PRESENTATION AND ANALYSIS OF THE MAIN FINDINGS
4.3 THE RESULTS OF THE STUDY
4.3.4 The Action and Interactional Strategies
4.3.4.2 Implementing (launching) the CoP
Analyzing the interactional strategies and activities that were embedded within the implementation of the CoP, it was evident that the activities were processual and dynamic in
nature. The phases which described the process of implementing the CoP included:
(a) Formation: coalescing, learning and developing; (b) Transitioning: consciousness awakening and experiential learning; and (c) Transformation: becoming critical and transformed identity.
4.3.4.2.1 Formation Phase (coalescing, learning and developing).
The formation phase of the emergent CoP began with a brainstorming session with the purpose of establishing a baseline level of understanding on the concept critical reflection. The formation phase in the process of the emergent CoP extended over the first three to four data collection
151 sessions. Emerging from the data sources, it was evident that during the brainstorming sessions, participants explored elements that were needed to develop their critical reflective practice skills.
Participants requested that the researcher gave them some exercises on how to begin with reflective practice so that they could start their journey of critical reflective practice. The following extracts from the data sources illustrate this.
“Researcher: maybe at this meeting where we are going to get started with the CoP we should start off by getting a sense of where everyone is with the idea of reflection and critical reflection… Participant 6…for me this is new…what I think is needed is some teaching about reflection and how we must start doing it…(Rural-FGD)
“..we are excited to learn about this reflection…like it was said this thing can help us to think more clearly about our practice…but we never did it before…so I can see that a lot of training is needed…” (Urban-FGD)
It became evident, however, that certain group dynamics needed to be established so as to start forming coherence among the participants. The mix of both senior and junior nurse practitioners within the groups created uneasiness among the participants, which resulted in a lack of cohesion among the participants. Some of the participants expressed anxiety in terms of having to work with each other for a prolonged period of time. This is evident in the selected extracts below.
“….the group members seem very shy among each other…not a lot of mixing…some of the junior members sitting away from the senior members…need to foster some group norms so that they can start synergizing…” (Researcher field-notes-Session 4 Rural group)
“…I think for some of us it is the first time we will be working with each other…we see each other maybe when just in the passage… but it will be a first time to work together like this in this group…so it is like somewhat worrying to see what is going to happen….” (Urban FGD, Participant 5)
Further analysis of the dimensional properties of the formation phase revealed interplay of reflective skills development and group formation. Two distinct dimensions emerged from the
152 data sources, these were characterized as: (a) learning to reflect and (b) group formation:
learning to work together.
Learning to Reflect. The driving force behind the emerging CoP was developing critical
reflective skills among the participants. The participants had to learn how to reflect critically on their practice. The data sources revealed a certain process in developing the participants as reflective practitioners. This process included a number of phases of development, namely (a) concept clarification; (b) application of the concept critical reflection to practice; (c) hesitation and resistance; (d) transitioning and familiarity with reflective practice; and (e) learning how to reflect deeply.
Concept Clarification. The first step in learning to reflect began with the facilitator assessing the
participants’ knowledge or familiarity with the concepts reflection and/or critical reflection.
Emerging from the data sources, it was evident that none of the participants had any experience or knowledge of reflection. Two of the senior professional nurses had heard of the concept critical, and tried to relate it to reflection. Others perceived it to being a new concept and thus attributed their lack of knowledge or familiarity to their basic nursing training being outdated.
The following selected extract reflects some of the conversations:
“…I used to remember one of our tutors saying… “Nurses you must be critical nurses and you must be critical thinkers!”…so is that what critical reflection is?” (Urban-FGD, participant1)
“Cha’ (No in isiZulu) we have not used this thing of reflection…you know most of us did our training a long time ago so these new things were not taught to us” (Rural-FGD, participant 4)
An interactive lecture was held in which the facilitator introduced the group to the concept of reflective practice. Participants started to clarify in their own understanding what they understood reflection to be. This was an important task as it not only allowed the understanding
153 of the term reflection to begin to crystallize, but also allowed initial misconceptions to be rectified. During these activities of clarification, an element of sense-making emerged. This was charcterized by the participants brainstorming their understanding of the concept reflection, questioning, debating and clarifying so as to deconstruct and reconstruct their ideas of reflection and make it meaningful for their own understanding. The following selected extracts below highlights this process of sense-making.
“…so it can be said that reflection is like thinking back on something….” (Rural FGD, participant 4)
“…I think for me reflection can be like something we do all the time…like when we remember something that has happened to us…then that is also reflecting….” (Urban FGD participant 3)
“…is it right to say that to be a reflective nurse….we must think of our goals…or maybe to say what we want to do better in our practice…then we reflect and think on what we must do to get to that goal…” (Urban FGD, participant 10)
Some of the participants understood the terms reflection as a meaning daydreaming and meditating. These had to be unpacked further during the session in relation to the concept reflection. The selected extracts below illustrate this.
“Participant 6: maybe it means to daydream about something…err like to sit somewhere….and think about your life or something like that….Researcher: that is a good start…maybe you want to elaborate a little more....Participant 5: err ja…okay so it can be like thinking back like what you do when you are just daydreaming…your mind is not blank is it? So I think just like that when we are alone…then we sit back and think…so we must think back on our nursing and what we have done…” (Urban-FGD)
“Participant2:is it like meditating or like praying?…when you are quiet and like for meditation...just channeling your thoughts somewhere else…like to surrender to something bigger” Researcher: can you explain a little deeper into how this aspect of meditating can be applied to reflection?...Participant 9: I think that maybe just like when you are quite and focusing on one thing in meditation…err then with this reflections…you also have to take some time for our busy schedule…and to just think about how we are nursing…(Rural FGD)
154 It was evident that participants started developing an understanding of the term reflection in a professional manner. The participants started relating the term to their experiences and practice in the context of HIV/Aids nursing. This is evidenced in the following extracts:
“like it means to learn from someone…like if someone can do something…it can be a long time ago…but now when you are in that same position you think about it and learn from it” (Rural- FGD, participant 9)
“…maybe it can mean like to be more professional… I can say it will help us to think about our actions and maybe we can then do them more properly so as not to harm the patients...” (Urban- FGD, participant 8)
“…I think it is like to keep questioning yourself…to ask ourselves if it what we are doing is the right way and if not how I can make it better…” (Urban- FGD participant 1)
The data also revealed how participants further unpacked the concept, and related it to thinking of day to day practices. Other understanding of the concept was related to thinking of situations that may have not gone well with patients and how to handle such situations in the future. One participant was able to link the concept of reflection with the attribute of critical thinking, in that it was not just thinking of situations that nurse practitioners may have experienced, but thinking that required a change or alteration in themselves to improve their practice. This is explained in the following selected extracts.
“… reflection means we must be always thinking…it means that we will be asking ourselves what we did today and what was good and bad…and what I can learn from it….”(Rural-FGD, participant 4)
“…now I think that it can be daydreaming but you are not just thinking of nothing…you can use something that happened to you…like for example if I did not do something right with my patient…then I must sit and reflect on it and then I can see where I made mistakes and then I can change it…” (Urban FGD, participant 4)
“…nazo’ (yes)…so that is what that old tutor meant by we must be critical thinkers…because reflection can mean that one must not just to think about something but it must be
“critical”(high pitch voice)…ya’bona…we must not just think of what we did…but we must
155 think…okay how can I do it better, what will make me to be a better midwife...or what must I do differently in my ward to improve certain things” (Urban FGD, participant 1)
Application of the concept critical reflection to practice: Following the clarifying the concept
and construction of the term reflection into a meaningful and purposeful definition for the participants, it emerged that the participants needed to learn how to reflect at a fundamental level. They needed to learn how to make sense of their experiences, and how to recognize and be conscious of incidents or experiences that caused uneasiness in their practice, with an aim of bringing about change. Therefore, a series of more informative sessions were conducted in which the facilitator guided the participants through a deeper and more practical way of understanding the concept of reflection. This was done in the form of teaching sessions on the concept of reflection, unpacking the use of reflective discourses sessions, the use of paper based exercises and the introduction of reflective diaries as the medium in which reflection can be practiced.
The aim was to activate and demonstrate to the participants the various dimensions of experiences, to create an awareness of what experiences are and how to reflect on experiences and past behaviours and create learning opportunities. The following selected excerpts illustrate the participant’s engagement in the information sessions of critical reflection.
“Yes…this can be very interesting to do…err...like I am thinking of a incident in the ward...so I can see from this paper (referring to paper exercise) that I must ask myself what I was doing when it happened, and what I did to respond to it…so there is a lot that goes into this thing of reflection…(laughing) ja..it is not just sitting in a nice quite place and thinking…”(rural FGD, participant 5)
“okay so these questions we ask doing on this worksheet…so it means every time…err…like every time we come across something in our practice…yabona’…err…we must then be asking such questions like this one so that we can then say we are reflecting….” (Urban FGD, Participant 9)
156 Emerging from the data, it was evident that this process of learning to reflect was characterized with excitement and curiosity to learn more. Participants freely shared incidences that they could reflect on and the questions that they needed to ask themselves to begin the process of applying themselves in reflective practice. This is evidenced in the selected FGD extracts.
“this is the first time, I am thinking so much about small things that happen to us..normally I just move onto something else not asking myself such things like how it made me feel and if I can do something about what happened… we go through many things in the wards…so now for me to learn from what happened…err..does it mean I must ask myself all these things? and think about it and write down all these things?” (urban FGD participant 8)
“there are so many things one must ask just to think back on something….I never knew it will mean thinking about all these questions….but I am excited to learn this new thing…” (urban FGD participant 4)
“so many questions to ask just on something that has happened…and what if I can’t remember all these things to answer the questions?” (urban-FGD participant 1)
Hesitation and Reluctance. Despite the curiosity and interest in the concept of reflection and its
benefit in nursing practice, the data sources showed that for some participants, the fear of letting go of emotions related nursing in a context of HIV/Aids was a barrier. Some participants indicated that having to reflect back on certain experiences of their nursing practice was an overwhelming and fearful challenge, as many had chosen to bury some of the painful and emotionally exhausting feelings of being burdened with the challenges of HIV/Aids nursing care.
In addition, the uncertainty on where to begin in the process of reflection created a time of reluctance and hesitation. The following extract reflects this fear.
“…you know it is scary to just start thinking of all the incidents about our practice…cha’ me I try to normally block out the negative things because some of the the things we face in our nursing or what the patients tell us…it is so painful…so I am just wondering…like now with this reflection…we must start to think about all our experiences…err…so it means that even some of these painful things we must bring it back to see how we can learn from it…” (Rural FGD, participant 7)
157
“…we all are knowing of some things of our practice…it is better off staying in the past…because when you think of the things some people tell you in your practice…or what we do in our nursing…haibo’ (utterance of resignation)...it is too much to face….like I mean for your mental health…but I can see now that we must start to unpack all things from our practice…if we want to really learn to be different and critical…” (Urban, FGD, participant 1)
It also emerged that another source of hesitation and reluctance on the process of learning to reflect stemmed from the uncertainty on how to proceed with the reflection process and the confusion that went with this was expressed by the participants.
“(laughing)…It was so nice when we was just talking about what this idea of reflection is…hai!
but it is something else when you are alone…and you have to think about ideas to reflect on…it is so confusing to me…” (Rural FGD, participant 5)
“….one doesn’t know where to begin with this reflection…because everything just happens all at one when you are in the ward….it was not easy to do it now in real…when I was on my own…I was even asking the other nurse…and she too was just saying let us wait to hear from the others…how we can do this reflection in this books (referring to journal)…” (Urban FGD, participant 3)
Most participants expressed that amidst their current challenges of keeping up with changes in terms of HIV/Aids care, they still felt grounded in their general knowledge of nursing and their specialist field of midwifery, and were thus accustomed to being the “knower” of information.
The process of learning to reflect challenged the participants to learn and be open to a new way of thinking and learning, and caused a state of “not knowing” and loss of control in terms of what they were used to. This resulted in apprehension in terms of how to move forward with the practice of reflection. This is evident in the following selected extracts which illustrates the paradigm shift.
“…hai…this thing of reflecting…where you have force yourself to think about your practice…it is not easy….I really felt like I was not in control of what was to be done…you know…even with all this new things with ARVs …at least we still know how to do the deliveries…now with this…we have to think of something…and then to think on what we must change to do that task better…it was confusing…” (Rural-FGD, participant 4)
158
“…when I started to try and do this reflection thing….then I could see that I did not know everything…it was confusing me a lot…to think of how to reflect and what to reflect on….ya’bona (you see)…even with HIV when we don’t know like the policies…but at least we still know our midwifery and we can still do the deliveries and such…but now…this thing makes you to feel like you are not in control…” (Urban-FGD, participant 5)
Emerging from the data sources, it was apparent that as the participants unpacked more fully the requirement in terms of engaging with critical reflective practice, they viewed the time involved for introspection of an experience and thinking through their actions and outcomes of the experience as a barrier, especially with regards to maintaining the reflective journals. At the initial level of reflective practice, participants felt uncertain of what to expect in terms of their own emotional investment in the reflective process. Moreover, factors of time and a greater level of investment in clinical practice that the reflective practice required in terms of thinking back on clinical experiences were sources of hesitation and reluctance. The following excerpts presented below are evidence of this.
“…it is to make the time to remember to write in these books….sometimes you are alone in the wards and it is so demanding…so you have to think of where you can steal some time to reflect…it can be challenging…”( Rural FGD, participant 5)
“…you have to have something to write…and I keep thinking of some many things I want to write…or I want to come here and talk about…but is hard to know how to write these things…also the time is a factor…you got to make time to do such things….(Urban FGD, participant 6)
Transitioning and familiarity with reflective practice. Channeling the difficult and emotionally
charged experiences into a learning experience required participants to become familiar with the practice of sharing openly. It emerged that through sustained engagement and decreased fear of peer judgment more open reflective discourses were observed. As the participants became more familiar with each other and realized that they all shared similar challenges they became less