PRESENTATION AND ANALYSIS OF THE MAIN FINDINGS
4.3 THE RESULTS OF THE STUDY
4.3.4 The Action and Interactional Strategies
4.3.4.1 Planning and preparing the CoPs
The following subcategories emerged that explain the process involved in planning and designing the proposed CoP among the HIV nurse practitioners. These included: (a) conceiving the establishment of the CoPs; (b) negotiating with stakeholders and garnering support; (c) establishing a shared vision and goal; (d) collaboratively tailoring the logistics; and (e) the participation in in the planning process.
4.3.4.1.1 Conceiving the establishment of the CoP.
Analysis of the various data sources, namely the FGDs, individual interviews, researcher’s field- notes and text analysis of the reflective diaries illuminated the many challenges participants experienced in terms of the changing nature of nursing in a climate of HIV/Aids. As evidenced in the discussion of the causal conditions or antecedents (refer to section 4.4 several challenges
137 emerged as determining factors which illuminated the need for establishing a CoP. Subsequent to the emergence of these challenges, the researcher, as facilitator, created a platform that would be used to raise the consciousness of the participants to the issues experienced. Bringing participants together triggered them to think and reflect on their state of being in a field of HIV and to come up with a host of issues. During an individual interview, one participant stated the following:
“…we all were excited to come together in the group to discuss our issues in HIV nursing…something like this was not done with us nurses before …and for me I could see this was going to address of the challenges we are experiencing as nurses…”(Urban- individual interview)
The participants identified various issues or challenges, which included their inadequate training;
how they felt confused and frustrated with the state of change; the fragmented practice of nursing; lack of support and a culture of working in isolation; the emotional burden and loss of professional identity; and the absence of a platform for information and knowledge sharing, to name a few. These themes are illustrated in the following extracts:
“nurses feel challenged on many levels to cope with the many changes in how they nurse in the context of HIV/Aids… they spoke about their training needs where they felt unprepared with the policies and treatment plans…they spoke of how these are changing all the time and this causes frustrations and confusion among the nurses…” (Researcher Fieldnotes-Session 1, urban group)
“very often nurses work alone…you feel alone and lost all at the same time because you are really unsure what you are doing…and there is no space where we can come and talk about these things or even learn new things that can help us improve the way we do things…”(Urban- FGD2)
“…lots of confusion and a break in communication and practice is evidenced from today’s session…some nurses only know of what happens in their own ward…yet we are one unit for maternal care .. nursing care is routine and no questioning is occurring…if a doctor comes and changes something some of us do not even know about it…we just end up doing the wrong thing or changing when we are told…”(Rural, Individual interview)
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“you feel like giving up with nursing…sometimes one even thinks of starting a business just to escape this...because every day is one in the same thing…you are just drained emotionally we deal with sick, sick mothers, and you know how the babies will end up…so you just think this is not the nursing I wanted to do when I trained…one doesn’t feel like a nurse anymore…I sometime feel like I am nursing the dead…because that is what happens…” (Rural- FGD, participant 3)
Because they felt isolated in their practice, the participants realized that a structured space for nurse practitioners to share their challenges and experiences of working in the field of midwifery which were compounded by HIV/Aids nursing care activities would provide them with the support they needed from peers and experts. More importantly, participants required a forum where they could keep abreast with some of the changing policies and guidelines. Critical reflection emerged as one of the tools to promote ongoing learning, as stated in the extracts below:
“…we sometimes are isolated…we all keep to our units, not knowing what is happening in other units…yet we are in the same department…I think sharing together…like this group we are having…it will give us that support we need...”(Urban FGD, participant 3)
“I think this is the first time we have had such a opportunity…to share all our problems about the PMTCT and about working all the time with this HIV…I will like to keep learning more…and be part of some group like this…we need something to help us to cope…”(Rural, FGD, participant 3)
“…this reflection will be good for us…so we can think about how we nurse…it will also help us to see where we need some help to improve our care…” (Urban,FGD, participant 2)
Analysis of the challenges described the nature of the activities in the process of conceiving and negotiating the idea of establishing the CoPs. This involved an action-orientated approach, and it was apparent that planning the envisioned CoP needed mutual co-operation of all stakeholders.
In addition to this, given that the concept of CoPs, especially in the health discipline, is a novel one, the idea needed to be collaboratively embraced by all stakeholders so as to achieve full participation and ownership, and it also needed to be directed by a leader or facilitator who has
139 some knowledge on the concept so as to direct and guide the stakeholders into understanding the envisioned idea. The following extracts highlight this.
“during that first meeting…where we all shared our experiences and our issues with nursing and HIV…we also had the nursing services manager and our zonal matron there…it was good to hear from them that they also wanted us to be part of the group meetings...” (Rural,FGD, participant4)
“…it was exciting to hear of this CoP thing…like the first group meeting we had...I very much liked it…and was happy to be in the group…this the first time we heard of this…it was interesting to hear how it was going to help us work through our problems and find our own solutions…(Urban-individual interview)
While the idea of a CoP for HIV nurse practitioners was being discussed, participants highlighted the importance of having a facilitator who would give direction and clarify the process and expectations. This is evidenced in the following extracts;
“…this idea was something new to us…so we relied on the facilitator (i.e. researcher) to give us some direction … to tell us more about the CoP and to lead us in the process…” (Urban - Individual interview)
“… while we are still talking about and thinking about how this CoP will operate in our hospital..we will also need to know what is expected from us… what must we do for this CoP…
from the hospital what will we be required for us to do… what kind of support will be needed for the nurses who will be joining the CoP…”(Rural Health service manager-Individual interview)
4.3.4.1.2 Negotiating with stakeholders and garnering support.
With the intention of promoting ownership and partnership, and soliciting support with regards to the conceived idea of establishing a CoP among the participants; the researcher approached the relevant stakeholders, who comprised of the nurse practitioners and the nursing management team from both hospitals. Emerging from the data sources, this activity in the process of planning and preparing for the envisioned CoP was collaborative in nature and ignited a lot of curiosity with respect to understanding what the concept of establishing a CoP meant. Some of
140 the participants viewed the establishment of a CoP as an intervention they needed to be part of.
This is evidenced in the selected extracts:
“…this idea of a CoP sounds exciting and different…no we have never been part of something like this before…I am interested to learn more about what this CoP is all about…it is nice to be part of the process…where we can have a say in how we want to design this type of intervention…to suit our needs…” (Urban - FGD participant 3)
“…this is my first time to be part of something like this…it is new for me...but very interesting to hear…in the past we just had a one day talk…sometime just a short in service training…with this group…we will be coming all the time...we will belong to it..”(Rural-FGD participant 1)
Another attribute that was made apparent from the data, was the positive reaction of the stakeholders. Negotiating support and buy-in from the relevant stakeholders regarding the envisioned CoPs involved unpacking expectations and responsibilities that were required. This was an important stage in the process of establishing the CoPs, especially as the stakeholders needed to know more about the level of commitment required and the nature of support required from the institutional and nursing management perspective. This is evidenced from the selected extracts.
“…I think this idea of community of practice…of making some kind of group is good …where we come together to discuss our problems and get information (laughing)…for me it reminds me of err… “community nursing” … yabona’ (means “you know” denoting or seeking affirmation from others) we used to learn that micro-community in a system…it will be like our own community... where we work as a system… so I think it will be like that where we can work together to build one another up and not suffer with our problems on our own…” (Urban-FGD participant 1)
“…from the management… we are happy to support this group…I can see it will be beneficial for our nurses…because they will learn…but we must talk about what is needed from our side…as the management team” (Urban- Health service manager)
The strategy of garnering support and facilitating the relevant stakeholders to take ownership in the planning process was for the researcher to provide a platform for open discussion which she
141 did in the initial data collection sessions in the form of individual interviews with the relevant hospital’s management and FGDs with the nurse practitioners. During this stage, the facilitator guided the dialogue by sharing information about the nature of CoPs and what was required for a CoP to be effective and successful, such as the time required for meetings and the nature of venues that would be suitable for effective group discussion. Various ideas about the emerging CoP were brainstormed by the group under the guidance of the facilitator. This is evident in the following excerpt of an urban participant’s reflection of how the process started.
“during that time when we were still discussing the idea of forming a CoP structure in our hospital, we were given information about what is a CoP …we also spoke about what we needed to know and do for this CoP, like how much time we will need for the meetings..this was nice to know at the beginning because then we could decide properly after hearing what is really needed…so that we do not get any surprises…” (Rural- Individual interview)
The data sources also reflected how participants from both sites brainstormed the idea of establishing the CoPs and discussed ideas with the guidance of the facilitator on how the elements of the CoP could be tailored to respond to their needs. Ownership and coalescing emerged as properties within this subcategory as participants unpacked the concept of establishing a CoP and agreed to move forward with the idea as they felt a CoP had the potential to address some of the challenges they had identified. This is evidenced in the following selected excerpts below.
“…we will need to think of how we can make this work here in our hospital…like I can already see that we will need to think about how the nurses will get time off for the meetings…and we can use our staff boardroom for the meetings...because we do not have a lot of meetings there..there are also plugs and chairs in that room...the day and time we can work out as well but Wednesdays are generally not so busy days…I am thinking of other meetings we have”
(Urban nursing services manager)
“…this group is very important…because we are experiencing many problems…our biggest challenge is the nurse’s knowledge with the PMTCT process…we should try and start with discussing these things in our group” (Rural FGD participant 4)
142 Participants discussed the requirements or expectations in terms of the meeting venue, time to attend the meetings, frequency of the meetings, and nature of the CoPs. As evident in the following excerpts, although the stakeholders brainstormed and tailored their expectations in terms of setting and resources, there was overall agreement and join in to the idea of establishing the CoP.
“as an operational manager, what I can say is that it will be good to support our nurses…so much of time is spent with patients and they need to be kept updated with this kind of information…” (Urban FGD participant8)
“…I support what this will do (referring to CoP idea)...I can speak to the unit manager for the maternity departments to let the nurses who want to join your group...to get that time out of the ward…” (Rural- individual interview)
4.3.4.1.3 Establishing a shared vision and goal.
The facilitator and the relevant stakeholders were collaboratively involved with the planning phase, and analysis of the data sources indicated that the dimensional properties which explained this process included: (a) mutual understanding and establishing common ground and; (b) determining the focus and knowledge needs of the CoP
Mutual understanding and establishing common ground: The participants of this study, who formed the “members” of the community, were nurse practitioners working in HIV care within the discipline of maternal and child health. They revealed that the social nature of the introductory FGD sessions created a sense of commonality and familiarity within the group.
Participants shared that the initial group meetings created a platform for them to highlight the everyday problems and challenges they experienced. Through sharing, participants became aware that others in the group were experiencing the same challenges in their clinical care. The
143 excerpt of one of the rural participant’s individual interviews describes her experience of this stage in the planning phase.
“…in that meeting when we shared what we experience in the wards…our experience of nursing and dealing with changes when it comes to HIV/Aids policies or the treatment…I could see that we were all the same...we had the same problems we were facing…” (Rural in-depth interview)
Through mutual understanding of the commonalities which occurred among the participants, the facilitator initiated the process of defining the focus and intention of the CoPs at each site.
Emerging from these discussions it was evident in the data sources that the facilitator provided discipline specific guidance in terms of what core elements were needed within the framework of the CoPs and CR, and the participants mutually discussed, defined and agreed on the contents that would form this structure. As reflected in the following extracts, the meetings were interactive in nature as participants and hospital management took ownership of this process of determining the scope of the CoPs.
“…you (referring to facilitator) gave guidance…about what makes up a CoP, so we learnt a lot from this different aspects…you (referring to facilitator) also broke this down for us… for this group the focus was to learn more on HIV and also how to be critically reflective nurses …to that helped us to see our main aim and our focus…ja’ it gave us direction where we are going with this group…” (Rural-Individual interview)
“the session was interactive, most participants shared except for two quieter members, who agreed on the ideas but did not give any ideas…”(Research Fieldnotes_Rural group meeting 3)
“We came together as a group…and we started brainstorming… sharing our ideas of what we was thinking the group will be like….even the hospital manager was at that meeting…to hear about what the plans are for the group and to also advise on where she thinks the needs for the hospital and nurses were…I think that is what helped us to structure our group…” (Urban- Individual interview)
144 4.3.4.1.4 Determining the focus and knowledge needs of the CoP.
The initial phase of planning the envisioned CoP was also characterized by establishing the knowledge needs of the participants. This was promoted through the act of bringing the participants together and allowing them to express their challenges and share their every day stories, which allowed them to see the potential value of being part of a community of nurses.
The following excerpts illustrate the participant’s experiences.
“I used to think I was the only one who was feeling not prepared…like with training and knowledge for dealing with HIV/Aids in our nursing…there is always new policies or workshops and we all do not attend…so you feel alone when you are faced with this problem in your clinic...and it is frustrating….you just feel hopeless but now I can see that this group might change that…if we are going to learn about different topics on HIV…we can start using it in our practice…” (Rural FGD participant 7)
“it was nice to come and share like this …we normally do not do this… we maybe meet only the nurses we know…yet we are all working in the same maternity department…I think it will be so nice to support one another through the group..I can see that I will learn a lot from this group…I am happy to be part of this…” (Urban FGD participant 3)
“…every nurse shared something similar to what I was going through in the ward…just that we did not have the opportunity to talk about like this before…” (Rural-Individual interview)
The process entailed asking the participants within the FGDs what their key learning needs were and what they expected to gain from participating in the CoP. Participants indicated that changes in the PMTCT policy, which were made in early 2010, and HIV/Aids knowledge of the different drugs and regime of antiretroviral therapy were key learning areas that they wanted addressed.
The complex nature of the ART regimen and the difference between prophylaxis and ongoing treatment was unclear to them. From the data, it was also revealed that participants required information and training relating to the stigma attached to HIV. The participants recognized that this was an important aspect in their nursing practice and they wanted to address it so as to break