Pictures of a Client's Silent Distress

The client was celebrating his birthday and the family was present. The candles on the birthday cake were blown out, the food was almost gone, and the birthday wishes had all been offered. One thing remained to be done: the family picture taking.

The family members gathered warmly around the client and called out, “One, two, three … say cheese!” Snap! The family picture had captured the joy of the family … or so we'd assume. My client has suffered from chronic obstructive pulmonary disease for the past three years. Recently, he has been suffering from severe smokers ‘cough and, after he expelled blood twice at home, the family decided to admit him to the hospital for treatment and observation. His birthday fell on the third week of his admission.

The client's family had thanked me for caring for their dad and had happily shared with me family pictures from the birthday celebration. One glance at the client's face told me he didn't enjoy the occasion. The picture captured the client's long face, expressing rueful emotions and depicting a troubled spirit. His arms were crossed and he pasted on a smile that couldn't reach his eyes. I felt that the picture was beckoning me to address my client's unspoken distress. Because of the picture, I was able to identify the client's lack of interaction with his family. Although he was the guest of honor at the event, he stayed in the corner, silent and brooding. In fact, soon after the picture was taken, he immediately requested to be taken back to his room.

I said goodbye to my client's family and went into his room. As I helped him lie down on the bed, I asked, “Mr. Jones (name changed to protect privacy), how are you feeling?” He pursed his lips and grumbled from deep in his chest. “Did you enjoy your birthday party?” I continued after a few minutes. He turned to me and said,

How can I enjoy my birthday when all I want is to die? Why can't I just fall asleep and die? I can't eat the food they prepared. I'm weak and have to be carried outside. I wish my suffering would end already so I don't have to be a burden anymore. I feel so utterly useless, when I used to be the one they looked up to for so long.

Without words, his expression in the family picture had alerted me to his psychosocio–spiritual problems. In fact, that picture became a starting point for further assessment of intrapersonal and interpersonal distress that the client may have been experiencing during his illness.

Advancements in technology have provided myriad ways to capture precious and vulnerable moments easily. Photos have been used in health care settings for forensic investigation (Brown, 2010), for documentation of physical symptoms (Bhatia, Desai, Brodell, & Horvath, 2010), and for education and research purposes. Day-to-day comparisons of the healing of wounds, whether traumatic or surgical, can be done through photos (Harty-Golder, 2004). These pictures, taken with permission, serve as evidence that thorough health assessment has been done, and specific care planning and quality care activities have been implemented.

However, it is rare to hear health care professionals talk or write about using photographs to assess client's psychosocio–spiritual problems in day-to-day caring activities. We are accustomed to regarding interviews with clients as the gold standard. Additionally, there are concerns that health care providers may invade a client's privacy through the use of the latest mobile and entertainment devices with built-in cameras (Young & Massey, 2008). I became acquainted with that issue a few years ago when a medicolegal case with a similar scenario in my local community was addressed by news media.

In some cases, a client may voluntarily share photographs from childhood or of his or her family. When accessed through personal disclosure, these photos, whether printed or electronic, can become an objective nursing diagnostic tool, not only in depicting physical aspects, but also the psychosocio–spiritual aspects of client's health needs. Photos can depict a halfhearted smile, a pained expression, or a distant interaction between people.

Photo sharing is often followed by a narrative of what was happening in the picture. During this conversation, our mental cameras should work to capture any silent distress that the client may be harboring. Photo sharing can then be a modified version of narrative therapy. Narratives are effective caring approaches to clients with internal distresses (Aloi, 2009). Being able to reveal their emotion through words, whether verbal or written, can be stress relieving (Seaward, 2011). Narratives can be even more therapeutic if combined with photo sharing because the visual depiction of events tends to trigger a stronger memory.

Similarly, nurses encounter scenarios wherein they do not feel right about their client's environment, although physical improvement is evident. Even in the absence of photographs that objectively depict the client's unspoken distress, nurses sense their client's anguish from the tone of voice, hidden meaning in words spoken, body language, or the negative “aura” of the environment.

By using their intuition and their senses, nurses activate the natural camera of the human being to capture the unfiltered moments of clients and, thus, to be able to reach out to them. This is the best camera equipment that a nurse could ever have. A good example of the use of our mental cameras is the general mental health assessment of a client. During assessment, we observe how our clients interact with us and with other people, how they carry themselves, and how they express their thoughts during conversations. Sometimes, our intuition tells us that something isn't right with our client. Through observation, listening, and conversing, we are able to encourage our clients to open themselves to us. They may not have spoken the words that pinpoint a specific nursing problem, but their body language or tone of voice speaks for them. Our five senses are truly a great tool for us to use throughout the holistic nursing assessment.

By using their intuition and their senses, nurses activate the natural camera of the human being to capture the unfiltered moments of clients and, thus, to be able to reach out to them.

Nurses can use kinesics to interpret other people's behavior, and use awareness of their own body language to facilitate communication.

The project called Transforming Care at the Bedside (TCAB) has advocated the use of situational awareness as a quick assessment to determine the need for immediate nursing care (Struth, 2009). A tool called 60 Second Situation Assessment is particularly helpful for prioritization of client care when handling a high census. It is also used as a teaching tool for students to develop situational awareness of the client's condition. Before report, the nurse visits the client for 60 seconds to observe and interact with the client and family, while mentally sensing the client's environmental condition. This helps the nurse answer questions that aid in determining the level of nursing care needed. Without touching the patient, the nurse can gather data in the following categories: airway, breathing, and circulation (ABC); presence of and problems with client's tubes, lines, and respiratory equipment; client safety; sensory and intuitive observation of client's environment (“rightness of the situation”); and whether additional information is necessary to expose unexpressed concerns of the client (Struth, 2009).

Client's silent distresses fall under the latter two categories. Observing clients ‘and family members ‘facial expressions and interactions, along with the feel of the situation in the environment (positive, depressing, or awkward), will help the nurse formulate further questions about the client's psychosocio–spiritual status.

Constant practice in using the mental camera can reduce the time needed to complete the situational assessment. With experience, I have been able to reduce the length of time to complete the situational assessment from 60 to 40 seconds. TCAB faculty learned that students have improved their time from 60 to 15 seconds (Struth, 2009).

Actual and mental photos with narratives provide evidence of the need to address the client's silent distress. A subjective assessment of client distress is a strong foundation in implementing psychosocio–spiritual nursing care, but a specific statement paired with an objective description of the client's disposition would be much stronger.

During photo sharing, situational assessment, and interactions, nurses can use the science of kinesics (body language) to further explore the client's silent distresses. Nurses can use kinesics to interpret other people's behavior, and use awareness of their own body language to facilitate communication. There are several uncommon body language behaviors that, when interpreted, can provide insight into the client's status. For example, if the client scratches his or her neck during conversation, this behavior often indicates that he or she is doubtful. Or, if a client tends to hold his or her head up high, this may be a signal that he or she is maintaining his or her pride or feeling resistant to the care given (Chapman, 2009).

Applying kinesics to Mr. Jones's case, I recognized that the patient's pasted smile indicated that he was not genuinely happy during the event. He was also trying to distance himself from his family when he crossed his arms and kept himself isolated in the corner of the room. When he pursed his lips while conversing with me, he was contemplating whether to open up about his frustrations.

By using a kinesics interpretation of the photograph and the follow-up narrative, I was able to identify five nursing problems. From his response to the questions, I sensed the client's spiritual distress. He desired to be freed from his illness … to be free from the physical suffering. He struggled with ambivalence about wanting to live or to die. The client described ineffective role performance because of his inability to fill his important role as head of the family after becoming severely ill. He felt powerless and had low self-esteem because he assumed that he was just a burden, useless as a father and as a provider. Furthermore, from his silence during the festivities and lack of interaction with his family, the nurse can diagnose that the client is having impaired social interaction with his family.

I listened to Mr. Jones's stories of pain, frustration, and ambivalence regarding death during the course of his illness. I provided emotional support, helped him to connect with his family members again, and assisted him in recognizing that his family has been cheering him on throughout the ordeal rather than thinking of him as a burden. On the day of his discharge, he held my hand and smiled. “Thank you,” was his simple message to me.

Often, it is difficult to hear a client's cry for help because it is internal and silent. If a client shares photos, be observant and listen to the stories diagnostically and therapeutically. Also, do not forget to practice mental photography skills to capture the client's distress in the clinical setting. Through the use of the situational awareness assessment tool, we can assess his or her needs and provide nursing care holistically.