Activos y Pasivos Financieros

Interpreting Joanna’s story through Phase 1 begins with my reflective monologue in the form of a biographical account immediately following the biographical event.

Chorus

“Prior to the interview I felt a little nervous; I had not met Joanna before and not been to this health centre before either. I didn’t realise the car park was ‘pay and display’ only and I didn’t have any change. This caused me to be late which created some anxiety as I didn’t want to give a poor impression. I was also anxious that I did not want to inadvertently suggest her time was not valued by arriving late. This was not helped further by the fact that the entrance was locked. This meant I could not

91 access the building and had to spend several more minutes trying to let Joanna know I had arrived. Hence I finally arrived feeling rather frazzled and apologetic!! It took me a while to settle down as I felt I had created a bad impression by being late. I felt keen to get started and so I refused her offer of a hot drink as I felt this would delay the start of the interview even more. Although the interview went well I think it would have been wiser to have accepted a drink in order to provide an opportunity to engage in more small talk beforehand. This may have allowed me to get to know Joanna a little more before the interview as I felt I had rushed the process”.

(Excerpt from reflective journal following meeting with Joanna).

Reflexivity interpretation and how the story was told (Chorus)

“Listening back to the audio tape and comparing it to the transcription of the story, it would appear that there were no discrepancies. However, it would appear that I seem to give less positive cues such as saying “yes… see what you mean…” in comparison to the other transcripts. Joanna spoke very quickly, hardly pausing for breath at times wanting to ensure her story was told. This may be because school nursing services are to be commissioned and move to the control of Local Authorities which sits outside of the NHS. There is currently much anxiety within the profession as to what the impact of this will be. She seemed pleased that someone seemed to be listening to what she has to deal with on a daily basis”.

The language used by Joanna would indicate this had been a considered story. At the start of the interview without any hesitation she said “I can think of a child

92 about what she wanted to say. At times this considered approach gave way to a sense of frustration and concern in her voice about the future as if time is running out.

Joanna spoke about one young girl that she had supported with issues relating to weight management. She felt frustrated that despite all of her input and those by other professionals including paediatricians the girl remained significantly overweight.

“I feel sad and frustrated… I worry about her and her future as she just keeps putting on more weight…”

Joanna seemed to think that she personally had somehow let her down, as she had wanted to do more intensive work with her, but was unable to because of workload capacity constraints. There were elements of contrast within her story. While she stated she could not offer structured support, she also said she felt school nurses were more generalists, as opposed to specialists offering specific interventions. However, Joanna did feel that building trusting relationships was very important in working with young people, but again this was often denied because of heavy workloads. It may seem that asking practitioners about their experiences of providing support that this opens up fundamental issues about how they perform this role. This may be a defensive mechanism by looking to blame outside factors.

Joanna indicated she felt she was not doing a good enough job, because of time constraints and workload capacity issues. There was a sense of a distinct lack of agency and feeling of disempowerment. She used phrases like “we just can’t

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cope…”, and that she faced dilemmas within the role as she had let young people

down at times, as she had to cancel appointments because she was called to attend a case conference and “you just have to go”. Joanna spoke about how much she gives on an emotional level, describing how she often felt worried about some of the individual young people she worked with and also about school nursing as a profession “…well that worries me as what do they mean by that and how can we

without extra funding?..” However, as the story progressed Joanna adopted more

of a collective stance, and began to depersonalise the issues using the term “we” as opposed to “I “. For example “we needed to do more… we the system have let them

down… that would generate more work and we won’t be able to cope”. This

highlights Joanna’s sense of a lack of transformational power not only as an individual practitioner but as a collective group/profession.

The importance of credibility and how this could be enhanced indicates that there are issues relating to professional identity. Joanna likened school nursing to health visiting, a service that has seen considerable investment. However, she voiced concern that once children reached school age, the amount of support will be negligible compared to what they have received preschool. Joanna felt school nursing services should offer a more standardised service within the UK like health visiting, which would then provide a more credible, dependable service.

The dramatic heart of this story seemed to lie in letting this young person down. The emotional impact of this on Joanna was the thread that guided my rewriting of the biographical account in the form of a poetic re-presentation. “I let her down” is a poem that portrays the drama of her story and the way in which it was

94 performed in practice. It highlights the complexities and frustrations of working with a child and family over a long period of time when there appears to be little engagement or improvement.

I let her down

I can think of a child straight away

I think about her a lot

Worked with her for about 2 years and Considering how little time we have had She has had a huge amount of input. She is 9 years old

Overweight.

I thought that it would be a simple case Healthy eating, good diet, exercise But it soon became clear

There were more issues going on Living with mum

Then dad at weekends Mum doesn’t work and Has alcohol problems.

Uses food to keep the little girl quiet I feel sad and frustrated

Despite the input

Seems we had no impact at all. I feel like I have let her down

She is going to go into secondary school Will be bullied and teased

I feel like I have let her down She wouldn’t speak to me at first She kept looking down.

Now when she sees me She gives me a high five

Took a long time to develop that relationship. Problem is

We let them down Sometimes

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With these children

On our caseload for 14 years Building trusting relationships Hugely important

But it doesn’t always seem valued There’s too much paperwork Not enough staff

We can’t provide everything these young people need We

The system Let them down

I feel like I have let her down

Joanna’s story centred on the challenges of supporting a young person whose parents may not always make positive health choices, and its narrative thread illustrates the frustration Joanna felt in that she “has let her down”. She portrayed her worries that the girl could be bullied at secondary school, and indirectly this uncovered her belief that this will have a negative impact on the girl’s emotional wellbeing and self-esteem. Joanna described how “you invest a lot emotionally with

these children; they are on your caseload a long time”. Thereby suggesting this can

impact on her personal emotional wellbeing. Working with young people can be rewarding but challenging (Chase et al., 2010). However, it may be about focusing on small steps as intimated by Joanna, “She wouldn’t speak to me at first, kept

looking down, but now she sees me she gives me a high five, that took a long time”,

that are just as important as the final resolution of a major problem and a complete change in health behaviour.

Towards the end Joanna emphasises how a lack of staff and too much paperwork takes her away from the frontline making her think that direct engagement with young people is not always valued by the organisation:

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“We The system Let them down”

By telling us that school nursing services “cannot always provide everything some

young people need”, she asserts a wider responsibility to work collaboratively with

other agencies, to provide ongoing specialist support for particular young people and their families with long term difficulties.

However, things are never straightforward. Joanna admits there has been considerable input into this family. But school nursing is not a statutory agency, and therefore can only offer advice and support which may not always be taken up by the family. This may appear detrimental insofar as the service may have limited effectiveness in achieving long term positive health outcomes. From April 2013 many school nursing services have been commissioned by other agencies outside the NHS such as Local Authorities, causing considerable concern within the profession as to the effect of this change (Godson, 2013a; 2013b; 2014). Therefore measuring impact and improving outcomes will become an important consideration for those managing school nursing services, to ensure they are cost and clinically effective (DH, 2010a; DH, 2011b). Yet despite her apparent feelings of frustration that she let this particular young person down, elsewhere in her story Joanna offered a positive insight into why she is a school nurse.

“I enjoy it all really, there’s nothing that I enjoy more, the role is very diverse and so interesting”.

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SCENE 3: Performance of individual narratives: Phase 1