Research Article

Caring Integrating Yoga for Development of Wisdom among Persons with Stroke in Acute Stage

Kalpana Paudel Aryal*

Associate Professor Pokhara Nursing Campus Institute of Medicine Tribhuvan University Nepal

Corresponding Author

Kalpana Paudel Aryal, Associate Professor Pokhara Nursing Campus Institute of Medicine Tribhuvan University Nepal.

Received Date: February 22, 2023;  Published Date:March 06, 2023

Abstract

Wisdom is a quality of persons having positive life experience, practical knowledge and actions. It can be enhanced through spiritual/religious practices and mindfulness meditation whereas suffering is the main barrier for obtaining wisdom. The study aimed to explore the experience of using a caring program incorporating yoga for developing wisdom among persons with stroke in an acute stage. From the accounts of 16 purposively sampled registered nurses, 16 stroke patients and their family caregivers, three themes emerged that were related to the experience of a caring incorporating yoga for developing wisdom: (1) caring relationship facilitated through cultural specific compassionate care incorporating yoga namaste and om; (2) wisdom development facilitated through mindfulness and surrender as a result of caring incorporating yoga namaste, pranayama and om, and (3) wisdom lived by stroke patients. Nurses have an important role in establishing caring relationships and facilitating wisdom development of the stroke patients. In the present study, wisdom was found to be effectively developed through caring incorporating yoga as it could influence mindfulness and well-being of stroke patients. Thus, it is suggested that nurses can apply integrated caring practices for promoting recovery through developing wisdom among person with stroke in the acute stage.

Keywords:Caring; Chanting om; Namaste; Pranayama; Stroke; Wisdom; Yoga

Introduction

Stroke, a common and complex neurovascular disease, is the leading cause of death and disabilitiesworldwide [1]. The burden of stroke is increasing globally, particularly in developing countries. Nepal is a developing country where stroke is the fastest emerging health problem and the third leading cause of death and disability among the young [2]. In addition, stroke recovery itself is a complex and fluctuating process that needs wellness-based holistic care starting from the acute stage for getting better outcomes [3]. It has been reported that early initiation of neuro rehabilitation following stroke promotes better long-term outcomes [4]. However, poorly managed stroke in the acute stage may cause serious effects and long-term impairments in multiple facets of health as well as impose a financial burden to the patients, families and the nation [5,6].

With the disease onset, a person with stroke commonly experiences multiple problems related to physical, psychological, emotional, and spiritual health [5]. Furthermore, collective forms of negative experiences of life had a profound impact on a client’s attitudes and behaviors that made the recovery more complex and prolonged and worsened the condition as well [7]. If a person is overwhelmed by negative feelings, they do not have room for thinking about the future and for recovery, thus further hindering one’s ability to fully move on to recovery [8] along with getting the positive health outcomes.

Likewise, one important health outcome that is markedly impaired among stroke patients is wisdom. It is a trait of a wise person having positive life experience, practical knowledge, and actions that are demonstrated in one’s behavior [9]. Emerging research suggests that wisdom is linked to better physical and mental health along with well-being among older adults [9,10]. The greater association between wisdom and well-being suggests that wise persons enhance mental health by pursuing meaningful activities. However, the perceived meaning of wisdom or being wise may differ and depend on the context and culture.

In Hinduism, wisdom is attributed to having the right knowledge and understanding about the reality of life, emotional regulation, duty and work, insight and compassion, faith in God, and integration of self [11]. It is closely linked to spirituality, and a Hindu way of life as well as constituting its ultimate goal. Jeste and Lee [9] highlighted that wisdom is unique but multidimensional and holistic. Spiritual and religious practices can enhance wisdom and the latter is also promoted through mindfulness meditation because mindfulness is a way for cultivating wisdom whereas suffering is the main barrier for obtaining wisdom [12]. Stroke patients in the acute stage were suffering from multiple problems and experience profound negative emotions that may hinder in development of wisdom among them because good mental health and the patient’s active effort are prerequisites for wisdom development [11]. While acknowledging the limitation of clinical trials involving wisdom development, it could be possible through caring interventions for stroke patients in the acute stage.

The present study thus aimed to develop a caring program incorporating yoga for promoting physical health and wisdom among people with stroke in the acute stage. It was evident that an integrated form of caring with religious/spiritual practices acts as a powerful holistic intervention even for critically ill patients resulting in healing and spiritual well-being [13,14]. It has also the potential to create a good caring relationship among nurse-patientfamily [13] which is essential for providing caring for stroke in acute care setting [15]. Thus, the conceptual framework of the study is based on yoga, a Hindu Philosophy [16], and on a modified form of Roach’s [17] caring concepts of 6Cs (care, compassion, courage, competence, communication and commitment) as a guide for the study to provide culturally sensitive caring practices.

For stroke survivors, participation in yoga intervention has been proven to bring positive outcomes in multiple facets of health [18,8]. Furthermore, those reported to regularly practice yoga were more likely to have better mental health, motivation, positive attitude, and active participation which are fundamental assets for recovery but are lacking in conventional rehabilitation therapies [19]. Therefore, some concepts of yoga i.e. yoga asana, namaste, pranayama (breathing), and meditation through chanting om as a part of spiritual practices were selected, modified and incorporated in the caring practice of nurses. This integrated program may help stroke patients to develop the state of mind or quality of mind, the key ingredient of a good life in Hinduism which can lead to the progression of wisdom [20]. Therefore, it is vital to develop a yoga intervention for caring that is practical, feasible, and easily applicable to achieve positive health outcomes among medically stable stroke patients soon after the onset of the disease. The study aimed to explore the experiences of using care incorporating a yoga program for the development of wisdom among persons with stroke.

Methods

Study Design

A technical action research design was used to conduct the study with two complete cycles of action research consisting of four phases, namely: planning, acting and observing, reflecting, and revising the plan [21]. The specific technical action research design selected to conduct this study allowed the participants to proceed inductively using the caring incorporating yoga program for developing wisdom among stroke patients.

Study Setting and Participants

The neurology ward of a teaching hospital in Nepal was selected as the study setting. Since it is a tertiary level public hospital, people come to this hospital for treatment from various parts of the country. The neurology ward has 35 beds and provides services to clients having neurological problems, around 50% of whom were stroke patients at the time of the study. In this ward, stroke patients who did not need life support care were admitted and received acute care as well as rehabilitation services for their recovery. A total of 52 samples of 16 nurses, 16 first ever stroke patients, and their family caregivers as well as four physicians were recruited purposively for the focus group discussions and individual interviews. Nurses who met the inclusion (registered nurses, Hindu by religion, having any level of nursing education, and working in the neurology ward) were the key participants. Similarly, 16 stroke patients and their caregivers as well as four physicians were recruited as associate participants. The stroke patients admitted in the neurology ward were selected based on the following inclusion criteria: clinically confirmed, medically stable, possessing verbal command and conscious as revealed by the Glasgow Coma Scale examination (GCS), Hindu by religion, and willing to participate in the study. The family caregivers were adult family members staying with clients during hospitalization and who continued involvement in care at home, while those physicians who were working in the neurology ward and willing to participate in the study were included in the study.

Ethical Considerations

The study was approved by the research committee of the Faculty of Nursing, Prince of Songkla University, Thailand, and Nepal Health Research Council (Reg.no. 471/2017) and the researcher was granted a permission letter from the hospital administration in Nepal. All participants were informed regarding the purpose of the study, the data collection process, voluntary participation, and the right of refusal or withdrawal from participating at any time without prejudice. Before data collection, written and verbal informed consent was obtained using an informed consent form in the Nepali language. Additionally, all information related to the participants was kept confidential by giving code numbers instead of names and locked in the personal computer of the researcher. Even though, some asana poses may involve some risks, in the current study the selected poses were modified to match the condition of the patients and they were encouraged to practice them with mindfulness to avoid any risks that might occur. In case of developing symptoms of increased intra cranial pressure i.e. severe headache, and raised blood pressure, they were asked to stop the practice.

Data Collection

The study followed the technical action research design underpinned by post-positivism philosophy [21,22]. The ultimate purpose of the action research was for refining the tentative program of caring incorporating yoga with the collaboration and participation of nurses, stroke patients and their family caregivers as well as the input of the physician. Sixteen nurses were accepted as key participants and prepared for implementation of the program through training workshops, coaching, and daily yoga sessions lasting thirty minutes per day for four weeks in a seminar room within the ward. The whole program was facilitated by the first researcher.

The program was implemented by the nurses among stroke patients in the acute stage with the active involvement of their family caregivers. Initially, yoga namaste was used for showing the culturally congruent respect, communication, and compassionate care for establishing the caring relationship among nurse patients and family caregivers. Then, knowledge about stroke and its recovery process was gradually delivered verbally using the booklet containing information on stroke and yoga. Afterwards, nurses helped the patients to practice modified forms of yoga asanas, namaste, pranayama, and meditation through chanting om with the help of family caregivers. Yoga asana was started with simple poses i.e. hand movement using namaste, leg movement, gradually moving toward more complex poses i.e. breech pose, bending forward pose, leg raised pose which helped them with warming up the body and enhanced physical recovery. Similarly, meditation through chanting om and pranayama (vastrika) and alternative nostril breathing (anulom-vilom) were taught to the patients to help mindfulness cultivation and wisdom development among stroke patients. In the beginning, patients were asked to voice out om as much as they could. Likewise, a simple breathing exercise (vastrika) was practiced by the stroke patients followed by alternative nostril breathing. It was practiced during their preferred time from early in the morning to late at night for at least four times a day. The duration of practice ranged from 5-30 minutes at a time and 10-24 days in the hospital until discharged. After discharge, family caregivers helped the patients to do self-practice continuously at home for eight weeks. Hence, the total duration of the program was 9-11 weeks and the initiation of the program was varying in individual patients.

Data collection was conducted initially, after one week of implementing the program, and on the day of discharge in the hospital using semi-structured interview guidelines. A focus group discussion was conducted to gain collective views about the program among nurses who provided direct care to stroke using the program. Each FGD, lasting approximately 60-90 minutes, was conducted in the meeting room within the ward and included 5-6 participants. Meanwhile, face to face interviews were conducted in a meeting room within the ward except for the first interview with the patients that took place at their bedsides and lasted for approximately 30-45 minutes. The participants’ characteristics and nonverbal clues of the situations were recorded using field notes during the interview.

The data were collected until data saturation when no new information was obtained from the participants. Further meetings were held biweekly with the key participants to reflect on and verify their interviews and FGD and discussions were conducted on how to improve the practice as well as the outcomes of the patients. All the data were collected by the first researcher. In addition, mindfulness score of each stroke patient was measured using Freiburg Mindfulness Inventory for supporting the qualitative data. It was used at baseline, before discharge, at 4-5 weeks, and 8-9 weeks after discharge through telephone calls at home.

Data Analysis

Qualitative data were analyzed following the steps of content analysis formulated by Elo, et al. [23]. The first researcher transcribed verbatim data from the audio recording obtained from in-depth interviews and focus group discussions. The researcher read each transcript several times to immerse into the data and took notes and marked ideas related to wisdom development among the stroke patients for the initial coding. The written notes were thoroughly read several times and as many headings and codes were written down in the margin as needed to describe all the aspects of the contents. Afterward, codes were transferred from the margins on to coding sheets, and subcategories were classified under the categories with a higher level of abstraction. Finally, all the processes in the analysis, categories, and subcategories as well as the key findings related to the topic were discussed and confirmed by the research team until consensus was reached.

Rigor of the Study

To increase the accuracy and strength of the qualitative study, the researcher used four criteria, i.e. credibility, dependability, transferability, and confirmability based on Lincoln and Guba [24]. Data credibility was obtained through prolonged engagement in the study setting which lasted for about one year, and data triangulation as well as peer debriefing through discussion among the research team. Dependability was enhanced through repeated observation of the same events and audit trials to clearly explain the data collection process and recording all the raw data. The transferability of the results was obtained through a detailed explanation of the research process and providing a thick description of the data. Conformability was achieved through the triangulation of data and an audit trail.

Results

The results of the study presented the experiences in the use of caring incorporating yoga to develop wisdom of stroke patients in the acute stage. The three different themes that emerged were related to: (1) caring relationship facilitated through cultural specific compassionate care incorporating namaste and chanting om; (2) wisdom development facilitated through mindfulness and surrender as a result of caring incorporating namaste, pranayama and chanting om; and (3) wisdom lived by stroke patients.

Caring relationship facilitated through cultural specific compassionate care incorporating yoga namaste and chanting om

A caring relationship is considered central to the effective caring process and vital for providing caring activities in acute care settings. This categorical theme is supported by the statements as: feeling cared for; becoming closer, and appreciated the caring behavior of nurses. In the study, nurses expressed their caring behaviors while dealing with stroke through culturally sensitive compassionate care and communication through namaste and chanting om. In Hindu culture, yoga is a way of life where people are using namaste (putting both hands together and moving them forward and upward until reaching the forehead) for greeting people as well as to worship God. Since namaste and om were used in everyday life, the patients, therefore, resumed both practices easily without difficulty even in the acute stage in which abilities were lost suddenly after the onset of disease. The shared culture and belief enriched compassionate feelings and brought nurses and patients to come closer and interact with each other more. A nurse expressed her experiences to support the theme of caring relationship as:

‘Om’ is a holy word and a symbol of God. It has meaning in the daily life of Hindu people. To listen and chant om the holy sound in the hospital, I feel that I am being with my family members and working at my home environment. Patients and families may also feel familiar with the environment as they are at their homes. Therefore, we feel closer to each other very quickly because we have faith and trust in our culture (N-10).

Becoming closer with the nurses was helped very much in their interaction. Ultimately, it enhanced a caring relationship among them. A father of a young stroke explored his feelings as follows:

In the initial 1-2 days of hospitalization, my son was lying on the bed silently with a sad mood. But now, he offers namaste to all nurses and doctors with a smile. He looks happy and cheerful after he chanted om. He cannot speak but he tries to spell out om by looking at the picture of the technique of chanting in the booklet. (F-10).

When there is a good relationship, caring behaviors could be appreciable. A husband of a young stroke patient appreciated the nurses’ caring behaviors. He stated:

I found that nurses have very soft and polite behaviors in here. If I asked any questions, they replied nicely with a smile. I feel that now they are being knowledgeable and skillful (F-4).

Wisdom development facilitated through mindfulness and surrender as a result of caring incorporating yoga namaste, pranayama, and chanting om

This categorical theme is supported by the statements as “promoting the motivation and hope for recovery and being active and alert”. Participants of the study believed that yoga is good for health whereas om is the symbol of God, and is one of the Mantras for chanting with many purposes such as meditation, worship. Furthermore, people use those practices to surrender to God by uttering the mantras om and offering namaste to cope with any difficulties. When the mind is calm and serene, this will allow wisdom to develop. Ultimately, motivation and hope were created that might amplify the progression toward wisdom among stroke patients.

Furthermore, patients were encouraged to practice yoga by allowing modification and flexibility in yoga practice in terms of time, duration, and frequency. The flexibility in practicing yoga with some modifications that suit their current condition might motivate them to do self-practice. Nurses caring behaviors i.e. respect through namaste, paying attention, compassionate care, and communication while teaching and caring also helped them in creating hope and motivation toward recovery. To support the statement, a nurse expressed the following

Even though they are doing practice accordingly, it is better if we give them encouragement, counseling, and motivation in between as what I am doing right now. For instance: you are doing better, your condition is improving because of all these practices (N-2).

A nurse also explored her experiences and gave the following a supportive verbatim account:

When a patient offers namaste using the disabled hand making it able with the support of a good hand, he/she may feel some achievement of previous daily work. This is the point that created hope and inner strength inside the patients (N-6).

Nurses further incorporated yoga practice in caring practices after establishing a caring relationship. Yoga asana and namaste were targeted for working toward the physical body whereas the pranayama and meditation through chanting om worked on the mind which ultimately helped to cultivate mindfulness of the patients. Mindfulness is a foundation for development of wisdom that resulted in the active engagement of the patients and family into the care which was evident by being active and alert. Being active and alert signified the positive attitude towards life by acknowledging the lost function of body parts as well as understanding the problematic situation caused by stroke. It was reflected in a patient’s behaviors and actions. To this statement, a family caregiver gave the following a supportive verbatim account:

Um...for this, he is being active now. I think, he understood the benefits of all activities and yoga because I don’t need to force him to do any activities such as reading booklets, movement from bed to chair, namaste, and all. The interesting point is using savasana, which he uses to overcome tiredness after exercise and walking, as well as diversion of the mind when he felt bored (F -13).

A female patient explored her daily activities in the hospital reflecting on her being active as follows:

I felt very good when chanting om. When chanting om while taking deep breaths, it helps me to improve the word. I also feel that my mind is being peaceful and refreshed, vibration in the whole body (P-9).

Another supportive account was given by a nurse. She stated:

Usually, clients were lying on the bed without doing any activities but now, they are using their leisure time effectively by doing exercise and chanting om, moving hands using namaste; walking around. Therefore, they look more active than before (N- 12).

Wisdom lived by stroke patients

The theme represented the perception of all participants regarding the meaning and attributes of wisdom in stroke patients after their participation in caring incorporating yoga. The theme is supported by three categorical sub-themes: 1) gaining knowledge and understanding of life with stroke and skills in caring for self; 2) perceived constant spiritual connection: faith in God and becoming connected as evident by feeling safe and secure; and 3) perceived positive feelings toward life after having a stroke as evident by feeling peace, calm and happy.

Gaining knowledge and understanding of life with stroke and skills in caring for self

Patients and family caregivers obtained information about the disease and yoga from the nurses’ teaching and self-practice of yoga as well as self-reading of booklets related to stroke and yoga practice. Such experiences helped them in understanding the disease self-care technique: transfer, mobility, and yoga practices. After being involved in the self-practice of yoga while focusing on self, the mind will be calm and peaceful which may provide time for thinking about life and recovery. This condition is conducive to developing motivation and promoting learning capacity to care for self. Collectively, all of those above may help patients further to enhance the development of right understanding, and insight in their health problems and limitations without the interference of fear and anxiety. A male stroke client explored his feeling about increased self-understanding on the recovery process as follows:

The disease is not like having a fever that can be cured and from which one recovers by only taking paracetamol or pills. I feel that it takes time for the full recovery of my problems (P-12).

A nurse also expressed the following supportive verbatim account:

Now, patients practice the activities of the program easily and frequently without any difficulties. This may be because of familiar concepts to them but they never used it for recovery. After understanding that yoga is beneficial for them and gaining improvement after self-practice of yoga, the patients became motivated and hopeful for recovery (N-4).

Perceived constant spiritual connection: faith in God and becoming connected

This meant all participants had perceptions about spiritual feelings after participation and supported these by statements about faith in God; becoming connected. But the specific explanations were quite different among nurses, patients, and family participants. Faith in God: Nurses mentioned that Nepalese people are very spiritual and religious. They believe in om as a symbol of God and that it is a powerful mantra. It is commonly chanted by Hindu people in their daily life for praying as well as sharing with God their happiness and difficulties. Because of this faith, chanting loudly of this mantra had become a powerful source of dealing with and tackling the difficulties caused by stroke. A nurse explored her feelings to support the statement about faith in God. She stated:

We Nepalese people believe in spirituality and religion. The program contains om, the name of God. The om is a common holy word; everybody has chanted it in various situations of life such as happiness and suffering. When they chanted at the hospital, they may feel calm and spiritually satisfied and having a feeling of being able to call the name of God during illness (N-2).

Some of the nurses pointed out that people in Nepal have faith and trust in yoga practice for good health. However, they never used it in a critical stage in a hospital setting. After establishing a good caring relationship, patients, therefore, could easily accept the yoga program. Afterward, they started to self-practice it even in the acute stage.

Becoming connected: feeling safe and secure. It reflected the connection of the clients with self, others, and with God that was commonly achieved as a result of pranayama and chanting om. The majority of them, along with family caregivers, particularly the elderly, mentioned that this program helped them to remember and re-establish a connection with God which was lost due to the sudden onset of life-threatening problems. After being connected stroke patients felt secure because they believed that God has the power to provide a solution. Practicing the slow and modified form of yoga asana hand in hand with breathing may allow a tolerable level of practice as well as meditation with pranayama and chanting om that allows the time to think toward recovery and life that further motivates them to do self-practice. Supportive dialogues are presented as follows:

Before this disease, I prayed to God and chanted om daily in the morning at home. But I forgot God after getting the disease suddenly. When you explained the disease and om was shown in the booklet, I heard and noticed the word om, the name of God. After that, the om helped me to connect with God again. I feel safe and secure when I call the name of God om. Since that day, my mind is connected at the same pace and it became more powerful to handle the situation (P-12).

Perceived positive feelings towards life after having a stroke

When wisdom was attained, ideally, the patients could accept, adapt, and live their lives in harmony and feel peace, comfort, calm, and happiness instead of stress, anxiety, fear, and worry. A nurse explored her perception to support the above statement. She stated:

For obtaining wisdom and happiness, we have to keep our mind peaceful and spiritually connected. The program especially “om” chanting is very good for making the mind peaceful and relaxed. It is also excellent for creating a social relationship that enhanced the happiness in the clients (N-6).

Furthermore, yoga is known to convey good health and selfunderstanding by providing information about the disease and its own experience through participation in the program. In addition, being mindful and serene further allowed them time for thinking about their recovery and understanding their strength and limitations posed by stroke. A patient explored his understanding about the recovery as follows:

The mind, it cannot be controlled at once because it was grossly disturbed after getting a stroke. But I believe that it will be stable gradually because I feel better in my body after doing namaste by holding my weak hand with the support of a strong hand. I also feel peace and relaxed in my mind after chanting om (P-12).

Another family caregiver also explored her positive feelings as follows:

This program made both me and my husband busy all the time in the hospital. If I have free time I open the booklet and read it. I helped my husband in doing yoga asana especially leg poses. I chanted om together with my husband since the early morning. We have no time to worry, time to dwell on anxiety. Where did the worry go? This is also a good thing about this program, isn’t it? (F- 13).

Likewise, mindfulness, or being present was also achieved through the practice of yoga pranayama and meditation through chanting om. It is also a stepping stone toward achieving wisdom in Hinduism. Therefore, it is not surprising that the perceived wisdom among the stroke patients was confirmed by the mindfulness scores. The mindfulness score was assessed in four different stages: before implementation of the program i.e., initially, at the time of discharge, and in the 4th and 8th weeks after discharge from the hospital by using the Freiburg Mindfulness Inventory (FMI). The findings showed that the initial FMI score was a very poor level of mindfulness. After implementation of the program, it increased gradually among all patients at the time of discharge, in the fourth week after discharge, and at the end of the study. This mindfulness score also helps confirm that the caring program incorporating yoga could be useful and contribute to wisdom development among stroke patients in the acute stage.

Discussion

This current study explored the unique experiences of the nurses, stroke patients, and their family caregivers after participation in caring incorporating yoga practice, aimed at developing wisdom among Hindu stroke patients. The perceived wisdom revealed the effectiveness of the program that was culturally congruent with the socio-cultural background of the participants as all of them were Hindu by religion. The findings also showed that they could practice yoga asana, namaste, pranayama, and meditation with chanting om during hospitalization in the acute stage.

The development of wisdom was one of the primary outcomes of the caring program which was achieved by yoga practice through the caring approach. In the present study, nurses employed culturally specific caring to establish caring relationships with the patients and their families and guided the yoga practice toward physical recovery which was the main concern of the patients as well as promoting wisdom development. Even though wisdom had been overlooked by the participants, it was important for them to have the right understanding and awareness for their recovery and well-being. Therefore, wisdom development was also identified as a main expected health outcome that could help direct the goal, and process of practice toward physical recovery and well-being. It should be noted that the present article highlighted the wisdom development while related physical recovery was primarily addressed for overview understanding.

The caring approach incorporating yoga was found to be a quick way to gain trusted caring relationships with patients and families. These findings are in line with several studies reported about how culturally specific caring relationships can be established quicker by employing culturally sensitive care [25,13,26,27]. Previous studies also reported that establishing good caring relationships among nurses-patients-family caregivers is an essential step in an acute care setting to ensure an active participation of the patients for meeting their health care needs [15,3] as well as optimize the sense of recovery [28] and harmonize body-mind-spirit [13].

It was evident in the previous studies that yoga practice can effectively improve multiple physical problems among stroke patients [8,29], while regular practice of short mindfulnessbased meditation has been shown to promote mindfulness and comfort among stroke in the acute phase [30,31]. Furthermore, it was found that being mindful or focusing on breathing improves the awareness and wisdom which can be achieved from spiritual practices. According to the Geeta (Hindu Holy book), people have different levels of wisdom which can be learned and taught for its progression from lower to higher level by practicing yoga, a spiritual practices [11]. In the present study, nurses guided wisdom development along with physical recovery by using yoga. While practicing yoga especially the pranayama and meditation with chanting om, nurses guided the stroke patients to concentrate their mind on their breath and sound of chanting to cultivate mindfulness. The stage of mindfulness helped ease the learning of yoga practice and get connected with God.

The constant spiritual connection was driven by faith in God through the practice of namaste, pranayama, and om. As a result, experiences of becoming connected were achieved which was attributed to feeling safe and secure, feeling calm, peaceful, and happy as well as experiencing a decreased level of stress, anxiety, worry, and fear. Such findings are consistent with previous studies regarding wisdom, yoga, and stroke [32,11,29]. Agoramoorthy [20] revealed that happiness and insight can be achieved through the religious route in Hinduism. A previous study on wisdom in Hindu people conceptualized it as a state of mind having positive life experiences, practical knowledge, and actions [11] and this can be enhanced by cultivating a state of mind or peace of mind through spiritual and religious activities among stroke patients. Consistent with this, participants in this study reported stroke patients to experience positive feelings toward life with stroke and recovery which is signified by gaining the right information and understanding of life with stroke and the capacity of care for self. Furthermore, the findings of the present study were congruent with the findings of Alexander, et al. [33] and Bhavanani [34]. Both studies revealed that yoga, as a spiritual practice, acts as a buffering against emotional and spiritual distress by allowing participants to re-engage with their preferred activities, self-awareness, and continuous spiritual connection.

Similarly, positive feelings toward life and recovery were also attributed to perceiving inner strength, hope, confidence, and motivation and the patients becoming active and alert after the participation of caring incorporating yoga program which indicated the state of mind or integrated self. Consistent with previous studies, the state of mind or integrated self is the indicator of holistic health which grips the three dimensions of human beings i.e. body-mindsoul [26]. Holistic health also enables a person with stroke to accept and adjust to the sense of new life because the primary concern of holistic nursing care is to fulfill the needs of a human being [35]. Indeed, improvement of state of mind symbolizes the wisdom level among stroke patients in the study.

Therefore, it can be confirmed from the present study that the caring program incorporating yoga can be applied successfully among conscious stroke patients in the acute stage during hospitalization. Nurses should incorporate those practices in their daily nursing practice to provide culturally congruent care to the Hindu stroke patients in the hospital. It is consistent with a previous study arguing that Hindu patients demanded the health care providers to treat their religious and spiritual needs [36]. Additionally, the program should be added to the spiritual care competency by the professional nurses for achieving positive health outcomes among acutely ill Hindu patients in the clinical setting.

Conclusion

Based on the results and discussion, knowledge of caring incorporating spiritual/ religious practices can be applied among Hindu stroke patients in acute care. The caring program incorporating yoga is much valued as a cultural health resource that could be easily practiced in the daily life of stroke patients in the acute stage for wisdom development. Wisdom is attributed to having right knowledge and right understanding of their real-life situation that can further influence right actions for continuing self-care practice toward better physical recovery and well-being of the stroke patients. Therefore, this study suggested for nurses to support, motivate and encourage stroke patients in the acute phase through creating an environment conducive to learning and practicing yoga to enhance wisdom for living a meaningful life after having a stroke. Moreover, based on the findings of this study, nurse researchers can embark on an experimental study in the future to identify the effectiveness of caring incorporating yoga practice as a rehabilitation program for optimizing healing of stroke in the acute stage. Concerning the implication of the findings of this study to non-Hindu population, it is worth to consider yoga practice as an acknowledged body and mind approach that can lead to mindfulness development and transformation states. Under the guidance of caring nurses to those based on their personal preference and faith on yoga as a secular method, the program should be also beneficial to promote wisdom development.

Acknowledgment

None.

Conflict of Interest

No conflict of interest.

References

1. Feigin Valery L, Bo Norrving, George A Mensah (2017) Global burden of stroke. Circulation Research 120: 439-448.
2. Thapa Amit, KC Bidur, Bikram Shakya, Dipesh K Yadav, Karjome Lama, et al. (2018) Changing epidemiology of stroke in Nepalese population. Nepal Journal of Neuroscience 15: 10-18.
3. Peterson-Burch, Frances, Karin Reuter-Rice, Taura L Barr (2017) Rethinking recovery: Incorporating holistic nursing perspectives in post-stroke care. Holistic Nursing Practice 31(1): 3-10.
4. Mweshi Margaret (2016) The best time to start stroke rehabilitation: A review of the evidence in resource-adequate and resource constrained settings. Journal of Preventive and Rehabilitative Medicine 1: 7-12.
5. Clarke David J, Anne Forster (2015) Improving post-stroke recovery: The role of the multidisciplinary health care team. J Multidiscip Healthc 8: 433-442.
6. Simeone Silvio, Marlene Z Cohen, Serenella Savini, Gianlucca Pucciarelli, Rosaria Alvaro, et al. (2016) The lived experiences of stroke caregivers three months after discharge of patients from rehabilitation hospitals. Professioni infermieristiche 69(2): 103-112.
7. Crowe Claire, Robert F Coen, Nick Kidd, David Hevey, John Cooney, et al. (2016) A qualitative study of the experience of psychological distress post-stroke. Journal of health psychology 21(11): 2572-2579.
8. Schmid Arlene A, Marieke van Puymbroeck (2019) Yoga Therapy for Stroke: A Handbook for Yoga Therapists and Healthcare Professionals. London and Philadelphia: Singing Dragon.
9. Jeste Dillip V, Ellen E Lee (2019) Emerging empirical science of wisdom: Definition, measurement, neurobiology, longevity, and interventions. Harvard Review of Psychiatry 27(3): 127-140.
10. Hayat Saba Z, Saira Khan, Rayna Sadia (2016) Resilience, wisdom, and life satisfaction in elderly living with families and in old-age homes. Pakistan Journal of Psychological Research 31: 475-494.
11. Jeste Dillip V, Ipsit V Vahia (2008) Comparison of the conceptualization of wisdom in ancient Indian literature with modern views: Focus on the Bhagavad Gita. Psychiatry 71(3): 197-209.
12. Webste Jeffrey Dean, Gerben J Westerhof, Ernst T Bohlmeijer (2014) Wisdom and mental health across the lifespan. Journals of Gerontology Series B: Psychological Sciences and Social Sciences 69(2): 209-218.
13. Ismail Suhartini, Urai Hatthakit, Praneed Songwathana (2018) Exploring Islamic based caring practice in intensive care unit: A qualitative study. Nurse Media Journal of Nursing 7: 91-100.
14. Komariah Maria, Urai Hatthakit, Nongnut Boonyoung (2020) Impact of Islam-based caring intervention on spiritual well-being in Muslim women with breast cancer undergoing chemotherapy. Religions 11: 361-373.
15. Feo Rebecca, Philippa Rasmussen, Rick Wiechula, Tiffany Conroy, Alison Kitson (2017) Developing effective and caring nurse-patient relationships. Nursing Standard 31(28): 54-63.
16. Kumar V Ravi, Shubhra Aanand (2015) Yoga: A case of reverse innovation. Purushartha - A Journal of Management, Ethics and Spirituality 8: 12-18.
17. Roach M Simone (2016) Caring: The human mode of being. Caring in Nursing Classic: An Essential Resource. New York: CHA Press pp. 165-180.
18. Garrett Robyne, Maarten Immink, Susan Hillier (2011) Becoming connected: The lived experience of yoga participation after stroke. Disability and Rehabilitation 33(25-26): 2404-2415.
19. Morris Jacqui H, Tracey Oliver, Thilo Kroll, Sara Joice, Brian Williams (2017) Physical activity participation in community dwelling stroke survivors: Synergy and dissonance between motivation and capability: A qualitative study. Physiotherapy 103(3): 311-321.
20. Agoramoorthy Govindasamy, Minna J Hsu (2015) Religious route to happiness insights from ancient Hindu scriptures. European Journal of Science and Theology 11: 139-150.
21. Holter Inger M, Schwartz Barcott, Donna (1993) Action Research: What is it? How has it been used and how can it be used in nursing? Journal of Advanced Nursing 18(2): 298-304.
22. Creswell John W (2013) Qualitative Inquiry & Research Design: Choosing among Five Approaches (3^rd), Thousand Oaks, CA: SAGE.
23. Elo Satu, Mario Kaariainen M, Outi Kanste O, Tarja Polkki, Kati Utriainen, et al. (2014) Qualitative content analysis: A focus on trustworthiness. SAGE Open 4: 1-10.
24. Lincoln Yvonna S, Egon G Guba (1985) Naturalistic Inquiry. Beverly Hills, California: Sage Publications.
25. Drahosova Lenka, Darja Jarosova (2016) Concept caring in nursing. Central European Journal of Nursing and Midwifery 7: 453-26.
26. Jasemi Madineh, Leila Valizadeh, Vahid Zamanzadeh, Brian Keogh (2017) A concept analysis of holistic care by hybrid model. Indian Journal of Palliative Care 23(1): 71-80.
27. Pajnkihar Maida, Gregor Stiglic, Dominika Vrbnjak (2017) The concept of Watson’s carative factors in nursing and their (dis) harmony with patient satisfaction. PeerJ 5: e2940.
28. Mardiyono (2012) Effect of the Nursing-Based Intervention Integrating Islamic Relaxation on Anxiety and Perceived Control in Indonesia Patients with Acute Myocardial Infarction Admitted in ICCU. PhD Thesis Report. Prince of Songkla University, Thailand.
29. Van Puymbroeck, Marieke, Jared Allsop, Kristine K. Miller, Arlene Schmid (2015) ICF-based improvements in body structures and function, and activity and participation in chronic stroke following a yoga-based intervention. American Journal of Recreation Therapy 13: 23-33.
30. Jani Bhautesh D, Robert Simpson, Maggie Lawrence M, Sharonm Simpson, Stewart W Mercer (2018) Acceptability of mindfulness from the perspective of stroke survivors and caregivers: A qualitative study. Pilot and Feasibility Studies 4(1-9): 57-65.
31. Wang Mian, Weijing Liao, Xiaoli Chen (2019) Effects of a short-term mindfulness-based intervention on comfort of stroke survivors undergoing inpatient rehabilitation. Rehabilitation Nursing Journal 44(2): 78-86.
32. Garrett Robyne, Maarten Immink, Susan Hillier (2011) Becoming connected: The lived experience of yoga participation after stroke. Disability and Rehabilitation 33(25-26): 2404-2415.
33. Alexander Gina, Kim E Innes, Terry K Selfe, Cynthia J Brown (2013) “More than I expected”: Perceived benefits of Yoga practice among older adults at risk for cardiovascular disease. Complement Ther Med 21(1): 14-28.
34. Bhavanani Ananda B (2013) Yoga Chikitsa: The application of Yoga as a therapy, 1st ed. Pondicherry, India: Dhivyananda Creations, Sarguru printographs India.
35. Adams Lisa Y (2016) The conundrum of caring in nursing. International Journal of Caring Sciences 9: 1-8.
36. Boreson Hedvig, Lisanja Askesjo (2015) Nepalese Nurses' Experiences of the Family´s Importance in Health Care: An Interview Study Conducted in Kathmandu, Nepal.