promoting self awareness in nurses to improve nursing practice.pdf

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Promoting self-awareness in nurses
to improve nursing practice
NS388 Jack K, Smith A (2007) Promoting self-awareness in nurses to improve nursing practice.
Nursing Standard. 21, 32, 47-52. Date of acceptance: March 8 2007
Surnniary
This article expiores the concept of self-awareness and describes
how it can be bénéficiai to nurses on a personai and professional
levei. Practicai toois such as the Johari Window are presented to
assist the reader in this process. The authors discuss portfolio
development, which provides the opportunity to document personai
and professional growth.
Authors
Kirsten Jaci< is senior lecturer in adult nursing, Manchester
iVletropoiitan University; Anne Smith is director of nursing studies,
University of Reading, Reading. Emaii: i

learning zone professional issues
At times, emotions may take over and we can
feel as though we are being swept away, Goleman
(1995) suggests the self-aware person is able to
manage his or her feelings and emotions and stay
in charge, rather than be overwhelmed by them,
Menzies ( 1970) describes the way that nurses
attempt to manage the stress and emotion that
often accompanies caring by detachment and
compartmentalising patient care, so that they
maintain control rather than becoming
emotionally unable to cope. That is not to say
that, as nurses, we should not feel any emotion at
all. However, knowledge of how certain
situations can make us feel affords us the
opportunity to plan ahead and prepare.
Therefore, rather than avoid dying patients, the
nurse should develop appropriate coping skills
when supporting the patient and his or her family.
Reflect on an occasion in practice when your feelings
! may have influenced your thoughts and behaviour. Did you~
I feel in control of the situation? Did your emotions affect your
i level of confidence in this situation or how you perceived
I others? Emotions can prompt action and inaction, intervention
and withdrawal. Write your thoughts down or discuss this
I occasion with a friend.
Discovery of the self is an ongoing, continuous
process which, at times, can be painful as hidden
aspects are slowly uncovered. When confronted
with difficult situations in the working
environment, we are expected to behave
professionally, although feelings of vulnerability
and uncertainty may challenge our perceived
abilities. Being more self-aware can help us to
cope in such circumstances, helping us to respect
our anxieties and concerns and prompting
questions about how these could be overcome.
Self-awareness can help us present ourselves
more appropriately in the therapeutic
relationship (Sundeen et al 1998). It involves
recognising what we know, what skills we employ
and what limitations affect our ability to
intervene. It can also enable us to present
ourselves as knowledgeable, expert in some
areas and as still learning but supportive in
others. It is necessary to question the effect we
have on others in the caring environment
(Hoffman 2001). Certainly, the self can be used
therapeutically to develop the patient's trust
and to promote a sense of wellbeing (McCabe
2000). By increasing our self-awareness, we
can be more effective in our personal and
professional lives.
Comnninication and caring
^^^
Communication skills are essential in the caring
relationship and are an important aspect of nurse
education (Nursing and Midwifery Council (NMC)
2005). The need for effective skills is emphasised
by the Department of Health (DH) (2006) in its
proposals for reform. The four main goals set out
focus on: preventing ill health, promoting more
patient choice, reducing inequalities and supporting
patients with long-term needs. The aims will not be
realised without effective communication skills,
which enable us to gather and give information,
explain intentions and actions and use ourselves
in a therapeutic manner. The ability to do this
may be enhanced by a greater level of selfawareness
(Rowe 1999).
Generally, communication begins with nonverbal
cues and the tone of the voice or inflection
used can be more influential than the words spoken.
If we are unaware of our body language by, for
example, presenting a closed posture, or not making
eye contact, this could have a negative impact or
change the message received by the patient. Ways of
overcoming this can be learned, and conscious
recognition of how our initial presentation will
affect the ongoing communication should be
considered. Conscious integration of theories,
such as that described by Egan (1998), could
influence the communication process in a more
therapeutic way. At first, integration of theory into
communication may seem false - almost like
acting; however, as with all skills, the more these
are practised the more accomplished we become,
Egan (1998) uses the acronym SOLER to
describe the body language that could be
consciously considered (Box 1).
Consider two or three conversations
that you have over the next week with
different people, for example, your partner,
a patient or a colleague. Consider your use of
body language with the different people you
meet. This exercise will help you to think about
the aspects of body language that are more or
less effective in different situations. For
example, do you fiddle with a pen or item of
jewellery when speaking? Do you use your
hands to get your message across? Could this
distract others?
Application of Egan's model can help us to look
attentive and take in what a patient is saying. This
can encourage patients to disclose issues that they
may normally find difficult to discuss. Patients
seek to trust nurses as professionals and are
sensitive to cues they receive through the tone
of voice and other paralinguistic behaviour.
48 april 18 :: vol 21 no 32 :: 2007 NURSING STANDARD

Egan's model
• Sit squarely
• Open posture
• Lean forward
* Eye contact
• Relaxed and unhurried appearance
(Egan 1998)
However, there may be times when we are
allowing our own thoughts and feelings to
interfere with our understanding of what the
patient is saying (Rungapadiachy 1999).
If we are going to gain a deep understanding of
what a patient is telling us then we need to listen
to what they are saying and observe how they are
saying it and what body language is being used.
Morrison and Burnard (1997) suggest that there
are three levels of listening. These range from the
superficial - when we are not fully listening and
may have other things on our mind - to the
deepest level - when we truly feel that we can fully
acknowledge the patient's position. They refer to
this as'resonance'.
Reflect on two to three conversations
that you have had with patients recently.^
; Were you aware of how attentively you were
listening to what was being said? Were you
listening on a superficial or deeper level? Do
I you think that your listening style may have |
put the patient off opening up more fully to
you? Were you engaging with the patient and
reflecting their emotions or concerns, that is, j
listening at a deeper level?
It can sometimes be easier to act as if you are
busy rather than engage with a patient in a
conversation. This is a natural way to behave and
is used as a form of defence against the potential
strain of nursing work (Menzies 1970). As nurses
it is not easy to predict what the patient wants to
discuss, and the conversation may stray into
territory with which we feel uncomfortable. It is
not surprising that we may find it difficult to deal
with patients' feelings and block communication
when they start to share their feelings with us
(Booth etal 1996). If we do not know our own
self, we are more likely to feel vulnerable when
patients express themselves (Jourard 1971).
Therefore, by developing skills of self-awareness,
we may be able to respond in a more appropriate
way, thus helping the patient and saving personal
feelings of embarrassment.
Heron's (1990) six category intervention
analysis is a useful framework for examining our
perceptions about how we communicate with
patients (Box2).
An examination of nurses' interpersonal skills
was undertaken by Burnard and Morrison
(2005). The authors found that nurses felt less
skilled in facilitative interventions and more
skilled in authoritative ones, although there were
some exceptions.
Drawing on your own experiences, which categories
do you feel more or less skilled in? What influences your
use of the different types of intervention? For example, you
may feel less skilled in the cathartic style of intervention. How
can you develop the skills needed, and what support do you
need when patients release fear or anger?
What has been described is the way in which
self-awareness can be beneficial when caring for
and communicating with patients. However, the
development of self-awareness is also important
for our own wellbeing (Freshwater 2002). Being
more self-aware helps us to take control of
situations and become less of a victim. Burnard
(1992) describes this as becoming less 'acted
upon'. Becoming more aware of our environment
and what may cause us anxiety enables us to plan
ahead and organise our lives to prevent situations
getting out of control.
For example, the thought of giving a
presentation to a group of people may invoke fear
and anxiety that can be so profound that the
presenter is unable to speak and becomes
disabled. Of course, by merely being aware of the
issues, the presenter will not suddenly become
more relaxed about presenting - this requires a
certain amount of forward planning. Plans could
include breathing exercises or thinking of a
trigger which will initiate a more calm and
resourceful state, a technique referred to as
Six category intervention analysis
Authoritative categories
Prescriptive interventions
Direct behaviour by offering advice.
Informative interventions
Offer and impart information.
Confronting interventions
Confront patients about a limiting
attitude or behaviour of which they
may be unaware.
(Heron 1990)
Facilitative categories
Cathartic interventions
Enable the patient to release
emotions, such as anger or grief.
Catalytic interventions
Attempt to draw out self-discovery
and promote problem-solving
in patients.
Supportive interventions
Encourage and affirm patients'
qualities and actions.
NURSING STANDARD april 18 :: vol 21 no 32 :; 2007 49

learning zone professional issues
anchoring (McLeod 2003 ). It may also involve
enlisting the help of others who can help to
evaluate the performance by giving critical,
constructive feedback.
about our hidden selves and the more we learn
about our blind area, the more our unknown area
will shrink. This process helps us to develop a
greater understanding of ourselves and others. It
involves an element of risk, since we have to
disclose something of ourselves and be prepared
to receive feedback from others.
Think about aspects of your life that may cause you
; anxiety. It may be, for example, that you have an interview^
or an important meeting coming up. Think about the strategies
or education that you need to support you. You may need to
enlist the help of someone else or consider a role model that you
have met. Think about and learn from the way that they would
; deal with this situation. By being self-aware we are more able to
become a role model to others.
Understanding ourselves well enough to know
what can make us anxious and less resourceful
helps us to take action to improve our situation.
Therefore, rather than becoming overcome by
situations, we can act to improve the outcome.
Developing self-awareness
Self-awareness should not be viewed as a state that
we can attain completely - it is a constant voyage of
discovery tbat is never complete (Burnard 1988).
Rungapadiachy (1999) states that the nature of
being self-aware means there is no 'saturation
point'. He proposes three layers of self-awareness.
First is superficial, for example, awareness of one's
age and gender. Second is selective, which includes
awareness of things that we feel we may need to be
aware of, such as our outward appearance and
attitudes. Third is deeper awareness - issues
known only to ourselves. This level reflects our
deepest secrets and thoughts.
One way of exploring these ideas is by thinking
about the Johari Window (Luft 1969) (Figure 1 ).
This is a model that can be used to explore aspects
of ourselves and consists of four quadrants:
• Open.
• Blind.
• Hidden.
• Unknown.
50 april 18 :: vol 21 no 32 :: 2007
The open area is the area that we know about
ourselves and is also known to others. The blind
area includes the things that others know but we
do not. The hidden area includes things we know
about ourselves but do not reveal to others. The
unknown area is unknown to both us and others.
As we learn more about ourselves the quadrants
will change in size. The more we reveal to others
\ Examine the Johari Window (Figure 1)
and then draw one for yourself. Make
notes in each of the sections.
• Open area: What is known to me and also
to others? This could include feelings,
attitudes and behaviours, likes and dislikes.
• Blind area: This may be more difficult but try
to imagine how others see you. This could
include your friends, colleagues at work or
a patient. They may think you have certain
mannerisms of which you are not conscious.
• Hidden area: What do you know about
yourself but would not disclose to others?
• Unknown area: This may be challenging
since this is the part that is unknown to you
and others. Delve beneath the surface and
consider what you are really like. This may
be a different self to the one you present
both to others and yourself. This is the area
that will change as you develop new skills [
and new knowledge. |
Reflect on what you have written. Did it i
surprise you in any way? Could you do this I
exercise with someone else to learn more [
about what others think of you?
Palmer eííj/(1994) warn that examination of
ourselves does involve risk as we are never sure
what we may find. They state that this can be
powerful in identifying characteristics of which we
may be unaware but which are painful. They also
examine the fact that most individuals base their
concept of themselves on other people's
perceptions, which may not be accurate. This
causes further disorientation. However, the
benefits should be a much enhanced sense of self
and a further sense of openness to new experiences.
Reflective practice
Becoming self-aware is an ongoing process that is
never complete. Therefore, self-evaluation needs
to be undertaken at regular intervals. This
evaluation process helps us to see how far we have
come, identify what we still need to learn and plan
how we are going to get there (Burnard 1988). One
way to self-evaluate may be through a reflective
diary which will be discussed later.
In nursing, reflection is a commonly used term
but is not necessarily an activity performed
NURSING STANDARD

effectively. Reflection may be associated with a
certain amount of stress; however, it does have the
potential to increase self-awareness (Newell
1992). Reflective practice helps us to examine our
thoughts and feelings - not only our reactions to
these but also the effect they may have on others
(Smith 1995).
To help nurses reflect, certain models can
provide a framework or an aide-mémoire, for
example, Gibbs' (1988) cycle. In this instance you
are asked to consider your feelings as part of the
cycle. Once the scenario has been described the
next part of the cycle asks you to consider your
feelings about it, considering what it was that
caused you to reflect on this and your personal
perception and response, whether good or bad.
This acknowledges that often reflection is
triggered by some uncomfortable feelings or,
conversely, by feeling that things went well.
Boudeffl/(1985) recognised the centrality of
our feelings to everything that we do and how we
reflect regularly on our behaviour whatever the
context. They refer to the cathartic elements of
reflection, just as Heron (1990) identified. They
recognise that it is vital for us to be in touch with
our emotions and feelings and to have an outlet
for negative and irrational thoughts. This
promotes a heightened level of self-awareness and
deeper self- knowledge. It is only when we have
explored our own feelings that we can help others
(Burnard 1992).
Heron (1990) also points out that it is vital to
be able to discharge or transform any barriers so
that it is possible to move forward. You may have
identified issues in your own life that affect your
performance and may inhibit your ability. Boud et
al (1985) discuss the way that new knowledge
may become so related to the self that it enters our
identity and changes our world view. They call
this appropriation. So when people say an
experience has changed their lives, they are
demonstrating that they were open to such a
possibility and recognised it was happening as
they were self-aware enough to perceive it.
Portfolios^
Portfolios have become an accepted way for
nurses to demonstrate their learning. A portfolio
is a useful document for supplying evidence of
achievements and of lifelong learning. It can be
individualised and compiled creatively to
illustrate skills and competencies across a wide
spectrum of experiences. This can capture the
essence of nursing in a variety of ways and
provide a shop window to display a range of
talents. For example, information technology
accomplishments may range from basic computer
skills to more advanced skills in the use of
information and communication technology.
Reflective accounts are normally included.
Actually compiling the portfolio can in itself
stimulate reflection and challenge practice (Hull
and Redfern 1996). When you are developing
your portfolio it will be a unique record of your
working and personal life.
Keeping reflective accounts in a diary enables
you to chart and record your progress or areas
needing further development. Boud eifl/( 1985)
proposed useful practical tips to aid diary writing.
These have been adapted for a more
contemporary audience:
• Be honest. Write it as it is, not as it should or
might have been.
• Have a positive approach rather than just
being critical.
• Be spontaneous. Do not spend too long on
deciding how to write it.
• Express yourself in any way that is meaningful
to you, such as with diagrams or shorthand. It
does not have to be written in a linear fashion.
• This is your personal workbook so you can
add, underline, circle or doodle as you wish to
aid your recall.
FIGURE 1
Johari Window
Known to others
Not known
to others
(Luft 1969)
WÊÊÊÊÊÊÊÊÊÊÊÊ^gÊÊ^^^^^^M
Known to self
Open area
Example: This is what I
know about myself and
what others know about
me, for example, I am
female and easy going.
Hidden area
Example: This is what I
know about myself but
hide from others. I may
hide more or iess from
different people. My
family may know more of
this hidden area than my
work colleagues. The
more I disclose from this
area, the bigger my open
area will become and the
more I may learn about
myself in the process. For
example, I may cry at
sad films but do not
want my work colleagues
to know.
Not known to self
Blind area
Example: My friends may
have a view of me of which
I am unaware. I can uncover
these views if others tell
me about them. This will
increase my 'open' area. For
example, my friends may
think that I talk too much
and I may be completely
unaware of this fact.
Unknown area
Example: The unknown
area is not known to
ourselves or others.
As we receive feedback
from others and tell others
more about ourselves, we
can develop into this
unknown area and it will
shrink in size.
NURSING STANDARD april 18 :: vol 21 no 32 :: 2007 51

learning zone professional issues
• Use the language that suits you.
• Be experimental in how you keep this record.
You may divide the page into sections or come
back and add something later.
• Set time aside for this important activity and
persevere.
• Consider keeping it as an e-journal, or
personal blog. You could invite your friends to
participate and offer feedback.
Your diary can become a highly personal
document and one which you may only want to
share with close friends and colleagues. However,
by engaging in this process in a trusting
environment, you can discuss your entries with
others and receive feedback. It may be useful to
enlist the help of a trusted supervisor or mentor in
this process who may also consider sharing their
diary with the group, resulting in a more
reciprocal approach (Burnard 1988). By
challenging and discussing incidents and
dilemmas from practice, we can develop different
ways of thinking about and understanding our
reactions, which leads to further development of
our self-awareness. We can then apply this new
knowledge to future situations (Smith 1995).
Conclusion
The more knowledge we have about ourselves, the
easier it becomes to relate to others. This article
has encouraged you to explore the benefits of
becoming more self-aware. It is hoped that by
reading and working through the activities, either
alone or with a supportive colleague, you will
discover how becoming more self-aware can assist
in your personal and professional life NS
Now that you have completed the
article you might like to write a practice
profile. Guidelines to help you are on page 56.
USEFUL RESOURCE
The Consortium for Research on Emotional Intelligence
in Organizations: The Emotional Competence Framework
v^/ww.businessballs.com/emotionalintelligence
competencies.pdf (Last accessed: April 5 2007)
This document provides useful information on some of
the key components of seif-avi/areness.
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52 april 18 :: vol 21 no 32 :: 2007 NURSING STANDARD

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