1 Running Head: INTERACTIONAL PROCESS RECORDING 1 Interactional Process Recording Kristi R. Rittenhouse Psychiatric Nursing and Mental Health Nursing Care- NURS Laura Brison October 20, 2010
2 Running Head: INTERACTIONAL PROCESS RECORDING 2 Interactional Process Recording J.G., a 23 year old-white male, was admitted to Heartland Behavioral Health on Wednesday September 29, 2010 with depression. He admitted he was going to kill himself after drinking the night of Tuesday, September 28 th, J.G. was cooperative in a two-on-one conversation on the 29 th with J.V. and me in a quiet, lighted, and warm environment in the dining room. I think the quietness was a positive to our therapeutic communication because it allowed few distractions and allowed J.G. to self-disclose more than he would have if people were in the room. We were able to develop an informal social control contract with J.G., which means we listened to what was going on in J.G. s life at the moment and attempted to solve some problems that J.G. was experiencing at the time of the conversation. These problems included ways of relieving stress and coming up with a safety plan the next time he feels like hurting himself. We also attempted to set short-term goals, which included when to use the safety plan. Prior to our interaction, I felt anxious and nervous because I realize how serious of an issue suicide/depression is and I feel like I have a major responsibility in this person s life. This responsibility I have is to show that I care, and to give hope and reassurance; as well as, setting into motion his desire to change his life around so he can have the opportunity to live a fulfilling life. I have not happen prior experience before this class with communicating with a depressed person, let alone someone who wants to commit suicide. I think I also feel anxious because I always want to know what to say to make things better, and sometimes I fear I am not at the communication level I need to be at in order to have an effective conversation.
3 Running Head: INTERACTIONAL PROCESS RECORDING 3 Yes. (Looking at me with puzzlement and a sad expression.) I guess, what do you want to talk to me about? (Walking to dining room and looking down at floor) NURSE Hi, are you J.G. (approached patient, smiling, sat down in the chair next to him to get to his level to make eye contact) My name is Kristi and this is Jasmine. We are student nurses at Kent State and we re wondering if you would be willing to speak with us for a bit in the dining room? (still smiling) (Walking to dining room) We just want to ask you some questions and learn about what brought you here. (Opened up the door to the dining room.) Greeting. Establishing recognition. I am nervous, but made sure I did not show it to J.G. He looks like he isn t interested in talking. I was not 100% certain this was J.G.; therefore, I asked. I felt odd asking if it was him because I thought that maybe J.G. would think that he was my assignment for the day, and that I did not really care to speak to him. I thought that if he thought this, then it would interfere with our effectiveness with the communication. Looking back, I probably should have double checked with the nurse so I could just approach him without having to ask if he was J.G. J.G. seemed confused about why we would talk to him as evidence by his puzzled look on his face. Also, his affect is almost always sad, which is consistent with his diagnosis of Depression (Boyd, 2008, 350). Giving information. Offering self. Beginning negotiation of an informal contract. Introducing and offering self is the orientation phase of the nurse-patient relationship. It aides in establishing rapport (Boyd, 2008, 149). I feel like I am becoming a little less nervous, but he still doesn t look interested in communicating. This may be a bad sign. Am I ever going to get a good conversation so I can use for my IPR. An informal contract is negotiated. I was grateful that he agreed to a 2:1. This means that I can possibly use our conversation for my IPR if it is decently good. He still seems withdrawn and hesitant to participate in a 2:1, but this is often a sign of depression (Boyd, 2008, 350). Giving information. I don t want to get into a lot of detail when explaining what J.V. and I want to talk about because I feel like the conversation can go anywhere based on what J.G. opens up about. Therefore, I think what I said worked well.
4 Running Head: INTERACTIONAL PROCESS RECORDING 4 (Sat down at table) Okay, well what do you want to ask me? (Leaning forward, looking at my hands and me messing with my rings, then made eye contact) I like to read, it relaxes me. I usually don t have time to read, but now I do since I am here. I am reading Robinson Crusoe now. NURSE (Sat down at table across from patient, hands on table and turning my wedding rings around my finger) Well, lets first just talk about what activities you like to do. (Still messing with my ring while looking at J.G.) (I stopped messing with my ring and folded my hands) So, what brought you here to Hartland? (I leaned toward J.G, and made eye contact) I guess I was not clear as to what I wanted to talk about, or does he want to know what my first question is going to be? It must be what we are going to first ask as I thought I made myself clear as to what I wanted to figure out. Wow, I am nervous, I thought it was decreasing. It may be because I feel like it is my responsibility to change how he is thinking, and I realize I cannot do that in one conversation. Open-ended or broad question. This allows us to initiate conversation and encourage J.G. to talk about his activities (Foley, 2010, 40). I want to attempt to create rapport with J.G., so I don t want to jump into why he was brought to Hartland. This is also my way of letting him get more comfortable with me. It is the least invasive subject. Creating rapport with the patient is important in establishing and building the nurse-patient relationship (Boyd, 2008, 143). I realized I was messing with my rings and saw that it was a distraction by the way he kept looking at my hands, so I folded them and was hoping I wouldn t distract J.G. again. I am beginning to feel a little more comfortable. Changing topic (Psychiatric nursing and mental health nursing care, 2010, 20). This is a non-therapeutic technique that hinders rapport and thus affects the nursepatient relationship (Boyd, 2008, 143). I am not sure why I changed the subject. Looking back, I should have asked if gets stressed often and what he does to relieve his stress. Mental Note to Self: Ask this Later. I also used the therapeutic technique of using an Openended or broad question. By leaning forward, I show J.G. that I am interested in
5 Running Head: INTERACTIONAL PROCESS RECORDING 5 NURSE what he has to say. A bad weekend. (Looking down, slouched and leaned back in chair) (Still looking down) (Made eye contact with me for a brief moment.) (Looked away and crossed arms.) Drank too much. Said some things I shouldn t have. (Still looking away, at table) Silence (Looked to J.V.) What do you mean by a bad weekend, what happened? (I reestablished eye contact for a brief moment.) Like what? (Leaned forward a little more.) This must be a bad subject for J.G. as he quickly looks down at the table, slouching, leans back, and is silent for awhile. Also, his nonverbal tell me he is withdrawn. This is a common psychosocial assessment finding in a depressed individual (Foley, 2010, 384). He doesn t like to say more than he has to. This is as evidenced by the fact that he only answers the questions with short phrases. Therapeutic use of silence. It when we remain quiet to allow J.G. to gather his thoughts and to proceed at his own pace (Boyd, 2008, 139). The silence seemed to take forever, so I looked toward J.V. to see what we should do, but I wanted to give him the opportunity to explore his feelings and his to elaborate on what he meant by A bad weekend. Exploring. Focusing. By using these therapeutic techniques, I can get more information about a certain topic (Psychiatric nursing and mental health nursing care, 2010, 17). I am a little more nervous now because I know we are about to talk about his suicidal thoughts. This makes me nervous because I don t want to say the wrong thing. I notice J.G. is uncomfortable with speaking about what he did and said by the crossing of his arms and losing the eye contact. He is closing himself off. I wish he would go into more detail and help me out here. Substance abuse, such as alcohol in this situation is an associated behavioral finding in someone with depression (Boyd, 2008, 350). Probing: Non-Therapeutic (Psychiatric nursing and mental health nursing care, 2010, 19). Oops, that was probing. Why didn t I think about what to say before I said that? Looking back, I can tell it is probing. I should have used a therapeutic technique using exploring, for example: A lot of people say and do things they want to take back all the time, can you tell me what it was you said.
6 Running Head: INTERACTIONAL PROCESS RECORDING 6 I said I was going to kill myself. (Very quiet voice, still looking down at table.) (Still looking down at table.) I just wanted to push someone s buttons. (Brief eye My mom s mostly, and my girlfriends a little. (Brief eye (Looking down.) NURSE What was going on that caused you to say you were going to kill yourself? (Spoke quietly, trying to establish eye Whose buttons did you want to push? (Spoke quietly, and trying to establish eye Silence (Trying to establish eye I am wondering if J.G. is ashamed of what he said or just uncomfortable speaking to females around the same age as him. I am wondering this because of how he leaves a lot of information out at first until we probe to get the answer. Also, he speaks very quiet and avoids eye contact. Suicidal thoughts are a common psychosocial assessment finding in an individual who is depressed (Foley, 2010, 384). Exploring. Focusing. I almost asked why he said that, but quickly realized it was non-therapeutic. I felt relieved with how I asked this question because I feel like I wasn t probing, but still interested with what lead to his verbal cry for help J.G. is definitely minimizing his situation. His comment irritated me a little because I feel like he is leaving so much out. Also, I don t believe someone would say they are going to kill themselves just to upset others. Focusing, but probing at the same time, which is nontherapeutic (Psychiatric nursing and mental health nursing care, 2010, 19). Looking back, I feel like I was demanding him to tell me. I would have rather asked Can you tell me me more about that. J.G. seems to not be very spontaneous with explanations or his feelings. He answers questions to the bare minimum. Therapeutic use of silence. I wanted to give him an opportunity to elaborate on why he wanted to push his mom s and girlfriend s buttons.
7 Running Head: INTERACTIONAL PROCESS RECORDING 7 My mom was being too much of a mom, too controlling, and it was stressing me out. (Looked away.) I drink beer. (Sounded a little irritated, arms crossed.) Quite a bit. Every chance I get. I m drunk about every day. It s like I start drinking and I get to a point where I don t think and my problems seem to go away. (Brief eye contact, less irritable sounding.) NURSE Why did you want to push buttons? (Held eye What are some things you do to relieve your stress. (Brief eye (Started messing with my rings.) How much would you say you drink? (Spoke softly, hands folded.) Requesting an Explanation: Non-therapeutic (Psychiatric nursing and mental health nursing care, 2010, 19). I can t think of how else to get J.G. to explain this. Looking back, a better way to ask this is, Can you explain some of the reasons that caused you to want to push their buttons? It seems as if every time I establish eye contact and say what I need to, he looks away, then answers me. Anxiety is an associated behavioral finding related to depression (Boyd, 2008, 350). Exploring. Focusing. I feel like his main problem is the stress; therefore, I wanted to focus on some things he could do to relieve that stress. I am beginning to mess with my rings again because I am getting nervous, but I stop. I believe I am getting nervous because J.G. is sounding a little irritated and I don t want anything to happen. For a depressed individual, irritability is a common psychosocial assessment finding (Foley, 2010, 384). Probing: Non-Therapeutic I should have been more direct with him so he wouldn t minimize the amounts that he drinks. Looking back, I should have rephrased the wording, but even now I don t know how else I would have asked without probing. Ah, I should have worded my previous question a little differently so that I could get an actual number or average a day instead of quite a bit. It is common for an individual with depression to not want to think (Boyd, 2008, 362). Which I believe is the case in J.G. s situation.
8 Running Head: INTERACTIONAL PROCESS RECORDING 8 It does, but I don t have the time. (Good eye contact, uncrosses arms, and sits up.) No, I never really thought about it. (Shook head, no.) I guess that would work. (Looks down.) NURSE Earlier you said you enjoy reading and that it relaxes you. (Re-establishing eye Have you thought of ways you could make time to do what you want to do that relieves stress? (Eye Do you ever think about giving up the beer? If you get stressed, maybe instead of drinking you can spend that time reading. (Maintaining eye contact, hands folded, leaning forward.) Restating. Changing Topic: Non-therapeutic. I made a mental note to self to bring this up again, I am glad I remembered. By asking this we can solve problems together about reducing his stress level, but looking back, I should not have changed the topic. I should have pursued what his problems were and what he wanted to stop thinking about. He leaned forward and uncrossed arms, he must either be feeling more comfortable with us students, or he is just feeling more comfortable with the conversation since it became a little less invasive. Encouraging formulation of a plan of action. This is a therapeutic technique used to encourage the patient to come up with their own ideas (Psychiatric nursing and mental health nursing care, 2010, 18). It would be healthier if he stopped drinking and in place of that he could read. I don t want to give him advice at this point. I want him to come up with it on his own, which made me like what I said. Wow, if stress is a big problem, why has he not thought about this? I do not understand. This is kind of Advising in a way, which is a nontherapeutic technique. This is when I offer the patient specific suggestions (Foley, 2010, 42). Alcoholism is a prominent factor in suicide. Its destabilizing effects increases suicidal risk (Boyd, 2008, 264). Therefore, he should try to stop drinking. Looking back I should have probably left the second part out (the advising part). I don t think he seems very willing to give up the beer at this point. What should I do to make him more willing?
9 Running Head: INTERACTIONAL PROCESS RECORDING 9 No, I don t. (Looked down and shifts in chair.) I don t know, I haven t thought about it. (Eye Contact.) (Eye Contact.) I guess now I could talk to my mom about being too controlling and when I feel like hurting myself I could NURSE Do you still have thoughts of killing yourself? (Direct eye contact) Next time you feel depressed enough to want to hurt yourself, what might you do so you don t get far enough to do that? (Hands still together, reestablishing eye Silence (Eye Contact.) Focused Question: Therapeutic technique. I wonder if he still thinks about killing himself. Should I just come out and ask it? Yeah. Looking back, I think I should have said hurting instead of killing. Killing is an intense word in which I feel uncomfortable saying. I don t know if I should believe him. His nonverbal are not congruent with his verbals. The shifting in the chair and loss of eye contact gives me the impression that he is either contemplating it, ashamed of his feelings, or uncomfortable with the situation. Encouraging formulation of a plan of action. I feel like he may have these feelings again, so I think it is essential we come up with a plan of action so he can do something productive to keep from harming himself. I am surprised he has not thought about a safety plan. If it were me, I would want to know my warning signs and what to do if I notice those signs. Therapeutic use of silence. I wanted him to think more about what he would do so he wouldn t harm himself. I guess I can t look at it like I was in his situation. Looking back, I realize we all think differently and when one is in a depressed state, one does feels hopeless and helpless, and therefore, can t think straight or just don t want to do anything about it (Boyd, 2008, 350). He is coming up with some good solutions. I hope I am being helpful. The workers here don t talk much with them, so I really want to make a difference in his life and have him view it a little differently now.
10 Running Head: INTERACTIONAL PROCESS RECORDING 10 talk to someone. (Speaking softly, and sitting up.) NURSE I could attempt to stop drinking. (Brief eye Yes, I can call them too when I need someone to talk to. (Eye Contact.) Ok, can you think of anything else? (Eye Contact.) Do you know about the Crisis Center Hotline? (Hands still together, reestablishing eye Well, you are on the right track and we wish you luck. We have some other people to speak with, so we will have to go. Thank you so much for speaking with us. (Eye contact, smiling.) Accepting: Therapeutic technique Focused question. I want him to realize drinking is a major problem. My hope is that he can think of it on his own to stop. Good, Good, Good. We are getting somewhere. Focused Question. If he has no one to talk to, the Crisis Center Hotline would be a great service. I wonder if he knows about it. Good, he knows about it. My only hope is that he will use it to his advantage. It is a wonderful service to those who don t know where to turn. Giving Recognition: Therapeutic technique (Psychiatric nursing and mental health nursing care, 2010, 17).Now only if he sticks to what he said he can do for his safety plan. It is about time to go talk to other people I suppose; I might want to wrap this up.
11 Running Head: INTERACTIONAL PROCESS RECORDING 11 You re welcome. Thank you. (Smiling.) NURSE I hope we helped in some way. Have a good day. (Getting up from table and smiling.) I feel rewarded that he is smiling. He seems to have been thankful for our conversation; I only hope he remembers it all. I really hope we were helpful and he is not just smiling because he is free from us.
12 Running Head: INTERACTIONAL PROCESS RECORDING 12 Patient Themes J.G. is diagnosed with depression. He stated prior to his arrival to Hartland Behavioral Health that he was going to kill himself. Throughout our interaction, J.G. was withdrawn, difficulty thinking, sad expression, irritable, minimizing his situation, and not offering much information. These are all consistent with the diagnosis of depression. Anxiety and alcoholism were also common patient themes throughout our interaction. Anxiety was created from the too controlling mother and the alcoholism was his escape route from all of his problems. Alcoholism is a prominent factor in suicide. Its destabilizing effects increases suicidal risk (Boyd, 2008, 264). Hence, his drunkenness when he said he was going to kill himself. During our interaction, I attempted to show empathetic understanding, respect, and genuineness. I did all these things by speaking quietly, and by trying not to judge. In this situation, I do not feel like action dimensions would have affected our interaction. I was not comfortable using confrontation and we are not to do this unless we have the teacher there. Also, I didn t have anything to self-disclose and there wasn t a time for role-playing. I felt a little resistance on J.G. s behalf when he would not open up about his thoughts and feelings. Also, when he would only answer with the bare minimum, I felt resistance. He would not elaborate on much when it was truly needed. I do not believe transference or countertransferance took place during our interaction. My non-verbal communication showed that I was nervous in that I would twist my ring around my finger. This caught J.G. s attention and distracted him for a minute until I stopped. Outcomes of therapeutic nurse-patient interaction By the end of J.G. and my interaction, we ended up in the orientation or introductory phase. This is the phase where the introduction occurs, the contract is established, data is
13 Running Head: INTERACTIONAL PROCESS RECORDING 13 gathered, and feelings, thoughts and actions are beginning to be explored (Foley, 2010, 45). Looking back, I realize that J.G. did not go into much detail about his thoughts and feelings. This is one of the main reasons we were still in the orientation phase. If I had a second chance to speak to him, I would ask him to explain what he was thinking and feeling at certain times. During our orientation phase, I believe J.G. benefited from our interaction. He said he was going to talk to his mom about being too controlling. Also, when he feels like hurting himself he is going to talk to someone and if no one is available to speak with, he will call the Crisis Center Hotline. And finally he is going to attempt to stop drinking and possibly read or do something he like to do that is fun in order to reduce his stress level. During my therapeutic nurse-patient interaction, I realized that I still have a ways to go to being a more effective communicator. I learned that speaking therapeutically is much harder than just talking with them, and that at times I need to think more before I speak. At times, I felt like I would just spit out words and most of the time it was non-therapeutic. I became much more comfortable speaking with J.G. about half way through the conversation. Therefore, I was able to focus a little more on the non-verbal communication and how it relates to J.G. s diagnosis of depression. Reflecting back on my therapeutic nurse-patient interaction, I learned that I change the topic a little too often, which is when one says a statement that ignores the current topic and introduces a new topic (Foley, 2010, 42). This is non-therapeutic because it hinders rapport and thus affects the nurse-patient relationship. I also used other non-therapeutic techniques that I need to work on eliminating from my interactions with patients. I am going to do this by studying these non-therapeutic techniques in more depth, and at the same way taking a statement and rewording it so it becomes therapeutic.
14 Running Head: INTERACTIONAL PROCESS RECORDING 14 I also learned that I need to be more aggressive in certain topics. For example, J.G. says he wanted to kill himself because he wanted to push buttons due to his mother. Now, that I look back, I realize there must be so much more going on in his life than his mother being too controlling. From what we learned in class, suicidal thoughts or ideations develop from a combination of things. Next time, I would be more aggressive, and ask what else was going on in his life and I would have come out and asked if he had a plan. This would have allowed the interaction to become more effective because I could have gotten the whole story and we could have together attempt to solve some of those problems. Through completing this interactional process recording, it has helped me become more self-aware and has given me the ability to demonstrate what I have learned about the therapeutic nurse-patient relationship as a basis for providing behavioral change in mental health patients. It has also assisted me in my ability to examine components of the communication process and identify functional and dysfunctional communication. Finally, I learned and understand that a nurse s response influences a therapeutic outcome for mental health patients.
15 Running Head: INTERACTIONAL PROCESS RECORDING 15 References (2010). Psychiatric nursing and mental health nursing care. NURS Kent, OH: Kent State University College of Nursing. Boyd, M. A. (2008). Psychiatric nursing: contemporary practice (4 th ed.). Philadelphia, PA: Wolters Kluwer Health- Lippincott Williams & Wilkins. Foley, M. (2010). Lippincott s handbook for psychiatric nursing and care planning. Philadelphia, PA: Wolters Kluwer Health- Lippincott Williams & Wilkins.