Mental Health Nursing

“PROCESS
RECORDING”
Submitted to : Submitted by:
Respected Prerna Ikra 04650306620
Ma’am Riteka 04550306620
CON, VMMC & BSc. (Hons.) Nursing 3rd year
SJH
 OBJECTIVES
• Introduction
• Purposes
• Goals & objectives
• Pre-requisite of process Recording
• Application to nursing
• Advantages and disadvantage of Process Recording
• Process Recording outline
 INTRODUCTION

Psychiatry process recording, also known as a clinical process

recording or simply process recording, is a method used in
psychiatric and mental health settings to document and analyse
interactions between a healthcare professional (e.g., psychiatrist,
psychologist, social worker, nurse) and a patient
The primary goal of process recording is to gain insights into the
dynamics of the therapeutic relationship, explore patient
experiences, and improve the quality of care provided
 CONTD….

The process recording captures the verbal and non-verbal

communication that occurs during the session and helps the nurse to
analyse the interaction
Process recording is a written account or verbatim recording of all
that transpired, during or immediate following the nurse –patient
relationship
The recording is usually done in real-time or immediately after the
interaction to capture the details accurately
 PURPOSES

To critically analyse communication & its effect on behaviour of the

individual
To gain the patient’s confidence & get his cooperation
To establish rapport with the patient
To study the patient’s psychological social & emotional behaviour
To help to increase their ability to identify problems and develop skill in
solving them
Give the student in opportunity to gain there ease and function in
written expression that are important for professional development
 GOALS & OBJECTIVES

• Establish a therapeutic nurse-patient therapeutic relationship

• To give necessary health education to the patient
• To obtain the identification data of the patient
• To assist the insight of the patient
 PRE-REQUISITE OF PROCESS
RECORDING

• Getting consent of the patient for the possibility of

Cassette recording
• Confidentiality should be maintained
• Physical setting ,calm and quiet environment
• Each process recording should be conclude with
summary
 A P P L I C AT I O N TO N U R S I N G

• It is a valuable tool in for psychiatric nursing as it helps nurses to reflect on

their communication skills, identify areas for improvement, & develop
strategies to enhance their therapeutic communication with patient
• It provide the basic concept to interacting with patient
• This will help the student nurse to use various techniques so that he/she may
developed effective therapeutic nurse-patient relationship
• It will also provide the method by which the nurse can interview the patient
skilfully
• It will provide nurse with a guideline to apply the knowledge in a clinical
setting while interacting with patient
 IMPORTANCE OF PROCESS RECORDING

Enhanced communication skills: Process recording helps healthcare

professionals identify areas where communication can be improved,
leading to more effective patient care
Self-awareness and professional growth: By reflecting on their own
reactions and emotions during sessions, professionals can better
understand their strengths and areas for development
Improved patient care: Understanding the dynamics of the therapeutic
relationship can lead to better treatment planning and patient outcomes
Identifying patterns: Process recording can reveal recurring themes or
patterns in patient behaviour, which can inform treatment approaches
 ADVANTAGES OF PROCESS RECORDING

• It helps in differentiating thoughts and feelings

• It helps to clarify the purpose of interview or intervention
• It helps to improve written expression
• Helps to identify strengths and weakness
• It helps to improve self-awareness
• It helps to separate facts from judgement
• It helps to explore the interplay of values operating between the student and
the patient system through an analysis of the of the filtering process used in
the session
DISADVANTAGES OF PROCESS RECORD

• It is more time-consuming
• Technical problem are frequent and become source of
frustration
• The process is laborious because it required actual observation
and subsequent participation by the clinical instructor during
student- patient interviews
 STEPS INVOLVED IN PROCESS RECORDING

1. Preparation:
Before the session begins, the mental health professional should
ensure they have the necessary tools to record the interaction
effectively
This may include a notepad, electronic recording device, or
specific forms designed for process recording
2. Consent:
The mental health professional should obtain the patient's
informed consent to record the session
It is essential to explain the purpose and benefits of process recording while
assuring the patient that their privacy and confidentiality will be respected
3. Objective Setting:
The mental health professional may set specific objectives for the session
based on the patient's treatment plan or current concerns
This helps focus the conversation and ensures the recording captures
relevant information
4. Active Listening:
During the session, the mental health professional practices active listening,
paying full attention to what the patient is saying and expressing
They observe verbal cues, non-verbal cues, emotions, and changes in the
patient's demeanour
5. Verbatim Dialogue:
As accurately as possible, the mental health professional records the
conversation, including the patient's exact words and the clinician's
responses
This verbatim dialogue helps to identify communication patterns and
understand how certain phrases or words impact the patient.
6. Non-Verbal Cues:
In addition to verbal communication, process recording also involves
capturing non-verbal cues, such as body language, facial expressions,
gestures, and eye contact
These cues provide valuable insights into the patient's emotional state
and level of engagement
7. Emotions and Reactions:
The mental health professional records their emotional reactions and
responses to the patient's statements and emotions
Being aware of their emotional responses allows the clinician to reflect
on any potential countertransference and maintain objectivity
8. Reflection:
After the session, the mental health professional reviews the recorded
material and reflects on the dynamics of the interaction
They analyse the session to identify patterns, themes, and underlying
issues that may be contributing to the patient's concerns
9. Supervision and Feedback:
Mental health professionals often discuss process recordings with
their supervisors or colleagues to gain additional perspectives and
feedback
 Supervision provides an opportunity for professional growth and
ensures ethical and effective clinical practice
10. Intervention and Treatment Planning:
Insights gained from process recording may inform the treatment plan
It helps mental health professionals tailor their interventions to meet
the patient's needs more effectively
 THERAPEUTIC COMMUNICATION

1) Pre-interaction Phase Prior to 1st meeting, the nurse may have

thoughts and feelings related to the 1st clinical session
2) Orientation phase1st time that nurse and patient meet: -Initial
interview occurs,Establish rapport,Parameters of the
relationship,Formal or informal contract,Confidentiality,Termination
3) Working phase Allows patient to experience increased levels of anxiety
and demonstrate dysfunctional behaviours in safe setting while
trying out new and more adaptive coping behaviours
4) Termination phase Final phase of the nurse-patient relationship-May
occur when the patient is discharged or instruct about follow-up
 PROCESS RECORDING OUTLINE

A. Introductory Material
1. description of the patient include name, age ,education level,
health problem, length of hospital stay
2. Date, Time, place & duration of interaction
3. Recording of nurse own thoughts and feelings before the
interaction
4. Reason for choosing the patient for process recording
B. Objectives
1. Objective should be formed prior to meeting
2. Objectives should be specific and function as a guide for
interaction
3. It should be short-term goal: to establish therapeutic relationship
with patient
4. Long-term goal: to prepare the patient and family for follow-up
and rehabilitation
 C. RECORD OF INTERACTION BETWEEN
NURSE & PATIENT

1. Nurse should be truthful in recording what is said and did by

self and by the patient
2. Observe for non-verbal response ( eye contact ,restlessness,
pacing ,beating nails, changing position)
3. Nurse own thoughts and feelings should be recorded separately
after writing the interaction process
4. Patient overall response towards the interaction to be recorded
 D. ANALYSIS OF THE INTERACTION

1. Analysis of interaction should be done by interacting the verbal and

non-verbal behaviour and patient thought and feeling evident from
the interaction
2. Communication techniques used by the nurse also be recorded
3. Nurse thoughts and feelings at the end of interaction and plan made
for further interaction should be state
4. Time required to record is 30 minute( 20 minute for active
interaction 10 minute for conclusion planning for next interview )
E. Summary

1. The recording process should end with a brief summary to

evaluate whether the initial objectives for the interaction were met
2. If the objectives were not met provide a brief analysis of the
reason

F. Introspection

• Introspection is a psychological process that involves looking

inward to examine one's own thoughts, emotions, judgments, and
perceptions
EXAMPLE
THANK YOU!