Structural analysis/Reflective activity. In this activity you will explore your practice through a reflective process. If you have any concerns and need further clarification please contact me. The reflection will take a little time but keep in mind you have already submitted stories that enhance or constrain practice in your first discussion board. You have also addressed these stories in your assignments to some extent.Each submission will be different so it is not one size fits all. This is a time where you can let your creative side do what it needs to do. THE PROCESS Step 1: Read the document ‘Narrative reflection’ in the learning materials in module 3, weeks 11-12, then return to this page. Step 2: Open the document ‘Story template’ in module four and work through it. At the end of this template is an example of two stories to help guide you. They don’t have to be this long as the ones in the examples. Step 1: 1.Narrative reflection: Changing Practice Through Story As health or social work professionals you use stories every day to talk about what you do, and how you do it. These stories help build trusting relationships with client’s, patients, families and colleagues. You carry stories of health, social situations and people’s lives in particular ways because of the circumstances and situations which bring people to you, health or community services. Stories about health, illness and social distress change personal/professional perspectives and ‘imagined’ positions of others. These perspectives can provide a basis for developing empathy and change professional practice. This narrative reflection has been adapted from the work of Greenhalgh and Collard (2003, pp. 65–66). It uses Bourdieu’s concepts of field,doxa, habitus and capital to help you construct a story of practice to demonstrate how they work in practice. While the language and concepts may seem new and unfamiliar to you, you enact Bourdieu’s concepts in your everyday practice. His ideas are presented here to assist you in understanding why things are the way they are in your area. But, before you begin, consider what a story is. For the purposes of this activity, a story: focuses on a particular practice situation is told from the perspective of the storyteller and includes what is relevant to you, the storyteller. has a plot. The storybegins, things happen andsomething emerges in terms of action. identifies possible causes about why things happened or why things are the way they are. is an attempt by the teller tofind meaning in what happened. has tension, complicating action or unresolved feeling, thought or actions. includes a description of the feelings and emotions of the patient/client, health professional or other people, such as what they said or did that indicated an attitude, feeling or thought. is shared as a story, and so requires a listener or a reader. (Discussion board). provides aspace for the teller to reflect on the story and construct an alternative ending (perhaps your journal) provides a basis for sharing the learning points for professional practice with colleagues. provides an opportunity for changing practice to deliver i health care a person might experience as safe and secure. 2. A template to guide you through the process of constructing your story. Narrative reflection: Changing practice through story This activity requires online interaction within your group in Forum 3. When you have completed the tasks submit your story and analysis to discussion forum 3. The story template and an example is in the next item – see below before starting the activity. Task: Part 1 Choose a practice situation that means something to you in relation to the unit learning materials. For example, you might recall a situation where care or the service, demeaned, diminished or devalued the identity or wellbeing of a patient, client, family, colleague or youself. It might be a situation where professional values and subsequent care was compromised. It could involve the power of the health professional or patient/client challenging the service or the institution, creating tension or conflict (Welch, 2005). When you have decided on your story, work through the following template systematically. You might want to write it as a free-flowing story rather than use the headings the questions suggest. You might want to tell the story to another person first. Tell the story as a story , see above, either written or spoken, with a beginning, middle and end. If you have told the story to someone make sure you write it down. This is your story about what happened. Task: Part 2- Telling the same story from your ‘imagined’ perspective of the person or one person in your story. Now tell thesame story in the first person from yourimagined perspective of the person’s experience. This is the story of one of the people identified above. Start with I am ….. A patient, client, resident,family member etc. ‘This is my story about what happened … It is about how it affected me at the time and how it is continuing to affect me…’ At the end of your story, from the imagined position, identify three things that the health professional/s involved did to help you) maintain a sense of wellbeing and hopefulness (see example). Make sure you write it down. Note: This isyour interpretation of how another person might have experienced the same situation. You tell itas if you were the other person. It is important to note that it is not knowing how the other person thinks or feels. Every day we are imagining how another person might be and we respond accordingly. It is called empathy, responsiveness, compassion, understanding and relationship. Task: Part 3 Reflect on the following questions and make notes to capture the thoughts and feelings. 1. What questions or issues does this story raise in relation to your practice? 2. What have you learned from constructing these stories? 3. Submit both of your stories (from Part 1 and Part 2) to one other person in your group. Choose one person only. But have a look at other postings if you choose to. 4. Have a discussion with the person to whom you have sent your stories. Post your full stories to the Discussion Forum titled: Structural analysis/ Reflective activity. Access the Forum through the left hand green menu ‘Discussion Forum and Groups’ You can either post in the discussion board or attach a word document. Please make sure you not disclose any identifying information of person or place. Step :2 Story template This template will guide you through the structure of recording and reflecting on the story. 1. What is the story about? For example, is it a story about hope, despair, morality, power, racism, resistance, strength, resilience, struggle, dignity or …?) 2. Who is the story about? (Patient, client, resident, customer, family member, colleague) 3. What kind of setting did it place in? 4. Why have you chosen this story? (What is the first thing that comes to mind when you see this question). Is it something unresolved, or was it a good experience demonstrating best practice? 5. What happened in the story? Tell the story. To get you in the story telling mood you could start with ‘Once upon a time…..’ 6. Who are the key people, objects or structures in the story (A key person may not be the most obvious person. A key person may have a minor role in the overall story. Note also that objects may play a part in the telling of the story. For example, the interview room, the assessment processes etc.) 7. How did you or some of the other people in the story react to what was happening? 8. What was the outcome? 9. What constrained best practice? What enabled best practice? 10. Do you think anything could have been done differently? If so, who could have done what, and why would it have been better? What questions or issues do the stories raise in relation to your practice? What have you learned? What can you do differently? What do you need to make a change- resources, relationships, things/objects/structures Here is one example: This is a story about overcoming resistance, struggle, maintaining dignity and doing what’s right. Louise’s story Part 1: The context. Once upon a time people were admitted to psychiatric hospitals for care and treatment for mental illness. Many of these people were never discharged home or to the community. This was because they were thought to be chronically mentally unwell, or their families did not want them, so they spent most of their adult lives living in mental institutions. Their lives consisted of routine and repetition until they became institutionalised. This meant they could lose their motivation to live productive lives. While their important friendships were with other patients, they were dependent on staff for contact with the world beyond the walls of the institution. Then, in the mid1980s there was a change in attitude toward people who were mentally ill and the Government decided to move people who had been in hospital for many years, into houses in the community. Here they could take part in the wider community participate more fully as community members. This story is about struggle and dignity and doing things differently. The people in the story are the patient, the storyteller (Louise), other staff members, family and the team leader. The structures are the house and the routine. The objects are the teapot, milk, sugar and porridge and the seasons. I chose this story because it demonstrates that while some things are done for the right reasons we always have to work with what has gone before. What might be practiced in one situation, however inappropriate is not applicable in another. I also chose this story because it demonstrates the complexity of everyday ordinary practices which constrain the full expression of a person’s identity and wellbeing. (Louise’s story, 2010) cited in Richardson (2010). The story with plot, tension, action. I was a new graduate and keen to take my learning into a new environment. My first job was in a community mental health residential home. As a new graduate I got a lot of resistance from staff I worked with especially with people who had been in that field for some time. A lot of people had come from [name of place ] and had been in a structured environment. I remember I had this particular patient who was diagnosed with diabetes so I was there to help him. I noticed that tea was being made in a big teapot and the milk and sugar was put in there so they all got cups of tea like that. And then this man wanted to have porridge for breakfast and this was February. The staff said ‘We make porridge in the winter for all residents’ so because it was summer he couldn’t have porridge and they weren’t going to treat him any differently from anybody else. The outcome: I had to be careful how I handled this so the team leader agreed we shouldn’t make cups of tea like that because it did not allow for individuality. That was good. The one with the porridge, I just had to present that as a personal goal with the person. Having porridge for breakfast was what he was used to. It was not a summer winter thing for him. I put his want out to the team as a personal need and because it was backed by his family I put down in his notes that we had talked about it and negotiated that ‘He will request porridge when he would like to have it’. In that way it came from him and not me telling the staff what to do and it worked. What constrained best practice: Taken for granted assumptions that practices that had been transferred from one setting to another were appropriate. A belief that all people would be treated the same. The whole point of deinstitutionalisation was to give people their dignity and self -determination back. Collective staff attitudes that ‘This is the way things are done round here’. Awareness from Louise that she was new to the situation and had to tread carefully. What enabled best practice? The newly registered nurse coming into a new working environment and seeing things that went against what she had learned. Her ability to reflect and think about how she would work with staff resistance to ensure a positive outcome for the person. Her planned approach in the first instance by working with the team leader responsible for leading the team. In the second instance negotiating with the person and his family that having porridge when he wanted it was an important part of him having some autonomy over his life. What could have been done differently to change or improve the situation for the client/patient/consumer? Had the team been more focused on the needs of the people for whom they were providing care, neither of these situations would have occurred. There could be support for staff who had worked in a different kind of health setting to help them feel confident and competent in a setting where care was person focused rather than institution centered. Jim’s story Part 2: The ‘as if’ story Hello my name is Jim and I am 65 years old and I was first admitted to [name] when I was 20 years old. I was diagnosed with many different kinds of mental illness. Although I recovered with the help of medication, I did have bouts of aggression from time to time so I was never discharged and my family did not want anything to do with me. Anyway about six months ago they closed the hospital down and they sent us here to this community house. I live here with 12 other people. It is quite good and we get to go out and do things. I have made a couple of good friends, we play cards. One thing that bothers me though is that I am diabetic and when they give us cups of tea they put the milk and sugar in the teapot. This is how it used to be in the hospital. This means that I don’t have a hot drink at all and I like my tea. I’ve tried to say something but the staff just say it’s easier to make it this way. Also I have always had porridge for breakfast come rain or shine and they say porridge is just for winter. I have tried to say something here as well but the staff just say that if we make an exception for one person then we will have to do it for all. So I just gave up trying to do anything about it. About a month ago Louise arrived here to work. She was a new nurse, she was my key worker. I found I could talk to her, she seemed interested in what was important for me. I noticed that she has got the tea thing sorted. We now have cups of tea and we are asked if we wnat milk or sugar or we can put our own milk and sugar in as we need or like. It makes a difference having some control over things. I have had a bit of a problem with my breakfast. Having porridge in the morning just sets me up for the day. What would happen if your breakfast routine was upset? Anyway this Louise met with me and spoke with my sister, who I have reconnected with. We had a talk about how we could best organise for me to get my porridge. I know the staff are good but can be a bit tricky when it comes to change. So we decided that when I want porridge for breakfast I will request it. There may be the odd times I don’t want it. I would hate to get into a situation where I had porridge every day because that is what I said I like. That would be just as bad as not having it at all. Anyway small changes but they have made a big difference to my life here, I feel like a person again thanks to Louise. How did Louise make a difference for me and give me hope. She was interested in me. She made me feel that what I wanted was ok and i had a right to ask for it. She changed the way things were done for me and gave me a sense of dignity. Anyway, it is good now, I feel a little bit more in control of my life. Louise catches up with me every day and I feel as if I have my dignity again, I can speak for myself. The thing is that when I thanked Louise for what she did. She said, ‘that’s alright Jim. This is what I am here for, this is my job, working with people like you so that you can be well and feel ok about living your life. Note: I have imagined Jim’s story based on my own experience of working in situations like this. You all have rich store of experiences to draw on to imagine a story. if you are not in practice currently, draw on your life experience for a story. References: Greenhalgh, T., & Collard, A 2003, Narrative based health care: Sharing stories-Amultiprofessional workbook, BMJ Books, London. Richardson, F 2010,Cultural safety in nursing education and practice in AotearoaNew Zealand, PhD Thesis, Massey University, Palmerston North, New Zealand. Another example from my friend Claire’s Story<?xml:namespace prefix = “o” /> The context: Australia is rich with cultural diversity and we are home to one of the oldest continuing cultures, Australian Aboriginals. Recent Australian history saw European settlement and unethical interventions and implementation of policies in the Indigenous populations. Our newest populations are diverse, including humanitarian entrants from developing countries and regions of unsafety and political unrest, including areas of Africa, Asia and the Middle East, such as Afghanistan, Bhutan, Iran, Nepal, Pakistan, and the Democratic Republic of Congo. We have accessible education and optimal work conditions, and many new Australian’s are able to provide different skills and knowledge to communities. Who is the story about: Samara, Afghani Student Nurse. Claire (myself) Registered Nurse. Rose, Clinical Nurse. Maree, Clinical Nurse Educator. What was the setting: Clinical rehabilitation, aged care and palliative unit Why tell this story: This story is something I think of often as a Registered Nurse. I reflect on it a lot when I care for new mothers and their babies of different cultures, but particularly when I work alongside health care workers of diverse cultural backgrounds. As a health care professional we cannot avoid our multicultural surroundings, and it is imperative to ensure our practice is culturally safe and competent. This includes safe and appropriate practice towards our patients, including consideration of beliefs, values and appropriate communication, and also appropriate interprofessional practice when working alongside our multicultural colleagues. Claire’s Story Part 1: I had just finished Uni when I worked alongside a number of students in my clinical work-place, a small private aged care facility. This unit was held in high esteem, with a number of very wealthy residents. Residents would develop preferences to different nurses, and often would be heard gossiping about who “helped them shower properly” and who knows “how to make their bed the best”. The new placement block had commenced, and I had to work with a few of the Student Nurses. I hadn’t worked with all of the students, but in the second week I worked with a young Afghani student, Samara. She was quiet and polite and took her time chatting with patients as she attended to their daily cares. I noticed she would never say no, and was always offering to help and assisting with other nurse’s work-load. Her time management was fantastic and she prioritised her work well. We often chatted in the staff room over lunch and I was interested in her story; how her father moved here before her, her sisters and her mother. She said they wanted to make a better life in Australia, a better future. It was drawing near to the end of the placement block, and was time to have a meeting with Maree. So far, I could see Samara would be a very competent and successful nurse. In the appraisal meeting Maree began asking how Samara felt about her progress in the last few weeks, it only took a few moments and Samara’s face had crumpled and she was using her Hijab scarf to dab at her eyes. Maree was shocked and asked her what had upset her but Samara was reluctant to say. Finally, she admitted that Rose, had been bullying her, asking her to take on unsafe amounts of work as a Student Nurse (or an RN), and had be criticizing her ability to achieve the expectations. Maree and I were very upset. I felt sick to my stomach that a member of staff, a senior nurse, had acted in such an appalling way. I assured Maree that Samara had been working hard, but had no idea that this had taken place, and that Samara had not disclosed it to anyone else. The outcome: Maree had a meeting with Rose the next day, however I was not present. Maree had said to Samara that she was not to work with Rose, or take on any allocated duties from her, and was only to work with her preceptor RNs. Due to the nature of the issue, Maree requested that Samara notify her immediately if there were any other problems and was not to discuss the matter further with any staff or students. To this day I am unsure whether Maree had spoken to the Clinical Practice Coordinator and reported the issue, or whether Rose had just been confronted about her inappropriate behaviour. There was never any form of apology to Samara. What constrained best practice: Racial generalisations and stereotypes prevented Rose from behaving professionally, appropriately and safely. Essentially, she practiced outside of the expectations of registration that guide our practice as a nurse. Rose’s negative attitudes prevented her from treating Samara fairly and gave no thought of the effect that her behaviour would have on Samara and her patients. The unit failed to provide or implement culturally safe practice or promote a culturally safe environment. This incident also did not promote a safe teaching/learning environment. What enabled best practice: The resolution process between myself, Maree and Samara. It ensured that Samara felt competent as a nurse, despite the bullying. Maree dealt with the situation in a timely and professional manner. What could have been done differently to change or improve the situation for the individual: Often individuals form stereotypes and prejudice towards individuals or groups who have different beliefs and values, gender or culture. In this circumstance, everything was done to resolve the issue. Firstly, it was unacceptable that it occurred. Secondly, it was unfortunate that it had occurred without anyone knowing apart from the individuals involved. But once all parties were informed, prompt intervention had taken place. In this clinical setting there was far less education on cultural safety or emphasis on practicing within a cultural framework. I am unsure whether this was due to the demographic and clientele of the clinical environment. Regardless, the behaviour was not acceptable, and the senior staff member was required to assist in the learning experience of the student. Samara’s Story Part 2 Hello, my name is Samara. I am biologically 24 years old, although my Australian legal paperwork states I am 21 years old. Three years ago I migrated from Afghanistan to Australia with my mother and 3 siblings. My father had left 2 years prior to open a business, a small bakery, in the outer suburbs of Adelaide. He wanted to save money to help the whole family move over and also assist with our sponsorship. When we finally moved to Australia, I began study to become a Registered Nurse. My English is ok, as my family was able to have basic education and English tutors back at home. My first clinical placement was exciting and different. I felt that I had so much nursing care to give and wanted to prove to my family that I could do it. Although some patients were reluctant to have a student nurse care from them, particularly a student wearing a Hijab scarf, I seemed to be getting along ok. Sometimes I worked alongside Claire, who was supportive and kind, even curious of my family and culture here and back at home. She was patient and explained things thoroughly, helping me to complete my logbook and offering to be my clinical referee. I didn’t want to tell anyone about the senior nurse, Rose, who ran the area. She was rude and dismissive and constantly telling me conflicting ways of doing things. I couldn’t seem to get anything right, even when I followed the correct clinical procedures. One morning she discreetly allocated me 8 patients, yet another student with a Registered Nurse only had 5. She was angry I hadn’t completed my appropriate workload and couldn’t allow me my morning break. I kept this a secret, hoping it was just because I was a student. Deep down, I felt isolated and knew it was because of my heritage and my scarf. I had my final assessment with my clinical educator, Maree, and Claire was present too. I couldn’t contain my emotions, and embarrassingly broke down. Claire and Maree were upset this had happened and without their knowledge too. They were supportive, stating that I would become a fantastic nurse, and Maree was certain I would pass the clinical placement well. She organised a meeting with Rose, as harassment and racism are strictly unacceptable in any work place. I think Maree must have resolved this issue with Rose in the meeting, because Rose didn’t speak to me much after the meeting occurred and never allocated patients to me again. I felt I should have had better trust in Claire and Maree, and disclosed this incident sooner, so that this hadn’t become an issue, although they were very supportive and listened to how I was feeling and what had happened. This situation was deeply hurtful, but I am a proud Muslim, and will never let people think lowly of my beliefs and values, or my heritage. I am confident that I will be a good nurse, and my culture will never impact on that. Reflection and change of practice: All health care professionals are required to work within a culturally safe and competent framework. The professional frameworks which guide our practice also encompass multiculturalism, directed towards both our clients/patients and our colleagues. In my clinical work place I provide care for a very diverse population, and also work along side nurses and multidisciplinary staff of many different nationalities. There is no excuse for racism and racial stereotyping, we need to be embracing of this diversity, particularly as health care workers.