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L2 Process Recording 2
Behavioral Health Nursing (NSG-322)
Grand Canyon University
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Process Recording
PURPOSE: Process recordings are used to help students develop interviewing and communication skills. By completing a written record of the nurse-client interview, students can reflect on the verbal and nonverbal communication that took place.
OBJECTIVE:
Apply therapeutic communication with clients in the psychiatric hospital setting. Apply critical thinking skills in analyzing a conversation as recorded in a process recording.
EVALUATION:
Refer to the rubric for the Process Recording assignment in LoudCloud.
Process Recording Guidelines
The process recording is a systematic method of reconstructing a nurse-client interaction. It is a written account of what transpired before, during, and after a nurse-client interview.
Steps:
Pre-interview: Write a paragraph that describes the client and setting. In this section, document your thoughts and feelings concerning the interaction. Describe three outcome criteria you would like to achieve.
Interaction: This is the verbatim content of the conversation. Do not paraphrase. Include all of your statements and number each one. Include a corresponding number for the client’s response. Remember to include nonverbal behaviors. For each therapeutic communication technique used, correctly code it using a “C.” Identify all incorrect communication techniques with an “I.” Remember to provide a rationale and cite the source for each technique used. Next to each incorrect technique, write a correct technique that could have been used. Name the correct technique, include a citation, and identify why it should be used instead.
Post-interaction outcome: Include a description on whether or not you accomplished your three goals for this process recording. For each goal, identify evidence of successful achievement or failure. Everyone will have failures. No one is a perfect communicator. This is a learning process, as communication skills will take time to develop. This process will help you identify strengths and weaknesses in your therapeutic communication techniques.
The length of interaction should be 10-15 minutes. No more than two pages of the process will be needed.
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Pre-interview:
The interview took place in the nurse’s station of the SAGE unit. What I hoped to get out of this conversation was an understanding of the patient’s twitching, how they were doing in their sobriety, and if they were experiencing suicidal thoughts.
Interaction:
Nurse/Student Interaction Include verbal and nonverbal.
Client Response Include verbal and nonverbal.
Analysis/Interpretation Identify if interaction was correct (C) or incorrect (I). If incorrect, write a correct response.
ME: “Hello S. L. how are you doing today?”
ME: “I am so sorry you’re in pain. Is there anything besides your medicine that helps you?”
ME: “Your nurse should be back shortly with your medication. How long have you experienced your twitching?”
ME: “What drugs were you using? Great job with your rehabilitation”
ME: “That is great to hear you are halfway there. Where is your daughter?”
ME: “That is a great goal to have, have you been feeling hopeful?”
ME: “What do you usually do when you feel this way?”
ME: “It is good to have friends here to help, do you have any crafts or activities you participate in?”
ME: “It would be good to attend roadmap, that session gives great examples of coping skills when you are feeling down”
S.: “I’m fine just in a lot of pain and it just won’t stop I am due for my medication.” S.: “Nothing helps it hurts all the time it burns my hands and fingers. My nurse is getting my medication right now” S.: “For three years now it was bad it started because I did too many drugs. I am clean now.” S.: “I did meth and marijuana. Sometimes I did heroin too, but I stopped 3 months ago. If I get to 6 months clean, I can see my daughter out of state.” S.: “She is in Iowa, with her grandparents. I get to go there at 6 months. S.: “Yeah, I guess but it just is a lot of pressure it makes me feel hopeless and sad.” S.: “I have been here a while so I have friends to talk to but that is about it. I try to keep busy.” S.: “I like to make bracelets with the craft guy
- C. I inquired about what the patient was feeling that day.
- C. I showed empathy and questioned about patient’s coping skills.
- C. I inquired about the patient’s symptoms.
- C. I reassured patient they were doing great at rehab.
- C. I showed interest in the patient’s life and goals they set.
- C. The patient stated feeling hopeless about seeing child and I went in deeper on that feeling.
- C. I inquired about coping skills and offered support.
- C. I inquired about how the patient takes advantage of the resources provided.
- C. I offered support and resources for the patient to use.
- C. I inquired about the patient’s conversation regarding group therapy.
- C. I asked for clarification on the patient’s hallucinations.
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References
Varcarolis, E. M., & Fosbre, C. D. (2021). Essentials of psychiatric mental health nursing: A
communication approach to evidence-based care (4th ed.). Elsevier.
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L2 Process Recording 2
Course: Behavioral Health Nursing (NSG-322)
University: Grand Canyon University
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