In the domain of psychiatry and specifically in the area of mental health nursing, it is essential that an early, quality assessment with accurate information is gathered about the patient. Psychotic, neurotic and depressed behaviours are all different. Sullivan (1990) makes it clear that poor assessment and/or misinterpretation of a patient’s presentation can be critical to their well-being and subsequent treatment or therapies. Bearing this in mind, it becomes vital that the mental health nurse is adept at conducting effective assessments.
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This account considers such exemplars through witnessing a one to one interview in an acute unit, will analyse and reflect on those skills employed to assess the bio-psycho-social needs of the patient and include references to clarify evidence-based practise. In keeping with the Code of Confidentiality as is required by (An Bord Altranais (ABA) 2000), relating to client confidentiality, names and locations involved have been changed. Thus, the client will be called Mary.
The Gibbs cycle (1988), is used as a reflection tool to create a structured account of the discussion, and clearly show that true reflection in practise has occurred during its research. Mary is a 38-year-old married female depressive and more recently has had a secondary diagnosis of Anorexia. She has been a frequent patient over ten years to the acute ward where I was on placement. Mary was assigned a nurse whom I shadowed during this time to make my observations who was very helpful and pointed out pertinent features of mental health care practice to me. Mary refuses to eat and drinks only when her body demands it. When unfamiliar people are near, she gives distressed cries. She is on high protein fluids and is weighed every few days. I was shown how to observe her eating pattern and left to perform my task. I was embarrassed and horrified that she wouldn’t eat for me and as she wouldn’t talk I had no idea whether she liked what was offered to her. I felt out of my depth and didn’t know what to do. She would scream and shout out at me and I’m not sure whether this was her way of trying to communicate with me. I felt I should be doing more for her but not sure what. I informed my preceptor that she would not eat what was offered and was told not to worry he would try again, she turned her head. I felt totally useless as I could see this lady was fading away from lack of food but as she refused to eat there wasn’t much I could do and as she would not talk I didn’t know how to communicate with her.
Deliberate self-harm may refer to any act of non-accidental, self-inflicted injury. It covers a broad spectrum of behaviour from successful suicides to non-fatal overdoses or self-inflicted wounding, which may have been previously classed as attempted suicide McAlaney ( 2004). Whilst Mary’s medical condition was not assessed as being immediately life-threatening her psychological presentation gave the nurse no other alternative than to contact the on call senior psychiatric house officer to conduct an assessment (bio/soc/psy evaluation) of her mental state. It must contain a detailed and precise record of what happened and any answers given to often very structured forms of psychological questioning. Thompson and Mathias (2000) likewise describe the process as acquiring information about a person or situation that may include a description of the person’s wants and ambitions. Although I was not allowed to sit in with this interview I was fortunate to be present when Mary’s assigned nurse was talking to Mary on a one to one basis. Before entering the room where the assessment was to take place, I obtained the required consent from Mary (A.B.A. 2000) to be present.
Control of the environment and assuring privacy can be central to successful assessment. Despite not being specifically designed for the assessment of distressed patients the nurse quickly checked for comfort, that chairs were the same height, distanced suitably from each other to avoid invasion of personal space yet allowing easy discussion.
The nurse remained at the same level as his patient at all times and practised positive body language; leaning slightly forward in his chair, maintaining an open posture and remaining relaxed throughout. These characteristics have been well documented by Farley (1992). He further ensured that Mary had sufficient water and nutrition prior to the assessment- as far as she was willing that day considering her condition. The important thing was to have Mary at ease. Thompson and Mathias (2000) suggest that careful attention should be given to these points. He then asked Mary how she would prefer to be addressed. Holland and Hogg (2001) reported that professionals must not assume that everyone wishes to be known by their listed name. This clarification promotes affability as well as professionalism.
Brief periods of general chat opened the session to set an ambient atmosphere for the interview. This introductory phase is also referred to as the orientation or pre-helping phase. Forchuk (2002), states that Health professionals with well-honed listening skills, empathy and who display understanding allow patients to express their concerns, discuss options and build trust.
The nurse interviewing Mary didn’t rush the interview, let silence prevail for her to consider her answers and further supported Mary with encouraging statements to draw information such as, “Tell me a little more what makes you feel this wayâ€¦” Martin (1995), concludes silences actually maximise interaction with a patient. At this stage of the process Mary tentatively began disclosing some information to the nurse and it could be noticed that a therapeutic relationship was beginning to formulate. Actually engaging in conversation whether disclosure or otherwise was a big step for Mary. The works of Burnard (1999) further promoted this observation.
Mary seemed to be doing most of the talking while the nurse responded with active listening. Listening with attention and commitment is a caring response and forms the basis of all effective communication. Eye contact and continuation sounds, body language and gesture all gave safe non-verbal messages and encouraged continued conversation. Brereton (1995) has identified that listening skills dominate talking skills; in the context of a psychiatric assessment this showed that a client’s condition gives added value if the doctor is able to give time to the patient to express herself rather than give her (the doctor) interpretation of what she may have been trying to say.
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Mary was now helping herself and seemed a little relieved to be sharing her thoughts at this time. Mary’s mood was important to the assessment. The nurse identified her presentation as familiar with that of depression and her diagnosis was supported by her confirmation of not wanting to eat or drink and feeling uncomfortable around people. She became distressed and was unable to maintain eye contact. These symptoms are classic of the depressed patient Barker (1997).
To support this diagnosis, both open and closed questions were necessary. A closed question directly requires a yes or no response but does not necessarily invite any elaboration. Barker (1997) suggests that closed questions are appropriate in the initial stages of the assessment to establish simple facts and clarification as they put fewer demands on the patient. In this assessment the nurse had managed to establish rapport quite quickly and asked more open questions (using how/why) like “I am interested that you say you don’t want to eat any more, can you tell me a little more why you feel like this?” as opposed to, “Are you eating well?” but Mary began to withdraw. This cue told the experienced nurse to hold back and it began to identify the content of her thoughts and he noted the responses discreetly whilst attempting to retain eye contact with her as much as possible.
The process of maintaining eye contact was further used to examine her ability to reciprocate. Nelson-Jones, (2002) mentions that the inability of patients to maintain prolonged eye contact would indicate he/she may be in a withdrawn state or feel uncomfortable in his/her condition. Barker (1997) further stated that over enthusiasm about eye contact might cause an aggressive or confrontational experience. The use of this method was appropriate as the assessment progressed. The nurse summarised in terms that Mary could understand, and identified key points discussed, gaining Mary’s affirmation that her interpretation was valid. Nelson-Jones (2002) said this process gives the patient a clear feeling of acknowledgement from another of their deepest feelings while aiding the recovery process.
The skills used in Mental Health assessments emphasise the need for a holistic approach in the work of the Mental Health Nurse. There is no standard format or panacea in the profession of Mental Health Nursing; the many tools and strategies used throughout the process depend fundamentally on the skill of treating each person as an individual, with their own set of needs and concerns as paramount. The assessment witnessed demonstrated that combining these skills promotes a good rapport with the patient and most importantly getting a full picture that can be interpreted and shared with the multi disciplinary team for the onward process of the care pathway approach.
I have discovered that being objectively caring and non-judgmental in assessing the current situation at presentation is a key attribute in assessment skill. Often when interviewing known clients it can be difficult to avoid simply replicating their previous diagnosis or being frightened by the available evidence. I have further reflected on the necessity to question a patient using inter personal skills and effective non-verbal stimuli to encourage exploration and expression of their feelings, sometimes when they are particularly vulnerable, in order to help them. Academic research and observed practise-based experience can help the development of these skills. I have further learnt that people in crisis need continual support and assistance through their acute phase. This will make me more aware of my communication skills.
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