In Section 2, I discuss how each of the six participants described their unique experiences using self-reflection in the clinical setting and how participants creatively used abstract ideas to describe their experiences. For Lucy and Nicole, the experience of using self-reflective practice is like being at the epicenter of an experience. Lucy described the act of self-reflecting in the clinical setting like being at the center of a stack of mirrors:
I’m standing in the middle of two of them and I’m able to look through one mirror and it reflects back through the other mirrors. I’m looking, and that is reflecting off experiences that I’ve had. And then . . . I’m actually in the center and in charge of my surroundings. (personal communication, November 24, 2018)
128
It’s really re-centering myself. I was on Google Maps and I think I opened it too far and it asked me, do you want to re-center. For some reason, that just clicked to me. To me, that is what this is. When I self-reflect, I’m making a very conscious effort to not just be a negative event at work. It could’ve been something that happened that was positive. Why can I also not be enriched or re-centered by that? I’m trying to find those opportunities where, okay, yes absolutely, I expect it with an unexpected event, with a negative event. But I also want to stop and take a moment when things are going really well, and just self-reflect on that. (personal communication, November 30, 2018)
Nicole described her experience as a struggle between using self-reflection after experiencing negative events or after positive ones. For Beth, the ability to use self-reflection was always present on the unit. Though not as apparent as other medical tasks, self-reflection can occur at any moment, especially, during moments of solitude. Beth stated:
It’s automatic because when I walk away from someone, my mind starts going. It’s like an emotional barometer, like how did that go? When I’m not talking with someone else, I’m walking down the hallway. I go walk to the supply room and I go draw up a
medication. I have a moment by myself where I’m not interacting with someone. I’m thinking to myself . . . . It’s when I walk out of a patient’s room and I get a feeling when I’m with people. The energy in the room, is it positive, negative, tense, happy, joyful, sad, angry? There are all those emotional responses when I walk out of that room. I’m always asking myself, well, how do I feel? Then if it’s something that’s not so good, then what do I need to do here to make it better for myself, for the person, for my colleagues? (personal communication, December 4, 2018)
129
Amanda shared a similar experience as Beth and described her experience in the clinical setting using visual perception. To Amanda, an experience on the unit can be viewed as colorless until she reflects and adds her own mixture of details:
If there aren’t a lot of tasks that need to be done and there’s more time, then I would take a little bit more time to self-reflect. At that point, I’m self-reflecting not only about the current scenario, but I’m incorporating all of these past experiences and how that might feed into how I handle this current scenario . . . self-reflection is where I take the black and white framework and I put my color on it, and I say, to me, this looked this way. To me, this part looked this way. It’s the personal component of it that makes it self-
reflection. (personal communication, October 19, 2018)
Although participants were able to reveal the unique characteristics of their experiences using self-reflective practices, the nature of the clinical environment posed a challenge to experienced nurses when they desired to use a nurse-centric (i.e., nurse only) reflective practice.
Challenges to Using Clinical-Based Reflective Practice
Melissa said nurses have time only to acknowledge their feelings but cannot often process their feelings adequately or in-depth. She shared:
Some shifts you don’t have time to reflect. You’re chasing the whole day; you’re running all day long, you don’t have the time to reflect. Those rare occasions that it’s a slow day, the only thing I could think about is that it brings back other experiences you’ve done and you talk about it. But, self-reflection during the day doesn’t happen much for me. It doesn’t, really—There’s always something to do. So to turn my brain off, to relax and self-reflect, yeah, I don’t think I could do that. (personal communication, August 6, 2018)
130
Melissa described self-reflection as a process that requires the mind to shut off and relax, but without the time to relax, self-reflection cannot be fully accomplished. Emily went a step further and specifically described the challenges nurses face when trying to self-reflect in clinical settings. Emily described how nurses value using self-reflection during their shifts but rarely found adequate time to fully process emotions:
As it is right now when we double-check chemo, two nurses have to check chemo. We’re not supposed to be interrupted because that’s a really crucial thing. We have to make sure all the calculations are correct. It’s hard to even get through a chemo check without the phone ringing or an interruption of any kind like a nurse asking questions and coming in. Or you need to re-evaluate because they need to get medication. It’s hard to find time. (personal communication, September 27, 2018)
According to participants in this study, nurses need adequate time to effectively use self-
reflective practices. Without adequate time for self-reflection, Emily described feeling there was always something else she could be doing for patients. Although self-reflection did occur in the clinical setting, Emily described needing more time during her shift:
We’re supposed to get 15 minutes before lunch, sometimes 15 after. We never ever, ever, take those two 15-minute breaks. We just don’t do it. The whole time I’ve been there, I’ve never done that. I’ve been guilty of that. Some units are able to do that. They’ve come to help us out. Then they’ll call and say, I want to take my 15-minute break. And I’m looking at them and feeling like, we don’t take 15-minute breaks. I’ve been guilty, and I know it, because I started thinking about it one day . . . there’s times I just have to take a deep breath to help calm down, relax, not be so stressed out and then keep on going. I take a deep breath because it’s easy getting caught up and you really don’t
131
breathe. You’re just so locked into a stressful situation. I have to remember to go and relax. Relax just take a deep breath, relieve some of that stress and let it out. (personal communication, November 15, 2018)
Emily described how she perceives the value of taking “a deep breath” and being able to “calm down and relax” while working on the unit. Emily believed that nurses need adequate time on the unit to rest and use self-reflection. Beth acknowledged the challenges to using self-reflection in the clinical setting and described a process of ongoing reflection as a possible solution:
I’m always reflecting on how it went all the time. When a lot is going on, like a lot of people need me, or maybe a patient is crashing and they’re a full code still. I have to move fast and think fast and hustle, call the doctor. I don’t have a lot of time to really go deep into myself, like for the emotional part of it. Or I’m being more objective and trying to get my task done to keep that patient alive. (personal communication, December 4, 2018)
In some cases, not having time for self-reflection may translate into not wanting to delve into the emotional aspects related to the process. For example, Nicole believed that some nurses might not want to share their feelings in the clinical setting. Nicole stated, “I also know nurses that don’t want to have to do that when they’re there . . . because they feel they’re going to fall apart and won’t be able to recompose and continue” (personal communication, October 1, 2018). Nicole described other challenges nurses experience, such as emotionally and mentally falling apart:
Emotionally and mentally—It’s hard to do it during the shift because what if I break down and I can’t recompose . . . . It’s not always easy. As a nurse, you don’t want to feel like, oops, I messed up. Something happened and that affected my patient. Sometimes
132
self-reflection is scary because of that . . . . The disadvantages are that sometimes I might find something that I don’t like. I don’t want to be the person to have messed up, made a mistake, made an error; I don’t want to have to be the one like, oops, I was responsible, I dropped the ball, and I did this. (personal communication, October 1, 2018)
Beth also described the difficulties of using self-reflection in the clinical setting:
I have to shut down and take a step back. There’s a moment and all of sudden something takes over. I don’t know how to describe that but I get this clarity . . . . It’s when there’s the weight of the world on my shoulders. I can feel it at the end of the shift. I’m like, oh I feel drained. Then I have to find a way to vent, and then fill my energy level back up so I can come back and do it again the next day, or a week later whenever I have to come back . . . . I have to process all those emotions. I mean I can tell when I feel this heaviness in my heart, or on my shoulders. I’m like, okay, what’s going on? Then I have to let myself feel sad or cry. I have to let it go and then move on. It’s a new day the next day . . . . Sometimes I’m at a loss for words. Inside, I’m reflecting like, what can I say in this situation? It’s really sad right now . . . . Maybe the challenge or disadvantage is I’m always wondering what my families need or are going through. It does take a lot out of me. (personal communication, November 29, 2018)
Both Nicole and Beth agreed that using self-reflective practices could sometimes make nurses realize feelings that could be more harmful than beneficial during the shifts. Using a nurse- centric reflective practice may be best after the shift has ended and when nurses move away from the hospital setting. After describing the challenges of using a nurse-centric reflective practice in the clinical setting, the nurses revealed something unexpected in the data. When experienced
133
nurses described their experiences using self-reflective practices in-depth, they find themselves often reflecting outside of the clinical setting, as described in the next section.
Section 3: The Experience of Using Self-Reflective Practice Away From the