It is often thought, that engagement within the nursing field should be predominantly initiated by the nurse him/herself. Though to facilitate effective engagement, both nurse and client need to find ‘common’ ground. Barker (2005) discusses, that patient empowerment is key to rehabilitation/management of mental health illness. He suggests that a metaphorical bridge needs to be built, that allows both client, and nurse, to cross back and forth to each others domain. This theory allows the nurse to appreciate the client’s problems/needs/goals, and allows the client to obtain insight into their condition, and to understand what the nurse is trying to facilitate.
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Building a bridge between client and nurse, in theory, has a great advantage, though the problem in building this bridge is obtaining the resources to do so. Nurse-client rapport is a very sensitive process, and one that could take weeks/months to establish, or sometimes never. This thought puts an incredible amount of pressure upon a nurse to facilitate a connection, especially when considering that a nurse may have to make a formal assessment of a patient/client within minutes of meeting each other.
In order to assess a client, a therapeutic relationship between the caregiver and the client needs to be implemented as soon as possible. Peplau (1991) informs us that; the therapeutic relationship is the central element in the nursing process. Without this relationship a client may feel as though there is no trust, empathy, or sympathy offered by the nurse. This ideology is also supported by Barker (2004), who states that in order to assess a client by means of interview, the caregiver must try to obtain a clients trust in order to establish a therapeutic relationship. It is only then, that the client will trust a caregiver enough, to be open and expressive.
Client assessment is the key principle to the standard of care that a client receives. As Norman & Ryrie (2009) point out, assessment permeates all aspects of nursing care, and is the cornerstone of mental health nursing. The importance of mental health nurses possessing the skills to conduct a comprehensive assessment of mental health problems is a key competency, as identified in The Capable Practitioner (SCMH, 2001). One must also take into account that other teams must be able to work from the same assessment, and this is where a patient-centred approach is paramount in order for all caring teams to work collaboratively in providing an effective plan of care (Harrison et al, 2004). In order to care for a client holistically, many differing teams will need to be incorporated into a future care plan.
The process of assessment should be followed by means of a bio psychosocial framework. O’Carroll & Park (2007), suggest that any biological, psychological, and sociological issues that the client has must be recognised, and incorporated into any future plan of care. By only addressing the psychological issues that a client has, then often the main cause of the mental health problem/s may not be dealt with, such as family/financial/medical, etc issues that contribute to the diagnoses.
A large proportion of researched literature concentrates on the means of formal assessment via interviews. Though in essence, assessment starts upon the very first encounter between client and nurse, and sometimes before a formal assessment has been arranged or discussed. Upon the thought of a formal assessment being arranged, a client may very well become reclusive about expressing their thoughts and feelings. This is a belief shared by Norman & Ryrie (2009), when pointing out that some people enjoy talking communally, whereas others who are shy and anxious may benefit from a more private, structured, and formal interview. This can sometimes be recognised within the first few moments of engagement, and may also be useful to obtain information that a client may not discuss openly or privately.
In order to highlight how principles, theories, frameworks, and ethical legalisations impact positively or negatively upon the engagement process of client assessment, a reflective account of client assessment will follow. This reflection will be that of a mental health nursing student’s observation of client assessment whilst on clinical placement at a Crisis Recovery Unit (CRU). The student accompanied a qualified Community Mental Health nurse (CPN), upon assessment of a client attending the CRU.
The CRU is a community mental health facility that engages with clients recovering from a mental health crisis. It offers interventions and support to those referred via the Community Mental Health Team (CMHT) and the Crisis Resolution and Home Treatment (CRHT), to help prevent relapse and support rehabilitation back into the community. The SCMH (2006) supports the CMHT and CRHT in its attempts to offer early interventions to prevent hospitalisation of those suffering mental health conditions. The CRU also helps in avoiding the stigma associated with hospitalisation, and offers communal support due to all clients experiencing a mental health condition. During clients’ attendance at the CRU, they are constantly assessed, informally and formally, for any changes to their psychological, sociological, and biological needs. This is done via differing engagements and interventions identified within their care plans.
Introducing the client
To adhere to the laws of confidentiality, as stated in The Code of Professional Conduct (NMC, 2008), the clients identity will be changed to that of a pseudonym. Furthermore, no reference to the location of client, service, or family members will be identified.
Miss B had been referred to the CRU via the CMHT upon discharge from acute hospitalisation. She had been admitted to an acute psychiatric hospital following a third overdose of pain killing tablets, in an attempt to commit suicide. Miss B had been previously diagnosed with depression and social anxiety, and also had history of alcohol abuse. It was the feeling of hopelessness, as Miss B later explained, that was the major contributing factor for her attempted suicide. Barker (2004) acknowledges that those suffering with depression, alcoholism, and social isolation, may have a high tendency to commit suicide. Though he also goes on to suggest that many people who commit suicide have no formal diagnosis of any form of mental illness.
As a requirement to Miss B’s early discharge, she has to attend the CRU on a daily basis. Miss B was discharged from hospital on section 117 of the Mental Health Act. The Mental Health Act (1983, amended 2007), stipulates that those who meet satisfactory requirements whilst detained, can receive care and treatment under the direct supervision of the CMHT.
Reflection of Engagement
Upon arrival to the CRU, Miss B was greeted by both the student and a qualified CPN. It was evident that Miss B was showing visual symptoms of anxiety. This was indicated by her biting her nails profusely, and a slight tremor in her body, and as Barker (2003) discusses, these are signs of anxiety when encountering a new situation. Upon reflection, and further time spent with Miss B, it was evident that anxiety was the issue here, as through the course of the day, these visual symptoms gradually decreased. One must also take into consideration that these visual symptoms could have been caused the Extra Pyramidal Side-effects of her medication (Owens 1999).
After the formal handover of Miss B to the care of the CRU had been completed, the clients personal CPN left the building. It was at this point that Miss B was offered a cup of tea/coffee, and a tour of the CRU building. It was decided between both student and CPN, that any formal interview/assessment should be delayed, in order to help Miss B feel more settled, comfortable and less pressured. The offer was greeted with a nervous smile, and audible (though very timid) thank you. This was the first audible comment received from the client, and deemed as the first vocal interaction between staff and client. Miss B was asked by the CPN, if she would like to make the coffee herself, or if she would prefer the staff to do it for her. This suggestion was offered to promote client independence at the earliest opportunity. Miss B subsequently decided that the student could make the coffee, as she did not know where the coffee, milk, etc, were.
Both student and CPN sat down at a table with Miss B whilst she drank her coffee. This action was taken to offer the client companionship, and to initiate a therapeutic relationship. Roth & Fonagy (2005) imply that, if a client feels that the relationship between her/him and medical staff is good, then there will be a greater chance of success in rehabilitation. Although it had been agreed between student and CPN, that any formal assessment should be delayed slightly, informal assessment of the client had started upon noticing her anxiety levels upon the first interaction. By spending time with the client informally, and discussing superficial matters (when possible), it was believed that this would help gain an element of trust between both parties (Norman & Ryrie, 2009).
After a brief period of time, the CPN explained to Miss B, that a formal assessment would need to be undertaken. She was also asked if she minded the student being present in an observational role, in order to facilitate the students learning requirements. Miss B’s consent to this request was required to uphold patient autonomy (Thomas et al 1997). It was explained, that although an assessment had been undertaken whilst Miss B was in hospital, a further assessment would be required now that she was under the CRU’s care. This was in order to facilitate a future care plan for the client, and to address any changes in mental/physical/social well-being, needs, and goals.
The Care Programme Approach for Mental Health Service Users (CPA) (2003), in conjunction with The National Service Framework for Mental Health (NSFMH) (1999), is a unified assessment and care plan policy that incorporates holistic assessment and care of a client. This was to be the assessment form used, and one that runs systematically throughout this specific trust.
After consent was received from the client, she was shown to an empty relaxation room. Though not always possible, it is ideal for a client suffering with anxiety to be interviewed in privacy. This potentially allows a client to be more expressive in terms of engagement, and disclosing confidential information (Tschudin 1995). The room itself was plain and natural looking, with no obvious distractions to influence or have a negative impact upon the assessment. The room consisted of four chairs that faced each other, thus allowing all persons in the room to maintain eye-contact. Eye contact is a valuable form of non-verbal communication, which allows the client to feel, reassured that the nurse is listening to him/her with interest (Knapp 1978).
As all parties sat down to commence the assessment, the student was observing the CPN’s posture, as she sat in the chair. Many differing theories of posture have been analysed, to find out which is the most efficient when interacting with a client. After reflection, it was evident that the CPN was using the Egan (2002) acronym of ‘SOLER’. Egan suggests that the behavioral framework to demonstrate that ‘you’ are paying attention, is to sit squarely, open postured, lean forward, eye contact, and relax. This is the acronym ‘SOLER’, that she suggests is an effective engagement tool to make the client feel valued.
Like any form of engagement, cultural diversity will dictate as to what framework should be used. If this model of interaction were to be used when engaging with certain cultures from East Asia, for example, then it could be deemed offensive and intimidating to make such eye contact, and to sit so closely (O’Carroll & Park, 2007).
Miss B appeared nervous, still, and the CPN notably observed this by asking the client; if she had any concerns regarding the assessment. Miss B responded that she does not like talking about some of the issues that were exposed on her previous assessment. The CPN asked; “can you explain why not?” The student observed that this was an open ended question, which the client could elaborate on if she wanted to. Barker (2004) explains that open ended questioning is a vital process of the interviewing procedure, as it encourages the client to feel valued and respected. It also shows that the interviewer is listening and responding reflectively to the clients concerns.
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Miss B responded that she felt guilty and embarrassed, regarding some of things that her family has had to endure. To this, the CPN told the client that she did not have to talk about any matters that she did not want/felt comfortable to, and that anything she did talk about would be held in confidentiality amongst the Multi-Disciplinary Team (MDT), in accordance with the Data Protection Act (1998). This response appeased the client somewhat; who then said that she knew this process is an aim to help her, but found it hard and raw.
The CPN continued to explain the process of formal assessment to the client, explaining that it is a means of gathering information towards identifying needs, interventions, risk, and goals (Savage, 1991). It was also explained that, due to Miss B’s previous attempted suicide, then a risk assessment would also need to be undertaken. The student observed the facial expression of Miss B and noticed how she suddenly looked upset. It was assumed by the student, that Miss B felt embarrassed or guilty in regards to her attempted suicide. Remembering Heron (2001) six category intervention model, the student told Miss B; that it is a requirement of the CPA that all clients are risk assessed during an initial assessment, in order to keep the clients safety, paramount. The student was using an aspect of Heron’s model, called informative intervention. This was in hope that it gave the client information, and also assures the client that her reaction of being upset was noticed.
As the assessment progressed, it was evident that the CPN was reflecting upon the clients answers, and then repeating the answers back to the client. Martino et al (2002), state that reflective listening is a vital motivational interviewing micro skill that infuses the whole interviewing process and enables the interviewer to understand what the patient has said. Although reflective listening clarifies what the client has said to the interviewer, is heard correctly and confirmed, it is an approach that requires skill and experience to adopt correctly. Elder et al (2005) acknowledges that reflective listening requires a good therapeutic relationship, though also states that over-use of reflective listening could seem contrived and stilted. Reflecting upon what Elder suggests, there were points during the interview, when Miss B looked at the CPN in confusion as if to suggest that the CPN had trouble with her hearing.
As part of the psychological, biological, and sociological assessment, Barker (2004) emphasizes that both subjective and objective aspect’s of the clients self and community need to be explored. It was whilst trying to gather information in regards to Miss B’s family situation, that she became distressed. Miss B stated that she had lost all connection with her family, due to instances of verbal and physical abuse she had subjected them to. At the time of the assessment, it was unclear whether, subjectively, this was the client feeling guilty for what she had put her family through, or if objectively, this was the true situation in regards to her family situation. People often experience self-reproach for past misdeeds, and subject them-selves to self persecution, which is a delusional process (Barker, 2004).
As information on this matter was trying to be obtained, it was evident that Miss B was becoming more distressed. Her eye contact was less focused, and she started to pick at her nails. Being unable to maintain eye contact, as Perry (1998) implies, can be a symptom of depression, and low self-esteem.
As Miss B’s anxiety levels rose, the student did not know whether to reach out and put his hand upon the clients shoulder, as an offer of assurance. It felt a natural process of empathy to do so, though the student did not know if this approach may have been deemed, invading. Morse et al (1991) acknowledge that, empathy is a therapeutic means of acknowledging that the nurse understands the clients’ perception of reality. Distinguishing when/if is the right or wrong time to touch a client, relies upon a high level of self awareness. Hizar (1997) points out, that even when somebody thinks it is an appropriate time to touch somebody; it is not always recognized, or interpreted, as a positive, empathetic gesture.
The student did not reach across to touch the client, as he was not entirely self-aware if this course of action was appropriate, or not. Though the student felt as though he could relate to broken family connections, through means of his own experience, he was unsure if his projected interaction would be displayed as so. Crisp (1980), found in Norman (2009), states that; those who are in touch with their own adolescent struggles, can offer a client greater help and support, by means of sharing similar experiences.
What became apparent as a difficult process was the act of therapeutically responding, whilst documenting information. During the interview, the CPN was asking questions, actively listening and responding, whilst filling in the CPA assessment form, and the Health of the Nation Outcomes Scales (HoNOS) form. Both assessment forms are an essential requirement of the bio-psychosocial assessment, and to promote health, social care and well being (HSCWB) for a client (Adult Mental Health Services, 2005). It became evident to the student that it requires skill, experience, and concentration to efficiently meet these demands whilst performing an assessment. The CPN was continuously documenting information on both assessment forms, with what seemed like relative ease. Though when questioning the CPN after the assessment, she stated that it would be easier if two nursing members were present upon reflection, so that one could mainly document information, whilst the other engaged with the client. She did go on to say that; staff and resources implicate this method, and both nurses would need to have the same levels of subjective, and objective thinking in order to correlate information correctly. This is outlined in the Department of Health (2004) The Ten Essential Shared Capabilities, where it states that all clinical staff should be equally trained to an acceptable/best level of competence, before qualification registration is obtained. She also stated that; it would be hard to initially identify if a client would be as open/expressive with a second nurse present, due to initial impressions that a client has regarding the nursing staff.
Due to the client becoming more anxious and agitated, The CPN asked Miss B if she would prefer to conclude the assessment when she visited the next day. The student thought at the time, that the assessment needed to be competed in the initial interview, but upon reflection, this was an ideal time to postpone the interview, as the client was becoming more unfocused and agitated.
The CPN concluded the interview by reviewing specific details with the client. Hawkins (1986) found in Harrison et al (2004), observes that focusing on specific details of identified problems, acknowledges to the client that key factors regarding specific problems within all aspects of the clients life, have been identified. This is a necessary requirement in terms of assessing, planning, implementing and evaluating (Issel, 2008).
Through observationally assessing a client, the student has developed a wider understanding of the implications concerned, in regards to assessing a client holistically. It is essential to treat each individual, as an individual, and to approach with an open mind when regarding clients needs, goals and satisfactory interventions to promote recovery.
It has been observed that initial contact with a client can be the underlying factor in developing a therapeutic relationship between both nurse, and client. The willingness to engage at the earliest opportunity can have a major influence upon the clients’ willingness in expression of thought, and trust towards the nurse.
Models and frameworks of care and assessment are a vital ‘tool’ in aiding a practitioner to facilitate engagement with a client. Without these ‘tools’ of care, engagement and assessment, a nurse could easily provide negligent care and recovery of the client concerned. I t could also lead a nurse to provide care based from his/her own assumptions, without taking the clients’ holistic needs and goals into account.
The student has learnt from reflection that a wide range of engagement procedures are required in order to make the client feel comfortable, appreciated and valued as a human being. Facilitating positive-ness within somebody who feels worthless is a very skilled and valued requirement. This can only be achieved through education, experience, self-awareness and reflections upon one’s own actions.
A nurse needs to identify all aspects of verbal/non-verbal communication when assessing a client, and to identify what is subjective or objective in terms of clients’ feelings. It is often these feelings, which prevents a client from engaging with mental health services and staff.
Although there is an abundance of research and literature that was not incorporated into this reflection, the research that has been incorporated, identifies how differing engagement models can have a positive, or negative effect upon the act of engaging itself. It also shows how the theories of engagement do not always mirror the physical act of engagement. This is where reflection of a situation aids the practitioner upon their next occurrence, or course of action. It is only through experience and research, which the well-being of a client can progress and evolve. It is also this reflection that increases a nurse’s level of self awareness, and systematical approach to care.
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