Introduction

Assessment is a pivotal part of any patient journey within the healthcare system and forms the cornerstone of high-quality care. In this chapter we consider the guiding philosophies and principles that underpin the assessment process. We also discuss the aims and the process of assessment and introduce you to the range of tools and assessment frameworks that you may encounter in the practice setting. Some of these tools and frameworks will be generic and some will have been developed specifically for older people. Within the context of assessment, we also discuss how communication, assessment and care planning are interconnected facets that underpin effective care for older people. We also consider the importance of communication, both as an intrinsic part of the assessment process and as a separate sphere as part of our wider role in working with older people in everyday care situations.

We consider the specific issues for older people and how nurses who work with older people need to ensure that they take individual needs into account as part of the patient experience as a whole. Effective communication is a core requisite for nurses in all care encounters, as well as one of the four domains and learning outcomes specified by the Nursing and Midwifery Council (NMC 2010) that students have to achieve to qualify as a registered nurse. It also forms an integral part of the assessment and care planning process and for this reason we consider assessment, care planning and communication together in this chapter.

We ask you to consider the role of communication, assessment and care planning in terms of establishing and maintaining high-quality person-centred approaches to patient care with older people, and it would be timely prior to reading this chapter to read Chapter 8 on the core philosophies. These core philosophies of care are a central tenet of assessment, care planning and communication and we refer to respect for individuality and using person-centred care approaches as an integrated part of assessment, care planning and communication throughout this chapter, thereby giving you the opportunity to think about how philosophies of care are translated from conceptual models into foundations of care and care practices with older people. In this way, we add another piece to the complexity of the ‘holistic’ jigsaw of caring for older people.

Activity

Before exploring communication, assessment and care planning in detail, think about what you consider to be the key components of communication generally, for example effective listening skills, a shared understanding of experiences and the ability to give and receive information. You may wish to think about this in terms of a care encounter with an older person while you have been on a placement. Equally, however, you may wish to consider this within a context of a recent social gathering or event with a group of friends or relatives.

Now take a few moments to consider a conversation that you have had with an older person either as a patient, a client or socially. Reflect on the conversation and consider what you feel was positive about the encounter and also if there was anything that was especially challenging. For example, was there mutual understanding in the giving and receiving of information? Were there any barriers to effective communication within the conversation?

You may wish to note down your thoughts as we return to this later in the chapter.

Introduction to communication

We all use various forms of communication which may be defined as spoken (oral), written or non-verbal communication. It is rarely transparent or uncomplicated. It shapes and transforms the world, establishes who we are and who others are in relation to us (Crawford et al 2006). However, for the most part, communication is a taken-for-granted part of our daily lives and one which we probably do not spend a great deal of time thinking about. For example, we may not always be aware of the many complex skills that we use in everyday communication encounters yet this is the very essence of how we establish and maintain relationships with those around us. Equally, it is hard to imagine how we would communicate if some of these taken-for-granted skills were no longer available to us, for example not being able to hear what is being said or to see the person with whom we are holding a conversation.

Within the context of health care, communication is a core, if not the core, aspect of nursing practice and we all need to develop excellent communication skills in order to develop therapeutic relationships with patients and clients and to be competent nurses (McCabe & Timmons 2006). Moreover, communication is not purely confined to the immediacy of the nurse–patient–client relationship but also includes carers, relatives and friends and at an organisational level. There is a need to develop and maintain effective communication strategies and understanding across many different disciplinary boundaries.

As nurses, the way in which we communicate with others has a profound effect on the people around us, and how we speak, write, gesture non-verbally, use signs and images and respond to the communication of others will have a great impact on the quality of care that patients receive. Effective communication, both verbal and non-verbal, for example the use of body language, enables us as nurses to establish and maintain rapport with patients/clients and our colleagues.

Moreover, it is only through effective communication that we as nurses are able to work with patients, clients and carers to identify their needs as individuals and to plan care appropriately, and as Faulkner (1996:2) has observed:

Communication needs to be effective so that care can be planned on the basis of the patient’s authentic problems rather than what we [the health professional] think the problems are.

However, while we all recognise the importance of effective or ‘good’ communication skills, there are a number of factors which may inhibit effective communication in practice. In the following section we consider some of the issues that can impact on the quality of communication from the particular perspective of older people.

Quality of communication and the older person

As we noted earlier, communication is not just concerned with language, it is inherently bound within the wider context of the attitudes and the values that individuals hold. Negative attitudes and stereotypes towards older people may impact significantly on how individuals communicate with an older person, for example ignoring older people during a conversation or using inappropriate terms of address. This in turn has the potential to impact on the way in which an older person may feel about themselves and ultimately their self-esteem. Moreover, poor communication and pervading stereotypes of older people may profoundly affect the quality of care and treatment that older people receive. Blomqvist (2002), for example, found that the effective management of older patients’ persistent pain and pain relief in the clinical setting was inhibited by a number of factors including poor communication.

Negative attitudes towards older people and the impact on communication is an enduring theme in many publications, reports and studies relating to older people. For example, The National Service Framework (NSF) for Older People (Department of Health 2001) has identified the need to communicate effectively with older people as a central facet in the development of person-centred approaches to care and the eradication of age discrimination.

Brown & Draper (2003) have highlighted that older people may experience what they describe as a ‘mismatch’ between an older person’s ability to communicate and others’ perceptions of this ability. They suggest that this mismatch may lead to the use of inappropriate language, for example language used in health encounters with older people that may be ‘patronising’ or ‘infantilising’. The authors further suggest that this can exert a significant and negative impact on older people’s psychological and physical health.

Language is very powerful and the theme of ‘infantilisation’ has been explored elsewhere by Kitwood (1997) within the field of dementia care. As we considered earlier, personhood is clearly linked with status or ‘standing’ through the context of relationships, and Kitwood used the term ‘malignant psychology’ to describe the impact of a number of depersonalising tendencies that he observed during care encounters, one of which he described as ‘infantilisation’. Kitwood gives an example of this term where older patients in a dementia setting were described as ‘the babies’.

Efraimsson et al (2003) also illustrate the power of language and communication in their study which explored the interactions taking place during a discharge conference involving an older person. In this Swedish study, the authors video-recorded the discharge case conferences and used discourse analysis (this is a method of analysis that enables researchers to describe both the structure and content of a particular interaction) to explore the older person’s experience of the discharge planning case conferences. The authors found that the older person was often spoken ‘about’ in the third person during the conference discussions and that the content and structure of the meetings was mainly controlled and influenced by the professionals present rather than acknowledging the wishes of the older person or their family.

Activity

If you have been involved in the discharge from hospital of an older person, identify what happened in a one-to-one discussion between one professional and another. Contrast it with a team approach to discharge, possibly involving relatives or carers. Discuss this with your mentor.

Different forms of communication

Communication has a number of elements, and while the way in which we shape communication encounters (for example, our attitudes, language and posture) are a central tenet of this process, there are a number of sensory barriers that may also impact on the ability and quality of effective communication with older people. Sensory loss is not uncommon among older people and can result from the ageing process or occur as part of an illness (for example, changes in vision, hearing or speech) and this needs to be taken into consideration when working with older people. We would also stress that sensory loss is not a necessary part of ageing, however the link between sensory loss and communication difficulties is well established. Heine and Browning (2004) also highlight that dual sensory loss, for example hearing and sight, affects a number of older people and again can have a significant impact on psychosocial functioning.

Our senses are crucial for us to effectively interpret and understand our environment. Being able to hear during a healthcare encounter, for example, enables us to interact verbally in terms of holding a spontaneous conversation, understanding an explanation or seeking clarity through question and answer, while sight enables us to receive and interpret non-verbal cues, for example posture, body language and eye contact.

The environment is also important in this context. For example, many hospital and care environments are noisy or lack sufficient privacy and as such may inhibit conversation.

Activity

Returning to the reflective activity at the beginning of the chapter you can now reflect on your earlier notes. Were there any difficulties and, if so, were these difficulties based on understanding and attitudes or the result of sensory difficulties or both?

We can enhance and promote effective communication with older people through a range of approaches and Box 9.1 explores a number of ways in which communication with older people can be optimised in everyday encounters. These are not exhaustive and you may also wish to add some effective strategies that you have used from practice. You may also wish to consider how these strategies may have helped you in earlier encounters. You will observe or will have observed your mentor and other practice staff carrying out assessments. You may also have carried out nursing assessments with an older person yourself under supervision while on your placements.

Box 9.1 Maximising communication opportunities