| Wyona M. Freysteinson MN | Critical Care Nursing Quarterly April/June 2009 Volume 32 Number 2 Pages 89 - 93 |
Abstract
There is no known literature to guide the critical care nurse in the use of mirrors in patient care. This article explores how the author came to believe that mirrors were essential to nursing practice. Misconceptions and assumptions concerning mirrors are explored. A framework that conceptually explores the experience of viewing self in the mirror from the perspective of a person is presented. Five situations in which the mirror may be used in critical care are discussed. This article does not present an authoritative view on mirrors in nursing; rather, it is an invitation to dialogue about a unique element in the environment that may be used to enhance nursing care.
CRITICAL CARE NURSES are educated in working with fragile critically ill patients. Their education is extensive and covers physical, psychosocial, and spiritual aspects of care. They are not, however, taught about the use of mirrors in their schools of nursing.1 Nursing mirror practice is based on one's patterns of knowing, beliefs, and values because there are no known guidelines to guide nurses in the use of the mirror with patients. This article discusses the potential use of the mirror in the care of some (not all) critical care patients.
In the 1960s, an elderly woman, aged 78, was in a hospital intensive care area. Her physician notified the family that there was little else that could be done for her worsening condition. The family gathered at her bedside. Knowing that her great grandmother loved to have her hair combed, her 9-year-old great granddaughter found a comb and a mirror. After her hair was combed, the elderly woman serenely gazed into the mirror for several minutes. Within hours, she lapsed into a final coma (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994).
In the 1970s, a woman in her late 90s was lying in bed. Her body and face were severely contorted from rheumatoid arthritis. At best, she weighed 75 pounds, and her pain level was off the scale. She asked the 16-year-old aide to get a wet washcloth and wet her lips. She then asked the aide to retrieve her hand mirror from the drawer. The aide was terrified to show the elderly woman her face in the mirror: she was afraid the woman would be frightened to death by her own image. The aide stared in fascination as the elderly woman viewed her own face and appeared to be, for a moment, almost at peace (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994).
The author of this article was the great granddaughter and the aide in these case studies. In her school of nursing, her nursing instructor pointed out the equipment at the bedside, including the mirror in the overbed table. On the basis of her intimate experience with mirrors, and the mirror in the overbed table, the author assumed that mirrors were essential to nursing practice. The mirror became a small, but important part of her practice in many areas of nursing including trauma, intensive care, and coronary care. For those times when the bathroom mirror and overbed table mirrors were inadequate, she carried a pocket mirror.
In a survey of 46 hospital wards in 3 hospitals in England, there was 1 mirror recommendation: “Mirrors should be lowered or enlarged to make washing, shaving and grooming easier for those who need to sit for this activity.”2(p237) Nurses from Africa, Egypt, Japan, the Netherlands, Panama, Russia, Singapore, and the United Kingdom indicated that there were few mirrors in their hospitals. They reported more mirrors in the lobby and elevators of hospitals than in patient rooms.1 Freysteinson and Cesario 3 found that mirrors for the bed bound were not available in 70% of the American hospital units they surveyed.
There are several assumptions concerning mirrors in healthcare. Each of these assumptions may be true for some patients some of the time. Literature suggests, however, that these assumptions are not true all of the time.
In 1990, when Freysteinson suggested a study of mirrors, a nursing leader viewed the project as preposterous. She said, “People who are sick and dying do not want to look in mirrors.” A study of 7 terminally ill women's perceptions of viewing self in the mirror indicated that this statement may be a misconception (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994). Nurses from around the world 1 indicated that although there are few, if any, mirrors in patient rooms, many patients do view self in the mirror. This is not to suggest that all patients want to look in mirrors. It does suggest, out of dignity and respect for human beings, that nurses may consider offering patients a choice in whether or not they wish to view self in the mirror.
In an intensive care burn unit, there was a young man in his early 20s, who had suffered severe burns. For 3 weeks, he viewed the charred remains of his fingers, chest, pubic area, feet, and toes. On a daily basis, one of the nurses shaved his face and combed his hair. When the author asked whether he had seen his face in a mirror, his nurse said, “Oh my, I have not even asked him if he wants to look in a mirror. His face was untouched by the fire.” The young man also did not ask for a mirror.
Freysteinson uncovered that asking to view self in a mirror in a hospital may be viewed as narcissistic: “Maybe some people would be suspicious if they saw you looking in the mirror all the time” (unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994, p. 109). In the Greek myth of Narcissus, a handsome young man falls in love with his reflection, which he views in a quiet pool of water. This myth may have had influence on present-day beliefs about the association between vanity and viewing self in a mirror.
Researchers in Belgium conducted a study of several patients in postcomatose state. Their concern was accurate diagnosis of vegetative state. Three tracking mechanisms were used: a person, an object, and a mirror. Eleven patients did not track a person or an object. They did, however, successfully track their reflection in a mirror. The researchers indicate that these 11 subjects would have been misdiagnosed as being in vegetative state without the use of the mirror.4
The author observed that in neurotrauma, patients with severe brain injuries may begin to focus on their reflection in the mirror in the early stages of recovery. As patients became well enough to be taken to a sitting position in bed, the author would open the overbed table mirror up when providing everyday hygiene care (ie, shaving, combing hair). She found that patients would stare at their reflection. Some patients would begin to assist in their own care while viewing self in the mirror.
A study of the experience of viewing self in the mirror may be approached from a phenomenological perspective. One description of the experience of mirroring or viewing self in the mirror consists of 4 meaning moments that may occur sequentially or simultaneously: decision, assessment, knowledge, and consent (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994).4 Before these moments may occur, a person must be physically able to view self in a mirror, and mirrors must be readily accessible.
Viewing self in the mirror begins with a decision. “It is almost as if one converses with self and declares, ‘I am or I am not going to look in the mirror’” (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994, p. 45). Viewing self in the mirror may be habitual (ie, the habit of checking one's image in the mirror when washing one's hands). A person's decision may be a strong desire, or it may be a paradoxical decision of wanting, not wanting to view self in the mirror. One may fear what the mirror will reflect (ie, recent facial or chest trauma), and at the same time one may want to really know how one looks. The decision to view self in a mirror is based on any number of reasons. One woman was hospitalized after an accident that left her face severely bruised:
The first time I saw my black face was in the emergency room. I knew I would look bad, but when the nurse showed me in the mirror I couldn't believe it. I didn't think it could be so swelled up and so black, so fast…. The nurse didn't give me enough time. She gave me a look and flashed me away again…. She (the nurse) looked so grim about it. When she would go, I'd take another look. You'd think, am I looking worse or am I so repulsive…. I looked in the mirror more after I had visitors, because everyone kind of had different expressions on their faces. (W.M.F., unpublished master's thesis, University of Saskatchewan, Saskatoon, Saskatchewan, 1994, p. 105)
Before looking in the mirror, there is an anticipated glimpse in the mind's eye of what one may look like. Typically, one anticipates that one will look the same as the last time one glanced in the mirror. If a patient has suffered a traumatic injury to the face or chest, there may be dread, as one imagines what the mirror may reveal. There may also be anxiety and fear when one feels something foreign on one's face (ie, endotracheal tube, nasal gastric tube). The nurse may help the patient anticipate a truer picture of self through describing what the patient may see (ie, there is a little clear colored tube in your right nostril) before positioning a mirror for the person to see self.
When a person does view self in the mirror, one sees and evaluates the image. The image is compared with one's anticipated image. For the patient who can speak, the nurse may hear the image referred to as it or that. This is an indication of distanciation of body from self. On the other hand, the nurse may hear the words I or me. These words indicate an appropriation of the self to the self.
Assessing and evaluating self in the mirror brings one to a self-explanation: I look like this because of such and such (ie, the accident, the surgery, I deserved this, etc). In critical care, it is important when patients are able to comprehend that nurses explain in simple terms the reason for various tubing, facial injuries, etc. These explanations may help to ease anxiety and clarify the image the patient sees in the mirror.
Self-knowledge is also colored by an individual's way of being in the world. One may face the world, for example, through a way of being that may be broadly described as anxiously, graciously, angrily, humbly, etc. Discerning this overall way of being may help guide the nurses in mirror and other interventions.
One consents to the knowledge of one's self in the mirror. Critically ill patients who are unable to speak may simply nod in acknowledgment, avert their eyes, or gently close their eyes to indicate that they have consented to the image in the mirror. Consent is lived on a horizon of hope to despair. A patient may hope that the tubes will be removed and the incision will heal, or the patient may feel despair and hopelessness. The nurse may help to alleviate hopelessness by discussing, for example, the length of time a tube may be present (ie, awhile, a few days).
In order that nurses may use mirrors in patient care, having adequate mirrors available is essential. Mirrors for bed-bound and chair-bound patients are appropriate for critical care. Overbed table mirrors need to be in working order. If overbed table mirrors are not available, portable small unbreakable mirrors that attach to a table with suction caps may be used. Hand mirrors that are large enough to view one's entire face are also appropriate. For the patient who is able to sit in a chair at the bedside, a portable full-length mirror may be suitable. Bathroom mirrors should be equipped with tilting mirrors or a full-length mirror for the patient who uses a wheelchair.
Unbreakable mirrors may be found using the following Internet search terms: acrylic, chrome-plated, pediatric, shatterproof, tilting, and unbreakable mirrors. Perhaps future hospital rooms may be equipped with mirrors on flexible arms, which are attached to the bed, headboard, or ceiling. A mirror of this type would allow the bed-bound patient lying or sitting at any angle to use a mirror to visualize self and/or the environment.
Viewing self in the mirror is frequently something one may do in private. If viewing self in public, one may simply glance or glimpse oneself in a mirror. When considering the use of mirrors, nurses may need to consider the degree of privacy a patient may want and the amount of privacy possible in a critical care unit.
Nurses may consider using mirrors as tracking devices to determine whether a patient is in a vegetative state, or to determine whether a patient may recognize self in the mirror (orientation to self). Mirrors may even be of benefit in helping a patient become orientated to self.
Patients may simply want to assess or inspect themselves in a mirror. Nurses may facilitate this decision by having mirrors readily accessible and/or by gently asking whether a patient may want to view self in the mirror (ie, after shaving, etc).
Mirrors may also be used to orient a patient to facial tubing. An explanation of the tubing, together with allowing the patient to assess and evaluate the tubing by using a mirror, may help decrease anxiety, and the tendency to want to touch and feel the tubing with one's hands.
Mirrors of various sizes may be appropriate for the patient who requires mirrors to visualize the environment (ie, Stryker frame, halo traction). Mirrors may also be useful for patients who have to lie flat after a procedure for several hours. With an appropriately placed mirror, a patient may observe the environment (ie, people coming and going) more readily that may help decrease apprehension, anxiety, and/or boredom.
Nurses in the Netherlands use mirrors to allow a child look at his or her chest as a nurse punctures an implanted access device with an appropriate needle. Nurses suggest when children are older than 4 years, this helps calm the child. Mirrors are also used to help the patient see during echocardiographic procedures.1 Mirrors may be considered during facial and upper-body dressing changes. It may be relatively easy for a patient to glance down at the incision site of a recently amputated arm during a dressing change; it is impossible, however, to view the incision on one's face or chest without the use of a mirror.
For many individuals, mirrors are a typical part of daily hygienic activities. Combing one's hair, washing one's face, or shaving is almost impossible without the use of a mirror. For the patient who has progressed to the point of being alert and/or active during a bed bath, using a mirror is yet another way to return to daily living. When setting up bed-bound patients for self-care (ie, shaving), the nurse will want to position the mirror so that the patient may adequately see self.
In the case of severe facial trauma, surgery, or burns, it is difficult to ascertain when and whether there is a best time to offer a patient a mirror.1 A patient on a positive medical trajectory will inevitably view self in a mirror. The possibility of a patient viewing self for the first time in the mirrors in a public hallway or elevator during the transfer is of concern. The initial viewing ought to be in the critical care area where professional support is available prior to transfer to a step-down unit. For the patient who is capable of viewing self in the mirror, the nurse may ask whether the patient wants privacy, the nurse, or the loved one to be present when looking in a mirror the first time after trauma or surgery. Developing consistent unit processes for the routine use of mirrors is recommended.
The study of mirrors in nursing is in its infancy. Research is needed on essentially all aspects of the nursing practices suggested in this article. If, however, nursing is a practice with a concern for the perspective of patient, a concern for the perspective of patient viewing self in the mirror is inevitable. Let the mirror dialogue begin.
1. Freysteinson WM. International reflections on knowledge and use of the mirror in nursing practice. Nursing Forum. In press. [Context Link]
2. Monro A, Mulley GP. Hospital bathrooms and showers: a continuing saga of inadequacy. J R Soc Med. 2004;97:235–237. [Context Link]
3. Freysteinson WM, Cesario SK. Have we lost sight of the mirrors?: the therapeutic utility of mirrors in patient rooms. Holist Nurs Pract. 2008:317–323. [Context Link]
4. Vanhaudenhuyse A, Schnakers C, Bredart S, Laureys S. Assessment of visual pursuit in post-comatose states: use a mirror. J Neurol Neurosurg Psychiatry. 2008;79:223. [Context Link]
Key words: critical care nursing; mirror; patient care
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