International Journal of Nursing Studies 41 (2004) 755–765

ARTICLE IN PRESS

*Correspond

Studies, Univer

Cardiff, Wales,

E-mail addr

0020-7489/$ - se

doi:10.1016/j.ijn

Culture and communication in Thai nursing: a report of anethnographic study

Philip Burnarda,b,*, Wassana Naiyapatanab

aSchool of Nursing and Midwifery Studies, University of Wales College of Medicine, Heath Park, Cardiff, Wales, UKbThe Royal Thai Army Nursing College, Bangkok, Thailand

Received 9 December 2003; received in revised form 25 February 2004; accepted 9 March 2004

Abstract

Most nurses live and work in multicultural settings. Given the need for all nurses and health-care workers to

communicate—with patients, with families and with other health-care professionals—the study of the relationship

between culture and communication can help to inform practice.

This paper offers the findings from an ethnographic study of culture and communication, carried out in Thailand.

The aim of the study was to address the question: ‘in what, if any, ways do Thai cultural issues influence interpersonal

communication patterns in Thai nursing and Thai nursing education?’. Data were collected from a variety of sources,

including direct and indirect observation, interviews and discussions and the literature on the topic. For the interviews,

the sample was a convenience and purposive one made up of clinical nurses and nurse educators (n ¼ 14). Those data

were analysed with the aid of a computerised, qualitative data analysis program.

Findings reported in this paper include those relating to ‘Thainess’, Buddhism, the nursing profession and nurse–

patient/doctor–patient relationships. The report ends with a ‘portrait’ of Thai nursing communication. It is suggested

that understanding the cultural aspects of nursing in various contexts can help nurses, internationally.

r 2004 Elsevier Ltd. All rights reserved.

Keywords: Thailand; Culture; Communication; Ethnography; Nurse–patient relationships; Nursing international

Communication between nurses and their colleagues

and patients is a key issue in sensitive nursing. Given

that we almost all live and work in multicultural

settings, it is useful to attempt to understand

differences and similarities in communication pat-

terns in and between different cultures (McLaren,

1998).

1. Introduction

This paper offers a report of part of an ethnographic

study in which the researchers explored the ways in

ing author. School of Nursing and Midwifery

sity of Wales College of Medicine, Heath Park,

UK.

ess: burnard@cardiff.ac.uk (P. Burnard).

e front matter r 2004 Elsevier Ltd. All rights reserve

urstu.2004.03.002

which cultural issues impinge on the ways Thai nurses

and nurse educators communicate, interpersonally.

Sources of data for the study were various: data were

collected over a 2-year period and the first researcher

spent some time working in a Thai College of Nursing

and recorded field notes from direct observations. The

second researcher lives and works in Thailand. The

paper offers a review of some of the literature, a

description of the research methods used and a report of

the findings.

1.1. Background

In this section, a short description of culture is offered,

followed by a discussion of some aspects of communica-

tion in nursing and of Thai culture and Thai nursing.

For a more detailed review of the available research

and descriptive literature, the reader is referred to the

d.

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765756

full report of this study (Burnard and Naiyapatana,

2004). In the style of anthropological ethnography,

further reference to the literature is made in the report of

the findings.

1.2. Culture

Culture is often described as that which includes

knowledge, belief, morals, laws, customs and any

other attributes acquired by a person as a member of

society (McLaren, 1998). Nemetz Robinson (1985)

made the following distinction about definitions of

culture:

1. The categories of behaviours and products reflect a

notion of culture as observable phenomena.

2. The category of ideas reflects a notion of culture as

not observable: something which is internal but which

can also be explicitly described (Robinson, 1985).

Thus culture may involve observable behaviours but

also a felt sense—a sense, perhaps, of identify, of who we

are. When we communicate, interculturally, we not only

communicate words and ideas but, also, something of

ourselves and of our roots. A range of similar and

different definitions of culture may be found elsewhere

(see, e.g. Bodley, 2000; Boyle and Andrews, 1989;

Gudykunst and Kim, 1992; Hofstede, 1994; Rubel and

Rosman, 2003).

Clearly, culture is a changing thing. No society or

community is static. Just as language evolves, so do all

of the other aspects of culture. As one respondent, in

this study, put it ‘no one wants to live in a museum!’

Cultures continue to modify themselves in the light of

things like technology, research-based evidence, political

change and even fashion (Klausner, 1993). Communica-

tion patterns also change in this way.

1.3. Communication

How well we communicate depends on how we

behave (Gudykunst and Kim, 1992). After language,

non-verbal communication seems to be the key factor

that enhances or detracts from the way we communicate

with others (McLaren, 1998). The behaviours involved

in non-verbal communication need to be clear and

unambiguous—but, cross-culturally, they are often

confused and confusing (Kim, 1991). Knowing more

about a country’s culture is likely to help those from

outside of it understand communication patterns more

clearly.

There are huge numbers of cultural variables to be

considered when thinking about verbal and non-verbal

communication. A study of this sort can only consider a

few of them. The types of communication alluded to in

this study include communication between nurses and

patients, communication between nurses, patients and

doctors and, more generally, the ways in which Thai

nurses communicate.

1.4. Thai nursing

Since its beginning more than 100 years ago, bacca-

laureate nursing education programmes in Thailand

have grown to 63 nursing institutions. Within these 63

nursing institutions, 32 nursing colleges are under the

jurisdiction of the Ministry of Public Health (MOPH);

nine nursing colleges, which also offer masters and

doctoral nursing programmes, are under the Ministry of

University Affairs (MUA), 16 nursing college are under

the private sectors; three nursing colleges are the

Ministry of Defence; the remainder are under the

Ministry of Interior, the Bangkok Municipality, and

the Thai Red Cross Society.

Chuaprapisilp (1989) argued that clinical nursing, in

Thailand, focused on ‘doing rather than learning’. She

suggested that student nurses’ clinical learning was not

effective because clinical teachers focussed too much on

content. She also noted that some Thai behaviour such

as non-confrontation seemed to inhibit students from

being critical and effective in clinical conferences.

Chuaprapisilp’s work was, it would seem, undertaken

in the US and it may be that she is imposing a ‘Western’

view on a ‘Thai’ situation. ‘Being critical’ is very much a

‘Western’ activity and not, necessarily, a South East

Asian one.

Saksomboon et al. (2002) in an evaluation of a

baccalaureate nursing program in Thailand found that

students in their study had positive perceptions of

clinical placement preparation and skills development

but that they also questioned the adequacy of

their practical skill teaching. A need was found for

improvements in the organisation and management of

quality clinical education. Saksomboon et al. (2002)

point out.

Whilst [Thai] nurses are requested to respond to

global trends in education and in meeting health

service needs, they are also expected to exhibit their

traditional Thai manners (Saksomboon et al., 2002).

It was ever thus. All nurses, in all countries, are

‘expected to exhibit their traditionalymanners’. In this

sense, nurses, like many service and health care workers,

nurses are ‘carriers of the culture’. It is difficult to

imagine that nurses in any countries are required not

to defend cultural norms. Other Thai studies that are

of interest, from nursing and cultural points of view,

may be found elsewhere (Ekintumas, 1999; Juethong,

1997, 1998; Muecke and Srisuphan, 1989; Sasat et al.,

2001; Kunaviktikul et al., 2001; Lundberg and

Boonprasabhai, 2001).

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765 757

2. Methods

2.1. Aim of the study

The aim of the study was to explore the question ‘in

what, if any, ways do Thai cultural issues influence

interpersonal communication patterns in Thai nursing

and Thai nursing education?’ In answering the question,

it was hoped that the researchers would be able to

illuminate the answers to it through examples from

everyday life.

2.2. Study design

This study was an ethnographic one, in accordance

with the features that Hammersley (1990) describes

(a)

People’s behaviour is studied in everyday contexts,

rather than under experimental conditions created

by the researcher.

(b)

Data are gathered from a range of sources, but

observation and/or relatively informal conversa-

tions are usually the main ones.

(c)

The approach to data collection is ‘unstructured’ in

the sense that it does not involve following through

a detailed plan set up at the beginning; nor are the

categories used for interpreting what people say and

do pre-given or fixed. This does not mean that the

research is unsystematic; simply that initially the

data are collected in as a raw form, and on a wide a

front, as feasible.

(d)

The focus is usually a single setting or group, of

relatively small scaley.

(e)

The analysis of the data involves interpretation

of the meanings and functions of human actions

and mainly takes the form of verbal descriptions

and explanations, with quantification and statis-

tical analysis playing a subordinate role at most

(Hammersley, 1990).

Specifically (a) people were studied in a Thai College

of Nursing and in everyday, communication with each

other; field notes were also kept of everyday commu-

nication and observations made while working and

living in Thailand; (b) data were gathered from

observation, conversations and interviews, (c) data

collection was relatively unstructured, although inter-

view were also carried out; (d) the focus was a group of

Thai nurse educators and clinical nurses but also friends

and colleagues; (e) analysis attempted to explain the

meanings and functions of Thai culture in communica-

tion in nursing and nurse education but also, more

broadly in everyday situations too. The findings,

reported in this paper, are all from discussions and

interviews with Thai nurse educators and clinical nurses.

The best approach to answering the research question

appeared to be the ethnographic (Hammersely and

Atkinson, 1995; Hammersley, 1990; Van Maanen,

1988). It seemed reasonable to work and live in a Thai

context and to ask Thai informants their views about

what they did and why they did it.

2.3. Sample

A convenience and purposive sample of 14, Thai,

clinical nurses and nurse educators were interviewed for

this study. A convenience sample is one made up of

respondents who are prepared to take part in the study.

A purposive sample is one comprised of people who are

likely to have a view on the topic under study. Interviews

were carried out by both researchers and were con-

ducted partly in English and partly in Thai.

2.4. Data collection and analysis

The main data collection period took place in a Thai

College of Nursing. The first (British) researcher spent

time working in the College as an observer and

interviewer. Consultations took place with 14 nurses

and nurse educators and full field notes were kept for

later analysis.

Data from field notes and interviews were managed

with the computer program Atlas-ti. No data manage-

ment programme ‘analyses’ research data but helps in

the organisation and management of it. Textual data

were read, re-read and organised into categories, in the

style of grounded theory and thematic content analysis

(Glaser and Strauss, 1967; Burnard, 1991; Miles and

Huberman, 1994; Sarantakos, 1992; Silverman, 1993).

In the style of a method described, elsewhere, by the

first author, the transcripts were ‘open coded’ (Burnard,

1991). Broad topics and key words were sought in the

body of the text. Next, the numbers of categories, thus

generated, were collapsed and reduced in number.

Finally, all of the text in the transcripts was accounted

for under this category system. The categories thus

developed were as follows:

* communicating Thainess;* communicating power;* Buddhism;* merit making;* khwan;* the nursing profession;* students and teachers;* the practice of nursing;* change;* communication in nursing.

The findings section of this paper reports those

categories and the some of the text within them.

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765758

Although there is a discussion, in the literature, about

the ‘trustworthiness’ of qualitative analysis, it is also

acknowledged that the analysis of such data is a

subjective process and, in the end, the researcher has

to stand by his or her own category system. For further

considerations on this issue, see Morse (1991), Silverman

(1993) and Romm (1997). One method of attempting to

‘validate’ the findings was that the interviewers, having

interviewed a person, asked subsequent respondents for

their views on a point made by a previous interviewee. In

this way, respondents were often able to verify (or not

verify) issues raised by other respondents. The point, in

qualitative research, however, is not, particularly, to

seek consensus, but to ‘map’ a range of views and

experiences.

There is also debate about the value or otherwise of

returning to respondents to ‘check’ the generated

category system (Parahoo, 1997; Burnard, 1991). Given

the subjective nature of the analytical process, in

qualitative research and the fact that the analysis was

carried out by both researchers—involving considerable

debate and ‘re-working’, it was decided, in this case, not

to return to the respondents in this way.

3. Findings

This section reports the findings from the study. Each

of the quotes is drawn from the interview transcripts,

having first been categorised as described above. The

letter and figure, in brackets, after each quote, represents

the number given to each respondent (e.g. [R4] is a quote

from the fourth respondent).

3.1. Communicating Thainess

The key to understand something of Thailand is

understanding Thai people. In this study, informants

were easily able to articulate what it means to be Thai.

Clusters of qualities were often offered together:

‘‘Characteristics of Thai people are: smiling, friendly,

simple, sincere...culturey religion.’’ [R1]

‘‘Being Thai means being proud, polite, patient,

willing to help. Related to Buddha. Thai Culture also

involves language, food, ways people act.’’ [R4]

‘‘Thais, living in Thailand, always think of

themselves as being Thai Buddhist. The monarchy

and the king are important.’’ [R6]

‘‘Nationality, culture, modesty, showing respect to

the elderly.’’ [R10]

This issue of Thai children looking after their parents

was noted by many informants and often in the context

of pointing out that western people did not do this.

‘‘Thai people look after their elderly relatives.’’ [R5]

‘‘Thai people take care of their elderly and obey

them. I still obey my mother!’’ [R2]

The issue of children looking after there parents is a

central one in the Thai Buddhist philosophy. A

respected Buddhist monk, Phr Dhammavisuthajahn

(1995, cited in Sasat, 1998) suggests that

Greatest of all is the recognition due to parents

for having given birth to and raised their children.

One way children can repay their enormous debt

to their parents is to look after them in return,

according to the teachings of Buddha: ‘since they

have raised us, so we have to raise them in return’

(Dhammavisuthajahn, 1995, cited in Sasat, 1998).

Sasat noted that few would readily speak of institutitio-

nalising their elderly relatives, even though caring for

them when they were demented, caused considerable

stress and strain. She suggests that ‘The institution is

seen as a place for elderly people who have no relatives

to care for them’ (Sasat, 1998).

Not expressing strong feeling is a Thai characteristic,

arising, perhaps, out of Buddhist beliefs and teachings.

It was noted, here, as an important element of being

Thai.

‘‘Being Thai means language, culture, being proud,

being Buddhist. Thai people think first before they

speak. The do not express emotions. They do not say

‘I love you’. Parents do not say ‘I love you’ to their

children. Thais in classrooms stay quiet and think

about questions. US people say whatever they think

and do not think about others. Thais are sensitive to

others.’’ [R9]

In not expressing personal feelings for others and not

saying ‘I love you’, Thai people demonstrate the

Buddhist quality of ‘non-attachment’. Non-attachment

is not just for objects and things, but for people too

(Klausner, 1993; Mulder, 2002). Acceptance and non-

attachment also affected people’s reaction to pain.

‘‘[Thai people] control their feelings. Older people

keep feelings inside. Older patients have more

experience and their experience might help commu-

nication Younger people might need more informa-

tion. Coping with painy Thai people cope with pain

easily because of their need not to worry other

people.’’ [R4]

On the other hand, helping to ease patient’s pain was

also an important function of the nurse—again in

keeping with the Buddhist precepts that we should help

others, respect them and attempt to make the feel

comfortable.

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765 759

Klausner (1993) offered a comprehensive summary of

what it means to be Thai, to think and act like a Thai

person:

As one gingerly traverses the Thai social and cultural

labyrinth, the paths chosen are curved, indirect,

circular. One avoids confrontation; one shuns direct

challenge; one evades visible expressions of anger,

hatred, displeasure, annoyance. Conflicts are resolved

through compromise. Emotional detachment and

equilibrium is valued. One must not become too

involved, engaged, attached. And yet, one has

obligations and duties. Emotional neutrality and

distance must accommodate to the reality of ‘social

place’, one’s position on the ladder of status, seniority,

wealth, rank, power and prestige. One must accord

proper deference, respect and diffidence towards those

in more exalted positions whether it be a parent,

teacher, patron, business or civil service superior. One

evidences ritual forms of respect through linguistic

labelling and language (Klausner, 1993).

3.2. Communicating power

Thai people are constantly assessing their position

and status in terms of those of other people (Vongvi-

panond, 2003; Mulder, 2002). The informants, in this

study, spoke of these relationships.

‘‘Big person/little person is a major issue. Thai’s

always attempt to work out who is big and who is

little. Sometimes, they are told by others, what that

person’s status is. My husband wanted to bring home

someone to have supper with us. He was a ‘big

person’ and my husband really wanted me to be

there. I might have to miss something at work to do

this but I would always try.’’ [R6]

Degrees of seniority were also found in the student nurse

groups of nursing colleges.

‘‘In the nursing college, each year is ‘senior’ to the

previous and students in each year must pay respect

to the people in the year above.’’ [R8]

Similarly, but less uniformly, patients had to find their

position in the health-care and nursing hierarchy. This

was the least clear area of status, for the people

interviewed in the study. There was often a tension

between the perceived, ‘universal’ nursing idea of

‘treating everyone the same’ and the problem of that

person’s status. The issue was further complicated by the

nurse’s own position in the health care hierarchy.

‘‘Patients may be either ‘big’ or ‘little’ according to

their status outside of the hospital.’’ [R2]

‘‘The big person/little person role is played out in

hospitals, usually in line with rank or ‘chain of

command’. Patients may be either big person or little

person, dependent on their position. ‘Sometimes

patients who are little persons, are treated the same

as those who are big persons. Nurses should treat

everyone the same. But, nurses can order people to

do things, if the patient is little person. The head

nurse occupies a middle position in the hierarchy.

Junior nurses are little persons while doctors are

often big persons. However, the head nurse can be

treated as reasonably much equal by doctors.’’ [R7]

3.3. Buddhism

The national religion, Buddhism, clearly permeated

all aspects of nursing and health care (see, also

Reynolds, 2002; Bukkyo Dendo Kyokai, 1966; Chai,

1985; Cittasobhano, 1993; Daoruang, 2003). Symbolic

representations of the Buddha, in the forms of statues,

play a large part in the processes of observing Buddhist

worship.

‘‘Sometimes we go to a Buddhist image and make

pledges to give money after the person is well again.

This is a form of merit making. We usually have a

Buddha imagine in our homes, too. Buddha images

are never bought: they are always only on loan’.’’

[R9]

‘‘I am planning that every patient who is admitted

to the ward is taken to a Buddha image or an image

of King [name omitted], to worship. [the King] who is

the ‘owner’ of this hospital and the patients will tell

him this and this will help khwan to come back. My

ward is a regular, open one. Relatives can stay 24

hours and sleep in chairs by the beds. Khwan will

come back if relatives are with the patients.’’ [R13]

This head nurse was clearly helping her patients to

‘make merit’—an issue discussed in more detail in the

next section. Her reference to ‘khwan coming back’ is

also discussed below. Khwan is the ‘life spirit’ that can

leave a person’s body in illness or shock. The head nurse

was helping patients to make sure that khwan came back

by encouraging them to have their relatives with them.

Elsewhere in the hospital, a regular ‘visitors hours’

system was in place and relatives could not, always, visit

at any time. However, two head nurses acknowledged

that they could use this system flexibly if relatives

wanted to stay.

3.4. Merit making

In the Thai Buddhist system, ‘merit making’ is the

notion of doing good, in order to help redress the

balance of one’s own, possible bad karma or to help the

positive balance of karma for another person (Caffrey,

1992; Sasat, 1998). Bad karma arises out of bad actions.

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765760

Karma determines the likely status that a person will

achieve in a future life. Merit making can help (but

rarely obliterate) the effects of bad karma. A relative

might make merit on behalf of a sick relative. Flowers

were used to help make merit for patients—usually in

the form of a small garland of jasmine and rose flowers,

available for sale on the streets. These garlands could be

seen hanging over the beds of patients in the hospital.

Most of the nurses interviewed in this study were of

the view that nursing, itself, was merit making (and

would thus help them in future lives).

‘‘Nursing is merit making? The most in the world! I

was born to be a nurse. My husband is a doctor and I

am a nurse, probably because we worked hard in a

previous life.’’ [R7]

‘‘I tell my nurses: do not go to the temple to make

merit: go to work! For nursing is merit making!’’

[R11]

Many nurses and relatives did go to the temple to make

merit.

‘‘Reasons for going to the wat [temple] are: to reduce

Karma, for fortune

telling and to make merit.’’ [R12]

The links between merit making, karma and illness were

sometimes made explicit.

‘‘Thais believe that illness is caused by Karma. I do

myself! Thais make merit after illnesses to make

positive karma.’’ [R6]

Others questioned the notion of karma—but questioned,

less, that of merit making.

‘‘Merit making: I used to think that nursing was

merit making, but now I think it is just a job. Nursing

is a duty: you do not choose to do it in the way that

you choose to go to the temple. Also, keeping a dying

patient alive is not merit making. We should help

relatives to accept that the person is dying and let it

happen naturally. It’s a dilemma.’’ [R2]

There are at least two issues here. First, the informant

is acknowledging that nursing is a duty. Merit making,

arguably, has to be an intentional act. Nursing,

presumably, is not chosen as a merit making activity

but as a career and a profession. The notion of accepting

that someone will die is part of the Buddhist teaching: all

of us age and die and we should accept those facts.

3.5. Khwan

Khwan is the ‘life spirit’ that is sometimes thought

to enter the body through the top of the head, during

birth (Vongvipanond, 2003). The idea of khwan is

not, usually, linked to more western concepts such as

‘self-esteem’ but is more usually conceptualised as a

form of ‘life force’. Many feel that ‘khwan goes away’

when a person is ill or in shock. When people return to

their villages, after a long journey, a khwan ceremony

will often be performed by an elderly member of the

community. In this ceremony, pieces of string that have

been blessed at the temple are tied around the wrist, to

‘bind the khwan to the body’. Similar ceremonies are

performed by monks in various temples.

‘‘When we are sick, our inner power/spirit becomes

reduced. Mental illness causes khwan to leave the

body. Mothers call back the khwan to their children,

when those children have a fall or accident.’’ [R1]

‘‘Khwan is power inside. Khwan can go because of

illness. Khwan goes in mental illness. Some intensive

care patients loose their khwan. Good and encoura-

ging relatives can help. Khwan depends on yourself,

too.’’ [R7]

‘‘Khwan and spirits Relatives will engage in merit

making to encourage khwan to come back. Flowers

in garlands also help khwan to come back.’’ [R14]

3.6. The nursing profession

Nursing, like everything else in Thailand—and else-

where—is changing. One of the informants offered this

analysis of recruitment to the nursing profession, today

‘‘Nursing in Thailand has been accepted by society as

a valuable career to help and enhance better social

health status for a long time. In the past, many Thai

female high school students choose nursing as a

career. Nowadays their values are changing. They

turn themselves to other careers that make them feel

happier with more pay and less hard tasks. The image

of nursing for high school students was: getting low

pay, hard working, helping physicians to work, not

being able to sleep as normal people, taking care of

sick people, wearing white and clean dresses, being an

angel, devoting themselves, caring, and so on. Some

students choose nursing as career under parental

pressure or failure of choosing other careers they like.

That caused the nursing system to have unqualified

input in term of their attitude toward nursing.’’ [R1]

Nowadays, the role of nurses has been more focus

on health promotion rather than illness curative.

Government and Non Government Organizations

(NGO’s) have offered more funds for research

projects that enhance society health status. However

it seems that in the rural area, nurses have to act all

roles: health prevention, promotion, curative, and

rehabilitation because we have small numbers of

physicians to cover a numbers of people. In both

rural and city areas, nurses become more skillful and

more advance in nursing practices. The Thai Nursing

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765 761

Council has accepted the idea of promoting the roles

of Advanced Practice Nurses. However, this idea has

not been widely known and accepted by other

professions especially physicians.’’ [R1]

3.7. Students and teachers

In Thai schools and colleges—and in nurse educa-

tion—teachers are highly respected and often viewed as

in loco parentis—they are surrogate parents. It is not

easy to get Thai students to challenge a teacher: what the

teacher has to say is important and to challenge him or

her, and for the teacher to be wrong would mean a loss

of face for both parties (Klausner, 1993). The teacher

would loose face for being wrong and the student would

loose face for causing the teacher the embarrassment of

being wrong.

From the western point of view, it appears that much

of the learning that takes places is rote learning: students

simply copy down what the teacher says and later,

reproduces it in exams and papers. There is, of course, a

long tradition of this form of ‘oral learning’. Many of

the great religious traditions rely on faithful transmis-

sion of ‘the truth’. Sometimes, this faithfulness in

teachers mystifies teachers visiting from the west, where

there is the opposite tradition: in the west, students are

encouraged to challenge what their teachers say and to

engage in free and open debate with them.

Juethong (1998), in her study of Thai student’s

relationships with their nursing instructors noted that

those students wanted a caring relationship with their

teachers and hoped that the teachers would provide a

‘home-like’ atmosphere in the school of nursing.

It is conceivable that a problem arises out of this deep

respect for teachers, by their students. With the Thai

reticence to challenge or question, forms of teaching and

learning often involve rote learning. Students are not

particularly required to be critical of what they learn and

would certainly not openly challenge what is taught. It

seems likely, too, that teachers enjoy the respect they get

from their students. This attitude of the ‘unquestioned’

knowledge of the teachers permeates the educational

system, from early schooling to university education.

Further, according to reports from our informants and

from column inches in national papers on the topic, Thai

people do not read a great deal. Books are expensive and,

presumably, reading is something of a solitary, rather

than congenial activity. The question that arises is with

regard to how the Thai knowledge base—in any

discipline, develops and grows. Klausner (1993) notes

that there are no Thai ‘philosophers’, developing out of

the Thai universities and suggests that university lectures,

having often studied abroad, quickly re-learn to adopt the

prescribed role of university lecturers.

It is, perhaps, difficult to see how ‘new knowledge’ can

emerge without any sort of critical evaluation of what

has gone before and without active debate. However, to

take this view may also be to demonstrate an

ethnocentric, ‘western’ bias.

3.8. The practice of nursing

Once again, Buddhism appeared to have an important

influence on many aspects of nursing and some of them

are reported here. One respondent noted the ways in

which Buddhism could help in care for the dying person.

‘‘Buddhist teaching can be applied to looking after

dying people. Buddhism helps in the acceptance of

dying, accepting pain. Pain must be accepted but

nurses and other health professionals, who have the

means of helping alleviated, must also use those

means.’’ [R4]

Buddhism emphasises the need to accept that we age and

die. Within the concept of kreng jai, it is also important

to accept pain when it occurs. Kreng jai is the notion of

always thinking of the other person first; of refusing to

worry another person with your own problems; of

respecting those perceived as being senior to you

(Naratpattanasai, 2002; Vongvipanond, 2003; Mulder,

2002). To complain too much about pain would be to

distress other people and this would not be in keeping

with kreng jai. However, one informant offered a more

detailed analysis of communication in nursing and of a

possible problem with kreng jai in the nursing context:

‘‘The best things in Thai nurses as communicators

are: nurses are good listeners and good mediators

between patients, their relatives, and doctors. We are

taught in nursing schools to use simple terms to

communicate with patients and their relatives. The

nature of Thai nurses is smiling and that enhances

good circumstances as communicators. However

amidst these good things, there are still some not so

good things happened in Thai nurses. The nature of

Thai people, including Thai nurses is shy modest, and

kreng-jai. Out of this nature, some points need to be

considered. The patients are kreng-jai. They some-

times do not want to disturb the nurses to ask some

questions. Nurses also have to work hard and

sometimes have less time to spend with each

individual patient, forget to smile, forget to show

that they are available to answer patients’ questions.

Besides, some nurses are not good writers, are not

good speakers. That may cause communication

between nurses and patients to be unfulfilled. In

addition, nurses are shy and have less confident to

talk or speak quietly. When they do so many useful,

valuable things to patients, societies, and commu-

nities, they do not speak out loud to let people know

what they have done for societies.’’ [R1]

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765762

Shyness, reticence and a culturally determined sense of

kreng jai, meant that patients did not always understand

what the doctor had told them. Nurses were often

mediators in the doctor/patient relationship:

‘‘Thais are indirect. Tha.ıs have good communication

between nurses and patients. They give information to

patients. They tell patients what the doctor said.’’ [R6]

‘‘Nurses should explain more about the illness and

how patients can take care of themselves. The patients

don’t like to ask the doctor, so the nurses should ask

for them and check if the patients have any problems

or questions. Nurses also need more practice at getting

information and knowledge. It is changing with

accreditation: nurses have to keep up to date.’’ [R5]

However, doubts were raised about the adequacy of

some nurse–patient communication:

‘‘Straight talking with patients? No! Indirectly,

mostlyy give information, see what happens.’’ [R3]

‘‘Am I dying? It is important to make relatives

happy and encourage a positive point of view, rather

than saying ‘you are dying’. Doctors are more direct,

and senior ones are most direct of all, because of their

status and knowledge.’’ [R9]

According to that informant, then, doctors where

perceived as more likely to have accurate knowledge

and because of this, and because of their status, they

were also able to be ‘more direct’ with patients. Another

factor, here, is likely to be the short consultation time

that doctors have with patients.

‘‘The Thai culture affects the way in which nurses

talk, think and act. It’s a circle. We do not have

adequate communication because the system, the

hierarchy of the system. It is so slow to change. We

have lots of one-way communication.’’ [R2]

Given that nurses are likely to defer to doctors and

patients defer to nurses, the reality of one-way commu-

nication seems likely.

3.9. Change

Other informants felt that nursing, in Thailand, was

changing and this, from the literature and from

observation is clearly the case. One, however, was less

certain that the change was for the better:

‘‘Thai nursing is changing. The younger nurses are

not so concerned about caring for the relatives of the

patients. They just do the job.’’ [R8]

Another offered the following analysis:

‘‘In summary, I view that the most important things

for the future of Thai nursing are four fold: First is

how to make nursing more interested for high school

students, so that they decided to choose nursing as

their career with love and taking care of patients with

heart. Second is how to make other professions or

society to more accept nursing as independent and

valuable career as the same as physician. Third is

nurses should be more proactive in political partici-

pation in the government so that we would be able to

make our own policy to enhance our status and

nursing quality. Fourth is the role of Advanced

Practice Nurses (APN) should be more accepted and

available in the health care system.’’ [R1]

3.10. Communication in nursing

The issues of volume, in speaking, issues to do with

the Thai language and non-verbal communication where

discussed.

‘‘Thais use tones in their language to communicate,

while westerners use more non-verbal communica-

tion and body language. Thais are taught to be quiet,

polite and demure and do not use their hands to

communicate in the ways that westerners do.’’ [R3]

‘‘Thai communication, try to be friendly. Try to

help. The language is sometimes a problem across

cultures. Thai people are sincere and optimistic about

foreigners. Communication can help the client to

understand themselves.’’ [R6]

‘‘Communication in families is good. It is not so

good between patients and nurses. Thai patients may

think they are bad, so they do not tell the truth.’’ [R10]

‘‘Non-verbal communication is not enough! We

must say it as well!’’ [R12]

One informant offered a challenge to the notion of the

high-context culture, in which much was successfully

communicated, indirectly (Hall, 1976). In the following

passage, the informant seems to suggest that such

communication is not always so clear:

‘‘In Thailand, it is difficult to know what people

really mean. Indirect communication. People are

polite, but what are they really thinking? Up to you!

They have such a desire to please others.’’ [R11]

Others pointed to the importance of teaching and

learning communication skills in nursing colleges.

‘‘The Thai Nursing Council has set up competences

for nurses and communication is one of the

competencies. It is one of the challenges for nurse

teachers in Thailand, to teach good communication

skills. Nurses are trained to be good communicators

and to be mediators between doctors and patients.

They need to be able to explain medical terms to

patients and to ‘translate what the doctor means.

They also need to be good communicators during

discharge planning and health education.’’ [R1]

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765 763

‘‘Thai people are reluctant to talk about their

feelings, because of their Buddhist background which

suggest that people should be accepting and not

confronting. We do not want to inflict our feelings on

others or talk about our feelings. Thais try never to

show their feelings in public. However, strides are

being taken to help patients to express their feelings

through support groups. Education and information

is not enough: people need to express their feelings

too.’’ [R13]

From the points raised here, it also seems that doctors

might also need further communication skills training.

The short amount of time they spend with patients

suggests that they may not have sufficient time to fully

answer any patient’s queries—a factor likely to be

complicated by the patient’s reticence to ask questions.

4. Discussion: a picture of Thai communication in nursing

From this study, Thai interpersonal communication,

in general, can be characterised as follows. Face to face,

Thai people will talk quietly and use limited eye

contact—particularly across the sexes, or between two

people who are not of equal status. Both parties will seek

to maintain kreng jai, to make sure that each feels

comfortable and that neither party is compromised.

Turn taking, between the two people, is likely to be less

marked than may be the case in many western cultures.

Importance will be attached to the status of the two

people and one person is always likely to defer to the

other as, in general in Thailand, ‘equal status’ is rare. All

Thais are likely to be good at quickly establish the

relative status of the other person, where this is not

known.

Communication and discussion is likely to be ‘round-

about’, rather than direct and too the point. It is

sometimes better for a person to say what the other

person wants to hear than to risk being controversial or

confrontational. As a rule, confrontation and conflict

are to be avoided. Gossip is likely to be a common

feature of Thai communication, as is the use of

compliments. In general, the aim is to ensure that both

parties are respected and made to feel comfortable.

In health care and nursing, patients are to be

respected, although their perceived status is likely to

vary, according to their status outside of the hospital or

health care facility. Whilst nurses feel that patients

should all be treated the same, very high status and very

low status patients are likely to be talked to differently.

Doctors are likely to be deferred to, although senior

nurses, such as Head Nurses, are likely to be ‘more

equal’ than more junior nurses and doctors. Senior

doctors are likely to spend little time with the patients

and their communication with them is likely to suffer as

a result. Nurses sometimes see themselves as mediators

between the doctor and the patient.

Nurses are likely to feel that illness and disease are a

result of bad karma. Given that nursing is viewed as a

form of merit making, nurses will be anxious to help and

look after their patients. Serious illness, such as cancer,

AIDS and mental illness are more likely to be attributed

to bad karma from either the present life or a previous

one. Some head nurses will make arrangements for

patients to make merit, by offering food to monks or

visiting a local shrine or replication of Buddha.

Student nurses will be respectful to their teachers. In

many Thai nursing colleges, there will be a yearly ‘Wai

Teachers Day’, on which students thank and pay

homage to their teachers. In the classroom, few students

will challenge their teachers and most teachers will not

expect to be confronted by their students. Nursing

teachers may often be in loco parentis to their students

and those students will want to be ‘mothered’ by their

teachers. This ‘child/parent’ relationship is likely to

further encourage students not to be challenging.

Students, like some of their teachers, are unlikely by

choice, to read very much and will depend on teachers to

point them to particular passages. Students are likely to

reproduce what their teachers expect of them, in examina-

tions and projects. Overall, the atmosphere in a School of

Nursing is likely to be a happy but respectful one. Students

undertaking higher degrees are unlikely to offer a

particularly critical review of the previous literature but,

more likely, a summary of what has gone before.

5. Conclusion

This paper has offered some of the findings from an

ethnographic study that considered culture and com-

munication in Thai nursing. It was noted that a strictly

hierarchical set of relationships exists within and

between Thai people; that Buddhism pervades the

culture and has implications for both communication

and the practice of nursing and that nurse teachers offer

something of an in loco parentis relationship to their

students. The topic is a huge one and more details from

this study will be published in subsequent papers. There

are, of course, limitations to every study. It is hardly

possible to capture all aspects of such a complicated and

pervasive topic as ‘culture’ in a study of this sort. Some,

too, would argue about the ‘subjective’ nature of

qualitative research and of ethnography. However, the

point is not to generalise from a study of this sort but to

offer a description, a ‘snapshot’ of a particular context at

a particular time. A summary of criticisms of qualitative

research is offered by Mays and Pope (1995):

The most commonly heard criticisms are, firstly, that

qualitative research is merely an assembly of

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765764

anedcdote and personal impressions; secondly, it is

argued that qualitative research lacks reproductibil-

ity—the research is so personal to the researcher that

there is no guarantee that a different researcher

would not come to radically different conclusions;

and, finally, qualitative research is criticised for

lacking generalisability (Mays and Pope, 1995).

Most of these points, are, of course, the case: but they

miss the point and use a ‘quantitative mindset’ to judge

qualitative studies. The point of research such as that

described in this paper is only to offer a description of a

situation. In the reading of it, others may acknowledge

‘Yes, that it also my experience!’ or ‘That is new to me

and I may dispute it!’. Such research allows for

comparisons to be made with other people’s life

experience but not, necessarily, comparisons with other

research findings—and certainly not ‘generalisability’—

although it is argued that many Thai people would

probably ‘recognise’ the points being made here.

Further ethnographic and cultural research is planned

by the researchers including a study of the ways in which

Thai culture does or does not impinge on nurse’s

experience of stress. It is hoped that the present account

offers some insights for both nurses in Southeast Asia

and for those in other parts of the world who want to

compare and contrast their own nursing styles with

those of others.

References

Bodley, J.H., 2000. Cultural Anthropology: Tribes, States and

the Global System, 3rd Edition. Mountain View, Mayfield,

CA.

Boyle, J., Andrews, M., 1989. Transcultural Concepts in

Nursing Care. Scott, Foresman, Glenview, IL.

Bukkyo Dendo Kyokai, 1966. The Teaching of Buddha.

Society for the Promotion of Buddhism, Tokyo.

Burnard, P., 1991. A method of analysis interview transcripts in

qualitative research. Nurse Education Today 11, 461–466.

Burnard, P., Naiyapatana, W., 2004. Culture and Communica-

tion in Thai Nursing. University of Wales College of

Medicine, Cardiff.

Caffrey, R.A., 1992. Caregiving to the elderly in northeast

Thailand. The Journal of Cross-Cultural Gerontology 7 (2),

117–133.

Chai, P., 1985. Buddhism and Thai world view. In: Chula-

longkorn University Social Research Institute/Southeast

Asian Studies Program: Traditional and Changing Thai

World Views. Institute of Southeast Asian Studies, Singa-

pore.

Chuaprapisilp, A., 1989. Improving learning from experience

through the conduct of pre- and post-clinical conferences:

action research in nursing education in Thailand. Unpub-

lished doctoral dissertation, New South Wales University,

Sydney.

Cittasobhano, P.N., 1993. The Triple Gems: The Research and

Experience of BA Students in Buddhism. Mahchula

Buddhist University Press, Bangkok.

Daoruang, N., 2003. Thailand Life. http://www.thailandlife.

com/spirithouses.htm.

Ekintumas, D., 1999. Nursing in Thailand: western concepts vs.

Thai tradition. International Nursing Review 46 (2), 55–57.

Glaser, B., Strauss, A., 1967. The Discovery of Grounded

Theory. Aldine, Chicago.

Gudykunst, W.B., Kim, Y.Y. (Eds.), 1992. Readings on

Communicating with Strangers. McGraw-Hill, New York.

Hall, E., 1976. Beyond Culture. Doubleday, New York.

Hammersley, P., 1990. Reading Ethnographic Research: A

Critical Guide. Longman, London.

Hammersely, M., Atkinson, P., 1995. Ethnography: Principles

and Practice, 2nd Edition. Routledge, London.

Hofstede, G., 1994. Culture and Organisations: Software of the

Mind. McGraw-Hill, London.

Juethong, W., 1997. Applying marketing concepts to nursing

student recruiting in Thailand. Unpublished manuscript.

Juethong, W., 1998. Thai baccalaureate Nursing students’

caring and uncaring lived experience with Thai nursing

instructors. Unpublished Ph.D. Thesis. George Mason

University, Fairfax, Virginia.

Kim, Y.Y., 1991. Intercultural personhood: an integration of

eastern and western perspectives. In: Samovar, P., Porter,

D. (Eds.), Intercultural Communication: A Reader, 6th

Edition. Wadsworth, Belmont.

Klausner, W.J., 1993. Reflections on Thai Culture: Collected

Writings. The Siam Society, Bangkok.

Kunaviktikul, W., Anders, R.L., Srisuphan, W., Chontaway,

R., Nuntasupawat, R., Pumarporn, O., 2001. Development

of quality of nursing care in Thailand. Journal of Advanced

Nursing 36 (6), 776–784.

Lundberg, P.C., Boonprasabhai, K., 2001. Meanings of good

nursing care among Thai female last-year undergraduate

students. Journal of Advanced Nursing 34 (1), 35–42.

Mays, N., Pope, C., 1995. Rigour and qualitative research.

British Medical Journal 311, 109–112.

McLaren, M.C., 1998. Interpreting Cultural Differences: The

challenge of Intercultural Communication. Peter Francis,

Norfolk.

Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analy-

sis: An Expanded Sourcebook, 2nd Edition. Sage, Thou-

sand Oaks, CA.

Morse, J.M., 1991. Qualitative Nursing Research: A Contem-

porary Dialogue. Sage, London.

Muecke, M.A., Srisuphan, W., 1989. Born female: the

development of nursing in Thailand. Social Science of

Medicine 29, 643–652.

Mulder, N., 2002. Inside Thai Society: Religion, Everyday Life,

Change. Silkworm Books, Bangkok.

Naratpattanasai, K., 2002. Exploring the many dimensions of

‘kreng jai’. http://www.geocities.com/econ 10330/kreng jai.

html.

Nemetz Robinson, G., 1985. Crosscultural Understanding:

processes and approaches for foreign language. English as a

Second Language and Bilingual Educators. Pergamon,

London.

Parahoo, K., 1997. Nursing Research: Principles, Process and

Issues. Macmillan, Basingstoke.

ARTICLE IN PRESSP. Burnard, W. Naiyapatana / International Journal of Nursing Studies 41 (2004) 755–765 765

Reynolds, C.J. (Ed.), 2002. National Identity and its Defenders:

Thailand today. Silworm Books, Bangkok.

Romm, N., 1997. Becoming more accountable: a comment on

Hammersley and Goom. Sociological Research Online, 2, 3.

http://www.socresonline.org.uk/socreseonline/2/3/2.html.

Rubel, P.G., Rosman, A., 2003. Translating Cultures: Perspec-

tives on Traslation and Anthropology. Berg, Oxford.

Saksomboon, K., McMillan, M., Cholwski, K., 2002. An

evaluation of the baccalaureate-nursing program within

the (MOPH), Thailand. Nurse Education Today 22,

641–647.

Sarantakos, S., 1992. Social Research. Macmillan, Basingstoke.

Sasat, S., 1998. Caring for Dementia in Thailand: a study

of family care for demented elderly relatives in Thai

Buddhist society. Unpublished Ph.D. Thesis, University

of Hull.

Sasat, S., Burnard, P., Edwards, D., Naiyapatana, W., Hebden,

U., Boonrod, W., Arayathanitkul, B., Wongmak, W., 2001.

Self-esteem and student nurses: a cross-cultural study of

nursing students in Thailand and the UK. Journal of

Nursing and Health Sciences 4, 9–12.

Silverman, D., 1993. Interpreting qualitative data: methods for

analysing talk, text and interaction. Sage, London.

Van Maanen, J., 1988. Tales of the Field: on Writing

Ethnography. University of Chicago Press, Chicago.

Vongvipanond, P., 2003. Linguistic perspectives on Thai

Culture. http://thaiarc.tu.ac.th/host/thaiarc/thai/peansiri.

htm.