Awareness of Self

Effective helpers must be able to answer the question, Who am I? Nurses who care for the biological, psychological, and sociocultural needs of patients see a broad range of human experiences. They must learn to deal with anxiety, anger, sadness, and joy in helping patients throughout the health-illness continuum. Self-awareness is a key part of the psychiatric nursing experience, and the nurse’s goal is to achieve authentic, open, and personal communication (LaTorre, 2005; Vandemark, 2006; Scheick, 2011). The nurse must be able to examine personal feelings, actions, and reactions. A good understanding and acceptance of self allow the nurse to acknowledge a patient’s differences and uniqueness.

A holistic nursing model of self-awareness consists of four interconnected components: psychological, physical, environmental, and philosophical (Campbell, 1980):

Together these components provide a model that can be used to promote the self-awareness and self-growth of nurses and the patients for whom they care.

Increasing Self-Awareness

No one ever completely knows the inner self, as shown in the Johari window (Figure 2-2).

• Quadrant 1 is the open quadrant; it includes the behaviors, feelings, and thoughts known to the individual and others.

• Quadrant 2 is the blind quadrant; it includes all the things that others know but the individual does not know.

• Quadrant 3 is the hidden quadrant; it includes the things about the self that only the individual knows.

• Quadrant 4 is the unknown quadrant, containing aspects of the self that are unknown to the individual and to others.

Taken together, these quadrants represent the total self. The following three principles help explain how the self functions:

1. A change in any one quadrant affects all other quadrants.

2. The smaller quadrant 1, the poorer the communication.

3. Interpersonal learning means that a change has taken place, so quadrant 1 is larger and one or more of the other quadrants is smaller.

The goal of increasing self-awareness is to enlarge the area of quadrant 1 while reducing the size of the other three quadrants. To increase self-knowledge, it is necessary to listen to the self. This means the individual allows genuine emotions to be experienced; identifies and accepts personal needs; and moves the body in free, joyful, and spontaneous ways. It includes exploring personal thoughts, feelings, memories, and actions.

The next step in the process is to reduce the size of quadrant 2 by listening to and learning from others. Knowledge of self is not possible alone. As we relate to others, we broaden our perceptions of self, but such learning requires active listening and openness to the feedback others provide. The final step involves reducing the size of quadrant 3 by self-disclosing, or revealing to others important aspects of the self. Self-disclosure is both a sign of personality health and a means of achieving healthy personality.

Compare panels A and B of Figure 2-3. Panel A represents a person with little self-awareness whose behaviors and feelings are limited. Panel B, however, shows an individual with great openness to the world. Much of this person’s potential is being developed and realized. Panel B represents an individual who has an increased capacity for experiences of all kinds: joy, hate, work, and love. This person also has few defenses and can interact more spontaneously and honestly with others. It is a worthy goal for the nurse to pursue.

Critical Reasoning

Draw your own Johari window. What changes would you like to make to any of the quadrants?

Clarification of Values

Nurses should be able to answer the question, What is important to me? Awareness of one’s own values helps the nurse to be honest, to better accept differences in others, and to avoid the unethical use of patients to meet personal needs. Nurses should avoid the temptation to use patients for their personal satisfaction or security. If nurses do not have personal fulfilment, they need to realize that fact. Their sources of dissatisfaction should be clarified to prevent them from interfering with the success of the nurse-patient relationship.

Value Clarification Process

The value clarification process allows individuals to discover their values by assessing, exploring, and determining what those values are and how they influence their own thoughts, attitudes, and behaviors. Value clarification does not determine what the individual’s values should be or what values should be followed. Value clarification focuses only on the process of valuing, or on how people come to have the values they hold.

Seven criteria are used to determine a value. These criteria should be considered in relation to a person’s strongest value and tested against the person’s own definition of a value. The seven criteria are grouped into the three steps listed in Table 2-1. The three criteria of choosing rely on the person’s cognitive abilities; the two criteria of prizing emphasize the emotional or affective level; and the two criteria of acting have a behavioral focus. A change takes place when certain contradictions are perceived in the person’s value system. To eliminate the distress that follows such a realization, the person realigns values to coincide with the new view of self.

TABLE 2-1

STEPS IN THE VALUE CLARIFICATION PROCESS

CHOOSING	Freely
	From alternatives
	After thoughtful consideration of the consequences of each alternative
PRIZING	Cherishing, being happy with the choice
	Willing to affirm the choice publicly
ACTING	Doing something with the choice
	Repeatedly, in some pattern of life

Exploration of Feelings

Some people think that helping others requires complete objectivity and detachment. This is definitely not true. Complete objectivity and detachment describe someone who is unresponsive, unapproachable, impersonal, and self-alienated—qualities that block the establishment of a therapeutic relationship. Rather, nurses should be open to, aware of, and in control of their feelings so that they can be used to help patients. The feelings that nurses have serve an important purpose as barometers for feedback about themselves and their relationships with others.

In helping others, nurses have many feelings: satisfaction at seeing a patient improve, disappointment when a patient regresses, distress when a patient refuses help, and anger when a patient is demanding or manipulative. Nurses who are open to their feelings understand how they are responding to patients and how they appear to patients. The nurse’s feelings are valuable clues to the patient’s problems. For example, despite the patient’s statement that “things are going real well,” the nurse might perceive a strong sense of despair or anger. So too, nurses should be aware of the feelings they convey to the patient. Is the nurse’s mood one of hopelessness or frustration? If nurses view feelings as feedback mechanisms, their effectiveness as helpers will improve.

Serving as Role Model

Formal helpers have a strong influence on those they help, and nurses function as role models for their patients. Research has shown the power of role models in molding socially adaptive, as well as maladaptive, behavior. Thus a nurse has an obligation to model adaptive and growth-producing behavior. If a nurse has a chaotic personal life, it will show in the nurse’s work with patients, thereby decreasing the effectiveness of care. The nurse’s credibility as a helper also will be questioned. The nurse may think that it is possible to separate one’s personal life from one’s professional life, but in caring for patients this is not possible because psychiatric nursing is the therapeutic use of self. This does not mean that the nurse must be a model citizen or must live a fully contented life. What it does mean is that the effective nurse has a fulfilling and satisfying personal life that is not dominated by conflict, distress, or denial, and that the nurse’s approach to life conveys a sense of growing, hopefulness, and adapting.

Altruism

It is important for nurses to have an answer to the question, Why do I want to help others? An effective helper is interested in people and tends to help out of a love for humanity. It also is true that everyone seeks a certain amount of personal satisfaction and fulfillment from work. The goal is to maintain a balance between these two needs. Helping motives can become destructive tools in the hands of naive or zealous users.

Another danger lies in adopting an extreme view of altruism. Altruism is concern for the welfare of others. It does not mean that an altruistic person should not expect adequate compensation and recognition or must practice denial or self-sacrifice. Only if personal needs have been appropriately met can the nurse expect to be maximally therapeutic. Finally, a sense of altruism also can apply to changing social conditions to meet human welfare needs. One goal of all helping professionals should be to create a people-serving and growth-facilitating society. Thus a necessary role for the nurse is to work to change the larger structure and process of society in ways that will promote the individual’s health and well-being.

Ethics and Responsibility

Personal beliefs about people and society can serve as guidelines for action. The Code for Nurses with Interpretive Statements (American Nurses Association, 2001) reflects common values regarding nurse-patient relationships and responsibilities and serves as a frame of reference for all nurses in their judgments about patient welfare and social responsibility. Responsible ethical choice involves accountability, risk, commitment, and justice. Related to the nurse’s sense of ethics is the need to assume responsibility for one’s own behavior. This means knowing one’s limitations and strengths and being accountable for them. Ethical issues related to psychiatric nursing are discussed in Chapter 8.

The preinteraction phase begins before the nurse’s first contact with the patient. The nurse’s initial task is one of self-exploration. This is no small task because psychiatric nursing clinical experience can bring both stress and challenge to the student (Happell and Gough, 2009). In the first experience of working with psychiatric patients, the nurse brings the misconceptions and prejudices of the general public, in addition to feelings and fears common to all novices (Halter, 2008; Webster, 2009) (Box 2-2). A major one is anxiety or nervousness, which is common to new experiences of any kind. Another feeling is ambivalence or uncertainty because nurses may see the need for working with these patients but feel uncertain about their ability to do so.

The informal nature of psychiatric settings may threaten the nurse’s role identity. A common first reaction among students is a feeling of panic when they realize that they “can’t tell the patients from the staff.” It is unsettling for some students to give up their uniforms, stethoscopes, and scissors, which emphasizes that, in this nursing setting, the most important tools are the ability to communicate, empathize, and solve problems. Without a physical illness to manage, new students may feel self-conscious and hesitant about introducing themselves to a patient and starting a conversation.

Some nurses express feelings of inadequacy and fears of hurting or exploiting the patient. They worry about saying the wrong thing, which might drive the patient “over the brink.” With their limited knowledge and experience, they doubt that they will be of any value. They wonder how they can help or whether they can really make a difference. Some nurses perceive the plight of psychiatric patients as hopeful; others perceive it as hopeless. A common fear of nurses is related to the stereotype of psychiatric patients being violent. Because this is the picture portrayed by the media, many nurses are afraid of being physically hurt by a patient. Other nurses fear being psychologically hurt by a patient through rejection or silence. A final fear is related to nurses’ questioning their own mental health. Nurses may worry about how working with psychiatric patients might affect their own psychological struggles.

The following clinical example contains many of the feelings and fears expressed by one nursing student in the preinteraction phase of self-analysis, as reported in the notes from her journal of her psychiatric rotation.

Introductory, or Orientation, Phase

It is during the introductory phase that the nurse and patient first meet. One of the nurse’s primary concerns is to find out why the patient sought help (Table 2-2). The reason for seeking help forms the basis of the nursing assessment, helps the nurse focus on the patient’s problem, and determines the patient’s motivation for treatment. It is important for the nurse to realize that help-seeking varies among different cultures, social, and ethnic groups. Another task is for the patient and nurse to establish their partnership and agree on the nature of the problem and the patient’s treatment goals. The focus is on the patient’s goals and not what the nurse believes should be done. Both the nurse and the patient may experience some degree of discomfort and nervousness in the introductory phase. Reasons that patients may have difficulty receiving help are listed in Box 2-3.

Working Phase

Most of the therapeutic work is carried out during the working phase. The nurse and the patient explore stressors and promote the development of insight in the patient by linking perceptions, thoughts, feelings, and actions. These insights should be translated into action and a change in behavior. They can then be integrated into the individual’s life experiences. The nurse helps the patient master anxieties, increase independence and self-responsibility, and develop constructive coping mechanisms. Actual behavioral change is the focus of this phase.

Termination Phase

Termination is one of the most difficult but most important phases of the therapeutic nurse-patient relationship. It is a time to exchange feelings and memories and to evaluate mutually the patient’s progress and goal attainment. Levels of trust and intimacy are heightened, reflecting the quality of the relationship and the sense of loss experienced by both nurse and patient. Box 2-5 lists criteria that can be used to determine whether the patient is ready to terminate.

Together the nurse and the patient review the progress made in treatment and the attainment of specified goals. It is appropriate to make referrals at this time for continued care or treatment. Successful termination requires that the patient work through feelings related to separation from emotionally significant people. The nurse can help by allowing the patient to experience and feel the effects of the anticipated loss, to express the feelings generated by the impending separation, and to relate those feelings to former symbolic or real losses. Helping the patient work and grow through the termination process is an essential goal of each relationship.

Learning to bear the sorrow of the loss while integrating positive aspects of the relationship into one’s life is the goal of termination for both the nurse and the patient. The patient’s response will be affected by the nurse’s ability to remain open, sensitive, empathic, and responsive to the patient’s changing needs. The impending termination can be as difficult for the nurse as for the patient. Nurses who can begin this process by reviewing their thoughts, feelings, and experiences will be more aware of personal motivation and more responsive to patients’ needs. The major tasks of the nurse during each phase of the nurse-patient relationship are summarized in Table 2-3.

Verbal Communication

Verbal communication occurs through words, spoken or written. Taken alone, verbal communication can convey factual information accurately and efficiently. It is a less effective means of communicating feelings or subtle meanings. It represents only a small part of total human communication. Another limitation of verbal communication is that words can change meaning with different social or cultural groups because words have both denotative and connotative meanings. The denotative meaning of a word is its actual or concrete meaning. For example, the denotative meaning of the word bread is “a food made of a flour or grain dough that is kneaded, shaped, allowed to rise, and baked.”

The connotative meaning of a word, in contrast, is its implied or suggested meaning. Thus the word bread can suggest many different connotative or personalized meanings. Depending on a person’s experiences, preferences, and present frame of reference, the person may think of French bread, rye bread, or pita bread. When used as slang, “give me some bread” may mean “give me some money.” Thus the characteristics of the speaker and the context in which the phrase is used influence the specific meaning of verbal language.

When communicating verbally, many people assume that they are “on the same wavelength” as the listener; but because words are only symbols, they seldom mean precisely the same thing to two people. And if the word represents an abstract idea such as “depressed” or “hurt,” the chance of misunderstanding or misinterpretation may be great. In addition, many feeling states or personal thoughts cannot be put into words easily. Nurses should try to overcome these problems by checking their interpretation and incorporating information from the nonverbal level as well.

Today more than ever before, nurses need to be prepared to communicate effectively with people from a variety of socioeconomic and ethnocultural backgrounds. For example, psychiatric patients may be evaluated in their second language, such as English, but competence in a second language varies depending on the individual and the stage of illness. In addition, cultural nuances in language often are not conveyed in translation, even when the patient uses similar words in the second language. Patients also may use a second language as a form of resistance to avoid intense feelings or conflicting thoughts, and events that may have occurred before a person learned English, if that is the second language, may not be easily communicated. The effective psychiatric nurse uses verbal communication sensitively to promote mutual respect based on understanding and acceptance of cultural differences. The nurse also may communicate respect for the patient’s dialect by adapting to the patient’s linguistic style by using fewer words, more gestures, or more expressive facial behaviors or by obtaining a trained interpreter.

Nonverbal Communication

Nonverbal communication includes all relayed information that does not involve the spoken or written word, including cues from all five senses. It has been estimated that about 7% of meaning is transmitted by words, 38% is transmitted by paralinguistic cues such as vocal tones, and 55% is transmitted by body cues. Nonverbal communication is often unconsciously motivated and may more accurately indicate a person’s meaning than the words being spoken. People tend to say what they think the receiver wants to hear, whereas less acceptable or more honest messages may be communicated by the nonverbal route.

The Communication Process

The three elements of the communication process are perception, evaluation, and transmission. Perception occurs when the sensory end organs of the receiver are activated. The impulse is then transmitted to the brain. Human beings mostly rely on visual and auditory stimuli for communications.

When the sensory impulse reaches the brain, evaluation takes place. Personal experience allows for the evaluation of the new experience. If the person encounters a new experience for which there is no frame of reference, confusion results. Evaluation results in two responses: a cognitive response related to the informational part of the message and an affective response related to the relationship aspect of the message. Most messages stimulate both types of responses.

When the evaluation of the message is complete, transmission takes place that the sender receives as feedback. This feedback influences the continued course of the communication cycle. It is impossible not to transmit some kind of feedback. Even lack of any visible response is feedback to the sender that the message did not get through, was considered unimportant, or was an undesirable interruption. Feedback stimulates perception, evaluation, and transmission by the original sender. The cycle continues until the participants agree to end it or one participant physically leaves the setting.

Structural Model

Theoretical models of the communication process show visual relationships more clearly and can help in finding and correcting communication breakdowns or problems. The structural model of communication has five components: the sender, the message, the receiver, the feedback, and the context (Figure 2-4):

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