Process recording Objectives: After 4 hours of varied teaching-learning activities, the level III students will be able to:

1. Define the following terms: 1.1 process recording 1.2 communication 1.3 context 1.4 content 1.5 congruent message 1.6 incongruent message 1.7 therapeutic communication 1.8 proxemics 1.9 active observation 2. explain the purpose of process recording 3. review the following: 3.1 therapeutic communication 3.2 non-therapeutic communication 3.3 phases of nurse-client relationship 3.4 defense mechanisms 4. explain the content of process recording 5. state the guidelines of process recording 6. enumerate the nursing responsibilities before, during and after 7. demonstrate beginning skills in making a process recording

1. definition of terms:

Process recording Is a tool used to analyze nurse-client interactions and is seen in various formats. Communication Is the process of sending a message to one or more persons Context Is the environment in which communication occurs and can include the time and the physical, social, emotional, and cultural environments. Context includes the situation or circumstances that clarify the meaning of the content of the message Content Is the literal words that person speaks. Congruent message A communication pattern in which the person sends the same message on both verbal and non-verbal levels When communication content and process agree

Incongruent message A communication pattern in which the sender gives conflicting messages on verbal and non-verbal levels and the listener doesnt know which message to accept

When communication content and process disagree

Therapeutic communication Is an interpersonal interaction between the nurse and the client during which the nurse focuses on the clients specific needs to promote an effective exchange of information. Proxemics Is the study of distance zones between people during communication. People feel more comfortable with smaller distances when communicating with someone they know rather than with strangers (DeVito, 2008). Active observation Means watching the speakers nonverbal actions as he or she communicates

2. purposes of process recording: Purposes of process recording The aim of process recording is to improve the quality of the interaction for better effect to the patient and as a learning experience for the nurse to continuously improve her clinical interaction pattern. When correctly used, it Assists the nurse or student to plan , structure and evaluate the interaction on a conscious rather than an intuitive level; Assists her to gain competency in interpreting and synthesizing raw data under supervision Helps to consciously apply theory to practice Helps her to develop an increased awareness of her habitual, verbal and non-verbal communication pattern and the effect of those patterns on others Helps the nurse to learn to identify thoughts and feelings in relation to self and others Helps to increase observational skills, as there is a conscious process involved in thinking, sorting and classifying the interaction under the various headings

Helps to increase the ability to identify problems and gain skills in solving them Used to teach communication skills to student nurses in the clinical setting and focuses on verbal and nonverbal communication

3. Therapeutic communication Is an interpersonal interaction between the nurse and the client during which the nurse focuses on the clients specific needs to promote an effective exchange of information. Skilled use of therapeutic communication techniques helps the nurse understand and empathize with the clients experience. All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their clients.

Essential Components of Therapeutic Communication 1. Confidentiality 2. Self-Disclosure 3. Privacy and Respecting Boundaries 4. Touch 5. Active Listening

Therapeutic communication can help nurses accomplish many goals: Establish a therapeutic nurse-client relationship Identify the most important client concern at that moment (the clientcentered goal) Assess the clients perception of the problem as it unfolds, this includes detailed actions (behaviors and messages) of the people involved and the clients thoughts and feeling about the situation, others, and self Facilitate the clients expression of emotions Teach the client and family necessary self-care skills

Recognize the clients needs Implement interventions designed to address the clients needs Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution

Establishing a therapeutic relationship is one of the most important responsibilities of the nurse when working with clients. Communication is the means by which a therapeutic relationship is initiated, maintained, and terminated. To have effective therapeutic communication, the nurse also must consider privacy and respect boundaries, use of touch, and active listening and observation. Privacy and respecting boundaries Privacy is desirable but not always possible in therapeutic communication. An interview or a conference room is optimal if the nurse believes this setting is not too isolative for the interaction.

Proxemics Is the study of distance zones between people during communication. People feel more comfortable with smaller distances when communicating with someone they know rather than with strangers (DeVito, 2008). Four zones of distance awareness or spatial territory:

Intimate zone :( 0 to 8 inches between people): this amount of space is comfortable for parents and with young children, people who mutually desire personal contact, or people whispering. Invasion of this intimate zone by anyone else is threatening and produces anxiety. Personal zone: (18 to 36 inches) : this distance is comfortable between family and friends who are talking Social zone: (4 to 12 feet) : this distance is acceptable for communication in social, work, and business settings Public zone: (12 to 25 feet) : this is an acceptable distance between a speaker and an audience, small groups, and other informal functions (Hall, 1963)

Touch As intimacy increases, the need for distance decreases. Knapp (1980) identified five types of touch:

Functional professional touch is used in examinations or procedures such as when the nurse touches a client to assess skin turgor or a masseuse performs a massage Social-polite touch is used in greeting, such as hand-shake and the air kisses some women use to greet acquaintances, or when a gentle hand guides someone in the correct direction Friendship-warmth touch involves a hug in greeting, an arm thrown around the shoulder of a good friend, or the backslapping some men use to greet friends and relatives Love-intimacy touch involves tight hugs and kisses between lovers or close relatives Sexual-arousal touch is used by lovers

Active listening and observation To receive the senders simultaneous messages, the nurse must use active listening and active observation. Active listening means refraining from other internal mental activities and concentrating exclusively on what the client says. Active observation means watching the speakers nonverbal actions as he or she communicates. Therapeutic communication techniques: Accepting- indicating reception Ex: Yes. I follow what you said. Nodding

 Broad openings-allowing the client to take the initiative in introducing the topic Ex: Is there something youd like to talk about? Where would you like to begin?

Consensual validation-searching for mutual understanding, for accord in the meaning of the words Ex: Tell me whether my understanding of it agrees with yours.

Encouraging comparison-asking that similarities and differences be noted Ex: Have you had similar experiences? Encouraging description of perceptions-asking the client to verbalize what he or she perceives Ex: Tell me when you feel anxious. What is happening?

Encouraging expression-asking the client to appraise the quality of his or her experiences Ex: Does this contribute to your distress?

Exploring-delving further into a subject or an idea Ex: Tell me more about that. Would you describe it more fully?

 Focusing-concentrating on a single point Ex: This point seems worth looking at more closely.

Formulating a plan of action-asking the client to consider kinds of behavior likely to be appropriate in future situations Ex: What could you do to let your anger out harmlessly?

General leads-giving encouragement to continue Ex: Go on. And then?

Giving recognition-acknowledging, indicating awareness Ex: I notice that youve combed your hair.

Making observations-verbalizing what the nurse perceives Ex: You appear tense.

Offering self-making oneself available Ex: Ill sit with you awhile. Ill stay here with you.

Placing event in time or sequence-clarifying the relationship of events in time

Ex: When did this happen?

Presenting reality-offering for consideration that which is real - Ex: I see no one else in the room. Your mother is not here; I am a nurse/ student-nurse.

Reflecting-directing client actions, thoughts, and feelings back to client Ex: Client: My brother spends all my money and then has nerve to ask for more. Nurse: This causes you to feel angry?

Restating-repeating the main idea expressed Ex: Client: I cant sleep. I stay awake all night Nurse: You have difficulty sleeping. Seeking information-seeking to make clear that which is not meaningful or that which is vague Ex: Im not sure that I follow. Have I heard you correctly?

Silence-absence of verbal communication, which provides time for the client to

put thoughts or feeling into words, to regain composure, or to continue talking Ex: Nurse says nothing but continues to maintain eye contact and conveys interest

 Suggesting collaboration-offering to share, to strive, and to work with the client for his or her benefit Ex: Perhaps you and I can discuss and discover the triggers for your anxiety Lets go to your room, and Ill help you find what youre looking for.

Summarizing-organizing and summing up that which has gone before Ex: During the past hour, you and I have discussed the causes of your anxiety.

Translating into feelings-seeking to verbalize clients feelings that he or she expresses only indirectly Client: Im dead. Nurse: Are you suggesting that you feel lifeless?

Verbalizing the implied-voicing what the client has hinted at or suggested Ex: Client: I cant talk to you or anyone. Its waste of time. Nurse: Do you feel that no one understands?

Voicing doubt-expressing uncertainty about reality of the clients perceptions Ex: Isnt that unusual? Really? Thats hard to believe. Non-therapeutic communication In contrast there are many nontherapeutic techniques that nurses should avoid. These responses cut off communication and make it more difficult for the interaction to

continue. Responses such as Everything will work out or Maybe tomorrow will be a better day may be intended to comfort the client, but instead may impede the communication process. Asking why questions (in an effort to gain information) may be perceived as criticism by the client, conveying a negative judgment from the nurse. Many of these responses are common social interaction. Therefore, it takes practice for the nurse to avoid making these types of comments. Nontherapeutic communication techniques: Advising-telling the client what to do Ex: I think you should do this.

Agreeing-indicating accord with the client Ex: Thats right. I agree.

Belittling feelings expressed-misjudging the degree of the clients discomfort

Ex: Client: I have nothing to live for... I wish I was dead. Nurse: Everybody gets down in the dumps, or Ive felt that way myself.

Challenging-demanding proof from the client Ex: But how can you be president of the Philippines? If youre dead, why is your heart beating?

Defending-attempting to protect someone or something from verbal attack Ex: This hospital has a fine reputation.

 am sure your doctor has your best interest in mind.

Disagreeing-opposing the clients ideas Ex: Thats wrong. I definitely disagree with your idea.

Disapproving-denouncing the clients behavior or ideas

Ex: Thats bad.

Giving approval-sanctioning the clients behavior or ideas Ex: Thats good.

Giving literal responses-responding to a figurative comment as though it were a statement of fact Ex: Client: Theyre looking in my head with a television camera. Nurse: Try not to watch television or what channel?

Indicating the existence pf an external source-attributing the source of thoughts,

feelings, and behavior to others or to outside influences Ex: What makes you say that? Who told you that you were a prophet?

Interpreting-asking to make conscious that which is unconscious; telling the client the meaning of his or her experience

Ex: What you really mean is.....

Introducing an unrelated topic-changing the subject Ex: Client: Id like to die. Nurse: Did you have visitors last evening?

Making stereotyped comments-offering meaningless clichs or trite comments Ex: Its for your own good. Keep your chin up.

Probing-persistent questioning of the client Ex: Now tell me about this problem. You know I have to find out. Tell me your psychiatric history.

Reassuring-indicating there is no reason for anxiety or other feelings of discomfort Ex: Everything will be alright.

Rejecting-refusing to consider or showing contempt fopr the clients ideas or behaviors Ex: I dont want to hear about your past experiences.

Requesting an explanation-asking the client to provide reasons for thoughts, feelings, behaviors, events

Ex: Why do you feel that way?

Testing-appraising the clients degree of insight Ex: Do you know what kind of hospital this is?

Using denial-refusing to admit that a problem exists Ex: Client: Im nothing. Nurse: Of course youre somethingeverybodys something.

Phases of nurse-client relationship The ability of the nurse to engage in interpersonal interactions in a goal-directed manner for the purpose of assisting clients with their emotional or physical health needs is the foundation of nursing practice. 1. Orientation phase The orientation phase can last for a few meetings or can extend over a long period, depending on the clients psychopathology, the complexity of the clients problems, the comfort and experience of the nurse, and other variables. As the relationship evolves through a series of ongoing reactions, each participant may elicit in the other wide range of positive and negative emotional reactions. The stirring up of feelings in the client by the nurse is referred to as transference, and the stirring up of feelings in the nurse or therapist by the client is referred to countertransference. During the orientation phase, four important issues need to be addressed: (1) The parameters of the relationship (2) The formal and informal contract (3) Confidentiality
(4) Termination

2. Working phase Moore and Hartman (1988) identify specific tasks of the working phase of the nurseclient relationship: 1. Maintain the relationship 2. Gather further data 3. Promote the clients problem-solving skills, self-esteem, and use of language 4. Facilitate behavioral change 5. Overcome resistance behaviors 6. Evaluate problems and goals and redefine them as necessary During the working phase, the nurse and client together identify and explore areas in the clients life that are causing the problems in living. The nurse can work with the client to identify these unconscious motivations and assumptions that keep the client from finding satisfaction and reaching his or her potential. The client may use various defenses against anxiety and displace his or her feelings onto the nurse. Therefore in the working phase, intense emotions such as anxiety, anger, self-hate, hopelessness, and helplessness may surface. Behaviors such as acting out anger inappropriately, withdrawing, intellectualizing, manipulating, denying, and others are to be expected. The nurses awareness of personal feelings and reactions to the client is vital for effective interaction with the client. The development of strong working relationship can allow the client to experience increased levels of anxiety and demonstrate dysfunctional behaviors in a safe setting, as well as to try out newand more adaptive coping behaviors. 3. Termination phase Terminated is discussed during the first interview. During the working stage, the fact of eventual termination may also be raised at appropriate times. Six reasons for terminating the nurse-client relationship (Campaniello 1980): 1. Symptom relief 2. Improved social functioning

3. Greater sense of identity 4. More adaptive defenses 5. Accomplishment of goals 6. Impasse in therapy that the nurse is unable to resolve In addition, forced termination may occur, such as when the student completes the course objectives. The termination phase is the final phase of the nurse-client relationship. It is important for the student to work with the client to bring into awareness the feelings and reactions the client may be experiencing in relation to separations. Summarizing the goals and objectives achieved in the relationship is part of the termination process. Reviewing situations that occurred during the time spent together and exchanging memories can help validate the experience for both nurse and client and facilitate closure of that relationship. A common response students have is feeling guilty about terminating the relationship.

4. The content of process recording

CONTENTS OF PROCESS RECORDING

Name of Patient: David Cheavers Age: 19 years old Diagnosis:

Student- Nurse: Torres, Nikko jade Date: September 1, 2012 PROCESS RECORDING #1

I.

OBJECTIVES: General Objectives: After 2 weeks of student nurse- client interaction, the client will be able to develop a trusting relationship, maintain contact with reality, gain insights about his condition and acquire socially acceptable coping skills. Specific Objectives: After 30-45 minutes of SN-client interaction, the client will be able to: 1. establish rapport and trusting relationship with the SN

2. acquire a sense of reality, restating the correct time, date and place 3. generate with the SN the rules of interaction 4. site the purpose and expectation of the interaction with the SN 5. show willingness to communicate openly, recall past experiences, verbalize thoughts, feeling and emotions 6. agree as to the time, date and place of next interaction II. Setting of Interaction Time: 7:30-10:00 Date: September 1, 2012 Place: room 323, 3rd floor of Cebu Doctors University *Drawing or sketch of the specific place of interaction III. Appearance, Behavior, Communication and Implication Appearance David Cheavers., a 19 year old male patient is wearing a white shirt and white pants. He has a brown complexion a medium built body. David Cheavers was sitting on the chair, listening to music alone. As observed, he was well dressed and looks calm. He has a beard, has pimples, no wounds are noted or observed.

Behavior During our conversation, David was standing upright with his hands at his side. Sometimes he makes jerky movements. He maintained good eye contact throughout the conversation and made appropriate facial expressions to emphasize a point. He is fond of hand shake gesture when you joke or tell something. When I approached him at first, he nodded and said yes. Communication He was hyperactive, attentive, and cooperative in answering my questions, and repeats the last word that the nurse verbalized. There are also some things that he is hesitant to share but other than that his mind is full of ideas. Implication Even though David has Tourettes disorder, he was able to verbalize his feelings freely and spoke frequently. He makes good eye contact which is a positive characteristic that he was attentively listening and is ready to answer

possible questions. Although he may be hesitant to open up more about his case, he still tries to show that he is willing to cooperate.

IV. Communication NURSES COMMUNICATION (verbal and nonverbal) Maayong hapon dira nimo. Ako si Jade Torres, isa ka student nurse sa Cebu Doctors University. Unsay pangan nmo? (approaches client in the basketball grounds) Salamat David Kamusta na man ka diri? Maayo ra imong pamati? CLIENTS COMMUNICATION (verbal and nonverbal) COMMUNICATION TECHNIQUE / DEFENSE MECHANISM ANALYSIS

Hello Jade, nga Giving mura og si Sanjie. information Ako si David cheavers. (smiles and give a shakehand with the SN)

Maayo ra man ko ug pamati, sige tan-aw TV. One piece noh? (smiles) O, pareha gani mi og nawng ni Luffy (making a strumming gesture and shakes hand with the SN). Kung di ko mu tanaw og TV, mag duwa kog basket og mu

Encouraging Expression

Maayo kay nalingaw ka, tig tanaw diay ka ana? Unsa pa man imong hilig buhaton David?

Exploring

tabang.

Kamatinabangon nimo David. gud, maayo na da. Unsa diay ang rason ngano gibutang ka diri David.?

Tahhhh, ambot unsa toy rason ( looks hesitant to share) Murag na.. (laughs)

Giving recognition

Sige David., unsa na yabag sa man? Ipadayon kamatchuk imong istorya. (laughs) ( hand gestures signaling patient to proceed) Unsa nang kamatxhuk David.? Mga shabu marijuana. Pero wan a ko ana ron, ayo na man ko. Naa paman gud koy pending na ko kaso pero murag giadto na man sa akong mama sa capitol Na ambot ato nya (client is hesitant to share and looks away) Ganahan bya ko mag paruy2 sa dagat (smiles)

Exploring

General Leads

Exlporing

sa imong pag ingon na naayo na ka, nganu dili pa man ka mugawas? Aw, maayo ay gi lihok sa imong mama. Unsa man diay na imong pending nga kaso David? Unsa pa mn imong gusto

Restating

Exlporing

nga storyaan nato? (smiles at client) Nindot bitaw maglargalarga noh. Unsa man imong sakyan?

Going Merry. Aw SuperFerry lang pero mangayo sa ko nmo kwarta kay mahal man na Aw mao ba? Sige niya ikaw akong kuyogon ha? E firstmait tika (smiles widely and exchanged high 5s with SN)

Broad Openings

Exlporing

Mahal jud bitaw, pero kung mu ad2 sa dagat barko jud atung sakyan, ang going merry kay para mana muadto sa lain langit Dili man ko pwede nmo e firstmate David. kay ako man imong student nurse. Ania man ko karon para matabangan tika sa imong kondisyon. (smiles at client) David.,hapit na man diay mi mangadto ( looks at watch) diri lang sa ta kutob ha? Magkita na lang ta balik diri uga sa basketan,

Bitaw- Bitaw (laughing and smiles)

Giving Information

sige Sanjie! (laughs) Jade diay. Ugma na pud (waves goodbye)

Presenting reality

Giving information

sityimbre 5, 2012 sa takna nga 10am. Salamat R.P. Amping kanunay!

5. State the guidelines of process recording

Student-client role-play situations are one method used to familiarize students with the process recording. Interview guidelines may be given explaining how to intervene with a client who gets up and leaves during an interview; what to do if another client interrupts the interaction; what to do if a client asks the student to keep a secret; and why a student should not write the interactions verbatim during the interview. Process recording can be written as short notes during the interaction and rewritten immediately after it. Total time spent on the recording can be around 30 minutes. The active time can be 20 minutes, with 10 minutes for conclusion and recording. Although video or tape recorders give more accurate recording, the impact of this equipment on the interaction will make an unnatural influence. How to Begin the interview

Effective communication could take place almost anywhere. However, because the quality of interaction, whether in a clinic, ward, or office, depends on the degree to which the nurse and client feel safe and secure, establish a setting that enhances the feelings of security can enhance the helping relationship. A specific location such as a conference room or a quiet part of the unit that has relative privacy but is within view of others is ideal. In all settings, chairs need to be placed so that conversation can take place in normal tones of voice and so that eye contact can be comfortably maintained or avoided. In the orientation phase, students tell the client who they are, the name of their school, and how long and when they will be meeting with the client. The issue of

confidentiality is also covered at some point during the initial interview. The nurse can ask how he or she like to be addressed. this question accomplishes several tasks: 1. it conveys respect 2. It gives client direct control over an important ego issue. 3. The nurse may learn something about the client when his or her preference is revealed Once introductions have been made, the nurse can turn the interview over to the client by using one of a number of open-minded statements. Where should we start? Tell me a little about what's going on with you What are some of the stresses you have been coping with recently? Tell me a little about what has been happening in the past couple of weeks. Perhaps you can begin by letting me know what some of your concerns have been recently. Tell me about your difficulties.

Tactics to avoid The nurse should avoid some behaviors: Do not argue with, minimize, or challenge the client Do not praise the client or give false reassurance Do not interpret to the client or speculate on the dynamics of the client's problem Do not question the client about sensitive areas Do not try to "sell" the client on accepting treatments

Do not join in attacks the client launches on her mate, parents, friends, or associates Do not participate in criticism of another nurse or any other staff member

6. Nursing responsibilities Before 1. Inform the client of the activity a day before the interaction 2. Establish a setting that enhances the feelings of security 3. Chairs need to be placed so that conversation can take place in normal tones of voice 4. Prepare and gathers the materials to be needed

During 1. Remind the client again of the planned activity on the day itself 2. Students tell the client who they are, the name of their school, and how long and when they will be meeting with the client. 3. The issue of confidentiality is also covered at some point during the initial interview. 4. The nurse can ask how he or she likes to be addressed 5. Once introductions have been made, the nurse can turn the interview over to the client by using open-ended statements 6. The nurse should avoid some behaviors

After 1. Acknowledge the client's presence and extend your gratitude to the client 2. Do aftercare

3. Do the documentation of process recording