Self-reflection: Foundation for meaningful nursing practice

By Norman C. Olsen | 02/03/2014

Florence Nightingale lived a life of reflection.


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How to gain wisdom and connect with truth and your inner self are important topics for nurses to explore. Ralph Waldo Emerson wrote, “None of us will ever accomplish anything excellent or commanding except when he listens to this whisper which is heard by him alone.” Self-reflection looks inward and listens to the whispers. Lautebach and Becher (1996) relate self-reflection to caring for the self. Purposeful reflection is a tool that helps nurses gain self-knowledge and insight (Palmer, 2007).

When nurses reflect, they purposefully “bend back” their attention in a focused attempt to discover personal meanings gained from professional nursing encounters and interaction with others. Lautebach and Becher suggest that self-reflection is a critical activity for nurses in their caring for others and, because it connects those who practice it with their inner selves and truth, is transformational. The Chinese philosopher Confucius (551-479 B.C.) wrote, “By three methods we may learn wisdom: first, by reflection, which is noble; second, by imitation, which is easiest; and third by experience, which is the most bitter.”
 
A spiritual act
Educator Parker J. Palmer (2007) defines self-reflection as a spiritual quest, evidenced by the way it connects our inner selves with the outer world and the humanness of others. This parallels Florence Nightingale’s view that caring about and providing nursing care to others are spiritual acts (Ortiz, 2010, p. 314). Palmer also associates the feeling of connectivity and the perception of humanity and oneness that come with reflection as essential parts of spirituality. This connection enables honest outward relationships that become spiritual acts (p. 5).
 
According to Denner (2009), reflection’s meditative aspect causes a change in brain wave activity, specifically increased alpha and theta wave activity. Moreover, radiographic imagery demonstrates that reflective meditation increases activity in the right hemisphere of the brain, which is associated with insight and “the sudden awareness of correct answers to verbal problems” (Denner, 2009, p. 326), the moment when the light bulb goes on and we say “aha.” The same process is associated with creativity.
 
To embrace reality and avoid burnout
More specifically, self-reflection involves the brain’s cortical midline structures (CMS). Research shows that damage to the CMS causes difficulty in evaluating problems and a tendency to overestimate one’s personal abilities (Van der Meer, Costafreda, Aleman, & David, 2010). In other words, the CMS helps provide a reality check.
 
Olsen_Norman_horses_SFWTo prevent burnout, nurses need to stay connected with their passion for nursing. Research suggests that nurses who find their career rewarding and are passionate about their work provide better care (Kearney, 2010). Self-reflection helps nurses maintain and rediscover passion, the antithesis of burnout, by facilitating insight and reconnecting them with their histories. In addition to avoiding burnout and improving the care nurses deliver, self-reflection helps nurses recapture the energy that accompanies passion, resulting in personal growth and feelings of fulfillment (Wright, 2010).
 
To transform learning
The process of critical self-reflection can foster transformational learning in adults, which Mezirow (1990) attributes to reflection’s higher-order mental process. This leads to: 1) rational examination of assumptions, 2) action based on the question What am I doing wrong?, 3) focus on presuppositions that relate to a problem, and 4) communication with self. Mezirow further suggests that individuals come to value reflection and its importance when they realize that not all learning involves learning to do.
 
Kanuka (2002) also writes that reflection is an essential component of understanding complex problems, issues, and concepts. Meanings, patterns, and purpose become clear. Allowing self-reflection to guide our nursing practice can improve outcomes, because a strong sense of self enables us to deal with problems better (Elder, Evans, & Nizette, 2009, p. 6). Self-reflection is a path toward wisdom. Understanding our inner panoramas can help us better understand our outer panoramas and make better, wiser decisions.
 
To function holistically
This search for patterns and meaning should extend to the roles and processes we engage with as nurses. To function as holistic healers, nurses must look for patterns and meanings within our clients. For example, nurses who practice holistically believe pain and disease are important signals of inner conflicts—that our bodies are dynamic, multidimensional systems and that disease or disability is a process best understood within the context of meaning and personal values (Dossey, Keegan, & Guzzetta, 2003, pp. 8-9). This works in one’s relationship with self as well as in relationships with others.
 
Reflection, which is thinking and being present with your thoughts, allows us to discover meanings and attach meaning to experiences that can foster identity, empathy, and self-worth. Christopher Johns (2009) writes that reflection allows the practitioner to see contradictions between values and practice. In other words, self-reflection can facilitate change in behavior. However, it “requires commitment, perseverance, discipline, and support” (p. 5), Johns observes.
 
To promote healthy relationships, with self and others
Nurses have unique relationships with their clients or patients. Wright (2010, p. 277) suggests that nurses nurse not just the body but also the soul of those for whom they provide care. Providing this “soulful” type of nursing requires nurses who are in touch with their inner selves. Developing this soulful aspect of nursing requires us to understand the uniqueness of others and ourselves. Understanding one’s beliefs and the uniqueness of others helps us avoid imposing our biases and values onto others, writes Ortiz (2010). This suggests that the reflective nurse, besides being more soulful and heartfelt in his or her practice, is more objective in perceiving clients and their needs.
 
Nurses who are self-reflective benefit their clients by practicing the art and heart of nursing. Such a nurse, while having more capacity for empathy, does not identify with others at the expense of his or her own inner identity and knowledge of truth.
 
Wright (2010) believes that nurses need to seek beyond the obvious or ordinary (p. 281) to pursue that part of transcendence that is spiritual. One measure of spiritual intelligence is the desire one has to truly find meaning and purpose, what some call the soul or the true self. To be present with someone who is suffering and still be able to attend to them and help them find meanings and purpose require spirituality. Clients feel connected to these nurses (Appleton, 1994). These nurses are also more imaginative and perceptively intuitive. Dossey, Keegan, and Guzzetta (pp. 52-53) identify six aspects that contribute to intuitive nursing judgment:  
  • Pattern recognition
  • Similarity recognition
  • Common sense and understanding
  • Skilled know-how
  • A sense of salience
  • Deliberate rationality
To keep our hearts and souls open
Self-reflection helps open our hearts and our souls and helps keep them open. Without the heart and soul being open, nursing care loses its humanity, says Wright (2010). Nurses work in environments that do not always value the heart and soul. To keep the heart in nursing care requires empathy. To keep the soul in nursing care requires that the nurse be connected to purpose and meaning.
 
Nurses learn and grow from mistakes. Without self-reflection and self-assessment, says Wright (2010), there is a tendency to blame others. Nurses can be reluctant to acknowledge the true self and sometimes “cling to that powerful archetype of the self-sacrificing angelic woman/nurse, rooted around in mythology that grew around Nightingale, yet one that she herself found repellent” (Wright, 2010, p. 278).
 
To promote healing
A small study by Thorpe and Barsky (2001) found that self-reflection can highlight an individual’s need for change, a necessary start for healing to begin. When we discover meaning through reflection, we become healthier beings. Meaning, emotion, and health go hand in hand. There is an intimate relationship between these aspects of our being, and recognizing that relationship requires us to pay attention to the inner self. Our personal journeys and life stories are relevant to our perceptions. They affect how we live, how we care for ourselves, and how we nurse. By attaching meaning to them, we allow them to be reference points for future experiences and contribute to our wisdom (Dossey et al., 2003, pp. 3-4).
 
Langley and Brown (2010) write that the practice of reflective journaling contributes to important learning outcomes for online graduate nursing students. While acknowledging lack of adequate research and studies about reflective journaling, they identify four learning outcomes that are evident in nursing and education literature. The learning objectives identified were: 1) professional development, 2) personal growth, 3) empowerment, and 4) facilitation of the learning process. The sense of empowerment the students felt resulted from being able to clarify beliefs and feelings. They were better able to create personal meanings, gain insights, and connect their inner realities with external realities. Reflective journaling strengthened their self-confidence, thereby helping the students become change agents in their work environments (Langley & Brown, pp. 13-15).
 
To promote satisfaction and empowerment
Self-reflection is a necessary foundation for meaningful nursing practice that allows for feelings of satisfaction and empowerment. As such, it is a critical nursing skill with the potential for enormous benefit. And while we call it “self” reflection, those nurses who have had a lifetime of experience in practicing this discipline and looking inward are the very nurses who, by sharing the insights they have gained, can help less experienced nurses improve practice, avoid burnout, and find solutions to problems they face.
 
In a world where people want answers that don’t require journeys of reflection or lengthy processes, it is even more important that we learn to deliberately take time to reflect and thus gain wisdom. When we learn to appreciate for ourselves the benefits that self-reflection offers, we increasingly value those nursing elders and thinkers who have demonstrated, by example, its importance. These nurses, with wisdom gained from insight into a life of nursing practice, understand the meanings and patterns of nursing care and offer us a path for holism, connectivity, and oneness within our nursing practice.
 
Florence Nightingale, even after she stopped actively engaging in bedside nursing care, continued to share the wisdom that she gained from reflective and thoughtful nursing practice. Though physically infirm, she wrote and vigorously advocated for changes in health care delivery and nursing education. Indeed, Nightingale lived a life of reflection, evidenced by writings that include deeply reflective letters (Dossey, 2010). The image of Nightingale walking through wards of injured and sick soldiers with her lantern shining was—and is—a powerful symbol of hope. The lighted lantern is also a symbol of her wisdom and healing presence. An examination of Nightingale’s life reveals a powerful and consuming commitment to following an inward reflective path and spiritual journey (Dossey, 2010, p. 186). The founder of modern nursing is an example of the power of self-reflection. RNL
 
Norman C. Olsen, MSN, CAGS, RN, CNE, a nurse educator certified by the National League for Nursing, has taught a variety of nursing subjects, including pharmacology and pathophysiology.
 
References:
Appleton, C. (1994). The gift of self: A paradigm for originating nursing as art. In P.L. Chinn & J. Watson (Eds.), Art and aesthetics in nursing, (pp.91-116). New York, NY: National League for Nursing.
 
Denner, S.S. (2009, December). The science of energy therapies and contemplative practice. A conceptual review and application of zero balancing. Holistic Nursing Practice, 23(6), 315-334.
 
Dossey, B.M. (2010). Florence Nightingale: Mystic, visionary, healer. Springhouse, PA: Springhouse.
 
Dossey, B.M., Keegan, L., & Guzzetta, C. E. (2003). Holistic nursing: A handbook for practice. Boston, MA: Jones & Bartlett.
 
Elder, R., Evans, K., & Nizette, D. (2009). Psychiatric and mental health nursing (2nd ed.). Australia: Mosby Elsevier.
 
Johns, C. (2009, Spring). Reflective practice: Looking in the mirror. AHNA Beginnings, 29(2), 4-7.
 
Kanuka, H. (2002). Guiding principles for facilitating higher levels of web-based distance teaching and learning in a post-secondary setting. Distance Education, 23(2), 163-181.
 
Kearney, G. (2010, December). We must not forget what we once knew: An exemplar for helping nurses reconnect with their history and rediscover their passion for nursing. Journal of Holistic Nursing, 88(4), 260-262.
 
Langley, M.E., & Brown, S.T. (2010, January/February). Perceptions of the use of reflective journals in online graduate nursing education. Nursing Education Perspectives, 31(1), 12-17.
 
Lautebach, S.S., & Becher, P.H. (1996, January). Caring for self: Becoming a self-reflective nurse. Holistic Nursing Practice, 10(2), 57-68. PMID: 8550691
 
Mezirow, J. (1990). Fostering critical thinking in adulthood: A guide to transformative and emancipator learning. San Francisco, CA: Jossey-Bass.
 
Ortiz, M.R. (2010, December). Commentary on “Nightingale in absentia: Nursing and the 1893 Columbian exposition.” Journal of Holistic Nursing, 28(4), 313-316. doi: 10.11771089010109360255
 
Palmer, P.J. (2007). The courage to teach: Exploring the inner landscape of a teacher’s life. San Francisco, CA: Jossey-Bass.
 
Thorpe, K., & Barsky, J. (2001, September). Healing through self-reflection. Journal of Advanced Nursing, 35(5), 760-768. doi: 10.1046/j.1365-2648.2001.01908.x
 
Van der Meer, L., Costafreda, S., Aleman, A., & David, A.S. (2010, May). Self-reflection and the brain: A theoretical review and meta-analysis of neuroimaging studies with implications for schizophrenia. Neuroscience and Biobehavioral Reviews, 34(6), 936-946. PMID: 20015455
           
Wright, S. (2010, December). Commentary on “Light still shines in the darkness: Decent care for all.” Journal of Holistic Nursing, 28(4), 275-283. doi: 10.1177/0898610383107
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