SAHLGRENSKA AKADEMIN
INSTITUTIONEN FÖR VÅRDVETENSKAP OCH HÄLSA
VIETNAMESE AND SWEDISH NURSING 
STUDENTS’ ATTITUDES TO PALLIATIVE 
CARE.
Sara Wikner and Sara Löfgren
Thesis: 15 credits
Program/course: Degree project in nursing
Level: Bachelor of nursing
Semester/year: Autumn 2019
Supervisor: Ida Björkman
Examiner: My Engström
                            
                               The institute of health and care sciences
Foreword
We want to thank the participants in Sweden and Vietnam who provided us with useful data 
for this thesis with the help of your thoughts and experiences. We also want to express our 
gratitude to our supervisor Ida Björkman for helping us throughout the process of writing this 
thesis. Last, but not least, we want to thank our supervisor in Hanoi, Truong Quang Trung, 
who helped us with recruiting students in Hanoi to interview and for being a great help during 
our time in Vietnam.  
Title (Swedish)
Title (English)
Vietnamesiska och svenska sjuksköterskestudenters attityder till 
palliativ vård.
Vietnamese and Swedish nursing students’ attitudes to palliative 
care.
Thesis: 15 credits
Program/course: Degree project in nursing
Level: Bachelor of nursing 
Semester/year: Autumn 2019
Authors: Sara Wikner and Sara Löfgren
Supervisor: Ida Björkman
Examiner: My Engström
Abstract:
When it comes to taking care of someone who is ill and dying, there are cultural differences 
regarding the role of the relative and the knowledge and access to palliative care differs 
between countries. The purpose of this study was to investigate Swedish and Vietnamese 
nursing students’ attitudes to palliative care. The method used was semi-structured interviews, 
which were performed in Sweden and Vietnam. A total of 17 interviews took place. The 
results reveal that in Sweden the individual is the main focus whilst in Vietnam it is the 
family. The decisions in Vietnam are made by the family and in Sweden the participants say 
that the decision should belong to the patient. The access of palliative care in Vietnam is 
limited, due to expensive care and therefore, the use of it is unusual compared to Sweden 
where it is an essential part of health care. In both countries the participants want what is best 
for their families. More research is needed to gain a wider understanding of different cultures 
and the attitudes to palliative care. By broadening the knowledge, it will hopefully improve 
the health care and the different aspects that needs to be considered when it comes to 
palliative care.
Key words: palliative care, individual, family, Sweden, Vietnam, nursing student, 
qualitative.
Content
1. Introduction .........................................................................................................................1
2. Background..........................................................................................................................1
2.1 Palliative care ....................................................................................................................1
2.2 Palliative care in Sweden ..................................................................................................2
2.3 Palliative care in Vietnam .................................................................................................3
2.4 The newly graduated nurse ...............................................................................................3
2.5 Problem definition.............................................................................................................4
3. Aim .........................................................................................................................................4
4. Method ....................................................................................................................................5
4.1 Study design ......................................................................................................................5
4.2 Selection of participants ....................................................................................................5
4.3 Data collection...................................................................................................................5
4.4 Data analysis .....................................................................................................................6
4.5 Ethical considerations .......................................................................................................8
5. Results.....................................................................................................................................8
5.1 Family relationship............................................................................................................9
5.1.1 Big differences when it comes to taking care of a family member in need of 
palliative care.......................................................................................................................9
5.1.2 The decision maker...................................................................................................10
5.2 Access to palliative care..................................................................................................10
5.2.1 Final wishes ..............................................................................................................11
5.2.2 Knowledge of palliative care....................................................................................11
5.2.3 The cost of health care – a major difference between the countries.........................11
6. Discussion .............................................................................................................................12
6.1 Method discussion...........................................................................................................12
6.2 Result discussion .............................................................................................................12
6.2.1 Family relationship ...................................................................................................14
6.2.2 Access to palliative care ...........................................................................................14
6.3 Implications for nursing ..................................................................................................17
6.4 Further research...............................................................................................................17
7. Conclusion ............................................................................................................................17
8. References.............................................................................................................................18
9. Appendix 1 Interview questionnaire.....................................................................................22
11. Introduction
The World Health Organization (WHO) states that:
Palliative care is an approach that improves the quality of life of patients and their families 
facing the problem associated with life-threatening illness, through the prevention and relief 
of suffering by means of early identification and impeccable assessment and treatment of pain 
and other problems, physical, psychosocial and spiritual. (World Health Organization, n.d 
“WHO Definition of Palliative Care”, par. 1).
From the start, palliative care was only meant for cancer patients but is now more common 
for other patient groups in need of palliative care. The use of palliative care has been known 
since the Middle Ages and later came to develop in the twentieth century through writings 
and lectures. It was emphasized that the patient’s needs can vary a lot at the end of life and 
that it needs to be considered when caring for patients. Even though pain management and 
symptom control are the main focus within palliative care, it is equally important to create 
meaningful time. This requires an interaction between many allied parts of the patient's 
surroundings which can include both palliative care professionals and relatives; whom may 
have different cultures and experiences (Randall & Downie, 2006). 
The aim of this study is to investigate the attitudes nursing students have to palliative care in 
Sweden and Vietnam. The experiences and approaches to palliative care is something that 
needs to be considered since it can differ between patients, caregivers, relatives and cultures. 
In the future we might provide palliative care for patients and their relatives, where some 
might have different culture background. Therefore, it is important to find out more within 
this topic to be able to provide good quality clinical care in our future profession. 
2. Background
2.1 Palliative care 
When it comes to palliative care, pain management is one of the most difficult areas. One of 
the reasons why this can be hard to manage is because pain is often multidimensional. This 
can be described with the help of Dame Cicely Saunders “total pain” term where the social, 
spiritual, physical and psychological types of pain are included. The total pain term is 
common in palliative care and can be a challenge for the health care staff since it is complex. 
Many different components can be the cause of the pain which can make it hard to manage 
(Mehta & Chan, 2008). In 1967, Dame Cicely Saunders opened a hospice which was the start 
of the extensive hospice movement. The reason for the movement was the people’s reactions 
to the inhumane way of dying. Because of this hospice movement, palliative care spread 
around the world and became fundamental for the health care (Aranda, 1999).
WHO (n.d) states that palliative care is about the patient as well as about creating a peaceful 
time for the family since a disease often affects them too. Therefore, a supportive system 
should be offered to make it easier for the family. At the same time, palliative care does not 
mean that the death should be hasten or postponed, instead it is about not exposing the patient 
or family to unnecessary suffering. Ternestedt, Österlind, Henoch and Andershed (2012) state 
that an essential aspect when it comes to palliative care is the relief of suffering. This includes 
2the relief of symptoms and being aware of how certain health issues can affect the wellness of 
the patient. Suffering consists of several aspects which are the psychological, social, 
existential and physical needs and problems the patient might have. By focusing on the relief 
of suffering, the patient’s self-esteem will be maintained and the patient can die as “healthy” 
as possible.  
2.2 Palliative care in Sweden
Since 1970, palliative care has grown gradually and is today an essential part of the Swedish 
health care. For the last 20 years, it has grown more rapidly and the awareness has increased 
(Henoch et al., 2016). When the research of palliative care in Sweden developed, four 
different categories were created; the patient, relationships, caregivers and dignity at the end 
of life (Ternestedt et al., 2012). In 2009, the first document of guidelines on how to practice 
palliative care was established. Three years later, a review of Swedish policy document was 
released, investigating knowledge about palliative care and human rights. From this review, 
several quality indicators, such as assessment and treatment of pain, were identified and it was 
discussed how to give the patient the best care possible by using the guidelines. The intent is 
that through a continuous development of these guidelines, the quality of palliative care will 
improve even more in Sweden (Lind, Adolfsson, Axelsson & Fürst, 2013). 
A model frequently used within palliative care is the 6 S model, which is the theoretical 
reference frame used in this essay. Ternestedt et al. (2012) state that the 6 S model is based on 
Dr. Weisman’s writings. Weisman stresses the importance of maintaining self-esteem and 
social relationships of patients at the end of life as well as giving sufficient symptom relief. 
The development of the model started during the 90's and is focusing on giving the patient a 
worthy end of their life by receiving health care based on these six areas. Maeda et al. (2016) 
state that an extensive part of palliative care is symptom relief as well as providing care using 
a holistic approach. The authors present how palliative care is multidimensional by 
maintaining relationships and preserving the patient’s self-image by continuing their everyday 
life to the maximum extent possible. These aspects can be seen in the 6 S model where these, 
among others, are in focus. These aspects need to be in consideration in order to accomplish a 
worthy death. Ternestedt et al. (2012) explain that the core in the 6 S is person centered care 
which is about the patient being in the center where the important people for the patient are 
included. The person centered care is based on the humanistic approach which focuses on 
how every person is a conscious, social and reflective human throughout their life. It is 
essential that the patient is viewed from a holistic perspective where the social, existential, 
spiritual, physical and psychological aspects are included.
The model consisting of 6 areas can be used to ensure that palliative care is given through a 
person centered and holistic perspective (Ternestedt et al., 2012). The areas are listed and 
described below. 
 Self-image: Preserving a positive self-image, so patients can be able to live their 
everyday life as normal as possible. 
 Self-determination: Making patients (and relatives) active partners in their care and in 
the decisions that must be made.
 Social relationships: Encouraging and providing possibilities to maintain social 
relationships that are important for the patient.
3 Symptoms relief: Trying to relieve all physical, emotional, social and existential 
symptoms that can occur during the course of the disease until life is ended.
 Context: Letting the patient converse about and interpret their life and therefore 
achieve a feeling of context. This will reflect on the patients existential and spiritual 
needs. 
 Strategies: Acknowledging the patients’ possibilities of approaching death in their 
own way for example by offering a conversation about expectations, fears, their 
funeral or how they want to be remembered (Ternestedt et al., 2012). 
A survey study done by Westerlund et al (2018) presents that the public awareness of 
palliative care is quite low and that 84 percent of the participants had little or no knowledge of 
it. Reasons discussed for this lack of knowledge is a general fear of talking about illness and 
death, where the unknown is frightening and thereby a social taboo. For example, the fear of 
dying was considered difficult to discuss, even with the closest family members. Younger 
people had the least awareness and the authors concluded that, by open discussions, the 
knowledge about palliative care could increase. According to Ternestedt et al. (2012) Sweden 
is an individualistic society where people tend to themselves, which could hinder these open 
discussions. 
2.3 Palliative care in Vietnam
In 2005, Vietnam’s Ministry of Health initiated palliative care, since the Ministry had 
detected an increased need for it amongst patients suffering from HIV/AIDS and cancer. 
When initiating this process, it became clear that there was a significant need for support, 
education and increased knowledge of symptom and pain management. Since then, palliative 
care has grown within the Vietnamese health care system but still one barrier concerning pain 
relief is that Vietnam, in general, is a country that has a fear of opioids. This fear has its roots 
in Vietnamese history and in the laws, opioids are described using pejorative language. This is 
attributed to a lack of knowledge and results in poor accessibility and usage of opioid 
analgesics which are often crucial in palliative care (Krakauer, Cham & Khue, 2010).
A study done by Nguyen, Yates and Osborne (2014) investigated Vietnamese nurses’ 
competence and knowledge within the area of palliative care. They found that a majority of 
nurses do not speak about death with their patients nor do they explain the process of dying to 
the family members. The reason the participants gave was that this is not their obligation as 
nurses. The authors discuss that a contributing factor might be that the nurses in Vietnam do 
not have the amount of time needed for these types of dialogues. Furthermore, the study 
presents that the nurses do not have enough knowledge concerning psychological and spiritual 
wellbeing nor about pain and symptom management. Despite this, the knowledge about the 
principles behind palliative care was found to be quite high. The authors note that there is no 
training at all on palliative care in Vietnam which can be a reason for the results found 
(Nguyen, Yates & Osborne, 2014).
 
In Vietnam where Buddhism is the leading religion, death is considered a natural and certain 
part of life. Karma is something a Vietnamese Buddhist believes in, which means; what one 
does in this life will reflect upon them in their next life (Nichols, 1997). In a study by 
Donovan and Williams (2015) the results present that caring for your ill or elderly family 
member is considered the right thing to do regardless of the age of the ill person or length of 
4time providing care. One participant in the study expressed that caring for a family member is 
something one does without the need to think twice about it. The reason for this act of caring 
is that the person who is now ill took care them while growing up and now it is time to give 
something back and take care of them instead. The needs of the family are valued higher than 
the needs of the individual. Another example, from the same study, was how one participant 
chose to take care of her sick mother, even though she had to leave school, since she viewed it 
as her duty to do so. Further, she explained that she did not see this as a sacrifice because she 
could continue her life after being the caregiver. Caring for your family members is seen as a 
token of love. Vietnam is a country with a household structure where the man is working 
outside the home and the woman does the domestic work and takes care of the family. Being 
a caregiver is hence seen as a natural part of being a woman and a Vietnamese man or boy 
would usually not help a family member with their personal hygiene. In addition to this, many 
Vietnamese want to maintain their privacy and do not want help from non-relatives which 
sometimes results in suffering of the ill (Donovan & Williams, 2015).
2.4 The newly graduated nurse
Odland, Sneltvedt and Sörle (2014) describe that the transition from nursing student to nurse 
is often difficult since they no longer have the supervision they are used to. Many new nurses 
feel that they lack competence and that there is a gap between what they have learnt in school 
and the actual practice of nursing. That feeling of not being sufficiently prepared can be 
shocking as well as dealing with the responsibility nursing entails. At the same time, they 
were expected to be efficient in their daily duties. Facing patients with grave illness is 
especially challenging to the newly graduated nurse. It can be difficult to find the right words 
when speaking to patients and family members as well as to take appropriate action when 
knowledge and experience is lacking. Cain, Surbone, Elk and Kagawa-Singer (2018) state the 
patient’s cultural background might affect how they view palliative care. Cultural differences 
are commonly misunderstood, particularly if the health care staff has another background than 
the patient. This lack of knowledge can result in lower quality regarding the palliative care. 
We chose to interview nursing students since they, like the authors of this essay, soon will 
graduate and face the challenges that are explained above. We hope that by performing this 
essay, it will bring forward knowledge about palliative care and probable cultural differences 
that can later be used when working as a nurse and meeting this patient group.
2.5 Problem definition
Providing palliative care is a complex task even for the experienced nurse and even more so 
for the newly graduated nurse. The 6 s model can be a guidance in providing high quality care 
at the end of life through focusing on self-image, self-determination, social relationships, 
symptom relief, context and strategies. Cultural differences can further add to the complexity 
of providing palliative care. The meaning of, for example, self-determination and social 
relationships can differ between a country with an individualistic culture, such as Sweden, 
and a more family oriented culture like in Vietnam. A lack of understanding of such 
differences can lead to misinterpretations and unnecessary suffering when caring for a patient 
in need of palliative care. Nursing students will soon graduate and face these challenges and 
therefor it is of interest to explore their attitudes to palliative care.
53. Aim
The aim with this study is to investigate attitudes to palliative care among nursing students in 
Vietnam and Sweden.
4. Method
4.1 Study design
In this study we are investigating the attitudes Swedish and Vietnamese nursing students’ 
have to palliative care. Since this is our aim, it is suitable for us to do a qualitative study. Most 
qualitative studies are done through interviews as this method provides a right insight of the 
subject. The interview method used in this essay was semi-structured interviews, which 
contains open questions that allows the participant to speak freely and the questions do not 
have to be in a certain order (Danielson, 2017b). 
4.2 Selection of participants
Danielson (2017b) states that a decent number of participants is 20 when performing 
interviews with open questions. While there might a be a loss of participants, it ensures that a 
fair number of data will be collected. A lower number of participants might result in not 
enough information, the goal was therefore to recruit ten nursing students in each country. 
One man and 16 women participated and the interviews were conducted in Sweden and 
Vietnam.
At Sahlgrenska Academy, Sweden, palliative care is introduced in the third semester of the 
nursing program. We used the network GUL, which is the platform lecturers and students use, 
to send out a question to nursing student in semester five for participation in the study. We 
recruited six students through this and the remaining four participants were recruited from our 
class, in semester four. This is called a convenience sample where accessibility and 
geographical factors are taken in consideration. With this type of sample, the participants 
must have certain characteristics which suits the purpose of the study (Dörnyei, 2007), in this 
case being a Swedish nursing student. For the Vietnamese students a convenience sampling 
was yet again conducted. Through our supervisor Mr. Trung in Hanoi, we got in contact with 
a student in year four whom we interviewed along with two of her classmates. We also 
contacted a student in year five whom we met in Sweden when she had her exchange at 
Sahlgrenska Academy. She brought three other students for us to interview.
Taking part in the study was voluntary and every informant had the right to terminate their 
partake at any time if they wished. The participants were informed that all answers would be 
anonymous, but not coded, once transcribed. All this information was given orally. In this 
study certain inclusion criterias were used, which are specific characteristics that the 
participants hold (Polit & Beck, 2004). Since the aim of this study was to learn about 
Vietnamese and Swedish nursing students’ attitudes, the informants in Vietnam needed to be 
of Vietnamese origin and the ones in Sweden of Swedish origin. Exclusion criteria can be 
explained as certain criterias that the participants are not allowed to have (Polit & Beck, 
2004). It did not matter if the student had been absent for a semester or what year they were 
in. We did not exclude anyone because of their level of knowledge since the study is focused 
on the attitudes of nursing students, not on how much they know about palliative care.
64.3 Data collection
The participants and the authors agreed to a time that was suitable for both parts regarding the 
interviews. Appendix 1 shows the questions used in the interviews in both countries. The 
wording of question number nine, see appendix 1, was changed during the study. At first, this 
question was a closed, only asking whether or not they would take care of their family 
member when in need of palliative care. During the first interview, the participant did not 
know what to reply followed but a moment of silence.  We then decided to add the last part of 
the question; “or will you leave that the health care staff?”. When this was changed no one 
else expressed this type of confusion. Some participants answered two questions in one which 
resulted in us not asking that person every question due to no need for repetition. All 
interviews were performed individually and were recorded on mobile phones. As the focus 
was on the participants and their answers, notes were not taken during the interviews. 
The interviews in Sweden were executed at Gothenburg university, some at the school café 
and some in private study rooms. We wanted to perform the interviews at the university, this 
to have the participants as comfortable as possible and to elaborate freely. Each interview 
lasted around 10-15 minutes and the main part of the discussion was about the questions 
asked. We spoke Swedish because it is the mother tongue of the participants and the authors. 
By doing so it was probably easier for them to answer the questions with the possibility to 
elaborate without any misunderstandings.
In Hanoi it was not easy to find secluded and quiet areas to perform the interviews as to why 
we did it in a café and in a dormitory. The interviews were recorded on mobile phone and 
each lasted around 20-25 minutes. Some part of the interview was a discussion about the 
differences between Sweden and Vietnam as well as some further explanation of the 
questions due to the language barrier. Some concerns regarding the need of a translator were 
discussed, but once conducting there was no apparent need of this. There were some silences 
where it was clear that the informant did not understand the question, and we had to explain it 
using other words. Once the interviews were recorded, they were divided between the two 
authors and transcribed. The reason for the division was because of the timeframe and number 
of interviews. The authors transcribed the recordings word by word and listened carefully 
several times. After this, both authors approved the transcriptions.
4.4 Data analysis
A qualitative content analysis was used to analyze the data. This method is appropriate to use 
when the data is collected through interviews (Danielson, 2017b). We chose to do a manifest 
analysis where the data is processed into categories and subcategories (Fridlund & 
Mårtensson, 2017). When using the manifest analysis, data is analyzed in a descriptive way 
and no interpretations are made. This can be compared to a latent analysis where an 
interpretative approach is used (Danielson, 2017b). It is essential to read and reread the 
transcriptions to make the analysis as clear as possible in order to not miss essential data. An 
inductive approach was chosen since the aim of the study was explorative and not based on a 
specific theoretical understanding (Henricson, 2017b). When using an inductive approach, 
one should observe a certain phenomenon, in this case attitudes to palliative care, and 
thereafter describe the phenomenon. Afterwards the author can try to create a conclusion that 
could be transferable on similar contexts unlike the deductive approach where the authors are 
creating assumption based on a theory (Priebe & Landström, 2017).
7After reading the data, with a few days between every reading, we searched for meaning units 
to organize all the collected data. We categorized and looked for patterns in the data to find 
the most important findings. After finding useful units they were condensed to make it ever 
more perspicuous. Thereafter different codes were created to see what patterns appeared as 
well as similarities and differences between them. Using these codes, subcategories were 
found which then formed categories (Danielson, 2017b). This process is presented below in 
Table 1.
Table 1. Data analysis schedule 
Meaning units Condensation Code Subcategory Category
“No focus on palliative 
care in Vietnam so you 
don’t see it often. We 
don’t have the real 
definition of real 
palliative care on our 
system.”
No focus on 
palliative care in 
Vietnam.
Focus Knowledge of 
palliative care
Access to 
palliative 
care
“In Vietnam we depend 
of family decision even 
if the patient is 
conscious. We ask the 
family what to do with 
the patient. But I think 
we should focus more 
on the patient because 
they have the right to 
decide what should 
happen to them.”
We ask the family 
what to do with the 
patient. 
Decision The decision 
maker
Family 
relationship
“If you don’t have 
enough money you 
can’t receive palliative 
care.”
“If the family cannot 
afford to pay for 
treatment the patient 
does not receive any.”
If you have no 
money you do not 
get care.
Money The cost of 
health care – a 
major difference 
between the 
countries
Access to 
palliative 
care
8“I would have tried to 
care for them as much 
as I could but you also 
have to be realistic and 
might have to get help 
from a nursing home or 
similar.”
“I want to say that I 
would. But I would be 
there in an emotional 
way and physical but I 
would leave the 
everyday-care to health 
care personnel.” 
You have to be 
realistic, might 
need help from a 
nursing home. I 
would be there in 
an emotional way.
Realistic, 
help
Big differences 
when it comes to 
taking care of a 
family member 
in need of 
palliative care
Family 
relationship
“I would like to die in 
a place where I feel 
comfortable and happy, 
if that is a nursing home 
or my apartment I don’t 
know.”
“With my family, in my 
home, but I wouldn’t 
want to burden my 
family so it might be 
better at a hospital and 
similar.” 
With my family at 
home but have 
heard good things 
about hospice.
Family, 
home
Final wishes Access to 
palliative 
care 
4.5 Ethical considerations
When performing a study that includes humans, ethical considerations must be made. This is 
not needed in an essay on a bachelor level though (SFS 2003:460), therefore we did not apply 
for an ethics approval. The participants were given oral information about the aim of this 
study. We did not let the need of data exceed the rights of the participants and the interviews 
were done respectfully by not forcing anyone to answer if they did not want to. The 
interviews were done in a way to protect the individuals and confidentiality was of essence, 
all done in accordance with WMA (2018), the declaration of Helsinki. The subject that was 
investigated might, for some participants, be sensitive but no informant was required to 
answer a question they felt was upsetting. The recorded interviews were not coded but 
anonymous. They were transferred from a mobile to a computer with a password, meaning 
that no outsider could get hold of them. The transcripts were also kept on the computer, all of 
this to protect the participants and their anonymity. When the essay is approved, all data 
collected will be destructed. 
95. Results
When the data had been analyzed, five subcategories appeared; big differences when it comes 
to taking care of a family member in need of palliative care, the decision maker, final wishes, 
knowledge of palliative care and the cost of health care – a major difference between the 
countries. The first three subcategories created the category family relationship and the last two 
created access to palliative care. The categories and subcategories are presented below in Table 
2. 
Table 2. Categories and subcategories
Category Subcategory
Family relationship Big differences when it comes to taking care 
of a family member in need of palliative care 
The decision maker
Access to palliative care Final wishes
Knowledge of palliative care
The cost of health care – a major difference 
between the countries
5.1 Family relationship
This category has two subcategories which are big differences when it comes to taking care of 
a family member in need of palliative care and the decision maker. The participants in both 
countries explain that they would like to help their family members as much as possible when 
needed, which is further explained in taking care of a family member. The Swedish students 
explain that the focus should be on the individual when it comes to palliative care and 
decisions whilst the Vietnamese keep focusing on the importance of making family decisions. 
This is further explained in the decision maker.
5.1.1 Big differences when it comes to taking care of a family member in need 
of palliative care
Only two participants in Sweden give an absolute yes when asked if they would care for their 
family member while in need of palliative care. In Vietnam, on the other hand, every 
participant say that they would provide care. They explain this by saying that the older 
generation depend on them and that they want their children to do the same for them when 
needed. This differs from Sweden where one says:
“I would have tried caring for them as much as I could because I have the competence. But 
you also need to be realistic, you have your own life and we are living in a society where we 
are not caring for many generations in the same home as you do in other countries.”
10
Some participants in Sweden will take care of their family member in need of palliative care 
but only to a certain level. They will provide emotional support but will leave the everyday 
care to health care professionals. The reasons stated for this is that palliative care can be hard 
work and very demanding. They also say that it is important that the family member is 
comfortable with them taking care of him or her, otherwise they will not do it. One 
Vietnamese participant say that the only time she will not care for the family member is when 
she will have to work. Since she is an only child, she might have to hire someone to take care 
of the family member during the time she is working, which is understood as the right thing to 
do when you cannot care for the person yourself.
5.1.2 The decision maker
Many generations live together in Vietnam and the older family members depend on their 
children to make decisions for them. This also affects the decisions when it comes to 
palliative care. Only one participant from Vietnam say that the decisions regarding care 
belongs to the patient since it is their life. The others say that the family should be the one 
making the decisions and one motivates this by saying:
 “The palliative care is about the individual patient but also its effects and impacts the 
relatives and the family and not only the patient. The mental pain is not only for the patient 
but for the whole family so their whole family needs to decide palliative care.”
Most of the Swedish participants are in agreement that it should always be the patient who 
makes the decisions. The fact that the family do not always know what is best for their loved 
one is discussed and one of the participants expresses: 
“It should be the patient. I think the family will always want curative treatment even when the 
patient may not want it. If they will keep treating the patient it might lower the quality of life.”
In Vietnam, even when the patient is conscious, the family might not give him/her all the 
information they have received from the doctor. The reason being that they do not think the 
patient should decide and accordingly not knowing all the information is in their best interest. 
The mentality to want what is best for your family member is thus the same in both countries 
but the Swedish participants keep their focus on the individual by stating that the dying 
person's wishes are more important to consider than the family members’.
Another similarity between Vietnam and Sweden when it comes to decision making is that it 
depends on the state the patient is in. Some Swedish participants express that the patient 
should be the decision maker as long as it is possible and diagnosis has to be considered. If 
the patient is not sensible enough the decision should belong to the family with support from 
health care professionals. By doing this, these participants find that the best decision possible 
can be made. In Vietnam many mention that a patient who is in need of palliative care might 
not be in the state of mind to make decisions. Therefore, it should be the family who decides 
instead of the individual.
5.2 Access to palliative care
This category has three subcategories which are final wishes, knowledge of palliative care and 
the cost of health care – a major difference between the countries. When it comes to final 
wishes, most participants emphasize the importance of being around loved ones. In Sweden 
11
nursing students have a compulsory course in palliative care, whilst in Vietnam they do not. 
This is further explained in knowledge of palliative care. The cost of health care in Vietnam 
limits the possibilities and access to palliative care whereas in Sweden this is not discussed.
5.2.1 Final wishes
Some of the participants from Sweden have no wish in where they would like to spend their 
last days but state that the important thing is that it is in a place where they feel comfortable. 
In Vietnam, they have similar thoughts where a strong wish to be around their loved ones is 
expressed. The word peaceful is mentioned, which can be compared to the Swedish 
participants who speak about the importance of the environment being stress, anxiety and pain 
free and the importance to not suffer. 
 
One participant from Vietnam mentions that her wish is not to die in a hospital because of the 
stressful environment. Another say that if she is not close to her family, she would like to 
spend her final days at a hospital. This is also mentioned in Sweden where hospital was seen 
as an option if they would be comfortable there. Hospice is mentioned by some as an 
alternative to hospital, whereas this do not seem to be an option among the Vietnamese 
participants.
 
One participant from Sweden mentions that she would prefer to die at a nursing home so that 
she will not be a burden to her family. This is mentioned repeatedly among the Vietnamese 
nursing students where there is a strong wish to not burden their families. Yet, the strong 
bonds within the family is often mentioned and how everyone is taking care of each other is 
put forward as an ideal by most participants.
5.2.2 Knowledge of palliative care
According to the participants, palliative care is very limited in Vietnam and that there is no 
focus on it, neither at the nursing program nor at the hospital. Only two of the Vietnamese 
participants have been in contact with palliative care through school. Whereas in Sweden all 
the participants have received knowledge on palliative care through school and some also got 
experience through clinical training. Some participants from Sweden also have personal 
experience due to family members needing palliative care. One participant from Vietnam 
answers the question “is there anything you would like to change about palliative care in your 
country?” with:
“The palliative care is not focused on the mental health. We don’t have enough staff to care 
about that.”
 
All participants from Vietnam agree that palliative care is very important but state that the 
two palliative departments they know of are not really based on palliative care models. For 
example, patients might receive pain relief but no emotional or psychological support. They 
discuss that the Vietnamese health care system needs more knowledge and focus on palliative 
care. The opinion that palliative care is important is also mentioned by the Swedish 
participants.
  
The participants mention that in Sweden there is a compulsory course about palliative care at 
the nursing. One Swedish student also mentions that another course on palliative care is 
12
offered later in the program. At the nursing program in Vietnam, on the other hand, they take 
courses on rehabilitation but the focus is still on treatment and cure. Because of this, all the 
participants in Vietnam express a wish to learn more about palliative care. When asked the 
question “do you think palliative care is a subject that should be talked about more? If so, 
why?” one of the participants answers:
 
“Yes of course! It’s a thing that is coming in the near future. As nursing students, we have to 
learn more and have to do it more in clinical placement and theory.”
This is also evident among the Swedish participants that all mention the wish to have more 
knowledge and experience of palliative care as well as a need to speak about death and dying 
in general. Even though the palliative care is more common in Sweden than Vietnam, all 
participants from both countries express the wish for and need of more knowledge. The 
reason for this being that the subject is seen as an important part of the health care practices in 
both countries.
5.2.3 The cost of health care – a major difference between the countries
Getting access to health care and medical treatment is, according to the Vietnamese 
participants, expensive. Although some have health insurance it does not cover everything 
and if the family does not have the financial means to pay for treatment the patient will 
simply not receive it. One participant states that morphine is not given outside the hospitals, 
but if you have the money you can buy anything, even though the law forbids. The issue of 
money and finances in relation to health care access is not mentioned by the Swedish 
participants. The Vietnamese students also mention how the older generation depend on the 
family financially because they do not work and have no income of their own.
One participant from Vietnam explains that there is not enough health care staff in the 
hospitals which means that at least one family member must stay there to take care of the 
patient. This results in less income and a lot of stress for the family and is one of the reasons 
why a hospital stay might not be an option. This issue is not mentioned in Sweden where the 
hinders and possibilities for caring for a family member relates to being realistic in terms of 
time and ability.
6. Discussion
6.1 Method discussion
Mårtensson and Fridlund (2017) describe that credibility with regards to qualitative studies 
implies that researchers should be able to prove to the reader that the knowledge found is 
reasonable and that the results are valid. This could be achieved by letting a “critical other” 
review the data. Dependability means that preunderstanding, the effects of this and how the 
interviews and transcriptions were carried out should be thoroughly described. For the study 
to have confirmability, the data analysis process should be accurately described, the decisions 
made explained, and by letting an outside person review the work (Mårtensson & Fridlund, 
2017). We strived for dependability and confirmability by explaining and carefully describing 
every step in the work with the study. Furthermore, we recorded the interviews, transcribed 
them word by word and both of us read the transcripts multiple times to make sure that our 
13
results correctly reflected the participant’s opinions. Our supervisor read our work along the 
way which further increases confirmability and credibility.
Since the authors are nursing students and have studied palliative care at the nursing program, 
having a certain preunderstanding on the subject is inevitable. Preunderstanding implies a 
certain understanding and knowledge about a subject before starting out an actual study. 
Preunderstanding might also come from life experiences outside of school which makes them 
even harder to distance oneself from (Priebe & Landström, 2017). Instead of trying to 
distance oneself from preunderstandings one can be aware and mindful of them which has 
been taken in consideration throughout the study. 
For the result to have transferability, it should be possible to transfer the results on other 
groups, situations and contexts. The results also need to be described clearly and the study 
should be considered to have credibility, dependability, confirmability (Mårtensson & 
Fridlund, 2017). Most of the Vietnamese students had similar opinions as well as the 
Swedish, which could point to a transferability to other nursing students or maybe even other 
groups of people in the two countries. But, because we cannot fully say that the study has 
credibility, dependability and confirmability, it means that it might not be transferable either.
One challenge with a data collection through interviews is to not steer the informant into a 
certain direction and it is therefore important that the person in charge of the interview is 
aware of this and reflects throughout the process. Furthermore, it is of essence to question 
who the most suiting informants are for the subject and if the best method will be used (Elo et 
al, 2014). Semi-structured interviews were a suiting choice of data collection since it contains 
open questions and which allowed the participants to speak more freely. This also meant that 
one does not steer interviewees into a certain direction, which can be considered a strength. 
The interviews resulted in a rich and informative data on the opinions to palliative care in the 
two countries, which was also the aim of the study. 
Being mindful of ethical aspect is very important when conducting a study based on 
interviews. We made sure that the participants knew it was voluntary and that they were not 
forced to answer any questions they felt was of a sensitive nature. Furthermore, we asked 
them if we could record the interview and made sure they knew that we would not reveal their 
identity. The sufficient number of participants has to be judged in relation to the aim of the 
study and when collecting data through semi-structured interviews striving for 20 participants 
was deemed enough (Danielson, 2017b). We believe that the recruitment process in Sweden 
was good as it was evident to the participants that is was voluntary to partake. However, as 
the Vietnamese participants were recruited through a teacher at the school, we cannot be sure 
that they wanted to partake in the study. We must acknowledge the fact that maybe they could 
not say no as it was an authoritarian who asked them as well as the possibility of the teacher 
choosing students that represent a certain opinion. These facts must be considered a weakness 
regarding the study. Although ten participants were the ambition, there were only seven in 
Vietnam since the others did not appear. Despite this, a saturation was achieved where certain 
patterns were detected and no new aspects surfaced (Carlson, 2017). Because of this, there 
was no need for further interviews.
It was easier not to steer the participants whilst interviewing in Sweden as Swedish was 
spoken which is the mother tongue of both parts. This meant that the participant was asked 
14
the question and we did not have to explain it further. In Vietnam, even though the 
participants level of English was good, there were at times confusion. This meant that we had 
to ask them the question again using different wording, which could be a weakness. Despite 
this, we consider it a strength that we did not use a translator because we think it made the 
environment more open being only the three of us partaking in the interview situation. 
Another possible weakness could be that we did not perform a pilot interview. Danielson 
(2017a) explains that a pilot interview is used to confirm that the questions are suitable and if 
they need to be adjusted. Despite not having performed a pilot interview, we discovered 
during the first interview that one of the questions had to be changed. It is a strength that we 
then decided to change the interview guide to make the question clearer for the participants. 
After completing all interviews, we realized that not every question resulted in useful data. 
However, these questions are still beneficial since they created a more comfortable and 
relaxed environment. 
6.2 Result discussion
The aim of this study was to investigate the attitudes that nursing students in Sweden and 
Vietnam have to palliative care and the main finding were that in Vietnam the family is in 
focus whilst in Sweden it is the individual. Differences were found between the countries 
when it comes to knowledge of and accessibility to palliative care. 
6.2.1 Family relationship
In both countries, the family was important to the participants and they were willing to 
provide their family members with palliative care. This willingness was expressed differently 
between the countries though. In Sweden the focus was on the individual, where most 
participants said that the patient should be the decision maker. The Vietnamese, on the other 
hand, expressed that the family is a unit as they depend on each other and live together over 
generations and thus should make decisions together. Another difference found was that only 
two of the Swedish but all the Vietnamese participants would provide care for their ill family 
member at the end of life. One participant said that she wanted her children to do the same for 
her. As explained by Donovan and Williams (2015), doing so is considered the right and 
natural thing to do within Vietnamese culture. The family unit is valued higher than the 
individual and caring for an elderly or ill family member is justified since they took care of 
them while growing up. Doing so is also seen as the ultimate expression of love towards the 
other person. 
One Swedish participant said that we do not have a society where we provide care for each 
other in such a way. Ternestedt et al. (2012) state that the patient and family members can be 
more satisfied if palliative care can be provided at home but that it also implies responsibility 
for family, for example regarding symptom control. Such advanced caring responsibilities can 
be seen as strenuous. Taking care of a family member who needs palliative care results in 
both positive and negative feelings; being close to the patient is seen as positive whilst the 
mental and physical stress is difficult to handle. In a study by Linderholm and Friedrichsen 
(2010) family caregivers were interviewed about their experiences of taking care of their 
family member. They found that doing so was seen the morally correct thing to do and 
sometimes as an obligation. A feeling of being overwhelmed because of all the duties it was 
also expressed since the family member becomes a caregiver. This role includes a lot of 
15
responsibility and puts pressure on the family. They also mentioned the essentiality of having 
good relationships between formal caregivers, the ill person and the family members. Some 
positive aspects of being a family caregiver were also found, such as thankfulness and being 
able to spend valuable time with their loved ones (Linderholm & Friedrichsen, 2010).
Nguyen (2015) describes that when an important decision is to be made in Vietnam, the 
family is included in the process as you must consider the effects it may have on the family. 
Although the decision might regard the individual’s health, they do not believe in autonomy 
since collectivity is emphasized. Donovan and Williams (2015) support this as they state that 
decisions are a family matter where care setting, treatments and lastly funeral arrangements 
are included. The participants in our study mentioned the family multiple times where only 
one expressed that it should be the individual that decides. Regionala cancercentrum i 
samverkan (Regional cancer centers in collaboration) (2016) explain that a big part of 
palliative care in Sweden is about the patient's right to make their own decisions about the 
care they receive. However, it is equally as important to involve the family member in the 
dialogue to optimize well-being. This is of great importance since palliative care does not 
only affect the patient but the family as a whole. The patient might end up not being able to 
communicate or express their needs and wishes, as to why the staff need to know who the 
decision maker is at this stage. This was expressed by the participants in Sweden; the 
individual should decide since it is their life. Despite the difference between the two 
countries, the participants in Sweden and Vietnam had similarities in their answer as to who 
the decision maker should be. This was if/when the patient is not in the state of mind to make 
decisions, then it should be the family.
6.2.2 Access to palliative care
The result showed that several factors contribute to the differences in accessibility of 
palliative care. Matters such as cost, lack of health care staff and knowledge are limiting the 
possibilities to obtain palliative care in Vietnam. In Sweden, it is commonly used and easily 
accessible (Westerlund et al., 2018) and for the past 40 years, palliative care has grown 
rapidly (Henoch et al., 2016). Westerlund et al. (2018) state that despite the development, the 
knowledge is fairly low amongst the general public. The study presented that awareness was 
higher amongst people working in health care or those with a higher level of university 
education. One reason presented was that accessibility to knowledge of palliative care is 
limited. Discussions about the subject are not common where a social taboo of talking about 
death could be a reason. The authors present strategies to increase the general knowledge of 
palliative care such as information in schools, informative websites and speaking of the topic 
to make it more visible. 
In Vietnam, palliative care has only been active since 2005 and the possibilities are limited 
(Krakauer, Cham & Khue, 2010). In a study by Green, Kinh and Khue (2006) the lack of 
health care staff is considered a reason of not receiving palliative care. Takaskima et al. 
(2017) explain that the lack of health care staff is an urgent issue in Vietnam, palliative being 
one of the most crucial areas. Thus, there is a shortage of training and knowledge in several 
areas where resources are limiting. This contributes to lower quality of care and the 
overcrowded hospitals are limiting the improvement. This can be confirmed by Nguyen, 
Yates and Osborne (2014) who present that nurses do not receive education regarding 
palliative care which can be a reason for the low awareness and knowledge about the subject. 
The same study showed that >51 percent of the nurses’ daily tasks focused on caring for 
16
patients in need of palliative care which makes the knowledge more essential. Neither do the 
nurses have the knowledge needed about the spiritual and psychological areas of palliative 
care. This fact can be recognized in a study by Green, Kinh and Khue (2006) where nurses 
treating patients suffering from HIV/AIDS and cancer were interviewed. It was revealed that 
only 26 percent knew strategies on how to manage pain. The did not have access to the 
medicine needed for this type of pain management nor did they have education about pain 
relief and suffering. Furthermore, amongst this patient group emotional suffering is extremely 
common, however the support is not great. Many things need to be emphasized for palliative 
care to reach a level of decent quality. National guidelines are needed, opioids should be 
easier to access, education needs to expand and the availability of palliative care must 
improve. Green, Kinh and Khue (2006) state that palliative care education should be part of 
the basic nurse education. Our participants expressed that they do not learn about palliative 
care, they focus on the rehabilitation and how to cure the patient. The students expressed that 
they wish palliative care would become more accessible because of the importance they 
believe it has. 
The results in our study showed that receiving care in Vietnam is expensive and the treatment 
needed might not be received. The participants mentioned that at times, a hospital visit is not 
an option because of this. This is presented in a study done by Meyerhoefer, Sahl and 
Younger (2007) where it is states that the high cost when seeking care in Vietnam has made 
the access more limited. Thus, it has created a disadvantageous health care system for those 
with less money. The reason for the high cost is primarily that the financial support received 
from the public sector is not adequate. The health of every individual affects the economy in 
the country which makes it even more essential in lower income countries, such as Vietnam. 
The same study indicated that poor people are higher users of private clinics as these usually 
are cheaper while wealthier people visit the hospital. Suggestion presented to improve these 
areas was to reduce the health care cost to increase the quality of care which might be a 
question of higher taxes (Meyerhoefer, Sahl & Younger, 2007).  
In a study performed in Sweden by Harstäde and Andershed (2006) it was presented that trust, 
participation and safety was emphasized when speaking of the final days of life. Since these 
three aspects were the definition of a decent place to die, the place of where was not really 
highlighted, which was a finding in our study. If a place had to be mentioned, a majority in 
the study said hospital rather than at home where safety was central. Green, Kinh and Khue 
(2006) conducted a study in Vietnam where they interviewed cancer patients and the results 
showed that 67 percent expressed a wish of receiving palliative care at a hospital. One reason 
was regarding the security and the possibility to receive care any time of the day which might 
not be possible at home. Only a few participants had the wish to receive treatment in other 
facilities such as hospice. The results in our study showed that in both countries, most 
participants had a strong wish of being around their loved ones in their last days as well as it 
being stress free. 
The Swedish participants mentioned how they do not want to suffer when in their final days 
of life, which was not discussed by the Vietnamese. This might be because suffering and the 
symptom relief is big part of the palliative care in Sweden as well as person centered care. 
The relief of symptoms is one of the areas in the 6 S model which is inspired by Dr. Weisman 
(Ternestedt et al., 2012). Since the Vietnamese nursing students expressed that they do not 
learn about the mental and emotional part of caring, it could possibly result in unnecessary 
17
suffering for the patient. After listening to the participants in Vietnam, we understood that 
they do not learn about palliative but have a desire to do so. If they were to learn about 
palliative care from a holistic perspective as Ternestedt et al. (2012) explain, the patient could 
be relieved of their suffering. This because caring for the patient from a holistic perspective 
means seeing the patient as a whole and thereby relieving them of symptoms such as pain. 
6.3 Implications for nursing
The results are useful for health care staff as it gives an insight on how palliative care can 
differ between cultures. Hopefully it can be used in practical work when caring for a patient 
with a different cultural background as they will have more knowledge in the area. There are 
differences between families as to at what extent they should be involved in the care. This 
might be because of the patient's wishes or culture and must be considered when working 
within health care. We think that it is of great importance that health care staff are aware and 
have knowledge of how cultural differences could be expressed. By doing this, they would 
respect the patient, family and give the best care possible. Through this study, the reader can 
learn about how palliative care is thought of in two different countries and receive a better 
understanding.
6.4 Further research
To obtain more knowledge of palliative care will broaden our competence as nurses as we 
might encounter patients in need of palliative care. Therefore, we believe that further research 
in other contexts is needed since it is a wide subject with many aspects. By interviewing 
patients, family members and nurses with different cultural backgrounds it would result in 
further understanding of palliative care. 
7. Conclusion
In Vietnam family is the priority and they take care of each other because the health care and 
society are structured in that way. Palliative care is not easily accessible in Vietnam since it is 
not common and because receiving care is expensive. Despite this, they care for their loved 
ones and there is no doubt that they would not. Swedish culture, on the other hand, means that 
whilst the family members want the best for their family, most would not take care of their 
loved ones when in need of palliative care. Ternestedt et al. (2012) explain that Sweden is an 
individualistic society where people tend to themselves, which might be why they are not as 
close to their families in Sweden as they are in Vietnam. Since everyone can receive good 
quality care, they do not have to care for their families in ways they are not comfortable with. 
This study can be used to gain a deeper insight of cultural differences and that everyone is not 
able to receive care when they are ill. The findings made would need more research for 
further conclusions regarding the topic.
18
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9. Appendix 1 Interview questionnaire
 What is your opinion on palliative care? 
 At what extent have you studied palliative care at the nursing program? 
 What did you know about palliative care before you started studying?
 Do you think the family or the individual should be the decision maker when it comes 
to palliative care and why?
 Do you think palliative care is a subject that should be talked about more? If so, why?
 Have you been in contact with palliative care been while working/at internship? If so, 
in what way? 
 How do you think the patients experience the palliative care they get? 
 Is there anything you would change about the palliative care in your country? If so, 
what?
 Will you take care of your family members when they are in need of palliative care or 
will you leave that to health care staff?
 When your life is coming to an end, how would you like the end to be?