This article was downloaded by: [Monash University Library]On: 14 January 2013, At: 21:44Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Reflective Practice: International andMultidisciplinary PerspectivesPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/crep20

No plan B: reflection on fieldobservations on ‘Skid Row’Katrina Mary Recoche a , Margaret M O’Connor a & Rosemary AnneClerehan ba Monash University, School of Nursing & Midwifery, PO Box 527,Frankston, 3199, Australiab Monash University, Faculty of Medicine, Nursing & HealthSciences, Building 15, Clayton Campus, Clayton, 3880, AustraliaVersion of record first published: 02 Jan 2013.

To cite this article: Katrina Mary Recoche , Margaret M O’Connor & Rosemary Anne Clerehan(2013): No plan B: reflection on field observations on ‘Skid Row’, Reflective Practice: Internationaland Multidisciplinary Perspectives, DOI:10.1080/14623943.2012.749232

To link to this article: http://dx.doi.org/10.1080/14623943.2012.749232

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representationthat the contents will be complete or accurate or up to date. The accuracy of anyinstructions, formulae, and drug doses should be independently verified with primarysources. The publisher shall not be liable for any loss, actions, claims, proceedings,demand, or costs or damages whatsoever or howsoever caused arising directly orindirectly in connection with or arising out of the use of this material.

No plan B: reflection on field observations on ‘Skid Row’

Katrina Récochéa*, Margaret O’Connora and Rosemary Clerehanb

aPalliative Care Research Team, School of Nursing & Midwifery, PO Box 527, MonashUniversity, Frankston, 3199, Victoria, Australia; bInternational Postgraduate AcademicSupport, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton,Australia

(Received 14 August 2012; final version received 9 November 2012)

A nurse’s personal reflection on a day in ‘Skid Row’ and Midtown Los Angeles(LA) highlighted issues related to homelessness and both public and not-for-profit sector solutions used in the United States (US). The experience not onlyraised awareness of the magnitude of the problem in that country, but alsoinspired consideration of the common issues and the potential for translating USstrategies to reduce homelessness to the Australian context. A reflective cyclewas used as the framework for this paper to highlight the component parts ofthe process for the author and the reader. The unexpected intensity of the expe-rience highlighted the need to prepare the health workforce for practice inunpredictable environments and to deliver flexible service beyond simply pro-viding food and shelter. It also served to more deeply personalise the relation-ship with the PhD research undertaken by the lead author (KR), exploringpalliative care for homeless persons.

Keywords: homelessness; non-participant observation; reflection; reflectivepractice; Gibbs’ reflective cycle

Introduction

Poverty and homelessness are not new phenomena, yet despite advances in manyareas of human endeavor such as technology, the sciences and medicine, issues ofdisadvantage and homelessness continue to grow. Literature on the topic is avail-able, but much lacks the experiential dimension of entering the field. The literaturecontains evidence of poorer health outcomes for homeless persons compared togeneral populations (Bhui, Shanahan, & Harding, 2006; Collier, 2011; Lewis,DiGiacomo, Currow, & Davidson, 2011; Vredevoe, Brecht, Shuler, & Woo, 1992),but little on how health delivery needs to accommodate survival requirements forthis group. That is, how the necessities of food and shelter must be met accordingto where and when these services are available before health and other care needscan be addressed. This paper aims to report on my (by KR) first-hand observationof homeless persons in public spaces, in an area known as ‘Skid Row’ in the areasurrounding the central business district of LA. Gibbs’ reflective cycle (Gibbs,1988) was used as the theoretical framework from which to explore theobservations.

*Corresponding author. Email: Katrina.recche@monash.edu

Reflective Practice2012, 1–13, iFirst Article

ISSN 1462-3943 print/ISSN 1470-1103 online� 2012 Taylor & Francishttp://dx.doi.org/10.1080/14623943.2012.749232http://www.tandfonline.com

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

The purpose of the visit to Skid Row was to attend an appointment with themanager of a homeless service organisation as part of my PhD research exploringpalliative care for homeless people. The immersion experience was a by-product ofthe trip to and from the appointment. The physical and emotional sensation of beingpresent in the area was so prodigious that I found myself drawn into a process ofobjectifying what was happening in order to more fully appreciate what I wassuddenly a part of.

Observation and reflection

Data collected through observation, and in consideration of the context in which itis collected, are accepted hallmarks of qualitative research methods. Observationand reflection are known to be critical to developing professional knowledge andevaluating evidence for practice (Avis & Freshwater, 2006; Mantzoukas, 2008).Observation can be either participant, where the researcher is situated in the activi-ties or behaviours being studied, or non-participant in which the researcher observesfrom the sidelines (Borbasi & Jackson, 2012; Moore & Savage, 2002). Althoughparticipant observation is valued as a way of representing as near to an insider’sview as possible, the differences between observation and participation can becomeblurred, and problems may arise as intimacy increases between researchers andparticipants (Moore & Savage, 2002). This may result in the paradox of successfulparticipatory observation resulting in participants losing sight of the fact that theyare the subjects of research. On the other hand, non-participant observation is oftencriticised for being too subjective, particularly if only one observer is used, as theycan be affected by their own culture, perception, memory and observation skills(Caldwell & Atwal, 2005).

Dewey (1933, as cited in Redmond, 2006) considered reflection a central com-ponent of learning and professional development. Rooted in the processes of obser-vation and learning, reflection is sometimes characterised as a sequence of linkedideas that lead to richer conclusions than would be possible without the process.How reflection itself is initiated is also important as it often arises from doubt, dis-comfort and confusion (Moon, 2004; Stockhausen, 2006). Schön (1983, 1987)argued that one should reflect on everyday practice and especially anything onemay find strange or puzzling about it. Reflection is transformative when observa-tions and actions synthesise with new learning and result in higher order cognition(Redmond, 2006). This is most powerfully demonstrated when the reflector is ableto clearly identify what they have learned from a new experience and link it to the-ory and research, or develop new knowledge. Artistry in practice comes from expe-rience, intuition, knowing and acting in uncertainty (Stockhausen, 2006). Reflectionthen is a conscious activity with purpose and both a past and a future orientation(Stockhausen, 2006).

Asking questions like, ‘What am I doing?’, ‘What happened?’, ‘What led up tothis?’ and ‘Why?’ facilitates reflection and self-awareness. It is regarded as anopportunity to learn more about oneself as well as one’s strengths and limitations.Reflection can be used as raw data for more formal analysis, which can facilitatepersonal development and inform professional practice. Reflection on non- partici-pant observation can assist in a deeper exploration of the experience and increaseawareness not only of the salient issues but also the effects of the observer’s cul-ture, occupational discipline, perception and observational skills (Hickson, 2011).

2 K. Récoché et al.

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

These are important factors as they also illuminate the underlying assumptions thatmake us focus or notice the things we do and ignore others. A structure or outlineto capture or guide objectifying a subjective experience is needed and may offer ameans for highlighting these issues. A reflective framework developed by Gibbs(1988) is used to structure reflection on the field experience.

Methods

Gibbs’ reflective cycle (Gibbs, 1988; Johns, 2004; Lawrence, 2008) was used as aframework for reflection on the observations. It provided a six-stage framework toguide reflection inclusive of a description, exploration of feelings, evaluation of whatwas good and bad about the experience, analysis of the learning, a conclusion and aplan for how things can be managed differently in the future. Gibbs (1988) proposedthat the framework should be used in situations such as structured debriefing, guidingexperimental work and tracking learning cycles. For the experiences and impressionspresented as data in this reflection, the six stages act as spaces to pause, examine,question and search for meaning. Figure 1 illustrates how these six stages fit together.

(1) Description of the incident/experience/interaction experienced. This can bequite detailed but should not comprise the major component of the reflection.

(2) Feelings: an exploration of feelings about the experience described. Whatemotions did it bring up?

(3) Evaluation: a more objective measure of what was good, bad or other aboutthe experience.

(4) Analysis: what sense can be made of the experience? For example, has itchanged thinking or perceptions, acted as a cautionary episode, or beeninformed by new knowledge, skills or theory?

(5) Conclusion: could you have done something else? Is there a better way?What was learned?

(6) Action Plan: what would you plan to do in a similar situation?

Figure 1. The reflective cycle.Source: Adapted from Gibbs (1988).

Reflective Practice 3

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

The method therefore involved initial immersion in the experience, followed by aperiod of note-making later that evening, with further notes on the feelings evoked.Over the next few days, extended notes were made evaluating the experience asobjectively as possible and analyzing what it meant in the context of my researchand in the context of future action for me as a nurse. Upon my return to Australia,I discussed and clarified my cycle of reflection with my two colleagues (MOC andRC).

Ethical issues: what to consider

The homeless are a vulnerable group and therefore consideration was given to ques-tions of ethics and the protection of their rights, privacy and interests (NationalHealth & Medical Research Council, 2007). The following observations, however,all occurred in public spaces so there was no invasion of personal privacy and theautonomy of individuals observed was respected. No identifying information of anytype was collected.

Description: entering the field

07.45 hours: I left my temporary apartment to travel by bus to an appointment witha homeless service provider in downtown LA. I caught the 720 Rapid Metro busfrom Wilshire Boulevard in front of the Los Angeles County Museum of Arts andthe La Brea tar pits. The surrounding apartments, shops, restaurants and businesseswere all occupied, well maintained and stylish. Streets were clean, wide and linedby trees and floral displays. The closer the bus progressed toward the DowntownLA area, the less attractive shops, apartment buildings and other structures became.The streets started to look shabby. The sidewalks were unwashed and rubbish waspiled up in corners or was being pushed around by passing gusts of wind like littertumbleweeds. There appeared to be more vacant shops and rundown buildings.Many of the advertising signs were crooked, faded or broken. There were few treesand apart from the occasional park, little other vegetation visible.

08.45 hours: I disembarked at the intersection of San Pedro Street and 6th Avenuein an area known as ‘Skid Row’. Skid Row covers an area of 50 blocks close tothe central business district of LA. As far as I could see, in all four directions, werehundreds of people, mainly men. There were hand carts, shopping trolleys and babyprams all piled high with clothes, umbrellas, bits of bedding and lots of black plas-tic bags tied up tightly – the contents a mystery. Some men further down 6th Ave-nue were dressed in gang colours of either red or blue. The smell of human urinewas all pervading.

A large African-American woman came running towards me screaming out atwhat appeared to be some imaginary adversary. She was dressed in bright red fish-net stockings and very tight red lycra shorts. Further down the street a man washosing down the pavement and the smell was less noxious there. Everything wasgrey and dirty and lots of shop fronts appeared either closed or abandoned. Thebuildings, the roads, the surroundings, and even the people had a washed out, greyhue. I had to walk for two very long city blocks to reach my destination past chari-table mission organisations where people were queuing for food or showers. Thepress of people, carts, trolleys, belongings and rubbish grew thicker so that there

4 K. Récoché et al.

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

seemed to be no space between individuals and things. I looked around as I passedone of the missions and saw a sign that read ‘Showers’ – people were lined upwaiting to go in, whilst others, looking freshly washed were coming out of thebuilding.

Groups of people were eating from paper plates or napkins piled high with food.Around them were abandoned plates with plastic cutlery and food spilling out ofthem onto the street. A middle-aged woman was rifling through the trashcan as shemuttered to herself. Further along the street two police officers were trying to draga couple of shopping trolleys away from a group of people. I passed anotherMission and there were more long orderly lines of people, food, carts and trolleys.Then, in stark contrast, stood two nylon camping tents, one blue and the otherorange, side by side like sentinels amidst the detritus surrounding them. The onlypeople who made eye contact with me appeared to be muttering to themselves orasking for money (Figure 2).

12.20 hours: My visit lasted for three hours and I had to find out where to get thebus that would take me back to my accommodation. At this time of day the atmo-sphere had changed. The frenetic activity of queuing up for showers and food hadfallen away. Carts and trolleys were lined up against buildings, many unattended.Groups were congregated near street corners, mainly men, and most looked boredor were engaged in quiet conversation.

A heavy-set blonde woman noticed my hesitation and asked me if I was lookingfor the bus. She led me to a different bus stop to the one I had alighted from. Thestreets in the area were one-way only and the bus route away from downtown wasnot the same as for the incoming journey. I caught the bus heading back to Mid-town. The distance between where I was staying and Skid Row was 6.1 miles. Thefurther away from Skid Row I travelled, the cleaner and brighter things once againbecame. The buildings were better maintained. Street and advertising signs werehanging straight and were clean and bright. All the shops were occupied. By thetime I arrived back near to where I was staying, I noticed the beautiful parkland,

Figure 2. Skid Row Los Angeles.

Reflective Practice 5

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

the trees and the flowers that were part of that streetscape. People sitting at outdoorcafé tables and walking along the street were well dressed. There was a lot of activ-ity around the local shops and late model cars were travelling along the roads.

13.35 hours: As I alighted from the bus I noticed a tall young African-Americanman lying on a park bench right in the Los Angeles County Museum of Arts park-land. He had an umbrella set up at an angle to shade his face from the sun and arolled up sleeping bag under his head. Beside him stood a duffle bag on wheels thathad plastic bagged items neatly attached to it by elasticised straps. Homeless peoplewere not confined to Skid Row in LA but could be encountered almost anywhere.He was something of a contrast to many of the people I had seen on Skid Row;even by the way his belongings were packed. There was an air of precision abouthim and his belongings.

19.00 hours: Later I went out to have my evening meal at a restaurant and becausethe quantity I was served was too much, I asked that half be saved in a take-awaycontainer. The images of people queuing for food flashed into my consciousnessand I thought about what food meant to me. My family showed love and respectby making special meals for one another. I had never really experienced hunger norbeen without the means to meet my basic need for nutrition and hydration. As Iwalked back to my accommodation I noticed an older Caucasian woman lying onthe side of the footpath, close to the intersection. She was wrapped in a bright yel-low animal print blanket. The wheelchair parked next to her was piled high withclothing and plastic bags. She wore no shoes and the soles of her feet, ankles andlower legs were caked with dirt as they poked out beneath the blanket. I spoke toher but she did not reply and did not make eye contact with me. I placed the take-away food container on the ground close to her. I glanced back once after I crossedthe road, and noticed a hand snake out from under the blanket, grasp the containerand pull it back underneath it.

Feelings: thoughts and emotions about the experience

I had started to feel uneasy as the surroundings deteriorated the closer the bus came tothe downtown area that was my destination. When the bus stopped at the corner and Ihad no choice but to get off, my unease progressed to moderate fear. I realised with astart that I had no ‘Plan B’ in case anything went wrong. The sheer numbers of home-less people shocked me and it was really hard to make sense of the situation. I feltangry about the contrast between wealth and poverty 6.1 miles apart. Part of me wasterrified and wanted to run away and not have to face the realities that were before me.I was also scared for my physical well being and afraid that someone might challengeor attack me. Perhaps my lack of experience, insight or maybe arrogance, was respon-sible for putting myself into a situation for which I was so clearly unprepared. When Iboarded the bus out of Skid Row I was relieved and the further I progressed awayfrom there the safer and more relieved I felt.

Pangs of guilt quickly followed relief as I grappled with the injustice andinequality in what I had observed. I was grateful that I was not homeless and livingon Skid Row, sad about witnessing the suffering of others in the modern world andhelpless to even consider how such suffering and injustice could be reversed. I wor-ried that perhaps I had been blind to the extent of homelessness in my own localcommunity and resolved to be more alert when I returned home.

6 K. Récoché et al.

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

Evaluation/discussion: the good, the bad and the objective

This reflection resulted from a trip to an appointment with the manager of a home-less service provider in Skid Row. The anticipated routine visit was transformedinto an experience that destabilised what I thought was my focus as a researcher,raising questions upon which I felt compelled to reflect. Being objective about thegood and the bad to be found in the experience was challenging. Poverty andhomelessness are not new evils. The Skid Row area and its inhabitants merely high-lighted the magnitude of the issues in a twenty-first century Western economy. Thenumber and variety of homeless shelters and aid organisations observed offeringservices to persons in need was the good part of the experience. Organisations withboth religious and secular philosophical foundations were represented and mostrelied heavily upon the input from volunteers (Downtown Womens’ ActionCoalition, 2011).

The United States has a total population of over 300 million people and accord-ing to US census data, 15.3% of them live below the poverty line (Bishaw, 2011),with up to 3.5 million homeless at some time during any given 12-month period(Hughes, 2010). According to Los Angeles Homeless Services Authority. (2011,p. 3) there were 51,340 homeless people in the County of Los Angeles, 23,539 ofthem in the City of Los Angeles. Of these, 63% were unsheltered, that is, livingrough on the streets, in parks, cars or other temporary structures, and 55% weredeemed chronically homeless (Los Angeles Homeless Services Authority, 2011,p. 13). Why were these people homeless? A review of risk factors for 1252 recipi-ents of care at a mission on Skid Row found that people fell into one of three maincategories for homelessness. These were either economic, such as loss of job ormigration seeking work, involved changing social patterns including single parent-hood, substance abuse and outpatient or no management of mental health issues, orpersonal crises such as destruction of home or family unit, prolonged illness, with-drawal from family, release from prison, illegal immigration, psychotic breakdowns,or personal (Vredevoe, Brecht et al., 1992; Vredevoe, Shuler, & Woo, 1992).

The Downtown Women’s Action Coalition represents service providers, resi-dents and advocacy groups in Skid Row. It conducted the first assessment ofwomen’s needs in the area in 2001 and the most recent in 2010. According to thegroup (Downtown Womens’ Action Coalition, 2011), women are the fastest grow-ing group within the homeless population in the US, and LA has the highest con-centration of homeless, transient and very low income persons in the country. The2010 needs assessment highlights the most pressing issues and needs facing womenin the area, explores violence against women, the availability of health services andhousing access. The noticeable trends identified since the previous assessment, in2007, are reduction in resources and access to housing and healthcare, the relation-ship with law enforcement and violence against women. Of the women surveyedfor the needs assessment, 52.7% identified as African American, 21.6% non-His-panic white and 12.2% were Hispanic/Latino; 50% had health issues and 62.5% adisability; and the median amount of time spent on Skid Row was three years(Downtown Womens’ Action Coalition, 2011). Despite the stigma associated withSkid Row, respondents cited access to food, public transport and social services asthe primary benefits of staying around the area.

In a series of studies, the barriers faced by homeless people accessing servicesat the end of life and their attitudes and preferences in relation to end of life deci-

Reflective Practice 7

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

sion making were explored (Song et al., 2007; Song et al., 2008). Homeless peoplehad higher morbidity and mortality rates than the general population, and were lesslikely to receive much care in the period leading up to their death (Hughes, 2010;Song et al., 2007). Many of the participants cited health professional attitudes andjudgements as barriers to care access. One participant stated that ‘We are not evenconsidered third-class citizens’ (Song et al., 2007, p. 432). Issues such as lack of aplace to live, no carer network, infrequent access to health services, particularly useof acute emergency departments as the primary health care service, mean thathomeless persons have less access to care and resources (Cagle, 2009; Hughes,2010).

Australia’s population is 23 million, and in 2011 a total of 230,500 peopleaccessed specialist homeless services (Australian Institute of Health and Welfare,2011). The most recently available census data on Australian census night 2006there were 104,676 people identified as homeless, as demonstrated by either theirlack of conventional accommodation or use of transitional or short-term housing(Chamberlain & MacKenzie, 2008).

Analysis: what does it mean?

What sense can be made of the experience? Analysis involves objectifying the fieldimmersion experience. In this case the data consists of sequential observations overa 12-hour time period. Factors such as why I choose to talk about some observa-tions and perhaps not others need to be considered. Chak (2006) recommended dis-tancing and observing self to focus attention before reflecting, and cautioned thatwe must try to ‘…refrain from dichotomizing an initial perception of a situation’(p. 55). However, there is a risk that the strongest impressions can hijack what isbeing noticed, leading to bias (Lindh, Severinsson, & Berg, 2008). So what, howand why something is noticed has an effect both on the nature and result ofreflection (Loughran, 2006). Personal factors such as knowledge, experience, cour-age and open-mindedness also shape how experiences are perceived (Barak, 2010;Chak, 2006).

I am an experienced nurse and volunteer working with homeless persons in mylocal community. On arrival in Skid Row, was my fear born of discomfort with soflagrant and numerous a representation of homelessness? It is difficult to commit tocaring in environments out of my comfort zone when I am uncertain or fearful. Onreflection, and considering my own experience, I wondered how inexperienced stu-dents and novice practitioners manage their feelings of discomfort and uncertaintyand how they can be best prepared for working in unpredictable environments(Farnell & Dawson, 2006; Vaismoradi, Salsali, & Ahmadi, 2011). Lindh et al.(2008) explored confrontations to moral responsibility for student nurses in prepar-ing for practice. They found students were at risk of moral distress if they couldnot uphold their personal morals, suggesting that this type of field experience needsto be well supported to facilitate professional growth and development.

Another important question is do the missions help, or just keep people main-tained in their poverty? The research literature does not provide a simple answer tothis question but rather highlights the efficacy of programs that address more thanthe basic need for food and shelter (Fitzpatrick-Lewis et al., 2011; Larimer et al.,2009; Wright & Tompkins, 2005). America’s welfare state has been described as anempire with an operating cost of around $700 billion for 185 federal means-tested

8 K. Récoché et al.

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

welfare programs (Ferrarra, 2011). Trying to find research that indicates the valueof the volunteer and mission support to homeless persons is difficult. The surveyconducted by the Downtown Women’s Action Coalition (2011) states that the ser-vices offered by missions and other support organisations on Skid Row are vital forthe ongoing survival of many women, particularly those who receive no benefits orincome. It appears unlikely that withdrawal of these services would act as a catalystto reducing homelessness.

Although welfare and health programs are important for the support of homelesspersons, shelter is a priority. The ‘Housing First’ model, which consists of indepen-dent community housing with access to mental health and other services as needed,is increasingly the focus of US Government policy regarding homelessness (Tsai,Mares, & Rosenheck, 2010) and for other jurisdictions (Sadowski, Kee, VanderWe-ele, & Buchanan, 2009). Organisations such as Community Solutions and CommonGround (Common Ground., 2011) are well known for their work in empoweringand supporting communities to look after themselves and their vulnerable popula-tions. They do not work directly with homeless people but at a macro level withcommunities who deal with the vulnerable. They help them network with otherorganisations and community groups to provide more efficient services. CommonGround addresses chronic street homelessness by developing supportive housing,and are property managers for over 2000 units, a 38-bed shelter and safe unit for avery high needs population (Common Ground, 2011). One permanent housing com-plex with 28 units was specifically funded for senior chronically homeless personsover the age of 62 with a mental illness. Ironically, finding people who met theadmission criteria was described as ‘… like finding a needle in a haystack [as] …people don’t live to sixty-two’ (personal communication CB, 2011).

A study by Tsai et al. (2010) compared the outcomes for groups of previouslyhomeless persons with mental health and/or addiction issues who were either placeddirectly into community housing or were transitioned through residential treatmentprograms before being placed in community housing. Although some research hassuggested poorer outcomes for homeless persons in independent housing, Tsai et al.(2010) found improved outcomes for groups in both independent community hous-ing and those who were transitioned first through residential treatment programs.Other studies have supported the efficacy of housing in conjunction with coordi-nated services to address underlying social, psychological and other issues forhomeless people (Fitzpatrick-Lewis et al., 2011; Larimer et al., 2009).

Conclusion: is there a better way?

Could I have done something else? In identifying the process of agonising overmoral and ethical dilemmas as fundamental to life, Little (2010, p. 321) recognisedthat the word ‘… agony derives from the Greek word agon, which means to con-tend, or wrestle’. He reflected both on his own experience of being faced withhomeless persons and the strong inclination of Westernised societies to judge peopleand then blame them for their lack of motivation or self-control. Little (2010, p.325) provided a frank self- assessment; ‘ I am confronted as well by my own moralinadequacy when I confront street people … We share humanity, but on differentterms’. He also acknowledged the paradox of charity in that it is easier to give char-ity to a depersonalised source such as an organisation than to a homeless personright in front of you. Giving at a distance is non-intrusive.

Reflective Practice 9

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

In reflecting on my own experience I recognise ‘agony’ or wrestling with con-flicting feelings and attitudes and the moral dilemmas underpinning what occurredon Skid Row. I was variously disturbed, delighted, scared and inspired by what Isaw. I could not forget that I was a transient spectator in the environment for asnapshot of time. I was not immersed in the culture, politics or social networks ofSkid Row, Los Angeles or the United States. Interpretations of my observationswere the subjective reflections of a stranger from another country observing a placeand culture without the context of living there. I had to ask myself what was thepoint of documenting a day in my life in this way? I have used the action plan fol-lowing to consider just this question.

Action Plan: what would I plan to do in a similar situation?

The Skid Row experience, by its confronting nature, was a source of motivation tolearn more about the extent of homelessness and the public and not-for-profit strate-gies used to address it. The philosophies and frameworks of some organisationswhich have worked so well in the US have been transported to the Australian con-text. For example, the principles and practices developed by Common Ground(Common Ground, 2011), as discussed earlier, have been successfully reconfiguredin the Australian context as either ‘Home Ground’ or ‘Common Ground’ (ElizabethStreet Common Ground, 2011; Mercy Foundation., 2011; Queensland Government.,2011). Lessons learned in the US have certainly been used to positively informthese programs. Having been struck by the power of reflecting on the field experi-ence, I would recommend including this in curricula for the health professions gen-erally, not just nursing. It is a valuable exercise even at the risk of some having toacknowledge that they have chosen a professional role or area of practice that isnot for them.

Concluding comments

The experience of being an observer in Skid Row highlights the need for healthand social care to be provided in non-traditional surroundings and in different waysto best serve the needs of populations affected by poverty, social disadvantage andmarginalisation. It also draws attention to the need to adequately prepare profession-als and students for such social realities by opening up opportunities for supportedpractice in organisations and services providing for homeless persons. Professionalsand students engaged in this area of practice should particularly be encouraged inreflective practice to help them identify their feelings and needs in relation to con-fronting situations. Gay (2012) discussed the different worlds inhabited by culturallydiverse students and their teachers, and the effects this has on their ability to appre-ciate each other’s realities relates well to the experiences of health professionals andstudents immersed in situations outside of their comfort zone. Reflection not onlyaids self-awareness but can also transform practice and lead to new knowledgegeneration.

Notes on contributorsKatrina Recoche is a lecturer in the School of Nursing and Midwifery at Monash University,Australia. She has had a long career in palliative care nursing and her current research isfocused on palliative care for homeless people.

10 K. Récoché et al.

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

Margaret O'Connor holds the Vivian Bullwinkel chair in Palliative Care Nursing, asuccessful partnership with three clinical organisations. She is responsible for the PalliativeCare Research Team and manages a number of clinical research projects.

Rosemary Clerehan is an educational linguist and an associate professor and director ofInternational Postgraduate Academic Support in the Faculty of Medicine, Nursing andHealth Sciences at Monash University, Australia.

ReferencesAustralian Institute of Health and Welfare. (2011). Government-funded specialist homeless-

ness services: SAAP National Data Collection annual report 2010–11: Australia.Canberra: AIHW. Retrieved from http://www.aihw.gov.au/publication-detail/?id=10737420853%3E

Avis, M., & Freshwater, D. (2006). Evidence for practice, epistemology, and criticalreflection. Nursing Philosophy, 7, 216–224.

Barak, L.O. (2010). The theoretical sentsitivity of the researcher: Reflections on a complexconstruct. Reflective Practice. International and Multidisciplinary Perspectives, 3(3),263–278.

Bhui, K., Shanahan, L., & Harding, G. (2006). Homelessness and mental illness: A literaturereview and a qualitative study of perceptions of the adequacy of care. InternationalJournal Social Psychiatry, 52(2), 152–165.

Bishaw, A. (2011). Poverty: 2009 and 2010 American Community Survey Briefs. RetrievedFebruary 1, 2012 from http://www.census.gov/prod/2011pubs/acsbr10-01.pdf

Borbasi, S., & Jackson, D. (2012). Navigating the maze of research: Enhancing nursing andmidwifery practice (3rd ed.). Chatswood, NSW: Elsevier.

Cagle, J. (2009). Weathering the storm: Palliative care and elderly homeless persons. Journalof Housing for the Elderly, 23(1–2), 29–46.

Caldwell, K., & Atwal, A. (2005). Non-participant observationb: Using video tapes to collectdata in nursing research. [research]. Nurse Researcher, 13(2), 42–54.

Chak, A. (2006). Dialogue on ‘reflecting on self’. Reflective Practice. International andMultidisciplinary Perspectives, 7(1), 55–57.

Chamberlain, C., & MacKenzie, D. (2008). Australian census analytic program: Countingthe homeless Australia. Canberra: Commonwealth of Australia Retrieved from http://www.ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/57393A13387C425DCA2574B900162DF0/$File/20500-2008Reissue.pdf

Collier, R. (2011). Bringing palliative care to the homeless. [News]. Canadian MedicalAssociation Journal, 183(6), E317–E318.

Common Ground. (2011, 31 January). Common Ground about us. Retrieved March 2, 2011,from http://www.commonground.org/?page_id=24

Downtown Womens’ Action Coalition. (2011). Downtown Womens’ needs assessment.Retrieved September 15, 2011, from http://www.dwcweb.org/needs/DWAC_NeedsAs-sessment2010.pdf

Elizabeth Street Common Ground. (2011). Elizabeth Street Common Ground supportiveHousing, from http://www.homeground.org.au/what-we-do/individual-services/elizabeth-street-common-ground-supportive-housing.

Farnell, S., & Dawson, D. (2006). ‘Its not like the wards’. Experiences of nurses new to crit-ical care: A qualitative study. International Journal of Nursing Studies, 43(3), 319–331.

Ferrarra, P. (2011). America’s ever expanding welfare empire. Forbes. Retrieved from http://www.forbes.com/sites/peterferrara/2011/04/22/americas-ever-expanding-welfare-empire/

Fitzpatrick-Lewis, D., Ganann, R., Krishnaratne, S., Ciliska, D., Kouyoumdjian, F., &Hwang, S.W. (2011). Effectiveness of interventions to improve the health and housingstatus of homeless people: a systematic review BMC Public Health, 11, 638–652.

Gay, G. (2010). Acting on beliefs in teacher education for cultural diversity. Journal ofTeacher Education, 61(1–2), 143–152.

Gibbs, G. (1988). Learning by doing. A guide to teaching and learning methods. OxfordPolytechnic.

Reflective Practice 11

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

Hickson, H. (2011). Reflective practice. International and multidisciplinary perspectives.Reflective practice, 12(6), 829–839.

Hughes, A. (2010). Poor, homeless, and underserved populations. In B.R. Ferrell & N.Coyle (Eds.), Oxford textbook of palliative nursing (3rd ed., pp. 745–755). New York:Oxford University Press.

Johns, C. (2004). Becoming a reflective practitioner (2nd ed.). Oxford: Blackwell.Larimer, M., Malone, D., Garner, M., Atkins, D., Burlingham, B., Lonczak, H., et al.

(2009). Health care and public service use and costs before and after provision of hous-ing for chronically homeless persons with severe alcohol problems. JAMA, 301(13),1349–1357.

Lawrence, P. (2008). Reflecting on events. Emergency Nurse, 15(9), 16–18.Lewis, J.M., DiGiacomo, M., Currow, D.C., & Davidson, P.M. (2011). Dying in the mar-

gins: Understanding palliative care and socioeconomic deprivation in the developedworld. Journal of Pain and Symptom Management, 42(1), 105–118.

Lindh, I.B., Severinsson, E., & Berg, A. (2008). Exploring student nurses’ reflections onmoral responsibility in practice. Reflective Practice. International and MultidisciplinaryPerspectives, 9(4), 437–448.

Little, J.M. (2010). On agonising: Street charity and first ethics. Bioethical Inquiry, 7, 321–327.

Los Angeles Homeless Services Authority. (2011). 2011 Greater Los Angeles homelesscount report.

Loughran, J. (2006). A response to ‘reflecting on self’. Reflective Practice. International andMultidisciplinary Perspectives, 7(1), 43–53.

Mantzoukas, S. (2008). A review of evidence-based practice, nursing research and reflection:Levelling the hierarchy. Journal of Clinical Nursing, 17(2), 214–223.

Mercy Foundation. (2011). Common Ground Sydney. Retrieved March 2, 2011, from http://www.mercyfoundation.com.au/homelessness/index.cfm?loadref=41

Moon, J.A. (2004). Reflection in learning and professional development: Theory and prac-tice. Abingdon: RoutledgeFalmer.

Moore, L., & Savage, J. (2002). Participant observation, informed consent and ethicalapproval. Nurse Researcher, 9(4), 58–69.

National Health & Medical Research Council. (2007). National statement on ethical conductin human research. Canberra: Australian Government.

Queensland Government. (2011). Brisbane Common Ground Retrieved 02/03/2011, 2011,from http://www.communities.qld.gov.au/housing/community-and-homelessness-programs/bisbane-common-ground.

Redmond, B. (2006). Reflection in action: Developing reflective practice in health and socialservices. Aldershot: Ashgate.

Sadowski, L.S., Kee, R.A., VanderWeele, T.J., & Buchanan, D. (2009). Effect of a hous-ing and case management program on emergency department visits and hospitaliza-tions among chronically ill homeless adults: A randomized trial. JAMA, 301(17),1771–1778.

Schön, D. (1983). The reflective practitioner. Aldershot: Avebury.Schön, D. (1987). Educating the reflective practitioner. San Francisco: Jossey-Bass.Song, J., Bartels, D.M., Ratner, E.R., Alderton, L., Hudson, B., & Ahluwalia, J.S. (2007).

Dying on the streets: Homeless persons’ concerns and desires about end of life care.Journal General Internal Medicine, 22(4), 435–441.

Song, J., Wall, M.M., Ratner, E.R., Bartels, D.M., Ulvestad, N., & Gelberg, L. (2008).Engaging homeless persons in end of life preparations. Journal of General InternalMedicine, 23(12), 2031–2036.

Stockhausen, L. (2006). Metier artistry: revealing reflection-in-action in everyday experience.Nurse Education Today, 26, 54–62.

Tsai, J., Mares, A.S., & Rosenheck, R.A. (2010). A multisite comparison of supportedhousing for chronically homeless adults: ‘Housing first’ versus ‘residential treatmentfirst’. Psychological Services, 7(4), 219–232.

Vaismoradi, M., Salsali, M., & Ahmadi, F. (2011). Nurses’ experiences of uncertainty inclinical practice. A descriptive study. [original research]. Journal of Advanced Nursing,67(5), 991–999.

12 K. Récoché et al.

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013

Vredevoe, D.L., Brecht, M., Shuler, P., & Woo, M. (1992a). Risk factors for disease in ahomeless population. Public Health Nursing, 9(4), 263–269.

Vredevoe, D.L., Shuler, P., & Woo, M. (1992b). The homeless population. Western Journalof Nursing Research, 14(6), 731–740.

Wright, N.M.J., & Tompkins, C.N.E. (2005). How can health care systems effectively dealwith the major health care needs of homeless people? (H. E. Network, Trans.).Copenhagen: WHO Regional Office for Europe.

Reflective Practice 13

Dow

nloa

ded

by [

Mon

ash

Uni

vers

ity L

ibra

ry]

at 2

1:44

14

Janu

ary

2013