Introduction
Interpersonal Process Analysis (IPA) is a way to identify patterns in student and patient communication. It is not an intake assessment nor question and answer session but a time to listen and demonstrate caring concern, and a time to recognize and identify a patient’s emerging feelings. IPA is a written record of a segment of the nurse-patient conversation that reflects as closely as possible the verbal, non-verbal, coping, and defense mechanisms utilized during the interaction. IPA has some disadvantages because it relies on memory and is subject to distortions, however, it can be a useful tool for identifying communication patterns. The purpose of the conversation is to give an opportunity to identify and practice communication strategies correctly. Note that the goal is not to solve the patient’s problems but to explore and use interactive therapeutic communication.
The student selects goals prior to the interactions that are realistic and measurable. Topics include such areas as behavioral issues (triggers like getting angry when called or made to feel “stupid”), replacing negative with positive coping mechanisms (reframing), identification of feelings (hungry, angry, lonely, tired, happy, etc.), plans for discharge, presence/absence delusions/hallucinations, etc. Therapeutic Communication demonstrates the use of mostly broad open-ended questions, clarification, confronting, reflecting, empathy, immediacy, focusing, etc. Identify the techniques used with rationales for use, and the effect of these techniques. Read and follow guidelines (template and rubric) and chapters on therapeutic communication. Is the patient able to answer? Are responses congruent with your statements?
Instructions
Select a patient to participate. Do not use a “script” for this interaction. Listen and respond to the patient without taking notes. Taking notes is distracting for both the student and the patient and the patient may resent or misunderstand the student’s intent or feel like a project. Write out and analyze a segment of the nurse-patient interaction using quotation marks around what both you and the patient said. Identify non-verbal actions such as body position changes, mood/affect changes, or conversation factors (looking down when discussing an uncomfortable subject). Describe the environmental setting where the interaction took place – did they contribute to a therapeutic (ease of conversation) or non-therapeutic setting (too cold, smoky, etc.). The interpretation sections will be completed later because these sections take time and reflection. Utilize ATI or the textbook for communication and defense/coping strategies.
The selected interaction is based upon the parts of the conversation most meaningful or therapeutic. Allow the interaction to flow, documented so that the Instructor can easily follow the content. As soon as the interaction is completed, thank the patient and excuse yourself. Begin to write the conversation verbatim (word for word) to the best of your recollection. Document both parties’ non-verbal behaviors. During documentation, insert information about any discontinuity, i.e. “patient needed to get ready for group therapy;” “patient left to use the bathroom;” or “we agreed to meet up directly after group.” If the student continues a conversation later and wishes to include parts of both conversations, identify the change or time lapse. (Always account for how an interaction ended when it is unplanned and abrupt, i.e., “patient stood up and said he didn’t want to talk about this anymore.”)
Steps:
Complete the patient demographic information and the environmental setting. (Was the setting conducive to talking?). In the patient description section, the patient should be described in such a way that no one can identify him or her (first and last initials only). Never use patient’s name in your papers.
Include grooming, affect, posture, and mood.
Quote both sides of the conversation and the non-verbal information. Verbal communication is concerned with the spoken word, including inflection and tone of voice. Non-verbal communication is concerned with gestures, body movements, posture and other unspoken forms of relaying ideas and feelings.
Identify student thoughts and feelings during the interaction. For example, “I was feeling nervous and scared. He had attempted suicide and I didn’t know if what I said would hurt him.” Focus on what is happening to you and the patient that has communication value.
The rest of the template will be completed later with time to analyze. Once all columns are complete, the student will have gained insight needed to look back and decide if the technique was therapeutic or non-therapeutic. If the patient responded favorably, yet a non-therapeutic statement was used such as closed statements (“why did you do that?”), document what could have been said that was more therapeutic. For example, I could have said, “Tell me more about what happened.”
The ability to look back and analyze conversation errors/ non-therapeutic responses is as valuable as providing therapeutic responses during the conversation and can provide insight into what is customarily used in your conversations.
Complete the type of communication techniques used and identify whether therapeutic or non-therapeutic. (Therapeutic communication is defined as a face-to-face process of interacting, focusing on advancing the patient’s physical and emotional well-being, and is used to support or inform.)
Identify coping or defense mechanisms the patient probably used in this interaction and whether these were adaptive or maladaptive.
Evaluate the effectiveness of this interaction.
Evaluate the goals. Are the responses relevant to the goal?
Did the patient initiate the conversation or did you?
Did you or the patient change the subject due to discomfort with the topic (like self-harm or abuse)? Did the patient answer you, look away, or hesitate?
Were only meaningless/social topics discussed (football teams, music, food, etc.)? Did you use closed communications, and if so was it because the patient was not cognitively communicative (Alzheimer, stroke, or dementia patient)? What communication techniques were used the most?
Is there congruence between the verbal and nonverbal communications?
Interpret behaviors. These relate to the perception of meaning behind the words.
Identify feelings involved. When possible, document the reasoning behind the feelings.
Identify and evaluate themes and strategies.
What did the communication mean to you and the patient? If you were to redo this interaction, what would you change?
These assignments are typed. Extra pages/rows may be added as needed for the conversation. Include a reference page in APA form.
Case study
Andres, a 41-year-old Caucasian man with a history of schizophrenia chronic paranoid type (SCPT), presented for the initial psychiatric evaluation per recommendations of his neurologist accompanied by his mother. During the past 20 years, the patient had 11 admissions to psychiatric hospitals and was treated with a wide range of first- and second-generation antipsychotics. For the first ten years, haloperidol was the most effective. Trials of ziprasidone and aripiprazole resulted in severe parkinsonism. Without antipsychotic medications, he had increasing hallucinations and paranoia. Anticholinergics were minimally effective and caused dry mouth and cognitive impairment.
During the initial psychiatric examination, the patient presented on a combination of Clozaril 25mg twice a day, zolpidem 10mg at bedtime, benztropine 1mg daily, and lorazepam 1mg three times daily. He appeared older than his biological age, pleasant, and cooperative at this time. His face was moderately masked; an intermittent tremor in his chin and resting tremor in his arms and legs bilaterally was noted. He had difficulties ambulating due to stiffness and muscle rigidity, his posture was stooped, and his gait was unsteady and wide; he required assistance to get in and out of the chair. Due to drooling, his speech was decreased in rate, tone, and volume. His language skills remained adequate. His mood was labile, and his affect was incongruent. His thought process was circumstantial with flight of ideas. His thought content was negative for suicidal and homicidal ideations, delusional beliefs, and paranoid ideations. He reported auditory hallucinations command type, telling him that he was a disciple of Jesus, to look for the sick, and heal them. Andres denies any visual and tactile hallucinations. His overall insight and social judgment were considered as poor. In addition to transient symptoms of psychosis and parkinsonism, he reported mild irritability and tachycardia. The patient reported some difficulties falling asleep at times.
After weighing the risks and benefits, the patient was admitted involuntarily under a Baker Act into the impatient unit for follow up treatment and stabilization of symptoms.
