Therapeutic Communication and Leave Out Judgment
On Tuesday morning, at the beginning of my clinical shift, I received report on my client, we’ll call him M.K., a middle aged male. This is what I heard from two different nurses and a patient care tech who gave me report: “He’s crazy” and “I think he’s lazy and very unmotivated.” Also, according to these same nurses and tech, they informed me that M.K. was completely dependent, needed to be fed (but most likely would refuse it), was incontinent and wearing a brief (and would probably refuse to be changed), that he would most likely sleep all day and that he refuses meds and food. I did some further investigating in the chart to find out that his diagnosis was: Failure To Thrive.
I decided to get his vitals and do a head to toe assessment on my patient, so that I could get a closer look myself. M.K. did not talk to me, but instead answered my questions with a head nod for yes, or a head shake for no. He was cooperative and calm during the assessment. One of his nursing diagnoses was Risk for Impaired Skin Integrity, but when I asked him to turn to his side so that I could assess his back, he was able to turn all by himself without any difficulty. Additionally, he had very good lower and upper extremity strength and ROM, and I’d call it a 5+. After the assessment, I got the feeling that M.K. was comfortable with me, so I felt it would be a good time to ask him if I could come back later in the day to get him cleaned up and change his bed linens. He nodded his head to say yes. Then, in my mind, I decided that during the bed bath, I’d try and build more trust with M.K. and possibly get him to open up to me a little more. Perhaps, I’d even get a chance to hear his voice.
After charting his vitals and head to toe assessment, I decided to take a deeper look at his past medical history, physician progress notes, current meds, and consultations. I gathered so much information and learned a lot about my patient that helped me understand him a little more. Here’s a brief look at the information I gathered from his chart:
Past Medical Hx:
- ARDS (acute respiratory distress syndrome)
- Acute Lymphocytic Leukemia
- Respiratory Failure- resolved
- Acute kidney injury
- Sepsis Syndrome
- PEG tube
- Percutaneous Tracheostomy
- Blind eye
Physical Therapy Notes- Pt. tolerated EOB ~ 10 min. Pt. refused OOB, and exercises at EOB. Pt. exercised supine.
Psychiatric Notes- Not cooperative. States he did not request a visit. Pt. anxious, angry and depressed. No delusions. No hallucinations. Thought process- circumstantial.
Pastoral Care- Chaplain made a visit on the 23rd. Pt. believes his medical condition is a result of the “bad things he’s done”. He’s frustrated and angry that he has become “a shell of a man.”
Chaplain documents: Grieving over death of father and brother over the past year and expressed a “renewed” appreciation for his children and family.
Pt. states he “has given up” and that he wants to die. Flat affect. Pt. also spoke to chaplain about his experience in Marine Corps combat operations.
Religion: Roman Catholic
Physician Progress Notes (pieces that I took from all of the notes)- Patient has lost two family members within the past year. He has a daughter and an ex-fiance. In Feb. he walked into the ER and was independent. By October, he is non-ambulatory and a Fall Risk. He was intubated sometime in March and had a tracheotomy performed. His Braden score from Feb. was 21 and now in October it is 14.
At Risk for Pressure Ulcer
At Risk for Falls
Self- Care Deficit
At Risk for DVT
With this information from M.K.’s chart, my nursing diagnosis quickly became Hopelessness, since the chart stated that he has no desire to live, is dealing with the loss of his father and brother, has declined a great deal in health over the past 8 months, is non-compliant, and is refusing meds, food, and help.
Later that morning, my fellow nursing student and friend Ali joined me in M.K.’s room to help him with a bed bath and to change his linens. He was very cooperative and helpful when we asked him to turn from side to side. He also started to slowly open up to both of us. I could tell by his non verbal communication, facial expressions and his head nods and shakes that he was fully oriented and cognitively sound. I’m not sure how I knew this, but I did. When he finally decided to speak, his speech was very slow and a little slurred, but understandable. I could tell he was self conscious about it. However, we managed to find out a little bit about his time in the Marine Corps and that he was born in Illinois. I could tell that M.K. enjoyed the attention he was getting from me and Ali, and we spoke to him as we would speak to any healthy middle aged man. Our speech was clear, regularly paced and we used no form of “baby talk”. His facial expressions were congruent with his speech. When Ali told M.K. that she was going to her friends graduation from Marine Corps, she followed with the statement, “ He says it was very hard.” Then when she asked, “Is that true?”, he shook his head no and gave her a look that said “come on……pleeeeease”, with raised eye brows and a crinkled forehead. It was so funny and all three of us laughed. Then Ali said that she planned on giving her friend a hard time for being a “wimp” about it, which in turn made M.K. smile. I could tell that M.K. has a sense of humor.
I made my visits throughout the day to check in on M.K. and to further build a relationship and trust with him. Then I said good-bye to him later that afternoon with the promise to return in the morning.
On Wednesday morning, I decided that I needed to get M.K. out of the bed and carry on a therapeutic communication with him at some point in the day. I felt M.K. needed some human interaction and activity since the day before he spent the entire day laying in bed, with no visitors and minimal contact with nurses, other then myself and Ali. I was hoping he would consent to walk the halls because his chart read up with assist, but he shook his head “no” to that idea. However, he was willing to get up into a chair. After checking his vitals and doing a head to toe assessment, I let him sleep for a bit while I got my thoughts together, came up with questions in my mind that I wanted to ask him, and found 2 chairs (one for him and one for me). By late morning, he agreed to get up and sit in the chair. He was very unsteady and weak upon transferring to the chair, but he worked hard to try and help me and the kind male nurse who helped out.
We sat and talked for about 30 minutes and here’s how our dialogue sounded:
Me: How does it feel to be up and out of bed?
M.K.: nods his head yes, which for him means “good”. Then out of the blue he says, “ My brother died last year”.
Me: Wow, I’m so sorry to hear this!
M.K. He shot himself in the head. He makes a gun shape with his hands.
Me: Do you miss him?
M.K. shakes his head no.
Me: Are you sad about it?
M.K.: shakes his head no
Me: Are you angry that he did this to himself?
M.K. nods his head yes.
Me: I’m so very sorry. Were you close with him?
M.K. shakes his head no
Me: Do you have any other siblings?
M.K. nods his head yes. I have an older brother. He lives 2 hours away.
Me: Do you get to see him often?
M.K. Yes, I saw him last week.
Me: That’s good!
The house keeper comes in and our conversation changes when M.K. asks her if she’s Polish. She says no and that she’s Italian. So, our conversation shifts to talk about food.
M.K.: asking the house keeper. Do you like to cook?
Me: I love to cook too! What nationality are you?
M.K. I’m Irish. I like to cook as well.
Me: What’s you favorite thing to cook?
M.K. Spaghetti. He smiles.
Me: Now I’m hungry for pasta.
We carry on a conversation about food and making homemade pasts and I can tell that M.K. is thoroughly enjoying human interaction. I go on to ask him what he does now after the Marine Corps and he tells me he was a manager of a big manufacturing company. He also shares with me that he lost his right eye in a bar fight (only after I carefully asked how he lost it) and that he has lived in Florida for 14 years and likes it here.
Me: Where do you plan on going when you leave the hospital?
M.K.: Port Charlotte.
Me: Does someone you know live in Port Charlotte?
M.K.: Yes, my mom. She’s crazy.
Me: Are you being sarcastic or literal?
M.K.: No, she’s literally crazy!
Me: Well, then she will probably love your help when you leave the hospital and go to Port Charlotte.
M.K. he nods his head yes.
M.K. goes on to tell me that his father died a year ago from cancer and a little more about his time in the Marine Corps. Also, he tells me that his speech is slow and slurred because of the tracheostomy, but that he still has his mind.
M.K.: I’m sharp in the head. He points to his forehead.
Me: I know you are! I knew that the minute I met you. Do you feel frustrated because you can’t speak as quickly as you used to?
Me: Well you have your mind and your heart is healthy, right?
M.K.: Yes! It’s just the rest of my body doesn’t cooperate.
Me: So, that makes you feel frustrated?
Me: I bet that is very frustrating.
M.K. tell me that he needs to use the bathroom, then points to the urinal on his bed rail. While maintaining privacy and dignity, I help him use the urinal and at the same time wonder why he is wearing a brief and labeled as “incontinent”, if he is able to ask for and use the urinal. He voided 600 cc. I think to myself that I will bring this to the nurses attention. Perhaps he feels powerless to ask the nurse and maybe his slow slurred speech stops him from asking for help with the urinal.
Then we finish our conversation.
Me: Does it feel good to be sitting in a chair?
M.K. Yes, all I do is lie in the bed. I feel like their puppet. I want to walk.
Me: You want to walk? That is wonderful.
M.K. I want to see a physical therapist. No one ever comes to see me.
Me: I will check on that for you. I think that is a great idea!
I went and checked the orders and emphasized to his nurse and the charge nurse his desire to ambulate. Prior to this, he was uncooperative and non compliant with no desire to ambulate or get better (or at least according to the chart notes).
Me: So, you want to begin the process of recovery and ambulate with physical therapy?
M.K.: Yes, I want to get out of here.
Me: You are ready to move on with your life, aren’t you?
Me: I talked with the charge nurse and she said that physical therapy is still on your case and that they should be visiting you this afternoon. How long would you like to stay in the chair today?
M.K.: One hour
Me: Ok, that would be until 12:20. I had a great time talking with you! Thank you for letting me sit with you. I will be back to check on you in a little bit and then at 12:20, we will get you back in bed. I think it’s wonderful that you want to start the process of recovery.
I continued to check on M.K. throughout the day and engage him in conversation as much as possible, and even tried to get him to play a card game with me. He refused the card game, but I did make progress.
Many questions flooded my mind after walking away from the hospital on Wednesday afternoon. Why is M.K. not up in the chair at least once a day, when he got up in the chair for me today? Why isn’t M.K. comfortable asking for a urinal or bedpan and why is he in a brief, when he proved to me today that he can ask for and use a urinal? Why is M.K. on continuous tube feed instead of being encouraged to eat meals throughout the day? Why is M.K. sleeping in bed all day long instead of being encouraged to engage in conversation and activity? There were more questions, but I’ll stop at those. Perhaps these things did/do happen, but on the days I was not there or during the night shift. I do believe though, that M.K. needs continuous consistently attentive and proactive care in order for him to move forward and make progress.
I walked away from my experience with M.K. with 4 major points that I will take with me in my work as a nurse. First, I learned that when receiving report, there is some valuable information to obtain, but that more importantly, I need to do my own assessment of my patients from “scratch”, free from judgements or un-factual information stated about the patient from the other nurses. If I had assessed M.K. based on what the nurses and tech had told me about him, I’d have gone into his room with the thoughts of “he’s lazy” and “he’s crazy” and “non-compliant”. If I had let these judgments become the basis for the care I planned on giving, then possibly I wouldn’t have given him a chance to tell me about himself or realized that he was able to do so much more for himself then what the other nurses had given him credit for. The fact that his speech is slow and slurred makes M.K. feel as though people think he’s not “all together there”, but in fact he is. He was compliant with everything I asked of him, and oriented to person, place and time. He knew where he was, the year, his name and the vice president (which he actually gave to me before I even asked him). He answered questions and made statements that gave me proof that he was cognitively healthy. The nursing diagnosis he obtained of Risk for Pressure Ulcers is important when he receives no attention, because he does lie in bed all day long. However, by taking the time to communicate and show care and interest in M.K., as well as treating him with dignity and respect and advocating for him, activity is welcomed by him and there is a big decrease in the chances of impaired skin integrity. He is able to turn himself, willing to sit in a chair and willing to communicate with the person who treats him as a human, implements communication and empowers him. He is also able and desires to use the urinal or bedpan. Who wants to lie in a brief all day long? He needs to be proactive along with the nurse in his care and recovery, including involvement in activity, eating meals throughout the day, regular communication and voiding in the urinal (as opposed to a brief).
Second, patients needs to be cared for by the nurse holistically. When treating a patient, especially those like M.K., if the nurse only treats the client based on physical needs, then someone like M.K. would be turned q2 hours, bathed, fed via tube feed and given meds. But, M.K. needs much more then just physical care alone. He needs care of his spirit, his mind and additional care of his body, such as ROM exercises and getting up to walk. I do believe M.K. struggles with powerlessness because of his physical condition and trouble expressing himself verbally. I also believe that he is in spiritual distress because of his “past mistakes” and statements of being “ a shell of a man”, as per the chaplain notes in the chart. Additionally, I thinking he’s still grieving the loss of his father and the horrible tragedy of his brothers suicide. All of these factors can definitely cause a person to obtain the diagnosis of Failure to Thrive. I feel that his emotional and spiritual health has deteriorated a great deal in the past 8 months (per chart notes), which in turn has caused many physical problems. But, I saw hope in him. Hope to walk again. Hope to get out of the hospital. Hope to work again and to help his mother. In my opinion, I think M.K. can recover quite well if he’s given the time and consideration he deserves. I also feel that all of the nursing diagnoses of Self Care Deficit, Nutrition Deficit, At Risk for Pressure Ulcers etc. stem from his feelings of Hopelessness and Powerlessness. If the latter two nursing diagnoses are treated, then I think everything else will fall into place. This was evident after my therapeutic communication with him because he was willing to get out of the bed and into a chair, showed signs of mood elevation, used the urinal instead of voiding in a brief and finally consented to taking his meds after refusing them on every other attempt prior to our meeting. Of the meds he consented to taking, one of those includes sertraline, which I feel will benefit him because its an antidepressant. Holistic care is crucial.
Third, I learned the importance of therapeutic communication. I made sure to set aside the judgmental statements from the nurses and techs who had worked with him before and purposefully got to know my client on my own terms, as though I’d never heard anything about him before. I learned that he was completely different then “crazy” and “lazy” as I had been told by others. I learned that he was very depressed, but still had hope at the same time. I learned so much about my patient, that neither the prior nurses nor the chart could tell me. All of this starts slowly though, with building trust and respect from the client. I will read this reflection periodically throughout my nursing career as a reminder of the importance of therapeutic communication.
Lastly, I learned the importance of collaborative care. For me to have made such progress with M.K., but then fail to share with the new nurse at change of shift, tech and the charge nurse on board, there could be regression in M.K.’s progress. It is important that every nurse and health care worker working with M.K. see the improvement he has made and be on board to continue empowering M.K. and advocating for his success and health holistically. If I’d been the one to give report to the new nurse during change of shift, I would have told him/her that we need to:
- Get M.K. up to a chair at least 3 x’s per day with the goal of ambulating.
- Practice R.O.M. exercises at least 2 x’s a day.
- Discontinue use of brief. Encourage patient to use the call light for help with using the urinal or bed pan. Check on patient during hourly rounds or sooner to ask patient if he needs to use urinal or bedpan.
- Continue to build trust with M.K.
- Implement therapeutic communication as often as possible (even if during bed bath or head to toe assessment).
- Provide human interaction or rounds every 30 min. to 1 hour and engage him in conversation and touch.
- Encourage use of meds and SCD’s and explain the purpose of both.
- Consult the physician to change order from continuous tube feed to only at night and encourage patient to eat food during the day.
- Provide pastoral care as needed
I would also make sure that everyone is aware of his self consciousness regarding the difficulty he has in expressing himself verbally. He doesn’t want to be treated as though he’s “crazy” or “not there” just because he has slow and slurred speech. I would reiterate the importance of speaking to him as you would any other healthy 48 year old person, leaving out language that would make him feel as though he’s “stupid”. I believe that all of these activities would benefit M.K. as he moves to independence and control over his life again. Also, collaborating with physical therapy is very important in helping M.K. recover fully, because prior to my time with him, he was non compliant with PT. He now has a desire to work with PT and walk again per his statements to me during our conversation. He’s making great improvements and that needs to be maintained by everyone caring for M.K. if progression is to continue.
In conclusion, I feel extremely grateful for the experience I had with my client M.K. and thankful that he was my client. I am reminded of why I chose nursing as the path for me. This experience taught me so much and will be a good reminder to me always of the importance of therapeutic communication, holistic care, and collaboration, to completely and fully care for the client. Additionally, I will always remember to treat and meet every patient free of judgment, even if others say judgmental things, like “ he’s crazy”. Almost always, there’s a reason behind the way people behave and with a little time, trust, and communication many things can be uncovered, and the “why” for the behavior revealed.