ADVANCED PSYCHIATRIC NURSING I
UNIVERSITY OF SANTO TOMAS
Espana, Manila
Prof. NENITA Y. DAVADILLA, R.N., MSN, MA. SpED
SELF-ASSESSMENT:
• Who is the client? Why did I choose him/her?
My client is Mr. A, a 45 year old, male, was born on October 7, 1962 at their town in Binangonan, Rizal. He is a Filipino, Iglesia ni Cristo, and married with Rachel at the age of 33 years old and blessed by two children, a girl,14y/o and a boy, 13y/o. His father was a military general and his mother is a sewer. They lived at 154 Lopez Jaena Street, Libid, Binangonan, Rizal.
Patient attended elementary level at Binangonan Elementary School. He was transferred at Libis Elementary School during Grade 4 due to accident happened at the former school. Patient finished high school at Thomas Claudio Memorial College in Morong, Rizal. He finished high school for almost 8 years due failing grades. Then, he was able to finished college with the degree of Bachelor of Science Industrial Education at Rizal Technological of Polytechnic Institute. Same year, patient took the board exam at Quezon City but failed with 64 %. After then, he worked as a meter reader at NAWASA, Binangonan, Rizal with compensation of P50 per day for more than 3 years.
Patient was admitted for the second time at National Center for Mental Health (NCMH) last July 18, 2005 at 4:35pm accompanied by his father with a complaint of unusual behavior. Mr. Arabit was suffering from mental disorder called Schizophrenia for almost 15 years.
Mr. A is my patient for almost 9 months. My purpose in choosing Mr. A as my patient is because I frequently noticed him listening to a sad love song with blank stare then cry silently. Whenever I asked him “what’s make him cry or Is there anything he want to share or he want to express?”, my patient will just answer “Wala po, Ma’am.” He also didn’t want to participate in NPI of student nurse for a reason that he doesn’t want to share anything with his life. So, I took his hesitancy as a challenge to choose Mr. A as my patient and primarily to have deeper understanding with his behavior and to help him for whatever is bothering his mind. As his psychiatric nurse, I want to do my responsibility not only to take care of his physical condition and merely give his daily medications, nutrition, maintaining hygiene but to go deeper and touch his psychological, emotional, spiritual and social aspect. Thus, in this way, I believe I can promote health in holistic approach and give him peace of mind and hopefully a happy and fruitful life despite of the dilemma having mental disorder.
• What does my client mean to me?
I see my patient as a person, as a human with dignity and worthy, a person who created in the likeness and image of God. I believe that my client is the most important person in my profession. Without my client, I am nothing and useless.
I view him as someone who cry in vain but no one can hear.
• What are my feelings about this client? Both positive and negative.
The moment I approached my patient with the goal to conduct a nurse-patient interaction, I was quite nervous because the fact that I’ve known my patient as very uncooperative that he might refuse our activity and will not work out. So, before hand, I make sure that I planned it to gain my patient’s trust and rapport. I am glad that during our orientation, my patient shows positive behavior such as being active in our interaction, no hesitance in answering and shows interest in the activity. He also immediately agrees with our contract and verbalized willingness to participate. That’s why, I become excited in our activity. I have a feeling that our interaction has a higher chance to be successful and finish with positive outcome primarily for my patient’s condition and also for my professional growth. I was touched that I felt I have learned something how to build trust, gain respect and establish rapport to my client.
Another thing that makes me feel happy with this activity is that during the course of our activity, I perceived the meaning and feelings of my client. I sense the importance of the situation of my client especially when he tells sad stories of his past. I was able to put my self in my patient’s shoes which helps me to further understand my patient. I was able to listen attentively with my patient but making sure that what I feel is not sympathizing my patient but rather empathy. I feel that somehow I was able to give help to my client and I was able to use and put into practice the knowledge I gained in the class.
The negative feelings I had was when Mr. A is very manipulative. I had a hard time to control him but honestly, I’ve learned how to stretch my patience for him. Though, there are times that my anxiety rises when my patient became disturb and shows positive symptoms such as hallucinations and became more manipulative and physically aggressive. In this situation, I should project firm and talk with authority as his nurse yet still therapeutic.
There are moments that I feel sad when I saw my patient with symptoms of schizophrenia which he cannot control. It is sad to see Mr. Arabit having distorted and bizarre thoughts which makes me eager to take care of him and be a therapeutic agent for change. I felt inadequate that as his nurse for almost a year, I used to give medications and followed orders from the doctor, still Mr. A is suffering from symptoms of his disorder.
There are also times when I feel afraid. When Mr. A showed his anger while telling his past story to me. His eyes look sharp and express angry. I just stop and I don’t know what to do but to listen and keep distance.
• What problematic behavior is being exhibited by the client?
My biggest problem I have encountered with Mr. A was when he is having hallucinations. There was a time that Mr. A hallucinates when we were having an activity to put his feelings through drawing. At first, the activity goes smoothly. I explained everything in a simple yet concrete instruction. Explain the purpose of the activity. When we are going to start, suddenly Mr. A verbalized that he doesn’t want to do the activity and after a few minutes, he became restless and stand in his chair. Then, he starts to hallucinate which he sees girls dancing in front of him.
Another problem is Mr. A is very manipulative. He always leading the conversation (good thing that he was active and leading the interaction) but sometimes, he go beyond our goals. Another instance is that there is one session that he doesn’t want to talk because he wants something in return for his sharing. He is asking for money to buy a stick of cigarette. I remind the purpose and goal of our interaction and reoriented him regarding our contract. In this case, he was able reluctant to participate because I didn’t give him money to buy his cigarette. I reoriented him regarding the rules and regulations inside the hospital. Eventually, I encouraged my patient to follow the rules and continue our interaction.
• What are my feelings about the client’s behavior?
Honestly, I felt sad especially when my patient manifested negative behavior such as hallucination though I know that his behavior is expected as symptoms of his disorder. But I’m trying to work it out to further understand my client for me not to feel sad. When I saw my patient that he can do his everyday, I felt glad that he can show that he can be functional and live to the community.
I am sometimes become fearful when Mr. A is exhibiting his hallucinations. Which sometimes, I don’t know what to do. Sad to say, there is one session I encountered that Mr. A can’t able to response relevantly and having hallucinations, out of fear, I stop our conversation and put back my patient in his ward. I know it is very non-therapeutic since I wasn’t able to handle him and don’t know what to do.
• How do I handle those feelings?
I know for a fact that as a nurse, I still do have feelings or emotions. I am somehow affected on every response I gain from my patient. But then, as a nurse I need to be strong and do something to handle my feelings.
The first thing I have to do is to continue knowing myself. Self-awareness, prior to interact with my patient and even after interaction to my patient – to check what’s wrong and what’s right I have done. Self-awareness makes me recognize my own feelings, beliefs and attitudes. I must be certain that my personal feelings and beliefs do not interfere with or hinder my patient’s care. It brings with it change and also reveals our basic stability. When I look at myself from a new point of view, I gain a wider perspective. Taking care of Mr. A is always a challenge for me. I was influenced by his behavior, thinking, values, his health, his outlook and his situation.
Supervision under my professor helped me a lot. She was able to comments what those therapeutic are and non-therapeutic I have done. She was able to criticize my work for better understanding what a psychiatric nurse should possess. Through our supervision and sharing of our work with my classmates, I found that it was not only me who experienced these things. When they share and handle the same experience and same feelings, I feel better and say it is a normal process in dealing this kind of challenge in our profession.
Of course, I also read books and study his disorder and right approaches and treatment to further understand him and so to handle my feelings. As his nurse I want to help my patient’s condition. I do believe that giving his medication and follow the order of the doctor are not the major treatment for my patient, maybe for a short period of time during the presence of positive symptoms such as restlessness, delusion or hallucination, but to go beyond physical treatment such as providing safe and therapeutic environment, communication and therapy. I do believe caring and everyday talking to
Mr. A will help him more. Therapeutic communications, consistency, trusting relationship, and other therapy have powerful impact to my patient.
• What other situations have I elicited the same feelings? How did I deal with the feelings in those situations?
I also experienced this kind of feelings when I met my friend’s auntie who was diagnosed with undifferentiated schizophrenia. His auntie was so very symptomatic. Usually talking to herself, repeatedly brushing her teeth and took two hours in taking a bath. She is usually naked unless you told her to put her dress on. She always fighting with her neighbors and throwing stones in their houses. I am so sad that Auntie wasn’t receive proper treatment and caring. I felt that her condition was deteriorating as time passed by. So, even with fear, I take the challenge to give my heart with her and try to take care of her whenever I go to my friend’s house. This is not easy for me since I am not yet a psychiatric nurse and it is my first time to encounter someone with this kind of disorder. I read so many books and study her disorder. Sooner, I established a good relationship with her and eventually my fear subsides.
• What kind of attitudes or opinions do I have about the client’s behavior?
Good thing in self- awareness is that it is a willingness to be open, positive and honest. It is being open to ourselves and to the world around that influences us and that we influence. In wanting to care, I already acting morally and ethically because I want to increase the influence of goodness in me so I really give values to caring. With the help of self-awareness, when I care, I cannot simply impose my own values and feelings but I need to respond with my patient’s own values and beliefs. A realistic self-awareness gives me personal boundaries and guides.
• Where these ideas, feelings and values do came from?
I think these ideas and values were come from the books and knowledge I have learned from my undergraduate and graduate course. The theories were also helpful. As with other areas of nursing practice, psychiatric mental health nursing works within nursing models, utilizing nursing care plans, and seeks to care for the whole person. However, the emphasis of mental health nursing is on the development of a therapeutic relationship. In practice, this means that as a nurse, I should seek to engage with the person in care in a positive and collaborative manner that empowers them to draw on their inner resources in addition to any other treatment my client may be receiving, not just merely giving medications and routine activity.
• To what extend does the way I am feeling right now interfere with my ability to relate therapeutically to this client?
Fear, anxiety, anger and other negative feelings I had honestly interfere me to be therapeutic to my patient. I sometimes don’t know what to say to my patient when my anxiety is high. I remember the time when my patient suddenly manifested manipulative behavior that he said he will not cooperate if I will not give him coins to buy cigarette. I honestly get mad on his behavior which I wanted to give punishment to him because I felt that he didn’t respect me as his nurse. Out of my anger, I told him to go to his ward and take his rest. I told to my attendant not to let my patient to go out to his ward for this day (just like I removed his privilege to be a ward helper). There was also a time that my patient hallucinates and I can’t get any relevant responses from him. I really fell anxious and fearful. I just said to him to go to his ward and just rest. I don’t know what to say or what to do so I just end our session. When I had my supervision, my professor said that I let the chance pass to elicit more information and to know what is inside my patient’s mind. So, sayang… but now I know and I learned….
• How am I feeling physically? Am I tired? Restless, apathetic, and so on?
Out of 10 sessions, 7 were handle normally yet challenging. Three sessions were unfortunately tiring. After interacting with my patient in these 3 sessions I feel so tired. I know that it is not a positive outcome when we are overwhelmed after interaction with patient since it is symbolizes that I was carried away and my feelings by my patient. But I just honestly saying this and I feel that I need a lot of things to do for the improvement of my knowledge, skills and attitude toward my patient and my profession.
• How do my perceptions compare with those of other team members?
I am glad that all my classmates in this course are really helpful and open in sharing their knowledge. I think my perceptions and their perceptions are almost the same.
• Does the setting for care influence my ability to interview effectively?
Yes.
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