8 Collaborative approach to nursing

assessment and care planning

• To outline the different types of assessment and consider what is required for an effective holistic assessment

• To identify the advantages and disadvantages of the different resources that may be used to conduct an assessment

• To understand goal setting and a collaborative approach to care planning

Introduction

This chapter provides an overview of assessment and care planning in mental health nursing practice and examines ways in which you can develop your skills in this area during your practice placements. It introduces the concept of holistic assessment, considering some of the areas that this might cover. The section highlights the different types of assessment that may be used, resources for the collection of, and some examples of, questions you may want to ask. The chapter also reflects on the issues faced by mental health professionals when asking questions that they may find embarrassing or difficult. Risk assessment and management are addressed separately in Chapter 9.

Assessment provides the opportunity to develop an understanding of the person and to identify their needs, problems, strengths and goals. Following on from this it is essential to work with the individual and (where they are involved) their family in order to meet their needs, help them work towards dealing with their problems and realising their goals. This involves making sense of the information gained during assessment and using this to collaboratively develop a plan which will support this to happen. The last section will outline the process of planning care. It will also locate this in the context of the Care Programme Approach which provides the overarching framework for structuring assessment and care delivery in the UK.

Assessment

Assessment is an essential process within mental health nursing care. Participating in assessment enables the healthcare professional and the person in distress to identify and prioritise problems, strengths, needs and goals. It underpins the delivery of care and facilitates the decision-making process. As such, assessment forms an integral part of the nursing process (assessment, planning, intervention, evaluation). As Barker (2004) highlights, this involves aiming to gain an understanding of that person and their circumstances. In this respect, assessment should be a holistic process. This term is often used within nursing practice, however one of the criticisms levelled towards health care is that we don’t always work with people holistically. In particular, mental health services have been criticised for tending to focus on problems alone without recognising people’s strengths or the context in which they are managing their experiences. A holistic assessment will therefore explore and evaluate the resources an individual has, or has access to, and their environment. Who we are, the meaning and impact of any health-related problem may in part be influenced by our culture, sexuality and spirituality. Working with the ‘whole’ person therefore entails recognising and considering this.

Activity

In the early part of your placement, identify the assessment frameworks or tools that are used in your practice area. This may involve:

Talking to your mentor about what frameworks or tools they use.

Looking at blank assessment forms.

Accessing individuals’ multidisciplinary records (though it is important to bear in mind this may inform your perception of that person if you haven’t already met them).

Review these frameworks in light of the list below. Do these attempt to collate holistic information? If not, what information are they attempting to gain? What areas are being assessed? You might also want to think about whether these link with any of the theories covered in Section 1.

This will help you gain some familiarity with the aims of some specific types of assessment and with their structure, which will be useful when you conduct assessments in your own practice.

Areas that may be covered within nursing assessment include the following:

• Social networks and relationships.

• Description of the problems that the person is experiencing and the impact they are having (this may be symptoms of mental distress but may also include, for example, housing, relationship or employment difficulties).

• Family relationships.

• Past history such as health problems (physical and psychological), life events.

• Risk – current and/or past.

• Strengths, e.g. previous successes and areas of interest or enjoyment.

• Ways the individual uses to cope with their experiences (coping strategies).

• Medication – history, current, concordance and side effects.

• Housing and environment.

• Spirituality – spiritual beliefs and expression.

• Cultural beliefs and expression.

• Sexuality (or sexual health) – may include expression and impact of health problems and medication.

• Physiology, such as physical health, blood pressure, body mass index and physical expression of distress such as hyperventilation.

• Thoughts and emotions, e.g. thoughts about suicide or problems with mood.

• Non-verbal communication.

• Speech and expression.

• The individual’s perception and meaning of their distressing experiences.

• Cognition – might include memory and orientation.

• Use of alcohol and illicit substances.

• Previous experiences of trauma and abuse.

• Occupation.

• Financial.

• Past treatment and support.

This is not a complete list but, as you can see, conducting a holistic assessment is extensive. It is important to consider this broad range of areas as this contributes to an understanding of that person and their context. It is also likely to facilitate a better informed, more accurate and therefore more effective process of making decisions, planning and delivering care. It also enables the health professional and person using the service to gain a picture of what is considered as ‘normal’ for that person in their life – a standard which is likely to differ for all of us. However, there are some challenges of examining assessment as a holistic process.

Gaining an understanding of people’s experiences in their context (through holistic assessment) is important at whatever stage people come into contact with mental heath services and to recognise that circumstances will change. However, this may be more the focus of assessment when people are new to services, to that particular practice area or at a point before a change, such as discharge from a service or annual review.

Reflection point

Have a think about going to visit your GP for the first time, the first time you met your lecturer at university or when a new neighbour moved in next door.

1. How would you feel if these people were to ask you a question about each of the areas of your life identified above?

2. What would be informing how you responded to these questions?

This reflection may be useful to keep and revisit when you have observed and/or participated in an initial assessment. At this point, it may be useful to consider the following issues to help you develop a reflective practice.

1. What are your perceptions of what a person may feel during an assessment?

2. What might inform how they respond to questions?

According to the Oxford English Dictionary (Thompson 1996), to assess means to ‘estimate the size or quality of’. Assessment in health care is clearly an essential process to help identify what support people would most benefit from. However, it is essential to bear in mind that its very purpose is to make judgements and that conducting an assessment involves exploring areas of a person’s world that may be quite private and that they may not have shared before. This process will be informed by the rapport that is developed with service users and the values and beliefs of the practitioner and their organisation. It is a clinical skill which must be developed and used with sensitivity.

Assessment is a dynamic and ongoing process. In this respect the aim and purpose of assessment may differ depending on what context and setting you are working with someone in. For example, assessment plays a vital role in the following:

• Finding out whether someone who comes to A&E having taken a paracetamol overdose is likely to repeat this and needs ongoing support or used it as an impulsive way of coping with a change in their life.

• Finding out in what situations someone’s derogatory voices are triggered and the way that they deal with this.

• Identifying what impact the side effects of newly prescribed medication are having.

This highlights that it is really important to differentiate between assessment and admission or acceptance by a mental health team. During an admission or being taken onto a community nurse’s case load, it will be essential to conduct an assessment. However, assessment is a continual process that happens in many different settings. Identifying the different types of assessment and how this is conducted by nurses in your practice area would highlight this and help you plan for how to contribute to mental health nursing assessments. This might be something you want to discuss with your mentor or a practitioner in a question and answer session to find out more about how assessment is conducted in your practice setting.

Types of assessment

Assessment is a process which will draw on all your senses as well as the therapeutic skills that a nurse develops. Effective and sensitive communication alongside being alert to non-verbal and environmental cues is important for all assessments. However, methods of conducting an assessment could be divided into three main groups:

1. Observation.

2. Interviews.

3. Structured questionnaires.

Observation

This mode of conducting an assessment will entail gathering information that is observable. It can be informal such as taking into account the environment or a person’s appearance (Ryrie & Norman 2009). How people act, communicate and express themselves can also be observed. In this respect, observation often informs assessments of behaviour. Physiological basic observations may also be considered under this type of assessment as they provide access to information about measurable changes in physiology such as blood pressure and blood glucose. Different levels of structured observations may be common within a range of in-patient settings such as acute care, forensic and child and adolescent. These are often used as tools or interventions to help manage risk. However, these can also operate to inform nursing assessment as during these periods staff will be observing, in particular, behaviour and communication. This can also help inform the assessment of risk.

Activity

The use of observation by looking at cues as to how individuals may present themselves, express themselves or their own environment is an assessment skill that you will be able to use in your placements throughout your training, if you are in the community, after you have been on a visit or if you are in an in-patient unit after spending one-to-one time with an individual. Consider the following:

1. What did you notice about the individual’s body language and non-verbal communication (Sect. 1 and Ch. 7)?

2. What did you notice about the person’s environment?

3. What might these have suggested about how they were feeling?

You may want to check these observations out with the nurse who you went on the visit with, a member of staff on the unit or the person’s notes in order to get an insight into the ‘norms’ for that person and check out the accuracy of your observations. This could be something you document and communicate to other staff (all these processes could contribute to the achievement of your outcomes). It is also important to remember that our own norms and standards for environment may be different to what is a norm for another person.

Ongoing

Barker (2004) describes the therapeutic value in regular and ongoing meetings. In terms of assessment, these can help to clarify difficulties, consider solutions, establish goals and review progress. Using solution- and strengths-focused questions (see following sections) and clarifying meanings can be useful in this area.

While it is helpful to think about the different types of interview situation and how these may be used, it is important to note that an interview may change between these different types and there is overlap between each.

Structured questionnaires

There is a broad and extensive range of structured assessment tools. These instruments use specific structured questions or rating scales to attempt to provide quantifiable information on an individual’s experiences. In this respect they often result in a numerical value or judgement according to a specific level (e.g. high, medium or low). Questionnaires may ask people to respond in a yes/no fashion or determine frequency or intensity by asking for a rating in response to a series of statements. These tools are often thoroughly researched prior to publication and being made available for use in clinical practice. This means that the tools have been tested to see whether they measure what they are supposed to (validity) and are consistent in doing this (reliability). This type of assessment may also include tools used to examine a specific area such as a voice or activity diary.

Gamble and Brennan (2006) highlight that tools should be considered for how user-friendly they are, whether they are relevant to practice and easy to follow. This is important to remember, particularly as it is advised that some assessment tools require specific training. Training helps to ensure that the tool is used in the way it was intended and therefore that the reliability and validity are maintained. Additionally, some of the structured questionnaires can be quite technical or invasive in the questions that they ask and, therefore, using them requires this to be thought through and explored. Examples of questionnaire assessment tools include the following:

• Mini-mental State Examination – measurement of cognition and memory used in people with dementia.

• Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS) – used to measure side effects of antipsychotic medication.

• Becks Depression Inventory – used to rate low mood.

• Beliefs About Voices Questionnaire – examination of voice-hearing experiences and the individuals’ perceptions of their voices.

Activity