Research article list

Thai Journal of Nursing Research
Vol. 6 No. 4 October - December 2002 ISSN-0859-7685
Factors Influencing Role Adaptation of Patients with Cervical Cancer
Receiving Radiation Therapy
Yupapin Sirapo-ngam, RN., DSN. Panwadee Putwatana, RN., D.Sc.
Luppana Kitrungroj, MNS. Virat Piratchavet, M.D.
Marital Developmental Tasks of Thai Spouses in Childrearing Families
Rutja Phuphaibul RN. , D.N.S. Arunsri Tachudhong RN. , M.S.
Chuanraudee Kongsaktrakul RN., M.P.H, M.N.S.
Self-regaining from loss of self-worth: A substantive theory of recovering
from depression of middle-aged Thai women
Acharaporn Seeherunwong, Tassana Boontong RN. Ed.D.,
Siriorn Sindhu RN., D.N.Sc., Tana Nilchaikovit M.D.
Chronic Dyspnea Self-Management of Thai Adults with COPD
Supaporn Duangpaeng RN, D.N.S. Payom Eusawas RN, Ph.D. Suchittra Laungamornlert RN, DNSc.
Saipin Gasemgitvatana RN, D.N.S. Wanapa Sritanyarat RN, Ph.D.
Exploring Ethical Dilemmas and Resolutions in Nursing Practice :
A Qualitative Study in Southern Thailand
Aranya Chaowalit RN. Ph.D. Urai Hatthakit RN. Ph.D. Tasanee Nasae RN. M.Ed.
Wandee Suttharangsee RN. Ph.D. Marilyn Parker RN. Ph.D.
Concept Analysis: Self-Efficacy
Wannipa Asawachaisuwikrom, Ph.D.
Spirituality: A Concept Analysis
Wanlapa Kunsongkeit RN. MNS.(Medical and Surgical Nursing)
Marilyn A. McCubbin RN. Ph.D. FAAN.

Vol. 6 No.2 1
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
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

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:
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 et.al.
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.

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.

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.

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

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

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

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.

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

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

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.

15. Jalowiec, A. & Powers, M. Stress and coping in
hypertensive and emergency room patients. Nursing
Research, 1981; 30, 10-15.
16. Pender, N. J. Health Promotion in Nursing Practice.
2nd
ed. Norwalk: Appleton & Lange, 1987.
17. Tongtanunam, Y. Role Adaptation of Mastectomy
Patients with Adjuvant Chemotherapy. Masterûs Thesis
in Nursing Science (Adult Nursing), Faculty of Graduate
Studies, Mahidol University, 1998.
18. Roy, S. C. & Andrews, H. A. The Roy Adaptation
Model: The Definitive Statement.Norwalk: Appleton
& Lange, 1991.
19. Cox JD. Stetz J.& Pajak TF. Toxicity Criteria of the
Radiation Therapy Oncology Group (RTOG) and The
European Organization for Research and Treatment of
Cancer (EORTC). International Journal Radiation
Oncology Biol. Phys 1995; 31(5) : 1341-1346.
20. Rosenberg, M. Society and the Adolesent Self-image.
Connecticut: Wesleyan University Press, 1979.
21. Soomlek, S. A Causal Model of Maternal Role
Mastery among First Time Mother. A Dissertation of
the Requirements for Degree of Doctor of Nursing
Science. Faculty of Graduate Studies, Mahidol University,
1995.
22. Ounprasertpong, L. A Causal Model of Role
Adaptation in HIV Infected and AIDS Patients.
A Dissertation of the Requirements for Degree of Doctor
of Nursing Science, Faculty of Graduate Studies,
Mahidol University, 1997.
23. Sujirarat D. Data Analysis with SPSS for window II.
2nd
ed. Bangkok : Judthong Printing, 1998
24. Roy, S.C. & Roberts, S. L. Theory Construction in
Nursing: An Adaptation Model. New Jersey:
Prentice-Hall, 1981.
25. Sompoo, J. Adaptation in Role Functions of Women
with Permanent Colostomy. Masterûs Thesis in Nursing
Science (Adult Nursing), Faculty of Graduate Studies,
26. Pittayapan, P. The Process of Stress Appraisal
Coping & Adaptation, and Outcomes in Cervical
Cancer Patients During Radiotherapy. A Dissertation
of the Requirements for Degree of Doctor of Nursing
Science. Faculty of Graduate Studies, Mahidol University,
1999.
27. Ruankon, A. A Study of the Quality of life of Patients
with Cervical Cancer Receiving Radiotherapy.
Masterûs Thesis in Nursing Science (Adult Nursing),
28. Graydon JE., Bubela N., Irvine, D.& Vincent, L.
Fatigue-reducing strategies used by patients receiving
treatment for cancer. Cancer Nursing, 1995; 18(1),
23-28.
29. Cohen S. & Wills, T. A. (1985). Stress, Social Support,
and the Buffering Hypothesis. Psychological Bulletin
1985; 9 : 310-357.
30. Dimond M. & Jones SL. Social Support: A review and
theoretical integration. In P.L. Chinn (Ed.), Advances
in Nursing Theory Development (pp. 235-249).
Maryland: Aspen, 1983.
31. Uphold, R. C. Social Support. In L.T. Creasia&
P. Barbara (Eds.), Conceptual Foundation of
Professional Nursing Practice (pp.445-470).St. Louis:
Mosby Years Book, 1991.
32. Khlueinak, U. The Relationship between Family
Support and Adaptation of the Head and Neck
Cancer Patient Receiving Radiotherapy. Masterûs
Thesis in Nursing Science (Adult Nursing), Faculty of
Graduate Studies, Mahidol University, 1997.
33. Kongchum, N. Health Related hardiness, Social
Supports, Selected Factors,and Adaptation in
PatientswithBreastCancerReceivingChemotherapy.
34. Ritudom, B. The Relationships between Spouse
Support, Self-Care Behavior, and Quality of Life in
Cancer Patients Receiving Chemotherapy after
Mastectomy. Masterûs Thesis in Science (Nursing),
35. Miller, J.F. Coping With Chronic Illness:
Overcoming Powerlessness. 2nd
ed. Philadelphia:
F.A. Davis, 1992.
36. Catanzaro M. Transitions in midlife adults with
long-term illness. Holistic Nursing Practice 1990,
1990; 4(3): 65-73.
37. Meisenhelder, J. B. Self-esteem in women: The
influence of employment and perception of husbandûs
appraisal. Journal of Nursing Scholarship, 1986;
18(1),8-13.
38. Uckanit, W. Self-Esteem and Self Care Practice in
Patients with Chronic Obstructive Pulmonary
Disease. Masterûs Thesis in Science (Nursing), Faculty
of Graduate Studies, Mahidol University, 1991.
39. Vichitvatee, S. The Relationship between Self-Esteem
and Self-Care Behavior of the Amputee. Masterûs
Thesis in Science (Nursing), Faculty of Graduate Studies,

Vol. 6 No. 4 175
40. Yoswattana, R. RelationshipamongHealthPerception
Role Functions and Self-Esteem of Patients with
Congestive Heart Failure. Masterûs Thesis in Science
(Medical and Surgical Nursing), Faculty of Graduate
Studies, Chiang Mai University, 1992.
41. Irvine, D.M., Vincent, L., Graydon, J.E., Bubela, N. &
Thompson,L. The prevalence and correlates of fatigue
in patients receiving treatment with chemotherapy and
radiotherapy: A comparison with the fatigue
experienced by healthy individuals. Cancer Nursing,
1994; 17(5), 367-378.
42. Pongthavornkamol, K. Coping with Side Effects And
Emotional Distress among Thai Cancer Patients
Receiving Radiation Therapy. A Dissertation of the
Requirements for Degree of Doctor of Philosophy.
Graduate School of Rochester University, 2000.
43. Kawsasri, A. Role Adaptation of Male Head and
Neck Cancer Patients Receiving Radiotherapy.
44. Muhlenkamp, A. F. & Sayles, J. A. Self-Esteem,
Social Support, and Positive Health Practices. Nursing
Research, 1986; 35(6), 334-338.
45. Kaveevichai, J. Relationship among Selected factors,
Uncertainty in Illness, Social Support, and Adaptation
of Breast Cancer Patients Receiving Chemotherapy.
Masterûs Thesis in Science (Nursing), Faculty of Graduate
Studies, Mahidol University, 1993.
46. Jaikaew, K. Relationship Among Self-Concept,
Self-Care Agency, and Quality of Life of Cervical
Cancer Patients Receiving Radiotherapy. Masterûs
Thesis in Science (Medical and Surgical Nursing),
Faculty of Graduate Studies, Chiang Mai University,
1994.

ªí®®—¬∑’Ë‡°’Ë¬«¢âÕß°—∫°“√ª√—∫µ—«„π¥â“π∫∑∫“∑Àπâ“∑’Ë¢ÕßºŸâªÉ«¬
¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‰¥â√—∫√—ß ’√—°…“
¬ÿæ“æ‘π »‘√‚æ∏‘Ïß“¡* D.S.N.(Adult Health Nursing) æ√√≥«¥’ æÿ∏«—≤π–* «∑.¥. (‚¿™π»“ µ√å)
≈—æ≥“ °‘®√ÿàß‚√®πå** æ¬.¡. (°“√æ¬“∫“≈ºŸâ„À≠à) «‘√—µπå ‰æ√—™‡«∑¬å*** æ.∫.
∫∑§—¥¬àÕ: °“√«‘®—¬‡™‘ß∫√√¬“¬π’È¡ÿàß»÷°…“ °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë ·≈–§«“¡ “¡“√∂¢Õß
§«“¡√ÿπ·√ß¢ÕßÕ“°“√¢â“ß‡§’¬ß §«“¡√Ÿâ ÷°¡’§ÿ≥§à“„πµπ‡Õß ·√ß π—∫ πÿπ∑“ß —ß§¡ ·≈–°“√»÷°…“
∑’Ë√à«¡°—π„π∑”π“¬°“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë¢ÕßºŸâªÉ«¬¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‰¥â√—∫√—ß ’√—°…“ ‚¥¬„™â
√Ÿª·∫∫°“√ª√—∫µ—«¢Õß√Õ¬ (1991)‡ªìπ°√Õ∫·π«§‘¥ »÷°…“„πºŸâªÉ«¬ 86 §π∑’Ë‰¥â√—∫√—ß ’√—°…“·∫∫
ºŸâªÉ«¬πÕ°¢Õß‚√ßæ¬“∫“≈ 6 ·Ààß„π°√ÿß‡∑æ¡À“π§√√–À«à“ß ‡¥◊Õπ°ÿ¡¿“æ—π∏å∂÷ß‡¥◊Õπ¡‘∂ÿπ“¬π 2543
§—¥‡≈◊Õ°°≈ÿà¡µ—«Õ¬à“ß∑’Ë¡’§ÿ≥ ¡∫—µ‘µ“¡∑’Ë°”Àπ¥ §◊Õ ¡’ ∂“π¿“æ ¡√ §Ÿà·≈–Õ“»—¬Õ¬Ÿà°—∫ “¡’ ‰¡à‡§¬
‰¥â√—∫√—ß ’√—°…“¡“°àÕπ ‰¥â√—∫√—ß ’√—°…“Õ¬à“ßπâÕ¬ 3,000 cGy.,3 —ª¥“Àå æŸ¥·≈–‡¢â“„®¿“…“‰∑¬‰¥â¥’
·≈–¬‘π¥’‡¢â“√à«¡„π°“√«‘®—¬ ‡°Á∫¢âÕ¡Ÿ≈¥â«¬·∫∫ Õ∫∂“¡ 5 ™ÿ¥ ‰¥â·°à (1) ·∫∫∫—π∑÷°¢âÕ¡Ÿ≈ à«π∫ÿ§§≈
·≈–¢âÕ¡Ÿ≈∑“ß§≈‘π‘° (2) §«“¡√ÿπ·√ß¢ÕßÕ“°“√¢â“ß‡§’¬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«¬‚√§¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‰¥â√—∫√—ß ’√—°…“ ¡’°“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë
‰¥â§àÕπ¢â“ß¥’°“√«‘‡§√“–Àå¥â«¬ ∂‘µ‘∂¥∂Õ¬æÀÿ§Ÿ≥·∫∫‡™‘ß™—Èπæ∫«à“·√ß π—∫ πÿπ∑“ß —ß§¡§«“¡√Ÿâ ÷°
¡’§ÿ≥§à“„πµπ‡Õß ·≈–§«“¡√ÿπ·√ß¢ÕßÕ“°“√¢â“ß‡§’¬ß “¡“√∂√à«¡°—πÕ∏‘∫“¬§«“¡·ª√ª√«π¢Õß
°“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë¢ÕßºŸâªÉ«¬¡–‡√Áßª“°¡¥≈Ÿ°∑’Ë‰¥â√—∫√—ß ’√—°…“‰¥â√âÕ¬≈– 54.8 °“√»÷°…“
¢ÕßºŸâªÉ«¬‰¡àæ∫«à“‡ªìπµ—«·ª√∑’Ë¡’π—¬ ”§—≠∑“ß ∂‘µ‘ „π°“√¥Ÿ·≈ºŸâªÉ«¬‚√§¡–‡√Áßª“°¡¥≈Ÿ° ®÷ß§«√„Àâ
§«“¡ ”§—≠°—∫ªí®®—¬¥â“π·√ß π—∫ πÿπ∑“ß —ß§¡ °“√‡ÀÁπ§ÿ≥§à“„πµπ‡Õß ·≈–§«“¡√ÿπ·√ß¢Õß¿“«–
·∑√°´âÕπ
§” ”§—≠: °“√ª√—∫µ—«¥â“π∫∑∫“∑Àπâ“∑’Ë ¡–‡√Áßª“°¡¥≈Ÿ° √—ß ’√—°…“
* √Õß»“ µ√“®“√¬å ¿“§«‘™“æ¬“∫“≈»“ µ√å §≥–·æ∑¬»“ µ√å‚√ßæ¬“∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
** Õ“®“√¬å§≥–æ¬“∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å
*** ºŸâ™à«¬»“ µ√“®“√¬å ¿“§«‘™“√—ß ’«‘∑¬“ §≥–·æ∑¬»“ µ√å‚√ßæ¬“∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈

Rutja Phuphaibul et.al.
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,.

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

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
between 6 and 13 years old.
2.4 Family with adolescent was the
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.

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 al.in 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

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

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

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.

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.

Vol. 6 No. 4 185
æ—≤π°‘®¢Õß§Ÿà ¡√ „π§√Õ∫§√—«√–¬–‡≈’È¬ß¥Ÿ∫ÿµ√
√ÿ®“ ¿Ÿà‰æ∫Ÿ≈¬å RN., D.N.S.* Õ√ÿ≥»√’ ‡µ™— Àß å RN. M.S.**
™◊Ëπƒ¥’ §ß»—°¥‘Ïµ√–°Ÿ≈ RN., M.P.H., M.N.S.
∫∑§—¥¬àÕ: °“√»÷°…“‡™‘ß‡ª√’¬∫‡∑’¬∫§√—Èßπ’È‡ªìπ°“√‡ª√’¬∫‡∑’¬∫æ—≤π°‘®¢Õß§Ÿà ¡√ „π§√Õ∫§√—«
√–¬–‡≈’È¬ß¥Ÿ ∫ÿµ√«—¬µà“ßÊ 4 √–¬– ‰¥â·°à√–¬–‡≈’È¬ß¥Ÿ∫ÿµ√«—¬∑“√° «—¬°àÕπ‡√’¬π «—¬‡√’¬π ·≈–«—¬√ÿàπ °≈ÿà¡
µ—«Õ¬à“ß ª√–°Õ∫¥â«¬ §Ÿà ¡√ 2,031 §√Õ∫§√—«„π‡¢µ°√ÿß‡∑æ¡À“π§√∑’Ë¡’∫ÿµ√§π·√°Õ“¬ÿÕ¬Ÿà„π√–¬–
°“√‡≈’È¬ß¥Ÿ∑’Ë°”Àπ¥ °≈ÿà¡µ—«Õ¬à“ß·µà≈–√–¬–¡’®”π«πª√–¡“≥ 500 √“¬ ‡°Á∫‚¥¬„™â·∫∫ Õ∫∂“¡∑’Ë
ºŸâ«‘®—¬ √â“ß„π‚√ß‡√’¬π·≈–‚√ßæ¬“∫“≈∑’Ë ÿà¡‡≈◊Õ°‡æ◊ËÕ„Àâ‰¥â°≈ÿà¡µ—«Õ¬à“ß„π·µà≈–°≈ÿà¡Õ“¬ÿ∫ÿµ√
·∫∫ Õ∫∂“¡¡’ 2 à«π‰¥â·°à ¢âÕ¡Ÿ≈∑—Ë«‰ª¢Õß§√Õ∫§√—«·≈–æ—≤π°‘®¢Õß§Ÿà ¡√ º≈°“√»÷°…“æ∫«à“
æ—≤π°‘®¢Õß§Ÿà ¡√ 4 ¥â“π§◊Õ ¥â“π°“√‡ß‘π ¥â“π°“√·∫àßÀπâ“∑’ ¥â“π —¡æ—π∏¿“æ§Ÿà ¡√
¥â“π —¡æ—π∏¿“æ°—∫‡§√◊Õ≠“µ‘ º≈°“√»÷°…“‡¡◊ËÕ«‘‡§√“–Àå§«“¡·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“ß§√Õ∫§√—«∑’Ë‡≈’È¬ß¥Ÿ∫ÿµ√«—¬°àÕπ
‡√’¬π°—∫°≈ÿà¡Õ◊ËπÊ Õ¬à“ß™—¥‡®π ·≈–æ∫§«“¡·µ°µà“ß√–À«à“ß°≈ÿà¡‡≈’È¬ß¥Ÿ∫ÿµ√«—¬‡√’¬π°—∫«—¬∑“√°
°≈ÿà¡∑’Ë¡’§–·ππµË” ÿ¥§◊Õ §√Õ∫§√—«√–¬–‡≈’È¬ß¥Ÿ∫ÿµ√«—¬∑“√° °≈ÿà¡∑’Ë¡’§–·ππ Ÿß ÿ¥§◊Õ §√Õ∫§√—«
‡≈’È¬ß¥Ÿ∫ÿµ√«—¬°àÕπ‡√’¬π À≈—ß®“°π—Èπ§–·ππ®–≈¥µË”≈ß„π√–¬–‡≈’È¬ß¥Ÿ∫ÿµ√«—¬‡√’¬π ·≈–«—¬√ÿàπ
§” ”§—≠: §Ÿà ¡√ æ—≤π°‘® §√Õ∫§√—«
* √Õß»“ µ√“®“√¬å ¿“§«‘™“æ¬“∫“≈»“ µ√å §≥–·æ∑¬»“ µ√å‚√ßæ¬“∫“≈√“¡“∏‘∫¥’
** ºŸâ™à«¬»“ µ√“®“√¬å ¿“§«‘™“æ¬“∫“≈»“ µ√å §≥–·æ∑¬»“ µ√å‚√ßæ¬“∫“≈√“¡“∏‘∫¥’

Self-regaining from loss of self-worth: A substantive theory of recovering from
depression of middle-aged Thai women
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 et.al.
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

(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

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

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

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

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

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.

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

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.

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

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.

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.

Vol. 6 No. 4 199
°“√§◊π§«“¡ ”§—≠„Àâµπ‡Õß¿“¬À≈—ß®“°°“√ Ÿ≠‡ ’¬§«“¡¡’§ÿ≥§à“
„πµπ‡Õß : ∑ƒ…Æ’‡™‘ß “√–Õ∏‘∫“¬°“√øóôπÀ“¬®“°§«“¡´÷¡‡»√â“
¢Õß µ√’‰∑¬«—¬°≈“ß§π*
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√≥å‡ªìπ‰ª‰¥â¬“°·≈–¡’§«“¡®”°—¥ °“√»÷°…“§√—Èßπ’È¡’
«—µ∂ÿª√– ß§å∑’Ë®– √â“ß∑ƒ…Æ’‡™‘ß “√–Õ∏‘∫“¬°√–∫«π°“√øóôπÀ“¬®“°§«“¡´÷¡‡»√â“„π∑—»π–¢Õß
µ√’«—¬°≈“ß§π∑’Ë¡’¿“«–´÷¡‡»√â“ √–‡∫’¬∫«‘∏’«‘®—¬∑’Ë„™â„π°“√»÷°…“§√—Èßπ’È §◊Õ°“√«‘®—¬‡™‘ß§ÿ≥¿“æ
·∫∫°“√ √â“ß∑ƒ…Æ’®“°¢âÕ¡Ÿ≈æ◊Èπ∞“π ¢âÕ¡Ÿ≈À≈—°„π°“√«‘‡§√“–Àå§√—Èßπ’È‰¥â®“° —¡¿“…≥å‡®“–≈÷° µ√’
∑’Ë‰¥â√—∫°“√«‘π‘®©—¬‚√§´÷¡‡»√â“™π‘¥√ÿπ·√ß∑’Ë¡“√—∫∫√‘°“√„π‚√ßæ¬“∫“≈„À≠à3·Ààß„π°√ÿß‡∑æ¡À“π§√
®”π«π 31 §π ´÷Ëß¡’∑—Èß µ√’∑’Ë¬—ß§ß¡’Õ“°“√´÷¡‡»√â“·≈–ª√“»®“°Õ“°“√´÷¡‡»√â“ «‘‡§√“–Àå¢âÕ¡Ÿ≈®“°
æ◊Èπ∞“π°“√‡ª√’¬∫‡∑’¬∫¢âÕ¡Ÿ≈·≈–°“√µ—Èß§”∂“¡Õ¬à“ß¡’§«“¡‰«‡™‘ß∑ƒ…Æ’
º≈°“√»÷°…“ª√“°Ø°“√≥å°“√øóôπÀ“¬®“°§«“¡´÷¡‡»√â“‰¥â∑ƒ…Æ’‡™‘ß “√–™◊ËÕ«à“ ç°“√§◊π
§«“¡ ”§—≠„Àâµπ‡Õß¿“¬À≈—ß®“°°“√ Ÿ≠‡ ’¬§«“¡√Ÿâ ÷°¡’§ÿ≥§à“„πµπ‡Õß¢Õß µ√’«—¬°≈“ß§π∑’Ë¡’
§«“¡´÷¡‡»√â“é ∑ƒ…Æ’π’È®”·π°‡ªìπ 3 ™à«ß ™à«ß·√°§◊Õ ç‡ß◊ËÕπ‰¢‡™‘ß “‡Àµÿ¢Õß§«“¡´÷¡‡»√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∑’Ë‡ªìπ»Ÿπ¬å°≈“ß·Ààß™’«‘µ¢Õß µ√’·≈–°“√ª√–‡¡‘πµ—¥ ‘π°“√°√–∑”¢Õß∫ÿ§§≈∑’Ë
‡ªìπ»Ÿπ¬å°≈“ß·Ààß™’«‘µ„π∑“ß≈∫´÷Ëß àßº≈„Àâ µ√’√—∫√Ÿâ«à“µπ‡Õß‰¡à¡’§ÿ≥§à“®÷ßµÕ∫ πÕß‡ªìπÕ“°“√´÷¡‡»√â“
®π°√–∑—Ëß “¡“√∂√–≈÷°√Ÿâ°“√‡ª≈’Ë¬π·ª≈ß„πµπ‡Õß‰¥â™à«ß∑’Ë Õß™à«ßç°“√‡√’¬π√Ÿâ‡°’Ë¬«°—∫§«“¡´÷¡‡»√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≈—ß¢÷ÈπÕ¬Ÿà°—∫‡ß◊ËÕπ‰¢¢Õß·µà≈–∫ÿ§§≈ °≈¬ÿ∑∏å¥—ß°≈à“«‰¥â·°à
°“√®—¥°“√°—∫§«“¡´÷¡‡»√â“¥â«¬µπ‡Õß°“√¢Õ§«“¡™à«¬‡À≈◊Õ·≈–°“√‰µ√àµ√Õßµπ‡Õß à«π™à«ß ÿ¥∑â“¬
‡ªìπ™à«ß ç°“√øóôπÀ“¬®“°§«“¡´÷¡‡»√â“é ª√–°Õ∫¥â«¬¡‚π∑—»πå°“√§≈“¬ª¡·≈–°“√‡µ‘∫‚µ„πµπ‡Õß
™à«ßπ’È‡ªìπ™à«ß∑’Ë µ√’ “¡“√∂øóôπÀ“¬®“°§«“¡´÷¡‡»√â“‰¥âÕ¬à“ß ¡∫Ÿ√≥å‚¥¬°“√§◊π§«“¡ ”§—≠„Àâ°—∫
µπ‡Õß®“°°“√∑’Ë‡§¬¬÷¥∂◊Õ·≈–„Àâ§«“¡ ”§—≠°—∫∫ÿ§§≈Õ◊Ëπ‡ ¡◊Õπ‡ªìπ»Ÿπ¬å°≈“ß·Ààß™’«‘µ ®÷ß∑”„Àâ√Ÿâ ÷°
∂÷ß§ÿ≥§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‘∑’Ë§”π÷ß∂÷ß§«“¡‡ªìπ
À≠‘ß™“¬ ·π«∑“ß°“√ªØ‘∫—µ‘°“√æ¬“∫“≈„π§≈‘π‘°·≈–„π™ÿ¡™π ·≈–°“√«‘®—¬‡æ◊ËÕ¢¬“¬§«“¡√Ÿâ‡°’Ë¬«
°—∫§«“¡´÷¡‡»√â“·≈–°“√æ—≤π“„Àâ‡ªìπ∑ƒ…Ø’∑’Ë¡’°“√π”‰ª„™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 æ¬“∫“≈»“ µ√å¥ÿ…Æ’∫—≥±‘µ ∫—≥±‘µ«‘∑¬“≈—¬ ¡À“«‘∑¬“≈—¬¡À‘¥≈
** ºŸâ™à«¬»“ µ√“®“√¬å ¿“§«‘™“ ÿ¢¿“æ®‘µ·≈–°“√æ¬“∫“≈®‘µ‡«™»“ µ√å §≥–æ¬“∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬¡À‘¥≈
*** §≥–°√√¡°“√§«∫§ÿ¡«‘∑¬“π‘æπ∏å

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 et.al.
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,

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

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

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

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

Causal
Conditions
Perceivedhealthdeviation,Perceivedsuffering,easytodie,and
retribution
Fearofdyspneaoccurring
Perceivedremittent&incurabling
Realizedhealthcondition
Recognizedself-responsibility
Perceivedlivingwithsuffering
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

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

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
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

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

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
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

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

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

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
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

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 it...it 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

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
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:
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 et.al.
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

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

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.

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.

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

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

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?

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
patients...you 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.

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.

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

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

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.

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.

§«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡·≈–°“√·°âªí≠À“§«“¡¢—¥·¬âß
„π°“√ªØ‘∫—µ‘°“√æ¬“∫“≈: °“√»÷°…“‡™‘ß§ÿ≥¿“æ„π¿“§„µâ
¢Õßª√–‡∑»‰∑¬
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 §≥–æ¬“∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å
** Õ“®“√¬å §≥–æ¬“∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å
*** ºŸâ™à«¬»“ µ√“®“√¬å §≥–æ¬“∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å
**** »“ µ√“®“√¬å ¡À“«‘∑¬“≈—¬ Florida Atlantic ºŸâ‡™’Ë¬«™“≠∑ÿπøÿ≈‰∫√∑å §≥–æ¬“∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬ ß¢≈“π§√‘π∑√å
∫∑§—¥¬àÕ: °“√«‘®—¬§√—Èßπ’È ¡’«—µ∂ÿª√– ß§å‡æ◊ËÕ»÷°…“§«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡„π°“√ªØ‘∫—µ‘æ¬“∫“≈
·≈–°“√·°âªí≠À“§«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡¢Õßæ¬“∫“≈„π¿“§„µâ¢Õßª√–‡∑»‰∑¬ ºŸâ„Àâ¢âÕ¡Ÿ≈§◊Õ
æ¬“∫“≈«‘™“™’æ∑’ËªØ‘∫—µ‘ß“π∑—Èß„π·ºπ°ºŸâªÉ«¬πÕ° ·≈–ºŸâªÉ«¬„π¢Õß‚√ßæ¬“∫“≈∑—Ë«‰ª 2 ·Ààß ·≈–
‚√ßæ¬“∫“≈»Ÿπ¬å®”π«π 2 ·Ààß„πæ◊Èπ∑’Ë¿“§„µâ¢Õßª√–‡∑»‰∑¬®”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√–‡¥Áπ§«“¡¢—¥·¬âß∑“ß¥â“π®√‘¬∏√√¡¢Õßæ¬“∫“≈ 8 ª√–‡¥Áπ§◊Õ 1) §«“¡¢—¥·¬âß
√–À«à“ß°“√‡≈◊Õ°ªØ‘∫—µ‘µ“¡∫∑∫“∑«‘™“™’æ∑’Ë§«√®–‡ªìπ ·≈–°“√ª°ªÑÕßµπ‡Õß®“°Õ—πµ√“¬
2) °“√¬◊¥™’«‘µ·≈–°“√¬◊¥§«“¡µ“¬ 3) °“√√—°…“§«“¡≈—∫¢ÕßºŸâªÉ«¬ ·≈–°“√‡ªî¥‡º¬¢âÕ¡Ÿ≈‡æ◊ËÕ‡µ◊Õπ
ºŸâÕ◊Ëπ∂÷ßÕ—πµ√“¬4)°“√ª°ªÑÕßºŸâªÉ«¬·≈–°“√§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∑’Ë‡ªìπ‰ª‰¥â ·≈–¢âÕ‡ πÕ
·π–„π°“√·°â‰¢ªí≠À“‡™‘ß®√‘¬∏√√¡„π°“√ªØ‘∫—µ‘æ¬“∫“≈¥â«¬
§” ”§—≠:§«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡°“√·°âªí≠À“§«“¡¢—¥·¬âß∑“ß®√‘¬∏√√¡°“√ªØ‘∫—µ‘°“√æ¬“∫“≈

Wanlapa Kunsongkeit et.al.
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
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

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

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

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

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

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.
Available:http.moph.go.th/ops/bhpp/plan%209.html.
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.

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:// www.clininfo.health.nsw. gov.au/hoopolic/
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.

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.

°“√«‘‡§√“–Àå·π«§‘¥‡√◊ËÕß®‘µ«‘≠≠“≥
«—≈¿“ §ÿ≥∑√ß‡°’¬√µ‘* æ¬.¡.(°“√æ¬“∫“≈Õ“¬ÿ√»“ µ√å·≈–»—≈¬»“ µ√å)
Marilyn A. McCubbin**RN., Ph.D., FAAN
* π—°»÷°…“À≈—° Ÿµ√æ¬“∫“≈»“ µ√¥ÿ…Æ’∫—≥±‘µ §≥–æ¬“∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à
** »“ µ√“®“√¬å ‚√ß‡√’¬πæ¬“∫“≈ ¡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—Èπ®‘µ«‘≠≠“≥¬—ß‰¥â√—∫°“√¬Õ¡√—∫®“°Õß§å°“√Õπ“¡—¬‚≈°
π—°∑ƒ…Æ’∑“ß°“√æ¬“∫“≈Õß§å°√æ¬“∫“≈·≈–√—∞∫“≈‰∑¬«à“‡ªìπ¡‘µ‘∑’Ë¡’§«“¡ ”§—≠„π°“√¥Ÿ·≈ºŸâªÉ«¬
Õ¬à“ß‰√°Áµ“¡®‘µ«‘≠≠“≥¬—ß‡ªìπ¡‘µ‘∑’Ë¡’§«“¡§≈ÿ¡‡§√◊Õ·≈–¡’ºŸâ„Àâ§”π‘¬“¡Õ¬à“ßÀ≈“°À≈“¬
ºŸâ«‘‡§√“–Àå®÷ß‰¥â«‘‡§√“–Àå·π«§‘¥‡√◊ËÕß®‘µ«‘≠≠“≥‚¥¬Õ“»—¬«‘∏’°“√¢Õß Walker ·≈– Avant ‡æ◊ËÕ„Àâ
‡°‘¥§«“¡™—¥‡®π‡°’Ë¬«°—∫·π«§‘¥„π¡‘µ‘®‘µ«‘≠≠“≥ º≈°“√«‘‡§√“–Àåæ∫«à“§ÿ≥≈—°…≥–∑’Ë ”§—≠¢Õß
®‘µ«‘≠≠“≥§◊Õ §«“¡√Ÿâ ÷°¢Õß°“√¡’ ‘Ëß¬÷¥‡Àπ’Ë¬« §«“¡‡™◊ËÕ ·≈– §«“¡À¡“¬·≈–‡ªÑ“À¡“¬„π™’«‘µ
‘Ëß∑’Ëπ”„Àâ‡°‘¥®‘µ«‘≠≠“≥∑’Ë ”§—≠§◊Õ ‡Àµÿ°“√≥å∑’Ë°àÕ„Àâ‡°‘¥§«“¡‡§√’¬¥ ¿“«–«‘°ƒµ‘ ∑ÿ°¢å∑√¡“π ·≈–
§«“¡µ“¬ ‘Ëß∑’Ëµ“¡¡“¿“¬À≈—ß°“√‰¥â√—∫°“√¥Ÿ·≈¥â“π®‘µ«‘≠≠“≥§◊Õ §«“¡√Ÿâ ÷°º“ ÿ° §ÿ≥¿“æ™’«‘µ
·≈–§«“¡‡ªìπ¡πÿ…¬åº≈°“√«‘‡§√“–Àå™à«¬„Àâ‡¢â“„®¡‘µ‘®‘µ«‘≠≠“≥·≈–π”‰ª Ÿà°“√»÷°…“‡°’Ë¬«°—∫°“√¥Ÿ·≈
¥â“π®‘µ«‘≠≠“≥µàÕ‰ª
§” ”§—≠: °“√«‘‡§√“–Àå·π«§‘¥ ®‘µ«‘≠≠“≥ §«“¡√Ÿâ ÷°¢Õß°“√¡’ ‘Ëß¬÷¥‡Àπ’Ë¬« §«“¡‡™◊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
Wannipa Asawachaisuwikrom,* Ph.D.
Instructor, Community Health Nursing Department, Faculty of Nursing, Burapha University

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

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

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

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

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.

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.

°“√«‘‡§√“–Àå¡‚π∑—»πå: §«“¡‡™◊ËÕ„π ¡√√∂π–µπ‡Õß
¥√.«√√≥‘¿“ Õ—»«™—¬ ÿ«‘°√¡
Õ“®“√¬å ¿“§«‘™“°“√æ¬“∫“≈™ÿ¡™π §≥–æ¬“∫“≈»“ µ√å ¡À“«‘∑¬“≈—¬∫Ÿ√æ“
∫∑§—¥¬àÕ: °“√«‘‡§√“–Àå¡‚π∑—»πå‡°’Ë¬«°—∫§«“¡‡™◊ËÕ„π ¡√√∂π–À√◊Õ§«“¡ “¡“√∂µπ‡Õßπ’È ®–™à«¬„Àâ
π—°«‘™“™’æ ÿ¢¿“æ‡¢â“„®§«“¡À¡“¬¢Õß¡‚π∑—»πå¥—ß°≈à“«°√–®à“ß™—¥¢÷Èπ ◊ËÕ§«“¡À¡“¬‰¥âµ√ß°—π
Õ—π®–‡ªìπª√–‚¬™πå„π°“√ªØ‘∫—µ‘ß“π¥â“π ÿ¢¿“æ √«¡∑—Èß “¡“√∂π”¡‚π∑—»πå‡°’Ë¬«°—∫§«“¡‡™◊ËÕ
„π ¡√√∂π–À√◊Õ§«“¡ “¡“√∂µπ‡Õß‰ªª√–¬ÿ°µå„πß“π àß‡ √‘¡ ÿ¢¿“æ∑’Ë‡πâπ°“√‡ª≈’Ë¬π·ª≈ßæƒµ‘°√√¡
§” ”§—≠: ¡‚π∑—»πå §«“¡‡™◊ËÕ ¡√√∂π–µπ‡Õß §«“¡ “¡“√∂µπ‡Õß

Research article list

More Related Content

Viewers also liked

More from BP KOIRALA INSTITUTE OF HELATH SCIENCS,, NEPAL