Clients Initials: M. M.

Date: November 24, 2009, Day 1 Setting: The nurse- patient interaction took place at the National Center for Mental Health, Pavilion 1. It was preceded by the morning exercises, newspaper therapy, music and art therapy and the clients snacks. My client and I stayed at the open field together with some of my group members. Approximately, after 10 minutes, we went for a walk around the area. Then, we settled ourselves adjacent to the foot of the basketball court. After quite some time again, we finally stayed at the foot of the basketball court where we spent the last minutes of the nurse- client interaction. Having a distance of at least 2 feet from the client, it was easy to talk to him without raising my voice because the place we chose was far from other clients and student members. The client wore the blue uniform and his white rubber slippers. Objectives: At the end of the nurse- patient interaction, the client will be able to: a. Display signs of recognition about the purpose of visits of the student nurse/s b. Respond to some basic queries c. Speak out present concern At the end of the nurse- patient interaction, the student nurse will be able to: a. Establish rapport with the client by utilizing therapeutic communication b. Set a contract about the time, frequency and place of the sessions c. Actively listen to clients concerns d. Develop a deeper sense of understanding and empathy to the client Insights Prior to Interaction: I was one of the few students who preferred to have a challenging patient. It was so unnerving before I got to meet him because I learned some of his previous behaviour. Slowly, I started to feel sick especially when I first saw him at breakfast. I was excited and nervous at the same time. What if I say something wrong that might agitate him? Or what if I would be unable to say anything at all? These thoughts flooded my mind.

Nurses Verbal and Non- Verbal Communication

Clients Verbal and Non- Verbal Communication

Therapeutic Communication Used

Analysis

Magandang umaga Michael, kumusta ka na? (Smiled and established eye contact)

The client looked at me briefly then shifted his gaze on the ground. He kept rocking back and forth and his feet were in constant motion. He did not utter a single word or response.

Giving recognition

Ako si Shane. Ako ang magiging student nurse mo. Nag- aaral ako sa St. Paul University Manila at 3rd year college student na. Nandito kami ngayon at bukas. Babalik ulit kami sa susunod na lingo, sa araw ng Martes at Miyerkules. (Smiled, tried to establish eye contact, paused for a while) Ngayong araw ng Martes, mag- uusap tayo ng mga 30 minuto hanggang isang oras. Ganun din bukas at sa susunod na Martes at Miyerkules, Michael. Dito lamang tayo sa loob maaring magusap. (Smiled and tried to establish eye contact) Sige Michael, anong gusto mong pagusapan ngayon? (Smiled and leaned forward)

Giving information

Giving information

Situational: It was my first meeting with my client so I kept all nervousness inside me and put on my best smile. I tried to establish eye contact but the client did not return the gesture. I called my client by his first name which indicated that I acknowledge and respect him as an individual. Aside from greeting him, I also asked how he is doing as I tried to convey that I care about his welfare. I understood his condition but I admit that I felt quite disappointed. I know it will take a long while to gain his trust as it was just our first interaction. Also, I feel his negativism towards other people not just with me. Though he was unresponsive, I still carried on with what I was saying because I was thinking that he might react. I noticed all his actions and made a mental note to remember all of them. Theoretical: According to Manfreda and Krampitz (1977), an individual with schizophrenia maintains strong negative attitudes, frequently becomes suspicious, and actively or passively resists persons who attempt to form a therapeutic relationship with him. Because of his loss of ability to affect a

Broad openings

satisfactory communicative feeling toward others, it frequently hinders him to make a positive transference to his therapist.

Ay oo nga pala, may art and music therapy tayo kanina. Maari mo bang ibahagi ang dahilan kung kayat ganito ang iginuhit mong larawan? (Gave the picture to him) Napansin kong isang kulay lang yung ginamit mo, anong dahilan ng kulay na ito? (Looked at him, slight pause) Paborito mo ba ang kulay black? (Pointed at the drawing and tried to maintain eye contact) The student nurse paused then smiled at the client.

The client took the picture in his hands and stared at it. He was still rocking back and forth and was shuffling his feet on the ground. He was unresponsive and has very poor eye contact. He also started to giggle by himself.

Encouraging description of perceptions

Making observations

Encouraging description of perceptions

Situational: Due to the lack of verbal communication, I dwelled about his artwork. I asked him about it but he just consciously stared at the picture. I was having a difficult time with him though we have only spent a couple of minutes. I stretched my patience meter and thought of other ways to make him express himself. I thought he had a hallucination when he laughed by himself. Also, I paused for a while to think of other means to communicate with him. I was thinking that he might need some silence. Theoretical: Again, in reference to Manfreda and Kampritz, clients lack trust and confidence to other persons. The client may exhibit negative methods to test the nurses/ therapists sincerity and interest in him. Ignoring the nurses presence, moving away or telling the person to leave are some of the attempts that a client usually does. And according to Videbeck (2008), the

Silence

Michael, sabi ni Sir Arianne magaling ka daw kumanta. (Smiled at him and clapped hands softly) Pwede bang makahiling ng isang kanta, Michael? Kahit maikli lang? (Smiled and tried to establish eye contact) Sige, halika. Lakad muna tayo sandali. (Stood up and guided the client to the right direction) Ako nga pala ulit si Shane, Michael. Ang student nurse mo para sa ngayong araw, bukas, at sa susunod na Martes at Miyerkules. (Smiled and tried to establish eye contact)

The client was still unresponsive and Making observations no changes in movements. When asked to walk around the pavilion, he stood up and walked side by side with the student nurse. His strides were very long and went to wrong paths. Encouraging expressions

Giving information

Giving information

client may show variances in mood and affect. The affect may be described as something silly. It is manifested by laughing frivolously for no obvious reason at all. Additionally, the nurse must maintain a nonverbal communication with the client if verbal communication is not effective. It can be achieved by spending time with the client through some periods of silence. Situational: I felt a tinge of hope when our clinical instructor offered some words of advice and informed me that the client loves to sing. I used that to reconnect with him but it didnt work. We walked around the area and he seemed to be unsure where to go. I was very careful in touching him to guide him where to go because he might misinterpret my actions. In the end, I introduced myself to him and oriented him again on the schedule of our meetings. At this point, I was unsure on how our nurse- client relationship will flow. He was verbally unresponsive but when asked to slow down during walking, he followed and his pace slowed down. Theoretical:

Mukhan makulimlim ngayong Martes ah. Ano sa tingin mo Michael? (Pointed at the sky then turned to the client)

Encouraging expressions

As said by Manfreda and Krampitz, the client may not be ready to socialize with others particularly at the beginning. The nurse must work hard to encourage the client by utilizing different means. Taking a short walk might also appeal to the client. In addition, according to Videbeck, assessment to the clients response to the use of touch should be carefully done. Caring and concern are the types of feelings implied with the use of touch. There are times when the client may misinterpret the nurses touch as a threatening act which leads to becoming undesirable. Situational: I gave him time of his own and with silence as I let him express his feelings through drawing. I was afraid that if I do so much talking, he would not appreciate it. So, I paused for a while and stayed quiet together with him. Theoretical: According to Manfreda and Kampritz, initiating activities to clients stimulate intellectual and creative functions. Many clients come to enjoy choosing their own colors for their drawing and creating new designs. Furthermore, it should also be noted that because some persons suffer from an urge to

Sige, dito na lang muna tayo umupo. Marami na kasing masyadong tao dun sa kanina nating pwesto eh. Ito nga pala ulit ung drawing mo kanina. Gusto mong dagdagan? Nandito yung crayons, pili ka ng gusto mong kulay. (Smiled, tried to establish eye contact and opened the box of crayons) The student nurse paused and arranged the crayons for the client.

The client took one of the crayons but did nothing. He just took hold of it and stared around the area. He kept fidgeting in his seat. Again, he laughed by himself.

Encouraging description of perceptions

Using Silence

Michael, lipat ulit tayo dun sa may ilalim ng basketball court. Mukhang mas mahangin dun eh. (Pointed at the foot of the basketball court) Gusto mo ba kong maging kaibigan? Kasi ako gustong gusto kitang maging kaibigan. Kung okay lang sayo, appear tayo. (Smiled and tried to gain the clients attention and eye contact) Mukhang matatapos yata ang araw na ito ng hindi tayo nakakapag- usap. Sana bukas mas maganda ang panahon para mas maganda ang simula ng araw natin, di ba? Babalik ulit ako bukas tapos mag- uusap ulit tayo at maglalaro. Sige, babye! Bukas ulit. (Smiled and waved at him)

The client complied with the student nurses request but mumbled something along the lines of Hay, naku. He did not return the initial gesture of the nurse and remained affixed in his position. He was glancing around the area and had minimal eye contact with the nurse.

Giving information

Offering self

maintain negative attitudes, it will be difficult for the client to cooperate. Situational: I encouraged him again to talk in another place. Maybe it was my desperate plea to hear a word from his mouth that I thought I heard him mumbled something. I was not sure and no one heard him as well. I told him that I want to be his friend because in that way, the great wall of ice in between of us might melt in due time. Stating that might also be a useful tool in conveying to him that I am sincere in my actions and communication with him. I anticipated his negativism so it did not give me that much of a shock when he rejected the therapeutic relationship Im trying to build with him. For some reason, I felt highly challenged to make him converse with me. Theoretical: Once more, in reference with Manfreda and Krampitz, clients are unconsciously defending themselves and attempting to communicate something to the nursing personnel through their behaviour. Withdrawal is a defense mechanism against rejection. This type of reaction is what the client has grown to expect in all types of

relationships. The nursing personnel play a very influential and active role in the clients recovery. A nurse who is attempting to establish a relationship with this type of clients will find it tough to persevere unless she realizes that the clients may use negative methods to test her. Anticipation and acceptance of clients negative responses must always be remembered on the part of the nurse. Time Span: 35 minutes Evaluation: The first day of my encounter with my client proved to be a challenging one. I was able to establish the contract and maintained therapeutic communication with him through the utility of both verbal and non verbal communication. However, due to clients negative responses/ negativism as it is the beginning of our nurse- patient interaction, I failed in helping him to talk about his concerns. Through all the silence we have passed through, I took that opportunity to observe him and keep those observations in mind to help me in my succeeding interactions with him. Though he did not utter any verbalizations, I understood him and allowed myself to be 100% committed to his care. Source: Videbeck, Shiela. (2008) Psychiatric- mental Health Nursing (4th edition). Lippincott Williams & Wilkins. Manfreda, L. and Krampitz, S. (1977) Psychiatric Nursing (10th edition). F.A Davis Company, Philadelphia