Therapeutic Nursing

Improving Patient Care through Self-Awareness and Reflection

Dawn Freshwater

• Publisher: SAGE Publications Ltd
• Year: 2002
• ISBN:
  9781446228401
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

?I found the book to be fascinating and so thought provoking that it made me consider more carefully the text and prose to really understand what the author said. It is skilfully written, very readable and has implications for a wide range of people such as the undergraduate, practitioner, lecturer and researcher? - Accident and Emergency Nursing

Gaining self-awareness is a vital aspect of professional development for all who work in the caring professions. In nursing especially, the ability to evaluate oneself affects all areas of practice, including direct patient care, working relationships with colleagues and maintaining one?s own well-being in the often pressured environment of health care.

This is an innovative text which explores the ways in which self-awareness can be used as a practical tool for continuing professional development and practice improvement. Divided into three parts, the book examines the role of the nurse as therapeutic practitioner, reflective learner and reflexive researcher.

For all those wishing to develop their skills as autonomous, reflective, accountable practitioners, this book will be an inspiring read. It will be of immense use to those who teach and supervise nurses at all levels.

1 The Therapeutic Use of Self in Nursing

Dawn Freshwater

The nature and/or the existence of the ‘self’ is a topic that is well rehearsed in the literature surrounding healthcare. Indeed the notion of what constitutes the self is a subject that has interested poets, artists and philosophers alike. Writers have described theories of self in philosophical terms (Satre, 1956), theories of self in psychological terms (Laing, 1961; Freud, 1963; Lacan, 1966), in spiritual and transpersonal terms (Rowan, 2001; Wilber, 1981), in biological terms (Ginsburg, 1984), modernist terms (Giddens, 1990) and more recently postmodernist terms. Postmodern versions of the self challenge both the permanence and indeed the presence of a self at all, that is in the sense usually proposed (Fee, 2000; Flax, 1990; Gergen, 1991; 1997). Whilst definitions of the self derived from these varying theoretical perspectives are diverse, there is also some convergence. This chapter explores some of these definitions, reflecting upon the meaning of the self in the therapeutic alliance both for the nurse and the patient. Introducing the concepts of the self, self-awareness, self-efficacy, self-esteem and the therapeutic use of self, this introductory chapter aims to signpost the basic ideas under consideration within subsequent chapters.

Recent debates divide the theories of the self into two types, those of ego and bundle theories (Gallagher & Shear, 1999). Ego theories (in some way the most natural way to think about the self) believe in a persistent self. A self that is the subject of experiences and whose existence ‘explains the sense of unity and continuity of experience’ (Blackmore, 2001: 525). This equates with the dominant modernist viewpoint which will be outlined in more detail shortly. Bundle theories deny any such thing. As Blackmore points out, ‘The apparent unity is just a collection of ever changing experiences tied together by such relationships as a physical body and a memory’ (2001: 525). This perspective can be likened to the postmodernist perspective of the self which it would seem is becoming ever more inescapable.

The self

Consideration of the nature of the self is deeply bound up with questions about consciousness, about which the scope of this book does not allow an in-depth exploration. Hence whilst the fathomless abyss of consciousness and unconsciousness, reality and subjectivity are fundamental to any exploration regarding the nature of the self, the subsequent discussion will be limited to points of contextual relevance. In addition, there may be a number of contradictory standpoints presented simultaneously within this chapter; I do not apologise for this, rather I encourage the reader to tease out these inherent contradictions in the understanding that the self is in fact a contradictory being, if indeed a self does exist. The reader is encouraged to pursue further writings as indicated in order to expand the ongoing conversation pertaining to the nature of the self.

It has been argued that the concept of a self possessed by a person is a product of both personal reflection and social interaction. Priest’s defines the self as ‘an individual that is conscious of the individual that it is while at the same time being conscious that it is the individual it is conscious of’ (1991:163). The experiencing self as described by Bohart (1993) and Maddi (1989) is essentially anti-reductionist in nature. Life is apprehended through experiencing, which involves an interplay of thought and feeling, without either of these concepts being conceived of as polar opposites (Bohart, 1993). Humanistic psychologists, however, describe the self as conceived of separate entities. Rogers (1991), for example, speaks of the organismic self and the self-concept. The organismic self is that aspect of the self which is essentially the ‘real’ inner life of the person and is present from birth. The organismic self consists of the basic force that regulates the individual’s physiological and psychological growth; growth and maturity are seen as the central aims of this aspect of the self (Hough, 1994; Rogers, 1991). Therefore the focus of the organismic self is essentially internal. This view of the self purported by humanistic psychology has recently been challenged by social constructivism, deconstruction and postmodernism. All of these theories say in their own way that there is no ‘real’ self as defined in the sense usually proposed by humanistic and modernist theories.

As some authors have observed, the dominant modernist view specifies that the self is a ‘finite, rational, self-motivated and predictable entity which displayed consistency with itself and across contexts and time’ (Gottschalk, 2000: 21). Hence from a modernist perspective the self can be either healthy or pathological; it could also be observed, diagnosed and indeed improved. Postmodern theory, however, challenges this assumption, positing that the self is a conversational resource, that is to say, it is a story we tell to others and ourselves. Androutsopoulou, for example, states that from the narrative and social constructivist viewpoint the self:

… equals to a continuous construction of a self-narrative, aiming to secure a sense of historical continuity, directionality and coherence among what often appear to be loosely connected ‘selves’ that may seem to act differently depending on the circumstances. (2001: 282)

Thus the ‘solid and stable modern self loses its’ footing and becomes fluid, liminal and protean selfhood’ (Gottschalk, 2000: 21, original italics). Postmodern theories then move beyond the concept of a stable and static self, rendering it obsolete, to the notion of the self as a continuous process, constituted through multiple and often contradictory relationships. Thus the self as postmodern selfhood is iterative, interactive and interdependent. This has obvious implications in the context of a book which focuses on the therapeutic use of the self in work which is largely relationship based; namely that of nursing.

The self as a concept and self-concept

The very conception of a self is conceived of as a by-product of the relationship between power and knowledge; it is inseparable from language games, from mass media and ideologies, and as Gergen (2000) comments, loses its sense of substance in the ongoing construction and dissolution encountered within everyday relationships. He says of the self ‘increasingly we find no “there” there’ (2000: 100). Hence self-identity becomes a reflexively organised endeavour constructed through intrapersonal and interpersonal dialogue (Freshwater & Robertson, 2002). Nevertheless, there are a multitude of theories and an ever-increasing amount of literature being written concerning the self and its various aspects. One such aspect is that of the self-concept.

According to Burns the self-concept is ‘forged out of the influences exerted on the individual from outside, particularly from people who are significant others’ (1982: 9). This definition is in accord with the humanistic school of psychology, which views the self-concept as the individual’s perception of himself, based on life experience and the way he sees himself reflected in the attitudes of others (Rogers, 1991).

According to this theory, the self-concept is acquired very early on in life and is continually reinforced by ongoing communications with significant others throughout life. As the self develops it needs to feel loved and accepted and as a result the organismic self (or the ‘real’ self) is neglected in favour of the self-concept. This is a point that Maslow (1970) illustrates in his hierarchy of needs (See Figure 1.1).

These ideas are not dissimilar to the theories of self developed by Carl Jung (1960). The self-concept can be likened to Jung’s idea of the persona, with the psyche sitting closely to the organismic self. For Jung, the self was buried in the unconscious and full of creative potential. Jung believed that the aim of the psyche was towards individuation, that is the growth of an individual towards becoming aware of all aspects of their personality, leading to a better balance between their internal and external worlds and a subsequent integration of opposites. Through the process of socialisation, the self is repressed and thwarted; a persona (or mask) is developed as the individual becomes absorbed in enacting roles. Thus the individual becomes alienated from who they are and who they might become. Self-alienation, in this sense, meaning that in which the ‘subject is no longer the author of the ongoing narrative of his self’ (Dawson, 1998: 164), implying a loss of control over the self.

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Need for

Self-actualization

(Am I myself?)

Recognition needs

(Am I successful/repected?)

Belonging needs

(Am I loved, do I belong?

Safety Needs

(Am I safe/comfortable?)

Physiological needs

(Will I survive?)

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Figure 1.1 Maslow’s hierarchy of human needs (1970)

The focus of the self-concept is predominantly external. Rogers (1991) believed that the tendency of the organismic self was towards harmony and integration of discomfort arising as a result of inconsistency in ideas and feelings between the organismic self (the inner) and the self-concept (the outer). Burns (1982) contends that the self-concept has three roles, one of which is that of maintaining consistency, the other two being determining how experiences are interpreted and providing a set of expectancies. Where consistency is not maintained, a degree of dissonance is experienced (Festinger, 1957) and the discomfort that this causes is likely to motivate the individual to take action towards harmony and comfort, at any cost. It is often the awareness of discomfort with self that motivates the individual to engage in reflection. Such reflection, when undertaken in relation to nursing practice, often leads to the practitioner examining the contradictions between their espoused theories (desired practice) and their theories in action (actual practice) (Arygris and Schon, 1974).

Self-concept in nursing

The self is an important concept in nursing as in any therapeutic alliance, for often when patients are physically ill or psychologically distressed ‘the most striking and consistent feature reported is a changed self-concept’ (Dawson, 1998: 164). The goal of any therapeutic alliance (and incidentally emancipatory and transformatory learning, a topic that is considered in more detail in Part II of this book) is to facilitate the emergence of the authentic self (Friere 1972; Hall, 1986). In his recent work refining the humanistic approach to human inquiry, John Rowan (2001) writes of the authentic self (which he also refers to as the true self, the real self and the Centaur). The authentic self, he determines, lies beyond self-images, self-concepts and sub-personalities; requires that the individuals take responsibility for being themselves and for being ‘fully human’ (2001: 115). In this sense Rowan aligns the authentic self with the mystical self and draws heavily on the existentialist traditions and the work of Ken Wilber (1996; 1997). So, for Rowan and others the real or authentic self, when fully autonomous, can assume responsibility for being-in-the-world (Heidegger, 1972).

There is a Hasidic tale that illustrates Rowan’s point beautifully:

Before his death, Rabbi Zusya said ‘In the coming world, they will not ask me “Why were you not Moses?” They will ask me “Why were you not Zusya?”’

Rogers also captures the centrality of this point when reflecting on the work of Kierkegaard, whom he says:

… pictured the dilemma of the individual more than a century ago, with keen psychological insight. He points out that the most common despair is to be in despair at not choosing, or willing, to be one’s self; but that the deepest form of despair is to choose to ‘be another than himself’. On the other hand ‘to will to be that self which one truly is, is indeed the opposite of despair’, and this choice is the deepest responsibility of man. (1961: 110)

From this vantage point the role of the nurse in caring can be seen to be to transcend the self-concept, the persona (or what Winnicott (1971) might term the false self) in order to give voice to the organismic self, authentic self and to encourage, through a therapeutic alliance, the emergence of the authentic self of the patient (Rogers, 1991). This process necessitates a great deal of self-awareness and self-consciousness, a subject that will be touched on briefly in the following section. However, this is probably a good point at which to introduce some scepticism in relation to the idea of a self-concept and an organismic real self. As I mentioned at an earlier juncture, postmodern theories question the whole idea of a real self; from this particular stance there is no such thing as ‘being authentic (true to oneself) or autonomous (taking charge of one’s life) or self actualisation (being all that one has it in oneself to be), (Rowan, 2001: 120). Rowan, however, works hard to reinstate the real self in his latest work on action research and the reader is pointed to this for an interesting and in-depth analysis (and indeed defence) of the idea of a real self (Rowan, 2001). Discussions on the real self, self-concept and authentic self cannot take place in isolation from Freud’s (1963) theories of the ego. In an earlier paper I attempted to highlight the impossibility of the human ego to perceive unity or wholeness, saying that ‘Immediately I call myself “I”, I cut myself off from everything that is “not I”’(Freshwater, 1999a: 136). Consciousness, splitting and dissecting experiences into pairs of opposites as it does, forces us to encounter the dualistic (and indeed pluralistic) nature of the self. It is to the idea of consciousness and the self that I now turn my attention, linking this to the theory of reflection and the notion of intentional action.

Self-consciousness and awareness of the ‘I’

The practice of reflection is a central skill in developing an awareness of the self. The ‘I’ being self-conscious disappears in repetitive doing and is only found again when reflected upon (Spinelli, 1989). The process of repetition of routine tasks and focus on ‘doing’ (something that tends to dominate nursing, see Menzies, 1970) leads to a loss of ‘I’ or the self. Reflection on self is proposed as helping the practitioner to ref...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• List of Figures and Tables
• List of Contributors
• Preface
• 1 The Therapeutic Use of Self in Nursing
• Part I: The Practitioner’s Perspective
• Part II: The Educationalist’s Perspective
• Part III: The Researcher’s Perspective
• Index