhist teachings). These patients and relatives had different coping
methods when dealing with their related illness. For maximising the various kinds of
related conditions about applying Buddhist teachings and reflecting the real
situations, I realised that I should include participants who were close to Buddhist
practices and were not necessarily close to religious practices.
Recruiting
participants
from
different
patterns
of
nurse-patient-relative
relationships
I approached and interviewed nurses, patients and relatives from various settings. In
each setting, I paid attention to the nurses who were recommended as a kind nurse of
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Chapter 4: Methods and processes
the ward, and who were perceived as having good relationships with patients,
relatives, and colleagues. Moreover, I saw that in very busy contexts, not every
nurse maintained good relationships with patients and relatives, and many nurses
experienced both good and bad relationships with different kind of clients. Some
patients and relatives were also having negative relationships with nurses. Some
patients and relatives mentioned several negative qualities of nurses, so I asked
nurses to share their experiences of being good and not so good nurses and asked
them what factors and under what conditions they were not always angels in
patients’ and relatives’ views. I approached some nurses who had experienced
conflicts with patients, and some patients and relatives who were having very good
relationships or having conflict with nurses, in order to understand actions/
interactions, conditions and consequences of good and not so good relationships in
order to gain deeper and richer experiences.
Collecting data
Building the researcher-participant relationship
After the participants understood the aims of the project and agreed with details in
the informed consent, I made an appointment with them at a place of their
convenience. I interviewed nurses at the meeting room of the ward where they
worked and some of them invited me to interview them at home, because they felt
more relaxed. For patients and relatives who were in the ward, I interviewed patients
at their bed, and I interviewed relatives at the conference desk or in the meeting
room of each ward. I interviewed patients and relatives who were discharged from
the hospital at their home. The main concern was to interview them in a private,
comfortable and silent venue. At homes, sometimes there was more than one relative
who joined the interview. Sometimes, some relatives wanted to join in and help
patients answer the questions, so I let them participate naturally. The atmosphere of
interviewing was warm and relaxed. I could see that patients and relatives provided
data especially about their religious beliefs and practice and their relationship with
nurses in positive and negative accounts. They were also very comfortable and open
to share with me about the negative issues of the nurse-patient-relative relationship.
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Interviewing, taking notes and memos, and asking specific questions
Generally, techniques for collecting data included semi-structured in-depth
interviews, audio tape recording, writing general notes, theoretical notes, and
memos, and journal writing. I always kept in mind the objectives of my research and
kept asking myself “Am I asking about applying Buddhist beliefs and practices in
various situations? “Am I asking them about the nurse-patient-relative relationship?”
Finally, I asked for their suggestions for nurses to improve nursing services. I said
thank you and asked again if they needed any help.
Firstly, I started the interview process by greeting participants in a respect manner
and saying “Sawasdee ka” (This is a greeting phrase meaning hello), as the norm of
Thai culture. I then introduced myself, my purpose for the interview, and continued
by asking about the participant’s general background in order to create rapport.
Secondly, biographical data were collected from all of participants. For the Buddhist
nurses, I asked about their age, gender, years of experience in work, and background
(educational level, marital status). For the Buddhist patients, I asked about their age,
gender, history illness, and personal background (educational level, occupation, and
marital status). For the Buddhist relatives, I asked about their age, gender, nature of
relationship with patient, period of care, and background (educational level,
occupation). I asked permission before recording each interview.
Thirdly, I asked the participant to tell about his/her knowledge, attitudes, beliefs, and
practices of Buddhism and how they apply Buddhist principles in their daily life.
The questions used to trigger the conversation were not executed rigidity, but they
included prompts, such as:
For the Buddhist nurses
“Thank you for agreeing to be part of this research. I’m interested in your perception
and experiences of being a nurse in Buddhist culture. How do Buddhist principles
affect your role as a nurse when you provide nursing care for clients and relatives?
Can you tell me about that please?”
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Chapter 4: Methods and processes
“How do you practice Buddhism to provide spiritual support to clients? Tell me in
detail and give me one or two examples of your caring activities, please?
“How do you feel when you apply Buddhist principles to help patients? Why do you
use the Buddhist principles?”
“Do you think Buddhist culture affects the nurse-patient relationship and nurserelative relationship? Give examples to support your ideas, please.”
“What help do you need to make your nursing care more effective, in using
Buddhist principles when caring for suffering clients?”
“How do Buddhist principles influence your life and work, including social
activities and solving personal problems in your daily life?”
“As a Buddhist nurse, what are the main Buddhist principles that you always follow
and what Buddhist activities do you usually practice in every day life? Why?”
To finish the conversation, the question was:
“How important is it for you to use Buddhist principles in giving the best nursing
care for patients and relating to patients’ relatives?”
For the Buddhist patients
“Thank you for agreeing to be part of this research. I’m interested in your perception
and experiences of being a patient in Buddhist culture. How do Buddhist principles
affect you when you get sick from chronic conditions? Can you tell me about that
please?”
“When you feel pain, distress, anxiety, or any kind of suffering with your illness,
how do you manage these situations? Tell me about it please.”
“How do you feel when you apply Buddhist principles to cope with suffering and
why do you use Buddhist principles?”
“How and why does the Buddhist culture affect the nurse-patient relationship and
patient-relative relationship? Give examples to support your ideas, please.”
“In the Buddhist view, what help do you need for coping with suffering?”
“How do Buddhist principles generally influence your life, work, social activities
and in solving personal problems in your daily life?”
“As a Buddhist patient, what are the main Buddhist principles that you always
follow and what Buddhist activities do you usually practice in every day life?
Why?”
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When the participant was hesitant in how to begin, or to maintain the flow of the
stories, conversational prompts were given such as:
“What was happening? How did that make you feel?”
To finish the conversation, I asked some questions such as:
“How important is it for you to use Buddhist principles in your experience of being
a Buddhist patient?”
“If you could give advice to your caregiver or a nurse about how you would like to
receive care when you experience physical, emotional or spiritual suffering, what
would it be?”
For the Buddhist relatives
“Thank you for agreeing to be part of this research. I’m interested in your perception
and experiences of being a relative of a patient in Buddhist culture. How do
Buddhist principles affect you when you care for/assist/help nurses to care for your
relative? Can you tell me about that please?”
“How do you feel when you see your relative suffer from chronic illness? Tell me
please.”
“How do you use Buddhist principles to support your relative when s/he suffers
from illness?”
“What help do you need from your local health agencies, in supporting you in the
care of your relative?”
“How and why does the Buddhist culture affect the nurse-patient relationship and
nurse-relative relationship? Give examples to support your ideas, please.”
“How do Buddhist principles influence your life, work, social activities and in
solving personal problems in your daily life?”
“If you could give advice to nurses or health care persons about how you would like
to your relative to receive care that suits the Buddhist ways, what would it be?”
To finish the conversation, I asked some questions such as:
“How important is it for you to use Buddhist principles in your experience of being
a Buddhist relative of a patient?”
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After finishing each interview, I said “Thank you very much for the time and the
valuable experiences you have shared with me.” I then made an appointment for
next time, should that be necessary.
Initially, I planned to interview each participant for about 1 hour, however after
considering participants’ conditions and willingness, they preferred to spend more
time to share their experiences. The duration of each interview was 30 minutes to 2
hours. I also valued multiple interviews, so I interviewed twice with a half of
participants, three times with one nurse and one relative, and four times with one
patient, in order to explore some specific issues and validate data.
Fourthly, after finishing each interview, I listed notes which included main ideas
from participants. I reflected on any feelings, ideas, issues and problems that arose. I
made several notes about the issues that needed more detail and issues that I needed
to further explore, in order to fill the gap between the emerged concepts and
categories.
I also gave to every participant a note book with a pen, in a folder, together with
documents which informed participants about objectives, and the guideline of
questions. See an example of the folder for participants in Figure 4.1.
Figure 4.1: The folder for participants
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Chapter 4: Methods and processes
I encouraged participants to write their stories, including examples of using
Buddhist principles in their sick, assisting, or caring roles. However, there were only
three participants, two nurses and one patient, interested in writing some ideas about
influences of Buddhist culture on nurses’ caring behaviours, patients’ coping
methods influenced by Buddhism, and relatives’ caring minds underpinned by
Buddhist teachings. However, these ideas provided a broader scope to look at the
influences of Buddhism on caring relationship, perception of illness and coping
methods.
At that time, this question came to my mind “Why do most participants not want to
write their experience in their journal?” Thai culture is an oral culture, people are not
used to reading and writing except students and academic people. Some people can
not read and write. For nurses, the main reason was they were too busy to write.
They also did not want to write about their experiences; rather they preferred to talk
about them.
Restating and performing ethical principles
Applying informed consent
Initially, I met face to face with each potential participant to give her or him the
information sheet and list of counselling services participants. I also explained the
information to them, including the possible benefits and risks of the research, and
told them they could have a relative or advocate present at any time during the
interview process. As some of patients and relatives could not read and one of them
had hearing impairments, I talked slowly and loudly when explaining the research. I
also encouraged them to ask questions, and asked them if they preferred to sign the
consent. In fact, they all preferred to be a participant verbally, as they told be they
were happy to be my participants. Just one nurse signed the informed consent,
however, she shared her idea that “It does not matter if I sign it or not sign it, as
long as I trust you (the researcher), as so far you were a good nurse, teacher and
researcher.” I also informed participants that they were free to withdraw at any time
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Chapter 4: Methods and processes
from the research and any information would be destroyed if they requested it and
their contributions removed from the transcripts (see attached information sheet and
consent form at Appendices A and B).
Performing confidentiality
Privacy, confidentiality, and anonymity were ensured throughout the research.
Strategies included the use of pseudonyms, instead of personally identifiable
information. The participants were interviewed initially for approximately one hour.
Code numbers were initially used, for example N1, N2,…, N17 for nurses, P1,
P2,…, P14 for patients, and R1, R2, …, R16 for relatives. Later I gave each
participant a pseudonym which was used to protect the participant’s identity (see
their names in Chapter 5, 6, and 7). I used Thai common names and some words
from Buddhist teachings, which reflect some of the positive qualities of each person.
Audiotaped interviews with Buddhist nurses, patients, and relatives, including their
perceptions of how Buddhist culture influences nurse-patient-relative relationship,
were protected by the use of pseudonyms and code names. All information was
confidential and not disclosed to anyone apart from my research assistant and
supervisor. I have kept the original cassettes in a locked cupboard at my parents’
home. I also kept two copies of Thai and English transcripts in a securely stored CD.
I intend to keep all of data at least five years. All participants were assured of
confidentiality of the personal information they shared.
A report of this project is in the form of this Ph.D. thesis for Southern Cross
University. Registered nurses and nursing students will be a primary audience for
the information. The research findings will be disseminated in Thai health
professional journals and conferences, as well as to Buddhist nurses, nursing
teachers and nursing students, Buddhist clients and their relatives, and other persons
and organisations concerned with spirituality as part of health and well-being. In any
presentation and publication, I will always maintain participants’ confidentiality.
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Being concerned about potential risks of the research
The participants had the right to full disclosure. All participants received a detailed
explanation, verbally and in writing in Thai language, of what the research involved,
including the aims and processes of the research, and the participants’ involvement.
They were offered the right to refuse to participate or to withdraw at any time,
without penalty of any kind. They had the opportunity to ask questions, make
comments, and voice concerns. A copy of the Consent Form and a Plain Language
Statement were translated into Thai Language then included in the folder for
participants. I informed each participant again at the beginning of the first meeting,
how I proposed to deal with the situation. I was mindful and was sensitive to any
indication that participants were uncomfortable by their words or behaviour.
Initially, I assured participants they could take “time out” during the interview, by
getting up and walking around, having a drink or getting some air, however, they
preferred to share their stories uninterrupted. Some nurses spent almost two hours
for one interview. I planned to turn off the tape recorder at this stage if needed, but
nobody was concerned about recording. Participants could choose to leave the
interview at any time, in fact, they were happy to participate without breaks.
Participants, especially nurses and relatives, shared stories within private settings.
However, I had to interview some patients at their hospital beds, because they
preferred there. Some patients were receiving oxygen or intravenous fluids, or they
had foot amputations, or were fatigued from having high blood sugar. During
interviewing, I observed participants’ feelings, actions and reactions, signs of
discomfort such as pain, agitation, crying, and silence, and asked them if they had
any problems, to please feel free to tell me. I asked patients if they wanted to take a
break, and I carefully observed for any abnormal symptoms; however none of them
needed physical assistance during the interviews.
Through sharing their stories, some uncomfortable feelings or memories were
mentioned, such as worrying about the future, having economic problems, having
conflict with nurses, not knowing how to cope with high blood sugar, having no
special beliefs, and having no idea about applying Buddhism. If participants
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experienced emotional discomfort, I provided immediate and appropriate emotional
support. I listened to them openly, sharing with them that I was concern about them.
I encouraged them to consult nurses as they were hesitant and did not dare to ask for
help. I confirmed participants that if they required further emotional support, I
would refer them to qualified counsellors who provide free service in the area. In
Thailand, counsellors are available free of charge at the provincial and university
hospitals. A list of counselling services is attached. See Appendix C. However, none
of participants needed counselling service.
I focused on mindful listening and maintaining the flow of interviewing following
the participants’ lead, using restatement to confirm the ideas and validate their
stories, asked specific questions to draw them back to the research objectives. For,
patients and relatives, I was also very careful for their reactions to their relationship
problems, especially when they talked about conflicts and dissatisfactions to nurses’
and doctors’ services. I acted as a neutral person, assured them to tell the story freely
as long as they could and to stop telling some experiences if they did not want to
talk about them. I told participants that their perspectives would not have any
negative effects on the health care services.
In fact, there was only one relative who called to consult with me because she had
more issues to tell me about her conflict with nurses. She told me that she called me
to release her tension and she phoned me twice. After I discussed the issue with the
nurses and head nurse, I found that they already knew about it and I assured this
relative that the nurses at that setting already respected her concern and they were
trying to support her over time. Finally, this relative told me that she felt relieved
after she shared her problems with me and she learnt to be positive and reframe her
perception of nurses in a the more positive way. Later, she said some nurses were
very kind and some nurses were “so so”. She was worried about her love one’s
severe illness. She then gave me a lot of suggestions for nurses, especially to listen
to clients, provide enough information, to not label relatives “difficult” who want to
be involved in helping their beloved sick ones, to develop their service minds and
improve communication. In this case, I also assured nurses at that area that I would
try my best to maintain confidentiality about the setting, by using pseudonyms.
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Preventing imposing researcher ideas
Sometimes I was asked by some participants, how other people applied Buddhist
teaching, so I was mindful to tell them after I finished interviews, because I did not
want to influence their ideas. At the end of last interview for each participant, I
asked participants if they needed to ask something. I encouraged them to maintain
their practices especially when they had sleeping problems or worries, I taught some
of them to do basic mindful breathing and movements, or basic chanting before
sleeping time. I also told them that I respected them as they were my teachers. I
ended the interview with saying “Khob Khun, Ka” (which means “Thank you very
much”).
Avoiding researcher’s power over participants
I made a strong commitment to balance potential power relationships between the
researcher and participants throughout the data collection processes. This was done
by encouraging openness and trust, especially in relation to participants telling their
perceptions about their problems. Respectfulness, cultural sensitivity, and
therapeutic communication techniques were enacted throughout the interviewing
process.
Appreciating positive responses and preventing harm for special participants
I realized that there were some positive and negative unintentional side effects of
interviewing participants about religious beliefs, practices and relationships. The
positive side happened when participants felt proud of themselves that their
experiences would make a positive contribution to nurses and other patients and
relatives. They also realised that their voices were heard to call for mutual
compassion. They also learnt and gained more confidence that Buddhist teaching
and Thai healing wisdom could help them cope with illness and death, deal with
hard work, accept any change in their life and for them to become better persons.
Some patients practiced religious rituals more frequently and some patients became
interested in practising meditation and continued learning Buddha Dhamma. Many
of them realised the positive effect of a strong mind on their spiritual health, as they
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stated that “When the body becomes sick our duty is to take care of our body, but we
shouldn’t fear illness. I don’t let my mind think about dreadful images of cancer,
because if I fear cancer then my mind will deteriorate. Rather, I think only that my
body is sick, but my mind is still strong. I must let the power of my mind heal my
disease (Patient 1: Pe Da).
Conversely, there were some situations that could harm participants. From my 10
years clinical and reaching experiences I observed patients’ and relatives’ problems
holistically. For example, when I approached a participant, who had chest pain and
heart failure, I waited until he felt better, his vital signs were stable and he had no
sign of ischemia. When I interviewed him, I let his wife stay with him so he could
feel relaxed, because he told me that if he needed to urinate his wife would help him.
I asked him if he had chest pain or felt uncomfortable every 5-10 minutes. I had to
talk to him quite loudly, because he had some level of hearing impairment. He did
not want to read the consent form, as his eye had a minor cataract, so I explained my
purpose and activities to him slowly. He (and also his wife), were happy to share the
stories about applying Buddhist wisdom and he also shared some issues about nurses
being impolite and disrespectful. Because he was an elderly person, he thought
young nurses should respect him as he was their grandfather. Then, I encouraged
him to suggest what he was expecting from nurses. Later, I dealt with this situation
by passing on some issues about respect for elderly patients to the head nurses. I
came back to explain to him that I already raised his concern to the head nurse to
respect his suggestion. I interviewed him just 30 minutes to prevent ill effects, then
encouraged him to rest. A day later I did the second interview, because I realised he
would be discharged soon. In the second interview I validated his previous
experiences by telling him issues that he already recounted. I told him if he had
some more issues to share he could. This time I wanted to explore his idea of
preparing for a good death as he mentioned before that he believed in the Buddha
teaching that “birth, old age, illness and death is a normal event”. He had a few near
death experiences from being shot and a heart attack, and he already thought he
could die at anytime (see details in Chapter 6, Patient 4: Lung Tongkam).
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Dealing with some patients who had economic problems
I did not plan for any financial support for participants. However, when I met some
patients who had severe economic problems, I gave them some money for buying
nutritious foods or for traveling back home. I checked with nurses to make sure that
they already knew about patients’ financial problems.
Preventing guilt and conflicts and dealing with conflicts
During data collection, the issue about conflict also emerged. Before interviewing, I
thought some patients might feel guilty that they were not a good Buddhist, or some
of them had never thought about the role of religion on health care. This was a
sensitive issue for which I already prepared myself, so I could react to this situation.
I could be a positive trigger, to remind them to start thinking of the benefits of the
Buddha teachings on their health, happiness and developing good relationships
within themselves and with others. I talked to participants who were not interested in
religion, so they could share any ideas about this issue, especially about the nursepatient-relative relationship. There were two patients at the wards, who wanted to
make merit after they shared their stories with me. As their relatives did not visit
them during the interviewing period, they asked me to buy foods and provide that
food to the monk at the temple in front of the hospital. The next day I made merit
and radiated merit for patients, then I discussed with nurses: “How we can support
patients who want to maintain their religious practices while they were admitted”.
We realised that many things will need to be done to answer this question.
Maintaining some good deeds within the researcher role
In order to do some good, I tried to transfer general issues causing patients and
relatives concern to the team leader or the head nurses, who I perceived were kind
and could made proper decisions. For instance, when one son wanted to stay
overnight with his mother who was in pain and could not move, the daughter
expected that nurses should to listen to her and provide information regularly. Also
one patient needed to make a decision whether to receive chemotherapy for late
stage cancer. Even though I informed patients and relatives in the beginning of
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recruiting them to be my participants, that “I am not a nurse, rather I am a student so
I might not be able to help you much” in fact, after balancing the risk/benefit ratio, I
realised a lot of relationship problems happened because nurses were too busy. I
provided some initial help, by just relaying messages for them. My main issue was
balancing doing good by not creating dependence by the participants. I opened
supportive channels by telling them that, during the interviewing process, they could
call me at any time if they wanted to talk or needed any help, so I could refer them
to talk to the right person. When patients and relatives complained about nurses’
negative qualities, sometimes, after finishing interviews, I tried to remind some
patients and relatives about nurses’ busyness, so they could better understand each
other, and have less conflict.
After interviewing each participant, I also spent some more time with some
participants who need help. I could not leave them, until I was confident that their
issues were taken care of by appropriate persons and they were calmed down. Being
positive, seeking help, chanting, and radiating metta (loving-kindness) to others,
were applied to remind some relatives, they could manage their own emotional
disturbance. Virtuously, as a researcher is a human being, when I related to suffering
people I maintained a spiritual caring relationship, to cultivate a compassionate
relationship between the participants and me, and these compassionate acts could
also return to support my mind.
Participants were very happy to share their experiences, because they had applied
Buddhist teaching unintentionally and this was a good time for them to share their
personal experiences. They also thought I could let their voice be heard and that
would be very beneficial for the future of Thai nursing, if we would have more kind
nurses in the health care system. Some of them also perceived that they could make
merit by being research participants.
Listening to cassettes and transcribing data
I decided to find research assistants who could help me make a verbatim transcript
in the Thai language and type all data for me, because my typing skill is very slow. I
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needed to spend most of the time looking for issues, codes, categories and patterns
of relationships in my data, rather than using too much time transcribing, writing
and typing data. As I planned to do data collection within six months, and I
interviewed extra participants in order to include many kinds of relationship issues
and Buddhist belief and practices, I needed to have at least two assistants.
Fortunately, there were three research assistants and two nursing students, who had
experience in transcribing and typing, and they devoted their time to help me. About
50 percent of interviews were transcribed and 80 percent of data were typed by
assistants. I explained to the assistants to respect participants’ experiences by not
wanting to know their name and not judging their experiences. I also reminded them
to listen carefully and type every word. They helped me record any problems from
the cassettes, such as unclear sound and interrupted situations. They asked me about
the words of which they were unsure, for example, the Buddhist words, and I
rechecked each interview again with the cassettes after I received the transcripts.
After each interview, I listened to the audiotape and made a verbatim transcript in
the Thai language at least once a week. I made notes of the issues that I had to
explore in breath and depth in the next interview. Sometimes I asked about these
issues with the next participants, and sometimes I returned to ask some more details
from the previous participants. I made another hard copy of all interviews to do a
preliminary analysis, before giving them to my assistants for typing.
Validating data
I planned to return a transcript of his/her interview to each participant, to check its
accuracy, and to add or delete information as required. No participant wanted to read
their data because of three main reasons which were: 1) most of patients and
relatives could not read and write, 2) nurses felt that they were too busy and they did
not want to gain more paper work, and 3) they trusted me that from my personal and
professional experiences, I would manage the data properly. This trust is the Thai
way.
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I asked myself: “How can I validate data when people can’t read and write?” I was
mindful to explore participants’ experiences by thinking about my objectives and
locating concepts and phenomena from participants’ experiences. I listened carefully
to participants’ experiences, took a note of the emerging issues, summarised lists of
important issues, and related their main ideas, during and at the end of the interview.
When I needed more data, I visited them and asked them for specific topics, such as
the meaning of a good relationship, factors which cause good and not so good
relationships, and examples of applying Buddhist principles. I took notes for short
interviews and used an audiotape for longer interviews (more than 30 minutes). On
some occasions, I called participants at home to interview them about some more
issues and to confirm the main issues as an informal validation technique.
Translating data
After transcribing and validating the data, as a novice grounded theory researcher, I
decided to translate all information from Thai language into English. I translated all
of participants’ experiences from the records, notes and memos from Thai language
into English language, some of which were expressed in Southern Thai dialect. For
example the word “plong (ปลง)” from Southern Thai dialect equals “ploiwang (ปลอย
วาง)” in formal Thai language, which means letting go of negative feelings/accepting
problems/illness or understanding the reality. I was very careful to preserve the real
meaning of participants when I translated from the Southern Thai dialect and Thai
formal language into English. This thesis includes some Thai language in the
brackets in order to remind Thai people of the origin of the participants’ language.
At this stage I had four editors, one Australian nurse, one Australian English teacher,
one Australian student from the School of Education, and one Thai university staff
who lived in Australia for nine years. It took me almost two years to translate and
edit data. Even though I had to work hard to prepare participants’ data for the formal
analysis, I also gained priceless benefits which were improving my English skills,
gaining a very deep understanding of the data, and seeing various applications of
Buddhist principles, and patterns of nurse-patient-relative relationships.
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I found that participants had their own meaning of the Buddhist teachings, which
were different from the Buddhist scriptures. For instance, some nurses were
applying the teaching about the Middle Way as “not being too kind”, and “nurses
had to accept that they could not do the best nursing care if the ward was too busy,
they needed not to feel guilt and to consider about the teaching about the Middle
Way” (Nurse 15: Khun Plong). It was difficult translating data to preserve the
authentic meaning of each participant’s experiences. However, I solved this problem
by keeping some participants’ words as they reflected the Thai Buddhist culture, for
example using the word “kreng jai (เกรงใจ)” to explain the Thai characteristic of
hesitancy.
Another complex issue for translating participants’ data from Thai into English was
dealing with many languages. I interviewed participants by using a language with
which they were comfortable. Most of patients and relatives spoke in Southern Thai
dialect, and nurses used formal Thai language. However, many of them talked about
Buddhist teachings in Pali language. In addition, it was not easy to find an English
word which could explain the real meaning of some Thai words, however I
consulted a Thai woman, who had a degree in teaching English as a second
language. She was my editor, and helped me find the correct English words.
When I reviewed some literature about Buddhist teachings and spirituality to find
some words equal to participants’ meanings, I found that Western literature used
Sanskrit language to explain Buddhist teachings in English form. I have learnt that
the Mahayana school of Buddhism uses Sanskrit language to explain the Buddha’s
teachings and the Theravada school of Buddhism uses Pali language to refer to the
teachings, as I explained in Chapter 1. These were some examples of different levels
of language.
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Table 4.3: Illustrated examples of different kinds of language
Southern Thai dialect
Formal Thai
Pali language
English language
language
Jai* dee (ใจดี)
Metta (เมตตา)
Metta
Kind
Hen jai* (เห็นใจ),
Karuna (กรุณา)
Karuna
Compassion,
Empathy, Sympathy
Kao jai* (เขาใจ)
Plong (ปลง),
Ubekkha (อุเบกขา),
Tam jai * (ทําใจ)
Ploi wang (ปลอยวาง),
Upekkkha
Letting go,
Equanimity, Resilience
Yom rab (ยอมรัย)
*Jai means heart or mind, which Thai people use frequently to talk about the quality
of mind.
Analysing data: techniques and processes
Analysis is “the interplay between researchers and data; it is both science and art”
(Strauss & Corbin, 1998: 13). It occurs simultaneously with the data collection
process (Eaves, 2001). I analysed the data by using computer-assisted analysis
methods, using Microsoft word. The steps of data analysis were guided flexibly by
Strauss and Corbin’s grounded analysis method and a multi-step data analysis
technique, which is a synthesis technique for grounded theory data analysis,
suggested by Eaves (2001). This researcher explained clearly the ways to apply
Strauss and Corbin’s analysis methods in her grounded theory of “Caregiving in
Rural African American Families for Elderly Stroke Survivors” (Eaves, 1997 cited
in Eaves, 2001), and this assisted me greatly.
Strauss and Corbin’s grounded theory analytic method suggested three main steps of
coding, including open coding, axial coding, and selective coding (Strauss &
Corbin, 1998; Priest et al, 2002; Woods et al, 2002). Strauss and Corbin (1998)
propose a microanalysis technique that includes a detailed line-by-line analysis at
the beginning of a study to generate initial categories (with their properties and
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dimensions) and to suggest relationships among categories. Three levels of analysis
of qualitative data include open, axial and selective coding.
Open coding is “the analytic process through which concepts are identified and their
properties and dimensions are discovered in data” (Strauss & Corbin, 1998: 101).
The interview material should be analysed line-by-line and a single speech can
address multiple issues (Woods et al, 2002). In addition, Priest et al (2002: 32)
summarised that:
This is the first part of the analytic process and primary involves
“fracturing”: taking the data apart and examining the discrete parts for
differences and similarities. By looking for similarities and asking questions,
concepts that are in essence very similar can eventually be labelled with the
same name. Each concept can then be defined in terms of a set of discrete
properties and dimensions to add clarity and understanding. In due time, the
list of concepts generated has to be sorted into groups of similar or related
phenomena, which in turn becomes categories.
This initial level of coding includes in vivo coding, using participants words to name
the meaning of experiences, and naming the code by using researcher experience or
some pre-existing concepts form literature (Eaves, 2001; Strauss & Corbin, 1998).
Axial coding is “the process of relating categories to their subcategories, termed
‘axial’ because coding occurs around the axis of a category, linking categories at the
level of properties and dimensions” (Strauss & Corbin, 1998: 123). Moreover,
Strauss and Corbin (1998: 126) stated that:
Procedurally, then, axial coding involves several basic tasks (Strauss, 1987).
These include the following: laying out the properties of a category and their
dimensions, a task that begins during open coding; identifying the variety of
conditions, action/interactions, and consequences associated with a
phenomena; relating a category to its subcategories through statements
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denoting how they are related to each other; and looking for cues in the data
that denote how major categories might relate to each other.
Axial coding is used to make tentative connections and relationships between the
first-level open codes and categories initially generated (Woods et al, 2002).
Selective coding is “the process of integrating and refining the theory. It is the point
in category development at which no new properties, dimensions, or relationship
emerged during analysis” (Strauss & Corbin, 1998: 143), and this state is called
theoretical saturation. Keddy et al. (1996, cited in Bluff, 2005) claimed that more
than one story might emerge from data. Selective coding was useful to select the
dominant core concept that best represented the basic social process for the
phenomenon (Strauss & Corbin, 1998).
While I collected data, I did a preliminary data analysis and made memos in order to
see the main phenomena emerging from participants’ experiences. In the process of
being a PhD student and a novice grounded theory researcher I decided to translate
all of Thai data into English, in order to learn grounded theory analysis methods. I
then did the formal analysis from English version of data.
There were 448 pages of qualitative data in English from the demographic data and
interviews, 221 pages of data from nurses, 110 pages of data from patients, and 117
pages of data from relatives. Nurses had deep and rich experiences about caring for
patients and relatives, and they shared many aspects of spiritual care and
relationships. Data from patients mostly came from patients who were not in crisis.
They could take care of themselves, had good relationships with nurses, and had
received good support from their relatives. The main issues from patients were
having communication problem and feeling hesitant to ask for help from nurses and
doctors. Relatives mostly cared for critical and severely ill patients for more than
two months. They experienced both good and not so good nurses. They also applied
religious beliefs and practices to support patients and their minds in crisis and stress
situations. (See detail of participants’ experiences in Chapter 5, 6, 7 and Appendices
E, F and G).
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From September 2003 to July 2005, I performed many steps of data management,
starting with interviewing, listening to the recordings, writing them down, doing a
preliminary analysis of the Thai version of data, translating all Thai data into
English, correcting data after discussion with the editors, and starting the formal
analysis. I undertook a formal analysis of the English version of data by colour
coding. I read and re-read the English version of each case at least twice. I could
remember almost every detail of the participants’ accounts and I became very
sensitive with the data, because I spent almost two years managing it.
Doing the formal analysis
In doing the formal analysis, I applied open, axial, and selective coding in order to
develop data into theory. These three processes were done forwards and backwards,
checking and rechecking for many steps, and the codes, categories and core
categories were compared and contrasted and placed where they fitted best,
throughout the theory development process. Sometimes open and axial, or axial and
selective coding overlapped.
Applying open coding
Initially, I started with analysing one nurse’s, one relative’s and one patient’s
account, as a pilot analysis. In this pilot process, I learned how to give the
appropriate name to the code and learned to focus on only one meaning in each part
of data. I also learned to forget participants’ contexts and let the whole data become
many pieces of data, with specific meaning, in order to move from descriptive to
abstract analysis. My supervisor told me how to follow guidelines to name the
codes, for the open coding. After I gained more confidence to name the codes, I was
apprehensive about how I could manage the mountain of data from 47 participants.
If I continued doing manual colour coding analysis, it would take a lot of time to
come back to transfer the analysis to my computer. Therefore, I stopped colour
coding and used Office Word to manage my document with computer assistance.
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Firstly, I read and re-read the transcript very carefully one by one, and looked at
each transcript to consider the meaning of the descriptive data. I underlined key
words, and then wrote the name of code above the first line of a piece of data. Some
examples of this process are in Chapter 5, 6 and 7. An example highlighting
equanimity follows:
Valuing nurses’ metta for building good relationships
The heart of being a good nurse is to have a good relationship with patients and
relatives naturally. Love the things that you do and do them with metta (loving
kindness). If you have good ideas to help patients you must do them as soon as you
can, don’t just think about it. Even if you have difficulties, you should still do it with
every effort. It is innate, from the bottom of your heart. If you work at a radiation
clinic in order to try to please some of the doctors to receive a special bonus or
salary, you will be disappointed. On the other hand, if you do so without expecting
repayment, you will receive many things. At least you will get love and trust from
the one who you give love to. The real value of selfless working is having self
esteem.
Crossing professional boundaries
In our profession, nursing teachers used to teach us to work within a professional
boundary, like have sympathy and don’t have empathy. I think it was because we
need to protect ourselves from having too much emotional connection with patients.
Sometimes when a patient dies, some nurses feel so sad they cry. This means we
can’t use equanimity with those patients. However, if we understand the Dhamma
(the absolute truth), we can practise the right things in the right time, at the right
place and with the right person because of our polite manners and speech which
come from our good thoughts. Patients respect, trust and love nurses because of our
polite words, good hands (care with skilful techniques) and good hearts (kindness).
Using equanimity for nurses when patients die
The most important issue for nurses is to have equanimity with patients. Sometimes,
even when you provide a high standard of care, you do good deeds and patients
inevitably get worse, you try to help them more and then patients die. You have to
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accept the reality and avoid too much grief or guilt. I compare it to playing football;
you can’t shoot every ball into the goals. For instance, one week I was asked to visit
and support five critical and terminal patients who were admitted into different
wards. Their relatives asked me to provide psycho-spiritual care for the patients. I
went to visit them after I finished my work from 5 p.m. to around 8 p.m., one person
a day. The patient’s relatives were really sad and agitated. They couldn’t accept
that the patient was dying. I would go back home wondering why I couldn’t help the
relatives to be calmer. I kept asking myself that repeatedly. I stopped visiting
patients for two weeks because at that time there was a Dhamma and Healing
workshop run by School of Nursing. At the workshop I met a Western monk and a
well known Thai nun and asked them my question. The monk gave me a good
answer. When we shoot a ball at the goals 100 times it will not get through every
time. Please do not work with kilesa (defilements). That Dhamma’s statement
reminds me of my sati (mindfulness, recollection).
Overall, I undertook open coding for 17 nurses, then moved to 14 patients and 16
relatives. The examples of open coding from five nurses, five patients and fives
relatives are showed in Chapter 5, 6 and 7.
Secondly, I put code phrases together, which could capture the main idea of what the
participants said. The outcome of this process was generating the first level codes
from the raw data. These initial codes were kept together without keeping the
descriptive part of data. This group of codes were ready to be separated from each
other in order to categorise them into the set of categories. The example of putting
open codes together is illustrated in Appendices E, F and G.
During this open coding process my supervisor helped me shape my ideas about
using proper gerunds to name the data. During this time my English skills were
improving, and my supervisor was my editor. She rechecked all of the codes in order
to make sure that I interpreted data appropriately. Because the data showed a lot of
examples of application of Buddhist beliefs and practices to care for patients and
relatives in every stage of illness, in order to remain the main ideas of participants’
examples, I needed to do a lot of paragraph-by-paragraph in-vivo coding, while
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doing some line-by-line and phase-by-phase analysis. This technique gave names to
each piece of data by using the participants’ own words. My professor told me that I
was good at doing micro-analysis because I always paid attention to details in the
data.
The third step was the fracturing process, in which I did a case by case analysis of
17 nurses, 14 patients and 16 relatives by using the cut and past computer function
to move the data within each case, and examine the discrete parts for differences and
similarities. Similarities codes were moved together, and then labelled them with the
same name, because they had specific properties and dimensions to add clarity and
understanding about influences of Thai Buddhist Culture on the nurse-patientrelative relationship. Later, the list of concepts was sorted into groups of similar or
related phenomena, which in turn became categories.
Applying axial coding
In this process, my supervisor suggested I select fives nurses, five patients and five
relatives, who shared rich experiences, to perform an analysis. This decision was to
help me manage mountains of data from 47 participants. It was very difficult for me
to chose just fives cases from each group to fully present in the main part of the
thesis document. It became apparent that 47 fully worked analyses would be too
lengthy in a thesis document. The remainder of the analysed examples appear in the
Appendices in abbreviated form. The 15 examples in the text of the document, plus
examples in the Appendices were combined to generate the grounded theory. I
valued and respected all of participants’ experiences and they all were connected
and supported each other. However, I felt pleased when I could use all related codes
from all participants in the process of developing the grounded theory as described
in Chapter 8.
At this stage, I did two main tasks which were firstly, moving data to a more abstract
level by developing categories from mixing data from five nurses, patients and
relatives. Secondly, I added the rest of codes and sub-categories from the rest of
participants under the similar categories.
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Section one of axial coding: developing categories from 15 selected cases (fives
nurses, five patients and fives relatives)
I applied Strauss and Corbin’s suggestions by trying to relate categories to their
subcategories, linking categories at the level of properties and dimensions, laying
out the properties of a category and their dimensions, identifying the variety of
conditions, action/interactions, and consequences associated with a phenomena;
relating subcategories to its category, looking at how they related to each other; and
looking for cues in the data that denote how major categories might relate to each
other. From doing these tasks, I made tentative connections and relationships
between the first-level open codes and categories initially generated.
In each group of five participants, after I finished case by case data analysis, I used
constant comparative method, finding similarities and differences of codes and
categories between patients and nurses, then between relatives and the nurses’ and
patients’ categories. I tried to identify the variety of conditions, action/interactions,
and consequences associated with applying Buddhism in the nurse-patient-relative
relationship. The word processing program was employed to help me move and/or
cut and/or paste all similar codes among three groups together. When similar codes
and categories were put together, I rechecked them and moved some unrelated codes
out of that group to find the place they fitted best, and then I rechecked and
confirmed the appropriate names of each group of data, to become sub-categories
and categories.
At the completion of this section, I developed more abstract levels of data by
moving all of codes away from the categories. In other words, I kept only categories
and put them together in only one document. Preliminary categories and core
categories started to emerge after I mixed categories from the 15 cases together.
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Section two of axial coding: adding the rest of codes and sub-categories from the
remaining participants under the similar categories
Before doing this section, I had already developed many sub-categories and some
main categories. I also could see the connection between each category. In this
section, I started adding the rest of codes and sub-categories from the rest of
participants, for which I had already grouped the codes with similar meanings, under
similar categories. I started to analyse the nurses’ accounts, adding codes and
categories from the remaining 12 nurses into the categories from the other five
nurses. Then, I analysed nine more patients and finished this section by analysing 11
more relatives’ accounts.
In the process of axial coding, I looked at the new codes and categories which were
different from previous participants, and asked myself: “Are there any codes that
need to be moved to under the other categories?” I then rechecked and sometimes
found that some codes need to be moved a more appropriate place. Some new
categories also emerged from adding the later 32 participants’ accounts to the former
15 participants. However, the data were similar which is important in higher level of
theory development; see detail in Table 8.2 (Appendix H). Finally, I focused on
looking at the order and flow of codes, the relationships of codes and categories, and
the logic of all the codes, categories and core categories, to make sure that they were
well placed and developed.
From adding together similar codes from all participants, I could see that the data
from 47 participants provided rich concepts and categories in relation to applying
Buddhist teaching to every stage of illness, from healthy states to death and dying.
The data also showed a variety of related concepts, action/interaction, strategies,
conditions and consequences of both good and not so good nurse-patientrelationships. More importantly, I could see clearly that among nurses, patients and
relatives, Buddhist teachings had strongly influenced the cultivation of
compassionate relationships between nurses, patients and relatives, and that they
used compassion, equanimity, religious beliefs and practices, personal, local wisdom
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and Thai traditional healing, as coping strategies to deal with suffering and health
related issues.
The axial coding process moved all of participants’ accounts to the abstract level,
from open codes to categories and core categories, which showed the links between
codes and categories, and categories and sub-categories. I made another copy of the
original data, and then collated all of the codes, remaining sub-categories, and core
categories, as show in Table 8.3, Appendix I.
At this stage, I found that I had two to three levels of categories (see Table 8.1,
Chapter 8). This was because of the complexity of the nurse-patient-relative
relationship and the various applications of Buddhist beliefs and practices from 47
participants. These categories represented concepts, action/interaction, strategies,
conditions and consequences of applying Buddhist beliefs and practices and building
relationships among nurses, patients and relatives, in tune with the grounded theory
development processes of Strauss and Corbin (1990, 1998). I told my supervisor that
the data had several levels of categories, and we discussed the ways to represent
them. I decided to call the first level of categories “minor-categories”, the second
level of categories “major-categories”, and the third level of categories “core
categories”, to represent the many co-concepts, co-conditions and co-consequences
of the selected social process as suggested (Strauss & Corbin, 1998).
In summary, subcategories are characteristics and properties of categories along a
continuum or dimensional range and categories are classifications of concepts
(Eaves, 2001). Core categories are the core concepts which show the relation of the
diversity ranges of properties (Strauss & Corbin, 1998). A core category is a central
theme or story line of the data, around which all the other categories can be
subsumed. Several core categories can be identified in any given set of data (Eaves,
2001). I then reached the selective coding process.
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Applying selective coding
In this refining and integrating process, I considered and selected the categories
which could represent major subcategories and had explanatory power as the main
concepts of the theory, to develop the core category. I considered the relationships
between each “minor” and “major” category, and between “major-categories” and
“core categories” until no new properties, dimensions, or relationships were
uncovered during the selective analysis. Finally, three core categories clearly
emerged, which were 1) facing suffering /understanding the nature of suffering, 2)
applying Dhamma (Buddhist beliefs and practices), personal/local wisdom, and Thai
traditional healing, and 3) embodying mutual compassion with equanimity. Each of
these core categories encompassed several concepts, dimensions, and consequences
of sub-processes, which are illustrated in Table 8.1, Chapter 8.
Each category had interconnection with other two categories. This is similar to
Buddha’s teaching about the law of cause and effect. Buddhists believe in the
interconnectedness of all things, beings and the universe. The nature of human
relationships, especially the nurse-patient-relative relationship is complex and nonlinear, and the relationship encompasses many processes, actions, and interactions.
All of related phenomena in the flow of relationships are related and interconnected
to each other. Considering this connectedness, I was mindful to look at the
connections between each part of data, from codes to categories, and between each
level of categories. I considered the link between each level of categories on vertical
and horizontal levels, from the beginning to the end of a relationship. Finally, the
interconnected processes of the nurse-patient-relative relationship emerged from the
data through the multiple steps of data analysis, as showed in Table 8.2-8.3,
Appendices H and I.
The emergence of the basic social process
The three core categories were related to each other, and they developed into the
basic social process (BSP) of “Cultivating Compassionate Relationships with
Equanimity between Nurses, Patients and Relatives”. This BSP had strong
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explanatory power to explain relationships between all of other core categories, subcategories and supportive codes. This BSP represented the discovery of how
Buddhist culture influences the nurse-patient-relative relationship. Eaves (2001)
contended that mini-theories are generated from core categories, and finally,
explanatory frameworks are developed and they represent the derivation of a
substantive theory, in the form of language. The next challenge is to explain the
middle-range theory in words. See the detail in Chapter 8.
Reaching theoretical saturation
In this research, the qualitative data were saturated during the interviewing process,
when no new important data emerged from nurses, patients, and relatives.
Furthermore, the theoretical saturation was also reached when no new categories
emerged from the data.
Writing memos and theoretical notes, and sorting memos
Strauss and Corbin (1998: 217) stated that “memos were written records of analysis
that may vary in type and form, they include codes notes, theoretical notes,
operational notes and diagrams.” Eaves (2001: 661) also explained that
Throughout the entire process of data analysis, memos will be written to: (a)
interpret in-vivo material, (b) articulate metaphors, (c) examine the
relationships among code categories, (d) explain major code categories, (e)
explore methodological issues and (f) generate theory. Memos will be
written explorations of ideas about data, codes, categories, or themes.
I wrote many theoretical notes from the start of this project. Overall, I filled four
exercise books with memos and notes. The issues that I noted while I interviewed
participant provided lists of incidents about the application and types of nurse,
patient, and relative relationships. Memos guided me in collecting new data and
developing the categories from the data. I also made several kinds of memos during
collecting, analysing, and preparing data for writing. The memos helped me to
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develop categories and link relationships of the process, conditions and
consequences of applying Buddhist teachings and developing spiritual caring
relationships. (See examples of memoing in the following section).
Illustrating examples of my memos and theoretical notes
Examples of memos included listing any intuitions and news ideas, raising and
answering some more questions, drawing diagrams and seeing the links between
data. I also did a lot of theoretical coding when I wrote my memos. These “intuitive
moments” usually occurred when my past experiences interacted with new data or
new experiences. It is a creative process of learning and gaining deeper
understanding about the interconnectedness and relationship of the participants’
ideas and researcher’s understanding.
Listing intuition and new ideas
My ideas usually emerged when walked slowly in the morning and evening during
the sun rise and sun set, practising mindful meditation. They also came many times
while I was cooking and taking a shower. When walking, I always took note books
and pens so I could note every idea that suddenly came to mind. These were some of
my intuitions and news ideas:
Memo 1: The Thai context: Thai holistic way of life (operational note)
• depends on family/temples/community members
• still depends on traditional healing/belief in supernatural power/use lots of
complementary care such as herbs, massage, rituals
• There are temples, monks and traditional healers every where
• Making merit is the main religious practice, doing more when getting
sick/death and dying
• Helping each other in daily life (except in modern life style)
• Repaying gratitude, taking care of parents and respect for older people are main
beliefs.
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Memo 1 (cont.)
• Just a few Buddhists practice meditation in daily life
• Using local and traditional beliefs (massage/amulets/make a vow, etc)
• Using a lot of herbs/local vegetables in daily life
• People feel more relaxed to consult the monk or seek help from traditional
healers (informal) than talking with nurses and doctors in hospital (formal)
• Most patients use some kind of alternative care while there are sick/they don’t
just depend on medication and treatments. They use more when facing incurable
illness
• Relatives stay with patients in the wards/private rooms
• Relatives help nurses provide nursing care in hospital
• There is no nursing home (except for healthy older people), so at home patients
are cared for by relatives
• Nurses are very busy, but try to support patients and relative in order to meet
holistic care goals
Raising and answering some more questions
In the field, I contacted some nurses and nursing teachers to inform them about my
research while I was waiting for the ethical approval from each setting. At that time,
I asked myself a lot of questions about suitable participants. I also had been asking
a lot of interesting questions and I applied self-reflection techniques to answer
myself and people who asked me. Sometimes when I was not sure that my idea
sounded right I emailed my supervisor and consulted some critical friends at my
school who had experience of doing grounded theory, or who knew about
Buddhism, for example:
Memo 2: Questions and answers (operational notes, and theoretical notes)
Question: Why don’t you explore the Buddhist healing or focus on studying
suffering? These topics seem clearer than exploring about relationships.
Answer: At that time I was so confused and asked myself “What is relationship?”
and “How is relationship related to spirituality?” Am I studying therapeutic
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Chapter 4: Methods and processes
relationship or relationship as a part of caring, ethical care, spiritualty or holistic
nursing care? I was trying to find the specific scope of relationship in nursing
because it appeared everywhere as a basic foundation of nursing. I took several
weeks to find the place where the word “relationship” is placed in the nursing world.
Finally, I think we realise the importance of caring or therapeutic relationships but
we do not know the nature of the relationship and how Buddhism influences the
relationship in Thailand. This project will provide a clearer understanding of the
relationship in the Thai Buddhist culture.
Drawing diagrams and seeing the links between data
These memos included pictures, tables, diagrams, and mind-maps about issues in
applying Buddhists teachings and characteristics of nurses, patients, and relatives.
When I had time I usually linked the concepts and related phenomenon in a Power
Point presentation program, in creative ways. This helped me relax my mind
because I loved to play with the Power Point presentation program and put my ideas
in diagram or mind-maps, rather than describe them as texts. These were some
example of my memos.
Memo 3: Emergent issues, some cultural differences (operational notes)
Language
Context/
culture
Thai Buddhist culture/
Eastern wisdom
Western culture from literature
and personal experience
Kindness/compassion
Empathy/Sympathy
Equanimity:1)surrender (no other choices); 2)
true acceptance (understanding the nature of
illness and death)
Resilience
Collective/strong kinship
Individual/personal concern
Formal care in hospital
/strong bio-medical model
Formal health care system/biomedical model
Informal/more holistic care at home; some
wards/hospitals
Informal traditional healing (provide by
family members and traditional/folk healers)
Formal alternative care services
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Chapter 4: Methods and processes
Memo 4: Diagram created after thinking of positive and negative qualities of people
including nurses
- busy, self-centered,
neglectful, impolite,
demanding,
overpowering
NPR
Relationship
+ very kind, friendly,
polite, helpful, flexible,
respectful, having
gratitude, making merit,
helping others, forgiving
P
P
N
N
R
R
Human Relationship
May all beings who are subject to birth,
aging, disease and death, be happy
Memo 5: Diagram drawn after thinking of some factors in Thai Buddhist culture
which influence good nurse-patient-relative relationships
Buddhi sm & Thai custom, Thai culture & Thai traditional healing
Spiritual Dimension
Better nursing
P
Harm onious
N
R
Relationship
Doctors, hospital context
Social context, kinship, humanity
Related factors
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Chapter 4: Methods and processes
After reviewing the literature, I drew some pictures which showed the links between
related concepts of the nurse-patient-relative relationships in the Thai Buddhist
culture, and another picture reflecting factors influencing the nurse-patient-relative
relationships. This kind of memo was guided by Strauss and Corbin (1998), in the
techniques of creating a conditional/consequences matrix.
Memo 6: The conditional/consequences matrix of related concepts which link to
nurse-patient-relative relationships in the Thai Buddhist Culture
Cultivating Compassionate Relationships with Equ animit y :
Influences of the Thai Buddhist Culture on the Nurse-Patient-Relativ e Relationship
Universal love
Healing
Environment
Consciousness-AwarenessAwakening
Consciousness-AwarenessAwakening
Holistic p erspectives
Altern ative choices
Spiritualit y
Ethics, moral , virtuous act s
Therapeutic Relation ships
Mutual participation
Culture &
Local
wisdom
Religion:
beliefs&
practices
Cultiv
Cultivating
ating
Compas
Compassionate
sionate
Relatio
Relationship
nship with
with
Equanimity
Equanimity betwee
betweenn
Nurses
Nurses--Patie
Patients
nts-Relatives
Relatives
Person:
values&
beliefs
Consciousness-AwarenessAwakening
Nursing
Family
Friends
Relatives
Consciousness-AwarenessAwakening
Sufficient Health Care R esources
Health
Environment
Universe
The following memos (memo 7-10, figure 4.2-4.5) came from my original handwritings reflecting participants and myself and the consistency of seeing the
interconnectedness of the nurse-patient-relationships and the influences of
Buddhism on compassionate relationships with equanimity.
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Chapter 4: Methods and processes
Memo 7: Cultivating Compassionate Relationships between Nurses, Patients and
Relatives.
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Chapter 4: Methods and processes
Memo 8: Clarifying the meaning of compassion, equanimity, and relationship from
dictionaries, participants’ meaning and literature.
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Chapter 4: Methods and processes
Memo 9: Seeing the interconnectedness of the nurse-patient-relationship and the
influences of Buddhism on compassionate relationships with equanimity.
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Chapter 4: Methods and processes
Memo 10: The application of Buddhist teachings in the Thai context.
These examples of various kinds of memos also showed the many dimensions and
complexity of the data analysis processes. They also reflected the multiple meanings
of qualitative data. I avoided using any preconceived ideas to analyse or force the
data, thus I allowed concepts and the nurse-patient-relative relationships to emerge
from participants’ experiences.
These memos reflected the development of my grounded theory. From the beginning
to the end, I worked hard and many times I became “lost” in mountains of data. In
grounded theory research the data speak for themselves, as suggested by Glaser and
Strauss (1967) and Strauss and Corbin (1998). Finally, participants’ accounts led me
to develop a middle range theory of “Cultivating Compassionate Relationships with
Equanimity between Nurses, Patients and Relatives”. I could see that Thai
participants applied Buddhist teachings and other coping methods to deal with
suffering from illness and death. I linked the main categories which were, facing
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Chapter 4: Methods and processes
suffering/understanding the nature of suffering; applying Dhamma, personal/local
wisdom and Thai traditional healing; and embodying mutual compassion with
equanimity, as described in Chapter 8.
Sorting memos and doing the final theory refinement
Sorting memos
After I developed the basic social process, I looked back on all of my notes and
memos over time. I could see the interplay between data and my ideas for the theory
development. The theory flowed freely from the data, my personal and professional
experiences and some literature, which included the processes of induction,
deduction and verification. In sorting memos, I tried to put my ideas together on
vertical and horizontal dimensions, and used them to confirm the categories and the
basic social process. I then prepared myself for writing the theory.
Doing the final theory refinement
In the final stage of theory development, I looked at the process and the relationship
between categories which supported the substantive theory of “Cultivating
Compassionate Relationships with Equanimity between Nurses, Patients and
Relatives”. I also rechecked all of the participants’ codes and categories, and
rechecked all relationships between codes, categories and their related concepts.
Clearly, the memos provided useful guidelines for developing the grounded theory
and writing the research results.
Ensuring trustworthiness and the quality of research
Taylor (2002: 378) claimed that
Qualitative research is no less rigorous than quantitative research, but it uses
different words to demonstrate the ways of making explicit the overall
processes and worthiness of the project, because it based on different
epistemological assumptions.
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Taylor (2002) explained that Sandelowski (1986) applied the ideas of Guba and
Lincoln (1981) who proposed rigour in qualitative research in general. Sandelowski
(1986) applied this concept to nursing research. The categories for determining
rigour are credibility, fittingness, audibility and confirmability. However, Polit and
Beck (2004: 444) pointed out that:
There is less agreement among qualitative researchers about criteria to use in
enhancing and documenting data quality. The most widely used approach is
Lincoln & Guba’s methods of evaluating the trustworthiness of data and
interpretations, using the criteria of credibility, dependability, confirmability
and transferability.
According to Polit and Beck (2004: 444) credibility refers to “the believability of the
data”. In other words, “the extent to which participants and readers of the research
recognize the lived experiences described in the research as being similar to their
own” (Taylor, 2002: 380). Techniques to improve the credibility include “prolonged
engagement, which strives for adequate scope of data coverage, and persistent
observation, which is aimed to achieving adequate depth” (Polit & Beck, 2004:
444). Fittingness refers to “the extent to which a project’s finding fit into other
contexts outside the study setting” and audibility is “the production of a decision
trail which can be scrutinized by other researchers to determine the extent to which
the project has achieved consistency in its method and processes.” Dependability of
qualitative data refers to “the stability of data overtime and over conditions, and is
somewhat analogous to the concept of reliability in quantitative studies” and
transferability is “the extent to which findings from the data can be transferred to
other settings or groups, transferability can be enhanced through thick prescriptions
of the context of the data collection.” Lastly, confirmability refers to “the objectivity
or neutrality of the data”, which “relies on the confirmation of participants” and “the
project achieved neutrality from the researcher’s stated biases”. Taylor (2002: 380)
claimed that “confirmability of a project is achieved when credibility, audibility and
fittingness can be demonstrated.”
Denzin (1989 cited in Taylor, 2002) suggested using triangulation to improve
quality of research. Triangulation is a way to validate the data by using more than
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one method in studying the same phenomenon, to reduce researcher bias (Adami &
Kiger, 2005; Taylor, 2002). There are two main purposes of triangulation which are
for confirmation, to confirm the accuracy of one’s data set; and for completeness,
using multiple methods, sources, theories and investigators in order to reveal varied
dimensions of the given nursing phenomenon being studied (Shih, 1998). There are
many kinds of triangulation such as data, investigator, theory, methodological and
theory triangulation.
Data triangulation uses multiple data sources such as interviewing many participants
about the same topic in a study. Data can be collected at different times (time
triangulation), from different places (place triangulation), or from people at different
levels (person triangulation), which can be individual, groups and collectives
Investigator triangulation uses many individuals, two or more skilled researchers
with different expertise examine, to collect and analyse a single set of data. Theory
triangulation uses many theoretical perspectives to interpret data. Methodological
triangulation uses many methods including interviews, document analysis, and
observation (within-method triangulation; it can also use a combination of methods
from two or more research tradition such as qualitative and quantitative in one study.
Data-analysis triangulation is the combination of two or more data analysis methods
(Taylor, 2002; Thurmond, 2001). The researcher needs to consider time and money
constraints as well as the complexity of data analysis method when apply
triangulation in their research (Shih, 1998).
Chiovitti and Piran (2003) applied the principles of credibility, audibility, and
fittingness in their grounded theory research. They summarised eight methods of
research practice they used to enhance rigor. Methods for enhancing credibility
were: letting participants guide the inquiry process, checking the theoretical
construction generated against participant’s meaning of the phenomenon, using
participants’ actual words in the theory, and articulating the researcher’s personal
view and insights regarding the phenomenon explored. Methods for enhancing
audibility were: specifying the criteria built into the researcher’s thinking, and
specifying how and why participants in the study were selected. Methods for
enhancing fittingness were: delineating the scope of the research in term of the
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sample, settings and levels of theory generated and describing how the literature
related to each category which emerged in the theory.
I ensured rigour or trustworthiness in my grounded theory research by applying the
principles of triangulation and by negative case analysis as mentioned by Strauss
and Corbin (1998). I also applied trustworthiness criteria of credibility, fittingness,
audibility and confirmability.
I performed data triangulation, which included multiple settings and multiple groups
of participants including positive and negative cases. In other words, my participants
had both good and not so good relationship between nurses, patients and relatives. I
did some investigator triangulation by having my supervisor, who was a skilled
qualitative researcher, helped me confirm the data throughout the analysing and
writing process. Methodological triangulation was applied by using more than one
method of data collection. My main data collection method was semi-structured indepth interviews, however, I wrote many memos in order to gain sensitivity to the
data and to explore various dimensions of the nurse-patient-relative relationship, I
also did informal observation to observe the participants’ contexts.
As well as doing triangulation, I also ensured credibility by spending six months in
field work, and this prolonged engagement helped me to gain a deep perspective of
the participants. Also, as Chiovitti and Piran (2003) suggested I let participants
guide the inquiry process and used participants’ actual words in the theory.
To promote fittingness, I clearly explained the scope of the research in terms of the
participants’ background, settings, levels and processes of theory development, so
this project could fit into other contexts outside the study setting. I also enhanced
audibility by describing my thinking processes and specifying how and why
participants in the study were selected. Confirmability was achieved because of
credibility, audibility, and fittingness were adequately demonstrated. Finally, in the
issue of transferability, I agree with Strauss and Corbin, as they contend “the
purpose of using a theory-building methodology is to build theory. Thus, we are
taking more the language of explanatory power rather than that of generalisability”
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The real merit of a substantive theory, which is developed from the study of one
small area of investigation and from one specific population, lies in its ability to
speak specifically for the population from which it was derived and applied to them
(Strauss & Corbin, 1998: 267).
From my experience, there were some more general issues that enhanced the quality
of this grounded theory research. Firstly, my background fitted this project. As I
grew up in a Buddhist family in a rural Thai village that is located in the same area
as the setting for this study, this led to the understanding of participants’ culture,
dialect, values and beliefs. I approached participants easily and developed trust,
which better enhanced rich data from participants. Prolonged engagement in the
field promoted the establishment of trust (Guba & Lincoln 1989). Secondly,
multiple interviews were another way of achieving trustworthiness. The second or
third interviews explored more data, clarifying data when important points from the
previous interview were unclear, and validating previous experiences. Thirdly, a
tape recorder helped to increase the reliability of data rather than relying on
memory. Lastly, the systematic approach enhanced the quality of the grounded
theory. I applied systematic data collection and analysis methods along with
theoretical sampling, in order to discover various conditions of the nurses-patientrelative relationships. In doing this, the substantive theory gained strong explanatory
power. However, I also agreed with Taylor (2002) that qualitative researchers work
on the assumption that “truth” is relative and context dependent, there is no absolute
truth and the truth changes in different times, places and circumstances.
Summary the processes of doing the grounded theory research
This project was undertaken between February, 2003 and September, 2006. A
summary of the main activities appears in Table 4.4.
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Chapter 4: Methods and processes
Table 4.4: Activities and processes of doing the grounded theory research
Duration
Research activities
February-March 2003
Overviewed literature in Australia
April-June 2003
Wrote and refined the research proposal
July 2003
Submitted the proposal to the Human Research Ethics
Committee of Southern Cross University
July-August 2003
Reviewed grounded theory literature
August, 11 2003
Gained ethics approval, then went to Thailand
September 2003-March 2004
Reviewed data collection methods and processes
Re-evaluated actual situations and considered proper
settings
Attended some workshops and seminars about palliative
care, alternative and spiritual care in Thailand
Contacted key persons at the Faculty of Nursing,
University hospital, regional, provincial and community
hospitals to ask about proper units/wards and
participants
Recruited participants and informed them about research
aims and methods, and asked for places for interviewing
Collected data, transcribed the records, and did
preliminary data analysis along with writing memos,
theoretical sampling, before doing the next interview
Continuing literature review of recent situations and
related research in Thailand
April 2004-April 2005
Returned to Australia, transcribed some more cassettes
for the three latest cases, and translated data from Thai
to English, edited English version of data
Wrote memos and theoretical notes, and did preliminary
data analysis
May 2005-July 2005
Undertook the formal analysis (open coding, axial, and
selective coding), analysed and re-analysed the data
Wrote memos and theoretical notes
July 2005
The basic social process emerged as “Cultivating
Compassionate Relationships with Equanimity between
Nurses, Patients and Relatives”. I presented the
grounded theory in the School Seminar, and refined the
final name of the grounded theory from the suggestions
of critical friends at the seminar session
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Chapter 4: Methods and processes
Table 4.4: Activities and processes of doing the grounded theory research (cont.)
Duration
Research activities
July 2005-October 2005
Refined axial and selective coding, selected the main
codes to support each categories, core categories, and
refined the relationships of each part under the basic
social process
October 2005-February 2006
Reviewed all related literature which supported the
research finding especially on compassionate
relationships with equanimity between nurses, patients
and relatives, Buddhist philosophy and principles
especially about suffering, compassion, equanimity and
Buddhist spirituality. Also all related grounded theory
about Buddhist perspectives on relationships, spiritual
care, caring, and ethical care in general and in Thailand
November 2005-August 2006
Constructed research chapters and started writing the
thesis chapters
Refined the supporting data to support the core
categories and basic social process while wrote the
theory development chapter
Wrote and re-wrote thesis
February 2006
Submitted the abstract to the Third National Conference
on Aging. Disability and Spirituality: Addressing the
Challenge of Disability in Later Life, Canberra
March 2006
Submitted an abstract to the 4th International
Multidisciplinary Conference on Spirituality and Health:
Interweaving Science, Wisdom, and Compassion,
Canada
May 2006
The abstracts were accepted to give an oral presentation
to both conferences. Because of having economic
problems I decided to present the research only at the
national conference in Canberra
August 2006
Finished the first draft of thesis
September 2006
Finished the full draft of the complete thesis
Presented the paper at the Third National Conference on
Aging. Disability and Spirituality, September 27, 2006
at the Brassey of Canberra, Barton
Submission of the thesis
October 2006-February 2007
Waiting for the comments from three external
examiners.
Refining the final writing for completing the study
Preparing for publishing the research results
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During the period of studying and researching, I developed direct experiences of
Buddhist practices to deal with my daily life changes and stressors, by reading and
understanding Buddhist teachings underpinning spiritual caring relationships of
nurses, patients and relatives in the Thai Buddhist culture. I used reflection,
mindfulness meditation and walking meditation to prevent stress and have a clear
mind to prevent bias while interpreting the data. Writing diary about the things that
worried me helped me learn in this spiritual growth process. I also felt gratitude to
the Thai Government and people who supported my study and provided me with the
best opportunity to do this research project, radiating loving kindness to participants,
the King, the Queen, the Thai people, parents, teachers, colleagues, friends,
neighbours, and creatures and sources of sacred power. Praying for a strong mind to
do good things benefits others and shares and extends Buddhist nursing wisdom and
compassionate care to nursing care both national and international health care
contexts.
Conclusion
I applied Strauss and Corbin’s grounded theory approach to explore the influences
of Thai Buddhist culture on the nurse-patient-relative relationship. Seventeen nurses,
14 patients and 16 nurses from four hospitals, one primary care clinic, and one
elderly centre were recruited, as guided by theoretical sampling. All people
volunteered actively to be participants. Ethical and trustworthiness issues were
implemented while managing systematic data collection and analysis methods. The
constant comparative data analysis method included open, axial, and selective
coding and writing memos developed the substantive theory of “Cultivating
Compassionate Relationships with Equanimity between Nurses, Patients and
Relatives.” The personal inspirations for doing grounded theory on the influences of
the Thai Buddhist culture on nurse-patient-relative relationships were also restated. I
ended this chapter by summarising the main processes of doing the grounded theory
research. The next sections, Chapter 5, 6, 7, present participants’ experiences of
applying Buddhist culture in spiritual caring relationship processes. The detailed
results of grounded theory development will be described fully in Chapter 8.
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Chapter 5: Nurses’ experiences and emerging codes
CHAPTER 5
NURSES’ EXPERIENCES AND EMERGING CODES
Introduction
Overall, 47 Thai Buddhists participated in this research. There were 17 registered nurses
(RNs: 15 females, two males), 14 patients (seven females, seven males), and 16
patients’ relatives (11 females, five males). They came from the university hospital, the
regional hospital, the provincial hospital, the community hospital, the primary care
clinic, and the elder promotion and rehabilitation centre. Participants were enthusiastic
to share their experiences and they were proud to be a part of this project. As one
female patient told me: “The ward was so busy, nobody spent time to talk to me in
detail. I felt so released after I told you about my hardship and you were kind to listen to
me.” One nurse also reflected that she can work harder and gained more energy to
work, because she thinks she cares for patients and relatives as if they are her own
family, and she would like to share this simple idea with other nurses. Many nurses
talked about walking in the others’ shoes (aou jai kao ma sai jai rao, เอาใจเขามาใสใจเรา).
Moreover, patients’ relatives shared their experiences about being with patients in the
ward, helping nurses to care for patients when hospitalised and applying Thai traditional
healing to care for patients, as well as making merit and praying for patients’ health.
Appreciably, one patient told me that she could make a pure merit by being a
participant, because she could see a lot of possibilities to help nurses to be
compassionate and better human beings, if they understood the truth of life from a
Buddhist perspective. There were many more rich and interesting experiences of
applying Buddhism and wisdom in Thai culture and Thai traditional healing as
recounted by nurses, patients, and patients’ relatives.
Because of the immense amount of data in the transcripts of the experiences of 47
participants, my supervisor and I agreed that it was better to present in the thesis
chapters the raw data in the form of open coding from one participant in each group.
Therefore, experiences of applying Buddhist principles and practices in the Thai
Chapter 5: Nurses’ experiences and emerging codes
Buddhist health care context from one nurse, patient and relative are presented in
Chapters 5, 6 and 7. This chapter presents the nurses’ demographic data, and one
nurse’s experiences, and emerging codes.
The nurses’ demographic data, experiences, and emerging codes
Nurses’ demographic data
Seventeen RNs from six settings participated in this study (see Table 5.1). Eleven
nurses (10 females and one male) came from the University hospital (U); two RNs from
the regional hospital (R); two RNs from the provincial hospital (P) (one female, one
male); two RNs worked at the community hospital (C), one at the primary health care
clinic (PHC) of another community hospital. Three RNs were the heads of the wards
and two nurses were clinical nurse specialists (CNS). The first CNS was a palliative
care nurse and another CNS provided long-term care and discharge planning for
patients with cerebrovascular accident and their family. The remaining participants
were RNs, with five to 30 years of practice experience. Their age range was from 26 to
53 years. Most nurses worked as full time professional nurses after graduating from a
Bachelor degree in nursing. One male was in private work owning a chemist shop, as
well as being a fulltime RN. The nurses were identified by pseudonyms of Pe Metta, Pe
Karuna, Pe Jaiyen, Pe Dee, Pe Aree, Nong Saijai, Pe Lamun, Nong Yindee, Pe Jampa,
Pe Mudita, Nong Mali, Pe Bua, Nong Dao, Pe Ake, Khun Plong, Pe Jaiboon, and Pe
Sukjai.
The terms Pe, Nong, Khun are typical Thai pronouns which Thai people use to call the
second or third persons. Pe means an older sister/brother, nong refers to a younger
sister/brother, and the word khun is being used for a person the same age or for persons
who are not close friends, who have just met each other.
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Table 5.1: Nurses’ demographic data
Participants
Age
Sex
Marital
status
Education
Field work
Position
Radiation
clinic (U)
Home Health
Care
(U)
Gynaecology
ward (U)
Intensive Care
Unit
(P)
Intensive Care
Unit (U)
Male
Orthopaedic
ward (U)
Male Medical
ward (U)
Male Medical
ward (R)
Female
Medical ward
(R)
Female
Medical ward
(U)
1. Pe Metta
46
Female
Married
Undergraduate
2. Pe Karuna
53
Female
Single
Master (Public
Health)
3. Pe Jaiyen
34
Female
Married
Undergraduate
4. Pe Dee
35
Female
Married
Master (Adult
Nursing)
5. Pe Aree
40
Female
Married
Undergraduate
6. Nong Sai Jai
32
Female
Single
Undergraduate
7. Pe Lamun
39
Female
Single
Undergraduate
8. Nong Yindee
26
Female
Single
Undergraduate
9. Pe Jampa
43
Female
Single
10. Pe Mudita
42
Female
Single
Master
(Nursing
Administration)
Undergraduate
11. Nong Mali
30
Female
Married
Undergraduate
12. Pe Bua
39
Female
Single
13. Nong Dao
26
Female
Single
Master (Adult
Nursing)
Undergraduate
14. Pe Ake
40
male
Single
Undergraduate
15. Khun Plong
33
Female
Single
Undergraduate
16. Pe Jaiboon
46
Female
Divorce
Undergraduate
17. Pe Sukjai
42
Female
Single
Master (Public
Health)
RN level 6
Experience
(year)
16
Income/
month
(Baht**)
~20,000
RN level 7
30
~20,000
RN level 6
12
~15,000
RN level 7
15
~15,000
RN level 7,
Head nurse
RN level 6
20
~20,000
12
~15,000
RN level 7,
Head nurse
RN level 6
17
~18,000
5
~10,000
RN level 8
Head nurse
21
~20,000
RN level 5
17 years
(PN* 8
years, RN
9 years)
7
~17,000
~15,000
RN level 8,
CNS: CVA
RN level 4
17
~24,000
5
~12,000
RN level 5
~15,000
Male Medical
ward (U)
Male Medical
ward (U)
General ward
(C)
Male Orthopeadic ward
(U)
RN level 5
Male Medical
ward (P)
Primary Care
Unit (C)
Female
Medical ward
(U)
RN level 6
16 years
(PN* 10
years, RN
6 years)
11
RN level 8
23
~15,00020,000
~24,000
RN level
8, CNS
(palliative
care), Head
21
~ 25,000
* PN = Pre-registered nurse,]
** in 2006, about 30-32 Thai Baht equals 1 Australian dollar
Nurses’ experiences and emerging codes
Seventeen nurses shared rich experiences of applying of some aspects of Buddhism and
Thai culture as spiritual healing methods to improve relationships between nurses,
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patients, and patients’ relatives. I present the experiences and emerging codes of Pe
Metta in this chapter. The remaining RNs’ emerging codes appear in Appendix E.
Pe Metta’s experience
Pe Metta, a 46 years old nurse had two children, a 17 year old son and a 13 year old
daughter. She was a special nurse for patients, patients’ relatives, colleagues, and the
hospital. Her main job was to care for cancer patients receiving radiation therapy, and
she devoted herself to be a frontline palliative care volunteer nurse, who spent her own
time after work and on weekends visiting and supporting dying patients and their
relatives in hospital and sometimes at patients’ homes, when requested. Because of her
enthusiasm, some patients called her “Kuan-Im goddess” a Bodhisattava, an
iconographic symbol of a compassionate carer, who encompassed Dhamma as a
medicine to heal the sick never tiring to help suffering people (Fuss, 1998).
After surviving a near death experience after giving birth to her daughter, Pe Metta
made a vow to spend the rest of her life to save other people’s life for repaying her
gratitude to all sacred powers who she believed saved her life. She expressed her
gratitude to be a nurse, who had many chances to help people. She was also very happy
to share her healing techniques, which she learnt and practiced for more than 20 years.
She was so proud to be a part of this project, so she could share her sacred caring with
other nurses. She was so kind to me, because she was always busy. Even so, she let me
interview her three times after finishing her work at 12-1 p.m. and 5-6 p.m. Her
experience was very valuable and she is one of the best models of a spiritual caring
nurse, who applies mindfulness and a compassionate mind to every phase of her life.
She was appreciative of her husband and children, who understand her interest and
always support her to do volunteer work. Pe Metta told me an important thing in her life
was her supportive family. She could do so many good things for patients, relatives, and
the hospital, because she had no family concerns.
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Pe Metta shared her perspectives on influences of Buddhism on the nurse-patientrelative relationship from 16 years of work experience. From about three hours of
interviewing, 69 codes emerged from her nursing experience, which were: helping more
patients; helping patients who have complex problems; receiving support from family to
do volunteer work; building good relationships with patients and families; supporting
and educating patients; assessing why relatives don’t tell the truth to patients;
supporting living with cancer peacefully; having less side effects through psychospiritual support; learning Dhamma and other therapies to help holistically; valuing
nurses’ Metta for building good relationships; crossing professional boundaries; using
equanimity for nurses when patients die; reflecting on raising self awareness by
applying Dhamma’s teachings; being aware of the effects of improper non-verbal
communication; having strong Thai kinship in the family; being kind and loving to help
others; using Buddhist thinking and working; making a vow to help patient with loving
kindness; supporting patients by nurturing patients’ strength; respecting and applying
patients’ belief to strengthen patients’ mind; suggesting religious beliefs; applying
Dhamma to accept the natural truth of life; developing merciful behaviour and loving
kindness; assisting sleeping by using mindful meditation; adapting meditation
techniques; building good relationships and trustfulness; respecting individual
differences; communicating with patients and relatives through the heart; receiving a
hug, respect and trust from patients; focusing on patient; remembering patients’ names
and touching them; helping patients to die peacefully; respecting all patients as teachers;
using music therapy and alternative ways to support non-religious patient; developing
Dhamma as a healing method; becoming an angel in the patient’s view; using polite
words and kind manners; remembering the real beauty of life is a beautiful mind;
remembering statements of life from Dhamma books; having Nam Jai (kindness water
in our heart, compassion) with patients; overcoming temper by nurse’s friendliness and
kindness; applying Dhamma practices and healing techniques to complex patients
problems; applying Buddhist beliefs to ask for forgiveness; feeling mercy radiating
from nurses; valuing nursing as a human caring; being concerned about patients as
human beings; helping patients without expecting reward; applying kindness,
forgiveness, and religious rituals in death any dying; raising mindfulness; reflecting on
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the day; applying the teaching about mindfulness; having concentration and self
controlling skills from practising meditation; recommending nurses practice meditation;
practising self reflection to create good relationships with clients; applying Dhamma to
overcome suffering; accepting individual differences; having positive attitudes towards
work; understanding the suffering of all human beings; transmitting loving kindness and
vowing to help patients; acknowledging the issue of bully nurses; understanding
relatives’ needs for kindness and flexibility; avoiding a bad mood and manner; avoiding
adding more distress to suffering clients; providing equal care; thinking of the patients’
benefit; being flexible while working; realizing that everyone is not perfect; making
merit; and being understanding and kind.
Helping more patients
I have been working in this hospital for more than 16 years. I worked at a 10 and a 30
bed public health hospital for 10 years and I was a private part time nurse at private
hospitals in the central part of Thailand for two years before moving here. When I first
started here I worked in the general Gynaecological ward, then moved to work in the
private Gynaecological ward and then moved to another private ward. In 2002 I made
the decision to move to work at the radiation clinic because in the private ward there
are only 18 beds for patients. There are lots of patients at the radiation clinic who
might need more education, support and holistic care from nurses. In addition, I can
help most cancer patients in the early and healthiest stage of their disease. I think if we
could help patients and relatives when they know their prognosis at the clinic it would
be more beneficial than waiting to care for them in the terminal stage on the wards.
Helping patients who have complex problems
My particular job is working as a palliative care volunteer to help difficult patient who
have complex problems and can’t open themselves up to be easily approached by
nurses on the ward.
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Receiving support from family to do volunteer work
My husband and children also agreed that I should do this, when I told them that I am
only doing good deeds to help patients and relatives. They do understand and let me do
anything that I think is really helpful. I go home around 7-8 p.m. almost every night.
My children can take care of themselves and my husband takes care of the children. My
life really seems to support me to do this voluntary work very well.
Building good relationships with patients and families
My main job at the radiation clinic is to provide nursing care for cancer patients who
are receiving radiation therapy. I do this before, during and after radiation. I care for
patients who are really weak due to the side effects of radiation, provide self care
education for patients to prevent the side effects of radiation and educate relatives to
care for the patient. I discuss with patients and relatives how to maintain good health
and good quality of life during radiation therapy especially the harmonious way, living
with full consciousness and mindfulness while dealing with cancer and radiation with
less discouragement. I haven’t much paper work to do, because there is a nurse
assistant and a clerk to do these tasks. So I can mainly focus on communication and
building a good relationship with patients and families. It makes me really happy when
patients and relatives fell less distressed after I educate and support them.
Approaching, supporting and educating patients
There are many kinds of patients with advanced cancer who come to this clinic … and
when I first meet them I never start with education. I prefer to explore how they
perceive their illness, how do they feel? What is their attitude to radiation and how will
they manage? I listen to them openly and let them ease their tension as much as they
can before I give them more information about radiation and then I let them ask
questions freely … When I first meet patients if they seem to have difficulty adapting to
the illness, I usually pay more attention to them and try to get close to them by greeting
them, smiling, showing my concern and making time for them. I encourage them to ask
questions every day until they trust me. We have to approach patients first, not wait
until they have to come to ask for help. If we can do this, patients will finally trust us
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and come close to us. We can learn their real problems and can find the proper way to
help them … Cancer patients usually fear radiation. I help them mostly by open
listening; discussing, providing information about radiotherapy and letting them make
decisions by themselves. I have to find out how they feel and ask for co-operation. I tell
patients that we should work together, help each other and each take 50 percent of the
responsibility to improve your health status. Doctors and nurses are boxing promoters
and you are the boxer. It depends on you if your illness will get better or not. Nobody
can do this for you, they can’t eat for you and they can’t exercise for you. We can help
you only by giving you some treatment and advice about self care techniques. If you do
and it doesn’t help much you can tell the nurses and try other ways, because some
methods are not suited to some people. Please feel free to consult the nurses and
doctors if you need help. Normally, I educate patients in self care to prevent the
complications of radiation. For example, I explain to them that if you drink more than
2,000 ml of water you won’t have a sore throat after the radiation … It is very easy to
have a close relationship with patients when I ask how they are and listen openly to
them. Then they usually tell me their needs. When I can understand their heart, even if
they are dying, they still tell me their parting instruction before they die.
Assessing why relatives don’t tell the truth to patients
There are a few patients who haven’t known that they have cancer because their
relatives try to conceal it from them. Their relatives have told them they have a blood or
lung disease or just a tumour. Most of them dread the word “cancer”. They fear cancer
and the distress from cancer because of past experiences where they have known that
many people suffer and die from cancer. They anticipate it with fear. For the patients
who have not been told by their family members, I normally invite all of the relatives to
come to my office and I encourage them to say why they didn’t want the patient to know
the truth. What did you fear? When were you going to tell the truth to the patient?
Because cancer is a terminal illness, how will you tell the patient when his/her illness
starts to progress? How will you answer the patient’s questions when he or she gets
worse after receiving the whole course of treatment? It is a double-edged sword which
you must think about carefully to find the best way for your loved one. Would it have
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been better if you had accepted reality and told the patient in the very beginning so that
you could provide the best care and support to the patient? Hard times will pass easily
and from my experience I have seen that patients who know their illness can cope with
all sorts of diasters and do self care better than patients who have had the real
diagnosis hidden from them. The policy of the radiologist here is to try to tell the truth
to patients gradually at a suitable time.
Supporting living with cancer peacefully
Almost all of the patients who receive radiation have known their diagnosis since they
had an operation and received chemotherapy. They all pass many obstacles before
coming to the radiation clinic. Essentially, I am trying to nurture them and lift up their
spirits in order to help them gain some strength to live with cancer more calmly and
peacefully.
Having less side effects through psycho-spiritual support
In my experience, most patients who have met me and opened their hearts to receive
psycho-spiritual support from me have fewer complications from radiotherapy.
Nevertheless, sometimes I cannot rapport with some patients. I can’t explore their
attitudes and don’t know the real cause of their suffering, so I can help them less than I
expect to. Obviously, that group usually doesn’t manage their self care well and they
have more complications in the second week of receiving radiotherapy.
Learning Dhamma and other therapies to help holistically
Initially, more than 10 years ago I started becoming interested in Dhamma, meditation
practice and alternative therapy because ten years ago I had a near death experience
from Eclampsia when I was pregnant with my second kid. I was admitted to the
intensive care unit and was ventilated for seven days. I arrested and I saw four nurses
and a gigantic leader in my mind wanting to take my life away. Quickly I told them that
I wasn’t ready to go with them, I didn’t want to die and I wanted to stay here to do only
meritorious deeds. My life was saved on the seventh day of my critical illness. After
that, to remain true to my word, I made a vow to devote myself to others, for altruistic
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reasons. Continually, I am open to learning and practising everything that I can so that
I can apply and modify it to help others. Before I tried to make merit but now I think it
isn’t enough to only to make merit, so I try to learn various kinds of meditation and
other therapies such as Tai Chi, Yoga, Thai and Chinese traditional massage plus
reflexology, music therapy and keep practising them until I can teach others effectively.
I enjoy learning both modern and traditional healing techniques that I can apply to help
patients. I am willing to use my vacation time or swap shifts with my friends and spend
my own money to pay the registration fees and buy the books, cassettes and all the other
material about healing techniques …I apply many techniques to help patients adapt to
their illness, such as positive suggestions which come from hypnosis, advise them to
listen to a hymn, chanting or a sermon, their favourite music, the pranic technique for
healing panic, massage, meditation, and information from the Dhamma and Healing
workshop. I also have my own media and teaching materials to lend and teach with and
I sometimes give them to patients as a gift if they can’t afford to buy them. When I went
to the temple I bought many Dhamma books and cassettes. I screen and select the ones
that could help particular patients and give them to the patients. This comes from my
heart.
Valuing nurses’ Metta for building good relationships
The heart of being a good nurse is to have a good relationship with patients and
relatives naturally. Love the things that you do and do them with Metta (loving
kindness). If you have good ideas to help patients you must do them as soon as you can,
don’t just think about it. Even if you have difficulties, you should still do it with every
effort. It is innate, from the bottom of your heart. If you work at a radiation clinic in
order to try to please some of the doctors to receive a special bonus or salary, you will
be disappointed. On the other hand, if you do so without expecting repayment, you will
receive many things. At the least you will get love and trust from the one who you give
love to. The real value of selfless working is having self esteem.
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Crossing professional boundaries
In our profession, nursing teachers used to teach us to work within a professional
boundary, like have sympathy and don’t have empathy. I think it was because we need
to protect ourselves from having too much emotional connection with patients.
Sometimes when a patient dies, some nurses feel so sad they cry. This means we can’t
use equanimity with those patients. However, if we understand the Dhamma (the
absolute truth), we can practice the right things in the right time, at the right place and
with the right person because of our polite manners and speech which come from our
good thoughts. Patients respect, trust and love nurses because of our polite words, good
hands (care with skilful techniques) and good hearts (kindness).
Using equanimity for nurses when patients die
The most important issue for nurses is to have equanimity with patients. Sometimes,
even when you provide a high standard of care, you do good deeds and patients
inevitably get worse, you try to help them more and then patients die. You have to
accept the reality and avoid too much grief or guilt. I compare it to playing football;
you can’t shoot every ball into the goals. For instance, one week I was asked to visit
and support 5 critical and terminal patients who were admitted into different wards.
Their relatives asked me to provide psycho-spiritual care for the patients. I went to visit
them after I finished my work from 5 p.m. to around 8 p.m., one person a day. The
patient’s relatives were really sad and agitated. They couldn’t accept that the patient
was dying. I would go back home wondering why I couldn’t help the relatives to be
calmer. I kept asking myself that repeatedly. I stopped visiting patients for 2 weeks
because at that time there was a Dhamma and Healing workshop run by School of
Nursing. At the workshop I met a Western monk and a well known Thai nun and asked
them my question. The monk gave me a good answer. When we shoot a ball at the goals
100 times it will not get through every time. Please do not work with Kilesa
(defilements). That Dhamma’s statement reminds me of my Sati (mindfulness,
recollection).
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Reflecting on raising self awareness by applying Dhamma’s teachings
I think Dhamma helps nurses to have full self-awareness and a calm and soft
personality when caring for patients and relatives … After that I apply the Dhamma’s
teachings to heal myself by asking myself each day: What things have I done? What do I
want? Did I make any trouble for others? How do I feel? What things should I improve?
How can I create new activities? I keep asking these questions and reflecting when I get
up around 4 a.m. every morning and I try to improve on my weak points when I start my
job. After I finish work and visit patients as a volunteer, I go back home, do breathing
meditation and then I can sleep easily. I never have sleep problems. When I think about
it, I can see that when I felt angry with my colleagues, my body language would show it
explicitly through my eyes, speech and posture. The ones who bore the effects were our
patients. The sick ones are more sensitive than a healthy person … Sati and Dhamma
can help you to be more aware of your manners. You will be more aware about the
present. What are you doing? How do the patients feel? If you have more awareness
you will have better self-control. You will respond better to patients’ reactions and can
reduce the unknown bad influences that can affect another’s emotions. Having Sati
helps me to stop being angry with others, I can forgive others easier and know the
things that I am doing in the present moment. I can use the Brahmavihara principles
(the four noble sentiments, the Highest conduct) including Metta (loving kindness,
friendliness, goodwill), Karuna (compassion, pity), Mudita (sympathetic or altruistic
joy), Upekkha (equanimity, neutral feeling) when providing nursing care … We must
learn the Dhamma teachings, practice them continually and apply them to help patients
and relatives. Patients and relatives will trust you if they can be touched by your heart
and see clearly that you can teach them with skill that doesn’t just come from secular
knowledge.
Being aware of the effects of improper non verbal communication
Patients would be unhappy and angry with the nurses. Nonverbal communication is our
body language and is 80% of our communication while the other 20 % is verbal. So
whether you smile or are angry, all of your behaviours can affect the patient
emotionally.
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Having strong Thai kinship in the family
I think Thai society and culture has dominant characteristics that include the extended
family where there is still strong kinship. Obviously, when patients get sick there are
many family members, relatives and friends to take care of them.
Being kind and loving to help others
Thai people, mostly who believe and practice the Buddha’s teaching are kind and love
to help others.
Using Buddhist thinking and working
I think our religion is very important because, from my experience, I can use and apply
the Buddha’s teachings to deal with both living and work situations. Buddhist principles
guide my way of thinking and working. I realise that the one who practices and applies
Dhamma in their daily life can have true happiness every moment. They also have a
strong mind and don’t have to worry about any disasters. This is especially true for
patients and relatives. I have seen that Buddhist beliefs and practices have a strong
influence on their quality of life. In addition, some patients still had peace and
happiness even with severe illness when they modified the Dhamma teachings to deal
with their health problems and dying moments. Furthermore, patients who use Dhamma
can make all of their close friends and relatives feel happier and even when they are
dying. They can die peacefully and with dignity.
Making a vow to help patients with loving kindness
As a palliative care volunteer, I have quite a lot of experience helping with dying
patients and their relatives. I have helped everyone, every religion, the rich and the
poor, the uneducated and even patients with a doctoral degree. Each time before I went
to visit those patients, I made a vow in my mind, a strong intention to help them. I
asked all of the virtues and powers in the world to improve and support me until I can
help all of the patients and relatives successfully. I really intend to help them. I put
loving kindness in my mind and try every way to help them overcome their suffering.
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Supporting patients by nurturing patients’ strengths
For those who don’t strongly believe in any religion or don’t have any religion, it is not
a problem for me because everybody has their good part inside. I usually approach
them and their relatives gently until I know their strengths and I support them by telling
them how wonderful they are to lift their life force. I have some examples to share with
you. I used to help one patient, she was the mother of a staff member in my hospital.
When she was dying I stayed with her and her children and I had visited her 2-3 times
before. Her daughter touched her hand and everyone prayed for her to pass away
peacefully and to have the best place (heaven) in the next life. At that time I called her
name and whispered to her “You are a very wonderful mother, even though your
husband passed away while your children were very young, you still took the best care
of your children until they all had a good education and great jobs. One of your sons is
a doctor and your daughter is a nurse. They both have virtuous jobs helping others.
There are few mothers can do as well as you. You have done a tremendous job, so
please have a good sleep and don’t worry about anything left behind you.” After I
spoke, that patient smiled and looked so peaceful. A day later she died peacefully. Her
relatives still have a good memory of that patient dying with dignity and have become
my Kalyanamittata (good friends/a spiritual friendship).
Respecting and applying patients’ beliefs to strengthen patients’ minds
Another last stage patient, was a Thai-Chinese woman living with her daughter in town
around 20 minute from my hospital. Her daughter, a friend of my friend, asked me to
visit her because she needed someone who could help her mother be more peaceful.
While I was visiting her at her home, she though that I had the Bodhisatava Kuan Im
inside my body. She also believed that all of my suggestions were sacred words, thus
she did every thing that I told her. Luckily, I could teach her some meditation
techniques. I told her to imagine the Bodhisatava Kuan Im in every breath and
reminded her to think about all the good deeds that she had done.
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Suggesting religious beliefs
In my opinion, a nurse who is interested in helping suffering clients and who cares for
dying patients should learn more about patients’ religious beliefs and Buddhist healing
doctrines such as the truth of life, the Brahmavihara principles, the four noble
sentiments and the Highest conduct and various kinds of meditation techniques such as
breathing, walking and sleeping and also the scripture that asks forgiveness from
others.
Applying Dhamma to accept the natural truth of life
For instance, when I run a self help support group for cancer patients receiving
radiotherapy, eight out of 10 patients can cope quite well with radiation. There was one
patient who felt depressed and couldn’t accept his cancer. He was a 50 year old male
who had been educated by nurses every week but he still didn’t take care of himself. He
was really fatigued and had complication from radiation. His relatives told me that he
always lay down and did nothing. After I approached him with a calm and compassion
manner, he asked me that “Why did he get cancer?” He thought he always did good
deeds. He had never molested or harassed others, he had never annoyed others, he had
never killed anyone and he usually made merit. Why did he still get sick? That day I
applied Dhamma, the teachings of Buddha to remind him to accept the natural truth of
life. I told him that it is a natural event that everybody in the world gets sick. Even
nurses, even me, I will get sick some day. So we must accept illness as a normal process
in everyone’s life. A week later, I invited the monks to chant prayers for patients and
relatives at the self-help session. He was starting to change his behaviour. He looked
more cheerful and was more active in self care. I also asked his relatives to observe his
status. His relatives told me a week later that he felt happier, could eat more food, and
had fewer complications. Follow up patients regularly, help them in every stage,
change helping strategies to match the patient’s condition, and give compassionate
support to patients. This can lead to positive coping for the patient and family. It takes
a few days to lift up patients’ spirits because the important thing that patients and
relatives should see in my behaviour is true loving kindness that can touch their hearts.
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Developing merciful behaviour and loving kindness
We must apply Buddhist principles and transform them into merciful behaviour when
providing nursing care for patients and their families. You will never succeed if you
teach patients about the three characteristics [which are; Aniccata (impermanence),
Dukkhata (state of suffering, illness), and Anattata (state of being non-self)] directly.
Dhamma in nursing is the way that nurses can provide real loving kindness merged
with good nursing care for patients and their families.
Assisting sleeping by using mindful meditation
I used to teach mindfulness techniques to patients who couldn’t sleep. For one person
the doctor drew a star at the corner of his chart showing that his sleep disturbance
needed urgent help. He couldn’t sleep even when he took strong hypnotic drugs. When
the radiologists talked about that person to me I thought it was a sign of severe stress.
So I taught him to practice mindfulness meditation by following his breathing in and out
while going to sleep, and told him that I was really concerned about his problem. I
helped him because I would love to see him get better and I will find a way to help him
as much as I can. I also told his wife to watch his condition and tell me every day
whether he is better or not. The next morning his wife told me that he slept better. I
don’t need to know what made him better, I just know that if we help full of authentic
compassion, patients’ minds feel more comfortable, more secure and they get better.
Adapting meditation techniques
I suggest to some patients that they apply meditation methods that I have learned to
relax themselves. Such as Mother Siri’s method where you fix the mind’s attention on
the belly and feel it inflate when you breathe in and go down when you breathe out or
the Anapanasati (Mindfulness with Breathing) method of Than Buddhadasa Bhikkhu. It
depends on the interests of each patient. If I teach a Muslim patient I modify it to teach
him to think of Allah while breathing in and out, because if I tell Muslim people to
meditate they would reject this word.
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Building good relationships and trustfulness
The key for success when I help patients to cope with their cancer and radiation is to
build up a good relationship with them until they trust me. Starting with general talking,
asking them about their family, educational background so that we can learn their
foundation, what they like and dislike. Do they like to listen to music? What are their
hobbies? How often do they go to temples or make merit? If they are children, they
might love to do painting, drawing or singing. There are lots of alternative ways to
relax cancer patients.
Respecting individual differences
We must open our minds to learn alternative ways and apply them to help patients
individually. Each one has his or her personal style, beliefs and ways of thinking and so
we must respect individual differences. The essential thing is that we have
unconditional love for patients and their family because they can feel the compassion in
the kindness of nurses.
Communicating with patients and relatives through the heart
We can communicate with patients through the heart. The friendly and welcoming type
of nurse makes patients feel more relaxed and the relationship is closer.
Receiving a hug, respect and trust from patients
Every morning plenty of female patients come to hug me and I hug them back warmly
like they are my relatives. They respect me and feel free to chat with me any time while
they seem afraid of and keep their distance from the doctors. This means that the
patients respect the goodness in me. The warm and positive responses from patients
nurture my spirit and give me a lot of power to deal with hard work without tiredness. I
am really happy with my job.
Note: Normally in traditional Thai style, we hardly hug other people except some
elderly patients. We respect each other by bringing the hands together in front of the
face to pay respect. Patients have little chance to hug a nurse like this.
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Focusing on patient
I provide nursing care by focusing on the patient as the centre of care.
Remembering patients’ name and touching them
I always remember the name of patients without using any notes. I call them by their
name and touch them when I visit.
Helping patients to die peacefully
There are many people who have asked me to stay with them for their last moments. I
am very proud that I can help them die peacefully.
Respecting all patients as teachers
I respect all of the patients as they all are my teachers, I can learn about life from
patients, the great teachers.
Using music therapy and alternative ways to support non-religious patient
There are some Buddhist patients who have never done any religious practices so I
approach them and provide psycho-spiritual support for them by suggesting to them
that they listen to their favourite music to release tension. I try to know a patient’s
spirit. What do they like? What are their concerns? What do they think about? I start
from those issues to find the best way to help them.
Developing Dhamma as a healing method
I call my techniques applying Dhamma as a healing method.
Becoming an angel in the patient’s view
When you reach a stage where the patients really trust and respect you every word that
you say they will believe and you will become an angel in the patient’s view. There was
one lung cancer patient whose daughter was a friend of a nurse in my hospital. He was
in the last stage and couldn’t eat. His daughter was really frustrated and tried to force
her father to eat more, but he couldn’t. One nurse contacted me to support this family. I
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met the patient and approached him politely, full of kindness, compassion and caring. I
told him that I was concerned and would like to help him. Surprisingly, after he met me
he changed his mind and ate more food and a few weeks later he gained more weight
and became healthier. I believe that we can communicate goodwill from one heart to
another. Patients really know the sense of caring from nurses who have good intentions
to help patients.
Using polite words and kind manners
Nurses’ polite words and kind manners are the key to successfully exploring patients’
personal secret issues which can unfold as the cause of their aggressive behaviours.
For example, the head nurse from the neurological ward asked me to help a 17 year old
girl who had behaved aggressively towards a doctor who tried to do a lumbar puncture.
She had been raped and was around two to three months pregnant. Her mother didn’t
give us much detail about the rape. Doctors had already done a sterile abortion for her
and a brain tumour removal. The doctor planned to draw the CSF (Cerebral-Spinal
Fluid) for more investigations after the brain operation but she didn’t like the doctor’s
manner. The patient had thrown the investigation set around her bed and cried. Her
mother was really suffering and needed someone who could make her daughter calm
down. I visited her that afternoon and didn’t mention the lumbar puncture instead I had
a look at her intravenous line where nurse had put antibiotics and medicines for her
and said “Do you want to get rid of this line sooner? I think it has been here too long.
Do you want to go back home earlier?” She said “Yes, of course”. I replied “If you
want to go back home earlier, you should let the doctor check your spinal fluid because
the brain is a very important organ. It would be dangerous if there were some bacteria
left, so to make sure that are better please let the doctor do the lumbar puncture, na ja.”
I also taught her to do breathing meditation to prevent tension and reduce pain during
the procedure. I told her that today the doctor had another job to do so we will check
your brain fluid tomorrow. So what time that you think it would be best for you? She
told me nine o’clock and that she would like to choose one doctor that she trusted. I
promised to do that for her and made an appointment with that doctor to do the lumbar
puncture tomorrow at nine a.m. I can’t tell you what techniques I use to approach these
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patients. All my ideas and strategies come up suddenly when I am in front of the patient
because I use my heart and goodwill to heal them.
Remembering the real beauty of life is a beautiful mind
Another issue for this girl was that she couldn’t speak after the brain operation. The
doctors sent her to speech training with the speech therapist who was my best friend.
She is a very kind woman who taught her to practice pronouncing the prayer sounds
like Ohm, Aha, Umm. We both try to apply Buddhist teachings to help patients. I visited
her at the ward another day and her relatives told me that she usually complains that
she has a horrible wound on her head because her head was bashed in and now she is
really ugly. I touched her arm, squeezed it and replied that ‘everyone’s life is not
perfect. Do you know what really makes people beautiful? It is a good heart, the real
beauty comes from inside.’ She also agreed with me that she used to see some beautiful
women who had really shocking moods. In addition, I was able to confirm that when
her hair got longer she would look good again. Please remember everything that is
good or bad depends on our hearts and a positive attitude. When people have a good
heart, they have good thinking and their speech will also be beautiful.
Remembering statements of life from Dhamma books
I read many Dhamma books and remember good statements to remind patients and
their families about the truths of life and how we can deal with problems naturally.
Having Nam Jai (kindness water in our heart, compassion) with patients
When I help patients, this means I give them alms. Sometimes I bring a small flower
basket that I have made myself to make a woman’s life livelier and if I know some
patients like amulets I usually bring a monk’s amulet to bless them. If they have
financial problems, I immediately ask the head nurse to consult the social support teams
to find a better way to help the patient. I always tell the nurses that we must have Nam
Jai (kindness water in our heart, compassion) with patients.
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Overcoming temper by nurse’s friendliness and kindness
There was another person who came to hospital with a haemorrhage of the brain
vessels which is a congenital abnormality. She lived with her relatives and she looked
sad and quite grumpy. Her father had a new wife and we knew just a week after
admitting her that her mother had been killed by a thief a month ago. From her
background I felt such compassion for her bodily and mental distress. I intended to help
her cope with her distress. I said “You will be better if you can control your temper; the
brain vessel is easily damaged from tension and bad moods. You still have an
opportunity for a good future, so let us practice the way to release anger together. If
you feel angry, please count from one to 10 and repeat it until the anger is gone. Can
you please do it? It would benefit your health. Please don’t let your anger destroy you.
You can choose which way is the best for you.” She was hiding her smile while I talked
with her and I realised that there were some positive changes inside her. She had not
smiled since her mother was killed, but after I visited her 2 or 3 times she smiled easily
and looked lively. I also gave her a relaxation song cassette. It was about smiling and
beauty when breathing in and out which was produced by a well known nun in
Thailand. I asked her relatives to buy a cassette player for her after I had lent her mine
for a while.
Applying Dhamma practices and healing techniques to complex patients problems
All the volunteer jobs that I have done I have to do after my normal working time. There
are about 12 people in our multidisciplinary palliative care team including doctors,
nurses, counsellors, physiotherapists, and a speech therapist. We have done a great job
and gain more inner strength to keep doing these good deeds thoroughly. Nurses and
doctors ask us to care for terminal and difficult cases. I mainly deal with the most
complex problems and I apply all of my Dhamma practices and healing techniques to
help patients. From my experiences I would like to say that Dhamma and alternative
techniques can be good coping strategies for healing the mind, body and spirit of both
patients and their families.
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Applying Buddhist beliefs to ask for forgiveness
A relative caring for a dying patient needed me to help them support the patient’s last
days as best as they could. After I discussed it with them I applied our Buddhist beliefs
and advised them to ask for forgiveness from their father. I told him he didn’t have to
worry about them and made merit for him. That patient passed away peacefully and all
of his relatives felt that they had done a great repayment job for their loved one.
Feeling mercy radiating from nurses
Nurses can be a spiritual guide for patients and relatives by applying religious beliefs
as a means of spiritual support. In a ward, the nurses can take some time to help the
patients suffering most. If you intend to, you still can support patients while you are
quite busy. Patients and relatives can feel the mercy radiating from nurses. You can see
that patients try to talk to some nurses and avoid contacting other nurses. The
difference is that a kindly nurse has a sense of service that comes from an authentic
heart more than a cruel one.
Valuing nursing as a human caring
We can’t claim that we have no time to provide psycho-social and spiritual support to
patients. If you think that nursing is human caring not disease curing, you can do more
for patients’ health.
Being concerned about patients as human beings
When nurses check patients’ vital signs they usually just count the pulse rate and don’t
chat with the patients and then they have some free time to watch television. If nurses
are concerned about patient as human beings, they could touch them gently and ask for
forgiveness if they have to do procedures that give the patients pain or discomfort and
tell them the reason for their nursing care. Patients would appreciate the nurses and
good nursing actions would satisfy patients.
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Helping patients without expecting reward
If we help others and expect something in return we will always be disappointed. Kindly
helping patients without expecting any reward is the basis of the nurse-patient caring
relationship.
Applying kindness, forgiveness, and religious rituals in death and dying
One day I was asked to support an unconscious patient. He was a policeman who fell
from a truck. He had a fractured cervical spine and was brain dead. I visited this
patient on the Orthopaedic ward. I said Sawasdee (to pay my respects and greet by
bringing the hands together towards the face) to his wife and relatives, then asked some
questions about the patient’s personality, past experiences and the beliefs of this family.
Then I knew that he had been ordained and that he has a son who became disabled
after a fall from a car and was in the private hospital too. I called the patient by saying
his name. I introduced myself to the patient and told the patient “Your wife and
everybody in your family love you because you are a good person. You have taken care
of your family perfectly and you are a responsible husband. You are so wonderful.
There are not many men as good as you. You also take responsibility for protecting
society.” Surprisingly, I saw a tear drop from his eyes. After that I told his wife to make
merit for him and everyone whispered to him to ask for A-Ho-Si-Kam (forgiveness), to
ask him to let go of this life and to be at peace. One day later, his wife took his disabled
son from the private hospital to pay his respects. He told his father that he loved him
very much and asked for his forgiveness. The patient cried again and died peacefully
three days later. When patients are dying I say that it is the time for you to have
absolute rest, please leave your physical body calmly, we have already collected plenty
of merits for you and so you can touch the saffron robe like when you were ordained.
All relatives have a good opportunity to help patients die with dignity. They can heal
their sadness with religious rituals and good family relationships. When I dream about
patients they usually die within 3 days of my dream. I think I can communicate with the
patient’s soul via a special channel. Anyway I can’t prove it, it is just my personal
experience that can help me to plan with relatives to help patients when they are dying.
I can talk with patients and relatives frankly about how to prepare for a peaceful death
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because I open my heart to help them. I respect their beliefs and we have a trusting
relationship with each other.
Raising mindfulness
Normally, every morning before I go to work I set my mind into a mindfulness state and
then ask for healing power from nature and the gods including the Bodhisatava Kuan
Im goddess. I chant loving kindness scriptures for humans, animals, things and all of
creation. Lastly I end my personal rituals by asking for good qualities from the Buddha,
I make a wish to do only good kamma and set the goal that I will never give up even if I
meet huge obstacles.
Reflecting on the day
At night after I finish taking care of my family, I usually sit down in my silent corner
and reflect on each day. What useful things have I done? What is not good? How did I
act with others? Also I consider all the events and suffering that occurred and ask
myself if I had to do the same things, how could I do it better than before.
Applying the teaching about mindfulness
In my opinion, Buddhism teaches us about self-awareness which helps us look inside
our minds, our thoughts and feelings with mindfulness. I am peaceful because I live in
the present moment. I learnt how to do mindfulness and live fully in the present from the
eight days and seven nights Vipassana courses that I have been to three or four times.
The present is the heart of living and working. I always Dern Jong Klom (do walking
meditation) when I walk to visit and support patients and their relatives. I know every
step of my walk, I know left and right. I know what I am doing and what will I do next.
Nobody knows that I always focus my mind on my walk, my movements and my six
senses. Because of my skill in maintaining Sati, my creative ideas come up accidentally
and I can get new methods to help each patient. Furthermore, living in the here and
now enhances my concentration when I listen to patients’ stories openly and completely
without becoming exhausted. When I listen to a patient with full concentration I am still
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and I attend only to that patient like there are only the two of us. I truly understand
patients with mindful communication.
Having concentration and self controlling skills from practising meditation
I am able to concentrate easily, even when I practice other kinds of meditation that I
haven’t done before. I get used to them so easily. I know myself, I know my sensations
and how I feel. This self-awareness can help me to have good self-control and express
feelings in the proper way when in contact with patients and relatives.
Recommending nurses practice meditation
I think nurses should learn how to live in the here and now, know their thinking and
feelings, so they can be kinder to patients. The best way to practice living with present
is to join a meditation course because it is quite hard to concentrate more without good
training and regular practice. Nurses can practice while they do nursing care, such as
when preparing medicines. That way they will never Jai Loy (loss of concentration) and
this can prevent the human error really effectively. When nurses approach patients they
must really concentrate on that patient to communicate with and help the patient
effectively.
Practising self reflection to create good relationships with clients
Another important issue for nurses is practising self reflection. After work each day they
should ask themselves how they feel and how they could improve their nursing role and
create a good relationship with clients.
Applying Dhamma to overcome suffering
Furthermore, if nurses can accept that all suffering is the nature of life and realise that
there are many ways to solve problems it would help support their feelings while they
work hard. Another way in my experience is to learn Dhamma which can be easily
applied to support patients. You can read the Dhamma poem and pocket books of Than
Buddhadasa Bhikkhu. These poems give me the inspiration to love all human beings
equally without discrimination. Learning Dhamma makes you aware that everybody
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suffers. Nobody is always happy, even if you are a prince or princess, they all suffer.
The heart of living is that you can deal with suffering with mindfulness. You can draw
on the Dhamma teachings to help you cope with troubled times.
Accepting individual differences
I think I can practice Dhamma along with all the activities and events that occur in my
life. For instance, when dealing with negative responses from colleagues I always keep
in my mind that everybody has both strong and weak points, as do I. Nobody is good at
every task. Because of this point of view I am never moody or angry with others. On the
other hand I think they might not know what they have done. They might have their own
reasons or have a background that formed that kind of behaviour. I have never felt
sorry for myself because I work really hard while others have more leisure time.
Having positive attitudes towards work
I have a positive attitude towards my work … From my principles, I work for the
happiness of all human beings, not for fame or honour, which is considered a kind of
craving in Buddhist theology. Also, if you think you have to build a complete family
before helping others, I guarantee that you will never have opportunity to help them in
this present life. However, people are different. I don’t expect other nurses to do as
many activities as me. I just hope to see them have kind relationships with patients and
relatives … When my older daughter saw some certificates of appreciation that I
received from my hospital she asked me why I have to sacrifice so much for others like
this. I told her that it comes when we do our best without expecting reward. I usually
teach my children about the good results of having a desire to provide a service that
helps the common good. My husband lets me do anything, because I told him that I am
doing good deeds and I have never done bad things like play a cards, drink alcohol, or
spend lots of money when I go shopping. The main idea is that nurses should have a
positive attitude towards their job. Do you bring with you a good attitude towards
everyone when you are caring for patients and relatives? If you provide nursing care
for patients with your heart and you love to see your patients happier, you will gain
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happiness in your nursing profession, too. Good-will, willingness to help others and
good conversation are simple and effective ways that nurses can provide care to clients.
Understanding the suffering of all human beings
Understanding others comes from knowing that everybody is suffering. We are all in the
same position as human beings. When I meet suffering patients I usually ask myself
whether if I were that person I might do something more inadequately than them. When
you understand patients’ suffering you will really understand their reactions, especially
when they can’t accept the severity of their illness and express aggressive behaviours
which need an enormous amount of nursing support. From my personal experience, I
can build a caring relationship with patients because I understand their suffering. I set
loving kindness in my mind and transmit it to every patient by praying before visiting
them.
Transmitting loving kindness and vowing to help patients
Before I visit them I think of them and give them Metta (loving kindness) and I make a
vow to put all of my effort and ability into helping them. I do walking meditation while
going to help them. I respect them and touch them gently. I focus on the patients and tell
them I intend to help them and will do my best. I ask them about their feeling and listen
actively. I teach Dhamma which is about the truth of life and support them following
their needs and beliefs. Nurses on the ward are usually surprised with my unique
relationship with patients that occurs within 10 minutes of our first meeting. Patients
usually cry and give me personal information which they hadn’t let nurses on the ward
know before. For example, I met one woman whose nurse asked me to support her
because she was depressed a week after the removal of a tumour. Before I visited her I
made an intention to help her and transmitted loving kindness to her and did walking
meditation on the way to her bed. After I greeted her and asked how she felt, she
immediately cried and told me the she would like to go back home because she had left
her young daughter with a very old grandmother and they might have no money left. In
addition the patient now had no money to pay for a bus back home. Doctors also
planned to send her to receive continuous radiotherapy but she wanted to go back home
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to cut the rubber trees so that she could earn some money to care for her daughter. She
didn’t dare tell the nurse and doctor and kept silent. After we knew the real cause of her
problems we discussed it with the doctors and changed the plan to let her go back home
and discussed her case with the social support department … I think that may patients
can feel the power of my Metta and they can connect with my good intentions. They
might like to think that I can help them. The mercy’s radiation shines through a nurse’s
eyes, face, posture and manner. That this can enhance the relationship between nurse,
patient and relative happens from the kind attitude of nurses who intend to help patients
and families.
Acknowledging the issue of bully nurses
In our nursing profession we still have some nurses who are coarse and bully the
patients. Some of our clients also feel hesitant with the nurses and feel it is hard to ask
for help or tell them their needs.
Understanding relatives’ needs for kindness and flexibility
Sometimes relatives want to stay with patients especially when the patient has paralysis
or feels too tired. Patients always need their loved ones to stay close by them, massage
them and help them contact the doctor, nurses and so on. Nurses should be more
flexible with relatives’ visiting times and be kind to them so they can consult nurses
without difficulty. Nurses should be friendly with patients and keep asking questions like
“Do you want any help from a nurse? Please feel free to let the nurses know and don’t
hesitate, na ka?”
Avoiding a bad mood and manner
In building a good relationship with patients and relatives the nurse should be aware of
their manners. They must have kindly speech and avoid showing their bad mood in front
of patients even if they are busy and really tired.
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Avoiding adding more distress to suffering clients
Moreover, nurses must not add more distress to suffering clients. Patients are one like
of our relatives.
Providing equal care
Never treat the rich better than the poor, and try to consult other departments to help
solve patients’ problems.
Thinking of the patients’ benefit
Sometimes, if for a personal reason you don’t like some doctors, for the patients’ benefit
you must remember that the patient is the centre of care and deal with those doctors
peacefully.
Being flexible while working
I think our world is like a drama, for the sake of patients and colleagues we should
flexible with others when at work.
Realizing that everybody is not perfect
If we consider that everyone has both weak and strong points and that nobody is
perfect, you can give forgiveness to others and help others with a good heart. Finally,
you may have Kalyanamittata (good friendships). Patients and relatives might become
your friends and you can have a human relationship with each other. There are many
patients and relatives who have a good impression of nurses and after they are
discharged from hospital they still come to visit me and join in the hospital activities.
Making merit
Some patients and relatives make donations to the hospital which is a kind of merit
making for Thai people.
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Being understanding and kind
A relationship between nurses, patients and relatives in Thai culture comes from
understanding others. The Buddha’s teachings can instruct us to be kinder nurses.
Conclusion
The experiences and codes which emerged from an open coding analysis of one nurse
were described in relation to her application of Buddhism and Thai traditional wisdom
into nursing care in the Thai Buddhist context. The remaining emerging codes from the
remaining nurse participants are listed in Appendix E.
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CHAPTER 6
PATIENTS’ EXPERIENCES AND EMERGING CODES
Introduction
Fourteen patients (seven females, seven males) participated in this research. Owing
to the vast amount of data in the transcripts, one patient’s account is presented in this
chapter. Patients shared their stories about perceptions of illness, the application of
Buddhism and wisdom in Thai culture and Thai traditional healing to care for
themselves and to cope with their illness in hospital and at home, and perceptions of
the nurse-patient-relative relationship. The experiences and emerging codes from the
remaining patients are listed in Appendix F.
The patients’ demographic data, experiences, and emerging codes
Patients’ demographic data
Patients who participated in this study had lived with chronic illness for six months
to 20 years with various kinds of illnesses including, leukaemia, hypertension, heart
failure, myocardial infarction, pulmonary disease, renal failure, diabetes mellitus,
and HIV/AIDS with pneumonia (see Table 6.1). The participants’ age range was
from 30 to 78 years. Half of the patients were single, divorced or widowed. Most of
them were gardeners with low education and low economic status. Five patients had
no income, however, they were looked after by parents, and family members
especially bothers and sisters. Some patients were highly educated and successful in
their life. Most male patients were looked after by their wives and daughters, while
female patients were mostly taken care of by their children and relatives. Six male
patients had an ordination experience so they could share their Buddhist beliefs and
practices from that perspective. The patients were identified by pseudonyms of Pa
Da, Na Lek, Lung Dam, Lung Tongkam, Na Noi, Na Nee, Na Nid, Na Malai, Nong
Orn, Nong Kla, Nong To, Lung Kur, Lung Mai, and Lung Chai.
Chapter 6: Patients’ experiences and emerging codes
Table 6.1: Patients’ demographic data
Participants
Age
Sex
Marital
status
Education
Occupation
Widow
3 daughter, 1
deceased
youngest son
Divorced with
3 daughters
Bachelor
Degree
(Primary
Education)
Year 4
Primary
School
Teacher
Year 3, was
ordained for 3
months at
age 20
Year 3, then
was ordained
and studied
Buddhism at
the temple for
12 years
Year 6
Farmer and
Gardener
2 years: COPD with acute
exacerbation
5 hours: severe dyspnea
Gardener
and has a
small
grocery store
20 years: HT,
15 years: MI, CHF
functional class 3, gouty
arthritis
2 Days: chest pain
~5,000
Rubber and
mixed fruits
Gardener
9 years: breast cancer
with malignant fibrous
histiocytoma
1month: multiple bone
metastases
6 months: Breast Cancer
stage 4
depends
on
brothers
and sisters
depends
on her
husband
~8,000
from the
interest
~20,000
1. Pa Da
57
Female
2. Na Lek
40
Female
3. Lung Dam
71
Male
Married with
4 daughters
and 1 son
4. Lung
Tongkam
78
Male
Married,
has 3
daughters and
3 nieces,
5. Na Noi
40
Female
Single
6. Na Nee
44
Female
Married, with
one teenager
son
Year 2
Labourer/
cleaner
7. Na Nid
49
Female
Divorced
Year 12
8. Na Malai
70
Female
Widow
Masters degree
in nursing
administration
(from England)
9. Nong Orn
35
Female
Widow
10. Nong Kla
30
Male
11. Nong To
31
Male
Divorced, has
one daughter,
used to be
ordained for
1 years
Single, used
to be
ordained for
3 months
Bachelor degree
in Education
(Rural
Development)
Certificate from
Technical
School
Business
(sells engine
oil)
Retired from
an overseas
health care
supervisor of
the Thai
Government
Rubber
Gardener,
sale women
12. Lung Kur
49
Male
13. Lung Mai
59
Male
14. Lung Chai
71
Male
Married, has
never been
ordained
Married with
3 married
children
Married, was
ordained for
6 months at
the age of 24
Rubber
Gardener
Previously
Constructor
Year 9
None
Year 4
Rubber and
fruits
Gardener
High School
teacher
Bachelor degree
in Education,
was ordained
before married
Bachelor degree
in Nursing and
Public Health
Retired from
community
nursing
Illness Experience
(year)
2 years: cervical cancer
stage 1, post total
hysterectomy
Recently: stage 3
10 year DM with a poor
control of blood sugar
4 years: DM and HT
2 months: right foot
amputation.
20 years: MI
10 years: MI with
chronic cardiac
myopathy (CCM)
functional class 2-3
10 years: HIV
3 years: PCP
2 years: Started using
antivirus regimens
3 years: HIV infection;
1 year: turned to AIDS
2 weeks: had a fever
and abdominal pain,
also lost appetite
10 years: hyperthyroid
2 years: nephrotic
syndrome
5 months: DM and liver
cirrhosis
4 years: AML,
3 Month: the cancer is
recurrent
16 years: CRF with
Hemodialysis, 5 years:
MI
6 years: colon cancer,
stage 1, no metastasis
Income/
month
(Baht*)
~20,000
depends
on her
brother
~5,000
~6,0008,000
depends
on his
parents,
and sisters
depends
on his
uncle and
aunt
~5,000
~12,000
~15,000
(from
Government)
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AIDS = acquired immune deficiency syndrome, AML = acute myeloblastic leukaemia, CCM =
chronic cardiac myopathy, CHF = congestive heart failure, COPD = chronic obstructive pulmonary
disease, CRF = chronic renal failure, DM = diabetes mellitus, HIV = human immunodeficiency virus,
HT = hypertension, MI = myocardial infarction, PCP = pneumococcus carinii pneumonia
* in 2006, about 30-32 Thai Baht equals 1 Australian dollar
The terms Pa, Na, Ar, Lung, are typical Thai pronouns, which Thai people use to
refer to second or third persons. Pa is used to refer to a female person, who is older
than one’s father. Na means a male or female person, who is younger than one’s
mother, while Ar means s/he who is younger than one’s father. Lung is used to refer
to a male person, who is older than one’s father/mother. Informally, nurses usually
refer to patients’ and relatives’ names by using the word Lung, Pa, Na, Pe, Nong
before their names, for example: Pa Da and Lung Dam, (also see meanings of the
terms Pe, Nong, Khun in Chapter 5). This tradition reflects that after knowing each
other for a while, Thai people value other people as their own relatives.
Patients’ experiences and emerging codes
Fourteen patients shared rich experiences of applying Buddhism and Thai culture as
self-healing and management methods to cope with illness and improve
relationships between themselves, nurses, and their relatives. The experiences and
emerging codes of one patient, Pe Da, are presented in this chapter.
Pe Da’s experience
Pe Da, a 57 years old primary school teacher, had cervical cancer stage 1 in 2002
and stage 3 in 2003. She was a widow, who had four children who were all working.
Her son, the youngest child, died five years ago. One of her daughters is a
community health care worker at the community hospital in the district. Her sister is
a nurse. She was a person who was very close to Dhamma; her Buddhist beliefs and
practices were well known and embodied. She has been ordained as a nun for the
last 10 years and provides food for monks every morning. She practiced Vipassana
and various kinds of meditation more than 10 times at the retreat centres around
Thailand. Moreover, she was an informal social worker who helped and supported
the activities of temples mostly in Southern parts of Thailand. In her daily life, Pe
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Da meditated every day about 5-10 minutes at her workplace and did breathing
meditation until bed time. She also chanted almost every night before going to sleep
and always did kind and loving acts for all types of people, animals and all of
creation. Two years ago she had cervical cancer stage 1. Post total hysterectomy, she
had to live with incontinence and constipation as complications of the operation. Her
blood cholesterol was increased from eating extra eggs while trying to reduce eating
meat. She believed that meat and animal products could induce cancer cells. She
accepted the illness by considering the law of nature, that is: birth, old age, sickness,
and death are the normal processes of life. It is inevitable. To do good deeds
(kamma), avoid thinking only about oneself and to help others was a suitable way to
spend the rest of her life. She valued kind nurses and she appreciated nurses’
intelligence and hard work so she could trust the competence of health care
personnel. She also devoted herself to support other cancer and chronically ill
persons. Pe Da told me she always prepared herself for a good death and prepared
her childern to accept the law of nature. My sister, who was Pe Da’s close friend,
told me that Pe Da passed away peacefully on October 2005. She prepared
everything, including her funeral ceremony herself. I wish Pe Da to stay in the best
place in this universe and to have a chance for a better reincarnation.
In her experiences, Pe Da shared her application of Buddhist teachings and self care
strategies while coping with change and living with illness in 53 codes, which
included: experiencing cervical cancer; facing side effects of the total hysterectomy;
using concentration techniques; maintaining work after becoming sick; dealing with
problems with mindfulness; relating illness and death to Dhamma; facing cancer
without fear; believing in the healing power of the mind; avoiding making other
people sad; letting go of worry as no self; accepting death by collecting and
preparing virtues; practising religious rituals; suggesting nurses encourage patients
spiritually; doing good deeds/ meeting good people; taking care of self; having a
healthy mind; helping others; believing in will power and moral support; believing
in positive effects of meditation; approaching a good death with mindfulness;
experiencing disinterest in Dhamma and meditation; recognising benefits of learning
Dhamma; accepting complementary care; living in a religious culture; recognising
the unselfish purpose of merit making; helping the monks and temples’ activities;
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seeking spiritual perfection; practising religious rituals in daily life; using different
ways of meditation; teaching meditation and religion; experiencing ordination as a
nun; recommending breathing meditation; valuing compassion of nurses for
patients; controlling pain by meditation; controlling incontinence by using
concentration techniques; applying meditation principles to calm the mind; receiving
good nursing care; trusting nurses and doctors; understanding and appreciating
nurses’ hard work; trying to take care of self; understanding some patients are
demanding; perceiving nursing is a meritorious occupation; appreciating daughters
as caregivers; understanding and accepting difference among individuals; helping
others without expecting any thing in return; feeling joy after helping others;
describing kamma, impermanence, right understanding and equanimity; keeping
oneself well before helping others; being ready to die because of the Four Noble
Truths; believing in effect of past kamma on health; and being a good listener when
helping others.
Experiencing cervical cancer
Two years ago, around August 2001, I had bleeding from the vagina and after a
physical examination the doctor told me that I had stage 1 cervical cancer. On
December 7, 2001 I had a total hysterectomy at the hospital in Bangkok.
Facing side effects of the total hysterectomy
Since the operation I have had incontinence and constipation problems. They are
side effects of the operation, which interfered with the nerves near the operation
area. The doctor said it takes time to resolve these problems.
Using concentration techniques
Now I feel better, because I used concentration techniques to heal my problems.
Maintaining work after becoming sick
I had three months rest after the operation and now I go to work every day. I still
have follow up every six months and in general I am quite healthy now. Luckily,
there are no signs of metastases. My operation wound is very long and it still feels
hypersensitive and it is quite painful when pressed.
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Dealing with problems with mindfulness
At first, the doctor was apprehensive about telling me the results of the
investigation. I asked him to please tell me frankly, as I was already preparing my
mind and ready to hear the result. I was shocked for a few minutes then the Sati
(mindfulness) came. I felt at peace, didn’t cry and asked the doctor about ways to
heal my disease. The doctor was stunned and surprised by my reaction and then the
doctor said “Because you have a very strong heart I will tell you precisely your
prognosis and treatment options”.
Relating illness and death to Dhamma
Firstly, the reason why I can control myself very well is because of my Dhamma
practices. Like any person who has Dhamma in his or her mind, we always say that
birth, becoming older, sickness and death are normal phenomena of life. Whether I
have cancer or not, I will die like everybody else. I believe that we were born and
that we live in this world in the Five Aggregates, which in general we call the body.
When we have finished our work on this earth we pass away.
Facing cancer without fear
When the body becomes sick our duty is to take care of our body, but we shouldn’t
fear illness. I don’t let my mind think about dreadful images of cancer, because if I
fear cancer then my mind will deteriorate.
Believing in the healing power of the mind
Rather, I think only that my body is sick, but my mind is still strong. I must let the
power of my mind heal my disease.
Avoiding making other people sad
Another reason is if I feel worried, it will influence everybody around me to become
sad, too. They won’t stop crying and they will live with fear, because of their
concern about my situation. I suddenly lifted my spirits and told my sisters,
daughters, and close friends that I was okay. Let us consult the doctor and find the
best way to treat my cancer. I successfully support my loved ones. Everybody always
praises me about my strength, all of it comes from the study of Dhamma.
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Letting go of worry as no self
Secondly, I don’t intend to think only about myself or my life, because I have no self.
I am only a compound of things made up from previous kamma.
Accepting death by collecting and preparing virtues
Thirdly, if I die, I am ready. I have nothing to worry about, because if I look back at
my life as a Buddhist lay follower or see my life through a Dhamma view, I have
already collected and prepared all of the virtues for the future or the next life. I
don’t intend to think only about myself or my life, because I have no self. I am only a
compound of things made up from previous kamma. Thirdly, if I die, I am ready. I
have nothing to worry about because, if I look back at my life as a Buddhist lay
follower or see my life through a Dhamma view, I have already collected and
prepared all of the virtues for the future or the next life.
Practising religious rituals
I usually do Buddhist activities such as Takbart (providing food for monks) every
morning, being ordained as a nun for the last 10 years, practising meditation and
Vipassana more than 10 times at the retreat centres around Thailand, being an
informal social worker, helping and supporting the activities of temples mostly in
the Southern part of Thailand, chanting almost every night before bed, meditating
every day for about five to10 minutes at work, doing deep breathing meditation until
I go to sleep and always doing acts of loving kindness for all types of people,
animals and all of creation. I also stopped eating meat and animal products and I
follow the Eight Precepts on monk days, Buddhist ceremony days, my birthday and
other special days.
Suggesting nurses encourage patients spiritually
From my experience, I think it is very important if nurses can remind patients about
the good deeds that they did before they got sick and persuade them to do more of
these meritorious activities.
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Doing good deeds/ meeting good people
Even after I had an operation and now have incontinence problems and an irritable
wound, when I travel, I still enjoy my life especially when I can help others. I have
lots of Dhamma friends, lay people and monks and we go to make merit together. I
am so lucky I always meet good people, good doctors, good nurses and have had
difficulties since I got sick.
Taking care of self
Nowadays, I intend to wear make up and make my appearance look bright and fresh
in order to be a role model for others. I always told my friends that we are sick only
in the body, but our minds aren’t sick. Actually I feel like I haven’t had any disease
since I devoted my free time to think about helping others. A good point is that I
have no time to think of myself … After I got cancer I realised that I should take care
of myself better than the way I taught and supported my friends.
I have an
inspiration to live and to be a good role model who can support other patients. I
have to show that I can live peacefully with cancer.
Having a healthy mind
I always told my friends that we are sick only in the body, but our minds aren’t sick.
Helping others
Actually I feel like I haven’t had any disease since I devoted my free time to think
about helping others. A good point is that I have no time to think of myself … Even if
I have to work hard I would still like to help others. If I introduce them to the heart
of Buddha’s teaching this lets me gain benefits from Dhamma that I can give to
others later.
Believing in will power and moral support
With cancer patients, the most important thing for them is Kam-Lang-Jai (good will
power and moral support). Those who understand this will gain benefit from being
sick.
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Believing in positive effects of meditation
Moreover, I believe that practising meditation can help cancer patients. One wellknown monk told me that in the meditative state when we become still and peaceful,
then the tumours can become smaller or be destroyed.
Approaching a good death with mindfulness
…If we are approaching death because the cancer has progressed, we will die
peacefully with mindfulness. When we are dying we can control our feelings by
watching the pain and accepting it as part of our destiny. If we can truly accept the
truth of life we will die peacefully. Our religious beliefs are that full focus when you
are dying can lead you to a good place or heaven in the next life. This is a good
result which prepares you for your next life without fear. I am ready to die and I
have planned for that time already. This understanding comes directly from my
experiences with Dhamma practice.
Experiencing disinterest in Dhamma and meditation
For people who have never studied Dhamma, I think it is not easy to help them. For
example, before I got cancer I used to support one of my friends. We studied at high
school together.
She is very clever. I knew she had cancer and I had much
compassion for her. I visited her after I finished the meditation retreat (10 day
course) at Wat Ampawan, Shingburi province. I took a number of Dhamma books to
her and told her about my experience of the benefits of practising meditation.
Obviously, she didn’t accept my ideas, because she never became interested in
Dhamma. My friend struggled to find the best medicine and the best doctor to cure
her cancer. She spent a lot of money. In my view, she tried to cure her body while
she forgot to heal her heart and everybody around her suffered.
Recognising benefits of learning Dhamma
I have learned the lesson that we should study Dhamma in normal life so that we
can use it when any suffering occurs.
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Accepting complementary care
After I had the operation, the monk that I used to help prepared a herbal medicine,
made by mixing fresh herbs, for me. I drank the herbal tea for 28 days. I also ate
more natural foods such as fresh vegetables, soy milk, tofu, fresh fruit juice and
some pills made with herbs to relieve constipation. I also chanted and did breathing
meditation almost every night. I have planned to do exercise, but I haven’t started it
yet. I plan to apply for early retirement this year and then I can have free time to
exercise and enjoy my life. I will run activities to help the temples and other people.
I am not happy taking chemical hormone replacements, so when my friend’s sister
bought a natural hormone product from Australia for me I have more confidence in
taking it. I have also tried many herbs, such as herbal mushroom and Peking grass
that my friends gave to me that they believe that can prevent cancer. I didn’t expect
much of these herbs; it’s just something more to do.
Living in a religious culture
I was born in this town and my home was near the temple. I saw that adults and the
elderly go to the temple, provide food for monks, chant and practice meditation. I
went there for fun and to follow them in practising meditation. As a child I didn’t
known the reason for those activities. At that time, there were no places to go to for
entertainment. Our life mostly revolved around the temples. We also had great fun
at the Royal fair. At that time the monks and temple committees had a major role in
setting Buddhist activities for people in the villages. Not until I got married and had
children did I have the chance to read more Dhamma books and gain more
understanding of the Buddha’s teachings. Also my mother loves to make merit, so
we would go to temples with my children. My life became closer to Dhamma
because of my mother.
Recognising the unselfish purpose of merit making
I always do Tam-Boon (make merit and give alms) without expecting repayment.
The heart of our principles is to help others. If we give and wait or expect something
in return it is not called merit making.
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Helping the monks and temples’ activities
My Buddhist activities mainly help the monks and the activities of Temples around
this area. I help them through social support. Throughout the year there are many
Buddhist rites and ceremonies such as Tot Pha-Pa, Tod Kathin, Magha Puja,
Visakha Puja, and so on. The monks always ask for my help to raise donations for
running the temple. Also when the monks get sick they usually tell me and I help take
care of them. I take them to hospital, provide special food and the other things
necessary for them. The money comes from my friends and myself so that we can
make merit. These activities are ways of making merit.
Seeking spiritual perfection
To achieve a high stage of spiritual perfection, I not only make merit, but also
practice meditation or Vipassana as a higher part of our life.
Practising religious rituals in daily life
Everyday, I get up and wake my daughter to cook rice and prepare food to offer to
the monks on their alms round. Then I go to work. After the operation I tire easily.
Teaching kindergarten children exhausts me. I try to take five minutes to
concentrate on breathing in and out. It really does work. I feel that my eyes shine
and the tiredness and tension are immediately gone. In my experience, it is not
necessary to have a set schedule for meditation. You can meditate anytime by
concentrating on your breathing. It is good, because nobody can tell. My favourite
time for meditation is when I am lying down. I feel so relaxed it is easy to sleep. If
some nights I can’t go to sleep easily, I just concentrate on my breathing and after
not more than 10 minutes I am asleep. If I say the word Budd when breathing in and
Dho when breathing out it seems not as easy to get to sleep.
Using different ways of meditation
So, from my experience in promoting good sleep we can advise patients to just
concentrate on breathing in and out. It is better than chanting the words Budd-Dho.
But the way that works for me might not suit others. Everybody should have their
own experience and practice regularly until they can find a way that suits them.
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Teaching meditation and religion
At school I sometimes teach junior students to do five to 10 minutes of breathing
meditation before class. Some students told me it makes them feel happy and most
of them love to meditate. If each school could train students like that I think students
could concentrate on their lessons more. Sometimes I take students to visit the
temple near the school and tell them about Buddhist rituals.
Experiencing ordination as a nun
Around 24 years ago I was ordained as a nun for a month and I practiced the BuddDho concentration method. After I joined a Vipassana course with one particular
monk, he taught me to watch my belly move in and out. I used to be confused about
the many ways of meditating. Now I know that watching my belly move in and out is
the best way for me. Also I used to practice focusing on the light and the Na Ma Pa
Ta method but I don’t think that is suitable for me. There are 40 kinds of meditation
in Buddhist teaching, so you can select the one that is best for you.
Recommending breathing meditation
I think breathing meditation is good for patients’ health. Last year, I couldn’t sleep,
because I didn’t take hormone replacements, so the doctor gave me plenty of
hypnotic drugs. I was worried about drug addiction, so I didn’t use them and solved
the problem through breathing meditation.
Valuing compassion of nurses for patients
The most important thing for patients is Metta, the loving kindness of nurses. When
you help patients with compassion that is authentic and from your heart, patients
feel the sense of caring. Patients will then feel confident and calm and ready to
practice breathing meditation with you.
Controlling pain by meditation
Five years ago, coming back from practising meditation, I had a motorcycle
accident. A car hit my motorcycle and I got long cuts on my arms and legs. I had
severe pain. I tried phoning to tell my daughter and sister, but couldn’t contact
anybody. The experiences of practising meditation came to my mind and then I
focused my mind by watching the characteristics of my pain. I had full
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understanding of how severe the pain was, but a few minutes later I had peace of
mind and my mind accepted the pain without feeling distressed. I dealt with this
problem alone until the nurse finished dressing my wounds and let me go home. I
have direct experience that there are lots benefits in using meditation as a self
control method … I only have physical pain after an operation and it can be cured
with pain relieving drugs. I still have pain at the wound when I lift heavy things or
when I have constipation. I still control this pain by using concentration techniques.
I use both hands to hold my tummy and imagine that I am holding my baby in my
womb. I make a vow and pray that the pain will lessen until it becomes better and
better.
Controlling incontinence by using concentration techniques
I also use this (concentration) technique to control my incontinence problem
especially when I travel and can’t find a toilet nearby. I can stop using Pamperse
(sanitary napkins) because I can control the symptoms by using meditation for
healing.
Applying meditation principles to calm the mind
While I was waiting to see the doctor for a follow up after the operation, I saw one
woman sit on a chair and wait for the doctor calmly. She closed her eyes and
looked peaceful when compared with the other patients, who felt unhappy about the
very long queue. We can calm our minds at any place and at any time if we
understand the way to apply meditation in our daily lives.
Receiving good nursing care
I feel that I have received good nursing care and the doctor also took care of me
very well. All of the nurses are lovely. They always pay attention to the patients.
Trusting nurses and doctors
I trust all the nurses and doctors and let them do their duties.
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Understanding and appreciating nurses’ hard work
Another good point is that the nurses are never moody even though they work very
hard. The wards are always busy and they have to deal with many kinds of bad
tempered patients. I saw that the nurses were very tired and stressed. I really
understood and appreciated them.
Trying to take care of self
So, I tried to take care of myself and report to them when I was pain. I didn’t have
any problems with them. My daughter left her job for three days to take care of me
before and after the operation. When the intravenous fluid was nearly empty my
daughter reminded the nurses and when we needed help we told the nurses and they
came to help us on time. We tried to help the nurse as much as we could to lessen
their workload.
Understanding some patients are demanding
I saw some patients who were more demanding of the nurses, because they couldn’t
cope with their illness. They had high expectations and were thinking only of
themselves. I think if we take some time to look at others we will be less selfish. If we
remain selfish we will easily suffer distress.
Perceiving nursing is a meritorious occupation
Nursing is a meritorious occupation. Nurses have to have plenty of understanding of
patients. Because patients are sick, they mostly have negative emotions. You should
approach them in a peaceful and cheerful way then patients will absorb your warm
heart to help them reduce their tension.
Appreciating daughters as caregivers
My daughters feel more relaxed now that they have seen my happiness. They all
know my purpose and let me do my activities. They only worry that I am so busy
helping others that I have no free time to take care of myself. They all take care of
me very well. One daughter that lives with me prepares healthy food for me every
day and usually goes with me to make merit and join in the social activities. Another
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daughter takes care of me when I go for follow up in Bangkok. They have all done
their duty as daughters perfectly.
Understanding and accepting difference among individuals
I am a teacher. I understand students, bosses and colleagues. I always understand
that others are different. I understand why and how that occurs. Because of this,
when something happens I understand that we have different opinions of the same
situation. The foundations of each person’s emotions are different. I can forgive
everybody. When problems come up I can’t change other people, but I can change
myself and improve my attitude. Everybody comes from a different background. I
can learn to tolerate ineffective teachers instead of getting stressed by them. We
shouldn’t suppress our bad feelings; instead we should let them go, so that we can
have more happiness in this complex world.
Helping others without expecting any thing in return
When we help others, we should not expect anything in return. When we grow trees
we can’t force them to produce fruit too early. You can help others by giving them
money or trying to think of ways to solve problems within your constraints and you
will feel happy.
Feeling joy after helping others
I don’t always need something from others, rather I am happy to give. When I give I
feel light hearted and peaceful, which the monks call Piti (joy or zest). Piti can
dismiss sickness. Like the peace in my mind when I meditate, when Piti comes I
sometimes have goose pimples and felt cool and fresh inside.
Describing kamma, impermanence, right understanding and equanimity
If problems occur after you do your best that means that there are some effects from
past kamma that they have to face until the past kamma is over. I always look at any
problems when they start and then change until eventually they are solved. Nothing
is permanent in our world. We should set our minds to do things properly. The
wheel of kamma is always circling. Our life is like the sun. It has sunrise and
sunset, dark and bright sides. Everyone should prepare their heart to deal with the
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dark side. We must live without Pamada (heedlessness). After I help others and
consider that I have put in the right amount of effort to help them, then I don’t need
to worry any more even if the situation gets worse. The way that helps me to accept
everything is equanimity.
Keeping oneself well before helping others
Before we can help others we should keep ourselves healthy, powerful and
energetic, because now in our world there are many people who need help and
support.
Being ready to die because of the Four Noble Truths
I always think I am ready to die, because I have fulfilled the role of a mother
completely. Birth, old age, sickness and death are the ultimate truths for everyone
in the world. My friends seem to worry about my cancer more than I do and I
usually tell them about the truths of life. I see that my sickness is natural. It is the
story of Sankhara, the Five Aggregates and the Law of Causation. When I become
sick I have to see the doctor to treat it. But I should not pay too much attention to it,
because in the near future the physical body will die and transform to the elements
that fill the land. Only the Vinnana (soul) is left and moves to another state, the state
of rebirth. We can’t select our destination after death, but we can nurture our body
as best as we can. I always ask my heart and get the best answer from the Dhamma
that I have learnt, is as the Buddha said about the Four Noble Truths that teaching
is really true. We should know our suffering and know why we are suffering so that
we can then find a way to transform it. Every coping strategy focuses our mind …
Nowadays, I think about death without fear. I have already prepared myself for a
peaceful death. I imagine that at that time I will be peaceful. I will sleep and focus
only on breathing in and out. I will let go of everything. I will never worry about
anyone or anything I will leave behind. We call this mindfulness of death or
meditation on death. I practice this method, thinking of death and accepting it
without any resistance ... Because of the understanding of Buddhist teaching that
comes directly from experience I have never felt anguished or worried about the
cancer progressing.
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Believing in effect of past kamma on health
After thinking about my life, I remembered when I was young I loved to eat pork and
didn’t like vegetables. I never cared for my body and ate everything I wanted. I took
in more toxic chemicals every day. This is the past kamma that might have caused
my cancer. There are also some effects from my unknown past behaviours that I
can’t explain. I may have done these things in a past life, but I am happy to accept
the results.
Being a good listener when helping others
Now there are many friends who come and consult me about how to deal with
illness, family and financial problems and so on. I am a good listener and help them
as much as I can until I have no other ideas and then I feel that I need not to worry
about them any more. I move to the state of Upekkha (neutrality). In the Buddhist
view the highest virtue is to help others with a pure mind. Compassion comes from
a real heart. It is less valuable if you make merit and ask for repayment with a better
life in the next life. I believe in the laws of action and reaction but it should occur
naturally without asking. For example, when you give a friend a helping hand, some
time later you receive help from another person. It is like 1+1 adding up to more
than 2. I believe that all human beings live within the law of kamma. If you do good
deeds, you unexpectedly feel happy. It is not necessary to expect a good life in the
next life. Boon (punna, merit) means pleasure and peaceful feelings from virtuous
acts. Virtuous acts occur when you make merit or help others through the Middle
Way, such as if you are not rich and can only donate five to 10 Baht instead of 100
Baht.
Conclusion
The experiences and codes which emerged from an open coding analysis of one
patient were described, in relation to her application of Buddhism and Thai
traditional wisdom in self care and coping with illness-related problems. Ideas
about effective and ineffective nurse-patient-relative relationships in nursing
contexts were also shared by the patient. The remaining emerging codes from the
other participants are listed in Appendix F.
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CHAPTER 7
RELATIVES’ EXPERIENCES AND EMERGING CODES
Introduction
In total, 16 patients’ relatives (11 females, five males) participated in this research.
Because of the vast amount of data in the transcripts of the relatives’ experiences,
demographic data, experiences, and emerging codes of one relative is presented in this
chapter. The experiences and emerging codes from the remaining relatives are listed in
Appendix G.
The relatives’ demographic data, experiences, and emerging codes
Relatives’ demographic data
Eleven females and five males were the significant caregivers. The time range of being
a main caregiver was from two months to 10 years. Patients had either acute or chronic
problems. Some patients were in critical and terminal stage; most of them were in the
chronic stage and needed long term care. Patients’ illness included acute and chronic
leukaemia, asthma with post arrest, cerebrovascular accident with asthma or diabetes
mellitus, elderly patients with DM, HIV/AIDS, lung cancer, myocardial infarction,
respiratory failure (RF), scleroderma with renal failure, severe head injury, and
thalassemia with post cardiac arrest. Periods of illness ranged from two months to 20
years. The main reasons for relatives to become fulltime caregivers were: being single,
being a mother or a husband, staying with patients, and having more time than other
family members. However, the most important reason for them was “being willing to
care for their loved one”, because of feelings of tender loving care, responsibility, and a
sense of repaying their gratitude to parents, which can be called “the virtue of Filial
piety” in Buddhism and Confucianism (Crigger, Brannigan & Baird, 2006: 3). Some
relatives had been a caregiver continually for more than 10 years.
Chapter 7: Relatives’ experiences and emerging codes
Patients’ relatives were aged 21 to 58 years. Three of them were single. They were a
student, house wives, workers, gardeners, nursing teachers, and a doctor, who had a
wide range of educational background and economic status. Some of the relatives could
not do other jobs and had less chance to earn money while caring for patients, so most
of them received financial and moral support from other family members and close
relatives. Some asked for help from other family members when they needed it.
However, one relative mentioned about having less support from other brothers and
sisters because they paid attention only on their work. Some relatives had to pay for one
or two caring assistants because they had to work and none of the family members had
enough time to care for patients or they lived far away from patients. Obviously, healthy
husbands and wives preferred to care for patients because they did not want to bother
their children who needed to maintain their work (see detail in Table 7.1).
In relation to religious background, two male patients, Khun Damrong and Lung Pong,
had an ordination experiences, and most relatives had learnt Dhamma and practises in
daily life as lay Buddhists. Moreover, two female participants, Pa Wandee and Pe Yai,
had practised Vipassana meditation continually for several years and they had applied
the Buddha’s teachings about the nature of suffering and meditation to keep their mind
calm and powerful while dealing with patients’ crises. Participants shared some of their
applications of Buddhist beliefs and practices to care for patients and deal with any
hardships while being the main caregivers. The relatives were identified by pseudonyms
of Khun Damrong, Lung Teera, Nong Rama, Nong Ya, Na Ree, Lung Pong, Khun Sakol,
Pe Urai, Na Su, Na Rin, Pa Wandee, Na Chaba, Pa Jin, Pe Yai, Na Uma, and Pa Muu,
(see meanings of the terms Khun, Lung, Na, Nong, Pa, and Pe in Chapter 5 and 6).
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Table 7.1: Relatives’ demographic data
Participants
Age
Sex
Year 6
Farmer
/retailer
~5,000
Relations
hip with
the
patient
husband
Year 12
Sale man
~6,000
husband
Studying
the first
year, at
the Open
University
Year 6
Student
no income
A middle
son (has a
twin
brother)
Rubber
Gardener
~15,000
Year 6
House
keeper
~6,000
The
Youngest
daughter
Mother
Married,
with 5
children
Year 6
Minibus
driver,
gardener
Male
Married, has
2 children
Specialist
in
Endocrine
/Medicine
Medical
Doctor
~12,000
(from
sisters/bro
thers)
~50,000
39
Female
Single
Bachelor
degree in
Business
Business,
Selling
clothes
and others
~30,000
Youngest
daughter
9.
Na Su
47
Female
Married, has
4 children
Year 6
~8,000
Middle
daughter
10.
Na Rin
54
Female
Separated
without
children
Bachelor
degree in
Education
~20,000
Middle
daughter
11.
Pa
Wandee
56
Female
Single
~20,000
Youngest
daughter
12.
Na Chaba
49
Female
Rubber
Gardener
~5,000
Wife
AML
(M/U)
13.
Na Jin
70
Female
Married, has
3 children, a
son also had
an accident
Married, had
5 children
Master
degree in
Public
Health
Year 6
Thai
dessert
maker
Retired
Thai
Drama
teacher
Nursing
Teacher
Year 4
Sell
grocery
~10,000
Wife
CVA
(H; M/R)
8 years
14.
Pe Yai
44
Female
Single
Nursing
teacher
~18,000
Middle
daughter
GBS
(PVR/U)
3 months
15.
Na Uma
54
Female
Married, has
4 children
Master
Degree in
Nursing
Science
Year 2
Female
Married, has
4 children
HIV with
PCP (H; R
,OPD/U)
AIDS with
splenic
infection
(G/C)
8 years
55
~10,000
(rubber
garden)
~5,000
from her
husband
Mother
16.
Pa Muu
Rubber
gardener/
grocery
House
wife, fruit
seller
1.
Khun
Damrong
2.
Lung Teera
36
Male
50
Male
3.
Nong
Rama
21
Male
4.
Nong Ya
27
Female
5.
Na Ree
49
Female
6.
Lung
Pong
58
Male
7.
Khun
Sakol
49
8.
Pe Urai.
Marital
status
Married with
1 son, 1
daughter
Married,
has 2
children
Single
Married,
has 2
children
Married, has
2 children
Education
Year 6
Occupation
Income/
month
(Baht)
The
Oldest
Son
The
youngest
son
Mother
Patients’
illness*/
(setting**/
hospital***)
severe head
injury/ (T/ P)
asthma with
post arrest/
(M/U)
scleroderma,
and ARF
turn to CRF/
(M/U)
3 months
CML with
shock
(M/U)
thalassemia
with post
cardiac arrest
(M/U)
CVA, DM,
MI, brain
infarction
(M/U)
CVA and
asthma
(H; M/U)
2 months
DM,
respiratory
failure (RF),
septic shock
(ICU/P)
lung cancer,
stage 4
(M,OPD/U)
elderly
patient with
DM,
(H; M/P; C)
CVA
(H; M/U)
Duration
of being a
caregiver
6 months
3 months
2 months
10 years,
need total
care for 2
years
Asthma
for 5
years,
CVA for
3 years
DM for
10 years,
RF 3
months
3 months
DM for
10 years/
total care
for 1 year
16 years
/total care
for 10
years
3 years 6
months
2 years
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* Illness: AIDS = acquired immune deficiency syndrome, AML = acute myeloblastic leukaemia, ARF =
acute renal failure, CRF = chronic renal failure, CVA = cerebrovascular accident, DM = diabetes
mellitus, HIV = human immunodeficiency virus, GBS = Gillian Barre syndrome, MI = myocardial
infarction, PCP = pneumocystic carinii pneumonia
** Setting: G = General ward, ICU = Intensive Care Unit, M = Medical ward, PVR = Private room, T = Trauma
ward, H = Home
*** Hospital: C = Community Hospital, OPD = Out Patient Clinic, P = Provincial Hospital, R = Regional
Hospital, U = University Hospital
Relatives’ experiences and emerging codes
Sixteen relatives shared rich experiences of applying Buddhism and Thai culture as
spiritual caring and management, to help patients cope with illness and maintain
effective relationships between patients, nurses, and themselves. The experiences and
emerging codes of one relative are presented in this chapter. The remaining patients’
emerging codes are listed in Appendix G.
Khun Damrong’s experience
Khun Damrong was a 36 years old farmer, who had one son and one daughter. He was a
farmer and helped his wife run a small grocery store in the village. He moved in to stay with
his wife’s family after getting married. He was ordained at the temple in his village for three
months when he was 25 years old following the religious tradition. The belief is that merit
from ordination before marriage belongs totally to one’s parents. This is also the best
way to repay one’s parents with utmost gratitude. Normally, his wife, mother and
grandmother-in-law would make merit for everyone in the family.
The history of his wife’s illness, was that around six months ago she had a head injury from
a motorcycle accident. After having brain surgery, she was unconscious for more than two
months. During that time Khun Damrong stayed close to her and helped nurses take care of
her as if he was her private nurse. He developed his basic nursing skill and could do the
bedside nursing care for his wife very well. He helped nurses prevent complications and
rehabilitated his wife until she gradually got better. He faced a lot of problems while being
a caregiver, especially the business of the ward and some nurses’ errors.
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At the time of interviewing Khun Damrong, his wife had been discharged from the
provincial hospital to home for nearly a month. His wife was not ambulating. Her coma
score was E4M4V3. She was lying on a hospital bed that a senior community nurse lent
them free of charge. She had a craniotomy scar on the left hand side of her skull. Her home
medications were Dilantin, Carbamazepine, and Vitamin Bl-6-12. Khun Damrong, his
mother and grandmother-in-law always prayed for her recovery and they tried their best to
help her, especially by massage, communication, and feeding with nutritious food. I
remember how the two children played with their mother and tried to teach her to count on
her fingers. I also prayed for her recovery.
Sixty nine codes emerged from Khun Damrong is experience of caring for his wife with
severe head injury for six months. These codes included: experiencing ordination to repay
gratitude; perceiving an accident from bad luck; experiencing shock; receiving health care
information; making a vow; asking the doctor for information; receiving moral support
from the neurosurgeon; staying with and caring for his wife; being his wife’s supporter;
experiencing fear of unsafe ventilator care; gaining confidence to care for his wife;
perceiving the ability to take over nursing care; appreciating nurses’ teaching and support;
realizing a good opportunity to care for patients; realizing the benefit of health insurance;
rehabilitating wife because nurses have no time; having children support his wife’s mind;
receiving support from the community nurses; hoping his wife can move by herself;
appreciating people who donate medical equipment; appreciating meditation to release
tension; not being interested in meditation; having no idea how to apply Buddhist practices and
teachings; realising his mother and grandmother made a vow; intending to repay a vow;
experiencing a mother’s offering; making merit; believing in the effects of supernatural powers;
having a helping relationship with the extended family; practising Buddhist and
traditional rituals; believing illness occurs from effects of past kamma and supernatural powers;
asking the monk to make holy water; receiving strong moral support from friends and
relatives; predicting patients’ health from a relative’s dream; making a votive offering;
rehabilitating patients by massaging; realising nurses ignore relatives care even when they
are not busy; perceiving nurses can help relatives do more bedside care; perceiving nurses
provide equality of care for relatives by not helping anyone; realizing nurses have no time to
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help; feeling sympathy with nurses and their hard work; appreciating nurses’ politeness;
experiencing some relatives cause problems for nurses; sharing good and bad times with
other relatives; donating blood for other patients; being a ward’s volunteer; having a good
relationship with the head nurse and others; receiving kind support; arguing with uncaring
nurses; experiencing mistrust of nurses; perceiving hygiene care of relatives can prevent
patients’ infection; preventing nurses’ errors; having no hesitation to call for help from nurses;
experiencing some relatives are hesitant to ask for any help from nurses; getting special
support; receiving praise from nurses; having health problems; receiving special support from
nurses; suggesting nurses let relatives stay with patients; suggesting nurses teach relatives to care
for patients; suggesting nurses ask relatives about their beliefs; suggesting nurses help quickly
when they need help; suggesting relative should not feel hesitant to ask help; suggesting nurses’
positive qualities; and suggesting the need for trust; and suggesting nurses do not sleep on
night shift.
Experiencing ordination to repay gratitude
I was ordained for 3 months when I was 25 years old at the temple near my village following
the religion tradition. We believe that the merit from ordination before marriage belongs
totally to your parents. This is the best way to repay your parents with the utmost gratitude.
My parents felt really appreciative and extremely happy for this religious practice. I didn't
learn much about Dhamma because at that time the abbot was sick. I only went on alms
rounds and chanted in the morning and evening. I had never practiced meditation before.
The abbot sometimes taught meditation but the novice monks were never interested in
doing it so he wasn’t strict on meditation. Instead, monk at that temple had to be good at
chanting.
Perceiving an accident from bad luck
One evening, seven months ago, I took her from our grocery shop to home on our
motorcycle. There was a herd of cattle that the owner hadn’t tied together. They ran past us
and I suddenly stopped the engine, but one cow hit the motorcycle. My wife fell and hit
her head on the road. I was lucky, I had only a few lacerations, but my wife had bleeding
in her brain. We always wore helmets, but that day I don’t know why we didn't put them
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on. It might have been our bad luck day, but if the cows' owner had been more careful and
hadn’t let the cows walk freely, it wouldn't have occurred. The cows' owner is the head of my
village and he has a lot of influence in this area. He paid us only 70,000 Baht to show his
responsibility. It wasn't because I drove too fast. It was an accident that might have come
from our bad luck.
Experiencing shock
I was shocked and immediately told my relatives to hire a car and take her to the provincial
hospital about 70 kilometres from the accident. We couldn’t go to the community hospital,
because everyone knew that they didn't have a neurosurgeon there. Around 40 minutes
later we arrived at the hospital. The nurses came and checked her vital signs. A few
minutes later, she was sent for an MRI. After that, the doctor came and explained to me
and a lot of our relatives that she had a swollen brain and bleeding in the brain. Her
prognosis was very poor and they couldn't guarantee a good result. They told us that it was
50:50 whether she would die or recover.
Receiving health care information
One of my sisters is a pre-registered nurse in the labour room of this hospital. She knew
almost all of the nurses there, so we received great help from the nurses, doctors and all
the staff. We could ask for any information.
Making a vow to save a beloved one’s life
I was really shocked and also felt anxious. I repeatedly asked the surgeon if she would
recover. The doctor said she would get better. My relatives and I didn't believe him
because from our past experience, severe patients like this always pass away. The doctor
also reassured us. He believed that my wife would get better and better, but it could take
time, nearly a year until she could speak and walk. At that time, the doctor asked all of us
to make a final decision on whether or not she should have brain surgery. If we make the
decision too slowly she would die soon. Even though we were extremely afraid of death
from the operation we accepted the inevitability of the operation and made a vow for her
long life.
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Asking the doctor for information
Her irises weren’t reacting to light and the doctor told us that he would need to observe
her level of consciousness for 15 days after the operation and then he give us more
information about her prognosis. Her operation took two hours and 30 minutes. The
doctor said she was safe during that time. She was sent to have a post operative MRI at the
regional hospital. Luckily, she didn’t re-bleed. He is the best surgeon, because he really
cares for the feelings in our minds. We are all very anxious, because we want our patients
to get better as soon as possible. I always told the doctor that if he needed a special drug, a
drug that could nurture her brain, even if it wasn't covered by the 30 Baht card, we were
all happy to pay for it.
Receiving moral support from the neurosurgeon
The doctor said that he had already prescribed the medicines that were vital for my
wife, so we should please keep the money to take care of her later, such as for preparing
good food to heal her brain. Her brain will need the best food. The best drugs alone can't
improve her condition. My sister I and always tried to contact the doctor when she looked
pale and not quite conscious. The doctor has never forgotten to order vitamins and the
nurses prepare it for my wife every day.
Staying with and caring for his wife
I stayed with her and devoted myself to helping the nurses take care of her all the time on
the trauma ward. Nurses usually let two relatives stay with unconscious patients in order
to help them with bathing, feeding and changing their position. I was the main caregiver
and my brother helped me some days when I was very tired. There was one nurse helped
me to bathe my wife for the first month, but later they let me bathe my wife by myself. My
brother I and did her nursing care so well that the nurse didn't help me with the bed
bath, feeding or changing her position anymore … My wife stayed in the trauma ward
for two months until she wasn’t dependent on the ventilator any more and then she was
moved to the female surgical ward with an oxygen mask into her tracheostomy tube. The
other relatives came and visited often, but they didn't stay at the hospital. Then it was
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the time to cut rice and my father did it for me so I didn’t have to worry about any jobs at
home so I could stay at the hospital all the time … My wife has been unconscious for four
months, but she might respond to me next month. She could open her eyes and move her hand
a bit … I always stayed with my wife beside her bed in the ward. When I went other places I
always informed her and when I went back home I told her that I went back to take care of our
kids … For a month in the surgical ward she didn't have much secretions. Her lungs were
clear and so the doctor changed the Portex tube to a Jackson tube. Two weeks later she had
the tracheostomy closed. This was another enormous pleasure for us. I started to feed water to
her, so wonderful, she could drink it. Later she drank 30 spoons of water. Then I made a half a
glass of orange juice for her every day. Finally, she could eat boiled rice. For her first meal, a
relative of the patient next to my wife divided some boiled rice for me to try to feed my wife. We
were all happy with her good condition. Even when she could eat a big bowl of boiled rice the
doctor said she still needed high protein food to heal her brain so she must get a blended diet
through her nasogastric tube continually. Boiled rice was not enough energy.
Being his wife’s supporter
Relatives of one patient near my wife's bed told me that she didn't sleep well when I didn't
stay near her. I knew that she needed a sense of security from me. I asked her if she was
really happy when she opened her eyes and saw that I was always near her. She nodded and
blinked her eyes.
Experiencing fear of unsafe ventilator care
Then my wife still used the ventilator. The first time that I had to do a bed bath I was
afraid that I might put the (endotracheal) tube in the wrong position or create some
problems that would be dangerous for her. I didn't understand the reason for the doctor's
treatment … I was afraid when I helped the nurse turn her position, because she had an
operation on the left hand side of her head and the doctor's order was that she wasn’t to
lie her on her left side. How could I avoid it when I changed her bed sheets? One nurse
told me we must be as quick as we can when we turn her on her left side. I also fed her
through her nasogastric tube very well. I did not feel confident the first two or three times
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but after that I got used to do it. After I fed her the blended food I put in 150 cc of boiled
water.
Gaining confidence to care for his wife
When I got used to it I even reconnected the ventilator tube by myself without calling the
nurse. I could see when the ventilator was going to have problems and would tell the
nurse when they began. I also asked the nurse the how to manage the water in the
ventilator's tubes, because the nurse told me that the water mustn’t go into the
endotracheal tube. I saw how it can give my wife a severe cough and make her very short
of breath. She suffered so. Then I knew that I had to pour the water out of the ventilator's
tubes before I changed her position and clean them with alcohol. All the techniques that
I use to help my wife came from the nurse. She told me to practice taking care of my wife
and taught me how to do it. I asked questions if I needed to confirm and make sure that I did
things right. I felt that there nothing was too hard to do for my wife, because every time I
have questions I have always got good answers from the nurses and doctors. They have
taught me from the beginning of her admission so I got very confident … The way the
nurses taught me to care for my wife such as with feeding, bathing, changing her bed,
and observing the ventilator, was by explaining and demonstrating the real situation. It felt
easy to learn from them. I copied their techniques.
Perceiving the ability to take over nursing care
… and I think I took care of my wife, especially bathing her, better than the nurses did,
because the nurses had many patients to care for and they didn't take enough care of some
areas of my wife's body, such as her perineum. I clean her body and make it dry. I pour
lotion on her skin and massage her. I think the nurse don’t have enough time to do that. I
take care of my loved one, but they care for the general patients. I don't want to blame
anybody, but this is an opportunity for nurses to let relatives be involved in basic nursing
care.
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Appreciating nurses’ teaching and support
In my mind, I appreciated the way that the nurses allowed relatives to practice nursing care
of patients. The nurses gave me the best reason, which is that I can take care of my loved
one in hospital and improve my caring skills so that I could take care of her at home after
she was discharged. I strongly agree with them.
Realizing a good opportunity to care for patients
I think that when relatives have the opportunity to care for patients in hospital it seems
that we can provide the best nursing care for patients. We might be better than others who
are not relatives. I was starting to get intimately acquainted with helping my wife by the
third month after her accident. It was not a hard job to do, because it all came from my
heart. My intention was to save her life.
Realizing the benefit of health insurance
We didn't pay for the total cost of treatment and care, because I have a Gold card, the 30
Baht health care card from the government. Also we had the right to use 50,000 Baht from
the basic road and traffic insurance from when we had the accident. I have paid only for
her pamperse and the cost of my living at the hospital. Her urethra was traumatised and
swollen after two months of catheterisation. The doctor ordered the nurse to take it out.
Now she can't control her pee and we bought pamperse for her to wear. It was quite
expensive, but helped me so much, because I didn't have to change her clothes so often.
Rehabilitating wife because nurses have no time
Three months after my wife's accident the doctor asked the physiotherapist to rehabilitate her.
The nurse told us that she asked the physiotherapist to teach me to do exercises for my wife.
Later, the rehabilitation of my wife was my main duty again. I did rehabilitation for my wife on
the surgical ward, because I can do it and there are only a few nurses. Nurses have no time to
rehabilitate patients, so it would be better if I could do the exercises for my wife. It was better
than waiting until the nurses had free time to help us.
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Having children support his wife’s mind
I have an eight year old son and a two year old daughter. The older one looked sad when he
knows that his mother has had an accident and has been admitted to hospital. My motherin-law and grandmother-in-law helped take care of my children very well while I was
staying with my wife at the hospital. Now my son is getting better. When he comes home
from school he teaches his mother to count on her fingers one, two, three, like the
teacher taught him. Now my wife can slowly say the words that my son has taught her, which
is fantastic.
Receiving support from the community nurses
She has been discharged for a month and a week. Two weeks ago the community nurse
helped us take out her NG tube. After that she looked really good. Her appetite was really
good and she was getting fat. We can’t control her weight, because we need to nurture her
brain. The patient's bed that we use at home we have borrowed from the primary care unit
which is run by community nurses. The nurse who takes care of my area is really kindhearted and
friendly. She told us that there was a patient's bed that an elderly woman in our village used
to use and now she has passed away. Her daughter donated it to the community hospital. She
let us borrow it. That was so helpful for my wife.
Hoping his wife can move by herself
Now, I am waiting until she can lift her neck and sit by herself. That would be our main wish.
Appreciating people who donate medical equipment
In our culture we believe that the person who makes donations to help patients like this can
receive great merit.
Appreciating meditation to release tension
At the hospital I have made a friend. He was watching over his mother, who was unconscious
and she seemed to get worse. He did meditation for two to three hours almost every
morning at around one to three a.m. on the floor near his mother’s bed in the surgical ward
near my wife's bed. He told me to practice meditation with him when he saw that I was
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really anxious and frustrated about my wife's condition. He told me that while meditating we
could stop thinking too much and our minds would be more relaxed and refreshed. He had
practiced meditation for many years and it really helped him to keep calm during serious
events like when he was really tried from taking care of his mother for more than six
months on this ward.
Not being interested in meditation
But I was never interested in practising meditation.
Having no idea how to apply Buddhist practices and teachings
I think that Thai Buddhists, who have done Buddhist activities, follow the old traditions. I have
never thought about using or applying Buddhist practices and teachings while taking care of
my wife. I just focused on caring for her as best as I could and asked the doctor what I
should do to improve her condition. I always take care of her, talk to her from before she
responded until she was conscious. I don't want to lose her.
Realising his mother and grand mother made a vow
Since the first day after the accident her mother and grandmother have done every
traditional activity that our family and the older generation used to do. Her mother
made a vow asking from the Triple Gem, the Buddha, the Dhamma and the Sangha, all the
ancestors, ghosts, deities and magical powers to save her life, focusing on her being able to
speak and walk.
Intending to repay a vow
If she survives, we will arrange for her to be ordained as a nun, to live a meritorious life,
to repay the kindness of all of creation.
Experiencing a mother’s does offerings
In addition, her mother went to do Sanghadana, offerings dedicated to the Sangha at about
seven temples in this province where we believe that there are sacred monks who can
dismiss all bad luck. The main purpose of doing Sanghadana was to extend her life.
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Also, she dedicated all of the merit that she has collected from the past to become a consecrated
power to heal her daughter.
Believing in the effects of supernatural powers
We also believe that the supernatural powers might be a partial cause of the accident and bad
luck. Before the accident, my wife loved to make merit and offer food to the monks. Her life was
doing meritorious acts.
Having a helping relationship with extended family
I moved from my home to live at my wife's home. Everybody loved me and I also worked hard
for the family. My mother and father came to visit my wife sometimes. In our family, everybody
helps and supports each other. While my brother and I watched my wife at the hospital,
grandmother mostly went to make merit at the temple. My wife's mother took care of my
children and prayed for us and my brother washed our clothes. He also helped me take care of my
wife when I got an infection. I put on a mask when I looked at her and kept myself away from my
wife when I got a cold in order to prevent her from catching any germs. At that time by brother
helped me take care of my wife. This is the wonderful life that we gain from good relationships with
everybody from our extended family.
(Note: The data from this following section came from patient’s mother and grandmother)
Practising Buddhist and traditional rituals
I (patient’s mother) did chanting every night and also taught my niece and nephew to
pray and meditate for their mother too. I always say a Buddhavandana, worshipping the
enlightened one, scripture prayers and meditate by focusing on breathing in saying Budd and
breathing out saying Dho for about 20 to 30 minutes every night. I get to a peaceful state easily
from this practice.
Believing illness occurs from effect of past Kamma and supernatural powers
I (patient’s mother) believe in the effect of past Kamma and the effect from devils, because I
used to learn this when I attended the Dhamma teaching by the monks many years ago. I felt calm
and happy after I made merit and transferred it to all the powers around us. After the devils
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receive our merit they will help my daughter. Her serious condition could decline and she
can get better and better. I went to do Sanghadana every two months.
Making merit
I (patient’s mother) have five children. She is the oldest, and most of them are working
far away from home. Only the youngest is studying year 11. We are rice farmers. My
daughter worked very hard. She was really energetic and the prime mover (main supporter)
in the family. When she finished in the rice field she opened her grocery shop and made
dresses for her clients. When she got sick we couldn’t accept it so we tried every way.
We depend on both hospital and traditional ways to help her and now I always keep making
merit for her. We wish that she could get better enough to work. Now she can understand
what she hears and sees, but she can't sit down and take care of herself. We all are very
pleased at this stage. However, I wonder whether she will be able to walk in the future. This
is the most worrisome issue for us …
Khun Damrong also said that “Every time that my mother comes back from the temples she
always comes to visit my wife and tells her that she made merit for her even when she was in a
coma. We all felt very happy that we have made merit for her and all the devils who might cause her
illness.”
Asking the monk to make holy water
Also the monks who our family respects made holy water and gave it to me and I (patient’s
mother) took it to the hospital. When we and all her relatives visited her, we sometimes
sprinkled a little bit of holy water on her body as a sacred protector from all bad devils.
Receiving strong moral support from friends and relatives
There are many relatives, friends and village members, who came to visit her in hospital.
We always have strong moral support from friends and relatives.
Predicting patients’ health from a relative’s dream
I (patient’s mother) also dreamed about my daughter that she was getting newly
married, but later that she was not. There are many flags around my home in my dream.
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This means that she still has some merit left and it wasn't her time to die. So she is getting
better and better every day.
Making a votive offering
Also I (patient’s mother) made a votive offering to do Manora dancing by myself in front of
the well known goddess statue near my village. The villagers usually make this vow and
most of them have good results.
Rehabilitating patients by massaging
I (patient’s mother) am a public health volunteer. I have helped the community nurses
with primary care issues in my village for many years. I have been trained by the health
care staff to do dengue virus infection prevention, HIV/AIDS prevention and care and I
always educate people to take care of their health. Recently, I have had 3 days training in
Thai traditional massage at a course run by the community hospital. I can help my
daughter a lot until she has no complications with her joints, muscles and skin. I massage
her every day and use herbal ointment to relax her muscles. This government project was
very useful for us. We don't need to depend on physiotherapy. I can massage her anytime
except when she is asleep.
(Note: End of data from the patient’s mother)
Realising nurses ignore relatives care even when they are not busy
Looking at the whole picture, I wasn’t satisfied with the nursing services in the surgical
ward, because when the nurses saw at least one relative was staying with any patient,
mostly they didn't come to help those relatives. Also when I made a bed I changed all the
bed sheets by myself. It wasn't easy to do. I really needed someone to help me.
Perceiving nurses can help relatives do more bedside care
In the first week after my wife was moved to this ward, there was one nurses’ aid helped me
bathe my wife. If they had free time they would help us but most of the time they were all
very busy due to the unlimited patient admissions policy.
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Perceiving nurses provide equality of care for relatives by not helping anyone
Sometimes I think that because there were so few nurses, if they helped with every bed, they
couldn’t do it. So to be fair to every relative they didn't help anyone. They only helped
when there weren’t any relatives there at that time.
Realizing nurses have no time to help
From my observation every nurse and staff member on the ward had a service mind. They
would like to help relatives, but they have no free time.
Feeling sympathy with nurses and their hard work
This ward was very crowded and I felt real pity for all the nurses. On the other hand, in the
trauma ward there was one nurse who helped relatives to bathe and change the bed for
every bed-ridden patient. That was better for both patients and relatives.
Appreciating nurses’ politeness
Recently, nurses have been well-trained. Most of them have polite conversations with
patients and relatives. As a joke, I think they might talk sweeter with the patients than
with their husbands.
Experiencing some relatives cause problems for nurses
I saw some Muslims’ relatives give the nurses some trouble. They had too many demands
without any hesitation.
Sharing good and bad times with other relatives
I made some good friends and between the relatives we helped and supported each other,
sharing all our sad and humorous stories. We had breakfast, lunch and dinner together…
Donating blood for other patients
… and when someone needed blood we would go to the blood bank to be their blood donor.
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Being a ward’s volunteer
I intended to help nurses as much as I could until I became like piece of furniture in this
ward. I became a volunteer in the surgical ward, because my wife was admitted there for
four months.
Having good relationships with the head nurse and others
I also had good relationship with the head nurse and everybody in all of the sections who
cared for and supported my wife. Nurses usually asked me to help other patients with lifting,
turning their position and blocking the IV flow before the nurse come to change to a new
bottle. I was a ward messenger and would take the patients’ stretcher back to its place when the
stretcher men were too busy and so on.
Receiving kind support
After six months, the doctor told me that it was time to discharge my wife. I had to take her to
rehabilitation at the hospital 3 times a week after discharge. I told the doctor that I did not
have enough money to hire a car three times a week. Our family had no car. It cost me 500
Baht each time to hire a car, so I couldn't afford to do it. The rehabilitation doctor was kind to
us. She let us stay two months longer than she had first planned because she wanted to make
sure that my wife had recovered well. Also, she could use my wife’s recovery as a
successful case study.
Arguing with uncaring nurses
The nurses in the surgical ward told me that I should take my wife home, because the ward had
plenty of bacteria and other germs. If she stayed longer she would get an infection. I argued
with the nurses that I didn't fear infection. I would take care of my wife's hygiene as best as I
could. My intention was to keep my wife near a doctor. This was the best choice for me.
Experiencing mistrust of nurses
I have never trusted nurses after I saw one patient, who wasn't hopeless, die one night shift. I
saw some patients’ IVs run out and the nurses didn't know. Some patients got infections,
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because of poor hygiene care by some nurses. I always took care of my wife's hygiene. I
changed my wife's pamperse nearly every two or three hours to prevent urinary infections
and rashes around her perineum. I have seen that patients who had no relatives, or their
relatives paid for a maid to care for them usually got an infection, while my wife has never had
any infection problems. Those patients were mostly ignored by the night shift nurses.
Sometimes the nurses slept at the counter and they weren’t aware that patients were sleeping
on heaps of urine and faeces until the bed bath time around five to six a.m. I always smelt the
bad odour of faeces from other beds while I watched over my wife.
Perceiving hygiene care of relatives can prevent patients’ infection
Some patients got infections because of poor hygiene care by some nurses. I always took care
of my wife's hygiene. I changed my wife's pamperse nearly every two or three hours to
prevent urinary infections and rashes around her perineum. I have seen that patients who had
no relatives, or their relatives paid for a maid to care for them usually got an infection, while my
wife has never had any infection problems.
Preventing nurses’ errors
I have never intentionally left my wife alone. If I went out of the ward my brother had to stay
with my wife instead of me. I never thought that I would leave my wife alone with the nurses and
without relatives.
Having no hesitation to call for help from nurses
It feels like the nurses give nursing care to patients when they don’t have relatives. Also I never
hesitated and I always walked to call the nurses at their counter when I needed help.
Experiencing some relatives are hesitant to ask for any help from nurses
After three months my wife was getting better, so I didn't need extra help from the nurses.
Some relatives felt too hesitant and didn't ask for any help from the nurses unless they had
really severe problems.
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Getting special support
On the surgical ward, there were not enough patients’ clothes. I always got them from
the ward keeper, because I got to know him. Relatives who were very shy usually didn't get
patients' clothes.
Receiving praise from nurses
Nurses also praised me by saying that I was the best caregiver on the surgical ward. Because
I bathed my wife so clean, cleaned her mouth with mouth wash solution with cotton balls,
wiped her body with soap then cleaned her with water twice until she smelt good, unlike some
nurses, who did a very quick and tainted bed bath for patients. I also shampooed her hair 3
times a week. Her bed and environment also looked so tidy and hygienic.
Having health problems
I had got a backache from lifting my wife, changing her position and sitting with her almost all
day and all night. Also, I got a cold four times while taking care of my wife. I was very patient
and did some exercises to keep myself healthy.
Receiving special support from nurses
The nurse who taught me a lot was my friend when we were studying in primary school and that
was really fortunate. Now, I can take care of my parents and any relatives automatically
without embarrassment.
Suggesting nurses let relatives stay with patients
The very important thing is that nurses let relatives stay with patients at the patients'
bedside…
Suggesting nurses teach relatives to care for patients
… and teach the relatives to care for patients in a friendly style.
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Suggesting nurses ask relatives about their beliefs
Nurses let relatives ask how they can do traditional care such using holy water to protect
patients from devils or for any reason that the patients and relatives believe.
Suggesting nurses help quickly when they need help
Nurses should be aware that relatives of unconscious or disabled patients always need help from
them. When relatives walk to call you that means that they really need help. Please be
concerned about the relatives' feelings and come to help them as quickly as you can. Accept the
abilities of relatives, especially when they are not too old and can stay with the patient in
hospital.
Suggesting relative should not feel hesitant to ask help
If relatives are hesitant, they must remember that nurses are nurses. They aren’t giants, they
won’t eat you, their duty is to help patients, so please didn't be hesitant. They can give you a
hand and also the knowledge to help you care for patients. Relatives could ask nurses to help
patients, it depends on how relatives act or respond to nurses. For example, when my wife had
constipation, I told the nurses that she hadn’t defaecated for three days. For a while a nurse
came and did an evacuation for my wife. She also taught me and later I could evacuate for
my wife by myself. Also, I saw one male relative try to push another relative to contact the
nurse instead of him when an IV nearly run out of fluid, because he was afraid of busy nurses.
Suggesting nurses’ positive qualities
Nurses should have a soft and flexible personality so that we can ask questions easily with less
hesitation. I saw many relatives not want to talk to a nurse who never smiled, they were afraid
of her. You should smile and let patients and relatives ask questions when you do patients'
rounds.
Suggesting the need for trust
Nurses must improve the quality of nursing care, so we can trust them.
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Suggesting nurses do not sleep on night shift
Please don't sleep on night shift, because it is not safe for patients.
Conclusion
The experiences and codes which emerged from an open coding analysis of one relative
were described, in relation to the application of Buddhism and Thai traditional wisdom
to care for the patient and for himself, and to help the patient cope with illness-related
problems. The relative also shared ideas about good and not so good nurse-patientrelative relationships in nursing contexts. The emerging codes from the remaining
participants are listed in Appendix G.
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CHAPTER 8
THE PROCESS OF THE GROUNDED THEORY DEVELOPMENT:
FROM OPEN CODINGS TO THE SUBSTANTIVE THEORY
Introduction
Overall, the process of the theory development consisted of three main parts, which
were: firstly, the theory development from nurses’ perspectives, secondly, the theory
development from patients’ perspectives, and lastly the theory development from the
relatives’ perspectives. Generally, the main theory development process started with
transforming the raw data from nurses’, patients’ and relatives’ experiences into a
middle range theory, or grounded theory, through the processes of open coding, axial
coding and selective coding, guided by Strauss and Corbin (1998). This chapter
illustrates nurses’, patients’, and relatives’ perspectives of the influences of Thai
Buddhist culture on the nurse-patient-relative relationship, which emerged as a spiritual
caring relationship in the contemporary Thai health care context. The basic
psychosocial process, which emerged from 47 participants’ experience was “cultivating
compassionate relationships with equanimity between nurses, patients and relatives”. It
is described and explained step by step by using Tables to show the links between
codes, categories, and concepts as a part of the basic social process. The detail within
the analysis is depicted in Tables which are attached in the appendices, because written
essay-form explanations would be exceedingly lengthy.
The process of theory development from all perspectives
The processes of theory development from the nurses’, patients’, and relatives’
perspectives developed the grounded theory of the influences of Thai Buddhist culture
on the nurse-patient-relative relationship. Initially, I did three levels of analysis of open
coding, axial coding, and selective coding, group by group for 17 nurses, 14 patients,
and 16 relatives. In each group, I undertook an open coding analysis, seeing the
similarity of codes and grouping them together, then I undertook axial coding by
Chapter 8: The process of the grounded theory development
moving the codes to similar ideas, which were called sub-categories, until they could
not be sorted further, without losing their uniqueness. Then, I developed core categories
by giving suitable names to the sub-categories, which were supported by many rich and
relevant codes. The last process was linking core categories to each other, to establish a
basic social process, which included the meaning of all codes, and categories and
reflected all related concepts.
The analysis of participants’ accounts was complex, in that each group of participants
spoke not only of their own experiences, but also of their perceptions of participants’
experiences within the groups. In other words, a nurse may have described her
experience of the Thai culture, Buddhism and the nurse-patient-relative-relationship,
while also adding in comments about relatives and patients. Therefore, speaking for
one’s experience and imaging what another person’s experience might or should be,
created levels of complexity within the data. To adequately reflect the differing foci of
participants’ accounts, I have opted to construct Tables to capture the data which are so
important in understanding the nurse-patient-relative relationship within a Thai,
Buddhist culture. (See Table 8.1 in this chapter and Table 8.2-8.3 in the Appendices H
and I).
Moreover, because of the depth and breadth scope of participants’ experiences, the vast
range of Buddhist beliefs and practices, and the variety of wisdom and traditional
healing in the Thai culture, I decided to divide the broad codes into minor subcategories and major sub-categories, before grouping similar ones into core categories.
Reaching this stage, there were three core categories, which were composed of the three
co-processes of the application of Buddhism and Thai culture on enhancing positive
relationships between nurses, patients and relatives. They included: 1) facing suffering/
understanding the nature of suffering, 2) applying Dhamma (Buddhist beliefs and
practices), personal/local wisdom, and Thai traditional healing, and 3) embodying
mutual compassion with equanimity. Each part was connected to the other. The last part
of the process was to link each core category to identify the basic social process.
Finally, the basic social process from the participants’ experiences emerged as
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“Cultivating Compassionate Relationships with Equanimity between Nurses, Patients,
and Relatives”, which was summaried and illustrated in Table 8.1.
Tables 8.2-8.3 demonstrate ways in which I analysed data from 17 nurses, 14 patients
and 16 relatives from initial or open coding through axial coding until reaching the
selective coding process. All open coding from nurses, patients, and relatives which
supported related concepts, categories, core categories, and basic social process of
Cultivating Compassionate Relationships with Equanimity between Nurses, Patients,
and Relatives are shown in Table 8.2 (see Appendix H). This Table shows open coding
which came from all participants’ accounts. Many codes are derived from in vivo codes
(participants’ words or phrases). The summary of open coding and selective coding
which supported related concepts, categories, core categories, and basic social process
of Cultivating Compassionate Relationships with Equanimity between Nurses, Patients,
and Relatives is shown in Table 8.3 (see Appendix I). This Table shows more abstract
levels of categories and relationships between concepts under each core categories.
Note: N = nurses, P = patients, R = relatives
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Table 8.1: Summary of selective coding, sub-categories (minor sub-categories and major sub-categories), core categories, and the basic social process from NPRs’ perspectives
Selective coding
-Pain, paralysis, can’t sleep, fatigue, unconscious
depending on the stage of each disease
-Anxiety, worry, fear, depression, boredom, uncertain
-Lack of support, -Having not enough money
-Waiting for hospital beds
-Guilt, conflict, misunderstanding, demanding, etc.
-Suffering is suffering, very hard to cope,
feeling hopeless
-Suffering is suffering , trying to cope with illness
-Suffering is nature, accepting illness and changes,
living simply and naturally, and etc.
-Believing in kamma and reincarnation
-Make merit, -Chanting, -Meditation, -Praying
-Listening to Dhamma
-Repaying gratitude
-applying Dhamma to death and dying and psychospiritual care, and etc.
-Thai food/herbs, -Thai massage
-Pray for the sacred power (from supernatural
sources), -Making a vow, -Manora or Puppet shadow
performance, and etc.
-Being kind and flexible, -Having an open mind
-Being sensitive to different beliefs
-Feeling sympathy, -Valuing gentle, polite, friendly
-Valuing compassion and meritorious acts
-Concerning about patients and relatives’ feelings
-Working hard, -Being skilful
-Receiving support from family to do volunteer work
-Avoiding moody nurses and having improper manner
-Avoiding adding distress to clients or blaming, etc.
-Building trust, -Sharing empathy, -Interacting
positively, -Staying with, -Touching patients
-Nurturing patients’ strength, -Supporting and
educating, -Valuing relatives’ roles
-Accepting illness and negative outcomes, and etc.
-Valuing good relationships
-Preventing conflict and complaints, and etc.
-Having good health, -Appreciating nurses
-Receiving trust and respect, and etc.
-High tech-Low touch, -Bullying, -Having negative
attitudes toward fussy clients, -Hesitancy (keang jai)
-Routines, -Unequal care, -Poor image of nursing
-Busyness, and etc.
-Cultivating nurses’ kindness and friendliness
-Building caring/psycho-spiritual care model and
caring environment, -Adding value and power through
continuing education, -Valuing the image of nursing
Sub-categories
Minor sub-categories
-Physical problems, -Psychosocial problems
-Economic problems
-Knowledge deficit
-Health care system problems
-Spiritual pain and distress, including communication
and relationship problems
- Suffering with hopelessness
- Suffering with hopefulness
- Suffering with understanding and accepting the nature
of life
-Approaching Dhamma
-Believing in Dhamma/Considering Buddhist philosophy
-Performing/Practising Dhamma (and for nursing care)
-Appreciating outcomes
-Concerning problems of applying Dhamma
-Suggesting ways to applying Dhamma
-Applying local wisdom and traditional beliefs
-Applying personal
methods)
-Good heart
wisdom
(using
other
coping
-Acting with equanimity
-Being aware of relationship problems
-Valuing a caring relationship
-Nurses’ benefits
-Patients’ and relatives’ benefits
-Personal factors
compassionate
Basic Social Process
Major sub-categories
1.1 Facing suffering
1.2 Understanding the
nature of suffering
1. Facing suffering and
understanding the
nature of suffering
2.1.Applying Dhamma
(The Buddha teachings)
2. Applying Dhamma,
personal/local wisdom,
and traditional healing
2.2 Applying personal/
local wisdom, and traditional
healing
3.1 Describing characteristics
of compassionate nurses
(from nurses’, patients’, and
relatives’ perspectives)
-Good experiences and skills
-Good social support
-Avoiding uncaring nurses, -Avoiding being uncaring
-Avoiding tension from patients’ and relatives
-Acting with compassion
-Professional factors
-Organisation factors
-Considering clients’ expectations
-Suggesting
paths
to
cultivate
relationships
Core-categories
3.2 Avoiding added suffering
(dehumanizing behaviours)
3.3 Acting with compassion
and equanimity
Cultivating
Compassionate
Relationships
with Equanimity
between Nurses,
Patients,
and Relatives
3. Embodying mutual
compassion with
equanimity
3.4 Being aware of
relationship problems
3.5 Appreciating relationship
outcomes
3.6 Being concern about
factors influencing
(promoting and inhibiting)
relationships
3.7 Considering clients’
expectations and suggesting
paths to cultivate
compassionate relationships
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Chapter 8: The process of the grounded theory development
After applying the micro-analysis methods through the processes of open coding, axial
coding and selective coding; I located codes and categories for nurses, patients and
relatives. The core social process emerged of “Cultivating Compassionate Relationships
with Equanimity Between Nurses, Patients, and Relatives”, which was composed of the
three co-processes (core categories) including (a) facing suffering/understanding the
nature of suffering, (b) applying Dhamma (Buddhist beliefs and practices),
personal/local wisdom, and Thai traditional healing, and (c) embodying mutual
compassion with equanimity. These co-processes demonstrated the grounded theory, as
illustrated in Table 8.1 are summarised in Figure 8.1.
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Chapter 8: The process of the grounded theory development
“เกิดทุกข และ เขาใจทุกข”
A: Facing
suffering
/understanding
the nature of
suffering
Cultivating
Compassionate
Relationships
with
Equanimity
“เกิดความกรุณา เขาใจซึ่ง
กันและกัน ยอมรับความ
เจ็บปวย และปลอยวาง
ความทุกข”
C: Embodying
mutual
compassion
with equanimity
B: Applying
Dhamma,
personal/local
wisdom, and
traditional
healing
“ประยุกตใช
ธรรมะและภูมิ
ปญญาไทย”
Figure 8.1: The connection of each core-category
Figure 8.1 depicts the interrelatedness of the categories, which are (a) facing suffering
/understanding the nature of suffering, in Thai “เกิดทุกข และ เขาใจทุกข”; (b) applying
Dhamma (Buddhist beliefs and practices), personal/local wisdom, and Thai traditional
healing. In Thai “ประยุกตใชธรรมะและภูมิปญญาไทย”; and (c) embodying mutual compassion
with equanimity, in Thai “เกิดความกรุณา เขาใจซึ่งกันและกัน ยอมรับความเจ็บปวย และปลอยวางความ
ทุกข”. Taken together, these categories create the grounded theory of “Cultivating
Compassionate Relationships with Equanimity between Nurses, Patients, and
Relatives”.
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Chapter 8: The process of the grounded theory development
This section described core components of the substantive theory of Cultivating
Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives,
as shown in Table 8.2 (see Appendix H). The nature of participants’ experiences
included structures and processes of action and interactions, related to concepts and
consequences of the spiritual caring relationship. Each part of experiences under each
core category was related to other core categories and sub-categories. The explanations
then showed the interrelatedness of the core components of the grounded theory. This
substantive theory included the spiritual caring relationship.
Core category 1: Facing suffering/understanding the nature of suffering
Facing suffering and understanding the nature of suffering were described by
participants when they expressed their own physical, economical, psychosocial and
spiritual distress or suffering and/or their experiences of caring for sufferers. This core
category consists of two major sub-categories, which include facing suffering and
understanding the nature of suffering.
The Buddhist’s teachings imply that life is suffering. Suffering is the natural
phenomenon; birth, old age, illness and death also natural phenomena. However,
suffering can be overcome by considering the teaching about the Eightfold Path.
Therefore, nurses have major roles to care for patients and relatives holistically, as they
face suffering every day. Nurses also are the co-sufferers of patients when they are sick
and/or their loved ones in illness and death. Nurses who participated in this study
perceived their spiritual care for patients and relatives as a vital part of day-to-day
nursing care. Nurses realised that they could care for each patient’s body, mind and
spirit in each nursing activity by applying Dhamma, personal/local wisdom and
traditional healing and caring with kindness, compassion and equanimity. The spiritual
caring relationship occurred in every nursing moment, when nurses met patients and
relatives and took care of them by raising good attitudes and intentions, working with
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mindfulness, acting with compassion and equanimity, respecting patient’ and relatives’
values and beliefs, and providing skilful nursing care.
Facing suffering
There are many aspects of suffering in the Thai health care context, which emerged
from the experience of nurses, patients, and relatives. The suffering includes personal
and family issues, issues about the health service and the health care system, especially
inequity of care, the number of occupied hospital beds, health care insurance, and so on.
The main suffering was from physical problems of diseases; emotional problems such
as fear, anxiety stress, depression, guilt and so on; economic problems: not having
enough money; social problems especially lack or insufficient of social support;
knowledge deficit about illness and self care; cognitive/percetion problems:
misinterpreting other’s behaviours; health services and health care system problems;
and spiritual pain and distress.
Suffering has very profound meanings which include:
1. Physical problems, such as: pain, paralyses, insomnia, fatigue, or
unconsciousness, depending on the stage of each disease.
2. Psychosocial problems: main emotional problems such as: anxiety, worry, fear,
depression, boredom, uncertainty. Some social problems are: lack of or insufficient
social support.
3. Economic problems such as: not having enough money.
5. Knowledge deficit about illness and self care.
6. Cognitive/perception problems, such as: misinterpreting nurses’ and doctors’
behaviours.
7. Health care system problems, such as traveling very far to hospital, and waiting
for hospital beds too long.
8. Spiritual pain and distress, including communication and relationship problems
such as guilt, conflict, misunderstanding, demanding, relationship issues especially
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feeling hesitant (kreng jai) from dependency, conflict between personal values and
beliefs and health care goals, and cultural aspects between modern treatments and
traditional healing.
Nurses who participated in this study cared for patients’ psychosocial problems, cared
for suffering patients and usually experienced that relatives were too worried about
patients’ health because of staying with patients all the time. Some nurses realised that
when they intended to provide compassionate care for patients, they faced problems of
having not enough caring skills and having knowledge deficits in some important
advanced nursing skills. Nurses realised that they needed to improve advanced
assessment skills and spiritual care skills. Thus compassionate nurses also need to be
being skilful nurses.
Nurses faced clients’ spiritual pain and distress including communication and
relationship problems, such as having conflict with patients and relatives who were
demanding and usually needed special care, but nurses were too busy and could not
provided any special support. Nurses, who were concerned about equal care, intended to
provide the same level of care for every patient and relative; they did not like patients
and relatives who demanded special care in selfish purposes. Some nurses also felt guilt
when they were too busy and had not enough time to educate patients or support
patients’ and relatives’ minds. Some nurses realised they had some levels of
attachments with patients and relatives who stayed in the ward for a long time, who
respected and trusted nurses as their own relatives and consulted nurses about their
personal problems. The bonding between nurses, patients and relatives motivated nurses
to take care of patients and relatives as if they were nurses’ relatives. When this
situation happened nurses realised that they needed to detach their bonding and apply
the teaching about equanimity.
Patients experienced many kinds of suffering, for instance, physical problems,
psychosocial problems, economic problems, knowledge deficit, health care system
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problems, and spiritual pain and distress, including communication and relationship
problems.
Patients’ psychosocial problems included worrying, uncertainty, fear, feeling hesitant to
depend on others and need to depend on brother and others when they were in pain, fatigued, tired,
and so on, and they could not take care of themselves. Many patients expressed that they faced
multiple suffering, having a lot of problems in top of being physically ill, such as worrying, having
economic problems and feeling hesitant when depending on others (especially relatives, nurses, and
doctors). HIV/AIDS patients reflected on more problems about unequal care and issues of facing
uncaring behaviours and being discriminated against by some nurses and doctors.
Experiencing uncertainty of life, living with uncertainty and fear, experiencing sadness
and loneliness, feeling sad and petulant about receiving late treatments, experiencing
loss of husband, daughter and brother from AIDS and others severe illness,
experiencing negative images of AIDS, having a weak mind, losing one’s mind, having
suicidal ideas, having suicidal ideas from boredom, worrying the illness will affect work,
and regretting inability to support family were the main patients’ experiences of
suffering. Many patients and relatives faced economic problems. Some patients and
relatives recounted financial difficulties from long term sickness and lack of income.
They perceived effects of poverty on poor health care, and needed financial support from
the social support services.
Worrying and feeling hesitant while depending on others, feeling hesitant with relatives
when readmitting often, feeling hesitant to ask for help from nurses, feeling ashamed from
being often readmitted and not adapting to illnesses, were the main problems of patients
who felt powerlessness. Some patients did not dare to ask for help from nurses and doctors,
rather they waited for help from their relatives. Normally, patients preferred to take care of
themselves; however, they inevitably depended on relatives and nurses when they could
not take care of themselves when having severe conditions. Many Thai patients need their
close relatives to help them make decision about risky treatments. They usually let
relatives talk to doctors and nurses, and made a decision for them.
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Patients’ spiritual pain and distress included communication and relationship problems.
The main problem was their perceiving nurses’ lack of communication with patients.
Some relatives experienced that nurses focus more on routine care and lack of
communication with patients. Some patients and relatives felt that they have less
education so they did not dare to ask for help from nurses, as some of them felt
powerlessness. Some patients who used the 30 Baht health care card perceived that they
had no power to ask for good nursing care.
One patient was questioning the real causes of his illness “Why did I have many
diseases since I was young?” This patient explained his illness with his past bad
kamma, but he still could not understand what he did wrong. This kind of spiritual pain
needed to be identified and explored.
Patients’ relatives faced many kinds of suffering. They were not only dealing with
patients’ multiple suffering, but they also had some health problems while being long
term, fulltime, caregivers, such as getting flu, backache, hypertension, and multiple
stresses. Many relatives had some health problems before being caregivers. Relatives
usually applied their personal health care techniques such as using herbs, cooking
healthy foods, massaging, making merit, seeing fortune tellers, and asking help from
sacred powers, in order to support patients’ minds and their own minds.
Relatives who were health care personnel, or had some relatives who were nurses,
doctors or worked in health care sectors, could seek special health care for patients and
provided good care for patients. This situation had positive and negative effects for
nurses. These relatives helped nurses to care for patients very well, however, they
sometimes asked for special care from nurses. Some nurses perceived that the VIP (very
important person) relatives usually asked for special care and some of the VIP patients
and relatives were too demanding. From nurses’ experiences, the people with high
positions in politics and the VIP group of highly educated and wealthy clients were
stereotyped as prone to be demanding. However, many VIP clients, who have practised
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Dhamma, were very kind. They tended to understand nurses’ situations and limitations
and did not ask for any special care.
Patients’ relatives faced many psychosocial problems such as experiencing shock,
experiencing fear of unsafe ventilator care, perceiving the patient cannot recover, feeling
sorry to be unable to help the patient, and perceiving the patient’s severe suffering. Many
relatives realised that they needed willpower and moral support. One daughter
perceived her father had severe illness. Her father did not fear death but he feared pain.
Another son felt it was hard to care for his fussy father.
One relative did not want to lose her beloved father. She was worrying about the
progress of her father’s cancer. Some more problems from relatives’ experiences
included: experiencing stress while caring for her mother in the beginning of her illness,
perceiving difficulty in taking care of her mother who uses a feeding tube, experiencing
frustration and tiredness from caring for her father for many years, feeling release and
having more personal life when her father is admitted to the hospital, dealing with many
kinds of parents’ caregivers, experiencing being unready to take paralysis father back
home because of having no co-caregiver, experiencing loss of one daughter from AIDS
and caring for son with AIDS, not wanting to know bad news, feeling stressed in
forcing husband to eat, not being permitted to stay overnight, upsetting her husband,
perceiving husband’s deteriorating condition, perceiving difficulties at home
maintaining working and caring for her husband, and experiencing siblings’ lack of
concern and support. Many relatives also had economic problems, however, they still
received financial support from some relatives, friends and neighbours. One man
regretted that he had no experience of helping his wife when she had an asthma attack and
could not breathe. Health care system problems, such as waiting for a hospital bed,
taking patients to see the doctor at other hospitals while waiting for a specialist, and
seeking good doctors, were also the main suffering of patients’ relatives.
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Understanding the nature of suffering
Understanding the nature suffering included three minor sub-categories: 1) Suffering
and hopeless; some participants perceive that suffering is distress and they feel hopeless
and think that they cannot cope with their suffering. 2) Suffering is suffering as well as
challenge, and trying to cope with suffering, and 3) Suffering is nature, it is a normal
phenomenon of human being, accepting it and dealing with suffering and illness with
understanding and less distress. Participants who believed according to the Buddha’s
teaching, that suffering is the nature of human beings and nobody can escape from this
reality, had less worry and distress. This belief led to accepting illness and death calmly.
In other words, there are three main patterns of participants’ responses to illness and
related suffering, which are: 1) not accepting problems and feeling helplessness and
anguish, 2) trying to accept probpems and trying to manage and ask for help, and 3)
accepting illness and problems as natural phenomena, managing problems with
calmmess and mindfulness.
Many lay Buddhist patients and relatives perceived that they faced a lot of problems
from being patients and relatives as I explained multiple suffering. Patients and relatives
were recounting many issues about their distress and hopelessness. Some patients, who
adapted with their illness for a few months and relatives who got used to being
caregivers and could develop their caring skills, were in a stage of maintaining
hopefulness and trying to cope with illness. A few patients and relatives could accept
their illness calmly. This groups of patients and relatives were well practised in
Buddhist Dhamma, attended meditation training, practised meditation regularly, and
understood the Buddhist teaching about the Four Ariyasacca (the Four Noble Truths),
the Eightfold Path, the nature of illness and death, and developed deep understanding
about suffering and the nature of suffering. Participants, who understood the nature of
suffering and the teaching about impermanence, could accept their illness and death
with less feelings of suffering. They could stay calm and cope with illness peacefully
and naturally.
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Nurses who practised Dhamma well and had learnt Vipassana meditation, shared their
kindness and compassion with clients and showed deep understanding of patients’ and
relatives’ negative relatives, without complaining of any caring difficulty. Nurses who
knew Dhamma shared their understanding about patients’ and relatives’ grief and loss,
negative reactions and suffering. They contended that the Buddha teaching about the
Four Noble Truths and the Eightfold Path, helped them to gain a deep understanding
about negative relations of patients and relatives, so they tried to avoid adding suffering
to clients and provide nursing care with compassion and equanimity. They stayed calm
when dealing with people’s problems and illnesses. They also prepared themselves for
dying, and the last day of his/her life. Understanding self and others and understanding
human emotions were developed in nurses’, patients’ and relatives’ minds, after
considering the causes of suffering and nature of illness and death from the Buddhist
teachings. Participants who had different levels of perceptions and understanding about
life, illness and suffering has different levels of adaptation, calmness and happiness
while dealing with illness and related problems.
Core category 2: Applying Dhamma (Buddhist beliefs and practices),
personal/local wisdom, and traditional healing
Applying Dhamma, personal/local wisdom, and traditional healing to cope with illness,
related to suffering, working, caring, and being a caregiver. This core category consists
of two major sub-categories which are: applying Dhamma, and applying personal/local
wisdom and traditional healing.
Applying Dhamma
This major sub-category consists of seven minor sub-categories including: approaching
Dhamma; believing in Dhamma/considering Buddhist philosophy, mainly about beliefs
in causes of illness (such as from the past kamma, feeling guilty from not yet repaying
gratitude for parents and deceased ancestors, not making enough merit, or having done
some bad things previously; and belief in bun and kam (good and bad kamma);
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performing/practising Dhamma; appreciating outcomes; concerning problems of
applying Dhamma; suggesting ways to apply Dhamma; and applying local wisdom and
traditional beliefs. This category was mainly about performing self-care and coping
strategies, including believing in kamma, merit-making, chanting, meditating, reciting
verses and incantations, respecting amulets and considering the nature of life, illness
and death, the aniccha (impermanence) accompanying dukkha (suffering) and anatta
(non-self). Also included were the Four Sublime States of Consciousness and Actions,
which were metta (loving kindness), karuna (compassion), mudita (sympathetic joy)
and ubekkha (equanimity), the Four Noble Truths and the Eightfold Path and so on.
When participants had health problems and/or were suffering, they usually tried to
manage and be independent and to not ask help from others (see more detail in Table
8.2).
Approaching/learning Dhamma
In general, nurses, patients, and relatives learnt Dhamma (the Buddha teachings)
because of having good Dhamma role models, especially parents, grandparents and the
respectful monks. Living in religious environments, such as staying close to temples,
and having chances to practise meditation while studying and/or working were also
supporting participants to learn about Dhamma. Participants realised that the Buddhist’s
teachings guided them to be a kind or a better person. Knowing Buddhist history, causes
of suffering, the truth of nature and life, emptiness, elements of body, kamma, the mind,
metta-karuna, and respect others, and helping others were the main teachings that
participants have learnt from living in the Buddhist culture.
However, some patients expressed that they were a non-religious person; they were
having no experiences in religious practices, and they used little Dhamma when they
deal with illness. They depended mainly on doctors’ treatments while being sick, and
many of them did many rituals as they related the cause of illness to the supernatural
powers. Some patients and relatives could not separate traditional beliefs and Buddhist
beliefs as they have practices them together while ask for sacred power for moral
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support, good health, and a chance for a patient’s recovery. Some participants realised
that they might use some Buddhist teaching but they have never explained their
application of Buddhist beliefs and practices formally in words. Many participants used
their own meaning to explain the teaching about Buddhist beliefs and practices, as they
hardly learnt Buddhist teachings formally. After finishing interviewing, some
participants realised that they would start learning Dhamma, especially chanting and
meditation, as they could use them to calm their minds.
Believing in Dhamma/considering Buddhist philosophy
Participants who shared the application of Buddhist teachings in their daily life
explained that the main teachings that they have applied for spiritual purposes were:
believing in kamma; having right understanding; using equanimity; explaining about
birth, duties, merit and sin; believing in merit/kamma on health; believing in power of
mind; understanding/considering impermanence; recognising the teaching about
changing; considering nothingness; relating illness and death to Dhamma (a natural
phenomenon); believing in dying before death and preparing for natural death. Some
nurses, patients, and relatives realised that they could die at any time. Then they were
focusing on living carefully, trying to do more good deeds and preparing for a good
death. Many patients made more merit while being sick. Many relatives made more
merit for patients and themselves. Some nurses made merit while working by being a
kind nurse, and providing good nursing care. Patients made merit by providing food for
the monks and radiating merit to other beings. Relatives made merit by taking care of
patients with an intention to repay gratitude to their parents or do the best for their
duties as mothers, wives, husbands, sons, daughters, and so on.
However, some patients, who had less interest in Dhamma, were wondering about the
results of doing good deeds. Some patients could not explain why when they were a
good person, they still had severe illness. Some patients who were very close to the
Dhamma, considered the Buddha teaching about the nature of life, the law of change
and impermanence. Then they could accept that illness and death are normal
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phenomena. Birth, old age, illness and death belonged to everybody, nobody could
avoid this inevitability.
Many participants perceived that Dhamma is duty. When they do the best in their duty
as nurses who provide good nursing care, caregivers who care for patients by their
heart, and patients who try to take care of themselves, they thought they already
practised Dhamma. They believed that they could gain some merit from doing good
deeds in every duty.
Nurses had various experiences about believing in Dhamma and considering Buddhist
philosophy, for instance, applying Buddhist philosophy in daily life, using Buddhist
thinking, applying meditation for reflecting life and work situations and raising the
importance of self-awareness. Nurses considered the teaching about the five precepts,
suffering and the ways to overcome suffering as parts of the Four Ariyasacca and the
Eightfold Path, the natural truth of life, loving-kindness, compassion, equanimity, the
Middle Way, kamma, merit and sin, good deeds and bad deeds, while caring for patients
and relatives, colleagues and people in the communities.
Nurses valued developing the power of mind, so they could work hard and be more
patient when dealing with many stressors at work. Some nurses learnt to let go of bad
feelings while dealing with many kinds of people and various kind of problems at work.
Nurses made good kamma with patients and relatives by being kind, being flexible and
respectful. Using right effort to work, valuing a peaceful mind, applying the four
iddhipada (the path to success), metta (kindness), karuna (compassion), upekkha
(equanimity) while caring for patients and relatives, were the influences of Buddhist
teachings on nurses’ caring. One home health care nurse realised that when she
considering the Buddha’s teaching about loka-Dhamma (worldly vicissitudes) she could
accept all successes and failures of health care outcomes. She explained that patients
and relatives needed to be reminded that nothing is permanent and every one has to
prepare themselves for the inevitable events of illness and death, so they can face illness
and death with calm minds.
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Some nurses explained the link between the Buddha’s teaching and the quality
management processes. Some nurses shared that they learnt to be patient and develop
peace from practising Dhamma, especially by chanting, and practising walking
meditation and mindfulness meditation.
Patients’ relatives mentioned that they believed in good kamma, merit and the power of
mind. They understood the mind’s function, which could do just one thing at one time.
A relative suggested that people should use their minds to think positively and to
develop compassion rather than holding a weak and worried mind. Considering the
teaching about changing, nothingness and suffering, also helped relatives to accept
patients’ deteriorated situations and accept the patients’ death. Some relatives realised
that many people died from accidents or other problems and it was time for their loved
one to die, but they wanted to see their loved ones die peacefully or with less distress.
Some relatives prepared to let patients die at home and refused to use modern
equipment to prolong patients’ lives. Some relatives wanted patients to receive many
further treatments and life support because they wanted do the best for patients. These
relatives could not accept losing their loved one. Nurses were faced by relatives who
could accept and not accept losing their loved ones. These relatives had different
expectations on nursing care. Some relatives who could not accept losing their loved
one needed compassionate nurses, who could understand their expectations and
negative reactions.
Some relatives believed in the result of good kamma for a better reincarnation, so they
made more merit and good deeds in order to collect good kamma for the patients’ better
life and for their better future. Many Buddhist patients and relatives, who considered the
nature of illness and death, preferred natural healing more than using aggressive
treatments. The Buddhist teachings influenced patients’ and relatives’ coping
behaviours. They applied many ways of natural healing and complementary care, such
as herbal medicine, vitamins and minerals from healthy foods and tablets, and Thai
massage to support each patient’s body, mind, and spirit.
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Performing/Practising Dhamma
Holding precepts, doing good deeds, making merit, receiving merit, chanting and
radiating merit, reciting an incantation, praying and vowing, repaying the vow by
ordaining, meditating, applying meditation, radiating loving-kindness to ghosts/all
creatures/trouble makers, taking care of the mind, controlling emotion, having an open
mind, letting things go, asking for forgiveness, giving forgiveness, raising sacred power
before working, asking for protection, repaying gratitude; respecting the monks,
supporting the monks’ activities, respecting beings and non beings, respecting the older
person; respecting beings, preferring natural ways of healing, preferring a simple life,
appreciating a peaceful death of their loved ones, were the main Buddhist teaching that
participants applied in their working and daily living.
Nurses, patients, and relatives in this study valued people’s good hearts. They valued
practising Dhamma in daily life and practising Dhamma in every duty as well as by
being generous, kind, and grateful. Having an open mind, listening openly, respecting
others, understanding others, having self discipline, being kind, feeling sympathy, being
patient, working hard, killing craving, forgiving and living in the moment were the
Buddha’s teachings that participants applied in every day living. Some nurses
mentioned that they applied the teaching about changes and impermanence to heal their
broken hearts.
Many participants used Dhamma to deal with life’s situations. They applied the
Buddhist healing with self care. One patient believed in the sacredness of the Buddha’s
relic. Many participants expressed that they gained mindfulness from practising
meditation. Some male participants claimed that they could better control their emotions
and behaviours after ordaining.
Patients can accept illness and death, and transform death thoughts after considering the
Buddha’s teachings about the nature of life as well as avoiding getting sin from killing
oneself. Some patients decided to donate their body for making merit. Many patients,
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including person living with HIV/AIDS, devoted the rest of their life to helping other
infected patients and families. One person living with HIV/AIDS shared her experience
that she was very happy after she could share her sympathy with infected friends. One
renal failure patient thought he could die at anytime, so he preferred to share his selfcare experiences as being a healthy renal failure patient to support new patients who
were just getting ill. Patients and relatives shared many examples about helping others
while being sick and being caregivers. Helping others was perceived as a good way to
make merit.
Relatives practised Buddhist rituals in daily life and applied the Buddhist teachings to
help patients cope with illnesses. They also intended to repay gratitude to patients, and
practising Dhamma by doing their duty. Relatives supported their minds and patients’
minds by respecting the Buddha and the monks’ images, thinking of the Buddha,
practising Buddhist rituals and Chinese traditions (some participants were ThaiChinese), making merit and radiating merit for patients, avoiding/bad deeds or sin,
making holy water for patients, making and repaying a vow for patients’ recovery,
chanting and reading Dhamma books to calm their mind and for patients’ peacefulness,
listening to Dhamma, inviting the monk to bless patients, and encouraging patients to
do meditation. Some relatives thought of receiving gratitude, while many of them gave
forgiveness to patients and asked for forgiveness from patients especially in the dying
period. Letting things go of sadness and attachment with patients were also applied.
Some patients and relatives made merit by donating.
Many relatives could accept that illness and death of their loved one were natural events
and some of them accepted losing their loved one with real understanding. On the other
hand, some patients and relatives used the word “plong”-letting go of suffering- as a
stage of surrender. While they had no other choices, they had to accept illness and
death. One patient, in her deteriorated state of an uncontrolled blood sugar level, prayed
and wished that other family’s members would not get severe illness like her. She also
tried to accept that her illness could not be cured and the final answer was being ready
to die.
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Relatives balanced their lives while being main caregivers by controlling emotions,
setting suitable life goals, living in a simple way, living carefully, trying to depend on
self, and working hard to earn more money for patients’ heath care cost. However, most
of patients’ relatives could ask for help from other relatives and friends when they
needed financial support. Many relatives devoted themselves to help other patients and
relatives by sharing various kinds of caring techniques, especially when they were
successful, to help and care for their loved one.
Applying Dhamma to nursing care
Nurses, who participated in this project, applied many aspects of Buddha’s Dhamma to
nursing care. For example, nurses were considering patients’ religious backgrounds,
understanding different interest in Dhamma, understanding patients’ perceptions of
kamma, setting the right mind to work actively with mindfulness in each shift, making
merit while working, caring with metta-karuna, avoiding sin, making ethical decisions
and providing ethical care.
Nurses applied Dhamma for psycho-spiritual care by remembering the truth of life so
they could remind patients and relatives about this teaching. Some nurses taught
patients that they could do good deeds by not doing harmful behaviours which cause ill
health, such as stopping drinking and smoking and maintaining healthy behaviours,
such as exercising, practising chanting and meditation. Some nurses were concerned
that relatives tried to help nurses to care for patients because relatives wanted to repay
gratitude to patients. Nurses appreciated the reasons for caring behaviours. Some nurses
also repaid their gratitude to their parents and grateful supporters by being a good nurse.
One nurse could radiate merit that she gained from going good deeds with patients to
her parents and relatives. Some nurses also wished that if their parents were sick, their
parents could receive good nursing care from other kind nurses, as they always provided
good care for patients and relatives. The beliefs about kamma have major influences on
nurses’ caring and compassion.
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One nurse shared her personal experience that she raised her consciousness by doing
walking meditation while visiting terminal ill patients. She also paid homage to the
Buddha, the Dhamma, and the Sangha, and asked for healing power from the Kuan Im
goddess and other sacred powers, so she could transfer healing energy to calm suffering
patients’ mind. Focusing on the present moment and good intention, and with her
compassionate mind, she could support dying patients to die peacefully. (See the detail
in Pe Metta’s account).
In the hospital setting, Buddhist nurses promoted patients and relatives to do religious
rituals. The main Buddhist activities in the ward were: providing the Buddha statue in
the ward, promoting and teaching chanting, promoting listening to Dhamma, promoting
merit making, teaching and applying meditation, talking about religious and traditional
beliefs and practices, reminding some patients to make merit. Some wards/units set
traditional ceremonies, such as pouring water on the Buddha image on Songkran day
and making merit for passed away patients of the hospitals.
Some nurses prayed for patients’ good luck, and sometimes they made merit and
radiated merit for some patients who were in severe suffering. Nurses usually supported
patients’ mind by reminding patients to think of their good deeds. Some nurses asked
for forgiveness from patients who were in dying stage, when they felt guilty that they
might not provide better care for patients. Nurses sometimes reminded relatives to
accept the deterioration of patients and patients’ possibility of death, so relatives could
do religious rituals, stayed with patients and had enough time to ask for and give
forgiveness to patients at the last moment.
Some nurses did action research to find ways in which nurses could provide better
holistic care for patients. Building spiritual care team work, consulting monks about the
Buddhist healing, and sharing caring experiences of applying Buddhist teachings were
also enacted by some nurses who realised the importance of Buddhist teachings and
spiritual health.
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Nurses applied many Buddhist beliefs and practices while caring for death and dying
patients and families, especially with palliative care. Performing death rituals to support
death and dying patients were shared by nurses who work at the hospital and the home
health care nurses. The main activities in which nurses applied Buddhist teachings with
their nursing knowledge to care for dying patient included: reminding about religious
rituals, performing religious rituals, using a patient-centred approach, accessing
patients’ religious backgrounds, respecting patients’ decisions, preparing happy and
warm environments, making proper and ethical decisions, providing tender loving care
and comfort, relieving pain, talking about previous meritorious acts and good kamma,
reminding about Dhamma through metaphorical stories, planning a good rebirth, and
providing comfort to terminally patients. (See more detail in Pe Karuna’s account).
The main activities in which nurses applied Buddhist teachings with their nursing
knowledge to care for relatives of dying patient included: preparing relatives’ mind to
accept death, supporting relatives to care for dead and dying, reminding relatives to
think about the natural law, reminding relatives to do their best to repay gratitude,
helping relatives who fear sin by doing more good deeds, thinking of patients’ good
parts, dealing with guilty by chanting and transferring merit, and asking for forgiveness
from patients even when they were unconscious.
Some nurses observed clues of patients’ good/bad death and explained that some
patients died peacefully after being blessed by the monks, listening to Dhamma
cassettes, having their loved one stay with them in the last moment, and receiving
forgiveness from friends and relatives. Many nurses realised that Buddhist beliefs and
rituals helped Buddhist patients died peacefully.
Some nurses who had bonded with some terminally ill and passed away patients went to
temple, made merit and transferred merit to patients and patients’ spirits. Some nurses
continued to support patients’ relatives after patients died. Some nurses went to the
patients’ funeral ceremonies because they felt better and had a chance to ask for
forgiveness from patients for their unintentional bad reactions. Some nurses felt guilty
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about a patient’s sudden death. Making merit for patients and asking for forgiveness
from spirits of pass away patients were good ways to support nurses’ mind and heal
nurses’ guilty feelings. Making merit helped nurses to release their tension from work
and release feelings of guilt when nurses felt that they could not help patients ideally.
Appreciating outcomes
Participants realised many good outcomes that occurred from their application of
Buddhist teachings.
Nurses perceived many positive outcomes from applying Dhamma to their living and
nursing care which included: having a good head-hand-heart from learning Dhamma,
being peaceful, gaining consciousness, having self control, learning the value of life,
understanding the nature of life, being mature, becoming a better person/nurse, being
kind and compassionate, being more gentle, being generous, gaining merit, gaining
inner power and positive inspiration for hard work, and perceiving trust. Nurses also
developed some level of understanding about the influences of Buddhist beliefs and
practices on patients’ quality of life. Nurses contended that Dhamma helped them to
respect patients’ and relatives’ values and beliefs, to prevent errors from work with
mindfulness and to accept illness and death as normal phenomena. Many nurses also
expressed that they already prepared their mind for unavoidable death, while some of
them intended to learn more Dhamma and practise meditation and planned for their own
peaceful death. Nurses also perceived that patients and relatives could accept illness and
death and have a peaceful death from learning Dhamma and practising meditation.
Patients reflected that Dhamma helped them to deal with illness and death properly.
Gaining joy, peacefulness and happiness, having will power to live and cope with
illness, being fearless, being patient, having medium levels of (balanced) emotions,
being transformed from a weak mind to strong mind, from wanting to die to preferring
to live naturally, accepting gain and loss, having morality, understanding others, and
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accepting illness and death were the positive outcomes for patients who applied
Dhamma.
Generally, relatives also confirmed that Buddhist Dhamma helped them to become
generous, humble, more flexible, less angry, more confident, have more selfunderstanding, a strong mind, less desire, happiness, meet kind people, set suitable life
goals, and change behaviours.
Concerning problems of applying Dhamma
Many participants gained a lot of benefits from applying Buddhist teachings for
spiritual care, however, they were concerned about problems of applying Dhamma.
These problems were: a lot of nurses, patients and relatives were not being concerned
about religious/meditation practices, few patients were interested in mediation, and
some nurses did not believe in traditional beliefs. Some nurses had no idea of how to
apply Dhamma with patients. Some nurses faced dilemmas of terminal patients’ life,
because the Buddha’s teaching about the five precepts did not support killing. Nurses
realised that there were different levels of people’s Dhamma interest and understanding.
Another problem was a difficulty in clarifying the application of Buddhism, because the
teachings were mainly written in Pali language. Nurses were concerned about effective
ways to learn Dhamma. Similar to patients, some nurses also questioned the results of
kamma, as the direct and instant results of good and bad deeds were not apparent. One
nurse avoided meditating because she usually saw a spirit while she meditated, while
many nurses did not meditate because they felt it was very hard to practise. Many
nurses realised the limitation of applying Dhamma to nursing care especially nurses
who were not interested in learning and practising Dhamma.
Some nurses realised that they were feeling guilty easily after they learnt Buddhist
teachings and tried to follow the moral conducts and the five precepts. Some nurses
realised that they would not be too kind because the kind people could not refuse
helping others, worked harder and were cheated easily. Some nurses who applied
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Buddhist rituals to support patients’ minds were concerned it was time consuming and
realised that, in a very busy context, nurses did not have enough time to support the
patients’ minds. In the ward, they had no time to teach patients to do meditation.
Some nurses realised that the modern organisation seemed to ignore local wisdom and
the Buddhist way. The image of the Buddhist society in Thailand was not always good.
Some nurses were concerned about negative images of monks and nuns and did not
appreciate misbehaving Buddhists, who were selfish, cheating or killing others.
Nurses were concerned about malpractice in merit making. Thai people tended to spend
money to make merit and to ask for many things in return such as winning lotto, good
luck, good health, and so on, with little concern about the quality of mind. Moreover,
the deviation and deterioration of Buddhist practices in modern Thai society made some
nurses appreciate other religions, such as Christianity. Many senior nurses asked
questions about the problems of modernity. They were worrying that a new generation
of nurses would not interested in practising Dhamma, because they preferred modern
lifestyles more than the ancient wisdom.
Some patients and relatives confessed that they were experiencing disinterest in
Dhamma and meditation. One patient complained that she was experiencing constraints
against religious practices, because the ward was too busy and nurses at that ward were
not concerned about her need for religious practices. Some patients had back pain while
doing sitting meditation, which they perceived was an obstacle for practising
meditation. Many male nurses and patients were ordained for some time to repay
gratitude for their parents. They said that they disconnected from meditation after
leaving from the monkhood. Practically, Buddhist people made merit, performed
religious rituals, and helped each other more than practising meditation.
In the ward, one relative realised that she could not invite four monks to chant special
verses for her unconscious son. She decided to make merit and radiate merit for her son,
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and she told her son to receive the merit. She also talked to her unconscious son every
day and reminded him to think of the Buddha image.
Participants perceived differences in understanding Buddha’s teaching, and complained
that some Dhamma books were not easy to understand. Some patients were concerned
about the distortion of the Buddha’s teaching in modern Thai society. Many participants
were worrying about the negative part of monks’ society, such as focusing on building
temples more than teaching people about mind development, or having relationship
with women. The negative outlook of Buddhism prevented some people from knowing
the heart of Buddhist teachings and gaining benefits from Buddhist practices about
spiritual health and well-being.
Some relatives did not have any idea how to perform religious rituals for supporting the
patients’ minds. They trusted modern medicine and treatments more than religious beliefs
and practices. Some relatives were concerned that some people were not considering the
value of Buddha’s teachings. Some nurses were aware that nurses should be very
careful to apply Buddhist teachings to support some patients and relatives who had no
interest in religion.
Suggesting ways for applying Dhamma
The main suggestions for nurses were: developing merciful behaviour and loving
kindness, practising meditation so they could develop a compassionate mind, practising
chanting so nurses could help patients to do chanting at the ward, developing Dhamma
as a healing method, so nurses could provide more holistic care to meet patients’ and
relatives’ needs. Nurses also suggested that nursing organisations should show that they
value Dhamma and make a policy to support nurses to practise Dhamma and to apply
Dhamma in nursing care.
Some nurses realised the importance of a clear mind. They suggested that it is better if
nurse can raise mindfulness before starting each shift. Nurses could prevent errors and
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be more patient to deal with any problems and hard work. Nurses were also concerned
about being sensitive to other cultures and beliefs, so they can provide spiritual care
which is appropriate to patients’ and relatives’ background, values and beliefs.
Patients and relatives also suggested nurses learn Dhamma, practise meditation, support
patients doing chanting, and perform death rituals, such as chanting for dying patients.
One patient suggested nurses look at good Buddhist role models of caring and
compassion in the Thai society, such as Mae Che (Nun) Sansanee. Patients also
suggested that if nurses valued happiness more than money they could be
compassionate nurses. Nurses were also advised to learn more Dhamma, so they could
support patients’ mind with their metta-karuna (kindness and compassion).
Applying personal/local wisdom and traditional healing
Applying local wisdom and traditional healing
Many participants valued Thai traditional wisdom, believed in traditional beliefs, used
both modern and tradition care, and applied alternative/complementary therapies. Some
nurses applied music therapy and alternative ways such as using herbs, relaxation,
nutritious foods, and energy healing, to support non-religious patients. There were
many coping methods which related to beliefs in supernatural power, such as respecting
creation, making a vow, praying and asking for help, and asking for protection from
sacred power. However, there were traditional rituals which Thai people performed for
respecting ancestors. Those rituals reflected respect for ancestors and value of kinship
in Thai culture.
Many patients’ relatives believed in supernatural power. They also had traditional beliefs
especially about avoiding harmful foods. Many relatives depended on traditional beliefs
while they were stressed and while they wanted patients to get better. Many relatives
made a vow for patients’ recovery and repaid a vow after patients got better.
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Some relatives seek moral support from the fortune tellers, so they can release their
tension while caring for patients. Some relatives set rituals for respecting and asking for
protection from ancestors. Many relatives applied traditional and alternative care such
as Thai massage, using herbal medicine, and cooking traditional foods for patients.
Some participants were Thai-Chinese; they applied Chinese traditions such as using
Chinese chanting cassettes, Chinese music, respecting Chinese gods and goddesses and
respect ancestors and asked for patients’ good health.
Some relatives claimed that they did not believe in supernatural power and did not
depend on traditional beliefs. They preferred to seek health care information and
decided for patients to use modern medicine and treatments. Relatives tried to maintain
hope and positive thinking. While being care givers, they paid attention to healing
environments, focused on taking care of self and maintained hard work, so they could
stay healthy and have more money to support patients’ health are costs.
Applying personal wisdom (using other coping methods)
Some patients applied few Buddhist practices to self care. Some patients and relatives
applied some teachings. However, Thai Buddhist patients and relatives shared that they
used some other coping methods to cope with illness. These coping methods provided
hope for them and made them comfortable. Patients applied personal wisdom by
balancing and nurturing happy and simple living. Understanding illness, seeking
treatments, seeking information, communicating/ expressing hardship, being patient,
thinking positively, avoiding negative thinking, maintaining hope/will-power, relaxing
by walking, helping other patients and planning about the property were the main
coping methods for Thai Buddhist patients. Moreover, patients reset personal health
goals after being sick. They tried to depend on themselves, take care of self and balance
living and working. However, some patients confessed that they were spoiling
themselves by continuing harmful behaviours such as eating harmful foods, drinking
alcohol or smoking. The main reason for continuing harmful behaviours was because
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patients did not want to control themselves too strictly. As they could not avoid illness
and death, while being sick they preferred to live more relaxed and still have some
happy time, for example, by eating their favourite foods.
In brief, applying personal/local wisdom and traditional healing included the application
of Thai foods and herbs, Thai massage for self care, coping, and traditional spiritual
practices such as making a vow, performing a Manora or Puppet shadow for a votive
offering, and beliefs about gods, sacred things and supernatural power. Participants,
especially patients and relatives usually mentioned applying personal wisdom, using
other coping methods that complement applying Dhamma and using orthodox
medicine.
Core category 3: Embodying mutual compassion with equanimity
Embodying mutual compassion with equanimity (feeling and acting compassionately
with equanimity to each other), consists of seven major sub-categories including:
describing characteristics of compassionate nurses from nurses’, patients’ and relatives’
perspectives; acting with compassion and equanimity; avoiding added suffering
(dehumanized behaviours); being aware of relationship problems; appreciating
relationship outcomes; realising factors supporting/inhibiting relationships; and
suggesting paths to cultivate compassionate relationships (see more detail in Table 8.2).
Describing characteristics of compassionate nurses from nurses’, patients’ and
relatives’ perspectives
Describing characteristics of compassionate nurses from nurses’, patients’ and relatives’
perspectives, which included: three “good” of minor sub-categories including: good
heart, good experiences and skills, and good social support.
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Good heart
Good heart means nurses are expected to be kind, polite, calm, gentle, and friendly.
Moreover, nurses should show their hospitality, control their emotions, not be moody,
express respect client’s values and beliefs and understanding client’s background, and
give moral support to patients and relatives. In addition, nurses perceived that they
should value human caring, value a beautiful mind, have positive attitudes to nursing,
have a good personality, build trust, be friendly, kind and compassionate, think
positively, be flexible, work hard, be sensitive to different cultures, be a good listener,
respect individual differences, be concerned about patients’ safety, and respect patients
as their teachers. Good heart also includes being concern about kinship relationship in
Thai family, understanding different kinds of patients and relatives, being concerned
about patients’ and relatives’ feelings, understanding patients’ and relatives’ problems
and needs, being concerned about patients’ and relatives’ special needs, realising the
potential of patients’ relatives, such as having a caring mind and strong kinship
tradition, and being willing to care for patients. Patients depend on relatives, relatives
are the significant caregivers and psycho-spiritual supporters, so relatives can reduce
nurses’ workloads. Relatives can repay their gratitude to patients by caring. (See more
detail in Tables 8.2 and 8.3, Appendices H and I).
Good experiences and skills
Good experiences and skills mean nurses should value nurses’ good nursing care,
provide ethical care, be responsible and kind, support and educate patients and relatives,
help patients and relatives on time, and help in patients’ complex problems. Nurses
reflected that they gain more experiences to deal with suffering because of experiencing
hard times in life, experiencing natural death, experiencing caring for dying relatives,
being responsible, valuing quality, being skilful, taking care of self and learning
relaxation, valuing life-long learning and being psycho-spiritual care volunteers.
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Good social support
Good social support means nurses perceived that they can work hard and devote their
energy, money, time and so on, to help patients and relatives, because they have fewer
problems at home and their family understand them and support them to help patients
and relatives.
Avoiding added suffering (dehumanizing behaviours)
Avoiding added suffering (dehumanized behaviours) included: avoiding a moody and
improper manner, avoiding added suffering, avoiding blaming, and avoiding mourning
patients, and fussy relatives, and avoiding unfriendly and solemn nurses (for patients
and relatives).
Patients and relatives in the ward expressed that usually avoided asking help from
uncaring nurses. They also avoided contacting moody nurses who had improper
manners, while nurses also tried to avoid getting tension from patients’ and relatives.
Nurses delayed approaching demanding patients and relatives when nurses were in bad
moods or too busy.
Acting with compassion and equanimity
Acting with compassion and equanimity included many activities, for instance: working
with mindfulness, working with Brahmavihara (the Four Sublime States of
Consciousness) and Iddhipada (The Four Iddhipada, or path of accomplishment. The
basis for success included chanda (will, zeal, aspiration), viriya (energy, effort,
exertion, perseverance), citta (thoughtfulness, active though, dedication), and vimamsa
(investigation, examination, reasoning, testing), providing psycho social-spiritual
support, valuing relatives’ roles, applying alternative care, balancing nurse-client
power, preventing guilt, and accepting health care outcomes.
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Acting with compassion
Buddhist nurses provided compassionate care by providing psycho-social support and
holistic care, applying Dhamma to promote compassionate care, and valuing relatives’
roles especially providing moral support to patients and relatives.
Compassionate nurses provided compassionate care for patients and relatives by giving
smiles,
building
friendship,
assessing
patients’
and
relatives’
background,
understanding individual differences, respecting human beings, and letting relatives stay
with patients when patients needed relatives.
Compassionate acts also included: being sensitive, being friendly, teasing patients and
relatives, being kind and compassionate, feeling/sharing sympathy and empathy, being
calm, honest, sincere, and flexible. Being connected with patients and relatives and
raising mindfulness and self-awareness were also helpful in promoting spiritual caring
relationships.
Communication was a very important part of developing spiritual caring relationships.
Compassionate nurses communicated with clients effectively by chatting, talking while
working, listening with politeness, valuing soft speech and soft personality, and using
local language with local people.
Reducing patients’ and relatives’ hesitation was another compassionate act of nurses.
Some Thai patients did not ask questions of nurses and doctors. If nurses asked what
they would like to know, and provide them with information, they could better
understand about their illness, treatments and self-care.
Being silent, concerning proper time, staying with and giving time, touching patients,
giving moral support, maintaining hope, empowering, nurturing patients’ strength,
enhancing patients’ confidence, encouraging to ask questions, sharing nurses’ suffering
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experiences, counselling, supporting patients and relatives were considered as
compassionate acts.
Compassionate nurses, sometimes, expressed their spiritual caring relationship by
making merit for patients, radiating loving kindness, giving excuses, and giving
forgiveness.
Being frank, preventing guilt, managing conflict, monitoring and reflecting staff’s
misbehaviours, helping junior nurses, building therapeutic relationships with
colleagues, asking for help from senior nurses, consulting experts, moving a patient to
another ward, and setting proper rules and orders for relatives were necessary for
developing and maintaining caring relationships.
Compassionate nurses need to work professionally with good nursing care skills. Being
skilful, providing effective care, providing equal care, maintaining professional
standards of care, providing comfort and safety care, being concerned about clients’
economic problems, teaching relaxation, helping making decisions, orientating,
informing, providing information, using simple language when providing information,
supporting and educating, balancing nurses’-clients’ power, balancing mutual goals,
asking for help from relatives, co-ordinating, continuing care, planning to discharge
patients and evaluating were the main skilful qualities of compassionate nurses.
Nurses, patients, and relatives expressed their mutual compassion to each other. Nurses
also realised about patients’ and relatives’ compassion when patients and relatives
understood nurses’ situations and limitations and were kind to nurses and doctors.
Patient also expressed that they received compassionate care from nurses and doctors
when nurses provided moral support, and psycho-spiritual support to them and their
relatives. Relatives also acted with compassion to nurses by respecting, trusting,
teasing, connecting with nurses, communicating, building good relationship with
nurses, understanding nurses’ situations and limitations, feeling sympathy for nurses,
and helping nurses to care for patients in hospitals and in homes.
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Patients and relatives also valued nurses’ equal care and appreciated nurses’ humour.
They gave forgiveness easily to nurses when nurses did some activities that
unintentionally hurt patients’ body and mind.
Patients also acted with compassion to relatives. For instance, one patient was
concerned about his wife’s safety while she took care of him everyday. The patient with
renal failure was compassionate to his wife by sharing all aspects of his life with his
wife and avoiding bad moods at home. A patient wanted his daughter to stay close to
him until he died. However, patients who could talk care of themselves preferred no
help from relatives, because they wanted their loves ones to continue working and did
not want to bother their children.
Some patients and relatives expressed that they felt sympathy for other suffering
patients; they understood other patients’ problems. Relatives also realised that some
patients and relatives were too demanding which caused relationship problems with
some moody nurses.
Many patients needed to depend on nurses’ and doctors’ suggestions, as being passive
they preferred to follow suggestions. Patients usually asked for gentle care and kindness
from nurses. Some patients asked for support from the ward (equipment for
rehabilitation such as a wheelchair). They felt that some nurses ignored rehabilitating
patients.
In the Thai nursing context, some VIP patients’ relatives used power with nurses by
giving gifts, and then asked for special care. Avoiding patients’ and relatives’
expectation, nurses shared all gifts to the ward, not taking any gifts just for themselves.
Moreover, some relatives, especially the VIP ones, used their power with nurses in the
form of using a personal relationship to ask for help as well as using special access to
health care via informal channels.
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Relatives provided compassionate care for patients by being willing to be supporters and
carers, caring for patient’s body and mind, willing to be a rehabilitator, keeping a healthy
life while being a caregiver, avoiding adding suffering to patients, avoiding telling bad
news to patients, valuing patients’ happiness and comfort, understanding patients’
emotions, being concerned about patients’ plans, being involved in caring at the ward,
asking for help when necessary, asking for support, asking for the truth (especially for
relatives of persons with HIV/AIDS), so they could better support patients and
themselves. Relatives were media for patients, because they communicated with nurses
and doctors for the sake of patients.
Expressing mutual compassion, relatives also expressed compassion for nurses and/or
doctors by appreciating nurses’ caring and support (careful and hard working),
appreciating nurses’ kindness and politeness, trusting nurses, appreciating doctors’
support; understanding nurses’ hard work, tension, workload, and busyness; understanding
effects of relatives on nurses, feeling sympathy with nurses, avoiding interfering with
nurses’ work, following the visiting rules, repaying gratitude for nurses, helping and
supporting nurses, and supporting nurses by giving gifts.
Relatives appreciated receiving compassionate care from compassionate nurses and doctors.
Receiving information from nurses and receiving compassionate support from nurses
and/or doctors were some examples of relatives’ appreciations. Patients’ relatives also
appreciated help, as moral, financial and material support, from their friends, other
relatives and other kind people.
In brief, compassionate nurses were mindful that they needed to avoid being uncaring
and adding distress to clients. Nurses were avoiding blaming difficult patients and
relatives because they understand the roots of patients’ and relatives’ negative reactions
to illness. They tried to control their emotions and keep distant in order to avoid tension
from fussy patients, VIP relatives, and fastidious co-workers. These acts helped nurses
prevent any conflict with patients, relatives and colleagues.
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Acting with equanimity
Nurses applied the Buddha teaching about equanimity by using their own meanings.
Not being too kind was an example of applying the idea of the Middle Way and letting
go of always being compassionate. For example, some nurses reflected that nurses who
were too kind will be called for help by patients and relatives all the time. They were
also too busy and worked harder than other nurses. When nurses did not want to work
too hard they intended to be persons who were not too kind, so they could have some
time to manage their shift.
Accepting health care outcomes, letting go of negative emotions and high expectations,
and avoiding needing things done perfectly were other ways of applying equanimity.
Understanding suffering, the law of nature, and impermanence helped nurses to
consider the teaching about equanimity and help patients accept illness and death.
One nurse considered the teaching about the Middle Way, when he explained why
nurses could not provide good spiritual care or meet holistic care goals. He observed
that nurses worked in very busy contexts with very limited resources. Some nurses
never sought for new knowledge and never improved their nursing care skills. Many
nurses preferred to maintain routine tasks and usually made decisions for patients and
relatives. He wanted to provide good care but he thought it was impossible to do the
best care with a lot of limitations. So, he worked in the Middle Way, to maintain some
level of quality, not overwhelmed by trying to make things change and working harder.
Nurses also worked with equanimity while they realised the nature of suffering, avoided
adding suffering and provided compassionate care with gentle and skilfulness. Patients
and relatives acted with equanimity when they realised the unavoidable nature of illness
and death and they could accept them as normal phenomena. Letting go of negative
emotions, being positive, giving forgiveness, and preparing for a good death, were the
consequences of the application of the Buddha’s teaching of compassion and
equanimity.
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Being aware of relationship problems
Being aware of relationship problems included: preventing conflict, being compliant
and valuing good relationships.
Many nurses realised that conflicts and poor relationships would cause formal
complaints and negative images to the ward, hospital, and nursing profession. Valuing
effective communication and a caring relationship, being aware of relationship
problems, and preventing complaints were the main issues that compassionate nurses
usually kept in mind.
Appreciating relationship outcomes
Similar to the benefits gained by practising Buddhist teachings and applying Dhamma
to care for patients, nurses realised that they gained powerful benefits from being
compassionate nurses. These benefits were: feeling joy and gaining self-value and
happiness; receiving trust, appreciation and respect; receiving praise; receiving gifts;
having no complaints; gaining positive rewards such as more salary; understanding the
truth of life; learning from patients; being strong; accepting negative health care
outcomes; appreciating help and support from patients and relatives; and trusting others.
Many nurses realised that they have done a virtuous job while being a nurse who could
help and support people who were in pain and suffering. In other words, compassionate
nurses perceived that they could make great merit while working.
Patients’ and relatives’ benefits of receiving compassionate care from nurses included:
being proud, gaining confidence, and experiencing feel lighter after being listened to.
Many relatives realised that while they were good caregivers they received a lot of
support from their siblings, friends, and neighbours. They also received inner rewards
and caring power for helping patients compassionately.
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Patients also perceived that receiving compassionate care from nurses and relatives
helped them have good health. They very much appreciated nurses’ help. Gaining
happiness and accepting illness and death were very important consequences for patients
receiving compassionate care.
Being concerned about factors influencing relationships
Being concerned about factors promoting relationships
Personal factors
Nurses perceived many factors influencing relationships. Personal factors which helped
nurses to be compassionate were: having kind models at home, in the community and at
workplace. Studying at higher degree level made nurses gain deep understanding about
spirituality and holistic care. Nurses also claimed that they had wide worldviews and
could understand others’ people backgrounds from continual education, especially
learning about holistic care, spiritual care, palliative care, stress and coping, and death
and dying. One nurse realised that she learnt to be very patient and flexible from
running a discharge planning program, because she had to communicate and maintain
good relationships with many kinds of relatives, including some VIP relatives who
sometimes used their power when they did not want to take patients home. This nurse
confirmed that she could avoid any conflicts and still maintain good relationships with
clients because she considered the teaching of the Buddha about working with good
intention. She could detach from negative feelings and deal with any problems with
calmness and kindness after considering that everyone wanted happiness and nobody
wanted suffering.
Repaying gratitude was another reason which underpinned some nurses’ caring
behaviours. One nurse said that she intended to provide nursing care for patients as if
she cared for her own parents (see Pe Mudita’s experience, Chapter 5).
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Many nurses mentioned that the teaching of the Buddha about doing good deeds and
avoid doing bad deeds, reminded them not to do bad things with patients and relatives.
Fear of sin from not helping patients helped nurses to be mindful and careful to prevent
errors while caring for human lives.
Professional factors
Facing social expectations, having a discharge planning project, and perceiving nursing
as a holistic care mission were the major professional factors that influenced nurses’
compassionate acts.
Organisational factors
Having good relationships between colleagues helped nurses to work in a happy
environment. Even though the ward was very busy, working with caring colleagues
helped nurses work happily and more effectively.
Health care coverage policy was perceived by some nurses as the government’s
compassionate act that supported the low income people. Nurses observed that even
though this policy was criticised as it caused financial burden to the hospital, many
patients gained benefit from free health care services.
Significantly, personal, professional and organizational factors, as well as cultural and
religious aspects that promoted compassionate relationship with equanimity mainly
included: understanding the nature of illness and suffering, considering the Buddha’s
teaching about kamma, valuing kindness and compassion, and valuing the Thai Culture
of respecting older persons and repaying gratitude.
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Being concerned about factors inhibiting relationships
Many nurses who live and work in the Thai Buddhist culture have applied many
teachings of the Buddha in day-to-day working and living. Patients and relatives also
apply some Buddhist teachings to cope with their illness and maintain spiritual caring
relationships with each other. However, in modern society, not every Buddhist people
learns and practises religious teachings in their daily life. New generation Thais practice
Buddhist teaching less and less (Wibulpolprasert, 2005). Thailand has also been in a
transitional period from agricultural culture to modernisation (Klausner, 2000, 2002).
Nowadays, materialism has major impacts on Thai society. In the health care context,
which is strongly influenced by Western modern medicine, nurses have been trained by
Western nursing system (Ekintumas, 1999; Lindbeck, 1984; Muecke & Srisuphan,
1989). Many patients and relatives perceived that some nurses did not provide good
care for clients, and some nurses were not working with their hearts.
Many nurses reflected on nurses’ personal problems and were worried about the
negative image of Thai nurses. Participants from this study shared their perceptions
frankly that there were many factors affecting nurses’ uncaring behaviours. These
factors also cause bad relationships, conflicts, harmed patients’ health and reduced
relatives’ satisfaction. Understanding factors that inhibited compassionate relationship
from nurses’, patients’ and relatives’ perspectives is essential for cultivating
compassionate care with equanimity. This understanding guides ways in which nurses
and the nursing profession can improve their services and develop spiritual caring
relationship within the highest Buddhist path of “Cultivating Compassionate
Relationships with Equanimity between Nurses, Patients, and Relatives”.
Personal factors
Nurses, patients, and relatives reflected that some nurses in the workplaces were
uncaring and unskilful. Many nurses, especially the new generation, who were born in
the Thai modern society, had negative attitudes toward nursing. Uncaring behaviours
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included: interacting improperly, being rough, being impolite, not being friendly,
having bad moods, bullying, insincerity, avoiding empathy, lack of communication and
having ineffective communication were inhibiting effective relationships.
Some nurses realised that some Thai nurses had narrow world views. Some nurses did
not read many nursing and health related books, and they also had less social life from
the heavy workload. These situations made nurses became narrow and rigid, and they
preferred to do just their routine work. These participants wanted to see nurses study
more and improve their narrow nursing world view to broader holistic worldviews. In
these ways nurses could become caring and work effectively.
Some nurses were concerned about the gap between genders, because in Thailand
women and men were taught not to touch each other except after getting married. Some
nurses who worked at the male unit were very careful about comforting the same age
clients. However, there were no problems with caring for older and younger patients.
Some nurses were assaulted by some male patients, but nurses hardly reported these
issues to the ward. Rather, they tried to avoid contact with patients and did not spend
much time with these patients.
Using action equals reaction responses, happened when nurses reacted to relatives in the
same pattern as when relatives acted to nurses. A nurse explained that she was very
good to patients who were kind and understood nurses’ situations, such as they were
concerned that nurses were very busy. She maintained basic care when she did not have
close contact with patients and relatives who were perceived as selfish and demanding.
In the general ward this nurse complained that she could not provide the best care for
some VIP relatives, because she had many patients to care for and she needed to care
for every patient and relative equally. She suggested that the VIP relatives should ask
for special nurses or book a private room for the patient. She would like patients and
relatives to understand nurses’ limitations and busy situations, not just wanting the
quickest and the best care.
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Some nurses perceived that a few nurses and pre-registered nurses in the workplace
used power over patients and relatives. This group of nurses were using self-centred or
nurse-centred approach when caring for patients and relatives. They controlled patients
by providing routine care, focusing on their routine tasks while they seldom asked for
the patient’s and relatives’ participation.
Many nurses had negative attitudes toward fussy clients. They sometimes tried to avoid
contact these clients by keeping busy with the treatments and routine jobs.
Neglecting, ignoring and leaving nursing job for relatives were perceived as the acts of
uncaring nurses. These situations were happening when some nurses were too tired, and
some nurses were less active and waited for other active nurses or patients’ relatives to
take care of patients. Again, this group of nurses preferred just to finish their routine
jobs. This situation caused some complications, such as bedsores and lung infections,
uncomfortableness and stress for patients, who could not communicate and could not
take care of themselves especially fatigued, paralysed and elderly persons.
High tech-low touch and modernity were the main factors that took time from nurses to
care for patients. In fact, nurses wanted to talk to and educate patients, but unavoidably
they had to do treatments and take care of a lot of modern health support equipment.
Within the limitation of nursing staff, and the high technology medical equipment,
nurses were being pulling away from spending time to care for patients’ and relatives’
mind. Fortunately, in Thailand many patients still have an extended family, and they
receive moral support and comfort care from their relatives, friends and neighbours.
Some nurses were having too much sympathy for patients. They felt sad with patients’
problems and sometimes they were crying with patients. Many nurses agreed that
nurses could feel sympathy with some patients but they could learn to detach and
maintain nursing care for clients within professional boundaries.
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Some personal issues, such as having poor self-discipline and low social responsibility,
and being concerned about family more than work, were perceived as factors inhibiting
the caring quality of some nurses.
Unskilled care caused poor nursing care. Some unskilled nurses made errors while
working and they were at risk of being sued or getting complaints. Many patients’
relatives, who stayed overnight with patients, usually observed nurses’ caring
behaviours. Some of them acted as nurses’ external auditors. Some relatives tended to
understand nurses’ situations, while many of them criticised nurses and discussed poor
nursing care, especially when nurses were unfriendly, could not control their emotions,
cared for patients roughly, or did not come quickly when patients needed help.
Therefore, nurses realised that they met many kinds of relatives. They were watched all
the time, so they needed to work carefully and improve their caring relationship and
nursing skills.
Unskilled about providing psycho-spiritual care, and having inadequate experience
about alternative and traditional care, were the other main issues that made nurses not
meet the holistic goals of nursing care. Some nurses realised that patients and relatives
used many alternative therapies. Buddhist beliefs and practices were also applied by
patients and relatives, but some nurses did not understand about the spiritual dimension
of clients. Therefore, nurses realised that they needed to develop spiritual and holistic
care qualities so they could better provided spiritual care which meets the client’s
background, values, and beliefs.
Ignoring alternative therapies was another factor that made some patients perceive that
nurses might not accept their use of alternative therapies. While practising religious and
traditional rituals were considered by relatives as a good way to calm their mind and
heal their spirit, they feared that doctors and nurses would not be able to accept their
coping styles.
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Lacking spiritual supporters was another concern of some nurses. New nurses could not
provide moral and spiritual support for patients and families, because they had rarely
seen seniors nurses model that behaviour. Rather, new nurses usually saw other nurses
care for patients’ physical problems and they had no time to provide spiritual support.
Some nurses raised the issue of unequal care because they had seen many nurses’ and
doctors’ sick relatives receive very good care, while ordinary sick people were not
treated the same. This issue made some nurses try to provide equal care for all clients.
Some relatives had conflicts with the nurses’ assistant or the ward cleaner, and
complaints were made that the staff were not friendly. Unfortunately, this perception
caused negative images of the ward. Problems about the poor relationships in the wards
and units sometimes came from staff who were non-nurses.
Many relatives complained about uncaring nurses. However, sometimes nurses and
nurses’ assistants dressed similarly and relatives could not recognise the difference
between registered nurses and pre-registered nurses. Pre-registered nurses or nurse
assistants, who were perceived as uncaring, sometimes did not value clients as the
centre of care. They had not received enough training about caring and psycho-spiritual
care for patients and relatives. On the other hand, some registered nurses could be
uncaring in some circumstances, especially when they did not like being a nurse, or had
negative attitudes to some clients, such as fussy relatives, or HIV/AIDS clients. Some
nurses were moody because they had personal problems, such as poor relationships in
the family, economic problems, or they resistant to hard work, and so on.
Some patients realised that they did not trust every nurse. They usually observed nurses’
behaviours and developed a sense of trust with nurses who were kind, friendly, showed
some level of respect and listened to their concerns.
Some patients could see that some nurses did not come to see them quickly when they
needed help. For example, some relatives were unhappy when the intravenous line was
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blocked because nurses did not change intravenous fluid on time. Some relatives
complained that patients could get complications, such as lung infection, or were not
resuscitated when nurses did not help patients quickly or were unskilled.
Many
relatives realised that patients could have bedsores easier when patients were in
hospital, because nurses did not change patients’ clothes quickly after episodes of
incontinence. While at home they never let patients sleep with urine and/or feces.
However, relatives who understood that nurses were very busy, preferred to help nurses
provide bedside care for patients.
Experiencing uncaring nurses from relatives’ perspectives included: ignoring relatives’ needs,
lacking concern, not helping relatives, showing slow responses, using horrible words
and improper manners, disrespecting and being impolite, blaming relatives when could
not help patients, being insensitive and expecting of relatives. Relatives who stayed with
patients in the ward were expected by some nurses to help nurses care for patients.
Many complaints were raised from many relatives.
Moreover, some relatives experienced that some nurses were impolite, moody, and
cruel, especially with some HIV/AIDS patients and relatives. Some nurses ignored
patients and some nurses blamed relatives when relatives could not come to help them
care for patients especially when bathing, feeding, or changing clothes.
Some relatives felt powerless and they thought that they had no power to ask for help,
because they were poor and non-educated. Some relatives felt that some nurses did not
listen to their concerns. One son wanted to stay overnight with his mother who was in
pain and could not move, but he was powerless when tried to ask nurses to let him stay
with his mother, because almost every nurse told him that the ward had no policy to let
relatives stay overnight with patients. He observed that there were few very kind and
flexible nurses in the ward, so he waited to ask the kind nurses. Finally, he felt more
relaxed and he was allowed to stay with his mother.
Relatives, who stayed with patients in the ward all the time, could see that some nurses,
nursing students and new doctors were unskilled and caused some errors, such as letting
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fluid clot often or causing some contamination when they did would dressings or
suction. Some relatives felt that some nurses did rough nursing care and caused severe
pain to patients especially when they did suction. These situations caused poor image of
nursing. Some nurses realised that nurses’ image became worse, because some relatives
commented on nurses with some emotions and some relatives had high expectations of
nurses.
Some relatives experienced uncaring doctors. The main problems came from ineffective
communication, that some doctors did not try listen to relatives’ problems. Some
patients complained that they met egoistic doctors, who made decisions by using
doctors’ medical knowledge, while they did not consider patients’ and relatives’
conditions and situations.
Thai patients, who thought they were not highly educated persons, respected that nurses
and doctors were knowledgeable persons. Many patients were passive and did not know
how to ask questions about their health. The communication barrier usually occurred
with the older person and people who felt inferior from having a lower status than
nurses and doctors.
Many patients felt hesitation (kreng jai) to nurses and doctors, especially when they saw
nurses and doctors were busy. Some patients had never asked questions because of
being shy and hesitating. They also did not dare to ask questions. Sometimes patients
waited for help from relatives and let relatives ask questions of nurses and doctors for
them.
Concern for others more than self was another patient problem. Some patients, when
they were sick, did not feel concern about their illness, but they were worried about
their children and other issues at home. Nurses found that patients who were more
concerned others than themselves did not take care of themselves well. They needed
their loved one to visit them and stay with them at the hospital.
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Nurses perceived that some patients were aggressive and they could not build good
relationship with moody and aggressive persons. Nurses could only maintain their
nursing care and wait until patients felt better and calmer.
Misbehaving or having improper health behaviours were issues. Nurses realised that
some patients did not take care of themselves well. For example, they still smoked and
drank alcohol when they were advised to stop harmful behaviours which could progress
their illness. Some nurses accepted that these patients caused their own illness and they
looked at patients by considering the law of kamma. Compassionate nurses tried to
persuade patients to behave well.
Being the main caregiver, relatives developed caring skills to care for the patients. One
relative had problems when she had another job to do and she asked another relative to
care for the patient for her. She found that other relatives could not take care of the
patient as well as she could. This relative found that the patient had diarrhoea from
being care for by an unskilled relative. This was another reason for the main caregiver
to devote his/her mind to care for the patient.
Many nurses explained that in their working lives they usually experienced uncaring
relatives. Problems from relatives were happening in many situations, for example,
relatives argued with nurses and mistrusted nurses. Some relatives who were moody and
disappointed bullied nurses by scolding when relatives thought nurses ignored patients.
Some relatives had no time to care for patients. Issues of neglecting came from both
relatives and nurses.
Nurses realised that they were busier because almost every patients had many visitors.
Relatives visited patients again and again and nurses had to explain and deal with many
questions from relatives repeatedly. Some nurses were inflexible with the visiting rules
because they could work faster and they could finish work sooner without relatives.
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Having emotions, fussy relatives, demanding service, mistrusting nurses, power from
VIP relatives, being blamed, misunderstanding and gossiping nurses, relatives not
providing good quality care and causing dirty environments were nurses’ perceptions of
factors inhibiting good relationships between nurses and relatives.
Professional factors
Professional factors which caused negative images of nurses included: patients
perceiving that nurses can’t make decisions about treatments, so they had to wait to talk
with the doctor instead of consulting nurses. Many educated patients and relatives
realised that nurses did routine work and worked follow the doctors’ orders, more than
using their own judgement and creativity.
Nurses identified issues about power imbalance between nurses and doctors and
between nurses and patients/relatives. Nurses also felt they had inadequate power to
change the system that did not give power to them.
Nurses’ felt that in the hospital their roles were very limited. They had no power to
make decisions, and they worked under doctor’s orders. When they tried to share some
ideas to improve caring situations, sometimes some doctors did not listen or cooperate
with them. Many nurses raised an issue about having coordinating problems with
doctors, and other departments such as pharmacy. Nurses realised that many
coordinating problems wasted their caring time. They were concerned that they had no
extra time for providing nursing care for patients and relatives. Recording problems and
paper work also inhibited nurses’ caring time.
Traditional nursing culture and a hesitating Thai culture were the professional issues
that made Thai Buddhist nurses work under the doctors’ hierarchy. Nurses’ traditional
culture was a top-down management and many nurses worked under doctors’ orders,
especially when they did not update their nursing knowledge and innovation.
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The poor image of nursing was an issue, because some patients and relatives treated
nurses as their servants, or looked at nurses as doctors’ servants. They demanded the
best care and quick service without any concerns about nurses’ busyness and
limitations.
Fastidiousness as a stereotype of women’s work was perceived by one male nurse. This
male nurse realised that many nurses work routinely and look at every detail of nursing
care. He worried that nurses could not make any changes in terms of the decision
making in the health care team, which was dominated by male doctors. Nurses were the
followers and could not be assigned as leaders of powerful doctors.
Being concerned about the theory-practice gap, some nurses realised that nurses had
many nursing theories and research projects which helped them to be caring nurses.
Nurses knew that they needed to provide holistic care and highlight body-mind and
spiritual support for patients and relatives. However, there were huge gaps between
theory and practice. Nurses were very busy because they had to deal with other staff
from many units. While nurses are closest to patients and relatives, and they are big in
numbers, practically, nurses realised that they have the least power in the health care
team. Patients had complex problems and needed help and support while nurses need to
spend time doing doctor’s orders. Nurses needed to monitor medical equipment,
coordinate with other sections and write all records while caring for and educating
patients and relatives. Nurses felt that the ideal of caring in nursing is excellent, but
when nurses had less decision power, they hardly made any changes for patients and
relatives.
Within limited support and busy contexts, nurses who did not like nursing were burnt
out and left the nursing career. Nurses who continued work were sometimes moody and
could not manage their workloads. However, nurses who were kind and devoted
themselves to do the best while caring for patients and relatives had to work very hard.
Under the professional constraints, compassionate nurses could still maintain the quality
of care and good relationships with patients and relatives. These nurses thought that the
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consequences of being a nurse were not about having big money, but of felling proud
when helping suffering people.
Organisational factors
Nurses’ busyness was the most important issue that all of participants found inhibited
nurses’, patients’, relatives’ spiritual caring relationships. Coordination problems and
limited support systems were issues which affected nursing care.
While the health care coverage policy supported some patients, it was perceived that it
was sometimes problematic. Some patients and relatives thought that nurses and doctors
did not provide good quality care, because they used the health care cover card. This
perception sometimes caused mistrust between nurses, doctors, patients and relatives.
Many Buddhist participants in this research applied the Buddha’s teaching about the
law of cause and effect (kamma) and the concept of dependent origination
(patityasamutpada). They could see that all related factors in the health care system and
nursing care from nurses’, patients’ and relatives’ perspectives would affect the nursepatient-relative relationship. Within the law of co-dependence, therefore, the
participants could see many personal, professional and organisation issues in the
nursing context of this study which affected nurse-patient-relative spiritual caring
relationships.
Considering clients’ expectations and suggesting paths to cultivate compassionate
relationships
Considering clients’ expectations
Participants suggested that Buddhist teachings were the core factors that could help
nurses develop and cultivate compassionate qualities. With limited resources, the
Buddhist teaching about kindness and compassion helped nurses control their emotions,
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so they could work without being moody and not feel burnt out while dealing with
complex health problems. These main teachings were about suffering, kamma, wisdom,
mindfulness, compassion, equanimity, and so on, as explained previously.
Participants discussed how compassionate nurses needed to consider clients’
expectations by developing understanding of other people’s suffering. However, nurses
also expected that patients and relatives should understand nurses’ situations and
limitations. Mutual understanding, understanding each other’s suffering, conditions, and
limitations were the basic foundations for enacting mutual compassion with equanimity.
Valuing a caring mind, asking for human caring, expecting caring nurses (kind, friendly,
polite, gentle, valuing, communicating), confirming the meaning of kind nurses (smiling
easily, coming quickly, cheerful, careful, gentle, encouraging patients to ask questions, and
concerned for patients’ needs), expecting the kinship relationship from nurses, expecting
moral support, valuing therapeutic touch, expecting communication and time to talk
openly, needing to learn about self care and relaxation, expecting quality care, expecting
information, and expecting nurses to update health care information, were the main
expectations which could help nurses provide compassionate care for patients and
relatives.
Valuing nurses’ unity was an issue raised by one patient who was a retired nurse. She
realised that nurses were many in number, but less in power. She wanted to see nurses’
unity, so they could voice their professional issues in order to develop power among
health care team. She realised that nurses should tell society that they are experts in
spiritual and holistic care.
Nurses were also expected by patients and relatives to be polite and kind. Cultivating kindness,
valuing patients’ experiences, respecting patients’ beliefs and listening to patients’
feedback were raised by nurses, patients, and relatives as the expected qualities of
caring nurses. Moreover, nurses were expected to learn about self awareness, in order to
develop their caring abilities and work happily with mindfulness.
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Patients needed nurses’ time and intentions, valued nurses’ effective communication,
listened to patients and families, and understood patients’ and relatives’ situations.
Being concerned about patients’ and relatives’ hesitation, reducing patients’ hesitancy,
letting relatives stay with patients when necessary and establishing home care services,
were the main expectations of patients and relatives.
Suggesting paths to cultivate compassionate relationships
Nurses who provide compassionate relationships or spiritual caring relationships with
patients and relatives need to cultivate mindfulness, kindness, compassion, wisdom,
equanimity and quality of mind. The main suggestions from nurses were: being
compassionate nurses; cultivating nurses’ kindness and friendliness; cultivating
compassionate relationships; providing psycho-spiritual care; developing psychospiritual support skill; building caring, psycho-spiritual care model and caring
environments; needing caring models, and valuing clients’ beliefs.
The participants confirmed that being compassionate nurses means having wholesome,
and meritorious service minds, working for the happiness of human beings, being gentle
and kind, controlling emotions, building compassion and comfort, providing psychosocial spiritual support and moral support, listening, fostering patients’ hope, realising
relatives’ supporting role, realizing supporting potential among relatives, being a good
listener, providing information, understanding and respecting patients and relatives,
understanding patients’ and relatives’ situations, and being concerned about patients’
and relatives’ values and beliefs.
Thai nurses were also expected to cultivate the Thai tradition, custom and decorum, so
they could preserve the Thai smiling and kindness qualities. Nurses also realised that
they need to learn relaxation and stress management techniques, because they faced
many complex problems every day from their workplace.
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Realising relatives’ problems, supporting patients and relatives, preventing a high workload
of relatives when they helped nurses care for patients, were suggested by some nurses
and relatives.
Relatives also suggested that nurses should tell them about nurses’ busyness frankly, so
they can understand nurses’ situations and stop complaining about nurses’ slow
responses. Some nurses considered relatives’ special needs and suggested that highdemand relatives should ask for private nurses or private unit for patients, because
nurses in the general ward did not have enough time to provide special care for patients
and relatives.
Being skilful included: having positive qualities, developing nurses’ supporting skills,
communicating, being responsible, providing accurate care, preventing errors, watching
critically ill patients closely to prevent any errors, attending to immobile patients, being
counsellors, educating patients and relatives, providing information, supporting patients,
visiting patients’ homes, and applying alternative healing methods, were the issues
about nurses’ caring competence participants perceived as important qualities for
compassionate nurses. Compassionate nurses who wanted to provide quality care for
patients and relatives always paid attention to patients’ safety and quality of life. Nurses
then opened their mind to learn discipline, in order to care for patients with effective
technical and holistic caring skills.
Some nurses suggested that nursing professionals should improve nursing qualities and
the image of nursing. They can value the image and the art of nursing, increase the
counselling role in nursing, improve nurses’ assessment and communication skills, add
value and power through continuing education, improve time management skills,
improving recording systems, and improve the health care system in terms of
supporting relatives who help nurses take care of patients at home. With home health
care and home visit services, nurses can release some relatives from the burden of being
long term caregivers.
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Finally, some nurses realised the importance of self-development and life-long learning.
They suggested that nurses improve their holistic caring skills, psycho-spiritual supports
and complementary care skills, by focusing on continuing self development, learning
from direct experience, and learning with creativity. Learning Dhamma in order to
understand nature of suffering, and to develop mindfulness, self awareness, kindness,
compassion, sympathy and equanimity, are also very important for Thai Buddhist
nurses, who value spiritual caring relationships between nurses, patients and relatives.
Essentially, compassionate equanimity relationship is a mutual process between nurses,
patients and patients’ relatives. It is the heart of human to human caring relationships,
and also the heart of nursing. It is the authentic virtue and the most beautiful part of
being human, which promotes spiritual caring and healing.
Compassionate care situations are when nurses meet patients and their relatives, and
nurses are raising mindfulness, using skilful nursing wisdom to approach and care for
patients and their relatives with loving-kindness, compassion and sympathy, to support
their mind, without impolite and harmful behaviours, to alleviate their suffering, and
promote health, healing and a peaceful death through the whole process of a caring
relationship. Nurses interact with patients with compassionate spiritual caring
consciousness and polite manners. When nurses raise their consciousness and cultivate
an equanimous state of mind to be calm and imperturbable while facing severe stress
such as, unsolved problems, and unexpected death, they consider the reality of suffering
and accept it as it is, in order to let go and move on and maintain a spiritual caring
process without feeling burnout and compassionate fatigue.
Patients feel compassion for themselves, trying to take care of their body and mind
while asking for help from others when they cannot help themselves. They also feel
compassion for their relatives and do not want to make their relatives suffer or to be a
burden for their loved ones by preferring to be independent and self-reliant. They also
feel compassion for nurses who work hard to care for a lot of patients including
themselves. Patients try to depend on themselves and relatives before asking for help
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from nurses. Patients balance their self independence and need to depend on relatives,
nurses and others. Patients usually came to the state of “kao jai (เขาใจ)","yorm rub
(ยอมรับ)", lae (และ) (and) "ploi wang (ปลอยวาง)"/“plong (ปลง)”, (feeling equanimity with
oneself and others) when they do not want to feel so much suffering and they consider
their past kamma and the nature of life and realise the truth of the Buddha’s teachings.
After they let things go, they accept their condition, even deterioration, dying and death.
They feel released, lighter and have less suffering. In this state, patients usually say that
“their body is sick but their mind is still strong” and they are ready to die and prepare
for a good death, while spending their life in meritorious ways and practising
concentration or mindfulness meditation.
In relation to relatives’ compassion, Thai patients’ relatives are the main moral
supporters of patients. They provide holistic care, comfort, and a sense of safety for
patients, which flow naturally from their heart, full of gratitude and respect. They
perceive they repay gratitude to patients and make merit as being caregivers. They help
to reduce nurses’ workloads by being willing to stay in the ward with patients and do
bedside nursing care for patients. After patients are discharged, they also maintain the
total care of patients, even if they have to deal with many problems. Relatives’
willingness and compassion can nurture patients’ bodies, minds and spirits, and enhance
a peaceful death, with nurses’ support. Patients and relatives also receive a lot of moral
and financial support from their close relatives, neighbours, friends, monks, folk
healers, and people in their communities. The power of the kinship relationship through
compassionate acts helps relatives to overcome patients’ problems with assistance of
nurses and health care providers. Relatives also “kao jai (เขาใจ)", "yorm rub (ยอมรับ)", also
"plong (ปลง)” and “mai yud tid (ไมยึดติด)” “wang jai pen klang (วางใจเปนกลาง)” while
learning to accept patients’ long term or deteriorating conditions and letting go of their
bad feelings. While being the main caregivers they consider the nature of life, illness
and death, and effects of past kamma. Applying equanimity with compassion helps
relatives to better accept patients’ negative health care outcomes, even death.
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With the knowledge gained through this research, nurses and health care providers,
patients and their relatives can help each other to nurture and cultivate compassionate
equanimous relationships in order to alleviate suffering, promote health and spiritual
well being, support a peaceful death and possibly promote a better reincarnation.
The Thai characteristics which reflect the original Buddha teachings also influence
nurse-patient-relative relationships in Thai nursing contexts, such as “yim (ยิ้ม)”
(smiling), “pen mitr (เปนมิตร)” (being friendly), “su parb (สุภาพ)” (politeness), “yud yun
(ยืดหยุน)” (flexible), “jai yen (ใจเย็น)” (calmness), “kreng jai (เกรงใจ)” (hesitation, care and
consideration), and “tob tan bun khun (ตอบแทนบุณคุณ)” (repaying gratitude).
The process of grounded theory development was described in this chapter, which
included the process of open coding, developing minor and major sub-categories,
deciding on three main core categories, and building a middle range theory of the basic
social process of this research. The final process which developed the basic social
process of “Cultivating Compassionate Relationships with Equanimity between Nurses,
Patients and Relatives” was also described. This middle range theory encourages nurses
and health care professionals to progress patient-relative-centred care. Such care
highlights the value of the relatives’ roles in spiritual caring that enhances the patients’
health and healing, especially in very busy health care contexts, with inadequate
staffing, and a focus on health economics and quality of holistic care. Cultivating
compassionate relationships with equanimity combines the art and science of nursing,
which focuses on holistic care, spirituality, social support, religion, cultural care,
traditional beliefs and wisdom, which are core components of human caring since
ancient times. In each moment of a harmonious spiritual caring relationship, nurses,
patients and their relatives engage in virtuous roles to cultivate compassionate
relationships with equanimity for each other. This theory promotes health and spiritual
wellbeing of all parties, including health care receivers, their relatives and health care
providers. Such a relationship is naturally enacted from a human’s compassionate mind
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and has a potential to influence spiritual well-being and/or a peaceful death for all
human beings, even beyond the Buddhist culture.
Conclusion
This chapter described and explained the process of grounded theory development. The
core components of basic social process of “Cultivating Compassionate Relationships
with Equanimity between Nurses, Patients and Relatives” was described and explained.
The main subcategories, concepts and relationship between three core categories and
supporting codes of the substantive theory were illustrated in form of Table and then
explained.
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CHAPTER 9
BUDDHISM AND THE NURSE-PATIENT-RELATIVE RELATIONSHIP
Introduction
This chapter describes literature describing relationships, especially the Buddhist
perspective, Buddhism and nursing theories, interpersonal relationships in nursing care,
holistic nursing care, ethics of care, and caring, in general, and spirituality in particular.
The main sources of literature are CINAHL, OVID FullText Nursing Collection,
Proquest, Medline, PubMed, and Digital Dissertations, and www.google.com. The main
keywords for searching included relationship, Buddhism and relationship, spirituality
and relationship, nurse-patient relationship, and nurse-patient-relative/family/informal
caregiver relationship.
Relationships: The Eastern Worldviews
Thing derive their being and nature by mutual dependence and are nothing in
themselves (Nagarjuna 1955, cited in Capra, 1992: 150)
The Eastern worldview focuses on the unity of all things. “Although the spiritual
traditions of Hinduism, Buddhism, Chinese thought, Taoism, and Zen are different in
details, their worldview is essentially the same” (Capra, 1992: 141). According to Capra
(1992: 141), “the most important characteristic of the Eastern worldview is the
awareness of the unity and mutual interrelation of all things and events, and the
experience of all phenomena in the world as manifestations of a basic oneness”. “All
things are seen as interdependent and inseparable parts of this cosmic whole; as
different manifestations of the same ultimate reality … it is called Brahman in
Hinduism, Dhammakaya in Buddhism, Buddhists also call it ‘Tathat’, or ‘suchness’.”
Capra (2001) also valued people’s respect and helping each other for cultivating
harmonious social relationships and social networks.
Chapter 9: Buddhism and the nurse-patient-relative relationship
Wright & Sayre-Adams (2000: 35) claimed that “from the Upanishads to Einstein, the
notion of the interconnectedness of all things in the universe, ourselves included,
provides the ethical thrust for our compassionate concern for ourselves, others and the
world.” This means the idea of interconnectedness is accepted as global, not just in the
Eastern world.
In summary, the Eastern and Buddhist worldviews consider the connectedness of
everything, an indivisible universe, in which all things and events are interrelated. This
being so, it is arguably the basic foundation of human relationships and caring
relationships for health care professions in the East and the West.
Buddhism and relationships
The Buddha’s teachings were compiled in the Tipitaka (known in the translated form as
the Three Baskets) after the Buddha passed away. The Tipitaka has 84,000 teachings.
The Buddha’s teachings were originally in Pali for the Theravada (Hinayana) school
and in Sanskrit for the Mahayana school. Hinayana Buddhism adheres to the purer form
of Buddhism exactly as it was during the time of the Buddha, based upon the original
teaching in Pali script (Punyanubhab et al, 2001). The Pali language is used in all the
hymns and sermons as it is considered to be the holy language for the Buddhist of the
Hinayana Sect, while the Mahayana Buddhists believe that religion must change with
time and must adapt according to circumstances (Jumsai, 2000). As the Buddha
instructed before his final departure, “Dhamma and discipline taught and enjoined by
me shall be your teacher when I am gone” (Punyanubhab et al, 2001: 17).
Jumsai (2000) claimed that the Buddha’s teachings are simple, for instance, how to end
desires by leading a virtuous life instead and not causing others any problems. At the
same time, one must practice kindness, generosity and selflessness with others. The
central Buddhist philosophy is: cease to do evil, learn to do good, and purify your mind
(Gnanarama, 2000; Ludwig, 2004). The Buddha taught that people’s lives depend on
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their kamma. Buddhists should take the Dhamma as their refuge, fill the mind with
love, compassion, sympathetic joy and equanimity, and take the Noble Eightfold Path
for more happiness and less suffering (Jumsai, 2000).
The essential teachings are the Four Noble Truths (Ariyasajja) and the Noble Eightfold
Path. The Buddha also taught that “everything is impermanent (anatta), life is transient
and changes will either pass away or disappear” (Jumsai, 2000: 31). Buddhists should
find every opportunity to do good things, spend time effectively by practising metta
(kindness), karuna (compassion), mudita (sympathetic joy), and upekkha (equanimity)
(Jumsai, 2000).
Punyanubhab et al (2001: 19) proposed that Buddhists must value spiritual development
as well as value worldly education, as he pointed out:
While most academic subjects lay stress on worldly interest, Buddhism
recognises the importance of worldly benefit and happiness including ethical
and higher spiritual development, that is that being free from defilement and
suffering. The most important part is Buddhism has it interdisciplinary as well
as integrated academic components, that is, it has theory, process, investigation,
experimentation, and application.
Buddha teachings lead to cultivating good relationships between self and others and
Nature. However, in the Thai context there are several main teachings concerning good
relationships with other people, which promote human relationships.
The Four Sublime States of Consciousness (Brahma-vihara)
The Four Sublime States of Consciousness is “the Buddhist teaching which promotes
boundless thoughts of goodwill towards the whole world. It denotes four qualities of the
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heart which, when developed and magnified to their fullest, lift people to the higher
level of being” (Punyanubhab et al, 2001: 146). These qualities are:
Metta (loving kindness), which means all-embracing kindness or the desire to
make others happy, as opposed to hatred, ill-will, or the desire to make others
suffer. Metta builds up generosity in one’s character, giving it firmness, freeing
it from irritation and excrement, thus generating only friendliness and no enmity
nor desire to harm or cause suffering to anyone, even to the smallest creatures,
through hatred, anger or even for fun.
Karuna, which means compassion or desire to free those who suffer from
suffering, as opposed to the desire to be harmful. Karuna also builds up
generosity in one’s character, making one’s character, making one desirous to
assist those who suffer. Karuna is one of the greatest benefactions of the Buddha
as well as of the monarch and of such benefactors as our fathers and mothers.
Mudita, which means sympathetic joy or rejoicing with, instead of feeling
envious of, those who are fortunate. Mudita builds up the character in such a
way that it promotes only virtues and mutual happiness and prosperity, which
opposites to jealousy.
Upekkha, which means equanimity or composure of mind whenever necessary,
for example, when one witnesses a person’s fortune, one’s mind remains
calmed. One does not rejoice because that person is one’s enemy nor grieve
because that person is one’s beloved. One should see others without prejudice or
preference but in the light of kamma or will-action. Everyone is subject to
his/her own kamma, heir ti the effects of his/her own will-actions. Earnest
contemplation of kamma or the law of cause and effect will lead to the
suppression of egocentric contemplation and result in the attainment of a state of
equanimity. Upekkha builds up the habit of considering everything from the
point of view of right or wrong and ultimately leads to a sense of right-doing in
all things and beings, which is opposite to partiality or prejudice (Punyanubhab
et al, 2001: 146-148):
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The teaching about Brahma-vihara “provides a framework for nurses to work with
compassionate care for all clients”. It also serves as the wisdom of nursing to help
nurses realise things as they really are (Tongprateep & Soowit, 2002: 56). When people
can replace their hatred and anger with kindness and compassion, the fruitful outcomes
can enhance happiness, peaceful and health.
The six directions of relationship
The teaching about the six directions of relationship Buddhist were taught to respect
and value the gratitude of people from six directions which are: parents as the east or
the direction in front; teachers as the south or the direction in the right; husband, wife
and children as the west or the direction behind; friends and companions as the north or
the direction in the left; servants and workmen as the nadir; and monks as the zenith
(National Identity Board, 2003). This teaching underpins the idea of taking care of each
other and repaying gratitude to supporters.
The path to accomplishment (The Four Iddhipada)
The path to accomplishment (The Four Iddhipada) is the path of accomplishment, basis
for success including chanda (will, zeal, aspiration), viriya (energy, effort, exertion,
perseverance), citta
(thoughtfulness, active though, dedication), and vimamsa
(investigation, examination, reasoning, testing) (Payutto, 2003). These qualities
promote nurses’ caring behaviour while dealing with hard work.
In summary, the Buddha’s teachings about Brahma-vihara, the six directions of
relationship, and the Four Iddhipada have underpinned Thai people’s behaviours which
guide them in respectfulness and kindness.
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Issues from the Thai Buddhist culture that influence relationships
Issues from the Thai Buddhist culture influence the nurse-patient-relative Buddhist
teachings about kamma have major influences on Thai people’s characters, especially in
relation to care and consideration, kindness, helpfulness, responsiveness to situations
and
opportunities,
self-control,
tolerance,
politeness,
humbleness,
calmness,
cautiousness, contentedness and social and a sense of fun (Klausner, 2000; Komin,
1990; Mulder, 2000; Wongtes, 2000). However, sometimes Thai people hide their
feelings because they do not want to hurt others’ people feelings. Mulder (2000: 1)
observed the non-confrontation character of most Thai people:
A smile may be a sign of kindness, of forgiveness, of friendly inclinations; a
smile may also be merely polite, a way to smooth interaction or a sign that one
is willing to listen. A smile may indicate agreement, or self-confidence, but may
also be a means to gently express one’s opposition or doubt. A person on the
defensive may smile, and one may smile when sad, or hurt, or even insulted. It
has been said that the Thais have a smile for every emotion and with so many
nuances of smiling, the smile often hides more than it reveals (Mulder, 2000: 1).
These Thai Buddhist characteristics lead to not asking questions, fear of authority, not
sharing personal ideas and avoiding commenting on other people’s business directly.
Contrastingly, gossiping is a social characteristic of Thai people, especially women.
In the Thai health care context, several factors influence Thai characteristics, such as,
political injustice, economic problems, social and cultural changes, the deterioration of
morality in Thai society, and problems of religious organizations (Klausner, 2000;
Mulder, 2000; Payutto, 2001). Several issues influence the Thai Buddhist health care
culture, such as a strong medical model, hierarchal (top down) management, power
imbalances between nurses and doctors, and between patients and nurses/doctors. The
issue of hesitation (kreng jai) influences Buddhists to respect others (Bechtel &
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Apakupakul 1999). Patients who may feel inferior to nurses and doctors, such as AIDS
and low-income patients, may not ask for information and help from nurses and doctors,
so sometimes they become passive.
The teaching about kamma also influences patients’ and relatives’ perceptions about
causes of illness and some patients, especially elderly people, may refuse advance
treatments because they accept their illness and they are ready to die. The teaching
about respect for older people and respect for people who help them, leads Thai people
to feel concerned about repaying gratitude to parents, teachers and respectful people. In
the health care context, patients and relatives try to repay gratitude to doctors and nurses
by bringing fruits from their garden and they also try to help nurses and doctors care for
patients in the wards. On the other hand, in modern Thai society, patients and relatives
have more expectations about nursing care. People who can pay for high cost care
expect a higher quality of care and sometimes complain about ineffective care. In brief,
all of changes in the modern Thai world inevitably affect the nurse-patient-relative
relationship.
Buddhist paradigm on health and healing in Thai society
Paonil (2003) considered Buddhism as a paradigm to investigate its capacity to deal
with health problems especially in Thailand. Paonil (2003) proposed that economical,
environmental, social, and health crises originate from the same foundation; that is
misunderstanding of the nature of human life and the world.
Paonil (2003) interviewed seven people who applied Buddhist paradigm in their way of
life. He focused on their lives and health experiences, and found that the Buddhist
paradigm gradually changed their lives and worldviews. Their lifestyles were easier and
involved less suffering than those of people who studied and practiced less Buddhism.
In addition, Paonil (2003) used case study to explore life in a small hospice caring for
AIDS patients. Two monks and a few staff applied Buddhadhamma, rituals, and some
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modern medicine to treat patients and promoted health, healing and a peaceful death for
the patients. Paonil (2003) concluded that Buddhism can be seen as a paradigm, which
has its own realities about life and the world, which differ from scientific and holistic
paradigms. People who apply the Buddhist paradigm into their life seem to have less
suffering when they get health problems. He also argued that the Buddhist paradigm is
still effective in solving health problems in Thailand.
Tongprateep (1998, 2000) studied the essential elements of spirituality among rural
Thai elders. The purpose of the study was to understand and describe the essential
elements of spirituality among rural Thai elders. The research question that guided the
study was: How do rural Thai elders experience and describe spirituality in their daily
lives? This question was explored through in-depth, audio-taped, face-to-face
interviews with 12 rural Thai elders living in the Nakhorn Prathom Province in the
central part of Thailand. Through the process of hermeneutic phenomenological data
analysis, three categories and nine themes emerged. The categories were spiritual
beliefs, religious practices, and the consequences of spirituality. The spiritual belief
category consists of two themes: the law of karma and life after death. The religious
practice category consists of four themes: merit making, observance of moral precepts,
gratitude and caring in the family, and meditation. The consequences of spirituality
category include three themes: coping with the vicissitudes of life, being hopeful, and
having a peaceful mind. These themes represented the main focus and meaning of the
essential elements of spirituality among the participants. Spiritual beliefs and religious
practices were interwoven throughout the descriptions of the participants in each theme.
Buddhism was central to the thoughts and practices of the participants, especially the
law of karma and life after death.
In an ethnographic study, Pincharoen and Congdon (2003) described spirituality as
experienced by older Thai people living in the United States, focusing on how
spirituality helped them maintain health, and to describe what they valued most as they
aged. The interviews included open-ended questions such as “Describe how you keep
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healthy as you age” and “Describe what is most important to you in your life at this
time.” Five major themes were identified: connecting with spiritual resources provide
comfort and peace; finding harmony through a healthy mind and body; living a valuable
life; valuing tranquil relationship with family and friends; and experiencing meaning
and confidence in death. The authors concluded that for these participants, spirituality
and health were integrated, coexisting in all of life, and should not be separated in
health care.
Kunsongkeit, Suchaxaya, Panuthai, and Sethabouppha (2004) studied the spiritual
health of Thai people using Heideggerian phenomenology. The results showed that
spiritual health is composed of three themes. The first theme was having a sense of
connectedness in life. It was divided into three categories, which were adherence to a
religion, belief in a supernatural power and relationship with persons. Adherence to a
religion was presented through faith in religion, having religious principles as guidance
in life and a practice of religious activities. Belief in supernatural power was reflected in
worships of supernatural things, and relationship with persons was reflected in a sense
of bonding with the family, relationship with friends and faith in respected persons.
The second theme was happiness in life, which resulted from life satisfaction and a
meaningful life. Life satisfaction was comprised of satisfaction with one’s personal life,
family life and social life, whereas a meaningful life came from self-esteem and pride in
oneself. The third theme was power for living. It came from the will to live and the
ability to cope with life’s problems. The will to live was reflected in courage, inner
strength, hope and plans for the future, while the ability to cope with life’s problems
was shown through the ability to face one’s life problems and make changing in life and
life style to solve these problems. This research result provided implications for health
professional to promote spiritual health and further develop a body of knowledge
regarding the Thai context and effective holistic care.
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Chailangka, Chuaprapaisilp, Triprakong and Wonnawong (2005) developed a model to
apply of the Dhamma in giving nursing care to the adult patients with leukemia
receiving chemotherapy. The study aimed to develop nursing therapeutics from
Buddhist teachings that would assist the leukemia patients to overcome suffering during
chemotherapy and to explore ways of living with leukemia peacefully. Action research
was employed through spirals of planning, acting, observing, and reflecting. The study
was divided into three phrases. The first was phenomenological study of 10 patients to
understand all aspects of the patients’ suffering and to identify methods to alleviate it.
The second phase consisted of training researchers and nurses to assist patients to
overcome suffering. A three days retreat for 15 nurses and researchers was conducted to
train mindfulness cultivation, meditation, relaxation, metta phrana (radiation of loving
kindness, wishing self and others to be well and happy) and healing through balance.
The last phase was the implementation phase, which involved nurses and researchers
applying techniques to assist 10 patients. Data were collected by participant observation
and interviews.
The data were analysed through qualitative methods and critical reflection. The results
revealed that the patients suffered severely from physical, psychological and spiritual
problems. Methods of overcoming suffering, apart from standard medical treatments,
were meditation, chanting, metta phrana, anicca (impermanent), recitation, offering
food to monks, setting animals free, thinking of a new and better life after death and
asking for help through magic powers. Nurses and researchers, following training, were
more open, calm, active, respectful and willing to help patients. As a result most
patients were able to cope with chemotherapy in a more cheerful and calmer manner.
They also gained techniques to reduce their suffering. The most effective techniques
were meditation, mindfulness, metta phrana, and praying. Self-sufficient ways to living
(Chevit–Por-Peang), calming the mind, taking extra self-care, making merit,
meditation, chanting, asking forgiveness from wrong doings (kamma) were identified as
ways of living with leukemia peacefully. Nurses were able to develop “meditation as
nursing therapeutics” based on Buddhist principles and energy therapy.
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Aphichato and Tulathumkit (2005) studied experiences of Dhamma and meditation in
cancer patients receiving radiation therapy. The purpose of this phenomenological study
was to describe and understand the use of Dhamma and meditation to care for the health
of cancer patients who received radiation therapy. Ten informants in one hospital in the
southern part of Thailand participated in the study. Data were obtained by in-depth
interviews, non-participant observation, and tape-recording. Data were analysed using
the Colaizzi, s method. The findings revealed that patients who were diagnosed with
stage 2-3 cancer perceived Dhamma as behaving as a good person, doing good deeds,
being grateful to parents, and merit making. Patients perceived meditation as a peaceful
mind and brightness. When participants were informed that they would receive
radiation, they were afraid of death and pain. When they were undergoing radiation
therapy participants reported worries about families, living with uncertainty, irritability,
worries of being unable to eat, hopelessness, and fear of suffering. Results from this
study suggest to nurses that the provision of holistic care integrates Buddha’s doctrine
with Thai culture to enhance cancer patients, quality of life.
Hirst (2003) discussed perspectives of mindfulness for mental health nursing. The
therapeutic potential of mindfulness is now being recognized and researched in a
diverse range of healthcare settings including mental health. Being mindful suggests
that individuals whose awareness is not impaired have a choice in what phenomena they
attend to and how they act. Understanding the idea and practice of mindfulness is useful
for developing transcultural awareness and recognizing that personal inattention can
compromise care. Hirst (2003) explored the notion of mindfulness from a number of
perspectives and concluded that the Buddhist understanding of mindfulness provides an
excellent strategy for preparing to be active in caring relationships.
Bruce and Davies (2005) explored the experience of mindfulness among hospice
caregivers who regularly practiced mindfulness meditation at a Zen hospice in America.
Nine meditation practitioners practiced different traditions of Buddhism, for example,
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there were five Zen practitioners, three Tibetan Vajrayana practitioners, and one
Theravadin practitioner. They decided that meditative awareness constituted themes of
meditation-in-action, abiding in liminal spaces, seeing differently, and resting in
groundlessness.
Buddhism and Nursing
Nursing serves the health’s needs of people in societies. Nursing is an art and science
that focuses on integration and application of nursing knowledge through the nursing
process to care for patients and family (Crisp & Taylor, 2005). Nurses also apply
knowledge from a number of disciplines, such as social science, physical sciences and
bio-behavioural sciences. Crisp and Taylor (2005: 3) claimed that “nursing is a melding
of knowledge from the physical sciences, humanities, social sciences, and the clinical
competencies needed to meet the individual needs of clients and their families.”
Nursing roles expand and develop through holistic care. Nursing not only draws from
nursing knowledge and medical, spiritual and emotional components, it also uses
complementary therapies.
Nursing concepts and theories, partly including spirituality, have evolved since the time
of Nightingale, who claimed that the nature of nursing is a profession requiring
knowledge distinct from medical knowledge (Nightingale, 1959). Nursing has
developed a growing body of knowledge. From the time of Nightingale until now, there
are more than 23 nursing published theories about the spiritual nature of the nursepatient relationship. Levine (1990) proposed holism is maintained by conserving
energy. Rogers (1970) highlighted the energy field between person and environment.
Orem (1971) suggested a self care theory, and Roy (1974) highlighted an adaptive
system. Peplau (1952), Orlando (1961), Travellbee (1976), King (1971), Paterson and
Zderad (1988), Leininger (1978), Watson (1979, 1985, 1999a,b, 2005), Parse (1987),
and Benner and Wrubel (1989) emphasised the importance of the interpersonal process
and human caring in nursing care.
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Some nursing scholars are interested in Buddhism and have indirectly applied Buddhist
principles in their theories, especially Martha Rogers, Margaret Neuman, and Jean
Watson. They value humanistic approach and the power of consciousness and presence,
which are congruent with the Buddha’s teachings.
Rogers’ Theory and Buddhist Teachings
Rogers proposed that nursing is a humanistic science. According to Crisp & Taylor
(2005: 66)
Martha Rogers (1970) considers the individual (unitary human being) as an
energy field co-existing with the universe. The individual is in continuous
interaction with the environment, and has a unified whole, possessing personal
integrity and manifesting characteristics that are more than the sum of the parts.
A unitary human being has a four-dimensional energy field pattern, manifesting
characteristics that are specific to the whole and which cannot be predicted from
the knowledge of the parts. … Openness, pattern, organisation and
dimensionally are used to derive principles related to human development.
In response to Roger’s theory Hanchett (1992) proposed that Eastern philosophy has
contributed directly and indirectly to the development of some nursing frameworks.
Commonalities exist between many nursing perspectives and elements of Buddhist
philosophy. She explored four concepts from early Indian philosophy, which contribute
to the development of the Middle Way (Madhyamika Prasangika) School of Tibetan
Buddhist philosophy, which describes action (kamma), direct perception, emptiness,
and dependence within Martha Rogers’ science of unitary human beings. Hanchett
(1992) concluded that Buddhist concepts of action, direct valid perception and
emptiness are considered in Rogers’ notion of the human energy field.
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Newman’s Theory and Buddhist Teachings
Newman (1997) valued nurses’ hermeneutic dialectic process with clients and
undivided wholeness. Ken Wilber, an American philosopher and psychological theorist,
described the coming together of Eastern and Western worlds (Wilber, 1977). Wilber
(1981) asserted the world has no boundaries. While Newman (2003) acknowledged that
Ken Wilber’s philosophy of no boundaries provided a backdrop for letting go of
boundaries between art and science, research and practice, and nursing theories, she
proposed that her major nursing concepts are cited from a variety of theoretical
persuasions to illustrate a unified perspective of the discipline of nursing.
Watson’s Theory and Buddhist teachings
Watson (1985) applied the concept of transpersonal caring, the ideas of Carl Rogers in
the definition of the self, but she has her own value and beliefs about person and life
which are reflected in the inclusion of the soul as an important force in her concept of
the person. Her orientation is clearly “phenomenological-existential” and spiritual.
Watson’ philosophy of transpersonal caring (1979, 1985, 1988, 1999a,b) defines the
outcome of nursing activities regarding the humanistic aspects of life. Nurses need to
understand the interrelationship of health, illness and human behaviour. Nursing is
concerned with promoting and restoring health and preventing illness. Watson’s model
is designed around the caring process, assisting clients to attain or maintain health or to
die peacefully. This caring process requires the nurse to be knowledgeable about human
behaviour and human responses to actual or potential health problems, individual needs,
how to response to others, and strengths and limitations of the client and family as well
as those of the nurse. In addition, the nurse comforts and offers compassion and
empathy to clients and their families, caring represents all of factors the nurse uses to
deliver health care to the client (Crisp & Taylor, 2005; Watson, 1987).
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Sitzman (2002) provided explanation and comparison using Thich Nhat Hanh’s concept
of inter-being (Hanh, 2000) and the practice of mindfulness as a bridge to understanding
Jean Watson’s theory of human caring. She found that simple mindfulness practices of
non-judgemental attention to thoughts and awareness of breath are described to provide
a starting point for teaching and action. A deeper understanding of inter-being and
theory of human caring, and how they relate to one another, is possible through the
practice of mindfulness. Watson (1997: 51) concluded that “creative utilisation of this
alternative teaching approach may enhance understanding of complex principles of
Watson’s theory.”
Erci, Sayan, Tortumluoglu, Kilic, Sahin and Gungormus (2003) applied Watson’s
theory to study “the effectiveness of Watson’s caring model on the quality of life and
blood pressure of patients with hypertension.” They determined the effectiveness of a
nurse’s caring relationship-according to Watson’s model-on the blood pressure and the
quality of life of clients with hypertension. A pre- and post-design was used in which 52
clients with hypertension who had consented to take part in the study completed
questionnaires focusing on their quality of life and demographic details; the participants
also had their blood pressure recorded. Nurses who had trained to use Watson’s caring
model then visited the clients and their families once a week for blood pressure
measurement over a period of 3 months. At the end of that time, the participants
completed the quality-of-life measure and their blood pressures were noted. Significant
improvements were found in the participants’ scores for wellbeing, physical symptoms
and activity, medical intervention and their level of hypertension.
Watson (2005) promoted human ontological heart-centred self-healing phenomena and
practice processes which include forgiveness, gratitude, surrender and compassionate
human service. She applied Buddhist teachings about compassion into the
compassionate human services to proliferate caring and peace in the world. She also
proposed some more abstract human endeavours we all share in our humanity as well as
our common work, regardless of professional/personal background. We may not even
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be aware that these are activities we are engaged in until they are brought to our
conscious attention and awareness. These endeavours are: healing our relationship with
self/other/planet/earth/universe; understanding and transforming our own and other’s
suffering; deepening and expanding the shadow-light cycle of the great sacred cycle of
life; and preparing for our own death.
In the past decade, Western journal articles and nursing textbooks seemed interested in
applying the Buddhist teachings into nursing care, especially in the area of palliative
care, spiritual care, transcultural nursing, alternative care and nursing ethics. Rodgers
and Yen (2002) suggested nurses’ scholars re-think nursing science through
understanding of Buddhism. They asserted that Western thought has dominated
scientific development for a long time, and nursing has not escaped the influence of
such ideology.
Fiandt, Forman, Megel, Pakieser and Burge (2004) proposed an integrated nursing
model by applying Ken Wilber’s All-Quadrant/All-Level framework (Wilber, 1977,
2000a,b), and Beck and Cowan’s spiral Dynamics development model (Beck & Cowan,
1996). They hoped that the nursing professional would benefit from the addition of a
comprehensive framework that can integrate various aspects of nursing and serve as a
device to effectively interface nursing with the rest of the health care system. (See
Wilber’s All-Quadrant Model in figure 9.1). They observed that this integrated nursing
model can integrate with theory of Newman (1986, 1995) Roger (1970), Paterson and
Zderad (1988), Parse (1987), and Leininger (1978, 2002).
Apart from applying Ken Wilber’s consciousness philosophy into holistic nursing
paradigm, several nursing theorists apply a holistic worldview and an understanding
about Eastern wisdom (Capra, 1975, 1985, 1994, 1997). The article “East and West:
Ancient Wisdom and Modern Science (Grof, 1994) was also applied in the
complementary and holistic nursing concepts.
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Interior
Individual
Collective
Exterior
•
•
•
•
Intentional
Cognitive capacity
Emotional maturity
Moral development
Spiritual development
•
•
•
•
•
•
•
•
•
•
Cultural
Group/institutional norms
Shared understanding
Share terminology
Share values
Share vision
Team moral
•
•
•
•
•
•
Behavioural
Physiology
Biochemistry
Health and fitness
Skill development
Systems/Processes (or social)
Organisation structure
Regulatory environment
Vendor and other contracts
Information technology
Financial/billing systems
Other measurement systems
Figure 9.1: Wilber’s All-Quadrant Model (adapted from Fiandt et al, 2004: 20)
Caring and therapeutic relationships are foundations of holistic nursing. The holistic
nursing perspective values relationship-centred care. Dossey and Guzzetta (2005)
demonstrated guidelines for addressing the bio-psycho-social-spiritual dimensions of
individuals in integrating caring, healing, and holism into health care. There are various
kind of basic concepts which relate to human interaction and relationship to be
implemented which mainly include self-awareness, recognising a patient’s life story and
its meaning, view health and illness as part of human development, developing and
maintaining caring relationships by attending fully to the patient, facilitating hope, trust
and faith, and being aware of power inequalities and conflicts. Moreover, nurses should
have effective communication skills, which focus on listening, accepting the patient’s
emotion, educating and facilitating coping skill and self care abilities, and valuing the
meaning of family and community. The holistic perspective claims “relationships and
interactions among people constitute the foundation for all therapeutic activities.” The
three components of relationship-centred care include: “the patient-practitioner
relationship, the community-practitioner relationship, and the practitioner-practitioner
relationship” (Dossey & Guzzetta, 2005: 24).
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Relationships in Nursing
The word relationship in the nursing context has a wide meaning which includes human
relationship, interpersonal relationship, therapeutic relationship, and caring relationship
(Brykcznska & Jolley, 1997; Hagerty & Patusky, 2003; McCrea, Atkinson, Bloom,
Merkh, Najera & Smith, 2003; O’Brien, 2003; Sheldon, 2004; Taylor, 2000).
Transpersonal relationships (Watson, 1785, 1999, 2005) are “the spiritual dimensions of
human experience; beyond the personal” (Kornfield, 1993: 350). It also means a human
connection and caring connection (Stein-Parbury, 2005); and therapeutic or healing
communication in which nurses are fully present, listening, speaking with self
awareness and developing trust with patients and families. Each interaction between
nurse and client, whether brief or extended, is an opportunity for healing (Williams &
Davis, 2004). “The therapeutic relationship forms the basis of nursing for patients and
the patient’s family throughout the spectrum of health and illness” (Sheldon, 2004: 40).
Interestingly, Taylor (2000: 1) expressed “nursing as a human relationship” while SteinParbury (2005: 3) confirmed that “the relationship meshes the nurse’s compassion and
knowledge with the patient’s experience of health events. Through their relationships
with patients, nurses express concern, care and commitment.” Mauk and Schmidt
(2004) concluded professional caring in nursing involves the 5 Cs which are
compassion, competence, confidence, conscience and commitment. Among these
qualities, compassion is obviously the first and most vital quality of caring nurses, who
can promote therapeutic relationships.
Taylor (2000: 251) claimed that “nurses and patients are the same in their humanity”.
Facilitation, fair play, familiarity, family, favouring, feeling, fun and friendship are the
aspects of ordinariness in nursing that can enhance the nurses-patient relationship,
which is the therapeutic nature of nursing. McMahon and Pearson (1998) proposed
nursing as therapy, while Wright and Sayre-Adams (2000) valued right relationship in
nursing. Freshwater (2002) highlighted therapeutic nursing and encouraged nurses to
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improve patient care through self awareness and reflection. Bradshaw (1997) as well as
Taylor (2000) pointed out the crucial qualifications of health care professionals include:
being aware of unequal relationships between nurses and patients, and valuing
genuineness and mutuality in a professional relationship.
The Judaeo-Christian tradition guided “the moral base and norm of care which relied on
the theological understanding of agape-a non-sexual compassionate caring for another,
regardless of who they are or what they have done” (Wright & Sayre-Adams, 2000: 31),
“which is the foundation and objectivity of the I-Thou relationship” (Bradshaw, 1997:
14). Right relationship leads to a spiritual caring relationship, and it begins within us.
Nurses need to re-explore and enact spiritual values in their caring work. When in right
relationship, the healing potential blooms “new relationships … which recognise the
value of being with people as much as doing to them” (Wright & Sayre-Adams, 2000:
41). O’ Brien (2003: 84) called the nurses-patient relationship “a sacred covenant”. She
mentioned that the covenant-related concepts, such as bonds of royalty and
responsibility, mutual obligations, unconditional faithfulness, and not expecting a return
for good services, have relevance for the nurse-patient relationship. The fruits of a
proper relationship between nurses and patients are tremendous and they can heal both
nurses and patients’ hearts.
Nurses, patients, and relatives learn from each other during therapeutic relationships.
Nurses who see a potential to learn coping strategies from patients and appreciate
patients’ experiences respect patients as their teachers. Patients and relatives learn about
their illness and health care techniques and respect nurses as their teachers. Trust and
mutual participation are foundations of good interpersonal relationships between nurses
and clients.
Authors agree on factors which promote and inhibit spiritual caring
relationships between nurses, patients, and relatives (see Table 9.1).
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Table 9.1: Summarised factors that influence “spiritual caring relationships” between
nurses, patients, and relatives when focusing on nurses and nursing professional issues
Contexts
Personal factors
(adapted from Brykczynska &
Jolley, 1997; Crisp & Taylor,
2005: 433-437; Morrison &
Burnard, 1997; Sully & Dallas;
Williams & Irurita, 2004)
Factors influence spiritual caring relationship
between nurses, patients, and relatives
Factors promote relationships:
Therapeutic communication and intervention
Having positive attitude toward nursing, facilitating
communication, developing relationships, indicating availability,
active listening, using verbal and non-verbal communication,
sharing observations, offering hope, sharing humour, sharing
feelings, using touch, using silence, asking relevant questions,
paraphrasing, and clarifying
Authoritative communication
Displaying competence, providing information, focusing,
summarizing, self-disclosing, confronting, suggesting, advising,
instructing, persuading, encouraging, and offering direst assistance
Factors inhibit relationships:
Non-therapeutic/blocking communication and intervention
Asking personal questions, giving personal opinions, changing the
subject, automatic responses, and false assurance
Negative attitude toward nursing and/or unskillful
Displaying incompetence, not being available, insufficient
provision of information, lacking of proper verbal and non-verbal
communication (lack of eye contact, absence of touch, not smiling
and not sympathy), judging participants’ ideas and decisions,
having defensive, passive or aggressive responses, arguing,
moody, impolite, rude, bully, labeling patients and relatives as a
difficult or demanding
Professional factors
Social expectation, nursing image, and professionalisation
Organizational factors
Health care reforms, nursing shortage, and the need of evidencebased practice.
Relatives in the relationships
In general, nurses always include patients’ families in their nursing care (Wright &
Leahey, 2005); however a few nursing research projects studied the aspects of the
nurse-patient-relative relationship (Stiles, 1990; Logue, 2003). Most studies explored
the role of family or informal caregiver to help and support patients, especially patient
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with cancer, disability, dementia, stroke, children, elderly, and in death and dying. In
addition, numbers of research projects which include relatives as caregivers have
increased gradually.
Kristjanson (1989: 22) applied family theory, looked at family as a system and
explained that “illness in one family member sends reverberations throughout the
family system” and “family is influenced by the social context or environment” which
includes some level of participation in the health care system. Families identified key
important issues for nurses, such as responding quickly to patient’s needs, and the
“patient knows it is okay to call for help at anytime”, and “the patient is treated as a
whole person”.
Sethabouppha & Kane (2005: 1) explored Thai Buddhist caregiving from caregivers'
perspectives in order to explore the meaning of the lived experiences of Thai Buddhist
caregivers through the question: How do Thai Buddhist caregivers experience their
daily lives when a family member is seriously mentally ill? Using a phenomenological
approach, they illuminated:
Five major themes: caregiving is suffering, caregiving is Buddhist belief,
caregiving is compassion, caregiving is management, and caregiving is
acceptance … Thai caregivers practised their Buddhist beliefs when caregiving,
particularly (1) practising metta (caring) and karuna (support) to generate
compassion in caregiving, (2) practising the Noble Eightfold Path (the middle
way) to create management in caregiving, and (3) practising ubekkha
(equanimity) to promote acceptance in caregiving.
Limpanichkul & Magilvy (2004) used a qualitative descriptive study informed by
grounded theory and ethnography to generate a beginning substantive theory that
iluminates the process of caregiving in Thai families living in the United States. A
purposive sample of seven Thai caregivers of chronically ill relatives in the western and
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the midwestern regions of the U.S. participated in interviews, provided observations and
wrote memoranda. Three categories emerged from "managing caregiving at home:"
being caregivers, the consequences of caregiving and coping with the difficulties of
caregiving. The study participants described caregiving as a willing burden and an
unavoidable duty, attitudes which are clearly influenced by Buddhist beliefs. The results
of this study provide nurses with a better understanding of the caregiving process,
especially as it exists in the Thai American population.
Studies indicate that Thai nurses, patients and relatives apply Buddhist beliefs and
practices in their nursing care. For example, Thai nurses, nursing students and patients’
relatives usually make merit for patients and some nurses believed that “Nursing is
making merit”. Thai patients thought that to complain too much about pain would
distress other people and this would not be in keeping with “kreng jai” (hesitation)
(Hebden & Burnard, 2004).
Zaner (1991 cited in Rich & Butts, 2005: 41) argued that health care professions must
promise “not only to take care of, but to care for the patient and family–to be candid,
sensitive, attentive, and never to abandon them.” Wright (2005) valued patient and
family as centred care and persuaded nurses to include family members to help and
support patients. Recently, some researchers have shown the benefit of including
families’ perceptions and reflections of the quality nursing care. Taylor, Glass,
McFarlane and Stirling (2001) studied views of nurses, patients and patient’s families
regarding palliative nursing care, they found that nurses brought many personal
qualities into their palliative nursing care, while patients and families reflected on the
positive and negative aspects of nurses’ qualities and activities. For instance, personal
qualities relatives perceived as effective in palliative nursing were: accepting, caring,
being flexible, helpful, likable, natural, understanding, accommodating, dedicated,
friendly, thoughtful, pleasant, promoting trust, affectionate, empathetic, gentle,
humorous, loving, careful, personalised in their approach, part of the family, patient in
tending to care, respectful of independence and privacy, coping with dying, creating an
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aura of love, having time to relate to patients and their families with nothing being too
much trouble, taking time to be available, and walking to become involved emotionally
(Taylor, Glass, McFarlane & Stirling, 2001: 189). Rich and Butts (2005: 43) contended
several issues can affect the nurse-patient-relative relationship, these are “personal
dignity, patient advocacy, and unavoidable trust, intimate conversations and activities,
such as touching and probing that normally do not occur between strangers are
commonplace between patients and health care professionals.”
In summary, nurses’ value and perception of other people is important to a right
relationship. Buddha paid much attention to the quality of mind, as Thai people usually
said that “We will be happy or unhappy depending on our own thoughts.” Right thought
leads to right actions; this teaching comes from the Noble Eightfold Path. Wright &
Sayre-Adams (2000) suggested ways for nurses to improve relationship such as
changing the way of thinking, “so watch yourself about complaining, sister; if you
cannot change a thing, change the way you think about it” (Maya Angelou, 1994 cited
in Wright & Sayre-Adams, 2000: 20).
Caring relationships
Because nursing is a profession which deals with every aspect of a human’s health
status, among nurses daily interactions and relationships with clients and co-workers,
some problems or conflicts, which come from individual differences among people
from various backgrounds of sex, race, education, nation, sub-cultures, faith, value and
beliefs, can occur inevitably. Rich and Butts (2005) explained that moral suffering such
as uneasiness and anguish is a common experience for nurses. It mostly occurs when
nurses disagree with imperfect institution policies, work overload, physicians’ orders
and the way a family treats a patient makes patient care decisions, which inevitably
affect the nurses-patient-relative relationship and sometimes cause errors and
ineffective care. They compared this suffering to the Buddhist concept of dukkha - life
is impermanence and imperfect, and also can be experienced unsatisfactorily.
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The Dalai Lama (1999 cited in Rich & Butts, 2005) suggested that people are often
affected by suffering. Some see “suffering is something to accept and transform” and
this way of thinking leads nurses to change their perception of conflict and problems
and make better circumstance for clients. Hanh (1998: 5) said that “without suffering,
you cannot grow.” When nurses realise that “they cannot grow without suffering” or
“growth occurs from suffering”, they can cultivate other possibilities to grow and deal
with problems harmoniously.
When nurses are burnout or having compassionate
fatigue, they cannot provide quality of care. This situation effects nurses’ compassion
and sometimes causes pain. Wright & Sayre-Adams (2000) postulated the practical idea
of a sacred space, which is a good/right or sacred relationship between nurses, patients,
families, and other people in the workplace.
In this decade, nursing roles have expanded extensively. In order to meet the goal of
holistic care nurses can work as healers and spiritual teachers and also they can apply a
variety of alternative therapies such as meditation, prayer, energy healing, counselling,
therapeutic touch and so on, to promote healing with patients. However, nurses have
been taught to set boundaries between themselves and clients in a professional
relationship. “Being a compassionate nurse means being a feeling person but not being
so emotionally close to the patient that objectivity is impaired” (Sheldon, 2004: 48).
Even though nurses work as clinical nurses, nurse specialists, and nurse practitioners,
nurses still need to balance the personal dimension with professional boundaries. Wellbalanced nurses can apply healing methods and professional nursing care to promote
health, healing and peace to patients and relatives.
Much research has been done about caring (Carmack, 1997; Coulon, Mok, Krause &
Anderson, 1996; Davenport, 2004; Georges, Grypdonck & de Casterle, 2002; Hagerty
& Patusky, 2003; Hem & Heggen, 2003; Meehan, 2003; Radwin, Farquhar, Knowles &
Virchick, 2005; Sahlsten, Larsson, Lindencrona & Plos, 2005; Sasat, 1998; Stark,
Manning-Walsh & Vliem, 2005; Sundin & Jansson, 2003; Swanson, 1999; and Wilkin
& Slevin, 2004). For example, Swanson (1991) found that the empirical understanding
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of caring included knowing, being with, doing for, enabling and maintaining belief.
However, in nursing profession, Jean Watson is the most distinguished theorist, who is
the foundation of theory of caring in nursing. Watson (1985, 1999a,b, 2005) asserts the
concept of Transpersonal Caring Relationships, which are well-known and have been
extensively applied to developing caring in several nursing contexts around the world.
Her caring theory is the vital path of the nursing profession.
A transpersonal caring relationship refers to “a human-to-human connection that goes
beyond the personal, physical ego self and connects with deeper more spiritual,
transcendent, even cosmic connection in the wider universe” (Watson, 2005: 203).
Watson’s caring theory values a spiritual part of nursing and she provides practical
paths for nurses to develop caring relationship with clients and family. In addition, all of
research projects which have been done about caring in nursing, guide nurses to care
and to avoid uncaring relationships.
The concept of the nurse-patient-relative relationship is related to many other concepts
and can be explained as caring and uncaring relationships. As an example, see Graber
and Mitcham (2004: 91) shown in Table 9.2.
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Table 9.2: A preliminary model of effective clinician-patient interactions (Graber &
Mitcham, 2004: 91)
Level of clinicianpatient interaction
IV.
Transcendent
Primary
Expression
Love
Compassion
III.
Personal/feeling
Intimacy and
friendly patient
relations
II.
Personal/social
Friendly patient
relations
Emotional involvement
Fulfilling job
responsibilities
Superficial patient
relations
Detached concern
I.
Impersonal/
practical
Primary motivation
source
Feeling and intuition
Secular or religious
values
Sense of duty (higher)
Altruism
Social needs
Social needs
Altruism
Material reward
Sense of duty (lower)
Focus of
concern
Primary concern for
patient
Minimal concern
for self
Concern for patient
and self
Concern for self
and patient
Concern for self
From all previous literature and my personal experience I decided that “a relationship is
spirituality” (as shown in Table 9.3). While nursing scholars have valued relationship as
the core component of nursing, they also have put the word “relationship” in almost
every aspect of nursing, especially in the contexts of holistic care, caring, nursing ethic,
and spirituality. The word “relationship”, especially in the nurse-patient-relative
relationship, means everything in the “nursing” world. However, the scope of the
relationship in this research is “the spiritual caring relationship”. This kind of
relationship goes beyond any rules and laws, because it authentically emerges from the
compassionate heart of caring nurses, patients and patients’ relatives.
The concept of spirituality as “a unifying theme in our lives demonstrates the
importance of the spiritual dimension influencing a person’s physical, psychological,
social and developmental health” (Crisp & Taylor, 2005: 609). The spirituality concept
in nursing is complex (Barnum, 2003; Bash, 2004; Conner & Eller, 2004; Cusveller,
1998; Dawson, 1997; Gall et al, 2005; Greasley, Chiu & Gartland, 2001; Henery, 2003;
Knestrick, 2005; MacLaren, 2004; Mahoney & Graci, 1999; Malinski, 2002; McEwen,
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2004; McSherry & Draper, 1998; McSherry & Ross 2002, 2004; Narayanasamy, 1999,
2001; Patterson, 1998; Speck, 2005; Sellers, 2001; Stoll, 1989; Touhy, Brown & Smith,
2005).
Spirituality is often referred to in the literature as being synonymous with religiosity.
However, spirituality is broader than religiosity (Baldacchino & Draper, 2001).
Spirituality includes related concepts, such as: spiritual development, spiritual
assessment, spiritual care, spiritual caregiving, spiritual goals, spiritual imagery,
spiritual loss, spiritual value, spiritual suffering, spiritual support, spiritual counselling
(O’Brien, 2003); spiritual dimension, spiritual belief system, spiritual self, spiritual
wellness, spiritual journey (Schmidt, 2004; Schmidt & Muak, 2004); spiritual pain
(McGrath, 2004); spiritual well-being, spiritual health, spiritual problems, spiritual
distress, spiritual needs, spiritual healing, holism, faith, transcendence, hope, religion,
compassion, trust (Crisp & Taylor, 2005); spiritual preferences (Wright, 2005); burnout
(Carson, 1989; Wright & Sayre-Adams, 2000) and compassionate fatigue (Figley, 1995;
Vander Zyl, 2002).
There are different meanings of health and spirituality among different groups of
patients (Cook, 2004; Mira, 2004), such as in acute illness, chronic illness, aging,
advanced illness, near-death, and so on (Carson, 1989; Crisp & Taylor, 2005; Jewell,
2004; O’Brien, 2003; Ronaldson, 1997; Sorajjakool & Lamberton, 2004). Common
nursing diagnoses for clients in need of spiritual support are: spiritual well being,
spiritual distress, ineffective individual coping, ineffective family coping, altered family
processes, dysfunctional grieving, anxiety, fear, hopelessness, powerlessness and selfesteem disturbance. The major goal of spiritual care is spiritual well being (Crisp &
Taylor, 2005).
From a nursing perspective, the spiritual needs most commonly recognized are: the
search for meaning and purpose in life, a sense of forgiveness, the need for love, the
need for hope, the need for belief and faith in self, in others and in a God or a higher
being. Spiritual health is a balance between a person’s life values and goals and their
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relationship with themselves and others, that can be threatened by illness or loss.
Spiritual healing is a complex phenomenon, a journey in itself, which restores
wholeness to the person. Spiritual healing brings an equilibrium, in which the person
recovers from pain and anguish. The personal nature of spirituality requires open
communication and the establishment of trust between nurses and client.
An important part of spiritual assessment is learning if the client’s family or friends
share a community faith. Part of a client’s care is providing environment for the
presence of family, friends and spiritual advisors. Nurses’ spiritual connections to
clients are at a very basic human level, involving trust, compassion and respect for the
person and their dignity (Crisp & Taylor, 2005). Many interventions are available to
nurses for meeting spiritual needs, including the nurses’ presence and touch, the use of
prayer and religious reading materials, facilitation of a client’s participation in religious
rituals while hospitalized, protection of a client’s religious articles, use of the clergy,
and advocating the client’s position when his or her religious beliefs conflict with the
medical regimen (Carson, 1989). Being present so as “to touch another’s spirit requires
five essential elements which are: listening, empathy, vulnerability, humility, and
commitment” (Fish & Shelly, 1985 cited in Carson, 1989: 165).
McGrath (1998) discussed Buddhist spirituality as a compassionate perspective on
hospice care. This discussion explore the connection between these two compatible
discourses by detailing some of the finding of research completed in a Brisbane
community-based, Buddhist hospice service (the Karuna Hospice Service).She asserted
that the practical, everyday metaphysics of Buddhist philosophy, which are based on
notions of compassion and wisdom, a willingness to serve, tolerance a duty to do no
harm, and the significance of death, shares commonality with hospice discourse.
The spiritual nature of nursing allows nurses to provide quality nursing care to clients.
Nurses cannot provide spiritual care when they are influenced by stress, unrealistic selfexpectations, and undesired changes in life circumstance (Arnold, 1989).
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Table 9.3: Spirituality and relationships in the Western and the Eastern worldviews
Concepts
Western
(Christianity)
Positive
Characteristics
Compassion (Good
Samaritan)
Sympathy, Empathy
Bridge, Interconnection
Hope, Faith
Gods, Angels
Acts
Caring, Listening
Outcomes
Healthful
Caring relationship
Satisfaction
Cost-effectiveness
Negative
Uncaring, Blocking
Harmful/Bullying
Guilt, Denial
Love
Attachment
Relationships
In between (can be
positive and
negative, depend on
the interpretation
and contexts)
Spiritual distress
Spiritual wellbeing
Spiritual healing
Spirituality
Related concept of
spirituality
Illness
Suffering
Hope
Compassion
Moral support
Caring, Presence
Gods/Angels present
Prayer, meditation
Active listening
Energy healing
New age therapies, Etc.
Faith, trust, empathy
Caring, healing
Therapeutic nursing
Competence
Commitment, etc.
Eastern
(Buddhism*
and the Thai Culture**)
Characteristics
The Four Sublime States*
1. Loving kindness (metta)
2. Compassion (karuna)
3. Sympathetic joy (mudita)
4. Equanimity (upekkha)
Non-violence or Ahimsa*
Interconnection*,
Liked-mother**
Moral (Khun)**,
Amoral (Decha)**
Merit**
Acts
Helping, Support
Outcomes
Caring relationship, healthy
Peace, happiness, accepting death
Sin, Harmful
Disrespectful (i.e. touching head)
Impolite, Violence
Non-attachment (Detachment)
Kreng jai (hesitation, care and
consideration)**
Suffering (from the teaching about
the Four Noble Truths and The
Eightfold path)
Compassion
Repaying gratitude
Moral support
Meditation
Mindful living (living with present)
Prayer, Rituals
Religious beliefs and practices
Vowing , Radiate merit
Forgiveness, etc.
Kamma
Impermanence
Interconnectedness, Presence,
Inter being
Nibbana, Enlightenment,
Transcendence, etc.
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Burkhardt and Nagai-Jacobson (2005) suggest that spiritual caregiving requires an
understanding of the holistic caring process that is integrative, in which assessment and
intervention may be the same process, and where description may be more useful than
labeling. Identification of needs in the area of spirituality does not necessarily indicate
pathology or impairment. They also explained that:
Research on spirituality and health continues to highlight the importance of
describing the human spirit in the language of each person’s unique experience
and expression, and exploring individual meaning according to the particular
person’s values. Nurses can provide spiritual care by tending to the spirit,
touching, fostering connectedness, using rituals to nurture the spirit, developing
centering, mindfulness, and awareness, praying and meditating, and ensuring
opportunities for rest and leisure. Spiritual care may incorporate “experts” such
as representatives of particular religious traditions or other spiritual support
people, but nurses need to do more than merely refer matters of the spirit to
these persons. Tending to matters of the spirit may include incorporating ritual,
prayer, meditation, rest, art and any activities that enhances awareness of oneself
and one’s place in the world (Burkhardt & Nagai-Jacobson, 2005: 167).
Buddhist culture and the nurses-patient-relative relationship in Thailand
Several research results showed the relationship of Buddhism and Thai culture on
nursing, especially on nursing care; nursing education; nurses’, nursing students’,
patients’ and relatives’ caring behaviours. In addition, there were some research studies
about the nurse-patient relationship and the relationship between patients and their
family members or patients and informal caregivers. However, I was unable to locate
research which specifically explored the nurse-patient-relative relationship in Thailand.
In a phenomenological study, Chinnawong (1999) did indepth-interviews and nonparticipant observation with ten lung cancer patients receiving chemotherapy, about
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their perception and coping with illness and chemotherapy for nine months. Patients
described illness as being complicated, chemotherapy that provided hopefulness, living
with discomfort and distress, and living with uncertainty. Their coping strategies
included: maintaining physical wellness, releasing tension and distress, making merit,
planning about end of life and distribution of property, and make amends with family
and friends before dying. The participants’ needs were being healthy and free from
diseases, having few side-effects, harmony of mind, making merit, receiving tenderloving care, quality of nursing services, and family’s acceptance of dying.
Lundberg & Trichorb (2001) surveyed feelings, coping, and satisfaction with nurseprovided education and support of 90 male and 89 female Thai Buddhist patients with
cancer undergoing radiation therapy at a Bangkok hospital outpatient radiation therapy
clinic. The results showed that the most common feelings of both genders at first
knowledge about radiation therapy were acceptance/calmness, and the women more
often than the men felt anxiety and fear. The most common ways of coping with
radiation therapy for both genders were rest, talking with family/friends, visiting doctor,
and meditating, and in this regard there were no significant gender differences. The men
expressed their highest satisfaction when the “nurse has knowledge about
disease/treatment” and “nurse listens to patient’s problem,” whereas the women
expressed their highest satisfaction when the “patient dares to ask questions” and “nurse
likes to explain information.” The satisfaction with different aspects of nurse-provided
education and support was commonly higher among the men.
Burnard & Naiyapatana (2004) studied culture and communication in Thai nursing
using an ethnographic study. Data were collected from direct and indirect observation,
interviews and discussions and the literature. Findings reported issues relating to
“Thainess”, Buddhism, the nursing profession and nurse-patient/doctor-patient
relationships.
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Subgranon and Lund (2000) studied caregiving processes of Thai caregivers for elderly
stroke relatives, using a grounded theory approach. After analysing data from
interviewing 20 primary caregiver at their homes, also using observation and memos,
“Maintaining caregiving at home” emerged as a substantive theory. The process of
maintaining caregiving at home by caregivers included seven aspects which were
caregiving as an integrated part of life; caregiving as an unavoidable task; caregiving
with love, sympathy and attachment; family and kinship support; community support;
managing treatment; and managing problems and difficulties.
Limpanichkul and Magilvy (2004) applied grounded theory research and ethnography
to generate a substantive theory of “managing caregiving at home: Thai caregivers
living in the United States”. Three categories emerged from seven Thai caregivers of
chronically ill relatives who participated in the research: being caregivers, the
consequences of caregiving and coping with the difficulties of caregiving. Seeing
caregiving as a willing burden and an avoidable duty were the influences of Buddhism
on caring attitudes of Thai caregivers.
Conclusion
This chapter described Buddhism and its influences on the nurse-patient-relative
relationship. Eastern and Western worldviews differ on the subject of relationships and
Eastern perspectives of Buddhism influence nursing and health care globally. Nursing
scholars have incorporated Buddhist principles in their caring theories and the nursepatient-relative relationship reflects spiritual dimensions of care. The next chapter
brings all of these ideas and the grounded theory together, in a final discussion and
conclusion.
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Chapter 10: Discussion and Conclusion
CHAPTER 10
DISCUSSION AND CONCLUSION
Using the heart (of a co-sufferer) to heal the world (of suffering)
With compassion, costs nothing
With equanimity we will never hurt
With consciousness, we will be safe
With wisdom, we will grow
Altogether, we can cultivate the wheel of virtue, freedom,
unconditional love, health, healing and peace
(My own poem, November 9, 2005)
Introduction
This final chapter discusses the core components of the grounded theory of “Cultivating
Compassionate Relationships with Equanimity between Nurses, Patients and Relatives”,
which relates to the spiritual caring relationship between nurses, patients and their
relatives in the Thai Buddhist nursing context. The related literature on suffering,
compassion and equanimity, which supports this grounded theory, is also discussed.
Insights from this research, reflections on the lessons learned from applying the Buddha’s
teachings, the strengths and weaknesses of this grounded theory research, and the
implications of this middle range theory for nursing practice, education, management and
future research are also discussed.
The Grounded Theory of Cultivating Compassionate Relationships with
Equanimity
Thai Buddhist people apply Buddhist Dhamma to deal with various kinds of suffering,
especially crises, illness and death. In contemporary Thai health care contexts, which are
strongly influenced by Western medicine, there is much to learn about how Buddhist
beliefs and practices among nurses, patients and their relatives affect collaborative
relationships, health and spiritual well-being. In this study a grounded theory approach
was used to explore the influences of Buddhist culture on nurse-patient-relative
Chapter 10: Discussion and Conclusion
relationships in Thailand. The purposes of this study were 1) to generate a middle range
theory of the nurse-patient-relative relationship, 2) to highlight the importance of the
spiritual dimension in nursing care; and 3) to examine ways in which nurses can use
Buddhist principles to improve nursing care.
Seventeen registered nurses, 14 patients and 16 patients’ relatives were purposively
selected. All of the participants self-identified as Buddhist. The semi-structured
interviews and audio tape recording took place in Southern Thailand from October 2003
to March 2004. Through systematic interviewing, theoretical sampling, memo writing
and three steps of analysis, open, axial and selective coding (Strauss & Corbin, 1998),
influences of Buddhist culture on the relationships from nurses’, patients’, and relatives’
perspectives were described.
“The Cultivation of Compassionate Relationships with Equanimity between Nurses,
Patients and Relatives” emerged as the basic psychosocial process (basic spiritual caring
process). Such relationships showed influences of Buddhist and Thai culture, and
highlighted patient-relative centered care. The core social process was composed of the
three co-processes (core categories) including 1) facing suffering/understanding the
nature of suffering, 2) applying Dhamma (Buddhist beliefs and practices), personal/local
wisdom, and traditional healing, and 3) embodying mutual compassion with equanimity,
with each part naturally connected to each other.
The core social process was a natural process of facing suffering (“Kerd Dukkha”) and
understanding the nature of suffering ("Kao Jai Dukkha"); applying Dhamma,
personal/local wisdom, and traditional healing to cope with illness, related sufferings,
working, caring, and being a caregiver (“Chai Dhamma" lae (and) "Phum Panya”); and
feeling and acting with compassion and equanimity (“Kerd Kwarm Karuna” , prom
(with) "Kao Jai", "Yorm Rub", lae (and) "Ploi Wang”) between nurses, patients and
relatives.
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Chapter 10: Discussion and Conclusion
The relationships developed when nurses, patients and patients’ relatives showed concern
about each others’ situations as if it were their own. They tried to help and support each
other with understanding. The cultivation of compassionate relationships with equanimity
combines the art and science of nursing, and focuses on holistic care, spirituality, social
support, religion, cultural care, traditional wisdom and healing. These have been the core
components of human caring since ancient times.
Personal, professional and organisational factors, as well as cultural and religious aspects
that promote and inhibit compassionate relationships with equanimity, were carefully
considered in order to maintain and promote spiritual caring relationships.
This section discusses the middle range theory in terms of related concepts, and core
categories which support the basic social process of “Cultivating Compassionate
Relationships with Equanimity between Nurses, Patients and Relatives”. The related
literature about suffering, compassion and equanimity are also discussed.
Suffering and understanding the nature of suffering
Suffering is the first teaching of the Buddha in the Four Noble Truths. In Buddhism, the
meaning of suffering includes many contexts. Suffering take places when human beings
are “being trapped in cyclic existence-birth, aging, sickness, and death, as “stemming
from ignorance and nourished with attachment and grasping” (Hopkins, 2001: 161).
In the Noble Truth of suffering, the Buddha says: “association with the unloved is
suffering, separation from the loved is suffering, not to get what one wants is suffering”
(author unknown, 2006). The reality of suffering is dukkha, the Pali word dukkha, in
ordinary usage means “suffering”, “pain”, “sorrow” or “misery”. In the context of the
First Noble Truth, dukkha, also means “imperfection”, “impermanence”, “emptiness”,
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and “insubstantiality” (author unknown, 2006, http://dharma.ncf.ca, retrieved January 4,
2006).
From the Buddhist perspective, there are three kinds of suffering: ordinary sufferingdukkha-dukkha; suffering produced by change-virapinama-dukkha; and suffering as
conditioned states-samkara-dukkha.
Suffering is another component of the teaching about the Three Characteristics
(Tilakkhana), the Three Signs of Being: including Aniccata (impermanence, transiency),
Dukkhata (state of suffering or being oppressed), and Anattata (soullessness, state of
being not self). Understanding and acceptance of Tilakkhana lead to the acceptance of
illness, changes, and death and having less suffering (Hanh, 1998; Payutto, 2001).
The Eightfold Path promotes the right understanding, which to Buddhists suggests that
there are Three Marks of Existence: suffering, impermanence, and no-self; the
wholesome (generosity, love, and wisdom) and unwholesome (greed, hatred, and
delusion) (Payutto, 2003), and the dependent origination (paticcasamuppada) in order to
avoid suffering by not against the law of nature and the law of impermanence (Bhikkhu,
2002; Hanh, 1998).
In nursing and health care, suffering is a key concept of spiritual distress (Muak &
Schmidt, 2004; Wright, 1997, 2005). Suffering is an ongoing state of distress that affects
a person’s sense of well being. It includes physical, emotional, social and spiritual
problems (O’Brien, 2003). Each person’s suffering experience is unique, and the
alleviation of patients’ and relatives’ suffering has always been at “the heart of nursing”
(Wright, 2005: 128).
Suffering refers to evil, hurt and struggle (Lindholm & Erikson, 1993). “Patient feels that
their suffering will be discovered only when they ask for help”, while “every nurse
assumes that suffering can be alleviated, but at the same time she (sic) feels uncertain
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about how it can be alleviated” (Lindholm & Erikson, 1993: 1356). However, Thompson
(2004) claimed that Buddhism, especially Zen Buddhism, provides a deep understanding
about suffering and ways to overcome suffering and gain happiness, while dealing with
any life changes.
Leners and Beardslee (1997) claimed that nurses should focus on intuition, relationships
and empathy more than rationality, when caring for suffering patients ethically. In
addition, Raholm and Lindholm (1999) suggested nurses provide ethical care by being
with patients, confirming patients’ absolute dignity, and acting with love and compassion,
while being in the world of suffering patients. Rundqvist and Severinsson (1999) and
Richardson (2004) also confirmed that communication skills, touching, mutual
confirmation, and the caregiver’s valuing in the caring culture, were the main factors
which influenced the caring relationship between nurses and patients suffering from
dementia.
Lindholm and Erikson (1993) stated that “suffering is the point from which caring
begins.” Compassion is the most important quality of nurses, supporting suffering
patients and families (Lindholm & Erikson, 1993; Muak & Schmidt, 2004; Rodgers &
Cowles, 1997). Accepting suffering and alleviating suffering are the main purposes of
caring, and the nurses’ own philosophy on suffering influences his or her nursing.
Suffering clients need someone to understand and care for them, to treat them with
honour and respect (Eriksson, 1992, 1997). Eriksson (1997) encouraged nurses to create a
good caring culture to prevent suffering caused by nurses, because patients already face
multiple suffering caused by illness and treatments. Florence Nightingale (1959) realised
the importance of a caring and healing environment since the beginning of the nursing
profession. Macrae (2001) added that Nightingale also valued spiritual health,
compassion, and respect, which aims to comfort suffering patients.
Rowe (2003) was concerned about the suffering of nurses and healers, which comes in
the form of severe stress and burn out. Many nurses researchers were concerned about
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nurse suffering and compassionate fatigue (Figley, 1995; Henry & Henry, 2004; Jezuit,
2003; Sherbun, 2006; Vander Zyl, 2002). Wright and Sayre-Adams (2000) and Macrae
(2001) suggested nurses and clinician can learn relaxation and spend time in retreat, to
renew body-mind-spirit by using art, writing a journal, practising yoga, meditation, and
so on.
Wright (2005: 130) realised that the influences of family members’ spiritual and religious
beliefs on their illness experiences, had been “one of the most neglected areas in
individual and family nursing practice”. She initiated the Trinity Model, for nurses to use
with family members, to alleviate patients’ suffering and promote patients’ health and
healing. This model is useful to explore the complex concepts and interconnections of
beliefs, suffering, and spirituality, within the context of serious illness (Wright, 2005).
Similar to the grounded theory of “Cultivating Compassionate Relationships with
Equanimity”, Wright’s project valued compassionate relationships between nurses,
patients, and families. However, Wright applied Western concepts of suffering, and
spiritual care and did not apply equanimity in her Trinity Model.
Cultivating compassion
Understanding suffering and wanting to help sufferers
According to Hopkins (2001: 157), compassion is “the heartfelt wish that sentient beings
free from suffering and the causes of suffering”. Compassion is “a major theme of all
Buddhist traditions”, as the Buddha taught it directly. It is “the beginning of the path for
bodhisattava-those dedicated to becoming to fully enlightened to be of benefit to other
beings”. In the Mahayana Buddhist tradition, compassion is considered “the root of all
aspects of enlightenment” (Friedland, 1999: 35; Fuss, 2000). Friedland (1999) also
contended that compassion relied on shared judgments and sensitivity to the inner aspects
of life and it helps people to understand others and respond to others in the most
beneficial manner. Therefore, developing compassion requires clear and non-judgmental
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minds. Roshi (2000, cited in Bloom, 2000: IX) claimed that fully facing the truth of
one’s own impermanence can open up a flood of tenderness and compassion that often
heals the deepest wound. There are three types of compassion (Hopkins, 2001).
The first is compassion seeing suffering beings, qualified by the suffering of
being caught in a process of contaminated conditioning. The second is
compassion seeing evanescent beings, qualified by impermanence and
insubstantiality. The third is compassion seeing empty beings, qualified by not
having any apprehensible signs of inherent existing (Hopkins, 2001: 159).
Subjectively, there are three forms of compassion (Hopkins, 2001: 159). Firstly, “How
nice it would be if all beings were free from suffering and the causes of suffering!”
Secondly, “May they be free from suffering and the causes of suffering!” and thirdly, it is
the perspective of “I will free them from suffering and the causes of suffering.”
The nature of compassionate acts is unselfish and non-violent
Hem and Heggen (2004: 22) claimed that “a compassionate person acts without thought
of reward. Practical care means acting in response to the patient’s appeal for help and
without expecting any return from the person being care for.” A crucial benefit in the
growth of holistic nursing is the potential to promote compassionate care, not only of our
clients, but also of our peers and ourselves.
World religions teach people to do good deeds and avoid bad deeds. Compassion is the
main quality that needs to be cultivated in people’s hearts. Compassion is a virtuous act,
which is taught mainly in Mahayana Buddhism. As the Dalai Lama (1998, 2000, 2001,
2005a,b) and other Buddhist teachers (Bhikkhu, 2001; Hanh, 1976, 1991, 1998, 2003;
Hopkins, 2001; Kornfield, 1993; Ladner, 2004; McConnell, 1995; Payutto, 2001;
Rinpoche, 2002; Sthirasuta, 2005; Subhuti, 2004; Suddhiyano, 2000; Walsh, 1999; Wasi,
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Chapter 10: Discussion and Conclusion
2002) suggest people should try to cultivate compassionate thoughts and acts against
violence and promote spiritual friendships, people’s inner peace and a peaceful world.
Promoting holistic care and healing
Compassionate care is an essential component of holistic care (Graber & Mitcham,
2004). However, compassion is neglected in a business-focus and economically
concerned health care industry (Muak & Schmidt, 2004).
The word compassion “implies more than feeling sympathy, but the active participation
or experience of one individual in another individual’s suffering. The ability to provide
compassionate care clearly “has its source in individual motivation and wisdom” (Graber
& Mitcham, 2004: 87).
Aung (1996: 81, 82) claimed that compassion and loving kindness are seen as “the
Buddhist medicine” and included in every Buddhist healing act is “loving kindness,
selflessness, compassion, and sympathetic joy”. Compassion and loving kindness
promote gentle, warm, open and intelligent communication, and remind health care staff
that “their services must be safe, reliable and effective” which is important for primary
care (Aung, 1996: 81). The Buddhist teaching about the Noble Eightfold Path provides
comprehensive guidelines for attaining and sustaining loving kindness and compassion,
which prevent harmful acts and promote healing and quality of care (Aung, 1996).
Picard (2002: 151) explained that Newman’s (1995) basic concept of “compassionate
consciousness” is important for nurses, because it is “the nurses’ capacity to be fully
present to the patients”. Compassion is expressing thoughtful dialogue and listening.
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Promoting ethics and ethics of care
Ladner (2004: XVI) claimed that empathy and compassion are “fundamental for natural
ethics and for a positive relationship.” Cultivating compassion is “the single most
effective way to make oneself psychologically healthy, happy and joyful” (Ladner, 2004:
xvii). It is a direct antidote to prejudice and aggression. It can heal suffering and promote
health, promote peace in ourselves and in the world (Ladner, 2004).
Von Dietze and Orb (2000), and Jormsri, Kunaviktikul, Katefian and Chaowalit (2005)
claimed that compassionate care is a moral dimension of nursing. Von Dietze and Orb
(2000) contended that compassion is a moral virtue, which gives context and direction to
nurses’ decisions and actions, and which exhibits excellence in nursing practice. Von
Dietze and Orb (2000) also claimed that compassion is more than just a natural response
to suffering, rather that it is a moral choice. Compassion is often considered to be an
essential component of nursing care; however, it is difficult to identify the specifics of
compassionate care. Jormsri et al (2005) studied moral competence in Thai nursing
practice, based on personal, social and professional value. They found that lovingkindness, compassion, sympathetic joy, equanimity, responsibility, discipline, honesty,
and respect for human values, dignity and rights were the main indicators of Thai nurses’
moral competence.
Balancing self-compassion and compassion for others
Fox (1999: iv) promotes living compassion as a way of life. He asserted that compassion
is “not pity but celebration”. Compassion is “not sentiment, but is making justice and
doing works of mercy.” Compassion is “not egocentric but public.” Compassion is “not
about ascetic detachments or abstract contemplation, but is passionate and caring.”
Compassion is “not anti-intellectual, but seeks to know and to understand the
interconnection of all things.” Compassion is “not a moral commandment, but a flow and
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overflow of the fullest human and divine energies.” Finally, compassion is “not altruism,
but self-love and other-love at one.”
Neff (2003) claimed that Buddhist psychology values analyzing and understanding the
self, therefore self-compassion is needed in order to act compassionately with others.
Neff (2003: 223) also explained that:
Self-compassion entails being kind and understanding toward oneself in instances
of pain or failure rather than being harshly self-critical; perceiving one’s
experiences as part of the larger human experience rather than seeing them as
isolating; and holding painful thoughts and feeling mindful awareness rather than
seeing over-identifying with them.
Focusing on compassion in the Christian perspective
Aung (1996: 83) argued that a compassionate approach is not the only caring quality
found in Buddhism. Jesus, like Buddha, is considered to be a supreme healer (Harper,
1988 cited in Aung, 1996: 83). Among many teachings in the Bible, “Agape, the classic
Greek and Christian concept of loving one’s neighbour, spiritually rather than sensually,
is analogous to Buddhist loving kindness.” It also implies tender loving care (metta)
(Aung, 1996: 83).
A Christian story about the good Samaritan has also been applied to teach nurses about
compassionate care as “a model of caring compassion” (Hem & Heggen, 2004). In brief,
while traveling from Jerusalem to Jericho, the good Samaritan helped injured people with
empathy, while other people did not care for the sufferers. This idea promoted charity and
stewardship for Christian people (Blocher, 2002). Blocher (2002: 3) also claimed that,
“the Samaritan is not good with compassion alone, he (sic) must also have wisdom”, and
“wise compassion required both resources and thoughtful allocation.”
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Compassionate acts play an important role in nursing as well as medicine, and “it has
been a cornerstone of western hospital tradition since 400 CE.” The ideal is expressed as
“the duty to love and care for the weak and the sick regardless of their social rank or
status” (Nortvedt, 2002 cited in Hem & Heggen, 2004: 20). Compassion includes an idea
and a practice (Hem & Heggen, 2004). Milner (2003: 6) also contended that “compassion
is essential to nursing practice”.
Cultivating equanimity
Glaser (2005) claimed that “although central to the cultivating of love and compassion,
equanimity is largely overlook in our society.” Equanimity is a wonderful quality, a
spaciousness and balance of heart (Kornfield, 1993: 331). From a Buddhist perspective,
equanimity means equality, and unconditional acts (Glaser, 2005), detachment, nonjudgment, freedom from bias and prejudice, self-reliance, accepting limitations due to
kamma (Harris, 1997), but it does not mean neutrality or indifference (Glaser, 2005).
Equanimity is the last part of the Buddha’s teaching on the Four Sublime States of
Consciousness, which include loving kindness, compassion, sympathetic joy and
equanimity (Punyanubhap et al, 2001; Tongprateep & Soowit, 2002).
Equanimity in Buddhism also means “even-mindedness”, which is cultivated by
“learning to place at the core of your relationships with others the deeply felt realisation
that everyone equally aspires to gain happiness and to be rid of suffering.” As a Buddhist,
meditators, contemplate: “Just as I want happiness and don’t want suffering, this person
wants happiness and doesn’t want suffering” (Hopkins, 2001: 34). Friedland (1999: 39)
claimed that “equanimity allows one to feel compassion for the suffering of others
without becoming overwhelmed by or neglect it.”
From a psychological point of view, equanimity includes understanding and compassion
(Kornfield, 1993). Glaser (2005: 133-4) identified three stages of equanimity:
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Chapter 10: Discussion and Conclusion
The first is called wishing or motivating equanimity … we deeply wish for all
beings-without exception-to have happiness and be free from suffering … The
second level of equanimity focuses on dissolving projections of friends, enemies,
and neutral persons by investigating and seeing through our attachment, anger,
and indifference … The third level of equanimity builds upon the other two. At
this level, we focus on establishing equality between ourselves and others, by
contemplating every being’s wish to experience happiness and be free from
suffering.
However, cultivating equanimity is “not an easy thing to do; it is something very
complicated and difficult”, which needs patience, hard work and persistent practice
(Glaser, 2005: 134). Wick (2005) illustrated many examples of the Zen master’s
compassionate relationships while training and practising medication and wisdom.
Equanimity is the main teaching of Buddhism, however, this concept has been explored
very little in nursing and health care research projects. In nursing language, equanimity is
a part of serenity and resilience concepts. Equanimity is a component of resilience (Felten
&Hall, 2001; Jecelon, 1997; Polk, 1997; Wagnild, 2003).
Resilience is defined as the ability to transform disaster into a growth experience and
move forward (Polk, 1997: 1). It is an important concept for nurses who care for people
in illness and ageing (Jecelon, 1997). There are four patterns of resilience which are: the
depositional pattern, such as intelligence, health, temperament, and self confidence; the
relational pattern, such as roles, relationship and social networks; the situational pattern,
such as cognitive appraisal and problem solving skills; and the philosophical pattern,
such as personal beliefs. The concepts of “the energy field, openness, pattern, and
pandimensionally are fundamental to a nursing model of resilience” (Polk, 1997:15). For
women older than 85, resilience is “the ability to achieve, retain, or regain a level of
physical or emotional health after devastating illness or loss” (Felten & Hall, 2001: 46).
Finfgeld (1992) contended that a sense of equanimity also provides courage for the
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Chapter 10: Discussion and Conclusion
chronically ill elderly. Reynolds and Alonzo (1998) also stated that HIV informal
caregivers face severe uncertainty and distress, but they could experience a heightened
sense of coherence and personal growth after developing a state of equanimity.
Equanimity is an important part of the serenity concept (Roberts & Whall, 1996). Roberts
and Whall (1996) claimed serenity is a goal of nursing practice. By synthesising the
conceptual framework of serenity in nursing perspective, Roberts and Whall (1996)
proposed four levels of serenity, which are: safe, wise, beneficent and universal self.
Level one, the personal self or the safe self serenity, is a stage when clients perceive
personal safety by valuing the inner heaven, detachment, self-belonging, developing trust,
and using problem-solving. Level two, the wise self serenity, refers to patients forming a
perspective of acceptance, using cognitive learning, focusing on the present and using
problem-solving. Level three is the extended self or the beneficent self serenity, when
patients reach the state of valuing connectedness, altruism, peacefulness and forgiveness.
The last is level four, the universal self serenity. Reaching this stage, patients have
heightened awareness, value nature and universal consciousness. Therefore, nurses can
provide different levels of nursing activities, while caring for clients who have different
levels of serenity.
In brief, equanimity promotes understanding people’s suffering and equal caring
relationships. It helps nurses to cultivate equanimious compassionate relationships with
patients and relatives, while valuing spiritual caring relationships.
Cultivating compassion with equanimity
The Buddha’s main teaching underpinning compassionate relationships emerges as the
Four Sublime State of Consciousness (Punyanubhap et al, 2001). This teaching comprises
the four qualities of the caring mind, which are: loving kindness, compassion,
sympathetic joy and equanimity (Tongprateep et al, 2002).
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Glaser (2005: 132) provides a clear observation that “although central to the cultivation
of life and compassion, equanimity is largely overlooked in our society” especially in
psychology, nursing, and medicine. Even those who speak of love and compassion, rarely
speak of equanimity. There are few projects that study and see the value of a concept of
equanimity in health and therapeutic relationships. Scholars, who discuss equanimity,
always discuss love and compassion at the same time (Frakes, 2004; Kornfield, 1993;
Glaser, 2005).
Graber and Mitcham (2004: 87-94) asserted that compassionate clinicians take patient
care beyond the ordinary. However, clinicians need to learn about detached concern,
which is similar to the teaching about equanimity in Buddhist teachings. Some health
care professionals particularly in medicine, have long advocated that “clinicians
demonstrate an affective equanimity or neutrality and maintain professional distance
between themselves and patients” (Graber & Mitcham, 2004: 87).
Graber and Mitcham (2004: 90) discussed how nurses need to balance detachment and
intimacy. They contented that “generally the clinicians enjoyed close relationships with
their patients. However, they acknowledged that at times some professional distance was
necessary.”
Burns (2001: 159) suggested basic ideas for cultivating compassion in nurses and health
care providers, for example, “empathy can be healing, care helps ease fear (and increases
comfort), kindness can diminish depression, wisdom comes from combining knowledge
and compassion.”
A Buddhist understanding of compassion is “grounded in equanimity in order to solve the
problem of the potential painfulness of the virtue of compassion” (Frakes, 2004: iii). In
addition, Frakes (2004) argued that the virtue of compassion, by responding to suffering
with equanimity, is the most effective way to care for and heal sufferers. Dealing with
suffering with compassion and equanimity prevents carers from being painful and
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Chapter 10: Discussion and Conclusion
sorrowful (Frakes, 2004). Adler (2002: 887) also believed that “compassionate
equanimity” is a core value of a doctors’ caring behaviour. It can promote the doctorpatient relationship. Conveying compassionate equanimity is the art of a clinician-client
relationship, which can be good for both the clients’ and doctors’ health, and can reduce
admissions and hospitalised time, thereby reducing health care costs. As the immediate
effect of caring relationships promotes balanced endocrine response patterns, and
promotes psychoneuroimmunologic balances, non-caring relationships can cause staff
burn out, poor patient outcomes and increased costs of care (Adler, 2002).
All the Buddha’s teachings are based on compassion for self and others, which makes
people’s lives simpler and more peaceful. Mae Chee (Nun) Sansanee (Sthirasuta, 2005)
stated that the metta (compassion) needs to be balanced with wisdom, as the left hand
holds metta and the right hand holds wisdom. People need to feel compassion for
themselves first, because after they open their mind and relinquish their biased attitudes,
they have more patience to listen to and understand other people’s suffering.
People
who realise the truth of life live carefully and prepare themselves for any changes in their
lives and a good death. Buddhism also nurtures a peaceful environment and promotes
non-violence, which supports patients’ healing environments. Practising mindfulness
meditation helps to develop consciousness and enhances clear and non-judgemental
mind. These are good ways for nurses to develop reflective practice skills and for patients
and relatives to calm their minds.
Essentially, Buddhism accepts all other disciplines to uphold the Noble Eightfold Paths.
Nurses can apply the Buddha teachings to promote spiritual caring relationships with
patients, relatives, significant persons, groups of people in a community, and between all
sentient beings and sacred sources of power in the universe. Cultivating compassionate
relationship with equanimity between nurses, patients, and relatives allows nursing
professionals to enact holistic care goals and to be compassionate people, who devote
themselves to helping others with compassion and equanimity. In doing this, the quality
of care will be enhanced, and burnout and compassionate fatigue will be diminished.
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Chapter 10: Discussion and Conclusion
Health, healing, spiritual growth, satisfaction, and peacefulness will be the consequences
of “Cultivating Compassionate Relationships with Equanimity between Nurses, Patients
and Relatives”.
In addition, this study found that the core concept of embodying compassion with
equanimity valued the compassion as a core characteristic of nurses, which is identified
as a caring quality by holistic nurses from the Western literature (Crigger, Brannigan, &
Baird, 2006; Dossey, Keegan, & Guzzetta, 2005; Muak & Schmidt, 2004). However,
equanimity is applied by nurses, patients and relatives from the Buddhist culture more
explicitly than in Western countries. Few Western philosophers discuss the role of
equanimity in spiritual care provided by nurses (Frakes, 2004), and no previous studies
discussed compassion and equanimity applied by patients and relatives in Western
countries.
Influence of Buddhist and traditional beliefs and practices
Participants shared various kinds of Buddhist beliefs and practices, and they provided
choices for complementary care, alternative self care, and coping, as described in Chapter
8. Therefore, beliefs about the nature of illness and death and the teaching about kamma
have major influences on participants’ self care, coping and caring behaviours.
Most participants in this research, including patients, their relatives, and nurses usually
said that “...birth, old age, sickness, and death is inevitable … it is what it is … it is the
truth, so I can accept my illness and can face the disease with a strong mind.” (See Pe
Da’s account in Chapter 6).
Almost all patients and relatives believed in kamma. Some patients believed that their
illness was a result of their past bad kamma, but the meaning of kamma was different
from person to person. While village people linked past kamma with bad luck or the
effect of supernatural powers, educated patients thought that their past kamma meant
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Chapter 10: Discussion and Conclusion
behaving improperly. For example, eating too much food could cause high cholesterol
and coronary heart disease.
Influence of Buddhism on Thai caring characteristics
Participants shared various characteristics of compassionate nurses and uncaring nurses
(see Chapters 8). Smiling, repaying gratitude, supporting family, and respecting the
elderly, were examples of Thai caring characteristics influenced by Buddhism.
I have wondered for several years about what underpins the hard work, calmness, and
kindness of many Thai nurses. The research participants told me that Thai nurses can
cultivate their strong compassionate qualities even though they work very hard. Nurses
have low incomes when compared with other health care professionals, however, they
work with compassionate hearts.
Factors influencing the nurse-patient-relative relationship
Factors that support a compassionate mind include having a good Dhamma role model,
living in kind Buddhist society, learning and practising Dhamma in daily life, applying
Buddhist thinking to consider illness and death as normal phenomena, and developing
mutual compassion with equanimity. Regardless of other inhibit factors, such as
busyness, Thai Buddhist nurses can maintain their compassionate care by maintaining
good caring attitudes, cultivating nursing care with compassion, accepting the results of
illness and letting go of negative feelings. Because they want to help patients and
relatives and they do not want to add more suffering to others, by trying to do good and
avoiding doing harm, nurses can use a pure compassionate mind to guide every action
and interaction while caring for patients and relatives. (See literature about factors
promoting and inhibiting the relationship in Chapters 9).
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Chapter 10: Discussion and Conclusion
In the modern Thai world, values of many nurses have changed from “helping others” to
“wanting more money”. Nowadays, staffing in Thai nursing organisations is not seriously
lacking, but the value of nursing has changed from wanting to care for others to wanting
to find a job. Valuing compassionate care must be cultivated by nursing organisations, in
order to balance the organisational and personal values of nurses. The authentic value of
wanting to help others by being kind and compassionate in nursing care is vital.
In conclusion, the substantive theory of cultivating compassion with equanimity provides
compassionate paths for nurses to develop spiritual caring relationships between nurses,
patients and their relatives. The outcomes of caring with compassion and equanimity
include: promoting happiness, peace, health, well being, healing, and a peaceful death for
both care-givers and care-receivers.
Insights
Buddha’s teaching focuses on suffering and the paths to alleviate, overcome, tolerate, and
accept suffering. Nurses have a responsibility to help patients and families release their
suffering, to be healthy, happy or die peacefully, therefore, all of the teachings of Buddha
are related to nurses and nursing care. The teachings are based on the Five Precepts, the
Four Noble Truths, The Eightfold Path, loving kindness, compassion, sympathetic joy,
and equanimity, support the holistic perspective of nursing professionals, highlight
virtues and guide spiritual caring relationships.
Resulting from participants’ experiences, this substantive theory of “Cultivating
Compassionate Relationships with Equanimity between Nurses, Patients and Relatives”
supports the core values of nurses’ applications of Buddhist principles and practices to
spiritual care by six qualities, which are: promoting holistic care, valuing meritorious
acts, reducing the health care budget, being simple and practical, preventing caregiver’s
compassionate fatigue, and enhancing quality of human dignity and quality of care.
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Chapter 10: Discussion and Conclusion
The philosophy of the Thai Buddhist culture values harmony and integration without
boundaries between art and science; between the orthodox tradition and Buddhist
paradigms; between the medical model, holistic model, and Buddhist model; and between
self-sufficiency and dependence on technology. The Buddhist teachings about law of
kamma and impermanence helps Buddhists value nature and simple living, so Buddhists
learn to balance simple living and perfect living, especially when facing illness and
changes. Buddhist nurses, patients and relatives respect healing activities that do not
thwart the Eightfold Path, however, the most important quality is to value the
compassionate quality of mind and to apply the Buddha’s teachings about suffering,
compassion and equanimity.
Lay Buddhist nurses, patients and relatives from the Thai Buddhist Culture value the
Middle Way, between traditional wisdom and modern wisdom; between patronage and
democratic management; between Eastern and Western worldviews; between local
wisdom, religious beliefs and practices and universal love; between being self-centred
and selfless (non-self); between permanence and impermanence; between self-care and
care for others; and between self-reliance and dependence on others.
Lay Buddhist nurses, patients and relatives also value balancing power and mutual
respect between nurses and clients, balancing amoral power with moral acts, balancing
hierarchy and being decentralised, by valuing the participation of patients and relatives
and patient-relative centred care.
Finally, cultivating equanimous compassionate relationships means nurses provide
holistic care from their hearts. Nurses value human beings and provide spiritual care to
promote health, healing and a good death. Nurses realise the interconnectedness of every
concept in nursing theories and apply them to care for patients, families and themselves.
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Chapter 10: Discussion and Conclusion
Reflections
Reflecting on the research participants
My research participants linked some of their caring and self-care experiences with the
Buddha’s teachings, but they could not express all of their experienced to me within one
or two hours. I decided to undertake several interviews for the participants to be happy
and willing to share their applications of Buddhism. After more interviews, participants
expressed more details of their experiences of applying Buddhism. My interviewing
sessions were flexible and fruitful. Within the open-semi-structured interview, I gained
insight into the heart of Buddhist teachings, applied by nurses, patients and relatives. The
values of participants’ experiences were like leaves in Buddha’s hand – they have applied
Buddhist teachings in their whole life-cycle in as many experiences as leaves in the
forest, but they could only tell part of their applications, possibly as many experiences as
leaves in Buddha’s hand. In essence, everything is Dhamma, Dhamma is duty, Dhamma
guides every level of relationship, and everything is interconnected, were the main
participants’ experiences.
Reflecting on the grounded theory research
In brief, knowledge and application of Buddhist teachings are not new ideas, because
they have been adapted by Buddhist and non-Buddhist persons for more than 2500 years.
As a researcher exploring the influences of Thai Buddhist culture on nurses, patients, and
relatives relationships, I did not have to use any personal and professional experiences
while collecting data from participants, because all of them had unique meanings of the
applications of Buddhist teachings. However, my personal and professional of application
of Buddhist teachings helped me gain sensitivity to the participants’ experiences and
helped in theoretical sensitivity, theoretical sampling, and coding.
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Chapter 10: Discussion and Conclusion
It was very useful for me to review some literature about Buddhist teachings and
relationships in the Thai context, in order to explain the similarities and differences
between
previous
results
and
the
new
substantive
theory
of
“Cultivating
Compassionate Relationships with Equanimity between Nurses, Patients and Relatives”.
This theory confirmed the sacred Buddha teachings of 2549 years, which hold the values
of promoting spiritual care, health, and a peaceful dead.
Reflecting on the qualitative research
The grounded theory of Cultivating Compassionate Relationships with Equanimity
between Nurses, Patients, and Relatives reflects the holistic worldview of people from the
non-western world. As Leininger (1985: 9), proposed:
Ontological and teleological positions or views of human beings from Western
and non-Western worlds have had a major impact upon the evolution of the two
major types of research. In addition, historical, anthropological, philosophical and
sociological knowledges have influenced ideas about the nature of human beings,
world views, and the way of knowing people.
Leininger (1985: 9-12), explained some major contrasts between Western and nonWestern world views that help researchers to understand qualitative and quantitative
types of research as showed in Table 10.1
In brief, the substantive theory reflected many wholistic aspects of non-Western
worldview as described above, especially the ancient philosophy of Buddhist teachings,
highlighted the spiritual caring relationship in the Thai Buddhist context. It also focuses
on spiritualism, magic, healing potential, aestheticism, and mysticism, as natural
lifestyles and coping methods of people in the Buddhist community, who are influenced
by traditional and supernatural beliefs, as well as Buddhist beliefs and practices.
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Chapter 10: Discussion and Conclusion
Reflecting on the nursing theory
This grounded theory of “Cultivating Compassionate Relationships with Equanimity
between Nurses, Patients and Relatives” values compassion, kindness, universal love,
humanistic care, patients’ and relatives’ participation, and cultural /complementary care,
in the spiritual caring relationship. This middle range theory provides many practical
spiritual care and complementary care activities, which support the caring concepts of
many nursing theorists, who emphasised the importance of the interpersonal processes
and human caring in nursing care, especially Nightingale (1959), Peplau (1952), Orlando
(1961), Travellbee (1976), King (1971), Paterson and Zderad (1988), Leininger (1978,
2002), Watson (1979, 1985, 1999a,b, 2005), Parse (1987) and Benner and Wrubel
(1989). Some nursing scholars, for example, Martha Rogers, Margaret Neuman, and Jean
Watson have indirectly applied Buddhist principles in their theories. They also value
humanistic approach and the power of consciousness and presence, which are congruent
with the Buddha’s teachings and the research participants’ experiences.
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Chapter 10: Discussion and Conclusion
Table 10.1: Contrasts between Western and non-Western philosophical world view influencing research paradigms
(Leininger, 1985: 10-11)
1.
Western orientation
Focus is on recent human conditions, events, and future developments
1.
Non- Western orientation
Focus is on early historical and prehistorical human conditions or
events
Emphasis is on philosophical, historical, epistemological and esthetical
explanations about human behaviour, Deal with rational and irrational
thought
Use a contemplative and reflective focus to know and understand
reality or non reality
Use humanistic, cultural, social, experiential, philosophical, historical,
and a variety of other means to know and explain circumstances
Emphasis is on biological, chemical, economic, technological,
psychological, and genetic factors to explain human behaviours,
especially rational thinking modes
Use an action and testing focus to “prove” reality and causes
2.
4.
Use logical deductions and systematized data base to study and explain
phenomena
4.
5.
Focus is primarily on individuals and small groups who are to be
studies and explained
5.
6.
Human are complex, but can be known by a few significant variables
of a biophysical, emotional, economical, and social nature. Reduction
to uni-cause or a few variables prevails.
6.
7.
Research largely focused on objective reality to verify phenomena
(extrinsic factors important)
7.
8.
Focus on discrete human behaviour, problem solving, and proving
reality by testing
8.
9.
Emphasis on experimental and quasi-experimental (measurement)
research
10. Holds that reality experiences are objective and definable
9.
11. Time and changes are very important (now and in the near future)
10. Focus on spiritualism, magic, healings potential, aestheticism, and
mysticism to be understood
11. Changes within cultural values and within historical, contextual, and
environment factors are important, especially past history factors
12. Totality of life experiences is important (the “wholistic perspective”)
2.
3.
12. Parts, objects, and selected aspects of life are important (the “pieceperspective”)
13. Objects, things, and relationships are of prime important
3.
Focus is on families, institutions, corporation groups, history,
civilisations, and humanistic experiences which are to be explained and
understood
Human behaviour is complex and multifaceted, but it is human
conditions, lifeways, and quality of life through time that are important
with religion, culture, values, and history providing multi-explanatory
findings
Research focused on both subjective and objective factors to know the
situation or condition (intrinsic factors slightly more important than
extrinsic ones)
Emphasis on human conditions, symbols, rituals, lifeways, and patterns
are important (measurement) research
Emphasis on naturalistic (environmentalist) research
13. Context, people, and historical situations are most important
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Chapter 10: Discussion and Conclusion
Strengths and limitations of the research
Strengths
Reaching a high level of theory development
This research moved from the level of description and conceptual ordering through to
theory, which Strauss and Corbin (1998: 15) state provides a set of well-developed
concepts related through statements of relationship. It also meets many criteria of
trustworthiness, as described in Chapter four. Moreover, when I considered the quality
of research as Strauss and Corbin (1998) suggested, I found that I met these criteria.
Firstly, the grounded theory of “Cultivating Compassionate Relationships with
Equanimity between Nurses, Patients and Relatives” revealed itself as a quality middle
range theory, in the substantive area of relationships in spiritual and holistic health.
Secondly, I showed adequacy of the study’s research process and grounding of findings.
Strauss and Corbin (1998) were concerned that the set of concepts are grounded in the
data. I presented links between individual categories and their subcategories, as well as
to larger core categories. As shown in Table 8.1 (in Chapter 8) Table 8.2 and 8.3 (see
Appendices H and I) categories were theoretically dense, with many properties and
dimensions. This theory has been examined under a series of different conditions and
developed across a range of dimensions as suggested by Strauss and Corbin (1998),
however, some categories overlapped and were connected to others, for example, some
codes and categories “facing suffering/understanding suffering” were placed under the
sub-categories “acting with compassion”. By understanding patients’ and relatives’
situations, needs, values and beliefs, they supported and referred to each other.
Thirdly, I explained macro and micro conditions, which were derived from participants’
accounts, such as personal issues, processional issues, and organisational issues, that
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influenced and inhibited compassionate relationships between nurses, patients, and
relatives, as explained in Chapter 8.
Fourthly, I developed a middle range theory by fully drawing on creativity and
developing insight into what the data were reflecting. This was in a process of interplay
between the researcher and the data. Strauss and Corbin (1998: 272) remarked that “this
depends on three characteristics of the researcher: analytic ability, theoretical
sensitivity, and sufficient writing ability to convey the findings.” I applied Vipassana
(mindfulness) meditation to enhance these qualities, by practising mindful breathing,
mindfulness movements, waking and sitting meditation throughout the research process.
I did not do these activities every day, but I did them every time I needed to clear my
mind for interviewing, so I could and hear participants’ experiences as they were, and
for analysing, and writing, so I could see the right directions to continue my work. This
practice also helped me to deal with hard work and to be more patient to deal with
multiple stressors during studying, especially in improving my English skills, and
gaining a clear understanding about grounded theory, qualitative research language, and
the complexity of grounded theory analysis processes. As I mentioned previously,
various kinds of memos, some artworks, and pictures were very helpful for me to
develop imaginative analysis. Balanced lifestyles, healthy eating, enough sleep, rest,
relaxation, and having good friends, were also very beneficial to complete this research.
Finally, this theory will be “meaningful to laypersons and professionals alike … to
explain phenomena, to direct research, and to guide action programs” (Strauss &
Corbin, 1998: 272).
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Chapter 10: Discussion and Conclusion
Limitations
There were some limitations when collecting data in Thailand and maintaining other
research processes in Australia.
The complexity of the participants’ experiences
While exploring the complex and interconnected codes, categories, and related
concepts, during the axial and selective analysis, there were many times that I could not
divide the connecting codes that supported sub-categories, within compassionate
relationships with equanimity. Because of the multifaceted data, I had to set minor and
major sub-categories, in order to include as many codes as possible to support the
categories.
At the same time, this issue can be considered a research strength. Because of the
variety of data, I built very strong levels of theory, which is the highest level of theory
development, Strauss and Corbin (1998: 15) called “theorising”.
Managing the overlapping of data collection and analysis processes
Data collection, analysis, memo writing, theoretical sampling/coding/noting happened
at the same time. Because of this, I could not explain everything that I did in linear
form; however, I explained the process of theory development as clearly as I could. The
main focus was letting the data tell their own stories and putting each part of data in
their best position, to represent the categories.
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Chapter 10: Discussion and Conclusion
Implications
If you are in doubt about what to do next in your spiritual life, do something for
other people (Dhardo Rinmpoche cited in Sangharakshita, 1999: 4).
The theory may or may not be transferable, however, in this final part I discuss
implications of the grounded theory, in relation to ways in which nurses can apply
Buddhist principles and practices to spiritual care. I also suggest possible paths to apply
this theory in nursing education, administration and future research projects.
The right path for nursing care
Times change and Thai society is becoming more modern. In this project, unethical
caring issues emerged in day-to-day nursing practices by uncaring nurses. Thai
Buddhist nurses who value the Buddha’s teachings need to learn how to apply Buddhist
teachings to build spiritual caring relationships with clients. With good intention and a
compassionate mind, nurses can cultivate compassionate relationships with equanimity
with patients and relatives in every nursing activity. Nurses need to cultivate their own
compassionate quality as well as to develop compassionate relationship with patients
and relatives. Practising meditation is important for developing a compassionate mind.
Every Buddhist nurse who provides spiritual care for clients needs to practice
meditation, well as to practice religious rituals.
While providing spiritual nursing care, nurses need to be concerned about personal,
professional and organizational factors, as well as cultural and religious aspects, that
promote and inhibit compassionate relationships with equanimity. Nurses need to
promote religious and spiritual practices for patients, who are admitted to hospital.
Nurses need to realise and respect individual differences and different levels of religious
beliefs and practices of patients and relatives, while providing spiritual care. Nurses also
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Chapter 10: Discussion and Conclusion
need to understand Buddhist spirituality, by practising, not by reading. For example,
nurses need to have good meditation experiences before they can apply them to teach
patient and relatives. Nurses also need to develop cultural sensitivity.
As Snyder and Lindquist (2006: 8) claimed that “complementary therapies and their
basic philosophies have been a part of nursing science since its beginnings” Therapies
such as “meditation, imagery, supports groups, music therapy, humour, journaling,
reminiscence, care-based approaches, massage, tough, healing touch, active listening
and presence have been practiced by nurses throughout time”. As Buddhist philosophy,
Buddhist rituals and Thai culture combine many rituals and practices for spiritual
health, especially meditation, prayer, chanting, massage, traditional food, herbal
medicines, death rituals and many other traditional rituals. Because nurses do not have
to know all complementary therapies, they should know who can perform the therapies
when clients need them. Snyder and Lindquist (2006: 8) also suggest that nurses also
need to:
1) provide guidelines in obtaining health histories and assessing patients, 2)
answer basic questions about the use of complementary therapies and refer
patients to reliable resource of information, 3) refer patients to competent
therapists, and 4) administer a selected number of complementary therapy.
Therefore, Thai nurses need to know the main therapies Thai Buddhist patients and
relatives usually access, to deal with illness and promote wellness. Nurses also need to
know how to apply Buddhist rituals and traditional beliefs as complementary care and
spiritual support.
Nurses need to open their minds to understand different patients’ and relatives’
backgrounds, problems, values and beliefs. Nurses also need to value relatives’ roles
while caring for patients and to support relatives who need to stay with patients in the
ward. Nurses need to support relatives who are tired from being long term caregivers.
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Chapter 10: Discussion and Conclusion
In addition, nurses need to consider relatives’ caring roles and to balance between
letting the relatives care for patients and helping to reduce the relatives’ caring
workload.
Nurses need to value healing environments in the wards/units to provide personal and
peaceful spaces for patients to do religious practices such as chanting, practising
meditation and so on.
Nurses in general wards, need to be concerned about patients’ and relatives’ needs,
especially when they need to stay together in the ward. Nurses need to be flexible in
using visiting rules, especially letting relatives stay with patients when they or patients
want to stay.
Nurses need to understand negative responses of patients’ relatives and to change their
attitudes to fussy and VIP relatives, so they can maintain caring relationships with all
clients. Moreover, nurses need to consider patients’ decision making styles, which are
mainly collective decision making. Thai families usually involved in helping make
decisions for patients.
Nurses need to value caring relationships and avoid uncaring relationships (as described
in Chapter 8), especially by spending more time to support the patients’ mind and
spirits, applying concept of being with and doing for, using a simple language, trying to
improve effective communication and by helping to reduce issues involving hesitancy.
Senior or expert nurses, who work for more than five years, need to be good caring
models for junior nurses. Finally, nurses who work more than five years need to be
experts on providing spiritual care and working within holistic nursing contexts.
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Chapter 10: Discussion and Conclusion
The right path for nursing education
อันความกรุณาปราณี จะมีใครบังคับก็หาไม หลั่งมาเองเหมือนฝนอันชื่นใจ จากฟากฟาสุราลัยสูแดนดิน
Loving kindness and compassion, doesn’t come from any other people’s force,
it comes naturally into our (nurses’) hearts, like a pure rain falls from the vast sky
through the soil on the land.*
*Note: This is a beginning part of the Traditional Thai Nursing Song named March PaYa-Ban (nursing song), that every nursing student sings in the first step when they
decide to become a nurse, when they are concerned about others’ well being, and want
to alleviate suffering and care for the patients’ health, promoting healing and a peaceful
death. This song was translated from the Thai language to English and interpreted by
the researcher, November 26, 2005.
This song for nursing values nurses’ kindness and compassion. Therefore, Buddhist
nursing teachers have a major role to cultivate compassion and loving kindness in
nursing students and nurses, who later continue their education. Implementing Buddhist
principles and practices for spiritual health and complementary care in the nursing
curriculum at undergraduate and post-graduate levels, needs to be done. Nursing
schools need to run short courses on spiritual care based on Buddhist spirituality, for
nurses in their professional development. Nursing schools also need to implement
meditation courses for Buddhist nursing students, in order to develop nurses’
consciousness, kindness, and compassion. However, non-Buddhist nursing students can
also be taught about the spiritual concepts according to their sects and beliefs. Other
religions, such as Christianity, also value caring and compassionate relationships.
Nursing teachers need to be compassionate models for nursing students and create
effective experiential and creative learning (Freshwater, 2002; Morrison & Burnard,
1997) and reflective practice (Taylor, 2006), to teach students and nurses about spiritual
health.
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Chapter 10: Discussion and Conclusion
Concepts about facing and understanding the nature of suffering, applying Dhamma,
personal/local wisdom and traditional healing and the grounded theory of Cultivating
Compassionate Relationships with Equanimity should be implemented in the
fundamental components of Thai nursing curriculum, as this research and many other
researchers; for example, Crigger, Brannigan and Baird (2006), Doane and Varcoe
(2005), and Falk-Rafael (2005) have confirmed that compassionate action is the heart of
the caring relationship.
Nursing teachers need to teach nursing students and nurses about complementary care
which are popular with Thai Buddhist people, especially the use of Thai traditional
medicine and Buddhist healing wisdom such as meditation, chanting, local healthy
food, massage, and so on. The influences of traditional and religious beliefs on clients’
health self care and coping also need to be discussed.
Nursing students and nurses also need to be trained to do self study about relaxation, in
order to get ready to deal with hard work and develop a deeper understanding of
spiritual and holistic health, so they can learn to relax themselves and teach patients and
relatives to relax while facing multiple suffering.
The right path for nursing management
Head nurses, nurse managers, leaders, and administrators need to value Thai culture and
find better management strategies to promote spiritual health based on clients’ values
and beliefs. The main ways to promote spiritual caring relationships are by using
cultural approaches and respecting each patient’s dignity.
Nursing needs to develop as a spiritual organisation, as suggested by Hume, Richardt
and Applegate (2003) and Giacalone and Jurkiewicz (2003), where all staff and clients
relate to each other in a compassionate ways. The idea of compassionate organisations
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Chapter 10: Discussion and Conclusion
needs to be placed in the organisation’s policy. The head nurses need to give times to
nurse to practice mindfulness and learn alternative care therapies.
In the modern health care, Western-influenced health care context, nurses are very busy.
The management level needs to deal with nurses’ workload more effectively, so nurses
can have more time to communicate and provide spiritual support to clients.
Nurses from the management level need to develop nursing care plans and standard
guidelines for spiritual care based on Buddhist perspectives. They also need to analyse
nursing caring time and find the best ways to reduce nurses’ busyness, so nurses can
have more time to provide holistic care.
The head ward nurse needs to ask for some money or find some ways such as
donations, in order to prepare enough equipment to support patients and relatives to do
their religious beliefs and practices, such as Dhamma tapes, chanting books, and make
chanting books in large alphabets for the elderly.
Some relationship problems come from non registered nurses and other staff. These can
be reduced by training all staff about compassionate manners and the importance of
cultivating good health care provider and client relationships.
The most important thing that the nursing profession needs to do is to promote the
compassionate image of nurses, to improve the nursing image and promote the art of
nursing.
The right path for future nursing researchers
Not only Buddhism and Thai culture, but also many other factors influence the nursepatient-relative relationship. Therefore, nurse researchers need to explore personal,
professional, organisation and management factors that influence the nurse-patientrelative relationship.
315
Chapter 10: Discussion and Conclusion
This research did not explore the nurse-patient-relative relationship in private units and
private hospitals. To understand the whole picture of the nurse-patient-relative
relationship, more research projects need to be done to explore pattern of the nursepatient-relative relationships in other units, such as the private rooms and private
hospitals, which represent different backgrounds of clients and different styles of
nursing services. Moreover, the research needs to apply grounded theory research or
other descriptive qualitative research methodologies to explore related issues about
relationships from other religions and faiths, such as Islam and Christianity, so Buddhist
nurses can provide spiritual care for clients from different belief systems equally.
Nurse researchers, clinical nurses and other health care staff should apply the
substantive theory of “Cultivating Compassionate Relationships with Equanimity” to
their daily practice. This grounded theory has many aspects to guide nurses to provide
spiritual care and develop compassionate relationship with patients and relatives. For
doing this kind of research in practice, action research could be useful. Participatory
action research can help nursing organisations sustain the compassionate quality of
nurses and related staff while they are support cultivating compassion with equanimity
and promote spiritual caring relationships with clients.
There were many codes, categories and concepts which explained this grounded theory.
All of these data have the potential to be modified and developed as a caring tool to
measure nurses’ characteristics and spiritual caring activities in the Thai nursing
context.
Finally, qualitative researchers in nursing can cultivate compassionate relationships
with equanimity between researchers and participants. As Bentz and Shapiro (1998) and
Pongpaibul (1999) suggested, using mindful inquiry from a Buddhist perspective is
similar to the concepts of applying Buddhist mindful inquiry to social research. I
focused on the present to understand other’s people suffering and applying the Eight
Noble Paths to do research, feeling and expressing empathy to participants’ situations,
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Chapter 10: Discussion and Conclusion
while maintaining detachment, showing empathy with participants and providing them
with opportunities to discuss problems with nurses, head ward nurses and counsellors. I
also encouraged participants to do spiritual activities after the interview process.
The right path for Thai people and Buddhist organisations
I think that the Thai culture is a good mixture of Buddhism, traditional ways of life and
modernisation. I am very happy to know that participants still value compassionate
relationships and many of them apply the teaching about equanimity when dealing with
suffering.
As Capra (1992: 357) argued, the similarities between modern physics and eastern
mysticism, constitute a period of a profound cultural transformation. Western people
influences by Eastern thought, changed their worldviews in science and society. I am
happy to know that people from the Thai Buddhist culture have cultivated
compassionate caring in their minds. I would like to inform Thai people to be proud of
their Buddhist culture and to walk the right path of cultivating compassionate
relationships among each other. Cultivating compassionate relationships between
oneself and other people is also an implication of this research.
Promoting compassionate acts and other Buddhist teachings, trying to help people learn
Dhamma by promoting religious practices; supporting the practice of meditation; using
simple language to teach Dhamma, making interesting books, cassettes and Dhamma
materials, creating effective ways to teach Dhamma; and solving the negative image of
the monks and religious organisations are important activities for Buddhist
organisations.
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Chapter 10: Discussion and Conclusion
The final thought
Helping sufferers is a vital goal of both Buddhism and nursing. When nurses learn how
to provide nursing care holistically and equally, nurses will also learn to develop all
related nursing competences, in order to provide safe and effective nursing care.
Buddhists need to learn to be better people by being kind and compassion to others,
regardless of race, sex, religion, economic status, and so on. If nurses, who have good
skills to care for patients and relatives, develop a spiritual caring relationship with
clients and relatives with compassionate hearts, they can heal and comfort patients and
provide a good moral support for patients’ relatives. In this final section, I strongly
recommend that nurses cultivate compassionate relationships with equanimity between
nurses, patients and relatives, and suggest that nurses nurture compassionate qualities in
their nursing practice, education and management.
Without practice, without contemplation, a merely intellectual theoretical,
and philosophical approach to Buddhism is quite inadequate …
Mystical insights cannot be judged by unenlightened people
from the worm’s eye view of book-learning, and a little book knowledge
does not really entitle anyone to pass judgement on mystical experiences
(Bhikhu Vimalo, 1974 cited in Sheikh & Sheikh, 1989: 552).
318
References
References
Adami, M. F., & Kiger, A. (2005). The use of triangulation for completeness
purposes. Nurse Researcher, 12(4), 19-29.
Adler, H. M. (2002). The sociophysiology of caring in the doctor-patient
relationship. Journal of General Internship Medicine, 17, 883-890.
Annells, M. (1997). Grounded theory method, part I: within the five moments of
qualitative research. Nursing Inquiry, 4, 120-129.
Annells, M. (2003). Grounded theory. In Z. Schneider, D. Elliott, G. LoBiondoWood & J. Haber (Eds.), Nursing research: methods, critical appraisal and
utilisation (2nd ed., pp. 163-178). Sydney: Mosby.
Aphichato, A., & Tulathumkit, K. ( 2005). Experiences in using Dhamma and
meditation of cancer patients receiving radiation therapy. A research report.
Songkhla: Faculty of Nursing, Prince of Songkla University.
Arnold, E. (1989). Burnout as a spiritual issue: rediscovering meaning in nursing
practice. In V. B. Carson (Ed.), Spiritual Dimensions of Nursing Practice
(pp. 320-353). Philadelphia: W.B. Saunders Company.
Arpanantikul, M. (2004). Midlife experiences of Thai women. Journal of Advanced
Nursing, 47(1), 49-56.
Aung, S. (1996). Loving-kindness: the essential Buddhist contribution to primary
care. Humane Health Care International, 12(2), 81-84.
Author unknown. (2006). Buddhist value: like a lotus flower http://www.buddhanet.
net/e-learning/buddhism/meditate/lotus.htm. Retrieved August 29, 2006.
Author unknown. (2006). The first Noble Truth: the reality of suffering:
http://dharma.ncf.ca. Retrieved: January 4, 2006.
Backman, K., & Helvi, A. (1999). Challenges of the grounded theory approach to a
novice researcher. Nursing and Health Sciences, 1(3), 147-153.
Baldacchino, D., & Draper, P. (2001). Spiritual coping strategies: a review of the
nursing research literature. Journal of Advanced Nursing, 34(6), 833-841.
Bao, J. (2005). Merit-making capitalism: re-territorialising Thai Buddhism in Silicon
Valley, California. Journal of Asian American Studies, 8(2), 115-142.
Barnum, B. S. (2003). Spirituality in Nursing: From Traditional to New Age.
Springer Publishing Company: New York.
References
Bash, A. (2004). Spirituality: the emperor's new clothes? Journal of Clinical
Nursing, 13, 11-16.
Bechtel, G. A., & Apakupakul, N. (1999). AIDS in Southern Thailand: stories of
krengjai and social connections. Journal of Advanced Nursing, 29(2), 471475.
Beck, D., & Cowan, C. (1996). Spiral dynamics. Malden: Blackwell.
Benner, P., & Wrubel, J. (1989). The primacy of caring: stress and coping in health
and illness. Menlo Park: Addison-Wesley Publishing Company.
Benoliel, J. (1996). Grounded theory and nursing knowledge. Qualitative Health
Research, 6(3), 406-428.
Benson, H. (1996). Timeless healing: the power and biology of belief. New York:
Scribner.
Bentz, V. M., & Shapiro, J. J. (1998). Mindful inquiry in social research. Thousand:
Sage Publications.
Bhikkhu, B. (1996). Handbook for mankind. Bangkok: Dhammasapa.
Bhikkhu, B. (2001). Mindfulness with breathing: a manual for serious beginners.
Chiang Mai: Silkworm Books.
Bhikkhu, B. (2002). Paticcasamuppada: practical dependent origination. Bangkok:
Thammasapa.
Blocher, M. B. (2002). The virtue of compassion, the sanctity of human life, and the
problem of scarcity. Biblical Bioethics Advisor, 6(2), 1-4.
Bloom, P. (2000). Buddhist acts of compassion. California: Conari Press.
Bluff, R. (2005). Grounded theory: the methodology. In I. Holloway (Ed.),
Qualitative Research in Health Care (pp. 147-167). Berkshire, England:
Open University Press.
Bodhi. (2005). The Buddha, the man and his mission. http://www.beyondthenet.net
/THEDWAY/THD_MAIN.ASP?content=Emotiona. Retrieved: 8/11/2005.
Bonadonna, R. (2003). Meditation's impact on chronic illness. Holistic Nursing
Practice, 17(6), 309-319.
Boyd, A., Ratanakul, P., & Deepudong, A. (1998). Compassion as common ground.
Eubios Journal of Asian and International Bioethics, 8, 34-37.
Bradshaw, A. (1997). Teaching spiritual care to nurses: an alternative approach.
International Journal of Palliative Nursing, 3(1), 51-57.
320
References
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: mindfulness
and its role in psychological well-being. Journal of Personality and Social
Psychology, 84(4), 822-848.
Bruce, A., & Davies, B. (2005). Mindfulness in hospice care: practising meditationin-action. Qualitative Health Research, 15(10), 1329-1344.
Brykczynska, G., & Jolley, M. (1997). Caring: the compassion and wisdom of
nursing. London: Arnold.
Burkhardt, M. A., & Nagai-Jacobson, M. G. (2005). Spirituality and health. In B. M.
Dossey, L. Keegan & C. E. Guzzetta (Eds.), Holistic nursing practice (4th
ed., pp. 137-172). Boston: Jones and Bartlett Publishers.
Burnard, P., Claewplodtook, P., & Pathanapong, P. (2000). Education and research
links between the UK and Thailand. Journal of Psychiatric and Mental
Health Nursing, 7(5), 463-465.
Burnard, P., & Naiyapatana, W. (2004a). Culture and communication in Thai
nursing: a report of an ethnographic study. International Journal of Nursing
Studies, 41(7), 755-765.
Burnard, P., & Naiyapatana, W. (2004b). Some cultural influences in Thai nursing.
Asian Journal of Nursing Studies, 7(2), 1-7.
Burns, G. W. (2001). 101 Healings stories: using metaphors in therapy. New York:
John Wiley & Sons, Inc.
Byrne, M. (2001). Grounded theory as a qualitative research methodology. The
Association of Perioperative Registered Nurses, 73(6), 1155-1156.
Capra, F. (1975). The tao of physics. Boston: Shambhala.
Capra, F. (1982). The turning point: science, society, and the rising culture. New
York: Simon and Schuster.
Capra, F. (1992). The hidden connections: a science for sustainable living. London:
Flamingo.
Capra, F. (1994). The new vision of reality: toward a synthesis of Eastern wisdom
and Western science In S. Grof (Ed.), Ancient wisdom and modern science
(pp. 135-148). Albany: New York Press.
Capra, F. (1997). The web of life: a new synthesis of mind and matter. London:
Flamingo.
Capra, F. (2001). No boundary: Eastern and Western approaches to personal
growth. Boston: Shambhala.
321
References
Carmack, B. J. (1997). Balancing engagement and detachment in caregiving. Imagethe Journal of Nursing Scholarship, 29(2), 139-143.
Carpenter, D. R. (2003). Grounded theory as method. In H. J. Streubert & D. R.
Carpenter (Eds.), Qualitative Research in Nursing: Advancing the
Humanistic Imperative (3rd ed., pp. 107-122). Philadelphia: J. B. Lippincott
company.
Carson, J. W., Keefe, F. J., Lynch, T. R., Carson, K. M., Goli, V., Fras, A. M., et al.
(2005). Loving-kindness meditation for chronic low back pain. Journal of
Holistic Nursing, 23(3), 287-304.
Carson, V. B. (1989). Spiritual dimensions of nursing practice. Philadelphia: W.B.
Saunders Company.
Carter, H., MacLeod, R., Brander, P., & McPherson, K. (2004). Living with a
terminal illness: patients' priorities. Journal of Advanced Nursing, 45(6),
611-620.
Chailangka, P., Chuaprapaisilp, A., Triprakong, S., & Wonnawong, S. (2005). A
model of an application of the Buddhist Dhamma in caring for adult
leukemic patients receiving chemotherapy. A research report. Songkhla:
Faculty of Nursing, Prince of Songkla University.
Charmaz, K. (2000). Constructivist and objectivist grounded theory. In N. K. Denzin
& Y. S. Lincoln (Eds.), Handbook of Qualitative Research (2nd ed., pp. 509535). Thousand Oaks, CA: Sage Publications.
Charmaz, K. (2003). Grounded theory: objectivist and constructivist methods. In N.
K. Denzin & Y. S. Lincoln (Eds.), Strategies of qualitative inquiry (2nd ed.,
pp. 249-291). Thousand Oaks: Sage Publications.
Charmaz, K. (2006). Constructing grounded theory: a practical guide through
qualitative analysis. London: Sage Publications.
Chenitz, W. C., & Swanson, J. M. (1986). From practice to grounded theory:
qualitative research in nursing. California Addison-Wesley Publishing
Company.
Chinnawong, T. (1999). Perception and coping of lung cancer patients receiving
chemotherapy: a phenomenological study. Master Thesis: Prince of Songkla
University, Songkhla.
322
References
Chinnawong, T. (2006). The influences of Thai Buddhist culture on cultivating
compassionate relationships with equanimity between nurses, older patients
and relatives: a grounded theory approach. Paper presented at the third
national conference on aging, disability and spirituality: addressing the
challenge of disability in later life, 27 September, 2006: The Brassey of
Canberra, Canberra, Australia.
Chiovitti, R., & Piran, N. (2003). Rigour and grounded theory research:
methodological issues in nursing research. Journal of Advanced Nursing,
44(4), 427-435.
Choowattanapakorn, T. (2004). Nursing older people in Thailand: embryonic
holistic rhetoric and the biomedical reality of practice. Geriatric Nursing,
25(1), 17-23.
Chuaprapaisilp, A. (1989). Improving learning from experience through the conduct
of pre- and post-clinical conferences: action research in nursing education
in Thailand. PhD Thesis: New South Wales University, Sydney.
Chuaprapaisilp, A. (2002). Thai Buddhist philosophy and the action research
process. In C. Day, J. Elliott, B. Somekh & R. Winter (Eds.), Theory and
practice in action research (pp. 189-193). UK: Cambridge University Press.
Cohen-Katz, J. (2004). Mindfulness-based stress reduction and family systems
medicine: a natural fit. Families, Systems, and Health, 22(2), 204-206.
Conner, N. E., & Eller, L. S. (2004). Spiritual perspectives, needs and nursing
interventions of Christian African-Americans. Journal of Advanced Nursing,
46(6), 624-632.
Cook, C. (2004). Addiction and spirituality. Addiction, 99, 539-551.
Coulon, L., Mok, M., Krause, K., & Anderson, M. (1996). The pursuit of excellence
in nursing care: what does it mean? Journal of Advanced Nursing, 24(4),
817-826.
Crigger, N. J., Brannigan, M., & Baird, M. (2006). Compassionate nursing
professionals as good citizens of the world. Advances in Nursing Science,
29(1), 15-26.
Crisp, J., & Taylor, C. (2005). Potter & Perry's fundamental of nursing (2nd ed.).
Sydney: Elsevier.
Cusveller, B. (1998). Cut from the right wood: spiritual and ethical pluralism in
professional nursing. Journal of Advanced Nursing, 28(2), 266-273.
323
References
Cutcliffe, J. (2000). Methodological issues in grounded theory: methodological
issues in nursing research. Journal of Advanced Nursing, 31(6), 1476-1484.
Dalai Lama. (1998). The art of happiness: a handbook for living. Sydney: Hodder.
Dalai Lama. (2000). The transformed mind: reflections on truth, love and happiness.
London: Coronet Books, Hodder and Stoughton.
Dalai Lama. (2001). An open heart: practicing compassion in everyday life. Sydney:
Hodder.
Dalai Lama. (2005a). Practicing wisdom: the perfections of Shantideva's
Bodhisattva way. Boston: Wisdom Publications.
Dalai Lama. (2005b). Widening the circle of love. London: Rider.
Davenport, D. O. (2004). Generation of an explanatory model of human caring in
registered nurses. PhD Thesis: Texas Women's University, Texas.
Dawson, P. J. (1997). A reply to Goddard's spirituality as integrative energy.
Journal of Advanced Nursing, 25(2), 282-289.
Denzin, N., & Lincoln, Y. (2000). Handbook of qualitative research (2nd ed.).
Thousand Oaks, CA: Sage Publications.
Denzin, N. K., & Lincoln, Y. S. (2003a). Strategies of qualitative inquiry (2nd ed.).
Thousand Oaks: Sage Publications.
Denzin, N. K., & Lincoln, Y. S. (2003b). Collecting and interpreting qualitative
materials (2nd ed.). Thousand Oaks: Sage Publications.
Dey, I. (2004). Grounded theory. In C. Seale, G. Gobo, J. F. Gubrium & D.
Silverman (Eds.), Qualitative research practice (pp. 80-93). London: Sage
Publications.
Doane, G. H., & Varcoe, C. (2005). Toward compassionate action: pragmatism and
the inseparability of theory/practice. Advances in Nursing Science, 28(1), 8190.
Dossey, B. M., & Guzzetta, C. E. (2005). Holistic nursing practice. In B. M. Dossey,
L. Keegan & C. E. Guzzetta (Eds.), Holistic nursing: a handbook for
practice (4th ed., pp. 5-38). Boston: Jones and Bartlett Publishers.
Duangpaeng, S., Eusawas, P., Laungamornlert, S., Gasemgitvatana, S., &
Sritanyarat, W. (2002). Chronic dyspnea self-management of Thai adults
with COPD. Thai Journal of Nursing Research, 6(4), 200-215.
Duchscher, J., & Morgan, D. (2004). Grounded theory: reflections on the emergence
vs. forcing debate. Journal of Advanced Nursing, 48(6), 605-612.
324
References
Eaves, Y. D. (2001). A synthesis technique for grounded theory data analysis.
Journal of Advances Nursing, 35(5), 654-663.
Ekintumas, D. (1999). Nursing in Thailand: Western concepts vs Thai tradition.
International Nursing Review, 46(2), 55-57.
Elliott, D. (2003). Approaches to research. In Z. Schneider, D. Elliott, G. LoBiondoWood & J. Haber (Eds.), Nursing research: methods, critical appraisal and
utilisation (2nd ed., pp. 21-37). Sydney: Mosby.
Erci, B., Sayan, A., Tortumluoglu, G., Kilic, D., Sahin, O., & Gungormus, Z.
(2003). The effectiveness of Watson's caring model on the quality of life and
blood pressure of patients with hypertension. Journal of Advanced Nursing,
41(2), 130-139.
Eriksson, K. (1992). The alleviation of suffering-the ides of caring. Scandinavian
Journal of Caring Science, 6(2), 119-123.
Eriksson, K. (1997). Understanding the world of the patient, the suffering human
being: the new clinical paradigm from nursing to caring. Advanced Practice
Nursing Quarterly, 3(1), 8-13.
Euswas, P. (1991). The actualise caring moment; a grounded theory of caring in
nursing practice. PhD Thesis: Massey University.
Euswas, P. (1993). The actualize caring moment: a grounded theory of caring in
nursing practice. In D. A. Gaut (Ed.), A global agenda of caring (pp. 309326). New York: National League for Nursing Press.
Falk-Rafael, A. (2005). Advancing nursing theory through theory-guided practice:
the emergence of a critical caring perspective. Advances in Nursing Science,
28(1), 38-49.
Felten, B. S., & Hall, J. M. (2001). Conceptualising resilience in women older than
85: overcoming adversity from illness or loss. Journal of Gerontological
Nursing, 27(11), 46-53.
Fiandt, K., Forman, J., Megel, M. E., Pakieser, R. A., & Burge, S. (2004). Integral
nursing: an emerging framework for engaging the evolution of the
profession.Unpublished manuscript, University of Nebraska Medical Center
College of Nursing, Omaha.
Field, P. A., & Morse, J. M. (1985). Nursing research: the application of qualitative
approaches. London: Croom Helm.
325
References
Figley, C. R. (1995). Compassionate fatigue: coping with secondary traumatic
stress disorder in those who treat the traumatised. New York: BrunnerRoutledge.
Finfgeld, D. L. (1992). Courage in the chronically ill elderly: a grounded theory
study. PhD Thesis: The University of Texas at Austin, Texas.
Florida, R. E. (1994). Buddhism and the four principles. In R. Gillon (Ed.),
Principles of Health Care Ethics (pp. 105-116). Chichester: John Wiley &
Sons.
Fongkaeo, W. (2002). Normalizing: a study of young Thai children’s experiences
with postoperative acute abdominal surgical pain. PhD thesis: University of
Washington.
Fontaine, K. L. (2005). Complementary & alternative therapies for nursing
practices (2nd ed.). New Jersey: Prentice Hall Health.
Fox, M. (1999). A spirituality named compassion: uniting mystical awareness with
social justice. Vermont: Inner Traditions International.
Frakes, C. R. (2004). The virtue of compassion: responding to suffering with
equanimity. PhD Thesis: State University of New York at Binghamton, New
York.
Freshwater, D. (2002). Therapeutic nursing: improving patient care through self
awareness and reflection. London: Sage Publications.
Friedland, J. (1999). Compassion as a mean to freedom. The Humanist, 59(4), 3539.
Fuss, M. (1998). Health, illness, and healing in the great religions: I. Buddhism.
Dolentium Hominum; No. 37, 13(1), 108-111.
Gall, T., Charbonneau, C., Clarke, N. H., Grant, K., Joseph, A., & Shouldice, L.
(2005). Understanding the nature and role of spirituality in relation to coping
and health: a conceptual framework. Canadian Psychology, 46(2), 88-104.
Garrett, C. (2005). Gut feelings: chronic illness and the search for healing.
Amsterdam: Rodopi.
Georges, J., Grypdonck, M., & de Casterle, B. D. (2002). Being a palliative care
nurse in an academic hospital: a qualitative study about nurses' perceptions
of palliative care nursing. Journal of Clinical Nursing, 11(6), 785-793.
Giacalone, R. A., & Jurkiewicz, C. L. (2003). Handbook of workplace spirituality
and organisational performance. Armonk: M. E. Sharpe.
326
References
Glaser, A. (2005). A call to compassion: bring Buddhist practices of the heart into
the soul of psychology. Berwick, ME: Nicolas-Heys, Inc.
Glaser, B. G. (1978). Theoretical sensitivity. California: The Sociology Press.
Glaser, B. G. (1992). Emerging vs forcing: basics of grounded theory analysis. Mill
Valley, CA: Sociology Press.
Glaser, B. G. (1998). Doing grounded theory: issues and discussions. Mill Valley,
CA: Sociology Press.
Glaser, B. G. (2005). The grounded theory perspective III: theoretical coding. Mill
Valley, CA: Sociology Press.
Glaser, B. G., & Strauss, A. L. (1965). Awareness of dying. New York: Aldine
Publishing Company.
Glaser, B. G., & Strauss, A. L. (1967). Discovery of grounded theory: strategies for
qualitative research. New York: Aldine De Gruyter.
Gnanarama, P. (2000). Essentials of Buddhism. Singapore: Buddha Dharma
Education Association Inc.
Graber, D. R., & Mitcham, M. D. (2004). Compassionate clinicians: take patient
care beyond the ordinary. Holistic Nursing Practice, 18(2), 87-94.
Greasley, P., Chiu, L. F., & Gartland, R. M. (2001). The concept of spiritual care in
mental health nursing. Journal of Advanced Nursing, 33(5), 629-637.
Grof, S. (1994). East and West: ancient wisdom and modern science. In S. Grof
(Ed.), Ancient Wisdom and Modern Science (pp. 3-23). Albany: New York
Press.
Guba, E. G., & Lincoln, Y. S. (1981). Effective evaluation. San Francisco: JosseyBass Publishers.
Guba, E. G., & Lincoln, Y. S. (1989). Fourth generation evaluation. Newburry
Park: Sage Publications.
Hagerty, B. M., & Patusky, K. L. (2003). Reconceptualising the nurse-patient
relationship. Journal of Nursing Scholarship, 35(2), 145-150.
Hanchett , E. S. (1992). Concepts from Eastern philosophy and Roger's science of
unitary human beings. Nursing Science Quarterly, 5(4), 164-170.
Hanh, T. N. (1976). The miracle of mindfulness. London: Rider.
Hanh, T. N. (1991). Peace is every step. New York: Bantam.
Hanh, T. N. (1998). The heart of the Buddha's teaching: transforming suffering into
peace, joy and liberation. London: Rider
327
References
Hanh, T. N. (2000). Interbeing: fourteen guidelines for engaged Buddhism. Delhi:
Full Circle.
Hanh, T. N. (2003). Creating true peace: ending conflict in yourself, your family,
your community and the world. London: Rider.
Harris, E. J. (1997). Detachment and compassion in early Buddhism. Buddhist
Publication Society Bodhi Leaves No. 141, retrived November 16, 2005 from
http://www.accesstoinsight.org/lib/authors/harris/b1141.html.
Hatthakit, U., Parker, M., & Niyomthai, N. (2004). Nurses' experiences in
integrating complementary therapies into nursing practice. Thai Journal of
Nursing Research, 8(2), 126-143.
Hebden, U., & Burnard, P. (2004). Thai Buddhism and Thai nursing. Asian Journal
of Nursing Studies, 7(3), 5-11.
Hem, M. H., & Heggen, K. (2003). Being professional and being human: one nurse's
relationship with a psychiatric patient. Journal of Advanced Nursing, 43(1),
101-108.
Hem, M. H., & Heggen, K. (2004). Is compassion essential to nursing practice?
Contemporary Nurse, 17(1-2), 19-31.
Henderson, S. (2003). Power imbalance between nurses and patients: a potential
inhibitor of partnership in care. Journal of Clinical Nursing, 12(4), 501-508.
Henery, N. (2003). Constructions of spirituality in contemporary nursing theory.
Journal of Advanced Nursing, 42(6), 550-557.
Henry, L. G., & Henry, J. D. (2004). The soul of caring nurse: stories and resources
for revitalising professional passion. Washington, DC: American Nurses
Association.
Hirst, I. S. (2003). Perspectives of mindfulness. Journal of Psychiatric and Mental
Health Nursing, 10, 359-366.
Hopkins, J. (2001). Cultivating compassion: a Buddhist perspective. New York:
Broadway Books.
Hughes, J. J., & Keown, D. (1995). Buddhism and medical ethics: A bibliographic
introduction. Journal of Buddhist Ethics, 2, 1-14, from http://www.change
surfer.com/Bud/BudBioEth.html. Retrieved: November 12, 2005.
Hume, R., Richardt, S., & Applegate, B. (2003). Spirituality and work:
Indianapolis's Seton Cove Center seeks to integrate spirituality into the
workplace. Health Progress, 84(3), 20-25.
328
References
Jecelon, C. S. (1997). The trait and process of resilience. Journal of Advanced
Nursing, 25(1), 123-129.
Jewell, A. (2004). Aging, spirituality and well-being. London: Jessica Kingsley
Publishers.
Jezuit, D. L. (2002). The manager's role during nurse suffering: creating an
environment of support and compassion. JONA's Healthcare Law, Ethics,
and Regulation, 4(2), 26-29.
Johns, C. (2004). Being mindful, easting suffering: reflections on palliative care.
London: Jessica Kingsley Publishers.
Jormsri, P., Kunaviktikul, W., Katefian, S., & Chaowalit, A. (2005). Moral
competence in nursing practice. Nursing Ethics, 12(6), 582-594.
Jumsai, M. (2000). Understanding Thai Buddhism (5th revised ed.). Bangkok:
Chalermnit.
Junda, T. (2004a). Living with breast cancer: Thai women's perspective. Thai
Journal of Nursing Research, 8(3), 208-222.
Junda, T. (2004b). Our family's experiences: a study of Thai families living with
women in the early stages of breast cancer. Thai Journal of Nursing
Research, 8(4), 260-275.
King, I. M. (1971). Toward a theory for nursing. New York: John Wiley and Sons.
Klausner, W. J. (2000). Reflections on Thai culture (5th ed.). Bangkok: The Siam
Society.
Klausner, W. J. (2002). Thai culture in transition: revised edition (4th ed.).
Bangkok: The Siam Society.
Klunklin, A. (2001). Thai women’s experiences of HIV/AIDS in the rural North: A
grounded theory study. PhD thesis: University of Western Sydney, Sydney.
Klunklin, A., & Greenwood, J. (2005). Buddhism, the status of women and the
spread of HIV/AIDS in Thailand. Health Care for Women International,
26(1), 46-61.
Knestrick, J. (2005). Spirituality and health: perceptions of older women in a rural
senior high rise. Journal of Gerontological Nursing, 31(10), 44-50.
Komin, S. (1990). Psychology of the Thai people: values and behavioral patterns.
Bangkok, Thailand: Research Center, National Institute of Development
Administration (NIDA).
329
References
Kongin, W. (1998). Self-care of the rural Thai elderly. PhD thesis: The Catholic
University of America.
Kornfield, J. (1993). A path with heart: a guide through the perils and promises of
spiritual life. New York: Bantam Books.
Krasner, M. (2004). Mindfulness-based interventions: a coming of age. Families,
Systems, and Health, 22(2), 207-212.
Kristjanson, L. J. (1989). Quality of terminal care: salient indicators identified by
families. Journal of Palliative Care, 5(1), 21-30.
Kunsongkeit, W., Suchaxaya, P., Panuthai, S., & Sethabouppha, H. (2004). Spiritual
health of Thai people. Thai Journal of Nursing Research, 8(1), 64-82.
Ladner, L. (2004). The lost art of compassion. New York: HarperSanFrancisco.
Leininger, M. M. (1978). Transcultural nursing: concepts, theories and practices.
New York: John Wiley & Sons.
Leininger, M. M. (1985). Nature, rationale, and importance of qualitative research
methods in nursing. In M. M. Leininger (Ed.), Qualitative research methods
in nursing (pp. 1-25). Philadelphia: W.B. Saunders Company.
Leininger, M. M., & McFarland, M. R. (2002). Transcultural nursing: concepts,
theories, research and practices (3rd ed.). New York: McGraw-Hill.
Leners, D., & Beardslee, N. Q. (1997). Suffering and ethical caring caring:
incompatible entities. Nurse Ethics, 4(5), 361-369.
Levine, M. E. (1990). Conservation and integrity: Levine's Conservation Model. . In
M. E. Parker (Ed.), Nursing theories in practice (pp. 189-201). New York:
National League for Nursing.
Limpanichkul, Y., & Magilvy, K. (2004). Managing caregiving at home: Thai
caregivers living in the United States. Journal of Cultural Diversity, 11(1),
18-24.
Lindbeck, V. (1984). Thailand: Buddhism meets the Western model. The Hastings
Center Report, December, 24-26.
Lindholm, L., & Eriksson, K. (1993). To understand and alleviate suffering in a
caring culture. Journal of Advanced Nursing, 18, 1354-1361.
LoBiondo-Wood, G., & Haber, J. (2006). Nursing research: methods and critical
appraisal for evidence-based practice (6th ed.). St. Louis: Mosby.
Lofland, J. (1971). Analyzing social settings: a guide to qualitative observation and
analysis. Belmont, California: Wadsworth.
330
References
Logue, R. M. (2003). Maintaining family connectedness in long-term care: an
advanced practice approach to family-centred nursing homes. Journal of
Gerontological Nursing, 29(6), 24-31.
Ludwig, T. M. (2004). Buddhist traditions. In K. L. Mauk & N. A. Schmidt (Eds.),
Spiritual care in nursing practice (pp. 151-164). Philadelphia: Lippincott
Williams and Wilkins.
Lukkahatai, N. (2004). The Thai cancer pain experience: relationships among
spiritual beliefs, pain beliefs. pain appraisal, pain coping, and pain
perception and outcomes. PhD Thesis: The University of North Carolina at
Chapel Hill.
Lundberg, P., & Trichorb, K. (2001). Thai Buddhist patients with cancer under
going radiation therapy: feelings, coping, and satisfaction with nurseprovided education and support. Cancer Nursing, 24(6), 469-475.
Lundberg, P. C. (2000). Culture care of Thai immigrants in Uppsala: a study of
transcultural nursing in Sweden. Journal of Transcultural Nursing, 11(4),
278-280.
Lundberg, P. C., & Boonprasabhai, K. (2001). Meanings of good nursing care
among Thai female last-year undergraduate nursing students. Journal of
Advanced Nursing, 34(1), 35-42.
MacLaren, J. (2004). A Kaleidoscope of understandings: spiritual nursing in a multifaith society. Journal of Advanced Nursing, 45(5), 457-462.
Macrae, J. A. (2001). Nursing as a spiritual practice: a contemporary applications
of Florence Nightingale's views. New York: Springer Publishing Company.
Mahoney, M. J., & Graci, G. M. (1999). The meanings and correlates of spirituality:
suggestions from an explanatory survey of experts. Death Studies, 23(6),
521-528.
Maijala, H., Paavilainen, E., & Astedt-Kurki, P. (2003). The use of grounded theory
to study interaction. Nurse Researcher, 11(2), 40-57.
Malinski, V. M. (2002). Developing a nursing perspective on spirituality and
healing. Nursing Science Quarterly, 15(4), 281-287.
Mallinson, R. K., Relf, M. V., D., D., Dolan, K., Darcy, A., & Ford, A. (2005).
Maintaining normalcy: a grounded theory of engaging in HIV-oriented
primary medical care. Advances in Nursing Science, 28(3), 265-277.
331
References
Mauk, K. L., & Schmidt, N. A. (2004). Spiritual care in nursing practice.
Philadelphia: Lippincott Williams and Wilkins.
McCallin, A. (2003). Designing a grounded theory study: some practicalities.
Nursing in Critical Care, 8(5), 203-208.
McCann, T., & Clark, E. (2003a). Grounded theory in nursing research: part 1methodology. Nurse Researcher, 11(2), 7-18.
McCann, T., & Clark, E. (2003b). Grounded theory in nursing research: part 2critique. Nurse Researcher, 11(2), 19-28.
McCann, T., & Clark, E. (2003c). Grounded theory in nursing research: part 3application. Nurse Researcher, 11(2), 29-39.
McConnell, J., A. (1995). Mindful mediation: a handbook for Buddhist
peacemakers. Bangkok: Asia Books.
Mcconnell, J. (2004). Dhamma, healing and palliative care. The manuscript for the
Dhamma and healing workshop Songkhla: Faculty of Medicine, Prince of
Songkla University, Thailand.
McCrea, M. A., Atkinson, M., Bloom, T., Merkh, K., Najera, I. L., & Smith, C. J.
(2003). The healing energy of relationships: a journey to excellence. Nursing
Administration Quarterly, 27(3), 240-248.
McEwen, M. (2004). Analysis of spirituality content in nursing textbooks. Journal
of Nursing Education, 43(1), 20-30.
McGrath. (1998). Buddhist spirituality: a compassionate perspective on hospice
care. Mortality, 3(3), 251-263.
McGrath, P. (2004). Strategies for coping with spiritual pain: a comparison of
insights from survivors and hospice patients. The Australian Journal of
Holistic Nursing, 11(1), 4-15.
McMahon, R., & Pearson, A. (1998). Nursing as therapy (2nd ed.). UK: Stanley
Thornes.
McSherry, W., & Draper, P. (1998). The debates emerging from the literature
surrounding the concept of spirituality as applied to nursing. Journal of
Advanced Nursing, 27(4), 683-691.
McSherry, W., & Ross, L. (2002). Dilemmas of spiritual assessment: considers for
nursing practice. Journal of Advanced Nursing, 38(5), 479-488.
McSherry, W., & Ross, L. (2004). Meaning of spirituality: implications for nursing
practice. Journal of Clinical Nursing, 13(8), 934-941.
332
References
Meehan, T. C. (2003). Careful nursing: a model for contemporary nursing practice.
Journal of Advanced Nursing, 44(1), 99-107.
Miller, M. A. (1995). Culture, spirituality, and women's health. Journal of Obstetric,
Gynecology and Neonatal Nursing 24, 257-263.
Milner, J. (2003). Compassionate care nursing with meaning: incorporating holism
into nursing practice. Chart, Journal of Illinois Nursing, 100(6), 4-6.
Mira, L. (2004). Spirituality in Korea: a fog of religion & culture. Journal of
Christian Nursing, 21(1), 29-31.
Mohan, K. (2004). Eastern perspectives and implications for the West. In A. Jewell
(Ed.), Aging, spirituality and well-being (pp. 161-179). London: Jessica
Kingsley Publishers.
Mok, E., Chan, F., Chan, V., & Yeung, E. (2003). Family experience caring for
terminally ill patients with cancer in Hong Kong. Cancer Nursing, 26(4),
267-275.
Morgan, A. K. (2001). A grounded theory of nurse-client interactions in palliative
care nursing. Journal of Clinical Nursing 10(4), 583-584.
Morrison, P., & Burnard, P. (1997). Caring and communicating: the interpersonal
relationship in nursing. New York: Palgrave.
Muecke, M. A., & Srisuphan, W. (1989). Born female: the development of nursing
in Thailand. Social Science and Medicine, 29(5), 643-652.
Mulder, N. (2000). Inside Thai society: religion, everyday life change. Chiang Mai:
Silkworm Books.
Namjantra, R., Hanucharurnkul, S., Panpakdee, O., Kompayak, J., & Sitthimonkol,
Y. (2003). The process of struggling to live normally among persons with
long-term HIV infection. Thai Journal of Nursing Research, 7(2), 105-120.
Narayanasamy, A. (1999). Learning spirituality dimensions of care from a historical
perspective. Nurse Education Today, 19, 386-395.
Narayanasamy, A. (2001). A critical incident study of nurses' responses to the
spiritual needs of their patients. Journal of Advanced Nursing, 33(4), 446455.
National Identity Board. (2003). Buddhist questions and answers: book 4. Bangkok,
Thailand: Office of the Prime Minister.
Neff, K. D. (2003). The development and validation of a scale to measure selfcompassion. Self and Identity, 2, 223-250.
333
References
Nelson, C. J., Rosenfeld, B., Breitbart, W., & Galietta, M. (2002). Spirituality,
religion, and depression in the terminally ill. Psychosomatics, 43(3), 213220.
Newman, B. (1995). The Newman systems model (3rd ed.). Norwalk: Appleton &
Lange.
Newman, M. A. (1986). Health as expanding consciousness. St. Louis: The C.V.
Mosby Company.
Newman, M. A. (1997). Experiencing the whole. Advances in Nursing Science,
20(1), 34-39.
Newman, M. A. (2003). A world of no boundaries. Advances in Nursing Science,
26(4), 240-245.
Nightingale, F. (1959). Notes on nursing: what it is and what it is not. London:
Dover Publications.
Northcott, N. (2002). Nursing with dignity, part 2: Buddhism. Nursing Times,
98(10), 36-38.
Norton, L. (1999). The philosophical bases of grounded theory and their
implications for research practice: Issues in Research. Nurse Researcher,
7(1), 31-43.
O’Brien, M. E. (2003). Spirituality in nursing: standing on holy ground (2nd ed.).
Boston: Jones and Bartlett Publishers.
Oaksford, K., Frude, N., & Cuddihy, R. (2005). Positive coping and stress-related
psychological growth following lower limb amputation. Rehabilitation
Psychology, 50(3), 266-277.
Orem, D. E. (1971). Nursing: concepts of practice. New York: McGraw-Hill.
Orlando, I. J. (1961). The dynamic nurse-patient relationship: function, process, and
principles. New York: GP Putnam & Sons.
Ott, M. J. (2004). Mindfulness meditation: a path of transforming and healing.
Journal of Psychosocial Nursing and Mental Health Services, 42(7), 22-29.
Oumtanee, A. (2001). Exploring family adaptation in caring for a person with
HIV/AIDS. PhD thesis: Virginia Commonwealth University., Virginia.
Panpakdee, O., Hanucharurnkul, S., Sritanyarat, W., Kompayak, J., & Tanomsup, S.
(2003). Self-care process in Thai people with hypertension: an emerging
model. Thai Journal of Nursing Research, 7(2), 121-136.
334
References
Paonil, V. (2003). Buddhist paradigm on health and healing in Thai society. Health
Care System Research Institute, Bangkok, Thailand.
Parse, R. R. (1987). Nursing science: major paradigms, theories, and critiques.
Philadelphia: WB Saunders.
Paterson, J. G., & Zderad, L. T. (1988). Humanistic nursing. New York: National
League for Nursing.
Patterson, E. (1998). The philosophy and physics of holistic health care: spiritual
healing as a workable interpretation. Journal of Advanced Nursing, 27(2),
287-293.
Payutto, P. A. (2001). Thai Buddhism in the Buddhist world. Bangkok:
Buddhadhamma Foundation.
Payutto, P. A. (2003). Dictionary of Buddhism. Bangkok: Sahadhammic Company.
Peplau, H. E. (1952). Interpersonal relations in nursing. New York: GP Putnam &
Sons.
Phosrithong, A. (1993). Variables relating to nursing behavior for old age patients
of nurse in the Department of Medical Services, Ministry of Public Health.,
Master Thesis: Srinakharinwiroj University, Bangkok.
Picard. (2002). A praxis model of research for therapeutic nursing. In D. Freshwater
(Ed.), Therapeutic nursing: improving patient care through self awareness
and reflection (pp. 149-161). London: Sage Publications.
Pincharoen, S., & Congdon, J. G. (2003). Spirituality and health in older Thai
persons in the United States. Western Journal of Nursing Research, 25(1),
93-108.
Polit, D., & Beck, C. (2004). Nursing research: principles and methods (7th ed.).
Philadelphia: Lippincott Williams & Wilkins. .
Polk, L. V. (1997). Toward a middle-range theory of resilience. Advances in Nursing
Science, 19(3), 1-13.
Pongpaibul, S. (1999). The theory for social science research from the Buddhist
perspective. Bangkok: The Thai Research Fund Organisation (in Thai).
Priest, H., Roberts, P., & Woods, L. (2002). An overview of three different
approaches to the interpretation of qualitative data. Part 1: Theoretical issues.
Nurse Researcher 10(1), 30-42.
Pulphatharachevin, J., & others. (2003). Spiritual health promotion. Bangkok:
Chulalongkorn University (in Thai).
335
References
Punyanubhab, S., & others. (2001). Questions and answers about Buddhism: volume
3. Bangkok: The Committee of National Identity, Thailand.
Quint, J. C. (1967). The nurse and the dying patient. New York: Macmillan.
Radwin, L. E., Farquhar, S. L., Knowles, M. N., & Virchick, B. G. (2005). Cancer
patients' descriptions of their nursing care. Journal of Advanced Nursing,
50(2), 162-169.
Raholm, M., & Lindholm , L. (1999). Being in the world of the suffering patient: a
challenge to nursing ethics. Nurse Ethics, 6(6), 528-539.
Ratanakul, P. (1986). Bioethics, an introduction to the ethics of medicine and life
sciences Bangkok: Mahidol University.
Ratanakul, P. (1988). Bioethics in Thailand: the struggle for Buddhist solutions.
Journal of Medicine and Philosophy, 13, 301-312.
Ratanakul, P. (1999a). Buddhism, health, disease, and Thai culture. In H. Coward &
P. Ratanakul (Eds.), A cross-cultural dialogue on health care ethics (pp. 1733). Waterloo, Ontario: Centre for Studies in Religion and Society,
University of Victoria: Wilfred Laurier University Press.
Ratanakul, P. (1999b). Love in Buddhist bioethics. Eubios Journal of Asian and
International Bioethics, 9, 45-46.
Ratanakul, P. (2004). Buddhism, health and disease. Eubios Journal of Asian and
International Bioethics, 15, 162-164.
Ratinthorn, A. (2000). Being A commercial sex worker in Thailand: experiences and
health care seeking behaviours. PhD thesis: University of California, San
Francisco., San Francisco.
Reynolds, N. R., & Alonzo, A. A. (1998). HIV informal caregiving: emergent
conflict and growth. Research in nursing and Health, 21, 251-260.
Rich, K. L., & Butts, J. B. (2005). Values, relationships, and virtues. In J. B. Butts &
K. L. Rich (Eds.), Nursing ethics: across the curriculum and into practice
(pp. 29-52). Boston: Jones and Bartlett Publishers.
Richardson, A. (2004). Creating a culture of compassion: developing supportive care
for people with cancer. European Journal of Oncology Nursing, 8, 293-305.
Rinpoche, S. (2002). The Tibetan book of living and dying: revised and updated.
London: Rider.
336
References
Roberts, K. (2002). Ethics in nursing research. In K. Roberts & B. Taylor (Eds.),
Nursing research processes: an Australian perspective (2nd ed., pp. 95-125).
Australia: Nelson Thomson Learning.
Roberts, K., & Taylor, B. (2002). Nursing research processes: an Australian
perspective (2nd ed.). Australia: Nelson Thomson Learning.
Roberts, K. T., & Whall, A. (1996). Serenity as a goal for nursing practice. Image The Journal of Nursing Scholarship, 28(4), 359-364.
Rodgers, B., & Cowles, K. V. (1997). A conceptual foundation for human suffering
in nursing care and research. Journal of Advanced Nursing, 25(5), 10481053.
Rodgers, B. L., & Yen, W. J. (2002). Re-thinking nursing science through the
understanding of Buddhism. Nursing Philosophy, 3, 213-221.
Rogers, M. E. (1970). An introduction to the theoretical basis of nursing.
Philadelphia: F. A. Davis.
Ronaldson, S. (1997). Spirituality: the heart of nursing. Melbourne: Ausmed
Publications.
Rowe, J. (2003). The suffering of the healer. Nursing Forum, 38(4), 16-20.
Roy, C. (1974). Introduction to nursing: adaptation model (2 ed.). Englewood
Cliffs, NJ: Prentice Hall.
Rujkorakarn, D., & Sukmak, V. (2002). Meaning of health and self-care in married
men and women. Thai Journal of Nursing Research, 6(2), 69-75.
Rundqvist, E. M., & Severinsson, E. I. (1999). Caring relationships with patients
suffering from dementia-an interview study. Journal of Advanced Nursing,
29(4), 800-807.
Rungreangkulkij, S., & Chesla, C. (2001). Smooth a heart with water: Thai mothers
care for a child with schizophrenia. Archives of Psychiatric Nursing, 15(3),
120-127.
Sahlsten, M., Larsson, I. E., Lindencrona, C., & Plos, K. (2005). Patient
participation in nursing care: an interpretation by Swedish registered nurses.
Journal of Clinical Nursing, 14(1), 35-42.
Sandelowski, M. (1986). The problem of rigour in qualitative research. Advances in
Nursing Sciences, 8(3), 27-37.
Sandelowski, M. (1995). On the aesthetics of qualitative research. Image -The
Journal of Nursing Scholarship, 27(3), 205-209.
337
References
Sangharakshita. (1999). The Bodhisattava ideal: wisdom and compassion in
Buddhism. Birmingham: Windhorse Publications.
Santati, S., Ratinthorn, A., & Christian, B. (2003). Parents’ experiences in asthma
attack prevention: struggling to take control. Thai Journal of Nursing
Research, 7(3), 186-198.
Sasat, S. (1998). Caring for dementia in Thailand: a study of family care for
demented elderly relatives in Thai Buddhist society. PhD Thesis: University
of Hull.
Schmidt, N. A., & Mauk, K. L. (2004). Spirituality as a life journey. In K. L. Mauk
& N. A. Schmidt (Eds.), Spiritual care in nursing practice (pp. 1-20).
Philadelphia: Lippincott Williams and Wilkins.
Schreiber, R., & Stern, P. (2001). Using grounded theory in nursing. New York:
Springer Publishing Company, Inc.
Seale, C., Gobo, G., Gubrium, J. F., & Silverman, D. (2004). Qualitative research
practice. London: Sage Publications.
Seeherunwong, A. (2002). Recovering from depression of middle-aged Thai women:
a grounded theory study. PhD thesis: Mahidol University, Bangkok.
Sellers, S. C. (2001). The spiritual care meanings of adult residing in the Midwest.
Nursing Science Quarterly, 14(3), 239-248.
Sethabouppha, H., & Kane, C. (2005). Caring for the seriously mentally ill in
Thailand: Buddhist family caregiving. Archives of Psychiatric Nursing,
19(2), 44-57.
Sethabouppha, H. P. (2002). Buddhist family caregiving: a phenomenological study
of family caregiving to the seriously mentally ill in Thailand. PhD thesis:
University of Virginia, Virginia.
Shaw, M. (2004). Aggression toward staff by nursing home residents: findings from
a grounded theory study. Journal of Gerontological Nursing, 30(10), 43-54.
Sheikh, A. A., & Sheikh, K. S. (1989). Eastern and Western approaches to
healings: ancient wisdom and modern knowledge. New York: John Wiley &
Sons.
Sheldon, L. (1998). Grounded theory: issues for research in nursing. Nursing
Standard, 12(52), 47-50.
Sheldon, L. K. (2004). Communication for nurses: talking with patients. Thorofare:
Slack Incorporated.
338
References
Sherbun, M. A. (2006). Caring for the caregiver: 8 truths to prolong your career.
Boston: Jones and Bartlett Publishers.
Sherwood, G. D. (2000). The power of nurse-client encounters: Interpreting spiritual
themes. Journal of Holistic Nursing 18(2), 159-175.
Shih, F. (1998). Triangulation in nursing research: issues of conceptual clarity and
purpose. Journal of Advanced Nursing, 28(3), 631-641.
Silva, P. (1990). Buddhist psychology: a review of theory and practice. Current
Psychology, 9(3), 236-254.
Silva, P. (1991). An introduction to Buddhist psychology. Hampshire, London:
Maclillian Academic and Professional Ltd.
Simpson, J. A., & Weiner, E. S. C. (1989). The Oxford English Dictionary (Vol. V ).
Oxford: Clarendon Press.
Sindhu, S. (1992). Role clarity and health perceptions: Thai women with valvular
heart disease. PhD thesis: University of California, San Francisco, San
Francisco.
Singhakhumfu, L. (2002). Managing everyday life among Thai men with
paraplegia: a grounded theory study. PhD thesis: Chiang Mai University,
Chiang Mai.
Sitzman, K. L. (2002). Interbeing and mindfulness: a bridge to understanding Jean
Watson's theory of human caring. Nursing Education Perspectives, 23(3),
118-123.
Snyder, M., & Lindquist, R. (2006). An overview of complementary/alternative
therapies. In M. Snyder & R. Lindquist (Eds.), Complementary/alternative
therapies in nursing (pp. 3-14). New York: Springer Publishing Company.
Sohn, P. M., & Loveland, C. C. (2002). Nurse practitioner knowledge of
complementary alternative health care: foundation for practice. Journal of
Advanced Nursing, 39(1), 9-16.
Songwathana, P. (1998). Kinship, karma, compassion, and care: domiciliary and
community based care of AIDS patients in Southern Thailand. PhD thesis:
Griffith University, Queensland.
Songwathana, P. (2001). Women and AIDS caregiving: women's work? Health
Care Women International, 22(3), 263-279.
Sorajjakool, S., & Lamberton, H. (2004). Spirituality, health, and wholeness. New
York: The Haworth Press.
339
References
Speck, P. (2005). The evidence base for spiritual care. Nursing Management, 12(6),
28-31.
Sripichayakan, K. (1999). Dealing with wife abuse: a study from the women’s
perspectives in Thailand (women victims). PhD thesis: University of
Washington., Washington DC.
Sritanyarat, W. (1996). A grounded theory study of self-care processes among Thai
adults with diabetes. PhD thesis: The University of Texas at Austin., Texas
Stark, M. A., Manning-Walsh, J., & Vliem, S. (2005). Caring for self while learning
to care for others: a challenge for nursing students. Journal of Nursing
Education, 44(6), 266-270.
Stein-Parbury, J. (2005). Patient and person: interpersonal skills in nursing (3rd
ed.). Sydney: Elsevier, Churchill Livingstone.
Sthirasuta, S. (2005). Autobiography: Mae Chee (Nun) Sansanee Sthirasuta. In M.
Jutaputhi (Ed.), Mae Che (Nun) Sunsanee Satheansuit: the walk of wisdom
(3rd ed.). Bangkok: Sam Se Publication (in Thai).
Stiles, M. K. (1990). The shining stranger: nurse-family spiritual relationship.
Cancer Nursing, 13(4), 235-245.
Stoll, R. I. (1989). The essence of spirituality. In V. B. Carson (Ed.), Spiritual
dimensions of nursing practice (pp. 4-23). Philadelphia: W.B. Saunders
Company.
Strauss, A. (1987). Qualitative analysis for social scientists. UK: Cambridge
University Press
Strauss, A. L., & Corbin, J. (1990). Basics of qualitative research: techniques and
procedures for developing grounded theory. Thousand Oaks: Sage
Publications.
Strauss, A. L., & Corbin, J. (1998). Basics of qualitative research: techniques and
procedures for developing grounded theory (2nd ed.). Thousand Oaks: Sage
Publications.
Subgranon, R. (1999). Caregiving process of Thai caregivers to elderly stroke
relatives: a grounded theory approach. PhD thesis: The University of Utah,
Utah.
Subgranon, R., & Lund, D. A. (2000). Maintaining caregiving at home: a culturally
sensitive grounded theory of providing care in Thailand. Journal of
Transcultural Nursing, 11(3), 166-173.
340
References
Subhuti. (2004). Buddhism and friendship. Birmingham: Windhorse Publications.
Suddhiyano, J. (2000). Buddhism and holistic nursing and health care. Songkhla:
Faculty of Nursing, Prince of Songkla University.
Suginunkul, N. (1998). Family, work and personal factors related to performance of
professional nurse. Srinakharinvirot University, Bangkok, Thailand.
Sully, P., & Dallas, J. (2005). Essential communication skills for nursing.
Edinburgh: Elsevier Mosby.
Sundin, K., & Jansson, L. (2003). "Understanding and being understood" as a
creative caring phenomenon in caring of patients with stroke and aphasia
Journal of Clinical Nursing, 12(1), 107-116.
Suttharangsee, W., Chetchaovalit, T., & Lerdpaiboon, J. (2002). Experiences of
Prince of Songkla University students in using Buddhism for improving
mental health. Thai Journal of Nursing Research, 6(1), 52-64.
Swanson, K. M. (1991). Empirical development of middle-range theory of caring.
Nurses Researcher, 40(3), 161-166.
Swanson, K. M. (1999). What is known about caring in nursing science: a literature
meta-analysis. In A. S. Hinshaw, S. Fleetham & J. Shaver (Eds.), Handbook
of clinical nursing research (pp. 31-60). Thousand Oaks, CA: Sage
Publications.
Synder, M., & Lindquist, R. (2006). An overview of complementary/alternative
therapies. In M. Synder & R. Lindquist (Eds.), Complementary/alternative
therapies in nursing (5th ed., pp. 3-14). New York: Springer Publishing
Company.
Tangkuptanon, P. (2001). The influence of Buddhism on Thai culture: A study of
Sekhiyavatta in patimokkha on Thai conduct and etiquette. Master thesis:
Mahidol University, Bangkok.
Taylor, B., Glass, N., McFarlane, J., & Stirling, K. (2001). Views of nurses, patients
and patients' families regarding palliative nursing care. International Journal
of Palliative Nursing, 7(4), 186-191.
Taylor, B. J. (2000). Being human: ordinariness in nursing. Lismore Southern Cross
University Press.
Taylor, B. J. (2002a). Qualitative interpretive methodologies. In K. Roberts & B. J.
Taylor (Eds.), Nursing research processes: an Australian perspective (2nd
ed., pp. 304-339). Australia: Nelson Thomson Learning.
341
References
Taylor, B. J. (2002b). Qualitative methods. In K. Roberts & B. Taylor (Eds.),
Nursing research processes: an Australian perspective (2nd ed., pp. 374405). Australia: Nelson Thomson Learning.
Taylor, B. J. (2006). Reflective practice: a guide for nurses and midwives (2nd ed.).
Berkshire: Open University Press.
Terwiel, B. J. (1995). The role of the laity in modern Thai Buddhism.Unpublished
manuscript, Faculty of Asian Studies, Australian National University,
Australia.
Thampanichawat, W. (2000). Thai mothers living with HIV infection in urban areas.
PhD thesis: Washington University, Washington DC.
The Nursing Council of Thailand. (2006). Past and present executives.
www.moph.go.th/ngo/nursec/webcom.htm, Retrieved: October 29, 2005.
Thompson, M. G. (2004). Happiness and change: a reappraisal of the psychoanalytic
conception of suffering. Psychoanalytic Psychology, 21(1), 134-153.
Thurmond, V. A. (2001). The point of triangulation. Journal of Nursing
Scholarship, 33(3), 253-258.
Tongprateep, T. (1998). The essential elements of spirituality among rural Thai
elders. D.S.N Thesis: The University of Alabama at Birmingham.
Tongprateep, T. (2000). The essential elements of spirituality among rural Thai
elders. Journal of Advances Nursing, 31(1), 197-203.
Tongprateep, T., & others, A. (2002). Buddhism for nursing. Bangkok Eak Pim Thai
Press (in Thai).
Tongprateep, T., Pitagsavaragon, P., & Panasakulkarn, S. (2001). Metaparadigm in
nursing based on Buddhist view. The Thai Journal of Nursing Council,
16(3), 13-24.
Tongprateep, T., & Soowit, B. (2002). Brahma vihara: the wisdom of nursing. In T.
Tongprateep & others (Eds.), Buddhism for nursing (pp. 55-68). Bangkok:
Eak Pim Thai Press (in Thai).
Touhy, T. A., Brown, C., & Smith, C. J. (2005). Spiritual caring: end of life in a
nursing home. Journal of Gerontological Nursing, 31(9), 27-35.
Travellbee, J. (1976). Interpersonal aspects of nursing (2nd ed.). Philadelphia: F. A.
Davis Company.
Tuckett, A. (1999). Nursing practice: compassionate deception and the Good
Samaritan. Nursing Ethics, 6(5), 383-389.
342
References
Tungpunkom, P. (2000). Staying in balance: skill and role development in
psychiatric caregiving. PhD thesis: University of California, San Francisco,
San Francisco.
Vander Zyl, S. (2002). Compassion fatigue and spirituality. Nursingmatters, 13(12),
4.
von Dietze, E., & Orb, A. (2000). Compassionate care: a moral dimension of
nursing. Nursing Inquiry, 7(3), 166-174.
Wagnild, G. (2003). Resilience and successful aging: comparison among low and
high income older adults. Journal of Gerontological Nursing, 29(12), 42-49.
Walsh, R. (1999). Essential spirituality: the seven central practices to awaken heart
and mind. New York: John Wiley & Sons.
Walton, J. (1999). Spirituality of patients recovering from an acute myocardial
infarction: a grounded theory study. Journal of Holistic Nursing, 17(1), 3453.
Wannapornsiri, C., Sindhu, S., Phancharoenworakul, K., & Gasemgitvatana, S.
(2005). Caring process of Thai women with breast cancer receiving
chemotherapy. Thai Journal of Nursing Research, 9(2), 121-132.
Wasi, P. (2002). Human life in the twentieth century: for the new era of
development. Bangkok: Sodsri Saridwong Foundation (in Thai).
Watson, J. (1979). Nursing: the philosophy and science of caring. Boston: Little
Brown.
Watson, J. (1985). Nursing: human science and human care. Norwalk: AppletonCentury-Crofts.
Watson, J. (1987). Nursing on the caring edge: metaphorical vignettes. Advances in
Nursing Science, 10(1), 10-17.
Watson, J. (1988). Nursing: human science and human care: a theory of nursing.
New York: National League for Nursing.
Watson, J. (1997). The theory of human caring: retrospective and prospective.
Nursing Science Quarterly, 10(1), 49-52.
Watson, J. (1999a). Postmodern nursing and beyond. Edinburgh: Churchill
Livingstone.
Watson, J. (1999b). Nursing: human science and human caring: a theory of nursing.
Boston: Jones and Bartlett Publishers.
343
References
Watson, J. (2005). Caring science as sacred science. Philadelphia: F. A. Davis
Company.
Weaver, A. J., Flannelly, L. T., & Flannelly, K. J. (2002). A review of research on
religious and spiritual variables in two primary gerontological nursing
journals: 1991-1997. Journal of Gerontological Nursing, 27(9), 47-54.
Wibulpolprasert, S. (2005). Thailand health profiles 2001-2004. The Ministry of
Public Health, Thailand. http://www.moph.go.th/ops/health_48, Retrieved:
October 29, 2005.
Wick, G. S. (2005). The book of equanimity: illumination classic Zen koans. Boston:
Wisdom Publication.
Wilber, K. (1977). The spectrum of consciousness. Wheaton, Ill: The Theosophical
Publishing House.
Wilber, K. (1980). The atman project: a transpersonal view of human development.
Boston: Shambhala.
Wilber, K. (1981). No boundary: Eastern and Western approaches to personal
growth. Boston: Shambhala.
Wilber, K. (2000a). A theory of everything: an integral vision for business, politics,
science, and spirituality Boston: Shambhala.
Wilber, K. (2000b). Integral psychology: consciousness, spirit, psychology, therapy.
Boston: Shambhala.
Wilkin, K., & Slevin, E. (2004). The meaning of caring to nurses: an investigation
into the nature of caring work in an intensive care unit. Journal of Clinical
Nursing, 13(1), 50-59.
Williams, A. (1998). The delivery of quality nursing care: a grounded theory study
of the nurse's perspective. Journal of Advanced Nursing, 27(4), 808-816.
Williams, A., & Irurita, V. (2004). Therapeutic and non-therapeutic interpersonal
interactions: the patient's perspective. Journal of Clinical Nursing, 13(7),
806-815.
Williams, C., & Davis, C. (2004). Therapeutic interaction in nursing. Thorofare, NJ:
Slack Incorporated.
Wiman, E. (2004). Caring and uncaring encounters in nursing in an emergency
department. Journal of Clinical Nursing, 13(4), 422-429.
344
References
Wiroonpanich, W., & Strickland, J. (2004). Normalizing: postoperative acute
abdominal surgical pain in Thai children. Journal of Pediatric Nursing,
19(2), 104-112.
Wisesrith, W., Nuntaboot, K., Sangchart, B., & Tuennadee, R. (2003). The meaning
of death: perspectives of AIDS and their family members. Thai Journal of
Nursing Research, 7(3), 213-225.
Wongtes, S. (2000). The Thai people and culture. Bangkok: The Public Relations
Department, Foreign Office, Thailand.
Woods, L., Priest, H., & Roberts, P. (2002). An overview of three different
approaches to the interpretation of qualitative data. Part 2: practical
illustrations. Nurse Researcher 10(1), 43-51.
Worthington, E. L., Kurusu, T. A., & others, a. (1996). Empirical research on
religion and psychotherapeutic processes and outcomes: a 10-year review
and research prospectus. Psychological Bulletin, 119, 445-487.
Wright, L. M. (1997). Suffering and spirituality: the soul of clinical work with
families. Journal of Family Nursing, 3(1), 3-14.
Wright, L. M. (2005). Spirituality, suffering, and illness: ideas for healing.
Philadelphia: F.A. Davis Company.
Wright, L. M., & Leahey, M. (2005). Nurses and families: a guide to families
assessment and intervention (4th ed.). Philadelphia: F. A. Davis Company.
Wright, S. G., & Sayre-Adams, J. (2000). Sacred space: right relationship and
spirituality in health care. Edinburgh: Churchill Livingstone.
Zen Master Seung Sahn. (2006). Buddhist wisdom about detachment from thoughts:
Email from: [email protected] (April 24, 2006).
345
APPENDIX (E)
Pe Karuna (Nurse 2)
The 35 codes for Pe Karuna were: 1) applying Dhamma for psycho-spiritual care; 2) teaching the
truth of life; 3) teaching breathing meditation; 4) applying the Buddha’s Dhamma to help patients
cope with cancer; 5) realising not everybody can do Anapanasati meditation; 6) finding simple ways
to teach meditation; 7) perceiving a meritorious act to help suffering patients; 8) gaining more
understanding about the nature of cancer patients; 9) realising the law of kamma while helping
patients; 10) accepting the real result of treatments even if they became worse; 11) using a
metaphorical story when applying Dhamma; 12) telling relatives to use mindfulness when patient is
reaching death; 13) recharging power; 14) preparing to die; 15) intending to write books; 16)
appreciating nurses’ caring; 17) practising mindfulness meditation; 18) building a therapeutic
relationship with patients and relatives; 19) considering patients’ religious backgrounds before
teaching Dhamma and meditation; 20) applying Dhamma with the Kubler-Ross’s grief and loss
processes; 21) having Kalyanamittata (good friendships) with patients; 22) learning Dhamma by
practising regularly; 23) dealing with complicated problems by Metta, Upekkha and Loka-Dhamma
principles; 24) accepting death; 25) realizing direct experience of Dhamma understanding; 26) seeing
possibilities to apply Dhamma; 27) respecting patients as nurses’ teachers; 28) perceiving Dhamma is
the core of nursing; 29) perceiving body and mind’s suffering is a common problem; 30) suggesting a
heart of caring relationships; 31) understanding patient’s and relatives’ satiations; 32) working with
mindfulness; 33) having Iddhipada while working; 34 perceiving Dhamma teachings guide patient to
accept illness and death; and 35) and perceiving the importance of a good patient-centred care.
Pe Jaiyen (Nurse 3)
The 65 codes for Pe Jaiyen were: 1) running a psycho-spiritual support project for patients in the
ward; 2) perceiving limitations of nurses’ roles to tell patients about their diagnosis; 3) having a poor
relationship with doctors; 4) perceiving different kinds of cancer patients; 5) building therapeutic
relationships with cancer patients; 6) reminding patients to consider the Buddha’s teaching about
impermanence; 7) supporting a patient’s mind with kindness and understanding; 8) appreciation a
good relationship between patients and husband and health care staff; 9) avoiding bad reactions with
moody patients; 10) transferring patients’ emotional problems to the next shift nurses for maintaining
continuity of care; 11) improving the recording system about psycho-spiritual care; 12) applying
Buddhist rituals into nursing care in order to meet holistic goals; 13) realising few nurses can run
psycho-spiritual support sessions; 14) feeling joy and gaining self-value while providing psychospiritual support; 15) realising some patients don’t believe in Dhamma; 16) realising busyness is a
barrier to providing psycho-spiritual support; 17) being a psycho-spiritual support volunteer; 18)
politeness and respectfulness are basic parts of a professional relationship; 19) perceiving sympathy,
cheerfulness, politeness, kindness, understanding, listening, helping, not neglecting, not letting them
wait too long and encouraging patients to practice rituals, lead to good relationships between nurses
and clients; 20) respecting patients as human beings; 21) respecting different patients’ beliefs about
kamma; 22) having good relationships, nurses can help patients accept their illness more readily; 23)
caring for patients like caring for nurses’ relatives; 24) perceiving elderly patients can accept illness
and the teaching about the truth of life better than young patients; 25) talking about positive thinking
while giving moral support to patients; 26) accepting success and failure of patients’ coping
outcomes; 27) providing physical care with politeness; 28) perceiving problems about coordinating
with other people; 29) valuing sharing nurses’ feelings with patients; 30) respecting each other; 31)
building good relationships with patients and providing psycho-spiritual care; 32) maintaining
patients’ hope; 33) dealing with non-supportive relatives with kindness; 34) reducing patients’
hesitation by giving chances for patients to ask questions; 35) experiencing practising Dhamma; 36)
understanding the meaning of open listening from learning Dhamma; 37) focusing more on patients’
perspectives while educating patients; 38) using time to support patients’ mind; 39) being more
flexible while supporting patients; 40) being concerned with patients’ reactions more than just doing
routine care; 41) feeling empathy with patients; 42) perceiving time limits to support patents’ mind;
43) trying to measure patients’ psycho-spiritual outcomes; 44) supporting patients with understanding
the nature of illness and process of treatments; 45) appreciating patients’ positive thinking; 46)
experiencing patient’s explanations of their illness from Dhamma view; 47) experiencing patients
from the village use more Dhamma when they are sick; 48) having no answers for patients who
question about the result of kamma; 49) perceiving a limitation of young nurses to understand about
Dhamma; 50) expecting the head of the ward to understand the Dhamma; 51) thinking of patients’
mind form nurses own feeling; 52) thinking of patients as parents or relatives while having conflict
about choices of treatments; 53) feeling guilt when helping patients made decision to refuse
aggressive treatments; 54) modifying the teaching about the truth of life to remind patients to accept
their illness; 55) Realising the importance of nurses’ moral support, love and kindness of nurses to
patients (Patients need kam lung jai (moral support), kwarm rug (love) and kwarm metta (kindness)
and I think I can give these 3 things to patients; 56) being more sensitive to others’ feelings; 57)
feeling happiness from helping others; 58) perceiving Dhamma people are more kind; 59) pausing
and considering thinking before acting or expressing feelings; 60) developing self awareness and
reflection skills from practising meditation; 61) perceiving the difficulty of Dhamma language; 62)
perceiving the benefit of learning Dhamma such as being kind, friendliness, working with
mindfulness, and managing think-speak-acts well; 63) changing from the inside when practising
meditation; 64) encouraging patients to maintain their religious rituals while staying in the hospital
such as making more merits, reading Dhamma books, listen to Dhamma teachings; and 65)
perceiving the value of setting rituals for patients’ happiness
Pe Pranee (Nurse 4)
The 26 codes for Pe Pranee were: 1) describing studying, working and family background; 2)
maintaining good relationships and avoiding conflicts with patients, relatives, and co-workers by
looking at one’s own part, considering individual difference; 3) maintaining good relationships and
avoiding conflicts with patients, relatives, and co-workers by walking away from the conflict
situation to reset mindfulness, and understanding others; 4) maintaining good relationships and
avoiding conflicts with patients, relatives, and co-workers by letting bad things go, thinking of others’
good parts, understanding others, and giving forgiveness; 5) maintaining good relationships with
aggressive patients by being a good listener, calm, gentle, respecting patients, calling patients’ name
politely, giving excuse when nurses do wrong, setting mindfulness, avoiding argument, emotion and
impolite manners; 6) building trust of curious relatives by showing respect, providing deeper
information; 7) being friendly with patients and relatives; 8) believing in kamma; 9) following the
teaching about the four Iddhipada; 10) being kind to patients; 11) seeing the connection of doing
good deeds for patients to receiving good care in the future; 12) implementing more holistic care for
patients who use ventilators especially issues about anxiety, thirst, communication, and the beliefs of
patients and relatives; 13) encouraging relatives of terminally ill patients to do rituals to follow their
beliefs; 14) realising positive outcomes of reminding relatives to do religious rituals for dying
patients; 15) perceiving spiritual needs of critical and terminal ill patients and their relatives; 16)
supporting patients to listen to Dhamma teaching; 17) letting relatives stay with patients who are in
crisis and when doing CPR; 18) being a mediator in communicating effectively between health care
team and patients and relatives; 19) perceiving the influence of hospital accreditation on improving
holistic care; 20) perceiving the influence of studying Master courses in nursing on understanding
about spirituality and holistic care; 21) thinking of jai khao-jai rao (other minds as our minds), and
respecting others is a good way to build good relationships; 22) gaining inner power from working
hard to help patients; 23) dealing with high demands from relatives with politeness; 24) listening to
complaint and suggestion from patients and relatives openly; 25) perceiving impolite manners are a
main problem of nurses; and 26) being expected to have a soft voice, good manners, politeness, and
an open mind to listen to others.
Nurse 5 (Pe Aree)
The 63 codes for Pe Aree were: 1) informing patients and relatives about services and different kind
of staff, showing nurses’ best practice and providing enough information as ways to build trust and
good relationships; 2) implementing a good orientation system and providing information regularly;
3) being concerned about issues about communication problems with Muslim people; 4) being
concerned about caring personalities of nurses who are being trained to be smart and have good
manners; 5) promoting patients to listen to chanting and Dhamma cassettes; 6) guiding and
supporting relatives to do religious rituals for patients; 7) being concerned about private places to
perform rituals; 8) perceiving senior nurses are more interested in spiritual care than junior nurses; 9)
gaining understanding about the truth of life while caring for patients and relatives; 10) having
problems about recording psycho-spiritual care; 11) helping patients to be calm and have a good
death; 12) helping relatives to accept a patient’s dying; 13) perceiving nurses are not concerned about
2
their religious practices; 14) perceiving limitations of practising meditation by some nurses; 15)
chanting and transferring merit to other beings every night; 16) recommending nurses practice
chanting about radiating loving kindness and transferring merit to other beings; 17) recommending
every family and school teaches chanting to children; 18) realising the benefits of chanting; 19)
learning about chanting, self discipline, understanding others, and having a cool mind to listen others
from family and school; 20) understanding fussy relatives and opening channel to communicate with
them; 21) avoiding assigning junior nurses to deal with fussy relatives; 22) preventing conflicting
relationships by rotating nurses’ assignments; 23) dealing with too many relatives is a normal event
in Thai culture; 24) maintaining good relationships with relatives by giving enough information about
the patient’s condition; 25) using working experience to predict patients’ condition and plan for
closure with relatives; 26) being concerned about patients’ quality of life more than curing diseases;
27) helping relatives make proper decisions for terminally ill patients; 28) receiving trust and
respectful from patients; 29) having attachment with patients when nurses have too much
understanding and work across professional boundaries; 30) experiencing patients and relatives have
attachment with the critical care nurses; 31) building trust and being friendly while maintaining
professional relationships with terminate cases; 32) explaining patients’ condition and accepting
patients’ outcomes by considering the result of their kamma; 33) believing in kamma; 34) suggesting
relatives make more merit for critical ill patients; 35) believing in the power of the mind to control
pain and feelings; 36) dealing with life stress by chanting; 37) encouraging colleagues to make merit;
38) perceiving good result of practising eastern wisdom such as meditation, chanting, Tai Chi, Yoga
regularly; 39) having no interest in practising meditation; 40) applying Buddhist rituals when patients
die suddenly; 41) performing death rituals in the proper place such as at the post mortem room; 42)
performing the patient’s death rituals in their tradition; 43) believing modern work procedures
destroy authentic informal nature of nurses; 44) perceiving relatives in modern times have less time
to visit and support patients; 45) linking Buddha’s teaching to the working process of quality
management; 46) perceiving Thai culture is a hesitant culture; junior people should not give feedback
to older people; 47) providing spiritual care by preparing relatives’ minds to accept patients’ critical
conditions; 48) experiencing doctors and nurses ignore care for patients’ minds; 49) providing
psycho-spiritual care for patients and relatives by providing information regularly and letting them do
rituals to follow their beliefs; 50) having problems about recoding psycho-spiritual care; 51) allowing
relatives to stay closer to critically ill patients; 52) experiencing unawareness of patient’s psychospiritual needs; 53) having subconscious connections and dreams about patient; 54) making merit for
some dying patients; 55) preparing relatives’ mind to accept uncertainty of accident patients; 56)
preparing relatives’ mind to accept death of young patient; 57) suggesting relatives make merit and
do death rituals for patient; 58) supporting relatives continually after patients die; 59) being ordinary
nurses can prevent the gap between the head nurse and relatives; 60) doing deep psycho-spiritual
approaches and caring with higher knowledge and skills; 61) assigning senior nurses to approach
patient holistically data and build good relationships with patients; 62) donating nurses’ money to
support poor patients-nurses can make merit with patients; and 63) perceiving good relationships are
basic to all nursing care.
Nong Saijai (Nurse 6)
The 65 codes for Nong Saijai were: 1) perceiving the value of being a nurse who helps and supports
others; 2) dealing with conflict in family with the teaching about love, kindness, understanding and
forgiveness; 3) appreciating good relationships in patients’ families; 4) confirming that love and
kindness can heal others’ suffering; 5) experiencing practising Dhamma and being a novice nun; 6)
learning about beautiful parts of human beings and the truth of nature from reading and practising
Dhamma; 7) being taught by the monk to provide tender care for patients; 8) practising Vipassana
with mother to apply Dhamma to solve daily life problems; 9) having good monks as Dhamma
teachers; 10) perceiving both nurses and patients gain happiness from caring relationships; 11) using
Dhamma as a way to stop craving; 12) healing a broken heart by realising the kindness of the
Buddha; 13) dealing with life events by focusing on the present moment; 14) valuing taking more
time to get to know patients; 15) being kind with patients and relatives without being a proficient
nurse; 16) avoiding contact patient while having a bad mood; 17) dealing with anxiety and
nervousness by raising mindfulness; 18) dealing with emergencies with a calm manner and
mindfulness; 19) calming relatives, giving information, letting relatives support patients while patient
is in an emergency situation; 20) taking care of nurses’ own self well allow nurses to educate patients
more effectively; 21) having a good personality and kindness to build trust with patients; 22) giving
power to patient and talking good things rather than ignoring and being a bully; 23) learning value of
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life from patients; 24) forming a kind mind from having good friends (kalyanamit) and reading
Dhamma books; 25) nurturing self and patient’s life with nature; 26) being friendly with teenage
patients; 27) educating patients according to their background and talking with them in every aspect
of life, not only about illness; 28) being concerned about a relative’s ability and background when
letting them become involved in helping patients; 29) applying Buddha’s teachings about letting
things go, doing good kamma, being flexible, and respecting all human beings in daily life; 30)
applying Buddha’s teachings about natural law in spiritual care; 31) valuing a good heart; 32) giving
moral support to Muslim patients; 33) perceiving busyness is a barrier to providing psycho-spiritual
care; 34) being more gentle after learning about true love from patients; 35) learning about life stories
from patients; 36) learning to deal with disrespectful relatives with calm manners; 37) trying to
support patients’ mind by concern about their interesting and religious background; 38) perceiving
many ways to make merit; 39) making merit by giving smelling inhalant and massage to some elderly
patients; 40) wishing patients have a chance to do more relaxing activities; 41) respecting individual
difference of patients, being more flexible, giving smiles, being kind, and appreciating patients’
wisdom, giving respect, ready to listen and understand are the ways to build good relationships; 42)
encouraging patients to do rituals that follow their beliefs; 43) reminding a patient to think of the
Buddha in the dying stage; 44) applying the teaching about the truth of life to support relatives of
dying patients; 45) thinking of a patient’s good aspects and paying respect to a dying patient; 46)
being concerned about a patient’s privacy while bathing; 47) perceiving nurses are gentle and show
concern and respect the patient’s rights; 48) being concerned about relatives’ feeling and safety; 49)
being more gentle while nurses respect patients as human beings; 50) avoiding approaching patients’
deep aspects when there is not enough time to support; 51) trying to provide more psycho-socialspiritual support in busy wards; 52) being a volunteer is a way to develop palliative care skills and
knowing social support networks; 53) realising the importance of good communication; 54) being
concerned about the narrow world view of nurses; 55) being concerned about the patients culture; 56)
having high confidence and using nurses’ power are barriers to improving the relationship between
nurses, patients and relatives; 57) realising patients and relative need tender loving care, kindness and
compassion from nurses; 58) wishing nurses could set their mindfulness and relax before starting
their work; 59) realising the importance of policy on developing spiritual care skills and applying
Buddhist teaching to nursing care; 60) becoming more gently when practising meditation; 61)
realising some nurses are not interested in Dhamma; 62) having more social responsibility and
avoiding exploiting others when nurses understand Dhamma; 63) perceiving the city hospitals stand
far away form the local wisdom and Buddhist ways; 64) expecting nurses to be more flexible with the
visiting rules; and 65) learning in the world with open mind is the Buddhist way of living.
Pe Lamun (Nurse 7)
The 61 codes for Pe Lamun were: 1) being taught to apply Buddhist ways about The Four Noble
Truth principles to reduce suffering while studying a short course in nursing care for chronic illness;
2) having a mother as a religious role model; 3) reading Dhamma books and practising meditation; 4)
practising meditation with develop mindfulness skills project for nurses who care for chronic
patients; 5) practising religious rituals; 6) having less temper and being more peaceful from learning
Dhamma; 7) using breathing meditation to control headache and period pain; 8) teaching patients
who have meditation experience to do breathing meditation; 9) perceiving elderly patients practise
religious rituals more than other ages; 10) encouraging patients to do chanting before sleeping; 11)
being concerned about the time to apply rituals to heal patients and providing psycho-spiritual care;
12) perceiving that the Nursing department is more concerned to develop nurses’ skills to provide
psycho-spiritual support to patients; 13) teasing young patients as though they are nurses’ brothers;
14) being concerned that more patients need advanced psycho-spiritual support; 15) realising the sick
monk don’t apply Buddhist practices; 16) realising relatives do religious rituals for dying patients;
17) introducing relatives to chanting and religious rituals to promote peaceful death for terminally ill
patients; 18) asking relatives to watch patients while nurses are very busy; 19) respecting patients and
relatives’ beliefs; 20) seeing effects of patients’ beliefs on health seeking behaviors; 21) experiencing
relatives make merit for patients; 22) valuing living with present more than anticipating the results of
making merit in the future; 23) experiencing loss of self control when teaching new nurses; 24)
believing in kamma; 25) controlling emotions better after learning Dhamma; 26) considering the
natural law of birth, old age, sickness and death when caring for dying patients; 27) letting relatives
of dying patients stay with patients; 28) reminding patients to think of their good aspects in the dying
moments; 29) not being able to support dying patients and relatives when nurses are busy; 30)
applying meditation techniques to teach non religious patients without using religious words; 31)
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learning about the uncertainty of life from patients; 32) perceiving patients have different levels of
Dhamma understanding; 33) acknowledging the lack of time to provide psycho spiritual care; 34)
taking with patients while providing nursing care; 35) encouraging patients do chanting before
sleeping; 36) having the Buddha statue in the ward; 37) being concerned about sin if nurses take out
unconscious patients’ breathing tube before relatives take patient back home; 38) finding ethical and
proper ways to let relatives take unconscious patients back home; 39) having good relationships with
patients and relatives can prevent their complaints; 40) having aggressive manners causes bad
relationships with highly educated patients and relatives; 41) being polite while providing nursing
care to prevent complaints; 42) informing patients and relatives give feed back to nurses when staff
are impolite; 43) realising the importance of building good relationships with patients and relatives
and providing enough information for them; 44) preferring to provide more psycho-spiritual care
every day rather than doing research in this topic; 45) gaining benefit from providing psycho-spiritual
care for patients; 46) being more flexible to let relatives stay with patients in the ward; 47) being
concerned about cross infection of AIDS patients’ relatives; 48) realising that ward keepers cause
relationship problems with relatives; 49) realising some patients have improper health behaviors
when some relatives visit them; 50) building good relationships with patients by giving information,
talking with patients, using good manners, listening to patients’ needs and problems, and asking
patients’ first; 51) having good relationships with patient while providing comfort and safe care; 52)
having good relationships with patients because nurses give information to patients regularly and love
to talk with patients; 53) perceiving the belief about Kamma and traditional healings of Thai people
influence patients’ self care; 54) valuing the kindness of nurses; 55) realising nurses should have
skills about various kinds of relaxation techniques and providing holistic care; 56) improving
relationships with patients by trying to introduce patients to breathing meditation to relax themselves;
57) accepting individual differences and understanding life events from considering the Buddha’s
teachings about Tilakkhana, where aniccata, dukkhata, and anattata mean impermanence, the state of
suffering or being oppressed; and soullessness, the state of not being self; 58) reducing errors while
providing nursing care from raised consciousness after practising meditation; 59) realising patients
committed suicide because they could not release their tension or nobody listened to them; 60)
applying nurses’ understanding on the heart of Buddhism such as Tilakkhana into nursing through
caring with metta and karuna; and 61) building good relationships with patients by having good
manners, speech and thoughts, radiating loving kindness to patients, and teaching them to do
meditation.
Nong Yindee (Nurse 8)
The 63 codes for Nong Yindee were: 1) practising Dhamma while studying Bachelor degree in
Nursing; 2) changing from opposition to Dhamma to enjoying listening Dhamma teaching; 3)
believing in the teaching about the Middle Way, 4) realising the nature of disappointment in human
beings; 5) dealing with scolding from relatives by not adding emotion and keeping calm; 6) realising
dislike of nursing but trying to help suffering clients; 7) facing high expectations from privileged
patients and relatives by understanding and using a calm manner; 8) perceiving appreciation and
respect of some patients and relatives to nurses; 9) feeling tired from hard work in the unlimited
wards; 10) preparing her mind to deal with hard work by raising mindfulness and deep breathing; 11)
thinking of the value of helping patients and relatives to maintain the nursing; 12) expecting help
from relatives while having inadequate nursing staff; 13) realising some relatives have no time to
help nurses to take care of patients; 14) realising patients and relatives feel unsatisfied in nursing care
because nurses wait for help from relatives; 15) realising some relatives don’t want to help patients;
16) realising some relatives want to help patients but they have no time; 17) realising nurses can’t
provide good quality bedside nursing care when relatives don’t help them; 18) perceiving relatives
understand the limitations of nurses; 19) going away from the situation for a while when facing with
too much demand from relatives; 20) feeling tired and not happy from working too hard; 21) working
too hard from the unlimited patients’ beds policy; 22) perceiving kind-heart, sympathy and trying to
do good kamma is basic to Thai people and colleagues; 23) realising good friendship among the
teams can support nurses to overcome their hard work; 24) perceiving the belief about repaying
gratitude influences relatives’ decision-making and caring behaviours; 25) perceiving relatives would
like elderly patients to die more naturally and to refuse aggressive treatments; 26) not being involved
in making decisions for relatives about stopping aggressive treatments for elderly patients; 27)
perceiving that caring for HIV/AIDS patients is better after feeling more sympathy for their suffering;
28) experiencing the barrier of building good relationships with relatives of HIV and AIDS patients
when nurses can’t tell patients’ diagnosis to relatives; 29) being concerned about relatives’ safety
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while they help HIV and AIDS patients without knowing their diagnosis; 30) encouraging relatives to
do traditional and religious rituals according to their beliefs for severely ill patients; 31) believing in
good results of doing religious and traditional rituals; 32) being concerned about and helping patients
manage their economic problems; 33) understanding different levels of perception and expectation of
patients and relatives on nursing care; 34) dealing with high expectations from patients and relatives
with calmness, politeness and understanding; 35) being impolite and unfriendly when nurses are
really busy; 36) perceiving a barrier of building good relationships with patients and relatives comes
from nurses’ busyness; 37) perceiving barriers to psycho-spiritual care come from nurses’ busyness;
38) reacting with patient and relatives by considering their actions; 39) perceiving relatives have both
negative and positive influences on the nursing care of patients; 40) maintaining a standard care for
patients even when nurses don’t feel sympathy for bullying relatives; 41) considering the Middle
Way principle to deal with busy shifts; 42) being concerned about an elderly caregiver, not letting
them bathe a patient; 43) having no time to educate patients; 44) trying to educate patients while
providing nursing care; 45) perceiving good outcomes of the 30 Baht policy on helping poor people;
46) perceiving negative perceptions of patients and relatives on the 30 Baht policy such as receiving
low quality medicines and minimum health care from staff, influencing negative nurse-patientrelative relationships; 47) misunderstandings between patients, relatives and nurses come from letting
relatives stay with every patient; 48) gaining a strong mind from dealing with complex situations
while working; 49) gaining positive rewards from hard working; 50) using nursing knowledge to help
elderly people in the community; 51) chanting when feeling worried; 52) experiencing guilt from
being an unskilled nurse; 53) chanting and transferring merit to patients when feeling guilty with
them; 54) expressing good wishes to deceased patients; 55) guiding relatives to do death rituals for
patient in the dying state; 56) accepting a broken heart after considering the Dhamma teachings about
cause of suffering; 57) improving life by reflecting on and learning from past deeds; 58)
recommending nurses practice meditation and learn Dhamma; 59) expecting nurses to have a caring
heart, kindness and generosity with colleagues, patients and relatives; 60) perceiving patients’ health
is improved while receiving good care from relatives; 61) providing information regularly with
simple words and respect is a good way for nurses to building good relationships with patients and
relatives; 62) avoiding using commands with patients and relatives; and 63) listening to the patient’s
feelings.
Pe Jampa (Nurse 9)
The 59 codes for Pe Jampa were: 1) using aggressive behaviours to deal with injustice in the
workplace; 2) perceiving another as not being a religious person; 3) valuing balancing between
nurses’ EQ (Emotional Quotients) and IQ (Intelligence Quotients); 4) understanding others, giving
love to others, knowing how to give (opportunities, sincerity, or forgiveness), and having compassion
creates good EQ nurses; 5) perceiving kind nurses are more flexible and unkind nurses are selfcentred; 6) being wary to prevent being taken advantage of by other people; 7) treating patients and
relatives according to their behaviours; 8) expecting nurses understand other’s suffering; 9) expecting
nurses to provide nursing care at professional standards; 10) having enough knowledge, therapeutic
techniques, and good assessment skills to help suffering patients; 11) gaining deep understanding of
patients’ problems by observing, talking and having skills to predict relate problems; 12) being aware
that some patients don’t want to talk constantly; 13) being aware of the cultural background of
patients while providing nursing care; 14) working with good intention; 15) being aware of good
quality of care; 16) being responsible in nursing care; 17) having knowledge, skills, good human
relationships, and kindness as good foundations to help and support patients and relatives; 18) being a
nurse to help others and support parents; 19) perceiving the core of nursing care is giving and helping
others; 20) experiencing some nurses in the hospitals where they don’t let relative stay with patients
are not friendly with relatives; 21) experiencing relatives are happier to stay with relatives while they
are admitted; 22) having problems such as a) nurses can’t control a clean environment in the ward b)
not having enough equipment and c) nurses don’t have time to recheck the quality of care provided
by relatives, from being too flexible to let relatives stay with every patient; 23) experiencing relatives
are too worried about patients’ health because of staying with patients all the time; 24) experiencing
too many relatives affects the ward keeper’s work; 25) realising nurses get annoyed easily from
having too many relatives stay with patients; 26) setting proper rules and orders for relatives while
letting them stay with every patient; 27) realising nurses have conflict with some relatives who don’t
want to care for patients while patients are hospitalised; 28) expecting nurses to talk properly with
clients especially older people; 29) realising nurses are annoyed with grumpy relatives and keep their
distance from them; 30) experiencing grumpy relatives destroy the working atmosphere; 31)
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acknowledging that nurses avoid talking to high status, overpowering relatives; 32) helping junior
nurses deal with arrogant relatives; 33) perceiving a strong relationship in Muslim patients and
relatives; 34) appreciating Muslim relatives bless patients by reading religious books for them; 35)
appreciating good discipline and faith in religion of Muslim people; 36) perceiving some
misbehaviour of Buddhist people, such as asking and waiting for good luck without doing anything;
37) realising the Buddha’s teaching about the nature of illness and life; 38) considering the five
precepts is a heart of Buddha’s teaching for lay people; 39) applying the teaching about the nature of
illness and life to AIDS patients; 40) helping patient to accept their real situation; 41) setting a right
mind to prevent the boredom of being a nurse; 42) feeling better from hard working when seeing life
is better than some patients; 43) realising AIDS patients who have strong mind and receive good
support from family can live longer; 44) respecting the privacy of patients while using their
experience to support other patients; 45) learning the reality of life from reading novels books
without learning Dhamma; 46) learning by open listening; 47) having a direct and strong personality
when asking for justice; 48) feeling one cannot guarantee that people who learn Dhamma are always
good; 49) appreciating a Christian funeral ceremony about singing songs for a dead person and being
joyful in the ceremony; 50) wondering why a lot of Thai relatives still cry in a funeral ceremony, why
they can’t accept the Buddha’s teaching about nature of death; 51) believing in good results of good
kamma; 52) wondering about the unpredictable results of people’s kamma; 53) valuing the
effectiveness of nurses who have good nursing, education, and coordination skills; 54) providing
information to patients and relatives in simple language; 55) perceiving relatives can support patents’
mind better and deeper than nurses do; 56) experiencing nurses get moody when relative don’t come
to help them care for patients; 57) being concerned about poor self-discipline and low social
responsibility in new generation nurses and teenagers; 58) thinking our minds are similar a basic way
to build good relationships with patients and relatives; and 59) perceiving Pali language is a barrier to
learning Buddha Dhamma.
Pe Mudita (Nurse 10)
The 107 codes for Pe Mudita were: 1) practising meditation; 2) realising the power of mind; 3)
becoming a better person through meditation; 4) contacting with ghosts and spirits; 5) avoiding
meditation; 6) learning different ways of meditating; 7) experiencing family traditional rituals; 8)
getting used to traditional and temple related rituals; 9) thinking of repaying gratitude; 10) intending
to be a good nurse; 11) feeling guilty; 12) understanding patients’ negative responses to illness; 13)
realising the benefit of practising Vipassana meditation; 14) experiencing aggressive patients; 15)
persuading nurses to practice meditation; 16) experiencing different nurse-patient interactions; 17)
praying for unconscious patients; 18) caring for dying relatives; 19) making merit for spirits of dead
relatives; 20) having strong psychic senses; 21) reminding patients to think of good deeds; 22)
realising differences in patients’ readiness to die; 23) perceiving different personal experiences with
dead patients’ spirits; 24) asking the spirit of the dead to go to a better place; 25) allowing relatives to
visit dying patients; 26) telling dying patients not to worry; 27) applying meditation to hard work; 28)
avoiding tension during work; 29) realising nurses’ bad mood can influence a busy ward; 30) staying
with and touching crying patients; 31) realising patients’ emotional needs; 32) understanding moody
patients; 33) avoiding mourning patients; 34) considering the nature of death; 35) repaying gratitude
for parents; 36) accepting the possibility of death; 37) making merit and transferring it to relatives;
38) perceiving some nurses don’t understand patients; 39) having open minds to listen to patients; 40)
wanting to see patients and nurses interact positively; 41) expecting nurses to always maintain good
relationships with patients; 42) respecting patients as human beings; 43) realising negative effects of
nurses’ improper manners; 44) perceiving nurses do not like high status and fussy patients and
relatives; 45) using routine work to avoid emotions; 46) needing to be patient-centered; 37) realising
rural patients believe in black magic; 48) respecting patients’ and relatives’ beliefs about black
magic; 49) coping with life problems by making merit; 50) considering the life cycle of human
beings; 51) preparing for a peaceful death; 52) thinking on good deeds; 53) informing relatives about
patient’s deterioration; 54) telling a patient not to worry; 55) asking relatives to chant for patients; 56)
asking relatives to invite the monks to bless the patient; 57) positive effects after receiving blessing
from the monks; 58) avoiding telling relatives about the time of death; 59) encouraging relatives to
prevent guilt in the future; 60) not touching often; 61) touching male and female patients differently;
62) having more sympathy for female patients; 63) perceiving female patients are more patient than
males; 64) appreciating sharing relationships between patients; 65) perceiving relatives are sources of
patients’ strengths; 66) appreciating when male relatives become good caregivers; 67) allowing
relatives to stay overnight with patients; 68) realising a major role of relatives is to support the
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patients’ mind; 69) recognising the equality of nurses’ and clients’ power; 70) differentiating nurses
respect for patients; 71) reminding pre-registered nurses to improve their manners; 72) realizing time
limits on care; 73) understanding patients’ and people’s needs; 74) understanding high expectations
from rich patients and relatives; 75) avoiding blaming others while working; 76) believing every
nurse has a good heart; 77) valuing a caring model and environment; 78) being unwilling give
feedback to moody nurses; 79) suggesting behavioral change through meditation; 80) expecting
nurses to understand patients; 81) perceiving patients usually trust kind nurses; 82) experiencing
uncaring nurses; 83) perceiving nurses’ moodiness when busy; 84) perceiving nurses stay with their
routine tasks; 85) respecting patients’ values and beliefs; 86) providing effective care; 87) being more
flexible with their relatives; 88) allowing relatives to support patients’ physically and mentally; 89)
understanding patients’ perception on natural and traditional ways; 90) understanding patients’
feeling; 91) looking at patient’s problems from the patients’ view points; 92) spending time to learn
new technologies; 93) perceiving technology separates nurses from patients; 94) having inadequate
time to support patients’ minds; 95) requiring more time to apply Dharma to support patients’ mind;
96) recommending nurses have meditation leave; 97) understanding self and others; 98)
understanding impermanence; 99) understanding human beings; 100) applying meditation
techniques; 101) accepting illness and planning natural ways of healing; 102) Believing in a nonsuffering mind; 103) working hard with a good heart; 104) accepting death as a normal life cycle;
105) having a simple life; 106) realising the effects of nurses’ positive attitudes on patients’ and
relatives’ happiness; and 107) valuing gaining merit
Nong Mali (Nurse 11)
The 131 codes for Nong Mali were: 1) being a research team member trying to provide more
psycho-spiritual support for patients; 2) experiencing nurses complain about having no time to
support patient’s mind; 3) experiencing nurses realise the importance of the psycho-spiritual aspect;
4) having problems about not recording a psycho-spiritual support activities; 5) providing
information is the way to support patients’ minds; 6) realising the need to communicate with patients
deeply; 7) perceiving nurses work too hard; 8) feeling sympathy for patients and relatives when
thinking of them as family members; 9) applying Buddhist rituals such as chanting and transferring
merit to patients to help Buddhist patients in terminal stage; 10) learning chanting and Dhamma from
her grandfather; 11) living in the Dhamma environment; 12) having religious life styles; 13) being
taught ideas about repayment, to be respectful to the older person, being generous, kind, and grateful;
14) having too much sympathy until being cheated easily; 15) being encouraged to be a nurse since
she was young; 16) experiencing a role model of a kind and gentle nurse; 17) feeling happier when
not busy and having a chance to support patients’ minds; 18) perceiving coordinating with doctors
and other departments is very boring; 19) chanting and radiating merit to others before sleep; 20)
having problems about unclear communication and some unkind staffs while working; 21) applying
teaching into nursing care about the Four Brahmavihara including metta-karuna; 22) talking with
patients about their religious and traditional beliefs and practices; 23) caring for patients as though
they were nurses’ relatives to raise their compliance; 24) perceiving elderly patients need love and
respect from nurses; 25) perceiving some nurses don’t believe in traditional beliefs; 26) believing in
traditional beliefs such as an incantation, a fortune, a vow, auspicious days, folk healing methods,
local herbal medicine, and religious rituals; 27) helping patients to avoid using harmful herbal
medicine; 28) being a mediator between patients and doctors when patients want to use herbal
medicine; 29) receiving trust from elderly patients; 30) trying to support patients’ mind at least one
case per shift; 31) educating patients is a way to support their minds; 32) respecting privacy of
HIV/AIDS patients; 33) perceiving a lot of patients use alternative ways of healing such as herbal
medicines, magic healing, vitamin and minerals and massage; 34) being consulted about how to use
alternative ways of healing properly with modern medicine; 35) perceiving nurses should have more
understanding about complementary care in order to give proper suggestions to patients; 36)
experiencing relatives bring some magic things to keep at the patients’ bed for protecting the patient
from bad luck; 37) experiencing relatives refuse modern medicine when they believe that illnesses
come from black magic; 38) experiencing relatives get angry with the doctors who don’t respect their
beliefs about black magic; 39) listening to patients and relatives beliefs openly is a good way to
support patients’ minds; 40) perceiving mature, calm, and warm nurses open their mind to respecting
patients’ beliefs better than impatient nurses; 41) understanding various beliefs of Thai patients and
relatives for using traditional healing methods; 42) feeling happier while listening to stories about
patients beliefs and background and helping them use it properly when they are sick; 43)
experiencing patients don’t dare to tell doctors about their complementary methods, but they will to
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tell kind nurses; 44) respecting a patient’s beliefs can build therapeutic relationships; 45) receiving
appreciation from patients and relatives because of politeness and cheerfulness; 46) being connected
with patients; 47) receiving gifts from patients; 48) feeling empowered to do good nursing care
because of receiving gratitude from patients; 49) inspiring new nurses to appreciate patients’
traditional beliefs; 50) realising the role of nurses in transferring merit and do religious rituals to
terminal patients; 51) experiencing few patient do meditation while hospitalised; 52) perceiving few
nurses extend their knowledge about alternative therapies such as energy healing, yoga, and
meditation to support patient; 53) perceiving nurses consume a lot of time to help the patients’
healing; 54) realising that having a balanced relationship with patients and relatives takes much time;
55) being concerned about continual care in psycho-spiritual issues; 56) building good relationships
on admission helps relatives plan further treatments for dying patients easily; 57) building good
relationships by listening to patients and relatives, providing enough information about the patients’
condition and plan, and letting them make decisions for further conditions is very helpful; 58)
perceiving the positive outcome of discharge planning on provide psychosocial and spiritual care for
patients and relatives; 59) perceiving relatives are the most important person who can support
patients’ minds; 60) perceiving different kinds of relatives including caring, non-caring and overcaring; 61) being flexible about visiting time; 62) teaching a main caregiver of chronic patients to do
basic nursing such as such as feeding via nasogastric tube, bathing, toileting, doing a range of motion
exercises, suctioning, elimination, shampooing for their home care; 63) perceiving relatives feel
proud of themselves when they can do nursing tasks; 64) building friendship and supporting friends
among a patient’s relatives; 65) avoiding involving relatives in complex nursing care such as care of
critically ill patients; 66) massaging patients is a great job for relatives; 67) being a traditional nurse;
68) respecting the Buddha image and asking for power before starting work; 69) dealing with hard
work by thinking of a chance for making merit when helping patients; 70) suggesting nursing
teachers inform nursing students about the influence of patients’ beliefs on health behaviours; 71)
believing in the sixth sense and ghosts; 72) making merit and radiating merit to ghosts and all
creatures; 73) asking for protection from the Buddha’s and monks’ amulets and reciting a sacred
scripture before driving; 74) doing traditional rituals by washing face every morning, wash chest
every mid day and washing feet every evening for maintaining wisdom and dignity; 76) chanting the
incantations to be safe while going to other places; 77) experiencing husband’s success solving a
problem about a jealous colleague by radiating metta; 78) valuing traditional teaching about
awareness, raising mindfulness, carefulness and kindness and paying respect to all people and things;
79) preferring a simple life and thinking about “giving more than I get”; 80) feeling sympathy to
people who are in trouble or their life has more suffering than her; 81) gaining deep understanding
about patients with an open nurses’ minds to listen to patients’ beliefs; 82) perceiving some nurses
pay less attention to working while being concerned about family issues; 83) appreciating kindhearted colleagues; 84) building good relationships between nurses and staff; 85) feeling sympathy
for cancer patients; 86) having a strong relationship with cancer patients from helping them cope with
their illness; 87) considering the nature of death and let things go when feeling emotion for deceased
patients; 88) realising a lot of patients’ and relatives’ complaints come from improper manners of
some staff in the ward; 89) being concerned about nurses’ words which can affect patients’ feelings;
90) talking with patients and relatives while providing nursing care; 91) helping patients to have a
clear understanding about the high level of doctors’ language; 92) dealing with any conflict from
patients and relatives by listening to them openly and respecting them by using polite words and
manners; 93) asking other senior nurses to help when being unready to deal with any conflict from
patients and relatives; 94) facing high expectations from fussy and wealthy relatives; 95) perceiving
people from rural areas are more patient and self-dependent; 96) suggesting high-demanding relatives
ask for a private nurse to care for their patient; 97) understanding the need of relatives and letting
them stay overnight when patients are in crisis conditions; 98) providing more psycho-support for
patients by giving enough information; 99) experiencing mistrust from relatives who have high
expectations about gentle nursing care; 100) dealing with high bad impression of relatives by moving
a patient to another ward; 101) realising nurses ignore patients’ spiritual needs; 102) caring for
patients as though they were the nurses’ parents is a way to provide good care; 103) experiencing
relatives would like to take a patient in the terminal stage back home; 104) supporting patients’ need
when they want to die at home; 105) appreciating a peaceful death of her grandma surrounding with
relatives and monks who performed Buddhist rituals for her at home; 106) perceiving different
aspects of Buddhist and Muslim relatives doing death rituals for dying patients; 107) preventing all
conflicts from patients and relatives by consulting medical jurisprudence and maintaining proper
communications; 108) preferring chanting more than meditation; 109) reciting the Buddhist scripture
to transfer merit to dead patients and other beings and telling the corpse to a good place, and please
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not worry about everything left behind; 110) connecting with some deceased patients in dreams; 111)
making merit to deceased patients with whom one has had strong relationships; 112) chanting when
having nightmares; 113) believing in heaven and hell, do good to get good, do bad to get bad, and the
next life; 114) respecting every being and non-being; 115) applying the breathing meditation to teach
elderly chronic patients to relax; 116) applying music therapy for teenage chronic patients to relax;
117) having no leaflets and media to teach patients to do mediation or relaxation; 118) appreciation
nurses’ educating activities; 119) making merit make patients feel happy; 120) reminding some
patients to make merit with the mink for happiness; 121) talking with local patients and relatives by
using the local language; 122) realising patients relate causes of their illnesses with previous bad
kamma; 123) realising modern patients relate causes of their illnesses with bad health behaviours;
124) experiencing some patients and relatives do some rituals following their beliefs before coming
to see the doctor in hospital, such as checking a sign of the zodiac and rectifying bad luck by making
merit or doing Sanghadana; 125) teaching patients who can’t sleep to recite and radiate merit
scripture; 126) applying music and meditation for releasing patients’ tension while they feel pain;
127) smiling and greeting is a basic way to build good relationship with patients and relatives; 128)
learning to let thing go and detach from bad feelings; 129) avoiding a rebuke while training new
nurses; 130) avoiding expressing anger in front of others; and 131) giving forgiveness and radiating
merit to trouble makers.
Pe Bua (Nurse 12)
The 93 codes for Pe Bua were: 1) trying to improve nursing care with discharge planning for
cerebrovascular accident patients (CVA), 2) understanding CVA patients’ and relatives’ problems, 3)
realising the limit of support systems for CVA patients out of hospital; 4) realising patients and
relatives who are in the shock stage of stress are not ready to listen to any information; 5) realising
CVA patients and families need to trust nurses who understand their situation, give suitable
information and be a good counsellor; 6) realising the constraints of not having good relationships
with patients are nurses’ busyness and the rotation of nurses; 7) expecting nursing organizations to
prepare counselling nurses to help to provide more psychosocial and spiritual support to patients and
relatives; 8) being an informal counsellor for CVA patients’ relatives; 9) expecting every nurse can
be a patient’s counsellor; 10) perceiving nurses are very tired from the workload; 11) balancing the
needs of relatives and the hospital’s goals; 12) building a good relationship with patients’ relatives
from the beginning of an admission to prevent any conflict and dissatisfaction from relatives; 13)
feeling sympathy with relatives of CVA patients; 14) perceiving ineffective communication can lead
to patients’ and relatives’ dissatisfaction; 15) experiencing some relatives expect influential people in
the hospital or the well known people to act against hospital rules; 16) perceiving some relatives care
for patients to repay their gratitude; 17) having no complaints because of helping patients with
understanding and respect; 18) reminding nurses to have good speech with hasty relatives; 19)
perceiving relatives appreciate and respect nurses; 20) perceiving relatives feel fear of sin from not
helping patients; 21) experiencing relatives have a conflict about helping or not helping to prolong
patients’ lives when patients’ conditions are worsening; 22) supporting patients who fear sin by
suggesting to them to do the best to suit their conditions; 23) helping relatives transferring terminally
ill patients near dead to die a home ethically and safety when relatives decide to take patient back
home; 24) supporting relatives when they feel confused and can’t manage their situation in the
patient’s final stage; 25) talking with relatives about their need to do religious and traditional rituals
such as inviting the monks to do chanting for patients, encouraging relatives do chanting for patients,
turning the Dhamma on for dying patients if patients are religious people; 26) coordinating with
doctors to inform relatives about a patient’s prognosis, 27) planning to discharge patients when
relatives are unwilling to take them home; 28) recommending nurses who support both VIP and
ordinary patients and relatives successfully must have a sense of sincerity, a good personality
including a calm face, respectful posture, and polite speech, good nursing skills, teaching,
counselling, co-ordinating and time management skills and enough confidence; 29) experiencing that
the VIP relatives blame nurses who aren’t qualified in their estimation; 30) managing conflict
between VIP relatives and health care team with open listening and understanding their background
and perceptions and trying to support patients; 31) understanding holistic care from continuing study
can help nurses look at each person in deep and broad views and open the mind to understanding
others’ problems; 32) understanding the nature of human beings; 33) understanding negative
responses of patients and relatives such as aggression and being demanding; 34) avoiding expressing
anger and staying calm while dealing with patients and relatives who are in trouble; 35) giving
forgiveness and not getting angry easily are ways to keep calm; 36) expecting to have a good health
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care system in the community to support chronic patients such as a community rehabilitation centre,
day care centres for dependent patients, support equipment for disability patients, high cooperation
from health care teams, and improvement in continuing care for patients; 37) having a warm heart
and being a patient person because of mother; 38) realising all the teachings of Buddhist religious are
about reality, the truth of suffering and ways to overcome it; 39) learning Dhamma by reading
Dhamma books; 40) having life’s motto from the Buddha’s teaching that there is “no other utmost
happiness except peacefulness”; 41) having no interest in the formal styles of learning Dhamma of
Vipassana or meditation courses; 42) believing that all happiness and sadness is caused by our own
state of mind; 43) believing that sincerity is the basis of human relationships; 44) believing that
nurses can do both merit and sin; 45) believing that sources of merit and sin all come from our own
thinking, speech and actions; 46) recommending nurses use a generous mind as a simple caring tool;
47) perceiving fundamentals of a good relationship between nurses, patients and relatives are being
willing to help patients and relatives, having sincerity mind and never disparaging clients; 48)
perceiving a good relationship between relatives and patients influences the patient’s health; 49)
realising patients and relatives have been treated in improper ways from bullying and insincere staff;
50) putting oneself in another’s shoes is a way to maintain a good relationship with clients; 51)
experiencing nurses have been treated in improper ways from bullying and insincere staff; 52)
perceiving the kindness of nurses comes from how they were brought up; 53) keeping friendly even
when busy, intending to give a gentle smile to patients, greeting them, and asking them how are they;
54) having a positive attitude to helping others can prevent nurses from stress; 55) giving a smile to
patients and relatives even when busy; 56) doing every job without expecting something in returnbelieving in kamma; 57) being happy to work hard; 58) experiencing study in the Sunday Buddhist
School when studying in primary school; 59) being interested in Buddha’s history and appreciating
Buddha’s teachings; 60) living with peace of mind because of not having a high expectation and
letting things go easily; 61) believing that birth, old age, sickness and death are natural phenomena;
62) realising the reality of the Buddha’s teaching about the Four Noble Truths; 63) applying the
Buddhist view to solve problems at the mind level; 64) experiencing severe suffering from losing her
beloved mother; 65) understanding patient’s problems and being concerned about their quality of life;
66) understanding relatives’ feelings when their loved ones are in crisis or reaching death and
encouraging them to get involved in helping the patients; 67) being aware and having true
understanding and good intention when reminding relatives to accepting the death of their loved one;
68) supporting relatives who are in grief by keeping silent and using suitable words in a proper
context; 69) sharing caring experience of senior nurses with new nurses is a way to develop their
caring skill; 70) providing spiritual care for patients with real sympathy, sincerity and understanding
is a way to transfer spiritual power from the nurse’s mind to the patient’s mind; 71) caring for
relatives who have spiritual distress problems with understanding, being polite, giving time,
encouraging questions, sharing nurses’ suffering experiences, reminding her to think about the natural
law, letting her do her best for the patient, reminding her to use the best chance to repay all
gratefulness for the patient in a terminal stage; 72) helping relatives to accept patients’ illness and
death with sincerity and kindness; 73) caring for terminally patients comfortably and supporting the
relatives’ minds with kindly willingness; 74) building trust with patients and relatives along side
nursing jobs; 75) providing proper information to patients and relatives regularly can prevent
relationship problems which come from their dissatisfaction; 76) supporting relatives in a crisis
period by walking close to them, touching their hands, telling them to keep mentally calm, staying
with them a few minutes, explaining to them what is happening to patients until they can manage
situations; 77) experiencing nurses and doctors don’t support patient’s relatives after patients die; 78)
building trust with relatives from the beginning of a patient’s admission can prevent relatives’
negative perceptions especially when patients become unconscious or die unexpectedly; 79)
perceiving the nurse is a person who is always ready to support other people when they are suffering;
80) being honest with patients, talking with them friendlily and telling them honestly when you are
very busy; 81) perceiving nurses need good role models in supporting patients’ and relatives’ minds;
82) being concerned that new nurses from modern society have less caring minds; 83) perceiving
sympathy, sincerity and kind-heartedness are highly important characteristics of nurses who are good
spiritual supporters; 84) perceiving the real value of nurses is feeling happy when helping others; 85)
learning about generosity from observing Buddhist monks’ lifestyles; 86) valuing the importance of
learning from direct experience, creativity and kindness in providing more holistic care; 87) realising
the value of understanding Buddha’s teaching about the negative results of attachment, hate, anger
and engrossment, to have less suffering while working and living in modern society; 88) taking care
of patients and relatives as though they were the nurses’ own parents or relatives; 89) realising the
value of accepting suffering and letting things go; 90) believing people are suffering because of their
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own kamma; 91) believing that maintaining doing good kamma and avoid doing bad things are ways
to have less suffering; 92) applying health care techniques from others patients and relatives to care
for a CVA’s father; and 93) feeling empowered to help patients and relatives, from understanding the
teaching about suffering and the law of nature.
Nong Dao (Nurse 13)
The 58 codes for Nong Dao were: 1) having a father as a good religious model; 2) making merit
when having nightmares; 3) believing in the fortune teller; 4) having patience to be a nurse; 5)
perceiving a chance to make merit while helping patients; 6) experiencing working hard since
becoming a nursing student; 7) experiencing Muslim and Buddhist patients practice religious rituals
in the ward; 8) experiencing patients use traditional healing methods to heal illnesses; 9) respecting
patients’ beliefs even when it is not a hundred percent belief; 10) wishing to see patients receive
treatment in the hospital more than using magic healing; 11) perceiving patients who have good
support from relatives have less psycho-spiritual problems; 12) feeling sympathy for AIDS patients;
13) giving moral support to AIDS patients; 14) being friendly with AIDS patients; 15) experiencing
some AIDS patients read Dhamma books while others are not interested in using Dhamma to cope
with illness; 16) not knowing how to introduce patients to read Dhamma books or do religious rituals;
17) learning a lot about psycho-spiritual issues from helping AIDS patients; 18) thinking of practising
meditation in order to apply it to help AIDS patients; 19) expecting to have more knowledge about
antivirus drugs in order to advise patients better; 20) appreciating patients’ value while they can live
with their illness; 21) experiencing some patients still maintain harmful health behaviour while sick.
22) understanding various kinds of patients’ psychological problems; 23) experiencing practising
meditation and learning Dhamma for self development while studying nursing, 24) being taught by
nursing teachers about the benefits of meditation in nursing life, such as having good concentration to
prevent errors while providing nursing care; 25) experiencing deep concentration and peacefulness
while practising meditation; 26) raising consciousness while helping patients who are in crisis; 27)
perceiving less benefit of learning mediation by just listening to others’ experiences; 28) being
mentally calm even when stressed; 29) approaching and helping patients with a calm manner, never
being moody and intending to provide good nursing care with proper manners because of believing in
kamma; 30) maintaining good relationships with patients by chatting with them and educating them
to know how to take care of themselves; 31) providing spare beds to elderly relatives who stay
overnight with patients; 32) being flexible in visiting rules; 33) accepting inconvenience while doing
nursing care while relatives stay at patient’s bed; 34) gaining benefit while relatives help nurses do
basic care for their patients; 35) perceiving a lot of relatives would like to help nurses care for
patients; 36) perceiving relatives can help patients make decisions about further treatments and
referrals; 37) helping a dyspnoeic patient to calm down by staying close to him and using soft speech
to give moral support; 38) building trust with a patient by doing the best care; 39) ordering food for
patients even though doctors forget it; 40) educating patient is a way to support patients’ minds; 41)
educating relatives to help nurses observe and report patients’ conditions; 42) educating relatives to
rehabilitate CVA patients; 43) receiving some complaints about nurses’ improper speech and slow
referral systems; 44) being a kind nurse who patients call for help easily; 45) needing to improve
advances in physical assessment skills in order to help patient effectively while no doctors are
present; 46) valuing nurses’ kindness and politeness; 47) perceiving some nurses have rough words
and ignore patients’ needs; 48) experiencing patients feel discouraged from being ignored; 49)
supporting the patients who are ignored by another nurse; 50) balancing bullying nurses by assigning
kind nurses in every shift; 51) having a caring mind, concern for the patient’s feelings and having
polite words are very important for nurses; 52) expecting nurses love to give information to patients;
53) having a soft personality; 54) receiving praise from patients and relatives about politeness; 55)
being patient when feeling stress in daily working; 56) counting 1 to 10 and calm and avoid
expressing emotion while dealing with patients or relatives who are too demanding; 57) talking with
many demanding patients and relatives politely and waiting to explain when they calm down; and 58)
dealing with relatives who are dissatisfied in treatment outcomes with respect and having open
listening.
Pe Ake (Nurse 14)
The 56 codes for Pe Ake were: 1) having life purpose to repay gratitude for patients by being
ordained and graduating with a Bachelor degree; 2) building good relationships with patients by
giving information regularly; 3) giving encouragement to patients to trust in the health care team and
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treatments; 4) experiencing learning Dhamma and practising meditation, chanting and preaching
while ordaining; 5) learning about patience and a peaceful state while ordaining; 6) believing in the
power of mind; 7) reading Dhamma books and meditating; 8) introducing patient to breathing
meditation to control post operative tension; 9) perceiving doing meditation is not a main choice to
control post operative pain; 10) perceiving teenagers are not interested in meditation while patients
who join Buddhist rituals in the temple can meditate; 11) perceiving doing meditation is not easy for
people who have never learnt or practiced meditation before; 12) perceiving time limits to teach
meditation to patients because nurses have so many jobs to do; 13) realising kind-heartedness is a
basis of building good relationships with patients and relatives; 14) needing more time to listen to the
patients’ psychosocial and spiritual problems; 15) realising the busyness of nurses; 16) letting
relatives become involved in bathing for their patient with pre-registered nurses; 17) educating
relatives to do basic procedures for patient such as bathing, mouth care and feeding, and to observe
and report the patient’s conditions; 18) perceiving male patients feel more comfortable receiving
nursing care from male nurses; 19) caring for patients as though they were the nurses’ relatives; 20)
talking with patients about issues including funny stories; 21) being more flexible with patients than
female nurses; 22) understanding needs of male patients; 23) caring for patients better and being
calmer and more polite while dealing with fussy patients after ordaining; 24) doing nursing care to
make merit; 25) believing in kamma; 26) feeling happy from helping patients; 27) having selfawareness can help nurses maintain good relationships with patients and relatives; 28) learning about
self awareness and how to control emotions from the three months of ordination; 29) living and
working with doing good deeds; 30) having awareness about errors while working; 31) being friendly
to patients and relatives and avoiding adding tension to them; 32) following the Buddha’s teaching
about using right effort with aspiration is the path of accomplishment; 33) walking in the middle way
while working; 34) recommending nurses practice Vipassana meditation to understand the nature of
life and illness; 35) respecting patients and relatives; 36) telling relatives to motivate patients to
rehabilitate and encouraging relatives to do passive exercises for patients; 37) talking with and being
a relative of patients who have no relatives; 38) being friendly and chatting informally with patients
and relatives; 39) encouraging patients to tell their needs without hesitation; 40) encouraging patients
to help other patients who can not walk; 41) experiencing patients’ respect of the Buddha image and
making merit by donating money and Dhamma and other books to the hospital; 42) setting up
traditional ceremonies such as Songkran Day and New Year in the ward; 43) respecting and trying to
help patients and relatives as though they are nurses’ relatives; 44) perceiving Thai patients and
relatives usually forgive and do not make formal complaints when nurses or doctors who are kind and
polite did something wrong such as hurting patients; 45) trying to do best nursing care and not cause
errors; 46) perceiving moral support from relatives is very important for patients’ happiness; 47)
encouraging patients to be patient to fight with their illness and get better; 48) supporting patients
who have had an amputation to consider the value of life; 49) perceiving Thai people are compassion,
kind and smiling; 50) knowing patients’ background deeply after having good relationships with
them; 51) believing if nurses believe in sin, merit, retribution, the result of kamma and also can
forgive easily, they would approach and care for patients with good thoughts, good speech and good
manners, respecting every patient and their relatives; 52) understanding that nurses are very busy can
reduce patients’ and relatives’ dissatisfaction and mean fewer complaints; 53) respecting older people
is a norm of Thai people; 54) accepting the truth of life about birth, old age, sickness, and death while
caring for the terminally ill patients; 55) recommending nurses remind relatives about the truth of life
while providing supportive care for incurable patients; and 56) encouraging relatives do religious
rituals for dying patients in order to help them die peacefully with dignity.
Khun Plong (Nurse 15)
The 102 codes for Khun Plong were: 1) being concerned for patients’ and relatives’ feelings, 2)
putting the heart into the work, 3) feeling guilty if unable to do the best for patients; 4) perceiving
nurses are unacknowledged; 5) realising nurse-doctor problems can affect patients and relatives; 6)
perceiving female nurses are too fastidious; 7) perceiving nurses do huge amounts of paper work; 8)
perceiving problems of nurses’ recording styles; 9) working in a strong seniority system resistant to
change; 10) perceiving patients and relatives consider nurses as their slaves; 11) perceiving nursing
work is routine tasks; 12) understanding others through a hard time in life; 13) becoming care and
concern for feelings are fundamental; 14) studying nursing because of getting a job easily; 15)
believing nursing is a virtuous job; 16) experiencing too many patients and relatives and too many
demand; 18) experiencing some patients and relatives abuse nurses; 19) perceiving complaints come
from lack of communication; 20) recommending positive feedback to nurses; 21) recommending
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more concern for nurses’ morale and quality of life; 22) considering teaching about the middle way;
23) applying Buddhist beliefs to care for late stage Thai Buddhist patients; 24) appreciating religious
practices of Muslim patients and relatives; 25) preparing relatives for accepting patients’ deaths; 26)
perceiving patients use religious beliefs for coping; 27) changing from a nurse-centred tradition to
patient-centred care; 28) respecting patient’s decision to die naturally; 29) appreciating a peaceful
death; 30) realising nurses are concerned about terminally ill patients in pain; 31) perceiving
unequally care between patients; 32) perceiving doctors are distrustful of nurses’ abilities; 33)
recognising errors by unskilful doctors and nurses; 34) using Buddhist teaching to accept sudden
death of patients; 35) perceiving nurses are coordinators between patients, relatives and doctors; 36)
perceiving some wealthy relatives perceive nurses as servants; 37) expecting nurses to improve the
image of nursing; 38) perceiving the gap of communication between old and new generation of
nurses; 39) exercising the potential of patients’ relatives; 40) balancing doctors’ and nurses’ value
and responsibilities to improve the nursing image; 41) allowing relatives to stay with every patient;
42) preparing relatives to help nurses care for patients; 43) realising value of relatives willing to care
for patients; 44) realising patients want relatives to stay with them: 45) perceiving relatives can repay
their gratitude to patients by caring; 46) encouraging relatives to help care for patients; 47) realising
relatives can reduce nurses’ workload; 48) recognising nurses’ workloads; 49) having no time for
better care; 50) recommending clients needing special care request a private room; 51) not having
enough qualified nurses; 52) perceiving nurses’ negative management skills and moods cause
relationships problems; 53) decreasing nursing services with increasing numbers of patients; 54)
perceiving nobody can do an excellent job in a limited and busy context; 55) realising the importance
of nurses’ basic nursing care skills; 56) not changing or improving routine jobs; 57) practising
Buddhist tradition; 58) perceiving religion is rooted in daily life; 59) repaying gratitude for parents by
ordination; 60) learning about patience and non-attachment from ordination; 61) perceiving difficulty
in clarifying which parts of life are influenced by Buddhism; 62) applying the Middle Way and the
law of kamma; 63) accepting illnesses because of past kamma; 64) realising some errors come from
unskilled staff; 65) perceiving patients’ relatives are the significant caregivers and psycho-spiritual
supporters; 66) realising nurses need help from relatives to help and rehabilitate patients in long term
care; 67) offering spiritual alternatives; 68) questioning the scope of relatives’ role in caring for
patients in hospital; 69) realising Thai patients worry about family more than health problems; 70)
perceiving nurses care for patients’ physical parts and relatives care for patients’ psycho-spiritual
parts; 71) believing nurses can give friendship; 72) expecting nurses to listen to patients and relatives
openly; 73) appreciating the caring mind of Thai family; 74) appreciating the strong kinship tradition
of Thai people; 75) perceiving Thai people depend on family members and relatives when dealing
with problems; 76) perceiving Thai people accept their destiny easily because of past kamma; 77)
perceiving nurses help patients and teach relatives to care for patients; 78) perceiving nurses relieve
patients’ anxiety by giving information; 79) suggesting relatives support the dying patient’s mind; 80)
enhancing patients’ confidence to cope with illness; 81) having too many relatives visiting patients
can be harmful; 82) perceiving differences in visiting styles of Buddhists and Muslims; 83)
experiencing inconvenience while working; 84) experiencing loss of the hospital’s property; 85)
perceiving Buddhist patients and relatives are usually kreng jai (hesitant); 86) perceiving some nurses
and doctors are not pen gun aeng (friendly) with clients; 87) trying to provide information to reduce
clients’ hesitation; 88) waiting to ask for help from friendly nurses; 89) perceiving moody nurses; 90)
misinterpreting nurses’ behaviors and gossiping; 91) recommending nurses deal with problems
unemotionally; 92) accepting all people and problems; 93) avoiding blaming and feeling angry with
patients or relatives; 94) helping relatives to solve conflicts between patients’ relatives; 95)
cultivating kindness and friendliness in new nurses; 96) adding value and power to nurses by
continuing education; 97) perceiving relationships between patients and nurses are better; 98)
perceiving nurses do not get full respect from patients and relatives; 99) seeing nurses as servants;
100) realising the importance of the art of nursing; 101) improving the image and art of nurses; and
102) improving recording systems to save time and build relationships
Pe Jaiboon (Nurse 16)
The 36 codes for Pe Jaiboon were: 1) working as a community nurse; 2) looking at the causes of
illness from patients’ family and financial background; 3) perceiving new nurses do not enjoy
working in the community; 4) building a fun atmosphere in the work place; 5) reaching a stage of
making merit while working and living; 6) valuing the Dhamma principle about doing good deeds; 7)
helping nurses by reflecting on the real causes of economic problems; 8) applying the teaching about
doing good deed to help people in community; 9) experiencing practising Dhamma; 10) preferring to
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practise Dhamma in daily life; 11) practising Dhamma in every duty; 12) realising the gratitude of
parents; 13) intending to help others-making merit while working; 14) being kind and helping AIDS
patients, 15) believing in kamma-giving up from all bad deeds; 16) realising the improper manners of
the monk and nuns in this period; 17) supporting caregivers’ minds; 18) helping family members and
patients without expecting things in return; 19) reminding people in the community to do their best to
repay gratitude to parents; 20) believing in good effects of doing good deeds, bad effects of doing bad
deeds; 21) applying Dhamma teaching to help others; 22) accepting preparations for death; 23)
dealing with a debtor by radiating loving-kindness to them, and asking for their luck and wealth; 24)
believing in the power of mind; 25) putting her heart into her work; 26) being kind to every patient;
27) respect all human beings; 28) valuing mind development; 29) helping AIDS patients; 30)
applying meditation; using the eating air technique to teach AIDS and cancer patients; 31) relating
illness to merit and results of past kamma; 32) making ethical decisions by considering the teaching
about kamma; 33) applying Dhamma teaching in daily life; 34) perceiving a lot of people make merit
improperly; 35) having father as a good model a of Buddhist follower; and 36) respecting every
religion.
Pe Sukjai (Nurse 17)
The 84 codes for Pe Sukjai were: 1) coming to appreciate Buddhist teaching; 2) perceiving little
Buddhist knowledge and practice; 3) using little religion when caring for patients; 4) trying to access
patients’ values, beliefs and minds; 5) having no time for psychosocial support; 6) letting relatives do
rituals; 7) trying to actively provide psycho-social support; 8) informing relatives to do their religion
rituals for patients; 9) having insufficient confidence to approach death any dying; 10) having few
nurses interested in religious practices; 11) perceiving nurses practising Dhamma are more gently,
calm and polite; 12) doing action research project to promote psycho-spiritual care; 13) having an
expectation to meet holistic care criteria; 14) realising the importance of providing holistic care; 15)
experiencing difficulty in approaching patients’ psycho-spiritual dimensions; 16) improving
supporting skill; 17) perceiving a gap between theory and practice in psycho-social and spiritual care;
18) avoiding crying with patients; 19) having no answer for patients’ spiritual questions; 20)
consulting the monk to answer patients’ spiritual questions; 21) practising spiritual care experiences;
22) applying Buddhist principles in psycho-spiritual care indirectly; 23) learning from more
experienced colleagues; 24) realising nurses support cancer patients at superficial level; 25) having
insufficient time; 26) realizing the importance of a good relationship; 27) working with doctors and
team to help a patient to accept dying, 28) knowing patients can accept death by believing in kamma,
29) respecting patient’s belief; 30) understanding the process of grief and loss; 31) having empathy
and crying with patients; 32) avoiding empathy with patients and relatives; 33) recommending nurses
stay with patients in sad moments; 34) perceiving nurses’ work as a task-oriented; 35) needing to
improve time management skills; 36) needing to maintain continual care and communication with
other nurses; 37) trying to access patients’ psycho-spiritual dimensions; 38) concerning patients needs
time for conversation and listening; 39) perceiving patients and relatives are usually hesitant; 40)
perceiving some nurses prefer routine jobs; 41) not wanting to do more work; 42) expecting good role
models in psycho-spiritual care; 43) needing to stay and talk with patients; 44) fearing blame from
other nurses; 45) working as a functional care system; 46) having few nurses as spiritual supporters;
47) needing kindheartedness, knowledge and good counselling skills; 48) working in a
multidisciplinary palliative care team; 49) having more people to care for patients’ minds; 50) sharing
spiritual care experience with others; 51) developing psycho-spiritual assessment and helping skills;
52) having no interest in practising meditation; 53) learning Dhamma by reading and asking for
Dhamma from monks; 54) realising not many people understand Buddha Dhamma; 55) perceiving
barriers to learning Dhamma; 56) applying the teaching about the Four Ariyasacca to understand
people’s suffering; 57) referring the teaching about the Four Ariyasacca to the concept of grief and
loss; 58) understanding patients’ negative reactions by Buddhist teaching about the Four Ariyasacca
and the Eightfold Path; 59) gaining a deeper understanding about patients’ reactions and suffering;
60) judging sin or not sin; 61) valuing information for relatives; 62) being a coordinator between
patients, relatives and doctors; 63) receiving information from doctors; 64) making proper and ethical
decisions for terminally ill patients; 65) perceiving different kinds of relatives; 66) finding solutions
for terminally ill patients to prevent guilt; 67) experiencing guilt; 68) asking for a forgiveness when
feeling guilty; 69) rethinking about prolonging a patient’s life with technology; 70) doing religious
activities in the ward; 71) improving assessment and approaching skills of nurses for psycho-spiritual
aspects; 72) trying to find more psycho-social and spiritual care; 73) having problems about recording
psycho-social and spiritual assessment and care; 74) questioning the proper time to ask about
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patients’ values, beliefs and body image; 75) persuading relatives to be involved in helping patients;
76) believing poor communication skills might cause conflict; 77) experiencing relatives willing to
help the patients; 78) experiencing some relatives wanting to stay with patients all the time; 79) being
politeness and explaining reasons; 80) trying to flexible about visiting time; 81) having inadequate
experience about alternative and traditional care; 82) applying some alternative methods for releasing
stress; 83) recognizing the trend in alternative therapies for patients and relatives; and 84) questioning
the effectiveness of alternative therapies
16
APPENDIX (F)
Na Lek (Patient 2)
The 22 codes for Na Lek were: 1) experiencing poor control of blood sugar level; 2) controlling blood
sugar by taking medicines, adjusting diets and drinking herbal teas; 3) having economic problems; 4)
accepting illness and death because of having no other choices to manage illness; 5) worrying and
feeling hesitant while depending on brother and mother; 6) having no experiences in religious practices;
7) receiving merit from daughter; 8) perceiving effects of poverty on poor health care; 9) feeling hesitant
to bother brother when often readmitted; 10) feeling ashamed to nurses and doctors from being often
readmitted; 11) feeling hesitant to ask help from nurses; 12) waiting for help from brother while hospitalized;
13) not expecting support from other relatives; 14) depending on brother’s decisions about health care and
further treatments; 15) receiving direct information from nurses; 16) experiencing nurses focus more on
routines care and lack of communication with patients; 17) following doctor’s order, the nurses
cannot decide on further treatments; 18) realizing the limitation of asking for good care while using the
health care card; 19) giving meaning to kindest nurses (comes quickly, cheerful, careful, gentle, let patients
ask questions, concerned about patients’ needs and smile easily); 20) trusting nurses’ abilities and
knowledge; 21) expecting time to talk openly with kind nurses in order to reduce hesitancy and
release worry; and 22) expecting to be educated and taught about self care and relaxation.
Lung Dam (Patient 3)
The 18 codes for Lung Dam were: 1) experiencing recurrence of chronic lung disease; 2) worrying the
illness will affect his work; 3) recognizing the teaching about the middle way and equanimity while getting
sick from working hard; 4) taking care of himself by avoiding causes of illness, taking modern medicine and
using traditional massage; 5) following the ancestors’ beliefs and rituals about basic precepts and merit making;
6) supporting the monks’ activities; 7) learning Dharma, meditation and Buddhist rituals from the
ordination; 8) practising religious rituals, transferring merit to others and ancestors, praying for good
luck, sufficient income and good health; 9) performing rituals at the temples; 10) respecting ancestors,
repaying gratitude to them and asking for their protection; 11) joining neighbours’ ceremonies; 12) making
merit regularly; 13) asking for health by making a vow to the sacred things and repaying by being a nuntraditional beliefs in his family; 14) receiving help from daughters when sick; 15) communication with
doctors and nurses and asking for information via his daughter; 16) valuing respect among family and
relatives; 17) appreciating nurses and doctors; and 18) trusting in nurses’ and doctors’ abilities.
Lung Tongkam (Patient 4)
The 48 codes for Lung Tongkam were: 1) having heart disease for a long time; 2) preferring to have
relatives stay while being admitted; 3) accepting illness; 4) preferring risky foods; 5) relating long life
and good health with kamma; 6) providing work for doctors; 7) accepting death; 8) reducing
suffering by calmness and peacefulness; 9) dealing with heart attack by chanting, praying and letting
life go; 10) avoiding harmful foods; 11) using herbs from Buddha’s time; 12) learning Dhamma from
ordination; 13) believing in the impermanence of life; 14) experiencing uncertainty of life; 15) coping
with life changes by preferring a simple life; 16) performing religious rituals; 17) performing death
rituals for terminally ill persons at home; 18) raising mindfulness for hardship and health problems;
19) reciting an incantation for wound healing; 20) reducing cardiac symptoms by raising mindfulness
and chanting; 21) having no fear of death; 22) explaining birth, duties, making merit and sin; 23)
completing duties to make merit; 24) making merit by repaying with gratitude; 25) making merit by
suitable donation; 26) making merit by helping temple’s activities and helping others; 27) being
happy make merit; 28) chanting to promote good sleep; 29) not-clinging to emotions; 30) considering
the impermanence of a physical body; 31) considering nothingness; 32) reminding patients to accept
illness; 33) explaining good death as finishing retribution; 34) performing death rituals for terminally
ill patients in hospitals; 35) reminding terminally ill patients not to resist death; 36) being ready to
die; 37) non-resisting death; 38) recommending chanting and thinking of the Buddha when dying; 39)
appreciating present good acts more than expecting a better reincarnation; 40) being clever in
following the Buddha’s teachings; 41) focusing on Buddha, not buildings; 42) valuing religious study
and practising meditation; 43) recommending nurses learn Buddha Dhamma; 44) appreciating
concern and support from family; 45) appreciating help and support from wife; 46) valuing a simple
virtuous life more than money; 47) valuing happiness makes nurses happier; and 48) expecting
understanding and respectfulness from polite nurses.
Na Noi (Patient 5)
The 15 codes for Na Noi were: 1) relating history of illness; 2) making merit; 3) receiving supporting
from relatives; 4) feeling hesitant; 5) being patient; 6) accepting sickness; 7) accepting death; 8)
having personal goals of care; 9) experiencing a communication barrier; 10) feeling hesitant to call
nurses; 11) being more comfortable at home; 12) accepting illness and death; 13) experiencing
constraints against religious practices; 14) practising religious rituals; and 15) suggesting nurses to be
good carers by being friendly, kindly to others.
Na Nee (Patient 6)
The 53 codes for Na Nee were: 1) refusing folk medicine; 2) being referred to folk medicine by
elderly people; 3) accepting orthodox medicine; 4) expressing financial difficulties; 5) relating illness
to bad luck; 6) worrying about the tumour; 7) trying to express personal hardship to the doctors; 8)
losing my mind; 9) receiving psycho-spiritual support from son; 10) regretting inability to support
family; 11) having suicidal ideas; 12) facing financial problems; 13) living with uncertainty; 14)
experiencing sadness and loneliness; 15) hoping to go back home; 16) controlling worry by chanting;
17) asking for the big alphabet of chanting books; 18) trying to exercise; 19) feeling better after
telling stories to the researcher; 20) hoping to be independent; 21) receiving support from other
patients and relatives; 22) feeling sad and petulant about receiving late treatments; 23) relating severe
illness to previous bad kamma; 24) practising religious rituals; 25) believing in good results from
making merit; 26) wondering about the results of good deeds; 27) accepting illness; 28) asking for the
Buddha’s protection; 29) practising Dhamma (making merit, paying homage to the Buddha image).;
30) asking for forgiveness and help from spiritual sources; 31) doing chanting before sleeping; 32)
sending merit to family members ; 33) requesting merit; 34) repaying all past kamma by making
more merit; 35) living with suffering; 36) praying for good health; 37) making a vow for good health;
38) rrepaying gratitude to mother; 39) hoping to win lotto; 40) receiving support from nurses; 41)
appreciating kindness from nurses, doctors and staff; 42) hoping to get better; 43) accepting the
destiny of life; 44) receiving food and money from other patients and their relatives; 45) feeling relief
by talking with other patients; 46) praying for son’s good luck; 47) appreciating moral support from
family; 48) wanting to make merit; 49) taking refuge in sacred things; 50) preparing to be very
patient with family; 51) trying to take care of herself; 52) avoiding some foods; and 53) expecting to
receive care and support from kind health care providers.
Note from the researcher: After the patient talked with me she felt she would like to make merit, so
she gave me 5 Baht. It was money which relatives of other patients gave her. Another patient who
stayed near her bed also wanted to make merit as well. So, the next morning I bought rice, curry, and
fruits and provided foods to the monks and asked the monk to radiate merit to patients. I also visited
the patient again and told them that I already made merit for them. I also told the head nurses that
when patients wanted to make merit, how they could support patients’ needs. Luckily, at the New
Year party many patients had chances to make merit with the monks, who were invited to bless
patients and staff at the radiation clinic.
Na Nid (Patient 7)
The 76 codes for Na Nid were: 1) experiencing uncaring nurses; 2) asking for gentle care and
kindness from nurses; 3) giving gifts to the nurses for repaying their help (plus expecting special
care); 4) meeting compassionate doctors; 5) accepting when we gain something we can lose
something; 6) experiencing misbehaviours worker and co-workers; 7) planning about the property
after death (giving to mother and donating to the temple); 8) thinking of repaying mother’s gratitude;
9) experiencing a huge loss in one life; 10) experiencing lack of health; 11) preparing to receiving
treatments; 12) strengthening her mind after being inspired by other patients-trying to exercise and do
gardening; 13) experiencing loss of appetite from receiving many antibiotics; 14) drinking soy milk
when unable to eat; 15) asking help from other patients’ relatives; 16) balancing blood sugar leveleating proper food; 17) avoiding Bird flu illness; 18) respecting the statue of the sacred monk-praying
for healing; 19) accepting illness; 20) building good relationships with nurses and doctors in order to
2
receive special care; 21) finding well-known people who can help to receive special care; 22)
knowing staff at the hospital as a way to receive special care; 23) trying other choices of care to
promote healing and avoid side effects of modern medicine (eating lizards and scorpions to control
blood sugar, dressing diabetic wounds with bootleg whisky mixed with a bolus); 24) being introduced
to alternative healing by friends; 25) learning alternative healing methods from the television; 26)
finding it difficult to accept illness; 27) asking help from all sacred things; 28) accepting death; 29)
receiving changing book from friends-hanging sometimes; 30) having DM is having suffering; 31)
praying to not have other diseases and family members’ health; 32) facing suffering before getting
sick-be more patient when getting sick-having multiple suffering; 33) being patient to deal with
illness; 34) considering the nature of life: everybody experiences birth, old age, sickness, and death;
35) considering the uncertainty of death; 36) believing the bad effect on health of bad kamma
(crookedness) such as getting sick and having accidents; 37) hoping to pass all hard times because
she has never done bad deeds; 38) being a non religious person; 39) making merit some days; 40)
respecting the sacred monks at her province; 41) giving forgiveness to cheated friends; 42) believing
the result of bad kamma-Relating cheating others to having troubles in life, such as an accident and
premature death; 43) believing illness (DM) is not related to kamma or fortune; 44) accepting the
changing nature of work and life; 45) having health problems because of improper eating behaviours;
46) feeling sympathy to other suffering patients; 47) understanding other patients’ problems; 48)
having a strong heart to fight illness; 49) having enough patience; 50) strengthening the mind; 51)
living alone in the hospital with no problems; 52) depending on oneself; 53) communicating to
relatives by using a mobile phone; 54) asking help from mother and daughter at any time; 55)
respecting nurses and doctors; 56) meeting polite nurses, but not conversing with patients; 57)
focusing on their task: the nurses; 58) teasing the nurses; 59) wanting the nurses to be friendlier with
patients and talk with patients more; 60) meeting some impolite nurses; 61) meeting some rough
nurses; 62) experiencing a criticised nurse, some nurses are disrespectful and command their patients;
63) wishing all nurses are polite gentle and friendly; 64) wishing nurse to talk more with patients
while working; 65) expecting to communicate with nurses; 66) having a chance to talk with nurses;
67) building good relationships with nurses by saying thank you and giving nurses some gifts and
teasing them not to be “crabby”; 68) connecting with nurses after receiving long term care; 69)
experiencing negative responses from nurses such as very loud voices, snarling at patients, moody,
blaming patients, sarcastic, impolite; 70) expecting respect from nurses; 71) expecting care from kind
and mature nurses; 72) donating things to the ward to build good relationship with nurses; 73)
expecting nurses to see the value of patients; 74) asking for support from the ward (rehabilitation
equipment such as wheel chair); 75) experiencing nurses’ ignoring; unconcerned patients when
patient lose belongings; and 76) wishing nurses could pay more attention to promoting patients’
normal activities.
Na Malai (Patient 8)
The 57 codes for Na Malai were: 1) being proud of herself; 2) realising heart disease relates to
nutrition; 3) discussing diseases of the elderly; 4) controlling emotion by considering Buddha’s
teaching and meditation (accepting illness and deterioration of health-influences of Buddhist practice,
accepting illness as a normal event, staying calm when having heart attack, perceiving the mind is
sick while the body is not sick, having unconditioned mind); 5) emphasising the need for self care; 6)
being kind to ourself and others; 7) reading Dhamma books; 8) understanding the impermanence of
life and a virtuous life; 9) believing in the sacredness of the Buddha’s relic; 10) using wisdom and
mindfulness to deal with life’s situations; 11) feeling sympathy to others; 12) talking with monks to
learn Dhamma; 13) answering life problems from the Dhamma view; 14) experiencing no meditation;
15) understanding benefits of practising meditation: (keeping one's manners, speech, and thoughts
under control, having focussed state); 16) living with Dharma, living with mindfulness; 17)
respecting others reasons: Accepting individual differences; 18) sharing proper world view and better
choices of others; 19) experiencing peace from having mindfulness; 20) praying for others, even for
robbers; 21) having self awareness; 22) chanting while driving and swimming; 23) respecting the
sacred monks, water and land, and all of the creators; 24) learning Dharma as self directed learning;
25) having a developed mind from living in a religious family; 26) opening the mind to learn other
religions; 27) doing good deeds day by day: believing in kamma, 28) being gently and having kindheartedness while telling the truth to patients; 29) expecting not to reborn after doing good kamma,
30) making merit by donating her body; 31) controlling self by setting mindfulness and keeping calm
while having the heart attack; 32) doing deep breathing while having a heart attack; 33) accepting
death-letting it go; 34) reminding daughter to be calm and accept her death; 35) understanding illness
3
and death; 36) adjusting amount of medication depending on conditions; 37) expecting more chances
to talk with doctors comfortably; 38) experiencing egoistic novice doctors; 39) giving forgiveness to
unkind doctors; 40) expecting fast and effective care; 41) using the Buddhist healing (dealing with
the heart attack by radiating merit to the body and the heart, trying to take care of myself by taking a
rest, adjusting the amount of my medicine thinking of the gratitude of the Buddha); 42) living with
merit and good kamma; 43) understanding the limitation of nursing context: roles overload, limited
time; 44) feeling sympathy for nurses; 45) busyness is causing ineffective nursing care; 46) nursing is
a busy job; nurse is a hard working person, so need to be patient; 47) raising issues about nurses’
image, power and unity (Thai nurses do everything, having a gap within professional roles; nurses
don’t love each other, and not being honoured by others); 48) expecting the spirit of a nursing
professional (nurses love each other); 49) valuing therapeutic touch in nursing; 50) becoming closer
when calling people by name like calling our close relatives; 51) valuing the kin relationship between
nurses and patients; 52) imparting a caring mind to every nurse is a major role of nursing teachers;
53) having no chance to be concerned about one’s own mind: influences of modernity; 54) expecting
nurses to provide moral support to patients; 55) suggesting nurses cultivate the Thai tradition, custom
and the decorum; 56) suggesting nurses learn about relaxation and stress management techniques to
support patients’ minds; and 57) suggesting nurses support patients by doing chanting and preparing
chanting books for patients.
Nong Orn (Patient 9)
The 72 codes for Nong Orn were: 1) living with HIV, 2) experiencing loss of her husband, daughter
and brother from AIDS; 3) being strong; 4) having parents as helpers and supporters; 5) having
connections with deceased daughter by feeling; 6) making and radiating merit to passes away
daughter and ancestors; 7) asking all dead ancestors to protect the spirit of her dead daughter; 8)
being transformed from sadness to helping others after meeting the self help group and kind people;
9) moving from loneliness to a lighter life after telling the truth of illness to others; 10) experiencing
negative images of AIDS; 11) gaining acceptance from people, who did not discriminate; 12)
learning to take care of self: updating health care news; 13) experiencing living with fear; 14)
devoting self to helping others; helping HIV/AIDS people; 15) raising awareness and building true
understanding about AIDS; 16) sharing experiences of living with HIV/AIDS with health care staff;
17) working too hard and thinking too much will cause illnesses; 18) readjusting life after
experiencing imbalance of working and rest. Resigning from fulltime work to work at home in the
rubber garden; 19) receiving reward from helping HIV/AIDS people; 20) having free anti-virus
drugs; 21) managing life while taking the anti-virus drugs; 22) experiencing side effects of anti-virus
drugs; 23) helping infected friends by being a volunteer, supporting friends; 24) helping others by
letting infected friends call to consult her at home; 25) devoting self to help other suffering people;
26) having a kind mother; help each another to help others; 27) making merit by helping others;
staying in touch with infected friends-support each others; 28) intending to depend on her selfmaintaining work; 29) having a strong mind leads to a healthy body; 30) maintaining will-power
(kam lung jai) and taking care of herself; 31) having parents as a refuge; 32) willing to live longer to
repay gratitude to parents and avoid making parents feel regret; 33) having a strong mind to accept
AIDS in the family: experiences of parents ; 34) accepting illness and death of the family members;
35) maintaining activity about AIDS; 36) caring kind of relationship in the family; 37) having caring
parents and relatives; 38) being an important person in the family, even with HIV; 39) helping each
other-living in a kind hearted family; 40) having no money but plenty of love; 41) experiencing the
infected person; 42) accepting illness (plong); 43) relating illness to the effects of past kamma; 44)
accepting the truth of life: influences of Buddhist beliefs about illness and death; 45) feeling better
after accepting illness; 46) accepting illness and death; 47) living and taking care of heath day by day;
48) believing in kamma; 49) doing more good deeds leads to live longer, and having good chances,
such as receiving free anti-HIV drugs; 50) helping others and repaying gratitude to parents leads to a
longer live; 51) having no dept to repay; 52) helping others; 53) avoiding comparing herself with
other successful friends; 54) feeling better when looking at people who have the same problems; 55)
sharing empathy with infected friends; 56) having sympathy while being a counsellor; 57) collecting
merit with mother; 58) sharing stories with infected friends-helping others; 59) transforming her mind
after overcoming her suffering; 60) talking in the same language-having no gap in relationships; 61)
connecting from the heart to the heart while having no gap in relationships; 62) perceiving the gap
between infected persons and nurses and doctors; 63) selecting contact only with kind nurses, not
trusting every nurse; 64) perceiving different levels of trust between nurse and patients; 65) asking
for human caring from the nurses-asking for compassion (non-discrimination) between infected
4
patients and other patients; 66) experiencing caring nurses (kind, smiling, controlling feeling well,
calm and having polite manners); 67) experiencing a kind doctor; 68) reading nurses’ sincerity from
looking at their eyes; the channel for nonverbal communication; 69) having sincerity is a way to build
long term relationships; 70) lack of communications is a barrier to being a caring nurse; 71) expecting
caring nurses (welcoming, smiling, cheerful, friendly, willing to help patients); and 72) experiencing
uncaring nurses (rude, dehumanising, having negative feelings for infected patients): dehumanising
relationships.
Nong Kla (Patient 10)
The 60 codes for Nong Kla were: 1) receiving treatments to treat infection; 2) causing his own
illness; 3) receiving support from parents; 4) feeling better after meeting other infected friends; 5)
being told by the nurse to be mentally strong; 6) refusing the antiviral regimens; 7) accepting the
illness; 8) being more awareness about morality; 9) living a simple life; 10) transforming mind
through Dharma learning; 11) not wanting others to suffer; 12) learning to live simply; 13) learning to
respect every person equally; 14) resetting life goals; 15) maintaining positive thinking; 16) raising a
fighting mind; 17) appreciating moral support from family; 18) doing bad things when feeling bored;
19) wanting to help father; 20) giving up misbehaviors; 21) believing in the chance to be healthy and
live longer; 22) maintaining a social life with friends; 23) being the same as uninfected people; 24)
following the precepts; 25) accepting illness; 26) living for doing good deeds; 27) maintaining hopes;
28) valuing nurses’ personalities-gently, polite, friendly; 29) valuing equal care from nurses; 30)
appreciate nurses’ sense of humour; 31) experiencing the bully nurses; 32) experiencing kind nurses;
33) expecting to receive enough information from nurses and doctors; 34) feeling afraid to ask for
information; 35) perceiving caring and uncaring nurses; 36) trying to understand nurses’ weak points;
37) expecting moral support from kind nurses; 38) perceiving nurses moods can affect patient’s
feeling and health; 39) understanding nurses’ situations; 40) overcoming suicidal ideas; 41)
transforming death thoughts; 42) being a good model for others patients; 43) connecting with a
daughter until death; 44) planning death; 45) Practising meditation; 46) helping other creatures; 47)
believing in the effect of merit on health; 48) helping others by not to expecting any return; 49)
questioning the problems of modernity ; 50) discontinuing meditation; 51) looking at others and
things positively; 52) realising the relationship between meditation and health; 53) setting simple life
goals; 54) forgiving others; 55) valuing peacefulness and happiness in life; 56) radiating merit to
parents and beings; 57) making merit; 58) being at ease while living near parents; 59) disliking other
people’s views and gossip; and 60) raising will power to fight with AIDS.
Nong To (Patient 11)
The 30 codes for Nong To were: 1) living with relatives after parents divorced; 2) receiving health
care from the government hospitals; 3) perceiving kidney problems occur because of eating salty
food; 4) trying to cut down on alcohol and to eat good food; 5) receiving warm support from relatives
and friends; 6) accepting the ordination for repaying the vow, not to be enlisted as a soldier in the
Thai Army and repaying gratitude to patents and relatives; 7) learning Dharma while being a monk;
8) perceiving back pain was an obstacle to practise meditation; 9) disconnecting with meditation after
leaving the monkhood; 10) having sleep problems; 11) hoping to get better; 12) drinking with friends;
13) experiencing both kind and drawl nurses; 14) appreciating health care outcomes; 15) expecting
information from nurses and doctors; 16) appreciating greeting and helping from nurses; 17) not
knowing the relationship between meditation and health; 18) believing the teaching about kammatrying to do some more good deeds; 19) preferring a private life; 20) avoiding stress by considering
the Buddha’s teaching about nature of illness and death; 21) having suicidal ideas from boredom; 22)
coping with boredom by going for a walk in the field; 23) questioning getting renal disease at a young
age; 24) valuing authentic purposes of the ordination; 25) following some precepts; 26) gaining
happiness from walking around the temple and chatting with the monks; 27) thinking of being reordained to get better control of drinking and smoking; 28) feeling better after accepting illness and
the destiny of life; 29) having a weak mind; and 30) continuing harmful behaviours.
Lung Kur (Patient 12)
The 25 codes for Lung Kur were: 1) having hereditary blood disease; 2) wishing to go back home;
3) receiving support from wife; 4) appreciating help and support from skilful nurses and doctors; 5)
experiencing hesitant nurses and doctors; 6) exchanging conversations with the nurses and doctors; 7)
5
receiving moral support and encouragement from the nurses and doctors; 8) helping the nurses by
letting relatives care for him to reduce nurses’ load; 9) trusting the nurses and doctors; 10) asking for
protection from the sacred monk’s amulet; 11) receiving merit from his wife; 12) respecting the god
of the land, water, and all creations; 13) showing respect to deceased ancestors; 14) asking for good
luck and protection from the ancestors, gods, and creatures; 15) depending on nurses’ and doctors’
suggestions; 16) gaining confidence in the hands of kind nurses and doctors; 17) relating the
recovering from illness with merit and luck; 18) avoiding harmful food; 19) receiving thoughtful care
from his wife; 20) eating for health, not for taste; 21) wishing no side affects from chemotherapy; 22)
concerning the safety and health status of his wife; 23) rotating another relative to care for him while
main relatives are absent; 24) experiencing diarrhoea after being looked after by unskilfulled
relatives; and 25) valuing the role of relatives as main caregivers.
Lung Mai (Patient 13)
The 52 codes for Lung Mai were: 1) living with hemodialysis; 2) coping with despair by seeking
traditional and modern medicine; 3) realising the ability to live longer; 4) trying to encourage other
patients’ exercise; 5) maintaining positive thinking; 6) keeping healthy by regular exercise; 7)
perceiving factors to promote good health including good taking care of himself, good medicines and
treatments and good support from family; 8) seeking information about proper foods for renal failure
patients; 9) believing in his body signals more than laboratory results; 10) adjusting amount of foods
by considering his body signals; 11) having organic chemical free food; 12) perceiving unacceptable
patients’ experiences from nurses and doctors; 13) developing personal health care methods; 14)
realising the uncertainty of medical knowledge; 15) realising the ignorance of nurses and doctors on
Thai health care wisdom; 16) preventing back pain; 17) asking doctors in health related issues; 18)
sharing all aspects of his life with his wife; 19) avoiding a bad mood at home; 20) experiencing
ordination for relaying gratitude to parents; 21) perceiving the negative part of monks; 22) believing
death is a way to go to the state of deliverance; 23) doing human duties completely; 24) spending the
rest of life learning Dhamma and travelling; 25) perceiving some Dhamma books are not easy to
understand; 26) valuing practising Dharma without waiting for the result; 27) applying meditation
techniques to daily activities such as exercise and singing; 28) applying meditation techniques to
control pain and to rehabilitate after a heart by-pass operation; 29) explaining the profound reasons
for chanting from a Buddhist perspective; 30) expecting nurses learn the benefit of exercise from
renal failure patients to encourage other renal failure patients to do more exercise; 31) expecting to
receive up to date information from the nurses; 32) expecting nurses to talk more with patients, listen
to patients’ feedback and suggestions and improve their services; 33) valuing Thai health related
wisdom; 34) understanding meditation and Dhamma from reading; 35) feeling peaceful from reading
a Dhamma book named ‘Bojjhanga’; 36) staying healthy even with renal failure; 37) being
recognised by nurses to be a good role model for other renal failure patients; 38) not trusting the
doctors and modern medicine; 39) experiencing a renal transplantation; 40) accepting illness; 41)
accepting death; 42) having good children and grandchildren; 43) knowing well to manage his illness;
44) using herbal bathing; 45) concerning abnormal signs; 46) realising the teaching about changing;
47) appreciating the scientific part of Buddhism; 48) doing breathing meditation; 49) having a good
life; 50) recommending the benefit of exercise to other patients; 51) expecting doctors and nurses
open their mind to listen to patients about their belief in traditional care; and 52) appreciating the
efficiency of modern hemodialysis machines.
Lung Chai (Patient 14)
The 51 codes of Lung Chai were: 1) learning Dharma from ordination; 2) setting simple life goals; 3)
understanding the essence of the Buddha’s teaching about the truth of nature; 4) understanding the
essence of the Buddha’s teaching about emptiness; 5) understanding the essence of the Buddha’s
teaching about kamma; 6) understanding the authenticity of the Buddha’s teaching about the mind; 7)
recognising the generosity of the Buddha; 8) mentioning the heart of Buddha’s teachings; 9)
understanding the history of Buddhism; 10) understanding the authentic teaching of Buddhism about
respecting others; 11) understanding the authentic teaching of Buddhism about metta-karuna; 12)
having religious teachers and models; 13) understanding the causes of suffering; 14) learning
Dhamma by scrutinising analysing; 15) being concerned about distortion of the Buddha’s teaching;
16) valuing the real Buddha’s teachings; 17) practising meditation and considering the teaching of
Buddha; 18) considering elements of the body while meditating; 19) accepting illness and death by
considering the nature of life; 20) having medium levels of emotions for a harmonious health; 21)
6
gaining benefits from practising meditation; 22) explaining the mind matter from the Buddhist view;
23) perceiving differences in understanding in Buddha’s teaching; 24) receiving orthodox treatments
for treating colon cancer; 25) being independent; 26) taking care of self; 27) understanding busy
nurses; 28) volunteering to support other patients; 29) applying healing experiences to help other
patients; 30) applying meditation experiences to help other patients; 31) valuing compassion in
helping others; 32) suggesting nurses learn Dhamma; 33) learning Dhamma by practising; 34)
suggesting ways to introducing meditation to patients; 35) understanding health status; 36) reminding
others to deal with problems by settling mindfulness; 37) relating the success and failure of
meditation with past kamma; 38) realising the truth of life; 39) living with consciousness; 40)
believing the teaching about dying before death; 41) taking care of mind while getting sick; 42)
preferring no help from relatives; 43) perceiving the nurses do a virtuous job; 44) expecting the
nurses can control their mood; 45) understanding the nurses’ situations; 46) expecting the nurse has a
wholesome mind; 47) expecting the nursing students and the nurses have service minds; 48) wanting
nurses to work for the happiness of all human beings; 49) educating meritorious minds in nurses; 50)
introducing good Buddhist role models for nurses; and 51) suggesting nurses developing the
meritorious minds.
7
APPENDIX (G)
Lung Teera (Relative 2)
The 29 codes for Lung Teera were: 1) giving his wife’s illness history; 2) having no experience of
helping patients who cannot breathe; 3) perceiving his wife cannot recover; 4) talking with unconscious
wife, being with and not neglecting her; 5) being taught to care for unconscious wife, such as feeding,
suctioning, exercising; 6) wishing to take care of his wife at home if she can breathe; 7) not wanting help
from his children and preferring to care for his wife by himself; 8) living in a simple way; 9) having back
pain and hypertension ; 10) preferring less control and more relaxation while sick; 11) expecting his wife could
pass away without distress-having no other choices; 12) accepting the possibility of losing his wife; 13)
perceiving patients have less suffering when unconscious; 14) feeling sorry to be unable to help his
wife; 15) understanding the nature of suffering which can go away some day; 16) having no ideas how to
do religious rituals for patients; 17) having no belief about supernatural power on illness; 18)
understanding some people believe about a supernatural power; 19) valuing caring for patients more than
expecting good outcomes from a supernatural power; 20) visiting, being with, touching and playing with his
unconscious wife everyday; 21) appreciating nurses’ good services and doing hard and careful work; 22)
believing that all nurses and doctors provide ethical care to prolong a patient’s life; 23) appreciating some
kind nurses and that no nurses are moody or give rebuke; 24) having no expectation to receive special care;
25) appreciating nurses’ responsibility and kindness-answer questions well, come to help quickly,
have no omissions and bad manners; 26) perceiving nurses have done a virtuous job and can make merit
while helping patients; 27) appreciating nurse are calm, very patient and kindhearted, even when dealing
with aggressive patients and relatives; 28) trusting nurses’ and doctors’ abilities, having moral and skillful
care; and 29) trying to help his wife and avoiding bothering nurses’ and doctors’ time.
Nong Rama (Relative 3)
The 38 codes for Nong Rama were: 1) perceiving causes of illness from supernatural causes; 2)
experiencing relatives asking for forgiveness and making merit; 3) experiencing a vow; 4) perceiving
severe suffering; 5) needing willpower; 6) having an extended family; 7) leaving study to stay with
relatives; 8) receiving financial support from relatives; 9) avoiding talking about mother’s prognosis;
10) having financial problems; 11) feeling tired and ill from caring; 12) asking nurses to care for
mother at night; 13) experiencing lack of caring nurses; 14) feeling powerless to ask for help; 15)
being told to leave the female ward; 16) providing comfort; 17) perceiving the benefits of overnight
stay; 18) worrying nurses will not permit overnight stay; 19) being expected by nurses to provide
care; 20) being hesitant to ask for help; 21) perceiving some nurses are kind; 22) perceiving some
nurses ignore relatives’ needs; 23) perceiving there are not enough nurses; 24) having problems
asking for help from nurses; 25) waiting to ask for help from friendly nurses; 26) perceiving mother’s
beliefs in illness due to kamma; 27) having difficulty to understand medical language; 28) developing
confidence to ask nurses how to care; 29) perceiving doctors have direct and uncaring personality;
30) trying to find other ways to help mother; 31)reminding mother to do short chanting to relax; 32)
trying to support mother; 33) not appreciating nurses; 34) recognising effects of unskilful nursing
students; 35)suggesting nurses should attend to immobile patients; 36) suggesting more nurses per
shift; 37) expecting rapid responses from nurses; and 38) experiencing horrible words and improper
manners from nurse assistants.
Nong Ya (Relative 4)
The 39 codes for Nong Ya were: 1) perceiving her father has severe illness; 2) appreciating her
father’s good deeds; 3) being taught by her father to be kind and polite to others; 4) confirming with
doctor her wish not to take her father to die at home; 5) consulting other close relatives to make
decisions about her sick father; 6) realising problems from doctors who talk with relatives improperly
in front of patients, her father is frightened after knowing his possibility of dying if relatives cannot
donate enough blood; 7) reminding doctors not to hurt patients’ feeling by providing sad news in the
improper place and time; 8) avoiding letting patients know bad news; 9) realising patients need kam
lung jai (moral support); 10) reminding that doctors tell bad news to relatives rather than to patients;
11) intending to tell a lie in order to support patients’ minds; 12) appreciating kind nurses and staff;
13) being allowed to be involved in caring for her sick father; 14) appreciating that nurses give moral
support to patients; 15) receiving information about her father’s further treatment plans from the
doctors; 16) co-operating with the doctors’ plan; 17) support her father’s mind; 18) realising her
father needs relatives to stay close to him at night time; 19) realising relatives from the village want to
stay close to patients in the hospital; 20) perceiving her father plans to die at the hospital; 21)
perceiving her father trusts in modern medicine and refuses to use traditional healing; 22) perceiving
her father’s religious background helps him to accept illness and death; 23) appreciating a lot of
support from relatives and neighbours from the village; 24) perceiving his father believes in boon
(merit); 25) feeling proud to have a chance to take care of her sick father; 26) trying to stay close to
her father in the ward to help and support him; 27) experiencing her father asking for good luck by
thinking of the sacred monks; 28) perceiving her father does not fear death but he fears pain; 29)
perceiving her father is a compliant patient; 30) perceiving her father eats herbs, a bitter Mara
(Momordica), to control his cancer; 31) valuing her father’s happiness and comfort in the last stage of
cancer; 32) receiving information from nurses about how to take care of her father; 33) avoiding
giving additional worry to her sick father; 34) expecting her sick father has a strong heart; 35)
appreciating her mother makes a vow and ask for her father’s good health; 36) making merit for her
father; 37) watching her father closely in order not to let a spirit (ghost) take him away-having
traditional beliefs about spirits; 38) perceiving as a daughter she can take care of her father and
support his mind better than nurses; and 39) perceiving as a daughter she has more sensitivity to her
father’s feeling than nurses.
Na Ree (Relative 5)
The 30 codes for Na Ree were: 1) trying to do her best to take care of her thalassemic son; 2) feeling
honoured to receive total support for her son’s health care costs from the Queen’s project; 3)
believing that 25 years old is a bad year for any person including her son; 4) giving history about her
son’s unconsciousness; 5) following the visiting rules of the ward; 6) asking her brother to ask for
information about her son for her; 7) wishing her son can recover; 8) letting her husband to make a
decision about a suitable last solution for her son; 9) making a wish that if her son could be healed she
would ask him to ordain again; 10) praying and chanting for her unconscious son’s recovery; 11)
asking for a protection from the Kuan Im goddess for her unconscious son; 12) making merit for her
unconscious son; 13) chanting short scriptures in her son’s ear every time she visits; 14) doing some
nursing care for her son by herself; 15) respecting and asking for good luck from monks’ amulets, a
small image of Buddha, gods and goddesses; 16) doing Buddhist rituals and Chinese traditions; 17)
having no ideas about the story of kamma; 18) receiving financial support from her sister and her
boss; 19) appreciating nurses’ work; 20) appreciating nurses work hard; 21) trying to care for her son
to reduce some workload from the nurses; 22) thinking to maintain her son’s job; 23) wishing her son
to pass away peacefully, not to worry about any person and anything that you would leave behind; 24)
reminding her unconscious son to keep chanting; 25) telling her son “We already made special merit
for you”; 26) wishing her son would recover or pass away comfortably; 27) planning to organise a big
chanting ceremony if her son recovers; 28) realising she can not invite four monks to chant special
verses for her son in the ward; 29) planning to invite a monk to bless her son in the ward; and 30)
experiencing listening to some Dhamma cassettes.
Lung Pong (Relative 6)
The 32 codes for Lung Pong were: 1) giving history of his father with stroke; 2) being taught by
nurses to take care of his stroke father at home; 3) modifying caring techniques for his father until can
do some jobs such as preventing bed sores better than nurses; 4) receiving help from his wife to
prepare blended food for his father; 5) trying to care for his father because of feeling hesitant to call
for help from nurses; 6) thinking of giving some sacrifices for nurses; 7) appreciating nurses’ good
work; 8) appreciating doctors and nurses are polite and friendly; 9) perceiving nurses are very busy;
10) perceiving nurses at the private ward are not very busy; 11) perceiving some nurses release their
tension by talking with patients and relatives while some nurses don’t talk with clients much while
working; 12) valuing nurses’ good nursing care more than good talking skills; 13) perceiving nurses
are always aware and are concerned about patients’ conditions; 14) appreciating the caring mind of
the head nurses; 15) Having a simple and happy life; 16) keeping healthy while being a caregiver by
exercising everyday; 17) massaging his father everyday; 18) receiving financial support from his
brothers and sisters to care for his father; 19) being a caregiver because none of his other sisters and
brothers feel free to take care of his father; 20) maintaining his job while providing the best care for
his stroke father at home; 21) feeling tired from taking care of his stroke father; 22) having no need to
ask for help from his children and other relatives; 23) getting used to a hard work; 24) feeling
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satisfied in his life; 25) feeling it is hard to care for a fussy father; 26) practising religious and
Chinese traditional rituals; 27) expecting his children will take care of him the same as he does for his
father; 28) planning to making merit for his father; 29) planning a coffin for his father; 30) donating a
coffin to another person; 31) planning to let his father die in the hospital in order to receive good
care; and 32) living carefully.
Khun Sakol (Relative 7)
The 31 codes for Khun Sakol were: 1) having ability to book a private room for his father every
admission; 2) helping his sisters to take care of his stroke and asthma father; 3) appreciating nurses’
abilities; 4) concerning roles of nurses and staff to prevent infection in the hospital; 5) understanding
the limit of nurses’ work in the private unit; 6) experiencing relatives help nurses care for his father
while admitting to a private room; 7) refusing non scientific healing methods to care for his father; 8)
perceiving frustration is a normal problem of paralysis patients; 9) refusing to use religious practise to
help his father; 10) relaxing his father by putting on his favourite Chinese movies and songs; 11)
recommending preventing workload of relatives while caring for paralysis patients by having at least
two main caregivers; 12) expecting nurses and doctors to understand reasons of patients’ families
when they are not ready to take patients back home; 13) valuing nurses’ help of patients’ family to
care for patients at home; 14) expecting nurses do home visits to help relatives care for chronic
patients at home; 15) expecting nurses to play a major role in teaching relatives to take care of
patients who need long term care; 16) expecting to have a nursing home to release relatives’ tensions;
17) realising the limit of hospitals to let relatives borrow equipment to take home; 18) realising the
hospital has insufficient nurses to provide home visits; 19) realising relatives have to manage their
life well while caring for patients at home; 20) recommending nurses must give them their telephone
number to relatives so they can call to consult nurses when they need help; 21) recommending the
hospital promotes fund raising activities, such as asking for donations so relatives can donate medical
equipment after patients have died or become well; 22) having a chance to assess privileged services
from the hospital; 23) accepting illness is a normal event of old people; 24) intending to provide the
best care for his father; 25) having no traditional beliefs about illness and health care; 26) valuing
having enough caregivers to care for patients at home more than applying any traditional beliefs to
support patients; 27) appreciating a helping atmosphere in the family; 28) having health problems
while being a caregiver, such as backache; 29) realising relatives spend huge costs to care for patients
at home; 30) suggesting that nurses should set up some more support systems for patients’ relatives
by establishing a hotline which relatives can call to consult nurses 24 hours a day; and 31) suggesting
that nurses should know resources in communities, such as where relatives can go to fill oxygen
tanks.
Pe Urai (Relative 8)
The 40 codes for Pe Urai were: 1) being the main caregiver; 2) complaining about a bedsore; 3)
recognising infection and deterioration; 4) allowing relatives to be involved in care in the intensive
care unit; 5) feeling proud to have a chance to help; 6) feeling mistrust of some nurses; 7) being
thought of as a fussy and difficult relative; 8) experiencing nurses’ disrespect and impoliteness; 9)
perceiving lack of concern; 10) expecting nurses to understand patients’ and relatives’ situations; 11)
perceiving relatives do not ask for information; 12) experiencing nurses’ blame; 13) experiencing
nurses’ insensitivity; 14) not appreciating unsupervised nursing students; 15) having bad experiences
with unskilled and impolite nurses; 16) trying to achieve good care for mother; 17) expecting nurses
to control their emotions; 18) expecting mutual respect and understanding; 19) expecting nurses to
appreciate relatives’ help; 20) reminding mother to think of the Buddha; 21) supporting mother’s
mind; 22) making merit for sick mother and dead father; 23) celebrating mother’s birthday with
nurses; 24) inviting the monk to bless mother weekly; 25) seeking moral support from the fortune
teller; 26) not wanting to know bad news; 27) experiencing siblings’ lack of concern and support; 28)
receiving moral support from sister; 29) believing people can gain merit form repaying gratitude to
parents; 30) expecting staff in the hospital to show their hospitality; 31) recommending nurses
provide information about patient’s progress; 32) expecting nurses to be kind and professional; 33)
valuing nurses’ friendliness, politeness, and willingness; 34) expecting nurses to show concern; 35)
expecting nurses to provide accurate care; 36) expecting nurses to not be moody; 37) expecting
nurses to watch critically ill patients closely to prevent any errors; 38) expecting nurses to focus on
caring for patients; 39) recognising the need for more nurses; and 40) expecting nurses to listen to
patients and their families.
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Na Su (Relative 9)
The 31 codes for Na Su were: 1) appreciating healthy life styles and the kindness of her father; 2)
seeking for the best health care for her father who has a lung cancer; 3) experiencing her husband
ceased smoking after knowing his father in law had a lung cancer; 4) receiving good moral support
from relatives and neighbours; 5) not wanting to lose her beloved father; 6) seeking healthy food and
good herbal medicine to prolong her father’s life; 7) perceiving her father can accept death and
already prepares for his funeral ceremony; 8) appreciating her father practices religious rituals; 9)
worrying about the progress of her fathers’ cancer; 10) perceiving her father plans to die at home; 11)
planning to invite the monk to bless her father in his dying period; 12) experiencing patients can have
good death when they die among relatives; 13) experiencing patients can have good death when they
are blessed by the monks; 14) perceiving the need to consult nurses about beliefs about harmful
food/proper food for cancer patients; 15) perceiving the need to consult nurses about further plans for
her father; 16) perceiving the need to consult nurses about using herbal medicine with cancer
patients; 17) consulting the doctor informally because of having a personal relationship with him; 18)
avoiding negative reactions from nurses by asking permission to repay her gratitude to every nurse
and staff by giving some fruit and desserts; 19) believing in kamma; 20) valuing doing good deeds,
having good words and not hurting other’s feelings; 21) keeping a healthy life style; 22) valuing
making merit; 23) experiencing being peaceful after practising meditation; 24) experiencing winning
lotto because of getting the numbers from a meditative state; 25) experiencing having six senses
which can be a good warning sign for safety; 26) reading Dhamma books; 27) massaging her sick
father; 28) feeling better after father looks better; 29) perceiving her father has got a lot of moral
support from family, relatives and neighbours; 30) deciding to let her father take herbal medicines for
strengthening the immune system; and 31) applying a caring experience to support other patients’
minds.
Na Rin (Relative 10)
The 26 codes for Na Rin were: 1) appreciating good support from community nurses; 2) trying to
learn how to care for her mother because of hesitancy to ask for help from nurses; 3) realising the
importance of nurses to educate relatives to care for patients at home; 4) perceiving patients need
gentle care; 5) cooking healthy food for her mother using fresh herbs, vegetables, grains and fish; 6)
calling for help from community nurses to do complex nursing care for her mother at home, such as
changing the urine catheter and checking the blood sugar; 7) perceiving community nurses are very
busy; 8) preventing her mother from constipation by feeding her bananas and the ancient herbal
medicine and doing evacuation; 9) having ideas to repay gratitude to nurses; 10) using a personal
relationship to seek better health care services in the hospital; 11) being a caregiver in order to repay
her gratitude to her mother; 12) experiencing stress while caring for her mother in the beginning of
her illness; 13) perceiving difficulty in taking care of her mother who uses a feeding tube; 14)
perceiving it is easy to inject insulin for her mother; 15) observing her mothers’ abnormal signs; 16)
keeping a healthy life while being a caregiver; 17) learning about letting things go to gain happiness
and equanimity; 18) practising religious rituals sometimes; 19) believing we can gain a merit from
taking care of parents; 20) believing in the circle of birth and rebirth, the law of kamma; 21) make
merit for mother and her deceased father to relay her gratitude; 22) perceiving her mother loves to
make merit; 23) inviting the monk to bless her sick mother at home; 24) appreciating her mother’s
good deeds; 25) expecting nurses come to help patients on time; and 26) valuing the importance of
nurses to educate relatives to care for patients.
Pa Wandee (Relative 11)
The 63 codes for Pa Wandee were: 1) being a main caregiver for stroke mother and father for 16
years; 2) experiencing being unready to take paralysis father back home because of having no cocaregiver; 3) receiving permission from the senior doctor to take father back home when ready; 4)
being forced by intern doctors to take father back home; 5) experiencing her father being readmitted
every one to two months from respiratory infection; 6) experiencing her father had constipation from
being fed with hospital food; 7) dealing with many kinds of parents’ caregivers; 8) having good times
with parents’ caregivers; 9) experiencing massaging and rehabilitation of father by the
physiotherapist and Thai traditional masseur; 10) developing health care techniques to take care of his
father and prevent complications from paralysis (such as cooking high fibre and vitamins blended
diet, preventing any ulcer and bed sores, keeping perineum clean and dry after voiding and excreting
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faeces, clapping his lung to clear secretion); 11) supporting caregivers’ minds; 12) appreciating good
support from nurses; 13) expecting to consult nurses who are expert in caring for paralysis patients
about how to care for her father; 14) applying natural ways of healing including the Chevachit
concept to care for her father; 15) experiencing difficulty from cooking food from the hospital’s
recipes; 16) practising a walking meditation to be calm and release stress; 17) listening to Dhamma
cassettes with her father for accepting illness and death; 18) experiencing practising Vipassana
(mindful) meditation; 19) experiencing frustration and tiredness from caring for her father for many
years; 20) expecting to have home care services to release relatives’ tiredness; 21) receiving good
help from the nurse assistant who becomes like a real relative; 22) never neglecting her stroke father;
23) feeling release and have more personal life when her father is admitted to the hospital; 24)
chanting and reading Dhamma books to feel peace, be less tired, strengthen her heart and understand
everybody’s life; 25) realising that everything is always changing, Aniccata, everything is Dukkhata,
nothing is true happiness; 26) considering the teaching about nothingness, nothing absolutely belongs
to us, in order to become peaceful; 27) believing that she has to repay her gratitude for her father in
this life because of the result of her past kamma; 28) believing in the next life; 29) radiating merit to
her sick father after meditation; 30) valuing nurses’ supporting patients and relative to accept their
illness and death; 31) perceiving nurses are busy and they have no time to have direct contact with
patients; 32) perceiving relatives seem afraid of nurses and doctors, they don’t want to bother nurses
when nurses are very busy; 33) deploring that nurses who are very good at doing nursing care and
have a lot of knowledge do not have time to talk with patients and relatives; 34) perceiving nurses
lack a good relationship with patients and relatives because they are very busy; 35) appreciating kind
and polite nurses; 36) perceiving nurse assistants have time to talk with the patients and relatives
more than nurses; 37) expecting nurses have more time to provide information to patients and
relatives; 38) appreciating nurses and doctors at the private hospital because they listen to clients and
are easy to ask for information; 39) experiencing patients’ relative feels frustrated because she had
never had a chance to ask questions from nurses and doctors; 40) trusting in nurses’ technical skills;
41) perceiving nurses don’t give opportunities for patients and relatives to ask questions; 42)
expecting nurses spend some time with patients when they come to do nursing care, to give
opportunities for patients and relatives to ask questions; 43) experiencing uncaring doctors; 44)
expecting to have home care and home visit services in order to release the tension of relatives; 45)
perceiving the benefit of meditation and Buddha Dhamma in dealing with every situation with
mindfulness, having less anxiety and accepting the reality; 46) looking at sickness, suffering, and
death more positively after considering the Buddha’s teaching; 47) accepting death is a normal event;
48) expecting nurses can support sad patients and relatives properly by staying with them, keeping
silence and letting them release their tension if they would