This article describes some of the experiences of a small group of second year adult nursing students during an optional module – Student Community Engagement (SCE), at the School of Health Sciences, University of Brighton. Their experience was reflected on in the context of being a volunteer and working with socially excluded groups of children and young people. Their reflections are discussed in relation to the importation of new skills into their wider course work and are interpreted using educational and communication theory.
In year two of the BSc Nursing undergraduate curricula students are able to choose between a range of optional modules. Students electing to participate with the SCE module are then invited to a ‘matching event’ which is jointly coordinated by staff from the Active Student Volunteering Service, based with University of Brighton’s Careers Service. Local voluntary organizations are invited to discuss potential learning opportunities within their organizations and to attract motivated volunteers. Significantly, many of the volunteering placements are not for profit organizations with a social care orientation, this offers the students a distinct change from their usual health based organizations.
Early in the placement students are asked to complete a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis and a learning agreement which are later reflected upon. One of the key aims of the module is the recognition and importation of transferable skills and knowledge back into their existing repertoire of professional nursing skills. The module’s summative assessment constitutes a short report describing the host organization and its function, an account of how they have spent their time, an impression of their effectiveness in their volunteering role, the benefits of their activity to the community and the skills and attributes developed while volunteering within the organization. The module is supported by six theoretical sessions looking at volunteering, active citizenship, relevant social policy and project planning. Two action learning sets are facilitated by senior lecturers, making use of narratives, story-telling and the use of reflective dialogue.
The Volunteering Learning Opportunity
At our matching event a range of volunteering options was presented, including the opportunity to volunteer with CCHF – All About Kids (previously Children’s Country Holiday Fund). As students training in the adult branch of nursing we rarely get to work with directly with children, this experience was viewed as an opportunity to broaden our skill-set with this specific group and to challenge ourselves by working with children from disadvantaged backgrounds with potentially difficult behavior.
CCHF was established in 1884 and is a registered charity. It aims to give disadvantaged children respite and residential breaks in order to improve their quality of life and to help them to recognize their own potential (CCHF 2013). It focuses on children aged seven to eleven living mainly within London or the immediate surrounding areas; it relies totally on donations from the public and corporate partners to fund their activities. Children can be referred by anyone who works with disadvantaged children such as teachers and social workers; their eligibility is then assessed against the CCHF criteria. This criteria includes a range of factors such as poverty, abuse, low self-esteem, children that care for a family member, or other family factors such as having a parent who abuses substances or who has a mental health issue. Each child is gently monitored for the duration of the camp due to their circumstances. CCHF works closely with statutory organizations in order to address any issues or concerns encountered throughout the duration of the camp. As such the experience represented our first opportunity to patrol the tensions of a safeguarding role.
It is estimated that of the 1.1million families living on low income in London in 2010 / 11; 60% could not afford to take their children away for a week’s holiday (London’s poverty profile, 2011). Cummins et al (2013) suggest that children that are brought up in poverty can be at greater risk of suffering from low self-esteem. This is one of the key areas that the charity works to improve. Their annual report demonstrates that many of the children that arrive on camp with low self-esteem and leave feeling much happier and far more confident (CCHF All About Kids, 2013).
The wider community also benefits from those accessing the opportunity as children with greater confidence and self-belief are more likely to have better health and are also less likely to engage in criminal activities (Chen et al 2013). Knapp et al (2011) supports this notion by suggesting that individuals who suffer from low self-esteem in childhood are likely to have worse economic prospects in adulthood. Conversely research by the Child Poverty Action Group (2013) using Department of Education data, suggests that children receiving free school meals attain an average of 1.7 grades lower than wealthier students.
A King’s Fund report (Buck et al 2013) suggests that in our modern society volunteers are sometimes under appreciated and used instead of paid workers – however this was found not be the case at CCHF where they have always relied upon the goodwill of volunteers to enable their existence. The role of the volunteer in society has become ever more important as a result of reforms put in place by the Health and Social Care Act, 2012, (Naylor et al 2013). As such, volunteering is now a key part of the current governmental strategy, and is included in their ‘Big Society’ vision. This aims to encourage people to participate in local projects, by giving them more power to influence the running of services and facilities in their community (Cabinet Office 2010). It believes that the inhabitants of communities understand the needs of the local area most, and this will help create “attractive and thriving” neighbourhoods.
Volunteering is traditionally associated with the concept of altruism (Haski-Leventhal 2009) – the motivational selfless desire to increase the wellbeing of others. Alternatively, Carpenter and Myers (2010) argue that the main drive for volunteering is not altruism, but the perceived benefits, whether these are career benefits or purely self-satisfaction. Sigmund and Hauert (2002) take this point further, suggesting that any act in which both parties gain is more co-operation than altruism, as both the volunteer and the organization benefit from the partnership. CCHF utilize this sense of co-operation in their organization; the vast majority of the workforce is made up from volunteers. Most of them are students who are hoping to both enjoy the experience and improve their future career prospects.
Amy’s reflection Before camp I had little experience of working with children or even managing large groups of people. At one point I managed a group of 15 challenging children for an hour with another first time volunteer. The children were well behaved, safe and actually enjoyed themselves, and at no point did I find myself worrying or panicing. Later on in the day, the senior leader praised at CCHF this activity, which helped to build my confidence for future situations on camp. Although these individuals were children, my confidence in leading larger groups of adults has definitely improved and this has made a noticeable difference in clinical practice, for example, when managing a bay of patients in a ward.
A potential weakness that I discovered during the camp that I had not previously identified in the SWOT analysis was my hesitance when trying to find the words to set and enforce interpersonal boundaries with the children and young people. As the week progressed I began to see the consequences of not doing so, I therefore realized that I needed to take some advice from our senior leader, who encouraged a certain amount of careful risk taking. This gave me the confidence to gradually experiment by trying different approaches within the interaction’s, in doing so I eventually over-rode my fears of causing offence or humiliating myself. I found that upholding boundaries did not alter the relationship that I had with the child, nor reduce their respect for my position; it was mostly accepted and often helped to harmonize power structures in the group. Reflecting on this process has helped me in subsequent nursing roles, for example, at timely moments I am more confident when offering health promotion advice, such as advice to reduce smoking, drinking or other harmful activities that I anticipated I would be perceived in an authoritarian or negative light.
One of the most significant experiences that occurred to me during the camp was dealing with a disobedient child and their parents. A particular child had consistently demonstrated aggressive behavior towards others in the early days of the camp. Bullying is not tolerated and so it became my responsibility to liaise with the parent about the child’s behavior and return them to home ahead of schedule. The parents were understandably upset and concerned when I contacted them; I myself felt awkward and did not want to exacerbate the situation further. I tried to remain calm, be professional and listened attentively to the parents; eventually we came to a mutual agreement. The way in which I dealt with this situation and the camp as a whole, reinforced my own ‘self-efficacy’, this is the belief in one’s own capabilities to produce a desired effect by one’s own actions (Lopez and Snyder 2011).
Laura’s reflection Although quite personal, my experience and subsequent reflections have helped me to surface, confront and alter some unconscious attitudes, raising my self-awareness in the process. The demographics of children on the camp was incredibly diverse as was their range of ethnicities and socio-economic backgrounds. This was in contrast to my own quite stable upbringing and I felt a little under confident in my abilities to engage and relate to them. One of the competencies for entry to their register, the NMC requires that:
“All nurses must practice in a holistic, non-judgmental, caring and sensitive manner that avoids assumptions, supports social inclusion; recognizes and respects individual choice; and acknowledges diversity.” (NMC 2013)
At first I found the encounters quite difficult, I just wasn’t consciously judging the children and young people, just uncertain as whether they would accept me and how the interactions would go. However, after I had spent some time with the children I realized that most of my pre-conceived fears were in fact unfounded, and by the end of the camp my I sensed that my confidence had changed. During my nursing career I will encounter people from all walks of life; this episode forced me to think about my own attitude and values. I believe this realisation equates to a shift in values which will stay with me for years to come.
I feel that working with children that may be distressed or upset during the camp has improved my communication skills, insight and confidence in clinical areas where I might encounter and treat children on a regular basis. Having not previously worked with children, I found being able to interact and to make appropriate interventions, a valuable leap for me which in turn forms a valuable part of a child’s development.
Sam’s reflection By the end of the camp I felt proud to be a part of each child’s accomplishments and saying goodbye to them was one of the hardest things that I experienced. As a caring professional it is vital to maintain healthy relationships with the patients and people that you work with. Making use of attachment theory Skovholt and Trotter-Mathison (2011), helpfully describe the ‘caring cycle’ as consisting of four stages: Empathetic Attachment, Active Involvement, Felt Separation and finally, Re-creation. I related this model to the time with the children and it is directly transferable to the relationships I form in my nursing practice.
Knowledge and use of the model has helped me to think differently about the process of attachment. Failure to reach the recreation stage of the caring cycle may indicate an unwanted level of attachment or unprofessional attitudes. My belief is that I will now be able to take part in further camps, being able to recreate healthy, professional relationships again and again.
My experience of volunteering has brought to the fore many considerations into my own education as a student nurse and responsibilities as a future health care practitioner and leader. Due to the personal circumstances of the children at CCHF, I became more aware the importance of safeguarding practices, namely remaining vigilant for possible signs abuse and malnourishment. Being responsible for a group of children meant observing for any issues and reporting them immediately; this aspect of social care applies more broadly to nursing and the responsibility nurses have to the wellbeing of their patients. I have found this experience correlates with my current placement in a Community Nursing Team as we regularly see vulnerable adult patients in their own homes.
Facilitator’s reflection Having supported the students during other academic sessions over the previous year I felt I understood the students well enough to sense the impact that volunteering had on them personally and on their learning. Their sheer enthusiasm evoked a positive sense of dissonance which inspired me to try and capture and analyse their experiences. In our action learning set I probed their narratives, asking what it was about the experience that so differed to other experiences on their course. My overriding sense was that it was the immersive nature of the summer camp combined with their interactions with the young people that had helped to transform their attitudes towards themselves, their practice and their ability to form and maintain relationships.
To interpret the students’ experience I have found it helpful to locate their experience on a two dimensional map of ‘reality’ and ‘learning outcomes’, created by Morgan and Burrell, (1979, cited by Brockbank and McGill, 2006). It is my view that their collective experience moved the group away from the objectivism and towards the subjectivism end of the reality dimension, and from the equilibrium towards the transformation end of the learning outcomes dimension.
Arguably, much of the learning taking place on the adult pre-registration nursing programme, such as clinical skills or anatomy and physiology, depends heavily on notions of an objective reality and maintaining the equilibrium of power structures, as per the conceptual dimensions. Such learning reflects ‘imposed objectives, based on perceived objective reality’ (Brockbank and McGill, 2006). At the ‘equilibrium’ end of the dimension, the status quo and ‘taken for granted’ ideas go unchallenged and are therefore upheld by the prevailing discourses and scripts.
My analysis is, the summer camp experience nudged the students towards the subjectivist end of the continuum as they were immersed in a new social world and a common language became ‘understood and continuously reconstructed, reproduced and transformed through interaction’ with the children and young people, (Brockbank and McGill, 2006). The students’ perspectives appear to have been altered as a consequence of the developmental experience, pushing them away from the stability of the equilibrium element towards the transformative end of the scale.
This is consistent with a symbolic interactionist perspective on perceptions of self and on developing relationships. Symbolic interactionism can be defined as ‘a theory of human communication that can account for the process by which everyday nursing situations become defined and redefined’, (Stevenson, Grieves and Stein-Parbury, 2004). Symbolic exchanges occurred during their interactions and these appear to have shaped understandings and cemented social relationships. For a short time they had been thrown off their usual student nurse ‘script’ (Stevenson, Grieves and Stein-Parbury, 2004), into a completely different domain and the students had adapted to the challenge and risen to the responsibility. In doing so they had achieved new understandings by being part of the young people’s world, using their language, interpreting and making meaning of their communication.
Johnson and Webb (1995, cited by Stevenson, Grieves and Stein-Parbury, 2004) found that ‘nurses do judge the social worth of people and that such judgments do have moral consequences’. However, in our students’ case we have seen these relatively negative evaluations were negotiated and renegotiated throughout their interactions. Once such attitudes are brought into awareness through the process of reflection, corrective thoughts were assumed. In thinking about the collective experience of the group, all three students have processed their experience and engaged with their inner dialogue to make meaning of what occurred in their week with CCHF. Significantly, by processing the subjective cues that occurred, small and hopefully lasting shifts and transformations of attitude occurred impacting on their outlook and learning.
Warren Stewart Senior Lecturer School of Health Sciences, University of Brighton, Laura Brown Adult Nursing BSc (Hons) student, Sam Harris Adult Nursing BSc (Hons) student and Amy Isaac Adult Nursing BSc (Hons) student
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