Before he or she can begin to understand clients, the nurse must first know himself or herself. Self-awareness is the process of developing an understanding of one’s own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths, and limitations and how these qualities affect others. It allows the nurse to observe, pay attention to, and understand the subtle responses and reactions of clients when interacting with them.
Values are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living. Sample values include hard work, honesty, sincerity, cleanliness, and orderliness. To gain insight into oneself and personal values, the values clarification process is helpful.
The values clarification process has three steps: choosing, prizing, and acting. Choosing is when the person considers a range of possibilities and freely chooses the value that feels right. Prizing is when the person considers the value, cherishes it, and publicly attaches it to himself or herself. Acting is when the person puts the value into action. For example, a clean and orderly student has been assigned to live with another student who leaves clothes and food all over their room. At first, the orderly student is unsure why she hesitates to return to the room and feels tense around her roommate. As she examines the situation, she realizes that they view the use of personal space differently (choosing). Next, she discusses her conflict and choices with her adviser and friends (prizing). Finally, she decides to negotiate with her roommate for a compromise (acting).
Beliefs are ideas that one holds to be true, for example, “All old people are hard of hearing,” “If the sun is shining, it will be a good day,” or “Peas should be planted on St. Patrick’s Day.” Some beliefs have objective evidence to substantiate them. For example, people who believe in evolution have accepted the evidence that supports this explanation for the origins of life. Other beliefs are irrational and may persist, despite these beliefs having no supportive evidence or the existence of contradictory empirical evidence. For example, many people harbor irrational beliefs about cultures different from their own that they developed simply from others’ comments or fear of the unknown, not from any evidence to support such beliefs.
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Values clarification process
Attitudes are general feelings or a frame of reference around which a person organizes knowledge about the world. Attitudes, such as hopeful, optimistic, pessimistic, positive, and negative, color how we look at the world and people. A positive mental attitude occurs when a person chooses to put a positive spin on an experience, a comment, or a judgment. For example, in a crowded grocery line, the person at the front pays with change, slowly counting it out. The person waiting in line who has a positive attitude would be thankful for the extra minutes and would begin to use them to do deep-breathing exercises and to relax. A negative attitude also colors how one views the world and other people. For example, a person who has had an unpleasant experience with a rude waiter may develop a negative attitude toward all waiters. Such a negative attitude might cause the person to behave impolitely and unpleasantly with every waiter he or she encounters.
BOX 5.2 CULTURAL AWARENESS QUESTIONS
ACKNOWLEDGING YOUR CULTURAL HERITAGE
To what ethnic group, socioeconomic class, religion, age group, and community do you belong?
What experiences have you had with people from ethnic groups, socioeconomic classes, religions, age groups, or communities different from your own?
What were those experiences like? How did you feel about them?
When you were growing up, what did your parents and significant others say about people who were different from your family?
What about your ethnic group, socioeconomic class, religion, age, or community do you find embarrassing or wish you could change?
Why?
What sociocultural factors in your background might contribute to being rejected by members of other cultures?
What personal qualities do you have that will help you establish interpersonal relationships with people from other cultural groups? What personal qualities may be detrimental?
The nurse should reevaluate and readjust beliefs and attitudes periodically as he or she gains experience and wisdom. Ongoing self-awareness allows the nurse to accept values, attitudes, and beliefs of others that may differ from his or her own. Box 5.2 lists questions designed to increase the nurse’s cultural awareness. A
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person who does not assess personal attitudes and beliefs may hold a prejudice or bias toward a group of people because of preconceived ideas or stereotypical images of that group. It is not uncommon for a person to be ethnocentric about his or her own culture (believing one’s own culture to be superior to others), particularly when the person has no experience with any culture than his or her own. (See Chapter 7 for further discussion of cultural competence.) Box 5.3 provides an example of a value clarification exercise that can assist nurses to become aware of their own beliefs and thoughts about other cultures.
Therapeutic Use of Self
By developing self-awareness and beginning to understand his or her attitudes, the nurse can begin to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients. This is called therapeutic use of self. Nurses use themselves as a therapeutic tool to establish therapeutic relationships with clients and to help clients grow, change, and heal. Peplau (1952), who described this therapeutic use of self in the nurse–client relationship, believed that nurses must clearly understand themselves to promote their clients’ growth and to avoid limiting clients’
choices to those that nurses value.
BOX 5.3 VALUES CLARIFICATION EXERCISE
VALUES CLARIFICATION
Your values are your ideas about what is most important to you in your life—what you want to live by and live for. They are the silent forces behind many of your actions and decisions. The goal of “values clarification” is for their influence to become fully conscious, for you to explore and honestly acknowledge what you truly value at this time. You can be more self-directed and effective when you know which values you really choose to keep and live by as an adult and which ones will get priority over others. Identify your values first, and then rank your top three or five values.
Being with people Being loved Being married Having a special partner Having companionship Loving someone Taking care of others Having someone’s help Having a close family Having good friends Being liked Being popular
Getting someone’s approval Being appreciated Being treated fairly Being admired Being independent Being courageous Having things in control Having self-control Being emotionally stable Having self-acceptance
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Having pride or dignity Being well organized Being competent Learning and knowing a lot Achieving highly Being productively busy Having enjoyable work Having an important position Making money
Striving for perfection
Making a contribution to the world Fighting injustice
Living ethically
Being a good parent (or child) Being a spiritual person Having a relationship with God Having peace and quiet Making a home Preserving your roots Having financial security Holding on to what you have Being safe physically Being free from pain Not getting taken advantage of Having it easy
Being comfortable Avoiding boredom Having fun
Enjoying sensual pleasures Looking good
Being physically fit Being healthy
Having prized possessions Being a creative person Having deep feelings Growing as a person Living fully
“Smelling the flowers”
Having a purpose
Joyce, S. (2000). In M. E. Bernard & J. L. Wolfe (Eds.). The RET resource book for practitioners. New York, NY: Albert Ellis Institute.
The nurse’s personal actions arise from conscious and unconscious responses that are formed by life experiences and educational, spiritual, and cultural values. Nurses (and all people) tend to use many automatic responses or behaviors just because they are familiar. They need to examine such accepted ways of responding or behaving and evaluate how they help or hinder the therapeutic relationship.
One tool that is useful in learning more about oneself is the Johari window (Luft, 1970), which creates a
“word portrait” of a person in four areas and indicates how well that person knows himself or herself and communicates with others. The four areas evaluated are as follows:
Quadrant 1: Open/public—self-qualities one knows about oneself and others also know.
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Quadrant 2: Blind/unaware—self-qualities known only to others.
Quadrant 3: Hidden/private—self-qualities known only to oneself.
Quadrant 4: Unknown—an empty quadrant to symbolize qualities as yet undiscovered by oneself or others.
In creating a Johari window, the first step is for the nurse to appraise his or her own qualities by creating a list of them: values, attitudes, feelings, strengths, behaviors, accomplishments, needs, desires, and thoughts.
The second step is to find out others’ perceptions by interviewing them and asking them to identify qualities, both positive and negative, they see in the nurse. To learn from this exercise, the opinions given must be honest; there must be no sanctions taken against those who list negative qualities. The third step is to compare lists and assign qualities to the appropriate quadrant.
If quadrant 1 is the longest list, this indicates that the nurse is open to others; a smaller quadrant 1 means that the nurse shares little about himself or herself with others. If quadrants 1 and 3 are both small, the person demonstrates little insight. Any change in one quadrant is reflected by changes in other quadrants. The goal is to work toward moving qualities from quadrants 2, 3, and 4 into quadrant 1 (qualities known to self and others). Doing so indicates that the nurse is gaining self-knowledge and awareness. See the accompanying figure for an example of a Johari window.
Patterns of Knowing
Nurse theorist Hildegard Peplau (1952) identified preconceptions, or ways one person expects another to behave or speak, as a roadblock to the formation of an authentic relationship. Preconceptions often prevent people from getting to know one another. Preconceptions and different or conflicting personal beliefs and values may prevent the nurse from developing a therapeutic relationship with a client. Here is an example of preconceptions that interfere with a therapeutic relationship: Mr. Lopez, a client, has the preconceived stereotypical idea that all male nurses are homosexual and refuses to have Samuel, a male nurse, take care of him. Samuel has a preconceived stereotypical notion that all Hispanic men use switchblades, so he is relieved that Mr. Lopez has refused to work with him. Both men are missing the opportunity to do some important work together because of incorrect preconceptions.
Carper (1978) identified four patterns of knowing in nursing: empirical knowing (derived from the science of nursing), personal knowing (derived from life experiences), ethical knowing (derived from moral knowledge of nursing), and aesthetic knowing (derived from the art of nursing). These patterns provide the nurse with a clear method of observing and understanding every client interaction. Understanding where knowledge comes from and how it affects behavior helps the nurse become more self-aware (Table 5.1). Munhall (1993) added another pattern that she called unknowing: For the nurse to admit she or he does not know the client or the client’s subjective world opens the way for a truly authentic encounter. The nurse in a state of unknowing is open to seeing and hearing the client’s views without imposing any of his or her values or viewpoints. In psychiatric nursing, negative preconceptions on the nurse’s part can adversely affect the therapeutic relationship; thus, it is especially important for the nurse to work on developing this openness and acceptance toward the client.
Johari window
Table 5.1 Carper’s Patterns of Nursing Knowledge
Pattern Example
Empirical knowing (obtained from the science of nursing) Client with panic disorder begins to have an attack. Panic attack will raise pulse rate.
Personal knowing (obtained from life experience) Client’s face shows the panic.
Ethical knowing (obtained from the moral knowledge of nursing) Although the nurse’s shift has ended, he or she remains with the client.
Aesthetic knowing (obtained from the art of nursing) Although the client shows outward signals now, the nurse has sensed previously the client’s jumpiness and subtle differences in the client’s demeanor and behavior.
Adapted from Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Sciences, 1(1), 13–23.