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Nursing older people in Thailand
Nursing Older People in Thailand: Embryonic Holistic Rhetoric and the Biomedical Reality of Practice
Tassana Choowattanapakorn, BSc, MSc, PhD, RN, Rhonda Nay, BA, Mlitt, PhD, RN, FRCNA, FCN (NSW), FAAG, and Deirdre Fetherstonhaugh, DipAppSc, BA, MA, RN, Renal Cert
Qualitative research, informed by grounded theory, was used to investigate gerontic nursing practices in Bangkok, Thailand. Indepth interviews with older persons, their families, and nurses were conducted and the data were analyzed using constant comparison. Five inter-related major themes in gerontic nursing practice were revealed: the reality of nursing practice, family caregiving, views of gerontic nursing, tension, and communication. It was concluded that, though nursing rhetoric supported holistic care, the reality of everyday practice is still biomedical in focus. (Geriatr Nurs 2004;25:17--23)
January/February 2004
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H
ealth care services in Thailand are under the authority of the Ministry of Public Health and are classified into five levels: self care (support of the family and their elderly relatives to care for themselves), primary health care (care provided for persons in the community at the village level by volunteers), primary care (care provided for persons in the community by trained personnel), secondary care (care provided by medical and health personnel in general and specialized facilities), and tertiary care (high level care).1 Thailand’s health care system is financed primarily through four types of programs: voluntary health insurance, which covers between 2.2 and 3.6 million people (recent figures put the total population at 63.583 million2); mandatory programs like Workmen’s Compensation and Social Security, which cover firms with ten or more employees; social welfare programs, which help lower-income families, the elderly, and other vulnerable groups; and fringe benefits, which are provided by large private firms, government agencies, and state enterprises.3 Twenty-three million people in Thailand are not covered by any health financing scheme.3 In Thailand, elderly persons, defined as 60 and older, are increasing significantly in numbers. The proportion of elderly persons in the Thai population rose from 4.8% in 1970 to 6.3% in 1990.4 By 1997, the percentage of elderly persons had risen to 8.4%. By the year 2020 it is projected that the proportion of the population older than 60 in Thailand will be 13%.5 Within this sector of the population, women outnumber men, as is the case in many other countries.6 The life expectancy of Thai women and men is different. According to the World Health Organization, the life expectancy at birth of women is 72.2 years, whereas for men it is 65.7 years.7 Government policy support for the elderly in Thailand has moved gradually from maintaining welfare homes to focusing more on health care services. For those persons older than 60 who were not civil servants or privately employed, a health care card is provided covering fees for hospitals and health centers under the Ministry of Public Health. The health fees of civil servants (who were employed for 25 years) are covered, and some private companies provide pensions for their employees.1 However, despite these developments, according to Chongvatana et al8 and Wongsith and Saengtienchai,9 most elderly persons rely on their own efforts and their family support. “Thai society is characterized by a hierarchical tradition in which people occupy differently ranked social positions. Social relationships are marked by superiority and inferiority. Children are taught early to respect older people and people of higher status.”10 Old persons are valued, respected, and honored by their children as they are considered to have had significant life experiences, and they are expected to provide advice and to consult on family matters and society in general.10 Most elderly people live with their children. Although their children may be married, at least one child remains living with them.11,12 It is
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estimated that approximately 94% of the elderly live with their children. Their children, therefore, are the principal caregivers.13 Within the doctrine of Buddhism, children are taught to pour affection on their parents. The raising of children is seen in part as the goodness of parents, and it in turn bestows a great debt upon the children. This debt is expected to be repaid by children when their parents grow older.1416 Unlike most debts, this goodness debt is never completely repaid.17 Moreover, it is believed that misadventure will fall upon the children if they neglect to care for their aging parents. Hence, taking care of elderly parents is doing good to them,14,15 and Thais perceive that adherence to this custom brings merit, which they hope will mean a better life in the future according to the Buddhist belief in a chain of rebirth.10 Thai persons have espoused this culture of caring for elderly parents for a long time. However, the growing number of the aged along with socioeconomic changes occurring in Thailand at present (such as the trend for more women to enter paid employment and the economic imperative whereby many younger persons leave rural areas to take jobs in larger cities) is shifting the burden of caring from children toward society and, more specifically, government. Research on the impact that an aging population has on health care, especially nursing in Thailand, is sparse. The needs of this sector of the population and their caregivers have been largely overlooked in the education and training of health professionals. Aged care has been addressed in Thai nursing curriculums for approximately two decades and only then as a small part of adult nursing subjects in undergraduate courses. Specific knowledge about nursing the elderly is therefore not comprehensive enough for current requirements. Though some graduate courses provide specific knowledge for nurses, such as a short course in gerontic nursing, and the masters of nursing science, which offers majors in gerontic nursing, many nurses caring for the elderly are never exposed to these courses. Most nursing research in Thailand uses a quantitative approach, which generally focuses on healthier elderly persons in the community or at elderly clubs, which offer some health and social care. Little use is made of qualitative approaches in the study of nursing.18 Moreover, the majority of projects are focused on one aspect of care, which results in the failure to either establish a broader picture or to address issues related specifically to the nursing care of the elderly.12 The aim of this study was to investigate nursing care of the elderly in hospitals in Thailand as it is experienced and described by nurses, families, and patients. Qualitative research was determined to be the most appropriate means of exploring this area. Many studies about aged care in western countries have investigated issues and experiences of residents in nursing homes and hospitals. Recently a few nursing homes have been established in the larger cities of Thailand, such as
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Bangkok. However, most elderly persons still receive health care in hospitals. For the care required in chronic illness, many older persons stay at home, and their families care for them. Very few persons move to nursing homes or homes for the elderly,11-13 so for this study the hospital was an appropriate setting to study nursing care of the elderly. RESEARCH QUESTION The question that this study addressed was how gerontic nursing practice is experienced and described by elderly patients, family members, and nurses in Thailand. SETTINGS The settings for this study were two hospitals in Bangkok, Thailand. One was a public hospital under the Ministry of Public Health and the other a university hospital. Medical wards from which the population was drawn were selected. The three targeted groups were elderly patients, their family members, and nurses. The inclusion criteria for each group were as follows: Elderly patients • Age 60 and older • Experience of a minimum of 5 days in a medical ward • No history of a mental disease or a cognitive disorder such as dementia • No hearing or speech impairment • Can communicate in the Thai language Family members • More than 15 years of age with frequent visits to an elderly relative in the hospital • Ability to communicate in the Thai language Nurses • Working full time • Female or male • Willing to share their experience of aged care • Ability to communicate in the Thai language D ATA C O L L E C T I O N A N D A N A LY S I S Data collection and analysis was informed by the grounded theory method of theoretical sampling and saturation.19 The data were collected via in-depth interviews from the three population groups. Most interviews were conducted at the participants’ own homes. A few participants talked at convenient places nearby their houses or the hospitals. Each interview lasted approximately one hour in duration. Constant comparative analysis was conducted on the data. The stage of data collection was concluded when the data were saturated or insufficient new information emerged to warrant continued data collection. In total, 23 participants were interviewed: seven elderly patients, five family members, and 11 nurses. FINDINGS Five major related themes issues emerged from the data: the reality of nursing practice, family caregiving, January/February 2004
views of gerontic nursing, tension, and communication. This study found that the nursing of elderly persons in two hospitals in Bangkok did not reflect holistic nursing care.
The Reality of Nursing Practice The nursing curriculum and rhetoric related to the nursing care of the elderly is based on a holistic model, but the everyday practice of participants in the study was consistent with the biomedical model. The holistic model is based on a belief that care should respect the whole individual—physical, psychologic, social, and spiritual—taking into account the context in which the person lives.20,21 The biomedical model, on the other hand, focuses on the presenting disease and its treatment and largely ignores the person and their context. The care is organized around the physician’s treatment rather than the patient’s goals.22 Therefore, nurses focus on the physical care of patients and neglect their psychologic and social care.23,24 The following quotes from nurse participants in the study demonstrate the influence of the biomedical model: Nursing care will focus on medical treatment by doctors… We do not focus on nursing care, but rather doing injections, giving saline. …We only do our routine work and finish it without having enough time to get in touch with the patients in terms of learning their problems or their feelings while staying in the hospital. We give them less time and concentrate on the treatment of their illness without taking into account their emotions/feeling or spiritual aspects.
The physical nursing care of elderly persons involves several tasks. Non-nursing work presents even further tasks for which nurses must be responsible. In Thailand these further tasks tend to distract nurses from their nursing practice. Nurses reported that they were involved in massive amounts of work that were not nursing care for older patients. Examples of non-nursing work included billing, storing medicine for patients in the ward, and managing of the different health cards and insurance cards for the patients’ payments. Nurses spent much of their time on these tasks. Unfinished tasks were perceived to be a reason for disciplinary action, whereas providing insufficient psychologic care was not. Nurses tended to approach their work in terms of getting the job done. Their inability to provide sufficient nursing care was explained as a consequence of the nurses having too many non-nursing tasks. Nurses had no time to get to know the older patients. This finding is similar to that of an Australian study by Nay,25 which reported that nurses have no time to talk with the patients. This prioritizing of tasks, whereby the needs of the whole person—including those of the mind and spirit— are not addressed, was of concern to the nurses in the Thai study. Nursing care delivered in this way led to claims by patients and family members in the study of rough hand care, rushed patients, tardy responses, no response, lack of explanation, and poor communication with nurses. 19
The development of primary nursing is a challenge for traditional nursing in Thailand if holistic care for patients is to be achieved. Primary nursing is nursing care that focuses on the patient as the center.26,27 The nurse has his or her own patients, a feature central to this model. One nurse is assigned to plan and provide the principal care to the same patients during their admission stay. This type of nursing is believed to move nurses toward being with the patients and the development of continuing care for the patients.28
Family Caregiving Most nurses in the study revealed that family members who were actively involved with elderly patients had a significant impact on the patients. The elderly patients appeared to recover more quickly when family members participated in their care. At the same time, family members were able to show their willingness to care for their aging parent with the underlying sense of filial obligation being central to the caring process. Assistance with activities of daily living was seen to be an example of the responsibilities that family members engaged in so that they could support their aging relatives. The nurses believed that the family had an obligation to care for their relatives in the hospital. Families who did not participate in the care of a relative often were condemned. A nurse demonstrated this belief as follows: I observed that the elderly patients look well and fresh when their relatives come to visit. The others who have no visitors would look at those people around with visitors. They are quiet. I don’t know what they think.
Likewise, most of the patients’ families reported that it was their obligation to take care of their relatives, including during hospital stays. This suggests that the sense of filial obligation is ever present and strong in Thai persons.14,15 The family’s obligational sense of care was explained by the participants as the bond between parents and children. Family members also maintained that their parent preferred care from children as demonstrated in the following quote: Being her daughter, I think I can give her better care. It’s like we can communicate mentally. Mothers would also prefer to be taken care of by their children…
Given the traditional hierarchy within society, Thai people respect the elderly and accept that they will take care of them when they get older. Some nurses in this study liked caring for elderly persons and they felt comfortable and viewed the elderly as their own relatives. A simple technique that they used to approach their patients was to greet them nicely, take a bit more time to talk with them, and even call them uncle, grandmother, grandfather, as if they were their relatives. Other nurses, who disliked caring for elderly persons, felt uncomfortable and wanted to be transferred to another ward that did not have elderly patients.
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Views of Gerontic Nursing Some nurses in the study had some negative views of the declining physical health of the elderly, in particular that they were often sick, risked accidents, and were prone to infection. The following quotes from interviews illustrate these perceptions: Sixty year olds and up become less independent, forgetful, white hair, wrinkled skin. People get sick when they are old. When the elderly get sick, it is difficult for them to recover. For example, the elderly with wounds would risk infection. …They have to receive more care from nurses because there are a lot of complications. They can easily become infected and have accidents.
Though Thai nurses respect elderly persons, they also tend to stereotype them. Nurses in the study who had adopted this stereotype saw older persons as dependent persons. Therefore, they tended to provide nursing care that overprotected their patients from possible perceived injuries. They provided custodial care. Custodial care mirrors how mothers protect children.29,30 Raising side rails most of the time and not allowing their patients to go to toilet, but giving them the bed pans, were some simple examples from the study. Custodial care does not promote independence in the elderly. Age stereotyping and negative attitudes toward elderly persons have been evident in the public domain for a long time in Thailand. The worst type of this particular stereotyping is that some persons see the elderly as a problem for society. They believe that too much tax money is allocated to provide health services, social security, and welfare for elderly persons. This type of ageism is not the only prejudicing factor against the elderly; the biomedical model also has an influence. The power of biomedicine has convinced the elderly that technology, cosmetic products, and dietary supplements will maintain their good health.13 This stereotyping and prejudice against the aged has meant that there is a perception that the elderly are of less value than other members of society and are different than everyone else.31 Recently, however, and contrary to this negative view of the elderly, a new positive concept of aging has been promulgated. This positive paradigm sees aging as a normal part of the life cycle. Butler32 suggests that the myths of aging must be removed from the public perception and the virtuous attitude of respecting the aged should be cultivated. In nursing practice, this may decrease the delivery of the custodial model of care. The stereotyping of age has meant that many elderly persons have also adopted this perception and are likely to accept their sick role and comply with the nurses’ regimen. Those in the study who adhered to this stereotyping tended to adopt the passive role in the hospital. It was also common for these persons to have their family members help them and interact with nurses. Ageism has led nurses to presume that they are the experts in health care management. They expect patients and
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their families to comply with their regimen.24 In the study compliant patients were seen as lovely, whereas noncompliant patients were labeled as stubborn. Nurses were discouraged by non-compliant patients. This study found similar findings to that of Nay25 and Nehemkis.33 Though the nursing profession was perceived as a valuable career, nurse participants had two different attitudes (as aforementioned) about caring for the aged. The group who felt comfortable working with elderly persons stated they could get along well with their patients and used the older patient’s language and dialect and greeted them with nice words. These nurses felt that this promoted good relationships between nurses and their patients. Thais often use specific words when speaking to senior persons because this is a sign of politeness, respect, and being meaningful. Some of the group of nurses who did not feel comfortable caring for the aged reported that they did not live with elderly persons. They saw elderly persons as being sick and stubborn and differing greatly from healthy persons. Some of these nurses preferred to care for children after they had experienced a couple of years of caring for the elderly.
Tension All participants in the study felt a variety of tensions. Feelings of guilt because of the contrast and conflict between the reality of nursing practice in Thai hospitals and the theories taught within nursing education were manifested as tension. As aforementioned, beliefs and nursing practice were influenced by the biomedical model, whereas nursing care was learned through the holistic model. Physical care and tasks were focused upon, whereas there was insufficient provision for the psychologic care of patients. Nurses themselves spoke of this as the following quote points out: When I feel tired, I don’t want to talk. I might be too mean. Patients should be cared for in all aspects: body, mind, and social life. I admit that I missed out on some parts of it.
Unfair allocation of work was another tension builder among nursing staff. Generally speaking, the tradition in Thailand is that nursing work is allocated according to the level of complexity in the tasks being performed and the knowledge and expertise of the nursing staff. Registered nurses handle more complex work than members of the lower level nursing teams.34 In Thailand, registered nurses take the role of team leaders, with technical nurses and nursing assistants being team members. Simple technical and unpleasant work, such as giving bedpans and cleaning, is often assigned to technical nurses and nursing aides. Some team members expressed feelings of inferiority when given these lower jobs. This caused evasion of unpleasant duties among nursing staff. Elderly patients and their families in the study were not satisfied with these models of nursing care but tended to January/February 2004
avoid criticism. Similar to a study conducted by Nay,35 many elderly clients displayed a fear of neglected care retaliation from nurses. Conflict among the elderly and their families was therefore kept quiet. Consequently, elderly patients often asked their family members to help them with their basic daily living care activities. Because of the culture of filial obligation, Thai families were almost always willing to assist their older relatives,16,17 and most participants identified the necessity of filial obligation and family caregiving. Therefore, family members often visited their elderly relatives in the hospital and stayed by the bedside. However, some nurses in the study had observed a few family members abandoning their elderly relatives in the hospital. These families were from lower-income homes. As aforementioned, many older persons who are not retired from the government sector are ineligible to receive a pension but may apply for a health card. The limitation of this type of card, however, is that it is available solely for hospitals under the Ministry of Public Health, where some fees are waived. Persons from lower income groups who attend other hospitals may still have to worry about partial expenses of health care costs, and this may cause family members to avoid the responsibility of paying the fees by not acknowledging that they are related to the patient. Patients who are poor and who do not have relatives who would be responsible for health care payment fees come under the special category of destitute patients, and their health services fees at the public hospitals are waived. The poverty and hardship of living in the present society in Thailand has meant that members of some families have had to put their employment ahead of taking care of their elderly relatives. Tension can occur in these types of families when members are unable to repay the goodness of their elderly relatives. As the following transcript shows, nurses in the study commented on the fact that some visitors, who called themselves neighbors, looked like the elderly patients: …In another case, an aging neighbor came with a young girl to visit the patient. That girl looked so much like the patients. She said she was a neighbor… I wonder why they do not say they are relatives. We never told them to pay but just asked how they are related to the patients and try to encourage them to visit the patients.
These neighbors seldom came to the hospital. The fact that some nurses identified this situation indicates that there is tension between the sense of filial obligation and the need to keep oneself and family above the poverty line.
Communication Communication is important in the interaction between nurses and elderly patients and their families. Nurses in the study frequently avoided answering questions from their clients and families and asked them to discuss their 21
problems with their physicians. This lack of information and explanation about illness, treatment, and the progress of elderly patients’ conditions reduced the confidence that patients and their family had in the nurses. Nurses in the study perceived talking with patients as a waste of time and focused more on finishing their tasks instead. Likewise, some elderly patients said they had little communication with nurses. They often used their family members to ask nurses for assistance or information. Moreover, they also looked for information in books, on television, on radio, and in brochures about their disease and how to care for themselves. …I let my children know and they will in turn ask the doctor or the nurse. They sometimes wait for the doctor and tell him about my doubts or conditions. I usually do not discuss with the nurses…
Communication is an important factor in alleviating tension because it builds better understanding, and therefore more appropriate nursing care can be provided to elderly patients. Inadequate communication lowers the expectations of quality care. CONCLUSIONS The biomedical model of care in Thai nursing was the dominant mode of practice identified in this study. There were not enough Thai nurses who believed in and were prepared to implement holistic nursing care to change the biomedical traditions of nursing practice. This seems to be related to a strongly embedded belief in science and the tradition that accepts that good nurses are female, caring, and obedient assistants of physicians. The Nightingale theory of nursing, or at least an interpretation thereof, has been a model for nurses since Nightingale was acknowledged as the founder of modern nursing. It is only relatively recently that this model has been challenged in western countries.36,37 It is not uncommon to still hear physicians comment that they hold this handmaiden view of the nurse. The issues identified in this study, reality of nursing practice, family caregiving, views of gerontic nursing, and communication, are all interrelated through an underlying theme of tension. Thai cultural influences related to families caring for elderly persons, financial problems, and social welfare also contribute to a context that impacts nursing practice. Broader considerations and better understanding of elderly patients and their surroundings would help nurses move from a traditional nursing approach to a more holistic model of nursing. Expectations of independent roles and autonomy for nurses will help this change and facilitate higher quality nursing care of elderly persons in Thailand in the future. R E C O M M E N D AT I O N S The findings reflect many true practices, thoughts, and feelings about the nursing care of elderly persons in
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Thailand. Guides of worthy directions for developing nursing education, practice, and research along with the government are recommended. Clear, solid, and specific aged care curriculum is needed in schools of nursing to better prepare nursing students in understanding how to provide the elderly with quality nursing care. Another step in the right direction would be to replace stereotyping of the aged with an understanding of normal life processes of aging. It is important that nursing instructors adopt positive new attitudes toward the elderly. They are in the best position for providing role models for nursing students. Changing times dictate that nursing practice move from the power of the biomedical model and the dominance of physicians to the holistic model of nursing. In today’s world, holistic nursing can better recognize the psychologic, spiritual, and environmental needs of patients and their families and can address individual differences. Though the basic daily tasks of nursing cannot be overlooked, the fact must be acknowledged that nursing has changed in the 21st century to encompass the concept of caring for all aspects of the individual. Nursing care that supports independence of the elderly is strongly advocated. Research on the nursing care of the elderly must continue to better understand the feelings, beliefs, thoughts, behaviors, and experiences of the elderly population so that excellent quality care may be provided to this sector of the Thai population. The Thai government needs to contribute more to the maintenance and improvement of health care services and social welfare for the aged, especially for those in the lower-income brackets of Thai society. REFERENCES 1. Choowattanapakorn T. Nursing older people in Thailand: embryonic holistic rhetoric and the biomedical reality of practice. Unpublished PhD thesis: La Trobe University, Victoria; 2001. 2. The World Health Group. Available at: http://www.who.int/country/tha/en/. Cited 2003 March 13. 3. The World Health Group. Available at: http://www.worldbank.org/eapsocial/ countries/thai/health1.hubtm. Cited 2003 March 13. 4. Chayovan J, Knodel J. A report on the survey of the welfare of the elderly in Thailand. Bangkok: Institute of Population Studies, Chulalongkorn University; 1997. 5. National Statistical Office. The status of Thai elderly. Bangkok: P. A. Living; 1998. 6. National Statistical Office. The statistics of elderly in Thailand. Bangkok: P.A. Living; 1998. 7. The World Health Organization. Available at: http://www.who.int/country/tha/ en/. Accessed 2003 March 26. 8. Chongvatana N, Wongboonsin K, Kowatanakul R. Morbidity pattern and medical welfare policy for the Thai elderly. Bangkok, Thailand: Population Institution Chulalongkorn University; 1998. 9. Wongsith M, Saengtienchai C. Thailand. In: Kosberg JI,editor. International handbook on services for the elderly. Westport, Conn: Greenwood Press; 1994. p. 430-44. 10. Choowattanapakorn T. The social situation in Thailand: the impact on elderly people. Int J Nurs Pract 1999;5:95-9. 11. Knodel J, Saengtienchai C, Sittitrai W. Living arrangements of the elderly in Thailand: views of the populace. J Cross-Cult Gerontol 1995;10:79-111. 12. Wongsith M, Siriboon S. Family and the elderly: case study of Bangkok and Phra Nakhon Sri-Ayuddhaya. Bangkok Population Institution: Chulalongkorn University; 1998. 13. Chayovan J, Knodel J. Living arrangement and family support of Thai elderly. Bangkok: Chulalongkorn University; 1999. 14. Caffrey RA. Family care of the elderly in Northern Thailand: changing patterns. J Cross-Cult Gerontol 1992;7:105-16. 15. Mulder N. Inside Thai society: an interpretation of everyday life. Bangkok: Duang Kamol; 1992.
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16. Limanonda B. Families in Thailand: beliefs and realities. J Comp Fam Stud 1995;16:67-82. 17. Podhisita C. Buddhism and Thai world view. In: Pongsapich A, editor. Traditional and changing Thai world view. Bangkok: Chulalongkorn University Press; 1998. p. 31-62. 18. Sombat P. A survey of nursing research related elderly population in Thailand. Unpublished Master of Nursing, Mahidol, Bangkok, Thailand; 1997. 19. Strauss A, Corbin J. Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park: Sage; 1990. 20. Longino CF, Murphy JW. The old age challenge to the biomedical model paradigm strain and health policy. New York: Baywood; 1995. 21. Marcus MT, Liehr PR. Qualitative approaches to research. In: LoBiondo-Wood G, Haber J, editors. Nursing research: methods, critical appraisal, and utilization. 4th ed. St. Louis: Mosby; 1998. p. 215-45. 22. Memmler RL, Cohen BJ, Wood DL. The human body in health and disease. 7th ed. Philadelphia: Lippincott; 1992. 23. Estes CL, Binney EA. The biomedicalization of aging: dangers and dilemmas. Gerontologist 1989;29:587-96. 24. Pearson A, Vaughan B, FitzGerald M. Nursing models for practice. 2nd ed. Oxford: Butterworth-Heinemann; 2000. 25. Nay R. Benevolent oppression: lived experiences of nursing home life. Unpublished PhD, University of New South Wales, Australia; 1993. 26. Pearson A. Primary nursing. In: Pearson A editor. Primary nursing: nursing in the Burford and Oxford nursing development units. London: Croom Helm; 1988. p. 23-39. 27. Ersser S, Tutton E. Primary nursing a second look. In: Ersser S, Tutton E, editors. Primary nursing in perspective Oxford: Scutari Press; 1991. p. 3-30. 28. McMahon R. Power and communication issues in primary nursing. In: Ersser S, Tutton E, editors. Primary nursing in perspective. Oxford: Scutari Press; 1991. p. 217-26. 29. Fuller D. Challenging ageism through our speech. Nurs Times 1995;91:29-31. 30. McMinn B. Ageism: The challenge for nursing. Australia Nurs J 1996;3:18-24.
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31. Kart CS. The realities of aging: an introduction to gerontology. 4th ed. Boston: Allyn and Bacon; 1994. 32. Butler RN. A disease called ageism. J Am Geriatr Soc 1990;38:178-80. 33. Nehemkis AM. The eye of the beholder: Staff perceptions of noncompliance. In: Gerber KE, Nehemkis AM, editors. Compliance: the dilemma of the chronically ill. New York: Springer Publishing Company; 1986. p. 158-181. 34. Merchant J. Why task allocation? Nurs Pract 1985;2:67-71. 35. Nay R. Benevolent oppression: experiences of older women aging “out of place”. In: Onyx J, Leonard R, Reed R, editors. Revisioning aging: empowerment of older women. New York: Peter Lang; 1999. p. 141-56. 36. Condon J. Nursing theorizing in the United States and Australia. In: Greenwood J, editor. Nursing theory in Australia: development & application. Australia: Harper Educational; 1996. p. 75-104. 37. Meleis AI. Theoretical nursing: development and progress. 3rd ed. Philadelphia: Lippincott; 1997.
TASSANA CHOOWATTANAPAKORN, BSc, MSc, PhD, RN, is a lecturer in nursing at the Chiangmai University in Thailand. RHONDA NAY BA, Mlitt, PhD, RN, FRCNA, FCN (NSW), FAAG, is professor of gerontic nursing at the La Trobe University School of Nursing and Midwifery in Victoria, Australia. DEIRDRE FETHERSTONHAUGH, DipAppSc, BA, MA, RN, Renal Cert, is a research officer at La Trobe University School of Nursing and Midwifery in Victoria, Australia. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0197-4572(03)00243-X
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Tassana Choowattanapakorn, BSc, MSc, PhD, RN, Rhonda Nay, BA, Mlitt, PhD, RN, FRCNA, FCN (NSW), FAAG, and Deirdre Fetherstonhaugh, DipAppSc, BA, MA, RN, Renal Cert
Qualitative research, informed by grounded theory, was used to investigate gerontic nursing practices in Bangkok, Thailand. Indepth interviews with older persons, their families, and nurses were conducted and the data were analyzed using constant comparison. Five inter-related major themes in gerontic nursing practice were revealed: the reality of nursing practice, family caregiving, views of gerontic nursing, tension, and communication. It was concluded that, though nursing rhetoric supported holistic care, the reality of everyday practice is still biomedical in focus. (Geriatr Nurs 2004;25:17--23)
January/February 2004
17
H
ealth care services in Thailand are under the authority of the Ministry of Public Health and are classified into five levels: self care (support of the family and their elderly relatives to care for themselves), primary health care (care provided for persons in the community at the village level by volunteers), primary care (care provided for persons in the community by trained personnel), secondary care (care provided by medical and health personnel in general and specialized facilities), and tertiary care (high level care).1 Thailand’s health care system is financed primarily through four types of programs: voluntary health insurance, which covers between 2.2 and 3.6 million people (recent figures put the total population at 63.583 million2); mandatory programs like Workmen’s Compensation and Social Security, which cover firms with ten or more employees; social welfare programs, which help lower-income families, the elderly, and other vulnerable groups; and fringe benefits, which are provided by large private firms, government agencies, and state enterprises.3 Twenty-three million people in Thailand are not covered by any health financing scheme.3 In Thailand, elderly persons, defined as 60 and older, are increasing significantly in numbers. The proportion of elderly persons in the Thai population rose from 4.8% in 1970 to 6.3% in 1990.4 By 1997, the percentage of elderly persons had risen to 8.4%. By the year 2020 it is projected that the proportion of the population older than 60 in Thailand will be 13%.5 Within this sector of the population, women outnumber men, as is the case in many other countries.6 The life expectancy of Thai women and men is different. According to the World Health Organization, the life expectancy at birth of women is 72.2 years, whereas for men it is 65.7 years.7 Government policy support for the elderly in Thailand has moved gradually from maintaining welfare homes to focusing more on health care services. For those persons older than 60 who were not civil servants or privately employed, a health care card is provided covering fees for hospitals and health centers under the Ministry of Public Health. The health fees of civil servants (who were employed for 25 years) are covered, and some private companies provide pensions for their employees.1 However, despite these developments, according to Chongvatana et al8 and Wongsith and Saengtienchai,9 most elderly persons rely on their own efforts and their family support. “Thai society is characterized by a hierarchical tradition in which people occupy differently ranked social positions. Social relationships are marked by superiority and inferiority. Children are taught early to respect older people and people of higher status.”10 Old persons are valued, respected, and honored by their children as they are considered to have had significant life experiences, and they are expected to provide advice and to consult on family matters and society in general.10 Most elderly people live with their children. Although their children may be married, at least one child remains living with them.11,12 It is
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estimated that approximately 94% of the elderly live with their children. Their children, therefore, are the principal caregivers.13 Within the doctrine of Buddhism, children are taught to pour affection on their parents. The raising of children is seen in part as the goodness of parents, and it in turn bestows a great debt upon the children. This debt is expected to be repaid by children when their parents grow older.1416 Unlike most debts, this goodness debt is never completely repaid.17 Moreover, it is believed that misadventure will fall upon the children if they neglect to care for their aging parents. Hence, taking care of elderly parents is doing good to them,14,15 and Thais perceive that adherence to this custom brings merit, which they hope will mean a better life in the future according to the Buddhist belief in a chain of rebirth.10 Thai persons have espoused this culture of caring for elderly parents for a long time. However, the growing number of the aged along with socioeconomic changes occurring in Thailand at present (such as the trend for more women to enter paid employment and the economic imperative whereby many younger persons leave rural areas to take jobs in larger cities) is shifting the burden of caring from children toward society and, more specifically, government. Research on the impact that an aging population has on health care, especially nursing in Thailand, is sparse. The needs of this sector of the population and their caregivers have been largely overlooked in the education and training of health professionals. Aged care has been addressed in Thai nursing curriculums for approximately two decades and only then as a small part of adult nursing subjects in undergraduate courses. Specific knowledge about nursing the elderly is therefore not comprehensive enough for current requirements. Though some graduate courses provide specific knowledge for nurses, such as a short course in gerontic nursing, and the masters of nursing science, which offers majors in gerontic nursing, many nurses caring for the elderly are never exposed to these courses. Most nursing research in Thailand uses a quantitative approach, which generally focuses on healthier elderly persons in the community or at elderly clubs, which offer some health and social care. Little use is made of qualitative approaches in the study of nursing.18 Moreover, the majority of projects are focused on one aspect of care, which results in the failure to either establish a broader picture or to address issues related specifically to the nursing care of the elderly.12 The aim of this study was to investigate nursing care of the elderly in hospitals in Thailand as it is experienced and described by nurses, families, and patients. Qualitative research was determined to be the most appropriate means of exploring this area. Many studies about aged care in western countries have investigated issues and experiences of residents in nursing homes and hospitals. Recently a few nursing homes have been established in the larger cities of Thailand, such as
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Bangkok. However, most elderly persons still receive health care in hospitals. For the care required in chronic illness, many older persons stay at home, and their families care for them. Very few persons move to nursing homes or homes for the elderly,11-13 so for this study the hospital was an appropriate setting to study nursing care of the elderly. RESEARCH QUESTION The question that this study addressed was how gerontic nursing practice is experienced and described by elderly patients, family members, and nurses in Thailand. SETTINGS The settings for this study were two hospitals in Bangkok, Thailand. One was a public hospital under the Ministry of Public Health and the other a university hospital. Medical wards from which the population was drawn were selected. The three targeted groups were elderly patients, their family members, and nurses. The inclusion criteria for each group were as follows: Elderly patients • Age 60 and older • Experience of a minimum of 5 days in a medical ward • No history of a mental disease or a cognitive disorder such as dementia • No hearing or speech impairment • Can communicate in the Thai language Family members • More than 15 years of age with frequent visits to an elderly relative in the hospital • Ability to communicate in the Thai language Nurses • Working full time • Female or male • Willing to share their experience of aged care • Ability to communicate in the Thai language D ATA C O L L E C T I O N A N D A N A LY S I S Data collection and analysis was informed by the grounded theory method of theoretical sampling and saturation.19 The data were collected via in-depth interviews from the three population groups. Most interviews were conducted at the participants’ own homes. A few participants talked at convenient places nearby their houses or the hospitals. Each interview lasted approximately one hour in duration. Constant comparative analysis was conducted on the data. The stage of data collection was concluded when the data were saturated or insufficient new information emerged to warrant continued data collection. In total, 23 participants were interviewed: seven elderly patients, five family members, and 11 nurses. FINDINGS Five major related themes issues emerged from the data: the reality of nursing practice, family caregiving, January/February 2004
views of gerontic nursing, tension, and communication. This study found that the nursing of elderly persons in two hospitals in Bangkok did not reflect holistic nursing care.
The Reality of Nursing Practice The nursing curriculum and rhetoric related to the nursing care of the elderly is based on a holistic model, but the everyday practice of participants in the study was consistent with the biomedical model. The holistic model is based on a belief that care should respect the whole individual—physical, psychologic, social, and spiritual—taking into account the context in which the person lives.20,21 The biomedical model, on the other hand, focuses on the presenting disease and its treatment and largely ignores the person and their context. The care is organized around the physician’s treatment rather than the patient’s goals.22 Therefore, nurses focus on the physical care of patients and neglect their psychologic and social care.23,24 The following quotes from nurse participants in the study demonstrate the influence of the biomedical model: Nursing care will focus on medical treatment by doctors… We do not focus on nursing care, but rather doing injections, giving saline. …We only do our routine work and finish it without having enough time to get in touch with the patients in terms of learning their problems or their feelings while staying in the hospital. We give them less time and concentrate on the treatment of their illness without taking into account their emotions/feeling or spiritual aspects.
The physical nursing care of elderly persons involves several tasks. Non-nursing work presents even further tasks for which nurses must be responsible. In Thailand these further tasks tend to distract nurses from their nursing practice. Nurses reported that they were involved in massive amounts of work that were not nursing care for older patients. Examples of non-nursing work included billing, storing medicine for patients in the ward, and managing of the different health cards and insurance cards for the patients’ payments. Nurses spent much of their time on these tasks. Unfinished tasks were perceived to be a reason for disciplinary action, whereas providing insufficient psychologic care was not. Nurses tended to approach their work in terms of getting the job done. Their inability to provide sufficient nursing care was explained as a consequence of the nurses having too many non-nursing tasks. Nurses had no time to get to know the older patients. This finding is similar to that of an Australian study by Nay,25 which reported that nurses have no time to talk with the patients. This prioritizing of tasks, whereby the needs of the whole person—including those of the mind and spirit— are not addressed, was of concern to the nurses in the Thai study. Nursing care delivered in this way led to claims by patients and family members in the study of rough hand care, rushed patients, tardy responses, no response, lack of explanation, and poor communication with nurses. 19
The development of primary nursing is a challenge for traditional nursing in Thailand if holistic care for patients is to be achieved. Primary nursing is nursing care that focuses on the patient as the center.26,27 The nurse has his or her own patients, a feature central to this model. One nurse is assigned to plan and provide the principal care to the same patients during their admission stay. This type of nursing is believed to move nurses toward being with the patients and the development of continuing care for the patients.28
Family Caregiving Most nurses in the study revealed that family members who were actively involved with elderly patients had a significant impact on the patients. The elderly patients appeared to recover more quickly when family members participated in their care. At the same time, family members were able to show their willingness to care for their aging parent with the underlying sense of filial obligation being central to the caring process. Assistance with activities of daily living was seen to be an example of the responsibilities that family members engaged in so that they could support their aging relatives. The nurses believed that the family had an obligation to care for their relatives in the hospital. Families who did not participate in the care of a relative often were condemned. A nurse demonstrated this belief as follows: I observed that the elderly patients look well and fresh when their relatives come to visit. The others who have no visitors would look at those people around with visitors. They are quiet. I don’t know what they think.
Likewise, most of the patients’ families reported that it was their obligation to take care of their relatives, including during hospital stays. This suggests that the sense of filial obligation is ever present and strong in Thai persons.14,15 The family’s obligational sense of care was explained by the participants as the bond between parents and children. Family members also maintained that their parent preferred care from children as demonstrated in the following quote: Being her daughter, I think I can give her better care. It’s like we can communicate mentally. Mothers would also prefer to be taken care of by their children…
Given the traditional hierarchy within society, Thai people respect the elderly and accept that they will take care of them when they get older. Some nurses in this study liked caring for elderly persons and they felt comfortable and viewed the elderly as their own relatives. A simple technique that they used to approach their patients was to greet them nicely, take a bit more time to talk with them, and even call them uncle, grandmother, grandfather, as if they were their relatives. Other nurses, who disliked caring for elderly persons, felt uncomfortable and wanted to be transferred to another ward that did not have elderly patients.
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Views of Gerontic Nursing Some nurses in the study had some negative views of the declining physical health of the elderly, in particular that they were often sick, risked accidents, and were prone to infection. The following quotes from interviews illustrate these perceptions: Sixty year olds and up become less independent, forgetful, white hair, wrinkled skin. People get sick when they are old. When the elderly get sick, it is difficult for them to recover. For example, the elderly with wounds would risk infection. …They have to receive more care from nurses because there are a lot of complications. They can easily become infected and have accidents.
Though Thai nurses respect elderly persons, they also tend to stereotype them. Nurses in the study who had adopted this stereotype saw older persons as dependent persons. Therefore, they tended to provide nursing care that overprotected their patients from possible perceived injuries. They provided custodial care. Custodial care mirrors how mothers protect children.29,30 Raising side rails most of the time and not allowing their patients to go to toilet, but giving them the bed pans, were some simple examples from the study. Custodial care does not promote independence in the elderly. Age stereotyping and negative attitudes toward elderly persons have been evident in the public domain for a long time in Thailand. The worst type of this particular stereotyping is that some persons see the elderly as a problem for society. They believe that too much tax money is allocated to provide health services, social security, and welfare for elderly persons. This type of ageism is not the only prejudicing factor against the elderly; the biomedical model also has an influence. The power of biomedicine has convinced the elderly that technology, cosmetic products, and dietary supplements will maintain their good health.13 This stereotyping and prejudice against the aged has meant that there is a perception that the elderly are of less value than other members of society and are different than everyone else.31 Recently, however, and contrary to this negative view of the elderly, a new positive concept of aging has been promulgated. This positive paradigm sees aging as a normal part of the life cycle. Butler32 suggests that the myths of aging must be removed from the public perception and the virtuous attitude of respecting the aged should be cultivated. In nursing practice, this may decrease the delivery of the custodial model of care. The stereotyping of age has meant that many elderly persons have also adopted this perception and are likely to accept their sick role and comply with the nurses’ regimen. Those in the study who adhered to this stereotyping tended to adopt the passive role in the hospital. It was also common for these persons to have their family members help them and interact with nurses. Ageism has led nurses to presume that they are the experts in health care management. They expect patients and
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their families to comply with their regimen.24 In the study compliant patients were seen as lovely, whereas noncompliant patients were labeled as stubborn. Nurses were discouraged by non-compliant patients. This study found similar findings to that of Nay25 and Nehemkis.33 Though the nursing profession was perceived as a valuable career, nurse participants had two different attitudes (as aforementioned) about caring for the aged. The group who felt comfortable working with elderly persons stated they could get along well with their patients and used the older patient’s language and dialect and greeted them with nice words. These nurses felt that this promoted good relationships between nurses and their patients. Thais often use specific words when speaking to senior persons because this is a sign of politeness, respect, and being meaningful. Some of the group of nurses who did not feel comfortable caring for the aged reported that they did not live with elderly persons. They saw elderly persons as being sick and stubborn and differing greatly from healthy persons. Some of these nurses preferred to care for children after they had experienced a couple of years of caring for the elderly.
Tension All participants in the study felt a variety of tensions. Feelings of guilt because of the contrast and conflict between the reality of nursing practice in Thai hospitals and the theories taught within nursing education were manifested as tension. As aforementioned, beliefs and nursing practice were influenced by the biomedical model, whereas nursing care was learned through the holistic model. Physical care and tasks were focused upon, whereas there was insufficient provision for the psychologic care of patients. Nurses themselves spoke of this as the following quote points out: When I feel tired, I don’t want to talk. I might be too mean. Patients should be cared for in all aspects: body, mind, and social life. I admit that I missed out on some parts of it.
Unfair allocation of work was another tension builder among nursing staff. Generally speaking, the tradition in Thailand is that nursing work is allocated according to the level of complexity in the tasks being performed and the knowledge and expertise of the nursing staff. Registered nurses handle more complex work than members of the lower level nursing teams.34 In Thailand, registered nurses take the role of team leaders, with technical nurses and nursing assistants being team members. Simple technical and unpleasant work, such as giving bedpans and cleaning, is often assigned to technical nurses and nursing aides. Some team members expressed feelings of inferiority when given these lower jobs. This caused evasion of unpleasant duties among nursing staff. Elderly patients and their families in the study were not satisfied with these models of nursing care but tended to January/February 2004
avoid criticism. Similar to a study conducted by Nay,35 many elderly clients displayed a fear of neglected care retaliation from nurses. Conflict among the elderly and their families was therefore kept quiet. Consequently, elderly patients often asked their family members to help them with their basic daily living care activities. Because of the culture of filial obligation, Thai families were almost always willing to assist their older relatives,16,17 and most participants identified the necessity of filial obligation and family caregiving. Therefore, family members often visited their elderly relatives in the hospital and stayed by the bedside. However, some nurses in the study had observed a few family members abandoning their elderly relatives in the hospital. These families were from lower-income homes. As aforementioned, many older persons who are not retired from the government sector are ineligible to receive a pension but may apply for a health card. The limitation of this type of card, however, is that it is available solely for hospitals under the Ministry of Public Health, where some fees are waived. Persons from lower income groups who attend other hospitals may still have to worry about partial expenses of health care costs, and this may cause family members to avoid the responsibility of paying the fees by not acknowledging that they are related to the patient. Patients who are poor and who do not have relatives who would be responsible for health care payment fees come under the special category of destitute patients, and their health services fees at the public hospitals are waived. The poverty and hardship of living in the present society in Thailand has meant that members of some families have had to put their employment ahead of taking care of their elderly relatives. Tension can occur in these types of families when members are unable to repay the goodness of their elderly relatives. As the following transcript shows, nurses in the study commented on the fact that some visitors, who called themselves neighbors, looked like the elderly patients: …In another case, an aging neighbor came with a young girl to visit the patient. That girl looked so much like the patients. She said she was a neighbor… I wonder why they do not say they are relatives. We never told them to pay but just asked how they are related to the patients and try to encourage them to visit the patients.
These neighbors seldom came to the hospital. The fact that some nurses identified this situation indicates that there is tension between the sense of filial obligation and the need to keep oneself and family above the poverty line.
Communication Communication is important in the interaction between nurses and elderly patients and their families. Nurses in the study frequently avoided answering questions from their clients and families and asked them to discuss their 21
problems with their physicians. This lack of information and explanation about illness, treatment, and the progress of elderly patients’ conditions reduced the confidence that patients and their family had in the nurses. Nurses in the study perceived talking with patients as a waste of time and focused more on finishing their tasks instead. Likewise, some elderly patients said they had little communication with nurses. They often used their family members to ask nurses for assistance or information. Moreover, they also looked for information in books, on television, on radio, and in brochures about their disease and how to care for themselves. …I let my children know and they will in turn ask the doctor or the nurse. They sometimes wait for the doctor and tell him about my doubts or conditions. I usually do not discuss with the nurses…
Communication is an important factor in alleviating tension because it builds better understanding, and therefore more appropriate nursing care can be provided to elderly patients. Inadequate communication lowers the expectations of quality care. CONCLUSIONS The biomedical model of care in Thai nursing was the dominant mode of practice identified in this study. There were not enough Thai nurses who believed in and were prepared to implement holistic nursing care to change the biomedical traditions of nursing practice. This seems to be related to a strongly embedded belief in science and the tradition that accepts that good nurses are female, caring, and obedient assistants of physicians. The Nightingale theory of nursing, or at least an interpretation thereof, has been a model for nurses since Nightingale was acknowledged as the founder of modern nursing. It is only relatively recently that this model has been challenged in western countries.36,37 It is not uncommon to still hear physicians comment that they hold this handmaiden view of the nurse. The issues identified in this study, reality of nursing practice, family caregiving, views of gerontic nursing, and communication, are all interrelated through an underlying theme of tension. Thai cultural influences related to families caring for elderly persons, financial problems, and social welfare also contribute to a context that impacts nursing practice. Broader considerations and better understanding of elderly patients and their surroundings would help nurses move from a traditional nursing approach to a more holistic model of nursing. Expectations of independent roles and autonomy for nurses will help this change and facilitate higher quality nursing care of elderly persons in Thailand in the future. R E C O M M E N D AT I O N S The findings reflect many true practices, thoughts, and feelings about the nursing care of elderly persons in
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Thailand. Guides of worthy directions for developing nursing education, practice, and research along with the government are recommended. Clear, solid, and specific aged care curriculum is needed in schools of nursing to better prepare nursing students in understanding how to provide the elderly with quality nursing care. Another step in the right direction would be to replace stereotyping of the aged with an understanding of normal life processes of aging. It is important that nursing instructors adopt positive new attitudes toward the elderly. They are in the best position for providing role models for nursing students. Changing times dictate that nursing practice move from the power of the biomedical model and the dominance of physicians to the holistic model of nursing. In today’s world, holistic nursing can better recognize the psychologic, spiritual, and environmental needs of patients and their families and can address individual differences. Though the basic daily tasks of nursing cannot be overlooked, the fact must be acknowledged that nursing has changed in the 21st century to encompass the concept of caring for all aspects of the individual. Nursing care that supports independence of the elderly is strongly advocated. Research on the nursing care of the elderly must continue to better understand the feelings, beliefs, thoughts, behaviors, and experiences of the elderly population so that excellent quality care may be provided to this sector of the Thai population. The Thai government needs to contribute more to the maintenance and improvement of health care services and social welfare for the aged, especially for those in the lower-income brackets of Thai society. REFERENCES 1. Choowattanapakorn T. Nursing older people in Thailand: embryonic holistic rhetoric and the biomedical reality of practice. Unpublished PhD thesis: La Trobe University, Victoria; 2001. 2. The World Health Group. Available at: http://www.who.int/country/tha/en/. Cited 2003 March 13. 3. The World Health Group. Available at: http://www.worldbank.org/eapsocial/ countries/thai/health1.hubtm. Cited 2003 March 13. 4. Chayovan J, Knodel J. A report on the survey of the welfare of the elderly in Thailand. Bangkok: Institute of Population Studies, Chulalongkorn University; 1997. 5. National Statistical Office. The status of Thai elderly. Bangkok: P. A. Living; 1998. 6. National Statistical Office. The statistics of elderly in Thailand. Bangkok: P.A. Living; 1998. 7. The World Health Organization. Available at: http://www.who.int/country/tha/ en/. Accessed 2003 March 26. 8. Chongvatana N, Wongboonsin K, Kowatanakul R. Morbidity pattern and medical welfare policy for the Thai elderly. Bangkok, Thailand: Population Institution Chulalongkorn University; 1998. 9. Wongsith M, Saengtienchai C. Thailand. In: Kosberg JI,editor. International handbook on services for the elderly. Westport, Conn: Greenwood Press; 1994. p. 430-44. 10. Choowattanapakorn T. The social situation in Thailand: the impact on elderly people. Int J Nurs Pract 1999;5:95-9. 11. Knodel J, Saengtienchai C, Sittitrai W. Living arrangements of the elderly in Thailand: views of the populace. J Cross-Cult Gerontol 1995;10:79-111. 12. Wongsith M, Siriboon S. Family and the elderly: case study of Bangkok and Phra Nakhon Sri-Ayuddhaya. Bangkok Population Institution: Chulalongkorn University; 1998. 13. Chayovan J, Knodel J. Living arrangement and family support of Thai elderly. Bangkok: Chulalongkorn University; 1999. 14. Caffrey RA. Family care of the elderly in Northern Thailand: changing patterns. J Cross-Cult Gerontol 1992;7:105-16. 15. Mulder N. Inside Thai society: an interpretation of everyday life. Bangkok: Duang Kamol; 1992.
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16. Limanonda B. Families in Thailand: beliefs and realities. J Comp Fam Stud 1995;16:67-82. 17. Podhisita C. Buddhism and Thai world view. In: Pongsapich A, editor. Traditional and changing Thai world view. Bangkok: Chulalongkorn University Press; 1998. p. 31-62. 18. Sombat P. A survey of nursing research related elderly population in Thailand. Unpublished Master of Nursing, Mahidol, Bangkok, Thailand; 1997. 19. Strauss A, Corbin J. Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park: Sage; 1990. 20. Longino CF, Murphy JW. The old age challenge to the biomedical model paradigm strain and health policy. New York: Baywood; 1995. 21. Marcus MT, Liehr PR. Qualitative approaches to research. In: LoBiondo-Wood G, Haber J, editors. Nursing research: methods, critical appraisal, and utilization. 4th ed. St. Louis: Mosby; 1998. p. 215-45. 22. Memmler RL, Cohen BJ, Wood DL. The human body in health and disease. 7th ed. Philadelphia: Lippincott; 1992. 23. Estes CL, Binney EA. The biomedicalization of aging: dangers and dilemmas. Gerontologist 1989;29:587-96. 24. Pearson A, Vaughan B, FitzGerald M. Nursing models for practice. 2nd ed. Oxford: Butterworth-Heinemann; 2000. 25. Nay R. Benevolent oppression: lived experiences of nursing home life. Unpublished PhD, University of New South Wales, Australia; 1993. 26. Pearson A. Primary nursing. In: Pearson A editor. Primary nursing: nursing in the Burford and Oxford nursing development units. London: Croom Helm; 1988. p. 23-39. 27. Ersser S, Tutton E. Primary nursing a second look. In: Ersser S, Tutton E, editors. Primary nursing in perspective Oxford: Scutari Press; 1991. p. 3-30. 28. McMahon R. Power and communication issues in primary nursing. In: Ersser S, Tutton E, editors. Primary nursing in perspective. Oxford: Scutari Press; 1991. p. 217-26. 29. Fuller D. Challenging ageism through our speech. Nurs Times 1995;91:29-31. 30. McMinn B. Ageism: The challenge for nursing. Australia Nurs J 1996;3:18-24.
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31. Kart CS. The realities of aging: an introduction to gerontology. 4th ed. Boston: Allyn and Bacon; 1994. 32. Butler RN. A disease called ageism. J Am Geriatr Soc 1990;38:178-80. 33. Nehemkis AM. The eye of the beholder: Staff perceptions of noncompliance. In: Gerber KE, Nehemkis AM, editors. Compliance: the dilemma of the chronically ill. New York: Springer Publishing Company; 1986. p. 158-181. 34. Merchant J. Why task allocation? Nurs Pract 1985;2:67-71. 35. Nay R. Benevolent oppression: experiences of older women aging “out of place”. In: Onyx J, Leonard R, Reed R, editors. Revisioning aging: empowerment of older women. New York: Peter Lang; 1999. p. 141-56. 36. Condon J. Nursing theorizing in the United States and Australia. In: Greenwood J, editor. Nursing theory in Australia: development & application. Australia: Harper Educational; 1996. p. 75-104. 37. Meleis AI. Theoretical nursing: development and progress. 3rd ed. Philadelphia: Lippincott; 1997.
TASSANA CHOOWATTANAPAKORN, BSc, MSc, PhD, RN, is a lecturer in nursing at the Chiangmai University in Thailand. RHONDA NAY BA, Mlitt, PhD, RN, FRCNA, FCN (NSW), FAAG, is professor of gerontic nursing at the La Trobe University School of Nursing and Midwifery in Victoria, Australia. DEIRDRE FETHERSTONHAUGH, DipAppSc, BA, MA, RN, Renal Cert, is a research officer at La Trobe University School of Nursing and Midwifery in Victoria, Australia. 0197-4572/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0197-4572(03)00243-X
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