Neosho County Community College

Mary Grimes School of Nursing NURS 261 Mental Health Nursing Mini Process Recording Instructions and Example LEVEL I, II and Bridge

Student Nurse:_____________________________ Date of interaction:___________________________ Group: A B C D E F

Writing A Process Recording The purpose of a process recording is to communicate, identify, practice, and record the use ofTherapeutic communication techniques vs. having a general conversation. A Process Recording allows the conversation to focus on specific issues and feelings the client may have. Being therapeutic does not focus on giving advice or asking why questions, but will focus on a style of communication involving listening, observation, clarifying, using open ended questions, seeking accurate information and being aware of your client s belief processes and behaviors. THE PROCESS RECORDING IS A LEARNING TOOL. The Process Recording is a written report of a verbal interaction with a client. This is a verbatim account written by the student and is a tool for improving interpersonal communication techniques. The Process Recording helps the student to look at the content and pattern of the interaction. The Process Recording is not doing THERAPY but is a helping communication process. It also is not just conducting an interview,nor is it a tool to persuade the client to reveal secrets. Your assignment: Level 1 and Bridge students will complete one Mini Process Recording. Level 2 students (Mental Health, NURS 261) will complete two Mini Process Recordings. HOW: The format will follow the Phases of relationship development. You will conduct a therapeutic interaction based on a problem/ goal/outcome that your client identifies and would be willing to discuss. This verbal interaction when written out becomes a Process Recording. From your verbal interaction, you will identify and record: y TT: therapeutic techniques used y FW: Feeling words your client uses y DM: defense mechanisms your client uses y NTT: Non- therapeutic techniques you use y NV: non-verbal behaviors you notice your client uses and what you yourself use

MINI PROCESS RECORDING Instructions and Example

y ST: subjective thoughts you experienced during your interaction

Use your text book and handouts for examples. WHAT YOU DISCUSS WITH YOUR CLIENT: You will follow the phases of the relationship outlined below. y y Ask your client if there are any concerns that they would like to discuss. Sometimes the person does not identify a problem or concern. Consider: What concerns or issues do they see as stressful or have difficulty coping with. Focus can be on their coping skills or how the person handles stress.

YOUR GRADE: Write a brief setting the scene in the Pre-orientation phase. This will include brief information about the client and describing the environment where the interaction took place. Identify a minimum of: y y y y y y 4 TT s (therapeutic techniques) 2 FW s (feeling words) 1 DM (defense mechanisms with rationale) 1 NTT (non-therapeutic technique you made and what would make it therapeutic). NV behaviors used by the client and yourself ST: (subjective thoughts you have)

Additionally, you will: y y y y Write one NANDA Nursing Diagnosis Establish one client centered outcome (goal) that can be accomplished during this interaction Evaluate the outcome - state if met or not-met with as evidenced by Write the student s evaluation

Your ability to complete the required criteria and have continuity will be evaluated. The Process Recording does not need to be long, try to keep it no more than 3 total pages. Word Processing is preferred and an electronic copy will be available on Inside NC. Neatness, spelling, and legibility will be considered in your overall grade.

MINI PROCESS RECORDING Instructions and Example

Important Tips to remember: Do not take notes while you are engaged in your therapeutic interaction - take a break if necessary. Maintain therapeutic boundaries with the client. Avoid touching or allowing the client to touch you. Do not isolate yourself in a private room with the client - find an area where you can maintain confidentiality yet have access to others. Always report to the staff and clinical instructor all threats the client may express of hurting self or others. Do not promise to keep secrets - between us type statements. Be honest and tell the client this. You will address all of the /steps of the PR unless your instructor directs your otherwise. Always report any emergency situations to the nurse and instructor immediately. Review the examples of Process Recordings to help you with the format. Maintain a professional approach with the client If the client does not want to talk, contact the nurse or instructor to help you meet another client.

MINI PROCESS RECORDING Instructions and Example

Grading The Process Recording

Each Process recording is worth 40 points. See the PROCESS RECORDING GRADE SHEET . (What s discussed in each step of the Process Recording) Step I: Pre-Interaction Stage: This stage of the interaction process considers the student s feelings as to their ability to work with a client. You will gather information from the medical record and staff that can be included in the Setting the Stage section. Step 2: Orientation Stage: This is the beginning of your process recording. You are gathering assessment information in this stage. YOU WILL DISCUSS THE FOLLOWING USING THERAPEUTIC TECHNIQUES: y IDENTIFY YOURSELF - STATE YOUR PURPOSEIDENTIFY THE PROBLEM ISSUE YOUR CLIENT WANTS TO DISCUSS y SET AN OUTCOME y DEVELOP A NURSING DIAGNOSIS . During this stage you will start to develop trust and rapport, and also establish where to meet. You will be completing a general bio/psycho/social assessment. _________________________________________________________________________________ Step 3: Working stage: YOU WILL DISCUSS THE FOLLOWING USING THERAPEUTIC TECHIQUES: THE MAIN FOCUS IN THIS STAGE IS TO DISCUSS THE SPECIFICS OF THE PROBLEM IDENTIFIED AND THE OUTCOME (GOAL) SET IN THE ORIENTATION STAGE. You will discuss specific feelings, do some teaching, help the client look at coping skills and explore the use of new skills. This is the time to talk about the problem. You may encounter the use of defense mechanisms, Although you may encounter inappropriate behavior, you may also encounter positive behaviors and willingness to change. Your job is to verbally clarify and guide your client s responses in order to keep the conversation going. _____________________________________________________________________________________ Step 4: Termination stage: YOU WILL DISCUSS THE FOLLOWING USING THERAPEUTIC TECHNIQUES. THE MAIN FOCUS OF THIS STEP IS TO ASSESS AND SUMMARIZE WITH THE CLIENT WHAT WAS DISCUSSED IN STEPS 2 AND 3. This can include progress made,and how the client can better cope with the problem or concern. You may also assess the client s ability or willingness to try new coping strategies. SHOW CLOSURE OF THE INTERACTION. (How did you end the interaction - use verbatim words) EVALUATE THE OUTCOME WHICH WAS SET. Identify positive outcomes, the need for ongoing assessment, or discharge planning if appropriate. If not met, what would you change?

MINI PROCESS RECORDING Instructions and Example

_____________________________________________________________________________________ COMPLETE THE STUDENT EVALUATION

LEVEL 1/11/BRIDGE: MENTAL HEALTH NURSING

Student name: A Student Group: A B C D E Instructor: T. Instructor

Preorientation: Setting the Stage: Admission Date: 7/10/10 Describe environment: Day Hall. Sat at the end of the day hall to decrease noise and stimuli.

What was the client s behavior that required admission and/or what requires the person to remain at the facility: (briefly describe): Client was court ordered because he became aggressive and hit his Father. He had been refusing to take his medication for a month and on admission told staff that he was able to heal himself and didn t need that stuff making me into a zombie . States I m angry and says his Father tries to run his life . Step #2 ORIENTATION Nurse statements & nonverbal behavior Client s statements &nonverbal behavior Subjective thoughts Interpretation of therapeutic techniques

Hello, who are you? Good Morning ---- I am_______ a student. Oh, you re a student. (frowns, then smiles) I hope this goes well. He looks okay. TT: Giving recognition

I would like to spend some time talking with you today. (smile, eye contact) We can talk about any of your concerns. (sit at table with client) You sound concerned about your medication. Tell me more.

What about? I can t say too much, but I can tell you some things. Well, it s the medicine, always the medicine. (waves his hands in the air) I don t like to take my medicine. I get upset when people tell me to take it, It made me sleepy. (shakes head back and forth). I am 22 years old you know.

TT: Offering self

This may be hard, he seems like he will talk, but who knows?
FW: Like, upset TT: Making observation TT: Offering general lead

MINI PROCESS RECORDING Instructions and Example

NANDA NURSING DX: Non-compliance with medication regimen r/t refusing medication based on side effect of increased sleepiness and feeling like a zombie

Client centered outcome (goal) to be achieved: Client will verbalize one benefit for taking medication by 1100 today. (9/22/10) Working stage: Step 3
Nurse statements & nonverbal behavior When people tell you to take the medication, it upsets you. Client s statements & nonverbal behaviors Yes, I should be able to make my own decisions. Subjective thoughts

Interpretation of therapeutic techniques

TT: Restating

I hear you saying you want to make your own decisions. (look down, move back in chair) What happens when others tell you to take your medicine?

Yes.

Well, I get mad. My Father does that all the time. I hit him, but that was wrong and I m sorry I did that. (looks away) He tries to run my life, but I don t want to talk about him. I need to talk about my medicine with you, right? (smiles& leans back). The medicine slows me down & I can t do my work. It makes me sleepy. I like to feel energy, I want to keep moving.

I wonder if it makes him anxious. I think he needs to talk about his anger.

DM: Suppression: (doesn t want to talk about his Father) FW: Mad, I m sorry DM: Projection: Blaming My Father does that all the time NTT: Probing: Asking several questions & why Better to say: Yes, tell me more about your medication. OR: What are some of the reasons you stopped taking your medication? TT: restating

Now, I wonder if he is testing me.

If you want to talk about your medication, that s fine. Why did you stop taking your medication?

Is this part of his symptoms?

It slows you down? (look at him)

Yeah. Like a zombie. My Doc has changed my medication and I am not as sleepy now. I like that I can do something. I guess so. I just want to make my own decisions. I decided to take my meds.

I wonder if he will stay on his medication?

FW: feel like a zombie

So, is this something you see as positive?

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Working stag: Step 3 continued

They tell me I may go home soon so I had better work with them. That means taking my medication So, your plans are to continue taking your medication after discharge. It sounds like you have decided your medications help you to do your work better. (looking at my watch) Well, it s about noon. It s time for me to leave. Who knows. Yes, I plan to go back to work at McDonald s. I need to do my job well. Yeah, I can think and do my work better and follow orders. (smiles) Wow, something positive. TT: Verbalizing the implied.

Is there some doubt about taking the medication?

Yeah, it s time to go. I am off to take my meds.(smiles, leans forward, loud voice)

NTT: Looking at my watch. May imply I am anxious to leave. Also, I changed the topic abruptly. Better to say I see people lining up, is it time for lunch?

Step 4 TERMINATION
Nurse statements & nonverbal behaviors I have enjoyed talking with you this morning. We talked about your medication and how you aren t feeling so sleepy now and how it helps you to concentrate on your job. Also, how important it is to you to make your own decision. (make eye contact) Thank you, have a good day. (stand up)

Client s statements & nonverbal behavior Yeah, I liked talking with you too.

Subjective thoughts

Interpretation of therapeutic techniques

FW: liked

Well, made it through without him getting upset with me.

TT: summarizing

Right. I am 22 years old.

You too. (smiles and walks over to

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the medication room.

Grading Criteria
Outcome evaluation: Met. He stated that the medication he is on now doesn t make him as sleepy. Also, suggested that he needed the medication to help him do his work at McDonald s by increasing his ability to do his work and to concentrate. Student Evaluation: I was really anxious and I asked the why question & probed. I need to work on my anxiety. I am close to this client s age and I need to think about being therapeutic. It would be easy to just talk about every day things, like music. I think the interaction went pretty well, I was able to use some therapeutic techniques & managed some teaching, but it is hard to think of the right thing to say. I am not sure if he will stay on his medication once he leaves so I think he needs continued education and reinforcement regarding his medication. Also, I think there are unresolved issues with his Father that he needs to work on. I wonder where he plans to live once he leaves. This could be important.

PROCESS RECORDING GRADE SHEET CRITERIA Setting the stage Nurse Client Subjective Thoughts Therapeutic Techniques (4) Non-verbal for nurse & client Client s feeling words (2) Non-therapeutic techniques with Alternative Defense Mechanism with rationale Nanda Nursing DX Client centered outcome (goal) Outcome (goal) evaluation Student evaluation Neatness, legibility, spelling POINT VALUE 2 points 6 points 4 points 2 points 2 points each 8 points total 1 point each 2 points total 1 point each 2 points total 2 points 2 points 2 points 2 points 2 points 2 points 2 points 40 POINTS POSSIBLE STUDENT GRADE 2 6 4 2 8 2 2 2 2 2 2 2 2 2 TOTAL POINTS 40 % _100____________________

MINI PROCESS RECORDING Instructions and Example

Instructor Comments: You recognized where you can improve and worked to encourage the client to verbalize his concerns. Also, were able to look at future concerns for the client. Continue to work on developing therapeutic communication skills.
N: Mental Health Nursing < 2010 < Clinical Criteria < Mini Process Recording: Instructions and Example R: 08/10 bar