Table 1.

Patients’ personal (often private) strategies

Influence	Operational definition	Subthemes and supporting evidence*†
Self-comforting strategies	During times of distress and uncertainty, patients work to maintain a sense of comfort using personal strategies that include positive thinking, looking for reassuring signs of safety and normality through surveillance of self and others, self-care routines, getting informed, planning and learning to trust. The success of these strategies is moderated by patient characteristics and influences from family, staff, other patients and the clinical environment. Some patients may use withdrawal (disengagement from staff and service) or at least thoughts of doing so, as a strategy to promote short-term but potentially self-harming relief from discomfort and distress.	The operational definition for the theme ‘Self-comforting strategies’ was generated from data coded to four subthemes: ‘Maintaining positivity and strength’ Positive thinking helped patients stay positive and mentally strong when faced with fear and uncertainty of personally challenging treatment and care. Examples include celebrating small milestones during postoperative recovery and focusing on the benefits of surgery rather than the risks. ’I just kept on saying to myself I’m part of the majority [who survive], that kept me going because I was going to walk straight out’ (P5). ‘Safety through surveillance of self and others’ Patients sought to reassure themselves of their safety through surveillance of their own symptoms and surveillance of staff. Not being able to rationalise symptoms as ‘normal’ (NZE8) could cause significant distress. Conversely, patients drew comfort from the knowledge that symptoms or odd sensations were to be expected under the circumstances. ‘I just told myself it was something from the surgery you know I knew exactly what it was’ (NZE7). Observing that staff were watchful and checking on them ‘when they’re supposed to’ (NZE7) also provided reassurance of safety. ‘They’ll pop their head in when it’s not their time to see how you are. I know, I keep an eye on their schedules’ (M1). ‘Strategies to develop a sense of ease’ Distraction (watching TV, listening to music and seeking out people to chat with) eased emotional discomfort by helping patients take their mind off unpleasant or unsettling events. ‘I didn’t like being in a separate room, I didn’t like that … I felt quite isolated. I mean I’m a bit of a chatty person, not everybody likes to talk but you know you like to know the people around’ (NZE4). Self-care routines (mindfulness and meditation), pulling curtains for privacy, making the effort to connect with one’s roommates temporarily eased discomfort associated with disturbing factors within the hospital environment (such as noise and room sharing with strangers). ‘I’ll just go into the room and I tend to pull the curtains across, I’ve got an iPod there, I usually listen to a bit of music’ (NZE2). Some patients used withdrawal and disengagement to ease discomfort and distress. Examples included withdrawing from interactions with staff, with other patients, contemplating not going through with the surgery, or self (early) discharge after surgery. ‘I was a bit emotional before the operation … I was crying, I want to go home, I want to go home’ (NZE6). ‘They say oh I’ll be back in five min and they’re gone. And then ring the bell, ring the bell, that’s why I said to my daughter I’m ready to go home’ (P1). ’Strategies promoting acceptance’ Underpinning a sense of comfort was developing acceptance of one’s situation using strategies that included use of humour, getting informed (reading and asking questions), developing some sort of plan or way forward for situations causing concern and focusing on the necessity of unpleasant treatments, surgery, lifestyle changes and so forth. ‘[I was] quite chirpy and cheeky to the (theatre) nurses just to try and keep myself cool, you know, just to cool myself down and get ready to accept the inevitable, you know’ (M8). Patients also gained comfort by developing a sense of trust in either the process or the people around them. Trust was integral to feeling able to accept care and treatment by choice. ‘I don’t ask much because I haven’t been concerned about anything really. I trust them. My first operation really gave me the trust you know, people that trained years to be there, you’ve got to trust them’ (M7).
Culturally connected	Patients find it hard to be fully comfortable in hospital because they miss home, family and invariably encounter cultural norms, values and practices that may be different to their own. Comfort is enhanced in an environment that patients perceive to be welcoming to them and their family, culturally familiar and there is the sense that others (staff, other patients) understand and respect their cultural norms and values. These perceptions help patients develop a sense of comfort related to connecting positively with people and place without tension or the need to repress personally important values, beliefs and preferences for care.	The operational definition for the theme ‘Culturally connected’ was generated from data coded to three subthemes. The first two subthemes provide the context for a cultural dimension of comfort, the third indicates the importance of staff competence in culturally safe care. ‘Missing home and family - hospital as a culturally unfamiliar environment’ Patients described the discomfort of needing to live—although temporarily—in an environment patients variously described as ‘alien’, ‘foreign’ and very ‘different’ to home. Different things were missed by different people but, overall, unfamiliar routines, certain expectations of behaviour and missing home life exacerbated patients’ sense of unease associated with being in the healthcare setting. ‘… I’ve had my brother in law and his children come up and his kids are like my grandkids you know, full of life. The doctors say keep quiet, and I keep quiet and let them make the noise. I love the children …’ (M4). ‘…I just couldn’t go anywhere and feel that you were finally away in your own private little area that you could just chill out in with your family and things like that. So that’s pretty hard, you’re just trapped’ (NZE2). ‘I miss my kids and my husband and my grandchildren. It’s the love that you have at home. It’s your privacy your own privacy at home’ (P1). ‘Culturally important values and care preferences’ All patients held important values and care preferences related to, for example, meaning of family (who should visit and expected visitor behaviour); room sharing; communication styles and deference to hospital rules; attitudes around treatment regimens, putting up with pain and body modesty; expectations of caring (notion of service and being treated like family), food preferences and spiritual beliefs (use of prayer/karakia). Underlying tensions associated with cultural differences were evident. For example, perspectives may differ between patients, staff and other visiting families about who should visit and acceptable visitor behaviour. ‘It’s what Pacific Islanders do. We all have the same sort of morals…They [visitors] just come to show their support, respect and love, yeah’ (P7). ’Feeling welcome, connecting positively with others amidst cultural differences’ Crucial to comfort (feeling at ease, safe and positive connections) was patients’ sense of welcome and that others (staff and other patients) understood and accepted culturally important values and care preferences. Patients sought signs of welcome, of respect and of cultural acceptance. Examples include observing culturally diverse staff working as a team, the quality of communication between staff and other patients (‘no racism here’ M4), family being able to visit or share karakia outside of visiting hours, availability of cultural support staff and culturally diverse décor. ‘… [I]t was a lot easier within our room because we were Māori, we understood. Like one whanau [family] came in first and I said kei te pai (good, that’s fine) you fellows have your time … They felt like they were taking up too much space’ (M3). Attitudes, treatment regimens, rules and routines not congruent with one’s personal values (eg, differing interpretations of body modesty, expectations of service and care) or based on a stereotypical understanding of cultural preferences undermined patients’ sense of welcome and could distress. ‘[S]ometimes they leave you there naked (under a sheet) you know, and you can’t do anything’ (P1).
Spiritually connected	Some patients gain a sense of comfort from feeling connected to a higher power and sustaining that connection through personally significant spiritual or religious practices. Patients’ need for spiritual comfort may be intensely private and not always related to strongly held religious or spiritual beliefs. The need for spiritual comfort is dynamic, intensifying during times of distress or uncertainty.	The operational definition for the theme ‘Spiritually connected’ was generated from data summarised in two subthemes: ’In God’s Hands’ During times of uncertainty, some patients gained a sense of comfort (feeling safe, strengthened and at ease) through their trust in God, believing that ‘God would do the right thing’ (NZE6) and events were ‘part of God’s plan… no doubt, no fear’ (M4). ‘I pray for them [staff], when I went in to the operation and the nurses going to take care of me in there. …When you put your trust in the Lord He will come then, show them the way’ (P1). To those of no spiritual or religious affiliations, the idea of putting one’s faith in a higher power neither provided nor detracted from their comfort. ‘… I can understand people being of faith probably being comforted by the fact that they think someone’s out there looking after them but I’ve never gone with that… (NZE2). ’Sustaining spiritually important practices, connecting with God’ Staying connected to (sometimes re-establishing) one’s faith provided comfort during times of distress. ‘… [A]ll the time I feel pain God helped me…I am very close to God when I’m sick, when I’m okay I run around and do everything I want and I forgot. I only remember Him when I’m sick…’ (P4). Not being able to sustain important spiritual values and practice could be distressing, for example, if food options or treatment regimens conflicted with spiritual beliefs, or if there was no space for sharing prayer (karakia) with family. Family, Kaumātua (Māori elder held in high esteem) and chaplains helped sustain spiritually important connections. ‘I asked for a Kaumātua … could he say something (a karakia before surgery) for me. And I was happy. I was happy what he said to me, what he did to me. I’m happy about it’ (M6).

* Patient interviews were coded by ethnicity and interview order, that is, M1 is the first Māori interview, P1 for the first Pacific interview and NZE1 is the first New Zealand European (NZE) interview.

†Examples are from stage 2 semistructured interviews of patients undergoing heart surgery.

NZE, New Zealand European.