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Southern Cross University ePublications@SCU 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 ePublications@SCU 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 38 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 39 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) 40 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 41 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). 42 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. 43 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. 44 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 45 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 46 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 47 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. 48 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 49 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 50 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). 51 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; 52 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 53 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 54 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 55 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 56 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 57 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 58 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 59 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 60 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 61 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, 62 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. 63 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 64 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. 65 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 67 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. 68 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 69 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 70 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. 71 Chapter 4: Methods and processes 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 72 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. 73 Chapter 4: Methods and processes 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 74 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 75 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 76 Chapter 4: Methods and processes 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 77 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 78 Chapter 4: Methods and processes [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 79 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. 80 Chapter 4: Methods and processes 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?” 81 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?” 82 Chapter 4: Methods and processes 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?” 83 Chapter 4: Methods and processes 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 84 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 85 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. 86 Chapter 4: Methods and processes 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 87 Chapter 4: Methods and processes 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. 88 Chapter 4: Methods and processes 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 89 Chapter 4: Methods and processes 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). 90 Chapter 4: Methods and processes 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 91 Chapter 4: Methods and processes 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 92 Chapter 4: Methods and processes 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. 93 Chapter 4: Methods and processes 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 (ปลอย 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. 94 Chapter 4: Methods and processes 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. 95 Chapter 4: Methods and processes 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* (เขาใจ) Plong (ปลง), Ubekkha (อุเบกขา), Tam jai * (ทําใจ) Ploi wang (ปลอยวาง), 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 96 Chapter 4: Methods and processes 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 97 Chapter 4: Methods and processes 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). 98 Chapter 4: Methods and processes 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. 99 Chapter 4: Methods and processes 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 100 Chapter 4: Methods and processes 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 101 Chapter 4: Methods and processes 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. 102 Chapter 4: Methods and processes 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. 103 Chapter 4: Methods and processes 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 104 Chapter 4: Methods and processes 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. 105 Chapter 4: Methods and processes 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 106 Chapter 4: Methods and processes 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 107 Chapter 4: Methods and processes 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. 108 Chapter 4: Methods and processes 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 109 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 110 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 111 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. 112 Chapter 4: Methods and processes Memo 7: Cultivating Compassionate Relationships between Nurses, Patients and Relatives. 113 Chapter 4: Methods and processes Memo 8: Clarifying the meaning of compassion, equanimity, and relationship from dictionaries, participants’ meaning and literature. 114 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. 115 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 116 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. 117 Chapter 4: Methods and processes 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 118 Chapter 4: Methods and processes 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 119 Chapter 4: Methods and processes 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” 120 Chapter 4: Methods and processes 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. 121 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 122 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 123 Chapter 4: Methods and processes 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. 124 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, เอาใจเขามาใสใจเรา). 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. 126 Chapter 5: Nurses’ experiences and emerging codes 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, 127 Chapter 5: Nurses’ experiences and emerging codes 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. 128 Chapter 5: Nurses’ experiences and emerging codes 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 129 Chapter 5: Nurses’ experiences and emerging codes 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. 130 Chapter 5: Nurses’ experiences and emerging codes 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 131 Chapter 5: Nurses’ experiences and emerging codes 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 132 Chapter 5: Nurses’ experiences and emerging codes 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 133 Chapter 5: Nurses’ experiences and emerging codes 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. 134 Chapter 5: Nurses’ experiences and emerging codes 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). 135 Chapter 5: Nurses’ experiences and emerging codes 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. 136 Chapter 5: Nurses’ experiences and emerging codes 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. 137 Chapter 5: Nurses’ experiences and emerging codes 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. 138 Chapter 5: Nurses’ experiences and emerging codes 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. 139 Chapter 5: Nurses’ experiences and emerging codes 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. 140 Chapter 5: Nurses’ experiences and emerging codes 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. 141 Chapter 5: Nurses’ experiences and emerging codes 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 142 Chapter 5: Nurses’ experiences and emerging codes 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 143 Chapter 5: Nurses’ experiences and emerging codes 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. 144 Chapter 5: Nurses’ experiences and emerging codes 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. 145 Chapter 5: Nurses’ experiences and emerging codes 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. 146 Chapter 5: Nurses’ experiences and emerging codes 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 147 Chapter 5: Nurses’ experiences and emerging codes 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 148 Chapter 5: Nurses’ experiences and emerging codes 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 149 Chapter 5: Nurses’ experiences and emerging codes 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 150 Chapter 5: Nurses’ experiences and emerging codes 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 151 Chapter 5: Nurses’ experiences and emerging codes 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. 152 Chapter 5: Nurses’ experiences and emerging codes 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. 153 Chapter 5: Nurses’ experiences and emerging codes 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. 154 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) 156 Chapter 6: Patients’ experiences and emerging codes 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 157 Chapter 6: Patients’ experiences and emerging codes 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; 158 Chapter 6: Patients’ experiences and emerging codes 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. 159 Chapter 6: Patients’ experiences and emerging codes 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. 160 Chapter 6: Patients’ experiences and emerging codes 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. 161 Chapter 6: Patients’ experiences and emerging codes 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. 162 Chapter 6: Patients’ experiences and emerging codes 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. 163 Chapter 6: Patients’ experiences and emerging codes 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. 164 Chapter 6: Patients’ experiences and emerging codes 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. 165 Chapter 6: Patients’ experiences and emerging codes 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 166 Chapter 6: Patients’ experiences and emerging codes 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. 167 Chapter 6: Patients’ experiences and emerging codes 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 168 Chapter 6: Patients’ experiences and emerging codes 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 169 Chapter 6: Patients’ experiences and emerging codes 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. 170 Chapter 6: Patients’ experiences and emerging codes 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. 171 Chapter 7: Relatives’ experiences and emerging codes 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). 173 Chapter 7: Relatives’ experiences and emerging codes 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 174 Chapter 7: Relatives’ experiences and emerging codes * 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. 175 Chapter 7: Relatives’ experiences and emerging codes 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 176 Chapter 7: Relatives’ experiences and emerging codes 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 177 Chapter 7: Relatives’ experiences and emerging codes 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. 178 Chapter 7: Relatives’ experiences and emerging codes 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 179 Chapter 7: Relatives’ experiences and emerging codes 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 180 Chapter 7: Relatives’ experiences and emerging codes 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. 181 Chapter 7: Relatives’ experiences and emerging codes 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. 182 Chapter 7: Relatives’ experiences and emerging codes 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 183 Chapter 7: Relatives’ experiences and emerging codes 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. 184 Chapter 7: Relatives’ experiences and emerging codes 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 185 Chapter 7: Relatives’ experiences and emerging codes 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. 186 Chapter 7: Relatives’ experiences and emerging codes 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. 187 Chapter 7: Relatives’ experiences and emerging codes 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. 188 Chapter 7: Relatives’ experiences and emerging codes 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, 189 Chapter 7: Relatives’ experiences and emerging codes 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. 190 Chapter 7: Relatives’ experiences and emerging codes 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. 191 Chapter 7: Relatives’ experiences and emerging codes 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. 192 Chapter 7: Relatives’ experiences and emerging codes 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. 193 Chapter 8: The process of the grounded theory development 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 195 Chapter 8: The process of the grounded theory development “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 196 Chapter 8: The process of the grounded theory development 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 197 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. 198 Chapter 8: The process of the grounded theory development “เกิดทุกข และ เขาใจทุกข” A: Facing suffering /understanding the nature of suffering Cultivating Compassionate Relationships with Equanimity “เกิดความกรุณา เขาใจซึ่ง กันและกัน ยอมรับความ เจ็บปวย และปลอยวาง ความทุกข” C: Embodying mutual compassion with equanimity B: Applying Dhamma, personal/local wisdom, and traditional healing “ประยุกตใช ธรรมะและภูมิ ปญญาไทย” 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 เขาใจทุกข”; (b) applying Dhamma (Buddhist beliefs and practices), personal/local wisdom, and Thai traditional healing. In Thai “ประยุกตใชธรรมะและภูมิปญญาไทย”; and (c) embodying mutual compassion with equanimity, in Thai “เกิดความกรุณา เขาใจซึ่งกันและกัน ยอมรับความเจ็บปวย และปลอยวางความ ทุกข”. Taken together, these categories create the grounded theory of “Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives”. 199 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 200 Chapter 8: The process of the grounded theory development 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 201 Chapter 8: The process of the grounded theory development 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 202 Chapter 8: The process of the grounded theory development 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. 203 Chapter 8: The process of the grounded theory development 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 204 Chapter 8: The process of the grounded theory development 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. 205 Chapter 8: The process of the grounded theory development 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. 206 Chapter 8: The process of the grounded theory development 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); 207 Chapter 8: The process of the grounded theory development 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 208 Chapter 8: The process of the grounded theory development 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 209 Chapter 8: The process of the grounded theory development 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. 210 Chapter 8: The process of the grounded theory development 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. 211 Chapter 8: The process of the grounded theory development 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, 212 Chapter 8: The process of the grounded theory development 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. 213 Chapter 8: The process of the grounded theory development 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. 214 Chapter 8: The process of the grounded theory development 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. 215 Chapter 8: The process of the grounded theory development 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 216 Chapter 8: The process of the grounded theory development 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 217 Chapter 8: The process of the grounded theory development 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 218 Chapter 8: The process of the grounded theory development 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, 219 Chapter 8: The process of the grounded theory development 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 220 Chapter 8: The process of the grounded theory development 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. 221 Chapter 8: The process of the grounded theory development 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 222 Chapter 8: The process of the grounded theory development 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. 223 Chapter 8: The process of the grounded theory development 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. 224 Chapter 8: The process of the grounded theory development 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. 225 Chapter 8: The process of the grounded theory development 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 226 Chapter 8: The process of the grounded theory development 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. 227 Chapter 8: The process of the grounded theory development 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. 228 Chapter 8: The process of the grounded theory development 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. 229 Chapter 8: The process of the grounded theory development 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. 230 Chapter 8: The process of the grounded theory development 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. 231 Chapter 8: The process of the grounded theory development 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). 232 Chapter 8: The process of the grounded theory development 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. 233 Chapter 8: The process of the grounded theory development 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 234 Chapter 8: The process of the grounded theory development 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. 235 Chapter 8: The process of the grounded theory development 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. 236 Chapter 8: The process of the grounded theory development 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. 237 Chapter 8: The process of the grounded theory development 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 238 Chapter 8: The process of the grounded theory development 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 239 Chapter 8: The process of the grounded theory development 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. 240 Chapter 8: The process of the grounded theory development 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. 241 Chapter 8: The process of the grounded theory development 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. 242 Chapter 8: The process of the grounded theory development 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 243 Chapter 8: The process of the grounded theory development 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, 244 Chapter 8: The process of the grounded theory development 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. 245 Chapter 8: The process of the grounded theory development 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. 246 Chapter 8: The process of the grounded theory development 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. 247 Chapter 8: The process of the grounded theory development 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 248 Chapter 8: The process of the grounded theory development 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 (เขาใจ)","yorm rub (ยอมรับ)", lae (และ) (and) "ploi wang (ปลอยวาง)"/“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 (เขาใจ)", "yorm rub (ยอมรับ)", also "plong (ปลง)” and “mai yud tid (ไมยึดติด)” “wang jai pen klang (วางใจเปนกลาง)” 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. 249 Chapter 8: The process of the grounded theory development 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 (เปนมิตร)” (being friendly), “su parb (สุภาพ)” (politeness), “yud yun (ยืดหยุน)” (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 250 Chapter 8: The process of the grounded theory development 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. 251 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 253 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 254 Chapter 9: Buddhism and the nurse-patient-relative relationship 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): 255 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 256 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 & 257 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 258 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 259 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 260 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 261 Chapter 9: Buddhism and the nurse-patient-relative relationship 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, 262 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 263 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 264 Chapter 9: Buddhism and the nurse-patient-relative relationship 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). 265 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 266 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 267 Chapter 9: Buddhism and the nurse-patient-relative relationship 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). 268 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 269 Chapter 9: Buddhism and the nurse-patient-relative relationship 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). 270 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 271 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 272 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 273 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 274 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 275 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 276 Chapter 9: Buddhism and the nurse-patient-relative relationship 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, 277 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 278 Chapter 9: Buddhism and the nurse-patient-relative relationship 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). 279 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 280 Chapter 9: Buddhism and the nurse-patient-relative relationship 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 281 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 282 Chapter 9: Buddhism and the nurse-patient-relative relationship 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. 283 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. 285 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”, 286 Chapter 10: Discussion and Conclusion 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 287 Chapter 10: Discussion and Conclusion 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 288 Chapter 10: Discussion and Conclusion 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 289 Chapter 10: Discussion and Conclusion 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, 290 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. 291 Chapter 10: Discussion and Conclusion 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 292 Chapter 10: Discussion and Conclusion 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.” 293 Chapter 10: Discussion and Conclusion 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: 294 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 295 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). 296 Chapter 10: Discussion and Conclusion 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 297 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. 298 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 299 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). 300 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. 301 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. 302 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. 303 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. 304 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. 305 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 306 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 307 Chapter 10: Discussion and Conclusion 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). 308 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. 309 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 310 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. 311 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. 312 Chapter 10: Discussion and Conclusion The right path for nursing education อันความกรุณาปราณี จะมีใครบังคับก็หาไม หลั่งมาเองเหมือนฝนอันชื่นใจ จากฟากฟาสุราลัยสูแดนดิน 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. 313 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 314 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, 316 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. 317 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. 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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 3 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) 4 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 5 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) 6 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 7 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 8 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 9 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 10 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 11 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 12 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 13 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 14 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 15 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 2 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. 3 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 4 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 like to cry, asking questions or expressing their feelings; 49) realising ways to develop supporting skills of novice nurses; 50) realising the need to cultivate kindness in children when they are young; 51) suggesting organising activities for nursing students in order to let them learn about self awareness such as the meditation courses; 52) absorbing good Dhamma foundation from parents and in daily life; 53) being less angry and not blaming others after understanding Dhamma; 54) having more self-understanding after understanding Dhamma; 55) having a strong mind after understanding Dhamma; 56) applying the Buddhist way of thinking and basic meditation to advise people who had sleeping problems such as chanting Budd-Dho; 57) listening to people’s feelings and their concerns is a way to build good relationship with others; 58) realising nurses can not build trust and good relationships with patients and relatives because nurses have very little time to communicate; 59) suggesting nurses should tell patients and relatives frankly when they cannot help patients as quickly as patients and relatives expect; 60) suggesting nurses support patients and relatives’ minds by listening to them and letting them ask questions of concern; 61) suggesting nurses try to talk with patients and relatives so they can have a chance to tell their feelings, release tension and ask questions; 62) perceiving people can learn Dhamma when they go to temples; and 63) having life goals to have the peaceful state of my mind, doing good deeds, not doing bad deeds, and being happy with the present moment. Na Chaba (Relative 12) The 64 codes of Na Chaba were: 1) giving a history; 2) travelling to see the specialist doctors; 3) having difficulty understanding the doctor’s language; 4) appreciating kind suggestions from the oncologist; 5) cooking fresh clean and healthy food; 6) avoiding chemicals and harmful food; 7) trying to think of the cause of cancer; 8) believing people with cancer die sooner if they go to a funeral ceremony; 9) perceiving husband’s happiness in listening to chanting; 10) being a main caregiver; 11) trying to stay with her husband in the ward; 12) recounting relatives who passed away 5 from blood cancer; 13) perceiving being a caregiver in hospital is not hard work; 14) perceiving difficulties at home maintaining working and caring for her husband; 15) receiving help from daughter; 16) perceiving husband’s deteriorating condition; 17) waiting for a hospital bed; 18) taking her husband to see the doctor; 19) appreciating kindness from doctors and nurses; 20) appreciating friendly doctors with a sense of humour; 21) asking questions of nurses and doctors; 22) avoiding obstructing a ward keeper’s work; 23) feeling sympathy for busy nurses; 24) trying to take care of husband without calling for help; 25) appreciating nurses’ suggestions; 26) appreciating nurses’ concern; 27) developing hypertension; 28) feeling stressed in forcing husband to eat; 29) not being permitted to stay overnight; 30) appreciating religious activities; 31) trying to be calm after listening to Dharma preaching; 32) bringing an amulet to hospital for protection; 33) supporting her husband; 34) appreciating nurses’ education in taking care of patients; 35) appreciating a suggestion for chanting; 36) respecting the Buddha and the monks’ images; 37) repaying a vow; 38) realising husband’s belief in black magic; 39) perceiving her husband’s vow to be ordained and be a monk if he recovers; 40) asking for help from nurses; 41) upsetting her husband; 42) receiving information regularly from the oncologist; 43) massaging her husband; 44) appreciating help from nurses and nurse’s assistant; 45) realising nursing students and new nurses can make some errors; 46) missing a chance to make merit; 47) realising her husband need to make merit while hospitalised; 48) refusing to use herbal medicine to cure cancer; 49) being a nun to repay a vow after recovering from illness; 50) chanting and radiating merit; 51) chanting to be calm; 52) practising Buddhist rituals; 53) trying to relax; 54) expecting hospital services; 55) experiencing some relative complain about nurses’ lack of care; 56) reminding other relatives that nurses are very busy; 57) realising patients’ relatives can support each other; 58) reminding husband to appreciate nurses’ close observation and support; 59) appreciating nurses’ hard work; 60) realising nurses can release tension with relatives; 61) realising nurses are being blamed by patients’ relatives; 62) valuing nurses’ conversation skills; 63) experiencing ill effects of a novice doctor; and 64) expecting the doctors should talk with relatives more politely Na Jin (Relative 13) The 24 codes for Na Jin were: 1) experiencing care of paralysis husband at home for many years; 2) giving history about her husband with stroke; 3) healing her stroke husband by doing Thai traditional massages for many years; 4) learning alternative healing methods from heath care program on television; 5) taking care of herself while taking care of her paralysed husband; 6) healing her gastric pain by not eating too much chilli, avoiding fermented food, drinking milk and eating a lot of bananas; 7) doing her best to take care of her paralysed husband; 8) maintaining a good relationship and giving moral support to her paralysed husband by not shouting or expressing any negative emotions to him; 9) repaying gratitude to her husband by staying close to him, touching and massaging, and cooking healthy food for him; 10) preparing a traditional bed made with a bamboo mat to massage his back and prevent pressure sores; 11) practising religious rituals by making merit, respecting Luang Pho Tuad’s (the sacred monk) image and chanting the Chinabanchorn scriptures; 12) sleeping well after chanting; 13) chanting the Chinabanchorn scriptures to be calm after having nightmares; 14) radiating merit to her husband and everyone in her family; 15) chanting the Vessondon incantation to be protected from any bad luck; 16) receiving financial support from her children; 17) having her son to help her take care of her husband especially to move and change position; 18) being taught from parents to be a kind, patient, self-disciplined and hard working person; 19) receiving home visits from community nurses; 20) appreciating services of nurse and doctors from the hospital; 21) expecting nurses smile and are friendly with people who go to hospital; 22) expecting nurses to care for patients with kindness; 23) expecting nurses to teach relatives to help patients; and 24) expecting nurses do not let relatives care for patients in the ward alone. Pe Yai (Relative 14) The 51 codes for Pe Yai were: 1) applying mindful meditation; 2) listening to Dhamma cassettes; 3) reminding mother to do sleeping meditation; 4) caring for mother’s body; 5) reminding her mother to relax; 6) accepting the possibility of mother’s death; 7) controlling emotions while mother is in crisis; 8) realising benefit of quiet and private places; 9) experiencing mindful movements during physiotherapy; 10) having a strong mind; 11) appreciating good support from doctors and nurses; 12) providing holistic care; 13) repaying gratitude; 14) dealing with life situations with spiritual practices; 14) perceiving belief in kamma; 16) perceiving preference for natural healing; 17) understanding the mind’s function in detachment; 18) recognising the value of meditation; 19) needing professional 6 communication; 20) valuing relatives’ roles in providing comfort and supporting the patient’s mind; 21) realising nurses need more time to provide psycho-social spiritual support and holistic care; 22) realising the delicacy of psycho-social spiritual support; 23) realising the cost-free nature of psychosocial spiritual support; 24) recommending nurses provide healing methods to provide psychospiritual support; 25) realising the need for time and good intention; 26) realising relatives’ major role in psycho-spiritual support to patients; 27) recommending short training courses in psycho-spiritual care for nurses; 28) realising various kinds of patients’ healing methods; 29) experiencing practising Vipassana (mindful) meditation; 30) becoming more flexible through meditation and healing techniques; 31) experiencing chanting; 32) listening to Dhamma and chanting cassettes; 33) becoming generous and humble after practising meditation; 34) gaining more confidence; 35) not considering the value of Buddha’s teachings; 36) learning to have less desire from Dhamma; 37) learning good things from kind people in the meditation centres; 38) healing oneself by meditation and other healing methods; 39) setting suitable life goals; 40) doing loving kindness meditation; 41) applying meditation for calmness; 42) recommending nurses practise meditation; 43) suggesting nurses ask Buddhist patients whether they want to make merit; 44) suggesting nurses foster patients’ hope; 45) suggesting nurses persuade elderly patients do chanting; 46) recommending nursing schools teach meditation; 47) recommending nurses apply meditation techniques in patient care; 48) realising nurses can support patients and relatives to do religious rituals; 49) realising nurses should not ignore patients’ values and beliefs; 50) recommending nurses and doctors join Vipassana meditation courses; and 51) recommending nurses chant or let relatives chant in the dying period. Na Uma (Relative 15) The 46 codes for Na Uma were: 1) having a warm extended family; 2) accepting and understanding people living with HIV/AIDS; 3) accepting death by reminding herself that everyone cannot avoid dying. People who don’t get HIV disease will also die; 4) relating her children’s illness to past kamma; 5) thinking positive and accepting HIV infection of her children; 6) receiving help and support from relatives while her children are sick; 7) making merit by helping other people; 8) wishing her sick daughter and all children will be happy; 9) appreciating her HIV daughter has a chance to help other HIV/AIDS friends; 10) perceiving helping others is a meritorious job; 11) realising when our mind is strong our body becomes healthier; 12) accepting situations when other people gossip about her HIV children; 13) seeing a positive side of her HIV infected daughter; 14) thinking of helping others; 15) believing her daughter is healthy because she have done a lot of meritorious things; 16) experiencing caring for her HIV infected granddaughter; 17) believing her granddaughter was born to repay her past kamma and she will die; 18) believing her granddaughter had the highest meritorious act by dying when she is so young, passing away in the young age is not about her sin, but her virtue; 19) making merit to deceased children and granddaughter; 20) receiving moral support from friends and neighbours; 21) trying the best to take care of her granddaughter until she passes away; 22) making merit and passing merit to everybody in my family; 23) practising religious rituals by chanting before sleep, going to make merit at the temple, meditating; 24) praying and asking for all the best from passed ancestors, all gods, and all sacred creators from both under the earth and up to the sky; 25) reminding her children and grandchildren to respect relatives and deceased ancestors; 26) asking for protection from deceased ancestors; 27) being good to other people because of believing in good effects of meritorious acts; 28) sharing her experiences with people in the communities to raise their understanding of AIDS patients; 29) receiving moral support from people in the communities; 30) appreciating moral support from nurses; 31) trying to take care of her sick granddaughter while she is hospitalised; 32) asking for help from nurses when it is really necessary; 33) sharing the same feeling with relatives of other HIV infected patients; 34) appreciating equal care of nurses and doctors; 35) preventing negative reactions from other people by not telling others about the real diagnosis; 36) maintaining hard work to be healthy; 37) inviting the monk to bless her sick children and granddaughter; 38) being taught by the monk to make merit to deceased relatives to help them go to a better place; 39) being a public health volunteer; 40) understanding that people are individual and different because of their past kamma; 41) wishing everybody in the family has a better life; 42) working hard for the better life; 43) making more merit to repay all of her previous bad kamma; 44) recommending people to make merit when they are in trouble; 45) feeling compassioned on nurses about their hard work; and 46) expecting nurses avoid using rude words and expressing bad temper with patients, and trying to support patient’s mind with polite words. 7 Pa Muu (Relative 16) The 45 codes for Pa Muu were: 1) caring for the infected son, nurturing his body and spirit; 2) avoiding making her infected son feel oppressed; 3) willing to share money to support patients; 4) experiencing loss of one daughter from AIDS; 5) perceiving her son causes his own HIV infection; 6) experiencing her son decided to be ordained because he wants to give up drugs; 7) preparing her mind to lose another child from AIDS; 8) asking the doctors to tell the truth about her son is HIV infection; 9) receiving moral support and information from nurses; 10) being concerned about her son’s feelings; 11) reminding her son not to get sin by spreading this disease to others; 12) preparing her mind to accept as if her son died; 13) communicating with doctors for her son; 14) trying to do her best to take care of her son; 15) planning to ask for help from her children when necessary; 16) refusing harmful treatments for her son; 17) keeping a clean environment; 18) realising her son appreciates her support; 19) perceiving relationship problem with unskilled doctors and some staff; 20) perceiving it is hard to communicate with doctors; 21) perceiving it is hard to understand a referral letter in English; 22) experiencing a bad impression with a doctor who made a patient die unexpectedly; 23) staying with her son at the ward all the time to make sure her son is safe because she can’t trust nurses and doctors; 24) reminding doctors, nurses, and staff to care more gently for her son who has severe pain; 25) experiencing some moody nurses; 26) appreciating supporting nurses; 27) perceiving some staff have sweet words but their hearts are so cruel; 28) appreciating nurses who are kind, welcoming and have never talked badly with patients and relatives; 29) perceiving some nurses talk loudly with patients and are strict but their hearts are very kind; 30) appreciating nurses’ politeness; 31) expecting that nurses are polite; 32) expecting that nurses reduce patients’ hesitation by asking patients first; 33) experiencing nurses annoy and blame relatives who contact them often to ask for help for patients; 34) expecting nurses to talk with patients and relatives politely; 35) experiencing nurses being ironic with her; 36) experiencing nurses will not be rude to patients; 37) experiencing nurses give moral support to patients; 38) experiencing an impolite ward keeper; 39) asking for permission to sleep with her son on the bed in order to help him quickly; 40) believing in good results of merit making; 41) preparing her mind to accept losing her son; 42) accepting her own illness; 43) practising religious rituals such as making merit on some occasions by offering food to the monks and asking for blessing and donating money; 44) believing in kamma and the next life; and 45) relating her son’s illness is the result of his previous bad kamma. 8 Table 8.2: Illustrated all open coding which supported related concepts, categories, core categories, and the basic social process 17 Nurses Core category 1: Facing suffering and understanding the nature of suffering Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients 16 Relatives Facing suffering Facing suffering Facing suffering Caring psychosocial problems Caring for suffering patients Experiencing relatives are too worried about patients’ health because of staying with patients all the time Facing physical problems Having poor blood sugar control Experiencing cervical cancer, P1 Facing side effects of the total hysterectomy, P1 Having heart disease for a long time, P4 Receiving treatments to treat infection, P10 Having colon cancer, P14 Experiencing poor control blood sugar level, P2 Experiencing loss of appetite from receiving many antibiotics, P7 Experiencing being unhealthy, P7 Living with HIV, P9 Experiencing the infected person, P9 Experiencing side effects of anti-virus drugs, P9 Perceiving kidney problems occur because of eating salty foods, P11 Having sleep problems, P11 Having blood disease from heredity, P12 Living with hemodialysis, P13 Experiencing the renal transplantation, P13 Telling the history of illness, P5 Experiencing recurrence of chronic lung disease, P3 Facing physical problems Having health problems while being a caregiver Having back pain and hypertension, R2 Preferring less control and more relaxation while sick, R2 Having health problems while being a caregiver, R1 Feeling tired and ill from caring, R3 Living with a bronchiectasis, R12 Developing hypertension, R14 Having health problems while being a caregiver, such as backache, R7 Telling the patients’ illness Giving his wife’s illness history, R2 Giving history about her son’s unconsciousness, R5 Giving history of his father with stroke, R6 Feeling tired from taking care of his father with stroke, R6 Experiencing her father being readmitted every 1-2 months from respiratory infection, R11 Experiencing her father had constipation from being fed with hospital food Giving history about her husband with stroke, R13 Caring for GBS’s mother, R12 Giving a history, R14 Trying to think of the cause of cancer, R14 Facing psychosocial problems Living with suffering, P6 Having DM is having suffering, P7 Facing suffering before getting sick-being more patient when getting sick-multiple suffering, P7 Worrying about the tumour, P6 Experiencing uncertainty of life, P4 Living with uncertainty, P6 Experiencing sadness and loneliness, P6 Feeling sad and petulant about receiving late treatments, P6 Experiencing loss of husband, daughter and brother from AIDS, P9 Experiencing negative images of AIDS, P9 Experiencing living with fear, P9 Having a weak mind, P11 Losing my mind, P6 Having suicidal ideas, P6 Having suicidal ideas from boredom, P11 Facing psychosocial problems Experiencing shock, R1 Experiencing fear of unsafe ventilator care, R1 Perceiving his wife cannot recover, R2 Feeling sorry to be unable to help his wife, R2 Perceiving mother’s severe suffering, R3 Needing willpower, R3 Perceiving her father has severe illness, R4 Facing knowledge deficit Needing to improve advanced assessment skill and spiritual care skills Caring for spiritual pain and distress including communication and relationship problems Having conflict Feeling guilt Having attachments (see detail in applying Dhamma/personal/local wisdom and traditional healing, and acting with compassion) Perceiving her father does not fear death but he fears pain, R4 Feeling it is hard to care for a fussy father, R6 Not wanting to lose her beloved father, R9 Worrying about the progress of her fathers’ cancer, R9 Experiencing stress while caring for her mother in the beginning of her illness, R10 Perceiving difficulty in taking care of her mother who uses a feeding tube, R10 17 Nurses Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients Preferring a private life, P11 Living with relatives after parents divorced, P11 Worrying the illness will affect his work, P3 Regretting inability to support family, P6 Core category 1: Facing suffering and understanding the nature of suffering Feeling hesitant to depend on others Worrying and feeling hesitant while depending on brother and mother, P2 Feeling hesitant to bother brother when often readmitting, P2 Feeling hesitant to ask help from nurses, P2 Feeling ashamed to nurses and doctors from being often readmitted, P2 Depending on brother/others Waiting for help from brother while admitting, P2 Non-expecting support from other relatives, P2 Depending on brothers decisions about health care and further treatments, P2 Facing economic problems Having economic problems, P2 Perceiving effects of poverty on poor health care, P2 Expressing financial difficulties, P6 Facing financial problems, P6 Facing spiritual pain and distress including communication and relationship problems Having conflict Experiencing nurses have conflict with some relatives who don’t want to care for patients while patients are admitted, N9 Feeling guilt Feeling guilt when helping patients to make a decision to refuse aggressive treatments, N3 Experiencing guilt while being an unskilled nurse, N8 Experiencing guilt, N17 Having attachments Experiencing patients and relatives have attachment with the critical care nurses, N5 Having subconscious connection with and dreams about patient, N5 Having attachment with patients when nurses have too much understanding and cross professional boundaries, N5 Facing spiritual pain and distress including communication and relationship problems Perceiving nurses lack of communication with patients Experiencing nurses focus more on routine care and lack of communication with patients, P2 Having no power Realizing the limitation of asking for good care while using the health care card, P2 16 Relatives Experiencing frustration and tiredness from caring for her father for many years, R11 Feeling release and have more personal life when her father is admitted to the hospital, R11 Dealing with many kinds of parents’ caregivers, R11 Experiencing being unready to take paralysis father back home because of having no co-caregiver, R11 Experiencing loss of one daughter from AIDS and caring for son with AIDS, R16 Not wanting to know bad news, R8 Feeling stressed in forcing husband to eat, R14 Not being permitted to stay overnight, R14 Upsetting her husband, R14 Recounting relatives who passed away from blood cancer, R14 Perceiving husband’s deteriorating condition, R14 Perceiving difficulties at home maintaining working and caring for her husband, R14 Experiencing siblings’ lack of concern and support, R8 Facing economic problems (see detail in coding about receiving financial support from relatives and friends) Knowledge deficit Having no experience of helping patients who cannot breathe, R2 Health care system problems Waiting for a hospital bed, R14 Taking her husband to see the doctor at other hospitals, R14 Travelling to see the specialist doctors, R14 Facing spiritual pain and distress including communication and relationship problems (see detail in experiencing uncaring nurses) Questioning about real causes of illness Questioning about getting renal disease at a young age, P11 2 17 Nurses Core category 1: Facing suffering and understanding the nature of suffering Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients 16 Relatives Understanding the nature of suffering Understanding the nature of suffering Understanding the nature of suffering Suffering with hopelessness (see facing suffering especially facing psychological problems) Suffering with hopelessness (see facing suffering especially facing psychological problems) Suffering with hopelessness (see facing suffering especially facing psychological problems) Suffering with hopefulness Trying to cope (see applying Dhamma and other copings methods) Suffering with hopefulness Trying to cope (see applying Dhamma and other coping methods) Suffering with understanding and accepting the nature of life Understanding/concerning suffering, N1, N2 Understanding patients and relatives (grief and loss, negative reactions and suffering) through the Four Ariyasacca and the Eightfold Path, N17 Understanding self and others, N10 Understanding human emotions, N10 Suffering with understanding and accepting the nature of life Accepting illness and death (see applying Dhamma and other copings methods, and accepting illness and death) Suffering with hopefulness Trying to cope (see applying Dhamma and other coping methods) Suffering with understanding and accepting the nature of life Accepting illness and death (see applying Dhamma and other coping methods, and accepting illness and death) (also see applying Dhamma and other coping methods, and accepting illness and death) 3 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Applying Dhamma (The Buddha teachings) Applying Dhamma (The Buddha teachings) Applying Dhamma (The Buddha teachings) Approaching Dhamma Approaching Dhamma Approaching Dhamma Having Dhamma role models and environments Having mother as a religious role model, N7 Having good monks as Dhamma teachers, N6 Learning chanting and Dhamma from her grandfather, N11 Living in the Dhamma environments, N11 Having religious life styles, N11 Being a non religious person Being a non religious person, P7 Not knowing the relationship between meditation and health, P11 Knowing superficial Dhamma Knowing superficial Dhamma, R5 Having no ideas about the story of kamma, R5 Having no idea how to apply Buddhist practices and teachings, R1 Not being interested in meditation, R1 Valuing/Appreciating Dhamma Perceiving Dhamma people have more kindness, N3 Perceiving benefit of learning Dhamma such as kindness, friendliness, working with mindfulness, and thinking-speakingacting well, N3 Valuing religion, N15 Appreciating Dhamma nurses, N17 Realising benefits of chanting, N5 Believing in good results of doing religious and traditional rituals on better health, N8 Appreciating religious practices, N15 Practising Dhamma (religious rituals) Practising meditation (mindfulness meditation, Vipassana meditation), N1, N2 Experiencing Practising Dhamma, N3, N16 Experiencing Practising Dhamma and being a novice nun, N6 Practising Vipassana with mother to apply Dhamma to solve daily life problems, N6 Reading Dhamma books and Practising meditation, N7 Practising meditation and developing mindfulness skills project for nurses who care for chronic patients, N7 Practising religious rituals, N7 Experiencing Practising Dhamma while studying Bachelor degree in Nursing, N8 Changing from being against Practising Dhamma to enjoy listening to Dhamma teaching, N8 Learning Dhamma by reading Dhamma books Having no interest in the formal styles of learning Dhamma of Vipassana or meditation courses, N12 Experiencing studying in the Sunday Buddhist School when studying in primary school, N12 Experiencing interest in Buddha’s history and appreciating the Buddha’s teachings, N12 Practising Buddhist tradition, N15 Having no experiences in religious practices Having no experiences in religious practices, P2 Discontinuing meditation, P10 Experiencing never Practising formal meditation, P8 Valuing Dhamma Recognising benefits of learning Dhamma, P1 Valuing practising Dhamma without waiting for the result, P13 Appreciating the scientific parts of Buddhism, P13 Valuing Dhamma and meditation, P4 Recognising the generosity of the Buddha, P14 Valuing the real Buddha’s teachings, P14 Valuing religious study and Practising meditation, P4 Using a few Dhamma/Learning Dhamma Learning Dhamma while being a monk, P11 Following some precepts, P11 Learning Dhamma, meditation and Buddhist rituals from the ordination, P3 Practising religious rituals, P6 Practising Dhamma (making merit, paying homage to the Buddha image), P6 Living in a religious culture, P1 Being clever in following the Buddha’s teachings, P4 Focusing on Buddha, not buildings, P4 Learning Dhamma from ordination, P4, P10, P14 Learning Dhamma by scrutinising analysing, P14 Having religious teachers and models, P14 Mentioning the heart of Buddha’s teachings, P14 Reading Dhamma books, P8 Learning Dhamma as a self directed learning, P8 Talking with monks to learn Dhamma, P8 Having a developed mind from living in the religious family, P8 Learning Dhamma Reading Dhamma books, R9 Practising religious rituals sometimes, R10 Experiencing Practising Vipassana (mindful) meditation, R11 Perceiving people can learn Dhamma when they go to temples, R11 Learning Dhamma, R12 Practising meditation, R12 Experiencing Practising Vipassana (mindful) meditation, R12 Appreciating religious activities Appreciating meditation to release tension, R1 Appreciating religious activities, R14 Having religious model Appreciating her father practices religious rituals, R9 Appreciating her father’s good deeds, R4 Being taught by her father to be kind and polite to others, R4 Absorbing good Dhamma foundations from parents and in daily life, R11 Being taught from parents to be a kind, patient, self-disciplined and hard working person, R13 4 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Practising Dhamma (religious rituals) (cont.) Experiencing Practising meditation and learning Dhamma for self development while studying nursing, N13 Experiencing deep concentration and peacefulness while Practising meditation, N13 Being thought by nursing teacher about the benefits of meditation in nursing life such as having good concentration to prevent errors while providing nursing care, N13 Experiencing learning Dhamma and Practising meditation chanting and preaching while ordaining, N14 Reading Dhamma books and meditating, N14 Believing in Dhamma/Considering Buddhist philosophy Using Buddhist thinking Using Buddhist thinking, N1 Reflecting/self-awareness Reflecting, practising self reflection N1 Raising awareness, N1 Improving life by reflecting and learning from past deeds, N8 Learning about self awareness and how to control emotions from three months of ordination, N14 Considering the five precepts Considering the five precepts is the heart of Buddha’s teaching for lay people, N9 Suffering/the Four Ariyasacca and the Eightfold Path Understanding/concerning suffering, N1, N2 Applying the Four Ariyasacca and the Eightfold Path Understanding patients and relatives (grief and loss, negative reactions and suffering) through the Four Ariyasacca and the Eightfold Path, N17 Understanding grief and loss processes, N2 Realising the nature of disappointment in human being, N8 Understanding self and others, N10 Understanding human emotions, N10 Understanding the nature of human beings, N12 Believing in Dhamma/considering Buddhist philosophy Perceiving Dhamma is duty Doing human duties completely, P13 Spending the rest if life to learning Dhamma and travelling, P13 Believing in kamma Doing good deeds/meeting good people, P1 Believing the result of bad kamma-relating cheating others to having troubles in life such as an accident and premature death, P7 Illness (DM) is not relating to kamma or fortune, P7 Having health problems because of having improper eating behaviours, P7 Doing good deeds day by day-believing in kamma, P8 Expecting not to reborn after doing good kamma, P8 Living with merit and good kamma, P8 Believing in good results from making merit, P6 Believing in kamma, P9 Relating illness with the effect of past kamma, P9 Believing the teaching about kamma-trying to do some more good deeds, P11 Wondering about results of doing good deeds Wondering about results of good deeds, P6 Believing in Dhamma/Considering Buddhist philosophy Believing in kamma and merit Perceiving mother’s beliefs in illness due to kamma, R3 Perceiving belief in kamma, R12 Realising her husband needs to make merit while hospitalised, R14 Missing a chance to make merit, R14 Believing in kamma, R9 Valuing doing good deeds, having good words and not hurting other’s feelings, R9 Valuing making merit, R9 Perceiving his father believes in Boon (merit), R4 Believing we can gain merit from taking care of parents, R10 Believing in the circle of birth and rebirth, the law of kamma, R10 Believing that she has to repay her gratitude for her father in this life because of the result of her past kamma, R11 Relating her children’s illness to past kamma, R15 Believing her granddaughter was born to repay her past kamma and she will die, R15 Believing her granddaughter had the highest meritorious act by dying when she was so young, passing away in the young age is not about her sin, but her virtue, R15 Understanding that people are individual and different because of their past kamma, R15 Believing in good results of merit making, R16 Believing in kamma and the next life, R16 Relating her son’s illness to his previous bad kamma, R16 5 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Suffering/the Four Ariyasacca and the Eightfold Path (cont.) Realising all the teachings of Buddhist religious are about reality, the truth of suffering and ways to overcome it, N12 Realising the reality of the Buddha’s teaching about the Four Noble Truths , N12 Applying the Buddhist view to solve problems at the mind level, N12 Experiencing severe suffering from losing her loved mother, N12 Realising 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, N12 Realising the value of accepting suffering and letting things go, N12 Believing people are suffering because of their own kamma, N12 Believing that maintaining doing good kamma and avoiding doing bad things are ways to have less suffering, N12 The natural truth of life/equanimity/the Middle Way Accepting the natural truth of life, N1 Learning about beautiful parts of human beings and the truth of nature from reading and Practising Dhamma, N6 Considering the natural law of birth, old age, sickness and death when care for dying patients, N7 Realising the Buddha’s teaching about the nature of illness and life, N9 Accepting individual difference 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 being not self, N7 Considering the life cycle, N10 Considering the nature of death, N10 Understanding impermanence, N10 Using equanimity, N1 Walking in the Middle Way while working, N14 Considering the Middle Way, N15 Living with believing in the teaching about the Middle Way, N8 Considering the Middle Way principle to deal with busy shiftsaccepting standard care while have no time to do perfect care, N8 Being non-attached, N15 Believing that birth, old age, sickness and death are natural phenomena, N12 Knowing history, causes of suffering, the truth of nature and life, emptiness, elements of body, kamma, the mind, Metta, respect for others Recognising the unselfish purpose of merit making, P1 Understanding the history of Buddhism, P14 Understanding the causes of suffering, P14 Understanding the essence of the Buddha’s teaching about the truth of nature, emptiness, kamma, the mind, Metta, respecting others, P14 Explaining the mind matter from the Buddhist view, P14 Realizing the truth of life, P14 Considering elements of the body while meditating, P14 Believing in kamma, impermanence, right understanding and equanimity Describing kamma, impermanence, right understanding and equanimity, P1 Appreciating present good acts more than expecting a better reincarnation, P4 Birth, duties, making merit and sin Explaining birth, duties, making merit and sin, P4 Believing in merit/kamma on health Believing in effect of past kamma on health, P1 Relating long life and good health to kamma, P4 Relating the recover from illness with merit and luck, P12 Believing in the effect of merit on health, P10 Believing the bad effect on health of bad kamma (crookedness) such as getting sick and having accidents, P7 Relating severe illness to previous bad kamma, P6 Doing more good deeds and living longer, having good chances such as receiving free anti-HIV drugs, P9 16 Relatives Believing in the power of mind Realising when our mind is strong our body becomes healthier, R15 Understanding the mind’s function Understanding the mind’s function in detachment, R12 Considering the teaching about changing Realising that everything is always changing, Aniccata, everything is Dukkhata, nothing is true happiness, R11 Considering the teaching about nothingness Considering the teaching about nothingness, nothing absolutely belongs to us, in order to become peaceful, R11 Considering the teaching about suffering Looking at sickness, suffering, and death more positively after considering the Buddha’s teaching, R11 Believing in reincarnation Believing in the next life, R11 Preferring natural healing Perceiving preference for natural healing, R12 Believing in the power of mind Believing in will power and moral support, P1 Believing in positive effects of meditation, P1 Believing in the healing power of the mind, P1 Having a healthy mind, P1 Understanding/considering impermanence Believing in the impermanence of life, P4 6 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing The natural truth of life/equanimity/the Middle Way (cont.) Accepting illness and death are natural phenomena, N12 Letting things go, doing good kamma, being flexible, and respectful Applying Buddha’s teachings about letting things go, doing good kamma, being flexible, and respecting all human beings in daily life, N6 Kamma, merit and sin, good deeds and bad deeds Realising the law of kamma, N2 Believing in kamma, N15 Believing in kamma, N4, N5, N7 Seeing the connection of doing good deeds for patients to receive good care in the future, N4 Perceiving the belief about kamma and traditional healing on Thai people influence patients’ self care, N7 Perceiving kind-hearted, sympathy and trying to do good Kamma is a basic of Thai people and colleagues, N8 Believing in good results of good kamma, N9 Believing in heaven and hell, do good get good, do bad get bad, and the next life, N11 Considering patient’s belief about kamma, N17 Believing that nurses can do both merit and sin, N12 Believing that sources of merit and sin all come from our own thinking, speech and actions, N12 Believing in kamma, N14 Living and working with doing good deeds, N14 Perceiving many ways to make merit, N6 Believing in kamma -giving up from all bad deeds, N16 Believing in good effects of doing good deeds, bad effects of doing bad deeds, N16 Valuing the Dhamma principle about doing good deeds, N16 Reaching a stage of making merit while working and living, N16 Intending to help others–making merit while working, N16 Applying Dhamma teaching to help others, N16 16 Relatives Understanding/considering the impermanence (cont.) Considering the impermanence of a physical body, P4 Understanding the impermanence of life and a virtuous life, P8 Recognising the teaching about changing Realising about the teaching about changing, P13 Considering nothingness Considering nothingness, P4 Relating illness and death to Dhamma Relating illness and death to Dhamma, P1 Believing in dying before death Believing the teaching about dying before death, P14 The power of mind Believing in the power of mind to control pain and feelings, N5 Believing in the power of mind, N10, N14, N16 Valuing mind development, N16 Using right effort Following the Buddha’s teaching about using right effort with aspiration is the path of accomplishment, N14 7 17 Nurses Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients 16 Relatives Valuing peacefulness Having life’s motto from the Buddha’s teaching that is “no other utmost happiness except peacefulness”, N12 Believing that all happiness and sadness is caused by our own state of mind, N12 The four Iddhipada Following the teaching about the four Iddhipada, N4 Applying teaching about the Four Brahmavihara including Metta into nursing care, N11 Metta, Upekkha and Loka-Dhamma Using Metta, Upekkha and Loka-Dhamma principles, N2 Linking the teaching to quality management Linking the teaching about to working process of quality management, N5 Learning about patience and peace Learning about patience and peaceful state while ordaining, N14 Performing/Practising Dhamma Performing/Practising Dhamma Performing/Practising Dhamma Applying Dhamma in daily life Practising Buddhist rituals in daily life/*to cope with illness Practising Buddhist rituals in daily life/)*to cope with illness Practising Dhamma in every duty Applying Dhamma teaching in daily life, N16 Practising Dhamma in every duty, N16 Preferring Practising Dhamma in daily life, N16 Valuing good heart Valuing on good heart, N6 Practising Buddhist rituals in daily life Performing religious rituals, P1, P4, P5 Experiencing ordination as a nun, P1 Seeking spiritual perfection, P1 Performing rituals at the temples, P3 Being generous, kind, and grateful Being taught ideas about being generous, kind, and grateful, N11 Holding precepts Following the precepts, P10 Following the ancestors’ beliefs and rituals about basic precepts and merit making, P3 Open mind Learning about the world with open mind is the Buddhist way of living, N6 Doing good deeds Living for doing good deeds, P10 *Giving up misbehaviours, P10 Listening Learning about having a cool mind to listen to others from family and school, N5 Preferring a simple life Valuing a simple virtuous life more than money, P4 Coping with life changes by preferring a simple life, P4 Living a simple life, P10 Practising Buddhist rituals Practising Buddhist and traditional rituals, R1 Practising religious rituals by making merit, respecting Luang Pho Tuad’s (the sacred monk) image and chanting the Chinabanchorn scriptures, R13 Sleeping well after chanting, R13 Practising religious rituals by chanting before sleep, going to make merit at the temple, meditating, R15 Practising religious rituals such as making merit on some occasions by offering food to the monks and asking for blessing and donating money, R16 Dealing with life situations with spiritual practices, R12 Controlling emotions Controlling emotions while mother is in crisis, R12 Having a strong mind, R12 Setting suitable life goals/living in the present Having life goals to have the peaceful state of mind, doing good deeds, not doing bad deeds, and 8 17 Nurses Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients Respecting Respecting all human beings, N16 Preferring a simple life (cont.) Setting simple life goals, P10, P14 Understanding others Learning about understanding others from family and school, N5 Taking care of the mind *Taking care of the mind while getting sick, P14 Self discipline Learning about self discipline from family and school, N5 Patience Being patient, N15 Working hard Working hard, N10 Killing craving Using Dhamma as a way to kill her craving, N6 Being kind and forgiving Dealing with conflict in the family with the teaching about love, kindness, understanding and forgiveness, N6 Healing a broken heart Healing a broken heart by realising the kindness of the Buddha, N6 Accepting a broken heart after considering the Dhamma teachings about cause of suffering, N8 Living in the present moment Dealing with life events by focusing on the present moment, N6 Chanting and radiating merit Chanting and transferring merit to other beings every night, N5 Dealing with life stress by chanting, N5 Learning about chanting from family and school, N5 Chanting when feeling worried, N8 Chanting and radiating merit to others before sleep, N11 Doing chanting when having nightmares, N11 Preferring chanting more than meditation, N11 Meditating Using breathing meditation to control headache and period pain, N7 Applying meditation Releasing tension from working by concentrating on breathing, P1 Using concentration techniques, P1 *Controlling pain by meditation, P1 *Controlling incontinence by using concentration techniques, P1 Doing meditation before sleeping, P1 Using different ways of meditation, P1 Teaching meditation and religion, P1 Applying meditation principles to calm the mind, P1 Dealing with problems with mindfulness, P1 *Letting go of worry as no self, P1 *Raising mindfulness for hardship and health problems, P4 *Realising the relationship between meditation and health, P10 Living with consciousness, P14 Practising meditation and considering the teaching of Buddha, P14 Gaining benefits from Practising meditation, P14 Relating the success and failure of meditation with past kamma, P14 Practising meditation, P10 Understanding meditation and Dhamma from reading, P13 Applying meditation technique to daily activities such as exercise and singing, P13 *Applying meditation technique to control pain and to rehabilitate after the heart by-pass operation, P13 *Doing breathing meditation, P13 Controlling emotion *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 isn’t sick, having an unconditioned mind) , P8 16 Relatives being happy with the present moment, R11 Living in a simple way Living in a simple way, R2 Having a simple and happy life, R6 Feeling satisfied in his life, R6 Living carefully Living carefully, R6 Depending on self Having no need to ask for help from his children and other relatives, R6 Working hard Getting used to a hard work, R6 Maintaining his job while providing the best care for his stroke father at home, R6 Respecting the Buddha and the monks’ images Respecting the Buddha and the monks’ images, R14 *Bringing an amulet to hospital for protection, R14 Trying to relax, R14 Thinking of the Buddha *Reminding mother to think of the Buddha, R8 Practising Buddhist rituals and Chinese traditions Doing Buddhist rituals and Chinese traditions, R5 Practising religious and Chinese traditional rituals, R6 Making merit Experiencing relatives making merit, R3 *Making merit for her father, R4 Making merit, R4 *Thinking of the Buddha, R4 *Experiencing her father asking for good luck by thinking of the sacred monks *Making merit for her unconscious son, R5 *Telling her son “We already made special merit for you”, R5 *Planning to make merit for his father, R6 9 17 Nurses Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients Thinking of practising meditation in order to apply it to help AIDS patients, N13 Making merit Making merit, N10 Making merit when having nightmares, N13 Radiating loving-kindness to ghosts/all creatures/trouble makers Making merit and radiate merit to ghosts and all creatures, N11 Dealing with a debtor by radiating loving-kindness to them, and asking for their luck and wealth, N16 Letting thing go Learning to let thing go and not attach to bad feelings, N11 Giving forgiveness Giving forgiveness and radiating merit to trouble makers, N11 Raising sacred power before working Respecting the Buddha image and asking for power before starting work, N11 Asking for a protection Asking for a protection before driving from the Buddha’s and monks’ amulets and reciting a sacred scripture, N11 Repaying gratitude Repaying gratitude, N10, N15 Accepting death/preparing for good death, N10 Being taught ideas about repayment, N11 Having life purpose to repay gratitude for patients by ordaining and graduating Bachelor degree, N14 Realising the gratitude of parents, N16 Respecting the older person Being taught ideas about respecting the older person, N11 Respecting elder people is a norm of Thai people, N14 Respecting beings Respecting everything being and non-being, N11 Preferring natural way of healing, N10 *Controlling self by setting mindfulness and keeping calm while having the heart attack, P8 *Doing deep breathing while having a heart attack, P8 Controlling behaviour by ordaining Thinking of being re-ordained to better control drinking and smoking, P11 Being kind Being kind to ourself and others, P8 Sharing proper world view and better choices to others, P8 Praying for others, even for robbers, P8 Feeling sympathy Feeling sympathy for others, P8 Having an open mind Opening the mind to learn other religions, P8 Being awareness Having self awareness, P8 Using Dhamma to deal with life’s situations Answering life problems from the Dhamma view, P8 Using wisdom and mindfulness to deal with life’s situations, P8 Applying the Buddhist healing with self care *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), P8 Believing in the sacredness of the Buddha’s relic Believing in the sacredness of the Buddha’s relic, P8 Gaining mindfulness from meditating Understanding benefits of Practising meditation: (keeping one's manners, speech, and thoughts under control, having concentration), P8 Living with Dhamma, living with mindfulness, P8 Experiencing peacefulness from having mindfulness, P8 16 Relatives *Making merit for mother and her deceased father to relay her gratitude, R10 *Making merit for sick mother and dead father, R8 Perceiving her mother loves to make merit, R10 *Appreciating her mother’s good deeds, R10 Making merit by helping other people, R15 *Making merit to deceased children and granddaughter, R15 Perceiving helping others is a meritorious job, R15 Believing her daughter is healthy because she had done a lot of meritorious things, R15 *Making more merit to repay all of her previous bad kamma, R15 Making merit and passing merit to everybody in my family, R15 Being good to other people because of believing in good effects of meritorious acts, R15 Being taught by the monk to make merit to deceased relatives to help them go to a better place, R15 Avoiding/bad deeds or sin Reminding her son not to get sin by spreading this disease to others, R16 Experiencing her son decided to be ordained because he wants to give up drugs, R16 Making holy water *Asking the monk to make holy water, R1 Making and repaying a vow *Appreciating her mother makes a vow and asks for her father’s good health, R4 Chanting and reading Dhamma books *Reminding mother to do short chanting to relax, R3 *Chanting short scriptures in her son’s ear every time she visits, R5 *Praying and chanting for her unconscious son’s recovery, R5 *Reminding her unconscious son to keep chanting, R5 Chanting and reading Dhamma books to feel peace, be less tired, strengthen her heart and understand everybody’s life, R11 *Chanting the Chinabanchorn scriptures to be calm after having nightmares, R13 10 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Preferring a simple life Preferring a simple life and thinking about “give more than I get”, N11 Having a simple life, N10 Appreciating peacefully death Appreciating peaceful death of her grandma surrounded by relatives and monks who perform Buddhist rituals for her at home, N11 Applying Dhamma to nursing care Considering patients’ religious backgrounds Considering patients’ religious backgrounds, N2 Perceiving elderly patients practise religious rituals more than other ages, N7 Understanding different interest in Dhamma Experiencing some AIDS patients read Dhamma books while others are not interested in using Dhamma to cope with illness, N13 Understanding patients’ kamma Experiencing patients relate causes of their illnesses with previous bad kamma, N11 Relating illness to merit and result of past kamma, N16 Setting the right mind Setting the right mind to prevent a boredom of being a nurse, N9 Making merit while working Dealing with hard work by thinking of making merit when helping patients, N11 Caring with Metta-Karuna Applying nurses’ understanding on the heart of Buddhism such as Tilakkhana into nursing through caring with Metta and Karuna, N7 (see detail at the third core categories) Avoiding sin/making ethical decision/providing ethical care Concerning getting sin if nurses take of unconscious patients’ breathing tube before relatives take patient back home, N7 Finding ethical and proper ways to let relatives take unconscious patients back home, N7 Respecting beings and non beings Respecting the sacred monks, water and land, and all of the creators, P8 Respecting others’ reasons-accepting individual difference, P8 Learning to respect every person equally, P10 Respecting the monks *Respecting the statue of the sacred monk-pray for wounded healing, P7 Respecting the sacred monks at her province, P7 Support the monks’ activities Support the monks’ activities, P3 Making merit Joining neighbours’ ceremonies, P3 Making merit regularly, P3 Sending merit to family members, P6 *Requesting merit, P6 *Repaying all past kamma by making more merit, P6 *Wanting to make merit, P6 Making merit in some days, P7 Having connection with passed away daughter by feeling, P9 *Making and radiating merit to passed away daughter and ancestors, P9 *Collecting merit with Mum, P9 Making merit, P1, P5, P10 *Completing duties to make merit, P4 Making merit by repaying with gratitude, P4 Making merit by suitable donation, P4 Making merit by helping temple’s activities and helping others, P4 Radiating merit to parents and beings, P10 Receiving merit Receiving merit from daughter, P2 Receiving merit from his wife, P12 16 Relatives Chanting the Vessondon incantation to be protected from any bad luck, R13 Experiencing chanting, R12Chanting and radiating merit, R14 *Chanting to be calm, R14 Listening to Dhamma Experiencing listening to some Dhamma cassettes, R5 *Listening to Dhamma cassettes with her father for accepting illness and death, R11 Listening to Dhamma and chanting cassettes, R12 *Trying to be calm after listening to Dhamma preaching, R14 *Blessing Planning to organise a big chanting ceremony if her son recovers, R5 Making a wish that if her son could be healed she would ask him to ordain again, R5 Asking for a protection from the Kuan Im goddess for her unconscious son Respecting and asking for good luck from monks’ amulets, a small image of Buddha, gods and goddesses, R5 Planning to invite a monk to bless her son in the ward, R5 Planning to invite the monk to bless her father in his dying period, R9 Experiencing patients can have good death when they are blessed by the monks, R9 Inviting the monk to bless her sick mother at home, R10 Inviting the monk to bless her sick children and granddaughter, R15 Inviting the monk to bless mother weekly, R8 *Applying meditation Experiencing being peaceful after Practising meditation, R9 Practising a walking meditation to be calm and release stress, R11 Perceiving the benefit of meditation and Buddha Dhamma in dealing with every situation with mindfulness, having less anxiety and accepting the reality, R11 Applying mindful meditation, R12 Asking for forgiveness *Asking for forgiveness and help from spiritual sources, P6 11 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Making ethical decision by considering the teaching about kamma, N16 Applying Dhamma for psycho-spiritual care Applying healing techniques and Dhamma, N1 Applying Dhamma for psycho-spiritual care, N2 Applying Buddhist philosophy to nursing care about impermanence/the truth of life/kamma. N3 Being taught to apply Buddhist ways about The Four Noble Truth principles to reduce suffering while studying short course in nursing care for chronic illness, N7 Overcoming patient’s and relatives’ suffering, N1 Reminding the truth of life Accepting the truth of life about birth, old age, sickness, and death while caring for the terminally ill patients, N14 Recommending nurses remind relatives about the truth of life while providing supportive care for incurable patients, N14 Reminding patients to consider the Buddha’s teaching about impermanence Modifying the teaching about the truth of life to remind patients to accept their illness, N3 Applying Buddha’s teachings about natural law into spiritual care, N6 Applying the teaching about the nature of illness and life to remind AIDS patients Helping patients to accept their real situations, N9 Teaching the truth of life, N2 Teaching good deeds Applying the teaching about doing good deeds to help people in the community, N16 Focusing on repaying gratitude Reminding people in the community to do their best for relaying gratitude to parents, N16 Promoting religious rituals Encouraging relatives to do religious rituals for dying patients in order to help them die peacefully with dignity, N14 Promoting patients to maintain their religious rituals while staying in the hospital such as making more merit, reading Dhamma books, listening to Dhamma teachings, N3 Encouraging patients to do rituals to follow their beliefs, N6 Performing Buddhist rituals, N17 Forgiving/giving forgiveness Giving forgiveness to cheated friends, P7 *Forgiving others, P10 Chanting Chanting, P1, P5 *Chanting to promote good sleep, P4 *Reducing cardiac symptoms by raising mindfulness and chanting, P4 Explaining the profound reasons of chanting from a Buddhist perspective, P13 Doing chanting before sleep, P6 *Controlling worry by chanting, P6 Asking for the big alphabet of chanting books, P6 Chanting while driving, swimming, P8 Reciting an incantation *Reciting an incantation for wound healing, P4 *Praying and vowing Praying for good health, P6 Praying for son’s good luck, P6 Asking for the Buddha’s protection, P6 Taking refuge in sacred things, P6 Making a vow for good health, P6 Repaying the vow by ordaining Accepting the ordination for repaying the vow, not to be enlisted as a solder in Thai Army, P11 Repaying gratitude *Repaying gratitude to mother, P6 Thinking of relaying Mum’s gratitude, P7 *Helping others and repaying gratitude to parents lead to having longer live, P9 Having no dept to repay-keeping on helping others, P9 Experiencing the ordination for relaying gratitude for parents, P13 Accepting the ordination for repaying gratitude to parents and relatives, P11 Valuing authentic purposes of the ordination, P11 16 Relatives Reminding mother to do sleeping meditation, R12 Experiencing mindful movements during physiotherapy, R12 Recognising the value of meditation, R12 Doing loving kindness meditation, R12 Applying meditation for calmness, R12 Healing oneself by meditation and other healing methods, R12 Radiating merit *Radiating merit to her sick father after meditation, R11 Radiating merit to her husband and everyone in her family, R13 Repaying gratitude *Repaying gratitude to her husband by staying close to him, touching and massaging, and cooking healthy food for him, R13 Experiencing ordination to repay gratitude, R1 Believing people can gain merit from repaying gratitude to parents, R8 Repaying gratitude, R12 Thinking of receiving gratitude Expecting his children will take care of him the same as he does for his father, R6 Forgiving *Experiencing relatives asking for forgiveness, R3 Letting things go *Learning about letting things go to gain happiness and equanimity, R10 Donating Donating a coffin to another person, R6 Accepting illness and death Accepting illness is a normal event of old people, R7 *Accepting the possibility of losing his wife, R2 Understanding the nature of suffering which may go away some day, R2 Accepting illness and death *Accepting illness, P6 Accepting the destiny of life, P6 Accepting illness-Plong, P9 12 17 Nurses Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients Providing the Buddha statue in the ward Having the Buddha statue in the ward, N7 Promoting/teaching chanting Encouraging patients to do chanting before sleeping, N7 Promoting patients do chanting before sleeping, N7 Teaching patients who can’t sleep to recite the radiate merit scripture, N11 Promoting listening to Dhamma Supporting patients to listen to Dhamma teaching, N4 Promoting merit making Experiencing relatives make merit for patients, N7 Valuing living with present more than expecting the result of making merit in the future, N7 Teaching/applying meditation Teaching patients to do meditation, N7 Teaching patients who have meditation experience to do breathing meditation, N7 Applying meditation techniques to teach non religious patients without using religious words, N7 Promoting relatives to do traditional and religious rituals following their beliefs for severely ill patients, N8 Applying mindfulness, N1 Applying the teaching about mindfulness, N1 Adapting meditation techniques, N1 Teaching breathing meditation, N2 Meditation to hard work, N10 Controlling pain with meditation, N10 Applying music and meditation for releasing patients’ tension while they feel pain Applying the breathing meditation to teach elderly chronic patients to relax themselves, N11 Introducing patient to breathing meditation to control post operative tension, N14 Perceiving doing meditation is not the main choice to control post operative pain, N14 Applying meditation: the eating air technique to teach AIDS and cancer patients, N16 Accepting illness and death (cont.) *Accepting the truth of life: influences of Buddhist beliefs about illness and death, P9 Feeling better after accepting illness, P9 *Accepting illness and death because of having no other choices to manage illness, P2 Accepting illness, P7 Accepting illness even though it is hard to accept, P7 Accepting death, P7 *Accepting death, letting it go, P8 *Reminding daughter to be calm and accept her death, P8 Accepting illness and death, P9 Understanding illness and death, P8 *Accepting death by collecting and preparing virtues, P1 *Approaching a good death with mindfulness, P1 *Being ready to die because of the Four Noble Truths, P1 Accepting illness, P4 Accepting death, P4 Being ready to die, P4 Non-resisting death, P4 *Having no fear of death, P4 *Explaining good death as finishing retribution, P4 Accepting illness, P5 Accepting death, P5 Accepting illness and death, P5 Causing his own illness, P10 Accepting illness, P10 *Not wanting others to suffer, P10 Planning death, P10 *Accepting illness and death by considering the nature of life, P14 Accepting illness, P13 Accepting death, P13 *Believing death is a way to go to the deliverance state, P13 Transforming death thoughts *Overcoming suicidal ideas, P10 Transforming death thoughts, P10 *Transforming mind through Dhamma learning, P10 Donating the body *Making merit by donating her body, P8 16 Relatives Accepting illness and death (cont.) *Perceiving her father’s religious background helps him to accept illness and death, R4 *Planning a coffin for his father, R6 *Planning to let his father die in the hospital in order to receive good care, R6 Perceiving her father plans to die at home, R9 *Perceiving her father can accept death and already prepares for his funeral ceremony, R9 *Experiencing patients can have a good death when they die among relatives, R9 Accepting death is a normal event, R11 Accepting and understanding people living with HIV/AIDS, R15 *Accepting death by reminding herself that everyone cannot avoid dying, R15 People who don’t get HIV disease will also die, R15 Accepting her own illness, R16 *Preparing her mind to lose another child from AIDS, R16 *Preparing her mind to accept as if her son died, R16 Preparing her mind to accept losing her son, R16 Accepting the possibility of mother’s death, R12 Helping others *Applying a caring experience to support other patients’ minds, R9 *Sharing good and bad times with other relatives, R1 *Donating blood for other patients, R1 *Being a ward’s volunteer, R1 Applying the Buddhist way of thinking and basic meditation to advise people who had sleeping problems, R11 Being a public health volunteer, R15 Thinking of helping others, R15 *Sharing her experiences with people in the communities to raise their understanding of AIDS patients, R15 *Sharing the same feeling with relatives of other HIV infected patients, R15 Wishing everybody in the family has a better life, R15 Talking about religious and traditional beliefs and practices Talking with patients about their religious and traditional beliefs and practices, N11 Applying statements of life from Dhamma books, N1 13 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Using a metaphorical story, N2 Setting tradition ceremony Setting tradition ceremony activates such as Songkran Day and New Year in the ward, N14 Reminding some patients to make merit Reminding some patients to make merit with the monk for happiness, N11 Making merit makes patients feel happy, N11 Experiencing patients respect the Buddha image and make merit by donating money and Dhamma and other books to the hospital, N14 Praying/making merit for patients Transmitting loving kindness and vowing for patients, N1 Making merit for patients, N1 Praying for patients, N10 Thinking of good deeds Reminding patients to think of their good deeds, N10 Asking for forgiveness Asking for forgiveness, N17 Accepting death of patients Guiding patient to accept illness and death, N2 Considering the nature of death and letting things to go when having emotion with passed away patients, N11 Appreciating a peaceful death, N15 Researching Researching, N17 Being a research team member trying to provide more psycho-spiritual support for patients, N11 Building spiritual care team work Building team work, N17 Consulting monks Consulting monks, N17 16 Relatives Helping others Helping others, P1 Keeping oneself well before helping others, P1 Being a good listener when helping others, P1 Helping others without expecting any thing in return, P1 Helping the monks and temples’ activities, P1 *Performing death rituals for terminally ill persons at home, P4 *Reminding patients to accept illness, P4 Reminding the terminally ill patients not to resist death, P4 Making merit by helping others, P9 *Maintaining helping infected friends-being a volunteer, supporting friends, P9 Staying in touch with infected friends-support each other, P9 *Devoting self to helping others-helping HIV/AIDS people, P9 Devoting self to help other suffering people, P9 Raising awareness and building true understanding about AIDS, P9 *Sharing experiences of living with HIV/AIDS to health care staff, P9 Helping others, letting infected friends call to consult her at home, P9 Maintaining activity about AIDS, P9 *Being a good model for other patients, P10 Wanting to help father, P10 Helping other creatures, P10 Helping others by not to expecting any return, P10 *Volunteering to support other patients, P14 *Applying healing experiences to help other patients, P14 *Applying meditation experiences to help other patients, P14 *Reminding others to deal with problems by settling mindfulness, P14 Sharing sympathy with friends *Sharing the same feeling with infected friends, P9 *Sharing stories with infected friends-helping others, P9 Having sympathy while being a counsellor, P9 *Talking in the same language-having no gap in between relationship, P9 Sharing caring experiences Sharing caring experiences, N1 14 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Performing death rituals/applying Dhamma to care for death and dying Helping death and dying Applying Buddhist rituals to perform for sudden death patients, N5 Performing death rituals in the proper place such as at the post mortem room, N5 Performing patient’s dead rituals following their tradition, N5 Helping patients to be calm and have a good death, N5 Helping patients to die peacefully, N1 Applying Buddhist beliefs to care for late stage Thai Buddhist patients, N15 Supporting patients for a peaceful death, N10 Reminding a patient to think of the Buddha in dying stage, N6 Applying the teaching about the truth of life to support relatives of dying patients, N6 Thinking of a patient’s good qualities and paying respect to a dying patient, N6 Using a patient-centred approach Using a patient-centred approach, N2 Perceiving relatives would like elderly patients to die more naturally and refuse aggressive treatments, N8 Trying to support patients’ mind concerning their interesting and religious background, N6 Accessing patients’ religious background Realizing the different level of Dhamma understanding, N2 Respecting patients’ decisions Respecting patients’ decisions, N2 Respecting patients’ decisions, N15 Preparing happy environment, N2 Building a fun environment, N2 Making proper and ethical decisions Judging sin or no sin, N17 Making proper and ethical decisions for terminally ill patients, N17 Rethinking about prolonging a patient’s life with technology, N17 Providing tender loving care and comfort Providing tender loving care and comfort, N2 15 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Relieving pain Realising nurses are concerned about terminally ill patients in pain, N15 Talking about previous meritorious acts and good kamma Talking about good parts and previous meritorious acts, N2 Reminding patients to think of good deeds, N10 Reminding Dhamma through metaphorical stories Reminding about impermanence of life through a metaphorical story, N2 Planning good rebirth Planning good rebirth, N2 Telling patients not to worry, N10 Telling dying patients not to worry, N10 Asking the spirit of the dead to go to a better place, N10 Reminding relatives to think about the natural law Caring for a relative who has spiritual distress problems by reminding her to think about the natural law, N12 Reminding relatives to do the best to repay gratitude Caring for a relative who has spiritual distress problems by reminding her to use the best chance to repay all gratefulness for patient in a terminal stage, N12 Caring for a relative who has spiritual distress problems by letting her do her best for patient, N12 Providing comfort to terminally patients Caring for terminally patients comfortably, N12 Support relatives’ minds with kindly willingness, N12 Helping relatives who fear of sin Supporting patients who fear of sin by suggesting they do their best to suit their conditions, N12 Helping to die at home properly Helping relatives transferring terminally ill patients near death to die at home ethically and safety when relatives decide to take patient back home, N12 Managing death and dying Supporting relatives when they feel confused and can’t manage their situation in a patient’s final stage, N12 16 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Reminding about religious rituals 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 patients if patients are religious people when patients reach the dying stage, N12 Performing religious rituals Making merit, N2 Making merit for some dying patients, N5 Chanting, N2 Giving Dhamma by listening Dhamma cassettes, N2 Encouraging relatives of terminally ill patients to do rituals to follow their beliefs, N4 Letting relatives of dying patients stay with patients, N7 Introducing relatives to chanting and religious rituals to promote peaceful death for terminally ill patients, N7 Guiding relatives to do death rituals for patient in the dying state, N8 Applying Buddhist rituals such as chanting and transferring merit to patients to help Buddhist patients in terminal stage, N11 Chanting and transferring merit to terminally ill patients Realising the role of nurses in transferring merit and doing religious rituals to terminal patients, N11 Reciting the Buddhist scripture to transfer merit to the dead patients and other beings and telling the corpse to go to a good place, and do not worry about everything that is left behind, N11 Making merit to passed away patients Making merit to passed away patients who have strong relationships with, N11 Thinking of patients’ good qualities Reminding patients to think of their good qualities in the dying moments, N7 Asking for forgiveness Applying Buddhist beliefs to ask for forgiveness, N1 Applying kindness, forgiveness, and religious rituals in death and dying, N1 Observing clues of good/bad death Realising differences in patients’ readiness to die, N10 17 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Accepting death Being strong and accepting reality, N2 Appreciating patients’ peaceful deaths, N2 Using Buddhist teaching to accept sudden death of patients, N15 Making merit for spirits Making merit for the spirits of dead relatives, N10 Expressing good wishes to passed away patients, N8 Dealing with guilt by chanting and transferring merit Chanting and transferring merit to patients when feeling guilty with them, N8 Preparing relatives’ mind to accept death Preparing relatives’ mind to accept uncertainty of accident patients, N5 Preparing relatives’ mind to accept death of young patient, N5 Suggesting relatives to make merit and do death rituals for patient, N5 Supporting relatives to care for dead and dying Informing relatives about patients’ deterioration, N10 Allowing relatives to visit dying patients, N10 Asking relatives to chant for patients, N10 Asking relatives to invite the monks to bless the patient, N10 Avoiding telling relatives about the time of death, N10 Encouraging relatives to prevent guilt in the future, N10 Supporting relatives after patients die Supporting relatives continually after patient died, N5 Appreciating outcomes Appreciating outcomes For patients For relatives Gaining joy/peacefulness and happiness Gaining happiness from walking around the temple and chatting with the monks, P11 Avoiding stress by considering the Buddha’s teaching about nature of illness and death, P11 Valuing peacefulness and happiness in life, P10 Feeling joy after helping others, P1 Feeling peaceful from reading Dhamma book names Bojjhanga, P13 Becoming generous and humble Becoming generous and humble after practising meditation Appreciating outcomes For patients and relatives Realising positive outcomes of reminding relatives to do religious rituals for dying patients, N4 Accepting illness and death Perceiving Thai people accept their destiny easily because of past kamma, N15 Accepting illnesses because of past kamma, N15 Having peaceful death Positive effects after receiving blessing from the monks, N10 Becoming more flexible Becoming more flexible through meditation and healing techniques Being less angry Being less angry and not blaming others after understanding Dhamma, R11 18 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing For nurses Having good head-hand-heart from learning Dhamma Believing if nurses believe in sin, merit, retribution, and the result of kamma and also can give forgiveness easily, they would approach and care for patients with good thoughts, good speech and good manners, respecting every patient and their relatives, N14 Being peaceful Living with peace in mind because of not having a high expectation and letting things go easily, N12 Being awareness Realising the benefit of Practising Vipassana meditation on working with awareness, N10 Understanding the meaning of open listening from learning Dhamma, N3 Gaining more understanding about the nature of cancer patients, N2 Having self control Having concentration and self controlling skills from practising meditation, N1 Learning value of life/understanding nature of life Learning value of life from patients, N6 Learning about life stories from patients, N6 Learning about uncertainty of life from patients, N7 Being mature Having less temper and more peaceful from learning Dhamma, N7 Controlling emotions better from learning Dhamma, N7 Becoming a better person/nurse Changing from inside when Practising meditation, N3 Becoming a better person through meditation, N10 Caring for patients better and being calm while dealing with fussy patients after ordaining, N14 16 Relatives For patients(cont.) Having will power Raising will power to flight with AIDS, P10 For relatives(cont.) Gaining more confidence Gaining more confidence, R12 Fearless Facing cancer without fear, P1 Having more self-understanding Having more self-understanding after understanding Dhamma, R11 Patience Being patient, P5 Having medium levels of emotions Having medium levels of emotions for a harmonious health, P14 Being transformed Being strong, P9 Being transformed from sadness to helping others after meeting the self help group and kind people, P9 Transforming her mind after overcoming suffering, P9 Moving from loneliness to lighter life after telling the truth of illness to others, P9 Accepting gain and lost Accepting when we gain something we can lose something, P7 Experiencing misbehave worker and co-workers, P7 Experiencing a huge lost in one life, P7 Accepting all changing of work and life, P7 Having morality Being more aware about morality, P10 Having a strong mind Having a strong mind after understanding Dhamma, R11 Having less desire Learning to have less desire from Dhamma, R12 Feeling happy Perceiving husband’s happiness in listening to chanting, R14 Meeting kind people Learning good things from kind people in the meditation centres, R12 Setting suitable life goals Setting suitable life goals, R12 Changing behaviours Experiencing her husband ceased smoking after knowing his father in law had lung cancer, R9 Keeping a healthy life style, R9 Understanding others Understanding and accepting difference among individuals, P1 Avoiding making other people sad, P1 Accepting illness and death Feeling better after accepting illness and the destiny of life, P11 (also see detail at applying Dhamma) Being kind and compassion Forming a kind mind from having good friends (Kalyanamit) and reading Dhamma books, N6 Valuing on nurses’ kindness and politeness, N13 19 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Being more gentle Being more gentle after learning about true love from patients, N6 Becoming more gently when nurses practice meditation, N6 Having more social responsibility and avoiding exploiting others if nurses understand Dhamma, N6 Being generosity Learning about generosity from observing Buddhist monks’ lifestyle, N12 Gaining merit Gaining the Bun (merit) from helping patients, N2 Gaining merit from working, N10 Valuing gaining merit, N10 Gaining inner power/positive inspiration Recharging power, N2 Gaining inner power from working hard to help patients, N4 Feeling better from hard work when seeing her life better than some patients, N9 Gaining power to do good nursing care because of receiving gratitude from patients Inspiring new nurses to appreciate patients’ traditional beliefs, N11 Gaining a lot of power to help patients and relatives, from understanding the teaching about suffering and the law of nature, N12 Perceiving trust Perceiving patients usually trust kind nurses, N10 Understanding influences of Dhamma on patients’ life Experiencing patients explain their illness from Dhamma view, N3 Experiencing patients from the village use more Dhamma when they are sick, N3 Respecting patients’ and relatives’ Dhamma beliefs Respecting the difference of patients’ beliefs about kamma, N3 Preventing errors with mindfulness Reducing errors while providing nursing care from having consciousness after Practising meditation, N7 Accepting death/preparing for death Accepting death, N2, Preparing to die, N2 Accepting death-preparing for death, N1 20 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Concerning problems of applying Dhamma Concerning problems of applying Dhamma Concerning problems of applying Dhamma Not concerned about religious/meditation practices Perceiving barriers to learning Dhamma, N17 Having few nurses interested in religious practices, N17 Perceiving nurses not concerned about their religious practices, N5 Realising some nurses aren’t interested in Dhamma, N6 Realising not many people understand Buddha Dhamma, N17 Realising some patients don’t believe in Dhamma, N3 Perceiving limitation of Practising meditation in some nurses, N5 Having no interest in Practising meditation, N5 Experiencing disinterest in Dhamma and meditation, P1 Experiencing constraints against religious practices, P5 Questioning the problems of modernity, P10 Perceiving a back pain was an obstacle for practising meditation, P11 Disconnecting about Practising meditation after leaving the monkhood, P11 Perceiving some Dhamma books aren’t easy to understand, P13 Being concerned about distortion of the Buddha’s teaching, P14 Perceiving differences in understanding in Buddha’s teaching, P14 Perceiving the negative part of monks, P13 Having no ideas how to do religious rituals for patients, R2 Not considering the value of Buddha’s teachings, R12 Realising she can not invite four monks to chant special verses for her son in the ward, R5 Few patients interested in mediation Experiencing few patient do meditation while admitted, N11 Nurses don’t believe in traditional beliefs Perceiving some nurses do not believe in traditional beliefs, N11 Having no idea to apply Dhamma with patients Having no idea to introduce patients to read Dhamma books or doing religious rituals, N13 Facing dilemma to terminal patients’ life Experiencing relatives would like to take a patient in the terminal stage back home, N11 Supporting patient’s need when they want to die at home, N11 Difference level of Dhamma interest/understanding Perceiving patients have different levels of Dhamma understanding, N7 Perceiving not being a religious person, N9 Perceiving little Buddhist knowledge and practice, N17 Coming to appreciate Buddhist teaching, N17 Using little religion when caring for patients, N17 Having no interest in practising meditation, N17 Perceiving teenagers are not interested in meditation while patients who usually went to join Buddhist rituals in the temple can meditate, N14 Difficulty in clarifying the application of Buddhism Perceiving difficulty in clarifying which parts of life are influenced by Buddhism, N15 21 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Perceiving the difficulty of Dhamma language, N3 Perceiving no answers for patients who question the result of kamma, N3 Perceiving a limitation of young nurses to understand Dhamma, N3 Concerning effective way to learn Dhamma Perceiving less benefit of learning mediation by just listening to others’ experience, N13 Question about results of kamma Feeling wonder about unpredictable results of kamma, N9 Avoiding meditation/hard to meditate Contacting ghosts and spirits while meditating, N10 Avoiding meditation, N10 Realising not everybody can do Anapanasati meditation, N2 Perceiving doing meditation isn’t easy for people who have never learnt or practiced meditation before, N14 Feeling guilt easily Feeling guilty if unable to do the best for patients, N15 Feeling guilty (when not providing good nursing care), N10 Time consuming Being concerned about time consuming to apply rituals to heal patients and providing psycho-spiritual care, N7 Modern organisation-ignoring local wisdom and Buddhist ways Perceiving the city hospitals are far away from the local wisdom and Buddhist ways, N6 Negative image of monks and nuns Experiencing sick monks do not apply Buddhist practices, N7 Realising the improper manners of the monk and nuns in this period, N16 Unappreciated misbehaviour of Buddhist Perceiving some misbehaviour of Buddhist people such as asking and waiting for good luck without doing anything, N9 Feeling can’t guarantee that people who learn Dhamma are always good, N9 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, N9 22 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing 16 Relatives Malpractice in merit making Perceiving a lot of people make merit improperly, N16 Perceiving barrier to learn Dhamma-using Pali language Perceiving Pali language is a barrier to learning Buddha Dhamma, N9 Learning the reality of life from reading novels books without learning Dhamma, N9 Appreciate others’ religion Appreciating Christian funeral ceremony about singing songs for a dead person and being joyful in the ceremony, N9 Suggesting ways of applying Dhamma Suggesting ways of applying Dhamma Suggesting ways of applying Dhamma Developing compassion Developing merciful behaviour and loving kindness, N1 Learning Dhamma Recommending nurses learn Buddha Dhamma, P4 Suggesting nurses learn Dhamma, P14 Learning Dhamma by Practising, P14 Practising meditation Recommending nurses practise meditation, R12 Recommending nursing schools teach meditation, R12 Recommending nurses and doctors join Vipassana meditation courses, R12 Practising meditation, Recommending nurses practice meditation, N1 Persuading nurses to practice meditation, N10 Suggesting behavioural changes through meditation, N10 Recommending the nurses have meditation leave, N10 Recommending nurses practice meditation and learn Dhamma, N8 Recommending nurses practice Vipassana meditation to understand the nature of life and illness, N14 Practising chanting Recommending nurses practice chanting about radiating loving kindness and transferring merit to other beings, N5 Recommending every family and school teaches chanting to children, N5 Developing Dhamma as a healing method Developing Dhamma as a healing method, N1 Valuing Dhamma in nursing professional/policy Expecting the head of the ward to understand the Dhamma, N3 Realising the importance of policy on developing spiritual care skills and applying Buddhist teaching into nursing care, N6 Raising mindfulness before starting each shift Wishing nurses have a chance to set their mindfulness and relax before starting their work, N6 Being sensitive to other culture and beliefs Concerning issues about communication problems with Muslim people, N5 Concerning patients’ culture, N6 Practising meditation Recommending breathing meditation, P1 Suggesting ways to introducing meditation to patients, P14 Supporting patients do chanting Suggesting nurses support patients doing chanting and preparing chanting books for patients, P8 Performing death rituals Performing death rituals for terminally ill patients in hospitals, P4 Recommending to chanting for dying Recommending chanting and thinking of the Buddha when dying, P4 Making merit Recommending people make merit when they are in trouble, R15 Recommending nurses apply Buddhist rituals Suggesting nurses ask Buddhist patients whether they want to make merit, R12 Suggesting nurses persuade elderly patients to do chanting, R12 Recommending nurses apply meditation techniques in patient care, R12 Realising nurses can support patients and relatives to do religious rituals, R12 Recommending nurses chant or let relatives chant in the dying period, R12 Introducing good Buddhist role models for nurses Introducing good Buddhist role models for nurses, P14 Valuing happiness Valuing happiness makes nurses happier, P4 23 17 Nurses Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients Applying personal/local wisdom, and traditional healing Applying personal/local wisdom, and traditional healing Applying local wisdom and traditional beliefs Applying local wisdom and traditional beliefs Valuing traditional wisdom Being a traditional nurse, N11 Perceiving good results of Practising Eastern wisdoms such as meditation, chanting, Tai Chi, Yoga regularly, N5 Valuing Thai wisdom Valuing Thai health related wisdoms, P13 Believing in traditional beliefs Experiencing family traditional rituals (such as repaying the vow by dancing the Manorha) N10 Getting used to traditional and temple related rituals (such as making merit, chanting, meditation, Manorha dancing) N10 Having strong psychic senses, N10 Perceiving different personal experiences with dead patients’ spirits, N10 Believing in traditional beliefs such as an incantation, a fortune, a vow, auspicious days, folk healing methods, local herbal medicine, and religious rituals, N11 Believing in the sixth sense and ghosts, N11 Chanting the incantations to be safe while going to other places, N11 Doing traditional rituals to my face every morning, wash my chest every mid day and wash my feet every evening for maintaining wisdom and dignity, N11 Valuing traditional teaching about awareness, raising mindfulness, carefulness and kindness and paying respect to all people and things, N11 Experiencing husband solve a problem about a jealous colleague successfully by radiating Metta, N11 Believing in fortune teller, N13 Applying alternative care/therapies Using music therapy and alternative ways to support non-religious patient, N1 Applying some alternative methods for releasing stress, N17 16 Relatives Applying personal/local wisdom, and traditional healing Applying local wisdom and traditional beliefs Using traditional beliefs Relating illness to bad luck, P6 Using modern and tradition care Taking care of himself by avoiding causes of illness, taking modern medicine and using traditional massage, P3 Coping with despair by seeking traditional and modern medicines, P13 Realising the uncertainty of medical knowledge, P13 Appreciating the efficiency of modern hemodialysis machines, P13 Not trusting the doctors and modern medicines, P13 Using herbal bathing, P13 Using alternative care/complementary care Accepting complementary care, P1 Controlling blood sugar by taking medicines, adjusting diet and drinking herbal tea, P2 Using herbs Using herbs from Buddha’s time, P4 Respecting creations Respecting the god of the land, water, and all creations, P12 Respecting ancestors Showing respect to the passed away ancestors, P12 Respecting ancestors, repaying gratitude to them and asking for their protection, P3 Believing in supernatural power Experiencing winning lotto because of getting the numbers from a meditative state, R9 Experiencing having six senses which can be a good warning sign for safety, R9 Perceiving an accident from bad luck, R1 Believing illness occurs from effect of past kamma and supernatural powers, R1 Predicting patients’ heath from a relative’s dream, R1 Believing in the effects of supernatural powers, R1 Perceiving causes of illness from supernatural causes, R3 Realising husband’s belief in black magic, R14 Having traditional beliefs Believing people with cancer die sooner if they go to a funeral ceremony, R14 Believing that 25 years old is a bad year for any person including her son, R5 Depending on traditional beliefs Watching her father closely in order not to let a spirit (ghost) take him away-having traditional beliefs about spirits, R4 Deciding to let her father take herbal medicines for strengthening the immune system, R9 Perceiving the need to consult nurses about beliefs about harmful food/proper food for cancer patients, R9 Perceiving the need to consult nurses about using herbal medicine with cancer patients, R9 Making and repaying a vow Realising his mother and grand mother made a vow, R1 Experiencing a mother’s offerings, R1 Intending to repay a vow, R1 24 17 Nurses Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients Applying alternative care/therapies (cont.) Recognizing the trend in alternative therapies for patients and relatives, N17 Offering spiritual alternatives, N15 Wishing patients have a chance to do more relaxing activities, N6 Helping patients to avoid using harmful herbal medicine, N11 Applying music therapy for teenage chronic patients to relax themselves, N11 Having no leaflets and media to teach patients to do mediation or relaxation, N11 Perceiving a lot of patients use alternative ways of healing such as herbal medicines, magic healing, vitamin and minerals and massage, N11 Being consulted about how to use alternative ways of healing with modern medicine properly, N11 Perceiving nurses should have more understanding about complementary care in order to give proper suggestion to patients, N11 Making a vow Asking for health by making a vow to the sacred things and repaying by being a nun-traditional beliefs in his family, P3 Praying and asking for help Practising religious rituals, transferring merit to others and ancestors, praying for good luck, sufficient income and good health, P3 Praying for not having other diseases and family members’ healthy, P7 Asking help from all sacred things, P7 Asking for good luck and protection from the ancestors, gods, and creatures, P12 Asking for protection Asking all dead ancestors to protect the spirit of dead daughter, P9 Asking for protection from the sacred monk’s amulet, P12 Using alternative care 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) , P7 Being introduced to alternative healing by friends, P7 Learning the alternative healing methods from the television–influence of media on patient’s self care, P7 16 Relatives Making and repaying a vow (cont.) Making a votive offering, R1 Experiencing a vow, R3 Perceiving her husband’s vow to be ordained and be a monk if he recovers, R14 Being a nun to repay a vow after recovering from illness, R14 Repaying a vow, R14 Seeking moral support from the fortune teller, R8 Seeking moral support from the fortune teller, R8 Respecting and asking for protection from ancestors Praying and asking for all the best from passed ancestors, all gods, and all sacred creators from both under the earth and up to the sky, R15 Asking for protection from deceased ancestors, R15 Reminding her children and grandchildren to respect relatives and deceased ancestors, R15 Applying traditional and alternative care Preventing her mother from constipation by feeding her bananas and the ancient herbal medicine and doing evacuation, R10 Cooking healthy food for her mother using fresh herbs, vegetables, grains and fish, R10 Experiencing difficulty from cooking food from the hospital’s recipes, R11 Applying natural ways of healing including the Chevachit concept to care for her father, R11 Learning alternative healing methods from heath care program on television, R13 Healing her stroke husband by doing Thai traditional massages for many years, R13 Preparing a traditional bed made with a bamboo mat to massage his back and prevent pressure sores, R13 Applying Chinese traditions Relaxing his father by putting on his favourite Chinese movies and songs, R7 Using herbal medicine Perceiving her father eats herbs, a bitter Mara (Momordica), to control his cancer, R4 25 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Applying personal wisdom (using other coping methods) 16 Relatives Applying personal wisdom: balancing living/nurturing happy living Applying personal wisdom (using other coping methods) Understanding illness Realising heart disease relates to nutrition, P8 Discussing diseases from being elderly, P8 Understanding health status, P14 Knowing well and can manage his illness, P13 Concerning abnormal signs, P13 Not-depending on traditional beliefs Not-believing in supernatural power, R2 Not-depending on traditional beliefs, R2 Having no belief about supernatural power on illness, R2 Refusing non scientific healing methods to care for his father, R7 Refusing to use religious practise to help his father, R7 Having no traditional beliefs about illness and health care, R7 Valuing having enough caregivers to care for patients at home more than applying traditional beliefs to support patients, R7 Understanding some people believe about a supernatural power, R2 Valuing caring for patients more than expecting good outcomes from a supernatural power, R2 Not-believing in supernatural power, R4 Perceiving her father is a compliant patient, R4 Perceiving her father trusts in modern medicine and refuses to use traditional healing, R4 (see providing compassionate care with equanimity) Seeking treatments Refusing folk medicine, P6 Being referred to folk medicine by elderly people, P6 Accepting orthodox medicine, P6 Seeking information Seeking information about proper foods for renal failure patients, P13 Asking doctors about health related issues, P13 Communicating/expressing hardship Communicating with doctors and nurses and asking for information by his daughter, P3 Trying to express personal hardship to the doctors, P6 Communicating to relatives by using mobile phone, P7 Being patient Preparing to be very patient with family, P6 Being patient to deal with illness, P7 Having a strong heart to fight with illness, P7 Having enough patience, P7 Strengthening the mind, P7 Setting personal health’s goal Having personal goals of care, P5 Resetting life goals, P10 Depending on oneself Being independent, P14 Depending on oneself, P7 Living alone in the hospital with no problems, P7 Intending to depend on her self-maintaining working, P9 Refusing to use herbal medicine to cure cancer, R14 Seeking for information Asking the doctor for information, R1 Maintaining hope/positive thinking Hoping his wife can move by herself, R1 Perceiving patients have less suffering when unconscious, R2 Wishing her son can recover, R5 Feeling honoured to receive total support for her son’s health care costs from the Queen’s project, R5 Thinking to maintain her son’s job, R5 Wishing her son would recover or pass away comfortably, R5 26 17 Nurses Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients Taking care of self/balancing living and working Readjusting life after experiencing imbalance of working and resting-resigning from fulltime work to work at home with the rubber garden, P9 Working too hard and thinking too much causes illness, P9 Living and taking care of health day by day, P9 Maintaining work after becoming sick, P1 Maintaining a social life with friends, P10 Being the same as uninfected people, P10 Taking care of self, P1, P14 Trying to take care of self, P6 Avoiding some foods, P6 Preparing to receiving treatments, P7 Strengthening her mind after being inspired by other patients-trying to exercise and do gardening, P7 Drinking soy milk eating less food, P7 Asking for help from other patients’ relatives, P7 Balancing blood sugar level-eating proper food, P7 Avoiding eating chicken to prevent Bird flu illness, P7 Emphasising the need for self care, P8 Adjusting the amount of medication depending on conditions-gaining benefit from changing an amount of medicine is maintaining life better than fixing it, P8 Doing deep breathing while having a heart attack, P8 Managing life while taking anti-virus drugs, P9 Learning to take care of self: updating health care news, P9 Avoiding harmful foods-receiving careful care from his wife, P12 Eating for health, not for taste, P12 Avoiding chemical hormone replacements, P1 Avoiding harmful foods, P4 Receiving orthodox treatments for treating colon cancer, P14 Believing in his body signals more than laboratory results, P13 Keeping healthy by regular exercise, P13 Perceiving factors to promote good health including good taking care of himself, good medicines and treatments and good support from family, P13 Adjusting amount of foods by considering his body signals, P13 Having organic chemical free food, P13 Developing personal health care methods, P13 Preventing back pain, P13 16 Relatives Maintaining hope/positive thinking (cont.) Wishing her son to pass away peacefully, not to worry about any person and anything that left behind, R5 Appreciating healthy life styles and the kindness of her father, R9 Wishing her sick daughter and all children will be happy, R15 Appreciating her HIV daughter has a chance to help other HIV/AIDS friends, R15 Seeing a positive side of her HIV infected daughter, R15 Accepting situations when other people gossip about her HIV children, R15 Thinking positive and accepting HIV infection of her children, R15 Realising healing environments, R12 Realising benefit of quiet and private places, R12 Taking care of self Taking care of herself while taking care of her paralysed husband, R13 Healing her gastric pain by not eating too much chilli, avoiding fermented food, drinking milk and eating a lot of bananas, R13 Working hard Maintaining hard work to be healthy, R15 Working hard for a better life, R15 Spoiling selves/continuing harmful behaviours Doing bad things when feeling bored, P10 Preferring risky foods, P4 Continuing harmful behaviours, P11 Trying to cut down on alcohol and eat good foods, P11 Drinking with friends, P11 27 17 Nurses Core category 2: Applying Dhamma, personal/local wisdom, and traditional healing Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 14 Patients 16 Relatives Thinking positively Maintaining positive thinking, P13 Having a good life, P13 Staying healthy even with renal failure, P13 Having good children and grandchildren, P13 Avoiding negative thinking Avoiding comparing herself with other successful friends, P9 Feeling better when looking at people who have the same problems, P9 Disliking other people’s views and gossip, P10 Maintaining hope/will-power Hoping to go back home, P6 Hoping to get better, P6 Hoping to be independent, P6 Trying to exercise, P6 Hoping to win lotto, P6 Hoping to pass all hard times because she has never done bad deeds, P7 Maintaining will-power (kam lung jai) and wellness by taking care of herself, P9 Having strong mind leads to having healthy body, P9 Willing to live longer to repay gratitude to parents and avoiding making parents feel regret, P9 Maintaining hopes, P10 Maintaining positive thinking, P10 Looking at others and things positively, P10 Raising a fighting mind, P10 Believing in the chance to be healthy and live longer, P10 Hoping to get better, P11 Wishing to go back home, P12 Wishing not to have side affects from chemotherapy, P12 Realising the ability to live longer, P13 Relaxing by walking Coping with boredom by going for a walk in the field, P11 Helping other patients Trying to encourage other patients’ exercise, P13 Recommending benefits of exercise to other patients, P13 Being recognised from nurses to be a good role model for other renal failure patients, P13 (see also helping others) Planing about the property Planning about the property after death (giving to Mum and donating to the temple), P7 28 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutualcompassion with equanimity Describing characteristics of compassionate nurses (from nurses’, patients’, and relatives perspective) 16 Relatives Describing characteristics of compassionate nurses (from nurses’, patients’, and relatives perspective) Describing characteristics of compassionate nurses (from nurses’, patients’, and relatives perspective) Good heart Good heart Valuing compassion and meritorious acts Valuing compassion of nurses for patients, P1 Perceiving nursing is a meritorious occupation, P1 Perceiving nurses do a virtuous job, P14 Valuing compassion in helping others, P14 Being kind Appreciating nurses who are kind, welcoming and have never talked badly with patients and relatives, R16 Perceiving some nurses talk loudly with patients and are strict but their hearts are very kind, R16 Good heart Valuing human caring Valuing nursing as a human caring, N1 Crossing professional boundaries, N1 Being concerned about patients as human beings, N1 Experiencing not liking nursing but trying her best to help suffering clients, N8 Valuing Dhamma Perceiving a meritorious act to help suffering patients, N2 Perceiving Dhamma is the core of nursing, N2 (to help nurses to have loving kindness, to understand patients’ suffering, to have good attitudes toward work, to provide enough time for patients, and to have mindfulness in every working moment), N2 Valuing a beautiful mind Remembering the real beauty of life is a beautiful mind, N1 Appreciating other religions Perceiving a strong relationship in Muslim patients and relatives, N9 Appreciating Muslim relatives bless patients by reading religious books for patients, N9 Appreciating good discipline and faith in religion of Muslim people, N9 Respecting every religion, N16 Having positive attitudes towards nursing Having positive attitudes towards work, N1 Appreciating nurses’ caring, N2 Perceiving the value of being a nurse who helps and supports others, N6 Setting the right mind to prevent a boredom of being a nurse, N9 Working with good intention, N9 Being a nurse to help others and support parents, N9 Perceiving the core of nursing care is giving and helping others, N9 Realising the effects of nurses’ positive attitude on patients’ and relatives’ happiness, N10 Valuing gentleness, politeness, friendliness Valuing nurses’ personalities-gently, polite, friendly, P10 Valuing sincere and heart to heart caring Connecting from the heart to the heart while having no gap between the relationship, P9 Having sincerity is a way to build long term relationship, P9 Reading nurses’ sincerity from looking at their eyes; the channel for nonverbal communication, P9 Valuing patients and relatives Valuing respect among family and relatives, P3 (also see Acting with compassion and considering clients’ expectations) Being polite Appreciating nurses’ politeness, R16 Expecting that nurses are polite, R16 Expecting nurses talk with patients and relatives politely, R16 Being calm Appreciating nurses are calm, very patient and kindhearted, even when dealing with aggressive patients and relatives, R2 Being gentle Experiencing nurses will not be rude to patients, R16 Reminding doctors, nurses, and staff to care more gently for her son who has severe pain, R16 Perceiving patients need gentle care, R10 Valuing the importance of nurses to educate relatives to care for patients, R10 Friendliness, politeness, and willingness Valuing nurses’ friendliness, politeness, and willingness, R8 Showing the hospitality Expecting staff in the hospital to show their hospitality, R8 Expecting nurses to focus on caring for patients, R8 Controlling emotions Expecting nurses to control their emotions, R8 29 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Believing every nurse has a good heart, N10 Being encouraged to be a nurse since she was young, N11 Experiencing good impressions of a kind and gentle nurse, N11 Having positive attitude to helping others can prevent nurses from stress, N12 Putting the heart into the work, N15 Studying nursing because of getting a job easily, N15 Believing nursing is a virtuous job, N15 Perceiving a chance to make merit while helping patients, N13 Doing nursing care to make merit, N14 Putting her heart into her work, N16 Being polite/having a good personality/building trust Politeness and respectfulness is a basic part of a professional relationship, N3 Perceiving sympathy, cheerful, politeness, kindness, understanding, listening, helping, bot being neglectful, being punctual and encouraging patients to practice rituals lead to good relationships between nurses and clients, N3 Maintaining physical care with politeness, N3 Building trust while maintaining professional relationship with terminal cases, N5 Having a good personality to build trust from patients, N6 Concerning caring personalities of nurses who are being trained to be smart and have good manners, N5 Concerning more polite manners while providing nursing care to prevent complaints, N7 Talking with patients using good manners, N7 Dealing with high expectations from patients and relatives with politeness, N8 Expecting nurses to talk with clients especially older people properly, N9 Caring for a relative who has spiritual distress problems by being polite, N12 Perceiving kind-heartedness is a highly important characteristic of nurses who are good spiritual supporters, N12 Building trust with patients and relatives along side doing nursing jobs, N12 Building trust with relatives from the beginning of a patient’s admission can prevent relatives’ negative perceptions especially when patients turn to be unconscious or die unexpectedly, N12 Reminding nurses to have good speech with hasty relatives, N12 16 Relatives Not being moody Appreciating some kind nurses and that no nurses are moody or give rebuke, R2 Expecting nurses to not be moody, R8 Expecting mutual respect and understanding Expecting mutual respect and understanding, R8 Giving moral support to patients and relatives Appreciating supporting nurses, R16 Experiencing nurses give moral support to patients, R16 Receiving moral support and information from nurses, R16 (also see Acting with compassion and considering clients’ expectations) 30 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity 16 Relatives Being polite/having a good personality/building trust (cont.) Recommending nurses who support VIP and ordinary patients and relatives successfully must have a good personality including a calm face, respectful posture, and polite speech, N12 Having polite words is very important for nurses, N13 Talking politely with demanding patients and relatives, N13 Building trust with patient by doing the best care, N13 Being polite and explaining reasons, N17 Giving encouragement to patients to trust in health care team and treatments, N14 Being more polite while dealing with fussy patients after ordaining, N14 Being friendly, kind and compassionate Being kind and loving to help others, N1 Having nam jai (kindness water in our heart, compassion) with patients, N1 Valuing nurses’ metta for building good relationships, N1 Realising the importance of moral support, love and kindness of nurses to patients (Patients need kam lung jai (moral support), kwarm rag (love) and kwarm metta (kindness) and I think I can give these 3 things to patients.), N3 Being kind to patients, N4 Being friendly with patients and relatives, N4 Being friendly while maintaining professional relationship with terminal cases, N5 Being taught by the monk to provide tender care for patients, N6 Being kind to build trust with patients, N6 Confirming that love and kindness can heal others’ suffering, N6 Being kind with patients and relatives without being proficient nurse, N6 Realising patients and relatives need tender loving care, kindness and compassion from nurses, N6 Valuing the kindness of nurses, N7 Using her nursing knowledge to help elderly people in her community, N8 Thinking of the value of helping patients and relatives to maintain the nursing job Expecting nurses have a caring heart, kindness and generosity with colleagues, patients and relatives, N8 Having good human relationships, and kindness, N9 Understanding others, giving love to others, knowing how to give (opportunities, sincerity, or forgiveness), and having compassion are good qualities for EQ nurses, N9 31 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity 16 Relatives Being friendly, kind and compassionate (cont.) Keeping friendly even when busy, intending to give a gentle smile to patients, greeting them, and asking them how are they, N12 Talking with friendliness, N12 Wishing to see patients receive treatment in the hospital more than using magic healing, N13 Having a caring mind, concern for the patient’s feelings, N13 Being friendly with AIDS patients, N13 Realising kind-heartedness is a basic of building good relationships with patients and relatives, N14 Being friendly to patients and relatives, N14 Replacing bullying with kindness Balancing bully nurses by assigning kind nurses in every shift, N13 Being patient Having patience to be a nurse, N13 Experiencing working hard since being a nursing student, N13 Having patience when feeling stress in daily working, N13 Thinking positively Thinking of others’ good parts, N4 Being the first supporting person Perceiving the nurse is a person who is always ready to support other people when they are suffering, N12 Being easy to call Being a kind nurse who patients call for help easily, N13 Willing to help without expecting rewards Helping family members and patients without expecting things in return, N16 Doing every job without expecting something in return-believing in kamma, N12 Perceiving fundamentals of a good relationship between nurses, patients and relatives are willing to help patients and relatives, having sincerity and never disparaged clients, N12 Helping more patients, N1 Helping patients who have complex problems, N1 Helping patients without expecting rewards, N1 Being a psycho-spiritual support volunteer, N3 Supporting caregivers’ minds, N16 Helping AIDS patients, N16 32 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity 16 Relatives Being ordinary Being ordinary nurses can prevent the gap between the head nurse and relatives, N5 Working hard Being happy to work hard, N12 Being gentle Being gentle, N4 Perceiving nurses are gentle, N6 Being more gentle while nurses respect patients as human beings, N6 Being calm Being calm, N4 Being flexible Being flexible while working, N1 Being more flexible while supporting patients, N3 Being more flexible to let relatives stay with patients in the ward, N7 Perceiving kind nurses are more flexible, N9 Being more flexible with relatives, N10 Being flexible in visiting rules, N13 Being flexible, N17 Being more flexible with patients than female nurses, N14 Being sensitive to different culture/having cultural sensitivity Being aware of cultural background of patients while providing nursing care, N9 Perceiving differences in visiting styles of Buddhists and Muslims, N15 Perceiving different aspects of Buddhist and Muslim relatives on doing death rituals for dying patients, N11 Experiencing Muslim and Buddhist patients practice religious rituals in the ward, N13 Having an open mind/being a good listener Accepting all people and problems, N15 Being a good listener, N4 Learning by open listening, N9 Having open minds to listen to patients, N10 Having open listening to relatives who are dissatisfied in treatment outcomes, N13 33 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity 16 Relatives Using patient-centred approach Focusing on patients, N1 Thinking of the patients’ benefits, N1 Perceiving the importance of an effective patient-centred care, N2 Needing to be patient-centred, N10 Changing from a nurse-centred tradition to patient-centred care, N15 Remembering patients’ names Remembering patients’ names, N1 Respecting individual differences Accepting individual differences, N1 Respecting individual differences, N1 Respecting individual difference of patients, N6 Respecting privacy Concerning patient’s privacy while bathing, N6 Respecting the privacy of patients while using their experience to support other patients, N9 Respecting privacy of HIV/AIDS patients, N11 Concerning safety Concerning cross infection of AIDS patient’s relatives, N7 Respecting the patients’ rights Showing concern and respect the patients’ rights, N6 Respecting patients’ and relatives’ values and beliefs Respecting and applying patients’ beliefs to strengthen patients’ minds, N1 Concerning and respecting patients and relatives’ beliefs, N7 Respecting patients’ values and beliefs, N10 Respecting patients as human beings, N10 Realising rural patients believe in black magic, N10 Respecting patients’ and relatives’ beliefs, N10 Respecting patient’s beliefs can build therapeutic relationships, N11 Experiencing some patients and relatives do some rituals following their beliefs before coming to see the doctor in hospital, such as check a sign of the zodiac and rectify bad luck by making merit or doing Sanghadana, N11 Experiencing relatives bring some magic things to keep at the patients’ bed for protecting the patient from bad luck, N11 34 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity 16 Relatives Respecting patients’ and relatives’ values and beliefs (cont.) Experiencing relatives refuse modern medicine when they believe that illness comes from black magic, N11 Listening to patients and relatives’ beliefs openly is a good way to support patients’ minds, N11 Perceiving mature, calm, and warm nurses open their mind to respect patients’ beliefs, N11 Understanding various beliefs of Thai patients and relatives on using traditional healing methods, N11 Feeling happier while listening to stories about patients’ beliefs and background and helping them use them properly when they are sick, N11 Respecting patients’ beliefs even don’t have a hundred percent belief, N13 Experiencing patients use traditional healing methods to heal illnesses, N13 Respecting patients’ beliefs, N17 Respecting patients and relatives, N14 Respecting patients as teachers Respecting patients as teachers, N1 Respecting patients as nurses’ teachers, N2 Appreciating positive thinking of patients, N3 Respecting patients, N4 Appreciating patients’ value Appreciating patients’ wisdom, N6 Appreciating on patients’ value while they live with their illness, N13 Respecting elderly patients Perceiving elderly patients need love and respect from nurses, N11 Concerning kinship relationship Having strong Thai kinship in the family, N1 Building kinship relationship Think of caring for patients the same as caring for nurses’ parents is a way to provide good care, N11 Caring for patients as nurses’ relatives to improve compliance, N11 Taking care of patients and relatives the same as taking care of nurses own parents or relatives, N12 Caring for patient the same as care for nurse’s relatives, N14 35 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity 16 Relatives Respecting and trying to help patients and relatives as if they are nurses’ relatives, N14 Accepting inconvenience from relatives Accepting inconvenience while doing nursing care while relatives stay at patient’s bed, N13 Understanding patients’ and relatives’ backgrounds and situations Understanding patients’ and relatives’ situation, N2 Being concerned about relative’s ability and background when helping patients, N6 Understanding different levels of perception and expectation of patients and relatives on nursing care, N8 Understanding patients and relatives (patients’ negative responses and feelings, patients’ emotional needs, moody patients, patients’ perceptions of natural and traditional ways high expectations from rich patients and relatives) , N10 Understanding various kind of patients’ psychological problems, N13 Knowing patients’ background deeply after having good relationship with them, N14 Being concerned about patients’ and relatives’ feelings Being concerned about relatives’ feelings and safety, N6 Being concerned for patients’ and relatives’ feelings, N15 Believing care and concern for feelings are fundamental, N15 Understanding patients’ and relatives’ problems and needs Understanding relatives’ needs for kindness and flexibility, N1 Realising CVA patients and families need to trust nurses who understand their situation, give suitable information and be a good counsellor, N12 Understanding patients’ problems and concern about their good quality of life, N12 Understanding negative responses of patients and relatives such as aggressive, demanding, N12 Understanding cerebrovascular accident patients’ and relatives’ problems, N12 Realising patients and relatives who are in the shock stage of stress are not ready to listen to any information, N12 Understanding the nature of human beings, N12 Understanding negative responses of patients and relatives such as aggressive, demanding, N12 36 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity 16 Relatives Understanding different kinds of relatives Perceiving different kinds of relatives including concerned, non-concerned and over-concerned, N11 Perceiving different kinds of relatives, N17 Concerning patients’ and relatives’ special needs Recommending clients needing special care request a private room, N15 Trying to be flexible about visiting time, N17 Needing to stay and talk with patients, N17 Experiencing relatives willing to help the patients, N17 Concerning more patients need advanced psycho-spiritual support, N7 Realising the potential of patients’ relatives (having a caring mind and strong kinship tradition, willing to care for patients, patients depend on relatives, relatives are the significant caregivers and psycho-spiritual supporters, relatives can reduce nurses’ workloads, relatives can repay their gratitude to patients by caring) Exercising the potential of patients’ relatives, N15 Perceiving relatives can repay their gratitude to patients by caring, N15 Appreciating the caring mind of the Thai family, N15 Appreciating the strong kinship tradition of Thai people, N15 Perceiving Thai people depend on family members and relatives when dealing with problems, N15 Realising the value of relatives being willing to care for patients, N15 Realising relatives can reduce nurses’ workloads, N15 Perceiving patients’ relatives are the significant caregivers and psychospiritual supporters, N15 Perceiving nurses care for patients’ physical aspects and relatives care for patients’ psycho-spiritual aspects, N15 Realising nurses need help from relatives to help and rehabilitate patients in long term care, N15 Questioning the scope of relatives’ roles in caring for patients in hospital, N15 Good life experiences and nursing skills Good experiences and skills Good experiences and skills Experiencing hard times in life Understanding others through a hard time in life, N15 (see Considering clients’ expectations) Valuing nurses’ good nursing care Valuing nurses’ good nursing care more than good talking skills, R6 Experiencing natural death Experiencing father’s dying naturally, N2 37 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Experiencing caring for dying relatives Caring for dying relatives, N10 Experiencing relatives do religious rituals for dying patients, N7 Having responsibility Having responsibility in nursing care, N9 Valuing quality Being aware of doing good quality of care, N9 Being skilful Having enough knowledge, therapeutic techniques, and good assessment skills to help suffering patients, N9 Gaining deep understanding of patients problems by observing, talking and having skills to predict problems, N9 Having knowledge, skills, N9 Valuing the effectiveness of nurses in having good nursing, educating, and coordinating skills, N9 Realising the importance of nurses’ basic nursing care skills, N15 Taking care of self and learning relaxations Taking care of nurses’ own self will educate patient more effectively, N6 Nurturing herself and patient’s life with nature, N6 Realising nurses should have skills of various kinds of relaxation techniques and holistic care, N7 16 Relatives Providing ethical care Believing that all nurses and doctors provide ethical care to prolong a patient’s life, R2 Being responsible and kind Appreciating nurses’ responsibility and kindnessanswering questions well, coming to help quickly, having no omissions or bad manners, R2 Supporting Appreciating good support from community nurses, R10 Educating Realising the importance of nurses to educate relatives to care for patients at home, R10 Helping on time Expecting nurses to come to help patients on time, R10 Visiting home Receiving home visits from community nurses, R13 Helping in patients’ complex problems 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, R10 Valuing life long learning Learning Dhamma and other therapies to help holistically, N1 Volunteering Being a volunteer is a way to develop palliative care skills and knowing social supporting networks, N6 Good social support Receiving support from others Receiving support from family to do volunteer work, N1 38 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Cultivating Compassionate Relationships with Equanimity 16 Relatives Avoiding added suffering (dehumanizing behaviours) Avoiding being uncaring/expressing emotion Avoiding a bad mood and manner, N1 Avoiding adding more distress to suffering clients, N1 Avoiding bad reactions to moody patients, N3 Avoiding arguments, emotions and impolite manners, N4 Avoiding using commands with patients and relatives, N8 Avoiding blaming others while working, N10 Avoiding a rebuke while training new nurses, N11 Avoiding expressing anger in front of others, N11 Avoiding relatives involved in complex nursing care such as care for unstable patients, N11 Avoiding expressing anger and staying calm while dealing with patients and relatives who are in trouble, N12 Having mental calm even when stressed, N13 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, N13 Counting 1 to10 and being calm to avoid expressing emotion while dealing with patients or relatives who are too demanding, N13 Avoiding adding tension to patients and relatives, N14 Keeping distance/avoiding tension from fussy patients, VIP relatives and co-workers Walking away from conflict situations to reset mindfulness, N4 Going away from the situation for a while when facing too much demand from relatives, N8 Experiencing nurses are annoyed with grumpy relatives and keep distance from grumpy relatives, N9 Acknowledging that nurses avoid talking to high status, overpowering relatives, N9 Avoiding mourning patients, N10 Avoiding tension during work, N10 Avoiding conflicts with patients, relatives, and co-workers, N4 Preventing conflict Preventing a conflict relationship by rotating nurses’ assignments, N5 Avoiding assign the junior nurses to deal with fussy relatives, N5 Avoiding contact with patient while having a bad mood, N6 39 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity 16 Relatives Avoiding approaching patients’ deep concerns when not enough time to support, N6 Being uninvolved in making decisions for relatives about stopping aggressive treatments for elderly patients, N8 Letting them make decisions for further conditions is helpful, N11 Dealing with any conflict from patients and relatives by respecting, N11 Dealing with any conflict from patients and relatives by using polite words and manners, N11 Preventing any conflict and dissatisfaction from relatives, N12 Acting with compassion and equanimity Providing compassionate care Providing psycho-social support/holistic care Being a psycho-spiritual support volunteer, N3 Perceiving spiritual needs of critical and terminal ill patients and their relatives, N4 Trying to actively provide psycho-social support, N17 Implementing more holistic care for patients who use ventilators especially issues about anxiety, thirst, communication, and the beliefs of patients and relatives, N4 Concerning about patients’ quality of life more than curing diseases, N5 Preferring to provide more psycho-spiritual care every day rather than doing research in this topic, N7 Trying to support patients’ mind at least one case per shift, N11 Experiencing nurses realise the importance of the psychospiritual aspects, N11 Providing spiritual care for patients with real understanding, N12 Caring for a relative who has spiritual distress problems with understanding, N12 Providing psycho-spiritual care indirectly, N17 Applying Dhamma to promote compassionate care Looking at one’s own part, N4 Setting mindfulness, N4 Walking away from a conflict situation to reset mindfulness, N4 Working with mindfulness, N2 Having Iddhipada while working, N2 Acting with compassion and equanimity Acting with compassion and equanimity Experiencing caring nurses/doctors Experiencing caring nurses (kind, smiling, controlling feelings well, calm and having polite manners), P9 Expecting caring nurses (welcoming, smiling, cheerful, friendly, willing to help patients), P9 Experiencing kind doctor, P9 Expressing compassion for patients Experiencing different kinds of nurses Experiencing both kind and drawl nurses, P11 Receiving compassionate care from nurses and doctors Receiving health care from the government hospitals, P11 Appreciating health care outcomes, P11 Receiving good nursing care, P1 Experiencing kind nurses, P10 Being told by the nurse to be mentally strong, P10 Receiving moral support and encouragement from the nurses and doctors, P12 Receiving direct information from nurses, P2 Valuing the role of relatives as main caregivers, P12 Receiving love, understanding moral support/psycho-spiritual support from relatives Receiving help from daughters when sick, P3 Receiving warm support from relatives and friends, P11 Receiving support from wife, P12 Willing to be a supporter, caring for patient’s body and mind Having children support his wife’s mind, R1 Being his wife’s supporter, R1 Staying with and caring for his wife, R1 Gaining confidence to care for his wife, R1 Perceiving the ability to take over nursing care, R1 Realizing a good opportunity to care for patients, R1 Perceiving hygiene care of relatives can prevent patients’ infection, R1 Having no hesitation to call for help from nurses, R1 Willing to be a caregiver/being a main caregiver, R2 Not wanting help from his children and preferring to care for his wife by himself, R2 Visiting, being with, touching and playing with his unconscious wife everyday, R2 Talking with unconscious wife, being with and not neglecting her, R2 Wishing to take care of his wife at home if she can breathe, R2 Expecting his wife could pass away without distresshaving no other choices, R2 Avoiding talking about mother’s prognosis, R3 Providing comfort, R3 Developing confidence to ask nurses how to care, R3 40 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Valuing relatives’ roles especially providing moral support Perceiving patients’ health is improved while receiving good care from relatives, N8 Perceiving relatives are the most important people to support patients’ minds, N11 Perceiving relatives can support patients’ mind better and deeper than nurses, N9 Experiencing AIDS patients who have strong mind and receive good support from family can live longer, N9 Appreciating sharing relationships between patients, N10 Perceiving relatives are sources of patients’ strengths, N10 Appreciating male relatives as good caregivers, N10 Realising a major role of relatives is to support the patients’ minds, N10 Encouraging relatives to help care for patients, N15 Preparing relatives to help nurses care for patients, N15 Perceiving nurses help patients and teach relatives to care for patients, N15 Persuading relatives to be involved in helping patients, N17 Helping relatives to solve conflicts between patients’ relatives, N15 Perceiving patients who have got good support from relatives having less psycho-spiritual problems, N13 Perceiving moral support from relatives is very important for patients’ happiness, N14 Letting relatives stay with patients Allowing relatives to support patients physically and mentally, N10 Allowing relatives to stay overnight with patients, N10 Gaining benefit while relatives help nurses do basic care for their patients, N13 Perceiving a lot of relatives would like to help nurses care for patients, N13 Perceiving relatives can help patients make decisions about further treatments and referring, N13 Allowing relatives to stay with every patient, N15 Letting relatives stay with patients who are in crisis and when doing CPR, N4 Realising patients want relatives to stay with them, N15 Understanding the need of relatives and letting them stay overnight with patients are in crisis conditions, N11 Letting relatives be involved in bathing for their patient with a pre-registered nurse, N11 Telling relatives to motivate patients rehabilitate/encouraging relatives to do passive exercises for patients, N14 Receiving love, understanding moral support/psychospiritual support from relatives (cont.) Rotating another relative to care for him while main relatives have other things to do, P12 Receiving psycho-spiritual support from son, P6 Receiving support from other patients and relatives, P6 Receiving food and money from other patients and their relatives, P6 Appreciating moral support from family, P6 Receiving chanting book from friends-changing sometimes, P7 Having parents as helpers and supporters, P9 Having kind mother-helping others, P9 Having parents as a refuge, P9 Having strong mind to accept AIDS in family: experiences of parents, P9 Accepting illness and death of the family members, P9 Caring relationship in the family, P9 Having caring parents and relatives, P9 Being an important person in the family, even with HIV, P9 Helping each other-living in a kind hearted family, P9 Having no money but plenty of love, P9 Appreciating daughters as caregivers, P1 Preferring to have relatives stay while being admitted, P4 Appreciating concern and support from family, P4 Appreciating help and support from wife, P4 Receiving supporting from relatives, P5 Receiving support from parents, P10 Appreciating moral support from family, P10 Being at ease while living near parents, P10 Feeling better after meeting other infected friends, P10 Asking for help from Mum and daughter at any time, P7 Being more comfortable at home, P5 Acting with compassion to nurses Respecting Respecting nurses and doctors, P7 Trusting Trusting nurses and doctors, P1 Trusting the nurses and doctors, P12 16 Relatives Willing to be a supporter, caring for a patient’s body and mind (cont.) Trying to find other ways to help mother, R3 Trying to support mother, R3 Leaving study to stay with relatives, R3 Trying to stay close to her father in the ward to help and support him, R4 Willing to be a supporter, supporting patient’s mind, R4 Confirming with doctor her wish not to take her father to die at home, R4 Trying to do her best to take care of her thalassemic son, R5 Doing some nursing care for her son by herself, R5 Trying to care for her son to reduce some workload from the nurses, R5 Massaging his father everyday, R6 Being a caregiver because none of his other sisters and brothers feel free to take care of his father, R6 Modifying caring techniques for his father until he can do some jobs such as preventing bed sores better than nurses, R6 Keeping healthy while being a caregiver by exercising everyday, R6 Helping his sisters to take care of his stroke and asthma father, R7 Intending to provide the best care for his father, R7 Being a main caregiver, R8 Trying to achieve good care for mother, R8 Celebrating mother’s birthday with nurses, R8 Supporting mother’s mind, R8 Massaging her sick father, R9 Feeling better after father looks better, R9 Seeking for healthy food and good herbal medicine to prolong her father’s life, R9 Seeking for the best health care for her father who has lung cancer, R9 Being a caregiver in order to repay her gratitude to her mother, R10 Perceiving it is easy to inject insulin for her mother, R10 Trying to learn how to care for her mother because of hesitancy to ask for help from nurses, R10 Observing her mother’s abnormal signs, R10 Being a main caregiver for stroke mother and father for 16 years, R11 41 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Giving smiles Giving smiles, N6 Smiling and greeting is a basic way to build good relationships with patients and relatives, N11 Giving a smile to patients and relatives even when busy, N12 Teasing Teasing the nurses, P7 Connecting with nurses Connecting with nurses from receiving long term care, P7 Building friendship Having Kalyanamittata (good friendships) with patients, N2 Building therapeutic relationship with cancer patients, N3 Believing nurses can give friendship, N15 Communicating Exchanging conversation with the nurses and doctors, P12 Assessing patients’ and relatives’ background Assessing why relatives do not tell the truth to patients, N1 Assessing patients’ psycho-spiritual dimensions, patients’ values, beliefs and minds, N17 Trying to assess patients’ psycho-spiritual dimensions, N17 Trying to assess patients’ values, beliefs and minds, N17 Building good relationships with nurses Building good relationships with nurses by saying thank you and giving nurses some gifts and teasing them not to be grumpy, P7 Building good relationship with nurses and doctors in order to receive special care, P7 Understanding individual differences Perceiving different kinds of cancer patients, N3 Perceiving elderly patients can accept illness and the teaching about the truth of life better than young patients, N3 Considering individual difference, N4 Understanding others, N4 Seeing effects of patients’ beliefs on health seeking behaviours, N7 Perceiving people from rural areas are more patient and selfdependent, N11 Understanding nurses’ situations and limitations Understanding and appreciating nurses’ hard work, P1 Understanding and appreciating nurses’ hard work, P10 Understanding nurses’ situations, P10 Understanding busy nurses, P14 Understanding nurses’ situations, P14 Understanding and appreciating nurses’ hard work, P14 Trying to understand nurses’ weak points, P10 Understanding the limitations of nursing contexts: role overload, limited time, P8 Nursing is a busy job; nurse is a hard working person, so patient, P8 Busyness is causing ineffective nursing care, P8 Raising issues about nurses’ image, power and unity (Thai nurses do everything, having the gap within professionals: nurses don’t love each other, being nonhonoured from others) , P8 Having no chance to be concerned about one own mind: influences of modernity, P8 Respecting human beings Respecting patients as human beings, N3 Respecting each other, N3 Being sensitive Being more sensitive to others’ feelings, N3 Concerned about patients’ reactions more than just doing routine care, N3 Being aware and having true understanding and good intentions when reminding relatives to accept death of their loved one, N12 Being friendly/teasing Being friendly with crazy teenage patients, N6 Teasing young patients as they are nurses’ brothers, N7 Talking with patients and relatives while providing nursing care, N11 16 Relatives Willing to be a supporter, caring for patient’s body and mind (cont.) Supporting other caregivers’ minds, R11 Never neglecting her stroke father, R11 Having good times with parents’ caregivers, R11 Experiencing massaging and rehabilitation of father by the physiotherapist and Thai traditional masseur, R11 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 faeces, clapping his lung to clear secretion) , R11 Caring for mother’s body, R12 Reminding her mother to relax, R12 Providing holistic care, R12 Experiencing care of paralysed husband at home for many years, R13 Doing her best to take care of her paralysed husband, R13 Maintaining a good relationship and giving moral support to her paralysed husband by not shouting or expressing any negative emotions to him, R13 Being the main caregiver, R14 Supporting husband, R14 Cooking fresh, clean and healthy food, R14 Avoiding chemicals and harmful food, R14 Massaging her husband, R14 Trying to stay with her husband in the ward, R14 Perceiving being a caregiver in hospital is not hard work, R14 Trying to help the patient, R15 Experiencing caring for her HIV infected granddaughter, R15 Trying her best to take care of her granddaughter until she passes away, R15 Preventing negative reactions from other people by not telling others about the real diagnosis, R15 Caring for the infected son, nurturing his body and spirit, R16 Trying to do her best to take care of her son, R16 Willing to share money to support patients, R16 Planning to ask for help from her children when necessary, R16 Refusing harmful treatments for her son, R16 Keeping a clean environment, R16 42 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Being kind and compassionate Dealing with non-supportive relatives with kindness, N3 Overcoming temper by nurses’ friendliness and kindness, N1 Being kind to every patient, N16 Being kind and helping AIDS patients, N16 Feeling/sharing sympathy and empathy Valuing sharing nurses’ feelings with patients, N3 Feeling empathy with patients, N3 Having empathy and crying with patients, N17 Thinking of patients’ mind from nurses own feeling, N3 Thinking of other minds is the same as thinking of our own mind, a basic way to build good relationships with patients and relatives, N9 Looking at patients’ problems from the patients’ view point, N10 Caring for patient the same as caring for nurses’ relatives, N3 Thinking as if patients were our parents or relatives while having conflict about choices of treatments-refuse or receive, N3 Thinking of jai khao-jai rao (other minds as our minds), and respecting others is a good way to build good relationships, N4 Caring for HIV/AIDS patients better after feeling more sympathy for their suffering, N8 Feeling sympathy to patients and relatives by thinking of them as our family members, N11 Feeling sympathy to people who are in trouble or their life has more suffering than her, N11 Feeling sympathy for cancer patients, N11 Putting oneself in others’ shoes is a way to maintain good relationship with clients, N12 Experiencing nurses have been treated in improper ways from bullying and insincere staff, N12 Providing spiritual care for patients with real sympathy is a way to transfer spiritual power from the nurse’s mind to the patient’s mind, N12 Feeling sympathy with relatives of CVA patients, N12 Perceiving sympathy is highly important characteristic of nurses who are good spiritual supporters, N12 Feeling sympathy for AIDS patients, N13 Being connected Being connected with patients, N11 Having strong relationships with cancer patients from helping them cope with their illness, N11 Connecting with some passed away patients with a dream, N11 Feeling sympathy Feeling sympathy to nurses, P8 16 Relatives Valuing equal care, P10 Valuing equal care from nurses, P10 Realising her son appreciates her support, R16 Perceiving her son causes his own HIV infection, R16 Being concerned about her son’s feelings, R16 Avoiding making her infected son feel oppressed, R16 Willing to be a rehabilitator Rehabilitating wife because nurses have no time, R1 Rehabilitating patients by massaging, R1 Appreciating humour, P10 Appreciating nurses’ sense of humour, P10 Keeping a healthy life while being a caregiver Keeping a healthy life while being a caregiver, R10 Giving forgiveness Giving forgiveness to unkind doctors, P8 Avoiding adding suffering to patients Avoiding giving additional worry to her sick father, R4 Helping nurses Helping the nurses by letting relatives care for him to reduce nurses’ load, P12 Acting with compassion to relatives Concerning safety and health status of his wife, P12 Sharing all aspects of his life with his wife, P13 Avoiding bad moods at home, P13 Connecting with a daughter until death, P10 Preferring no help from relatives, P14 Understanding other patients Feeling sympathy to other suffering patients, P7 Understanding other patients’ problems, P7 Understanding some patients are demanding, P1 Depending on nurses Depending on nurses and doctors Depending on nurses’ and doctors’ suggestions, P12 Asking for compassionate care (gentle care and kindness, help) Asking for gentle care and kindness from nurses, P7 Asking for support from the ward (rehabilitation equipment such as wheel chair) , P7 Avoiding telling bad news to patients Avoiding letting patients know bad news, R4 Intending to tell a lie in order to support patients’ minds, R4 Valuing patients’ happiness and comfort Valuing her father’s happiness and comfort in the last stage of cancer, R4 Feeling proud to have a chance to take care of her sick father, R4 Understanding patients’ emotions Perceiving frustration is a normal problem of paralysis patients, R7 Being involved in caring Experiencing relatives help nurses care for his father while admitting to a private room, R7 Asking for help Asking questions of nurses and doctors, R14 Asking for help from nurses, R14 Asking for support Asking for permission to sleep with her son on the bed in order to help him quickly, R16 43 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Communicating for a patient Communicating with doctors for her son, R16 Being involved in caring Being allowed by nurses to be involved in caring for mother in the intensive care unit, R8 Feeling proud to have a chance to help, R8 Being calm Learning to deal with disrespectful relatives with calm manners, N6 Dealing with scolding from relatives by not adding emotion and keeping calm, N8 Facing high expectations from privileged patients and relatives by understanding and using calm manners, N8 Dealing with high expectations from patients and relatives with calmness and politeness and understanding, N8 Dealing with scolding from relatives by not adding emotion and keeping calm, N8 Caring for patients’ body and mind Expecting her sick father has a strong heart, R4 Perceiving as a daughter she can take care of her father and support his mind better than nurses, R4 Perceiving as a daughter she has more sensitivity to her father’s feeling than nurses, R4 Realising relatives from the village want to stay close to patients in the hospital, R4 Caring for father’s body and mind better than nurses , R4 Supporting her father’s mind, R4 Realising patients need kam lung jai (moral support), R4 Being honest Being honest with patients, N12 Being sincere Providing spiritual care for patients with real sincerity, N12 Believing that sincerity is the basis of human relationships, N12 Recommending nurses who can support both VIP and ordinary patients and relatives successfully must have a sense of sincerity, N12 Perceiving sincerity is a highly important characteristic of nurses who are good spiritual supporters, N12 Helping relatives to accept patients’ illness and death with sincerity and kindness, N12 Being flexible Being more flexible, N6 Expecting nurses to be more flexible about the visiting rules, N6 Being flexible about visiting time, N11 Chatting/talking with while working Keeping taking with patients while providing nursing care, N7 Asking patient’s first, N7 Loving to talk with patients, N7 16 Relatives Asking for the truth Asking the doctors to tell the truth if her son has HIV infection, R16 Raising mindfulness/self-awareness Dealing with anxiety and nervousness by raising mindfulness, N6 Dealing with emergency with calm manner and mindfulness, N6 Raising consciousness while helping patients who are in crisis, N13 Having awareness about errors while working, N14 Having self-awareness can help nurses maintain good relationships with patients and relatives, N14 Being concerned about patients’ plan Realising her father needs relatives to stay close to him at night time, R4 Perceiving her father plans to die at the hospital, R4 Using power with nurses Using power with nurses Giving gifts Giving gifts to the nurses for repaying to their help (plus expecting special care), P7 Donating things to the ward to build good relationship with nurses, P7 Using a personal relationship Using a personal relationship to seek better health care services in the hospital, R10 Using special access to health care Having ability to book a private room for his father every admission, R7 Having a chance to access privileged services from the hospital, R7 Using power Finding well-known people who can help to receive special care, P7 Knowing staff at the hospital is a way to receive special care, P7 44 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Maintaining good relationships with patients by chatting with them and educating them to know how to take care themselves, N13 Talking with patients about issues including funny stories, N14 Talking with and being a relative of patients who have no relatives, N14 Being friendly and chatting informally with patients and relatives, N14 Communicating/listening with politeness Concerning patients needs time for conversation and listening, N17 Communicating with patients and relatives from the heart, N1 Using polite words and kind manners, N1 Calling patients’ name politely, N4 Dealing with high demands from relatives with politeness, N4 Listening to complains and suggestions from patients and relatives openly, N4 Listening to patients’ needs and problems, N7 Being a mediator to communicate effectively between health care team and patients and relatives, N4 Understanding fidgety relatives, opening channels to communicate with them, N5 Readying to listen and understand as ways to build good relationships, N6 Listening to patient’s feeling, N8 Building good relationships by listening to patients and relatives, N11 Gaining deep understanding about patient when open nurses’ minds to listen to patients’ beliefs, N11 Dealing with any conflict from patients and relatives by listening to them openly, N11 Realising the learning need to communicate with patients deeply, N11 Valuing soft speech/personality Having a soft personality, N13 Helping a dyspnea patient to calm down by using soft speech to give moral support, N13 16 Relatives Expressing compassion for nurses and/or doctors Appreciating nurses’ caring and support (careful and hard working) Appreciating nurses’ teaching and support, R1 Receiving health care information, R1 Receiving special support from nurses, R1 Receiving kind support, R1 Appreciating nurses’ good services and doing hard and careful work, R2 Appreciating nurses’ work, R5 Appreciating nurses work hard, R5 Appreciating nurses’ good work, R6 Appreciating the caring mind of the head nurses, R6 Appreciating a suggestion for chanting, R14 Reminding husband to appreciate nurses’ close observation and support, R14 Appreciating nurses’ education in taking care of patients, R14 Valuing nurses’ conversation skills, R14 Appreciating nurses’ concern, R14 Appreciating nurses’ suggestions, R14 Appreciating help from nurses and nurse’s assistant, R14 Appreciating nurses’ kindness Perceiving some nurses are kind, R3 Appreciating nurses’ politeness Appreciating nurses’ politeness, R1 Trusting nurses Trusting nurses’ and doctors’ abilities, having moral and skilful care, R2 Trusting in nurses’ technical skills, R11 Appreciating doctors’ support Receiving permission from the senior doctor to take father back home when ready, R11 Receiving moral support from the neurosurgeon, R1 Appreciating good support from doctors and nurses, R12 Managing conflict Managing conflict between VIP relatives and health care team with open listening, N12 Managing conflict between VIP relatives and health care team with understanding their background and perceptions, N12 45 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Managing conflict between VIP relatives and health care team by trying the best to support patients, N12 Dealing with relatives who are dissatisfied in treatment outcomes with respect, N13 Using local language Talking with local patients and relatives by using local language, N11 Reducing patients’ and relatives’ hesitation Reducing patients’ hesitation by giving chances to patients for asking questions, N3 Staying/being with/giving time Staying with and touching crying patients, N10 Caring for a relative who has spiritual distress problems by giving time, N12 Recommending nurses stay with patients in sad moments, N17 Valuing giving more time to know patients, N6 Supporting relatives in a crisis period by walking close to them, staying with them a few minutes until their can manage situations, N12 Helping a dyspnea patient to calm down by staying close to him, N13 Being silent Supporting relatives who are in grief by keeping silent, N12 16 Relatives Understanding nurses’ hard work, tension, workload, and busyness Perceiving some nurses release their tension by talking with patients and relatives while some nurses don’t talk with clients much while working, R6 Realizing nurses have no time to help, R1 Realising nurses need more time to provide psycho-social spiritual support and holistic care, R12 Feeling sympathy with nurses and their hard work, R1 Reminding other relatives that nurses are very busy, R14 Appreciating nurses’ hard work, R14 Perceiving community nurses are very busy, R10 Feeling compassion for nurses about their hard work, R15 Trying to take care of her sick granddaughter while she is hospitalised, R15 Asking for help from nurses when it is really necessary, R15 Perceiving there are not enough nurses, R3 Suggesting more nurses per shift, R3 Recognising the need for more nurses, R8 Understanding effects of relatives on nurses Realising nurses are being blamed by patients’ relatives, R14 Experiencing some relative complain about nurses’ lack of care, R14 Feeling sympathy with nurses Feeling sympathy for busy nurses, R14 Trying to take care of husband without calling for help, R14 Avoiding interfering in nurses’ work Avoiding obstructing a ward keeper’s work, R14 Concerning proper time Supporting relatives who are in grief by using suitable words in a proper place and time, N12 Waiting until patients calm down before explaining a situation, N13 Questioning the proper time to ask about patients’ values, beliefs and body image, N17 Following the visiting rules Following the visiting rules of the ward, R5 Touching patients Touching patients, N1 Touching crying patients, N10 Not touching often, N10 Touching male and female patients differently, N10 Supporting relatives in a crisis period by touching their hands, N12 Helping/supporting nurses Appreciating nurses’ abilities, R7 Understanding the limit of nurses’ work in the private unit, R7 Trying to help his wife and avoiding bothering nurses’ and doctors’ time, R2 Realising nurses can release tension with relatives, R14 Repaying gratitude for nurses Having ideas to repay gratitude to nurses, R10 46 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Giving moral support/maintaining hope Supporting patient’s mind with kindness and understanding, N3 Talking about positive thinking while giving moral support to patients, N3 Maintaining patients’ hope, N3 Using time to support patients’ mind, N3 Running a psycho-spiritual support project for patients in the ward, N3 Supporting patients with understanding the nature of illness and process of treatments, N3 Giving moral support to Muslim patients, N6 Trying to provide more moral support in busy wards, N6 Supporting relatives in a crisis period by telling them to keep mentally calm, N12 Giving moral support to AIDS patients, N13 Supporting patients who have had an amputation to consider value of life, N14 16 Relatives Supporting nurses by giving a gift Avoiding negative reactions from nurses by asking permission to repay her gratitude to every nurse and staff by giving some fruit and desserts, R9 Receiving compassionate care from nurses and doctors Enhancing patients’ confidence Enhancing patients’ confidence to cope with illness, N15 Encouraging patients to tell their needs without hesitation, N14 Appreciating doctors’ and oncologist’s support Appreciating kind suggestions from the oncologist, R14 Receiving information regularly from the oncologist, R14 Appreciating kindness from doctors and nurses, R14 Appreciating friendly doctors with a sense of humour, R14 Perceiving the need to consult nurses about further plans for her father, R9 Consulting the doctor informally because of having a personal relationship with him, R9 Appreciating good support from nurses, R11 Receiving good help from the nurse assistant who becomes like a real relative, R11 Valuing nurses’ supporting patients and relatives to accept their illness and death, R11 Appreciating services of nurses and doctors from the hospital, R13 Appreciating equal care of nurses and doctors, R15 Appreciating moral support from nurses, R15 Encouraging questions Caring for a relative who has spiritual distress problems by encouraging asking questions, N12 Receiving information from nurses Being taught by nurses to take care of his stroke father at home, R6 Nurturing patients’ strength/empowering Supporting patients by nurturing patients’ strength, N1 Giving power to patient and talking rather than ignoring and being a bully, N6 Encouraging patients to be patient to fight with their illness and get better, N14 Encouraging patients help other patients who can’t walk, N14 Sharing nurses’ suffering experiences Caring for a relative who has spiritual distress problems by sharing nurses’ suffering experiences, N12 Counselling Being an informal counsellor for CVA patient’s relatives, N12 Expecting every nurse can give a patient’s counselling, N12 Supporting patients Supporting the patient who is ignored by another nurse, N13 Ordering food for patients which doctors forget, N13 47 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Supporting relatives Giving a chance for relatives to stay closer to critically ill patients, N5 Letting relatives support patients while patient is in an emergency situation, N6 Calming relatives while patient is in an emergency situation, N6 Understanding relatives’ feeling when their loved ones are in crisis or reaching death and encouraging them to get involved in helping the dying patients, N12 Providing spare beds to elderly relatives who stay overnight with patients, N13 Being frank Telling them frankly when nurses are very busy, N12 Preventing guilt Finding solutions for terminally ill patients to prevent guilt, N17 Making merit for patients Donating nurses’ money to support poor patients-nurses can make merit with patients, N5 Radiating loving kindness Radiating loving kindness to patients, N7 Giving excuses Giving excuse when nurses do wrong, N4 Giving forgiveness Giving forgiveness, N4 Giving forgiveness and not getting angry easily to keep calm, N12 Monitoring/reflecting staff’s misbehaviours Reminding pre-registered nurses to improve their manners, N10 Informing patients and relatives to give feed back to nurses about impolite staff, N7 Helping junior nurses Helping junior nurses deal with swaggering relative, N9 Sharing caring experience of senior nurses to new nurses is a way to develop their caring skill, N12 Building therapeutic relationships with colleagues Building a fun atmosphere in the work place, N16 Helping nurses by reflecting on her real causes of economic problems, N16 Asking for help from senior nurses Asking other senior nurses to help when being not ready to deal with any conflict from patients and relatives, N11 16 Relatives Receiving compassionate support from nurses and/or doctors Receiving information about her father’s further treatment plans from the doctors, R4 Receiving information from nurses about how to take care of her father, R4 Receiving moral and financial support from relatives and friends Having a helping relationship with extended family, R1 Receiving strong moral support from friends and relatives, R1 Having financial problems, R3 Having an extended family, R3 Receiving financial support from relatives, R3 Receiving moral support from sister, R8 Consulting other close relatives to make decisions about her sick father Appreciating a lot of support from relatives and neighbours from the village, R4 Asking her brother to ask for information about her son for her, R5 Letting her husband make a decision about a suitable last solution for her son, R5 Receiving financial support from her sister and her boss, R5 Receiving financial support from his brothers and sisters to care for his father, R6 Receiving help from his wife to prepare blended food for his father, R6 Appreciating a helping atmosphere in the family, R7 Perceiving her father has got a lot of moral support from family, relatives and neighbours, R9 Receiving good moral support from relatives and neighbours, R9 Having her son to help her take care of her husband especially to move and change position, R13 Receiving financial support from her children, R13 Receiving moral support from friends and neighbours, R15 Having a warm extended family, R15 Receiving help and support from relatives while her children are sick, R15 Receiving moral support from people in the communities, R15 48 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compassion with equanimity Consulting experts Preventing all conflicts from patients and relatives by consulting the medical jurisprudence and maintaining proper communications, N11 Moving a patient to another ward Dealing with bad impressions of relatives by moving a patient to another ward, N11 16 Relatives Receiving financial and material support from others Realizing the benefit of health insurance, R1 Appreciating people who donate medical equipment, R1 Setting proper rules and orders for relatives Setting proper rules and orders for relatives while letting them stay with every patient, N9 Being professional (skilful) Being skilful Perceiving senior nurses are more interested in spiritual care than junior nurses Assigning senior nurses to approach patient holistically and build good relationships with patients, N5 Doing deep psycho-spiritual approach and care needs higher knowledge and skills, N5 Using working experience to predict patients’ condition and plan for terminal case naturally with relatives, N5 Looking at the causes of the illness from patients’ family and financial background, N16 Providing effective care Providing effective care, N10 Providing equal care Providing equal care, N1 Maintaining professional standards of care Maintaining standard care for patients even when nurses don’t feel sympathy for bully relatives, N8 Expecting nurses provide nursing care at professional standards, N9 Providing comfort and safety care Having good relationship with patient while providing comfort and safety care, N7 Being concerned about elderly caregivers, to not let them to bathe their patients, N8 Being concern about relatives’ safety while they help HIV and AIDS patients without knowing their diagnosis, N8 Being concerned about economic problems Being concerned about and helping patients manage their economic problems, N8 Teaching relaxation Improving relationships with patients by trying to introduce patients to breathing meditation to relax themselves, N7 Helping making decision Helping relatives make proper decisions for terminally ill patients, N5 49 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses Core category 3: Embodying mutual compassion with equanimity 14 Patients 16 Relatives Orientating/Informing/Providing information Implementing a good orientation system and providing information regularly, N5 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 relationship, N5 Providing psycho-spiritual care for patients and relatives by providing information regularly, N5 Maintaining good relationships with relatives by giving enough information about patient’s condition, N5 Giving information while patient is in an emergency situation, N6 Providing enough information, N7 Having good relationships with patients because nurses give information to patients regularly, N7 Providing information regularly with simple words and respecting a way for nurses to building good relationship with patients and relatives, N8 Perceiving nurses relieve patients’ anxiety by giving information, N15 Trying to provide information to reduce clients’ hesitation, N15 Valuing information for relatives, N17 Providing enough information about the patients’ condition and plan, N11 Providing information is a way to support patients’ minds, N11 Orientating/informing/providing information (cont.) Providing more psycho-support for patients by giving enough information, N11 Providing proper information to patients and relatives regularly can prevent relationship problems which come from their dissatisfaction, N12 Supporting relatives in a crisis period by explaining to them what is happening to patients, N12 Expecting nurses love to give information to patients, N13 Building good relationships with patients by giving information regularly, N14 Using simple language when providing information Providing information to patients and relatives with simple language, N9 Helping patients to clear understanding about high level of doctors’ language, N11 Supporting and educating Supporting and educating patients, N1 Supporting living with cancer peacefully, N1 Focusing more on patients’ perspectives while educating patients, N3 Educating patients following their background and taking with them in every aspect of life, not only about illness, N6 Trying to educate patients while providing nursing care, N8 Educating patients is a way to support their mind, N11 Appreciation educating activities of the nurses, N11 Building friendship and supporting friends among patient’s relatives, N11 Educating patient is a way to support patients’ minds, N13 Educating relatives to help nurses observe and report patients’ conditions, N13 Educating relatives to rehabilitate CVA patients, N13 Educating relatives to do basic procedures for patient such as bathing, mouth care and feeding, and observing and reporting on patient’s conditions, N14 50 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses Core category 3: Embodying mutual compassion with equanimity 14 Patients 16 Relatives Educating Relatives Teaching a main caregiver of chronic patients to do basic nursing such as such as feeding via nasogastric tube, bathing, doing range of motion exercises, suctioning, defecating, and shampooing for their home care, N11 Balancing nurses’-clients’ power Recognising the equality of nurses’ and clients’ power, N10 Balancing mutual goals Balancing the needs of relatives and hospital goals, N12 Asking help from relatives Asking relatives to watch patients while nurses are very busy, N7 Expecting help from relatives while having limitation of nurses, N8 Co-ordinating Perceiving nurses are coordinators of patients, relatives and doctors, N15 Being a coordinator between patients, relatives and doctors, N17 Receiving information from doctors, N17 Being a mediator between patients and doctors when patients want to use herbal medicine, N11 Continuing care Transferring patients’ emotional problems to the next shift nurses for maintaining continual care, N3 Needing to maintain continual care and communication with other nurses, N17 Concerning continual care in psycho-spiritual issues, N11 Planning to discharge patients Planning to discharge patients who relatives don’t want to take back home, N12 Evaluating Trying to measure patients’ psycho-spiritual outcomes, N3 Realising patients and relatives’ compassion Understanding nurses’ situations and limitations Perceiving relatives understand the limitation of nurses, N8 Experiencing relatives are happier to stay with relatives while they are admitted, N9 Understanding that nurses are very busy can reduce patients’ and relatives’ dissatisfaction and mean fewer complaints, N14 Being kind to nurses and doctors Perceiving Thai people are compassionate, kind and smiling, N14 Perceiving Thai patients and relatives usually give forgiveness and don’t want to make formal complaints when nurses or doctors who are kind and polite do something wrong, such as hurting patients, N14 51 Cultivating Compassionate Relationships with Equanimity between Nurses, Patients, and Relatives 17 Nurses 14 Patients Core category 3: Embodying mutual compa
