The Importance of Assessment in Mental Health Nursing
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The assignment will discuss the importance of assessment in Mental Health nursing, focusing on a 54 year old lady suffering from major depression. The Department of Health (DoH, 2010) pointed out that depression is a disorder of mood and may be characterised by low mood and feelings of unhappiness, exhaustion, self blame and suicidal thoughts. The assessment scale called Health of the Nations Outcome Scales (HONOS) (see appendix B) and the rational for using this scale will be explored. A brief profile of the patient and the practice setting will be discussed. The scale will be used on the patient and the details of the patient and the hospital will not be disclosed to protect the patient's identity according to the Nursing and Midwifery code of conduct (NMC, 2008), hence the name used will be fictitious. The process of the assessment and the involvement of the service user, family, carer and contribution of the multi-professional team will be highlighted in relation to the patient's future care planning needs. The good and drawbacks of the scale will be explored. A summary of the experience of using the assessment scale will be written.
Assessment is described as 'the first step of the nursing process,' Wolters et al. (2010 p.36). She pointed out that it is the act of collecting, organizing, evaluating and documenting information about the client's wellbeing, while Varcarolis (2011) mentioned that an assessment is an interview which examines the mental state of a patient. Furthermore, the National Institute for Clinical Excellence (NICE 2009) guidelines give emphasis to early access to assessment and treatment for people with psychological problems.
Assessment is essential because the health care professionals need to know the physical, social, psychological, and cultural aspect of the patient's life Wolters et al. (2008). An assessment is done to obtain information to create a detailed history about the patient, and to distinguish problems and to create a nursing diagnosis along with a suitable care-plan Varcarolis (2010 pp. 4-5). The DoH (2001) pointed out that it is essential to carry out an assessment because patients suffering from mental health problems may have problems with their physical wellbeing, such as poor diet. Assessment is crucial so as to look for vital signs such as checking for urinary tract infection, temperature, weight, pulse, respiration and blood pressure (Harris, 2002).
Assessment is essential because health care professionals need to know the patient's cognitive functioning: what they are thinking, their emotions, their values and beliefs and most of all 'what they might do next' such as suicide or serious self harm Barker (2009p.). Assessment may disclose any changes in the patient's family dynamics or lifestyle changes. It may reveal their beliefs or rituals.
HoNOS was first published in 1996 and there has been on- going review of the tool to improve its validity (The Royal College of Psychiatrist 2000). The tool consists of 12 items with 5-point scale which are completed by professionals within few minutes after an assessment, admissions and discharge of patients. The scale can be grouped into 4 section of which 1 to 3 measure behaviour, 4 and 5 measures impairment, 6 to 8 measure severity of symptoms, and 9 to 12 measure social functioning. The scale considers different aspects of mental health, each on scale 0-4, of which 0 means, 'no problem', 1 means 'minor problem requiring no action', 2 means 'mild problem but definitely present', 3 means 'moderately severe problem' 4 means severe to very severe problem and 9 means the professional do not know and the total score ranging from (0) being best and (48) being (worst) British Journal of Psychiatry 2002). The rational for choosing this assessment tool is to broaden my experience as a student nurse and to increase an in-depth knowledge of this particular tool as it is used in this placement area and its extensive use in mental health settings.
Chichi is a 54 year old lady who is divorced with two children whom she has little contact with. She was brought in by the police under section 136 which turned into section 3 of the mental health act (1983). Chichi has tried to commit suicide by drowning herself. She has a long history of suicide ideation influenced by her major depression and is known to the in-patient units and community mental health team. Most medical interventions seem to have failed. Chichi was admitted early this year in acute in-patient hospital which is a 23 bedded adult ward with single en-suit rooms for male and female patients aged between18-65 years. The service provides care for patients who are suffering from mental problems that need medium periods of in-patient care. The team is comprised of the ward matron, the manager, two deputy managers, nurses, support workers, psychiatric doctors, community mental health team and an administrator.
For the assessment to be successful, the police provided all the details of the patient's suicidal attempt. Varcarolis (2006, p 5) pointed out that a 'lot of information from the police has to be collected' as part of the assessment therefore therapeutic relationship was established. Williams and Wilkins (2010) pointed out that therapeutic relationship should be based on trust, reciprocated respect, expression of empathy and power sharing between the nurse and the patient. Time was spent with the patient in order to build a good rapport. The patient's notes were read from progress notes, and previous assessments. The multidisciplinary team contributed to my knowledge about the patient by sharing information in handovers, ward rounds, and review meetings where they discussed the best type of interventions, zoning and medication suitable for the patient. Other members of the team who contributed to this assessment process were the home treatment team, social workers and the care co-ordinator as they were the professionals involved with the patient's care prior to admission. Chichi did not want any members of her family to be involved.
Preparation and planning of the assessment was made before the interview to encourage future progress of a working relationship. DoH (2010) articulated that consent is an essential element in all phases of care and treatment, so verbal consent was gained from the patient and the reason why the interview was being conducted was explained to the patient. It was explained to her that she was under no obligation to participate in this interview and it was entirely up to her. The mentor who was present throughout the interview process signed the consent form (Appendix A). A quiet room within the ward was chosen away from the disruptive ward activities. The room was set-up in a way that would encourage good eye contact, sitting squarely, having open posture, and, a relaxed atmosphere was maintained to encourage the patient to relax and engage in the assessment process Egan (1998). The patient was offered a cup of tea and commenting on how well she was dressed made her feel relaxed. The questions were asked randomly to simplify the process. Chichi was asked how she was feeling. She presented tearfully and failed to make eye contact. She mentioned that she wanted to die and the only reason stopping her was the fear of not knowing how her children would cope. Chichi's emotions were reflected back to her in order to show her that the stuff was empathising with her. When Chichi was asked about her social life, she revealed that loosing contact with her children was one of the triggers for her depression and suicide attempts. Riley (2008) articulated that communication is the skill to convey and obtain messages. It was important to acknowledge what to say and to choose the right time. The patient was responsive to all the questions even though she appeared distressed. Keeping the questions short encouraged her to converse and gave incredible feed-back. Ensuring the questions were received as intended was essential because it facilitated good answers from the patient. Varcarolis (2010, p 24) pointed out that watching out for the patient's 'non-verbal cues' helps to know which questions to ask to avoid upsetting the patient. Due to the therapeutic relationship established, the patient remained comfortable and engaged well throughout the assessment. The whole assessment took around twenty minutes. The patient was asked if they had any questions and she was thanked for participating.
The patient scored 4 on question 2 which is under behavioural because of the seriousness of her suicidal attempt. McRory (2007) pointed out that women with personality disorders self harm and about 4% of these cases are the top five causes of acute medical admissions. The patient scored 0 on number 1 and number 3 because she had no problems with aggressive or disruptive behaviour and also she had no problems with drinking or taking illicit substances. However, scoring 4 on non-accidental self injury was very serious and required interventions. The patient scored 4 on question 7 which was a question about her depressed mood but did not have problems with other mental and behaviour problems such as hallucinations and delusions. Scoring 4 out of the possible 12 on symptomatic problems was considered to be severely depressed as she presented feelings of guilt and self blame emanating from the divorce from her husband and her children living far away. The score indicated that interventions were necessary because of the severity of her depression. Questions 9, 10, 11, 12 covered the social problems experienced by the patient. The patient scored 2 on question 10 which was a minor problem but will need minimum help from the team. The patient went on to score 2 on question 12 because she was worried about losing her job and lack of activities.
A future care plan and needs were obtained that included a one to one level of observations of a patient's whereabouts, behaviour and mood changes and Staff to monitor the patient for feelings of hopelessness. Electroconvulsive therapy to be started as it is known to have a beneficial effect for patients suffering from major depression RNC (2010). A course of anti-depression medication to be started to lift the patient's mood and to monitor for her concordance, effects and side effects of the medication and to encourage the patient to have contact with her children family and friends.
The tool has its advantages and disadvantages. The tool was ideal because it was the best way to measure her illness as it focused on her presenting problems. I found the tool to be subjective and there are inconsistencies as health care professionals produce different results within 24 hours of admission, for example, the results produced by the Home Treatment Team can be different from the results produced by the ward nurse within 24 hours of admission. The advantage was that the tool was easy for the team to complete in few minutes. Sukhwinder et-al (1999) pointed out that HoNOS showed moderate to good inter ratter and test-retest reliability within the adult mental health patients, while McGilloway et-al. (2000) pointed out that the tool cast doubts on its validity because their study showed low scores on HoNOS despite the high levels of morbidity in their sample. Malcolm et-al. (2000) supported the tool saying that their findings found the tool sensitive to variations in the illness type and severity and between admission and discharge of patients.
The assignment has broadened my mind on how to use the HoNOS. I have carried out an assessment in a holistic way and not just focusing on the patient's presenting illness. Developing a therapeutic relationship with Chichi has assisted me to feel more comfortable to carry out the assessment. I was nervous before the assessment but with the support of the mentor, the interview was a success. I would like to be more confident in caring out assessments and take less time. However, my mentor boost up my confidence by acknowledging me that my communication skills have improved.