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Profiling a Patient and Practice setting in Mental Health Nursing

This essay would briefly discuss the profile of the patient and the practice setting. In accordance with the Nursing and Midwifery Council (NMC 2008) Code of Professional Conduct and faculty guidelines confidentiality will be maintained throughout this essay referring to the client as James. The essay will also be exploring the importance of assessment to mental health nursing. An assessment scale Health of the Nation Outcome Scale (HoNOS) would be used in assessing the patient for which the rationale behind choosing and using this particular scale would be given. The process of assessment will also be mentioned and the involvement of the patient, carer and contribution of the Multi-Disciplinary Team (MDT) on RIO which is a ‘system for sharing electronic health-care records allowing mental health professionals to share information within their Trust and to work more effectively in the delivery of health care’ (www.ehi.co.uk) will be highlighted in the use of this scale. The outcomes of the assessments would be evaluated and needs related to future care planning highlighted. Finally a summary would be made and the experience of using the assessment tool will be highlighted.

James is a 62 year old white British gentleman. He was diagnosed with paranoid schizophrenia at the age of 20. He had a held belief that his father was demon coupled with command hallucinations telling him to “Stab people” which he has never acted on. On one occasion he destroyed his television set which he did by turning it off from the mains and cutting the cables and aerial but did not smash it for fear of hurting himself due to the voices telling him to. Currently James lives in sheltered accommodation where his allocated key worker visits him to continually administer an intra muscular injection and assess his living condition as he has ongoing physical and mental health issues. When he is relapsing he is at a risk of self neglect and ever present risk of acting on these command hallucinations.

The practice setting has 4 consulting rooms to facilitate meetings between patients and their care coordinators when they have appointments or assessments and a clinic room for the administration of medication. Care coordinators can also arrange meetings with their clients at various places like the General Practitioners (GP) Surgery, Day Centers, coffee shops or their homes where appropriate and places where clients feel at ease to discuss presenting problems. This facility is run by the Community Mental Health Team (CMHT) made up of the Receptionists, Secretaries, Consultants, Associate Psychiatrists, Doctors, Psychologist, Specialist Registrar, Social Workers who double up as Approved Mental Health Professionals, Mental Health Nurses, Senior recovery workers, Employment specialist and welfare rights officer. The team provides assessment, treatment and care to adults in their own homes and community, a service mainly for people with severe and enduring mental illness living in the community (www.rcpsych.ac.uk). Continuously assessing their mental state for signs of relapse and to provide assistance where needed to help maintain them in the community.

Barker (2008) states that “As people present themselves to nurses they reveal something of their personalities through behaviours and a little more as the interaction ensues” and the professional tries to provide a service or services tailored to meet a “perceived need” (Peplau 1992) through objective reasoning and experience. The professional must be able to sift through information provided by the person and their carers sitting in front of them, by collecting and organizing valid information about the issues patients present which can be termed as assessments. Swann (2004) states that “assessments are not only a formal requirement but also a desirable activity carried out in their own right as their outcomes when carried out correctly will be an improvement to the overall wellbeing of the people they are carried out on”. Meaning the appropriate form of treatment would be given to that effect. Halliday et al (2004) also suggested that formal assessment tools can be extremely valuable in terms of the learning that can result both from the process itself and from the outcomes of the assessment, normally a collaborative process between patients and nurse. Assessment should, where necessary take into account views of other professionals and carers. Mallett and Dougherty (2000) implies that nurses should be aware of the rationale for choosing a type of assessment tool, as if this is inappropriate would mean the wrong information collected meaning treatment to be given could be less effective than intended (Tierney 1998).

The team uses many assessment tools like Becks Depression Inventory used in assessing depression, Clustering which incorporates HoNOS but for the purposes of this essay HoNOS will be the main focus. HoNOS was chosen because it is used as part of an overall initial assessment scale when patients are referred to their services. Pirkis et al (2005) states that it is used when a new line of treatment is commenced to gauge the quality and effectiveness of mental health services been used, which can be monitored, evaluated and improved. Furthermore it is the most widely used routine outcome measures in British mental health services and across the United Kingdom National Health Service practitioners, administrators etcetera across the board understand their outcomes and what they mean to their services. Also HoNOS is used at admission, review and discharge in outpatient units and by CMHTs’ for patients with ongoing treatment and on discharge of patients from their services (Rees et al, 2004). As an initial assessment scale, Rees et al (2004) states that HoNOS is a practitioner-administered, 12-item measure comprising four components: behavioural; physical or cognitive impairment; symptomatic problems; and social problems. Each item scores from 0 (no problem) to 4 (severe to very severe problem).

As stated earlier HoNOS can be used when an individual has been diagnosed with a serious enduring mental health condition and also when the client has been under treatment for awhile to review treatment been given. As James meets both criteria this scale was deemed most appropriate in assessing him.

Considering the possibilities of making the intended client anxious or nervous, a background research had to be conducted, comprising reading the clients’ notes on RIO looking at previous diagnosis given to client and what the multi-disciplinary team (MDT) had documented about James, also his care coordinator was involved in the process of initial information gathering where he gave his professional objective point of view of James, briefly from first contact to present. Moreover an initial introduction was arranged with him and rapport built, considering Peplau’s model of building interpersonal relationships and when appropriate after a couple of visits, informed consent gained (NMC 2008) before the commencement of this essay. Due to the nature of terminology, the questions had to be simplified, avoiding the use of jargons, using opened ended questions at the start of administering the questionnaire to ensure that he felt at ease and closed ended questioning to illicit particular responses to some questions (Funnell et al, 2005). Paraphrasing where necessary to reassure patient and also to clarify understanding of points he had raised earlier and summarizing and reflecting where necessary to gain proper understanding and meaning to answers provided by client.

The interview was held in the clients’ home which was used advantageously, a seat was placed closer to him to ensure that an appropriate distance was maintained, an open body posture was used and appropriate eye contact maintained (Walsh 2002). The client appeared quite honest and open about his history from his perspective and the period which was in review. Another date was set for his next of kin and carer to be present and information gathered from her as well before assessment was completed. Ensuring that information from the MDT, client and carer were all collaborating.

As stated earlier, items in HoNOS can be arranged into sections namely

Behavioural problems are covered by questions 1- 3, Cognitive Impairment and physical questions under 4 and 5, Symptomatic 6 – 8 and Social problems 9 -12. Sub-scores can be identified for each section, but each section has different ranges (www.rcpsych.ac.uk).The range of total scores is 0 to 48, sub-scores and totals cannot be used if there are ratings of ‘9’ which means unknown (www.rcpsych.ac.uk). (See appendix 1.1 for score sheet)

James on the behavioural problems out of a possible 12 points scored 1 particularly on the question 1 indicating the presence of slight irritability and restlessness which requires no further intervention. This was due to having too many people in his flat at one time. On the second aspect of the scale looking at cognitive impairment, three items in the room were mentioned to James and at a later stage asked to recall them in the correct order which he did without hesitation also his orientation to time, day and year appeared intact, indicating no problem. On the physical aspect, James scored 3 as he has a pacemaker implanted a couple of years ago on account of an irregular heartbeat indicating moderate degree of restriction due to physical health problems, limiting the amount of activities he is able to carry out. Symptomatically he scored 2 with relation to hearing voices occasionally but stated been able to control them and challenging them meaning they are clinically present but mild. Also James stated having minor problems when it came to going to sleep. With regards to his social functioning James scored 2 on question 10 in that his self care was adequate but could not undertake complex skills like budgeting, organising his flat and shopping to cook himself a meal.

In relation to future care planning needs, James on the behavioural functioning scale from information gained from his carer implies that in future meetings timings should be either shortened or breaks can be had within meeting to prevent him feeling overwhelmed by information been discussed to lessen his irritability. With regards to his physical problem, Swann (2009) encapsulate the need for an occupational therapist assessment of his ability to carry out low to moderate levels of task that would not have strenuous effect on his heart which in the longer term would provide him with the needed confidence to undertake tasks and become more active. James did have a minor but non clinical problem with making and sustaining new friendship as he stated not having common interests as most people his age, another assessment can be carried out to assess his social functioning to assess his need in relation to this. On the whole James is relatively settled not requiring any intensive input with regards to his behavioural, cognitive and social functioning requiring immediate attention.

In using the HoNOS scale, I initially found it particularly difficult consolidating my knowledge around the wording in context of using the scale to rate treatment been offered patients. Until, I had the opportunity to go through it with colleagues and qualified staff pertaining to the use of this scale and its direct impact on their services. I also came to the realization that one has to be fairly conversant with the patient, that is, knowing the patient over a period as the scale is used by practitioners who have over a period built an overall picture of patients and their patterns and responses to clinical interventions and events that might not be easy to achieve without measurement (www.rcpsych.ac.uk) I had to build some a therapeutic rapport to gain background information from both carers and the MDT to build up a picture of the client before administering it, which can only be achieved by building positive working relationship with all concerned and most importantly the patient themselves. As Halliday et al (2004) also suggested that “formal assessment tools can be extremely valuable in terms of the learning that can result both from the process itself and from the outcomes of the assessment”. I noticed that carrying out this tool afforded me the opportunity to further expand my perceptions on assessment tools their uses and how informative when they become when the right tool is used in assessments.

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