Nurse Education in Practice (2008) 8, 170–176

Nurse

www.elsevierhealth.com/journals/nepr

Educationin Practice

Thank-you cards: Reclaiming a nursing studentritual and releasing its transformative potential

Margaret McAllister *

School of Health and Sport Sciences, Faculty of Science, Health and Education, University of the SunshineCoast, Room C2.05, Building C, Maroochydore, Queensland 4558, Australia

Accepted 11 May 2007

Summary The giving of a ‘‘thank-you card’’ to the staff of a health service inwhich clinical experience was gained, is common practice amongst nursing studentsin Australia. Group reflection, or debriefing, following the clinical experience is alsoa common practice. As rituals in nursing, they can become routinised, taken-for-granted and have little meaning or influence. This paper discusses an educa-tional activity devised by the author that aimed to transform a relatively innocuouspractice into one that had empowering potential for students, giving them voice inthe health service culture and emphasizing the need for a more humanized work-force, one that actively seeks out opportunities to give each other helpful feedbackso that change is ongoing. The activity drew upon narrative pedagogy, showing stu-dents how stories combined with rituals have transformative potential not only forthemselves as students, but for the entire culture of nursing. The paper argues thatcultural change need not be monumental for it to have enduring effect and it iswithin the jurisdiction of even the most junior student. The ‘‘thank-you card’’ ritualthat students commonly use can be reclaimed and extended so that studentsbecome activists in the building of a more humanistic, supportive nursing and learn-ing culture.

�c 2007 Elsevier Ltd. All rights reserved.

KEYWORDSAction;Activism;Humanism;Narrative pedagogy;Nursing culture;Ritual;Story-telling;Transformation

1d

Introduction

As a teacher of undergraduate nursing students forover 13 years, I knew from experience that stu-dents frequently had emotional stories to tell after

471-5953/$ - see front matter �c 2007 Elsevier Ltd. All rights reseroi:10.1016/j.nepr.2007.04.010

* Tel.: +61 7 5456 5032; fax: +61 7 5456 5004.E-mail address: mmcallis@usc.edu.auURL: www.usc.edu.au

they had completed guided clinical practice. Uponreflection of these events, the emotion generallycame from retelling experiences of pain, suffering,loss and grief. Students also had emotional storiesof resilience, transition and transcendence. Thenarratives stemmed from relationships that devel-oped with, or observations of, themselves, pa-tients, nursing staff, clinical colleagues, andclinical teachers. Typically, students are eager to

ved.

Thank-you cards: Reclaiming a nursing student ritual and releasing its transformative potential 171

tell their stories, perhaps because of the catharticfunction the retelling serves for individuals.

Embedded cultural tensions in nursing are com-monly revealed in this discussion. A tension be-tween the desire to belong and the need to avoidgetting in the way was common. For example, stu-dents often relayed experiences where their ideasor needs were either pushed aside or embracedby RNs and medical doctors. Responses could eithermake the student feel welcomed and safe, orunwelcome, afraid and frustrated.

Students frequently told of the anxiety they feltwhen commencing practice in an unfamiliar unitand how frightened they felt when expected to at-tend to a client with problems and issues studentshad never encountered before. Oftentimes, stu-dents were directed to be with a patient, withouthaving any opportunity to observe the way carewas delivered in the particular unit.

Students also frequently perceived a tension be-tween the expectation to imitate observed prac-tices and at the same time critique them. Forexample, students would talk of clinical teachersand nursing managers conveying the expectationthat students should be active in the health ser-vice, doing what the other RNs were doing. Yet atthe same time, students were criticised if they en-acted modelled practices that were incorrect orunscientific.

Another practice that commonly occurredseemed ironic, in the context of all the rich, deep,emotional and sometimes conflictual experiencesstudents had on clinical practice. Students collec-tively would ritually mark the ending of their rela-tionship with staff in the clinical environment andtheir RN colleagues, with the giving of a simplywritten ‘‘thank-you card’’. Regardless of how pow-erful the experience was – whether students weremoved, awakened, traumatised or saddened – thecards contained the same script and it was evidentto me that students missed an opportunity to usetheir voice, to offer feedback and to attempt tomake change for students of the future. I beganto wonder if there might be other ways that theexperiences could be interpreted, discussed andacted upon differently so that students might feelempowered, participants involved, and changemade possible. What follows then is a criticalreflection upon the meaning of story-telling, ritualand a description of an innovation that offers pos-sibilities for transformed experiences. The paperdiscusses in turn a number of cultural practicesbeing harnessed to undertake what is a simplelearning activity – but one that may have profoundeffects for both students and the health care cul-ture. The cultural practices include: shared story-

telling, the power of ritual, the practice of letterwriting and finally, the thank-you card ritual.

Shared story-telling

The growing body of work within the educationnursing disciplines, known as narrative pedagogy,rests in the belief that stories have communicative,connecting and transformative potential and thusare powerful learning tools (Connelly and Clandi-nin, 1990). Stories can convey context, emotion,ethics, values, culture, relationship and, when theyare shared, can move people to create change andtake political action (Van Manen, 1994). Foremostin advancing knowledge in this field, are nursingresearchers (c.f. Andrews et al. (2001), Diekel-mann (2001), Ironside (2006), Ironside (2003) Nehls(1995) and McAllister (2007)). The benefits of stu-dents engaging in shared story-telling are summa-rised in Table 1.

One common site for students to engage inshared story-telling is following clinical experi-ences, but post-clinical debriefing also has limita-tions when the event takes place withoutengaging the context and the people to which thestory relates. In the classroom setting, the sub-ject/s of the students’ stories (such as patients,clinical staff and teachers) are usually excludedfrom the listening experience, even though thiscan offer opportunity for rich feedback. When thesubjects are not present they are also not giventhe right of reply or the benefit of knowing thatthe encounters had with students may have madea deep and enduring impression. Without feedback,people do not have the opportunity to feel vali-dated and nor do they have a chance to change.Furthermore, the stories told are often critical ofhealth practices, and unless students are assistedto find remedies and do more than simply ‘debrief’,students are not empowered or assisted to engagein anti-oppressive nursing practice (Hopton, 1997).

Furthermore, classroom debriefing does not of-fer to the students themselves opportunity to rea-lise the transformative potential that story-tellingcan offer to nursing culture (McAllister, 2005). Sim-ply revealing tension is not sufficient to enact orcreate change in the system. In this way, studentswho simply offload stories from experience to theirstudent colleagues or teachers are performing anessentially conservative act because nothing aboutthe clinical environment is likely to change as a re-sult of this retelling. Yet, story-telling does havepowerful potential because it can become a politi-cal act such that it produces change, and in this actstudents may come to realise their agency and

Table 1 Positive functions of story-telling

� Story-telling gives an the oral/aural interpretation of an experience.�When a story is told it can have a cathartic function, offering release and understanding.�When a story is heard it can have a connective function.� Teller and listeners joined in a common way can build community and solidarity.� Each story is unique, offering different emphases and perspective.� Story relies on context. In a story a scene is set, a plot unfolds,interactions occur and these organize the information about the event.Without these, meaning about an event is incomplete or superficial.� Story-telling can evoke a subjective understanding, closer to the embodied human experience,offering an alternative to objectivity and empiricism.� Story-telling can evoke and transmit feelings, thereby allowing people to relateto the issue and to learn from it.� Powerful story-telling can awaken, enlighten, move, galvanise, activate and motivate.� Thus story-telling has a political function. It can make the personal, public and ignite change.

172 M. McAllister

their role in contributing to a better clinical and so-cial world. As ritual practices shared story tellingand thank-you card-giving have strengths and limi-tations and these need to be considered.

The power of ritual

Ritual, used in its spiritual or cultural sense, simul-taneously conveys, embodies and enriches meaningand thus, if used consciously, has powerful trans-formative potential.

Rituals, ceremonies, and rites of passage arepractices that can help individuals and groups feelin touch with previous generations and with tradi-tion, contributing to an awareness of the rich placeof history, the maintenance and development ofsociety and culture (Turner, 1997). Rituals can begrounding, offering a sense of purpose and connec-tion, keeping a person in touch with core values,humanity, with god and with life (Helman, 1990).Indeed, Helman also claims that rituals are neces-sary for human society. Rituals express and renewbasic values of a culture, especially regarding rela-tionships between human beings.

Ritual has an interesting and changing place innursing. In the contemporary world unfortunately,ritual and ceremony are not as much a part of nurs-ing or society as they used to be. Catanzaro (2002)and Strange (2001), argue that ritual has been stig-matized because of the rise of technical rational-ism in health and society. Such an ideologyemphasizes science and reason and dismissesimportant emotional aspects of humanity, associ-ating them with the primitive, and therefore non-sensical. Furthermore, all things religious havetended to be separated from scientific ways ofknowing. A similar trend has occurred in nursing’sdevelopment, such that there is a tendency to dis-

associate with anything religious. So, ritual inhealth care tends to be dismissed and consideredonly in its narrowest and negative connotation– as irrationality and thoughtless repetition, per-petuating habit and traditions that preventadvancement (Ford and Walsh, 1994; Parker,1999; Silberger, 1998; Tonuma and Winbolt, 2000).

Yet, amongst people interested in exploring howhumanistic, holistic and cultural aspects might im-prove and enrich health care, the value of ritual isre-emerging (Biley and Wright, 1997; Holland,1999; Philpin, 2002; Shelly and Miller, 1999).Strange (2001), for example, has argued and illus-trated how some of the difficult or taboo aspectsof health care – caring for the dying or dead per-son, caring for the soiled, leaking or smelly body—is assisted by ritual. Emotional intensity is reduced,some distance is enabled and the taboo nature isnormalised. Since nurses are commonly involvedin these health/illness/life transition rituals, it isnot taboo to talk about similar experiences withnurses. Perhaps this is one reason why peoplemay feel more willing and ready to talk with nursesabout issues that may be otherwise unspeakable.

Ritual has been examined for its many connota-tions, including the negative, and these vary,depending on disciplinary interests. The culturalanthropologist Linton (1945) explained that cultureis learned and transmitted through ritual, and thatritual itself has four important aspects: form, uses,social function and meaning. Strange (2001) usesthe example of the English ritual greeting, ‘‘howare you?’’ to illustrate. The question is the formof the ritual – ‘‘How are you?’’. Its use is to starta conversation. Its social function is to establishconnection amongst people through small talkand its meaning is that it establishes commonground. Given this connecting power, it may beuseful to reconsider and examine those rituals in

Thank-you cards: Reclaiming a nursing student ritual and releasing its transformative potential 173

nursing that have managed to continue and endure,and even those that have begun to disappear, be-cause of the prevailing discourses that devalueand dismiss them. Nursing needs connection andcommunity. Perhaps ritual may help to enablethat.

Ritual also involves a symbolic act designed toachieve an ends – whether it is to celebrate ormark an achievement or turning point; to preservea memory; to bond with a cultural group or to rouseemotion, courage or other feeling. As anthropolo-gist Mary Douglas (1970) explained, early on in aculture’s history a ritual may be performed withelaborate and precise detail in order that the com-munity appreciate and share the significant mo-ment it seeks to mark. As the culture develops,the ritual may not seem so elaborate or complex,but its meaning endures because of the embeddedsymbolism. The practice of a Catholic person genu-flecting in church is an example. In early times, thepractice may have been a more elaborate act ofbowing of the head and knee at the same time asmaking the sign of the cross by touching four pointson their body to show humility, awe and respect toGod. Now it is a simple gesture, but still imbuedwith meaning for many. In a similar way, simplegestures between nurses and others can be a pow-erful transmitter of meaning, respect andconnection.

As the previous example showed, another keycharacteristic of ritual is that it involves repetition.Some scholars have rightly criticised mindless rep-etition in nursing as a practice that effectively pre-vents or obstructs nurses from thinking before,during or after action (Chapman, 1983; Ford andWalsh, 1994; Menzies, 1970). But on the otherhand, an action that is regularly repeated alsohas potential for generational transmission. A ritualaction can be passed on from nurse to nurse and ifit has a meaning that is enriching for the profes-sion, then the culture has potential to grow and de-velop. Without repetition, a useful practice thatcould be shared may simply fade away.

Another important characteristic of ritual is thatit has an exaggerative effect and thus can empha-size or call attention to the issue it is seeking tomark. Thus, similar to metaphor, ritual can havean educative and enlightening effect for people(McAllister, 2000). Importantly to the issue of nurs-ing culture and the potential for transformation,ritual involves action. Ritual is not just thought,or intention, but action. Ritual participants dosomething and their actions have an effect on theworld.

In considering all of these characteristics ofshared story-telling and ritual there were opportu-

nities to further enrich the learning experiences forstudents as well as to empower them to make a po-sitive effect on the nursing culture through the per-formance of a renewed and enriched thank-youritual.

The transformative function of letterwriting rituals

Letter writing is a ritual that has deep and longstanding social connective function and over thelast 20 years has increasingly been used in thera-peutic relationships in different ways. For exam-ple, therapists have written letters to clientspointing out their strengths and achievements(Bacigalupe, 2003; Epston, 1994) and clients havewritten letters to significant others (Goldberg,2000) and this has been shown to raise the client’sself-efficacy, commitment to change and to healsuffering (Moules, 2003). Proponents of the valueof letter writing have argued that when utilizedeffectively, it has a greater effect than verballycommunicated meanings. Letters create an inti-macy, they can carry emotional tone, they aremeaning-rich, and they can preserve the message(Steinbaum, 1996; Wagner, 1977; Hirshfield,1997).

Letters of appreciation are a commonly knownpractice available to families and work supervisors,but such humble practices are rarely the subject ofsocial analysis. An exception is the work of Kecske-meti and Epston (2001), which used the device withprimary school students who sent letters to theirteachers describing the specific ways that the tea-cher had been helpful. In their evaluation, theauthors commented that this strategy helped theteachers see their practices through the eyes oftheir students and subverted a very common ten-dency in education – for teaching to be uni-direc-tional. The ritual emphasized the reciprocal natureof communication that can occur in good teaching.It also powerfully validated purpose for the teach-ers – teachers were given evidence that they canand do make a real difference in young peoples’lives.

Thus, letter writing is a practice that has poten-tial to give voice, and therefore, power to the wri-ter. It gives benefits also to the receiver and itopens up communication pathways between peo-ple, building connection and understanding. Inthe following section, the practice of letter writ-ing, specifically thank-you cards, from students tonursing colleagues is incorporated into a learningactivity that aims to empower students and bechange oriented.

174 M. McAllister

Extending the thank-you ritual

A one hour teaching and learning activity was de-signed for undergraduate nursing students andtook place following completion of a clinicalpracticum. It aimed to give students voice, toprompt reflection on practice, to challenge stu-dents to think laterally about solutions and thento encourage empowered action. The activitywas divided into three sections: a trigger activitydesigned to generate discussion; new informationto build knowledge and skills; and an activatingexercise to encourage students to contribute tochange.

In the trigger activity, students were shown typ-ical images of what I anticipated their practicum tobe like. These included: patients in need or en-gaged in a treatment intervention; a hurried, busyenvironment; technical equipment; group conver-sation; and apparent tension. Then I invited stu-dents to identify an image to which they couldmost relate and to offer their full and open critiqueof the nurses and doctors that they worked withand their overall experience. I was surprised to findthat there was more tension, bullying and margin-alisation of students and of difference, than I ex-pected. Students all had the experience ofinteractions with RNs characterised by impatience,exclusion and hostility, but equally they also allcould relate stories wherein RNs were supportive,instructive, kind and understanding. Unfortu-nately, the painful stories were the most memora-ble and left the deepest impression. Afteropportunity for discussion, students saw therewas value in achieving understanding, though thiswas explained as only one step in the change path-way. Talking on its own can also amount to anessentially conservative act. Important subsequentsteps are to become informed and learn strategicinterpersonal skills that protect the self from dis-empowerment, but also show others how kindnessand assertiveness can replace bullying anddisrespect.

In the information stage of the activity, theconcept of conflict transformation was explained(Chinn, 1999). Students were asked to try to re-late the concepts about to be heard with howthey could have responded in the encountersthey had just described. They were also askedto think about what they would do in the futurewhen they were in a position of authority as aregistered nurse.

Peggy Chinn, a feminist nurse scholar experi-enced in collaborative action, explains that work-place tensions are to be expected because peoplehave different interests, problems or issues and

that these are likely to compete with others’ interms of priority and importance. But people donot have to respond in powerless or aggressiveways. Indeed, it is possible to act in powerfulways that are positive and effective. Importantnotions about conflict transformation are that:conflict is no one person’s responsibility; no oneperson is to blame; rather, it is everyone’sresponsibility.

Chinn emphasizes the value of constructive crit-icism as a strategy to move away from a blamingstyle of communication, but appreciating thatopinion, perception and feedback are importantconversations to have between colleagues. Con-structive criticism is also a kind of art that needsto be practised, ideally in a safe context and thisis why classrooms and distance from practice envi-ronments, can be so important for the advance-ment of nursing and healthcare.

Students were encouraged to think laterallyabout ways to be constructive with others. Noticingstrong points, remembering shared values, and pro-viding validation were all suggested. This becamean important opportunity to reinforce with stu-dents the positive actions they had already takento be respectful with their clinical colleagues. Allof the students had taken part in signing and givinga card of thanks to the nursing team. It was empha-sized to students that such a gesture was thought-ful and likely to have been much appreciated.Students were then asked if they wanted to try toenrich and extend that important ritual of givingthanks.

So, students were asked to acknowledge and talkabout all of the positive behaviours they couldidentify in the people that they had just critiqued.And finally, they were invited to put these storiesand skills of conflict transformation into action,by writing a story of validation and critique ontoa specially designed university thank-you card andposting them to the relevant health service (foran example, see Fig. 1).

Note that in this card, students found a way tovoice the things that they found upsetting andfrightening – being told to speak with unfamiliarclients without adequate preparation, or opportu-nity to observe relevant skills; being expected tobe an ‘insider’ and have knowledge about proce-dures that are taken for granted by the RNs butwhich were unfamiliar to students. Students alsoprovided much needed validation of effective,supportive colleagues and showed the way forothers by specifically naming the positive supportstrategies such as patience and optimism and byreminding nurses that students admire and re-spect them.

Dear xyz clinic,

On our recent clinical practice experience, it was really helpful when nurses gave us

strategies for communicating with clients, and allowed us to show that we can be helpful

(thanks Tony!). Remember, we are your biggest fans, and when you are patient and

optimistic towards us it makes all the difference. We are the outsiders and are incredibly

grateful when you include us.

Thank you!

Figure 1 The text inside a card.

Thank-you cards: Reclaiming a nursing student ritual and releasing its transformative potential 175

Evaluation and the future

Feedback from students about the activity was allpositive. Students felt their grievances were under-stood and they felt personally supported. But morethan that, they felt optimistic about being able tomanage and direct future clinical experiences.They had knowledge to understand the nature ofconflict, skills to be able to transform it, and astrategy that gave them a voice to convey construc-tive criticism and also to show good leadership.

In this exercise, no formal responses were madeby the agencies that received the cards, althoughone person with whom I later spoke said that shewas thrilled to receive the card. Indeed, after ithad sat posted on the staff notice board for someweeks, she carefully mounted it in an album boughtespecially to store and showcase future cards andletters like it.

The ritual of sending thank-you cards has beenrepeated in subsequent classes and has also beenextended by individual students. One student sta-ted that at the end of each clinical placement henow has his own ritual of personally thanking eachstaff member and each patient for the privilege ofbeing able to work with and for them. Each time henotices the joy and fulfillment this small act pro-duces. This embodies what Driver (1998, p. 92)has said is the transformative power of ritual:‘‘Like art, rituals are likely to bear more meaningsthan words can say’’. Draper explains that ritualcan grow as we grow and conversely, we grow asour rituals grow. Ritual not only transmits knowl-edge, but also assists in the discovery of newknowledge, creating new pathways for us to follow.

Thus, in the future, the intention is to take thepedagogical innovation one step further and, tact-fully, invite clinicians to write a response. In this

way, as Kecskemeti and Epston (2001) suggest,mutuality is being emphasized and there is poten-tial for a two way benefit, where each person expe-riences agency and self-appreciation. Much moreof this connectivity needs to occur. Evaluationand ongoing development of the innovation are ofcourse needed. Whilst the personal gains madefor students and clinicians involved in the interac-tion may be clear, such a practice, especially ifmore widely utilized, may have long term, and sus-tained benefits for the student–clinician relation-ship. This would also give an indication of longterm outcomes of the change activity.

Conclusion

Since conveying thanks is a universal practice, thelearning activity described in this paper may haverelevance for nursing teachers all over the world.As a ritual it has been extended and made morepowerful by incorporating the principles of narra-tive pedagogy and transformative learning. It wasunderpinned by the belief that nurses, like allhuman beings, thrive when acts of kindness arebestowed upon them, that the health serviceneeds an injection of practical humanism. Andfurthermore, nurses deserve opportunities tolearn ways to better communicate and supporteach other. This can be achieved respectfullyand effectively in the simple and intimate act ofcommunicating stories of change. Extending thethank-you card ritual was one way to help stu-dents use their voice, and show clinical staffhow to be effective supports for future students.This is transformative learning in action – noticingoppression, refusing silence, and attempting so-cial change. Future work exploring this and other

176 M. McAllister

acts of communicating transformatively within thehealth care culture may further contribute to theproject of bringing applied humanism into com-plex health care environments.

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