A reflective account of valuing diversity and one aspect of anti-discriminatory practice which relates to a client from clinical placement
This is a reflective essay which will give an account of the concept of valuing diversity and one aspect of anti-discriminatory practice. Its aim is to demonstrate these concepts by explaining their relationship with regards to a ‘diverse’ client whom I have cared for during my placement. Valuing diversity is recognising differences and turning them into positive characteristics. Howard (2004) supports this theory by defining valuing diversity as being aware of, sensitive to, and appreciating differences. The Department of Health (2004) explain valuing diversity within the NHS and determines the importance that health professionals recognise, respect and value difference for the benefit of the organisation and its patients. The Nursing and Midwifery Council (2002) incorporates the idea of non-judgemental care into its code of professional conduct by maintaining clause 7 of the UKCC Guidelines for Professional Practice (1996, pp25) who instructed "as a registered nurse, midwife or health visitor you are personally accountable for your practice. In the exercise of your professional accountability you must recognise and respect the uniqueness and dignity of each patient and client and respond to their need of care, irrespective of their ethnic origin, religious beliefs, personal attributes and the nature of their health problems or any other factors". This emphasises the roles of health professionals in supporting people from different backgrounds, treating them fairly and protecting them from discrimination. Discrimination is the unfavourable treatment of people who are socially assigned to a particular category (Haralambos and Holborn 2000). They further explain how discrimination is closely linked with prejudices which are learned beliefs and values that make people biased against members of such groups. Discrimination within the nursing profession is explained by Moonie (2002) as a decision to deny one person or group the same rights as another. In order to examine these concepts it will be vital for the purpose of this paper to use reflection. Reflection on an experience has been developed as a learning tool in professional education in order to help promote the integration of theory into practice (Schon 1991). I have chosen to use Johns (2000) model of structured reflection as a framework. This will help me to describe and analyse an appropriately chosen scenario that has been extracted from my reflective journal, which is a structured diary that allows me to describe the incident, how I felt, what satisfied me, what troubled me and what would have liked to have done differently. It is important to use reflection to ensure a conscious effort is made to become self aware of my own actions and prejudices. Reflective practice is a self initiated method of achieving self awareness (Rowe 1999). Rawlinson (1990) suggests that it is not a matter of asking who we are, instead it is of great importance as a nurse to question the effects on clients after each interaction with them. Furthermore, we can become more objective in our thinking by making a commitment to understand ourselves and recognise how our values might influence our ability to understand others (Alfaro-LeFevre 1998). Reflection will also be used to question the verbal and non-verbal communication used within the nurse-patient relationship. Communication is defined by Dunne (2005) as the process where information, meanings and feelings are shared by people by exchanging verbal and non-verbal messages. This will play a fundamental role in order to distinguish both positive and negative attitudes toward my chosen client. Williams et al (1998) explains the extent to how good communication is demanded of nurses, therefore I will further show how communication with a particularly diverse client has made me more aware of diverse issues in health care. The scenario will allow me to examine the need to value diversity and the effect of anti discriminative practice in relation to my client and the provision of care, whilst paying attention to drug misuse and how communication can affect certain situations. Subsequently, this will show how I will endeavour to value diversity as a healthcare provider. In addition to reflection, Herons (2001) six category intervention analysis is a tool that identifies six basic intentions that a nurse may have in the course of a client interaction. It provides a framework for identification of intentions and interactions thus enables analysis of communication with others and will therefore attempt to demonstrate any improvements in a therapeutic relationship for the benefit of both myself and my client. Interventions will refer to my verbal and non-verbal communication. Heron (2001) describes how non-verbal behaviour is critical in determining how verbal communication comes across to the client.
In order to maintain confidentiality I have provided my client with a pseudonym (Nursing and Midwifery Council, 2002).
John was a 34 year old gentleman who presented himself to the Accident and Emergency Department (A & E) with swelling to his left leg. He was admitted on to the ward for investigations into a suspected deep vein thrombosis (DVT) which is the formation of a blood clot (Hinchliff et al, 1996). My first communication with John was on his admission to the ward. Initially, I carried out some admission forms, which involved gathering information from the client and other relevant sources such as his case notes. Alfaro-LeFevre (1998) explains the importance of assessment and information gathering in order to put together a clear picture of a person’s health state. My findings from case notes indicated that John was an intravenous drug abuser, who used heroin on a daily basis. Drug misuse or abuse, are the terms used to describe the use of illegal, prescription-only or over-the-counter drugs, for purposes other than intended by the manufacturer or doctor (NHS 2005). Heroin is a narcotic which is produced from morphine, a compound which comes from the opium poppy (Alderson and Rowland 1995). On finding the information relating to my clients health state, I recalled hearing two staff nurses joking in the office earlier that day by saying "oh joy, were getting another bloody smack head", it then became apparent who the nurses must have been talking about. Therefore, this remark was significant in relation to diversity and discrimination, and the possible effects this could have on Johns care. Another comment was made by the same nurse, as I collected some admission documents from the nurse’s station. This time she was explaining how John has had recurrent admissions to the ward with deep vein thrombosis, described him as awkward and questioned why the Trust allows such people to take up beds. At that time I felt sympathetic towards John, as I did not think it was fair for him to be spoke about in that context. It is true that up to 400,000 hospital admissions within the UK are linked to the use of illicit drugs (BBC 2005). As a Nurse, this form of stereotyping could have an adverse effect on holistic care and Pollard (2002) explains drug misuse is being overlooked, and does not receive the quantity of support that is needed. However, the Department of Health (2000) issued ‘The Vital Connection’, a framework that aims to ensure the NHS uses its resources to make a difference to the health and life opportunities of local communities by meeting the diverse needs of different groups and individuals.
The practical scenario I have decided to use expresses my own prejudice and how I blamed diversity in relation to drug addiction on my client’s communication and behaviour during his initial admission and without looking at the wider picture. Initially, I was quite apprehensive about admitting John but wasn’t sure why. I have carried out numerous admissions and maintained confidence in this task, but finding he was a young, male drug abuser made me feel uneasy. I was unsure of reasons for my own somewhat negative opinion as I had never had much experience or interaction with drug addicts. I hoped to see John as an individual and not as a member of a social deviant group. Monahan (2006) claims that people who use class ‘A’ drugs cause trouble within society. This leads me to believe that as a consequence of the society in which we live, I have only ever heard negativity about those who abuse drugs. The term deviance is used to describe differences from accepted standards within society and is closely associated with the labelling theory which focuses on the reaction of other people and the subsequent effects of those reactions which create deviance (Williams et al 1998). In addition, the lifestyles of heroin users are often portrayed in very negative ways by the media and it is likely that many people use labelling and form a negative stereotypical view of people who have used this drug (Clark 2005). Nevertheless, I assured myself to try and maintain professionalism and introduced myself to John, who was sitting on his bed looking very anxious and agitated. His non-verbal communication showed me that he probably had lack of trust for me. On asking how he was feeling his quick sarcastic reply "just great" made me feel quite belittled and embarrassed. Jones (1994) explains how building relationships to establish trust is sometimes difficult and time consuming and meeting the emotional needs of clients may involve some personal cost. Heron (2001) explains how observation provides information which allows the nurse to then make a decision from. In this situation, the indicating information was that John sat and bit his nails while staring at me, it was clear that something was making him feel unsettled. I had quickly made my own assumption that he obviously needed a ‘fix’ and firstly looked at his prescription chart to find when he had last consumed methadone, which is a potent synthetic narcotic drug that is less addictive than morphine or heroin and is used as a substitute for these drugs (Oxford Dictionary for Nurses 1998). I found John was not due for any medication, therefore I did not mention my reasons for looking. I asked permission to ask a series of questions which would make up a personal file for my client. John made a hand gesture that I interpreted as sit down therefore, I took this as implied consent and sat in a chair next to the bed. Implied consent relates to behaviour that indicates if the patient is agreeing to what has been proposed (NHS 2002). Firstly, I ensured to present a close open posture, maintain good eye contact and use open ended questions in an attempt for John to use some description in his answers, thus allowing me to retrieve as much information possible. I also hoped this would allow him to bring up his drug addiction as opposed to me having to ask. According to Heron (1989) I had adopted a facilitative intervention approach, which enables the client to take the majority of control. Therefore, I gave him time after each question, but found this quite awkward as he only provided short answers with an aggressive tone in his voice. Price (2005) explains how tempting it is to think that health assessment just means asking questions, but pausing long enough to see and hear can sometimes provide us with useful clues for further enquiries. John’s attitude towards me seemed quite negative and made me feel inadequate. Attitudes are learned predispositions to think, feel and behave towards a person in a particular way (Allport 1954, cited by Erwin 2001). John remained nervous and agitated just as I imagined drug addicts to be. However, reflecting on Johns non verbal communication and relating it with my own, I remember how my eyes would sometimes drift to glance at his arms thinking I might find needle marks and bruises and attempting to fulfil my own curiosity. I could sense that John was becoming irritated and appeared impatient which seemed to make my verbal communication quick. When reflecting on this part of the scenario, my communication did not meet the professional approach intended by myself at the beginning of the interview and could not have made any contribution to the therapeutic relationship that I was hoping for. I was very judging and blamed John’s behaviour on his addiction even though my own actions probably contributed to his behaviour towards me. On realising my failing attempt of communicating, I therefore composed myself and adopted a more proactive approach. This involved quick thinking and good use of self awareness. I ensured an appropriate pace and tone in my voice when specific questions were asked. Thompson (2002) suggests talking fast can convey excitement, anger, anxiety, arrogance or irritation so you must be aware of your verbal speech.
Having avoided the subject of drugs initially, I felt it was appropriate in relation to activities of living, therefore I approached the issue by asking "I believe you use heroin" on replying "correct", I further went on to ask how often he injected and if it affected his life". At the time, I doubted myself and thought I had bombarded John with such personal questions, and found myself to be quite uncaring with consideration to such a sensitive issue. When relating my intervention to Heron (2001), my behaviour was confronting, although, in a caring context. I felt that my initial attitude toward John reflected the way in which I approached the issue of drugs. Tschudin (1992) claims in order to meet the needs of a diverse client we need to go beyond the appearance, the misdeed, our fears and hang ups’, as these are the factors that affect the provision of care more than the weightier matters of moral behaviour.
I felt it was important to distinguish any relationship between John’s current health state and his drug addiction, although I jumped to the conclusion that John would probably be less precise when discussing this issue. Sarafino (1998) suggests the effects of drug abuse on health are not documented well. Drugs seem to be less prevalent than drinking or smoking and drug users are unwilling to admit they use drugs. However, I found him to be open about his addiction but less interested in discussing if or how it affected his daily activity. Use of reflection allowed me to realise how I underestimated both John and myself by being afraid he might be dishonest with me. However, Roes (2003) talks about addiction in general, he believes disinterested clients appear uncooperative because their agenda is different from ours. Therefore they might agree with our goals in relation to health but appear uncooperative because they do not believe better things will happen for them. I made it clear that the information he provided was imperative in order to ensure the correct care was given. At this point John informed me that his family were unaware of his addiction and health state and he did not want them to find out. In my opinion I found it immoral to hide such a dangerous factor in his life especially learning that he had young children, however, by critically analysing this information it is important to question if drug misuse harms just the drug user or could they have a negative and possibly dangerous effect on others too? Barnard (2005) explains a report for the Joseph Rowntree Foundation which exposes the devastating impact heroin addiction can have on the user’s family, stating "families are drawn into a downward spiral of problems". On reflection, it could be assumed that he was possibly defending his family, therefore this showed me a more compassionate side to John and my opinion of him began to change. I informed John that the legal documents I was completing were confidential. Clause 5.2 in the Nursing and Midwifery Council (2002) Code of Conduct states that you should seek client’s wishes regarding the sharing of information with their family and others. However, The British Medical Association (2005) argued when looking into views relating to confidentiality. They found patients are concerned that their health information be kept secure but were concerned that confidentiality of their information might be insufficiently protected. This was a particular concern for John as he explained how he had joined a rehabilitation group anonymously but received correspondence to his home address and ended his programme as a consequence. At this point John explained how fed up of lying put his head in his hands and although he wasn’t crying, it was obvious he was upset when talking about family. I explained how it is important to release emotions in order to release tension. As Heron (1990) describes a facilitative approach, I discovered I was being cathartic by trying to encourage John to release tension. I asked his permission to speak with a member of staff to find information relating to support services that might be of potential interest to him. I deliberately asked the staff nurse who had made the discriminative comments, she directed me in contacting the drug liaison team but also said that they had already referred him in the past and he hasn’t changed. I felt it was appropriate to inform her of the reason that he terminated the programme and stressed that he had lost his faith in gaining confidential help. I emphasised his interest and explained I had gained consent to find some information for him. In spite of this, Bunton and Macdonald (1992) claim that intravenous drug users form some deviant group that is sensitive to health promotion messages, which makes appropriate behaviour changes difficult in these peoples lives. Pettitt (2000) describes the Nurses role in advocacy involves upholding the rights of a person without prejudice or discrimination. On reflection, I took the risk of advocating on behalf of John, even though I knew I might have been in conflict with the trained nurse. However, I had begun to empathise with John and wanted to provide holistic care, especially as drugs had a negative effect on his health and a significant factor in the reason for his admission. Empathy is described by Tschudin (1992) as an ability to perceive feelings of the other person, and the ability to communicate this to them. The Department of Health emphasised in their ten year strategy in tackling drugs the need to ensure all problem drug misusers, irrespective of age, gender, race and drug with which they have a problem, have proper access to support from appropriate services. On looking at an even wider picture, his addiction was also a negative factor in his family life and a potential risk. According to Herons six category analysis, I was prescriptive as I had passed on advice that I had initially gained from senior staff, and directed John in gaining confidential help. In addition Heron would also suggest this communication as informative as I had imparted new knowledge on John and interpreted information for his benefit.
On completion of the assessments I felt more relaxed with John and continued with use of verbal and non verbal communication by asking about personal interests.On reflection, the issue of drugs was only brought up when discussing health and in the appropriate areas of the assessment. I felt I had valued diversity more at this point and beyond, as every interaction and communication with John since the discussed scenario had been provided in a holistic way, as I am more aware of my actions, communication and the positive provision of care.
When thinking about the scenario at this stage, It allowed me to realise that when initially meeting clients I sometimes expect too much of myself and expect everyone to like me instantly. Reflection has enabled me to clarify for my own needs that this is not always the case and I now understand that we meet as strangers and have to orientate each other and establish rapport while working together to clarify and define existing problems (Perry and Jolley 1991). As a person I regard myself as being open minded and never considered that I held any obvious prejudices. However, the use of reflection brought attention to how judgemental I was before knowing John as a person as opposed to a ‘drug addict’. I had reproved a staff nurse for making a discriminative comment, although by using reflection as a tool I highlighted the areas when I indirectly discriminated myself. At the beginning of the assessment I had not valued diversity, instead, I made assumptions about John based on the category that he was socially assigned to. I took a few moments to reflect in action during the scenario and become self aware of my communication. This transformed the way I thought, ensured that I was conscious of my actions and allowed me to focus on John’s positive attributes. The result of this approach significantly changed the situation as I felt relaxed, professional and sensitive to the fact that John, like many other patients was anxious about being admitted on to a hospital ward. Also, my pro active approach seemed to change John’s attitude towards me and thus creating what I felt was an effective nurse-client relationship.
After the event took place I took time to consider and understand my own thoughts and actions via my reflective journal. With great emphasis on Johns (2000) model, reflection signified how certain situations troubled me, such as the initial orientation between nurse and client, although the benefit of the model gives me an opportunity to create an action plan to aid my learning. It will be imperative in the future to always make a conscious effort in self awareness. On the other hand, there are also areas of such interaction that I am proud of, specifically when I used my initiative to provide information for the benefit of my client. This experience made me aware of the importance of valuing diversity, not just with those who misuse drugs but to appreciate all clients regardless of any diversity they are associated with. This scenario has not taken away any prejudices I may hold, although as a nurse and a valued member of our society this task has highlighted the growing importance of respecting diversity within healthcare and how putting prejudice aside can enable equality for those who I will care for now and throughout my career. I have also discovered how effective and beneficial it is for both nurse and client when diversity is valued. By this I mean utilising diverse issues and reflecting on them. I can focus on being self aware of communication and intervention skills to ensure a holistic approach is taken in all interactions with clients. On the whole, this experience proved useful for my learning and therefore my future as a healthcare provider.
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