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  • 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 Office : Thailand Nursing Council Nagarindrasri Building, Ministry of Public Health, Tiwanon Rd., Amphur Muang, Nonthaburi 11000 Tel. (02) 9510145-51 Administrative Advisory Board Tassana Boontong RN., Ed.D Wichit Srisuphan RN., Dr. P.H. Editorial Advisory Board Ada Sue Hinshaw RN., Ph.D, FAAN. Barbara B. Germino RN., Ph.D. FAAN. Gail Dû Dramo Melkus RN., Ph.D. Karin Olson RN., Ph.D. Marilyn E. Parker RN., Ph.D. Marjorie Meuke RN., Ph.D. Paula Milone - Nuzzo RN., Ph.D. Editorial Board Editor Somchit Hanucharurnkul RN., Ph.D Assistant Editor Yuwadee Luecha RN., Ed.D Renu Pookboonmee RN., D.N.S. Ampaporn Puavilai RN., Ph.D Editorial Board Jintana Unibhand RN., Ph.D Darunee Rujkorakarn RN., Ed.D Yajai Sithimongkol RN., Ph.D Veena Jirapaet RN., D.N.Sc. Linchong Pothiban RN., D.S.N. Siriporn Chirawatkul RN., Ph.D Orasa Panpakdee RN., DNS. Aranya Chaowalit RN., Ph.D. Prakin Suchaxaya RN., Ph.D Waraporn Chaiyawat RN., D.N.Sc. Warunee Fongkaew RN., Ph.D. Sujitra Tiansawad R.N., D.S.N. Ownership Thailand Nursing Council Administrative Manager Prakin Suchaxaya RN., Ph.D Advertising Manager Saiyoud Siriphaphon RN., B.Sc. Aims and Scope : Thai Journal of Nursing Research is a fully refereed journal that publishes research and methodological papers. All papers are peer - reviewed by at least two researcher expert in the field of the submitted paper. Subscription Rates: Thai Journal of Nursing Research is published four times per year and the prices for 2002 are as follows: Members 300 bahts Non-member: Local 400 bahts Oversea 50 US$ Students 200 bahts Single copy 100 bahts Disclaimer: Thailand Nursing Council and the editors cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed do not necessarily reflect those of The Thailand Nursing council or The Editors, neither does The publication of advertisements constitute any endorsement by The Publisher or the Editors of the products advertised Thai Journal of Nursing Research Vol. 6 No. 4 ë October - December 2002 ISSN-0859-7685
  • Thai J Nurs Res • April - June 20022 Instructions for Authors The Thai Journal of Nursing Research publishes research and methodological papers. Manuscripts should be sent to the Editors or permanent Secretary of Thailand Nursing council at Nagarindrasri Building, Ministry of Public Health, Tiwanon Rd., Amphur Muang, Nonthaburi 11000, Thailand Manuscripts are accepted for publication in the Thai Journal of Nursing Research on the understanding that the content has not been published or submitted for publication elsewhere, which should be clearly stated in the covering letter. Except where otherwise stated, manuscripts are peer reviewed by two anonymous reviewers. The editorial board reserves the right to refuse any material for publication and advises that authors should retain copies of submitted manuscripts and correspondence, as material cannot be returned. The Editors reserve the right to modify typescripts to eliminate ambiguity and repetition and improve communication between author and reader. If extensive alterations are required, the manuscript will be returned to the author for revision. Papers accepted for publication become the copyright of the journal and all authors will be asked to sign a Transfer of Copyright form. Authors will be required to submit the final version as a hard copy and on disk. Preparation of Manuscripts Manuscripts should follow the style detailed in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, as presented in JAMA 1997; 277:972-34. Or Vancouver system. All submissions should be stylistically consistent. Submission of Manuscripts The original plus two copies must be submitted. Submissions should be typed, double spaced, on one side only of A4 paper. The top, bottom and side margins should be 3 cm. Laser or near-letter quality print is essential. All pages should be numbered consecutively in the top right-hand corner, beginning with the title page. The manuscript should be presented in the following order: title page, abstract and key words, text, acknowledgements, references, table, figure legends and figures. Each of these sections should begin on a separate page. The following guidelines apply to all manuscripts submitted. Title page : The title page should contain the title of the paper, the name(s) of the author(s) and the address of the institution(s) at which the work was carried out. It should also contain a separate list of the qualification(s) and positions held by the author(s), and the full postal address, telephone and facsimile numbers and email address of the author to whom correspondence about the typescript, proofs and requests for off-prints should be sent. The title should be short, informative and contain the major key words. A short running title (less than 40 characters including spaces) should also be provided. Abstract and key words: Submit abstract in duplicate both in English and Thai which must describe the methods used and the principal findings and conclusions of the study. The abstract should not contain abbreviations or references. Up to five key words should be provided to assist with indexing of the article.
  • Vol. 6 No.2 3 Text: Authors should consider the use of appropriate subheadings to label sections of their manuscript. Acknowledgements: The source of financial grants and the contribution of colleagues or institutions should be acknowledged. References: In the text, references should be made using superscript Arabic numerals in the order in which they appear. If cited only in tables or figure legends, number them according to the first identification of the table or figure in the text. In the reference list, the references should be listed in order of appearance in the text. Cite the names of all authors when there are six or less; when seven or more list only the first three followed by et al. References to unpublished data and personal communications should appear in the text only. References should be listed in the following form: Journal articles 1. Armitage P, Champney-Smit J, Andrews K. primary nursing and the role of the nurse preceptor in changing long-term mental health care : an evaluation. Journal of Advanced Nursing. 1991;16:413-22. 2. Orem DE. Nursing : Concepts of practice. 4th ed. St Louis : Mosby Year Book, 1991. 3. Lockhart CA. Nursingûs future in a shrinking health care system. In Sorensen GE, ed. The Economics of Health Care and Nursing. Atlanta : American Academy of Nursing. 1985:19-29. Tables: Tables should be self-contained and complement, but not duplicate, information contained in the text. Tables should be numbered consecutively in Arabic numerals, with a descriptive title above the table. Column headings should be brief, with units of measurement in parentheses. All abbreviations should be explained in a footnote. Tables should be double spaced and vertical lines should not be used to separate columns. Figure legends: Legends should be self-explanatory and typed on a separate sheet. The legend should incorporate definitions of any symbols used, and all abbreviations and units of measurement should be explained. Figures: Figures must be high-quality black and white photographs, line drawing or laser-printed graphs. Each figure should be on a separate page and labelled on the back (in pencil) with the figure number, orientation (noted with an arrow) and name of first author. Figures should be sized to fit within the column width (70mm) or the full text width (150mm). Figures should be numbered consecutively in Arabic numerals. Written permission to publish must be obtained from any subjects recognizable in photographs. Measurements All measurements must given in metric units. Statistics and measurements should always be given in figures (i.e. 10 mm), except where the number begins a sentence. When a number does not refer to a unit of measurement it is spelt out, except where the number is greater than nine. Abbreviations Abbreviations should be used sparingly and only where they ease the readerûs task by reducting repetition of long technical terms. Initially use the word in full, followed by the abbreviation on parentheses. Thereafter use the abbreviation. Abbreviations such as e.g. and etc. should only be used in parentheses.
  • Thai J Nurs Res • April - June 20024 Manuscripts on disk Authors are required to provide their manuscripts on disk. Authors should use a new disk rather than a reformatted disk and the disk should contain the relevant file(s) only. Authors should supply their accepted paper as formatted text (most word-processing formats can be handled). It is essential that the hardware and the word processing package are specified on the disk (e.g., MS word for Windows), as well as the first authorûs surname, the Journal title and the manuscript number. The entire article - (i) title page, (ii) text, (iii) acknowledgements, (iv) references, (v) figure legends, (vi) tables and legends, (vii) appendices - should be saved in a single file; only electronic figures should be supplied as separate files. The following instructions should be adhered to. ë It is essential that the final, revised version of the manuscript and the file saved on disk are identical (i.e. authors should supply a new disk if the article is revised). ë Do not use the carriage return (enter) at the end of lines within a paragraph. ë Turn the hyphenation option off. ë Do not use I (ell) for 1 (one), O (upper case oh) for 0 (zero) or B (German esszett) for β (beta). ë Include all figure legends and tables with their legends, if possible. ë Use a tab, not spaces, to separate data points in tables. ë If you use a table editor function, ensure that each data point is contained within a unique cell; do not use carriage returns within cells. ë Complete and return the File Description Form (supplied by the Editorial Office) specifying any special characters used to represent non-keyboard characters. Proofs and offprint Page proofs will be sent to the corresponding author and should be returned to the editorial office within 7 days of receipts. Alterations to text and illustrations are unacceptable at proof stage and authors will be charged for the cost of alterations, other than the correction of typesetting errors. Authors may order offprint with 200 bahts for 10 copies
  • Thai Journal of Nursing Research Vol. 6 No. 4 October - December 2002 ISSN-0859-7685 Content 163 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. 177 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.** 186 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. 200 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. 216 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. 231 Spirituality: A Concept Analysis Wanlapa Kunsongkeit RN. MNS.(Medical and Surgical Nursing) Marilyn A. McCubbin RN. Ph.D. FAAN. 241 Concept Analysis: Self-Efficacy Wannipa Asawachaisuwikrom, Ph.D.
  • Yupapin Sirapo-ngam Vol. 6 No. 4 163 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.*** * 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 ascertain the predictive power of severity of side effects, self-esteem, social support, and education on role adaptation of patients with cervical cancer receiving radiation therapy. The Roy Adaptation Model was used as the conceptual framework for the study. Eighty-six patients with cervical cancer receiving radiation therapy were recruited from the outpatient radiotherapy unit of six hospitals in Bangkok during February to June 2000. The inclusion criteria for the sample selected were women who (1) were married and lived with their spouse, (2) had no treatment of radiation or chemotherapy prior to participation in this study, (3) had been receiving radiation therapy 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) Role Adaptation Questionnaire. It was found that patients with cervical cancer receiving radiation had a rather good level of role adaptation. The stepwise multiple regression analysis revealed that the combination of social support, self-esteem, and severity of side effects accounted for 54.8% of the variance in role adaptation of patients with cervical cancer receiving radiation. Education did not significantly account for the variance in role adaptation. The result of this study was congruent with the role function mode within the Roy Adaptation Model. Nurses should be concerned with the influence of social support, self-esteem, and severity of side effects on patientsû role adaptation and keep them in mind when caring of these patients. Future intervention research on role adaptation of patients with cervical cancer receiving radiation 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 with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002164 Background and Objectives According to the annual statistical reports of the National Cancer Institute of Thailand from 1994 to 1996,1 cervical cancer was the most prevalent female cancer, with the highest incidence in the middle-aged group (35-60 years). Radiotherapy (RT) is one of the most common treatment modalities for curing cancer of cervix in its initial stages and for reducing complications of the disease in the terminal stages2 (Einhorn, 1996). Although RT has many advantages, it can produce many side effects that impact physical and psychosocial health3-5 . Most women may also undergo major role changes. These include reducing and losing current role tasks and integrating the sick role into their life. Experiencing a major role change or transition to a new role can be a stressful situation. Role changing and the adoption of new roles require the incorporation of new knowledge and standards of behavior for role performances6 . There is also a guarded effort and difficulty for these patients to maintain other existing roles effectively during the course of radiation. This is important because these roles to which women must adapt are often permanent and usually include significant problems for the remainder of their lives7 . These patients need much support from others to adjust to effective role functioning. Social support refers to the psychosocial and tangible aid provided by significant others and/ or social networks8 . It is a major mean of assisting patients to develop greater self-confidence and feelings of autonomy and control in responding to and modifying their environment. A person receives various types of social support including intimacy, opportunities for social integration, opportunities for nurture and reassurance of worth. An availability of informational, emotional, and material supports is also important9 . Many studies have confirmed the importance of social support for chronically ill patients10-13 . Social support enhances adaptive role performance which improves physical recovery, psychological well-being, and social functioning10-13 . Level of education has also been associated with role adaptation. Several studies have shown the positive relationships between educational achievement and role adaptation14-17 . The objectives of this research were to describe role adaptation of patients with cervical cancer receiving radiation therapy and to ascertain the predictive power of severity of side effects, self-esteem, social support, and years of formal education on role adaptation of patients with cervical cancer receiving radiation therapy. The Roy Adaptation Model18 was used as a conceptual framework to study the severity of side effects, self-esteem, social support, and education on role adaptation of cervical cancer patients receiving RT. This study focuses on roles of being a wife, work (inside and outside the home), and the sick role. The focal stimulus was the external alteration produced by the radiation therapy. The stimulus is acted upon by the coping mechanisms through cognator and regulator subsystems. The effects of the cognator and regulator activities are observed in the four modes of adaptation. In this study, the physiological, self-concept, and interdependence modes were deducted from empirical indicators that were severity of side effects,self-esteem,andsocialsupport,respectively. The behavioral responses of these three modes may act as a pooled effect on the fourth mode, the role function mode which reflects role adaptation. The results of this study are important for professional nurses to develop effective nursing interventions that promote role adaptation of patients receiving RT for cervical cancer. Providing interventions focused on support and resources can enhance role performance and in doing so patients can achieve social integrity.
  • Yupapin Sirapo-ngam Vol. 6 No. 4 165 Method Subjects and Settings The subjects were patients with cervical cancer receiving radiation therapy who were recruited from the outpatient radiotherapy department of six tertiary care hospitals in Bangkok. Data were collected in a five-month period, February to June 2000. Purposive sampling was used. The inclusion criteria were women who: 1) were married and lived with their spouse, 2) had no prior treatment with radiation or chemotherapy, and 3) had been receiving radiation (3,000 cGy), at least for a 3-week period. Instruments The instruments used for data collection are composed of the 5 following parts: 1. Demographic and Clinical Data Form. This included demographic and clinical data obtained from interviews and medical records. 2. SeverityofSideEffectsQuestionnaire. The severity of side effects questionnaire was developed by the researcher which was based on the Acute Toxicity Criteria of The Radiation Therapy Oncology Group19 , and the literature review. Only the frequent acute complications associated with the major problems of these patients were selected. Thus, the questionnaire was comprised of 10 items, covering skin reaction, food intake, nausea, vomiting, diarrhea, dysuria, frequent urination, fatigue, and emotional alteration. There were four descriptions of severity of side effects ranging from normal/no symptom = 1 to severe/abnormal symptom = 4. Total scores ranged from 10 to 40. The higher the scores, the greater the severity of side effects. The alpha Cronbachûs coefficient of the severity of side effects in this study was .73. 3. Self-Esteem Questionnaire. The researchers used the Rosenberg Self-Esteem (RSE) Scale20 for measuring patientsû self-esteem. The scale contains 10 items; half positive-score items and half negative-score items. The scores of negative items are reversed. Each item was indicated on a 4-point Likert-type scale from strongly disagree to strongly agree. The RSE Scale can yield a score from 10 to 40, with higher scores indicating higher self-esteem. The internal consistency of the RSE scale was tested in this study and gained reliably adequate (Cronbachûs alpha coefficients = .86). 4. Social Support Questionnaire. The Personal Resource Questionnaire 85 (PRQ 85)- Part II was used to measure the adequacy of the individualûs perceived level of social support. This instrument was developed and revised by Brandt and Weinert9 . In this study, the researcher used Soomlekûs questionnaire,21 which was modified from the PRQ 85-Part II. It consists of 21 items on a 5 point-Likert scale including never true = 1, rarely true = 2, somtimes true = 3, often true = 4, and always true = 5. The total scores ranged from 21-105. For the present study, the Cronbachûs alpha coefficient of the PRQ 85-Part II was .86. 5. Role Adaptation Questionnaire. The original role adaptation questionnaire was developed by Ounprasertpong22 for HIV positive and AIDS patients based on role function mode of the Roy Adaptation Model. This questionnaire was used for assessing patientsû ability to perform role behaviors. The questionnaire emphasizes three sub-roles: wife role, work role, and sick role. The Role Adaptation Questionnaire was on a 5-point-Likert scale itemized as follows: never perform =1, rarely perform = 2, sometimes perform =3, often perform = 4, and always perform =5. It contains 28 items including 20 positive items and 8 negative items. Total scores ranged from 28-140. It was found that the reliability as measured by Cronbachûs alpha coefficient in this study was .80.
  • Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002166 Protection of Human Subjects The rights of the subjects were respected in this study. Eligible subjects were individually approached to participate in the study. The study objectives, the data collection processes, expected research outcomes, subject rights, the type of questionnaires, length of time for completing the questionnaires, and right to refuse to participate in the study were explained. The subjects who agreed to participate were assured that the data would be kept confidential and reported as group data. Data Collection and Data Analysis All eligible subjects who met the criteria were approached and the protection of human subjectûs protocol was explained as previously described. The subjects, who volunteered to participate, read and completed the questionnaires by themselves in the following order: the Demographic and Clinical Data Form, the Severity of Side Effects Questionnaire, the Rosenberg Self-Esteem Scale, the Personal Resource Questionnaire (PRQ-85 part II), and the Role Adaptation Questionnaire. During this procedure, the investigator provided more information and clarification when needed. The researcher read the items on the questionnaires to any participants experiencing difficulty in reading. Reading the questionnaires by the researcher was done to ninety percent of the subjects. The Statistical Package for Social Sciences for Windows Program (SPSS/ FW) version 9.0 was used for data analysis. The predictive powers of severity of side effects, self-esteem, social support, and education on role adaptation of patient with cervical cancer receiving radiation therapy were analyzed using stepwise multiple regression analysis. Results Eighty-six patients participated in the study. The age of cervical cancer patients ranged from 25 to 65 with the mean age of 45.90 years. The majority of the subjects (70.93%) were middle-aged women (36-55 years). Most of the subjects (65.11 %) completed formal primary education. Approximately half of the subjects were housewives and the rest worked outside the home. Around thirty six percent of subjects had family income of less than 5,000 baht per month; the remainder had family income ranging from 5,001 to 90,000 baht. Nearly 47% of families had an income that exceeded their expenses. Most of the subjects (70.93%) were able to reimburse their medical expenses from the government or from their private insurance companies. The majority of the subjects (77.91%) were diagnosed with squamous cell carcinoma of the cervix and approximately 59% were at stage II of the disease. Nearly 70% of the subjects received doses of radiation ranging from 3,001- 4,000 cGy for 16 to 20 days. Based on the range of scores set up for the interpretation, the mean scores of role adaptation (role set score) were listed by each item from highest mean score to lowest in Table 1. The mean scores of role adaptation were 109.52 (S.D. = 11.77, min = 82, max = 132). It can be interpreted that the subjects of this study had levels of çRather Good Role Adaptationé.
  • Yupapin Sirapo-ngam 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 1 prescribed Desiring to replace radiation with other alternative 4.90 .38 2 Treatments Appropriately caring for radiated skin 4.83 .51 3 Taking preserved, spicy, or strong tasting foods 4.67 .69 4 Being discouraged and desiring to discontinue the 4.67 .79 5 treatment Drinking adequate water 4.55 .90 6 Satisfied with my compliance with treatment 4.50 .72 7 regimens Being irritated by fighting with husband 4.31 1.09 8 Wishing to a love and care for my husband 4.19 .94 9 Choosing healthy diet 4.15 .86 10 Regularly taking good perineal care 4.15 .87 11 Sleeping adequately 4.01 1.1 12 Talking and listening to husband 4.00 .89 13 Being anxious but do not apparently express 3.85 1.31 14 Observing abnormal symptoms by myself 3.77 1.03 15 Working intentionally 3.76 1.05 16 Being inert at work 3.73 .95 17 Consulting physicians/nurses concerning health 3.67 1.23 18 problems Being proud of work. 3.66 .95 19 Exchanging experiences/ problems with other 3.57 1.15 20 similar patients Being bored with the trip to the hospital daily 3.57 1.32 21 Being worried about insufficient family care 3.53 1.32 22 Seeking information concerning self-care practices 3.50 1.33 23 Taking care of family expense 3.48 1.83 24 Providing time and being responsible for work 3.30 .90 25 Improving work 3.16 1.02 26 Helping friends who have problems 2.86 1.18 27 Exercising 10-15 minute a day 2.23 1.41 28 Min = 82 , max = 132 total 109.52 11.77
  • Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002168 As indicated in Table 2, the severity of side effects had a mean score of 19.02 (S.D.= 4.53, skewness = .37). It was found that the subjects tended 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 subjects potentially have high self-esteem and perceived high social support. Subjects tended to have a low 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 Actual Range Range Severity of side effects 10-40 10- 34 19.02 4.53 .37 Self-Esteem 10-40 18-40 34.30 4.46 -1.13 Social support 21-105 61-105 84.85 11.81 -.45 Education (year) ≥0 0-16 6.06 4.46 1.16 The correlations among predictor variables and role adaptation were computed by using Pearsonûs product moment correlation. The correlation matrix among the studied variables is presented in Table 3. The results revealed that the role adaptation had a significant negative correlation with the severity of side effects (r = -. 43, p < .001). However, it is positively correlated with self-esteem, and social support (r = .52, p < .001; r = .68, p< .001) respectively. There was no significant relationship between role adaptation and education (r= .15, p > .05). In addition, there were significantly low to moderate relationships among predictors. Severity of side effects was significantly and negatively correlated with self-esteem and social support (r = -.28, p < .01; r = -.33, p< .01). Social support was significantly and positively correlated 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 1.00 2.Self-esteem -.28** 1.00 3.Social support -.33** .48*** 1.00 4.Education -.01 .09 .22* 1.00 5.Role adaptation -.43*** .52*** .68*** .15 1.00 *** p <.001, ** p < .01, * p < .05
  • Yupapin Sirapo-ngam Vol. 6 No. 4 169 Assumptions of regression analysis, which involved considerations of residual scatter plots were examined. The residual scatter plots indicated that the assumptions of regression analysis were met. All pairs of variables had linear correlation. Multicollinearity, diagnosed by having correlations among independent variables greater than .65, was not found. All independent variables had low to moderate correlations with one another (r = - .33 to .48). A Durbin-Watson value was 2.19, which indicated that the regression error had no autocorrelation23 . As shown in Table 4, stepwise multiple regression was used to analyze the predictive power of severity of side effects, self-esteem, social support, to role adaptation. Social support, which had the highest correlation with role adaptation, was first selected in the regression equation. Social support accounted for 46.4 % of the variance in role adaptation (F change 1,84 = 72.66, p < .001). This indicated that a one unit change in social support will cause a 0.51 unit change in role adaptation in the same direction (β = .51, t = 5.89, p < .001). Next, self-esteem was selected, 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 unit change in self-esteem will cause a 0.22 unit change in role adaptation in the same direction (β = .22, t = 2.58, p < .05). Severity of side effects was lastly selected into the analysis and accounted for an additional 3.5% of the variance in role adaptation (F change1, 82 = 6.30, p < .05). This indicated that a one unit change in the severity of side effects will cause a 0.20 unit change in role adaptation in the opposite way (β = -.20, t = -2.51, p < .05). The findings indicated that the combination of social support, self-esteem, and severity of side effects significantly accounted for 54.8% of the variance of role adaptation of cervical cancer patients receiving radiation therapy (overall F 3, 82 = 33.11, p < .001). Education did not significantly account for the variance of role adaptation. Therefore, the result of hypothesis testing 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
  • Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002170 Discussion The mean score on role adaptation (role set) was 109.52 which suggested that patients with cervical cancer receiving radiation had levels of çRather Good Role Adaptationû. The overall role adaptation was viewed as the combination of adaptation to three sub-roles including wife, work, and sick roles. However, when considering the ranking of mean scores by each individual item, it was apparent that the seven highest mean scores were in the sick role adaptation (Table 1). This can be explained by the social mechanisms within the role function mode of the RAM24 . It could be reflected that the women with cervical cancer receiving radiation may appraise and set the sick role as the significant priority in setting behavior priorities. The patients may have attempted to integrate the sick role (new role) into their life, while they had many current roles within their role set (i.e., work and wife roles). When their integration processes were challenged, compensatory processes were activated. The women formulated their effective role transition in order to meet the goal of adaptation (i.e.maintain their health and survival) by increasing their adaptation level through cognator processes. They simultaneously delegated their usual tasks to family members or co-workers in order to comply with radiation therapy schedules. Nevertheless, they tended to maintain system balance between roles of being sick, wife and work. The findings from this study support Soompoo and Tongtanunamûs studies17,25 of role adaptation of patients with receiving cancer treatments. In general, patients receiving cancer treatments perform an effective role adaptation or have a good sick role adaptation. However, during the course of treatment, patientsû role adaptation may change. As reported in two studies conducted by Pittayapan26 and Ruankon27 , the results showed that the outcomes of role function and quality of life of patients with cervical cancer in the third and the fifth week of radiation were significantly lower than those outcomes prior to radiation. These studies used a longitudinal design that allowed changes to be collected over time. Therefore, it is not surprising that the findings of these previous studies are not congruent with this present cross-sectional study. Based on their sick role during radiation, the patients should exercise 10-15 minutes a day. The results showed that sixty-three percent of the patients never or rarely exercised. Therefore, the mean score of this item was the lowest (mean = 2.23). It is possible that the patients might believe that household activities were already good exercise. In addition, being fatigued as a result of the side effects of the treatment and daily transportation diminished the desirability of exercise. Graydon, et al.28 also reported that patients who underwent cancer treatments were often suggested to limit their activity and get plenty of rest. In this study, nearly 50% of patients indicated that they were reluctant to exercise because of various reasons. For instance, they were unsure if exercise might be risky for their health. In addition, they rarely received advice from health professionals in this respect. Accordingly, performing exercise was reported to be the greatest self-care deficit in cervical cancer patients undergoing radiation5 . Obviously, additional findings in this study relate to sexual issues. Eight patients addressed sexual and marital conflict. Specifically, they mentioned the inability to have sexual relations with their partner. Some patients said that they could no longer have sex. However, this issue was not able to be explored because it was regarded as an embarrassing issue for the subjects. Thus, the issues of exercise and sexual relationships may add to the important problems where patients tend to have an ineffective role adaptation. Nurses, therefore, should be aware and plan intervention to prevent ineffective role behaviors.
  • Yupapin Sirapo-ngam Vol. 6 No. 4 171 The findings indicated that the combination of social support, self-esteem, and severity of side effects significantly accounted for 54.8% of the variance of role adaptation is patients with cervical cancer receiving radiation therapy. Among predictors, social support was the strongest variable influencing role adaptation. The subjects reported that they received social support from various resources such as a spouse or close friends in several ways including intimate relationships and attachment, and instrumental support. Small social groups (i.e., a group of similar patients, neighbors) were potential sources of companionship and services. The work group may provide a sense of belonging, competence, and usefulness for them as well. Additionally, professional guidance is a useful resource. Taken together, it is not surprising that the subjects who participated in this study have adequate and compassionate social support that consequently may (1) give them a sense of self-esteem and personal efficacy, (2) enhance cognitive processing required for effective decision making and problem solving in stressful situations, and (3) reduce negative moods. As a result, social support would enhance cooperation in engaging in effective role performance, and consequently, role adaptation8,13,29-31 . These findings are similar to that of the previous studies in cancer patients receiving treatments12,25,32-34 The significant positive relationship between social support and role adaptation supports the conceptionwithintheRAM18 .Royûsconceptualization of interdependency and two major stimuli influencing role function, i.e., çaccess to facilitiesé and çcooperation or collaborationé was viewed as social support in this study. Thus, the findings support the proposition of the RAM which stated that there are interrelationships among adaptive modes. Specifically, social support, as a factor representing the interdependence mode, which helps modify role behaviors in the role function mode, influences role adaptation in this particular group of patients. Self-esteem was the second predictor influencing role adaptation. There was a positive relationship between self-esteem and role adaptation. It can be explained that self-esteem is an essential factor influencing behaviors leading to personal effective functions. High self-esteem empowers patients to be active participants in care, helps the patients develop confidence in interpersonal communication, and enhances the potential for successful role performance. Thus, patients with high self-esteem feel that they are worth the time and effort needed to maintain and improve health and eagerly take responsibility to meet self-care needs. Conversely, the individual with low self-esteem may be unable to make self-care decisions and assume responsibility for care outcomes35 . Obviously, during radiation, about 50% of the sample received their wages from actual employment. In addition, nearly half of the workers (22 cases) reported that their rela- tionship with friends and co-workers were as usual. The work settings and the support that they received in the work place or social environment possibly produced a positive self-esteem and value in these patients36-37 . In accordance with Uckanit38 , Vichitvatee39 , and Yoswattana40 , self-esteem was significantly and positively correlated with self-care behavior and role adaptation in patients with chronic diseases. Severity of side effects was selected last to enter in the regression equation, and had a negative relationship to role adaptation. It may be explained that the patients may have greater or lesser symptom distress depending on the perception of severity of side effects. According to Roy and Andrews18 , physical and/or emotional well-being affect the individualûs ability to fulfill the role. In this study, all subjects were informed about the disease, possible side effects, and how to deal with the side effects. Moreover, they had obtained information related to self-care practices from several sources. They also had developed strategies such as making appropriate
  • Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002172 plans for their routine activities, seeking information from similar cancer patients, or asking the physician to treat the side effects that would decrease the impact on their activities. These findings are consistent with the previous studies of Oberst and others4 and Irvine and others41 . These two studies found that symptom distress and fatigue were important factors contributing to the self-care deficit of role performance in cancer patients during chemotherapy or radiation. Similar to the study of Ruankon27 and Pongthavornkamol42 , the patients with cervical cancer receiving radiation who had greater complications of radiation had lower quality of life and more disruptions of function than those who had lesser complications. Also Kawsasri43 found that perception of radiation reactions could explain and accounted for 6.24% of the variance in sick role adaptation of patients with head and neck cancer who were receiving radiation therapy. Year of education was the only one predictor that was not significantly correlated with role adaptation. Possible explanations might be that a high proportion of the sample had a low formal education and received a high degree of support services. Another possible reason could be that most subjects in this present study were relatively homogenous with respect to education. Around 72% of the patients had primary school certificates, whereas only 12.79% of the patients had vocational or undergraduate education. With respect to receiving social support services, patients who had difficulty in reading still received information by listening to the instructions verbatim from their children or other family members. Moreover, the patients most likely received indirect information by talking to other patients, or learning through many other sources (e.g., television, radio, internet document). Receiving adequate information and increasing their understanding regarding their illness and treatments is helpful and may motivate them to express adaptive behaviors. One study has shown that patients who are informed about radiotherapy procedures, possible side effects, and therapeutic effectiveness do not experience disappointment, fear, and anger3 . These findings are similar to the study by Muhlenkamp and Sayle44 and by Kaveevichai45 , which reported that education was not correlated with positive health behaviors and adaptation in healthy adults, and in patients with mastectomy receiving chemotherapy. Education had no correlation with quality of life in a study of patients with cervical cancer receiving radiation46 , and adaptation in patient with head and neck receiving radiation32 . However, the studies by Changphuang14 and Tongtanuman17 found that education was correlated with adaptation or sick role adaptation in patients with mastectomy receiving chemotherapy. In conclusion, the combination of social support, self-esteem, severity of side effects accounted for 54.8% of the variance in role adaptation of patients with cervical cancer receiving radiation. The remaining 45.2 % other influencing factors were not covered in this study and need further investigation. Overall, the research findings were congruent with the RAM and contributed to the advancement of nursing knowledge. Recommendations The results of this study apparently signify the influences of social support, self-esteem, and severity of side effects. Nurses should consider the importance of these factors and keep them in mind when caring of these patients. Enhancing effective adaptation and preventing ineffective adaptation should be the primary focus. In doing so, factors influencing role adaptation should be assessed followed by specific nursing interventions based on the assessment. As the first leading factor influencing role adaptation, social support
  • Yupapin Sirapo-ngam Vol. 6 No. 4 173 should be assessed and facilitated. The essential element is the assessment of social support in terms of resource availability (e.g., social networks, financial or economic status, instrumental help), psychological conditions (e.g., sense of love and belonging, self worth), interpersonal relationships (e.g., spouse, family members, friends), and social activities. Interventions may include recognizing, contacting, and inviting significant others (i.e., spouse, children or relatives) to participate in assisting role adaptation of the patient during the course of radiation therapy. Nurses should facilitate formal or informal group support during treatment sessions as well as provide substantial information necessary for enhancing positive adaptation. Self-esteem, another important influencing factor on role adaptation, should be emphasized. Nurses should begin with an assessment of self- esteem to determine the level of the perception of self. Enhancing positive self-esteem is valuable. Nurses, therefore, should identify interventions to promote self-esteem. Family and sexual counseling should be provided to patients with cervical cancer receiving radiation therapy when needed. Although the severity of side effects was shown to be less predictive on role adaptation in this study, controlling the side effects is necessary because it enables the patient to be emotionally comfortable and be able to maintain daily activities. Nurses should regularly assess signs and symptoms indicating the side effects of radiation regularly. Assessment of patientûs knowledge regarding self-care practices to overcome such side effects and to provide required information is also essential. Moreover, a special topic of continuing education relating to role adaptation should be encouraged. This may result in an increase in nursesû awareness of the significance of this social aspect of the patients, consequently improving the quality of nursing care. This project was supported the research grant by the China Medical Board. References 1. National Cancer Institute of Thailand. Annual Report. 1994-1996. 2. Einhorn, N. Cervical Cancer (Cervix Uteri). Acta Oncologica (Supplementum 7) Vol. 2: A Critical Review of the Literature, 1996; 35, 75-80. 3. King,K.B.,Nail,L.M.,Kreamer,K.,Strohl,R.A.&Johnson, J.E. Patientsû descriptions of the experience of receiving radiation therapy. Oncology Nursing Forum, 1985; 12(4), 55-61. 4. Oberst, M. T.,Hughes, S. H.,Chang, A. S. & McCubbin, M.A. Self-care burden, stress appraisal, and mood among persons receiving radiotherapy. Cancer Nursing, 1991; 14(2), 71-78. 5. Teparux, S. Comparative Study the Effectiveness of Two Methods in Promotion of Self-Care on Self-Care Deficit and Radiation Side Effects among Cervical Cancer Patients. Masterûs Thesis in Science (Nursing), Faculty of Graduate Studies, Mahidol University, 1992. 6. Meleis, A. I. Role insufficiency and role supplementation: a conceptual framework. Nursing Research, 1975; 24(40), 264-271. 7. Nuwayhid, K.A. Role Transition, Distance and Conflict. In S.C. Roy & H. A. Andrews (Eds.), The Roy Adaptation Model : The Definitive Statement (pp.364-376). Norwalk: Appleton & Lange, 1991. 8. Tiden, V. P. & Weinert, C. Social Support and the Chronically Ill Individual. Nursing Clinics of North America, 1987; 22(3), 613-620. 9. Brandt PA. & Weinert C. The PRQ- A Social Support Measure. Nursing Research 1981; 30 : 277-280. 10. Cobb S. Social support as a moderator of life stress. Psychosomatic Medicine 1976 ; 38 : 300-314. 11. Gasemgitvatana S. A Causal Model Caregiver Role Stress among Wives of Chronically Ill Patients. A Dissertation of the Requirements for Degree of Doctor of Nursing Science. Faculty of Graduate Studies, Mahidol University, 1994. 12. Hanucharurnkul, S. Predictors of self-care in cancer patients receiving radiotherapy. Cancer Nursing, 1989; 12(1), 21-27. 13. Pender, N. J. Health Promotion in Nursing Practice. 3rd ed. Connecticut: Appleton & Lange, 1996. 14. Changpuang, V. The Relationship Between Perception of Disease, Spouse Support and Adaptation of Breast Cancer Patients. Masterûs Thesis in Science (Nursing), Faculty of Graduate Studies, Mahidol University, 1991.
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  • Factors Influencing Role Adaptation of Patients with Cervical Cancer Receiving Radiation Therapy Thai J Nurs Res ë October - December 2002176 ªí®®—¬∑’ˇ°’ˬ«¢âÕß°—∫°“√ª√—∫µ—«„π¥â“π∫∑∫“∑Àπâ“∑’Ë¢ÕߺŸâªÉ«¬ ¡–‡√Áߪ“°¡¥≈Ÿ°∑’ˉ¥â√—∫√—ß ’√—°…“ ¬ÿæ“æ‘π »‘√‚æ∏‘Ïß“¡* D.S.N.(Adult Health Nursing) æ√√≥«¥’ æÿ∏«—≤π–* «∑.¥. (‚¿™π»“ µ√å) ≈—æ≥“ °‘®√ÿàß‚√®πå** æ¬.¡. (°“√欓∫“≈ºŸâ„À≠à) «‘√—µπå ‰æ√—™‡«∑¬å*** æ.∫. ∫∑§—¥¬àÕ: °“√«‘®—¬‡™‘ß∫√√¬“¬π’È¡ÿàß»÷°…“ °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë ·≈–§«“¡ “¡“√∂¢Õß §«“¡√ÿπ·√ߢÕßÕ“°“√¢â“߇§’¬ß §«“¡√Ÿâ ÷°¡’§ÿ≥§à“„πµπ‡Õß ·√ß π—∫ πÿπ∑“ß —ߧ¡ ·≈–°“√»÷°…“ ∑’Ë√à«¡°—π„π∑”𓬰“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë¢ÕߺŸâªÉ«¬¡–‡√Áߪ“°¡¥≈Ÿ°∑’ˉ¥â√—∫√—ß ’√—°…“ ‚¥¬„™â √Ÿª·∫∫°“√ª√—∫µ—«¢Õß√Õ¬ (1991)‡ªìπ°√Õ∫·π«§‘¥ »÷°…“„πºŸâªÉ«¬ 86 §π∑’ˉ¥â√—∫√—ß ’√—°…“·∫∫ ºŸâªÉ«¬πÕ°¢Õß‚√ß欓∫“≈ 6 ·Ààß„π°√ÿ߇∑æ¡À“π§√√–À«à“ß ‡¥◊Õπ°ÿ¡¿“æ—π∏å∂÷߇¥◊Õπ¡‘∂ÿπ“¬π 2543 §—¥‡≈◊Õ°°≈ÿࡵ—«Õ¬à“ß∑’Ë¡’§ÿ≥ ¡∫—µ‘µ“¡∑’Ë°”Àπ¥ §◊Õ ¡’ ∂“π¿“æ ¡√ §Ÿà·≈–Õ“»—¬Õ¬Ÿà°—∫ “¡’ ‰¡à‡§¬ ‰¥â√—∫√—ß ’√—°…“¡“°àÕ𠉥â√—∫√—ß ’√—°…“Õ¬à“ßπâÕ¬ 3,000 cGy.,3  —ª¥“Àå 查·≈–‡¢â“„®¿“…“‰∑¬‰¥â¥’ ·≈–¬‘π¥’‡¢â“√à«¡„π°“√«‘®—¬ ‡°Á∫¢âÕ¡Ÿ≈¥â«¬·∫∫ Õ∫∂“¡ 5 ™ÿ¥ ‰¥â·°à (1) ·∫∫∫—π∑÷°¢âÕ¡Ÿ≈ à«π∫ÿ§§≈ ·≈–¢âÕ¡Ÿ≈∑“ߧ≈‘π‘° (2) §«“¡√ÿπ·√ߢÕßÕ“°“√¢â“߇§’¬ß (3) §«“¡√Ÿâ ÷°¡’§ÿ≥§à“„πµπ‡Õß (4) ·À≈àß ª√–‚¬™πå à«π∫ÿ§§≈ ·≈– (5) °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë º≈°“√«‘®—¬æ∫«à“ºŸâªÉ«¬‚√§¡–‡√Áߪ“°¡¥≈Ÿ°∑’ˉ¥â√—∫√—ß ’√—°…“ ¡’°“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë ‰¥â§àÕπ¢â“ߥ’°“√«‘‡§√“–Àå¥â«¬ ∂‘µ‘∂¥∂Õ¬æÀÿ§Ÿ≥·∫∫‡™‘ß™—Èπæ∫«à“·√ß π—∫ πÿπ∑“ß —ߧ¡§«“¡√Ÿâ ÷° ¡’§ÿ≥§à“„πµπ‡Õß ·≈–§«“¡√ÿπ·√ߢÕßÕ“°“√¢â“߇§’¬ß  “¡“√∂√à«¡°—πÕ∏‘∫“¬§«“¡·ª√ª√«π¢Õß °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë¢ÕߺŸâªÉ«¬¡–‡√Áߪ“°¡¥≈Ÿ°∑’ˉ¥â√—∫√—ß ’√—°…“‰¥â√âÕ¬≈– 54.8 °“√»÷°…“ ¢ÕߺŸâªÉ«¬‰¡àæ∫«à“‡ªìπµ—«·ª√∑’Ë¡’π—¬ ”§—≠∑“ß ∂‘µ‘ „π°“√¥Ÿ·≈ºŸâªÉ«¬‚√§¡–‡√Áߪ“°¡¥≈Ÿ° ®÷ߧ«√„Àâ §«“¡ ”§—≠°—∫ªí®®—¬¥â“π·√ß π—∫ πÿπ∑“ß —ߧ¡ °“√‡ÀÁπ§ÿ≥§à“„πµπ‡Õß ·≈–§«“¡√ÿπ·√ߢÕß¿“«– ·∑√°´âÕ𠧔 ”§—≠: °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë ¡–‡√Áߪ“°¡¥≈Ÿ° √—ß ’√—°…“ * √Õß»“ µ√“®“√¬å ¿“§«‘™“欓∫“≈»“ µ√å §≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ ** Õ“®“√¬å§≥–欓∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å *** ºŸâ™à«¬»“ µ√“®“√¬å ¿“§«‘™“√—ß ’«‘∑¬“ §≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
  • Rutja Phuphaibul Vol. 6 No. 4 177 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.** * 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 developmental tasks of spouses in families with infants, preschoolers, schoolagers, and teenagers. The sample consisted of 2,031 parents in the Bangkok metropolitan area whose first child fell into one of these age groupings. The sample size of each age group was approximately 500. Schools and hospitals were randomly selected to access families with children of various age groups. A questionnaire developed by the researchers was used in data collection. It was comprised of 2 parts , one of which addressed family demographic data and the second addressed marital developmental tasks. The results of the study revealed four major marital developmental tasks including : a) financial tasks, b) family function delegation, c) spousal relationship, and d) relationship with extended family members. In comparing families with children in the various age groupings on marital developmental tasks, the analysis of variance ( F=18.27, p<0.001) showed significant differences. Post hoc analysis (Scheffeûs test) indicated significant differences between families with preschoolers and all other age groupings, and between families with schoolagers and families with infants. The families with infants had the lowest score, and the highest score was in families with preschoolers. There was a decreasing trend in families with schoolagers and further decline in the families with adolescents. Thai J Nurs Res 2002 ; 6(4) : 177-185 Keywords: spouse, family, development task,.
  • Marital Developmental Tasks of Thai Spouses in Childrearing Families Thai J Nurs Res ë October - December 2002178 Rationale The family provides an important sociocultural context for individual members and represents the basic social subsystem. The structure of Thai families has changed gradually as shown in the survey results of the National Statistic Institution of Thailand. The findings showed a declining family size as well as a changing pattern of marital behavior1 Marital tasks remain essential in all couples during the family development stages. Marital and family relationship shows its impacts on mental health problems of its members2-4 . Pasch and Bradbury studied newly married couplesû participation in 2 interaction tasks : a problem-solving task in which spouses discussed a marital conflict and a social support task in which spouses discussed personal, nonmarital difficulties. The couples who exhibited relatively poor skills in both tasks were at particular risk for marital dysfunction 2 years later5 . From literature review on spousal marital tasks. a number of studies were found that focused on marital relationship in particular stages of family life such as the beginning family, late adulthood and retired couples, and couples who have a chronically ill spouse5-7 . There was no evidence of studies that examined the tasks of spouses in different stages of family life. Normally, Thai couples decided to have offspring after 2-3 years of marriage. The number of children desired has been between 1-2. Alterations in family roles from a couple without children to a family with children of different ages are expected to have an effect on spousal relationships and role sharing. Additionally, child rearing families at present have more dual-career parents. This will certainly add a burden on the nuclear family without child rearing support from relatives. These couples will have to share responsibilities in child care and household work. Thus, family role performances were expected to vary according to the family developmental stages, that are usually defined by the age of the first born child. Family developmental tasks consist of 8: 1) Being an independent family after marriage 2) Generating adequate income 3) Role sharing among members 4) Sexual satisfaction between couple 5) Communicating and relating among members 6) Relating to family relatives 7) Interacting with organizations, groups, and the community 8) Ability to provide care to offspring. 9) Having an appropriate life philosophy Objectives of the study The 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 developmental tasks of spouses among families with infants, preschoolers, schoolagers, and adolescents. Hypotheses There are significant differences among marital developmental tasks of families with infants, preschoolers, schoolagers, and adolescents. Scope of the Study The study was conducted among families with firstborn children from newborn to 19 years old living in Bangkok, whose children were receiving educational, health care, and child care services in various organizations. Conceptual Framework The conceptual framework of the study was derived from the early work of Duvall in 1977 9 , the researchersû pilot study in 1997, and a literature review that addresses the changing
  • Rutja Phuphaibul Vol. 6 No. 4 179 relationship within families according to the period of the family life cycle. Family developmental tasks 9 related to spousal relationships at various child rearing periods have been discussed in the literature. The spousal roles or so called çmarital tasksé, may therefore, be reconceptualized as çmarital developmental tasksé as they would be expected to change as the child grows older. Four dimensions of marital developmental tasks were derived from pilot study data collected by 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 function delegationé. Child care and housework flexibility are important aspects of this dimension. 3) Maintaining good relationship between the couple, including collaborative problem solving, sharing feelings, sharing leisure time, agreement on family planing, and sexual satisfaction. This dimension is referred as çspousal relationshipé. 4) Maintain good relationship between the couple and relatives. This dimension is referred to as çrelationship with extended family membersé. Definition of Terms 1. Marital developmental task performance is referred as the activities of both husband and wife in maintaining roles, functions, and optional interaction between the couple, family members, and relatives as measured by the questionnaire developed by the researchers. The questionnaire is based on Duvallûs Family Development Theory and the results of a pilot study by the researcher in 1997. A high score indicates good performance. A low score indicates poor performance of marital developmental tasks. 2. Family developmental stage signify periods of the family life cycle which change over time. The child-rearing families in this study were divided into 4 groups according to the age of the first child in the family. 2.1 Family with infant was the family with the first born aged between newborn and 2 and a half years old. 2.2 Family with preschooler was the family with the firstborn aged between 2 and a half years old and 6 years old. 2.3 Family with schoolager was the family with the firstborn aged between 6 and 13 years old. 2.4 Family with adolescent was the family with the firstborn aged between 13 and 19 years old. Literature Review Major concepts of family development theory include the integration of family structural and role functions during discrete time periods. Family structure and function are derived from structural functional theory10 . The interaction between family members was viewed as a semi-closed system which changes thoughout the cycle of family life Duvall described the essence of family development in child-rearing periods as follows 9 : Stage I : Beginning family. This stage starts from marriage through the pregnancy of the first child. During this period, the couple develop their life as a couple and acquire skills in understanding and adjusting to each other. Family planning is essential during this period. Stage II : Family with infant. The main family developmental task here is focused on adjusting to parenting roles and child rearing. Stage III : Family with preschooler. Preparation for school and socialization of the preschool child are emphasized here. The couple might plan to have the second child during this period.
  • Marital Developmental Tasks of Thai Spouses in Childrearing Families Thai J Nurs Res ë October - December 2002180 Stage IV : Family with schoolager. As the child is able to help himself more, the family focuses on providing educational opportunities and promoting the childûs academic skill. Parentsû role in socialization of the child and the influence of their philosophy of life become more evident. Stage V : Family with adolescent. Parents need to become more flexible in the relationship with their teen children. Teens are gradually allowed to become more responsible for themseleves. Communication between parents and their child is the most essential component of this period. Four family developmental stages have been selected for inclusion in this study (stagesII-V). Family life cycle theory of Carter & McGoldrick 1988 emphasized the expansion and contraction of family boundary and size, in addition to the adjustment in family relationships during the developmental course11 . Families with marital problems have been investigated in Thai couples revealing the need for better understanding of the problem. A study of familyûs problems in 115 couples from the Psychiatric Outpatient Unit, found that most of the clients who asked for assistance were female. The most frequent psychiatric problems were related to marital problem including depression (27%), dysthymia (22.6%), and adaptive disorder (19.1%), The main causes underlying these problems were their spouse having affairs with others (34.8%), psychological neglect (19.1%), inability to love their spouse (10.4%), fear that their spouse would have an affair (7.8%), their spouse not sharing family roles and child care (70%), their spouse being a drug addict (6.0%), their spouse being a gambler (5.2%), problems with relatives of their spouse (3.5%), sexual problems (2.6%), family violence (1.7%), financial problems (0.9%), and decision making power (6.9%)12 . Many studies suggested both positive and adverse impact of the marital relationship on physical and mental problems. Symptoms of depression and sudden cardiac risk in cardiac patients were adverse outcomes reported by Irvine et 19996 . A study in 2000 by Kung and Elkin indicated that the patientûs level of marital adjustment at termination of treatment of depression and the extent of marital improvement over the course of treatment significantly predicted the treatment outcome at follow-up3 . From the review of literature and pilot study, it was evident that family problems derived primarily from difficulties in the spouse relationship dimension. The problems of role sharing, finances, and relationship with relatives were less intense. There has not been a study comparing these tasks during various family stages according to child rearing periods. Therefore, this study was designed to explore the differences in marital task performance among the different child rearing stages. Methodology A descriptive design was used to examine and compare the marital developmental tasks among families with infants, preschoolers, schoolagers, and adolescents. Sample The study sample was comprised of parents in the Bangkok Metropolitan area with the firstborn children in 4 specific age groups, living in the same household. Only parents who were literate and who agreed to participate were included in the study sample. The data were collected from 2,031 parents which included 514 family with infants, 511 families with preschoolers, 506 families with schoolagers, and 500 families with adolescents. The table of random numbers was used for sample selection. Families with infants were selected from 10
  • Rutja Phuphaibul Vol. 6 No. 4 181 Bangkok hospitals in the Pediatric Out Patient and Obstetric Out Patient Departments. Families with preschoolers were selected from 6 settings : 2 hospitals, 2 day care centers, and 2 kindergartens. Families with school age children were selected from the following 10 settings : 5 government schools and 5 private schools. Lastly, the adolescentsû families were selected from 10 settings including 8 high schools and 2 University / Colleges. Instruments The instruments used in the study were questionnaires developed by the researchers and consisted of 1) Family demographic data and 2) Marital developmental tasks. Seven experts reviewed the questionnaire for its content validity. The Cronbachûs alpha was 0.82. The marital developmental tasks questionnaire was comprised of 22 items with 5 items on financial tasks, 4 items for family function sharing on delegation, 8 items on spouse relationship, and 5 items on relationship with relatives. The responses were measured on a Likert scale with scores ranging from 1-4 (from çneveré to çalways practiceé) Results The findings showed that the educational level of the majority of the parents was below 10th grade. The majority of the families with infants (52.7%) were living in an extended family structure. In families with preschoolers, schoolagers, and adolescents the proportion of extended family living situations decreased with the increasing age of the first child (49.1%, 38.3%, and 29.3%). (Here would be a good place to comment about how the fact that the majority of the families had more than one child was accounted for in your interpretation of the findings. Do you have data on what the ages of the children were in families with more than one child? I see this as a major confounding variable since a family may have a child in any 2 of the stages if there are 2 children or even 2 in one stage. I realize that developmental theorists base their ideas on the age of the first child, but this makes your research findings difficult to interpret with any confidence.) The majority of the subjects were families with 1-2 children who lived in urban areas. The mean scores in each of the 4 stages were as show in Table 1 and Figure 1. Table 1 and Figure 1 display the variation of subscores in families at different stages. It shows that the marital task score was highest in the preschool group (mean=68.14), while lower scores were found in the school-age group (mean=66.17) and the adolescent group (mean=65.20). The lowest 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 63.84 2. Role / function 12.25 12.79 12.59 12.21 68.14 3. Spouse 24.33 24.01 22.61 22.23 66.17 Relationship 4. Relative 11.96 13.27 12.67 12.64 65.20 Relationship
  • Marital Developmental Tasks of Thai Spouses in Childrearing Families Thai J Nurs Res ë October - December 2002182 The scores in each stage were then analyzed in order to identify the differences between each stage by comparing the mean differences using ANOVA and Scheffeûs Test. The results in Table 2 and 3 show that there were mean differences 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 differences in the means between infancy and preschool periods, infant and schoolage periods, schoolage and preschool periods ,and preschool and adolescent 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 92.8 Total 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) 1.36 Schoolage (66.17) 2.33* 0.97 Preschool(68.14) 4.30* 2.94* 1.97* *P < 0.05
  • Rutja Phuphaibul Vol. 6 No. 4 183 Discussion The study findings revealed a variation in marital task performance over the family life cycle from infancy through adolescence. The lowest marital task performance was found during the infant period while the highest was during preschool stage. After the preschool stage, the score again decreased. Possible factors contributing to decreased marital task performance during the infant period include the length of time that the couple has had to develop their relationship and their need to adjust to family life with child rearing. Although the comparing spouse task according to the family life cycle was limited, but when the tasks related to financial task, family function delegation, spousal relationship, and relationship with extended family are not yet well adjusted. Specially when the first child was an infant, the overwhleming tasks caused the interaction between distressed couple to be more negative. It is notably that when measure marital developmental tasks, the indicators are not only the marital relationship, but including other financial and relationship with extended family and so on. Thus, it is not based only on symbolic interaction framework like in many other studies13 , but focused on the different tasks at different developmental stages from developmental perspectives. Family at different stages of development focus on certain tasks that might as well effect the spouse relationship. It is suggestive that there should be further study to examine the relationship between developmental tasks and marital satisfaction. It will combined the family perspectives from both the family structure and functions and the interactionistic worldview. The study showed that the Thai families with adolescents show some difficulties in relation to task performances as evidenced by having the second lowest score on marital task performance. There should be family counseling services available to vulnerable families for adaptation difficulties, particularly at the infant child rearing and families with adolescents. Possible factors contributing to decreased marital task performance duringadolescenceincludedpotentialdisagreements about the degree of independence permitted for the adolescent in terms of sharing leisure time with the family, communicating feelings and collaborative problem solving. Findings from this study suggest that family counseling might best be targeted for families with infants and families with adolescents. Further study is needed to enhance understanding of the vulnerability to family problems during different stages of family development. Reference 1. 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 and community 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 ofConsultationandClinicalPsychology, 1998 ; 66(2): 219-230. 6. Irvine J.I. Basinski A. Baker B. Jandciu S. Paquette A. Cairns J. Connolly S. Roberts R. Gent M. and Dorian P. Depression and risk of sudden cardiac death after acute myocardiac infarction : Testing for the confounding 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 framework to study the family. In F.I. Nye and F.M. Berardo (ed.) Emerging Conceptual Frameworks Family Analysis. New York:Prager, 1981.
  • Marital Developmental Tasks of Thai Spouses in Childrearing Families Thai J Nurs Res ë October - December 2002184 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 Medical Archives, 1991; 74 (6) : 311-317. 13. Wampler K.S. and Halverson Jr. C.F. Quaniitative Measurement in Family Research. In P.G. Boss et al. (eds.) Sourcebook of Family Theories and Methods. New York :Prenum Press, 1993 ; 181-194.
  • Rutja Phuphaibul Vol. 6 No. 4 185 æ—≤π°‘®¢ÕߧŸà ¡√ „π§√Õ∫§√—«√–¬–‡≈’ȬߥŸ∫ÿµ√ √ÿ®“ ¿Ÿà‰æ∫Ÿ≈¬å RN., D.N.S.* Õ√ÿ≥»√’ ‡µ™— Àß å RN. M.S.** ™◊Ëπƒ¥’ §ß»—°¥‘ϵ√–°Ÿ≈ RN., M.P.H., M.N.S. ∫∑§—¥¬àÕ: °“√»÷°…“‡™‘߇ª√’¬∫‡∑’¬∫§√—Èßπ’ȇªìπ°“√‡ª√’¬∫‡∑’¬∫æ—≤π°‘®¢ÕߧŸà ¡√ „π§√Õ∫§√—« √–¬–‡≈’ȬߥŸ ∫ÿµ√«—¬µà“ßÊ 4 √–¬– ‰¥â·°à√–¬–‡≈’ȬߥŸ∫ÿµ√«—¬∑“√° «—¬°àÕπ‡√’¬π «—¬‡√’¬π ·≈–«—¬√ÿàπ °≈ÿà¡ µ—«Õ¬à“ß ª√–°Õ∫¥â«¬ §Ÿà ¡√  2,031 §√Õ∫§√—«„π‡¢µ°√ÿ߇∑æ¡À“π§√∑’Ë¡’∫ÿµ√§π·√°Õ“¬ÿÕ¬Ÿà„π√–¬– °“√‡≈’ȬߥŸ∑’Ë°”Àπ¥ °≈ÿࡵ—«Õ¬à“ß·µà≈–√–¬–¡’®”π«πª√–¡“≥ 500 √“¬ ‡°Á∫‚¥¬„™â·∫∫ Õ∫∂“¡∑’Ë ºŸâ«‘®—¬ √â“ß„π‚√߇√’¬π·≈–‚√ß欓∫“≈∑’Ë ÿࡇ≈◊Õ°‡æ◊ËÕ„À≥â°≈ÿࡵ—«Õ¬à“ß„π·µà≈–°≈ÿà¡Õ“¬ÿ∫ÿµ√ ·∫∫ Õ∫∂“¡¡’ 2  à«π‰¥â·°à ¢âÕ¡Ÿ≈∑—Ë«‰ª¢Õߧ√Õ∫§√—«·≈–æ—≤π°‘®¢ÕߧŸà ¡√  º≈°“√»÷°…“æ∫«à“ æ—≤π°‘®¢ÕߧŸà ¡√  4 ¥â“π§◊Õ ¥â“π°“√‡ß‘π ¥â“π°“√·∫àßÀπâ“∑’ ¥â“π —¡æ—π∏¿“槟ࠡ√  ¥â“π —¡æ—π∏¿“æ°—∫‡§√◊Õ≠“µ‘ º≈°“√»÷°…“‡¡◊ËÕ«‘‡§√“–À姫“¡·ª√ª√«π‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫§–·ππ æ—≤π°‘®„π·µà≈–°≈ÿà¡ æ∫«à“¡’§«“¡·µ°µà“ßÕ¬à“ß¡’π—¬ ”§—≠ (F=18.27, p<0.01) ‡¡◊ËÕ«‘‡§√“–ÀåµàÕ ‚¥¬ Post hoc analysis (Scheffeûs test) æ∫«à“¡’§«“¡·µ°µà“ß√–À«à“ߧ√Õ∫§√—«∑’ˇ≈’ȬߥŸ∫ÿµ√«—¬°àÕπ ‡√’¬π°—∫°≈ÿà¡Õ◊ËπÊ Õ¬à“ß™—¥‡®π ·≈–æ∫§«“¡·µ°µà“ß√–À«à“ß°≈ÿࡇ≈’ȬߥŸ∫ÿµ√«—¬‡√’¬π°—∫«—¬∑“√° °≈ÿà¡∑’Ë¡’§–·ππµË” ÿ¥§◊Õ §√Õ∫§√—«√–¬–‡≈’ȬߥŸ∫ÿµ√«—¬∑“√° °≈ÿà¡∑’Ë¡’§–·ππ Ÿß ÿ¥§◊Õ §√Õ∫§√—« ‡≈’ȬߥŸ∫ÿµ√«—¬°àÕπ‡√’¬π À≈—ß®“°π—Èπ§–·ππ®–≈¥µË”≈ß„π√–¬–‡≈’ȬߥŸ∫ÿµ√«—¬‡√’¬π ·≈–«—¬√ÿà𠧔 ”§—≠: §Ÿà ¡√  æ—≤π°‘® §√Õ∫§√—« * √Õß»“ µ√“®“√¬å ¿“§«‘™“欓∫“≈»“ µ√å §≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ** ºŸâ™à«¬»“ µ√“®“√¬å ¿“§«‘™“欓∫“≈»“ µ√å §≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’
  • Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002186 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. * 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 depressive symptoms, the opportunity of full recovery from depression in women is still limited. This study aimed to generate a substantive theory that described and explained how middle-aged Thai women, diagnosed with major depressive disorder, experience and manage the problems in their lives and move from depression toward recovery. The qualitative research method of grounded theory was used. The participants consisted of 31 women who were diagnosed with major depressive disorder in the three medical school hospitals in Bangkok. Building rapport 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 in DepressiveMiddle-agedThaiwomenéwasdiscoveredfromrawdata.çSelf-Regainingé has been found to be a basic social psychological process of recovering from depression. This process consists of 3 phases - Causal condition of depression, Learning about depression, and Recovering from depression. The first phase explains how the women lose their self-worth until they recognize the deviance of their life. The second phase consists of three overlapping sub-phases - Depression self-management, Help seeking, and Contemplation about my self. These sub-phases are strategies that contribute the women regained oneûs self. Finally, the final phase involves Untying the knot and performing Self-growth of which is the positive consequence in the process. By better understanding the process of recovering from depression, nurses and other healthcare providers can develop intervention to facilitate full recovery from depression of middle-aged Thai women. The healthcare policy and education policy can also be implicated with gender sensitivity. Future research also needs to be carried out to derive a formal theory and to expand the scope of knowledge about depression. Thai J Nurs Res 2002 ; 6(4) : 186-199 Keyword: grounded theory study/ middle-aged Thai women/ recovering from depression
  • Acharaporn Seeherunwong Vol. 6 No. 4 187 Introduction Women are more than twice as likely as men to experience clinical depression both in the clinic and in the community and in both developed and developing countries.1-4 Also, the number of out-patient Thai women in the year 1999-2000 were double the number of men.5 Moreover, one in four women can expect to develop clinical depression during her lifetime. Clinical depression can occur in any women, regardless of age, race, or income. In addition, it is serious enough to lead to suicide. Middle-aged women are one of the most at risk for depression in a life span. It has been found that 27% of the women aged 40 years and over in Thailand suffer from depression.6 Another research result shows that 13% of middle-aged out-patient women with somatic symptoms at Rachaburi hospital were detected for depression.7 In spite of an effort to decrease the numbers of people with depression, various countries demonstrates that major depression is a chronic, recurrent condition. Between 15% and 20% of patients have symptoms that persist for at least 2 years, and often these patients do not fully recover from depressive episodes.8 Also, the likelihood of an individual who has suffered one episode of depression will experience a second episode is probably greater than 40%.9-10 Furthermore, when a patient experiences a second episode of depression, the probability that he or she will develop a third episode is increased.9 Although, somatic treatment is a great success for recovery from syndromes symptoms, it is not successful for recovery from functional symptoms.11-12 Therefore, the results indicate a need for continued progress in developing optimal treatment strategies for full remission and to maintain long-term recovery. Understanding strategies that the client manages herself/himself toward recovery in their culture and context will be an advantage to complement the knowledge of health care providers to help clients recover from depression. Pluralistic management techniques to decrease the cost of medical treatment which corresponds with the special needs of women in Thai society is also expected to be discovered. However, research about depression in Thailand is very limited. This Knowledge gap regarding recovering from depression is needed to provide base knowledge to understand and provide support for Thai women with depression. As a result, Grounded Theory is a suitable methodology to investigate the phenomenon. The purpose of the study was to generate a substantive theory that described and explained how middle-aged Thai women, diagnosed with major depressive disorder, experience and manage the problems in their lives and move from depression towards recovery. Methods Grounded theory calls for an open approach to data collection rather than adherence to structured procedures. The purpose of data collection is to get as wide as possible in the effort to capture data that pertain to the phenomenon of interest.13-14 In this study, a variety of sources of data were obtained. Middle-aged women who were diagnosed with major depressive disorder were the primary sources of data collection. In-depth interviews were the main method for collecting data. The participants who had delusion or hallucination were 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. More than three-quarters of the participants were from Ramathibodi Hospital (n=27). The rest were from Siriraj Hospital and King Chulalongkorn Memorial Hospital. Almost half of the participants
  • Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002188 (n = 15) had a full recovery and 10 of them perceived stable health. Almost all of the participants were Buddhists (n = 27). The rest were Christian and Islamic. The home province of the participants was diverse; they came from every part of Thailand. The majority of the participants grew up in Bangkok (n = 16). Eight participants grew up in the central part of Thailand. However, 23 of them resided in Bangkok and the suburbs during the time of data collection, whereas eight of them resided in the provinces. Moreover, one-quarters of educational background for the participants were a bachelor degree (n=10). Nine had a primary education. Three participants did not attend any school and were unable to read and write. The majority of the participants (n = 10) were housewives. Nine of the participants were government official and six of them were employees. Tape-recorded, open-ended, interactive interviews were conducted with each participant after the informed consent form was signed. The interview began by asking for the symptoms of the interview day and tracing back to the history of their experience with depression from the first moment they realized that something was wrong with them, even if they did not initially define the problem as depression. When asked, çPlease tell me what it is like for you since the beginning of your illnessé at the beginning of the interview, five participants were encouraged to recollect their experience from beginning toward recovery as much as they could. The interview guide was employed as appropriate during the interviews. Gentle probes were also employed to enrich the description of the experience and to maintain the focus of the interview. Interview questions were modified throughout the study according to the emergence of the information to verify hypotheses and concepts. Evidently, discussion of issues related to depression often involves recounting painful and emotionally sensitive experiences. During the interviews, several participants expressed suffered feelings and cried. The interviews were paused and opportunity was given to the participants to express their feelings until they felt better. Before the end of each interview, the researcher made sure that the participants were in a peaceful state of mind, observing their feelings and asked for the feelings they were having at that moment. The researcher and the participants parted only when it was certain that they were emotionally calm. Each interview lasted at least 30 minutes and most ran for well over 21 /2 hours. The average was 112 minutes (S.D. = 48.85). The variation of the time was due to the personality of the participants as well as the richness and complexity of information. For instance, some participants had considerable self-observational skills and analytical skills, so they could describe their experiences in detail. Of the 25 participants, two were interviewed twice to capture the complexity and the richness of the participantsû experiences and to test some hypotheses. For other participants, the interview was conducted only once because they did not come to see the doctor on the appointment date and the researcher could not communicate with them because they lived in a remote province and they moved around, so they could not remember their address. Documents from technical literature and non-technical literature served as the secondary sources of data. Technical literature included research publication and existing theories related to experiences of depression, management, and recovery from depression. Non-technical literature included diaries, biographies, and other materials related to depressive persons in the magazines, or descriptive experience on a television talk-show program. Medical records of the participants, general observations made during interview process and during home visits, and interviews of psychiatrists were also employed as secondary sources. The reason for the use of secondary
  • Acharaporn Seeherunwong Vol. 6 No. 4 189 TyingtheKnot TheCenterofMylife NegativeAppraisalof theCenterofMy LifeûsReactions Perceived LossofSelf-Worth UntyingtheKnot -DiscoveringMySelf -RedefinedMySelf& theRelationWithOtherPeople -RestartingMySelf Self-Growth Regaininga NewPerson Figure1:TheSubstantiveTheoryofSelf-RegainingfromLossofSelf-WorthofDepressiveMiddle-AgedThaiWomen. ContemplationaboutMySelf -Self-Awareness -ReappraisalofReaction/Action ofThoseWhoWeretheCenter ofMyLife PhaseI Causalconditionofdepression PhaseII Learningaboutdepression Symptomsof Depression DevastatedSelf DepressionSelf-Management -Tamjai(AcceptingSituation) -DivertingMySelf Recognitionof Depression Recognizing Self-Deviance HelpSeeking -SeekingInformalHelp -SeekingProfessionalHelp PhaseIII Recoveringfromdepression
  • Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002190 sources was to increase theoretical sensitivity and guide questioning for collecting and analyzing data. As the study proceeded, data collection was modified as necessary in order to focus on concepts with relevance to the emerging theory. The data analysis procedure in grounded theory is the tool to generate new concepts and theories from the data in the phenomenon of interest. This analysis follow the Strauss and Corbinûs procedure.12-13 The analysis procedure began after the first interview was transcribed verbatim until the writing of the findings was finished, over one year and three months. Three types of coding (open coding, axial coding, and selective coding), constant comparison, theoretical sampling, and memo writing were used as the main strategies through the established theoretical sensitivity of the researcher. In addition, the trustworthiness of this study was established based on the four criteria of credibility, transferability, dependability, and confirmability. Formal member check technique was employed by having two fully recovered participants to verify the developed theory. The peer debriefing technique was also employed by having two nursing lecturers and members of research committee review analyzed data and findings. Findings The theoretical finding from grounded theory analysis is the çTheory of Self-Regaining from Loss of Self-Worth of Depressive Middle-Aged Thai Womené as shown in Figure 1. This developed theory consists of three phases including : Phase I : Causal condition of depression ; Phase II : Learning about depression ; Phase III : Recovering from depression. Definition of the constructs and concepts and their relationships obtained from the study are proposed. Phase I, ùCausal Condition of Depression:û The findings reveal that ùTying the Knotû is a basic social psychological problem. It is abstracted from the process of interaction between ùThe Center of My Lifeû and ùNegative Appraisal of the Center of My Lifeûs Reactionû lead to a consequence of ùPerceived Loss of Self-Worth.û The more ùPerceived Center of My Life,û the greater ùNegative Appraisal of the Center of My Lifeûs Reaction.û The more ùNegative Appraisal of the Center of My Lifeûs Reaction,û the greater ùPerceived Loss of Self-Worth.û This consequence leads to ùSymptoms of Depressionû abstracted from ùDevastated Self;û that is, the response of perceived Loss of Self-Worth,û until ùRecognition of Depressionû abstracted from ùRecognizing Self-Deviance.û Following, concepts in this phase are described: ùThe Center of My Lifeû referred to a person or a group of people who were important, and of great value for the women, as well as being their source of pride. The centers of these womenûs lives were not static and could be changed by places, times, and events which occurred in their lives. At the same time, the persons who were the centers could come from many sources, depending on which ones were considered more important than the others. The participantsû perception of ùThe Center of My Lifeû was based on Thai social values. The person or the group might be their children, husbands, or other people. As a participant stated: My children are my heart, I would die for them, 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 of participants who thought that they were treated as unvalued people, had overloaded burdens, and/or had sense of loss resulting from the behavior of the centers of life. Participants sacrificed their energy, ideas and intelligence to their centers of life according to the social beliefs and values to which they had been socialized. At the same time, the participants also expected to
  • Acharaporn Seeherunwong Vol. 6 No. 4 191 obtain proper reactions from the centers according to those beliefs and values. For example, they expected that their husbands would be faithful, give them respect, take care of them when they were sick and also function as the head of the family. Whenever the centersû reactions were not in line with what the participants anticipated and needed, the participants would appraise the reactions in a negative way. As a participant illustrated: Having another woman, I just could not accept it. I had an inkling that my husband had another woman who he really wanted to live with seriously. I really could not accept that. Then I told him that if this continued, we should get a divorce. I cannot stand it and separation is better...If anybody has not had this kind of experience, they would not understand it. It is difficult to explain that I am not worth enough for him. If he has someone else to take care of him and can stay with him happily, then I will let him go. I can live like this. ùPerceived Loss of Self-Worthû referred to the perception of the participants who considered that they were treated as unvalued people, had overloaded burdens and/or had the sense of loss resulting from the actions/reactions of the center of life. The meaning of self-worth of most participants depended on the appraisal of behaviors or reactions of the centers of life. If they were appraised in a negative way, it would lead to the perception of loss of self-worth which could be the cause of depression. ùDevastated Selfû was the change in oneself in destructive ways ranging from mild such as depression or gloomy feelings, desperation, fatigue, boredom, to severity conditions such as being unable to control their own self and having abnormal perception. Sometimes the participants avoided great suffering by attempting suicide. Various responses reflected continual cycle as the following statements: The first time it happened, I couldnût sleep for 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 to talk to anybody. Sometimes, I had to have a canvas bed at school so that I could sleep when I didnût have to teach. I separated myself 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 didnût help at all. It was all up to me. The range of the severity of the response depended on the intensity of the perceived loss of self-worth. The high intensity of the perceived loss of self-worth came from the negative appraisal reaction/action of the children and the husband, and the reaction/action that came from several persons who were the center of oneûs life. In other words, the husband and children were more focused as the center of oneûs life than the other persons, but if the negative appraisal of the reaction/action came simultaneously from many sources, they may be much devastated self as well. In addition, the context that lacked resources was likely to contribute to more expression of the devastated self. ùRecognizing Self-Deviance:û As long as the causes of depression were not dealt with or the problems solved, depressive symptoms would increase until the participants wondered, asked themselves questions, and found out that they were different from what they once were and/or they were different from normal people. Some participants, however, would not recognize such changes and continued living their lives until they realized their changes when they could no longer perform their work, or until the symptoms became so severe that they were life-threatening. Their means of recognition could vary depending on sign, degree of intensity, knowledge of
  • Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002192 depression, and ability to assess their thinking, feelings, and emotions. The road to recognition of self-deviances including recognition that they perceived the world differently from others, that they discovered that they cried without a good reason, that they discovered their physical symptoms, that they realized they could not work, that they believed their nightmares would come true, and that they thought it was abnormality of close persons. Such recognition led to ability to deal with their depression, search for help, and consideration of self. Phase II, ùLearning about Depression:û The recognition was become to be the condition that made the participants went to manage depressive symptoms. These strategies are categorized into 3 constructs including ùDepression Self-Management,û ùHelp Seeking,û and ùContemplation about My Self.û These constructs might occur simultaneously and/or occur respectively in some participants that found that the previous strategy was not successful. In this phase, the participants has learned to know more about depression in order to go to the fully recover from depression. However, some participants who were unable to fully recover, they have learned to live with depressive symptoms. ùDepression Self-Managementû refers to a deliberated process that aimed to decrease or eliminate symptoms of depression involving intention, action, evaluation of the action, and repetition of the action when the result was satisfactory. Conditions used to self-manage were skills and interests, advice, and various supports such as money, places, and persons. Depression Self-Management consists of two concepts including ùTamjaiû (accepting the situation) and ùDiverting my self.û ùTamjaiû was a method of dealing with oneûs own thought and feeling when facing unsatisfactory circumstances so that the person accepted what was happening, which led to temporary peace of mind. ùTamjaiû occurred when the participants realized their own emotions and feelings as well as the negative effect which could result if nothing was done about themselves, as can be seen in the following quote çHau hoo after my husband has passed away. çHau hoo Ama frequently trade abuses persons. I told to other person that if I endure at this time, I have to go to see a doctor and use the drug again. I have tried to ùtamjaiû...ùtamjaiû.é Tamjai was a method derived from past experiences or from othersû suggestions followed by a successful practical result, which was repeated when faced with similar circumstances. Tamjai included three types of action, which were ùReasoning,û ùLooking Forward to Better Things,û and ùReminding My Self.û ùDiverting my selfû was an act to divert oneûs feeling and interest temporarily. This method was derived from past experiences and/ or from following othersû suggestions. It was repeated when positive effect was a result. This method was done intentionally to temporarily reduce or eliminate depression. There were various types of ùDiverting My Selfû including leaving the depressive environment, meditating, praying, having hobbies, exercising, using vitamins and caffeine, keeping busy with work, finding something new in life, and using drugs. ùHelp seekingûrefers to a process composed of considering sources of help to see whether which source worked, weighing between advantages and disadvantages of seeking help, selecting information that would tell which source would reveal how much of personal information, and evaluating and repeating it when necessary. ùHelp Seekingû is one choice arising after participants found that something was not normal or after they had applied self-management with those abnormal without success. So, they would want to seek information and methods to make them feel good as before.ùHelp Seekingû was constructed from two concepts: ùSeeking Informal Helpû and ùSeeking Professional Help.û
  • Acharaporn Seeherunwong Vol. 6 No. 4 193 ùSeeking Informal Helpû refers to seeking help that had no definite format or pattern, but was natural, composed of processes to determine the source for help, to weigh between advantages and disadvantages of seeking help, to choose information that could be revealed, and to evaluate and repeat it. The sources for support were family members, friends, monks and priests, and media and information. Characteristics of the persons that participants sought 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 share similar background with the participants. Besides, supports could be tangible or intangible, and had to be given in a timely and opportunistic manner for them to be effective. ùSeeking Professional Helpû refers to seeking help with definite purposes from general health care providers and psychiatric health care providers. This was a multi-stage process composed of processes to determine the source for help, to weigh between advantages and disadvantages of seeking help, to choose information that could be revealed, and to evaluate and repeat it when necessary. The practice included giving medication, listening to problems, giving advice, and suggesting new thoughts and perspectives. Participants that had been ineffectively helped or denied the fact that they were mentally ill would stop seeking help and return to seeking help only when the symptoms became more severe. However, participants that had been helped effectively would continue to find other methods to fully recover, together with conducting depression self-management. They viewed that medical help using drugs had to be done concurrently with the attempt to try to change themselves. ùContemplation about My Self.û is a process that led them to ùSelf-Awarenessû and ùReappraisal of Reaction/Action of Those Who Were the Center of My Lifeû consisted of ùRestating,û ùReflecting,û ùConsidering,û ùValidating,û and ùComparing.û These actions were based on the new information obtained from religious teaching, psychological books, books concerning life and quotable quotes of other people. Sometimes the participants might rethink about their past experiences. Conditions that led to the successful ùContemplation about My Selfû depended on having peace of mind, learning new perspectives, and having analytical thinking skill. If the participants did not have these components, they might not recognize or be aware of themselves, and they might not be able to reappraise the reaction of those who were the center of their life. ùContemplation about My Selfû wasconstructedfromtwoconcepts:ùSelf-Awarenessû and ùReappraisal of Reaction/Action of Those Who Were the Center of My Lifeû ùSelf-Awarenessû refers to the realization about oneself and some issues related to depression. The contents of awareness included awareness of good and bad personality, awareness that depression came from the ineffective coping pattern, awareness of the impact of placing the center of life on external factors, and awareness of solving depression by oneself first. After self-awareness, the participants clearly realized the various situations which led to ùUntying the Knotû in the next phase. ùReappraisal of Reaction/Action of Those Who Were the Center of My Lifeû. refers to reconsideration and reevaluation of the reaction/action of persons who were the center of the participantsû life. The reappraisal of those reactions could be summed up in the following sentences: ùThe behavior is dynamic.û ùOther peopleûs behaviors will have an impact only when it is valued,ûand ûOther peopleûs behavior might be a response to own behavior.û The three constructs overlap, and any construct can happen before or after the others. Moreover, the three constructs are interrelated.
  • Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002194 The negative outcome of ùDepression Self-Managementû would positively influence ùHelp Seeking.û In turn, the positive outcome of ùHelp Seekingû would positively influence ùDepressionSelf-ManagementûandùContemplation about My Self.û The positive outcome of self-management would positively influence ùContemplation about My Self.û The negatively outcome of ùContemplation about My Selfû would influence the more ùHelp Seeking.û The outcome of these constructs is the turning point to the next phase. Phase III, ùRecovering from Depression:û Participants began to discover their value from internal self instead of external self. It means their sense of self-worth was not tied to those who were the center of their life; on the other hand, the recognition of self-worth lied in their sense of success. The participants, then, emerged to reform themselves. The length of time taken by each participant was varied, from a couple of years to several years. However, some participants did not reach this point; hence, they just lived with the absence of symptoms. This phase is the second turning point in the process of recovering from depression which consists of two constructs: ùUntying the Knotû and ùSelf-Growth.û ùUntying the Knotû was the concurrence of the absence of depressive symptoms, self-awareness, and reappraising reaction/action of those who were the center of oneûs life. As a result of the cognitive reconstruction, data could be theorized under three concepts: ùDiscovering My Self,û ùRedefining My Self and the Relationship with Other People,û and ùRestarting My Life.û ùDiscovering my selfû is the process of recognition of self-worth from oneûs internal development. This self-worth was the real self-worth because it emerged from the participantsû internal components, not from the action or appraisal of those who were the center of the participantsû life. The ùDiscovering My Selfû process 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 events around oneself and re-establishing relationships with other people. As for redefining oneself, the utilized approaches included: living with the present, being more flexible, seeking alternative thoughts, and developing self-reliance. As for the redefining of relationships with other people, the participantsû approaches included: helping other people as they could but not with all they had, understanding other people as they were and not imposing them to be as expected, giving help without expecting anything in return, and relying on each other. ùRestarting My Lifeû is the process of picking up various actions from the point where the actions were stopped or were left due to the sufferings from depression. The process gradually proceeded without exerting oneûs self and it resulted in self-worth for the person and other people. This process consisted of restarting activity, reconnecting with the society, being productive, and devoting for community services. The redefining oneûs self and relationship with other people in combination with restarting oneûs life resulted in self-growth. ùSelf-Growthû is constructed from ùRegaining a New Oneû that is the positive consequence in this theory. ùSelf-Growthû refers to the condition of the participants who had passed the process of recovery from depression. At this stage, the participants perceived themselves as a center of their life. They were able to control themselves, had internal motivation, and could generate mental happiness and peace. Discussion The result revealed that ùTying the Knotû was the social psychological problem that made the participants prone to occurring depressive
  • Acharaporn Seeherunwong Vol. 6 No. 4 195 symptoms. ùSelf-Regainingû was the basic social psychological process of which they used for recovery from depression. It was a process that they journeyed from the recognition of depression to the end of the process in which they were able to perceive their self-growth. Also, conditions that contributed to ùSelf-Regainingû were discovered. The comparisons between the findings and the existing theories and studies are discussed below. ùTying the Knotû revealed that the sense of self of the participants depended on the relationship with the significant others. The participants could not separate life of themselves from the life of their significant others or loved ones. It meant that the participants gave importance of themselves to the external factors. Whenever, the participants perceived the negative reactions of people who were the center of their lives, they experienced loss of sense of self. This perspective or this method of thinking led them mental sufferings. Consistently, previous researches suggested the importance of relationships for womenùs well-being,14-17 but did not specifically state how the depressive symptoms occurred. According to the study of Belenky et al.14 , women are socialized to ùreceived knowerû more than being ùconstructed knower.û The women are in the position to receive knowledge derived from a sense of ùwho am Iû from the definition others supply and the role they fill. Therefore, the evaluation of their own sense of self most likely is dependent on the reaction of others toward oneûs self. This is consistent with the work of Schreiber16 stated that social psychological problems of depressive women took place when they could not answer the question ùwho am I?û It can be a metaphor as some parts in the puzzle are lost. Hence, the causal condition of depression in the participants of this finding reinforced both works. ùSelf-regainingû the central concept is similar to other results of qualitative studies that they focused on the importance of self in the recovering process including ù(Re)Defining My Self,û16,18 ùTransformed Self,û ùSelf as Healer,û19 , ùIdentity Turning Pointû20 . Moreover, the main conditions that contributed to ùSelf-regainingû is mostly similar to other studies as well. In the phase of ùRecovering from Depression,û process of ùUntying the Knotû that translated insight into action, is congruent with concept of ùClueing Inû in the ù(Re)Defining My Self Process.û16,18 Women clue in or come to a cognitive and emotional realization of themselves in relation to the world. They seem to be able to put in place the final piece of the puzzle of who they are, that is what is their true self. However, ùRestarting My Selfû which is a concept was stated in this study, but not in Schreiberûs work. It may be because participants had more severe depressive symptoms than those in Schreiberûs study, so they had to force themselves to take action in various aspects. In addition, this study reinforced the phenomenology studies which aimed to understand the meaning of recovering from depression.15,19 According to Steen, the meaning of recovery process consisted of two turning points. First turning point, the women realized that they needed help for the reason that childhood experiences had affected their functioning as adults and their pattern of negative thinking. In the second turning point, the women became their own agent and sought out the sustenance they needed to feed and nurture themselves. As regards another feminist and symbolic interactionist perspective,19 reported the experiences in living with depression in six themes: transformed self, wanting and monitoring, the self as healer, revealing vs. concealing, acceptance and belonging, and making sense of depression-meaning and understanding. Both studies also gave the importance to the self-transforming.
  • Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002196 Regarding psychotherapy, ùSelf-Regainingû contributed to the process of change in Satirûs Model and Satirûs approaches.21 The Satirûs Model is a model of human growth which focuses on transformational or change therapy. The philosophy underpinning is ùChange is possible. Even if external change is limited, internal change is possible.û Change, according to Satir, is basically an internal shift that in turn brings about external change.21 The difference between the Satirûs Model and the current process is that in the Satirûs Model, the therapists provide context for positive change in the clients, but in the ùSelf-Regainingû process the participants tried to transform by themselves. Self-Growth was the positive consequence of the ùSelf-Regainingû process. This concept was similar to other consequences of the process of recovery from depression in related studies including ùSeeing with Clarity,û16 ùCultivating the Self,û15 ùGetting Past It.û20 These concepts or themes are positive events or state. All of the participants expressed having felt a profound shift in the life experience and appreciated where they were now. The participantsû perception of themselves as the center of their life was similar to a part of cultivating womenûs self, that they could look more realistically at what was already growing in their garden, to weed out some of the old ideas, and to plant new ideas they had learned from their experiences in life.15 Moreover, The participants in this study had the ability to control their thoughts, emotion, and situation to keep them from recurrence of depressive symptoms. This was congruent with ùMonitoring and Taking Corrective Actionû in the phase of ùSeeing with Clarityû defined by Schreiber.16 Conditions for self-regaining are strategies that led to the absence of depressive symptoms, resulting in self-awareness, and reappraisal of the reactions/actions of those who were the center of their life. These strategies are including depression self-management, help seeking, and contemplation about my self. After recognizing their self-deviance, the participants tried to manage depression by themselves by seeking help when they realized that they needed it, and contemplation about oneûs self. However, there were some differences in strategies used by each participants depending on the belief about illness, existing resource, and past experiences. ùDepression Self-Managementû concept expanded the ùBeing Strongû concept that Black West-Indian Canadian women used to ameliorate or manage their depression.18 However, the participants of the study were in the community. The participants in this study viewed depressive symptoms with a commonsense perspective as mental suffering, not as a disease or illness. They were most likely to find out the method to help them when they could not endure to go on. Nevertheless, if the symptoms were severe enough to threaten their life, they were most likely to seek someone to help and manage themselves simultaneously. Some of the self-management methods were underpinning the Buddhist beliefs such as meditation and prayers. Some were chosen based on past successful experience, while others from the suggestions of the health care providers and close relatives. The ùHelp-Seekingû concept expanded the previous ùHelp Seeking Behaviorû proposed by Mechanic22 as in this study included ùSeeking Informal Help,û depending on explains characteristics of the helper and suitable time for seeking help. In the ùSeeking Informal Help,û the Thai participants were most likely to seek help from close relatives and friends, or a monk and a priest. The characteristics were specific in the Thai culture and social context that the relatives and close friends were most likely to be interdependent all the times, when they were in trouble or happy. Particularly, for Thai women, the parents are the first source that they recognize. Beside that, another item that expanded the Mechanicûs theory was the characteristics of those participant who
  • Acharaporn Seeherunwong Vol. 6 No. 4 197 decided to seek help. These characteristics included ever having a similar problem, ever being interdependent, and realizing that the helper had an emphatic understanding. Furthermore, in this study, it was found that the effectiveness of help seeking behavior and support from others had to be congruent with the course of the illness or symptoms of depression, and the readiness of the help from the receiver. Regarding seeking help from health care providers, the majority of participants decided to seek help when they realized the physical symptoms or could not perform their function. This finding was consistent with the study by Lotrakul, Saipanit, and Theeamoke23 that most patients who were diagnosed with depression were presented with somatic symptoms at their first visits. Some pathoplastic cultural influences were found, among which were the infrequency of feelings of hopelessness and the idea of self-insufficiency. Nevertheless, when compared with studies from the west, these feelings in Thai women were less present than those in the western patients. The concept ùContemplation about My Selfû was consistent with the concept of ùSeeking Understandingû by Schreiber,16 ùFirst Turning Pointû by Steen,15 and theme of ùMaking Sense of Depression-Meaning and Understandingû by Chronomas19 on that the participants could connect between past experience and outcomes that they were facing at present. Moreover, they could be aware of the pattern of their thinking and their problem solving that led them to have depressive symptoms. In addition, ùContemplation about My Selfû concept supported the cognitive therapy by Beck.24 The cognitive therapy addressed the problem in order to help the client realize oneûs self and the world. Additionally, the learning about a new perspective was emphasized instead of the previous perspective which included negative thinking. Consistently, the effectiveness of ùContemplation about My Selfû had the underpinning of three conditions: peace of mind, learning new perspectives, and analytic thinking skills. Implication Further researches need to develop and test the relationships between concepts and model. In order to test the theory with quantitative methodology, the measurement of the concepts should be developed. Moreover, a participatory- action research or a quasi-experimental research should be developed base on this theory. Because this studyûs participants were middle-aged and more urban women than rural women, it would be useful to repeat this study with women less or older age, and living in rural area in order to increase explanatory power of the theory. In addition, understanding process of recovery from depression provides guidelines of nursing care for depressive women that meet the womenûs requirement in each phase of the recovery process. Acknowledgement This study was supported by a grant from the Doctoral Collaborative Program organized by the Ministry of University Affairs, Thailand. Special thanks and great appreciation go to Assoc. Prof. Napaporn Havanon for her valuable comments and suggestions.
  • Self-regaining from loss of self-worth: A substantive theory of recovering from depression of middle-aged Thai women Thai J Nurs Res ë October - December 2002198 Referrence 1. Nolen-Hoeksema S. Sex differences in unipolar depression: evidence and theory. Psychological Bulletin. 1987;101:259-82. 2. Weissman MM, Klerman GL. Gender and depression. Trends in Neurosciences. 1977;8:416-20. 3. Weissman MM, Klerman GL. Sex differences in the epidemology of depression. Archives of General Psychiatry. 1985;34:98-111. 4. Weissman MM, Leaf PJ, Holzer CE, Myers JK, Tischler GL. The epidemiology of depression : an update on sex differences in rates. Journal of Affective Disorders. 1984;7:179-88. 5. Mental Health Department, Ministry of Public Health. The statistical report of the psychiatric patients from the state hospital of the Mental Health Department, Thailand. Ministry of Public Health.1999-2001. 6. Sukwatana P, Meekhangvan J, Tamrongterakul T, Tanapat Y, Asavarait S, Boonjitrpimon P. Menopausal symptoms among Thai women in Bangkok. Maturitus. 1991;13:697-703. 7. Jittawatanakorn M. Pattanakumjorn W. The study in depression during the female climacteric period. Bullelin of the Department of Medical Services. 1999;24(8) : 489-99. 8. Keller MB, et al. Treatment received by depressed patients. JAMA. 1982;248:1848-55. 9. Lavori PW, Keller MB, Mueller TI, et al. Recurrence after recovery in unipolar MDD: an observational follow-up study of clinical predictors and somatic treatment as a mediating factor. International Journal Method of Psychiatric Research. 1994;4:211-29. 10. Van London L, Molenaar RPG, Goekoop JG, et al. Three-to-5-year prospective follow-up of outcome of major depression. Psychological Medicine. 1998;28: 731-35. 11. Glaser BG, Strauss A. The discovery of grounded theory: strategies for qualitative research. New York : Aldine, 1967. 12. Strauss AL, Corbin J. Basics of qualitative research. California : Sage Publications, 1990. 13. Strauss AL, Corbin J. Basics of qualitative research. 2nd ed. California : Sage Publications, 1998. 14. Belensky MF, Clinchy BM, Goldberger NR. Tarule JM. Womenùs ways of knowing: The development of self, voice, and mind. New York: Basic Books, 1986. 15. Steen M. Essential structure and meaning of recovery from clinical depression for middle-adult women: a phenomenological study. Issues in Mental Health Nursing. 1996;17(2):73-92. 16. Schreiber R. (Re)Defining my self: womenùs process of recovery from depression. Qualitative health research. 1996;6(4):469-91. 17. Sangon S. Predictors of depression in Thai women. Unpublished doctoral dissertation, University of Michigan, Michigan, United States. 2001. 18. Schreiber R. Clueing in: a guide to solving the puzzle of self for women recovering from depression. Health Care for Women International. 1998;19:269-88. 19. Chernomas WM. Experiencing depression : womenûs perspectives in recovery. Journal of psychiatric and Mental Health Nursing. 1997;4:393-400. 20. Karp DA. Living with depression: illness and identity turning points. QualitativeHealthResearch. 1994;4:4-30. 21. Satir V, Banmen J, Gerber J, Gomori M. The Satir Model: Family therapy and beyond. California: Science and Behavior Books, 1991. 22. Mechanic, D. (1968). Medical sociology. New York: The free press. 23. Lotrakul M, Saipanit R, Theeramoke W. Symptoms of depression in Thai patients. Journal of Psychiatric Association of Thailand. 1994;32(2):68-77. 24. Blackburn I, Davidson KM, Kendell RE. Cognitive therapy for depression and anxiety. A practitionerûs guide. Great Britain: Blackwell science, 1995.
  • Acharaporn Seeherunwong Vol. 6 No. 4 199 °“√§◊𧫓¡ ”§—≠„Àâµπ‡Õß¿“¬À≈—ß®“°°“√ Ÿ≠‡ ’¬§«“¡¡’§ÿ≥§à“ „πµπ‡Õß : ∑ƒ…Æ’‡™‘ß “√–Õ∏‘∫“¬°“√øóôπÀ“¬®“°§«“¡´÷¡‡»√â“ ¢Õß µ√’‰∑¬«—¬°≈“ߧπ* Õ—®©√“æ√  ’ËÀ‘√—≠«ß»å**∑—»π“ ∫ÿ≠∑Õß***RN. Ed.D. »‘√‘Õ√  ‘π∏ÿ***RN. D.N.Sc. ∏π“ π‘≈™—¬‚°«‘∑¬å***æ.∫. ∫∑§—¥¬àÕ: ∂÷ß·¡â«à“®–¡’¬“„À¡àÊ ∑’Ë¡’ª√– ‘∑∏‘¿“æ„π°“√≈¥Õ“°“√´÷¡‡»√â“ ·µà‚Õ°“ ∑’Ë µ√’®– øóôπÀ“¬®“°§«“¡´÷¡‡»√â“Õ¬à“ß ¡∫Ÿ√≥凪ìπ‰ª‰¥â¬“°·≈–¡’§«“¡®”°—¥ °“√»÷°…“§√—Èßπ’È¡’ «—µ∂ÿª√– ß§å∑’Ë®– √â“ß∑ƒ…Æ’‡™‘ß “√–Õ∏‘∫“¬°√–∫«π°“√øóôπÀ“¬®“°§«“¡´÷¡‡»√â“„π∑—»π–¢Õß  µ√’«—¬°≈“ߧπ∑’Ë¡’¿“«–´÷¡‡»√â“ √–‡∫’¬∫«‘∏’«‘®—¬∑’Ë„™â„π°“√»÷°…“§√—Èßπ’È §◊Õ°“√«‘®—¬‡™‘ߧÿ≥¿“æ ·∫∫°“√ √â“ß∑ƒ…Æ’®“°¢âÕ¡Ÿ≈æ◊Èπ∞“π ¢âÕ¡Ÿ≈À≈—°„π°“√«‘‡§√“–Àå§√—Èßπ’ȉ¥â®“° —¡¿“…≥凮“–≈÷° µ√’ ∑’ˉ¥â√—∫°“√«‘π‘®©—¬‚√§´÷¡‡»√â“™π‘¥√ÿπ·√ß∑’Ë¡“√—∫∫√‘°“√„π‚√ß欓∫“≈„À≠à3·Ààß„π°√ÿ߇∑æ¡À“π§√ ®”π«π 31 §π ´÷Ëß¡’∑—Èß µ√’∑’ˬ—ߧߡ’Õ“°“√´÷¡‡»√â“·≈–ª√“»®“°Õ“°“√´÷¡‡»√â“ «‘‡§√“–Àå¢âÕ¡Ÿ≈®“° æ◊Èπ∞“π°“√‡ª√’¬∫‡∑’¬∫¢âÕ¡Ÿ≈·≈–°“√µ—Èߧ”∂“¡Õ¬à“ß¡’§«“¡‰«‡™‘ß∑ƒ…Æ’ º≈°“√»÷°…“ª√“°Ø°“√≥å°“√øóôπÀ“¬®“°§«“¡´÷¡‡»√Ⓣ¥â∑ƒ…Æ’‡™‘ß “√–™◊ËÕ«à“ ç°“√§◊𠧫“¡ ”§—≠„Àâµπ‡Õß¿“¬À≈—ß®“°°“√ Ÿ≠‡ ’¬§«“¡√Ÿâ ÷°¡’§ÿ≥§à“„πµπ‡ÕߢÕß µ√’«—¬°≈“ߧπ∑’Ë¡’ §«“¡´÷¡‡»√â“é ∑ƒ…Æ’π’È®”·π°‡ªìπ 3 ™à«ß ™à«ß·√°§◊Õ ç‡ß◊ËÕπ‰¢‡™‘ß “‡Àµÿ¢Õߧ«“¡´÷¡‡»√â“é ‡ªìπ ™à«ß∑’ËÕ∏‘∫“¬‡ß◊ËÕπ‰¢ ‡™‘ß “‡Àµÿ¢Õß°“√‡°‘¥§«“¡´÷¡‡»√â“„π≈—°…≥–°√–∫«π°“√ª√–°Õ∫¥â«¬°“√¡’ ªØ‘ —¡æ—π∏å√–À«à“ß ‘Ëß∑’ˇªìπ»Ÿπ¬å°≈“ß·Ààß™’«‘µ¢Õß µ√’·≈–°“√ª√–‡¡‘πµ—¥ ‘π°“√°√–∑”¢Õß∫ÿ§§≈∑’Ë ‡ªìπ»Ÿπ¬å°≈“ß·Ààß™’«‘µ„π∑“ß≈∫´÷Ëß àߺ≈„Àâ µ√’√—∫√Ÿâ«à“µπ‡Õ߉¡à¡’§ÿ≥§à“®÷ßµÕ∫ πÕ߇ªìπÕ“°“√´÷¡‡»√â“ ®π°√–∑—Ëß “¡“√∂√–≈÷°√Ÿâ°“√‡ª≈’ˬπ·ª≈ß„πµπ‡Õ߉¥â™à«ß∑’Ë Õß™à«ßç°“√‡√’¬π√Ÿâ‡°’ˬ«°—∫§«“¡´÷¡‡»√â“é ª√–°Õ∫¥â«¬¡‚π∑—»πå∑’ËÕ∏‘∫“¬°≈¬ÿ∑∏å„π°“√®—¥°“√°—∫Õ“°“√´÷¡‡»√â“ 3 ¡‚π∑—»πå∑’ËÕ“®‡°‘¥¢÷Èπ æ√âÕ¡Ê °—π À√◊ÕÕ“®‡°‘¥°≈¬ÿ∑∏å„¥°àÕπÀ≈—ߢ÷ÈπÕ¬Ÿà°—∫‡ß◊ËÕπ‰¢¢Õß·µà≈–∫ÿ§§≈ °≈¬ÿ∑∏套߰≈à“«‰¥â·°à °“√®—¥°“√°—∫§«“¡´÷¡‡»√ⓥ⫬µπ‡Õß°“√¢Õ§«“¡™à«¬‡À≈◊Õ·≈–°“√‰µ√àµ√Õßµπ‡Õß à«π™à«ß ÿ¥∑⓬ ‡ªìπ™à«ß ç°“√øóôπÀ“¬®“°§«“¡´÷¡‡»√â“é ª√–°Õ∫¥â«¬¡‚π∑—»πå°“√§≈“¬ª¡·≈–°“√‡µ‘∫‚µ„πµπ‡Õß ™à«ßπ’ȇªìπ™à«ß∑’Ë µ√’ “¡“√∂øóôπÀ“¬®“°§«“¡´÷¡‡»√Ⓣ¥âÕ¬à“ß ¡∫Ÿ√≥å‚¥¬°“√§◊𧫓¡ ”§—≠„Àâ°—∫ µπ‡Õß®“°°“√∑’ˇ§¬¬÷¥∂◊Õ·≈–„À⧫“¡ ”§—≠°—∫∫ÿ§§≈Õ◊Ëπ‡ ¡◊Õπ‡ªìπ»Ÿπ¬å°≈“ß·Ààß™’«‘µ ®÷ß∑”„Àâ√Ÿâ ÷° ∂÷ߧÿ≥§à“¢Õßµπ‡Õß·≈–°≈—∫°≈“¬‡ªìπ∫ÿ§§≈„À¡à∑’Ë¡’§«“¡‡µ‘∫‚µ„πµπ‡Õß·≈––øóôπÀ“¬®“°§«“¡´÷¡‡»√â“ ‰ª„π∑’Ë ÿ¥ °“√»÷°…“§√—Èßπ’È„Àâ¢âÕ‡ πÕ·π–µàÕπ‚¬∫“¬ ÿ¢¿“æ·≈–°“√»÷°…“¢Õß™“µ‘∑’˧”π÷ß∂÷ߧ«“¡‡ªìπ À≠‘ß™“¬ ·π«∑“ß°“√ªØ‘∫—µ‘°“√欓∫“≈„π§≈‘π‘°·≈–„π™ÿ¡™π ·≈–°“√«‘®—¬‡æ◊ËÕ¢¬“¬§«“¡√Ÿâ‡°’ˬ« °—∫§«“¡´÷¡‡»√â“·≈–°“√æ—≤π“„À⇪ìπ∑ƒ…Ø’∑’Ë¡’°“√𔉪„™âÕ¬à“ß·æ√àÀ≈“¬µàÕ‰ª §” ”§—≠ °“√ √â“ß∑ƒ…Æ’®“°¢âÕ¡Ÿ≈æ◊Èπ∞“π  µ√’‰∑¬«—¬°≈“ß§π °“√øóôπÀ“¬®“°§«“¡´÷¡‡»√â“ * ¥ÿ…Æ’π‘æπ∏å 欓∫“≈»“ µ√å¥ÿ…Æ’∫—≥±‘µ ∫—≥±‘µ«‘∑¬“≈—¬ ¡À“«‘∑¬“≈—¬¡À‘¥≈ ** ºŸâ™à«¬»“ µ√“®“√¬å ¿“§«‘™“ ÿ¢¿“殑µ·≈–°“√欓∫“≈®‘µ‡«™»“ µ√å §≥–欓∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬¡À‘¥≈ *** §≥–°√√¡°“√§«∫§ÿ¡«‘∑¬“π‘æπ∏å
  • Chronic Dyspnea Self-Management of Thai Adults with COPD Thai J Nurs Res ë October - December 2002200 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 chronic dyspnea management, and to describe the factors influencing the process of chronic dyspnea management of Thai adults with Chronic Obstructive Pulmonary Disease (COPD) who live in Chonburi Province in the Eastern region of Thailand. A substantive theory explaining the process of chronic dyspnea management of Thai adults with COPD was developed. A grounded theory study was conducted with 31 participants with chronic dyspnea, who were recruited from the outpatient department and medical wards of Chonburi Regional Hospital. In-depth interviews, observations, and reviews of health records were the strategies used in data collection. The constant comparative method was used for data analysis. çBecoming an experté was the social psychological process that emerged from the data. The process of becoming an expert in chronic dyspnea self-management was composed of four sequential stages; entering as a novice, developing competency in self-management, developing expertise, and becoming an expert, which evolved over time. Self-learning and self-management were the important actions or interactive strategies of this process and were influenced by two major factors: personal factors, and contextual factors. The process of evolving from novice to expert in chronic dyspnea self-management is viewed as a developmental process. It resulted in competence in chronic dyspnea self-management, confidence in chronic dyspnea self-management, balanced reliance on self and others, and living as normally as possible. The findings of this study provide a basis for an understanding of the process of becoming an expert in chronic dyspnea self-management for Thai adults with COPD. In addition, it can be used as the basis for information to nurses and other healthcare providers. It can also aid policy makers to further develop nursing practice, healthcare policy-making, and for future research to help people with COPD 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 Vol. 6 No. 4 201 Background and Significance Chronic Obstructive Pulmonary Disease (COPD), which includes chronic bronchitis, emphysema, or a combination of these conditions, is currently one of the most important public health problems1,2 . In Thailand, COPD is the fifth leading cause of death with a mortality rate of 33.5 per 100,000 population, and the incidence rate of COPD is 403 per 100,000 population1 . The cost of COPD is estimated at about 25,969 million Bath annually3 . Furthermore, the Thai Ministry of Public Health has estimated that the prevalence rate of COPD will be 7035.3 per 100,000 population in 20101 . These statistics indicate that COPD is one of the most important health problems in Thailand. COPD is an irreversible condition and a slowly progressive disease characterized by chronic airflow obstruction, which results in air trapping,hyperinflation,andimpairedgasexchange. Currently, there is no specific curative measure. As a consequence, stabilization of the symptoms, in particular the symptom of dyspnea, is a major goal in the treatment of COPD at the moment2,4 . Traditionally, healthcare providers focus on the medical management of chronic dyspnea in COPD, especially the comprehensive pulmonary rehabilitation program, which includes a combination of physiological, psychological, social, and cognitive components. This program was recommended by the American Thoracic Society as a component of the treatment and care of people with COPD with the goal of achieving and maintaining the individualûs maximum level of independence and functioning in the community5 . Although previous studies have supported the effectiveness of comprehensive pulmonary rehabilitation programs in decreasing the symptoms of dyspnea, the long-term benefits are not sustainable. Ries and colleagues6 have found that the benefits from comprehensive pulmonary rehabilitation are partially maintained for at least one year but tend to diminish after that time. This study has indicated that chronic dyspnea management in COPD still cannot be considered successful. As a result, the majority of people with COPD are still faced with the burden of taking responsibility in chronic dyspnea management and they still suffer from episodes of acute dyspnea. In a review of existing literature related to chronic dyspnea management in COPD people, it has been found that chronic dyspnea management by healthcare providers is still not successful. This might result from the incongruence between the nature of dyspnea and the approach created by healthcare providers. This is because in chronic dyspnea management, healthcare providers systematically use literature-based approaches to define chronic dyspnea, manage chronic dyspnea, and help people with COPD manage their own chronic dyspnea. However, dyspnea is a subjective sensation that is perceived, interpreted, and responded to by the individuals concerned. Therefore, in order to assist people with COPD to manage their chronic dyspnea effectively, nurses should be concerned with descriptions of chronic dyspnea by people with COPD who have actually experienced chronic dyspnea. People with COPD may develop strategies and skills over time, some of which may not have a theoretical explanation. Much can be learned from studying the actual practices of people who have long-term experience with chronic dyspnea. In a study of the people with dyspneic lung cancer, it was found that none of the subjects reported that nurses had taught them helpful strategies to manage their dyspnea. Instead, most of them stated that they learned to manage dyspnea on their own7 . Thus, knowledge about people with COPDûs perception and experience in managing chronic dyspnea is an important guideline in developing appropriate approaches to the management of chronic dyspnea. Despite the increasing number of people with COPD and greater impacts of chronic dyspnea,
  • Chronic Dyspnea Self-Management of Thai Adults with COPD Thai J Nurs Res ë October - December 2002202 little is known about personal experience in chronic dyspnea management. In western countries, few studies have explored personal experience in chronic dyspnea management8,9,10 , while no study has explored personal experience in chronic dyspnea management from the Thai COPD perspective. Therefore, healthcare providers remain locked in their lack of understanding and insight into what people with COPD have experienced, interpreted, responded to, and into their management of their chronic dyspnea in their socio-cultural context. This study aimed to develop a substantive theory of chronic dyspnea management of Thai adults with COPD in order to obtain better understanding of the experience of chronic dyspnea management from their own perspective. A Grounded theory study, therefore, is particularly appropriate in developing a substantive theory to explain the process of chronic dyspnea management of Thai adults with COPD. Through the adoption of a holistic approach to care, the findings from this study will be useful in giving directions for care and in improving chronic dyspnea self-management in Thai adults with COPD. The Specific Objectives The purposes of this study were to understand the experience in chronic dyspnea management of Thai adults with COPD who live in Chonburi Province in the Eastern region of Thailand. A substantive theory was developed to explain the process of chronic dyspnea management of Thai adults with COPD. The specific objectives of the study were: 1. To explain the process of chronic dyspnea management of Thai adults with COPD 2. To describe factors influencing the process of chronic dyspnea management of Thai adults with COPD. Methodology Grounded theory methodology was used in this study to develop a substantive theory of chronic dyspnea management of Thai adults with COPD. As a qualitative research method, which aims to inductively generate theory, grounded theory was chosen. The emphasis was placed on developing an explanatory theory that is grounded on empirical data and derived from the persons who have experienced the phenomenon of interest. In addition, grounded theory study is particularly appropriate to studying complex areas of human behavior and social life where little research has been done or few adequate theories concerning a phenomenon of interest exist11,12 . As little is known about chronic dyspnea management of Thai adults with COPD, grounded theory methodology is particularly appropriate to expand knowledge for this study. Recruiting Participants Purposive sampling was used in the initial stage of data collection with the intention of obtaining participants who were Thai adults with COPD who had dyspnea experience. Those who met the criteria would then be asked to participate in the study. Inclusion criteria for participants were (1) confirmed diagnosis of COPD, (2) having had dyspnea experience, as determined by the participants, (3) willingness and availability to participate in the study, and (4) ability to discuss and communicate well. The researcher made the initial contact with potential participants after reviewing the health records and talking with nurses or physicians about appropriate persons to approach. After the researcher introduced herself to potential participants, the researcher explained the purposes, significance, and procedures of the study to all potential participants. Ethical considerations were also addressed, particularly those of confidentiality, potential risks, and participantsû
  • Supaporn Duangpaeng Vol. 6 No. 4 203 right to withdraw or refuse to participate in the study. A consent form was read by the researcher to those potential participants who were illiterate, while the literate potential participants read it by themselves. When the potential participants agreed to participate in this study, they were asked to give written consent and a convenient date, time, and place for interviewing. Thirty-two participants were recruited, with one participant refusing to participate because he had no time for interviewing and was not feel free for home visits. After the 31 remaining participants completed the interview, recruitment was stopped since the emerging data was redundant. Data Collection Data collection methods included in-depth interviews, observations during home visits and during participantsû hospitalization, and reviewing health records. Data collection and data analysis were conducted simultaneously until theoretical saturation was achieved. The data collection took place from April 2001 to December 2001. The number and the length of interviews for each participant varied according to the participantûs condition and the situation of each interview. Sixty-one interviews with 31 participants were done. Four participants were interviewed once. Twenty-four participants were interviewed twice and three participants were interviewed three times. The length of each interview was approximately 1-2 hours. Most interviewing took place at the participantûs home. Only the first interview of four participants took place at a private room of the outpatient department and six interviews of four participants were conducted at their bedsides when they were in the hospital. The second or additional interview was performed 2-8 weeks later depending on the participantûs condition. The participants who had acute exacerbation were interviewed after discharge from the hospital 1-2 weeks later or when their condition had stabilized after acute exacerbation. Twenty-six participants had family members present during the interview. Therefore, information given by family members was included in the tape-recorded interview. With the permission of the participants, all of the interviews were tape recorded and transcribed into written text by the researcher as soon as possible for the purpose of analysis. Observations were used in conjunction with the interviews during the home visit and during the participantsû hospitalization because the participants were sometimes unable to report accurately about certain behaviors. Observations were used as an additional means of obtaining information. Also, use of the method of observation could be considered as a strategy of validation to increase the credibility of the data collected by the interview and analyzed using the qualitative method13 . In this study, the researcher observed the participantsû families, communities, actions/interactions, relationships, events, incidents etc. Some of the interviews following observations were recorded by means of memos and field notes for further analysis. The researcher reviewed the participantsû health records at least two times. The first review aimed to screen potential participants, while the second review aimed to obtain additional data as well as to crosscheck the data from interviews and observations. Participantsû health records could provide important data such as participantsû biographies, history of illness, the results of investigation, diagnoses, history of treatment or hospitalization, and present medical condition and treatment. Data Analysis Three types of coding including open coding, axial coding, and selective coding, which were the strategies of grounded theory by Strauss and Corbin (1990)13 , were used. The constant comparative method of analysis was used until core categories or basic social process emerged. Theoretical sampling, memoing and diagramming
  • Chronic Dyspnea Self-Management of Thai Adults with COPD Thai J Nurs Res ë October - December 2002204 were also used in conjunction with the coding process. Finally, çbecoming an experté was the core category that emerged from this process of data analysis. There were four categories related to this core category including being a novice, developing competency in self-management, developing expertise and becoming an expert. Rigor of the Study Rigor in qualitative research is demonstrated through the researcherûs attention to and confirmation of information discovery. The goal of rigor in qualitative research is to accurately represent the study participantûs experiences. This study used four criteria of rigor in qualitative research, as proposed by Guba and Lincoln (1985)14 : credibility, fittingness, auditability, and confirmability. To increase the credibility of this study, firstly, the researcher selected the appropriate participants, Thai adults with COPD, who had dyspnea experience and had varied personal and medical histories with variations in age, sex, education, occupational, duration and severity of illness, and duration of chronic dyspnea. Secondly, the researcher established a good rapport with participants by prolonged contact with the participants until trust was built before collecting data. In addition, participants were interviewed more than one time. Thirdly, the researcher concluded the findings in accord with the empirical data, not the existing theory, by collecting adequate data and using triangulation approach across data sources (participant, family, health records), data settings (outpatient department, inpatient department, participantsû home) data collection methods (interviews, observations, review of health records), and data analysis (researcher, advisory dissertation committee members, colleague). Finally, member checking was also an approach that was used for establishing the creditability of this study. In the second or additional interviews, the researcher asked participants to confirm their previous interview. Moreover, seven interviews were conducted in the late stage of data collection when the tentative theory was developing. The researcher asked the participants if they agreed or disagreed with the descriptions that represented the overall experience with COPD. The researcher also discussed the findings with one colleague and asked whether the analyses were believable and familiar in her experience. To enhance fittingness, the researcher asked two Thai adults with COPD who had similar experiences to the participants in this study to confirm the findings. The researcher also asked one colleague who had experience in caring for Thai adults with COPD and of sitting on advisory dissertation committees to determine the congruence within the context of the findings. To meet the criterion of auditability in this study, the researcher recorded the activities in every stage of the research process for illustrating as clearly as possible the evidence and the thinking process that lead to the conclusions. In this way, other persons could follow these processes through and draw the same conclusions Finally, confirmability is achieved when credibility, fittingness, and auditability, are established. Theoretical Findings A substantive theory explaining a basic social and psychological process by which Thai adults with COPD who live in Chonburi Province manage their chronic dyspnea was developed. The study found that çbecoming an experté is the core category of such a process, and a substantive theory was entitled the çtheory of becoming an expert in chronic dyspnea self-management of Thai adults with COPD.é This theory is viewed as a developmental process in which one evolves from a novice to an expert in chronic dyspnea management. This process, becoming an expert, took place dynamically and moves from previous stages onto next stages depended upon the participantsû perceptions of chronic dyspnea, knowledge, abilities and skills in chronic
  • Supaporn Duangpaeng Vol. 6 No. 4 205 dyspnea management, which gradually accumulated. This theory comprises three essential 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 of Thai adults with COPD
  • Chronic Dyspnea Self-Management of Thai Adults with COPD Thai J Nurs Res ë October - December 2002206 Causal Conditions Perceivedhealthdeviation,Perceivedsuffering,easytodie,and retribution Fearofdyspneaoccurring Perceivedremittent&incurabling Fearofdyspneaoccurring Realizedhealthcondition Recognizedself-responsibility Perceivedlivingwithsuffering Fearofdyspneaoccurring Perceivedself-efficacy ConsequencesUnderstandcause&treatmentof COPD Knowalittlebitaboutdyspneaand itsmanagement Abletocomplywithregimen/advice RelyonHCP&familywhen dyspneaoccurs Comprehendaboutdyspnea,trigger, management Abletocontrolnotseveredyspnea Begintorelyonselfindoingroutine andmanageownillness Begintorealizehealthconditionsand oneûscapabilityindyspnea management Abletogivereasonsfortheactions butlackconfidence Acceptillnessasincurableand self-responsibilitytomanageit Complywithregimenbothin remissionperiod&hospitalization Comprehendcourseofchronicdyspnea Abletopreventandcontroldyspnea inadvance Abletorelyonself&others appropriately Increaserealizationofhealthcondition &oneûscapability Haveconfidenceinillnessmanagement andgivingreasonfortheactions Begintoparticipateindyspnea managementwhenhospitalized Knowhowtolivenormally Abletointegrateillness managementintodailyroutine Successfulmangecourseofillness Abletodevelopnewmethod/ strategiesforillnessmanagement Abletoparticipateinmanagement duringhospitalization Balancerelianceonself&others Satisfactioninlivingwithoneûsillness Self-learning Self-management Figure2.Processofbecominganexpertinchronicdyspneaself-managementofThaiadultwithCOPD Action/interation Strategies Expertise
  • Supaporn Duangpaeng Vol. 6 No. 4 207 Becoming an Expert Becoming an expert is the first component and the central focus of this theory. Becoming an expert in chronic dyspnea self-management is essential for people with COPD who live with the uncertainty of dyspnea. People with COPD must develop their knowledge, ability, and skill in management of their chronic dyspnea by themselves in everyday life. Therefore, çbecoming an experté is the social psychological process that emerged from the data which is described as competency developmental process in chronic dyspnea self-management of people with COPD. Becoming an expert consists of two important strategies including self-learning and self-management. Both self-learning and self-management have a reciprocal relationship that leads individuals to gradually gain more competency and confidence in chronic dyspnea self-management, balancing reliance on self and others, and living as normally as possible. Self-learning is a cognitive dimension of the process of becoming an expert in chronic dyspnea self-management by Thai adults with COPD. Self-learning in this process is stimulated by the individualsû perception of dyspnea as a threat to their life and cause of suffering that leads the individuals to realize that their usual behaviors couldnût solve their health problems. So they have to learn about their illness, and how to manage it. This perception of dyspnea results from individual experience of dyspnea, especially acute dyspnea exacerbation. Dyspnea exacerbation not only affects individualsû thoughts and feelings, but also affects individualsû behaviors. Since dyspnea is progressive by nature, the self-learning in the process of becoming an expert in chronic dyspnea self-management is an ongoing learning process. Individuals have to learn about their illness and its management from their own experiences as long as they have to live with it. This study found that people with COPD learned about their chronic dyspnea and its management through being involved in the dyspnea experience, taking actions in dyspnea management, and observing and learning from healthcare providers and other COPD people. Reoccurrence of dyspnea led the individuals to ponder on it, while taking actions in dyspnea self-management enabled individuals to learn through their actual management. However, learning management was a trial and error process. Observation learning reordered individualsû comprehension and ability through watching the actions of others or healthcare providers managing dyspnea. This self-learning not only enhances personal comprehension and ability, but also enables the individuals to develop self-awareness and increases perceived self-efficacy in chronic dyspnea self-management as well. These consequences increase gradually throughout the process of becoming an expert in chronic dyspnea self-management and make individuals ready to manage their own health problems. However, in order to achieve learning goals there are many factors that can facilitate or inhibit self-learning that will be described later. Self-management involves both cognitive and behavioral dimensions of the process of becoming an expert in chronic dyspnea self-management. People with COPD used a cognitive process in understanding the meaning of chronic dyspnea, monitoring the symptoms of dyspnea, and initiating or planning action to prevent or control dyspnea. In addition, they used it in evaluating the efficacy of these actions. This could result in the selection of alternative strategies or even changes in meaning of their illness and/ or making a new plan of action. The behavioral process was used in performing actions in order to achieve the goal of preventing, and controlling dyspnea. Self-management in chronic dyspnea by Thai adults with COPD arises from the individualsû perception of dyspnea as a threat to their life from the primary experience in dyspnea exacerbation that makes them live with fear of dyspnea
  • Chronic Dyspnea Self-Management of Thai Adults with COPD Thai J Nurs Res ë October - December 2002208 occurring. This perception of illness not only led the individual to learn about their illness but also led them to manage chronic dyspnea by themselves. An important characteristic of self-management of chronic dyspnea of Thai adults with COPD was the repetitive and dynamically changing process that depended upon the individualsû perceptions of chronic dyspnea. It also depended upon individualsû comprehension, ability, self-awareness, and perceived self-efficacy in chronic dyspnea self-management that resulted from self-learning and past experience in self-management of their illness. This study found four strategies of self-management in chronic dyspnea by Thai adults in the çbecoming an experté process. These are complying with the regimen,tryingself-management,self-management, and integrating it with their lifestyle. These strategies cover both individualsû management, with participation and relying on healthcare providers. As a result, in each stage of the çbecoming an experté process the individuals gradually increased comprehension, skill, and perceived self-efficacy in chronic dyspnea management, which led to the next self-management stage. As mentioned above, both self-learning and self-management have a reciprocal relationship that lead the individuals to gradually gain more competency and confidence in chronic dyspnea self-management, balancing reliance on self and others, and living normally as possible. The following are statements by the participants. A Buddhist monk, 57, who was diagnosed with COPD for twelve years stated: çAn experience is important. I do it better for Iûve achieved solving a problem before. My sickness often recurssoIûvenoticedmycondition.When Iûm slightly ill, I never go to see the doctor. Unless the tablets and spray dilator cannot control my sickness, Iûll go to see the doctor. I always notice the sound of my breathing to decide whether my condition is serious or not. The advantage that the patients gain from the sickness is that the more we learn about thedisease from our experience, the more we take care of ourselves. In other words, Iûve tried to prevent the recurrence and progression of my illness. If my sickness recurs, Iûll greatly suffer from it. What I do everyday was taught by nobody. I have learned it on my own. I was merely taught to use drugs. Occasionally, I forgot and walked hastily to my destination and got so tired that I had to use the dilator. Iûll never do it like this again. Iûll have a stroll and bring a spray dilator with me everywhere I goé. A Thai male, 74, who was diagnosed with COPD six years ago said: çI am now different from when I used to be firstly dyspneic. I hardly knew anything then. When I felt tired, I would try to fight it and work on, but now whenever I feel tired, I have to take some rest and use the spray dilator. If it does not work, I have to hurry to the hospital. I canût delay; otherwise, I may be panting which will be worse and out of my control. Oxygen may be needed. I learned this because I got used to it so often so I know my symptoms. I know how to deal with it moreé. Influencing Factors Influencing factors are the second component that comprises two categories of factors, personal factors and contextual factors, which affect the process of becoming an expert in chronic dyspnea self-management by Thai adults with COPD. Influencing factors are very important in the process of becoming an expert because they can lead to, facilitate or inhibit çbecoming an experté
  • Supaporn Duangpaeng Vol. 6 No. 4 209 actions. In each of the two categories of factors, several interrelated aspects need to be considered, and the two categories are related to one another and may interact to influence the çbecoming an experté actions. Personal factors include both antecedent and mediating factors. Antecedent factors are causal conditions that lead the individuals to learn and manage chronic dyspnea, while mediating factors facilitate or inhibit those actions. Antecedent factors, perception of and response to illness, plays a crucial role in leading people with COPD to take action in learning and managing their illness. Perception is the individualsû cognition of the characteristics and impacts of chronic dyspnea, which are changed in the respective stages of the process of becoming an expert in chronic dyspnea management. It changes from perceived health deviation at the first stage, to easy to die and suffering, being incurable and remittent, and living with suffering respectively. These perceptions cause the individual to develop skills in chronic dyspnea management. Therefore, perception of chronic dyspnea directly influences çbecoming an experté actions. Besides, it can interact with other personal and contextual factors to influence çbecoming an experté actions such as personal experience, knowledge, social support, perceived self-efficacy, and course of illness. Moreover, fear of dyspnea occurring, and individualsû reactions to dyspnea experience, were also important antecedent factors that led the individuals to learn about and manage chronic dyspnea. This study found that fear was a universal response of people with COPD who experienced shortness of breath. Once they faced shortness of breath, they felt fear and perceived it as life threatening. So they fear dyspnea reoccurring. Most of the people with COPD said that they fear dyspnea occurring more than they fear death because it led to suffering. In order to avoid dyspnea occurring, they learned about dyspnea and tried to prevent it on their own. Therefore, it can be concluded that both perception of and response to illness influence the çbecoming an experté actions. This study also found many mediating factors that facilitate or inhibit the çbecoming an experté process such as personal attributes, personal experience, knowledge, self-awareness, perceived self-efficacy, hope, and social support. These mediating factors may interact with other influencing factors to influence çbecoming an experté actions. Personal attributes are the characteristics of people with COPD that are different among individuals. In this study, it was found that self-concern and self-responsibility are the facilitating factors to çbecoming an experté actions. Both self-concern and self-responsibility lead people with COPD to seek information, comply with the regimen, and perform health behaviors, while beliefs and social values about cigarette smoking are inhibiting factors to çbecoming an experté actions. Personal experience refers to personal past experiences in dyspnea and dyspnea management. Gaining experience of dyspnea enables people to comprehend symptoms and their triggering as well as how to manage them. In living with chronic dyspnea, COPD people have to learn how to manage chronic dyspnea and develop skills in chronic dyspnea management from their experience, especially the experience in self-management. This study found that if the self-management is successful, the individual memorized it to apply it next time. On the other hand, if that self-management were an unsuccessful experience, they would seek other strategies to manage it. The study also found that past experiences in dyspnea and dyspnea management create individual comprehension, ability, and perceived self-efficacy in handling such dyspnea. As a result, individualsû perceptions of chronic dyspnea were changed. Therefore, personal experience not only influences çbecoming an experté actions but it also influences other
  • Chronic Dyspnea Self-Management of Thai Adults with COPD Thai J Nurs Res ë October - December 2002210 influencing factors such as perception of illness, knowledge, ability, and perceived self-efficacy. Knowledge is an individualûs comprehension of chronic dyspnea including cause, physiological change, symptoms, and their management. In this study, Thai adults with COPD have obviously reflected that knowledge about illness and how to manage it was needed in the developmental process of how to become an expert in handling chronic dyspnea by themselves. Comprehension of their illness properly leads people with COPD to perform actions appropriately. Knowledge can accelerate the developmental process towards being an expert sooner. Moreover, this study also found that knowledge was gained from both experiences in self-learning and self-managing. Therefore, it led the individuals to gradually comprehend their chronic dyspnea throughout the process of becoming an expert. Self-awareness is a very important influencing factor because it would give a motive for people to transit from passive control to active control in their illness. This study found that the perceived threat to life and the suffering from dyspnea are factors that make individuals realize that, if it is ignored, one may die easily. Therefore, they reconsider and paymoreattentiontoself-learning,self-observation, and self-warning. Perceived self-efficacy plays an important role throughout the process of becoming an expert. Perceived self-efficacy in chronic dyspnea self-management is a result of self-learning and experience in self-management of chronic dyspnea. Therefore, in living with chronic dyspnea, the individual perceived self-efficacy in chronic dyspnea self-management increasingly in each respective stage of the process of becoming an expert in chronic dyspnea self-management. This study found that in the novice stage most COPD people perceived that they had no capability to handle dyspnea by themselves. They had to rely upon healthcare providers whenever any problem or dyspnea arose. They consequently avoided performing activities that needed to be done regularly because of dyspnea. Later, they perceived their own ability after they had learned more about the nature of dyspneaandtheyhadexperiencedself-management. In this way, they were convinced to act in the development of being an expert in chronic dyspnea self-management. Perceived self-efficacy not only encouraged people to dare to manage their illness but it made people dare to search for new useful information or to share it with others. Factors that affected perceived self-efficacy in chronic dyspnea self-management were found in this study. The experiences that a person has can engender success if he sees possible good outcomes from someone having the same experience. This convinces them that they would be able to make it. In addition, obtaining useful information, suggestions or manageable facilitation and encouragement from social resources would enable them to perceive their ability to manage chronic dyspnea by themselves. Hope is vital energy for living for people with COPD who suffer from dyspnea as with those who suffer from other chronic diseases. For people with COPD, hope is situated on a factual base that such an illness is incurable and the symptom of dyspnea threatens their lives. Besides, they have to live with suffering all their lives so their hope is just a short-term goal and can be changed over time by internal or external factors such as individualsû perceptions of illness, course of illness, perceived self-efficacy, and social support. This study found that after the individual was diagnosed with COPD and the symptoms of dyspnea were not severe, they hoped for cure or improvement. Later, when dyspnea progressed, they hoped to have as prolonged a remission period as possible because they wonût suffer by it and they can perform their usual activities. Finally, as a result of acknowledgement of chronic dyspnea as incurable and remittent, they had to live with suffering. They perceived support from significant others. They hoped to have prolonged remission
  • Supaporn Duangpaeng Vol. 6 No. 4 211 periods and live for a longer period for a specific purpose of each individual. Hope enabled them to try to do whatever possible to manage their chronic dyspnea, such as more carefully take care of themselves or strictly comply with the doctors or healthcare providersû suggestions etc., in order to achieve their hope. Finally, Social support plays a crucial role in every stage of the process of becoming an expert in chronic dyspnea self-management. Because both perceived and received support make people with COPD feel that they still are valuable and this motivates them to cope with their illness themselves. When it is known that there are some social resources available, this can convince them that they can approach them for help or support when a problem happens. This can reduce a personûs anxiety or concerns. Moreover, information or instrumental supports that the individuals receive from others can help them gain more knowledge and ability to manage, and this leads them to self-management of their illness. However, social support may either facilitate or inhibit the people from becoming experts since most COPD people are elderly. By nature they are constrained in doing various activities due to their senility and fear of dyspnea recurring so they are prone to rely upon others, especially family members. The following are statements by participants about personal factors that influence çbecoming an experté actions. A Thai male, 79, who had been diagnosed with COPD for five years said: çAt present, I only fear the occurrence of dyspnea. When I canût follow up the appointment, I fear dyspnea. Now if I have to go somewhere, I will use my drug even though there is no symptom. I fear occurrence of dyspnea, but I donût fear death. This is because it makes me suffer (ID.012/9)é. A Thai male, 62, who had been diagnosed with COPD two years ago said: çI donût know how other persons help or take responsibility in my illness management because they donût know me. They only do something I told them to do. In my opinion, we have to take responsibility directly, not other persons. We must be supportive of ourselves, namely, we must know what will happen and prevent it in advanceé. A Thai male, 67, who had been diagnosed with COPD for six years said: çI have had dyspnea for a long time. I couldnût remember how many times this symptom had recurred. I continue to comply with the doctorûs orders and manage it by myself. Nowadays, I believe that I have the ability to deal with my illness more than in the past. In the past, if I had any problems, I hurried to see the doctors. Now I try to solve it by myself with confidenceé. Contextual factorsrefer to the environmental conditions that affect çbecoming an experté actions. It consists of a conducive and supportive environment. A conducive environment is the condition that induces çbecoming an experté actions easily to take place easily, while a supportive environment facilitates çbecoming an expertéactionsinchronicdyspneaself-management. Conduciveenvironmentrefers to the course of illness. In this study, the course of illness is severity of chronic dyspnea both in remission and exacerbation periods that resulted from pathology of COPD. COPD has similar characteristics to other chronic illnesses in that it consists of remission and exacerbation periods. In remission periods, the symptoms of dyspnea subside. So the individual perceives chronic dyspnea as not
  • Chronic Dyspnea Self-Management of Thai Adults with COPD Thai J Nurs Res ë October - December 2002212 severe. They can live normal lives like other people. In the exacerbation period, the symptoms worsen so individuals perceive a higher severity of chronic dyspnea. These perceptions lead to many different individual responses. This study found that during the remission period, the dyspneic people neither seek knowledge about their illness or how to handle it nor is strictly cautious about themselves. On the other hand, during the exacerbation period, individuals will strictly be cautious about themselves and seek knowledge in order to handle such illness. Therefore, the course of illness, especially the severity of dyspnea, plays a crucial role in the conducive environment that can lead to the process of becoming an expert taking place easily by interactions with the perception of illness. Supportive environment covers both physical and social environment. Physical environment includes home and hospital environments and medical facilities. Changes of these factors may cause changes in çbecoming an experté actions because those environments affect both learning and managing oneûs own illness. The facilitating environment for learning makes people with COPD know and comprehend the nature of their illness and how to manage that illness by themselves. However, a facilitating environment for self-management makes the people experience it. The consequence is their skill in doing it by themselves. Social environmentincludes family system, community, and healthcare service system, and that also affects both self-learning and self-managing of the people with COPD. These social environments are social resources of people with COPD. In particular, the family system is the closest environment of COPD people. In this study, it was found that this systemûs structure and function, which may influence çbecoming an experté actions include family characteristics or types of family, whether nuclear or extended, and open or closed, family member relationships, responsibility to each other, availability for support, beliefs or values, the familyûs relationship with other resources outside the family, and even location of the household. Community is an important social environment because COPD people spend most of their lives at home. In this case, the community is both a resource for learning and handling the illness. Community factors that may affect the action or interaction strategies of becoming an expert are beliefs or values, community resources and mutual dependability. Finally, the healthcare service system is another factor no less important than that of family and community because chronically diseased people are able to develop their potential and self-dependent. However, they still have to rely upon the healthcare service system. A good healthcare service system will enhance the developmental process of becoming an expert in self-management of the chronic dyspnea whereas those people need no struggle for self-development from trial and error by themselves or they need not wait for their own experiences. In so doing, it takes time and the disease may have developed too far before they approach being an expert. If the healthcare system is easily accessible, has high quality of care, and good relations between clients and health care providers, it can accelerate the çbecoming an experté process for COPD people. The following are statements about contextual factors that influence çbecoming an experté actions: A Thai monk, 57, who has been diagnosed with COPD for twelve years mentioned: çI am now quite knowledgeable. My illness is very severe. It makes me learn how to adjust myself.....Even squeezing the toothpaste tube, I have to do it deliberately, not like in the old days when I did it. Boop! Finished! Now I have to think it over such as when going
  • Supaporn Duangpaeng Vol. 6 No. 4 213 to the bathroom, my brain thinks what will happen if I walk this way. Can I reach it? Will I be tired? Will I need medicine? So, I would be prepared properly about how to do everything é. A Thai male, 64, who has been diagnosed with COPD for four years stated: çMy daughter bought oxygen and had it prepared in the car for use whenever in need. Nowadays we have an electric nembulizer that makes us more confident. We used to have only an oxygen tube that kept us worried whether the shop would be opened or not when we needed it. That is how are prepared now. I think I wonût go to the hospital unless I am in a serious condition because what we have now are what are used in the hospital-same medicines, same equipmenté. Consequence The consequence, the final component of the theory of becoming an expert in chronic dyspnea self-management, refers to the results of the process of becoming an expert in chronic dyspnea self-management. In this study, experts in chronic dyspnea self-management are the consequence, as the result of self-learning and self-management of chronic dyspnea for a long time. The important characteristics of the expert in chronic dyspnea self-management include competence and confidence in chronic dyspnea self-management, balanced reliance on self and others, and living as normally as possible. These characteristics of the expert in chronic dyspnea self-management gradually increase in every stage of the çbecoming an experté process. Competence in chronic dyspnea self-management is developed from accumulation of knowledge and skills from self-learning and self-management. Consequently, the individual can anticipate and preplan preventive measures, handle contingencies, seek or develop techniques in management, negotiate with others, and develop willpower. These competencies enable a person to be convinced that they can manage their illness successfully and keep a balance between self-reliance and dependence upon others in handling their illness and maintaining their routines. In addition, they enable the individual to live with chronic dyspnea as normally as possible. All consequences that are mentioned above are gradually increased to be congruent with individualsû competency in chronic dyspnea management. All of the consequences could have a recursive effect on çbecoming an experté actions and influencing factors such as hope, perceived self-efficacy, and perception of illness that lead to the next çbecoming an experté actions. The following are observations by the participants. A Thai male, 79, who was diagnosed with COPD five years ago said: çI nowadays come to it extremely...that is...I know when I am going to have dyspnea...what causes...all medicines must be prepared... I know well which of them is good or not. Next step is the monastery (laughing). The symptom frequently arises. It taught me automatically. At first I didnût know...but over and over it arises...I know it from my observation. I am now an expert. Nobody has to tell me about this é. A Thai male, 62, who was diagnosed with COPD three years ago mentioned: çDonût blame me that I am boasting. Currently, I am professional in chronic dyspnea management. If I can control
  • Chronic Dyspnea Self-Management of Thai Adults with COPD Thai J Nurs Res ë October - December 2002214 all situations, it means that I reach the final destination. Now...the very important thing is that dyspnea occurs due to my emotion. If I could control would reach its pacified peak point. I am an expert, but I do not mean I am good at everything. I merely know how severe the symptom is and how I could remedy or prevent it...because I knew myself...I couldreadmyself.Ilearnedthisone after another. I know myself more than the doctor, but I am not better than the doctor about treatment. I know more about myself, but I cannot be sure that the symptom wonût arise again, I cannot control that, but for one thing, it less frequently comes, so I am suffering less. So, I go to the hospital occasionally, only when the doctor makes an appointmenté. In summary, it may be concluded from this study that all theoretical components are related to each other as well as two categories of influencing factors. These relationships among various variables need further refinement or testing. Discussion and Recommendations This study provides a substantive theory entitled çThe theory of becoming an expert in chronic dyspnea self-management of Thai adults with COPDé, which is a middle-range theory. This theory explains a clear developmental process on how to become an expert in chronic dyspnea self-management of Thai adults with COPD. In addition, it gives an holistic view of the relationship between the meaning of chronic dyspnea, actions or interaction strategies, and influencing factors affecting the process becoming an expert in chronic dyspnea self-management of Thai adults with COPD. Therefore, it indicates directions in order to help or facilitate COPD people to develop themselves to become experts in chronic dyspnea self-management and also gives direction of further research in helping COPD people. The findings of this study are es- sential knowledge in nursing science. The findings of this study suggest several directions for clinical practice, future research, and health policy. The implications for clinical practice that arise from these findings are several. In particular, the findings can help healthcare providers, especially nurses, to understand the process of becoming an expert in chronic dyspnea self-management of Thai adults with COPD in a natural context. It also reveals the fact that by nature COPD people have potential in self-management of their illness. In addition, the findings of this study also provide directions for nursing interventions, which focus on helping these people to develop themselves to be experts in managing their chronic dyspnea. The implication for healthcare policy is that, in order to successfully develop nursing systems for COPD people, health policy should focus on: firstly, developing hospital or healthcare units in every level as potential healthcare resources for the community by preparing medical facilities and healthcare providers who are well prepared and qualified; secondly, developing one-stop service systems for COPD people who live with the unpredictability of dyspnea; thirdly, preparing nurses to be clinical nurse specialists or nurse practitioners in caring for persons with chronic illnesses like COPD; fourthly, establishing a medical network by enhancing cooperation among governmental organizations, private sectors and communities that can help COPD people effectively. Finally, strengthening the community by educating them to understand the health problems so that they can become virtual resources for COPD people. Regarding future research, the findings from this study would provide several directions. Firstly, this theory is a substantive theory emphasizing
  • Supaporn Duangpaeng Vol. 6 No. 4 215 the process of becoming an expert in chronic dyspnea self-management of Thai adults with COPD. This theory can be the basis for developing a formal theory explaining the same process in people with COPD who live in other areas or regions as well as people of higher socio-economic status and more highly educated groups in order to increase transferability of the findings. Moreover, replicating this grounded theory study with a longitudinal design to fully understand the process of becoming an expert in chronic dyspnea self-management and the influencing factors are also recommended. Secondly, the theory of becoming an expert in chronic dyspnea self-management of Thai adults with COPD emerging from this study needs to be refined through theory testing procedures in a quantitative study. The relationship among concepts and constructs needs to be identified and tested. Thirdly, according to theoretical concepts in this study, it should be used as a basis for developing nursing interventions, which is congruent with the stages of the process of becoming an expert in chronic dyspnea self-management. Testing the effect of nursing interventions in a quantitative study is also required. Finally, theoretical concepts and models generated in this study should be applied to guide healthcare practices through participatory-action research, wherein COPD people, their families and healthcare providers can jointly participate in similar research projects. It may enhance derivation of a proper pattern of experts in chronic dyspnea self-management that is more practical in clinical practice. References 1. Chooprapawan, J. (2000). Health status of Thai people. 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 chronic obstructive 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 outcomes in-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 emphysema. American Journal of Nursing, 73, 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: Its issues and processes. Image: Journal of Nursing Scholarship, 12, 20-35. 13. Strauss, A. & Corbin, J. (1990). Basics of Qualitative Research. Newbury Park: Sage. 14. Guba, E.G. & Lincoln, Y.S. (1985). Effective evaluation. San Francisco: Jossey Bass.
  • Exploring Ethical Dilemmas and Resolutions in Nursing Practice: A Qualitative Study in Southern Thailand Thai J Nurs Res ë October - December 2002216 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. Abstract: The purposes of this study were to explore ethical dilemmas in nursing practice encountered by nurses in Southern Thailand, and describe resolutions nurses used in dealing with the ethical dilemmas. Four focus group interviews were conducted with 40 nurses working in both out-patient and in-patient units in two general hospitals and two regional hospitals in Southern Thailand. Data were sought regarding ethical concerns of nursing practice. Thematic analysis of the transcribed interviews uncovered eight major ethical dilemmas. These themes are (1) balancing professional obligations vs. protecting self from harm, (2) prolonging life vs. prolonging dying, (3) maintaining patient confidentiality vs. warning others of harm, (4) advocating for patients vs. maintaining relationship with others, (5) intradisciplinary and interdisciplinary conflicts, (6) truth-telling vs. benevolent lying and withholding information, (7) end of life issues, and (8) discrimination vs. obligation to provide care equally. Resolutions to ethical dilemmas found in the study fell into five themes: (1) taking moral action, (2) acceptance, (3) expressing feelings, (4) discussing with others, and (5) ethical problem-solving strategies. Possibilities and recommendations about ethical dilemmas in nursing practice are discussed. 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 Vol. 6 No. 4 217 Background Advances in technologies and the changes of social, economic, and political factors have stimulated increased attention on ethical aspects of health care practice. Additionally, patientsû rights and dignities are also a focus of concern in the current context of health care reform in Thailand1 . However, knowledge on ethical dilemmas, resolutions of ethical dilemmas, and ethical decision-making of Thai professional nurses is very limited because of the lack of research studies in this area. Some previous research studies included ethical issues/dilemmas faced by nurses in caring for persons with AIDS,2,3 and terminal illnesses,4 and nurses working in intensive care units.5 One study on nursesû ethical decision-making was found in Thailand.6 On a daily basis, professional nurses are challenged by ethical dilemmas that occur when two or more mutually exclusive moral claims clearly apply and both seem to have equal weight.7 An ethical dilemma can be defined as a difficult problem seemingly incapable of a satisfactorily solution or a situation involving choices between equally unsatisfactory alternatives.8 It is evident that ethical dilemmas occur in connection with truth telling, quality of care, discrimination, withdrawal of life-sustaining measures, protecting patient confidentiality, or relationships with colleagues (physicians and nurses). For example, a study conducted by Wipamat9 found that of 110 nurses who provided care for HIV/ AIDS patients, more than 90% reported ethical dilemmas related to maintaining patient confidentiality, 62% reported dilemmas related to truth telling, and 59% conflicted with colleagues. Phenomenological studies by Kanda,5 Krisana,4 and Setiawan10 showed similar results that nurses in intensive care units experienced ethical dilemmas related to truth telling and continue (prolong life) or stop treatment. A study by Redman and Fry11 on 43 registered nurses certified diabetes educators found that disagreement with medical practice was the most dominant ethical conflicts. Similarly, Hartwell and Lavandero12 found that 29% of critical care nurses (N=1100) confronted conflicts with physicians related to ethical issues, 8% reported conflicts relating withholding and withdrawing of treatment, and 3% had conflicts with nursing staff related to ethical issues. Nurses are required to make decision and take actions to resolve ethical dilemmas in their daily practice. Ethical decision-making process is accepted as an effective strategy to resolve ethical dilemmas because it provides a method for the nurse to systematically and thoughtfully examine ethical dilemmas and to answer key questions about ethical dilemmas13,14 Broom15 proposed that to resolve conflicts that evolve from ethical dilemmas, the nurse recognizes how personal values affect and works with others to develop an integrative approach to patient care. Tucker and Friedson16 identified three methods to resolve difficult ethical dilemmas including; ethical case analysis using principle-based models of decision-making, simple communication tools, and consensus-building skills. Studies in Thailand4,5 and Indonesia10 showed similar results regarding resolutions nurses used when facing ethical dilemmas. These resolutions included taking professional actions, accepting, consulting/discussing, positive thinking, and adhering to religion. In preparing professional nurses who are capable in ethical decision-making and dealing with ethical dilemmas effectively, requires strategies to provide ethical knowledge and training to nurses since there are nursing students. Several teaching strategies have shown their effectiveness in promoting ethical behaviors of nursing students, for examples; case studies, value clarification, clinical inquiry, clinical conference and case presentation.17,18,19 However current teaching strategies in Thailand have failed to
  • Exploring Ethical Dilemmas and Resolutions in Nursing Practice: A Qualitative Study in Southern Thailand Thai J Nurs Res ë October - December 2002218 instill values or incorporate the ethical decision-making and ethical practice ability of nursing students.20 The national workshop of nurse educators and graduate students on nursing ethics held in Thailand a few years ago developed a list of research properties in nursing ethics that was intend to serve as a research agenda. They were categorized in three main areas; nursing practice, nurse educator, and nursing administrator.20 It is no doubt that research based knowledge is needed to guide development of ethical competency of nursing students and nurses. This study explored the current ethical dilemmas experienced by nurses within daily nursing practice, and their ethical dilemma resolutions. Unlike previous studies conducted in Thailand, this study focuses on ethical dilemmas and resolutions experienced by nurses working in various clinical settings. This will help to provide a better understanding of the positions of professional nurses, and their concerns regarding nursing ethics. Knowledge gained from the study will also help in the developing guidelines and strategies to guide nurses in their relating to ethical dilemmas and resolutions in Thai nursing practice. Purpose of the Study The purpose of this study was to describe ethical dilemmas in nursing practice and resolutions of these dilemmas experienced by hospital nurses in Southern Thailand. Research Questions 1. What are the ethical dilemmas in nursing practice experienced by nurses? 2. What are resolutions nurses use in dealing with ethical dilemmas? Methods Design Qualitative methods were used for data generation and analysis. Focus group interviews were conducted with nurses working in various clinical areas and content analysis was used to answer the research questions. Participants Participants in this study comprised 40 registered nurses from two general hospitals and regional medical centers in Southern Thailand. They were selected from each clinical setting based on their willingness to join the study. Most participants were female and between the ages of 23 and 47 years. Thirty-six were Buddhist and four were Muslim. Most participants had earned a bachelorûs degree or equivalent and had clinical experience of more than 5 years. One participant had a masterûs degree. Clinical areas represented included out-patient, obstetrics-gynecologics, emergency, medical, surgical, and intensive care units. Twenty-one participants had never attended any conferences regarding ethical aspects of nursing practice. Data Collection The main method for data collection was focus group interview. Four focus group interviews were conducted at times and places convenient to participants. Each group consisted of 10 participants. The discussions were held under the leadership of two experienced nurse educators in ethics. The interviews lasted 2 to 3 hours and were audio taped. At the initial meeting, the study was explained, questions were answered, consent forms were signed, and demographic data sheets were completed. Participants were asked to describe ethical concerns or dilemmas they experienced and decisions they made in their daily practice. Discussion among the group members was
  • Aranya Chaowalit Vol. 6 No. 4 219 encouraged to explore the issues raised. The major focus of the discussions was directed toward describing ethical dilemmas relating to nursing practice, and strategies they used to deal with the dilemmas. Data Analysis Data were transcribed verbatim and analyzed immediately following data collection. Content analysis described by Waltz, Strickland, and Lenz21 was used to uncover themes reflecting ethical dilemmas and resolutions. Results Ethical Dilemmas in Nursing Practice Ethical dilemmas described by participants were categorized into eight themes: (1) balancing professional obligations vs. protecting self from harm, (2) prolonging life vs. prolonging dying, (3) maintaining patient confidentiality vs. warning others of harm (4) advocating for patients vs. maintaining relationship with others, (5) intradisciplinary and interdisciplinary conflicts, (6) truth-telling vs. benevolent lying and withholding information, (7) end of life issues, and (8) discrimination vs. obligation to provide care equally. Theme 1: Balancing Professional Obligations vs. Protecting Self from Harm. Provision of care to patients suffering from diseases such as tuberculosis and AIDS causes nurses to worry about the possibility contracting the diseases from the patients. Participants mentioned that it was a nurseûs responsibility to provide high quality nursing care to patients without objections. On the other hand, nurses believed that they had the duty to protect themselves from harm. According to participants, some nursing care situations could lead to harm to nurses unless they were openly informed about patientsû conditions. One participant stated: We sometimes have to take care of patients with tuberculosis, but you know we donût even know this since the physician doesnût tell us about patientsû laboratory investigation. We should be able to know patientsû condition. Right? Then we can protect ourselves when contacting the patient. Theme 2: Prolonging Life vs. Prolonging Dying. Ethical dilemmas arose when participants took care of critically or terminally ill patients. Most participants expressed this dilemma, such as: çShould I take off the respirator?é çIs it a sin or wrong if I take off the tube?é It is always possible that an effort to maintain the life of a seriously ill person can actually be extending dying and prolonging suffering of both the patient and their family. One participant stated that: I hate the situation when a doctor decides no resuscitation for a critically ill child who is on a respirator and the doctor asks me to take off the tube. You know I am so unhappy with this situation. Another participant supported this statement, saying that: Rescuing patients from acute state to vegetative state is also a worry for nurses. We donût want to prolong suffering. In some cases we have spent a lot of money and time, and finally it becomes the burden for the family. I feel guilty to prolong their suffering and bring a burden to the family. One participant who has worked in a nursery said that: My conflict is to terminate life of disabled child. I felt pity for this child and didnût want him to suffer but I couldnût do anything to destroy life either.
  • Exploring Ethical Dilemmas and Resolutions in Nursing Practice: A Qualitative Study in Southern Thailand Thai J Nurs Res ë October - December 2002220 Theme 3: Maintaining Patient Confidentiality vs. Warning Others of Harm. Nurses have a clear obligation to maintain patientsû confidentiality. However, this can create conflicts when confidentiality may have harmful effects on others, especially the patientsû families. Participants in this study had been informed of negative impacts following a number of incidents in their clinical practice. An example was a case of an HIV-infected mother who was having an HIV-infected child, while her husband was free from the infection. In this situation should the nurse maintain confidentiality for the patient or disclose the truth to her husband in order to allow him to protect himself from contracting the disease? On the other hand, disclosing the truth to the husband may cause him to leave the family and lead to family breakdown. Consequences of disclosing the confidentiality of a patient can be very complicated. In the experience of one nurse, when the truth was disclosed to the husband, he left the family. There was an HIV infected wife who asked me not to let her husband know about her disease. I thought it was an obligation to protect her confidentiality, but it wasnût fair for her husband. I felt like I could help one but would have to neglect the other. Theme 4: Advocating for Patients vs. Maintaining Relationship with Others. Most participants realized that one of their roles was to advocate for patients when the patientsû rights were violated by health personnel. Dilemmas occurred whether they chose to advocate for the patientsû rights or to maintain relationships with their colleagues. This conflict was more likely to happen with junior nurses because of their lack of authority. An attempt in protecting patientsû rights, often led to dissatisfactions of other health personnel such as nurses, and physicians. One of the common problems is the difficulty in getting a doctor to assist clients when needed, especially in the afternoon and night shifts. They sometimes disappear and we donût know where to get them. I sometimes decide to lie to the patient that the doctor had already made a treatment order by phone for them because we didnût want to have problems with these doctors. Some doctors arenût really concerned about informing their patients about the treatment plan. They expect nurses to do this job for them. In one instance the patient was informed about an abscess to be drained, but in fact the doctor did incision and drainage to the patient. The patient was not informed until he discovered the fact himself. The patient was so angry with the nurse as she was the person who informed the patient. Doctors may ignore patientsû rights to access health information. Actually the doctor should not do a procedure without getting the patientûs permission. Nurses must advocate for quality treatment. In one case of subarachnoid hemorrhage and severe headache, the nurse should be brave enough to request a skillful doctor to solve the problem. It was sad when a junior staff failed to solve the problem and the patient would not trust the doctor and turned their back on the hospital. Fair allocation of health resources is also a conflict issue related to the advocacy role. Patients may request admission to the hospital for reasons such as their own security or lack of support at home. However, the physician may not allow them to be hospitalized if their condition indicates they are well enough to stay at home.
  • Aranya Chaowalit Vol. 6 No. 4 221 A conflict arises when the patient does not have confidence to stay at home while we try to keep the bed available for more serious patients. In this case, we need to convince the patient and their family to stay at home. Some of them are not happy but we have to be firm for a fair allocation of health resources. Some special equipment can be a problem, for example, a respirator 7200 model seems to be prioritized for special cases (from physicianûs private clinic or their own network). We know it is not right but we donût have authority to make any changes as it is the decision of the physician. Theme 5: Intradisciplinary and Interdisciplinary Conflicts. Dilemmas in nursing practice frequently occur when nurses have conflicts with other nurses (intradisciplinary conflicts), and when nurses have conflicts with physicians (interdisciplinary conflicts) in caring for patients. Intradisciplinary conflicts: Some conflicts arose among nurses. One nurse offered an example of this kind of conflict that may happen because of an inappropriate response to a patient by a nurse. One of my colleagues was not happy with a patientûs relative who came to inform her that the patient had a high fever. She perceived that the relative was over doing her job. She then pretended to be busy with other tasks. I thought it wasnût fair for the patient who needed urgent care. I decided to warn the nurse and she accepted it but she wasnût happy with me. Whenever there was something wrong, they are never the victims, especially the shift head. Interdisciplinary conflicts: Front line complaints (Nang-Naa-Fai): Nurses always work closely with patients and are the first persons to receive complaints from patients about the health services. Conflicts arise as nurses try to take a role to negotiate problems between patients and physicians. I was so empathized with patients who came from far away to see the physician in the hospital. They were kept waiting hours and hours to be called to see the physician at the clinic, but still didnût know when they could see the physician. Many of them came to me and asked me to help, otherwise they couldnût catch the last bus back home on the same day. I have to solve this sort of problem every day. Nurses sometimes choose to lie to patients in order to keep them calm. If the patients know the physician may take a long lunch break, they would be angry and not be cooperative. Frequently, even though nurses try to explain to patients, they do not understand and still become angry with the nurses. Some patients refuse to return to the clinic because of being made to wait too long. This is also a conflict for the nurse who knows the physician does not do his/her job, but the nurse will still need to turn the problem into a positive situation. There was a patient admitted with stomachache. He had treatment and his condition was stable but his father wanted the physician to see him. I tried to explain to them that the physician would come again the next morning or
  • Exploring Ethical Dilemmas and Resolutions in Nursing Practice: A Qualitative Study in Southern Thailand Thai J Nurs Res ë October - December 2002222 when we needed emergency care. However, the father still insisted to see the physician. You see we have to be the front line for a person who faces this kind of situation...why not the physician? I was frustrated that we have to be Nang-Naa-Fai. The patient or his family should scold the right person, not us. Most patients and family want to listen to their physician...we are Nang-Naa-Fai. Whatever you explain to the patient is not the same as the physician. In another similar case, an orthopedic patient did not feel well, so we reported it to the physician. The physician didnût come but ordered the treatments by phone. The patient and his family were so disappointed and decided to move to another hospital. When the director of the hospital got the report, the fault fell on this nurse who was accused of having the report late. I donût understand why every time we have problems with patients, involving the physician, we are always the victims. Theme 6: Truth-telling vs. Benevolent Lying and Withholding Information. Dilemmas regarding truth-telling occur when nurses have obligations to tell the truth to patientsû families about patientsû illnesses and prognoses in order to prepare the families to deal with problems. However, some physicians do not agree with telling the truth because they believe that knowing the truth about poor prognoses can disturb the patientsû families. In addition, truth-telling dilemmas occur when participants perceive that it is not their role to tell the diagnostic study results to their patients when they did not do the investigation themselves. Participants believe that physicians who do the investigations should tell the truth to the patients. As one participant stated: For some serious illness such as AIDS, I would try to avoid telling the patient the truth. I would rather leave it to the physician. Anyway, I sometimes canût avoid this role, so this is also my conflict in truth telling. Telling patientsû their prognoses can cause conflict to nurses since it leads to patient suffering. Familyûs judgment may be dictated by medical or economic reasons. When the physician informs that the patientûs prognosis is hopeless, such as five percent survival rate, the family may decide to take the patient home while he/she is still breathing. It is hard to see him tortured at the end of his life. In some situations, nurses cannot allow patients to know about the poor services they have received as this can cause anger. The nurse will try to hide the faults of the physician, other health personnel and the hospital services to keep them calm while waiting. I felt frustrated that I canût let the patients know the real problem of the poor services in order to protect the image of the hospital and also to calm them down when they have to wait too long for the physician. Iûm aware of their frustration but what else can I do. Theme 7: End of Life Issues. In this study many participants reflected their dilemmas about whether to continue or withdraw aggressive
  • Aranya Chaowalit Vol. 6 No. 4 223 treatments for terminally ill patients. At the end stage of life, some patients still have intact consciousness and some do not. Conflicts also arise about who should make the decisions. When should the aggressive treatments for terminally ill patients be ended? Conflicts may arise when providing care to a patient who is dying. Should the patient be resuscitated or should treatment be withdrawn? What will it be like for the patient if he/she survives this crisis? I had taken part in caring for a hopeless child. In my opinion, I thought he had already died. His blood pressure sharply dropped and heart rate couldnût be felt. His skin turned blue. The physician spent a lot of time, using a lot of medications to pump him. I didnût agree with that. Who should make the decision to end the patientûs life? Usually when a patient is conscious, it is common that he/she must be the one to make the decision about his life. However, within a society of extended families in Thailand, family members also have strong influence in the process. Conflicts about to terminate life arise when nurses consider whether to accept or ignore the familyûs involvement, or to what extent they should contribute to the process. There are several reasons for the family to decide to end aggressive treatments and take the terminally ill patient home. The first is a cultural belief and the family may want the patient to have religious activity at the end stage of life. According to Muslim concepts, the patient should have a chance to listen to the reading of this Koran before death. This will bring the patient to heaven in the next life. A second reason is economic resources, as the family may prefer to end the patientûs life rather than continuing to spend money and prolonging suffering. I experienced a case who was already on tube and respirator with the permission of his wife. Later their relatives came in to visit. They didnût agree with the treatments and wanted to take the patient home. I tried my best to explain the reasons for keeping the patient in the hospital, but failed. I therefore reported to the physician. He advised me to get the family to sign the denied treatment form and let them go. The physician didnût come to deal with the patient and the family. What should I do with the patient who was breathing with the aid of the respirator? I wouldnût take the tube off myself. I thought it wasnût fair for the patient who still has a chance to live. Nurses are always confronted with situations that force them to take off the tube when the patientsû family decides to take the patient home. It is a big conflict for us but we sometimes just need to do it. Another nurse reported: This happens all the time, you know. I had a patient who needed to be intubated as well. The difference was that this person had intact consciousness. His wife was okay, but other family members were not. They finally decided to take the patient home. I felt sad and upset with the case. I think that the patient should be the person who made the decision as it was his life and his consciousness was still fine. Should we listen to patientûs relatives or take action based on our medical judgments?
  • Exploring Ethical Dilemmas and Resolutions in Nursing Practice: A Qualitative Study in Southern Thailand Thai J Nurs Res ë October - December 2002224 I donût want to be seen as a murderer when the patient dies because the tube is taken off. Theme 8: Discrimination vs. Obligation to Provide Care Equally. A number of cases of patient discrimination and unequal access to care were identified by participants in this study. They perceived that access to some health services was based on ability to pay and personal relationship with the heath providers. Moreover, some patients were discriminated against due to age, serious or terminal illness, or religion. There are many cases that are treated as special in the obstetric ward. I mean the cases referred from private clinics run by the physician in the hospital. The physician always comes early to see the patient but he doesnût do this for other patients. This is questioned by other know? Some patients questioned us why that patient could have more frequent visits from the physician and nurses. We were not happy with that but we needed to be with the physician when he visited the patients. Another participant supported these statements: Health personnelûs family members always obtain special treatments. When their own children get sick, they always get better care while others are neglected. I think the doctors are sometimes too economic oriented. They are not very keen to assess aged patients, clients with coma score 6, patients with some serious diseases, for instance, AIDS. I think every life is valuable. We should not simply judge them by our own values. Religious discrimination may result from lack of understanding of other religions, especially Islam. Many Muslim beliefs present obstacles to the treatment plan and are not well accepted by health personnel. This may lead to unwillingness to deal with Muslim patients. Some participants felt that they failed to convince Muslim patients to obtain aggressive treatments when necessary. When being told that the patient needed a tube inserted to ease the breathing, their relatives refused and decided to take the patient home. I didnût quite understand why they didnût accept the treatment. My conflict was that I was unsuccessful in helping the patient receive proper treatment. Another participant added that even though she was informed about the urgent reason to take the patient back home, she still could not accept it. In hopeless cases of Muslim patients, they prefer to take their sick relatives backhomebeforedeath.Thisisinfluenced by the religious beliefs that birth and death are given by God. They tend to surrender to God and deny aggressive treatments. It is my conflict as we are pretty sure that the patient could be saved if they can obtain proper treatment but their family is more concerned about religious beliefs at the end of life. I nearly got mad with Muslim patients many times. I experienced one of them who took the IV line off, without informing me, every time he prayed. For me, this can increase the chance of infection at the needlepoint when he cleaned his hand before praying.
  • Aranya Chaowalit Vol. 6 No. 4 225 Some problems commonly identified in caring for patients who are Muslim include delayed and the need for adequate communication. Patientsû relatives always need time to confirm the decisions they have made with other significant family members or religious leaders. This could easily lead to unintentional religious discrimination as stated by a participant: Iûve had a similar experience with a patient whohadanoseabscess.Heneeded to be intubated to preserve his breathing but his relative didnût agree. I explained to them several times but failed. The family wanted to consult some other significant persons such as their village leader, and other family members. Later the patient got worse and died. I believed that if he had received the proper treatments quickly enough, he would have been better. In some circumstances, nursing actions may be inappropriate to religious belief and not acceptable to the patients. This is often found in Southern Thailand with Muslim patients who cannot speak the Thai language. Nurses cannot adequately communicate or provide the needed information to patients and families. ...relatives of the child who was seriously ill didnût allow nurses to care for or to even touch the child. We couldnût understand it, as the relatives couldnût speak Thai. We finally learned that this could mean torture for their child in the next life. Resolutions of Ethical Dilemmas Resolutions of ethical dilemmas described by the participants were classified into five themes: (1) taking moral actions, (2) acceptance (Plong), (3) expressing feelings, (4) discussing with others, and (5) ethical problem-solving strategies. Theme 1: Taking Moral Actions. Actions for dealing with dilemmas were based on expected outcome of the actions. Nurses usually tried to do their best for the patientsû benefit. This intention guided nursing action. Nurses often need to deal with emergency problems. For instance, a patient collapses from severe diarrhea. When there is no physician in the clinic, nurses may need to ask for a favor from another physician to assist the patient. I try to promote child-mother relationships by encouraging the mother to hold the baby and give the baby breast-feeding. I hope this will change the mothersû intention to leave the baby. I give information to the physician to let him know the patientûs situation, such as, this is the only child they can have, so we would try every way to save the baby. Iûm happy when I can advocate for the patients. Theme 2: Acceptance. In some circumstances, the participants tried to understand the situation and accept that nurses cannot always do the right things under pressure generated by great care demands of patients. Nurses might need to accept it as the way it is and then they might finally get used to it. We are not happy with unethical actions of some nurses but we canût expect other people to do as the way we want. We may need to accept it.
  • Exploring Ethical Dilemmas and Resolutions in Nursing Practice: A Qualitative Study in Southern Thailand Thai J Nurs Res ë October - December 2002226 With conflicts with religion, nurses may need to accept and tolerate the cultural and belief differences. Theme 3: Expressing Feelings. When confronted with ethical conflicts, participants usually cope by expressing their feelings with the head of the wards, friends, or colleagues. The main purpose of this resolution is to release their pressureratherthanintentionallysolvetheproblems. We sometimes canût find the way out. The problem is too far beyond nursesû ability to solve the problems solely. Then we just talk to friends to release the tension. Theme 4: Discussing with others. Occasionally nurses tried to solve ethical dilemmas by talking about causes of ethical problems with colleagues, administrators and physicians. With some serious ethical problems, we should discuss them among our colleagues and then report it to the head of the department. We may use personal approaches to discuss a problem involving a doctor with another senior doctor with a hope that this senior doctor can settle the problem for us. Theme 5: Ethical Problem-Solving Strategies. With some interdisciplinary conflicts, nurses may need reasonable, logical process to solve the problems and conflicts. For instance, many conflicts relating to unsatisfactory services of the patients can be minimized by good teamwork of health care providers, and effective communication 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 physicians closely work together for patients one day. I have been working in this hospital for nine years. There are only nurses trying to solve ethical problems for patients. Seeking for Outside Assistance--Regarding the truth-telling about AIDS, nurses may try to avoid making the decision and giving information themselves. The nurse may consult a counselor to solve the patientsû problems and conflicts. In some cases, the participants avoided giving direct information by advising patients to have their blood checked, so they can discover the results themselves. Providing Information--In the emergency unit, a patientûs family may perceive nurses as cruel because of injuries to patients while providing CPR. Nurses need to be aware that patientsû relatives are very worried with the acute condition of their family members, and must be patient and accept the disruption families may cause in the emergency unit. It is stressful for a patient to be kept waitingforthephysicianattheout-patient clinic. Nurses canût do much as they need the physician, not us. We can only provide them information and mental support to reduce their pressure. Discussion The nurses in this study identified that some ethical conflicts are inevitable and cannot be avoided. Findings show that ethical concerns and conflicts in nursing practice are rich with incidents related to concerns about maintaining patientsû confidentiality, advocating patientsû rights, truth-telling, terminating life, and issues of discrimination. Most of these conflicts occurred
  • Aranya Chaowalit Vol. 6 No. 4 227 in situations of disagreement with medical practice and their lack of authority to make changes. For example, the participants in this study provided evidence of unequal, inadequate, and mismanaged treatments by the physicians. Furthermore, there were also a large number of issues raised by nurses about how little information the physicians provide to their patients about illness, its treatment, the prospect of recovery, the available treatments, and the current extent of the disease. Participants indicated that physicians often did not give enough information about patientsû health. This finding was congruent with the earlier study reported by David, Cowley & Ryland22 and Kuuppelomaki23 that doctors provided the patients very little information about treatment availability, and terminal stage of illnesses. In some obvious cases, the physician ordered an operation for a patient by phone without direct explanation to the patient about the necessity of the surgery, the expected outcomes or adverse effects that might occur as a result of surgery. The nurses who most closely worked with patients and their families, were forced to deal with the problems and conflicts. Nurses usually take action to provide information about patientsû diagnosis, treatment and prognosis while they think that this should be the doctorûs role. Conflicts relating to religious discrimination were also a major concern especially in the Southern Thai region. Many participants could not accept the cultural differences as well as decision-making relating to care for the illness, for instance; care for patients with critical illnesses, and end-of-life issues. A way of reducing these conflicts is that nurses who work with patients from other cultures should be more culturally sensitive and culturally prepared, so they can deal with dilemmas associated with cultural differences more appropriately. In this study, nurses found themselves having limited capability to solve ethical problems. A sense of powerlessness may exacerbate the ethical conflicts in nursing practice in which nurses are not free to be moral. However, nurses took actions that included individual and interpersonal strategies to deal with dilemmas. It was apparent that nurses in this study often solved the conflict of ethical problems by accepting (Plong) the problems, and expressing their feeling when they found it was beyond the nurseûs capability to solve some problems especially those associated with physicians. The outcome expected from these two resolutions was to release their pressure resulting from conflicts rather than really solve the problems. Nurses believed that the effectiveness of solving ethical dilemmas would be enhanced by a systemic process involving a multidisciplinary health-care team rather that handling problems by nurses alone. A number of the resolutions that the nurses in this study described were made without a sense of satisfaction because they did not recognize their effectiveness. None of the nurses in this study reported involvement in joint with their colleagues or other health-care personnel. They made decisions based upon the desires of patients and their family members, what the doctors wanted, and their own judgment. Nurses did not readily identify the principles that guide their practice or the process of decision-making. Most of them lack opportunity to take ethical nursing courses, and to obtain skill-training in ethical around the issues actually occurring within their daily nursing practice. In this study, only about a half of the participants had ever attended a conference in ethical nursing. While the awareness of patientûs rights relating to health care is increasing, nurses may need to have some increased professional development in the ethics of nursing and health-care practice. Findings from this study indicate that nurses lack knowledge and skills in ethical practice. Consideration must be given to nursing education that is able to provide nursing students with culturally appropriate ethical content and skill-training program. Professional nurses are encouraged to understand and realize their current situation relating to ethical problems in
  • Exploring Ethical Dilemmas and Resolutions in Nursing Practice: A Qualitative Study in Southern Thailand Thai J Nurs Res ë October - December 2002228 nursing. This learning enhanced by discussing ethical issues both within and outside the nursing profession, and practicing skills of ethical in daily nursing practice. Additionally, factors influencing the work environment that promote high level of ethical practice by nurses such as rule/policies, and intra, and inter-professional relationships20 need to be considered. It is obvious that problems with physicians and ethical dilemmas relating to medical practice require higher authority to be involved in changing medical education and strategies to improving medical practice. Most medical schools have currently included components of ethical knowledge and training in their curricula in order to promote the medical studentsû ethical behaviors and their awareness of patientsû right. In an attempt to promote good medical practice and encourage physicians to pay attention on their patients, some medical schools pay extra wage to the physicians who do not run their own private clinics. Recently, national efforts have been made to state clearly the means and strategies to protect the patientsû right of receiving high quality health care services in a patientsû bill of right. One of the strategies is to establish a funding to support and assist the health service users who are poor and have received unethical or malpractice health services to sue the physicians who provide them the services. This has become a widely public debated issue and not accepted by the physicians in the country. However, solving ethical problems involving physicians requires a lot of strategies to promote ethical awareness, motivations, including policy measures. Recommendations Standard care manual of nursing practice guidelines. In the current period of health care reform, patients are more aware of their rights in accessing good quality health care. This creates added pressure for nurses to think about the standard of right and wrong and a personûs right to choose what they believe is best for them. A resolution that may decrease the conflicts, is a development of a standard care manual or nursing practice guidelines, for instance, practice guidelines for accident, or terminally ill patients. Ethics conference. It is apparent that discussion of ethical issues among nurses has received little attention as nurses may perceive that they do not have power to take action in conflict resolution, especially in the situation involving physicians. These conflicts or ethical dilemmas cannot be solved solely by nurses. A multidisciplinary ethics conference is a mean to encourage nurses to share their experience of this process. Further research should be focused on preparing new graduate nurses with competency in dealing with ethical problems and making ethical decisions as well as organizing work environment to promote high level of ethical practice by nurses. Research priorities in nursing ethics on areas of nursing practice, education and administration reported by Ketafian, Phacharoenworakul & Yunibhand20 are greatly relevant to increase nursesû ethical competency and concerns of working environment in promoting ethical nursing practice. In nursing education, research should be focused on appropriate teaching strategies for enhancing professional values and promoting the socialization atmosphere for learning the ethical behavior of nursing students. While in nursing practice, research regarding some common ethical issues, for example; end-of-life care, care for persons with AIDS, and the culturally appropriate ethical resolutions need to be explored to guide nursing practice. Research priority should also be given to promotion of working environments to enhance nurse practice ethically. This includes studies on rules/regulations, policies, and professional relationship.
  • Aranya Chaowalit Vol. 6 No. 4 229 References 1. Wasi. P. National health act: Health constitution of Thai people. Nonthaburi: Health Systems Research Institute, 2002. 2. Choawailt, A. Development and psychometric evaluation of Ethical Issues Scale (EIS) for HIV/ AIDS patient care in Thailand. Doctoral dissertation. Boston College. Boston: Massachusetts, 1997. 3. Somsri, S. Factors related to ethical issues of staff nurses in caring for HIV/AIDS patients. Master thesis. Faculty of Graduate Studies. Mahidol University. Bangkok, 1999. 4. Chaleawsak, K. Ethical dilemmas experienced by nurses in providing care for terminally ill patients. Master thesis. Faculty of Graduate Studies. Prince of Songkla University. Songkhla, 2545. 5. Rakchart, K. Ethical dilemmas experienced by nurses working in intensive care units. Master thesis. Faculty of Graduate Studies. Prince of Songkla University. Songkhla, 2000. 6. Boonguna, W. Ethical decision making among professional nurses in tertiary hospitals. Master thesis. Faculty of Graduate Studies. Chiangmai University. Chiangmai, 2001. 7. Burkhardt, M.A. & Nathaneil, A.K. Ethics & issues in 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. Faculty of Graduate Studies. Prince of Songkla University, Songkhla, 2001. 10. Setiawan. Ethical dilemmas experienced by nurses in intensive care units in Medan, Indonesia. Master thesis. Faculty of Graduate Studies. Prince of Songkla University. Songkhla, 2002. 11. Redman,B.K. & Fry, S.T. Ethical conflicts reported by 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, 2000 15. 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. Doctoral dissertation. Faculty of Education, Chulalongkorn University. Bangkok, 1997. 18. Piyasirisilpa, S. Relationship between professional values educational achievement, and the ability in making decisions concerning ethical behaviors in nursing practice of nursing students. Master thesis. Faculty of Nursing, Chulalongkorn University. Bangkok, 1997. 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 of terminal 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.
  • Exploring Ethical Dilemmas and Resolutions in Nursing Practice: A Qualitative Study in Southern Thailand Thai J Nurs Res ë October - December 2002230 §«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡·≈–°“√·°âªí≠À“§«“¡¢—¥·¬âß „π°“√ªØ‘∫—µ‘°“√欓∫“≈: °“√»÷°…“‡™‘ߧÿ≥¿“æ„π¿“§„µâ ¢Õߪ√–‡∑»‰∑¬ Õ√—≠≠“ ‡™“«≈‘µ* RN. Ph.D. Õÿ‰√ À—∂°‘®** RN. Ph.D. ∑—»π’¬å π–· ** RN. M.Ed. «—π¥’  ÿ∑∏√—ß…’*** RN. Ph.D. Marilyn Parker**** RN. Ph.D. * √Õß»“ µ√“®“√¬å §≥–欓∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å ** Õ“®“√¬å §≥–欓∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å *** ºŸâ™à«¬»“ µ√“®“√¬å §≥–欓∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å **** »“ µ√“®“√¬å ¡À“«‘∑¬“≈—¬ Florida Atlantic ºŸâ‡™’ˬ«™“≠∑ÿπøÿ≈‰∫√∑å §≥–欓∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å ∫∑§—¥¬àÕ: °“√«‘®—¬§√—Èßπ’È ¡’«—µ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“§«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡„π°“√ªØ‘∫—µ‘欓∫“≈ ·≈–°“√·°âªí≠À“§«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡¢Õß欓∫“≈„π¿“§„µâ¢Õߪ√–‡∑»‰∑¬ ºŸâ„Àâ¢âÕ¡Ÿ≈§◊Õ æ¬“∫“≈«‘™“™’æ∑’˪ؑ∫—µ‘ß“π∑—Èß„π·ºπ°ºŸâªÉ«¬πÕ° ·≈–ºŸâªÉ«¬„π¢Õß‚√ß欓∫“≈∑—Ë«‰ª 2 ·Ààß ·≈– ‚√ß欓∫“≈»Ÿπ¬å®”π«π 2 ·Ààß„πæ◊Èπ∑’Ë¿“§„µâ¢Õߪ√–‡∑»‰∑¬®”π«π∑—Èß ‘Èπ 40 §π ¢âÕ¡Ÿ≈°“√«‘®—¬ ‡°Á∫‚¥¬°“√ π∑π“°≈ÿà¡ ·≈–∫—π∑÷°‡∑ª º≈¢Õß°“√«‘‡§√“–Àå¢âÕ¡Ÿ≈¥â«¬°“√«‘‡§√“–Àå¥â“π‡π◊ÈÕÀ“®“° ∫∑ π∑π“æ∫ª√–‡¥Á𧫓¡¢—¥·¬âß∑“ߥâ“π®√‘¬∏√√¡¢Õß欓∫“≈ 8 ª√–‡¥Áπ§◊Õ 1) §«“¡¢—¥·¬âß √–À«à“ß°“√‡≈◊Õ°ªØ‘∫—µ‘µ“¡∫∑∫“∑«‘™“™’æ∑’˧«√®–‡ªìπ ·≈–°“√ª°ªÑÕßµπ‡Õß®“°Õ—πµ√“¬ 2) °“√¬◊¥™’«‘µ·≈–°“√¬◊¥§«“¡µ“¬ 3) °“√√—°…“§«“¡≈—∫¢ÕߺŸâªÉ«¬ ·≈–°“√‡ªî¥‡º¬¢âÕ¡Ÿ≈‡æ◊ËÕ‡µ◊Õπ ºŸâÕ◊Ëπ∂÷ßÕ—πµ√“¬4)°“√ª°ªÑÕߺŸâªÉ«¬·≈–°“√§ß‰«â´÷Ëß —¡æ—π∏¿“æ°—∫ºŸâÕ◊Ëπ5)§«“¡¢—¥·¬âß°—∫∫ÿ§≈“°√ ¿“¬„π«‘™“™’æ ·≈–§«“¡¢—¥·¬âß°—∫∫ÿ§≈“°√¿“¬πÕ°«‘™“™’æ 6) °“√∫Õ°§«“¡®√‘ß ·≈–°“√‰¡à∫Õ° §«“¡®√‘ß 7) ª√–‡¥Áπ°“√ ‘Èπ ÿ¥™’«‘µ 8) §«“¡‰¡à‡∑à“‡∑’¬¡ ·≈–§«“¡‡∑à“‡∑’¬¡¢Õß°“√¥Ÿ·≈  ”À√—∫°“√·°âªí≠À“§«“¡¢âÕ¢—¥·¬âß∑“ß®√‘¬∏√√¡‚¥¬æ¬“∫“≈ æ∫«à“ “¡“√∂·∫àßÕÕ°‰¥â‡ªìπ 5 ª√–‡¥Áπ §◊Õ 1) °“√ªØ‘∫—µ‘¥â«¬§ÿ≥∏√√¡ 2) °“√¬Õ¡√—∫ 3) °“√√–∫“¬§«“¡√Ÿâ ÷° 4) °“√Õ¿‘ª√“¬ °—∫ºŸâÕ◊Ëπ 5) °“√„™â°≈¬ÿ∑∏å„π°“√·°âªí≠À“ „π∫∑«‘®—¬π’È®–Õ¿‘ª√“¬·π«∑“ß∑’ˇªìπ‰ª‰¥â ·≈–¢âÕ‡ πÕ ·π–„π°“√·°â‰¢ªí≠À“‡™‘ß®√‘¬∏√√¡„π°“√ªØ‘∫—µ‘欓∫“≈¥â«¬ §” ”§—≠:§«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡°“√·°âªí≠À“§«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡°“√ªØ‘∫—µ‘°“√欓∫“≈
  • Wanlapa Kunsongkeit Vol. 6 No. 4 231 Spirituality: A Concept Analysis Wanlapa 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 quality of life in various disciplines and populations. It is recognized by WHO, nursing theorists, professional nursing and the Thai government as an important aspect of care to patients. However, spirituality is an elusive concept and defined in different ways. Concept analysis based on Walker and Avant 25 was used to clarify the concept of spirituality. Sense of connectedness, belief, and meaning and purpose in life are the critical attributes of spirituality. A stressful event, crisis, suffering, and death are the important antecedents. Sense of well-being, quality of life, and humanistic behaviors are consequences of spirituality. Model, borderline, related, and contrary cases are presented to illustrate the finding. This analysis develops an understanding of spirituality and further exploration in providing spiritual care. 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 Thai J Nurs Res ë October - December 2002232 Introduction Spirituality is an aspect of the whole person that influences and interrelates with the physiological and psychological aspects.1 It is recognized as one aspect of the definition of health by WHO2 and in the 9th national economic and social development plan (2002-2006) of Thailand.3 It is also acknowledged by many nursing theorists4-6 and professional nursing7 that nurses need to provide spiritual care. Therefore, for nurses who seek to adopt a holistic approach to care for patients, spirituality is an important concept. Spirituality has been found to influence the health, well-being, and quality of life in various disciplines and populations, for instance, patients with HIV;8-9 patients with cancer;10-13 elderly persons;14-15 medical illness;16-17 drug and alcohol consumers;18-20 and patients with cardiac disease. 21-22 Spirituality is an elusive concept and has been defined in different ways. The terms of spirituality and religion may be used interchangeably based on the assumption that religion and spirituality are very similar, the same entity, or concepts. However, they are not synonymous.23 The need to clarify the concept of spirituality has emerged because if a concept is unclear, then any work on which it is based will also be unclear.24 Therefore, the aim of this paper is to clarify and analyze the concept of spirituality in order to achieve clear understanding. The analysis will take place using the framework outlined by Walker and Avant.25 Concept Analysis of Spirituality Concept analysis is a strategy that allows us to examine the attributes or characteristics of a concept and is useful to clarify over-used, vague concepts that are prevalent in nursing Practice.25 Walker and Avant25 modified the eleven stages of Wilsonûs concept analysis to eight steps. These steps are as follows: 1. Select a concept 2. Purpose of analysis 3. Identify uses of the concept 4. Determine the defining attributes 5. Construction of a model case 6. Construction of an additional case 7. Identify antecedents and consequences of spirituality 8. Define empirical referents Step One : Select a concept. Spirituality is chosen for analysis because spirituality is ambiguous and defined in different ways that affect nurses in providing spiritual care to patients. Step Two : Purpose of analysis. The purpose of analysis is to clarify the meaning of spirituality. Step Three: Identify uses of the concept. Dictionary.Spirituality is derived from the Latin word çspiritusé meaning to breathe life, expressing oneûs value and beliefs about, self, humanity, life, and God.26 Websterûs dictionary defines spirituality as an attachment to the values of the spirit, while human spirit is described as the immaterial aspect of a person that never dies.27 The Chamber Dictionary28 defined spirituality as the state of being spiritual; that which is spiritual; property held or revenue received in return for spiritual service; the clergy. The American Heritage Dictionary29 defined spirituality as the state; quality, manner, or fact of being spiritual; the clergy or something such as property or revenue, that belongs to the church or to a cleric. Thai dictionary30 defined spirituality as soul; ghost; mind; intellectual. Theology. Spirituality is defined in different ways, depending on the standing point and experience of the speaker and on the wider religious tradition.31 OûMurchu32 proposed that
  • Wanlapa Kunsongkeit Vol. 6 No. 4 233 adherence to one or other religion is considered a prerequisite for spiritual growth and maturation. And each religion has developed its own spiritual vision. Submission in thought and action to a God like figure, according to a specific set of prescriptions or guidelines, is considered to be essential to an authentic spiritual journey. There is an important distinction between religion and spirituality. Religion refers to those formally institutionalized structures, rituals and belief, which belongs to one or other of the official religious system. On the other hand, spirituality concerns an ancient and primal search for meaning that is as old as humanity itself. Spirituality is more central to human experience than religion, a fact that is born out in the growing body of knowledge accumulated by cultural anthropology and the history of religious idea. OûMurchu32 defined spirituality as an innate quality of human life and existence. It is something we are born with, something essentially dynamic that forever seeks articulation and expression in human living. The characteristics of spirituality are the search for meaning, ultimacy, transcendence, and relatedness. Tracy-Coleûs33 definition of spirituality is about experience, not doctrine. Religion is a spiritual provider that steps in when someone is born, goes through puberty or dies. Harhill34 defines spirituality as the inner sense of searching for the light. It is a part of human being. Spirituality influences attitude, behavior, and life-style. It can be expressed in many different forms, not all specifically religions. Spirituality can be linked to all human experiences. It has a particularity close connection with the imagination, with creativity and resourcefulness, with relationships-with self, with other, with God, with a sense of celebration and joy, with adoration and surrender as well as with struggle and suffering.31 Religion. Spirituality is understood in the sense of religiosity. The spirituality and religion are co-extensive. The dictionary of Bible and religion35 defined spirituality as the condition of spiritual mindedness, or devotion to God and the things of the spirit, also a disciplined approach to the spiritual life, opposed to materialism, secularism, and sensuality (hedonism). Spirituality may involve ascetic practices such as voluntary poverty, chastity (including complete celibacy), and entire obedience to the laws of the church. The dictionary of belief and religion36 defined spirituality as the experiential side of religion, as opposed to outward beliefs, practices and institutions, which deals with the inner spiritual depths of a person. Spirituality has been presented in all religious traditions. Anthropology.Sengupta37 characterized spirituality as follows: 1.The finer perceptions of life; 2.The excellence in the function of intellect; and 3.The medium through which communications from the departed souls reach the living. Psychology. Kovel38 defined spirituality as the way people seek to realize spirit and soul in their lives. Wehr39 defined spirituality as the experience of the sacred. McKenna24 proposed that the 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, the transcendent, and it connects individuals to our own history and experience, to others and to the universe. By enabling individuals to establish a relationship with the events, persons, and places that have entered our lives, a life of spirit enlarges our soul. The idea of holding with reverence and awe a sense of connectedness to oneûs life experience, oneûs personal history, and indeed to all things is integral to the notion of spirituality. Spirituality involves beings in love, and that
  • Spirituality : A Concept Analysis Thai J Nurs Res ë October - December 2002234 being in love is ultimately a unifying experience, which engages our whole heart, whole soul, and whole mind. Medicine. Spirituality is defined as a personûs relationship with the transcendent, nature, music, the arts, friends, and a set of philosophical beliefs40 or a search for an existential meaning in a particular life experience, without reference to any external power or being.41 Daaleman and VandeCreek42 proposed that although there are multiple interpretations of spirituality within health care settings, constructs of meaning or a sense of lifeûs purpose have been suggested as primary components. Psychological states and quality of life outcomes have been the end points in end of life care studies that have incorporated a measure of spirituality. Nursing. In the nursing literature, the definition of spirituality is defined in several ways as follows: - The essence or life principle of a person;43-44 - The center of life force that gives rise to a sense of wholeness;45-46 - A personal journey to discover meaning and purpose in life;47 - An awareness of meaning and purpose in existence;48-49 - A life relationship or a sense of connection with self, nature, mystery, a higher power, God or Universe/ something greater than self (however defined by the individual);50-54 - A belief that relates a person to the world;55-56 - The dynamic principles developed throughout the life span that guide a personûs view of the world;57-58 - Interactive process (interpersonal, transpersonal, and /or intrapersonal experiences) that reflect the capacities of people for change and transformation which are the most salient features of our human nature;59 and - That which provides inspiration, motivation and hopes, directing the individual toward the values of love, truth, beauty, trust, and creativity.51, 60-61 From these descriptions, the spiritual dimension is divided into two dimensions, the vertical dimension of the personûs relationship with the transcendent (God, Supreme being or Supreme values or individualûs value system) and the horizontal dimension of relationships with oneself, other people, and the natural world (environment).62 The personûs relationships are grounded in expressions of love, forgiveness and trust, and resulting in meaning and purpose in life.63 Similarly, according to the concept analysis by Burkhardt50 and Walton,64 inner strength and peace, a sense of meaning and purpose, self-reflection, and interconnectedness are characteristics of spirituality. Saunders and Restsas45 also stated that faith, hope, trust, the giving and receiving of love, forgiveness, reconciliation and meaning in life were fundamental characteristics of spirituality which were basic determinants of the totality of people. Spirituality is intensified when people are experiencing stress related to emotion, physical illness or other forms of crisis,65 the moment in time of death.66 When facing illness, patients need help in their search for something to believe in and hope for.67 Frankl68 believed that human suffering provides an opportunity for spiritual encounters. During hospitalization, patients reflect on suffering, death, and their relationship with self, others, and God to make meaning of their life.69 In brief, spirituality is conceptually defined as a multidimensional concept that involves a sense of connectedness between oneself and: God, a higher being, environment in which one
  • Wanlapa Kunsongkeit Vol. 6 No. 4 235 participates, and/or person such as family, friend, and oneself. It makes one have meaning and purpose in life. Spirituality is an important resource in persons facing stressful situations such as illness and death. Step Four: Determine the defining attributes The purpose of identifying the defining attributes of a concept is to provide a basis for its occurrence as a phenomenon as differentiated from another similar or related one. The followings are attributes, which apply to each use of the concept, and are therefore identified as the defining attributes of spirituality: Sense of connectedness. A sense of connectedness implies a joining together of two or more elements, with a relationship formed between them. From analysis, a sense of connectedness in spirituality means the relationship to God or higher power, then to self, other people, family, and environment. Belief. Belief is a set of related ideas that are learned, shared and persist over some period of time.70 In spirituality, belief is not limited to religious belief. Belief will emanate from the driving force that gives meaning to the life of the individual, whether that be, for example, relationships with others, and whatever that individualûs God may be.71 Meaning and purpose in life. The search for meaning is the core of the individualûs being and is the driving force behind intellect and emotion.72 Frankl68 states that manûs primary concern was seeing a meaning in life. Having a purpose in life is essential in order to look forward to each day. Some clients have a purpose in life and only need to maintain their spirituality. Spirituality is the source of finding the meaning and purpose in life. Antonovsky73 identified the ability to find meaning as an influencing factor in a personûs ability to cope with stress. Step Five : Construction of a model case. Model cases offer real life examples of a concept 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 family left her after diagnosis. She felt hopeless. The nurse, who had previously spoken with her about her Christian belief and closely took care of her, suggested that Betty read the Scripture and pray to God. The nurse also introduced her to other AIDS patients. Betty learned many things from AIDS patients. Betty was not lonely anymore. She was touched by the nurseûs concern, belief in God, and relationship with other AIDS patients. She changed her mind to live again and found the meaning and purpose in her life. This case includes all three critical attributes; Betty began to practice and re-activate her Christian religious belief through prayer and reading of Scripture. She also developed a sense of connectedness with God, other AIDS patients, and the nurse. From this, she was able to find meaning and purpose in her life. Step Six : Construction of additional cases. Additional cases are constructed in order to provide examples of what is not the concept, and in order to clarify understanding of what the concept is about. These include borderline cases, which may contain some but not all of the critical attributes, related cases, which contain none of the critical attributes, contrary cases, which are clear examples of not the concept, and invented cases, which are cases that are constructed using ideas outside the ordinary context and oneûs own experience. Borderline case Paul, a 38-year-old engineer, became paraplegic after falling down from the third floor of his work place. He was laid off from his work. Since the injury, he had depression and several suicide attempts. Linda, who was his wife, closely took care of him. His
  • Spirituality : A Concept Analysis Thai J Nurs Res ë October - December 2002236 friends frequently visited and spent time to talk with him. His mother suggested that he read the Bible and asked the clergy to talk with him because Paul was a devoted Christian. Paul followed his motherûs suggestions. However, Paul thought that God did not love him and God had punished him. Therefore, Paul still had depression and feelings of hopelessness. This case is shown to have two critical attributes, which are sense of connectedness and belief. Paul believed in Christiannity. He also was connected to his wife and friends. However, he was unable to find the meaning and purpose in his life. Related case. Religion and spirituality are often used interchangeably but they are not synonymous. Spirituality is an çumbrellaé under which can be found both religious and existential needs23 . Religious needs are most often connected with specific religions or religious practices while existential needs are those needs all people share regardless of the presence or absence of a religious background or belief. Religion could also be channeled as an expression of oneûs spirituality48 . According to Steiger and Lipson74 , religion is a social institution in which a group of people participate rather than an individualûs search for meaning. Religion is more about systems of practices and beliefs within which a social group engages. Pace65 conceptualized the difference between religion and spirituality as the difference between a map (religion) and a journey (spirituality). Thus, one can be spiritual without being religious23 . Somsri is a Buddhist woman. She visits the temple and pays respect to the Buddha statue. She thinks she should do this because this practice is the activity, which Buddhists normally do. This case shows the concept, which is related to spirituality but it does not include any critical attributes of spirituality. Although Somsri is Buddhist, she did not believe in Buddhism. She carried out religious practices but she did not think about the meaning and purpose in life. She did as social process of Buddhist. Contrary case. Mr. Kay was a 68-year-old retired factory worker. He had been forced to retire at age 62 when his plant laid off a large number of workers. After three days of retirement, his wife died of an acute myocardial infarction. Without a regular job and his wife, Mr. Kay felt hopeless and useless. He spent most of his time in front of the television with a beer in his hand, or sitting in a bar until closing time. Finally, he was an alcoholic but refused help from Alcoholic Anonymous. This case is an example of what the concept of spirituality is not. Mr. Kay did not have any belief or anyone to connect with in his life. When he was faced with bad situations in his life, he did not know what to do. He could not find a purpose or meaning in his life. Finally, he became an alcoholic but refused services for help with his alcoholism. Step Seven : Identify antecedents and Consequences of spirituality. Walker and Avant25 believe that the antecedents to, and consequences of , a concept may shed considerable light on the social contexts in which the concept is generally used. They identify that both are events or incidents, implying that some occurrence must take place prior to, or as a consequence of, the concept. Equally, events or incidents can be the development of values or attributes, which are necessary for, or result from the exercise of the concept. Antecedents. Antecedents are those events or incidents that must occur prior to the occurrence of the concept. Antecedents are identified underlying assumptions about the concept being studied. Spirituality is an fundamental to humans as the act of breathing.75 Spirituality is in oneself when one is born and goes through life until death32 and is intensified when people encounter stress related
  • Wanlapa Kunsongkeit Vol. 6 No. 4 237 to emotion, physical illness, crisis or suffering. Consequences Consequences are those events or incidents that occur as a result of the occurrence of the concept. They are used to determine often neglected ideas, variables, or relationships that may yield fruitful new research directions.25 Consequences of spirituality are sense of well-being and quality of life,42 humanistic behavior, which was described by Duldt76 as positive regard, empathy, authenticity, caring, intimacy, and hope. Step Eight: Define empirical referents. Empirical referents are determined for the critical attributes. They are extremely useful in instrument development because they are a clear link to the theoretical base of the concept. They are also very useful in nursing practice because they provide the clinician with clear, observable phenomena, which can diagnose the concept.25 Spirituality can be measured in term of sense of connectedness, belief, and meaning in life. Some researchers have developed instruments to measure spirituality, for example, The Spiritual Well-Being (SWB) Scale,77 and The Spiritual Perspective Scale (SPS).9 These instruments have some limitations because some instruments were developed based on religionûs assumption. Some need to further test for reliability and validity in various populations. Implications for nursing The concept analysis of spirituality provides an understanding of the meaning of spirituality. Nurses can develop spiritual care for patients. Nurses also generate additional questions requiring further research in order to develop instruments to measure spirituality and increase research in this area. This analysis can be used for basic knowledge application for nursing education in teaching about spiritual dimension. Conclusion From the concept analysis of spirituality based on Walker and Avant,25 the critical attributes are sense of connectedness, belief, and meaning and purpose in life. A stressful event, crisis, suffering, and death are the important antecedents. The consequences of spirituality are sense of well-being, quality of life, and humanistic behaviors. This analysis develops a clearer understanding of spirituality and further exploration in spiritual dimension. Acknowledgement: The author wishes to acknowledge Prof. Dr. Marilyn A. McCubbin for her advice and support throughout my study in the Evidence-Based Practice: 1 course at the University of Hawaii at Manoa. She also gave the helpful comments on the manuscript. References 1. Wright KB. Professional, ethical, and legal implications for spiritual care in nursing. Image: Journal of Nursing Scholarship 1998;30:81-83. 2. World Health Organization. Executive broad meeting document 101, Geneva, January 1927:1998 ,1998. 3. Summary of the concept and direction of the 9th national economic and social development plan. February, 2001. 4. Neuman MA. The spirit of nursing. Holistic Nursing Practice 1989; 3:1-6 5. Reed PG. An emerging paradigm for the investigation of spirituality in nursing. ResearchinNursing&Health 1992;15:349-357. 6. Watson J. New dimensions of human caring theory. Nursing Science Quarterly 1988;1:175-181. 7. Stranahan S. Spiritual perception, attitudes about spiritual care, and spiritual care practices among nurse practitioners. Western Journal of Nursing Research 2001;23: 90-104. 8. Hall B. Patterns of Spirituality in persons with advanced HIV disease. Research in Nursing & Health 1998; 21: 143-153. 9. Reed PG. Spirituality and well-being in terminally ill hospitalized adults. Research in Nursing & Health 1987;10: 335-344.
  • Spirituality : A Concept Analysis Thai J Nurs Res ë October - December 2002238 10. Chiu L. Lived experience of spirituality in Taiwanese women with breast cancer. Western Journal of Nursing Research 2000; 22:29-53. 11. Halstead MT, Fernsler JI. Coping strategies of long-term cancer survivors. Cancer Nursing 1994;17:94-100. 12. Fredette SL. Breast cancer survivors: concerns and coping. Cancer Nursing 1995;18:35-46. 13. Kaczorowski JM. Spiritual well-being and anxiety in adults diagnosed with cancer. Hospice Journal 1989; 5:105-116. 14. Hungelmann J, Kenkel-Ross E, Klasses, L, Stollenwerk R. Focus on spiritual well-being: harmonious interconnectedness of mind-body-spirit-use of The JAREL Spiritual Well-Being Scale. Geriatric Nursing 1996; 17:262-266. 15. Manfredi C, Pickett M. Perceived stressful situations and coping strategies utilized by the elderly. Journal of Community Health Nursing 1987; 4:99-110. 16. Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. American Journal of Psychiatry 1998; 155: 536-542. 17. Racklin JM. The role of sense of coherence, spirituality, and religion in responses to trauma. [CD-ROM]. Abstract from: ProQuest File: Dissertation Abstracts item: AAINQ35410, 1998. 18. Ellelson R. A theory of spirituality related to chemical dependency recovery. [CD-ROM]. Abstract from: ProQuest File: Dissertation Abstracts item: AAC9908091, 1998. 19. Gundersen L. Faith and healing. Annals of Internal Medicine 2000;132:169-172. 20. Sloan H. God imagery and emergent spirituality in early recovery from chemical dependency: Ana-Maria Rizzuto and the alcoholics anonymous twelve steps. [CD-ROM]. Abstract from: ProQuest File: Dissertation Abstracts item: AAI9932795, 1999. 21. Toth JC. Faith in recovery: Spiritual support after an acute MI. Journal of Christian Nursing 1992; 9:28-31. 22. Walton J, Clair K. St. çA beacon of lighté: spirituality in the heart transplant patient. Critical Care Nursing Clinics of North America 2000; 12:87-99. 23. Burgess WA. Psychiatric nursing. Stamford: Appleton & Lange, 1997. 24. McKenna JF. On being at both center and circumference: The role of personal discipline and collective wisdom in our recovery of soul. In Miller ME, West AN, eds. Spirituality, ethic, and relationship in adulthood: clinical and theoretical explorations. Madison: Psychosocial Press, 2000:257-279. 25. Walker LO, Avant KC. Strategies for theory construction in nursing. 3rd ed. Norwalk: Appleton & Lange, 1995. 26. Wensley M. Spirituality in nursing. Available: http:// stvincents/1995/a04.html/, 1995. 27. Lexicon Websterûs Dictionary. New York: Lexicon, 1993. 28. The Chamber Dictionary. Edinberge: Chamber, 1994. 29. The American Heritage Dictionary of the English language. 4th ed. Boston: Houghton Mifflin Company, 2000. 30. Sethaputra S. New model English-Thai Dictionary. Bangkok: Thai Wattanapanitch, 1997. 31. King U. Introduction: Spirituality, society and the millennium-wasteland, wilderness or new vision. In King U, Beattie T, eds. Spirituality and society in the new millennium. Portland: Sussex Academic Press, 2001:1-13. 32. OûMurchu D. Reclaiming spirituality. New York: The Crossroad Publishing company, 1998. 33. Tracy-Cole D. Spirituality and healing in a scientific age. In King U, Beattie T, eds. Spirituality and society in the new millennium. Portland: Sussex Academic Press, 2001:136. 34. Hartill R. Mind, body, spirit-the new millennial age? In King U, Beattie T, eds. Spirituality and society in the new millennium. Portland: Sussex Academic Press, 2001:266. 35. Gentz WH, editor. The dictionary of Bible and religion. Nashville: Abingdon, 1986. 36. Goring R, editor. Dictionary of beliefs and religions. New York: Larousse, 1994. 37. Sengupta SC. Human existence, transcendence and spirituality. Simla: Indian Institute of Advanced Study, 1979. 38. Kovel J. History and spirit: an inquiry into the philosophy of liberation. Boston: Beacon Press, 1991. 39. Wehr DS. Spiritual abuse. In Young-Eisendrath P, Miller ME, eds. The psychology of mature spirituality: integrity, wisdom, transcendence. Philadelphia: Taylor & Francis Inc, 2000:49. 40. Astrow AB, Puchalski CM, Sulmasy DP. Religion, spirituality, and health care: social, ethical, and practical considerations. American Journal of Mediciane, 2001;110:283-287. 41. King M, Speck P, Thomas A.The royal free interview for Religious and Spiritual Beliefs: Development and standardization. Psychosocial Medicine, 1995; 25:1125-1134.
  • Wanlapa Kunsongkeit Vol. 6 No. 4 239 42. Daaleman T, VandeCreek LD. Placing religion and spirituality in end-of-life care. JAMA, 2000; 284:2514-2517. 43. Angelucci PA. Spirituality and the use of an intensive care unit on-staff/on-sit chaplain. Critical Care Nurse, 1999; 19:62-65. 44. Price J, Stevens H, LaBarre M. Spiritual caregiving in nursing practice. Journal of Psychosocial Nursing, 1995; 33:5-9. 45. Saunders J, Restsas A. Spirituality and nursing: toward an ontological understanding. Collegian, 1998; 5:16-19. 46. Harrison J. Spirituality and nursing practice. Journal of Clinical Nursing, 1993; 2:211-217. 48. Heriot C. Spirituality and aging. Holistic Nursing Practice, 1992; 7:22-31. 49. Murray, RB, Zentner JP. Nursing concepts for health promotion. London: Prentice Hall, 1989. 50. Burkbardt M. Spirituality: an analysis of the concept. Holistic Nursing Practice, 1989; 3: 69-77. 51. Golberg B. Connection: an exploration of spirituality in nursing care. Journal of Advanced Nursing, 1998; 27:836-842. 52. Hover-Kramer D. Creating a context for self healing: the transpersonal perspective. Holistic Nursing Practice, 1989; 3:27. 53. Lane J. The care of the human spirit. Journal of Professional Nursing, 1987; 3:332-337. 54. Nagai-Jacobson M, Burkhardt M. Spirituality: cornerstone of holistic nursing practice. Holistic Nursing Practice, 1989; 3:18-26. 55. Hay M. Principle in building spiritual assessment tools. American Journal of Hospice Care, 1989; Sept/Oct: 25-31. 56. Mickley J, Carson V, Soeken K. Religion and adult mental health: state the science in nursing. Issue in Mental Health Nursing, 1995; 6:345-360. 57. Carson VB. Spirituality. In Leahy JM, Kizilay PE, eds. Foundations of nursing practice: a nursing approach. Philadelphia: W.B. Saunders, 1998: 1075-1093. 58. Hicks TJ. Spirituality and the elderly: nursing implications with nursing home residents. Geriatric Nursing, 1999; 20:44-146. 59. Scott-Peck M. Further along the road less traveled: the unending journey toward spiritual growth. Sydney: Simon & Schuster, 1993. 60. Harrison J, Burnard P. Spirituality and nursing practice. Aldershot : Avebury, 1993. 61. Narayanasamy A. A review of spirituality as applied to nursing. International Journal of Nursing Studies, 1999; 36:117-125. 62. Stoll R. The essence of spirituality. In Carson VB, ed. Spiritual dimension of nursing practice. Philadelphia: W.B. Saunders, 1989: 4-23. 63. Carson VB. Spiritual dimensions of nursing practice. Philadelphia: W.B.Saunders, 1989. 64. Walton J. Spiritual relationship: a concept analysis. Journal of Holistic Nursing, 1996; 14:237-250. 65. Pace JC. Spiritual issues. In Moore-Higgs GJ, ed. Women and cancer: a gynecologic oncology nursing perspective. 2nd ed. Boston: Jones & Bartlett, 2000: 502-520. 66. Post SG, Puchalski CM, Larson DB. Physicians and patients spirituality: professional boundaries, contemporary, and ethics. Annals of Internal Medicine, 2000; 132:578-583. 67. Shaffer JL. Spiritual distress and critical illness. Critical Care Nurse, 1991; 11:42-45. 68. Frankl VE. Manûs search for meaning: an introduction to logotherapy. 4th ed. Boston: Beacon Press, 1992. 69. Highfield M, Carson C. Spiritual needs of patients: are they recognized? Cancer Nursing, 1983;6:187-192. 70. Borhek JL, Curtis RF. A sociology of beliefs. New York: Wiley & Sons, 1975. 71. Dyson J. The meaning of spirituality: a literature review. Journal of Advanced Nursing, 1997; 26: 1183-1188. 72. Bown J, William S. Spirituality in nursing: a review of the literature. Journal of Advances in Health and Nursing Care, 1993; 2:41-66. 73. Antonovsky A. Health stress and coping. London: Jossey Bass, 1979. 74. Steiger N, Lipson J. Self care nursing: theory and practice. Bowie: Brady Communcation, 1985. 75. Clifford M, Gruca A. Facilitating spiritual care in the rehabilitation setting. Rehabilitation Nursing, 1987;12:331-339. 76. Duldt BW. çI-Thoué in nursing: research supporting Duldtûs theory. Perspectives in Psychiatric Care, 1991;27:7-12. 77. Ellison CW. Spiritual well-being: conceptualization and measurement. Journal of Psychology and Theology, 1983;11:330-340.
  • Spirituality : A Concept Analysis Thai J Nurs Res ë October - December 2002240 °“√«‘‡§√“–Àå·π«§‘¥‡√◊ËÕß®‘µ«‘≠≠“≥ «—≈¿“ §ÿ≥∑√߇°’¬√µ‘* æ¬.¡.(°“√欓∫“≈Õ“¬ÿ√»“ µ√å·≈–»—≈¬»“ µ√å) Marilyn A. McCubbin**RN., Ph.D., FAAN * π—°»÷°…“À≈—° Ÿµ√欓∫“≈»“ µ√¥ÿ…Æ’∫—≥±‘µ §≥–欓∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à ** »“ µ√“®“√¬å ‚√߇√’¬π欓∫“≈ ¡À“«‘∑¬“≈—¬Œ“«“¬ ª√–‡∑» À√—∞Õ‡¡√‘°“ ∫∑§—¥¬àÕ: º≈°“√»÷°…“„πÀ≈“¬»“ µ√å·≈–À≈“¬°≈ÿà¡æ∫«à“®‘µ«‘≠≠“≥¡’Õ‘∑∏‘æ≈µàÕ ÿ¢¿“æ §«“¡º“ ÿ° ·≈–§ÿ≥¿“æ™’«‘µ πÕ°®“°π—È𮑵«‘≠≠“≥¬—߉¥â√—∫°“√¬Õ¡√—∫®“°Õߧ尓√Õπ“¡—¬‚≈° π—°∑ƒ…Æ’∑“ß°“√欓∫“≈Õߧå°√欓∫“≈·≈–√—∞∫“≈‰∑¬«à“‡ªìπ¡‘µ‘∑’Ë¡’§«“¡ ”§—≠„π°“√¥Ÿ·≈ºŸâªÉ«¬ Õ¬à“߉√°Áµ“¡®‘µ«‘≠≠“≥¬—߇ªìπ¡‘µ‘∑’Ë¡’§«“¡§≈ÿ¡‡§√◊Õ·≈–¡’ºŸâ„Àâ§”π‘¬“¡Õ¬à“ßÀ≈“°À≈“¬ ºŸâ«‘‡§√“–Àå®÷߉¥â«‘‡§√“–Àå·π«§‘¥‡√◊ËÕß®‘µ«‘≠≠“≥‚¥¬Õ“»—¬«‘∏’°“√¢Õß Walker ·≈– Avant ‡æ◊ËÕ„Àâ ‡°‘¥§«“¡™—¥‡®π‡°’ˬ«°—∫·π«§‘¥„π¡‘µ‘®‘µ«‘≠≠“≥ º≈°“√«‘‡§√“–Àåæ∫«à“§ÿ≥≈—°…≥–∑’Ë ”§—≠¢Õß ®‘µ«‘≠≠“≥§◊Õ §«“¡√Ÿâ ÷°¢Õß°“√¡’ ‘Ë߬÷¥‡Àπ’ˬ« §«“¡‡™◊ËÕ ·≈– §«“¡À¡“¬·≈–‡ªÑ“À¡“¬„π™’«‘µ  ‘Ëß∑’Ëπ”„À⇰‘¥®‘µ«‘≠≠“≥∑’Ë ”§—≠§◊Õ ‡Àµÿ°“√≥å∑’Ë°àÕ„À⇰‘¥§«“¡‡§√’¬¥ ¿“«–«‘°ƒµ‘ ∑ÿ°¢å∑√¡“π ·≈– §«“¡µ“¬  ‘Ëß∑’˵“¡¡“¿“¬À≈—ß°“√‰¥â√—∫°“√¥Ÿ·≈¥â“𮑵«‘≠≠“≥§◊Õ §«“¡√Ÿâ ÷°º“ ÿ° §ÿ≥¿“æ™’«‘µ ·≈–§«“¡‡ªìπ¡πÿ…¬åº≈°“√«‘‡§√“–Àå™à«¬„À⇢Ⓞ®¡‘µ‘®‘µ«‘≠≠“≥·≈–𔉪 Ÿà°“√»÷°…“‡°’ˬ«°—∫°“√¥Ÿ·≈ ¥â“𮑵«‘≠≠“≥µàÕ‰ª §” ”§—≠: °“√«‘‡§√“–Àå·π«§‘¥ ®‘µ«‘≠≠“≥ §«“¡√Ÿâ ÷°¢Õß°“√¡’ ‘Ë߬÷¥‡Àπ’ˬ« §«“¡‡™◊ËÕ §«“¡À¡“¬·≈–‡ªÑ“À¡“¬„π™’«‘µ
  • Wannipa Asawachaisuwikrom Vol. 6 No. 4 241 Abstract: This article aims to clarify the meaning of self-efficacy. Analysis of the concept of self-efficacy provides information related to clinical usefulness and assists health care professionals communicate the same notion when discussing the concept. Moreover, understanding self-efficacy as a concept is useful in approaching 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-Efficacy Wannipa Asawachaisuwikrom,* Ph.D. Instructor, Community Health Nursing Department, Faculty of Nursing, Burapha University
  • Concept Analysis: Self-Efficacy Thai J Nurs Res ë October - December 2002242 Concept Analysis: Self-Efficacy Walker and Avantûs concept analysis methodology is used in this article. These procedures include select a concept, determine the aims or purposes of analysis, identify all uses of the concept, determine the defining attributes, construct a model case and additional cases, identify antecedents and consequences, and define empirical referents.1 Select a concept Self-efficacy, used since 1977, is an important concept because it predicts human behavior. This concept has been of considerable interest in several disciplines related to human behavior such as sociology, psychology, and nursing. However, evidence has shown some misuses of the term ùself-efficacyû. For instance, Bandura pointed out that some authors used the term ùself-efficacyû and ùself-esteemû interchangably, although they were different concepts.2 Since the concept of self-efficacy may still be unclear, it is essential to elucidate its meaning. Aim of Analysis This article aims to clarify the meaning of self-efficacy in order to use the concept appropriately in further theoretical developments, particularly in promoting health of individuals. Uses of the concept Exploring for meanings of the term from various sources will result in a great amount of valuable information. Walker and Avant suggest considering all uses of the term,1 not only one aspect of the concept. Thus, dictionaries, thesauri and available literature from a variety of disciplines such as psychology, sociology, education, economics, pharmacology, kinesiology, nursing, medicine, and epidemiology were used to identify uses of the concept. Most dictionaries do not present the word ùself-efficacyû as a single word. The term ùself-û is quite easily understood. As defined through the word ùselfû, in the Oxford English Dictionary, ùself-efficacyû implies to efficacy by oneself of oneself, oneûs power, position, rights, desires, and ambitions. The word ùefficacyû has its origin in the Latin word ùeffecacitasû3 which means ùpowerû. A Concept Dictionary of English4 categorized ùefficacyû in the ùPOWRû category which refers to ùreferences to ability, achievement, strength, and braveryû. Included are such ideas as adeptness and skill, fearlessness and hardiness, success and accomplishment, 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 as an 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 various disciplines. For example, in economics, ùefficacyû has been used as a type of economic evaluation, referring to efficiency.6 In medicine, ùefficacyû is often used in terms of efficacy of a drug. In epidemiology, efficacy is evaluated as the benefit that such an agent produces under the conditions of a controlled trial. In statistics, a mathematical model is used in evaluating the efficacy of tests used in screening for a specific problem such as infections.7 Recently, the term ùefficacyû has been widely used in team sports. The association among player efficacy, team efficacy and team performance has been studies in many types of sports such as hockey.8 From theoretical literature, Bandura has been found to be a leading voice in the concept of self-efficacy. Bandura defined perceived
  • Wannipa Asawachaisuwikrom Vol. 6 No. 4 243 self-efficacy as peopleûs judgement of or beliefs in their capabilities to organize and execute the courses of action required to produce given levels of attainments.9-10 He described self-efficacy in terms of two types of expectation, efficacy expectation and outcome expectation. Efficacy expectation is the belief that one can successfully perform a particular behavior to achieve a specific outcome. Outcome expectation is concerned with expected result when the behavior is performed. These outcomes can be physical, social or self-evaluative effects.9-10 People who believe that they have no power to produce results will not attempt to make things happen. Power has been emphasized as a key factor of human agency which plays an essential part of self-efficacy.2 Self-efficacy judgements are based on considerations of task attributes, performance conditions, ability estimates, and effort requirements in a given situation.9 It is important to note that a sense of self-efficacy is tied to particular domains of functioning. Therefore, self-efficacy must be measured based on specific domains of functioning. There are no standard measurements applicable to all people in all situations. In addition, Maibach and Murphy pointed out that commitment, resourcefulness and perseverance are precisely the qualities addressed by self-efficacy.11 An expression of personal efficacy is an assertion of confidence in oneûs capability to overcome the difficulties inherent in achieving a specified level of behavioral attainment. Furthermore, mastery experiences are considered the most effective way of creating a strong sense of self-efficacy.10 Self-efficacy has been studied in relation to humanbehaviorinvariousdisciplines.Forinstance, in sports, evidence has demonstrated self-efficacy to 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 different from personal efficacy in that it is a group-level attribute. Bandura defined collective efficacy as a groupûs belief in their conjoint capabilities to produce given levels of attainments.2 Teams with high team efficacy beliefs should outperform and persist longer when behind than teams with low-perceived team efficacy. Self-efficacy has also been applied to the career area. Everhart and Chelladurai defined self-efficacy as an individualûs evaluation of personal talents and skills in relation to a specific task.12 They suggested that self-efficacy measurement focus on the specific tasks associated with these necessary abilities, skills, and dispositions, which were required for performing those tasks. In counseling training, Heppner and colleagues pointed out that if trainees had strong beliefs in their ability to perform the skills needed to be effective counselors, these convictions should then predict better actual performance.13 Recent works in the area of physical exercise have tended to focus on self-efficacy and exercise adherence in older adults. Numerous research studies indicated the reliable associations among self-efficacy and physical exercise.14-21 The findings have revealed that people who had less self-efficacy experienced more negative responses to exercise. On the contrary, people who have a greater sense of self-efficacy tend to maintain exercise programs. Furthermore, in a previous investigation by Hogan and Santomier, the researchers found that older people who participated in a swimming program increased in their self-efficacy.22 In a more recent study, Conn developed and tested the predictive ability of a model of exercise among the elderly. The results showed a strong effect of self-efficacy expectation on exercise. In contrast, outcome expectancy was a weak predictor of exercise.15 The findings of this study supported previous research findings in older women.23 In addition, Conn found that perceived barriers to exercise were related to self-efficacy.15
  • Concept Analysis: Self-Efficacy Thai J Nurs Res ë October - December 2002244 The findings of another study also supported the importance of perceived barriers.16 The authors have suggested that perceived barriers to exercise were the potential determinants of older peopleûs estimation of their ability to perform the behavior. Other studies demonstrated a significant relationship between prior experiences with exercise and self-efficacy.14,17 From reviewing available literature, most studies measured self-efficacy through respondentsû confidence in their capabilities. For example, confidence in exam taking was measured to indicate learning self-efficacy of students. Students responded by indicating whether or not they could get an ùAû on all exams. To indicate confidence in skills, the item such as ùHow would you rate you...û has been asked. It is important to note that the construct of self-efficacy differs from the colloquial term confidence since self-efficacy included both the affirmation of capability and the strength of that belief whereas confidence refers to only strength of belief.10 In summary, ùefficacyû can be applied to both human beings and objects. The meanings of ùefficacyû used in both cases are quite similar in that they refer to the inherent attributes. As provided in most dictionaries, the most applicable definition of ùefficacyû as it appears in the concept of self-efficacy is the power to produce effects. A sense of self-efficacy is concerned with perceived capabilities, which include the affirmation and the strength, to produce effects in a particular task. Although other definitions as described in this article are not relevant to human behavior, they provide useful insight. Defining Attributes The identification of attributes assists in differentiating the concept of self-efficacy from related concepts. Through exploring the uses of self-efficacy, critical attributes of self-efficacy should be as follows: ë A belief in personal capability to perform a particular task. ë Strength of belief in abilities to actually carry out the required behavior. ë Affirmation of confidence to overcome the difficulties inherent in achieving a specified level of behavior attainment. Construct a model case and additional cases A model case and additional cases are constructed to demonstrate various uses of the concept and to provide examples of what the concept is or what it is not.1 Model case Mrs. Jan is a 79 year-old woman who began exercise six years ago. By the age of 72, she had developed an arthritic limp and was hospitalized once at age 73. After she came home, a community nurse visited her and discussed with her about the benefits of exercise and gave her examples of how exercise helped improve the health of other patients. Mrs. Jan also learned about good exercising experiences from her friends. Despite her old age and her illness, she believed that exercise is the best way for recovering from her arthritis. Finally, she decided to participate in an exercise program with a strong belief in her ability and the advantages of exercise. When she began with a prescribed routine walk, her limp limited her walking to 100 feet. Although she was hurt from the initial exercise, she was patient and continued to exercise every morning. When she wakes up to each new day, feeling somewhat uncomfortable, she tells herself, çCome on, get yourself up and walk, you can do ité. After one month of engaging in exercise program, she said, çI think I am feeling better with this exercise plan, even at my old age. Before I began exercising, I had pains in nearly every joint, but now it barely phases meé. Because of her good feelings toward exercise, she becomes more active in her local
  • Wannipa Asawachaisuwikrom Vol. 6 No. 4 245 senior citizensû group. Furthermore, she firmly believes that if she seriously practices, she will succeed in walking one mile like others in her age bracket. As a commitment, she goes out walking every morning, although sometimes she does not want to get up in the morning. Gradually increasing her distance, Mrs. Jan is able to be free of medicines and her previous symptoms. After two years of the exercise program, she walks one mile every morning. Mrs. Jan demonstrated all of the defining attributes of self-efficacy. She had clear goals and an obvious confidence in her capabilities. These characteristics were illustrated in her decision to participate in the exercise program. The strength, affirmation of her confidence, perseverance, and mastery experience were seen through her exercise goal and practice. She is persistent in her efforts. Although she was in pain, she overcame the difficulty in walking at the beginning of her exercise program. In addition, she did the task with a strong sense of commitment to self. Contrary case Mrs. April is a 72 year-old woman who was diagnosed as having arthritis. After she came home, the community nurse visited her and discussed with her about the benefits of exercise and gave her examples of how exercise helped improve the health of other patients. However, Mrs. April ignored the nurseûs suggestion. She said, çAt my age, I cannot do much of anything, much less run around like a chicken with its head cut off.é This case does not exhibit the defining attributes of self-efficacy. Because of her convictions toward aging, she lacks confidence in her own abilities. She did not persist in her efforts to participate in exercise activity or even show a first attempt to exercise. Related case Related cases are similar to the concept of self-efficacy, but do not contain all of the defining attributes.1 Those terms, which appear to be used often and are related to self-efficacy, are as follows: ë Self-confidence ë Self-esteem ë Health locus of control ë Self-concept ë Self-control ë Perceived competence ë Self-actualization ë Perceived self-care agency The 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 been hospitalized for a week. While in the hospital, a nurse visited him and talked to him about exercising benefits. She tried to convey that his symptoms would lessen in severity if not disappear, if he would start an exercise program. Finally, he decided to participate in an exercise program with confidence in his abilities. When he began with a prescribed routine walk, his limp limited his walking to 100 feet. He complained to his nurse that he was hurting more from the exercise and he did not want to attempt it anymore. Although the nurse has explained about the process of the pain and convinced him to continue exercising, he quit exercising. This case does not contain all of the defining attributes of self-efficacy. Mr. March has confidence in his ability. However, he does not demonstrate an affirmation of confidence of his belief in abilities to overcome the difficulties in order to achieve the goal. Borderline case One day, Mrs. June who is 72 years old falls and fractures her hip. After being discharged from the hospital, the nurse suggested that she
  • Concept Analysis: Self-Efficacy Thai J Nurs Res ë October - December 2002246 rehabilitate herself in a nursing home since her husband may not be able to take care of her due to deteriorating health. However, her 75-year old husband insists that he will be able to handle it. He believes that he is able to provide care for his wife, although the nurse explains the complexity of care that will be necessary. However, her husbandûs assistance with her passive exercise is less effective. His ongoing attempt to learn how to rehabilitate her correctly causes further harm to her healing process. This case demonstrates some of the defining attributes of the concept of self-efficacy. The strength of Mr. Juneûs confidence in his ability to care for his wife is shown by his insistence that he would be able to perform the required task. He also illustrated his confirmation of confidence as he tried to master the passive exercise. However, he lacks the capability to learn how to successfully heal his wife through passive exercise. Antecedents ë Task or goal ë Previous mastery experiences ë Perception of confidence in his/her ca- pability to perform the task or achieve the goal Consequences ë Change in confidence level ë Some level of goal attainment Empirical referents In the standard methodology for measuring efficacy beliefs, individuals are presented with items of progressively more difficult performance requirements within a certain behavioral domain.2 The items are phrased in terms of whether they can or cannot perform the specific behavior. The strength and affirmation of individualûs confidence to overcome difficulties are rated on a 100-point scale, ranging in 10-unit intervals from 0 to 100. Recently, several scales have been developed for health behaviors such as physical activity and have been shown to have good reliability and validity.24 Conclusion Analysis of the concept of self-efficacy in terms of its defining attributes, antecedents, consequences, and empirical referents provides information related to clinical usefulness. It helps health care professionals communicate the same notion when discussing self-efficacy and can distinguish this concept from other related concepts. For researchers, clarification of the concept can assist them to generate or select a more effective tool for their research studies. Most importantly, understanding self-efficacy as a concept is useful to health professionals in approaching behavioral change such as participation in physical exercise of older people. Acknowledgements Thanks to Dr. Kay Avant, Associate Professor, The University of Texas at Austin, for her valuable suggestions. References 1. Walker LO, Avant KC. Strategies for theory construction in nursing. 3rd ed. CT: Appleton & Lange, 1995. 2. Bandura A. Self-efficacy: The exercise of control. New York: Freeman, 1997. 3. Klein E. Comprehensive Etymological Dictionary of the English Language. Amsterdam: Elsevier, 1971. 4. Laffal J. A concept dictionary of English. CT:Gallery Press, 1973. 5. Guralnik DB. Websterûs New World Dictionary of the American Language. 2nd ed. NY: Simon and Shuster, 1984. 6. Drummond MF, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press, 1987. 7. Qu Y, Hadgu A. A model of evaluating sensitivity and specificity for correlated diagnostic tests in efficacy studies with an imperfect reference test. Journal of the American Statistical Association 1998; 93: 920-9. 8. Feltz DL, Lirgg CD. Perceived team and player efficacy in hockey. Journal of Applied Psychology 1998; 83: 557-64.
  • Wannipa Asawachaisuwikrom Vol. 6 No. 4 247 9. Bandura A. Social foundations of thought and action: A social cognitive theory. NJ: Prentice-Hall, 1986. 10. Bandura A. Health promotion from the perspective of social cognitive theory. Psychology and Health 1997; 00: 1-27. 11. Maibach E, Murphy DA. Self-efficacy in health promotion research and practice: conceptualization and measurement. Health Education Research 1995; 10: 37-50. 12. Everhart CB, Chelladurai P. Gender differences in preferences for coaching as an occupation: The role of self-efficacy, valence, and perceived barriers. Research Quarterly for Exercise and Sport 1998; 69: 188-200. 13. Heppner MJ, Multon KD, Gysbers NC, Ellis CA, Zook CE. The relationship of trainee self-efficacy to the process and outcome of career counseling. Journal of Counseling Psychology 1998; 45: 393-402. 14. Clark DO, Patrick DL, Grembowski D, Durham ML. Socioeconomic status and exercise self-efficacy in late life. Journal of Behavioral Medicine 1995; 18: 355-75. 15. Conn VS. Older adults and exercise: Path analysis of self-efficacy related constructs. Nursing Research 1998; 47:180-9. 16. Hofstetter CR, Hovell MF, Sallis JF. Social learning correlates of exercise self-efficacy: Early experiences with physical activity. SocialScience&Medicine 1990; 31: 1169-76. 17. McAuley E. Self-efficacy and the maintenance of exercise participation in older adults. Journal of Behavioral Medicine 1993; 16:103-13. 18. McAuley E, Jacobson L. Self-efficacy and exercise participation in sedentary adult females. American Journal of Health Promotion 1991; 5: 185-91. 19. McAuley E, Shaffer SM, Rudolph D. Affective responses to acute exercise in elderly impaired males: the moderating effects of self-efficacy and age. International Journal of Aging and Human Development 1995; 41:13-27. 20. Stidwell HF, Rimmer JH. Measurement of physical sel-efficacy in an elderly population. Clinical Kinesiology 1995; 49: 58-63. 21. Wilcox S, Storandt M. Relations among age, exercise, and psychological variables in a community sample of women. Health Psychology 1996; 15: 110-13. 22. Hogan PI, Santomier JP.. Effect of mastering swimming skills on older adultsû self-efficacy. Research Quarterly of Exercise and Sport 1984; 55: 294-6. 23. Conn VS. Older women: social cognitive theory correlates of health behavior. Women Health 1997; 26: 71-85. 24. Sallis JF, Pinski RB, Grossman RM, Patterson TL, Nader PR. The development of self-efficacy scales for health-related diet and exercise behaviors. Health Education Research 1988; 3: 283-92.
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