Nondisclosure of emotions has been shown to inhibit a person's adjustment to illness. When this occurs, the development of coping mechanisms is not enhanced.1 A number of studies, using both qualitative and quantitative methods, show that psychosocial factors affect outcomes of illness and quality of life. Researchers suggest that emotional control, fatalism, helplessness, and psychological morbidity are related to negative outcomes.2 In contrast, positive outcomes were more likely to be enhanced by intimacy, open communication, incorporation of selective disclosure, and flexibility.3 Clinical nurse specialists are in a position as ethical experts to assist patients and family members to strengthen psychosocial skills to better cope with health crises. We also mentor other healthcare providers to understand the effects of psychosocial factors on healing. The purpose of this brief article is to describe reflection as a nursing intervention and review a research study about it using the population of people with diabetes as an exemplar.
Reflection is one method offered by which patients may move toward more positive results when faced with an illness or trauma. It provides an opportunity to review experiences, perceptions, and feelings that demonstrate the need for supportive and behavioral interventions. The concept of reflection includes a way of thinking that accepts uncertainty and acknowledges dilemma.4 One comprehensive definition provided by Boyd and Fayle5(p99) states that reflection is the process "of internally examining and exploring an issue of concern, triggered by an experience, which creates and clarifies meaning in terms of self, and which results in a changed conceptual perspective." Most definitions of reflection incorporate ideas of developing new knowledge, consciousness/self-awareness raising, developing intellectual skills, and creativity.6
Examples of reflective questions include the following: "What is the meaning of your experience to you?" "What are your feelings about the treatment?" and "What are your thoughts and feelings about having a certain condition?"1 The process can also include journaling and guided self-determination, with the goal of forming a deeper understanding of alternatives by which to take action to improve outcomes.4,6,7 Reflection has been the topic of numerous research studies in nursing and medical education, specifically about healthcare providers reflecting on their own practice.8-10 For example, Bethune and Brown9 examined the effects of self-reflection exercises used by residents in a family medicine training program. They found that the reflection exercises affected the patient-physician interaction positively by contributing to the physician's understanding of the relationship, augmenting clinical knowledge, and increasing personal insight.9 Holstrom and colleagues8 observed increased patient satisfaction with medical encounters after the healthcare providers participated in a yearlong self-reflection intervention.
The nursing literature has many examples of the use of self-reflection in nursing education and practice.10 However, there has been a paucity of studies looking at the use of reflection as an intervention for specific patient conditions. Although more has been done in looking at self-reflection and coping mechanisms in chronic illness such as breast cancer,1 little is found in the diabetes care field. One Danish study7 using guided self-determination in people with diabetes who had persistent poor glycemic control showed that the reflection intervention was effective in improving life skills and lowering hemoglobin A1c over a period of 1 year. The study was limited by a small sample size (20 patients), and all patients had type 1 diabetes. Another study used reflective journals to gain an understanding of gestational diabetes as the mother experienced it in order to address her needs more effectively.11 The goal of their analysis was to help shape guidelines of care for women with at risk pregnancies.
Evans and O'Brien11 examined the meaning of at-risk pregnancy, specifically gestational diabetes, in a qualitative study. A purposive sample of 12 women with diabetes who were 26 to 38 weeks pregnant were selected from a clinic in a large teaching hospital and invited to participate in the study. Interviews were conducted once before delivery and then again at 6 or 8 weeks postpartum. The interview protocol began by asking the women to describe what having gestational diabetes was like for them. Other open-ended questions followed. The reflective process was analyzed, and the researchers extracted words, statements, and paragraphs to describe the meaning of pregnancy with gestational diabetes to these women.
Four common themes were constructed from the results of the interviews. The first was the idea of "living in a controlled pregnancy."11(p71) There was a loss of control and a sense that the woman's body was now an adversary. Furthermore, the women felt that their lives were more closely scrutinized by their family, their social network, and their healthcare providers. A second common theme found was "balancing,"11(p72) or the woman's need to adapt and meet the challenges. In this stage, the participants were able to deal with the prescribed regimen and became active participants in managing their care. There was a sense of empowerment. The third theme was "being a responsible mother."11(p73) The baby was the focus of care, and the women felt that no matter what, they were to minimize any possible harm to the baby. Pressure from family and, often, the healthcare providers was felt. A sense of self-sacrifice was noted as well. The fourth and final theme was the idea of "being transformed."11(p73) This was a forward-looking stage in which the women evaluated their knowledge of diabetes and made choices regarding their health in the future.
In their review of the literature, the researchers noted that depression, fear, and anxiety are common responses when dealing with an at-risk pregnancy. Along with those feelings come a sense of heightened vulnerability, lack of control, and uncertainty. From findings reported in several studies, Evans and O'Brien11 concluded that having gestational diabetes negatively influenced a woman's perception of her health and was associated with poor psychosocial outcomes.
The women in Evans and O'Brien's study did report some negative impact from having gestational diabetes, but in contrast to the researcher's original assumptions, a majority of women recognized diabetes as a beneficial experience. The information acquired about their body, self, and diabetes led them to make positive lifestyle choices. The occurrence of an at-risk pregnancy was a transformative experience. Because the researchers were looking for the "meaning" of the at-risk pregnancy, the method of inquiry from a phenomenological point of view allowed for a richer understanding of the day-to-day world as it was immediately experienced rather than as it was conceptualized, categorized, or theorized.12 In this type of analytic process, a new appreciation of a lived experience that reveals an interest, emphasizes a phenomenon, or sensitizes one to the needs of others is formed.12
The study showed that the reflective process can be used as an intervention in helping women with gestational diabetes move though the pregnancy and discover meaning in an at-risk pregnancy. Based on the findings, it is possible to develop other interventions such as supporting the dietary changes needed to combat possible progression to type 2 diabetes or implementing maternal health programs. The researchers demonstrated that letting the patient self-reflect, discuss, and talk through an event/experience without an ulterior motive can produce therapeutic effects and foster respect and understanding, which is critically important for nursing practice.
According to Rew,13 self-reflection is a deliberative process of turning one's awareness inward to examine feelings, thoughts, and behaviors. Self-reflection activities are an essential component of expert nursing practice and may be used as interventions for patients who might benefit from increased self-understanding. In the words of one participant in a study of reflection, the essence of the value of the process is clear: "Don't try to fix it. Let me talk about it."11 The clinical nurse specialist can be a role model and facilitator of this intervention, which addresses holistic care from an ethical perspective.
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