Complementary therapies in rehabilitation: nurses’ narratives. Part 1

ORIGINAL ARTICLE

Complementary therapies in rehabilitation: nurses’ narratives. Part 1

Pamela van der Riet, Saowapa Dedkhard and Kannapatch Srithong

Aims and objectives. To document the narratives of nursing staff in a Thai rehabilitation centre where complementary therapies

are used and to discuss perceived progress of these complementary therapies on stroke patients. Specific complementary

therapies used at this rehabilitation centre include Thai massage and herbal therapies.

Background. In Thailand, there is cultural acknowledgement of a range of traditional therapies (including complementary

therapies) widely used in Thai health care. For example, meditation enjoys wide acceptance in Thai culture and attracts strong

participation from visitors to Thai Buddhist centres because of growing interest in developing a personal health regime for

future preventative health problems.

Design. Qualitative study using narrative inquiry and discourse analysis framed by poststructural theory.

Method. Six nursing staff and six stroke patients were interviewed about their involvement in complementary therapy practice

and treatments and their experiences of these therapies in rehabilitation. This paper reports the six nurses’ narratives of their

involvement with patients and complementary therapies.

Results. The overall findings revealed two strong themes: nurses’ professional landscape and changes in stroke patients’

embodiment. These two themes were interwoven in a main discourse of nurses attending to and enabling holistic care.

Conclusion. The contexts of temporality, spatiality and other people influencing the progress of patients’ recovery are significant

in this study. In particular, the findings illustrate the importance of the nurses’ discourse in preparing stroke patients for a state

of readiness to heal.

Relevance to clinical practice. The nurses’ role becomes much more significant in health care as demonstrated through these

stories. Their part in establishing a holistic approach through motivating, advising, educating, calming and imparting a sense of

family enables a strong connection with mind, body and spirit potentiating recovery for stroke patients.

Key words: herbal therapies, holistic care, narratives, rehabilitation, stroke patients, Thai massage

Accepted for publication: 2 June 2011

Introduction

This paper reports on a pilot study on complementary

therapies used for stroke patients at a rehabilitation centre in

Thailand. Complementary therapies embrace holistic prac-

tices, and the focus is on promoting health and well-being

(Royal College of Nursing Australia 1999). Underpinning

complementary therapies, there is a philosophy of mind–body

connection. This concept of holistic practice and philosophy

of mind body connection is reflected in the findings of this

research.

Stroke and hypertension are the third most common cause

of death among Thai people (Thailand Ministry of Public

Health 2007). Globally stroke is one of the main causes of

death and permanent disability (Arreola et al. 2009) adding

to the burden of chronic disease and its attendant

Authors: Pamela van der Riet, Dip Ed, BA, MEd, PhD, RN, Associate

Professor, School of Nursing and Midwifery, University of

Newcastle, Callaghan, NSW, Australia; Saowapa Dedkhard, Dip,

MSc, PhD, Lecturer, Boromarajonani College of Nursing;

Kannapatch Srithong, Dip, MSc, Lecturer, Boromarajonani College

of Nursing, Nakhon, Lampang, Thailand

Correspondence: Dr Pamela van der Riet, Associate Professor, School

of Nursing and Midwifery, University of Newcastle, Callaghan

Campus, Callaghan, NSW 2308, Australia. Telephone: +612

4921 6261.

E-mail: [email protected]

� 2011 Blackwell Publishing Ltd

Journal of Clinical Nursing, 21, 657–667, doi: 10.1111/j.1365-2702.2011.03852.x 657

complications. This is supported by a WHO report in 2005

that identified stroke as the second leading cause of death in

the world with an estimated 5Æ7 million deaths internation-

ally. Furthermore, over 85% of these deaths will have

occurred in low and middle socioeconomic countries with

one-third of persons affected aged <70 years (WHO 2005).

There have been a variety of research reports indicating the

value of complementary therapies in health care to assist

cancer, palliative care, midwifery patients and preoperative

surgical patients to reduce anxiety (van der Riet 1999, Adams

2006, Ernest et al. 2006, Conley 2007). However, there is

limited qualitative research on the topic of stroke and

complementary therapies.

The evidence validating the effects of complementary

therapies for stroke patients is restricted to quantitative

research and mostly non-western countries. For instance, the

literature search found studies in China, Korea and Hong

Kong. Tao et al.’s (2008) randomised control trial using

herbal therapies (Free and Easy Wanderer Plus) on stroke

patients demonstrated that herbal therapies were an option

for treating depression in this group of patients. Other

complementary therapies used on stroke patients included

massage, acupressure, acupuncture, aromatherapy and imag-

ery (Johansson et al. 1993, Wong et al. 1999, Mook & Woo

2004, Shin & Lee 2007).

Methods

Setting

The setting was a 42-bed rehabilitation centre in Thailand

that admits mainly stroke, head injury and spinal patients for

rehabilitation. The centre has been open for 15 years and has

both in- and outpatients. It is run by a Buddhist Monk who

was inspired by the experience of caring for his mother who

had a stroke. Only patients with the possibility of expectation

for rehabilitation are accepted. Furthermore, unstable pa-

tients with complex medical histories are not admitted to the

centre. The philosophy of the centre places great significance

on holistic practice involving the interrelatedness of body,

mind and spirit, giving and caring. At the centre, local people

are paid employees and trained (by the Monk) and work as

rehabilitation therapists using traditional Thai massage and

herbal treatments. All the nurses (including the Head Nurse)

are volunteers and work six-hour shifts at the centre.

Ethics approval

This research project was reviewed by the University of

Newcastle (NSW Australia) Ethics Committee and approval

obtained to initiate the pilot study. Written approval was

received from the Abbott to undertake the research at the

rehabilitation centre. Written informed consent was obtained

from the volunteer nurses.

Data collection

Six nursing staff were interviewed over two weeks at the

rehabilitation centre. Each interview varied between 60–

90 minutes, and interviews were conducted in a quiet room

away from interruptions. In attendance were the researcher,

the translator and the interviewed nurse. Each interview

began with a short explanation about the research, and

questions for each nurse were semi-structured and sought to

obtain basic information on the types of treatments and

modal effects these treatments had on patients. However,

several thematic elements were addressed in the interviews.

The interview questions were organised to obtain informa-

tion on:

1 The nurses’ experience: Nurses were asked to comment

on any changes or improvement in patients’ physical

abilities (i.e. improvement in activities of daily living,

dressing, toileting, transferring, movement, sleep and pain

and they were also asked about their mood. For example,

did they feel happy or sad or anxious?

2 The nurses’ role at the rehabilitation centre and their

involvement in complementary therapy practice.

Research question

The research question guiding the study was:

What are the nurses’ experiences working at a reha-

bilitation centre that treats stroke patients with complemen-

tary therapies and how do they explain progress of these

patients?

Methodology

This research involved a qualitative approach using narrative

inquiry and discourse analysis framed by a poststructural

perspective. A high proportion of research into complemen-

tary therapies relies on quantitative research involving the

issue of efficacy. Adams (2007) asserts that there is danger in

relying on efficacy alone when doing CAM research as it

potentially misses out on the participants’ experience. It is for

this very reason a qualitative approach has been selected as

the researchers wished to understand and capture the

experiences of our participants in this study.

Narrative inquiry was selected as a methodology to

capture the holistic notion of participants’ experience.

P van der Riet et al.


658 Journal of Clinical Nursing, 21, 657–667

Narrative inquiry is the process of collecting information

for the purpose of research through storytelling and has

been used by researchers as a way of understanding

participants’ experience in health and education (Klein-

mann 1988, Bytheway 2003, Overcash 2004, Riessman

2004, Clandinin et al. 2006, Telly et al. 2009). Clandinin

and Connelly have advocated narrative inquiry as a

qualitative methodology in education and write ‘the stories

we live and tell are profoundly influenced by the lived and

told narratives where we are embedded (2006, p. 1). The

researcher writes a narrative of the experience or phenom-

ena being studied. It has been argued that narrative inquiry

can help researchers and clinicians understand experience

more holistically as it provides context and encourages

reflection (Gosman-Hedstrom et al. 1998). Furthermore,

Aldridge (2007, p. 4) points out that narratives ‘are central

to the therapeutic relationship and vital to qualitative

research’.

Discourse analysis has been selected because of the focus

on language. Discourses involve social practices and are a

way of thinking and doing. They provide insight into

participant’s meanings (van der Riet et al. 2009) and

through careful analysis of language provide understanding

of the storylines of the participants. van der Riet et al.

write that ‘discourses provide subject positions which

constitute subjectivities in particular ways. They authorise

ways of making truth claims’ (2009, p. 2106), such as

the nurses’ beliefs about how they provide and enable

holistic practice for the stroke patients in the rehabilitation

centre.

Poststructuralism provides a theory for studying texts

through which the stories of the participants are told (P. van

der Riet, unpublished data) and was selected because of a

strong focus on language, power, history and subjectivity.

Foucault (1980) has pointed out that in discourse analysis,

you cannot analyse discourses just in the present. In this

study, the participants’ narratives draw on the past, present

and also look to the future.

Data in this study have been presented as a narrative, and

we have adopted Clandinin et al.’s (2006) approach to data

presentation by selecting word images from the data. The

reason for doing this was to reflect the subjectivity of the

participants. The authors have not used all the words from

the transcripts, but instead have taken keywords and phrases

and turned the extracts into word images. In this way, long

disjointed translated transcripts (from Thai to English) that

included much distracting detail could be peeled away to

discover the key storylines. The data have been treated as a

storyline and as an insight into the lives and feelings of the

participants.

Data analysis

Findings

This paper reports on the complex narratives of six nurses

who work in a rehabilitation unit where complementary

therapies are used. From these narratives, we have identified

one main discourse, i.e. attending to and enabling holistic

care and two main themes involving changes in stroke

patients’ embodiment and nurses’ professional knowledge

landscape. As stated previously in the introductory section of

this paper, a holistic approach to care is an implicit discourse

in complementary therapies. Also, as stated earlier, the phi-

losophy of this centre places a strong focus on holistic care

and this is reflected in the findings, especially in the main

discourse involving nurses attending to and enabling holistic

care. The above themes are interwoven and overlap in the

main discourse of attending to and enabling holistic care.

In our analysis, we looked for the following:

• Competing and conflicting stories and discourses. Stories

often bumped up against each other and when they do they

create tension. We hear the nurses comparing work in the

local hospital and the rehabilitation centre. For Foucault,

power is a function of and operates through discourse

(Foucault 1980). In their nursing discourse at the

rehabilitation centre, they can exercise power. However, in

their nursing discourse in the hospital, they are margina-

lised and constrained by an institutional discourse.

• Word images that captured the character of the partici-

pants

• Complex layers of text

• Metaphors

• Binaries

• Contexts involving temporality, spatiality and the context

of other people. In narrative inquiry, temporality, spati-

ality and others (people) are important contexts in nar-

rative inquiry (Connelly & Clandinin 1990). The nurse’s

stories in this paper are framed within these three life-

world existentials of temporality, spatiality and the con-

text of other people.

For each of the participants, word images have been

presented to tell their stories to live by and to speak to the

reader. In the following stories to live by, the stories are not

static; they shift in their multiplicity and are fluid in nature.

Nurses stories framed in contexts of temporality,

spatiality and the context of other people

Tonkhao: word image of stories to live by

Tonkhao is the Head Nurse at the rehabilitation centre and

has been a nurse for 16 years. She has worked at the centre

Original article Complementary therapies in rehabilitation


Journal of Clinical Nursing, 21, 657–667 659

for six years. Initially, she was a volunteer nurse. Here,

Tonkhao tells her story about working with patients at the

centre:

These patients need much more encouragement

The Barthel Index becomes a motivator as changes are reported back

To patient and relatives

Compared to home there is lots of social support (here)

Generally there are problems initially with sleep,

Especially for new patients because of the change in environment

However, after one week we see an improvement

They get acquainted with the Centre

The activities involving exercise help patients sleep.

When patients are admitted here most of them deny their illness

They are aggressive.

They can be very angry about their illness

This is why they cannot sleep

However, exercise helps

These patients feel hopeless

They can be anti social

I treat every patient the same way

After they get motivation

And encouragement from the nurses

They have trust

And after that they feel better.

Initially patients feel hopeless

They lack confidence and don’t believe in themselves

Having done the rehab program patients can walk more

And are happier

They change their life view

Not just the patients

It also helps the relatives

The Centre gives them ‘a new life.’

The story line here is of the stroke patient, who because of

their illness, is positioned as lacking in confidence, aggres-

sive, angry, antisocial and cannot sleep. However, when the

nurse attends to the patient with encouragement, motivation

and compassion, change in attitude occurs and patients

begin to respond in one to two weeks. They are more

interested in and able to follow through the rehabilitation

programme with the nurses and they are described as

gaining a ‘new life’. So, the context of other people, such as

nurses, is important in the rehabilitation process. The

context of temporality, that is time, is also important in

the patients’ recovery. In the following story lines, we were

privileged to hear Tonkhao’s conceptualisation of her

personal practical knowledge, of her philosophy of holistic

care, at the centre:

Body of the human has many components.

This involves the whole person,

Mental (emotional), social, physical and spiritual

Mind and body are connected.

There is no separation

I provide mental support, education, assessment

Respect, caring and communication

Motivate and encourage patients

Advise relatives

Relatives and patients have been stressed

I work with the relatives to coordinate care of the patient

Every time the nurse sees a patient they give mental support

I use sincere touch a lot

Providing touch provides a role model for relatives

To change their behaviour towards the patient

Some relatives don’t use touch

Hand, voice and heart

It is about intent in your heart

It is good

You use the tone of your voice

You work together

Working here I feel fulfilled

I learn from patients

It is meaningful

I feel proud

The storyline is about ‘respect, motivation, caring and

communication’. Tonkhao’s attending to holistic care in-

volves use of touch, advice, compassion, intent in ones heart,

tone of voice, encouragement and being a role model to the

relatives. Tonkhao is keen to tell us that there is no binary

here in her model of care as body and mind are connected.

Providing holistic care at the centre makes her feel fulfilled

and is meaningful because there are more opportunities to

communicate with patients and their family to support

rehabilitation and involve the family in behavioural change

that will help their family member to better adjust to the

situation and the treatment.

When Tonkhao told us her stories of working at the centre,

there was passion in her voice. She also told us several times

that she felt proud working at the centre. She is also very

proud of the good teamwork and proud that she can make a

difference to the lives of her patients and families.




Mee boon: word image of stories to live by

Mee boon is a nurse of 20-year experience and has been a

volunteer nurse for three years at the centre. Mee boon works

part time at the centre and also has a full-time job at a local

hospital. In response to a question about change she has

observed in patients, Mee boon talks about the response of

patients to their care:

The first thing I notice is muscle tone improves

I ask patients and they say

That muscle tone improves

It depends on the patient’s condition

I see changes after two weeks

The significant change is in walking.

There is less stiffness and muscle spasm after two weeks

Pain comes from stiffness and muscle spasm

For the first week actually patients might have pain

And this can interfere with sleep

At the Centre there are lots of activities which help sleeping,

After a week there is an improvement.

Both the contexts of temporality and other people (nurses and

other patients) play a significant role here in this nurse’s

narrative about patients’ progress. Mee boon’s storyline is

about both the care and support for patients and the

atmosphere where she works with patients. She suggests that

nurses work with patients in a ‘bonding’ of heart, hand and

trust. She talks of the time that it takes for patients to begin

to feel progress. Mee boon begins to see improvements after

two weeks, especially in walking and pain.

Mee boon does not talk about the word holistic care;

however, she does use metaphors of holism such as ‘heart

comes first’ and ‘tamboon.’ Tamboon is a cultural and

spiritual metaphor that in Thailand means making ‘merit’,

that is doing well to others, i.e. offering food to the Buddhist

Monks or donating money to the Temple and helping people.

When asked what would be the most significant thing

working at the centre, Mee boon responds:

Working at the hospital

It is regimented

It feels stressful

Working here is like being with’ sisters’ and being in a family

It makes me feel happy.

In the hospital there is the system to shape what I am doing

There is a hierarchical system

However, it is not the same here

Here I am happy

I can help people

And can make my own decisions myself

Here I am in charge and feel contented

And good that I can see an improvement in patients

I like to help other people

It is like ‘tamboon’

By helping others

It helps me feel ‘Jitjai Dee ‘(The Thai word ‘Jitjai Dee’ means good

hearted).

Yes satisfied and contented

I feel good,

When I see an improvement in patients

At the hospital it can be stressful

Working here gives me more calmness.

At the centre, she feels fulfilled in being able to help others. It is

a different story at the hospital as she is only able to exercise

limited power in decision-making. At the centre, she can

exercise power and has autonomy. Furthermore, it is like being

in a family. The metaphors of both ‘sisters’ and ‘families’ mean

there is closeness and trust between the staff and patients. In

Thai culture, family is very important. Nested in this story are

two storylines about two work place environments: one (at the

centre) where she can exercise power, feels calmer in control-

ling what she can do and recognise the benefit of the treatment

in changing patients’ attitudes. This gives her satisfaction and

fulfilment, and in the other workplace (a hospital where she

can only exercise limited power), she expresses a feeling of

powerlessness, stress and less ability to make decisions that

allow for her to work in a close and rewarding way with

patients and families. These story lines bump up against each

other, and whenever stories bump up against each other, there

is tension and a sense of unresolved achievement.

Jaisai: word image of stories to live by

Jaisai has been a nurse for 15 years and has worked at the

centre for two years. Like the other nurses, she also has a full-

time job in a local hospital and would pay someone else to do

her shifts in the local hospital, and so, she could work shifts

at the centre as a volunteer nurse:

Sometimes older patients may feel sad

And miss their family

However, not all patients have their relatives with them

And carers may be hired

This makes them feel sad

They may feel uncomfortable

Relatives may work

This is economic necessity




The centre gives them hope

Prior to coming here they feel ‘hopeless’

And ‘helpless’

After they recover they are proud of themselves

They can be confident in their self care.

In this paper, there are three influential contexts affecting

patients’ progress: temporality, spatiality (holistic environ-

ment) and other people (relatives offering motivation and

support). Jaisai’s storyline is not dissimilar to Mee boon’s

story as patients make big improvement in walking and pain

improves after two weeks. Here, Jaisai explains why some

patients are sad as their families may have to work and they

need to employ carers at the centre to look after them.

Families are important in supporting and motivating patients,

and it is not the same employing a carer. Motivation is the

key here in patients making good progress. In the following

story line from Jaisai, we are also privileged to hear this

nurse’s philosophy of holistic care at the centre and concep-

tualisation of personal practical knowledge that she brings to

the centre:

(She has tears in her eyes).

Working here at the Centre makes me very happy

At the community hospital the focus is on routine,

Mostly physical care

Where as at the Centre the care is more holistic

And there is compassion

Here we take care of the emotional,

The mind

I love working here

There is compassion in taking care of the patient

It is not only taking care of just the physical or just the mental

It works together

I get so much from the relatives from working here

Working here I am proud for working here

I am much more humanised

I am proud in helping people get better.

Working here has challenged me

Made me more confident

In Jaisai’s holistic care narrative, there are compassion,

humanist and pride discourses. There is no body and mind

schism. At the hospital, the binary body/mind and mental/

physical are present and operate through medical and

institutional discourses. Binaries are often created in dis-

courses (Davies 1993). A fundamental problem with binary

thought is that one part of the binaries is always valorised

over the other. In relation to holistic care, Jaisai has

compared her work at the centre to the work she does in

the local hospital and points out the differences and there is

tension here, in this storyline. Working in an holistic model of

care gives her satisfaction, emotional commitment and also

affects her professionally and personally. There is another

binary here, professional and personal; however, in this

holistic care discourse, the binary has been disrupted and

there is no valorisation over one or the other.

Duang dao: word image of stories to live by

Duang dao, a nurse of 10-year experience has, for the last

four years worked two to five days a month at the centre.

Duang dao works full time at an acute hospital nearby:

When patients come in they don’t sleep so well

Because of change in the environment

And it is a new environment

They can be ‘home sick’

Here they exercise and this helps them sleep

Living here people live as the same family

At the Centre they are in a ‘big family’

With lots of social support

They share their experience

With each other

Help each other

They feel better.

Here I can do decision making and can be a ‘real nurse’.

Interviewer: What does being a ‘real nurse’ mean?

Uses knowledge.

Everything is related to the community.

More than providing holistic and humanised care

It involves the community

Interviewer: What are the good things about working here at

the centre?

Respect for others

I work independently

Working here opens my vision, perspective

Gives me ‘new vision’

Here I can be what I want to be

A Director,’ Decision maker,’

Working here does not feel stressful,

But at the hospital I do feel stressed.

Working at the hospital there are many rules

Patients and families have different expectations

There is such pressure




That makes me feel stressed

The hospital is very stressful

Working here as a volunteer nurse role

I am more independent

More self directed

I work with my heart

That makes me happy.

In the narrative, we see the contexts of environment and others

(i.e. ‘family’) influencing how she views her work and provides

care for patients. Here, Duang dao has commented on the

different models of care at the hospital and at the centre. The

tension is evident. Duang dao emphasises through her discourse

that she is able to make independent decisions; she has

autonomy, unlike her work at the nearby hospital. The different

models of care create tension, and the metaphor of family is

raised again as a positive experience. The metaphor of the

centre as a ‘big family’ is raised again. For Duang Dao, a very

important part of holistic care is the community, working with

her heart, and in this model, she can be a real nurse involved in

decision-making and redefines herself as director. In Duang

dao’s use of the metaphor, ‘director’, she redefines herself as

taking charge, meaning she can direct and influence the care

of patients at the rehabilitation centre. This is a transitional

space she has created for herself and invites transformation of

her subjectivity. On transitional space Ellsworth (2005, p. 32)

tells us that ‘it exist always and everywhere as potential’. It

involves a person’s ability to see them.

Sopa: word image of stories to live by

Sopa is a very experienced nurse of 18 years with several

degrees and has worked at the centre for four years. She also

works at a local hospital. Threaded through her narrative are

the contexts of temporality, environment and others (nurses

and relatives making a difference to the progress of the stroke

patients):

First change is quite slow

The nurse uses the Barthel Index every week

Mostly after seven days you see a big improvement,

Except in severe cases or patients who are not disciplined

Or motivated

For patients who have had a big stroke

Changes are slower

Along with patients who have complications

Such as epilepsy.

I show patients their change on the Barthel Index

To motivate and encourage them

Generally there is an 86% improvement.

The following storylines capture Sopa’s philosophy of holistic

care at the centre and her conceptualisation of her personal

practical knowledge. In this model of care, Sopa talks about

her role in preparing patients for complementary therapy

treatments by motivating, communicating, assessing and

problem-solving and advising. She tells us that hypertension

is a contraindication for step 4 (herbal bath). She does not

just focus on the physical but on the emotional aspects of her

patients, i.e. heart coming first:

Heart comes first

Means providing emotional support

To the patients involving motivation

That is the standard of my nursing care

Nurses should have good communication

Problem solving (skills)

Assessment (skills)

I assess patients’ condition

Advise staff, patients

Liaise with staff

Tells them which step (of therapies) to leave out.

If a patient has hypertension then step 5

Involving the soak in a warm herbal bath is left out.

My philosophy is

Treat everyone like a family member.

(With) Respect,

Caring and also communication.

In this model of care, Sopa sees herself as the main actress.

She was asked how she felt working at the Centre and here is

her response:

Working at the Centre

I am ‘the main actress’

Everyone likes me

I feel happy inside

To help others

Everyone likes me,

I feel loved

If I see things that need to change,

Then I can make change happen.

I can do anything

If it is not harmful to the Centre

It is the independent decision making

And autonomy.

I am more self directed




Interviewer: how does this make you feel?

I feel very happy.

Something like ‘spiritual’

Tamboon

I do not like to do tamboon with money

Helping people here is my tamboon.

Tamboon is a part of spiritual (philosophy)

This is the way I tamboon.

Again, the spiritual metaphor of ‘tamboon’ has been raised

by another nurse and threaded throughout her talk. Spiritu-

ality has been described by others as a central philosophy of

life and having religious or transcendence perspective (Kaye

& Raghavan 2002). Here, Sopa’s story has both a religious

and transcendence plotline. Furthermore, the Thai cultural

metaphor of ‘main actress’ depicts her important and active

role in planning and adjusting treatment, explaining and

advising. In redefining herself as the ‘the main actress’, she

can exercise power and is popular and beautiful.

Tonnam: word image of stories to live by

Tonnam is a nurse of 13 years and has worked at the centre

for five months. She works full time in an emergency

department at a local hospital and part time at the centre:

Patients get more spiritual health here,

Nurses do Karma law

Patients are more accepting

Here, spatiality is linked to spirituality as patients gain

spiritual health and comfort from being in a spiritual

environment. This spiritual, cultural and Buddhist religious

metaphor of ‘Karma law’ means that if they do a good thing,

good things will happen. In this story, spirituality is

constructed as religious and an empowering discourse. In

this context, patients believe they might have done something

bad in a previous life and that has caused them to have a

stroke, and this makes it easy for them to accept their illness

experience. Like the other nurses, Tonnam views her role at

the centre involving assessment, mental support and offering

encouragement to patients. She does not talk about holistic

care, but does use metaphors such as ‘humanised’, depicting

holistic care:

The atmosphere is different

Working here affects the way I work

It is less stressful than other hospitals,

There is more focus on the family and the patient

It has changed the way I practise

I am more patient

I feel

‘Im jai’

I feel fulfilled,

Spiritual

After working here it makes me feel,

Calmer and softer

The cultural metaphor ‘Im jai’ here means fulfilled, satisfied

and happy. For this nurse, spirituality is linked to

transcendence and it allows her to achieve new experiences

and perspectives.

Main discourse

Attending to and enabling holistic care

This discourse involves encouraging, motivating, assessing

patients, spirituality, a focus on community and family, the

use of touch and calming of the patient. It specifies the nurses’

role at the centre, and they are all very clear about their role.

A recent quantitative study on the effectiveness of rehabili-

tation strategies provided by nurses for stroke patients raised

the importance of caregiver education (Arreola et al. 2009);

however, the study did not mention holistic care.

The therapeutic role of the stroke nurse has been described

in the literature (Rowat et al. 2009) as having four main

areas: helping patients understand stroke, providing emo-

tional support, preventing complications and lastly integra-

tion helping patients to meet rehabilitation goals. Again,

there was no mention of holistic care. A qualitative study in

Thailand by Choowattanapakorn et al. (2004) concluded

that holistic care is still in an embryonic state as nurses’

practices are biomedical and reductionist in nature. This

study, however, shows that nurses at the rehabilitation centre

are able to create a space where they can attend to and enable

holistic care. This paper has used the term holistic care to

mean care of the whole person in relation to body, mind and

spirituality.

In the main discourse, there are many other discourses, i.e.

there is a discourse of compassion (heart comes first), caring,

pride, coaching and spirituality. Spirituality discourse is seen

in the cultural metaphor of ‘tamboon,’ the Buddhist concept

of giving. It is a good thing to give to others, and any kind of

giving is a donation. The nurses give their time and energy to

the centre. They are not paid; they are volunteers. There are

other metaphors throughout the language such as ‘heart

comes first’, ‘sisters’ and ‘families’ that bind the family,

patient and nurse. Kaye and Raghavan (2002) writes about

spirituality being a resource for patients. However, in the




nurses’ stories, they use spirituality as a resource to attend to

and enable holistic care.

This discourse of attending to and enabling holistic care

also involved attending to stroke patients’ illness experience.

This takes time and having time is important for progress.

The illness experience went through stages with initial

progress taking one to two weeks before a positive response

occurs. The nurses in this study were all very committed and

proud and passionate about their work and prepared for a

time lag before seeing progress. Working at the rehabilitation

centre, they feel very happy, fulfilled and contented, or in a

state of ‘Im jai’ as they work in a trusting environment.

Most of these nurses apart from the Head Nurse also have

full-time jobs in other hospitals. In their other hospital

positions, they express a sense of distress in not being able

to take a more direct role in decision-making and they do not

see the same holistic model that exists at the rehabilitation

centre able to be implemented in their other hospital

roles. The hospital system shapes what they do. The more

hierarchical system that exists in institutional contexts stip-

ulates what is expected and what is done. Opportunities for

individual responsibility or decision-making are not available

to these nurses. There is less time and little opportunity for

them to focus on the patient and family in a holistic way that

would allow for the introduction of spirit, mind and body.

Theme: Nurses’ professional knowledge landscape

In this main discourse, there is a strong theme of nurses’

professional knowledge landscape and this is interwoven

throughout their stories. Professional knowledge landscape

has been described by Clandinin et al., ‘as a landscape

normatively constructed with historical moral, emotional and

aesthetic dimensions’ (2006, p. 6). Normative constructs

involve how the nurses normally behaved and this has been

influenced through shifting discourses and subjectivities. It is

a narrative construction of what they see and what they know

(Clandinin et al. 2006). It is also a narrative construction of

what they feel. They tell us that at the centre, they work with

their heart and many feel calmer.

Practice and knowledge are intertwined, and the binary

practice and knowledge have been disrupted by a discourse of

attending to and enabling holistic care. Working at the centre

has changed the way many of the nurses define and redefine

their subjectivities both professionally and personally. This

redefining of subjectivity is constructed through metaphors,

i.e. ‘main actress’ and ‘director’. These metaphors redefine

their subjectivity and create a transitional space where they

can exercise power and it takes them to another nurse

professional knowledge landscape.

Theme: Changes in stroke patients’ embodiment

A change in stroke patients’ embodiment is the second main

theme, and embodiment has been described in many different

ways. We use the term embodiment not as body (object) but

rather as process and subject. We have used it in a holistic

way to include both body and mind and resist creating a

binary separating body and mind. Embodiment presents a

state of being where mind and body together affect a sense of

being and well-being. This aligns with Connelly and

Clandinin’s (1990) view of embodiment as they assert ‘in

narrative inquiry people are looked at as embodiment of lived

stories’ (p. 43).

Two nurses felt that there were significant changes within

one week, and the remaining four nurses stated there were

changes after two weeks. In their stories, they reported

improvement in activities of daily living measured by the

Barthel Index (Barthel Index is an assessment tool that

measure activities of daily living) particularly in walking.

There was less pain from muscle spasm and stiffness. Patients

slept better, mostly because of exercise in the gym and their

mood improved. In relation to mood, there were numerous

variables including socioeconomic status (education, higher

career positions) and age. Older patients could be quite sad

but were more accepting of their situation; however, younger

patients could be angry and less accepting of their circum-

stances. Patients who did not have their families with them

needed to employ carers, and this group of patients were very

sad.

One cannot isolate just the therapies on their own as

improving pain, sleep, mood and walking. These changes

may have come about because of the nurse’s tamboon

discourse, i.e. giving encouragement and emotional support.

Encouragement is a big part of the nurses’ role, and without

this, we are left wondering whether these therapies would

work. Encouragement gives patients ‘heart.’

Motivating patient is a big part of nurses’ role/discourse,

and working with families involves all participants in

working towards common goals. The nurses’ role in this

model of care is very important in preparing stroke patients

and their families for a state of readiness to heal. Motivation

helps constructs their illness experience so that they do make

progress.

Limitations

This was a small study where the researchers have repre-

sented six nurses’ stories in narrative form. In qualitative

research, there is always the risk of imposing the researcher’s

own subjectivities and truths on the participants’ stories.




Every effort has been made to reduce this by collaborating

and meeting with the nurses to discuss our findings. For more

detail about how this was managed, please see Complemen-

tary Therapies in Rehabilitation: Patients’ narratives, Part 2.

Conclusion

The authors have used narrative inquiry in the way that

Connelly and Clandinin have used it, that is, not just as a

research methodology, but also as phenomena of research.

The phenomena for the researchers in this paper were the

subjectivities of the participants.

The research highlights the nurses’ role in attending to and

enabling holistic practice as an important part of the recovery

process for stroke patients. The importance of motivating,

advising, educating, calming and sense of family enables a

holistic approach to health care which needs to be emphas-

ised and transferred in the teachings and practices of all

rehabilitation health care delivery.

The nurses’ discourses of pride, coaching, compassion

and spirituality are understood as a unique embodiment of

their stories shaped by their knowledge’s involving past and

present. Threaded through this study are the contexts of

temporality, spatiality and influence of people such as

nurses and families progressing recovery of stroke patients.

In this study, there are layers of subjectivity and we have

unpacked many of them as discourses. The main discourse

attending to and enabling holistic care is about a philo-

sophical approach involving the centre’s philosophy and

nurse philosophy coming together. In this research, the

important role of the nurse in preparing patients for a state

of readiness to heal is evident. These are the stories of

nurses (through their own voices) about themselves and

their patients. Part two presents the stories of stroke

patients.

Relevance to clinical practice

This narrative research illustrates the importance of the

nurses’ role in establishing a holistic approach through

motivating, advising, educating, calming and imparting a

sense of family to enable a strong connection with mind,

body and spirit potentiating recovery for stroke patients. It

also illustrates the influence of carers, temporality and

spatiality in progressing patient recovery from stroke illness.

Contributions

Study design: PV; data collection and analysis: PV SD, KS and

manuscript preparation: PV, SD, KS.

Conflict of interest

We wish to declare there is no conflict of interest.

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Complementary therapies in rehabilitation: nurses’ narratives. Part 1