NU674 Unit 5 Reflective Narrative on a Rushed Intake Example

Eleven Minutes In, He Called It a Waste of Time: A Reflective Narrative on the Questions I Skipped and the Examination I Wrote the Next Morning

[Student Name]

Purdue University Global

NU674: PMHNP Diagnosis and Management Across the Lifespan Clinical I

Unit 5 Reflective Narrative

[Instructor Name]

[Date]

The patient is composite; details are bracketed.

What Happened

The intake was my fourth at the county clinic. Mr. [R.], [48], operates a grain elevator and was referred by his employer's assistance program after two arguments with coworkers. For the first ten minutes he answered briefly. At about minute [eleven], after I asked the second question of the depression screen, he said, "Look, I've got a truck to unload at four. Is all this really necessary?"

I said, "We can move faster," and began skipping. I left out the rest of the depression screen, asked one question about alcohol, "Do you drink?", accepted his answer, "Some beers, like anyone," and did not ask how much or how often. I finished the intake in [35] minutes instead of [55]. My preceptor, who was in the room, said nothing during the interview.

That evening I did not write the note. I wrote it the next morning from memory. In the mental status examination I wrote that he was "hostile," "guarded," and "minimizing." My preceptor returned the note with three comments: "What did he do that you are calling hostile?"; "Guarded about what?"; and "How do you know he was minimizing if you never asked how much he drinks?"

What I Felt

When he challenged me, I felt embarrassed and anxious, as if I had been caught wasting his time. I wanted him to like me, or at least not to complain. Underneath that I felt a little angry at him, which I did not notice at the time but can see in the words I wrote the next day.

What I Now Think Happened

Two errors followed from the same moment. First, I treated his complaint as an instruction to shorten the assessment, rather than as information about him. His impatience may have been exactly what the arguments at work were about, and it was worth exploring. Second, I avoided the alcohol questions I most needed to ask. A standardized screen such as the AUDIT asks about quantity, frequency and consequences in a way that is quick and less personal than improvised questions; it was developed for exactly this purpose across different countries and settings (Saunders et al., 1993). Ten questions would have taken two minutes.

The words I wrote the next morning carried my irritation. "Hostile" described my feeling more than his behavior; he had crossed his arms and looked at his watch, which I could have written. "Minimizing" was an interpretation I had no data for. I did not ask the questions that would have told me whether he was minimizing, and then I wrote that he was.

There is also a lesson about how I responded to challenge. Moyers and Miller argue that empathic counseling is associated with better outcomes and that low-empathy, confrontational styles are linked to dropout and less change in addiction treatment (Moyers & Miller, 2013). I did not confront him, but I did something close to its opposite: I withdrew. Neither is the empathic response, which would have been to acknowledge his frustration and explain why the questions mattered.

What My Preceptor's Silence Taught Me

I asked my preceptor afterward why she had not stepped in. She said she wanted to see what I would do, and that the note would show her what I had thought. That was uncomfortable to hear, but it was right: the note did show it. Her three comments were not corrections of my grammar; they were questions that asked me to separate what I saw from what I felt, and to notice that I had drawn a conclusion from missing data. I have kept the returned note and reread it before each intake this month.

What I Would Do Next Time

1. When a patient says the questions are a waste of time, I will acknowledge it and explain briefly: "I know it's a lot of questions. The next few help me understand whether drinking is part of the stress at work, and then we're nearly done." Motivational interviewing offers ways to respond to reluctance without arguing or retreating (Miller & Rollnick, 2013).

2. I will use the AUDIT for every adult intake, since a standard screen is less personal and harder to skip.

3. I will write the mental status examination the same day, and I will reread it for any word that describes my reaction rather than the patient's behavior.

4. I will ask my preceptor, at the start of an intake, to signal if I begin to cut the assessment short.

What Happened After

At his follow-up visit two weeks later I completed the AUDIT. His score was [17], in the range suggesting harmful drinking, and he said he had been drinking more since his divorce. The arguments at work were on Monday mornings.

References

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). Guilford Press.

Moyers, T. B., & Miller, W. R. (2013). Is low therapist empathy toxic? Psychology of Addictive Behaviors, 27(3), 878-884. https://doi.org/10.1037/a0030274

Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption: II. Addiction, 88(6), 791-804. https://doi.org/10.1111/j.1360-0443.1993.tb02093.x