The results of the study is presented the experiences in the use of caring integrating yoga to promote physical recovery of stroke patients since they were in the acute phase. The emerged thems are classified into three main parts as 1) caring as a tool to establish trusting relationship in acute phase; 2) yoga as a practical and powerful tool for physical recovery of stroke during acute phase; and 3) perceived physical recovery as a result of the caring incorporating yoga program.
Table 4
The main themes and related sub-themes
Themes | Sub-themes |
Caring as a tool to establish trusting relationship in acute phase | Developed the relationship and trust from the patients and family. |
Gaining knowledge and ability on caring for self and patients |
Perceived mutual benefits from the program |
Yoga as a practical and powerful tool for physical recovery of stroke during acute phase | Not time-consuming and easy to be implemented |
Self knowing and realizing |
Creating hope, motivation and will power for recovery in acute stage |
Perceived physical recovery as a result of the caring incorporating yoga program | Feeling comfort, relax, refresh and increased sensation |
Increased physical exercise and purposeful movements |
Improvement of self-care ability and ADLs |
Caring as a tool to establish trusting relationship in acute phase |
The meaning of the theme reflectes that the program specially caring works as a tool for developing the trusting relationship among the nurses, patients and their family members. By using this tool, nurses felt that they gain trust from the patients and their family members as well as perceived mitual benefits frm the program which was important for successful implementation of the program with good cooperation from their clients. Similarly, patients and family caregivers also developed trust toward the nurses' caring practices because they gained knowledge and skills to take care self and the patients and perceived benefits from the program. The supportive sub-themes included developed the relationship and trust from the clientsand family; gaining knowledge and ability on caring for self and the patients; and 3) perceived mutual benefits from the program.
Developed the relationship and trust from the patients and family.
This categorical theme was expressed by the nurses emphasizing the nurses’ caring actions that helped very much for establishing the interpersonal relationship and gaining trust from the patients and their family caregivers. Trust is a basic quality required to facilitate patient and family engagement in caring during hospitalization. Even though, initially many nurses admitted that communication with the clients in acute stage was difficult due to lost voice, denial and feeling shocked since they were at the maximum level of stress and anxiety. However, active communication was intentionally created in each moments and every encounters while interacting with the patients and family through verbal interaction and non-verbal means such as direct interactions, listening; touching, being silent presence, eye-eye contact, and paying attention. Establishing relationship and trust is supported by the verbatims given by the participants during hospitalization. A senior staff nurse stated:
Before using this program, I never thought about interaction with the patients as a part of care. But now we are often talking with patients. I am enjoying talking with them while providing care. I listen to them, pay attention to them, make eye to eye contact, and touch them. These interpersonal techniques are very effective in developing understanding and trusting relationships. (N-5)
Similarly, an in-charge nurse also perceived benefits of effects of relationship and trust while providng care using the program in hospital setting. She stated:
Because of a trusting relationship, they showed co-operation and active participation while implementing the program. They responded to us promptly while meeting, wanted to share about happiness by showing their success like smiling with us, sitting on a chair, walking, greeting, speaking and so forth. I found them looked happy and cheerful. (N-1)
The nurses also mentioned that the patient and family members were being closer with the nurses like a family members. Such relationship resulted in developing self-motivation and active participation in own care process.
Gaining knowledge and ability in caring for self and the patients.
This subtheme is emerged from the experiences of the nurses, patients and their family caregivers after implemention of the program. Educating the stroke patients in their acute stage of illness while urging them to practice it was challenging. They often were seen as not physically-mentally ready to learn new things due to sudden loss of muscle movement along with psychological disturbance. Provision of appropriate set of yoga practice through caring approach with genuine attention, understanding the physical limitation of the patients, encouraging, motivating, and being present of a nurse and family caregiver was used successfully in the study. In turn, such caring behaviors and actions of the nurses helped cheer up and motivate the patients as well as their family caregivers to continue self working for patients recovery. They gained both knowledge about the disease and ability to self-care after having stroke. The statement is supported by the verbatim given by a young female stroke patient during hospitalization in acute. She has spoken her experience as follow:
Sisters give me information and teach me how to do yoga. Now, I understand about my disease, and what to do for my recovery. I am trying to sit long time rather than lying on the bed all the time. I also practice some yoga poses while seated and lying.(P-4)
A young son of the female stroke patients also explore his experiences as he gained knowledge and skill for caring to his mother before discharged from the hospital. He has spoken as:
A sister taught me about the technique of transfer, walking and so on. Most importantly, you taught us about yoga. We’ve got a chance to learning new things. Now, I am able to provide care to my mom. As a result, we achieved an early improvement in my mom. (F-3)
Important strategies linked with caring that encourages the patients to actively participate in the program were being motivated, being confident and having hope to get recovery. A senior nurse mentioned her experience to support the above statement as follow:
They (patients) repeat the same activity many times accordingly without feeling bored. They presented more motivation and hope to get cure. Patients also follow our instruction easily This may be because we implement this program only in cognitively intact patients who are not severe. Our nurses pay attention and care to them using this program. (N-16).
Gaining mutual benefits from the program.
The program was aimed to bring expected health outcomes to the patients. After implementing the program, the nurses also experienced several of their own benefits, and changes from the program. It was often reflected by nurse participants that the program also helped very much to understand their crucial role in patients’ recovery. The nurses replied that their caring actions could significantly change their perception toward nurses’ professional role and practice that help to built the relationship among nurse, patients and family caregivers. As a result, it helped to uplift nurse profession as well as being satisfied and proud with their changed role in the care. The supportive verbatims are presented as follow:
Being involved with the program, I feel that nurses have played a vital role in patient’s rehabilitation and early recovery. Before this program, we just performed routine works then sat down at the station. I never felt satisfied like this before.(N-6)
A nurse in-charge also mentioned her experience about the benefits of the program.
Basically, we want positive health outcomes of the patients which are gained from the program like early transfer, early limb movement, walking, speech. Such positive outcomes directly help to increase our. Therefore, this program is good for us but it is far better to the stroke patients in their early recovery. (N-1)
Though, caring worked as a tool for establishing trusting relationship among nurses, patients and their family that can further influenced the strokes patients to practice yoga actively for their physical recovery.
Yoga as a practical and powerful tool for physical recovery of stroke during acute phase.
In this study, yoga was used with the main aim to emphasize physical recovery of stroke patients in acute phase. Thus, the yoga methods being selected to use were yoga asana to rehabilitate and strengthen the muscles. While the pranayama (breathing exercise) and aum chanting were used to calm down the mind and boost up the spirit which resulted in increased self awareness and motivation in self work toward expected physical recovery. Three supportive sub-themes included not time-consuming and easy to be implemented; self knowing and realizing; and creating hope and will power in recovery in acute stage.
Not time-consuming and easy to be implemented.
This subtheme reflected that yoga was practical and possible for stroke patients in the acute phase when the nurses were experiencing the use of yoga in the real clinical practice. The majority of the nurses shared their experiences by comparing own perception before and after implementation of the program with happy and cheerful face. The above explanation reflected about confidence,willingness and attention of the nurse participants toward the program. Supportive verbatims was spoken by a staff nurse as follow:
Now,we have just opposite thought than before about using program and yoga into the stroke patients. The yoga exercise is very simple, easy to practice and implement to acute stroke clients. Stroke patients are using it without any difficulties. We teach them only once and they consciously follow every pose properly. Afterwards, we just observe whether they can do them properly or not.(N-7)
An in-charge nurse has spoken her experience to support the above theme as follow:
In fact, in the beginning of the program, we scared that it might increase our workload and make routines more complex. In reality, it was easily applied. Patients, and their family caregivers took initiation themselves once we taught. Then, it did not put an extra load on us but made it easy. (N-2)
Most of the nurse participants also expressed the main reason for accepting it as easy practice and not time consuming for teaching the patients to do yoga even in the acute phase of stroke. Since yoga belongs to Hindu culture, therefore the nurses were familiar and perceived it as good for health as well as having experience. Supportive verbatims are presented as follow:
A senior staff nurse who is familiar with the benefits of yoga for health, explored her experiences about the reason of accepting the yoga easily by all participants. She stated .
Actually, in Nepal, most of the people are familiar with the term yoga and know well about its benefits, even heard the term yoga in their day to day life. Therefore, they feel easy to practice. This booklet also helps to understand it clearly. (N-3)
A wife (school teacher) of a stroke patient who was taking care her husband using the program for 3 weeks in hospital also mentioned similar perception as nurses of using the program as follow:
When a new patient was admitted, sisters respond promptly and taught yoga exercise immediately which I observed since I was here to care for my husband. This may be due to Hindu culture, doing yoga and chanting aum became possible, which we knew from our childhood.(F-13)
Likewise, the other reasons for possibility to use yoga with stroke patients was a variety of practice techniques of yoga that suits conditions of the stroke in an acute stage such as yoga asana, pranayama, and chanting Mantra that exist in the program. Furthermore, yoga asana also has different types of physical works ranging from very gental to rigorous movement that can be selected for stroke patients in acute phase.
Self-knowing and realizing
Self-knowing and realizing experienced by the strokes after continuing practice of yoga and were described as knowing the current health condition and surrounded environmental and social factors as they really are, and realizing the changes and self responsibility on the care for recovery. The development of self-knowing and self-realizing of the stroke participants helped them to participate in the program actively which resulted in early recovery of the physical function as reflected in these verbatim. A in-charge nurse in the hospital express her experience as follow:
After 2–3 days of practicing yoga, patients and family caregivers not only felt but also realized their own role and responsibility in patient's care. That’s why, they participated actively in own care from their side. (N-1)
A patient has spoken about his improvement after practicing of yoga at the 7th day of using yoga in the hospital as follow.
I found improvement after practing yoga in my voice, ability to move my weak leg and walk with support. I have confidence that and I can follow the program guided in the booklet. I feel that I will be better soon. (P-15)
Creating hope, motivation and will power for recovery in acute stage
Due to sudden onset of disease, patients lost hope and will power along with motivation that definitely impacts in participation in the program and recovery of the clients as reflected by these verbatim. A patient who practice yoga since her childhood explore her experience after 10 days of program implementation:
Yoga is the thing that I was doing previously since my childhood. Now, I felt confident that I would get well, with the feeling that now nothing untoward will happen to me, that I can do yoga. Then, I’ve got more courage to do other activities.(P-5)
Additionally, within 2nd and 3rd day after participation in the program in the hospital, stroke patients noticed a prompt but subtle change in their physical body that acted as a good facilitator resulted in creating will power, hope, motivation and self-confidence. This is supported by the verbatims given by the nurses.
Feeling of improvement in the acute stage of the patient, only small notable changes can play a vital role in creating hope and will power toward recovery and improvement. For instance, when patients can offer namaste by using the disabled hand with the support of good hand, they may feel some achievement in independence.(N-6)
As I observed in my night duty, a patient started to chant aum since early morning and also at night time until fall asleep. Her vocal has been improved very fast. Since that time, I extremely believe that aum chanting can bring vocal improvement faster. (N-12)
The above description of all themes explored the effectiveness of caring incorporating yoga that acted as a powerful tool in patients recovey. Ultimately, the program enhanced the physical recovery in many ways.
Perceived physical recovery as a result of the caring incorporating yoga intervention
The theme is reflected by narrative given by the stroke patients and family caregivers complimented by score of activities of daily living. The findings explored that meaning of recovery and purpose of life after stroke varied in person to person. The three supportive sub-themes were feeling comfort, relax, refresh and increased sensation; increased physical exercise and purposeful movements; and improvement of self-care ability and ADLs and described as follow.
Feeling comforts, relax, refresh and increased sensation.
While asking about their perception on the program in terms of physical health condition, most of the stroke patients explored their perception about feeling comfortable, fresh and relax and increased sensation on paralyzed site after participation in the program. Nurses and family caregivers also shared the same perception with the patients. The statement is supported by following verbatims expressed by a male patient in his own words at 8th day of the program implementation:
I am able to do all the exercises as mentioned in the book. I feel more relax and fresh in my body. Although I cannot move my right hand at all,but I can move it with the support of my left hand. Today, I rose up hands fully while doing yoga namaste. I’m feeling better.(P-11)
Similarly, a family caregiver also expressed his/her perception on the feeling of physical recovery of the stroke participants after a week of hospitalization. S/he stated:
My husband couldn’t even move his right hand and did not feel touch, hot, cold and pain in his right hand and leg. It was totally frozen when we arrived in the hospital. But now, after came to hospital and doing yoga practice his sensation feeling came back. (F-14)
Increased physical exercise and purposeful movements.
After stucked by a stroke, almost all patients were immobile and spent their time on bed. In contrast, after initiation of the program particularly yoga asana such as yoga namaste, chanting aum, movement of hands and legs along with neck movement and other yoga poses, several stroke patients often moved their hands and legs purposefully and independently in their own pace, free time and with little effort and support of the family members. Importantly, they also gain the independence in doing some previous tasks such as offering namaste using both hands; movement of fingers, chanting aum. The resuming previous tasks lead to development of positive attitudes and motivation toward care participation, recovery and future life. A senior staff nurse expressed her supportive verbatim as follow:
I observed that patients looked excited to move their hands, chanting aum and offerring namaste to others where family members encourage and help them for practicing the program. Several patients kept on moving their limbs. This may be because of independent practice and perceived improvement in health. Anyway, all those exercises to enhance the physical recovery of the patients.(N-5)
The above improvement and perception toward the program may enhance the improvement in self-care ability and level of independence in activities of daily living. Further regarding improvement in self-care ability and ADLs is described in next subtheme as described below.
Improvement in self-care ability and ADLs
Improvement in self-care ability and activities of daily living indicated that patient’s physical recovery has been improved that was reflected by narrative expressions and ADL scores. Following narrative expression of the nurses, and patients are presented to support the above statement.
A female stroke patient having moderate stroke mentioned about her improvement in activities of daily living. She expressed her experience after practicing of the program in the 5th day of practicing yoga in the hospital. She has spoken as:
At the beginning for 2–3 days of hospitalization, I laid on bed. I had a pipe for urine and another for feeding. Now, I can go to the toilet, can brush and eat myself. I need little support for wearing cloth, combing hair, walking and going to toilet. My daughter helps me for these. But I can clean my hand, wash face, brush my teath myself. I know that, the program has a great impact on gaining such improvement to me. (P-9)
A senior nurse remarked that the patient’s physical recovery after 10 days of hospitalization was partly improved by caring actions that motivated continuing self practice of the stroke patients as follows:
Do you know the patients bed no 56, a young boy? In the first 2–3 days of hospitalization, he was sleeping all the time, aphasic, weak, sad and depressed. His condition was very critical. He was partially dependent. After I taught some yoga practice along with continuous communication, counseling, and encouragement, he was motivated. Now,within he can move around, can speak some words, and eat with partial support. I felt that our encouragement and concern played a vital role in recovery of this patient as he hasn’t shown interest in the beginning, gradually he is motivated and can follow us. (N-3)
The physical recovery of the stroke participants was confirmed by the ADL scores. The ADLs scored was assessed in four different stages before implementation of the program i.e, initially, at the time of discharge, 4th and 8th weeks after discharge from the hospital by using Modified Barthel Index Scale (MBI) [41]. The MBI scale contains 10 items: feeding, bathing, grooming, bowel, bladder control, walking, toilet use, transfer, mobility and stairs. A total 100 score with higher score reflects the greater independence while lower score reflects lower independence or higher dependence to perform activities of daily living.
The findings shows that the initial ADLs score ranged from 15–55. Of 16, six patients scored below 20 whereas remaining 10 scored 21–60. It indicates that all the patients need support from others for doing ADLs in acute stage. However, at the day of discharge (8–24 days), nine patients were still in the stage of severe dependence (scored 21–60) whereas six patients were moderately dependence (scored 61–90). Only one patient was fully independence (scored 100). At the end of the program (9–11 weeks), half of the patients were slight dependence and independence (scored above 90) whereas half of them were moderately dependence (scored 60–90).
This ADLs score helps confirm the perceived health outcomes as a result of the program implementation that the caring incorporating yoga program should be useful and contributes to physical recovery of stroke patients in acute phase.