TIME PERIOD:
3-4 SESSIONS + 6 - 7 ½ HOURS
Categories and subcategories of the formation phase
.2.2 Transitioning phase: An awakening of consciousness.
Moving from the phase of learning to reflect, interactional strategies and activities became collectively described a transitioning phase. Within this phase, the data revealed that the participants transitioned from being non-reflective and learning how to reflect towards a new awakening and realization of mindful, deliberate and thoughtful clinical practice aided by critical reflective skills. During this transitioning phase, the participants progressed from a point of being dependent on the facilitator to guide the nature and content of the sharing sessions (i.e.
through the HIV/Aids teaching sessions) towards creating autonomy within the group and the activities thereof and coalescing towards ownership of the group process. This phase extended
LEARNING TO REFLECT
DEFINING CONCEPTS SENSE MAKING
EXCITEMENT AND CURIOSITY
HESITATION AND RELUCTANCE
BEING AFRAID OF LETTING GUARD DOWN FEAR OF UNKNOWN
TRANSITIONING IN REFLECTIVE PRACTICE
APPRECIATING THE LEARNING OUTCOMES YIELDED
LEARNING TO REFLECT DEEPLY
HAVING A "AHA" MOMENT, REALISING BENEFIT OF REFLECTION IN OWN PRACTICE
GROUP FORMATION:
NORMING AND STORMING
RESERVATIONS AND DEPENDENCE LACK OF TRUST
ESTABLISHING FAMILIARITY & RELATIONSHIP FEAR OF JUDGMENT
ESTABLISHING MIDDLE GROUND
STORMING AND CONFLICT
ESTABLISHING GROUP RULES & NORMS
168 Moving from the phase of learning to reflect, interactional strategies and activities became collectively described a transitioning phase. Within this phase, the data revealed reflective and learning how to reflect towards a al practice aided by critical reflective skills. During this transitioning phase, the participants progressed from a point of being dependent on the facilitator to guide the nature and content of the sharing sessions (i.e.
sions) towards creating autonomy within the group and the activities thereof and coalescing towards ownership of the group process. This phase extended
CONCEPT CLARIFICATION DEFINING CONCEPTS
SENSE MAKING
EXCITEMENT AND CURIOSITY
HESITATION AND RELUCTANCE
BEING AFRAID OF LETTING GUARD DOWN FEAR OF UNKNOWN
TRANSITIONING IN REFLECTIVE PRACTICE
APPRECIATING THE LEARNING OUTCOMES YIELDED FROM REFLECTIVE PRACTICE
LEARNING TO REFLECT DEEPLY
HAVING A "AHA" MOMENT, REALISING BENEFIT OF REFLECTION IN OWN PRACTICE
RESERVATIONS AND DEPENDENCE LACK OF TRUST
ESTABLISHING FAMILIARITY & RELATIONSHIP FEAR OF JUDGMENT
ESTABLISHING MIDDLE GROUND
STORMING AND CONFLICT
ESTABLISHING GROUP RULES & NORMS
169 over four to six reflective sessions, each session taking an average of 120 minutes. During this period, the data revealed that participants had become more proficient in critical reflective skills and that the groups had begun functioning as CoPs. These occurrences can be characterized as two dimensions, namely: (i) conscious reflection and experiential learning; and (ii) becoming autonomous.
Conscious Reflection and Experiential Learning. Unpacking the activities and strategies which
transpired as the participants progressed in their reflective skills; it was evident that the participants became conscious and aware of their actions and behaviour in their daily practice and became open to seeing their experiences as a platform for learning. A conscious reflective way of practicing and the use of experiential learning to enhance clinical practice manifested through the following dimensional properties: (i) Deeper awareness of practice, consciously reflective through experience based practice; and (ii) Deliberate and action orientated way of nursing.
Deeper awareness of practice, consciously reflective through experience based practice.
Gradual in its process, reflective practice and engaging in deeper, more conscious awareness of clinical practice was demonstrated by the participants. Through sustained contact over the initial three to reflective discourse sessions, trust and familiarity among the participants created a platform for open sharing of clinical experiences, as reflected in the selected extract below.
“…now that we are getting closer and getting to know one another…it makes it better to come to the group and share…there is no more feeling afraid that the others will think differently about you…I find it easier to talk about what I am going through…you just feel free to talk here (referring to CoP group session)…” (Rural FGD, participant 5)
170 This trust and openness enabled participants to reflect more fully on their clinical experiences, this time moving further and deeper in the process of reflection by also engaging in the affective, emotive side of the clinical experience related to HIV/Aids. The data sources also revealed that being open and sometimes vulnerable in their reflective discourses allowed for hidden emotions of nursing in the context of HIV/Aids to be addressed. This emerged as an important characteristic of the transitioning process, as it demonstrated that the nature of the participants’
reflections were evolving and had progressed from being focused on the identification of problems towards being more thoughtful and introspective regarding clinical experiences.
Furthermore, it became evident that the participants had begun to engage with reasons embedded in their nursing action and behaviours towards patients.The following excerpts illustrate the affective introspections of feelings and emotions within the participants’ experiences:
“if I can share what happened to me… there was this young women who came for HIV testing….so she opened up to me and said she suspects her other child died of HIV/Aids…the baby had chest conditions...i think it must have been TB…so this patient herself is knowing she is HIV positive...and not taking any treatment...yabona’ (you see) she is afraid of the husband now...who is himself denying this disease...so such things when I hear it...yes it makes you sad to hear this...even angry at some of our men...because this women...she is just forced to stay with him...like for the financial support...but then...when I am now in this group...I can see in me...that for this lady to share with me...it means there is trust in me...so I too must try and help her”
(Rural FGD, participant 6)
“...I can say that now that we discuss what happens to us as nurses...it also helps me to cope...because sometimes you are so afraid of this HIV...that I can see that yes...I feel sad for these women...but me...I was becoming so distant from working nicely with them...because you start feeling like this disease is a monster...and yet some of these women they don’t have a choice...they are just getting it from their husbands...so it makes me to also think of my role as a nurse to support her...and not to just keep them far because of me being afraid of them....”
(Rural FGD, participant 3)
Furthermore it emerged that as participants progressed in the development of reflective skills, there was a heightened awareness in terms of holistic nursing in the context of HIV/Aids.
Described as being “switched on”, participants shared how reflective practice illuminated a
171 greater sense of awareness and intuitiveness in their nursing practice. They reported that they had become more mindful of the patients reactions and non-verbal cues and acted on these to inform the patient wholly to foster better acceptance of the HIV diagnosis and promote adherence to the treatment, thus improving health outcomes. The selected extract illustrates a rural participant’s experience.
“...I am like more aware of the patients...in the past I used to just say oh...these patients they always take the NVP syrup when we discharge them....err...and then in the afternoon, you find that they left in the lockers in the wards...or they give it to the security at the gate...so it was just a normal thing...but now I am much more like awakened....err (laughing) I can say more switched on...because I even had this young mother...and I could see in how she was when I was explaining this medicine...err she was just going to leave it...and then I motivated her...I explained properly there is nothing to be scared of this treatment....because only when you ask you hear some are frightened of these drugs...so after a long time when she left....I see she did not leave it...even the guard never bring it back...so I am hoping it helped her...ja...I can see how me too I am more like awake for the patients needs...” (Urban FGD, participant 3)
172 Another attribute that emerged from the data sources was the process of knowledge generation through experiential learning. It was evident from the reflective discourse as well as from the participants’ self reflections that there was greater awareness of the routine and habitual behaviour of the current nursing practice. Iterations from the reflective discourses sessions demonstrated how the group discussions had became a platform where new and innovative ways of improving nursing practice were debated and shared. The following selected extract illustrates this.
“Participant 6: ...if I can share something...you know we had this talk some time ago here in this group...err...about all this different types of pills...so when I am in the ward...I can see that we just do our usual ward rounds...we don’t even do the proper health education...so you see that the mothers are just defaulting with the medication and even to come for the follow-up checkups after the delivery... Participant 4:...Hai...even with us...we are seeing that after the mother delivers...they have just made up their mind...that they maybe won’t keep taking the medication..they say it is like a poison for the baby... participant 6:...so me I was thinking it must a good idea for us to maybe make some sort of chart...then the patients can read for themselves...and if they see it time and time again when they come for their visit...it might help them to also accept...Participant1: no I think this is a good idea...because then we can also see that this can help with some problems of not adhering to medication because of wrong information...” (Rural FGD)
Higher order thinking, coupled with the autonomy in their group cohesion was evident in the innovative problem solving abilities to challenges and institutional restrictions regarding HIV/Aids care. Evident from the group dynamics; participants started to gain deeper trust and better working dispositions among each other. This, in turn, created a platform for creative thinking, use of critical thinking and pooling of ideas and resources to come up with unique ideas to address commonly experienced challenges. This is reflected in the following excerpt.
“Participant 5: for today’s session I wanted to share about this new HCT program …I think it is important to have this talk ...it will help us to make the changes…because now the nurses will have to do the counseling which they are not doing at the moment…so we must start to think together how we will solve this problem...Participant 1...what about if we use the lay counselors which we already have...some of them have this extensive training in err...this counselling...so
173 while we are waiting to get the training ourselves...like from the district...err then we can use this category to help us develop our skills....Participant 8...err...ja...I think it is good...see for me...I am just in the TOP clinic...so we only give this counselling on contraceptives...so it will help me a lot to know really what is this other counselling with the comprehensive HIV testing about...ja I think we must start looking for these ways to help ourselves....Participant 1....see some of us....we look down on these people...(referring to lay counselors, who are equivalent to community health workers...but it is time we work together... all of us...to address this new things in dealing with this disease...” (Urban, FGD)
Deeper engagement in reflective practice was also evident through the garnering of expert advice and peer assisted learning that took place in the reflective discourse sessions. Confidence in using reflective skills in clinical practice and recognizing the richness of their experiences as a catalyst for bringing about change in the nursing management of HIV/Aids, participants relied less on the facilitator for information about HIV/Aids and began to share their own ideas, experiences and expertise to create knowledge. Through peer supported knowledge participants began to apply what they had learnt within the CoP to their daily nursing practice. This is illustrated in the following excerpt:
“Participant 5: If others here can help on a problem about this formula feeding…err... I never thought about this before…but with this reflection we are doing...I am starting to think about this... err... many mothers when you ask them about the feeding choice… they just say they want to do formula feeding…but after a moths or so...the same one....they come back crying for this formula from us.... because now they can’t afford it. So in the past...even me...I used to just shout at them...and ask them if the government is here to support the,...because we are not here to give them this free milk...they should have thought of this before....Participant 10...no I know what my sister is saying...but you see...some of these women...they are relying on the boyfriend to buy these milk for them..then the boyfriend just leaves and they come back...Participant 6...so what I can share...because I went for the training some time ago for the infant feeding...you see these women they are afraid to breastfeed...because of this mixed messages they sometimes get...but we...we must also educate them properly...so for my colleague who is sharing of this problem...where they come back...yes it is true that the clinic cannot reissue the milk tins...so that is why when you are educating them...you must let them know how much this formula will cost...so they can know and be informed...and we too must also educate them properly about mixed feeding and even to breast feed exclusively is safe for the baby...so they don’t end up mixing..participant 5...ja sisi...what you are saying is true...maybe that is what we must advising these women...to help them not to be in this situation...” (Urban FGD)
174 It also became evident that participants’ growth in the process of becoming a reflective practitioner was demonstrated in a renewed consciousness in practice, moving away from habitual routine practices towards a focused way of nursing aligned to evidence and knowledge generated through experiential and reflective practice. This is illuminated in the following extracts:
“I have grown in my nursing care from being part of the group… the last time when we heard from someone here about how the mother was given NVP syrup for the baby... how the mother came back having said the syrup was finished… I reflected on this and said in the past when this was happening I too used to just reissue more syrup…but when my colleague was sharing her story...she told us that the mothers should not be coming back with remainders or it being finished in two weeks...so it means she is not dosing correctly or she is sharing with someone….so such things helped me to change my practice.” (Rural FGD, participant7)
“…I can see that every day I am using reflection to ask myself how did I do? Where can I do better? And I am learning from my own experiences…I have changed how I do the patients booking, because in the past I just ticked all the things I needed to just complete…but now I can see I try to engage with the mothers and ask them questions about what else is happening even at home and how she is taking any medications..now I learnt that other thing, like if she is comfortable to disclose and if she can share it with her partner…all these things can affect how she may take this PMTCT , so I must show her as her nurse I have to support her, so she does not default…” (Urban Reflective Journal Entry-Dated 3 June, 2010)
Findings showed that being consciously reflective resulted in participants experiencing a paradigm shift in terms of previously held world views or assumptions regarding people living with HIV/Aids and nursing in the context of HIV/Aids. Emerging from the reflective discourse, it was evident that participants were able to openly and honestly reflect on the sometimes stereotypical and prejudicial way of nursing that was practiced and consciously considered how these practices could be changed to improve nursing care. The excerpts presented below demonstrate this.
“..now that we have been learning so much about HIV/Aids and even about stigma...I can reflect now on some of my behaviour...and see how it is wrong...even to shout at them...or to ask them why they are keep getting pregnant...I am not proud of it...but even I used to ask them why they
175 are not using amaCondoms...so I am learning to be better...and to understand the women better so they too can trust us to maybe accept the HIV quicker …” (Urban FGD, participant 5)
“it has been good to be part of this group...and with this reflection..because sometime it forces you to see how you are nursing...err...to think about our behaviour...we get angry at the mothers and shout at them...and sometimes I say to myself...it is because they are not taking this HIV seriously...but some they don’t have this choice...they are just getting it from husbands...so I can see that I am changing my thinking....” (Rural FGD, participant 2)
“....before...if I just see them with their thin bodies...hai... I used to just say...look at this think
“tikki”...err...like a prostitute...you know to just think maybe she is just sleeping around....but I am learning...it is not for everyone....but I am seeing I am must change my attitude” (Urban FGD, 10)
Deliberate and action orientated way of nursing. Evident from the reflective discourse, it was
apparent that participants were engaging in two forms of reflection, which were reflection on clinical practice and reflection on learning what had been gained from the information sharing sessions of the CoPs. Participants expressed that engaging with both these processes of reflection fostered a renewed approach to nursing practice. Embedded within the deeper engagement of reflective practice, inquiry based skills were also emerging. The following excerpts describe these two reflective processes.
“...when I am thinking of how I nurse....so I think about what we learn here in this group...and that information that we get from her...err...I can say like for example...when we discussed the dosage for giving the NVP syrup to the baby...err...so that helped me to start to reflect like on my own practice...because I could then see check if this information we are receiving here....if my practice is correct with it...” (Rural, FGD, participant 3)
“...err...ja I can say that I am reflecting more...so I can share something....so we had this case in our ward...it was a very unusual case where this mother she had come back for the second time of the PMTCT program...so now we started with the AZT like we supposed to...but now I was thinking in me...if for this women she is now maybe like resistant to the same drugs like the others...so because I can say because of this reflection....it made me to go and learn about this...and find out more...so I see that in my practice...i am reflecting...err...I am thinking deeper about what I do...so that I can learn from it....”(Urban, FGD, participant7)