Process Recording

Description:
Students will conduct an approximately 15 min therapeutic interview with an assigned client noting all of the critical details and analyzing the interaction after completion. One satisfactory process recording is required.

Steps to Follow:
a. Introductory/orientation phase: Set a time to meet with your client. Select a setting that is conducive to a therapeutic interaction. Decide on a therapeutic goal for the session. Share the parameters with your client.
b. Working Phase/Termination phases: Begin your therapeutic interview, carefully observing the client and yourself for verbal and non-verbal behavior.
c. Complete at least 10 back and forth interactions (each Nurse said/Pt. said = 1 interaction).
d. Conclude the interview therapeutically.

PROCESS RECORDING GUIDELINES
INTRODUCTION
Communication is an essential component of the nurse-patient relationship. It impacts the nurse’s ability to positively influence the therapeutic relationship, moving clients towards an exploration of their feelings and attainment of their treatment goals. The process recording is a written record and analysis of the therapeutic communication (both verbal and nonverbal) between the nurse and her client. This exercise affords the student nurse an opportunity to analyze communication in an objective manner and examine the content and the process of the nurse-client interaction. Benefits include: learning to pay attention to the communication process; reflecting on the significance of nonverbal behaviors, and becoming comfortable using a variety of therapeutic communication techniques; becoming more self-aware by reconstructing and analyzing both your responses and those of your clients; and developing the ability to purposefully guide the process of the nurse-client relationship.

OBJECTIVES
• Initiate the nurse-client relationship using therapeutic communication techniques.
• Identify and describe both verbal and nonverbal data.
• Identify and describe therapeutic communication techniques used and rationale for use.
• Analyze blocks and alternatives to therapeutic communication techniques.
• Identify and analyze the nurse’s thoughts and feelings.

Include the following when filling out the Process Recording Form:

Setting: Describe your client including initials, age, diagnosis, ethnicity, and appearance. The orientation phase should be identified in the setting, including your initial efforts to establish rapport and identify goals of the communication. Describe the setting and environmental factors that affect the interaction including temperature, intrusions, noise level, distractions and lighting.

Nurse and Client Interactions( minimum 10 interaction): FOR EACH INTERACTION record and analyze the words spoken by you and your client verbatim from memory (you may not take notes or record conversations), as well as the nonverbal behaviors, including body language and affect. This content should encompass the working and termination phases of the nurse-client relationship and not include any interactions that take place in the orientation phase.

Analysis ( minimum 10 interaction): FOR EACH INTERACTION identify the therapeutic communication techniques utilized (page 155/156, Table 9-2 Halter text)and textbook rationale for use in each of the interactions between you and your client. Identify any blocks(page 156, Table 9-3 text)and evaluate what you might have said and done differently to elicit communication at a feelings level (write in direct quotes what should have been said to change this from a non-therapeutic to therapeutic communication)and further the therapeutic communication process. Reflect after each interaction and identify your thoughts and your feelings that occurred during that exchange.

Summary: Summarize your overall impressions of the interaction, and assess the role that the setting played in the communication process. Critically evaluate the effectiveness and therapeutic value of your exchanges and how you managed termination of the interaction. Discuss therapeutic communication techniques that were most useful and lessons learned from this interaction. Identify areas for improvement for the next interaction and any themes which you would continue to explore with your client.

Resources:
Halter textbook: Chapter 9 (see an example of a process recording on Table 9-4) Varcarolis care plan manual: Ch 2 & 3 (refer to Nurse’s Communication Self-Assessment Checklist on Table 2-3).

My patient is 43 yr old white bipolar . please improvise as if you interviewed the bipolar patient.