research article list

Thai Journal of Nursing Research

Vol. 6 No. 4 October - December 2002 ISSN-0859-7685

Factors Influencing Role Adaptation of Patients with Cervical Cancer

Receiving Radiation Therapy

Yupapin Sirapo-ngam, RN., DSN. Panwadee Putwatana, RN., D.Sc.Luppana Kitrungroj, MNS. Virat Piratchavet, M.D.

Marital Developmental Tasks of Thai Spouses in Childrearing Families

Rutja Phuphaibul RN. , D.N.S. Arunsri Tachudhong RN. , M.S.Chuanraudee Kongsaktrakul RN., M.P.H, M.N.S.

Self-regaining from loss of self-worth: A substantive theory of recovering

from depression of middle-aged Thai women

Acharaporn Seeherunwong, Tassana Boontong RN. Ed.D.,Siriorn Sindhu RN., D.N.Sc., Tana Nilchaikovit M.D.

Chronic Dyspnea Self-Management of Thai Adults with COPD

Supaporn Duangpaeng RN, D.N.S. Payom Eusawas RN, Ph.D. Suchittra Laungamornlert RN, DNSc.Saipin Gasemgitvatana RN, D.N.S. Wanapa Sritanyarat RN, Ph.D.

Exploring Ethical Dilemmas and Resolutions in Nursing Practice :

A Qualitative Study in Southern Thailand

Aranya Chaowalit RN. Ph.D. Urai Hatthakit RN. Ph.D. Tasanee Nasae RN. M.Ed.Wandee Suttharangsee RN. Ph.D. Marilyn Parker RN. Ph.D.

Concept Analysis: Self-Efficacy

Wannipa Asawachaisuwikrom, Ph.D.

Spirituality: A Concept Analysis

Wanlapa Kunsongkeit RN. MNS.(Medical and Surgical Nursing)Marilyn A. McCubbin RN. Ph.D. FAAN.

Vol. 6 No. 2 1

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Vol. 6 No. 4 ë October - December 2002 ISSN-0859-7685

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Journal articles1. Armitage P, Champney-Smit J, Andrews K. primary nursing and the role of the nurse preceptor

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Vol. 6 No. 4 October - December 2002 ISSN-0859-7685

Content163 Factors Influencing Role Adaptation of Patients with Cervical Cancer

Receiving Radiation TherapyYupapin Sirapo-ngam, RN., DSN. Panwadee Putwatana, RN., D.Sc. Luppana Kitrungroj, MNS.

Virat Piratchavet, M.D.

177 Marital Developmental Tasks of Thai Spouses in Childrearing FamiliesRutja Phuphaibul RN. , D.N.S. Arunsri Tachudhong RN. , M.S.

Chuanraudee Kongsaktrakul RN., M.P.H, M.N.S.**

186 Self-regaining from loss of self-worth: A substantive theory of recoveringfrom depression of middle-aged Thai womenAcharaporn Seeherunwong, Tassana Boontong RN. Ed.D., Siriorn Sindhu RN., D.N.Sc.,

Tana Nilchaikovit M.D.

200 Chronic Dyspnea Self-Management of Thai Adults with COPDSupaporn Duangpaeng RN, D.N.S. Payom Eusawas RN, Ph.D. Suchittra Laungamornlert RN, DNSc.

Saipin Gasemgitvatana RN, D.N.S. Wanapa Sritanyarat RN, Ph.D.

216 Exploring Ethical Dilemmas and Resolutions in Nursing Practice:A Qualitative Study in Southern ThailandAranya Chaowalit RN. Ph.D. Urai Hatthakit RN. Ph.D. Tasanee Nasae RN. M.Ed.

Wandee Suttharangsee RN. Ph.D. Marilyn Parker RN. Ph.D.

231 Spirituality: A Concept AnalysisWanlapa Kunsongkeit RN. MNS.(Medical and Surgical Nursing) Marilyn A. McCubbin RN. Ph.D. FAAN.

241 Concept Analysis: Self-EfficacyWannipa Asawachaisuwikrom, Ph.D.

Yupapin Sirapo-ngam et.al.

Vol. 6 No. 4 163

Factors Influencing Role Adaptation of Patients with CervicalCancer Receiving Radiation TherapyYupapin Sirapo-ngam, RN., DSN.* Panwadee Putwatana, RN., D.Sc.*Luppana Kitrungroj, MNS.** Virat Piratchavet, M.D.***

* Associate Professor, Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University.** Lecturer, Faculty of Nursing, Prince of Songkla University.

*** Assistant Professor, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University

Abstract: This descriptive study aimed to describe role adaptation and to ascertainthe predictive power of severity of side effects, self-esteem, social support, andeducation on role adaptation of patients with cervical cancer receiving radiationtherapy. The Roy Adaptation Model was used as the conceptual framework for thestudy. Eighty-six patients with cervical cancer receiving radiation therapy wererecruited from the outpatient radiotherapy unit of six hospitals in Bangkok duringFebruary to June 2000. The inclusion criteria for the sample selected were womenwho (1) were married and lived with their spouse, (2) had no treatment of radiationor chemotherapy prior to participation in this study, (3) had been receiving radiationtherapy for at least a 3-week period, (4) were able to understand, and speak Thai,and (5) agreed to participate in this study. There were five questionnaires used:1) Demographic and Clinical Data Form, 2) Severity of Side Effects Questionnaire,3) Rosenberg Self-Esteem Scale, 4) Personal Resource Questionnaire, and 5) RoleAdaptation Questionnaire.

It was found that patients with cervical cancer receiving radiation had a rathergood level of role adaptation. The stepwise multiple regression analysis revealedthat the combination of social support, self-esteem, and severity of side effectsaccounted for 54.8% of the variance in role adaptation of patients with cervicalcancer receiving radiation. Education did not significantly account for the variancein role adaptation. The result of this study was congruent with the role functionmode within the Roy Adaptation Model. Nurses should be concerned with theinfluence of social support, self-esteem, and severity of side effects on patientsûrole adaptation and keep them in mind when caring of these patients. Futureintervention research on role adaptation of patients with cervical cancer receivingradiation therapy should consider these factors.

Thai J Nurs Res 2002 ; 6(4) : 163-176

Keywords: role adaptation, cervical cancer, radiation therapy

Factors Influencing Role Adaptation of Patients withCervical Cancer Receiving Radiation Therapy

Thai J Nurs Res ë October - December 2002164

Background and ObjectivesAccording to the annual statistical reports of

the National Cancer Institute of Thailand from1994 to 1996,1 cervical cancer was the mostprevalent female cancer, with the highestincidence in the middle-aged group (35-60 years).Radiotherapy (RT) is one of the most commontreatment modalities for curing cancer of cervixin its initial stages and for reducing complicationsof the disease in the terminal stages2 (Einhorn,1996). Although RT has many advantages, it canproduce many side effects that impact physicaland psychosocial health3-5. Most women may alsoundergo major role changes. These includereducing and losing current role tasks andintegrating the sick role into their life.Experiencing a major role change or transition toa new role can be a stressful situation. Rolechanging and the adoption of new roles requirethe incorporation of new knowledge andstandards of behavior for role performances6. Thereis also a guarded effort and difficulty for thesepatients to maintain other existing roleseffectively during the course of radiation. This isimportant because these roles to which womenmust adapt are often permanent and usuallyinclude significant problems for the remainder oftheir lives7. These patients need much support fromothers to adjust to effective role functioning.

Social support refers to the psychosocial andtangible aid provided by significant others and/or social networks8. It is a major mean of assistingpatients to develop greater self-confidence andfeelings of autonomy and control in respondingto and modifying their environment. A personreceives various types of social support includingintimacy, opportunities for social integration,opportunities for nurture and reassurance of worth.An availability of informational, emotional, andmaterial supports is also important9. Many studieshave confirmed the importance of social support

for chronically ill patients10-13. Social supportenhances adaptive role performance whichimproves physical recovery, psychologicalwell-being, and social functioning10-13.

Level of education has also been associatedwith role adaptation. Several studies have shownthe positive relationships between educationalachievement and role adaptation14-17.

The objectives of this research were todescribe role adaptation of patients with cervicalcancer receiving radiation therapy and toascertain the predictive power of severity of sideeffects, self-esteem, social support, and years offormal education on role adaptation of patientswith cervical cancer receiving radiation therapy.

The Roy Adaptation Model18 was used as aconceptual framework to study the severity of sideeffects, self-esteem, social support, and educationon role adaptation of cervical cancer patientsreceiving RT. This study focuses on roles of beinga wife, work (inside and outside the home), andthe sick role. The focal stimulus was the externalalteration produced by the radiation therapy. Thestimulus is acted upon by the coping mechanismsthrough cognator and regulator subsystems. Theeffects of the cognator and regulator activities areobserved in the four modes of adaptation. In thisstudy, the physiological, self-concept, andinterdependence modes were deducted fromempirical indicators that were severity of sideeffects, self-esteem, and social support, respectively.The behavioral responses of these three modesmay act as a pooled effect on the fourth mode,the role function mode which reflects roleadaptation. The results of this study are importantfor professional nurses to develop effectivenursing interventions that promote roleadaptation of patients receiving RT for cervicalcancer. Providing interventions focused onsupport and resources can enhance roleperformance and in doing so patients can achievesocial integrity.


Vol. 6 No. 4 165

Method

Subjects and SettingsThe subjects were patients with cervical

cancer receiving radiation therapy who wererecruited from the outpatient radiotherapydepartment of six tertiary care hospitals inBangkok. Data were collected in a five-monthperiod, February to June 2000. Purposivesampling was used. The inclusion criteria werewomen who: 1) were married and lived with theirspouse, 2) had no prior treatment with radiationor chemotherapy, and 3) had been receivingradiation (3,000 cGy), at least for a 3-week period.

InstrumentsThe instruments used for data collection are

composed of the 5 following parts:1. Demographic and Clinical Data

Form. This included demographic and clinicaldata obtained from interviews and medical records.

2. Severity of Side Effects Questionnaire.

The severity of side effects questionnaire wasdeveloped by the researcher which was based onthe Acute Toxicity Criteria of The RadiationTherapy Oncology Group19, and the literaturereview. Only the frequent acute complicationsassociated with the major problems of thesepatients were selected. Thus, the questionnairewas comprised of 10 items, covering skinreaction, food intake, nausea, vomiting, diarrhea,dysuria, frequent urination, fatigue, and emotionalalteration. There were four descriptions ofseverity of side effects ranging from normal/nosymptom = 1 to severe/abnormal symptom = 4.Total scores ranged from 10 to 40. The higher thescores, the greater the severity of side effects.The alpha Cronbachûs coefficient of the severityof side effects in this study was .73.

3. Self-Esteem Questionnaire. Theresearchers used the Rosenberg Self-Esteem

(RSE) Scale20 for measuring patientsûself-esteem. The scale contains 10 items; halfpositive-score items and half negative-score items.The scores of negative items are reversed. Eachitem was indicated on a 4-point Likert-type scalefrom strongly disagree to strongly agree. The RSEScale can yield a score from 10 to 40, with higherscores indicating higher self-esteem. The internalconsistency of the RSE scale was tested in thisstudy and gained reliably adequate (Cronbachûsalpha coefficients = .86).

4. Social Support Questionnaire. ThePersonal Resource Questionnaire 85 (PRQ 85)-Part II was used to measure the adequacy of theindividualûs perceived level of social support.This instrument was developed and revised byBrandt and Weinert9. In this study, the researcherused Soomlekûs questionnaire,21 which wasmodified from the PRQ 85-Part II. It consists of21 items on a 5 point-Likert scale including nevertrue = 1, rarely true = 2, somtimes true = 3, oftentrue = 4, and always true = 5. The total scoresranged from 21-105. For the present study, theCronbachûs alpha coefficient of the PRQ 85-PartII was .86.

5. Role Adaptation Questionnaire. Theoriginal role adaptation questionnaire wasdeveloped by Ounprasertpong22 for HIV positiveand AIDS patients based on role function modeof the Roy Adaptation Model. This questionnairewas used for assessing patientsû ability toperform role behaviors. The questionnaireemphasizes three sub-roles: wife role, work role,and sick role. The Role Adaptation Questionnairewas on a 5-point-Likert scale itemized asfollows: never perform =1, rarely perform = 2,sometimes perform =3, often perform = 4, andalways perform =5. It contains 28 items including20 positive items and 8 negative items. Total scoresranged from 28-140. It was found that thereliability as measured by Cronbachûs alphacoefficient in this study was .80.



Protection of Human SubjectsThe rights of the subjects were respected in

this study. Eligible subjects were individuallyapproached to participate in the study. The studyobjectives, the data collection processes, expectedresearch outcomes, subject rights, the type ofquestionnaires, length of time for completing thequestionnaires, and right to refuse to participatein the study were explained. The subjects whoagreed to participate were assured that the datawould be kept confidential and reported as groupdata.

Data Collection and Data AnalysisAll eligible subjects who met the criteria were

approached and the protection of human subjectûsprotocol was explained as previously described.The subjects, who volunteered to participate, readand completed the questionnaires by themselvesin the following order: the Demographic andClinical Data Form, the Severity of Side EffectsQuestionnaire, the Rosenberg Self-Esteem Scale,the Personal Resource Questionnaire (PRQ-85part II), and the Role Adaptation Questionnaire.During this procedure, the investigator providedmore information and clarification when needed.The researcher read the items on the questionnairesto any participants experiencing difficulty inreading. Reading the questionnaires by theresearcher was done to ninety percent of thesubjects.

The Statistical Package for Social Sciencesfor Windows Program (SPSS/ FW) version 9.0was used for data analysis. The predictivepowers of severity of side effects, self-esteem,social support, and education on role adaptationof patient with cervical cancer receivingradiation therapy were analyzed using stepwisemultiple regression analysis.

ResultsEighty-six patients participated in the study.

The age of cervical cancer patients ranged from25 to 65 with the mean age of 45.90 years. Themajority of the subjects (70.93%) weremiddle-aged women (36-55 years). Most of thesubjects (65.11 %) completed formal primaryeducation. Approximately half of the subjects werehousewives and the rest worked outside the home.Around thirty six percent of subjects had familyincome of less than 5,000 baht per month; theremainder had family income ranging from 5,001to 90,000 baht. Nearly 47% of families had anincome that exceeded their expenses. Most of thesubjects (70.93%) were able to reimburse theirmedical expenses from the government or fromtheir private insurance companies. The majorityof the subjects (77.91%) were diagnosed withsquamous cell carcinoma of the cervix andapproximately 59% were at stage II of thedisease. Nearly 70% of the subjects received dosesof radiation ranging from 3,001- 4,000 cGy for16 to 20 days.

Based on the range of scores set up for theinterpretation, the mean scores of role adaptation(role set score) were listed by each item fromhighest mean score to lowest in Table 1. The meanscores of role adaptation were 109.52 (S.D. =11.77, min = 82, max = 132). It can beinterpreted that the subjects of this study hadlevels of çRather Good Role Adaptationé.


Vol. 6 No. 4 167

Table 1.Means, standard deviations, and rank of role adaptation of cervical cancer patients

receiving radiation therapy (n= 86)

Role Adaptation Mean S.D. Rank

Regularly receiving radiation as the physician 4.95 .26 1prescribed

Desiring to replace radiation with other alternative 4.90 .38 2Treatments

Appropriately caring for radiated skin 4.83 .51 3Taking preserved, spicy, or strong tasting foods 4.67 .69 4Being discouraged and desiring to discontinue the 4.67 .79 5

treatmentDrinking adequate water 4.55 .90 6Satisfied with my compliance with treatment 4.50 .72 7

regimensBeing irritated by fighting with husband 4.31 1.09 8Wishing to a love and care for my husband 4.19 .94 9Choosing healthy diet 4.15 .86 10Regularly taking good perineal care 4.15 .87 11Sleeping adequately 4.01 1.1 12Talking and listening to husband 4.00 .89 13Being anxious but do not apparently express 3.85 1.31 14Observing abnormal symptoms by myself 3.77 1.03 15Working intentionally 3.76 1.05 16Being inert at work 3.73 .95 17Consulting physicians/nurses concerning health 3.67 1.23 18

problemsBeing proud of work. 3.66 .95 19Exchanging experiences/ problems with other 3.57 1.15 20

similar patientsBeing bored with the trip to the hospital daily 3.57 1.32 21Being worried about insufficient family care 3.53 1.32 22Seeking information concerning self-care practices 3.50 1.33 23Taking care of family expense 3.48 1.83 24Providing time and being responsible for work 3.30 .90 25Improving work 3.16 1.02 26Helping friends who have problems 2.86 1.18 27Exercising 10-15 minute a day 2.23 1.41 28

Min = 82 , max = 132 total 109.52 11.77



As indicated in Table 2, the severity of sideeffects had a mean score of 19.02 (S.D.= 4.53,skewness = .37). It was found that the subjectstended to perceive a low severity of side effects.In contrary, self-esteem had a mean score of 34.30(S.D. = 4.46, skewness = -1.13) and social

support had a mean score of 84.85 (S.D. = 11.81,.45). So this indicated that the subjectspotentially have high self-esteem and perceivedhigh social support. Subjects tended to have alow formal education with a mean of 6.06.

Table 2 Ranges, means, standard deviations, and skewness of the severity of side effects, self-

esteem, social support, and education (n= 86)

Variables Range Mean S.D. Skewness

Possible ActualRange Range

Severity of side effects 10-40 10- 34 19.02 4.53 .37Self-Esteem 10-40 18-40 34.30 4.46 -1.13Social support 21-105 61-105 84.85 11.81 -.45Education (year) ≥0 0-16 6.06 4.46 1.16

The correlations among predictor variablesand role adaptation were computed by usingPearsonûs product moment correlation. Thecorrelation matrix among the studied variables ispresented in Table 3. The results revealed thatthe role adaptation had a significant negativecorrelation with the severity of side effects(r = -. 43, p < .001). However, it is positivelycorrelated with self-esteem, and social support(r = .52, p < .001; r = .68, p< .001) respectively.

There was no significant relationship betweenrole adaptation and education (r= .15, p > .05). Inaddition, there were significantly low tomoderate relationships among predictors.Severity of side effects was significantly andnegatively correlated with self-esteem and socialsupport (r = -.28, p < .01; r = -.33, p< .01).Social support was significantly and positivelycorrelated with self-esteem and formal education(r = .48, p < .001; r = .22, p < .05), respectively.

Table 3 The correlation matrix of the studied variables (n = 86)

Variables 1 2 3 4 5

1. Severity of side effects 1.002. Self-esteem -.28** 1.003. Social support -.33** .48*** 1.004. Education -.01 .09 .22* 1.005.Role adaptation -.43*** .52*** .68*** .15 1.00

*** p <.001, ** p < .01, * p < .05


Vol. 6 No. 4 169

Assumptions of regression analysis, whichinvolved considerations of residual scatter plotswere examined. The residual scatter plots indicatedthat the assumptions of regression analysis weremet. All pairs of variables had linear correlation.Multicollinearity, diagnosed by having correlationsamong independent variables greater than .65, wasnot found. All independent variables had low tomoderate correlations with one another (r = - .33to .48). A Durbin-Watson value was 2.19, whichindicated that the regression error had noautocorrelation23.

As shown in Table 4, stepwise multipleregression was used to analyze the predictivepower of severity of side effects, self-esteem,social support, to role adaptation.

Social support, which had the highestcorrelation with role adaptation, was first selectedin the regression equation. Social supportaccounted for 46.4 % of the variance in roleadaptation (F change 1,84 = 72.66, p < .001).This indicated that a one unit change in socialsupport will cause a 0.51 unit change in role

adaptation in the same direction (β = .51,t = 5.89, p < .001). Next, self-esteem wasselected, which accounted for an additional 4.9 %of the variance in role adaptation (F change1, 83= 8.39, p < .01). This indicated that a one unitchange in self-esteem will cause a 0.22 unit changein role adaptation in the same direction (β = .22,t = 2.58, p < .05). Severity of side effects waslastly selected into the analysis and accounted foran additional 3.5% of the variance in roleadaptation (F change1, 82 = 6.30, p < .05). Thisindicated that a one unit change in the severity ofside effects will cause a 0.20 unit change in roleadaptation in the opposite way (β = -.20,t = -2.51, p < .05). The findings indicated that thecombination of social support, self-esteem, andseverity of side effects significantly accounted for54.8% of the variance of role adaptation ofcervical cancer patients receiving radiation therapy(overall F 3, 82 = 33.11, p < .001). Education didnot significantly account for the variance of roleadaptation. Therefore, the result of hypothesistesting was partially supported.

Table 4 Stepwise multiple regression of role adaptation of cervical cancer patients receiving

radiation therapy (n = 86)

Predictors RSQ RSQ change F change β t

Social support .464 .464 72.66*** .51 5.89***Self-Esteem .513 .049 8.39** .22 2.58*Severity of .548 .035 6.30* -.20 -2.51*side effects

(Overall F 3, 82 = 33.11, p < .001),*** p < .001 ** p <.01 * p < .05



DiscussionThe mean score on role adaptation (role set)

was 109.52 which suggested that patients withcervical cancer receiving radiation had levels ofçRather Good Role Adaptationû. The overall roleadaptation was viewed as the combination ofadaptation to three sub-roles including wife, work,and sick roles. However, when considering theranking of mean scores by each individual item,it was apparent that the seven highest mean scoreswere in the sick role adaptation (Table 1). Thiscan be explained by the social mechanisms withinthe role function mode of the RAM24. It could bereflected that the women with cervical cancerreceiving radiation may appraise and set the sickrole as the significant priority in setting behaviorpriorities. The patients may have attempted tointegrate the sick role (new role) into their life,while they had many current roles within theirrole set (i.e., work and wife roles). When theirintegration processes were challenged,compensatory processes were activated. Thewomen formulated their effective role transitionin order to meet the goal of adaptation (i.e.maintaintheir health and survival) by increasing theiradaptation level through cognator processes. Theysimultaneously delegated their usual tasks tofamily members or co-workers in order to complywith radiation therapy schedules. Nevertheless,they tended to maintain system balance betweenroles of being sick, wife and work.

The findings from this study supportSoompoo and Tongtanunamûs studies17,25 of roleadaptation of patients with receiving cancertreatments. In general, patients receiving cancertreatments perform an effective role adaptationor have a good sick role adaptation. However,during the course of treatment, patientsû roleadaptation may change. As reported in two studiesconducted by Pittayapan26 and Ruankon27, theresults showed that the outcomes of role functionand quality of life of patients with cervical

cancer in the third and the fifth week of radiationwere significantly lower than those outcomes priorto radiation. These studies used a longitudinaldesign that allowed changes to be collected overtime. Therefore, it is not surprising that thefindings of these previous studies are notcongruent with this present cross-sectional study.

Based on their sick role during radiation, thepatients should exercise 10-15 minutes a day. Theresults showed that sixty-three percent of thepatients never or rarely exercised. Therefore, themean score of this item was the lowest (mean= 2.23). It is possible that the patients mightbelieve that household activities were already goodexercise. In addition, being fatigued as a result ofthe side effects of the treatment and dailytransportation diminished the desirability ofexercise. Graydon, et al.28 also reported thatpatients who underwent cancer treatments wereoften suggested to limit their activity and get plentyof rest. In this study, nearly 50% of patientsindicated that they were reluctant to exercisebecause of various reasons. For instance, they wereunsure if exercise might be risky for their health.In addition, they rarely received advice from healthprofessionals in this respect. Accordingly,performing exercise was reported to be the greatestself-care deficit in cervical cancer patientsundergoing radiation5.

Obviously, additional findings in this studyrelate to sexual issues. Eight patients addressedsexual and marital conflict. Specifically, theymentioned the inability to have sexual relationswith their partner. Some patients said that theycould no longer have sex. However, this issuewas not able to be explored because it wasregarded as an embarrassing issue for thesubjects. Thus, the issues of exercise and sexualrelationships may add to the important problemswhere patients tend to have an ineffective roleadaptation. Nurses, therefore, should be aware andplan intervention to prevent ineffective rolebehaviors.


Vol. 6 No. 4 171

The findings indicated that the combinationof social support, self-esteem, and severity of sideeffects significantly accounted for 54.8% of thevariance of role adaptation is patients withcervical cancer receiving radiation therapy. Amongpredictors, social support was the strongestvariable influencing role adaptation. The subjectsreported that they received social support fromvarious resources such as a spouse or close friendsin several ways including intimate relationshipsand attachment, and instrumental support. Smallsocial groups (i.e., a group of similar patients,neighbors) were potential sources of companionshipand services. The work group may provide a senseof belonging, competence, and usefulness for themas well. Additionally, professional guidance is auseful resource.

Taken together, it is not surprising that thesubjects who participated in this study haveadequate and compassionate social support thatconsequently may (1) give them a sense ofself-esteem and personal efficacy, (2) enhancecognitive processing required for effectivedecision making and problem solving in stressfulsituations, and (3) reduce negative moods. As aresult, social support would enhance cooperationin engaging in effective role performance, andconsequently, role adaptation8,13,29-31. Thesefindings are similar to that of the previous studiesin cancer patients receiving treatments12,25,32-34

The significant positive relationship betweensocial support and role adaptation supports theconception within the RAM18. Royûs conceptualizationof interdependency and two major stimuliinfluencing role function, i.e., çaccess to facilitieséand çcooperation or collaborationé was viewedas social support in this study. Thus, the findingssupport the proposition of the RAM which statedthat there are interrelationships among adaptivemodes. Specifically, social support, as a factorrepresenting the interdependence mode, whichhelps modify role behaviors in the role functionmode, influences role adaptation in this particulargroup of patients.

Self-esteem was the second predictorinfluencing role adaptation. There was a positiverelationship between self-esteem and roleadaptation. It can be explained that self-esteem isan essential factor influencing behaviors leadingto personal effective functions. High self-esteemempowers patients to be active participants in care,helps the patients develop confidence ininterpersonal communication, and enhances thepotential for successful role performance. Thus,patients with high self-esteem feel that they areworth the time and effort needed to maintain andimprove health and eagerly take responsibility tomeet self-care needs. Conversely, the individualwith low self-esteem may be unable to makeself-care decisions and assume responsibility forcare outcomes35. Obviously, during radiation,about 50% of the sample received their wagesfrom actual employment. In addition, nearly halfof the workers (22 cases) reported that their rela-tionship with friends and co-workers were asusual. The work settings and the support that theyreceived in the work place or social environmentpossibly produced a positive self-esteem and valuein these patients36-37. In accordance with Uckanit38,Vichitvatee39, and Yoswattana40, self-esteem wassignificantly and positively correlated withself-care behavior and role adaptation in patientswith chronic diseases.

Severity of side effects was selected last toenter in the regression equation, and had anegative relationship to role adaptation. It maybe explained that the patients may have greateror lesser symptom distress depending on theperception of severity of side effects. Accordingto Roy and Andrews18, physical and/or emotionalwell-being affect the individualûs ability to fulfillthe role. In this study, all subjects were informedabout the disease, possible side effects, and howto deal with the side effects. Moreover, they hadobtained information related to self-carepractices from several sources. They also haddeveloped strategies such as making appropriate



plans for their routine activities, seekinginformation from similar cancer patients, orasking the physician to treat the side effects thatwould decrease the impact on their activities.These findings are consistent with the previousstudies of Oberst and others4 and Irvine andothers41. These two studies found that symptomdistress and fatigue were important factorscontributing to the self-care deficit of roleperformance in cancer patients duringchemotherapy or radiation. Similar to the study ofRuankon27 and Pongthavornkamol42, the patientswith cervical cancer receiving radiation who hadgreater complications of radiation had lowerquality of life and more disruptions of functionthan those who had lesser complications. AlsoKawsasri43 found that perception of radiationreactions could explain and accounted for 6.24%of the variance in sick role adaptation of patientswith head and neck cancer who were receivingradiation therapy.

Year of education was the only one predictorthat was not significantly correlated with roleadaptation. Possible explanations might be that ahigh proportion of the sample had a low formaleducation and received a high degree of supportservices. Another possible reason could be thatmost subjects in this present study were relativelyhomogenous with respect to education. Around72% of the patients had primary school certificates,whereas only 12.79% of the patients hadvocational or undergraduate education.

With respect to receiving social supportservices, patients who had difficulty in readingstill received information by listening to theinstructions verbatim from their children or otherfamily members. Moreover, the patients mostlikely received indirect information by talking toother patients, or learning through many othersources (e.g., television, radio, internet document).Receiving adequate information and increasingtheir understanding regarding their illness andtreatments is helpful and may motivate them to

express adaptive behaviors. One study has shownthat patients who are informed about radiotherapyprocedures, possible side effects, and therapeuticeffectiveness do not experience disappointment,fear, and anger3. These findings are similar to thestudy by Muhlenkamp and Sayle44 and byKaveevichai45, which reported that education wasnot correlated with positive health behaviors andadaptation in healthy adults, and in patients withmastectomy receiving chemotherapy. Educationhad no correlation with quality of life in a studyof patients with cervical cancer receivingradiation46, and adaptation in patient with headand neck receiving radiation32. However, thestudies by Changphuang14 and Tongtanuman17

found that education was correlated withadaptation or sick role adaptation in patients withmastectomy receiving chemotherapy.

In conclusion, the combination of socialsupport, self-esteem, severity of side effectsaccounted for 54.8% of the variance in roleadaptation of patients with cervical cancerreceiving radiation. The remaining 45.2 % otherinfluencing factors were not covered in this studyand need further investigation. Overall, theresearch findings were congruent with the RAMand contributed to the advancement of nursingknowledge.

RecommendationsThe results of this study apparently signify

the influences of social support, self-esteem, andseverity of side effects. Nurses should considerthe importance of these factors and keep them inmind when caring of these patients. Enhancingeffective adaptation and preventing ineffectiveadaptation should be the primary focus. In doingso, factors influencing role adaptation should beassessed followed by specific nursing interventionsbased on the assessment. As the first leadingfactor influencing role adaptation, social support


Vol. 6 No. 4 173

should be assessed and facilitated. The essentialelement is the assessment of social support interms of resource availability (e.g., social networks,financial or economic status, instrumental help),psychological conditions (e.g., sense of love andbelonging, self worth), interpersonal relationships(e.g., spouse, family members, friends), andsocial activities. Interventions may includerecognizing, contacting, and inviting significantothers (i.e., spouse, children or relatives) toparticipate in assisting role adaptation of thepatient during the course of radiation therapy.Nurses should facilitate formal or informal groupsupport during treatment sessions as well asprovide substantial information necessary forenhancing positive adaptation. Self-esteem,another important influencing factor on roleadaptation, should be emphasized. Nurses shouldbegin with an assessment of self- esteem todetermine the level of the perception of self.Enhancing positive self-esteem is valuable.Nurses, therefore, should identify interventionsto promote self-esteem. Family and sexualcounseling should be provided to patients withcervical cancer receiving radiation therapy whenneeded. Although the severity of side effects wasshown to be less predictive on role adaptation inthis study, controlling the side effects isnecessary because it enables the patient to beemotionally comfortable and be able to maintaindaily activities. Nurses should regularly assesssigns and symptoms indicating the side effectsof radiation regularly. Assessment of patientûsknowledge regarding self-care practices toovercome such side effects and to providerequired information is also essential. Moreover,a special topic of continuing education relating torole adaptation should be encouraged. This mayresult in an increase in nursesû awareness of thesignificance of this social aspect of the patients,consequently improving the quality of nursing care.

This project was supported the research grant bythe China Medical Board.

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Rutja Phuphaibul et.al.

Vol. 6 No. 4 177

Marital Developmental Tasks of Thai Spouses in ChildrearingFamiliesRutja Phuphaibul RN. , D.N.S.*Arunsri Tachudhong RN. , M.S.**Chuanraudee Kongsaktrakul RN. , M.P.H, M.N.S.**

* Associate Professor, Pediatric Nursing Division, Ramathibodi Department and School of Nursing,Mahidol University, Thailand.

** Assistant Professor * Pediatric Nursing Division, Ramathibodi Department and School of Nursing,Mahidol University, Thailand.

Abstract: A comparative study was designed to compare the marital developmentaltasks of spouses in families with infants, preschoolers, schoolagers, and teenagers.The sample consisted of 2,031 parents in the Bangkok metropolitan area whosefirst child fell into one of these age groupings. The sample size of each age groupwas approximately 500. Schools and hospitals were randomly selected to accessfamilies with children of various age groups. A questionnaire developed by theresearchers was used in data collection. It was comprised of 2 parts , one of whichaddressed family demographic data and the second addressed maritaldevelopmental tasks. The results of the study revealed four major maritaldevelopmental tasks including : a) financial tasks, b) family function delegation,c) spousal relationship, and d) relationship with extended family members. Incomparing families with children in the various age groupings on maritaldevelopmental tasks, the analysis of variance ( F=18.27, p<0.001) showed significantdifferences. Post hoc analysis (Scheffeûs test) indicated significant differencesbetween families with preschoolers and all other age groupings, and betweenfamilies with schoolagers and families with infants. The families with infants hadthe lowest score, and the highest score was in families with preschoolers. Therewas a decreasing trend in families with schoolagers and further decline in thefamilies with adolescents.

Thai J Nurs Res 2002 ; 6(4) : 177-185

Keywords: spouse, family, development task,.



RationaleThe family provides an important

sociocultural context for individual members andrepresents the basic social subsystem. Thestructure of Thai families has changed graduallyas shown in the survey results of the NationalStatistic Institution of Thailand. The findingsshowed a declining family size as well as achanging pattern of marital behavior1

Marital tasks remain essential in all couplesduring the family development stages. Marital andfamily relationship shows its impacts on mentalhealth problems of its members2-4. Pasch andBradbury studied newly married couplesûparticipation in 2 interaction tasks : aproblem-solving task in which spouses discusseda marital conflict and a social support task inwhich spouses discussed personal, nonmaritaldifficulties. The couples who exhibited relativelypoor skills in both tasks were at particular riskfor marital dysfunction 2 years later5. Fromliterature review on spousal marital tasks.

a number of studies were found that focusedon marital relationship in particular stages offamily life such as the beginning family, lateadulthood and retired couples, and couples whohave a chronically ill spouse5-7. There was noevidence of studies that examined the tasks ofspouses in different stages of family life.

Normally, Thai couples decided to haveoffspring after 2-3 years of marriage. Thenumber of children desired has been between1-2. Alterations in family roles from a couplewithout children to a family with children ofdifferent ages are expected to have an effect onspousal relationships and role sharing.Additionally, child rearing families at present havemore dual-career parents. This will certainly adda burden on the nuclear family without childrearing support from relatives. These couples willhave to share responsibilities in child care andhousehold work. Thus, family role performances

were expected to vary according to the familydevelopmental stages, that are usually defined bythe age of the first born child.

Family developmental tasks consist of 8:1) Being an independent family after

marriage2) Generating adequate income3) Role sharing among members4) Sexual satisfaction between couple5) Communicating and relating among

members6) Relating to family relatives7) Interacting with organizations, groups,

and the community8) Ability to provide care to offspring.9) Having an appropriate life philosophy

Objectives of the studyThe objectives of the study were to:1. Examine the marital developmental tasks

of spouses in families with infants, preschoolers,schoolagers, and adolescents.

2. Compare the marital developmentaltasks of spouses among families with infants,preschoolers, schoolagers, and adolescents.

HypothesesThere are significant differences among

marital developmental tasks of families withinfants, preschoolers, schoolagers, and adolescents.

Scope of the StudyThe study was conducted among families

with firstborn children from newborn to 19 yearsold living in Bangkok, whose children werereceiving educational, health care, and child careservices in various organizations.

Conceptual FrameworkThe conceptual framework of the study was

derived from the early work of Duvall in 1977 9,the researchersû pilot study in 1997, and aliterature review that addresses the changing


Vol. 6 No. 4 179

relationship within families according to theperiod of the family life cycle. Familydevelopmental tasks 9 related to spousalrelationships at various child rearing periodshave been discussed in the literature. The spousalroles or so called çmarital tasksé, may therefore,be reconceptualized as çmarital developmentaltasksé as they would be expected to change asthe child grows older.

Four dimensions of marital developmentaltasks were derived from pilot study data collectedby of the researchers with 20 families as followed

1) Generating adequate family income,including financial management within the family.This dimension is referred to as çfinancial taské

2) Sharing family roles between spouses.This dimension is referred as çfamily functiondelegationé. Child care and housework flexibilityare important aspects of this dimension.

3) Maintaining good relationship betweenthe couple, including collaborative problemsolving, sharing feelings, sharing leisure time,agreement on family planing, and sexualsatisfaction. This dimension is referred as çspousalrelationshipé.

4) Maintain good relationship betweenthe couple and relatives. This dimension isreferred to as çrelationship with extended familymembersé.

Definition of Terms1. Marital developmental task performance

is referred as the activities of both husband andwife in maintaining roles, functions, and optionalinteraction between the couple, family members,and relatives as measured by the questionnairedeveloped by the researchers. The questionnaireis based on Duvallûs Family Development Theoryand the results of a pilot study by the researcherin 1997. A high score indicates good performance.A low score indicates poor performance of maritaldevelopmental tasks.

2. Family developmental stage signifyperiods of the family life cycle which change overtime. The child-rearing families in this study weredivided into 4 groups according to the age of thefirst child in the family.

2.1 Family with infant was the familywith the first born aged betweennewborn and 2 and a half years old.

2.2 Family with preschooler was thefamily with the firstborn agedbetween 2 and a half years old and6 years old.

2.3 Family with schoolager was thefamily with the firstborn agedbetween 6 and 13 years old.

2.4 Family with adolescent was thefamily with the firstborn agedbetween 13 and 19 years old.

Literature ReviewMajor concepts of family development theory

include the integration of family structural androle functions during discrete time periods.Family structure and function are derived fromstructural functional theory10. The interactionbetween family members was viewed as asemi-closed system which changes thoughout thecycle of family life

Duvall described the essence of familydevelopment in child-rearing periods as follows 9 :

Stage I : Beginning family. This stage startsfrom marriage through the pregnancy of thefirst child. During this period, the couple developtheir life as a couple and acquire skills inunderstanding and adjusting to each other.Family planning is essential during this period.

Stage II : Family with infant. The mainfamily developmental task here is focused onadjusting to parenting roles and child rearing.

Stage III : Family with preschooler.Preparation for school and socialization of thepreschool child are emphasized here. The couplemight plan to have the second child during thisperiod.



Stage IV : Family with schoolager. As thechild is able to help himself more, the familyfocuses on providing educational opportunities andpromoting the childûs academic skill. Parentsû rolein socialization of the child and the influence oftheir philosophy of life become more evident.

Stage V : Family with adolescent. Parentsneed to become more flexible in the relationshipwith their teen children. Teens are graduallyallowed to become more responsible forthemseleves. Communication between parents andtheir child is the most essential component of thisperiod.

Four family developmental stages have beenselected for inclusion in this study (stagesII-V).Family life cycle theory of Carter & McGoldrick1988 emphasized the expansion and contractionof family boundary and size, in addition to theadjustment in family relationships during thedevelopmental course11.

Families with marital problems have beeninvestigated in Thai couples revealing the needfor better understanding of the problem. A studyof familyûs problems in 115 couples from thePsychiatric Outpatient Unit, found that most ofthe clients who asked for assistance were female.The most frequent psychiatric problems wererelated to marital problem including depression(27%), dysthymia (22.6%), and adaptive disorder(19.1%), The main causes underlying theseproblems were their spouse having affairs withothers (34.8%), psychological neglect (19.1%),inability to love their spouse (10.4%), fear thattheir spouse would have an affair (7.8%), theirspouse not sharing family roles and child care(70%), their spouse being a drug addict (6.0%),their spouse being a gambler (5.2%), problemswith relatives of their spouse (3.5%), sexualproblems (2.6%), family violence (1.7%),financial problems (0.9%), and decision makingpower (6.9%)12.

Many studies suggested both positive andadverse impact of the marital relationship onphysical and mental problems. Symptoms ofdepression and sudden cardiac risk in cardiacpatients were adverse outcomes reported by Irvineet al.in 19996. A study in 2000 by Kung and Elkinindicated that the patientûs level of maritaladjustment at termination of treatment ofdepression and the extent of marital improvementover the course of treatment significantlypredicted the treatment outcome at follow-up3.

From the review of literature and pilot study,it was evident that family problems derivedprimarily from difficulties in the spouserelationship dimension. The problems of rolesharing, finances, and relationship with relativeswere less intense. There has not been a studycomparing these tasks during various family stagesaccording to child rearing periods. Therefore, thisstudy was designed to explore the differences inmarital task performance among the different childrearing stages.

MethodologyA descriptive design was used to examine

and compare the marital developmental tasksamong families with infants, preschoolers,schoolagers, and adolescents.

SampleThe study sample was comprised of parents

in the Bangkok Metropolitan area with thefirstborn children in 4 specific age groups, livingin the same household. Only parents who wereliterate and who agreed to participate wereincluded in the study sample. The data werecollected from 2,031 parents which included514 family with infants, 511 families withpreschoolers, 506 families with schoolagers, and500 families with adolescents. The table ofrandom numbers was used for sample selection.Families with infants were selected from 10


Vol. 6 No. 4 181

Bangkok hospitals in the Pediatric Out Patientand Obstetric Out Patient Departments. Familieswith preschoolers were selected from 6 settings :2 hospitals, 2 day care centers, and 2kindergartens. Families with school age childrenwere selected from the following 10 settings :5 government schools and 5 private schools.Lastly, the adolescentsû families were selectedfrom 10 settings including 8 high schools and 2University / Colleges.

InstrumentsThe instruments used in the study were

questionnaires developed by the researchers andconsisted of 1) Family demographic data and2) Marital developmental tasks. Seven expertsreviewed the questionnaire for its contentvalidity. The Cronbachûs alpha was 0.82. Themarital developmental tasks questionnaire wascomprised of 22 items with 5 items on financialtasks, 4 items for family function sharing ondelegation, 8 items on spouse relationship, and 5items on relationship with relatives. The responseswere measured on a Likert scale with scores rangingfrom 1-4 (from çneveré to çalways practiceé)

ResultsThe findings showed that the educational

level of the majority of the parents was below10th grade. The majority of the families with

infants (52.7%) were living in an extendedfamily structure. In families with preschoolers,schoolagers, and adolescents the proportion ofextended family living situations decreased withthe increasing age of the first child (49.1%, 38.3%,and 29.3%). (Here would be a good place tocomment about how the fact that the majority ofthe families had more than one child wasaccounted for in your interpretation of thefindings. Do you have data on what the ages ofthe children were in families with more than onechild? I see this as a major confounding variablesince a family may have a child in any 2 of thestages if there are 2 children or even 2 in onestage. I realize that developmental theorists basetheir ideas on the age of the first child, but thismakes your research findings difficult to interpretwith any confidence.) The majority of thesubjects were families with 1-2 children who livedin urban areas. The mean scores in each of the 4stages were as show in Table 1 and Figure 1.

Table 1 and Figure 1 display the variation ofsubscores in families at different stages. It showsthat the marital task score was highest in thepreschool group (mean=68.14), while lower scoreswere found in the school-age group (mean=66.17)and the adolescent group (mean=65.20). Thelowest scores were found in the infant group(mean=63.84)

Table 1 : Mean of the subscores and total scores of marital developmental task.

Tasks Stages (Families with) Total

Infant Preschool Schoolage adolescent Scores

1. Finance 15.30 18.07 18.16 18.12 63.842. Role / function 12.25 12.79 12.59 12.21 68.143. Spouse 24.33 24.01 22.61 22.23 66.17

Relationship4. Relative 11.96 13.27 12.67 12.64 65.20

Relationship



The scores in each stage were then analyzedin order to identify the differences between eachstage by comparing the mean differences usingANOVA and Scheffeûs Test. The results inTable 2 and 3 show that there were meandifferences among the 4 groups (F=18.30,

Figure 1 : Marital developmental Task Scores for families in 4 developmental stages

p < 0.001) and there were significant differencesin the means between infancy and preschoolperiods, infant and schoolage periods, schoolageand preschool periods ,and preschool andadolescent periods (p < 0.05).

Table 2 : Comparison of mean of marital developmental task scores between families with

infants, preschoolers, schoolagers, and adolescents.

Source SS MS F p.

Between group 5,087.8 1,695.3 18.3 0.000

Within group 187,987.3 92.8Total 193,073.0

Table 3 : Comparison of the mean score difference between each group using Scheffeûs test.

Stages Stages of Families

(Mean) Infant Adolescents Schoolage

Infant (63.84)Adolescent (65.20) 1.36Schoolage (66.17) 2.33* 0.97Preschool(68.14) 4.30* 2.94* 1.97*

*P < 0.05


Vol. 6 No. 4 183

DiscussionThe study findings revealed a variation in

marital task performance over the family life cyclefrom infancy through adolescence. The lowestmarital task performance was found during theinfant period while the highest was duringpreschool stage. After the preschool stage, thescore again decreased. Possible factorscontributing to decreased marital taskperformance during the infant period includethe length of time that the couple has had todevelop their relationship and their need to adjustto family life with child rearing. Although thecomparing spouse task according to the familylife cycle was limited, but when the tasks relatedto financial task, family function delegation,spousal relationship, and relationship withextended family are not yet well adjusted.Specially when the first child was an infant, theoverwhleming tasks caused the interactionbetween distressed couple to be more negative.

It is notably that when measure maritaldevelopmental tasks, the indicators are not onlythe marital relationship, but including otherfinancial and relationship with extended familyand so on. Thus, it is not based only on symbolicinteraction framework like in many otherstudies13, but focused on the different tasks atdifferent developmental stages from developmentalperspectives. Family at different stages ofdevelopment focus on certain tasks that might aswell effect the spouse relationship. It is suggestivethat there should be further study to examine therelationship between developmental tasks andmarital satisfaction. It will combined the familyperspectives from both the family structure andfunctions and the interactionistic worldview.

The study showed that the Thai families withadolescents show some difficulties in relation totask performances as evidenced by having thesecond lowest score on marital task performance.There should be family counseling services

available to vulnerable families for adaptationdifficulties, particularly at the infant child rearingand families with adolescents. Possible factorscontributing to decreased marital task performanceduring adolescence included potential disagreementsabout the degree of independence permitted forthe adolescent in terms of sharing leisure timewith the family, communicating feelings andcollaborative problem solving. Findings from thisstudy suggest that family counseling might bestbe targeted for families with infants and familieswith adolescents. Further study is needed toenhance understanding of the vulnerability tofamily problems during different stages of familydevelopment.

Reference1. Limanond P. A Survey of Thai Families. The Institution

of Population Studies. Chulalonkorn University, 1996.2. Gottman J. M. Psychology and the study of marital

process. Annual Review of Psychology, 1998 ; 49 :169-197.

3. Kulik L. Marital relationship in late adulthood :synchronous versus a synchronous couple. International

Journal of Aging and Human Development, 2001;52(4) : 323-339.

4. Margolin G and Gordis E.B. The Effects of family andcommunity violence on Children. Annual Review of

Psychology, (2000); 51:445-476.5. Pasch L.A. and Bradbury T.N. .Social support, conflict,

and the development of marital dysfunction. Journal

of Consultation and Clinical Psychology, 1998 ; 66(2):219-230.

6. Irvine J.I. Basinski A. Baker B. Jandciu S. PaquetteA. Cairns J. Connolly S. Roberts R. Gent M. andDorian P. Depression and risk of sudden cardiac deathafter acute myocardiac infarction : Testing for theconfounding effects of fatigue. Psychosomatic Medicine,1999 ; 61 : 729-737.

7. Kulik L. Marital relationship in late adulthood :synchronous versus a synchronous couple. International

Journal of Aging and Human Development, 2001;52(4) : 323-339.

8. Rowe G.P. The development of conceptual frameworkto study the family. In F.I. Nye and F.M. Berardo (ed.)Emerging Conceptual Frameworks Family Analysis.New York:Prager, 1981.



9. Duvall E. Marriage and Family Development, 5th

edition, Philadelphia: Lippincott, 1977.10. Friedman M. M.Family Nursing : Theory and

Assessment. 2nd edition,New York : Appleton-Century- Croft, 1986.

11. Carter B. and McGoldrick M.The Changing Family

Life Cycle : A Framework for Family Therapy. 2nd

edition. MA: Allyn and Bacon, 1989.

12. Paholpak S. Marital problem : an analysis of the

causes among 115 clinical couples. Thai MedicalArchives, 1991; 74 (6) : 311-317.

13. Wampler K.S. and Halverson Jr. C.F. QuaniitativeMeasurement in Family Research. In P.G. Boss et al.(eds.) Sourcebook of Family Theories and Methods.New York :Prenum Press, 1993 ; 181-194.


Vol. 6 No. 4 185

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Self-regaining from loss of self-worth: A substantive theory of recovering fromdepression of middle-aged Thai women


Self-regaining from loss of self-worth: A substantive theory ofrecovering from depression of middle-aged Thai women*Acharaporn Seeherunwong**, Tassana Boontong***RN. Ed.D.,Siriorn Sindhu***RN., D.N.Sc., Tana Nilchaikovit***M.D.

* A Dissertation for the Degree of Doctor of Nursing Science, Faculty of Graduate Studies, Mahidol University** Assistant Professor, Department of Mental Health and Psychiatric Nursing, Faculty of Nursing, Mahidol University

*** Dissertation Committee

Abstract: Although, somatic treatments can effectively decrease depressivesymptoms, the opportunity of full recovery from depression in women is stilllimited. This study aimed to generate a substantive theory that described andexplained how middle-aged Thai women, diagnosed with major depressivedisorder, experience and manage the problems in their lives and move fromdepression toward recovery. The qualitative research method of grounded theorywas used. The participants consisted of 31 women who were diagnosed with majordepressive disorder in the three medical school hospitals in Bangkok. Buildingrapport and in-depth interviews were the main methods for data collection.Constant comparison and theoretical sensitivity were the basic analysis methods.

The substantive theory entitle çSelf-Regaining from Loss of Self-worth inDepressive Middle-aged Thai womené was discovered from raw data. çSelf-Regainingéhas been found to be a basic social psychological process of recovering fromdepression. This process consists of 3 phases - Causal condition of depression,Learning about depression, and Recovering from depression. The first phaseexplains how the women lose their self-worth until they recognize the deviance oftheir life. The second phase consists of three overlapping sub-phases - Depressionself-management, Help seeking, and Contemplation about my self. Thesesub-phases are strategies that contribute the women regained oneûs self. Finally,the final phase involves Untying the knot and performing Self-growth of which isthe positive consequence in the process.

By better understanding the process of recovering from depression, nursesand other healthcare providers can develop intervention to facilitate full recoveryfrom depression of middle-aged Thai women. The healthcare policy and educationpolicy can also be implicated with gender sensitivity. Future research also needs tobe carried out to derive a formal theory and to expand the scope of knowledgeabout depression.

Thai J Nurs Res 2002 ; 6(4) : 186-199

Keyword: grounded theory study/ middle-aged Thai women/ recovering from depression

Acharaporn Seeherunwong et.al.

Vol. 6 No. 4 187

IntroductionWomen are more than twice as likely as men

to experience clinical depression both in the clinicand in the community and in both developed anddeveloping countries.1-4 Also, the number ofout-patient Thai women in the year 1999-2000were double the number of men.5 Moreover, onein four women can expect to develop clinicaldepression during her lifetime. Clinical depressioncan occur in any women, regardless of age, race,or income. In addition, it is serious enough tolead to suicide.

Middle-aged women are one of the most atrisk for depression in a life span. It has been foundthat 27% of the women aged 40 years and over inThailand suffer from depression.6 Another researchresult shows that 13% of middle-aged out-patientwomen with somatic symptoms at Rachaburihospital were detected for depression.7

In spite of an effort to decrease the numbersof people with depression, various countriesdemonstrates that major depression is a chronic,recurrent condition. Between 15% and 20% ofpatients have symptoms that persist for at least 2years, and often these patients do not fullyrecover from depressive episodes.8 Also, thelikelihood of an individual who has suffered oneepisode of depression will experience a secondepisode is probably greater than 40%.9-10

Furthermore, when a patient experiences asecond episode of depression, the probability thathe or she will develop a third episode is increased.9

Although, somatic treatment is a great successfor recovery from syndromes symptoms, it is notsuccessful for recovery from functionalsymptoms.11-12 Therefore, the results indicate aneed for continued progress in developingoptimal treatment strategies for full remission andto maintain long-term recovery.

Understanding strategies that the clientmanages herself/himself toward recovery in theirculture and context will be an advantage to

complement the knowledge of health careproviders to help clients recover from depression.Pluralistic management techniques to decrease thecost of medical treatment which corresponds withthe special needs of women in Thai society isalso expected to be discovered. However, researchabout depression in Thailand is very limited. ThisKnowledge gap regarding recovering fromdepression is needed to provide base knowledgeto understand and provide support for Thai womenwith depression. As a result, Grounded Theory isa suitable methodology to investigate thephenomenon.

The purpose of the study was to generate asubstantive theory that described and explainedhow middle-aged Thai women, diagnosed withmajor depressive disorder, experience and managethe problems in their lives and move fromdepression towards recovery.

MethodsGrounded theory calls for an open approach

to data collection rather than adherence tostructured procedures. The purpose of datacollection is to get as wide as possible in theeffort to capture data that pertain to thephenomenon of interest.13-14 In this study, avariety of sources of data were obtained.Middle-aged women who were diagnosed withmajor depressive disorder were the primarysources of data collection. In-depth interviewswere the main method for collecting data. Theparticipants who had delusion or hallucinationwere excluded.

The final participants contained 31 women,range of age from 35 to 63 years (mean=48,SD=8),whose depression experiences varied widely,ranging from two months to thirty years. Morethan three-quarters of the participants were fromRamathibodi Hospital (n=27). The rest were fromSiriraj Hospital and King ChulalongkornMemorial Hospital. Almost half of the participants



(n = 15) had a full recovery and 10 of themperceived stable health. Almost all of theparticipants were Buddhists (n = 27). The restwere Christian and Islamic. The home provinceof the participants was diverse; they came fromevery part of Thailand. The majority of theparticipants grew up in Bangkok (n = 16). Eightparticipants grew up in the central part ofThailand. However, 23 of them resided in Bangkokand the suburbs during the time of data collection,whereas eight of them resided in the provinces.Moreover, one-quarters of educational backgroundfor the participants were a bachelor degree (n=10).Nine had a primary education. Three participantsdid not attend any school and were unable to readand write. The majority of the participants(n = 10) were housewives. Nine of theparticipants were government official and six ofthem were employees.

Tape-recorded, open-ended, interactiveinterviews were conducted with each participantafter the informed consent form was signed. Theinterview began by asking for the symptoms ofthe interview day and tracing back to the historyof their experience with depression from the firstmoment they realized that something was wrongwith them, even if they did not initially definethe problem as depression. When asked, çPleasetell me what it is like for you since the beginningof your illnessé at the beginning of the interview,five participants were encouraged to recollect theirexperience from beginning toward recovery asmuch as they could. The interview guide wasemployed as appropriate during the interviews.Gentle probes were also employed to enrich thedescription of the experience and to maintain thefocus of the interview. Interview questions weremodified throughout the study according to theemergence of the information to verify hypothesesand concepts.

Evidently, discussion of issues related todepression often involves recounting painful andemotionally sensitive experiences. During the

interviews, several participants expressed sufferedfeelings and cried. The interviews were pausedand opportunity was given to the participants toexpress their feelings until they felt better.Before the end of each interview, the researchermade sure that the participants were in a peacefulstate of mind, observing their feelings and askedfor the feelings they were having at that moment.The researcher and the participants parted onlywhen it was certain that they were emotionallycalm.

Each interview lasted at least 30 minutes andmost ran for well over 21/

2 hours. The average

was 112 minutes (S.D. = 48.85). The variation ofthe time was due to the personality of theparticipants as well as the richness andcomplexity of information. For instance, someparticipants had considerable self-observationalskills and analytical skills, so they could describetheir experiences in detail. Of the 25 participants,two were interviewed twice to capture thecomplexity and the richness of the participantsûexperiences and to test some hypotheses. For otherparticipants, the interview was conducted onlyonce because they did not come to see the doctoron the appointment date and the researcher couldnot communicate with them because they livedin a remote province and they moved around, sothey could not remember their address.

Documents from technical literature andnon-technical literature served as the secondarysources of data. Technical literature includedresearch publication and existing theories relatedto experiences of depression, management, andrecovery from depression. Non-technical literatureincluded diaries, biographies, and other materialsrelated to depressive persons in the magazines, ordescriptive experience on a television talk-showprogram. Medical records of the participants,general observations made during interviewprocess and during home visits, and interviews ofpsychiatrists were also employed as secondarysources. The reason for the use of secondary


Vol. 6 No. 4 189

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sources was to increase theoretical sensitivity andguide questioning for collecting and analyzingdata. As the study proceeded, data collection wasmodified as necessary in order to focus onconcepts with relevance to the emerging theory.

The data analysis procedure in groundedtheory is the tool to generate new concepts andtheories from the data in the phenomenon ofinterest. This analysis follow the Strauss andCorbinûs procedure.12-13 The analysis procedurebegan after the first interview was transcribedverbatim until the writing of the findings wasfinished, over one year and three months. Threetypes of coding (open coding, axial coding, andselective coding), constant comparison, theoreticalsampling, and memo writing were used as themain strategies through the established theoreticalsensitivity of the researcher. In addition, thetrustworthiness of this study was established basedon the four criteria of credibility, transferability,dependability, and confirmability. Formalmember check technique was employed byhaving two fully recovered participants to verifythe developed theory. The peer debriefingtechnique was also employed by having twonursing lecturers and members of researchcommittee review analyzed data and findings.

FindingsThe theoretical finding from grounded theory

analysis is the çTheory of Self-Regaining fromLoss of Self-Worth of Depressive Middle-AgedThai Womené as shown in Figure 1. Thisdeveloped theory consists of three phasesincluding : Phase I : Causal condition ofdepression ; Phase II : Learning about depression ;Phase III : Recovering from depression. Definitionof the constructs and concepts and theirrelationships obtained from the study are proposed.Phase I, ùCausal Condition of Depression:û

The findings reveal that ùTying the Knotû is abasic social psychological problem. It is abstracted

from the process of interaction between ùTheCenter of My Lifeû and ùNegative Appraisal ofthe Center of My Lifeûs Reactionû lead to aconsequence of ùPerceived Loss of Self-Worth.ûThe more ùPerceived Center of My Life,û thegreater ùNegative Appraisal of the Center of MyLifeûs Reaction.û The more ùNegative Appraisalof the Center of My Lifeûs Reaction,û the greaterùPerceived Loss of Self-Worth.û This consequenceleads to ùSymptoms of Depressionû abstracted fromùDevastated Self;û that is, the response of perceivedLoss of Self-Worth,û until ùRecognition ofDepressionû abstracted from ùRecognizingSelf-Deviance.û Following, concepts in this phaseare described:

ùThe Center of My Lifeû referred to aperson or a group of people who were important,and of great value for the women, as well as beingtheir source of pride. The centers of these womenûslives were not static and could be changed byplaces, times, and events which occurred in theirlives. At the same time, the persons who were thecenters could come from many sources, dependingon which ones were considered more importantthan the others. The participantsû perception ofùThe Center of My Lifeû was based on Thaisocial values. The person or the group might betheir children, husbands, or other people. As aparticipant stated:

My children are my heart, I would die forthem, and whatever might happen to them,I wish it would happen to me instead.

ùNegative Appraisal of the Center of My

Lifeûs Reactionsû referred to the appraisal ofparticipants who thought that they were treatedas unvalued people, had overloaded burdens,and/or had sense of loss resulting from thebehavior of the centers of life. Participantssacrificed their energy, ideas and intelligence totheir centers of life according to the social beliefsand values to which they had been socialized. Atthe same time, the participants also expected to


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obtain proper reactions from the centers accordingto those beliefs and values. For example, theyexpected that their husbands would be faithful,give them respect, take care of them when theywere sick and also function as the head of thefamily. Whenever the centersû reactions were notin line with what the participants anticipated andneeded, the participants would appraise thereactions in a negative way. As a participantillustrated:

Having another woman, I just could notaccept it. I had an inkling that my husbandhad another woman who he really wantedto live with seriously. I really could notaccept that. Then I told him that if thiscontinued, we should get a divorce. Icannot stand it and separation is better...Ifanybody has not had this kind ofexperience, they would not understand it.It is difficult to explain that I am not worthenough for him. If he has someone else totake care of him and can stay with himhappily, then I will let him go. I can livelike this.

ùPerceived Loss of Self-Worthû referredto the perception of the participants whoconsidered that they were treated as unvaluedpeople, had overloaded burdens and/or had thesense of loss resulting from the actions/reactionsof the center of life. The meaning of self-worthof most participants depended on the appraisalof behaviors or reactions of the centers of life. Ifthey were appraised in a negative way, it wouldlead to the perception of loss of self-worth whichcould be the cause of depression.

ùDevastated Selfû was the change inoneself in destructive ways ranging from mildsuch as depression or gloomy feelings,desperation, fatigue, boredom, to severityconditions such as being unable to control theirown self and having abnormal perception.Sometimes the participants avoided great

suffering by attempting suicide. Various responsesreflected continual cycle as the followingstatements:

The first time it happened, I couldnût sleepfor months. I didnût sleep at all some nights.When I was like this, I could not teach.When I went to school, I didnût want totalk to anybody. Sometimes, I had to havea canvas bed at school so that I could sleepwhen I didnût have to teach. I separatedmyself from others. I didnût want to talk.I didnût want to do anything. I was so upset.Whatever people tried to talk to me, it didnûthelp at all. It was all up to me.

The range of the severity of the responsedepended on the intensity of the perceived loss ofself-worth. The high intensity of the perceivedloss of self-worth came from the negativeappraisal reaction/action of the children and thehusband, and the reaction/action that came fromseveral persons who were the center of oneûs life.In other words, the husband and children weremore focused as the center of oneûs life than theother persons, but if the negative appraisal of thereaction/action came simultaneously from manysources, they may be much devastated self as well.In addition, the context that lacked resources waslikely to contribute to more expression of thedevastated self.

ùRecognizing Self-Deviance:û As long asthe causes of depression were not dealt with orthe problems solved, depressive symptoms wouldincrease until the participants wondered, askedthemselves questions, and found out that they weredifferent from what they once were and/or theywere different from normal people. Someparticipants, however, would not recognize suchchanges and continued living their lives until theyrealized their changes when they could no longerperform their work, or until the symptomsbecame so severe that they were life-threatening.Their means of recognition could vary dependingon sign, degree of intensity, knowledge of



depression, and ability to assess their thinking,feelings, and emotions. The road to recognitionof self-deviances including recognition that theyperceived the world differently from others, thatthey discovered that they cried without a goodreason, that they discovered their physicalsymptoms, that they realized they could not work,that they believed their nightmares would cometrue, and that they thought it was abnormality ofclose persons. Such recognition led to ability todeal with their depression, search for help, andconsideration of self.Phase II, ùLearning about Depression:û Therecognition was become to be the condition thatmade the participants went to manage depressivesymptoms. These strategies are categorizedinto 3 constructs including ùDepressionSelf-Management,û ùHelp Seeking,û andùContemplation about My Self.û These constructsmight occur simultaneously and/or occurrespectively in some participants that found thatthe previous strategy was not successful. In thisphase, the participants has learned to know moreabout depression in order to go to the fullyrecover from depression. However, someparticipants who were unable to fully recover,they have learned to live with depressive symptoms.

ùDepression Self-Managementû refers to adeliberated process that aimed to decrease oreliminate symptoms of depression involvingintention, action, evaluation of the action, andrepetition of the action when the result wassatisfactory. Conditions used to self-manage wereskills and interests, advice, and various supportssuch as money, places, and persons. DepressionSelf-Management consists of two conceptsincluding ùTamjaiû (accepting the situation) andùDiverting my self.û

ùTamjaiû was a method of dealing withoneûs own thought and feeling when facingunsatisfactory circumstances so that the personaccepted what was happening, which led totemporary peace of mind. ùTamjaiû occurred when

the participants realized their own emotions andfeelings as well as the negative effect which couldresult if nothing was done about themselves, ascan be seen in the following quote çHau hoo aftermy husband has passed away. çHau hoo Amafrequently trade abuses persons. I told to otherperson that if I endure at this time, I have to go tosee a doctor and use the drug again. I have triedto ùtamjaiû...ùtamjaiû.é Tamjai was a methodderived from past experiences or from othersûsuggestions followed by a successful practicalresult, which was repeated when faced with similarcircumstances. Tamjai included three types ofaction, which were ùReasoning,û ùLooking Forwardto Better Things,û and ùReminding My Self.û

ùDiverting my selfû was an act todivert oneûs feeling and interest temporarily. Thismethod was derived from past experiences and/or from following othersû suggestions. It wasrepeated when positive effect was a result. Thismethod was done intentionally to temporarilyreduce or eliminate depression. There werevarious types of ùDiverting My Selfû includingleaving the depressive environment, meditating,praying, having hobbies, exercising, usingvitamins and caffeine, keeping busy with work,finding something new in life, and using drugs.

ùHelp seekingû refers to a process composedof considering sources of help to see whetherwhich source worked, weighing betweenadvantages and disadvantages of seeking help,selecting information that would tell which sourcewould reveal how much of personal information,and evaluating and repeating it when necessary.ùHelp Seekingû is one choice arising afterparticipants found that something was not normalor after they had applied self-management withthose abnormal without success. So, they wouldwant to seek information and methods to makethem feel good as before.ùHelp Seekingû wasconstructed from two concepts: ùSeeking InformalHelpû and ùSeeking Professional Help.û


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ùSeeking Informal Helpû refers toseeking help that had no definite format orpattern, but was natural, composed of processesto determine the source for help, to weighbetween advantages and disadvantages ofseeking help, to choose information that could berevealed, and to evaluate and repeat it. The sourcesfor support were family members, friends, monksand priests, and media and information.Characteristics of the persons that participantssought help from were trustful, reliable,considerate and thoughtful, and understanding.They were also good listeners, who were patient,and willing to sacrifice. In addition, they sharesimilar background with the participants. Besides,supports could be tangible or intangible, and hadto be given in a timely and opportunistic mannerfor them to be effective.

ùSeeking Professional Helpû refers toseeking help with definite purposes from generalhealth care providers and psychiatric health careproviders. This was a multi-stage processcomposed of processes to determine the sourcefor help, to weigh between advantages anddisadvantages of seeking help, to chooseinformation that could be revealed, and toevaluate and repeat it when necessary. Thepractice included giving medication, listening toproblems, giving advice, and suggesting newthoughts and perspectives. Participants that hadbeen ineffectively helped or denied the fact thatthey were mentally ill would stop seeking helpand return to seeking help only when the symptomsbecame more severe. However, participants thathad been helped effectively would continue tofind other methods to fully recover, together withconducting depression self-management. Theyviewed that medical help using drugs had to bedone concurrently with the attempt to try to changethemselves.

ùContemplation about My Self.û is aprocess that led them to ùSelf-Awarenessû andùReappraisal of Reaction/Action of Those Who

Were the Center of My Lifeû consisted ofùRestating,û ùReflecting,û ùConsidering,ûùValidating,û and ùComparing.û These actionswere based on the new information obtained fromreligious teaching, psychological books, booksconcerning life and quotable quotes of otherpeople. Sometimes the participants might rethinkabout their past experiences. Conditions that ledto the successful ùContemplation about My Selfûdepended on having peace of mind, learning newperspectives, and having analytical thinking skill.If the participants did not have these components,they might not recognize or be aware ofthemselves, and they might not be able toreappraise the reaction of those who were thecenter of their life. ùContemplation about My Selfûwas constructed from two concepts: ùSelf-Awarenessûand ùReappraisal of Reaction/Action of ThoseWho Were the Center of My Lifeû

ùSelf-Awarenessû refers to the realizationabout oneself and some issues related todepression. The contents of awareness includedawareness of good and bad personality, awarenessthat depression came from the ineffective copingpattern, awareness of the impact of placing thecenter of life on external factors, and awarenessof solving depression by oneself first. Afterself-awareness, the participants clearly realizedthe various situations which led to ùUntying theKnotû in the next phase.

ùReappraisal of Reaction/Action of

Those Who Were the Center of My Lifeû.refers to reconsideration and reevaluation of thereaction/action of persons who were the centerof the participantsû life. The reappraisal of thosereactions could be summed up in the followingsentences: ùThe behavior is dynamic.û ùOtherpeopleûs behaviors will have an impact only whenit is valued,ûand ûOther peopleûs behavior mightbe a response to own behavior.û

The three constructs overlap, and anyconstruct can happen before or after the others.Moreover, the three constructs are interrelated.



The negative outcome of ùDepressionSelf-Managementû would positively influenceùHelp Seeking.û In turn, the positive outcome ofùHelp Seekingû would positively influenceùDepression Self-Managementû and ùContemplationabout My Self.û The positive outcome ofself-management would positively influenceùContemplation about My Self.û The negativelyoutcome of ùContemplation about My Selfû wouldinfluence the more ùHelp Seeking.û The outcomeof these constructs is the turning point to the nextphase.Phase III, ùRecovering from Depression:û

Participants began to discover their value frominternal self instead of external self. It means theirsense of self-worth was not tied to those whowere the center of their life; on the other hand,the recognition of self-worth lied in their senseof success. The participants, then, emerged toreform themselves. The length of time taken byeach participant was varied, from a couple of yearsto several years. However, some participants didnot reach this point; hence, they just lived withthe absence of symptoms. This phase is thesecond turning point in the process of recoveringfrom depression which consists of two constructs:ùUntying the Knotû and ùSelf-Growth.û

ùUntying the Knotû was the concurrence ofthe absence of depressive symptoms,self-awareness, and reappraising reaction/actionof those who were the center of oneûs life. As aresult of the cognitive reconstruction, data couldbe theorized under three concepts: ùDiscoveringMy Self,û ùRedefining My Self and the Relationshipwith Other People,û and ùRestarting My Life.û

ùDiscovering my selfû is the process ofrecognition of self-worth from oneûs internaldevelopment. This self-worth was the realself-worth because it emerged from theparticipantsû internal components, not from theaction or appraisal of those who were the centerof the participantsû life. The ùDiscovering My Selfûprocess led to the setting up of oneûs life goals

and the action plan to achieve the goals.ùRedefining myself and relationship

with other peopleû is a process of the modifica-tion of life skill by explaining and defining eventsaround oneself and re-establishing relationshipswith other people. As for redefining oneself, theutilized approaches included: living with thepresent, being more flexible, seeking alternativethoughts, and developing self-reliance. As for theredefining of relationships with other people, theparticipantsû approaches included: helping otherpeople as they could but not with all they had,understanding other people as they were and notimposing them to be as expected, giving helpwithout expecting anything in return, and relyingon each other.

ùRestarting My Lifeû is the process ofpicking up various actions from the point wherethe actions were stopped or were left due to thesufferings from depression. The process graduallyproceeded without exerting oneûs self and itresulted in self-worth for the person and otherpeople. This process consisted of restartingactivity, reconnecting with the society, beingproductive, and devoting for community services.The redefining oneûs self and relationship withother people in combination with restarting oneûslife resulted in self-growth.

ùSelf-Growthû is constructed fromùRegaining a New Oneû that is the positiveconsequence in this theory. ùSelf-Growthû refersto the condition of the participants who had passedthe process of recovery from depression. At thisstage, the participants perceived themselves as acenter of their life. They were able to controlthemselves, had internal motivation, and couldgenerate mental happiness and peace.

DiscussionThe result revealed that ùTying the Knotû

was the social psychological problem that madethe participants prone to occurring depressive


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symptoms. ùSelf-Regainingû was the basic socialpsychological process of which they used forrecovery from depression. It was a process thatthey journeyed from the recognition of depressionto the end of the process in which they were ableto perceive their self-growth. Also, conditions thatcontributed to ùSelf-Regainingû were discovered.The comparisons between the findings and theexisting theories and studies are discussed below.

ùTying the Knotû revealed that the sense ofself of the participants depended on therelationship with the significant others. Theparticipants could not separate life of themselvesfrom the life of their significant others or lovedones. It meant that the participants gaveimportance of themselves to the external factors.Whenever, the participants perceived thenegative reactions of people who were the centerof their lives, they experienced loss of sense ofself. This perspective or this method of thinkingled them mental sufferings. Consistently, previousresearches suggested the importance ofrelationships for womenùs well-being,14-17 but didnot specifically state how the depressive symptomsoccurred.

According to the study of Belenky et al.14,women are socialized to ùreceived knowerû morethan being ùconstructed knower.û The women arein the position to receive knowledge derived froma sense of ùwho am Iû from the definition otherssupply and the role they fill. Therefore, theevaluation of their own sense of self most likelyis dependent on the reaction of others towardoneûs self. This is consistent with the work ofSchreiber16 stated that social psychologicalproblems of depressive women took place whenthey could not answer the question ùwho am I?ûIt can be a metaphor as some parts in the puzzleare lost. Hence, the causal condition of depressionin the participants of this finding reinforced bothworks.

ùSelf-regainingû the central concept is similarto other results of qualitative studies that they

focused on the importance of self in the recoveringprocess including ù(Re)Defining My Self,û16,18

ùTransformed Self,û ùSelf as Healer,û19, ùIdentityTurning Pointû20. Moreover, the main conditionsthat contributed to ùSelf-regainingû is mostlysimilar to other studies as well.

In the phase of ùRecovering from Depression,ûprocess of ùUntying the Knotû that translatedinsight into action, is congruent with concept ofùClueing Inû in the ù(Re)Defining My SelfProcess.û16,18 Women clue in or come to a cognitiveand emotional realization of themselves inrelation to the world. They seem to be able to putin place the final piece of the puzzle of who theyare, that is what is their true self. However,ùRestarting My Selfû which is a concept was statedin this study, but not in Schreiberûs work. It maybe because participants had more severedepressive symptoms than those in Schreiberûsstudy, so they had to force themselves to takeaction in various aspects.

In addition, this study reinforced thephenomenology studies which aimed tounderstand the meaning of recovering fromdepression.15,19 According to Steen, the meaningof recovery process consisted of two turningpoints. First turning point, the women realizedthat they needed help for the reason thatchildhood experiences had affected theirfunctioning as adults and their pattern ofnegative thinking. In the second turning point,the women became their own agent and soughtout the sustenance they needed to feed andnurture themselves. As regards another feministand symbolic interactionist perspective,19 reportedthe experiences in living with depression in sixthemes: transformed self, wanting and monitoring,the self as healer, revealing vs. concealing,acceptance and belonging, and making sense ofdepression-meaning and understanding. Bothstudies also gave the importance to theself-transforming.



Regarding psychotherapy, ùSelf-Regainingûcontributed to the process of change in SatirûsModel and Satirûs approaches.21 The Satirûs Modelis a model of human growth which focuses ontransformational or change therapy. Thephilosophy underpinning is ùChange is possible.Even if external change is limited, internal changeis possible.û Change, according to Satir, isbasically an internal shift that in turn brings aboutexternal change.21 The difference between theSatirûs Model and the current process is that inthe Satirûs Model, the therapists provide contextfor positive change in the clients, but in theùSelf-Regainingû process the participants tried totransform by themselves.

Self-Growth was the positive consequenceof the ùSelf-Regainingû process. This concept wassimilar to other consequences of the process ofrecovery from depression in related studiesincluding ùSeeing with Clarity,û16 ùCultivating theSelf,û15 ùGetting Past It.û20 These concepts orthemes are positive events or state. All of theparticipants expressed having felt a profound shiftin the life experience and appreciated where theywere now. The participantsû perception ofthemselves as the center of their life was similarto a part of cultivating womenûs self, that theycould look more realistically at what was alreadygrowing in their garden, to weed out some of theold ideas, and to plant new ideas they had learnedfrom their experiences in life.15 Moreover, Theparticipants in this study had the ability tocontrol their thoughts, emotion, and situation tokeep them from recurrence of depressivesymptoms. This was congruent with ùMonitoringand Taking Corrective Actionû in the phase ofùSeeing with Clarityû defined by Schreiber.16

Conditions for self-regaining are strategiesthat led to the absence of depressive symptoms,resulting in self-awareness, and reappraisal of thereactions/actions of those who were the center oftheir life. These strategies are includingdepression self-management, help seeking, and

contemplation about my self. After recognizingtheir self-deviance, the participants tried tomanage depression by themselves by seeking helpwhen they realized that they needed it, andcontemplation about oneûs self. However, therewere some differences in strategies used by eachparticipants depending on the belief about illness,existing resource, and past experiences.

ùDepression Self-Managementû conceptexpanded the ùBeing Strongû concept that BlackWest-Indian Canadian women used to ameliorateor manage their depression.18 However, theparticipants of the study were in the community.The participants in this study viewed depressivesymptoms with a commonsense perspective asmental suffering, not as a disease or illness. Theywere most likely to find out the method to helpthem when they could not endure to go on.Nevertheless, if the symptoms were severe enoughto threaten their life, they were most likely toseek someone to help and manage themselvessimultaneously. Some of the self-managementmethods were underpinning the Buddhist beliefssuch as meditation and prayers. Some werechosen based on past successful experience, whileothers from the suggestions of the health careproviders and close relatives.

The ùHelp-Seekingû concept expanded theprevious ùHelp Seeking Behaviorû proposed byMechanic22 as in this study included ùSeekingInformal Help,û depending on explainscharacteristics of the helper and suitable time forseeking help. In the ùSeeking Informal Help,û theThai participants were most likely to seek helpfrom close relatives and friends, or a monk and apriest. The characteristics were specific in the Thaiculture and social context that the relatives andclose friends were most likely to be interdependentall the times, when they were in trouble or happy.Particularly, for Thai women, the parents are thefirst source that they recognize. Beside that,another item that expanded the Mechanicûs theorywas the characteristics of those participant who


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decided to seek help. These characteristicsincluded ever having a similar problem, everbeing interdependent, and realizing that the helperhad an emphatic understanding. Furthermore, inthis study, it was found that the effectiveness ofhelp seeking behavior and support from othershad to be congruent with the course of the illnessor symptoms of depression, and the readiness ofthe help from the receiver.

Regarding seeking help from health careproviders, the majority of participants decided toseek help when they realized the physicalsymptoms or could not perform their function.This finding was consistent with the study byLotrakul, Saipanit, and Theeamoke23 that mostpatients who were diagnosed with depression werepresented with somatic symptoms at their firstvisits. Some pathoplastic cultural influences werefound, among which were the infrequency offeelings of hopelessness and the idea ofself-insufficiency. Nevertheless, when comparedwith studies from the west, these feelings in Thaiwomen were less present than those in thewestern patients.

The concept ùContemplation about My Selfûwas consistent with the concept of ùSeekingUnderstandingû by Schreiber,16 ùFirst TurningPointû by Steen,15 and theme of ùMaking Sense ofDepression-Meaning and Understandingû byChronomas19 on that the participants couldconnect between past experience and outcomesthat they were facing at present. Moreover, theycould be aware of the pattern of their thinkingand their problem solving that led them to havedepressive symptoms.

In addition, ùContemplation about My Selfûconcept supported the cognitive therapy by Beck.24

The cognitive therapy addressed the problem inorder to help the client realize oneûs self and theworld. Additionally, the learning about a newperspective was emphasized instead of theprevious perspective which included negativethinking. Consistently, the effectiveness ofùContemplation about My Selfû had theunderpinning of three conditions: peace of mind,learning new perspectives, and analytic thinkingskills.

ImplicationFurther researches need to develop and test

the relationships between concepts and model.In order to test the theory with quantitativemethodology, the measurement of the conceptsshould be developed. Moreover, a participatory-action research or a quasi-experimental researchshould be developed base on this theory. Becausethis studyûs participants were middle-aged andmore urban women than rural women, it wouldbe useful to repeat this study with women less orolder age, and living in rural area in order toincrease explanatory power of the theory. Inaddition, understanding process of recovery fromdepression provides guidelines of nursing care fordepressive women that meet the womenûsrequirement in each phase of the recovery process.

AcknowledgementThis study was supported by a grant from

the Doctoral Collaborative Program organized bythe Ministry of University Affairs, Thailand.Special thanks and great appreciation go to Assoc.Prof. Napaporn Havanon for her valuablecomments and suggestions.



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Chronic Dyspnea Self-Management of Thai Adults with COPD*Supaporn Duangpaeng** RN, D.N.S. Payom Eusawas*** RN, Ph.D.Suchittra Laungamornlert *** RN, DNSc. Saipin Gasemgitvatana*** RN, D.N.S.Wanapa Sritanyarat***RN, Ph.D.

* Dissertation for the degree of doctor of Nursing Science, Faculty of Graduate Studies, Mahidol University.** Faculty of Nursing, Burapha University

*** Dissertation advisory committee

Abstract: The purposes of this study were to explain the process of chronicdyspnea management, and to describe the factors influencing the process of chronicdyspnea management of Thai adults with Chronic Obstructive Pulmonary Disease(COPD) who live in Chonburi Province in the Eastern region of Thailand. A substantivetheory explaining the process of chronic dyspnea management of Thai adults withCOPD was developed.

A grounded theory study was conducted with 31 participants with chronicdyspnea, who were recruited from the outpatient department and medical wardsof Chonburi Regional Hospital. In-depth interviews, observations, and reviews ofhealth records were the strategies used in data collection. The constant comparativemethod was used for data analysis. çBecoming an experté was the socialpsychological process that emerged from the data. The process of becoming anexpert in chronic dyspnea self-management was composed of four sequential stages;entering as a novice, developing competency in self-management, developingexpertise, and becoming an expert, which evolved over time. Self-learning andself-management were the important actions or interactive strategies of this processand were influenced by two major factors: personal factors, and contextual factors.The process of evolving from novice to expert in chronic dyspnea self-managementis viewed as a developmental process. It resulted in competence in chronic dyspneaself-management, confidence in chronic dyspnea self-management, balancedreliance on self and others, and living as normally as possible.

The findings of this study provide a basis for an understanding of the processof becoming an expert in chronic dyspnea self-management for Thai adults withCOPD. In addition, it can be used as the basis for information to nurses and otherhealthcare providers. It can also aid policy makers to further develop nursingpractice, healthcare policy-making, and for future research to help people withCOPD to become experts in illness self-management.

Thai J Nurs Res 2002 ; 6(4) : 200-215

Keywords: chronic dyspnea, chronic obstructive pulmonary disease, self-management,becoming an expert, grounded theory study

Supaporn Duangpaeng et.al.

Vol. 6 No. 4 201

Background and SignificanceChronic Obstructive Pulmonary Disease

(COPD), which includes chronic bronchitis,emphysema, or a combination of these conditions,is currently one of the most important public healthproblems1,2. In Thailand, COPD is the fifth leadingcause of death with a mortality rate of 33.5 per100,000 population, and the incidence rate ofCOPD is 403 per 100,000 population1. The costof COPD is estimated at about 25,969 millionBath annually3. Furthermore, the Thai Ministryof Public Health has estimated that the prevalencerate of COPD will be 7035.3 per 100,000population in 20101. These statistics indicate thatCOPD is one of the most important healthproblems in Thailand.

COPD is an irreversible condition and aslowly progressive disease characterized bychronic airflow obstruction, which results in airtrapping, hyperinflation, and impaired gas exchange.Currently, there is no specific curative measure.As a consequence, stabilization of the symptoms,in particular the symptom of dyspnea, is a majorgoal in the treatment of COPD at the moment2,4.Traditionally, healthcare providers focus on themedical management of chronic dyspnea inCOPD, especially the comprehensive pulmonaryrehabilitation program, which includes acombination of physiological, psychological,social, and cognitive components. This programwas recommended by the American ThoracicSociety as a component of the treatment and careof people with COPD with the goal of achievingand maintaining the individualûs maximum levelof independence and functioning in thecommunity5. Although previous studies havesupported the effectiveness of comprehensivepulmonary rehabilitation programs in decreasingthe symptoms of dyspnea, the long-term benefitsare not sustainable. Ries and colleagues6 havefound that the benefits from comprehensivepulmonary rehabilitation are partially maintained

for at least one year but tend to diminish afterthat time. This study has indicated that chronicdyspnea management in COPD still cannot beconsidered successful. As a result, the majorityof people with COPD are still faced with theburden of taking responsibility in chronic dyspneamanagement and they still suffer from episodesof acute dyspnea.

In a review of existing literature related tochronic dyspnea management in COPD people, ithas been found that chronic dyspnea managementby healthcare providers is still not successful. Thismight result from the incongruence between thenature of dyspnea and the approach created byhealthcare providers. This is because in chronicdyspnea management, healthcare providerssystematically use literature-based approaches todefine chronic dyspnea, manage chronic dyspnea,and help people with COPD manage their ownchronic dyspnea. However, dyspnea is a subjectivesensation that is perceived, interpreted, andresponded to by the individuals concerned.Therefore, in order to assist people with COPDto manage their chronic dyspnea effectively, nursesshould be concerned with descriptions of chronicdyspnea by people with COPD who have actuallyexperienced chronic dyspnea. People with COPDmay develop strategies and skills over time, someof which may not have a theoretical explanation.Much can be learned from studying the actualpractices of people who have long-term experiencewith chronic dyspnea. In a study of the peoplewith dyspneic lung cancer, it was found that noneof the subjects reported that nurses had taughtthem helpful strategies to manage their dyspnea.Instead, most of them stated that they learned tomanage dyspnea on their own7. Thus, knowledgeabout people with COPDûs perception andexperience in managing chronic dyspnea is animportant guideline in developing appropriateapproaches to the management of chronic dyspnea.

Despite the increasing number of people withCOPD and greater impacts of chronic dyspnea,



little is known about personal experience inchronic dyspnea management. In westerncountries, few studies have explored personalexperience in chronic dyspnea management8,9,10,while no study has explored personal experiencein chronic dyspnea management from the ThaiCOPD perspective. Therefore, healthcare providersremain locked in their lack of understanding andinsight into what people with COPD haveexperienced, interpreted, responded to, and intotheir management of their chronic dyspnea in theirsocio-cultural context.

This study aimed to develop a substantivetheory of chronic dyspnea management of Thaiadults with COPD in order to obtain betterunderstanding of the experience of chronicdyspnea management from their own perspective.A Grounded theory study, therefore, is particularlyappropriate in developing a substantive theory toexplain the process of chronic dyspneamanagement of Thai adults with COPD. Throughthe adoption of a holistic approach to care, thefindings from this study will be useful in givingdirections for care and in improving chronicdyspnea self-management in Thai adults withCOPD.

The Specific ObjectivesThe purposes of this study were to understand

the experience in chronic dyspnea managementof Thai adults with COPD who live in ChonburiProvince in the Eastern region of Thailand. Asubstantive theory was developed to explain theprocess of chronic dyspnea management of Thaiadults with COPD. The specific objectives of thestudy were:

1. To explain the process of chronicdyspnea management of Thai adults with COPD

2. To describe factors influencing theprocess of chronic dyspnea management of Thaiadults with COPD.

MethodologyGrounded theory methodology was used in

this study to develop a substantive theory ofchronic dyspnea management of Thai adults withCOPD. As a qualitative research method, whichaims to inductively generate theory, groundedtheory was chosen. The emphasis was placed ondeveloping an explanatory theory that is groundedon empirical data and derived from the personswho have experienced the phenomenon ofinterest. In addition, grounded theory study isparticularly appropriate to studying complexareas of human behavior and social life wherelittle research has been done or few adequatetheories concerning a phenomenon of interestexist11,12. As little is known about chronic dyspneamanagement of Thai adults with COPD, groundedtheory methodology is particularly appropriate toexpand knowledge for this study.

Recruiting ParticipantsPurposive sampling was used in the initial

stage of data collection with the intention ofobtaining participants who were Thai adults withCOPD who had dyspnea experience. Those whomet the criteria would then be asked to participatein the study. Inclusion criteria for participants were(1) confirmed diagnosis of COPD, (2) havinghad dyspnea experience, as determined by theparticipants, (3) willingness and availability toparticipate in the study, and (4) ability to discussand communicate well.

The researcher made the initial contact withpotential participants after reviewing the healthrecords and talking with nurses or physicians aboutappropriate persons to approach. After theresearcher introduced herself to potentialparticipants, the researcher explained the purposes,significance, and procedures of the study to allpotential participants. Ethical considerations werealso addressed, particularly those ofconfidentiality, potential risks, and participantsû


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right to withdraw or refuse to participate in thestudy. A consent form was read by the researcherto those potential participants who were illiterate,while the literate potential participants read it bythemselves. When the potential participants agreedto participate in this study, they were asked togive written consent and a convenient date, time,and place for interviewing.

Thirty-two participants were recruited, withone participant refusing to participate because hehad no time for interviewing and was not feelfree for home visits. After the 31 remainingparticipants completed the interview, recruitmentwas stopped since the emerging data was redundant.

Data CollectionData collection methods included in-depth

interviews, observations during home visits andduring participantsû hospitalization, and reviewinghealth records. Data collection and data analysiswere conducted simultaneously until theoreticalsaturation was achieved. The data collection tookplace from April 2001 to December 2001. Thenumber and the length of interviews for eachparticipant varied according to the participantûscondition and the situation of each interview.Sixty-one interviews with 31 participants weredone. Four participants were interviewed once.Twenty-four participants were interviewed twiceand three participants were interviewed three times.The length of each interview was approximately1-2 hours. Most interviewing took place at theparticipantûs home. Only the first interview of fourparticipants took place at a private room of theoutpatient department and six interviews of fourparticipants were conducted at their bedsides whenthey were in the hospital. The second or additionalinterview was performed 2-8 weeks laterdepending on the participantûs condition. Theparticipants who had acute exacerbation wereinterviewed after discharge from the hospital 1-2weeks later or when their condition had stabilizedafter acute exacerbation. Twenty-six participants

had family members present during the interview.Therefore, information given by family memberswas included in the tape-recorded interview. Withthe permission of the participants, all of theinterviews were tape recorded and transcribed intowritten text by the researcher as soon as possiblefor the purpose of analysis.

Observations were used in conjunction withthe interviews during the home visit and duringthe participantsû hospitalization because theparticipants were sometimes unable to reportaccurately about certain behaviors. Observationswere used as an additional means of obtaininginformation. Also, use of the method ofobservation could be considered as a strategy ofvalidation to increase the credibility of the datacollected by the interview and analyzed using thequalitative method13. In this study, the researcherobserved the participantsû families, communities,actions/interactions, relationships, events,incidents etc. Some of the interviews followingobservations were recorded by means of memosand field notes for further analysis.

The researcher reviewed the participantsûhealth records at least two times. The first reviewaimed to screen potential participants, while thesecond review aimed to obtain additional data aswell as to crosscheck the data from interviewsand observations. Participantsû health recordscould provide important data such as participantsûbiographies, history of illness, the results ofinvestigation, diagnoses, history of treatment orhospitalization, and present medical condition andtreatment.

Data AnalysisThree types of coding including open coding,

axial coding, and selective coding, which werethe strategies of grounded theory by Strauss andCorbin (1990)13, were used. The constantcomparative method of analysis was used untilcore categories or basic social process emerged.Theoretical sampling, memoing and diagramming



were also used in conjunction with the codingprocess. Finally, çbecoming an experté was thecore category that emerged from this process ofdata analysis. There were four categories relatedto this core category including being a novice,developing competency in self-management,developing expertise and becoming an expert.

Rigor of the StudyRigor in qualitative research is demonstrated

through the researcherûs attention to andconfirmation of information discovery. The goalof rigor in qualitative research is to accuratelyrepresent the study participantûs experiences.This study used four criteria of rigor in qualitativeresearch, as proposed by Guba and Lincoln(1985)14: credibility, fittingness, auditability, andconfirmability. To increase the credibility of thisstudy, firstly, the researcher selected theappropriate participants, Thai adults with COPD,who had dyspnea experience and had variedpersonal and medical histories with variations inage, sex, education, occupational, duration andseverity of illness, and duration of chronic dyspnea.Secondly, the researcher established a goodrapport with participants by prolonged contactwith the participants until trust was built beforecollecting data. In addition, participants wereinterviewed more than one time. Thirdly, theresearcher concluded the findings in accord withthe empirical data, not the existing theory, bycollecting adequate data and using triangulationapproach across data sources (participant, family,health records), data settings (outpatientdepartment, inpatient department, participantsûhome) data collection methods (interviews,observations, review of health records), and dataanalysis (researcher, advisory dissertationcommittee members, colleague). Finally, memberchecking was also an approach that was used forestablishing the creditability of this study. In thesecond or additional interviews, the researcherasked participants to confirm their previous

interview. Moreover, seven interviews wereconducted in the late stage of data collection whenthe tentative theory was developing. The researcherasked the participants if they agreed or disagreedwith the descriptions that represented the overallexperience with COPD. The researcher alsodiscussed the findings with one colleague andasked whether the analyses were believable andfamiliar in her experience. To enhance fittingness,the researcher asked two Thai adults with COPDwho had similar experiences to the participants inthis study to confirm the findings. The researcheralso asked one colleague who had experience incaring for Thai adults with COPD and of sittingon advisory dissertation committees to determinethe congruence within the context of the findings.To meet the criterion of auditability in this study,the researcher recorded the activities in every stageof the research process for illustrating as clearlyas possible the evidence and the thinking processthat lead to the conclusions. In this way, otherpersons could follow these processes through anddraw the same conclusions Finally, confirmabilityis achieved when credibility, fittingness, andauditability, are established.

Theoretical FindingsA substantive theory explaining a basic

social and psychological process by which Thaiadults with COPD who live in Chonburi Provincemanage their chronic dyspnea was developed. Thestudy found that çbecoming an experté is the corecategory of such a process, and a substantivetheory was entitled the çtheory of becoming anexpert in chronic dyspnea self-management ofThai adults with COPD.é This theory is viewedas a developmental process in which one evolvesfrom a novice to an expert in chronic dyspneamanagement. This process, becoming an expert,took place dynamically and moves from previousstages onto next stages depended upon theparticipantsû perceptions of chronic dyspnea,knowledge, abilities and skills in chronic


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dyspnea management, which graduallyaccumulated. This theory comprises threeessential components. These are becoming an

expert, influencing factors, and consequences(See Figure 1, 2).

Figure 1. Theoretical model of becoming an expert in chronic dyspnea self-management ofThai adults with COPD



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Becoming an ExpertBecoming an expert is the first component

and the central focus of this theory. Becoming anexpert in chronic dyspnea self-management isessential for people with COPD who live withthe uncertainty of dyspnea. People with COPDmust develop their knowledge, ability, and skillin management of their chronic dyspnea bythemselves in everyday life. Therefore, çbecomingan experté is the social psychological process thatemerged from the data which is described ascompetency developmental process in chronicdyspnea self-management of people with COPD.Becoming an expert consists of two importantstrategies including self-learning andself-management. Both self-learning andself-management have a reciprocal relationshipthat leads individuals to gradually gain morecompetency and confidence in chronic dyspneaself-management, balancing reliance on self andothers, and living as normally as possible.

Self-learning is a cognitive dimension ofthe process of becoming an expert in chronic dyspneaself-management by Thai adults with COPD.Self-learning in this process is stimulated by theindividualsû perception of dyspnea as a threat totheir life and cause of suffering that leads theindividuals to realize that their usual behaviorscouldnût solve their health problems. So they haveto learn about their illness, and how to manage it.This perception of dyspnea results from individualexperience of dyspnea, especially acute dyspneaexacerbation. Dyspnea exacerbation not onlyaffects individualsû thoughts and feelings, but alsoaffects individualsû behaviors. Since dyspnea isprogressive by nature, the self-learning in theprocess of becoming an expert in chronic dyspneaself-management is an ongoing learning process.Individuals have to learn about their illness andits management from their own experiences aslong as they have to live with it. This study foundthat people with COPD learned about their chronic

dyspnea and its management through beinginvolved in the dyspnea experience, takingactions in dyspnea management, and observingand learning from healthcare providers and otherCOPD people. Reoccurrence of dyspnea led theindividuals to ponder on it, while taking actionsin dyspnea self-management enabled individualsto learn through their actual management.However, learning management was a trial anderror process. Observation learning reorderedindividualsû comprehension and ability throughwatching the actions of others or healthcareproviders managing dyspnea. This self-learningnot only enhances personal comprehension andability, but also enables the individuals to developself-awareness and increases perceivedself-efficacy in chronic dyspnea self-managementas well. These consequences increase graduallythroughout the process of becoming an expert inchronic dyspnea self-management and makeindividuals ready to manage their own healthproblems. However, in order to achieve learninggoals there are many factors that can facilitate orinhibit self-learning that will be described later.

Self-management involves both cognitiveand behavioral dimensions of the process ofbecoming an expert in chronic dyspneaself-management. People with COPD used acognitive process in understanding the meaningof chronic dyspnea, monitoring the symptoms ofdyspnea, and initiating or planning action toprevent or control dyspnea. In addition, they usedit in evaluating the efficacy of these actions. Thiscould result in the selection of alternative strategiesor even changes in meaning of their illness and/or making a new plan of action. The behavioralprocess was used in performing actions in orderto achieve the goal of preventing, and controllingdyspnea. Self-management in chronic dyspnea byThai adults with COPD arises from the individualsûperception of dyspnea as a threat to their life fromthe primary experience in dyspnea exacerbationthat makes them live with fear of dyspnea



occurring. This perception of illness not only ledthe individual to learn about their illness but alsoled them to manage chronic dyspnea by themselves.An important characteristic of self-managementof chronic dyspnea of Thai adults with COPDwas the repetitive and dynamically changingprocess that depended upon the individualsûperceptions of chronic dyspnea. It also dependedupon individualsû comprehension, ability,self-awareness, and perceived self-efficacy inchronic dyspnea self-management that resultedfrom self-learning and past experience inself-management of their illness. This study foundfour strategies of self-management in chronicdyspnea by Thai adults in the çbecoming anexperté process. These are complying with theregimen, trying self-management, self-management,and integrating it with their lifestyle. Thesestrategies cover both individualsû management,with participation and relying on healthcareproviders. As a result, in each stage of theçbecoming an experté process the individualsgradually increased comprehension, skill, andperceived self-efficacy in chronic dyspneamanagement, which led to the next self-managementstage.

As mentioned above, both self-learning andself-management have a reciprocal relationshipthat lead the individuals to gradually gain morecompetency and confidence in chronic dyspneaself-management, balancing reliance on self andothers, and living normally as possible. Thefollowing are statements by the participants.

A Buddhist monk, 57, who was diagnosedwith COPD for twelve years stated:

çAn experience is important. I do itbetter for Iûve achieved solving aproblem before. My sickness oftenrecurs so Iûve noticed my condition. WhenIûm slightly ill, I never go to see thedoctor. Unless the tablets and spraydilator cannot control my sickness, Iûllgo to see the doctor. I always notice the

sound of my breathing to decide whethermy condition is serious or not. Theadvantage that the patients gain from thesickness is that the more we learn aboutthe disease from our experience, the morewe take care of ourselves. In other words,Iûve tried to prevent the recurrence andprogression of my illness. If my sicknessrecurs, Iûll greatly suffer from it. What Ido everyday was taught by nobody. Ihave learned it on my own. I was merelytaught to use drugs. Occasionally, Iforgot and walked hastily to mydestination and got so tired that I had touse the dilator. Iûll never do it like thisagain. Iûll have a stroll and bring a spraydilator with me everywhere I goé.

A Thai male, 74, who was diagnosedwith COPD six years ago said:

çI am now different from when I usedto be firstly dyspneic. I hardly knewanything then. When I felt tired, I wouldtry to fight it and work on, but nowwhenever I feel tired, I have to take somerest and use the spray dilator. If it doesnot work, I have to hurry to the hospital.I canût delay; otherwise, I may bepanting which will be worse and out ofmy control. Oxygen may be needed. Ilearned this because I got used to it sooften so I know my symptoms. I knowhow to deal with it moreé.

Influencing FactorsInfluencing factors are the second component

that comprises two categories of factors, personalfactors and contextual factors, which affect theprocess of becoming an expert in chronic dyspneaself-management by Thai adults with COPD.Influencing factors are very important in theprocess of becoming an expert because they canlead to, facilitate or inhibit çbecoming an experté


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actions. In each of the two categories of factors,several interrelated aspects need to be considered,and the two categories are related to one anotherand may interact to influence the çbecoming anexperté actions.

Personal factors include both antecedentand mediating factors. Antecedent factors arecausal conditions that lead the individuals to learnand manage chronic dyspnea, while mediatingfactors facilitate or inhibit those actions.Antecedent factors, perception of and response toillness, plays a crucial role in leading people withCOPD to take action in learning and managingtheir illness. Perception is the individualsûcognition of the characteristics and impacts ofchronic dyspnea, which are changed in therespective stages of the process of becoming anexpert in chronic dyspnea management. It changesfrom perceived health deviation at the first stage,to easy to die and suffering, being incurable andremittent, and living with suffering respectively.These perceptions cause the individual to developskills in chronic dyspnea management. Therefore,perception of chronic dyspnea directly influencesçbecoming an experté actions. Besides, it caninteract with other personal and contextual factorsto influence çbecoming an experté actions suchas personal experience, knowledge, social support,perceived self-efficacy, and course of illness.Moreover, fear of dyspnea occurring, andindividualsû reactions to dyspnea experience, werealso important antecedent factors that led theindividuals to learn about and manage chronicdyspnea. This study found that fear was a universalresponse of people with COPD who experiencedshortness of breath. Once they faced shortness ofbreath, they felt fear and perceived it as lifethreatening. So they fear dyspnea reoccurring.Most of the people with COPD said that they feardyspnea occurring more than they fear deathbecause it led to suffering. In order to avoiddyspnea occurring, they learned about dyspneaand tried to prevent it on their own. Therefore, it

can be concluded that both perception of andresponse to illness influence the çbecoming anexperté actions.

This study also found many mediatingfactors that facilitate or inhibit the çbecoming anexperté process such as personal attributes,personal experience, knowledge, self-awareness,perceived self-efficacy, hope, and social support.These mediating factors may interact with otherinfluencing factors to influence çbecoming anexperté actions. Personal attributes are thecharacteristics of people with COPD that aredifferent among individuals. In this study, it wasfound that self-concern and self-responsibility arethe facilitating factors to çbecoming an expertéactions. Both self-concern and self-responsibilitylead people with COPD to seek information,comply with the regimen, and perform healthbehaviors, while beliefs and social values aboutcigarette smoking are inhibiting factors toçbecoming an experté actions. Personal

experience refers to personal past experiences indyspnea and dyspnea management. Gainingexperience of dyspnea enables people tocomprehend symptoms and their triggering as wellas how to manage them. In living with chronicdyspnea, COPD people have to learn how tomanage chronic dyspnea and develop skills inchronic dyspnea management from theirexperience, especially the experience inself-management. This study found that if theself-management is successful, the individualmemorized it to apply it next time. On the otherhand, if that self-management were anunsuccessful experience, they would seek otherstrategies to manage it. The study also found thatpast experiences in dyspnea and dyspneamanagement create individual comprehension,ability, and perceived self-efficacy in handlingsuch dyspnea. As a result, individualsû perceptionsof chronic dyspnea were changed. Therefore,personal experience not only influences çbecomingan experté actions but it also influences other



influencing factors such as perception of illness,knowledge, ability, and perceived self-efficacy.Knowledge is an individualûs comprehension ofchronic dyspnea including cause, physiologicalchange, symptoms, and their management. In thisstudy, Thai adults with COPD have obviouslyreflected that knowledge about illness and howto manage it was needed in the developmentalprocess of how to become an expert in handlingchronic dyspnea by themselves. Comprehensionof their illness properly leads people with COPDto perform actions appropriately. Knowledgecan accelerate the developmental process towardsbeing an expert sooner. Moreover, this study alsofound that knowledge was gained from bothexperiences in self-learning and self-managing.Therefore, it led the individuals to graduallycomprehend their chronic dyspnea throughout theprocess of becoming an expert. Self-awareness

is a very important influencing factor because itwould give a motive for people to transit frompassive control to active control in their illness.This study found that the perceived threat to lifeand the suffering from dyspnea are factors thatmake individuals realize that, if it is ignored, onemay die easily. Therefore, they reconsider andpay more attention to self-learning, self-observation,and self-warning. Perceived self-efficacy playsan important role throughout the process ofbecoming an expert. Perceived self-efficacy inchronic dyspnea self-management is a result ofself-learning and experience in self-managementof chronic dyspnea. Therefore, in living withchronic dyspnea, the individual perceivedself-efficacy in chronic dyspnea self-managementincreasingly in each respective stage of theprocess of becoming an expert in chronic dyspneaself-management. This study found that in thenovice stage most COPD people perceived thatthey had no capability to handle dyspnea bythemselves. They had to rely upon healthcareproviders whenever any problem or dyspnea arose.They consequently avoided performing activities

that needed to be done regularly because ofdyspnea. Later, they perceived their own abilityafter they had learned more about the nature ofdyspnea and they had experienced self-management.In this way, they were convinced to act in thedevelopment of being an expert in chronic dyspneaself-management. Perceived self-efficacy not onlyencouraged people to dare to manage their illnessbut it made people dare to search for new usefulinformation or to share it with others. Factors thataffected perceived self-efficacy in chronicdyspnea self-management were found in thisstudy. The experiences that a person has canengender success if he sees possible good outcomesfrom someone having the same experience. Thisconvinces them that they would be able to makeit. In addition, obtaining useful information,suggestions or manageable facilitation andencouragement from social resources wouldenable them to perceive their ability to managechronic dyspnea by themselves. Hope is vitalenergy for living for people with COPD who sufferfrom dyspnea as with those who suffer from otherchronic diseases. For people with COPD, hope issituated on a factual base that such an illness isincurable and the symptom of dyspnea threatenstheir lives. Besides, they have to live withsuffering all their lives so their hope is just ashort-term goal and can be changed over time byinternal or external factors such as individualsûperceptions of illness, course of illness, perceivedself-efficacy, and social support. This study foundthat after the individual was diagnosed with COPDand the symptoms of dyspnea were not severe,they hoped for cure or improvement. Later, whendyspnea progressed, they hoped to have asprolonged a remission period as possible becausethey wonût suffer by it and they can perform theirusual activities. Finally, as a result ofacknowledgement of chronic dyspnea asincurable and remittent, they had to live withsuffering. They perceived support from significantothers. They hoped to have prolonged remission


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periods and live for a longer period for a specificpurpose of each individual. Hope enabled themto try to do whatever possible to manage theirchronic dyspnea, such as more carefully take careof themselves or strictly comply with the doctorsor healthcare providersû suggestions etc., in orderto achieve their hope. Finally, Social support

plays a crucial role in every stage of the processof becoming an expert in chronic dyspneaself-management. Because both perceived andreceived support make people with COPD feelthat they still are valuable and this motivates themto cope with their illness themselves. When it isknown that there are some social resourcesavailable, this can convince them that they canapproach them for help or support when a problemhappens. This can reduce a personûs anxiety orconcerns. Moreover, information or instrumentalsupports that the individuals receive from otherscan help them gain more knowledge and abilityto manage, and this leads them toself-management of their illness. However,social support may either facilitate or inhibit thepeople from becoming experts since most COPDpeople are elderly. By nature they are constrainedin doing various activities due to their senilityand fear of dyspnea recurring so they are proneto rely upon others, especially family members.The following are statements by participants aboutpersonal factors that influence çbecoming anexperté actions.

A Thai male, 79, who had been diagnosedwith COPD for five years said:

çAt present, I only fear the occurrence ofdyspnea. When I canût follow up theappointment, I fear dyspnea. Now if I haveto go somewhere, I will use my drug eventhough there is no symptom. I fearoccurrence of dyspnea, but I donût feardeath. This is because it makes me suffer(ID.012/9)é.

A Thai male, 62, who had been diagnosedwith COPD two years ago said:

çI donût know how other persons helpor take responsibility in my illnessmanagement because they donût knowme. They only do something I told themto do. In my opinion, we have to takeresponsibility directly, not other persons.We must be supportive of ourselves,namely, we must know what will happenand prevent it in advanceé.

A Thai male, 67, who had beendiagnosed with COPD for six years said:

çI have had dyspnea for a long time. Icouldnût remember how many times thissymptom had recurred. I continue tocomply with the doctorûs orders andmanage it by myself. Nowadays, Ibelieve that I have the ability to dealwith my illness more than in the past. Inthe past, if I had any problems, Ihurried to see the doctors. Now I try tosolve it by myself with confidenceé.

Contextual factors refer to the environmentalconditions that affect çbecoming an expertéactions. It consists of a conducive and supportiveenvironment. A conducive environment is thecondition that induces çbecoming an expertéactions easily to take place easily, while asupportive environment facilitates çbecoming anexperté actions in chronic dyspnea self-management.

Conducive environment refers to the courseof illness. In this study, the course of illness isseverity of chronic dyspnea both in remission andexacerbation periods that resulted from pathologyof COPD. COPD has similar characteristics toother chronic illnesses in that it consists ofremission and exacerbation periods. In remissionperiods, the symptoms of dyspnea subside. Sothe individual perceives chronic dyspnea as not



severe. They can live normal lives like otherpeople. In the exacerbation period, the symptomsworsen so individuals perceive a higher severityof chronic dyspnea. These perceptions lead tomany different individual responses. This studyfound that during the remission period, thedyspneic people neither seek knowledge abouttheir illness or how to handle it nor is strictlycautious about themselves. On the other hand,during the exacerbation period, individuals willstrictly be cautious about themselves and seekknowledge in order to handle such illness.Therefore, the course of illness, especially theseverity of dyspnea, plays a crucial role in theconducive environment that can lead to theprocess of becoming an expert taking place easilyby interactions with the perception of illness.

Supportive environment covers bothphysical and social environment. Physical

environment includes home and hospitalenvironments and medical facilities. Changes ofthese factors may cause changes in çbecoming anexperté actions because those environmentsaffect both learning and managing oneûs ownillness. The facilitating environment for learningmakes people with COPD know and comprehendthe nature of their illness and how to manage thatillness by themselves. However, a facilitatingenvironment for self-management makes thepeople experience it. The consequence is theirskill in doing it by themselves. Social

environment includes family system, community,and healthcare service system, and that alsoaffects both self-learning and self-managing ofthe people with COPD. These social environmentsare social resources of people with COPD. Inparticular, the family system is the closestenvironment of COPD people. In this study, itwas found that this systemûs structure andfunction, which may influence çbecoming anexperté actions include family characteristics ortypes of family, whether nuclear or extended, andopen or closed, family member relationships,

responsibility to each other, availability forsupport, beliefs or values, the familyûs relationshipwith other resources outside the family, and evenlocation of the household. Community is animportant social environment because COPDpeople spend most of their lives at home. In thiscase, the community is both a resource for learningand handling the illness. Community factors thatmay affect the action or interaction strategies ofbecoming an expert are beliefs or values,community resources and mutual dependability.Finally, the healthcare service system is anotherfactor no less important than that of family andcommunity because chronically diseased peopleare able to develop their potential andself-dependent. However, they still have to relyupon the healthcare service system. A goodhealthcare service system will enhance thedevelopmental process of becoming an expert inself-management of the chronic dyspneawhereas those people need no struggle forself-development from trial and error bythemselves or they need not wait for their ownexperiences. In so doing, it takes time and thedisease may have developed too far before theyapproach being an expert. If the healthcaresystem is easily accessible, has high quality ofcare, and good relations between clients and healthcare providers, it can accelerate the çbecomingan experté process for COPD people. Thefollowing are statements about contextual factorsthat influence çbecoming an experté actions:

A Thai monk, 57, who has been diagnosedwith COPD for twelve years mentioned:

çI am now quite knowledgeable. Myillness is very severe. It makes me learnhow to adjust myself.....Even squeezingthe toothpaste tube, I have to do itdeliberately, not like in the old dayswhen I did it. Boop! Finished! Now Ihave to think it over such as when going


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to the bathroom, my brain thinks whatwill happen if I walk this way. Can Ireach it? Will I be tired? Will I needmedicine? So, I would be preparedproperly about how to do everything é.

A Thai male, 64, who has been diagnosedwith COPD for four years stated:

çMy daughter bought oxygen and had itprepared in the car for use whenever inneed. Nowadays we have an electricnembulizer that makes us more confident.We used to have only an oxygen tubethat kept us worried whether the shopwould be opened or not when we neededit. That is how are prepared now. I thinkI wonût go to the hospital unless I am ina serious condition because what wehave now are what are used in thehospital-same medicines, sameequipmenté.

ConsequenceThe consequence, the final component of the

theory of becoming an expert in chronic dyspneaself-management, refers to the results of theprocess of becoming an expert in chronic dyspneaself-management. In this study, experts in chronicdyspnea self-management are the consequence,as the result of self-learning and self-managementof chronic dyspnea for a long time. The importantcharacteristics of the expert in chronic dyspneaself-management include competence andconfidence in chronic dyspnea self-management,balanced reliance on self and others, and livingas normally as possible. These characteristics ofthe expert in chronic dyspnea self-managementgradually increase in every stage of the çbecomingan experté process. Competence in chronicdyspnea self-management is developed from

accumulation of knowledge and skills fromself-learning and self-management. Consequently,the individual can anticipate and preplanpreventive measures, handle contingencies, seekor develop techniques in management, negotiatewith others, and develop willpower. Thesecompetencies enable a person to be convincedthat they can manage their illness successfullyand keep a balance between self-reliance anddependence upon others in handling their illnessand maintaining their routines. In addition, theyenable the individual to live with chronic dyspneaas normally as possible. All consequences thatare mentioned above are gradually increased tobe congruent with individualsû competency inchronic dyspnea management. All of theconsequences could have a recursive effect onçbecoming an experté actions and influencingfactors such as hope, perceived self-efficacy, andperception of illness that lead to the nextçbecoming an experté actions. The following areobservations by the participants.

A Thai male, 79, who was diagnosed withCOPD five years ago said:

çI nowadays come to it extremely...thatis...I know when I am going to havedyspnea...what causes...all medicinesmust be prepared... I know well whichof them is good or not. Next step is themonastery (laughing). The symptomfrequently arises. It taught meautomatically. At first I didnût know...butover and over it arises...I know it frommy observation. I am now an expert.Nobody has to tell me about this é.

A Thai male, 62, who was diagnosed withCOPD three years ago mentioned:

çDonût blame me that I am boasting.Currently, I am professional in chronicdyspnea management. If I can control



all situations, it means that I reach thefinal destination. Now...the very importantthing is that dyspnea occurs due to myemotion. If I could control it...it wouldreach its pacified peak point. I am anexpert, but I do not mean I am good ateverything. I merely know how severethe symptom is and how I could remedyor prevent it...because I knew myself...Icould read myself. I learned this one afteranother. I know myself more than thedoctor, but I am not better than the doctorabout treatment. I know more aboutmyself, but I cannot be sure that thesymptom wonût arise again, I cannotcontrol that, but for one thing, it lessfrequently comes, so I am suffering less.So, I go to the hospital occasionally,only when the doctor makes anappointmenté.

In summary, it may be concluded from thisstudy that all theoretical components are relatedto each other as well as two categories ofinfluencing factors. These relationships amongvarious variables need further refinement ortesting.

Discussion and RecommendationsThis study provides a substantive theory

entitled çThe theory of becoming an expert inchronic dyspnea self-management of Thai adultswith COPDé, which is a middle-range theory.This theory explains a clear developmentalprocess on how to become an expert in chronicdyspnea self-management of Thai adults withCOPD. In addition, it gives an holistic view ofthe relationship between the meaning of chronicdyspnea, actions or interaction strategies, andinfluencing factors affecting the process becomingan expert in chronic dyspnea self-managementof Thai adults with COPD. Therefore, it indicatesdirections in order to help or facilitate COPD

people to develop themselves to become expertsin chronic dyspnea self-management and alsogives direction of further research in helpingCOPD people. The findings of this study are es-sential knowledge in nursing science.

The findings of this study suggest severaldirections for clinical practice, future research,and health policy. The implications for clinicalpractice that arise from these findings areseveral. In particular, the findings can helphealthcare providers, especially nurses, tounderstand the process of becoming an expert inchronic dyspnea self-management of Thai adultswith COPD in a natural context. It also revealsthe fact that by nature COPD people havepotential in self-management of their illness. Inaddition, the findings of this study also providedirections for nursing interventions, which focuson helping these people to develop themselves tobe experts in managing their chronic dyspnea.

The implication for healthcare policy is that,in order to successfully develop nursing systemsfor COPD people, health policy should focus on:firstly, developing hospital or healthcare units inevery level as potential healthcare resources forthe community by preparing medical facilities andhealthcare providers who are well prepared andqualified; secondly, developing one-stop servicesystems for COPD people who live with theunpredictability of dyspnea; thirdly, preparingnurses to be clinical nurse specialists or nursepractitioners in caring for persons with chronicillnesses like COPD; fourthly, establishing amedical network by enhancing cooperation amonggovernmental organizations, private sectors andcommunities that can help COPD peopleeffectively. Finally, strengthening the communityby educating them to understand the healthproblems so that they can become virtual resourcesfor COPD people.

Regarding future research, the findings fromthis study would provide several directions. Firstly,this theory is a substantive theory emphasizing


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the process of becoming an expert in chronicdyspnea self-management of Thai adults withCOPD. This theory can be the basis for developinga formal theory explaining the same process inpeople with COPD who live in other areas orregions as well as people of higher socio-economicstatus and more highly educated groups in orderto increase transferability of the findings.Moreover, replicating this grounded theory studywith a longitudinal design to fully understand theprocess of becoming an expert in chronic dyspneaself-management and the influencing factors arealso recommended. Secondly, the theory ofbecoming an expert in chronic dyspneaself-management of Thai adults with COPDemerging from this study needs to be refinedthrough theory testing procedures in a quantitativestudy. The relationship among concepts andconstructs needs to be identified and tested.Thirdly, according to theoretical concepts in thisstudy, it should be used as a basis for developingnursing interventions, which is congruent with thestages of the process of becoming an expert inchronic dyspnea self-management. Testing theeffect of nursing interventions in a quantitativestudy is also required. Finally, theoreticalconcepts and models generated in this study shouldbe applied to guide healthcare practices throughparticipatory-action research, wherein COPDpeople, their families and healthcare providers canjointly participate in similar research projects. Itmay enhance derivation of a proper pattern ofexperts in chronic dyspnea self-management thatis more practical in clinical practice.

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Bangkok, Thailand: Usa Printing.2. Celli, B.R. (1998). Standard for optimal management

of COPD: A summary. Chest, 113(4), 283s-287s.3. Pongpan, S. (1999). Financial expenditure of patients

with chronic obstructive pulmonary disease caused

by smoking. Master Thesis, Master of Epidemiology,Faculty of Graduate Studies, Mahidol University, Thailand.

4. Smeltzer, S.C. & Bare, B.G. (Eds) (1994). Brunner

and Suddarthûs textbook of medical-surgical nursing

(8th ed.). Philadelphia: Lippincott.5. American Thoracic Society (ATS). (1995). Standards

for the diagnosis and care of the patients with chronicobstructive pulmonary disease. American Journal of

Respiratory Critical Care Medicine,152, S77-120.6. Ries, A.L. et al. (1995). Effects of pulmonary

rehabilitation on physiologic and psychosocial outcomesin-patients with chronic obstructive pulmonary disease.Annual Internal Medicine, 122(11), 823-832.

7. Brown, M.L. et al.(1986). Lung cancer and dyspnea:The patientûs perception. Oncology Nursing Forum,

13, 19-24.8. Barstow, R.E. (1974). Coping with emphysema. Nursing

Clinics of North America, 9, 137-145.9. Fagerhaugh, S.Y.(1973). Getting around with

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94-100.10. Nield, M. (2000). Dyspnea self-management in African

Americans with chronic obstructive lung disease. Heart

& Lung, 29(1), 50-55.11. Chenitz, W.C. & Swanson, J.M.(1986). From practice

to grounded theory: Qualitative research in nursing.California: Addison-Wesley.

12. Stern, P.N. (1980). Grounded theory methodology: Itsissues and processes. Image: Journal of Nursing

Scholarship, 12, 20-35.13. Strauss, A. & Corbin, J. (1990). Basics of Qualitative

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evaluation. San Francisco: Jossey Bass.

Exploring Ethical Dilemmas and Resolutions in Nursing Practice:A Qualitative Study in Southern Thailand


Exploring Ethical Dilemmas and Resolutions in NursingPractice: A Qualitative Study in Southern ThailandAranya Chaowalit* RN. Ph.D. Urai Hatthakit** RN. Ph.D. Tasanee Nasae** RN. M.Ed.Wandee Suttharangsee*** RN. Ph.D. Marilyn Parker**** RN. Ph.D.

Abstract: The purposes of this study were to explore ethical dilemmas in nursingpractice encountered by nurses in Southern Thailand, and describe resolutionsnurses used in dealing with the ethical dilemmas. Four focus group interviewswere conducted with 40 nurses working in both out-patient and in-patient units intwo general hospitals and two regional hospitals in Southern Thailand. Data weresought regarding ethical concerns of nursing practice. Thematic analysis of thetranscribed interviews uncovered eight major ethical dilemmas. These themes are(1) balancing professional obligations vs. protecting self from harm, (2) prolonginglife vs. prolonging dying, (3) maintaining patient confidentiality vs. warning othersof harm, (4) advocating for patients vs. maintaining relationship with others,(5) intradisciplinary and interdisciplinary conflicts, (6) truth-telling vs. benevolentlying and withholding information, (7) end of life issues, and (8) discrimination vs.obligation to provide care equally. Resolutions to ethical dilemmas found in thestudy fell into five themes: (1) taking moral action, (2) acceptance, (3) expressingfeelings, (4) discussing with others, and (5) ethical problem-solving strategies.Possibilities and recommendations about ethical dilemmas in nursing practice arediscussed.

Thai J Nurs Res 2002 ; 6(4) : 216-230

Keywords: ethical dilemmas, ethical resolutions, nursing practice

* Associate Professor and Dean, Faculty of Nursing, Prince of Songkla University, Songkhla** Lecturer, Faculty of Nursing, Prince of Songkla University

*** Assistant Professor, Faculty of Nursing, Prince of Songkla University**** Professor of Nursing, Florida Atlantic University, Fulbright Scholar, Faculty of Nursing, Prince of Songkla University

Aranya Chaowalit et.al.

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BackgroundAdvances in technologies and the changes

of social, economic, and political factors havestimulated increased attention on ethical aspectsof health care practice. Additionally, patientsûrights and dignities are also a focus of concern inthe current context of health care reform inThailand1. However, knowledge on ethicaldilemmas, resolutions of ethical dilemmas, andethical decision-making of Thai professionalnurses is very limited because of the lack ofresearch studies in this area. Some previousresearch studies included ethical issues/dilemmasfaced by nurses in caring for persons with AIDS,2,3

and terminal illnesses,4 and nurses working inintensive care units.5 One study on nursesûethical decision-making was found in Thailand.6

On a daily basis, professional nurses arechallenged by ethical dilemmas that occur whentwo or more mutually exclusive moral claimsclearly apply and both seem to have equal weight.7

An ethical dilemma can be defined as a difficultproblem seemingly incapable of a satisfactorilysolution or a situation involving choices betweenequally unsatisfactory alternatives.8 It is evidentthat ethical dilemmas occur in connection withtruth telling, quality of care, discrimination,withdrawal of life-sustaining measures,protecting patient confidentiality, or relationshipswith colleagues (physicians and nurses). Forexample, a study conducted by Wipamat9 foundthat of 110 nurses who provided care for HIV/AIDS patients, more than 90% reported ethicaldilemmas related to maintaining patientconfidentiality, 62% reported dilemmas related totruth telling, and 59% conflicted with colleagues.Phenomenological studies by Kanda,5 Krisana,4

and Setiawan10 showed similar results that nursesin intensive care units experienced ethicaldilemmas related to truth telling and continue(prolong life) or stop treatment. A study byRedman and Fry11 on 43 registered nurses

certified diabetes educators found thatdisagreement with medical practice was the mostdominant ethical conflicts. Similarly, Hartwell andLavandero12 found that 29% of critical care nurses(N=1100) confronted conflicts with physiciansrelated to ethical issues, 8% reported conflictsrelating withholding and withdrawing of treatment,and 3% had conflicts with nursing staff related toethical issues.

Nurses are required to make decision andtake actions to resolve ethical dilemmas in theirdaily practice. Ethical decision-making processis accepted as an effective strategy to resolveethical dilemmas because it provides a methodfor the nurse to systematically and thoughtfullyexamine ethical dilemmas and to answer keyquestions about ethical dilemmas13,14 Broom15

proposed that to resolve conflicts that evolve fromethical dilemmas, the nurse recognizes howpersonal values affect and works with others todevelop an integrative approach to patient care.Tucker and Friedson16 identified three methodsto resolve difficult ethical dilemmas including;ethical case analysis using principle-basedmodels of decision-making, simplecommunication tools, and consensus-buildingskills. Studies in Thailand4,5 and Indonesia10

showed similar results regarding resolutions nursesused when facing ethical dilemmas. Theseresolutions included taking professional actions,accepting, consulting/discussing, positivethinking, and adhering to religion.

In preparing professional nurses who arecapable in ethical decision-making and dealingwith ethical dilemmas effectively, requiresstrategies to provide ethical knowledge andtraining to nurses since there are nursing students.Several teaching strategies have shown theireffectiveness in promoting ethical behaviors ofnursing students, for examples; case studies, valueclarification, clinical inquiry, clinical conferenceand case presentation.17,18,19 However currentteaching strategies in Thailand have failed to



instill values or incorporate the ethicaldecision-making and ethical practice ability ofnursing students.20 The national workshop of nurseeducators and graduate students on nursing ethicsheld in Thailand a few years ago developed a listof research properties in nursing ethics that wasintend to serve as a research agenda. They werecategorized in three main areas; nursing practice,nurse educator, and nursing administrator.20 It isno doubt that research based knowledge is neededto guide development of ethical competency ofnursing students and nurses.

This study explored the current ethicaldilemmas experienced by nurses within dailynursing practice, and their ethical dilemmaresolutions. Unlike previous studies conducted inThailand, this study focuses on ethical dilemmasand resolutions experienced by nurses working invarious clinical settings. This will help to providea better understanding of the positions ofprofessional nurses, and their concerns regardingnursing ethics. Knowledge gained from the studywill also help in the developing guidelines andstrategies to guide nurses in their relating toethical dilemmas and resolutions in Thai nursingpractice.

Purpose of the StudyThe purpose of this study was to describe

ethical dilemmas in nursing practice andresolutions of these dilemmas experienced byhospital nurses in Southern Thailand.

Research Questions1. What are the ethical dilemmas in

nursing practice experienced by nurses?2. What are resolutions nurses use in

dealing with ethical dilemmas?

Methods

DesignQualitative methods were used for data

generation and analysis. Focus group interviewswere conducted with nurses working in variousclinical areas and content analysis was used toanswer the research questions.

ParticipantsParticipants in this study comprised 40

registered nurses from two general hospitals andregional medical centers in Southern Thailand.They were selected from each clinical setting basedon their willingness to join the study. Mostparticipants were female and between the ages of23 and 47 years. Thirty-six were Buddhist andfour were Muslim. Most participants had earneda bachelorûs degree or equivalent and had clinicalexperience of more than 5 years. One participanthad a masterûs degree. Clinical areas representedincluded out-patient, obstetrics-gynecologics,emergency, medical, surgical, and intensive careunits. Twenty-one participants had never attendedany conferences regarding ethical aspects ofnursing practice.

Data CollectionThe main method for data collection was

focus group interview. Four focus group interviewswere conducted at times and places convenient toparticipants. Each group consisted of 10 participants.The discussions were held under the leadershipof two experienced nurse educators in ethics. Theinterviews lasted 2 to 3 hours and were audiotaped. At the initial meeting, the study wasexplained, questions were answered, consent formswere signed, and demographic data sheets werecompleted. Participants were asked to describeethical concerns or dilemmas they experiencedand decisions they made in their daily practice.Discussion among the group members was


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encouraged to explore the issues raised. Themajor focus of the discussions was directedtoward describing ethical dilemmas relating tonursing practice, and strategies they used to dealwith the dilemmas.

Data AnalysisData were transcribed verbatim and analyzed

immediately following data collection. Contentanalysis described by Waltz, Strickland, and Lenz21

was used to uncover themes reflecting ethicaldilemmas and resolutions.

Results

Ethical Dilemmas in Nursing PracticeEthical dilemmas described by participants

were categorized into eight themes: (1) balancingprofessional obligations vs. protecting self fromharm, (2) prolonging life vs. prolonging dying,(3) maintaining patient confidentiality vs. warningothers of harm (4) advocating for patients vs.maintaining relationship with others,(5) intradisciplinary and interdisciplinary conflicts,(6) truth-telling vs. benevolent lying andwithholding information, (7) end of life issues,and (8) discrimination vs. obligation to providecare equally.

Theme 1: Balancing Professional

Obligations vs. Protecting Self from Harm.

Provision of care to patients suffering fromdiseases such as tuberculosis and AIDS causesnurses to worry about the possibility contractingthe diseases from the patients. Participantsmentioned that it was a nurseûs responsibility toprovide high quality nursing care to patientswithout objections. On the other hand, nursesbelieved that they had the duty to protectthemselves from harm. According to participants,some nursing care situations could lead to harmto nurses unless they were openly informed aboutpatientsû conditions. One participant stated:

We sometimes have to take care ofpatients with tuberculosis, but you knowwe donût even know this since thephysician doesnût tell us about patientsûlaboratory investigation. We should beable to know patientsû condition. Right?Then we can protect ourselves whencontacting the patient.

Theme 2: Prolonging Life vs. Prolonging

Dying. Ethical dilemmas arose when participantstook care of critically or terminally ill patients.Most participants expressed this dilemma, suchas: çShould I take off the respirator?é çIs it a sinor wrong if I take off the tube?é It is alwayspossible that an effort to maintain the life of aseriously ill person can actually be extending dyingand prolonging suffering of both the patient andtheir family. One participant stated that:

I hate the situation when a doctordecides no resuscitation for a criticallyill child who is on a respirator and thedoctor asks me to take off the tube. Youknow I am so unhappy with this situation.

Another participant supported this statement,saying that:

Rescuing patients from acute state tovegetative state is also a worry for nurses.We donût want to prolong suffering. Insome cases we have spent a lot of moneyand time, and finally it becomes theburden for the family. I feel guilty toprolong their suffering and bring aburden to the family.

One participant who has worked in a nursery saidthat:

My conflict is to terminate life ofdisabled child. I felt pity for this childand didnût want him to suffer but Icouldnût do anything to destroy life either.



Theme 3: Maintaining Patient

Confidentiality vs. Warning Others of Harm.

Nurses have a clear obligation to maintainpatientsû confidentiality. However, this cancreate conflicts when confidentiality may haveharmful effects on others, especially the patientsûfamilies. Participants in this study had beeninformed of negative impacts following anumber of incidents in their clinical practice. Anexample was a case of an HIV-infected motherwho was having an HIV-infected child, whileher husband was free from the infection. In thissituation should the nurse maintain confidentialityfor the patient or disclose the truth to her husbandin order to allow him to protect himself fromcontracting the disease? On the other hand,disclosing the truth to the husband may causehim to leave the family and lead to familybreakdown. Consequences of disclosing theconfidentiality of a patient can be very complicated.In the experience of one nurse, when the truthwas disclosed to the husband, he left the family.

There was an HIV infected wife whoasked me not to let her husband knowabout her disease. I thought it was anobligation to protect her confidentiality,but it wasnût fair for her husband. I feltlike I could help one but would have toneglect the other.

Theme 4: Advocating for Patients vs.

Maintaining Relationship with Others. Mostparticipants realized that one of their roles was toadvocate for patients when the patientsû rightswere violated by health personnel. Dilemmasoccurred whether they chose to advocate for thepatientsû rights or to maintain relationships withtheir colleagues. This conflict was more likely tohappen with junior nurses because of their lackof authority. An attempt in protecting patientsûrights, often led to dissatisfactions of other healthpersonnel such as nurses, and physicians.

One of the common problems is thedifficulty in getting a doctor to assistclients when needed, especially in theafternoon and night shifts. Theysometimes disappear and we donût knowwhere to get them. I sometimes decideto lie to the patient that the doctor hadalready made a treatment order by phonefor them because we didnût want to haveproblems with these doctors.

Some doctors arenût really concernedabout informing their patients about thetreatment plan. They expect nurses todo this job for them. In one instance thepatient was informed about an abscessto be drained, but in fact the doctor didincision and drainage to the patient. Thepatient was not informed until hediscovered the fact himself. The patientwas so angry with the nurse as she wasthe person who informed the patient.Doctors may ignore patientsû rights toaccess health information. Actually thedoctor should not do a procedurewithout getting the patientûs permission.

Nurses must advocate for qualitytreatment. In one case of subarachnoidhemorrhage and severe headache, thenurse should be brave enough to requesta skillful doctor to solve the problem. Itwas sad when a junior staff failed tosolve the problem and the patient wouldnot trust the doctor and turned their backon the hospital.

Fair allocation of health resources is also aconflict issue related to the advocacy role.Patients may request admission to the hospitalfor reasons such as their own security or lack ofsupport at home. However, the physician may notallow them to be hospitalized if their conditionindicates they are well enough to stay at home.


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A conflict arises when the patient does not haveconfidence to stay at home while we try to keepthe bed available for more serious patients.

In this case, we need to convince thepatient and their family to stay at home.Some of them are not happy but we haveto be firm for a fair allocation of healthresources.

Some special equipment can be aproblem, for example, a respirator 7200model seems to be prioritized forspecial cases (from physicianûs privateclinic or their own network). We knowit is not right but we donût have authorityto make any changes as it is thedecision of the physician.

Theme 5: Intradisciplinary and

Interdisciplinary Conflicts. Dilemmas innursing practice frequently occur when nurses haveconflicts with other nurses (intradisciplinaryconflicts), and when nurses have conflicts withphysicians (interdisciplinary conflicts) in caringfor patients.

Intradisciplinary conflicts:

Some conflicts arose among nurses. Onenurse offered an example of this kind ofconflict that may happen because of aninappropriate response to a patient by anurse.

One of my colleagues was not happywith a patientûs relative who came toinform her that the patient had a highfever. She perceived that the relative wasover doing her job. She then pretendedto be busy with other tasks. I thought itwasnût fair for the patient who neededurgent care. I decided to warn the nurseand she accepted it but she wasnût happywith me.

Whenever there was something wrong,they are never the victims, especiallythe shift head.

Interdisciplinary conflicts:Front line complaints (Nang-Naa-Fai):

Nurses always work closely with patients and arethe first persons to receive complaints frompatients about the health services. Conflicts ariseas nurses try to take a role to negotiate problemsbetween patients and physicians.

I was so empathized with patients whocame from far away to see the physicianin the hospital. They were kept waitinghours and hours to be called to see thephysician at the clinic, but still didnûtknow when they could see the physician.Many of them came to me and askedme to help, otherwise they couldnût catchthe last bus back home on the same day.I have to solve this sort of problemevery day.

Nurses sometimes choose to lie to patientsin order to keep them calm. If the patients knowthe physician may take a long lunch break, theywould be angry and not be cooperative. Frequently,even though nurses try to explain to patients, theydo not understand and still become angry withthe nurses. Some patients refuse to return to theclinic because of being made to wait too long.This is also a conflict for the nurse who knowsthe physician does not do his/her job, but thenurse will still need to turn the problem into apositive situation.

There was a patient admitted withstomachache. He had treatment and hiscondition was stable but his fatherwanted the physician to see him. I triedto explain to them that the physicianwould come again the next morning or



when we needed emergency care.However, the father still insisted to seethe physician. You see we have to bethe front line for a person who facesthis kind of situation...why not thephysician?

I was frustrated that we have to beNang-Naa-Fai. The patient or hisfamily should scold the right person, notus.

Most patients and family want to listento their physician...we are Nang-Naa-Fai.Whatever you explain to the patient isnot the same as the physician.

In another similar case, an orthopedicpatient did not feel well, so we reportedit to the physician. The physician didnûtcome but ordered the treatments byphone. The patient and his family wereso disappointed and decided to move toanother hospital. When the director of thehospital got the report, the fault fell onthis nurse who was accused of havingthe report late.

I donût understand why every time wehave problems with patients, involvingthe physician, we are always the victims.

Theme 6: Truth-telling vs. Benevolent

Lying and Withholding Information. Dilemmasregarding truth-telling occur when nurses haveobligations to tell the truth to patientsû familiesabout patientsû illnesses and prognoses in orderto prepare the families to deal with problems.However, some physicians do not agree withtelling the truth because they believe that knowingthe truth about poor prognoses can disturb thepatientsû families. In addition, truth-tellingdilemmas occur when participants perceive that

it is not their role to tell the diagnostic studyresults to their patients when they did not do theinvestigation themselves. Participants believe thatphysicians who do the investigations should tellthe truth to the patients. As one participant stated:

For some serious illness such as AIDS,I would try to avoid telling the patientthe truth. I would rather leave it to thephysician. Anyway, I sometimes canûtavoid this role, so this is also myconflict in truth telling.

Telling patientsû their prognoses can causeconflict to nurses since it leads to patientsuffering. Familyûs judgment may be dictated bymedical or economic reasons.

When the physician informs that thepatientûs prognosis is hopeless, such asfive percent survival rate, the family maydecide to take the patient home whilehe/she is still breathing. It is hard to seehim tortured at the end of his life.

In some situations, nurses cannot allowpatients to know about the poor services they havereceived as this can cause anger. The nurse willtry to hide the faults of the physician, other healthpersonnel and the hospital services to keep themcalm while waiting.

I felt frustrated that I canût let thepatients know the real problem of thepoor services in order to protect theimage of the hospital and also to calmthem down when they have to wait toolong for the physician. Iûm aware of theirfrustration but what else can I do.

Theme 7: End of Life Issues. In this studymany participants reflected their dilemmas aboutwhether to continue or withdraw aggressive


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treatments for terminally ill patients. At the endstage of life, some patients still have intactconsciousness and some do not. Conflicts alsoarise about who should make the decisions.

When should the aggressive treatments forterminally ill patients be ended?

Conflicts may arise when providing care toa patient who is dying. Should the patient beresuscitated or should treatment be withdrawn?What will it be like for the patient if he/shesurvives this crisis?

I had taken part in caring for a hopelesschild. In my opinion, I thought he hadalready died. His blood pressure sharplydropped and heart rate couldnût be felt.His skin turned blue. The physician spenta lot of time, using a lot of medicationsto pump him. I didnût agree with that.

Who should make the decision to endthe patientûs life?

Usually when a patient is conscious, it iscommon that he/she must be the one to makethe decision about his life. However, within asociety of extended families in Thailand, familymembers also have strong influence in theprocess. Conflicts about to terminate life arisewhen nurses consider whether to accept or ignorethe familyûs involvement, or to what extent theyshould contribute to the process.

There are several reasons for the family todecide to end aggressive treatments and take theterminally ill patient home. The first is a culturalbelief and the family may want the patient tohave religious activity at the end stage of life.According to Muslim concepts, the patient shouldhave a chance to listen to the reading of thisKoran before death. This will bring the patient toheaven in the next life. A second reason iseconomic resources, as the family may prefer toend the patientûs life rather than continuing to

spend money and prolonging suffering.

I experienced a case who was alreadyon tube and respirator with the permissionof his wife. Later their relatives came into visit. They didnût agree with thetreatments and wanted to take thepatient home. I tried my best to explainthe reasons for keeping the patient inthe hospital, but failed. I thereforereported to the physician. He advisedme to get the family to sign the deniedtreatment form and let them go. Thephysician didnût come to deal with thepatient and the family. What should Ido with the patient who was breathingwith the aid of the respirator? I wouldnûttake the tube off myself. I thought itwasnût fair for the patient who still hasa chance to live.

Nurses are always confronted withsituations that force them to take off thetube when the patientsû family decidesto take the patient home. It is a bigconflict for us but we sometimes justneed to do it.

Another nurse reported:

This happens all the time, you know. Ihad a patient who needed to be intubatedas well. The difference was that thisperson had intact consciousness. His wifewas okay, but other family memberswere not. They finally decided to takethe patient home. I felt sad and upsetwith the case. I think that the patientshould be the person who made thedecision as it was his life and hisconsciousness was still fine. Should welisten to patientûs relatives or takeaction based on our medical judgments?



I donût want to be seen as a murdererwhen the patient dies because the tubeis taken off.

Theme 8: Discrimination vs. Obligation

to Provide Care Equally. A number of cases ofpatient discrimination and unequal access to carewere identified by participants in this study. Theyperceived that access to some health services wasbased on ability to pay and personal relationshipwith the heath providers. Moreover, some patientswere discriminated against due to age, serious orterminal illness, or religion.

There are many cases that are treated asspecial in the obstetric ward. I mean thecases referred from private clinics runby the physician in the hospital. Thephysician always comes early to see thepatient but he doesnût do this for otherpatients. This is questioned by otherpatients...you know?

Some patients questioned us why thatpatient could have more frequent visitsfrom the physician and nurses. We werenot happy with that but we needed to bewith the physician when he visited thepatients.

Another participant supported these statements:

Health personnelûs family membersalways obtain special treatments. Whentheir own children get sick, they alwaysget better care while others are neglected.I think the doctors are sometimes tooeconomic oriented. They are not verykeen to assess aged patients, clients withcoma score 6, patients with someserious diseases, for instance, AIDS. Ithink every life is valuable. We shouldnot simply judge them by our own values.

Religious discrimination may result from lackof understanding of other religions, especiallyIslam. Many Muslim beliefs present obstacles tothe treatment plan and are not well accepted byhealth personnel. This may lead to unwillingnessto deal with Muslim patients. Some participantsfelt that they failed to convince Muslim patientsto obtain aggressive treatments when necessary.

When being told that the patient neededa tube inserted to ease the breathing, theirrelatives refused and decided to take thepatient home. I didnût quite understandwhy they didnût accept the treatment.My conflict was that I was unsuccessfulin helping the patient receive propertreatment.

Another participant added that even thoughshe was informed about the urgent reason to takethe patient back home, she still could not accept it.

In hopeless cases of Muslim patients,they prefer to take their sick relativesback home before death. This is influencedby the religious beliefs that birth anddeath are given by God. They tend tosurrender to God and deny aggressivetreatments. It is my conflict as we arepretty sure that the patient could be savedif they can obtain proper treatment buttheir family is more concerned aboutreligious beliefs at the end of life.

I nearly got mad with Muslim patientsmany times. I experienced one of themwho took the IV line off, withoutinforming me, every time he prayed. Forme, this can increase the chance ofinfection at the needlepoint when hecleaned his hand before praying.


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Some problems commonly identified incaring for patients who are Muslim includedelayed and the need for adequate communication.Patientsû relatives always need time to confirmthe decisions they have made with other significantfamily members or religious leaders. This couldeasily lead to unintentional religious discriminationas stated by a participant:

Iûve had a similar experience with apatient who had a nose abscess. He neededto be intubated to preserve his breathingbut his relative didnût agree. I explainedto them several times but failed. Thefamily wanted to consult some othersignificant persons such as their villageleader, and other family members. Laterthe patient got worse and died. Ibelieved that if he had received theproper treatments quickly enough, hewould have been better.

In some circumstances, nursing actions maybe inappropriate to religious belief and notacceptable to the patients. This is often found inSouthern Thailand with Muslim patients whocannot speak the Thai language. Nurses cannotadequately communicate or provide the neededinformation to patients and families.

...relatives of the child who was seriouslyill didnût allow nurses to care for or toeven touch the child. We couldnûtunderstand it, as the relatives couldnûtspeak Thai. We finally learned that thiscould mean torture for their child in thenext life.

Resolutions of Ethical DilemmasResolutions of ethical dilemmas described

by the participants were classified into five themes:

(1) taking moral actions, (2) acceptance (Plong),(3) expressing feelings, (4) discussing withothers, and (5) ethical problem-solving strategies.

Theme 1: Taking Moral Actions. Actionsfor dealing with dilemmas were based on expectedoutcome of the actions. Nurses usually tried to dotheir best for the patientsû benefit. This intentionguided nursing action.

Nurses often need to deal withemergency problems. For instance, apatient collapses from severe diarrhea.When there is no physician in the clinic,nurses may need to ask for a favor fromanother physician to assist the patient.

I try to promote child-motherrelationships by encouraging the motherto hold the baby and give the babybreast-feeding. I hope this will changethe mothersû intention to leave the baby.

I give information to the physician tolet him know the patientûs situation, suchas, this is the only child they can have,so we would try every way to save thebaby. Iûm happy when I can advocatefor the patients.

Theme 2: Acceptance . In somecircumstances, the participants tried to understandthe situation and accept that nurses cannotalways do the right things under pressuregenerated by great care demands of patients.Nurses might need to accept it as the way it isand then they might finally get used to it.

We are not happy with unethicalactions of some nurses but we canûtexpect other people to do as the way wewant. We may need to accept it.



With conflicts with religion, nurses mayneed to accept and tolerate the culturaland belief differences.

Theme 3: Expressing Feelings. Whenconfronted with ethical conflicts, participantsusually cope by expressing their feelings with thehead of the wards, friends, or colleagues. Themain purpose of this resolution is to release theirpressure rather than intentionally solve the problems.

We sometimes canût find the way out.The problem is too far beyond nursesûability to solve the problems solely. Thenwe just talk to friends to release the tension.

Theme 4: Discussing with others.

Occasionally nurses tried to solve ethicaldilemmas by talking about causes of ethicalproblems with colleagues, administrators andphysicians.

With some serious ethical problems, weshould discuss them among ourcolleagues and then report it to the headof the department.

We may use personal approaches todiscuss a problem involving a doctorwith another senior doctor with a hopethat this senior doctor can settle theproblem for us.

Theme 5: Ethical Problem-Solving

Strategies. With some interdisciplinary conflicts,nurses may need reasonable, logical process tosolve the problems and conflicts. For instance,many conflicts relating to unsatisfactory servicesof the patients can be minimized by goodteamwork of health care providers, and effectivecommunication between nurses and physicians.However, this may not be of interest to physicians.A senior person may be needed to bring nurses

and physicians together to solve problems.

I wish I could see nurses and physiciansclosely work together for patients oneday. I have been working in this hospitalfor nine years. There are only nurses tryingto solve ethical problems for patients.

Seeking for Outside Assistance--Regardingthe truth-telling about AIDS, nurses may try toavoid making the decision and giving informationthemselves. The nurse may consult a counselorto solve the patientsû problems and conflicts. Insome cases, the participants avoided givingdirect information by advising patients to havetheir blood checked, so they can discover theresults themselves.

Providing Information--In the emergencyunit, a patientûs family may perceive nurses ascruel because of injuries to patients whileproviding CPR. Nurses need to be aware thatpatientsû relatives are very worried with the acutecondition of their family members, and must bepatient and accept the disruption families maycause in the emergency unit.

It is stressful for a patient to be keptwaiting for the physician at the out-patientclinic. Nurses canût do much as they needthe physician, not us. We can onlyprovide them information and mentalsupport to reduce their pressure.

DiscussionThe nurses in this study identified that

some ethical conflicts are inevitable and cannotbe avoided. Findings show that ethical concernsand conflicts in nursing practice are rich withincidents related to concerns about maintainingpatientsû confidentiality, advocating patientsûrights, truth-telling, terminating life, and issuesof discrimination. Most of these conflicts occurred


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in situations of disagreement with medicalpractice and their lack of authority to makechanges. For example, the participants in this studyprovided evidence of unequal, inadequate, andmismanaged treatments by the physicians.Furthermore, there were also a large number ofissues raised by nurses about how little informationthe physicians provide to their patients aboutillness, its treatment, the prospect of recovery,the available treatments, and the current extent ofthe disease. Participants indicated that physiciansoften did not give enough information aboutpatientsû health. This finding was congruent withthe earlier study reported by David, Cowley &Ryland22 and Kuuppelomaki23 that doctorsprovided the patients very little information abouttreatment availability, and terminal stage ofillnesses. In some obvious cases, the physicianordered an operation for a patient by phonewithout direct explanation to the patient aboutthe necessity of the surgery, the expected outcomesor adverse effects that might occur as a result ofsurgery. The nurses who most closely worked withpatients and their families, were forced to dealwith the problems and conflicts. Nurses usuallytake action to provide information about patientsûdiagnosis, treatment and prognosis while theythink that this should be the doctorûs role.Conflicts relating to religious discrimination werealso a major concern especially in the SouthernThai region. Many participants could not acceptthe cultural differences as well as decision-makingrelating to care for the illness, for instance; carefor patients with critical illnesses, and end-of-lifeissues. A way of reducing these conflicts is thatnurses who work with patients from other culturesshould be more culturally sensitive and culturallyprepared, so they can deal with dilemmas associatedwith cultural differences more appropriately.

In this study, nurses found themselveshaving limited capability to solve ethical problems.A sense of powerlessness may exacerbate theethical conflicts in nursing practice in which nurses

are not free to be moral. However, nurses tookactions that included individual and interpersonalstrategies to deal with dilemmas. It was apparentthat nurses in this study often solved the conflictof ethical problems by accepting (Plong) theproblems, and expressing their feeling when theyfound it was beyond the nurseûs capability to solvesome problems especially those associated withphysicians. The outcome expected from these tworesolutions was to release their pressure resultingfrom conflicts rather than really solve the problems.Nurses believed that the effectiveness of solvingethical dilemmas would be enhanced by a systemicprocess involving a multidisciplinary health-careteam rather that handling problems by nursesalone. A number of the resolutions that the nursesin this study described were made without a senseof satisfaction because they did not recognize theireffectiveness. None of the nurses in this studyreported involvement in joint with their colleaguesor other health-care personnel. They made decisionsbased upon the desires of patients and theirfamily members, what the doctors wanted, andtheir own judgment. Nurses did not readily identifythe principles that guide their practice or theprocess of decision-making. Most of them lackopportunity to take ethical nursing courses, andto obtain skill-training in ethical around the issuesactually occurring within their daily nursingpractice. In this study, only about a half of theparticipants had ever attended a conference inethical nursing. While the awareness of patientûsrights relating to health care is increasing, nursesmay need to have some increased professionaldevelopment in the ethics of nursing and health-carepractice. Findings from this study indicate thatnurses lack knowledge and skills in ethicalpractice. Consideration must be given to nursingeducation that is able to provide nursing studentswith culturally appropriate ethical content andskill-training program. Professional nurses areencouraged to understand and realize theircurrent situation relating to ethical problems in



nursing. This learning enhanced by discussingethical issues both within and outside the nursingprofession, and practicing skills of ethical in dailynursing practice. Additionally, factors influencingthe work environment that promote high level ofethical practice by nurses such as rule/policies,and intra, and inter-professional relationships20

need to be considered. It is obvious that problemswith physicians and ethical dilemmas relating tomedical practice require higher authority to beinvolved in changing medical education andstrategies to improving medical practice. Mostmedical schools have currently includedcomponents of ethical knowledge and training intheir curricula in order to promote the medicalstudentsû ethical behaviors and their awarenessof patientsû right. In an attempt to promote goodmedical practice and encourage physicians to payattention on their patients, some medical schoolspay extra wage to the physicians who do not runtheir own private clinics. Recently, nationalefforts have been made to state clearly the meansand strategies to protect the patientsû right ofreceiving high quality health care services in apatientsû bill of right. One of the strategies is toestablish a funding to support and assist the healthservice users who are poor and have receivedunethical or malpractice health services to suethe physicians who provide them the services.This has become a widely public debated issueand not accepted by the physicians in the country.However, solving ethical problems involvingphysicians requires a lot of strategies to promoteethical awareness, motivations, including policymeasures.

RecommendationsStandard care manual of nursing practice

guidelines. In the current period of health carereform, patients are more aware of their rights inaccessing good quality health care. This createsadded pressure for nurses to think about thestandard of right and wrong and a personûs right

to choose what they believe is best for them. Aresolution that may decrease the conflicts, is adevelopment of a standard care manual ornursing practice guidelines, for instance, practiceguidelines for accident, or terminally ill patients.

Ethics conference. It is apparent that discussionof ethical issues among nurses has received littleattention as nurses may perceive that they do nothave power to take action in conflict resolution,especially in the situation involving physicians.These conflicts or ethical dilemmas cannot besolved solely by nurses. A multidisciplinaryethics conference is a mean to encourage nursesto share their experience of this process.

Further research should be focused onpreparing new graduate nurses with competencyin dealing with ethical problems and makingethical decisions as well as organizing workenvironment to promote high level of ethicalpractice by nurses. Research priorities in nursingethics on areas of nursing practice, educationand administration reported by Ketafian,Phacharoenworakul & Yunibhand20 are greatlyrelevant to increase nursesû ethical competencyand concerns of working environment inpromoting ethical nursing practice. In nursingeducation, research should be focused onappropriate teaching strategies for enhancingprofessional values and promoting the socializationatmosphere for learning the ethical behavior ofnursing students. While in nursing practice,research regarding some common ethical issues,for example; end-of-life care, care for personswith AIDS, and the culturally appropriate ethicalresolutions need to be explored to guide nursingpractice. Research priority should also be givento promotion of working environments to enhancenurse practice ethically. This includes studies onrules/regulations, policies, and professionalrelationship.


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contemporary nursing Albany, NY: Delmar, 2002.8. Davis, A. J. & Aroskar, M.A. Ethical dilemmas and

nursing practice. Norwalk: Appleton & Lange, 1991.9. Wipamat, P. Nursesû ethical dilemmas and ethical

decision making in providing care of HIV/AIDS

patients in Songkhla province. Master thesis. Facultyof Graduate Studies. Prince of Songkla University,Songkhla, 2001.

10. Setiawan. Ethical dilemmas experienced by nurses

in intensive care units in Medan, Indonesia. Masterthesis. Faculty of Graduate Studies. Prince of SongklaUniversity. Songkhla, 2002.

11. Redman,B.K. & Fry, S.T. Ethical conflicts reportedby registered nurse/certified diabetes educators.Diabetes Education, 1996: 22: 219-224.

12. Thelan, L.A., Davie, J.K., Urden, L.D., & Lough, M.E.Critical care nursing: Diagnosis and management.

St. Louis: Mosby, 1994.13. Hudak, C.M., Gallo, B.M., & Morton, P.G. Critical

care nursing: A holistic approach. Philadelphia:Lippincott, 1998.

14. Catalano, J.T. Nursing now: Todayûs issues,

tomorrowûs trends. Philadelphia: F.A. Davis, 200015. Broom, C. Conflict resolution strategies: When ethical

dilemmas evolve into conflict. Educational Dimension

1991: 10(6): 354-363.16. Tucker, D.L. & Friedson, J. Resolving moral conflict:

The critical care nurseûs role. Critical Care Nurse

1997: 17(2): 55-63.17. Anansawat S. A development of the integrated

instruction model for promoting ethics of students

in nursing colleges. Ministry of Public Health. Doctoraldissertation. Faculty of Education, ChulalongkornUniversity. Bangkok, 1997.

18. Piyasirisilpa, S. Relationship between professional

values educational achievement, and the ability in

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19. Punyanontawart, K. Effects of using case studies in

clinical teaching on the intention to perform ethical

behaviors in obstetric nursing practice of nursing

students. Master thesis. Faculty of Nursing,Chulalongkorn University. Bangkok, 1996.

20. Ketafian, S., Phacharoenworakul, K., Yunibhand, J.Research priorities in nursing ethics for Thailand. Thai

Journal of Nursing Research 2001:5(2): 111-117.21. Gold, C., Chambers, J., & Dvorak, E.M. Ethical

dilemmas in the lived experience of nursing practice.Nursing Ethics 1995: 2: 131-42.

21. Waltz, C.F., Strickland, O.L., and Lenz, E.R.Measurement in nursing research. Philadelphia: FA.Davis, 1994.

22. David B., Cowley S., & Ryland R. The effect ofterminal illness on patients and their carers. Journal

Advanced Nursing 1996: 23: 512-20.23. Kuuppelomaki M. Ethical on starting terminal care in

difference health-care units. Journal Advanced Nursing

1993: 18: 276-80.



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Wanlapa Kunsongkeit et.al.

Vol. 6 No. 4 231

Spirituality: A Concept AnalysisWanlapa Kunsongkeit* RN. MNS.(Medical and Surgical Nursing)Marilyn A. McCubbin** RN. Ph.D. FAAN.

Abstract: Spirituality has been found to influence health, well-being, and qualityof life in various disciplines and populations. It is recognized by WHO, nursingtheorists, professional nursing and the Thai government as an important aspect ofcare to patients. However, spirituality is an elusive concept and defined indifferent ways. Concept analysis based on Walker and Avant 25 was used to clarifythe concept of spirituality. Sense of connectedness, belief, and meaning andpurpose in life are the critical attributes of spirituality. A stressful event, crisis,suffering, and death are the important antecedents. Sense of well-being, quality oflife, and humanistic behaviors are consequences of spirituality. Model, borderline,related, and contrary cases are presented to illustrate the finding. This analysisdevelops an understanding of spirituality and further exploration in providing spiritualcare.

Thai J Nurs Res 2002 ; 6(4) : 231-240

Key words: Concept analysis, spirituality, sense of connectedness, belief, meaning and purpose in life

* Ph. D. student, Faculty of Nursing, Chiang Mai University, Thailand.** Professor, School of Nursing, the University of Hawaii at Manoa, USA.

Spirituality : A Concept Analysis


IntroductionSpirituality is an aspect of the whole person

that influences and interrelates with thephysiological and psychological aspects.1 It isrecognized as one aspect of the definition of healthby WHO2 and in the 9th national economic andsocial development plan (2002-2006) of Thailand.3

It is also acknowledged by many nursingtheorists4-6 and professional nursing7 that nursesneed to provide spiritual care. Therefore, for nurseswho seek to adopt a holistic approach to care forpatients, spirituality is an important concept.

Spirituality has been found to influence thehealth, well-being, and quality of life in variousdisciplines and populations, for instance, patientswith HIV;8-9 patients with cancer;10-13 elderlypersons;14-15 medical illness;16-17 drug and alcoholconsumers;18-20 and patients with cardiacdisease. 21-22

Spirituality is an elusive concept and has beendefined in different ways. The terms of spiritualityand religion may be used interchangeably basedon the assumption that religion and spiritualityare very similar, the same entity, or concepts.However, they are not synonymous.23

The need to clarify the concept of spiritualityhas emerged because if a concept is unclear, thenany work on which it is based will also beunclear.24 Therefore, the aim of this paper is toclarify and analyze the concept of spirituality inorder to achieve clear understanding. The analysiswill take place using the framework outlined byWalker and Avant.25

Concept Analysis of SpiritualityConcept analysis is a strategy that allows us

to examine the attributes or characteristics of aconcept and is useful to clarify over-used, vagueconcepts that are prevalent in nursing Practice.25

Walker and Avant25 modified the eleven stages ofWilsonûs concept analysis to eight steps. These

steps are as follows:1. Select a concept2. Purpose of analysis3. Identify uses of the concept4. Determine the defining attributes5. Construction of a model case6. Construction of an additional case7. Identify antecedents and consequences

of spirituality8. Define empirical referents

Step One : Select a concept. Spirituality ischosen for analysis because spirituality isambiguous and defined in different ways thataffect nurses in providing spiritual care to patients.

Step Two : Purpose of analysis. Thepurpose of analysis is to clarify the meaning ofspirituality.

Step Three: Identify uses of the concept.

Dictionary. Spirituality is derived fromthe Latin word çspiritusé meaning to breathe life,expressing oneûs value and beliefs about, self,humanity, life, and God.26 Websterûs dictionarydefines spirituality as an attachment to the valuesof the spirit, while human spirit is described asthe immaterial aspect of a person that never dies.27

The Chamber Dictionary28 definedspirituality as the state of being spiritual; thatwhich is spiritual; property held or revenuereceived in return for spiritual service; the clergy.

The American Heritage Dictionary29 definedspirituality as the state; quality, manner, or factof being spiritual; the clergy or something suchas property or revenue, that belongs to the churchor to a cleric.

Thai dictionary30 defined spirituality as soul;ghost; mind; intellectual.

Theology. Spirituality is defined indifferent ways, depending on the standing pointand experience of the speaker and on the widerreligious tradition.31 OûMurchu32 proposed that


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adherence to one or other religion is considered aprerequisite for spiritual growth and maturation.And each religion has developed its own spiritualvision. Submission in thought and action to a Godlike figure, according to a specific set ofprescriptions or guidelines, is considered to beessential to an authentic spiritual journey. Thereis an important distinction between religion andspirituality. Religion refers to those formallyinstitutionalized structures, rituals and belief,which belongs to one or other of the officialreligious system. On the other hand, spiritualityconcerns an ancient and primal search for meaningthat is as old as humanity itself. Spirituality ismore central to human experience than religion,a fact that is born out in the growing body ofknowledge accumulated by cultural anthropologyand the history of religious idea.

OûMurchu32 defined spirituality as an innatequality of human life and existence. It issomething we are born with, something essentiallydynamic that forever seeks articulation andexpression in human living. The characteristicsof spirituality are the search for meaning, ultimacy,transcendence, and relatedness. Tracy-Coleûs33

definition of spirituality is about experience, notdoctrine. Religion is a spiritual provider that stepsin when someone is born, goes through pubertyor dies. Harhill34 defines spirituality as the innersense of searching for the light. It is a part ofhuman being. Spirituality influences attitude,behavior, and life-style. It can be expressed inmany different forms, not all specifically religions.Spirituality can be linked to all human experiences.It has a particularity close connection with theimagination, with creativity and resourcefulness,with relationships-with self, with other, with God,with a sense of celebration and joy, with adorationand surrender as well as with struggle andsuffering.31

Religion. Spirituality is understood inthe sense of religiosity. The spirituality and

religion are co-extensive. The dictionary of Bibleand religion35 defined spirituality as the conditionof spiritual mindedness, or devotion to God andthe things of the spirit, also a disciplined approachto the spiritual life, opposed to materialism,secularism, and sensuality (hedonism). Spiritualitymay involve ascetic practices such as voluntarypoverty, chastity (including complete celibacy),and entire obedience to the laws of the church.The dictionary of belief and religion36 definedspirituality as the experiential side of religion, asopposed to outward beliefs, practices andinstitutions, which deals with the inner spiritualdepths of a person. Spirituality has been presentedin all religious traditions.

Anthropology. Sengupta37 characterizedspirituality as follows:

1. The finer perceptions of life;2. The excellence in the function of

intellect; and3.The medium through which

communications from the departedsouls reach the living.

Psychology. Kovel38 defined spiritualityas the way people seek to realize spirit and soulin their lives. Wehr39 defined spirituality as theexperience of the sacred. McKenna24 proposed thatthe definition of spirituality is similar to spirit.Spirit concerns what is deepest and innermost;it gives expression to our profoundest yearnings;it is opened to the unknown, the mysterious, thetranscendent, and it connects individuals to ourown history and experience, to others and to theuniverse. By enabling individuals to establish arelationship with the events, persons, and placesthat have entered our lives, a life of spirit enlargesour soul. The idea of holding with reverence andawe a sense of connectedness to oneûs lifeexperience, oneûs personal history, and indeed toall things is integral to the notion of spirituality.Spirituality involves beings in love, and that



being in love is ultimately a unifying experience,which engages our whole heart, whole soul, andwhole mind.

Medicine. Spirituality is defined as apersonûs relationship with the transcendent,nature, music, the arts, friends, and a set ofphilosophical beliefs40 or a search for an existentialmeaning in a particular life experience, withoutreference to any external power or being.41

Daaleman and VandeCreek42 proposed thatalthough there are multiple interpretations ofspirituality within health care settings, constructsof meaning or a sense of lifeûs purpose have beensuggested as primary components. Psychologicalstates and quality of life outcomes have been theend points in end of life care studies that haveincorporated a measure of spirituality.

Nursing. In the nursing literature, thedefinition of spirituality is defined in several waysas follows:

- The essence or life principle of aperson;43-44

- The center of life force that gives riseto a sense of wholeness;45-46

- A personal journey to discover meaningand purpose in life;47

- An awareness of meaning and purposein existence;48-49

- A life relationship or a sense ofconnection with self, nature, mystery,a higher power, God or Universe/something greater than self (howeverdefined by the individual);50-54

- A belief that relates a person to theworld;55-56

- The dynamic principles developedthroughout the life span that guide apersonûs view of the world;57-58

- Interactive process (interpersonal,transpersonal, and /or intrapersonalexperiences) that reflect the capacities

of people for change and transformationwhich are the most salient features ofour human nature;59 and

- That which provides inspiration,motivation and hopes, directing theindividual toward the values of love,truth, beauty, trust, and creativity.51, 60-61

From these descriptions, the spiritualdimension is divided into two dimensions, thevertical dimension of the personûs relationshipwith the transcendent (God, Supreme being orSupreme values or individualûs value system) andthe horizontal dimension of relationships withoneself, other people, and the natural world(environment).62 The personûs relationships aregrounded in expressions of love, forgiveness andtrust, and resulting in meaning and purpose inlife.63 Similarly, according to the concept analysisby Burkhardt50 and Walton,64 inner strength andpeace, a sense of meaning and purpose,self-reflection, and interconnectedness arecharacteristics of spirituality. Saunders andRestsas45 also stated that faith, hope, trust, thegiving and receiving of love, forgiveness,reconciliation and meaning in life werefundamental characteristics of spirituality whichwere basic determinants of the totality of people.

Spirituality is intensified when people areexperiencing stress related to emotion, physicalillness or other forms of crisis,65 the moment intime of death.66 When facing illness, patients needhelp in their search for something to believe inand hope for.67 Frankl68 believed that humansuffering provides an opportunity for spiritualencounters. During hospitalization, patientsreflect on suffering, death, and their relationshipwith self, others, and God to make meaning oftheir life.69

In brief, spirituality is conceptually definedas a multidimensional concept that involves a senseof connectedness between oneself and: God, ahigher being, environment in which one


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participates, and/or person such as family, friend,and oneself. It makes one have meaning andpurpose in life. Spirituality is an importantresource in persons facing stressful situations suchas illness and death.

Step Four: Determine the defining

attributes

The purpose of identifying the definingattributes of a concept is to provide a basis for itsoccurrence as a phenomenon as differentiated fromanother similar or related one. The followings areattributes, which apply to each use of the concept,and are therefore identified as the definingattributes of spirituality:

Sense of connectedness. A sense ofconnectedness implies a joining together of twoor more elements, with a relationship formedbetween them. From analysis, a sense ofconnectedness in spirituality means therelationship to God or higher power, then to self,other people, family, and environment.

Belief. Belief is a set of related ideasthat are learned, shared and persist over someperiod of time.70 In spirituality, belief is notlimited to religious belief. Belief will emanatefrom the driving force that gives meaning to thelife of the individual, whether that be, for example,relationships with others, and whatever thatindividualûs God may be.71

Meaning and purpose in life. Thesearch for meaning is the core of the individualûsbeing and is the driving force behind intellectand emotion.72 Frankl68 states that manûs primaryconcern was seeing a meaning in life. Having apurpose in life is essential in order to look forwardto each day. Some clients have a purpose in lifeand only need to maintain their spirituality.Spirituality is the source of finding the meaningand purpose in life. Antonovsky73 identified theability to find meaning as an influencing factor ina personûs ability to cope with stress.

Step Five : Construction of a model case.

Model cases offer real life examples of aconcept and include all the critical attributes, i.e.are a paradigmatic example25.

Betty, a middle-aged woman with AIDS,wanted to die because her husband and familyleft her after diagnosis. She felt hopeless. Thenurse, who had previously spoken with her abouther Christian belief and closely took care of her,suggested that Betty read the Scripture and prayto God. The nurse also introduced her to otherAIDS patients. Betty learned many things fromAIDS patients. Betty was not lonely anymore.She was touched by the nurseûs concern, belief inGod, and relationship with other AIDS patients.She changed her mind to live again and found themeaning and purpose in her life.

This case includes all three criticalattributes; Betty began to practice and re-activateher Christian religious belief through prayer andreading of Scripture. She also developed a senseof connectedness with God, other AIDS patients,and the nurse. From this, she was able to findmeaning and purpose in her life.

Step Six : Construction of additional

cases. Additional cases are constructed in orderto provide examples of what is not the concept,and in order to clarify understanding of what theconcept is about. These include borderline cases,which may contain some but not all of the criticalattributes, related cases, which contain none ofthe critical attributes, contrary cases, which areclear examples of not the concept, and inventedcases, which are cases that are constructed usingideas outside the ordinary context and oneûs ownexperience.

Borderline case Paul, a 38-year-oldengineer, became paraplegic after falling downfrom the third floor of his work place. He waslaid off from his work. Since the injury, he haddepression and several suicide attempts. Linda,who was his wife, closely took care of him. His



friends frequently visited and spent time to talkwith him. His mother suggested that he read theBible and asked the clergy to talk with himbecause Paul was a devoted Christian. Paul followedhis motherûs suggestions. However, Paul thoughtthat God did not love him and God had punishedhim. Therefore, Paul still had depression andfeelings of hopelessness.

This case is shown to have two criticalattributes, which are sense of connectedness andbelief. Paul believed in Christiannity. He also wasconnected to his wife and friends. However, hewas unable to find the meaning and purpose inhis life.

Related case. Religion and spiritualityare often used interchangeably but they are notsynonymous. Spirituality is an çumbrellaé underwhich can be found both religious and existentialneeds23. Religious needs are most often connectedwith specific religions or religious practices whileexistential needs are those needs all people shareregardless of the presence or absence of a religiousbackground or belief. Religion could also bechanneled as an expression of oneûs spirituality48.According to Steiger and Lipson74, religion is asocial institution in which a group of peopleparticipate rather than an individualûs search formeaning. Religion is more about systems ofpractices and beliefs within which a social groupengages. Pace65 conceptualized the differencebetween religion and spirituality as the differencebetween a map (religion) and a journey(spirituality). Thus, one can be spiritual withoutbeing religious23.

Somsri is a Buddhist woman. She visitsthe temple and pays respect to the Buddha statue.She thinks she should do this because this practiceis the activity, which Buddhists normally do.

This case shows the concept, which isrelated to spirituality but it does not include anycritical attributes of spirituality. Although Somsriis Buddhist, she did not believe in Buddhism.She carried out religious practices but she did not

think about the meaning and purpose in life. Shedid as social process of Buddhist.

Contrary case. Mr. Kay was a68-year-old retired factory worker. He had beenforced to retire at age 62 when his plant laid off alarge number of workers. After three days ofretirement, his wife died of an acute myocardialinfarction. Without a regular job and his wife,Mr. Kay felt hopeless and useless. He spent mostof his time in front of the television with a beerin his hand, or sitting in a bar until closing time.Finally, he was an alcoholic but refused help fromAlcoholic Anonymous.

This case is an example of what theconcept of spirituality is not. Mr. Kay did nothave any belief or anyone to connect with in hislife. When he was faced with bad situations inhis life, he did not know what to do. He could notfind a purpose or meaning in his life. Finally,he became an alcoholic but refused services forhelp with his alcoholism.

Step Seven : Identify antecedents and

Consequences of spirituality. Walker andAvant25 believe that the antecedents to, andconsequences of , a concept may shedconsiderable light on the social contexts in whichthe concept is generally used. They identify thatboth are events or incidents, implying that someoccurrence must take place prior to, or as aconsequence of, the concept. Equally, events orincidents can be the development of values orattributes, which are necessary for, or result fromthe exercise of the concept.

Antecedents. Antecedents are thoseevents or incidents that must occur prior to theoccurrence of the concept. Antecedents areidentified underlying assumptions about theconcept being studied. Spirituality is anfundamental to humans as the act ofbreathing.75 Spirituality is in oneself when one isborn and goes through life until death32 and isintensified when people encounter stress related


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to emotion, physical illness, crisis or suffering.Consequences Consequences are those

events or incidents that occur as a result of theoccurrence of the concept. They are used todetermine often neglected ideas, variables, orrelationships that may yield fruitful new researchdirections.25 Consequences of spirituality are senseof well-being and quality of life,42 humanisticbehavior, which was described by Duldt76 aspositive regard, empathy, authenticity, caring,intimacy, and hope.

Step Eight: Define empirical referents.

Empirical referents are determined for the criticalattributes. They are extremely useful in instrumentdevelopment because they are a clear link to thetheoretical base of the concept. They are also veryuseful in nursing practice because they providethe clinician with clear, observable phenomena,which can diagnose the concept.25 Spirituality canbe measured in term of sense of connectedness,belief, and meaning in life. Some researchers havedeveloped instruments to measure spirituality,for example, The Spiritual Well-Being (SWB)Scale,77 and The Spiritual Perspective Scale(SPS).9 These instruments have some limitationsbecause some instruments were developed basedon religionûs assumption. Some need to furthertest for reliability and validity in variouspopulations.

Implications for nursingThe concept analysis of spirituality provides

an understanding of the meaning of spirituality.Nurses can develop spiritual care for patients.Nurses also generate additional questionsrequiring further research in order to developinstruments to measure spirituality and increaseresearch in this area. This analysis can be usedfor basic knowledge application for nursingeducation in teaching about spiritual dimension.

ConclusionFrom the concept analysis of spirituality

based on Walker and Avant,25 the critical attributesare sense of connectedness, belief, and meaningand purpose in life. A stressful event, crisis,suffering, and death are the important antecedents.The consequences of spirituality are sense ofwell-being, quality of life, and humanisticbehaviors. This analysis develops a clearerunderstanding of spirituality and furtherexploration in spiritual dimension.Acknowledgement: The author wishes toacknowledge Prof. Dr. Marilyn A. McCubbin forher advice and support throughout my study inthe Evidence-Based Practice: 1 course at theUniversity of Hawaii at Manoa. She also gavethe helpful comments on the manuscript.

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Wannipa Asawachaisuwikrom

Vol. 6 No. 4 241

Abstract: This article aims to clarify the meaning of self-efficacy. Analysis of theconcept of self-efficacy provides information related to clinical usefulness andassists health care professionals communicate the same notion when discussingthe concept. Moreover, understanding self-efficacy as a concept is useful inapproaching behavioral change such as participation in physical exercise.

Thai J Nurs Res 2002 ; 6(4) : 241-248

Key words: concept, self-efficacy

Concept Analysis: Self-EfficacyWannipa Asawachaisuwikrom,* Ph.D.

Instructor, Community Health Nursing Department, Faculty of Nursing, Burapha University



Concept Analysis: Self-EfficacyWalker and Avantûs concept analysis

methodology is used in this article. Theseprocedures include select a concept, determinethe aims or purposes of analysis, identify all usesof the concept, determine the defining attributes,construct a model case and additional cases,identify antecedents and consequences, anddefine empirical referents.1

Select a conceptSelf-efficacy, used since 1977, is an important

concept because it predicts human behavior. Thisconcept has been of considerable interest inseveral disciplines related to human behavior suchas sociology, psychology, and nursing. However,evidence has shown some misuses of the termùself-efficacyû. For instance, Bandura pointed outthat some authors used the term ùself-efficacyûand ùself-esteemû interchangably, although theywere different concepts.2 Since the concept ofself-efficacy may still be unclear, it is essentialto elucidate its meaning.

Aim of AnalysisThis article aims to clarify the meaning of

self-efficacy in order to use the conceptappropriately in further theoretical developments,particularly in promoting health of individuals.

Uses of the conceptExploring for meanings of the term from

various sources will result in a great amount ofvaluable information. Walker and Avant suggestconsidering all uses of the term,1 not only oneaspect of the concept. Thus, dictionaries, thesauriand available literature from a variety of disciplinessuch as psychology, sociology, education,economics, pharmacology, kinesiology, nursing,medicine, and epidemiology were used toidentify uses of the concept.

Most dictionaries do not present the wordùself-efficacyû as a single word. The term ùself-ûis quite easily understood. As defined through theword ùselfû, in the Oxford English Dictionary,ùself-efficacyû implies to efficacy by oneself ofoneself, oneûs power, position, rights, desires, andambitions.

The word ùefficacyû has its origin in the Latinword ùeffecacitasû3 which means ùpowerû. AConcept Dictionary of English4 categorizedùefficacyû in the ùPOWRû category which refersto ùreferences to ability, achievement, strength,and braveryû. Included are such ideas as adeptnessand skill, fearlessness and hardiness, success andaccomplishment, force and power.é

According to the Oxford English Dictionary,ùefficacyû has the following meanings.

(1) power or capacity to produce effects;power to effect the object intended (not used asan attribute of person agents),

(2) a process or mode of effecting a result(3) effect

Synonyms for the word ùefficacyû are virtue,potency, force, and efficiency.5

Searching by using ùefficacyû as a key word,the term ùefficacyû has been applied in variousdisciplines. For example, in economics, ùefficacyûhas been used as a type of economic evaluation,referring to efficiency.6 In medicine, ùefficacyû isoften used in terms of efficacy of a drug. Inepidemiology, efficacy is evaluated as the benefitthat such an agent produces under the conditionsof a controlled trial. In statistics, a mathematicalmodel is used in evaluating the efficacy of testsused in screening for a specific problem such asinfections.7 Recently, the term ùefficacyû has beenwidely used in team sports. The association amongplayer efficacy, team efficacy and teamperformance has been studies in many types ofsports such as hockey.8

From theoretical literature, Bandura has beenfound to be a leading voice in the concept ofself-efficacy. Bandura defined perceived


Vol. 6 No. 4 243

self-efficacy as peopleûs judgement of or beliefsin their capabilities to organize and execute thecourses of action required to produce given levelsof attainments.9-10 He described self-efficacy interms of two types of expectation, efficacyexpectation and outcome expectation. Efficacyexpectation is the belief that one can successfullyperform a particular behavior to achieve a specificoutcome. Outcome expectation is concerned withexpected result when the behavior is performed.These outcomes can be physical, social orself-evaluative effects.9-10

People who believe that they have no powerto produce results will not attempt to make thingshappen. Power has been emphasized as a keyfactor of human agency which plays an essentialpart of self-efficacy.2 Self-efficacy judgementsare based on considerations of task attributes,performance conditions, ability estimates, andeffort requirements in a given situation.9 It isimportant to note that a sense of self-efficacy istied to particular domains of functioning.Therefore, self-efficacy must be measured basedon specific domains of functioning. There are nostandard measurements applicable to all peoplein all situations. In addition, Maibach and Murphypointed out that commitment, resourcefulness andperseverance are precisely the qualities addressedby self-efficacy.11 An expression of personalefficacy is an assertion of confidence in oneûscapability to overcome the difficulties inherent inachieving a specified level of behavioralattainment. Furthermore, mastery experiences areconsidered the most effective way of creating astrong sense of self-efficacy.10

Self-efficacy has been studied in relation tohuman behavior in various disciplines. For instance,in sports, evidence has demonstrated self-efficacyto be a major determinant of athletic performance.8

In team sports, the concept of collective efficacy2

has been used to explain group choices, efforts,and persistence. Collective efficacy is differentfrom personal efficacy in that it is a group-level

attribute. Bandura defined collective efficacy as agroupûs belief in their conjoint capabilities toproduce given levels of attainments.2 Teams withhigh team efficacy beliefs should outperform andpersist longer when behind than teams withlow-perceived team efficacy.

Self-efficacy has also been applied to thecareer area. Everhart and Chelladurai definedself-efficacy as an individualûs evaluation ofpersonal talents and skills in relation to a specifictask.12 They suggested that self-efficacymeasurement focus on the specific tasksassociated with these necessary abilities, skills,and dispositions, which were required forperforming those tasks. In counseling training,Heppner and colleagues pointed out that if traineeshad strong beliefs in their ability to perform theskills needed to be effective counselors, theseconvictions should then predict better actualperformance.13

Recent works in the area of physical exercisehave tended to focus on self-efficacy and exerciseadherence in older adults. Numerous researchstudies indicated the reliable associations amongself-efficacy and physical exercise.14-21 Thefindings have revealed that people who had lessself-efficacy experienced more negative responsesto exercise. On the contrary, people who have agreater sense of self-efficacy tend to maintainexercise programs. Furthermore, in a previousinvestigation by Hogan and Santomier, theresearchers found that older people whoparticipated in a swimming program increased intheir self-efficacy.22 In a more recent study, Conndeveloped and tested the predictive ability of amodel of exercise among the elderly. The resultsshowed a strong effect of self-efficacy expectationon exercise. In contrast, outcome expectancy wasa weak predictor of exercise.15 The findings ofthis study supported previous research findingsin older women.23

In addition, Conn found that perceivedbarriers to exercise were related to self-efficacy.15



The findings of another study also supported theimportance of perceived barriers.16 The authorshave suggested that perceived barriers to exercisewere the potential determinants of older peopleûsestimation of their ability to perform the behavior.Other studies demonstrated a significantrelationship between prior experiences withexercise and self-efficacy.14,17

From reviewing available literature, moststudies measured self-efficacy throughrespondentsû confidence in their capabilities. Forexample, confidence in exam taking wasmeasured to indicate learning self-efficacy ofstudents. Students responded by indicatingwhether or not they could get an ùAû on all exams.To indicate confidence in skills, the item such asùHow would you rate you...û has been asked. It isimportant to note that the construct of self-efficacydiffers from the colloquial term confidence sinceself-efficacy included both the affirmation ofcapability and the strength of that belief whereasconfidence refers to only strength of belief.10

In summary, ùefficacyû can be applied to bothhuman beings and objects. The meanings ofùefficacyû used in both cases are quite similar inthat they refer to the inherent attributes. Asprovided in most dictionaries, the most applicabledefinition of ùefficacyû as it appears in the conceptof self-efficacy is the power to produce effects.A sense of self-efficacy is concerned withperceived capabilities, which include theaffirmation and the strength, to produce effects ina particular task. Although other definitions asdescribed in this article are not relevant to humanbehavior, they provide useful insight.

Defining AttributesThe identification of attributes assists in

differentiating the concept of self-efficacy fromrelated concepts. Through exploring the uses ofself-efficacy, critical attributes of self-efficacyshould be as follows:

ë A belief in personal capability to performa particular task.

ë Strength of belief in abilities to actuallycarry out the required behavior.

ë Affirmation of confidence to overcomethe difficulties inherent in achieving a specifiedlevel of behavior attainment.

Construct a model case and additionalcases

A model case and additional cases areconstructed to demonstrate various uses of theconcept and to provide examples of what theconcept is or what it is not.1

Model caseMrs. Jan is a 79 year-old woman who began

exercise six years ago. By the age of 72, she haddeveloped an arthritic limp and was hospitalizedonce at age 73. After she came home, a communitynurse visited her and discussed with her aboutthe benefits of exercise and gave her examples ofhow exercise helped improve the health of otherpatients. Mrs. Jan also learned about goodexercising experiences from her friends. Despiteher old age and her illness, she believed thatexercise is the best way for recovering from herarthritis. Finally, she decided to participate in anexercise program with a strong belief in herability and the advantages of exercise. When shebegan with a prescribed routine walk, her limplimited her walking to 100 feet. Although shewas hurt from the initial exercise, she was patientand continued to exercise every morning. Whenshe wakes up to each new day, feeling somewhatuncomfortable, she tells herself, çCome on, getyourself up and walk, you can do ité. After onemonth of engaging in exercise program, she said,çI think I am feeling better with this exerciseplan, even at my old age. Before I began exercising,I had pains in nearly every joint, but now it barelyphases meé. Because of her good feelings towardexercise, she becomes more active in her local


Vol. 6 No. 4 245

senior citizensû group. Furthermore, she firmlybelieves that if she seriously practices, she willsucceed in walking one mile like others in herage bracket. As a commitment, she goes outwalking every morning, although sometimes shedoes not want to get up in the morning. Graduallyincreasing her distance, Mrs. Jan is able to befree of medicines and her previous symptoms.After two years of the exercise program, she walksone mile every morning.

Mrs. Jan demonstrated all of the definingattributes of self-efficacy. She had clear goalsand an obvious confidence in her capabilities.These characteristics were illustrated in herdecision to participate in the exercise program.The strength, affirmation of her confidence,perseverance, and mastery experience were seenthrough her exercise goal and practice. She ispersistent in her efforts. Although she was in pain,she overcame the difficulty in walking at thebeginning of her exercise program. In addition,she did the task with a strong sense of commitmentto self.

Contrary caseMrs. April is a 72 year-old woman who was

diagnosed as having arthritis. After she camehome, the community nurse visited her anddiscussed with her about the benefits of exerciseand gave her examples of how exercise helpedimprove the health of other patients. However,Mrs. April ignored the nurseûs suggestion. Shesaid, çAt my age, I cannot do much of anything,much less run around like a chicken with its headcut off.é

This case does not exhibit the definingattributes of self-efficacy. Because of herconvictions toward aging, she lacks confidencein her own abilities. She did not persist in herefforts to participate in exercise activity or evenshow a first attempt to exercise.

Related caseRelated cases are similar to the concept of

self-efficacy, but do not contain all of the definingattributes.1 Those terms, which appear to be usedoften and are related to self-efficacy, are as follows:

ë Self-confidenceë Self-esteemë Health locus of controlë Self-conceptë Self-controlë Perceived competenceë Self-actualizationë Perceived self-care agencyThe related case of self-confidence described

below is clearly distinguishable from self-efficacy.Mr. March is a 72 year-old man. He has

developed an arthritic limp and has beenhospitalized for a week. While in the hospital, anurse visited him and talked to him aboutexercising benefits. She tried to convey that hissymptoms would lessen in severity if notdisappear, if he would start an exercise program.Finally, he decided to participate in an exerciseprogram with confidence in his abilities. Whenhe began with a prescribed routine walk, his limplimited his walking to 100 feet. He complained tohis nurse that he was hurting more from theexercise and he did not want to attempt it anymore.Although the nurse has explained about theprocess of the pain and convinced him to continueexercising, he quit exercising.

This case does not contain all of the definingattributes of self-efficacy. Mr. March hasconfidence in his ability. However, he does notdemonstrate an affirmation of confidence of hisbelief in abilities to overcome the difficulties inorder to achieve the goal.

Borderline caseOne day, Mrs. June who is 72 years old falls

and fractures her hip. After being discharged fromthe hospital, the nurse suggested that she



rehabilitate herself in a nursing home since herhusband may not be able to take care of her dueto deteriorating health. However, her 75-year oldhusband insists that he will be able to handle it.He believes that he is able to provide care for hiswife, although the nurse explains the complexityof care that will be necessary. However, herhusbandûs assistance with her passive exercise isless effective. His ongoing attempt to learn howto rehabilitate her correctly causes further harmto her healing process.

This case demonstrates some of the definingattributes of the concept of self-efficacy. Thestrength of Mr. Juneûs confidence in his ability tocare for his wife is shown by his insistence thathe would be able to perform the required task.He also illustrated his confirmation of confidenceas he tried to master the passive exercise. However,he lacks the capability to learn how to successfullyheal his wife through passive exercise.

Antecedentsë Task or goalë Previous mastery experiencesë Perception of confidence in his/her ca-

pability to perform the task or achieve the goal

Consequencesë Change in confidence levelë Some level of goal attainment

Empirical referentsIn the standard methodology for measuring

efficacy beliefs, individuals are presented withitems of progressively more difficult performancerequirements within a certain behavioral domain.2

The items are phrased in terms of whether theycan or cannot perform the specific behavior. Thestrength and affirmation of individualûs confidenceto overcome difficulties are rated on a 100-pointscale, ranging in 10-unit intervals from 0 to 100.Recently, several scales have been developed forhealth behaviors such as physical activity and havebeen shown to have good reliability and validity.24

ConclusionAnalysis of the concept of self-efficacy in

terms of its defining attributes, antecedents,consequences, and empirical referents providesinformation related to clinical usefulness. It helpshealth care professionals communicate the samenotion when discussing self-efficacy and candistinguish this concept from other relatedconcepts. For researchers, clarification of theconcept can assist them to generate or select amore effective tool for their research studies.Most importantly, understanding self-efficacy asa concept is useful to health professionals inapproaching behavioral change such asparticipation in physical exercise of older people.

AcknowledgementsThanks to Dr. Kay Avant, Associate Professor,

The University of Texas at Austin, for her valuablesuggestions.

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