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The influences of Thai Buddhist culture on cultivating compassionate relationships with equanimity between nurses, patients and relatives : a grounded theory approach
Chinnawong, Tippamas https://researchportal.scu.edu.au/discovery/delivery/61SCU_INST:ResearchRepository/1267148400002368?l#1367375620002368
Chinnawong, T. (2007). The influences of Thai Buddhist culture on cultivating compassionate relationships with equanimity between nurses, patients and relatives: a grounded theory approach [Southern Cross University]. https://researchportal.scu.edu.au/discovery/fulldisplay/alma991012821675802368/61SCU_INST:Research Repository
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The Influences of Thai Buddhist Culture on Cultivating Compassionate Relationships with Equanimity between Nurses, Patients and Relatives: A Grounded Theory Approach
Tippamas Chinnawong RN., B.N.S., M.N.S. (Adult Nursing)
A thesis submitted in total fulfilment of the requirements for the degree of Doctor of Philosophy
May, 2007
Department of Nursing and Health Care Practices School of Health and Human Sciences Southern Cross University Lismore, New South Wales, 2480
STATEMENT OF SOURCES
I, Tippamas Chinnawong, declare that the work presented in this thesis is, to the best of my knowledge and belief, original, aspect as acknowledged in the text, and that the material has not been submitted, either in whole or in part, for a degree at this or any other university.
Signed
………………………………………………………Date…………………………
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Dedication
This study is dedicated to nurses, patients, and patients’ relatives who are sharing the truth of life, facing both suffering and happiness in the process of caring for illness, death and dying, who are cultivating compassionate acts with equanimity and supporting each other in alleviating suffering, promoting comfort and preparing for a peaceful death.
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ACKNOWLEDGEMENTS
I am deeply honoured to have the chance to do grounded theory research in spirituality and holistic nursing care, exploring the influences of the Thai Buddhist culture on nurses’, patients’ and relatives’ relationships in Thailand. This thesis could not be completely finished without direct and indirect support from people and sacred power from all directions of my life. I believe that other people, the universe, and I always relate to and support each other by the gentle flow of breathing in and breathing out.
Thank you very much to Thai Government, the Ministry of Education (previously the Ministry of University), and related staff who offered a scholarship, provided a chance to study in Australia, and for their wonderful support. I give my thanks to the Office of the Civil Service Commission, Office of Educational Affairs in Canberra, Australia, for their assistance while I studied in Australia. Thanks to my supportive colleagues at the Faculty of Nursing, Prince of Songkla University, Thailand, expecially Associate Professor Arphorn Churprapaisilp, who introduced me to my supervisor. You all gave me the best chance in my life to study overseas, to learn and absorb the best from the Australian people, the university and a multicultural setting.
I pay homage to the Buddha, the Dhamma, and the Sangha for cultivating my compassion and guiding me to gain deep understanding about working and living with mindfulness, compassion and equaminity while dealing with multiple suffering in my personal, work, and study life especially in the four years of hard work during this PhD.
I am grateful to Barney G. Glaser, Anselm Strauss, Juliet Corbin, and the qualitative and grounded theory researchers who opened new ways of thinking, provided methods and processes for social and nursing research, and provided me with flexible guidelines to do grounded theory research.
A respectful acknowledgement is for my participants: nurses, patients and relatives, my great teachers, who shared their stories about compassionate and spiritual caring relationships.
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The greatest acknowledgement is to my superb supervisor, Professor Bev Taylor, who is my teacher, sister, and spiritual supporter. She has become my spiritual friend who always understands, helps, and supports.
Thank to all caring staff and PhD friends at the Department of Nursing and Health Care Practices, especially Ms. Chris Game, Associate Professor Dr Nel Glass, Dr Kierrynn Davis, Jill Barwick, Carmen Zammit, Susan Westwood, Linda, and Jane. Thanks to my critical friends: Dr Neville Jennings, Dr Leonie Jennings, Dr Arphorn, Pe Sukulya, Pe Sawangpong and Pe Steven, who shared the idea of doing qualitative research about Buddhist spirituality. To my wonderful editors, Jude Belcher, Sue Cronen, Kim Luckman and Pe Pratin, my English has gradually improved because of you.
Thanks to Tricia Freely and Chris Garlick, for being the best English teacher and moral supporter. Chris Tricia and English teachers from English Language Centre thank you also. Thanks to the friendly staff at the International Office, computer room, and library, at Southern Cross University, especially at the document supply section, and the learning assistance unit.
Thanks to my wonderful homestay families, Peggy and Mark Predebon, their warm family and friends: Cecily, Michel and Susie. Mark tried to teach me to drink wine, but I always failed this subject. Peggy will always be with me whenever I am happy or sad. She is my beloved sister. Bede, my brother, and Fabia, my dear sister, played with me and taught me to play with Barbie. She also tried to teach me to speak English with her dolls. Lexie and Peter, and Uncle Ken are my best friends in my homestay family, who took care of me as one of their daughters.
To my Thai friends and families, especially Pe Nee, Pa Su, Pe Rin, Pe Pa, Pe Tuk, Pe Wan. Thank you for very yummy hot and spicy Papaya Salad, Thai Curry, chilli paste and fresh spring rolls. You made my life comfortable and it felt like home. Also Pe Tin who always gave me some herbs, cheered me up and encouraged me to improve my writing skills. Thank you Pe Pok, P Boon, P Ta, Tony, Nong Jib, Leky, Noi, Goi, and nong Nan, who shared their happiness and support with each other.
I’d also like to thank all my good friends at Sirius College and at SCU, expecially Aethea, David, Judy, Alana, Nick, Belinda, Kim, Julia, Ankie, Vanessa, Diep, Vi, Bao, Sunny, Ephraim, Phosai, Gloria, and Atsushi.
Thanks to many Thai sisters and friends, especially Pe Sa, Pe Nai, Pe Nom, P Taew, Pe Su, Pe Ying, Pe Hong, Pe Aree, Nong O, Pe Peak, Pe Luay, Pe Ra, Ly, Tas, Jang, Maew, Lak, Cake, Pui, Pure, Pla, Yui, and Nok, who were always ready to listen to my sad stories and be with me when I needed help and suport. Thank you my spiritual friends for taking care of my sick parents while I studied overseas.
I am also remember with gratitude the very supportive environment, the bus drivers and friendly people from the very peaceful town of Lismore, a herd of cows in the farm near the Sirius residence, chilli trees and herb gardens at the Sirius college, and all the sacred power and sources of healing energy around us: the Australian blue sky, the sun, the moon, the rain, wonderful weather, beautiful birds, flowers, trees, parks, beaches, and the peaceful field in front of my unit which helped me calm my mind and get ready to keep writing my thesis.
Finally, I’d like to thank my parents, sisters, and brothers in Thailand for all their support. I am deeply grateful to Pe Sukanda Chinnawong who, since I was born, has taken care of me as the second mother and always nurtured my freedom and creativity with her kindness and compassion, Pe Wanpimol Chinnawong who devotes herself to help me take care of our sick parents while I am staying so far away from home.
Thank you, everybody and everything, for providing learning power and moral support so I could complete my thesis. May good health, peace and happiness be with you all. Thank you very much.
ABSTRACT
The Influences of Thai Buddhist Culture on Cultivating Compassionate Relationships with Equanimity between Nurses, Patients and Relatives: A Grounded Theory Approach
Thai Buddhist people, especially elderly patients, usually apply Buddhist teachings to deal with illness and death. This grounded theory research was developed to explore the influences of Buddhist culture on nurse-patient-relative relationships in Thailand. The purposes were to highlight the importance of the spiritual dimension in nursing care and examine ways in which nurses can use Buddhist principles to improve nursing care. Seventeen registered nurses, 14 patients and 16 relatives were purposely selected. The semi-structured interviews and audio tape recording took place in Thailand from October 2003 to March 2004. Three steps of analysis: open, axial and selective coding (Strauss & Corbin, 1998) were conducted. “The Cultivation of Compassionate Relationships with Equanimity between Nurses, Patients and Relatives” emerged as the basic social process, which were composed of the three co-processes including: 1) facing suffering/understanding the nature of suffering, 2) applying Dhamma (Buddhist beliefs and practices), personal/local wisdom, and traditional healing, and 3) embodying compassion with equanimity. Such relationships showed influences of Buddhism and Thai culture, and highlighted patient- relative centred care. Personal, professional and organisational factors as well as cultural and religious aspects that promote and inhibit compassionate relationships are discussed. Implications are discussed for nursing practice, education, management and research.
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TABLE OF CONTENTS
Page No. Statement of sources ii Dedication iii Acknowledgements iv Abstract v
Chapter 1: Introduction Introduction 1 The researcher’s background 6 Significance 7 Aim 8 Objectives 8 Research questions 8 Assumptions 9 Key terms 10 Glossary of Thai words 11 Thesis chapters overview 15
Chapter 2: Setting the Context Introduction 18 Thailand: “The Golden Land” and “The Land of the Yellow Robes” 18 Thai Buddhist culture 19 Fundamentals of Buddhism 22 The Four Noble Truths and the Noble Eightfold Path 23 The Five Precepts 24 Buddhism and health 24 Issues and trends in the Thai health care system 25 Thai National Health Development Plan 25 Health services and health seeking behaviours 26 Thai nursing 27 Conclusion 30
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TABLE OF CONTENTS
Page No. Chapter 3: Methodology Introduction 31 Grounded theory and its position in qualitative research 31 Strengths and weaknesses of the grounded theory 36 Approaches of grounded theorists 38 Development of grounded theory methodology 38 The commonality of the four approaches 40 The distinguishing components of grounded theory 41 Glaser and Strauss’s approach: the original version 41 The Glaserian approach: the classic version 42 Strauss and Corbin’s approach 43 Charmaz’s approach: the constructivist version 43 Major differences between Glaser’s classical approach and Strauss and 46 Corbin’s approach Strauss and Corbin’s grounded theory approach 46 Basic knowledge and procedures in Strauss and Corbin’s grounded 49 theory approach Responses to Strauss and Corbin’s grounded theory approach 50 Grounded Theory in Nursing 52 Grounded theory, spirituality and the nurse-patient-relative relationship 53 Examples of grounded theory using Glaser’s classical approach 54 Examples of grounded theory using Strauss and Corbin’s approach 56 Computer-aided theory-generating analysis 60 Grounded theory research in the Thai Buddhist context 62 Selecting the methodology and the specific approach 63 Conclusion 65
Chapter 4: Methods and Processes Introduction 66 Gaining ethical approval 66
TABLE OF CONTENTS
Page No. Considering ethical principles 66 Beneficence 67 Respect for human dignity 67 Justice 68 Engaging multiple ethical approvals 68 Settings and participants 69 The settings 69 The elderly centre 70 The primary health care clinic 70 The community hospital 71 The provincial hospital 71 The regional hospital 72 The University hospital 72 The wards and the chaos 74 Recruiting participants 77 Applying theoretical sampling to maximise different groups of 79 participants Recruiting participants from different Buddhist backgrounds 79 Recruiting participants from different patterns of nurse-patient- 79 relative relationships Collecting data 80 Building the researcher-participant relationship 80 Interviewing, taking notes and memos, and asking specific questions 81 Restating and performing ethical principles 85 Applying informed consent 85 Performing confidentiality 86 Being concerned about potential risks of the research 87 Preventing imposing researcher ideas 89 Avoiding researcher’s power over participants 89 Appreciating positive responses and preventing harm for special 89 participants
TABLE OF CONTENTS
Page No. Dealing with some patients who had economic problems 91 Preventing guilt and conflicts and dealing with conflicts 91 Maintaining some good deeds within the researcher role 91 Listening to cassettes and transcribing data 92 Validating data 93 Translating data 94 Analysing data: techniques and processes 96 Doing the formal analysis 99 Applying open coding 99 Applying axial coding 102 Section one of axial coding: developing categories from 15 103 selected cases (fives nurses, five patients and fives relatives) Section two of axial coding: adding the rest of codes and sub- 104 categories from the remaining participants under the similar categories Applying selective coding 106 The emergence of the basic social process 106 Reaching theoretical saturation 107 Writing memos and theoretical notes, and sorting memos 107 Illustrating examples of memos and theoretical notes 108 Listing intuition and new ideas 108 Raising and answering some more questions 109 Drawing diagrams and seeing the links between data 110 Sorting memos and doing the final theory refinement 117 Sorting memos 117 Doing the final theory refinement 117 Ensuring trustworthiness and the quality of research 117 Summary the processes of doing the grounded theory research 121 Conclusion 124
TABLE OF CONTENTS
Page No. Chapter 5: Nurses’ Experiences and Emerging Codes Introduction 125 The nurses’ demographic data, experience, and emerging codes 126 Nurses’ demographic data 126 Nurses’ experiences and emerging codes 127 Pe Metta’s experience 128 Conclusion 154
Chapter 6: Patients’ Experiences and Emerging Codes Introduction 155 The patients’ demographic data, experiences, and emerging codes 155 Patients’ demographic data 155 Patients’ experiences and emerging codes 157 Pe Da’s experience 157 Conclusion 171
Chapter 7: Relatives’ Experiences and Emerging Codes Introduction 172 The relatives’ demographic data, experiences, and emerging codes 172 Relatives’ demographic data 172 Relatives’ experiences and emerging codes 175 Khun Damrong’s experience 175 Conclusion 193
Chapter 8: The Process of the Grounded Theory Development: from Open Codings to the Substantive Theory Introduction 194 The process of theory development from all perspectives 194 Core category 1: Facing suffering/understanding the nature of 200 suffering Facing suffering 201 Understanding the nature of suffering 206 TABLE OF CONTENTS
Page No. Core category 2: Applying Dhamma (Buddhist beliefs and practices), 207 personal/local wisdom, and traditional healing Applying Dhamma 207 Approaching/learning Dhamma 208 Believing in Dhamma/considering Buddhist philosophy 209 Performing/Practising Dhamma 212 Applying Dhamma to nursing care 214 Appreciating outcomes 217 Concerning problems of applying Dhamma 218 Suggesting ways for applying Dhamma 220 Applying personal/local wisdom and traditional healing 221 Applying local wisdom and traditional healing 221 Applying personal wisdom (using other coping methods) 222 Core category 3: Embodying mutual compassion with equanimity 223 Describing characteristics of compassionate nurses from nurses’, 223 Patients’ and relatives’ perspectives Good heart 224 Good experiences and skills 224 Good social support 225 Avoiding added suffering (dehumanising behaviours) 225 Acting with compassion and equanimity 225 Acting with compassion 226 Acting with equanimity 230 Being aware of relationship problems 231 Appreciating relationship outcomes 231 Being concerned about factors influencing relationships 232 Being concerned about factors promoting relationships 232 Personal factors 232 Professional factors 233 Organisational factors 233
TABLE OF CONTENTS
Page No. Being concerned about factors inhibiting relationships 234 Personal factors 234 Professional factors 242 Organisational factors 244 Considering clients’ expectations and suggesting paths to cultivate 244 compassionate relationships Considering clients’ expectations 244 Suggesting paths to cultivate compassionate relationships 246 Conclusion 251
Chapter 9: Buddhism and the Nurse-Patient-Relative Relationship Introduction 252 Relationships: the Eastern worldviews 252 Buddhism and relationships 253 The Four Sublime States of Consciousness (Brahma-vihara) 254 The six directions of relationship 256 The path to accomplishment (The Four Iddhipada) 256 Issues from the Thai Buddhist culture that influence relationships 257 Buddhist paradigm on health and healing in Thai society 258 Buddhism and nursing 263 Rogers’ Theory and Buddhist teachings 264 Newman’s Theory and Buddhist teachings 265 Watson’s Theory and Buddhist teachings 265 Relationships in nursing 269 Relatives in the relationships 271 Caring relationships 274 Buddhist culture and the nurses-patient-relative relationship in Thailand 281 Conclusion 283
TABLE OF CONTENTS
Page No. Chapter 10: Discussion and Conclusion Introduction 284 The grounded theory of Cultivating Compassionate Relationships with 284 Equanimity Suffering and understanding the nature of suffering 286 Cultivating compassion 289 Understanding suffering and wanting to help sufferers 289 The nature of compassionate acts is unselfish and non-violent 290 Promoting holistic care and healing 291 Promoting ethics and ethics of care 292 Balancing self-compassion and compassion for others 292 Focusing on compassion in the Christian perspective 293 Cultivating equanimity 294 Cultivating compassion with equanimity 296 Influence of Buddhist and traditional beliefs and practices 299 Influence of Buddhism on Thai caring characteristics 300 Factors influencing the nurse-patient-relative relationship 300 Insights 301 Reflections 303 Reflecting on the research participants 303 Reflecting on the grounded theory research 303 Reflecting on the qualitative research 304 Reflecting on the nursing theory 305 Strengths and limitations of the research 307 Strengths 307 Reaching a high level of theory development 307 Limitations 309 The complexity of the participants’ experiences 309 Managing the overlapping of data collection and analysis 309 processes
TABLE OF CONTENTS
Page No. Implications 310 The right path for nursing care 310 The right path for nursing education 313 The right path for nursing management 314 The right path for future nursing researchers 315 The right path for Thai people and Buddhist organisations 317 The final thought 318
References 319
Appendices
Appendix A: Plain language statement for participants 1-3 Appendix B: Consent form 1-3 Appendix C: Counsellors contact list and research project supervisor 1-2 Appendix D: Southern Cross University memorandum: approval No.: 1-2 ECN-03-76, Human research Ethics Committee (HREC) Appendix E: Nurses’ emerging codes 1-16 Appendix F: Patients’ emerging codes 1-7 Appendix G: Relatives’ emerging codes 1-8 Appendix H: Table 8.2: Illustrated all open coding which supported 1-69 related concepts, categories, core categories, and the basic social process Appendix I: Table 8.3: Summary of open coding and selective coding 1-20 which support related concepts, categories, core categories, and the basic social process
FIGURES
Page No. Figure 4.1 The folder for participants 84 Figure 8.1 The connection of each core-category 199
Figure 9.1 Wilber’s All-Quadrant Model 268
MEMOS
Page No. Memo 1 The Thai context: Thai holistic way of life (operational 108-109 note) Memo 2 Questions and answers (operational notes, and theoretical 109-110 notes) Memo 3 Emergent issues, some cultural differences (operational 110 notes) Memo 4 Diagram created after thinking of positive and negative 111 qualities of people including nurses Memo 5 Diagram drawn after thinking of some factors in Thai 111 Buddhist culture which influence good nurse-patient- relative relationships Memo 6 The conditional/consequences matrix of related concepts 112 which link to nurse-patient-relative relationships in the Thai Buddhist Culture Memo 7 Cultivating Compassionate Relationships between 113 Nurses, Patients and Relatives Memo 8 Clarifying the meaning of compassion, equanimity, and 114 relationship from dictionaries, participants’ meaning and literature Memo 9 Seeing the interconnectedness of the nurse-patient- 115 relationship and the influences of Buddhism on compassionate relationship with equanimity Memo 10 The application of Buddhist teachings in the Thai context 116
TABLES
Page No. Table 2.1 Classification of Thai symbolic representations 21 Table 2.2 Health care seeking behaviours of Thai people 27 Table 2.3 Summary turning points in the development of nursing in 29 Thailand Table 3.1 Scientific and naturalistic terms appropriate to various 37 aspects of rigor Table 3.2 Comparison of the procedural steps of two versions of 47-48 grounded theory method Table 4.1 Nurse: Patient ratios and systems of nursing care in each 75 setting of the University hospital Table 4.2 Nurse: Patient ratios and systems of nursing care in each 76 setting of the hospitals under the Ministry of Public Health Table 4.3 Illustrated examples of different kinds of language 96 Table 4.4 Activities and processes of doing the grounded theory 122-123 research Table 5.1 Nurses’ demographic data 127 Table 6.1 Patients’ demographic data 156 Table 7.1 Relatives’ demographic data 174 Table 8.1 Summary of selective coding, sub-categories (minor sub- 197 categories and major sub-categories), core categories, and the basic social process from NPRs’ perspectives Table 9.1 Summarised factors that influence “spiritual caring 271 relationships” between nurses, patients, and relatives when focusing on nurses and nursing professional issues Table 9.2 A preliminary model of effective clinician-patient 277 interactions Table 9.3 Spirituality and relationships in the Western and the 280 Eastern worldviews Table 10.1 Contrasts between Western and non-Western philosophical 306 world view influencing research paradigms