Developing the Skill of Self-Reflection

New graduate nurses encounter numerous challenges during the transition from student to professional. As they learn to function in a busy clinical environment while thinking critically, making decisions, and acquiring knowledge quickly, they may overlook one essential skill: the skill of self-reflection. In nursing school, students are provided feedback at every turn. Students are evaluated, scored, and graded on every subject and interaction. This level of feedback drops dramatically during orientation to their first nursing job, and after orientation it scales back even further. Most nurse managers provide formal feedback to nursing staff only once or twice a year. The abrupt loss of structured evaluation can be especially unsettling to students who excelled in nursing school. Although they were successful in an environment where every task had a clear rubric, transitioning to practice as new nurses may leave them uncertain about whether they are meeting expectations. Self-reflection involves the active evaluation of one’s skills, understanding, and performance.1 Recognizing learning needs leads to establishing specific, measurable, achievable, realistic, and timely (SMART) goals and supports a continuous trajectory of self-improvement throughout one’s professional career.2 Whether you are a newly licensed nurse or have decades of experience, self-reflection should be a tool you use regularly. If this concept already guides your professional practice, consider incorporating self-reflection instruction into orientation and mentorship of newer nurses to help them thrive.As 2025 comes to an end, take a moment to reflect on the past year and all you have accomplished and set your SMART professional goals for 2026. Warfarin inhibits the synthesis of vitamin K–dependent clotting factors, thereby reducing clotting ability. Foods rich in vitamin K, like kale and spinach, can interfere with this action. Warfarin dosing is closely monitored via the prothrombin time and international normalized ratio (INR) to ensure optimal anticoagulation levels in all patients receiving warfarin therapy. Inconsistent intake of vitamin K–rich foods (B, C) may cause significant fluctuation in the INR, placing the patient at risk for thromboembolic events or bleeding complications. Avoiding vitamin K–rich foods completely (A) is not necessary and may be impractical, especially for patients who follow a vegan diet. This patient has a stable wide-complex tachycardia (WCT). A dysrhythmia with a heart rate exceeding 100/min and a wide QRS complex is a WCT. A WCT may originate in the ventricles as ventricular tachycardia or above the ventricles as supraventricular tachycardia with aberrant conduction causing a wide QRS complex. In patients whose condition is stable, obtaining a 12-lead electrocardiogram is essential to identify the origin of the WCT. Differentiating between ventricular tachycardia and supraventricular tachycardia with aberrancy is necessary to determine treatment of the dysrhythmia. A “code blue,” or emergency response protocol (A), is generally called only if a patient is very unstable or without a pulse. Synchronized cardioversion (B) may be indicated, but it is important to obtain a 12-lead electrocardiogram if the patient’s condition allows. Amiodarone (D) may be indicated for WCT, but the 300-mg intravenous push dose per advanced cardiac life support protocol is used for pulseless ventricular tachycardia. The primary risk factor for contrast-associated acute kidney injury is impaired kidney function. Other risk factors present in this patient are advanced age and diabetes mellitus. The use of furosemide or other diuretics may cause dehydration and urine concentration, potentially worsening the risk of contrast-associated kidney injury. Intravenous hydration with an isotonic fluid like normal saline (A) is an evidence-based strategy to prevent contrast-associated acute kidney injury in patients with renal insufficiency. Hydration expands intravascular volume, enhances contrast medium elimination, promotes diuresis, and decreases renal vasoconstriction. Encouraging oral fluid intake (B), as opposed to maintaining nothing-by-mouth status, is becoming more widely adopted on the basis of recent studies finding potential benefits and no greater risks for patients with impaired renal function. Metformin (C) is primarily excreted by the kidneys, and iodinated contrast medium may cause damage to the kidneys. Treatment of patients with a pulmonary artery catheter includes continuous monitoring of the pulmonary artery pressure waveform to identify catheter migration. The catheter may migrate forward into a smaller branch of the artery, potentially obstructing blood flow, or backward into the right ventricle, irritating the ventricular wall and causing ventricular dysrhythmias. After balloon deflation is ensured, the catheter should be carefully pulled back until a right atrial pressure waveform is noted on the monitor. Although provider notification (A) is important, immediate nursing intervention is needed to prevent life-threatening dysrhythmias due to ventricular irritation. Obtaining a chest radiograph (B) when a right ventricular pressure waveform is observed is not necessary and will delay addressing the dysrhythmia. Manipulating and attempting to advance the catheter (D) may worsen the ventricular irritation and increase the ectopy and is outside the nursing scope of practice. New-onset confusion in an older patient with a suspected infection and leukocytosis with band neutrophils suggest sepsis. Older patients often have an atypical presentation of sepsis. In this case the patient’s medication regimen may be masking the classic systemic inflammatory response syndrome criteria of fever and tachycardia. Early recognition and treatment of sepsis are key to significantly improving patient outcomes. Although checking for bladder distention (A) may be indicated, it is not the priority at this time. Monitoring neurological status (considering that this patient is also at risk for delirium) and implementing fall precautions (B) are important nursing actions, but the time-critical nature of sepsis treatment is the priority in this case. Continued use of a β-blocker should be reviewed with the provider (D). Despite established reference values, not every abnormality is concerning and requires any nursing action beyond accurate documentation. However, a prolonged QT interval poses a significant risk for triggering torsades de pointes, a life-threatening, multifocal wide-complex dysrhythmia. A PR interval that is slightly prolonged (0.22 milliseconds) is notable but not cause for concern (A). Multifocal atrial tachycardia (C) is not in itself a dangerous rhythm but may indicate a poor prognosis in patients with chronic lung disease. Occasional premature ventricular complexes, often defined as less than 10% of heartbeats, are considered benign (D). Pericarditis is a potential complication of acute myocardial infarction and classically presents with sharp chest pain that worsens on leaning forward and with deep inspiration. Auscultation may also reveal a pericardial friction rub. A systolic murmur (B) after myocardial infarction may indicate ventricular septal defect or mitral valve papillary muscle rupture, but these conditions would not cause these symptoms. Auscultation of bibasilar rales is a sign of systolic heart failure (C). Jugular venous distention (D) may also be a sign of systolic heart failure or cardiac tamponade. Causes of acute kidney injury can be classified as prerenal, as with diminished perfusion to the kidney (A); infrarenal, such as damage to the nephrons (C); or postrenal, due to outflow obstruction from the kidney. In this case, an enlarged prostate would most likely lead to postrenal acute kidney injury. Pararenal (B) is not a term used to classify acute kidney injury. Esophageal varices are most commonly caused by increased portal pressure from liver cirrhosis. Jaundice and increased INR are also signs of liver cirrhosis. The Cullen sign (ecchymosis around the umbilicus) and elevated serum lipase and amylase levels (B) are associated with severe pancreatitis. Constipation and elevated white blood cell count (C) are associated with lower-bowel obstruction or possibly diverticulitis. Although the hemoglobin level may be decreased in patients with esophageal varices, hematochezia (blood in the stool from a lower-bowel source) would not be part of this clinical picture (D). Syndrome of inappropriate antidiuretic hormone secretion is characterized by the overproduction of antidiuretic hormone. This syndrome causes decreased urine output, resulting in small amounts of concentrated urine and hypernatremia. Serum sodium level is a good measure of blood concentration; hypernatremia may indicate hypovolemia, and hyponatremia indicates hypervolemia. Copious dilute urine (A, B) is a symptom of diabetes insipidus, a decrease in antidiuretic hormone function caused by either underproduction by the pituitary gland or nonresponse to the hormone by the kidneys. Concentrated urine would not lead to dilute blood and low sodium concentration (D). AACN Certification Corporation publishes a study bibliography that identifies the sources from which items are validated. The document may be found in the AACN certification examination handbook. The contributor of each question written for this column has listed the source used in developing each item. Clinical practice should be based on primary sources of evidence when possible; this column will also include secondary sources to help nurses become aware of available resources for certification review.EBBERTSMarci Ebberts, MSN, APRN, FNP-C, is the department editor. Marci is program director of nursing research at BJC West, Saint Luke’s, Kansas City, Missouri, and a practicing occupational health nurse practitioner. She welcomes feedback from readers and practice questions from potential contributors at [email protected]. Marci wrote the introduction and the PCCN questions.COAKLEYSusan Coakley, BSN, RN, most recently worked as an intensive care unit staff nurse, ad hoc critical care educator, and rapid response nurse at Sarasota Doctors Hospital, Sarasota, Florida. Susan wrote the CCRN review questions.