Delivering patient care

Self-awareness skills are vital for all therapeutic interaction and development of such skills should be built into all training programmes (English National Board 1987). This essay will attempt to identify a variety of theories based upon the concept of the ‘self’ and acknowledge the importance as well as the problems in becoming self-aware. The author has chosen this topic to gain insight into the importance of developing self-awareness, as Stein-Parbury (1993) comments the more nurses understand about themselves, the easier it becomes to understand patients.

Self-awareness is described by Burnard (1994) as the evolving and expanding sense of noticing a wide range of aspects of the self. In identifying the need for greater self-awareness the nurse is first and foremost asserting the needs as an independent and autonomous human-being. By having an understanding of our own identity we are creating the ability to detach ourselves from the many problems that a patient may express in a variety of manifestations.

This then allows the nurse to view problem solving through greater perspectives which encourages empathy instead of sympathy, Kalisch (1971) defines empathy as the ability to perceive the feelings of another person and to communicate this understanding to them, it may even stop the fusion of ego’s where patient and nursing care boundaries are destroyed resulting in the patient losing guidance or help that they require and where role reversal may even become evident. As Burnard (1990 p.28) writes;

“If there is no differentiation between our own thoughts and feelings and those of others, we blur ego boundaries, our sense of ourselves as an independent, autonomous being. We risk not recognising the other persons independence and autonomy. We lose sense of whose problem is whose.” By becoming self-aware we also become aware of our own choices, we can assess our own needs and wants in a separate entity to those of our clients, and through our own choices we make clearer decisions on behalf of our clients. Through self-awareness we can identify why we have come to the many conclusions we make within our nursing careers, and by using self-awareness skills, critical and accurate assessments made upon effective thinking may be identified rather than theories based upon prejudice or clouded thinking.

In developing self-awareness the nurse is able to monitor their own behaviour, and in studying the self through a holistic perspective rather than a mere bodily existence create the ability to act in accordance with their own beliefs and feelings, thus forming a sense of ‘true’ self . Laing (1959) describes the true self as the private inner self and states a person who has a strong sense of true self gains ontological security. Burnard (1990) comments that this allows the person to act rather than be acted upon.

Having identified the need for self-awareness, the question that remains unanswered is how understanding of the self is obtained. The psychoanalytic theory maintains that early childhood experiences have a profound and lasting effect upon our ‘self’, shaping our behaviour into adulthood. Pyschoanalytical theorists do however acknowledge that behaviour created by childhood experiences can be modified throughout our adolescence and adulthood, but point out that childhood experiences lay foundations that stay with us throughout our lives.

This theory enables the nurse to identify behavioural patterns within them, and how and when these beliefs and attitudes were formed. It is necessary to emphasise that through self-awareness we often discover emotional dimensions which may have been repressed for many years. By creating a greater understanding of ourselves we also begin to view people on a deeper level and identify the reasons for often irrational behaviour without immediately attaching labels.

The dynamic theory suggests that the self is forever changing and that our beliefs and ideas are in a constant state of re-assessment which develop as life continues, this theory enables the nurse to look at their view of the world encouraging growth and development, allowing changes within the self to occur naturally as our life experiences grow and alter. The dynamic theorists suggest that the self is not a static thing and changes in behaviour occur for many reasons, such as in various peoples company, by identifying this aspect of the self we can assess our reasons behind our change in behaviour in a variety of settings and the need for behaviour modification without feeling that we are not following the true self.

The Looking Glass theory suggested by C.H. Cooley (1902) analyses that we are merely what people perceive us to be and that the self is a reflection of the reactions of other people. By absorbing feedback from a whole variety of people with whom we come into contact with we can begin to understand what we are and incorporate this feedback into our ‘self’. It is important to identify that not all reflections of the self will be positive and there is also the danger that by incorporating other peoples standards, we can often lose our own values and beliefs, behaving in away that may not be acceptable to the self, causing conflict and resulting in the loss of the authentic and true self.

Morrison and Burnard (1991) suggest several aspects of the self, these being, the physical, spiritual, darker and social aspects. The physical aspect conveys the totality of our physical body and how our self is bound up in the beliefs and feelings that we have about our body image, the spiritual aspect is the searching for meaning which motivates our behaviour, it has been suggested that this searching may be discovered through many sources such as the study of philosophy, psychology, and politics.

The social aspect of the self is the part that we choose to share with the people with whom we associate, this aspect of the self also changes in regards to a variety of social situations, this is important for nurses to note as the behaviour of a client/patient may not be typical of the person but the result of social circumstances, such as a hospital setting which may cause conflict and confusion. The social aspect is also dependent on others telling us about ourselves in the same way as Cooley’s Looking Glass theory.

The darker aspect of the self is the negative side, although the darker aspect may initially sound like the most undesirable aspect of the self, by acknowledging our darker side we can learn to accept that other people also possess a negative aspect of their self, and as Jung (1938) argues that to truly become self-aware we must explore the darker side of our personality.

The use of communication is also bound within the self, Bandler and Grindler (1975) comment that by becoming conscious of how we use verbal and non-verbal communication, we can become more skilful in enhancing our contact with others. As a nurse it is important to acknowledge that our past experiences, attitudes and our values and beliefs will have a profound effect upon how we convey our thoughts into speech. As Pearson & Nelson (2000 p.64) State; “An early step in considering yourself as a communicator is to contemplate your self-awareness; your sense of self; your accommodation with the past, your plans for the future and all the prejudices, potentialities, and possibilities that are you.”

As nurses we must also monitor our body movements as these can reflect our inner thoughts. In identifying how attitudes, situations and personalities affect our reactions, the nurse can use this knowledge in their communication with patients and clients. Stein-Parbury (1993) notes nurses need insight into messages associated with various actions, as this allows the nurse to adjust behaviours for the best possible outcome.

Jung divided the inner self into four aspects, thinking, feeling, sensing and intuiting. This concept takes into account the mind and body as a whole. The thinking aspect of the self identifies the need to think clearly in a bid to develop critical awareness, this enables the nurse to appreciate that feelings can alter our thought process and that our way of thinking is altered by our feelings. This allows nurses to understand the motives behind their actions. Our feelings incorporate the emotional self, Heron (1977) identified four dominant parts of the emotional aspects of a person, anger, grief, fear, and embarrassment, that through social and cultural beliefs are generally repressed or at least discouraged. This can lead to an excess baggage of emotions which can distort the thinking process.

By becoming self-aware we begin to explore all repressed emotions, Stein-Parbury (1993) states that without awareness, emotions can be expressed unconsciously to patients and that nurses in tune with their emotions have a greater chance of maintaining control. This exploration may not be a pleasant experience but is vital to be honest with ourselves and others.

The sensing self incorporates, touch, hearing, sight, taste and smell into improving self-awareness. Touch is important within the context of nursing as generally close physical contact with clients is frequent. Stein-Parbury (1993) suggests that touch is an important means of non-verbal communication, concluding that a thoughtful touch may dispel fear. Through touch many emotions are conveyed, but the nurse must identify whether the client reacts positively or negatively and in doing so increase awareness of the client and aspects of themselves.

By using the sense of hearing the nurse is able to listen and therefore gain insight into what a client is trying to convey, listening not only to words but also speed, tone and timing (Tschdin 1995). Being aware of the sight sense enables the nurse to observe body posture, gestures and facial expressions (Burnard 1990). Taste can be used in creating a bond between patient and nurse as Tschudin (1995 p.96) writes; “You may not often be called upon to use the sense of taste, but you could be in a situation when patients offer you sweets, or a cup of tea……..This can be an important token of sharing”.

The use of smell enables the nurse to acknowledge how as human-beings we use smell to enhance or neglect image (Tschudin 1995), this can lead to an awareness of how a client feels about their own identity. By developing our five senses we become more aware of the world around us and the effects upon the self (Burnard 1990). By incorporating senses into our self and consciously using them we can only enhance practice (Tschudin 1995).

The intuitive self is independent of the five senses and describes our knowledge and insight. Jung (1938) describes intuition as an involuntary event, dependent upon different external or internal circumstances, instead of an act of judgement. By using intuition new perspectives are identified and new possibilities analysed. Intuition may be helpful when levels of communication aren’t present or breakdown, when used along side more traditional methods of thinking intuition within nursing is vital.

Methods of developing self-awareness include introspection, feedback from others and role play. Introspection refers to how we pay attention to our thoughts and feelings, however it is only effective in increasing self-awareness when these thoughts and feelings are used for discovering more about the self (Stein-Parbury 1993). People provide valuable information through the way they react and respond, therefore feedback is effective in developing self-awareness. Within nursing an example of this input from others is how freely and comfortably a patient discloses information, thus showing how they perceive the nurse. Nurses need to be receptive to this input as it informs them about themselves (Stein-Parbury 1993).

Becoming self-aware is not an easy process and can not be a forced task, Heron (1977b) uses the voluntary principle within self-awareness groups saying people must take part of their own free will. Many problems associated with self-awareness may develop, it is possible for those who have developed their concept of the self to believe that the insights and understanding that they have developed sets them apart from other people, creating the belief that they are better and far superior to others.

Egocentricity within self-awareness has also been identified. This refers to becoming so caught up in the understanding of the self, that it is taken out of context. This can lead to self indulgence and self-centred behaviour. Burnard (1990 p.30) suggests that a sign of egocentricity may be the lack of humour, whereas; “True self-awareness tends to lead to lightness of touch and a sense of humanity at the sheer vastness at the task in hand”.

It has been suggested that a person can never fully obtain total self-awareness, Quinn (1995) concludes that since the self is an entity that changes over time, we can never say that total self-awareness has been achieved. To conclude many aspects of the self have been looked at, and why awareness of these aspects is important for growth and development of skills. The methods of achieving greater self-awareness have also been highlighted. The problems associated with obtaining self-awareness have been discussed, showing that true awareness may not be found and that many pitfalls may occur along the way.

Through self-awareness we learn to assess our own values and not to impose them on our clients (Stein-Parbury 1993), and by having a deeper understanding of ourselves we develop a sharper, clearer picture of what is happening to others (Burnard 1990), boundaries and prejudices can then be removed, which can only lead to more positive and effective results occurring in patient and client care.

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