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Mental Health Assessment Skills

By Mavivo May 06, 2013 22424 Words
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. The focus of this assignment is to show an understanding of the assessment process. A brief description of the patients profile and practice setting will be outlined. The setting’s name, location and patient’s name are not disclosed for confidentiality according to the Nursing and Midwifery Council, (NMC2008) hence the name will be fictitious. The patient has consented to the use of their personal information in this assignment. A consent form has been signed by the mentor. The patient’s name will be referred to as Jane. The assignment will discuss the importance of assessment and how the contribution of patient, family, or carer and multi professionals assist the process of assessment. The Mini Mental State Examination, (MMSE) tool will be used in the assessment of a patient and the rationale for using the tool will be discussed. The outcome of the assessment will determine the patient’s needs and future care plan and will therefore be highlighted. An analysis of the efficiency of the assessment tool, its advantages and disadvantages as well as my overall view on my experience of using the tool will conclude the assignment. Maria is an 81 years old lady who was referred by the Emergency General Hospital to an elderly acute Mental Health hospital for patients with dementia. She was in the Emergency general hospital for treatment of a chest infection following a chest drain. The referral was made after she became uncommunicative and had stopped feeding orally. Whilst she was in the General hospital she had been put on a nasogastric feeding machine and had been bed bound for four months. She was admitted on an informal basis for assessment and treatment with the hope to discharge her back home with a full package of care or into a nursing home with a continuing package of care. Jane’s past medical and non medical history confirmed that she suffered from anxiety and mild agoraphobia and has over the past few years had Cognitive Behavioral Therapy. She was reported by her son to have been forgetful over the past 3 years and had forgotten him. She has recurrent urinary tract infections. She mobilizes by use of a hoist and needs total nursing intervention. On admission she was found to be withdrawn and uncommunicative, she was diagnosed with depression and psychomotor agitation or pseudo dementia and acute confusion due to infection. Alongside nursing care and support, she was offered specialist expertise intervention which involved the contribution from nutritionists, Doctors, physiotherapists and other multi professionals and multi agencies. According to Phillip Barker, (2004), page 7, “An assessment is described as the process of making a decision, based upon the collection of relevant information, using a formal set of ethical criteria that contributes to an overall estimation of a person and circumstances, while Mosby’s Medical Dictionary (2009), defines as
sessment as identification of needs, preferences, and abilities of a patient. Phillip Barker, (2004, p6) says that it was suggested by most psychologists that a definition relevant to psychiatric and mental health nursing should focus on estimation of character or person’s worth and what they may become. An assessment is very important because it provides the scientific basis for a complete care plan. It is considered to be the first step towards treatment of a patient. An assessment has to be precise and accurate because it determines patient’s diagnosis and prescription of medication. An assessment involves an interview and observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient’s verbal and non verbal communication, the patient’s medical and social history and any other information available. The physical aspects assessed are vital signs, skin color and condition, motor and sensory nerve function, brain function, nutrition, rest, sleep, activity, elimination, and consciousness. The social and emotional factors included in assessment are religion, occupation, attitude towards hospital and health care, mood, emotional tone, and family ties and responsibilities. Medical Dictionary, Mosby, 8th edition, (2009). There are two forms of assessment methods, which are informal assessment, where information is collected by less structured questions even haphazard methods and formal assessment where structure to questions is emphasized and has been planned and studied carefully through research. However different kinds of assessment tools in form of questionnaires or guidelines where designed in order to assist nurses in carrying out a formal assessment and collect information about the nature and scale of a patient’s problem. A tool is selected and used if the questions meet the individuals assessment needs. The MMSE was first published in a Journal in 1975 as an appendix in an article written by Dr. Marshal Folstein , Dr Susan E. Folstein, and Dr.Paul R McHugh with the aim to separate individuals with cognitive functions from those without such disturbances. It was found to be highly reliable in detecting cognitive impairment and is now widely used around the world and in many clinical settings, and by General Practioners. The MMSE is a structured questionnaire that includes such categories as orientation to time and place, registration, attention, calculation, recall, language, ability to follow a three step command and visual construction. It contains standard wording and a total score of thirty points. Any score greater than or equal to 25 points (out of 30) is normal, 9 points and below indicate severity, 10-20 points indicate moderate and 21-24 points indicate mild cognitive decline. According to Folstein, a score below twenty was found in patients with dementia, delirium, schizophrenia, or affective disorder, and not in normal elderly people. He also states that an abnormal score on the MMSE is not diagnostic of dementia or delirium but does reflect the severity of cognitive impairment. Thirty seven studies were carried out over ten years using the MMSE to show progress of patients with dementia and an average change of score was3.3 points, Tom burgh and McIntyre (1992). The MMSE has its limitations , it is found that cognitive performance as measured by the MMSE varies within population by age and education, with lower scores for oldest age groups and those with less education and it is insensitive to very mild cognitive decline particularly in highly educated individuals, Miller et al: (August 1997). The MMSE was also found to be brief and can be easily administered in ten minutes. The rationale for using this assessment tool is that it is found to be appropriate for assessing elderly people with Dementia by the practice placement. The multi professional team also found the tool reliable and considered it to meet the patient’s needs and ensured clinical effectiveness and evaluation. In order to prepare for Jane’s assessment, her medical and non medical history was accessed through Rio. Mary received specialist care of a nutritionist for diet intake, and a physiotherapist for aiding with walking since the tendons of the back of her feet have shortened from being bed bound for four months. Weekly meetings are held by the Multi professional team in order to discuss her progress and review her care. Relatives are involved because they are considered to have an important role in planning of care and helping to evaluate the service and also in consenting for the patient if they do not have an advanced directive or capacity to consent. Jane’s history explains why she is low in mood and tired most of the time. Therefore, it was important to be very sensitive when building a rapport with her. A professional relationship was built everyday for a period of two weeks during assisting her with personal care, by initiating conversation with her during the day, by assisting her with feeding, and getting involved in her physiotherapy sessions. A lot of empathy and encouragement was demonstrated. A therapeutic relationship built on trust and respect was developed. When Jane seemed relaxed and less tired, she was asked if she would mind completing an MMSE and she consented. She was taken to a quiet room where an MMSE was administered. A quiet room was selected in order to reserve her privacy and to maintain concentration. Interview skills such as sitting squarely, maintaining eye contact, active listening and having an open posture and pleasant attitude where maintained (SOLAR). The questions were spoken clearly and softly and repeated for clarity when necessary. Jane remained calm, content and pleasant during the assessment and engaged appropriately throughout. Mary’s overall score was 13 out of 30. Jane’s results reflected poor orientation in time and place with a score of 4 out of 10, in registration test she was hesitant of repeating the three objects but mentioned all 3 very quickly, on attention she could not subtract, she became very confused. On recall she could not remember any of the three objects which is a sign of short term memory. Jane was found not to be very clear in speech but could follow instructions of folding a paper, closing eyes and so on without much confidence. Her drawing and writing was much affected by shaking; she scored 6 out of 9 points. Jane’s MMSE result is lower than 20 so it reflects poor cognitive function, memory problems, lack of insight and understanding possibly caused by dementia, urinary infections and maybe depression. Total nursing intervention is required. Her care plan requires a holistic approach based on physical, psychological, social, and spiritual needs. Jane was involved in preparing her care plan. Her care plan outlines, -Regular physical activities such as walking. Exercise is known to slow down decline in mobility associated with dementia. This will be achieved with the help of a physiotherapist. -Imply cognitive stimulation by talking to Jane and allowing her to discuss her feelings and thoughts, and introduce recreational activities such as problem solving activities that may enhance quality of life and wellbeing. -Reality orientation, by giving regular information about times, dates, season, places, or people to keep her oriented. - Cognitive behavioral therapy known to treat people with depression associated with dementia. This can be achieved with the help of an Occupational Therapist. -Reminiscence therapy by initiating discussions about her past so she can use her long term memory. This is known to be good in people with mild to moderate dementia. -Sensory stimulation by use of music, lights, massage, sounds to stimulate the brain; this is known to improve restlessness and lift moods. -A risk assessment with regular baseline observations to monitor self neglect and poor dietary intake and poor personal hygiene caused by poor cognitive function. -General observations to be maintained by monitoring improvement or deterioration of mental or physical state. -Two weekly MMSE’s to be carried out to monitor progress.

-Her son to be involved in weekly care reviews and in deciding her care. This is important because problems such as hearing, illiteracy, late onset of depression, urinary tract infections, underactive thyroid, drugs such as sedatives and pain killers can cause memory lose and confusion so they can interfere with interpretation of the MMSE, if not properly noted. Patient UK leaflet Print, page 1, Alzheimer’s society, 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. 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 way…” 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. 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.  

In this essay I will give a profile of a service user in whose care I participated in, during my clinical placement. The client’s background and history to date will be described, a critical analysis of the individual’s current psychological, physical and social needs will be provided by selecting and using published therapeutic/theoretical approaches. Furthermore a demonstration of how the therapeutic/theoretical approaches selected can provide a structure or guide the nursing care provided in assessment of needs, identification of aims/ gaols, therapeutic nursing interventions and clinical review. Finally the author will explore the therapeutic efficacy of the current clinical environment or service where care is being provided, consider possible alternative service provision options and discuss whether they may or may not be more beneficial for the individual. The client chosen for the purpose of this assignment is a 60-year-old gentleman of British origin. I will refer to him as Peter to maintain confidentiality in accordance with clause 5 of the Nursing and Midwifery Council (NMC) Code of Professional Practice (2002). Peter has a history of depression and alcohol abuse. He lives alone in a three bedroom semi detached house, having separated from his wife 7 months ago after being married for 28yrs. She had been battling with his alcohol abuse for many years and her frustration had just worsened that she was beginning to be depressed herself. The rational for choosing Peter for this essay is not only because of my interest in Depression, but because I was involved in his care from initial assessment to his discharge to community care and we developed a very good working relationship built on trust and confidence. Personal and Family History

According to Peter, he was born in Newcastle and is the eldest of his parent's 4 children (2 boys and 2 girls); he has lost contact with all his siblings. His parents are both deceased, mum died about 5 years ago (she had been battling with cancer for some years, he was her main carer) and Dad died when he was 15 years old (In a car accident, coming from work). There is no history of depression in his family but alcohol abuse is prevalent. Peter has been married twice, alleging that both his wives divorced him. He has twins with the first wife but after the divorce he lost contact with them, His second wife had a daughter from her own first marriage and they had another daughter together who now lives in Portugal. He left school without any GCSE's to pursue a carrier in Truck driving at the age of 18 which he has been doing until April 2010 when he was dismissed after his licence was suspended for a year because of a drink and driving incident he was involved in . He made known to the services that he started drinking at the age of 17 but it became a problem at the age of 30, he blamed it on the divorce from the first wife which he reported left him with nothing. Presenting Problem

From his General Practitioner (GP) referral notes, Peter has a diagnosis of depression, he has been under the GP's care for months but his condition has deteriorated, he has been having thoughts of suicide and self harm. He was prescribed 30mg/ day of Mirtazapine at the time of referral. The GP thought that he hasn't been compliant with his medication; this with alcohol abuse was making his condition worse. He reports having a low opinion of himself and worries a lot about his finances/debts. He presents with an overwhelming and extreme experience of sadness, hopelessness, despair and misery. His ability to meet his daily needs has been deteriorating e.g. his self care had been noticed to be deteriorating for a person who is reportedly to be usually self conscious of his personal hygiene and also the GP noticed that he has been losing weight. This prompted the GP to refer him to our team. The responsibility of our team is to try and help him during his crisis to prevent suicide and also to prevent unnecessary hospital admission, in accordance with the Standard 7 of the National Service Framework (NSF) for Mental Health (DoH 2002a). Hogston (1999) summarises that it is important to use a formalised framework of assessment as it enables the nurse to assess an individual holistically and form a sound theoretical base in the nursing process. He goes on to add that although individuals may present with the same characteristic of an illness, there is a considerable diversity in which individuals are affected by their illness. It is therefore important to adopt a framework that recognises the uniqueness of each individual and enable the totality of their situation to be understood (Alabaster 2000). According to Newell et al (2000) nursing models are well documented and have been widely used as an approach to assessing the needs of clients, identifying problems and formulating ways of helping them to improve their well being. The theoretical approach used to analyse Peter's current psychological, physical and social needs is the Stress Vulnerability model. The rationale for using this model is that it can assist in the engagement process with the client as a method of understanding why levels of stress should be monitored (Zubin and Spring 1977). Used also as an assessment tool is the twelve activities of daily living based on the Roper, Logan and Tierney model of care, the rationale being that it provides a structure for doing physical health assessments, which is the examination or inspection of first, the person as a whole, their general appearance then their mechanistic function of body parts as explained by Jarvis (2000) and the model also provides a holistic assessment of a patient. Aggleton and Chalmers (2000) state that it is simple to understand and devoid of confusing terminologies. To determine the extent to which our client was depressed we used the Geriatric Depression Scale (GDS) which is a basic screening measure for depression (Brink et al, 1982). According to Zubin and Spring (1977) they suggested that a vulnerability to psychosis is acquired through a genetic predisposition or as a result of environmental factors. This vulnerability, however, is not considered to be sufficient to manifest the disorder and must be 'triggered' by environmental processes. The environmental component can be biological (an infection, even drugs and alcohol) or psychological (e.g. stressful living situation). The 'stress' component of the model may take many forms, including: Traumatic life events, use of drugs and alcohol and stressful living conditions. Zubin and Spring (1977) postulated that individuals vary in the amount of vulnerability that they have for psychosis and also in their ability to withstand stressful events. It is an individual’s own perception of the stressfulness of an event that ultimately defines the severity of the load. Psychological needs

According to Peter and the GP's referral notes, he was diagnosed with depression a year ago though he was treated before for depression, 5 years ago. Isolation and loss of status i.e. being unemployed and a bachelor after so many years of being a hard working husband has been a big source of his psychological stress, also the bereavement (death of mum ) and loss of support networks on which he had relied on in the past. Personality style and the way Peter has learned to deal with his problems (by drinking alcohol and isolating himself) may have contributed to the worsening of his condition. Having financial difficulties combined with mounting debts including Mortgage repayments has been stressful , he reports that after years of paying his mortgage he can't stand the thought of his house being repossessed with only 5 years left to complete the repayment. Peter reports that he has been drinking a lot of alcohol which has caused most of his problems i.e. he lost his job, driving licence and his wife left him because of drinking . Physical needs

Poor physical health can lead to poor mental health, according to Harris and Barraclough (1998) people with mental health problems have a higher risk of premature death. The stress caused by loss of employment, isolation and loss of support has been making him abuse alcohol, he reports using alcohol as a coping mechanism to stop negative thoughts and being depressed. The reported loss of weight and possible malnutrition has been as a result of poor diet and eating habits according to him. However because of his deteriorating mental health and physical health, combined with the alcohol abuse lives him very vulnerable to other more severe physical health problems like Anorexia, lever problems or even becoming an alcoholic. Furthermore because of his low self esteem and lack of routine he is not motivated to get out of bed, do anything, has no structure to his day and lacks the skills needed to do activities of daily living. Social needs

Socially, from the information gathered from his history, he has a very poor level of social functioning. He is always very withdrawn, isolates himself in his house and his level of activity is very low. His life revolves around his house, he hardly has any friends, the person he used to confine in left him (his wife) and his biological daughter moved to Portugal (she has been his main support after the divorce). All this leaves him very vulnerable to self neglect, having low self esteem and social isolation. This social isolation is a relapse risk factor and can form a key point in the nursing intervention (Barker 2004). He reports being overly dependent on his wife for all household chores including cleaning , cooking , paying and organising the house hold bills, this shows his lack of household skills. He is currently unemployed since he lost his job due to the drinking & driving incident, this resulted in a change in his social role from being the bread winner for the family to relying on welfare benefits. The ongoing stress and social isolation associated with these family circumstances can lead to depressive symptoms (Bartha et al, 1999). As reported by Burns et al (1999) the GDS is essentially a self-reported inventory with a simple yes/no format which lends itself to ease of administration by the older person or by an interviewer, supported by a validation study by Yesavage et at (1993) cited by Norman et al (1997) the GDS adequately detects depression in medically in-patients in the acute setting, or their own homes and also in the continuing care setting. According to the GDS scoring system 0-9 is considered normal, 10-19 indicates mild depression and 20-30 indicates severe depression, he scored 22 which indicated his depression was severe. According to Roper et al (1996) the twelve activities of daily living model states that ‘human activities’ exist between two extremes, the dependence and independence continuum, with factors such as age, childhood and illness playing a major role in determining the exact location of each of the twelve activities of living. The focus of this model is on prevention of potential problems from becoming actual problems, resolving actual problems and effective management of problems that cannot be solved. The use of a holistic approach was supported by Ewles & Simnett (2000) who stated that all aspects of health are interrelated and interdependent. Furthermore according to standard 3 of the National Services Framework (DoH 2002) this model helps empower the client by empowering his ability to take steps to gain control and the will to a healthier lifestyle. Assessment of Needs

Physical Health needs Assessment:
This assessment was done using the activities of daily living as identified by Roper, Logan and Tierney, as follows: Breathing:
Baseline respiration count was 16 breaths per minute, which lies within the normal range. He does not smoke and did not have any breathing problems. Controlling body temperature:
His body temperature and blood pressure were taken so as to have a ‘baseline’, for the nursing team to be able to compare any rise or fall based on his normal range in the future. Maintaining safe environment:

Peter is unable to maintain his own safety because he is drinking too much, according to him, his house is in a total mess (the floor is full of rubbish); this poses a high risk to him. Eating and drinking:

His dietary consumption is inadequate; he hardly eats cooked meals at all citing that he is finding it difficult to cook (lack of skills). He just makes sandwiches, toast and drinks alcohol most of the time. Communication:

He can communicate very well though lately has been isolating himself from people including neighbours since the onset of his illness. Personal hygiene:
His personal hygiene has been very poor, according to his notes from the GP he used to be a very smart gentleman. Eliminating
His bowel movement is good though not as regular, this could be attributed to his lack of eating and drinking. No problems were identified with urination. Sleeping
He is having sleeping problems, he sleeps around 4 hours during the day and 3 hours at night, while staying up the rest of the night. Expressing sexuality;
Recently divorced, has not expressed interest by way of opposite sex, he has no female friends. Working and playing:
He was sacked from his job as a driver, spends his time drinking alcohol, watching TV and hardly does any activities. Mobilising:
He walks with no aid and can travel on public transport.
Dying:
He reports that he can't take the hurt any more and is unhappy with his life, he feels dying is the only solution to his problems. He reported having suicide thoughts, but does not have the will power to do it. Cited his children and grandchildren as his protective factors, they mean a lot to him (he did not want them to go through any pain). Other areas assessed include:

The stress Vulnerability model provided a structure for the assessment of needs by looking at all the factors causing him stress and the possible vulnerabilities. Relationships and sexual functioning

Recently divorced, can’t see himself with any other person except his ex wife. He reports that he has lost all interest in sex. The person who was supporting him has relocated to Portugal (his daughter); this leaves him vulnerable to further isolation and low self esteem. Interests and activities

He reports being interested in going to the cinema, watching football on TV or at the pub. He is not participating in any activities at the moment but would like to try and do as much as he can to occupy his time and reduce stress. Education, training and employment

He left school without any GCSE's and has a problem of writing though he can read well; finds it difficult to write letters. He would like to do a DVLA course about dangers of drink & driving which will reduce the suspension he was given to half the term. He was promised by his former boss that he can get his job back when his suspension is over. There is also need for him to learn about medication management and the importance of being concordant with medication. Benefits and finances

Currently unemployed and having financial difficulties. Receives unemployment benefit but it is not enough to cover all his debts. He requires help to apply for other benefits. Accommodation
Lives in a 3 bedroom house, due to non-payment of mortgage repayments, could lose his house; this has been a major source of stress which leaves him vulnerable to self harm, homelessness and more depressed. Risk:

Risk to self is currently medium/high due to frequent suicidal thoughts but no plans, intent or prior attempts owing to identifiable protective factors (Daughters and grandchildren). The following problems were identified:

1). Disturbed sleeping pattern and lack of sleep.
2). Peter is unable to maintain his own safety.
3). He has low level of interaction with other people (isolation and low self esteem). 4). Low in mood and expressing suicidal ideation.
5). Loss of weight and failure to meet dietary needs.
6). Self neglect and lack of good personal hygiene
7). Not attending to his dietary requirements and abusing alcohol. Aims/Goals
According to Zubin and Spring the Stress-Vulnerability model helps to guide nursing care is by identifying stressors and problems which will be helpful in the formulation of aims/goals. The three main goals of treatment according to this model are: 1). Reducing biological vulnerability

To control alcohol consumption
To manage his medication effectively
2). Reducing stress
To maintain good self-hygiene and healthy sleeping pattern
To encourage eating, drinking and maintenance of a balanced diet. To be able to maintain his own safety by demonstrating awareness of his surroundings, whenever possible To engage with welfare for help with finances/debts

To attend a DVLA course so that his suspension will be reduced 3).Coping with stress more effectively
To elevate the patient’s mood and self esteem
To encourage social inclusion and attend Occupation Therapy
To seek supportive relationships with nurses and therapists. To encourage positive self- talk
Therapeutic Nursing Interventions
(a) Develop a therapeutic relationship with client based on trust, empathy and understanding. Staff to arrange with client, once daily home visits to help him ventilate his feelings. Encourage interaction with other service users through referral to day centres for group activities. (b) Encourage good sleeping routines without need for medication by making client keep his own sleeping chart. (c) Client to be encouraged to eat and drink all meals, and be placed on a food-monitoring chart. (d) Client to be encouraged to have a wash every day and to meet all hygienic needs. (e) Client to be educated on the need to manage medication effectively by providing specific information about the medication he is taking and how to get the best results from them. (f) Client to be encouraged to avoid / reduce alcohol abuse by referring him to Alcoholics anonymous groups. (g) Risk assessment to be done on a regular basis in agreement with client. Review frequently,

Client to seek immediate assistance if fleeting thoughts become more serious or depression deepens. (h) Care plan to be reviewed weekly.
A nursing intervention is more likely to be successful in an atmosphere of trust and cooperation. According to Thomas et al (1997) the interpersonal relationship between the patient and their helper is considered the primary instrument for change. The relationship is necessary, but not the only condition for successful therapeutic outcome. If the patient distrusts their nurse they are less likely to accept help, neither will they listen or experience any hope of success. Having learnt to trust the nurse the client is able to open up and share his problems with the nurse, who can then help the patient to deal with his worries. Meeting and talking to the client everyday (one to one) not only helps the service user ventilate his feelings but it is also a form of counselling which helps the client feel worthy as a human being, provides a hand that conveys friendship and confidence, can also result in strengthening the therapeutic relationship. During the home visits, the nurse can continually assess how the client is doing on a daily basis thereby providing an accurate account of the patient’s progress. Being involved in-group activities can help the service user to make friends, share experiences and ideas about how to cope with depression and will also help distract him from negative thoughts, boredom and lack of social stimulation which tend to reinforce a sense of isolation and depression. To help the client reduce biological vulnerability the use of medications can help correct the chemical imbalances which lead to symptoms. According to Healy D (2002) medications are one of the most powerful tools we have for reducing or eliminating symptoms and preventing relapses. The client is to be educated on effective management of medication by providing specific information about the medication he is taking and how to get the best results from medication by not mixing with alcohol (interferes with the beneficial effects of medication). Sleep is a necessary part of life, to overcome his sleeping problems without using medication, Peter is to be encourage to stick to a particular sleeping routine, that is going to bed and waking up at a regular time and avoid napping for long hours during the day as it upsets the ‘body clock’. Peter would be encouraged to avoid drinking too much coffee or alcohol as these will disrupt his sleeping pattern. A sleep-monitoring chart is to be introduced to him to see if Peter is getting enough sleep and be able to evaluate how effectively the interventions are. According to Barker H (1996) for the problem of eating and drinking, it is important that immediate treatment should include monitoring food and fluid intake to prevent dehydration and further weight loss. By putting Peter on a food monitoring chart the nursing team will be able to see how much food he is eating so that if necessary supplements might have to be provided e.g. Fortisip or Complan. Peter should be encouraged to eat three meals per day. He should also be weighed on a regular basis, suggest weekly to help evaluating his progress. Since he reported having household skills problems, staff to refer him for Occupational Therapy (OT) to be taught and develop life skills e.g. cooking. According to Roper et al (1996) apart from taking pride in their appearance, people have a social responsibility to ensure cleanliness of body and clothing. It is important to explain the importance of good personal hygiene to Peter. He will be reminded and encouraged to attend to his personal hygiene i.e. have a wash, care for his hair, nails, teeth and mouth. A risk assessment needs to be done on a regular basis; this is in accordance with standard 7 of the National Service Framework (NSF) for mental health (DOH 2002), which is aimed at preventing suicide. When visiting the client there is need to ask him if he feels or has thoughts about harming himself so as to try and find ways to minimise the risk or prevent client from committing suicide. Clinical Review

The clinical review of Peter’s care was done by evaluating of all the interventions used to facilitate recovery. Evaluation is making judgements as to whether the care actions that you implemented have successfully resolved the patient’s problems or met his needs. A review meeting was held by the multidisciplinary team (MDT) once every week and the care plan reviewed. Over the few weeks during my placement there were only minor changes to his care plan but a lot of changes to Peter's presentation were noted. Initially we visited him once daily but as he became better at coping with stress we changed the visits to once every other day, with a phone call to him on alternate days. Peter had many social difficulties, but after a few weeks he had made friends and developed other interests like going to the Gym, cooking, bowling and playing golf. His medication was changed to Fluoxetine which helped him sleep better, elevated his mood, also a marked improvement in personal hygiene was observed and his biological vulnerability was reduced. There was also an improvement in his weight due to better eating habits. Attending Alcoholics anonymous helped him change his coping style; he saw the effects of alcohol and what it had done to others which were even worse than his situation. By completing other benefits forms and the completion of the DVLA course (which helped reduce the term for his suspension from driving), helped ease his financial worries and resulted in reduced stress. The Citizen Advice bureau helped him with his mortgage issue; he was able to arrange payments using his pension contributions. Therapeutic Efficacy of current clinical environment

Treating Peter at this own home offered a more personalised approach by including him into his own community rather than fitting him into the service system. It also impacted on the stigma associated with hospitalisation through emphasis on community integration, including life satisfaction, social networks and it also provided care in the least restrictive environment, without disrupting his life and providing flexibility in his daily routines. There was also an element of comfort, security, relaxation, confidence all which is associated with being treated at home according to Reynolds & Hoult (1984). On the other hand Reynolds & Hoult (1984) agreed that hospitalisation is a negative, upsetting and unhelpful experience because of the rules, restrictions, patient mix and lack of communication which applied. Other themes are well known such as deprivation of liberty, lack of autonomy, lack of status and recognition, an emphasis on behavioural conformity, oppression, medicalisation of social disharmony and removal from family. However if treatment at home does not produce good results, (e.g. the risk to client increases) hospitalisation may be considered, it has some known benefits which include 24 hour professional care i.e. having qualified carers within arm’s length all the times and being observed regularly helps to minimise risk of self harm. Conclusion

By examining the client’s background and history to date, the use of the Stress Vulnerability model and Activities of daily living model helped in making a holistic and individualised assessment as supported by Pearson et al (1996) of Peter's psychological, physical and social needs. Furthermore a demonstration of how the therapeutic approaches used guided the nursing care provided when the assessment of needs, identification of aims/ goals, therapeutic nursing interventions and clinical review was done. Though the stress-vulnerability model helped to identify stressors and problems, care was made more effective by incorporating the activities of daily living model which viewed the individual as having the ability to function dependently or independently. However the activities of daily living model was criticised by Salvage and Kershaw (1986) as being excellent for physical aspects of care, but social or educational aspects do not seem to be very important. On the other hand, Pearson et al (1996) appreciated the model for its clarity and being evidence based. To maintain confidentiality and protect anonymity, a pseudonym of John will be given to the patient; this is in compliance to Nursing and Midwifery Council (NMC) Code of Professional Conduct (2008). John is a 40 year old man of Africa Caribbean origin, living independently in the community. John experiences unpleasant and hostile auditory hallucinations mainly describing his actions and his thoughts. This normally happens when he is out of the house, in public places and at shops. He claims that he also hears these voices when alone and inactive at home usually in the evenings and at night. These experiences make him feel angry and frightened. John also experiences that other people can read his mind, this is particularly true of some teenagers in his neighbourhood whom he thinks are out to get him. He receives six hours support from the support workers every week to help maintain his mental health and independence as it is the organisation's philosophy to provide this support in order to allow patients to continually work towards an ordinary life. John is diagnosed with paranoid schizophrenia because he suffers from stable delusions, usually accompanied by hearing voices and disturbance of perceptions (The Diagnostic and Statistical Manual IV, 1994). The DSM IV, of Mental Health criteria for schizophrenia states that two or more of the above must be present for a significant period of time during one month period for a diagnosis to be made. John was previously admitted onto a psychiatric ward for eight months. Schizophrenia is a common disorder and has a devastating effect on sufferers and their families - patients typically hear voices in their heads and hold bizarre beliefs. On discharge from the ward, John was offered accommodation where he could live independently with the support he wants in the community. John is the second of three children born from one father. Pregnancy and delivery were normal, and developmental milestones were accomplished on time. History of the patient's father is unknown. John's elder brother is in prison for robbery and the other has had a number of admissions to psychiatric hospital with diagnosis of schizophrenia. During assessment, John was described by his mother as a shy boy and reports never having any close friends and knew primarily the street boys he hung around with. He has had a sexual relationship with a neighbourhood girl in the past but never had a steady girl friend. John reports that he never liked school and dropped out in his early age. He has never worked and lived at home until his first admission into mental health hospital three years ago. His mother who has her own mental health problem (Depression) is his primary source of emotional support and his main carer. His medical history and examination proved him healthy as there was no record to show that he has suffered any serious aliment, however he admitted to poly drug use including alcohol, cannabis and crack cocaine. He currently smokes a pack of twenty cigarettes a day. His general health is good at this moment. Through observation and talking with John, it became apparent that he suffers from anxiety and low mood. Davis et al. (2007) stated that anxiety plays an important role in producing and maintaining dysfunction in schizophrenia but these symptoms are often overlooked or viewed as less important than the positive and negative symptoms. At present, John does not appear to be experiencing any symptoms of schizophrenia although his low mood and anxiety are something he expresses as hurdles he has to battle with on a daily basis. The medication he receives for anxiety and low mood seem not to be eliminating the symptoms he suffers, although the medications are being reviewed to determine the correct therapeutic dose he requires (Lieberman and Tasman, 2006). He lacks motivation and self esteem, and due to his level of anxiety he finds it difficult to enjoy the amenities within his local community. Full assessment to determine John's mental health needs with specific assessments for his anxiety and low mood, where he can be supported to develop coping strategies which may assist his daily activities and engagement in activities where carried out. Assessment is an ongoing process which allows for all records and interventions to be current and up to date. Following an accurate and comprehensive assessment other elements of the nursing process such as planning, implementation and evaluation can be applied (Callaghan and Waldock, 2006). To carry out John's care, the author carried out Krawiecka, Goldberg and Vanghu (KGV) assessment and one to one session in partnership with John and his main carer. The KGV Manchester Symptom Scale modified version 6.2 by Stuartand Lancashire (1998) is a global assessment tool that allow nurses to carry out an assessment of the service user to ascertain symptoms severity and incidence, and further to identify further ways forward in care delivery (Barker et al. 2003).By adopting this tool, the author was able to carry through the nursing process and assess to identify a broad overview of John's needs, which aim to specific specifically clarify his problems, and assist in the nursing intervention aim to promote and enable recovery. Keke and Blashki (2006)state that mental health assessment includes symptoms, characteristics and psychological state as well as psychosocial factors applicable to the patient; consequently, the KGV is seen as an integral part of mental health assessment. This KGV tool is noted to be a global assessment tool that is used to assess an array of mental health problems, including intensity, severity and duration of symptoms within few weeks. It comprises fourteen items; the first six sections aimed at determining depression, anxiety, hallucinations, delusions, suicide and elevated mood and are based on a subjective description of their condition over the past few weeks. The other eight sections are based on the behaviour of the patient during assessment. This was fundamentally utilised as a starting point in assessing John's mental health problems. The author was already aware of the issues relating to anxiety and depression although it was thought that at this point of the assessment, all aspect of John's mental health needed to be reviewed; hence the use of KGV was an ideal tool to accomplish the task. With this tool, the author was able to recognise what symptoms John was experiencing and identify specific area of need which the author need to undertake to clarify the extent of the client's distress and symptoms. The KGV assessment tool does come with some limitation which is time consuming, though this time was spent in forming a therapeutic relationship with the patient, this is something that should be done over a series of interviews, taking in to consideration individuality of the patient and how long he can sustain interest and attention to the questions being asked. Engagement with a patient experiencing psychotic episode can extremely be problematic during assessment, like experiencing disturbances of thought, perception, mood and behaviour (Rigby, 2008). After completing a comprehensive assessment, screening tools were used to evaluate and measure severity of the identified symptoms (Stein, 2002).It was found that John was reporting issues of anxiety and depression; the author therefore decided to utilise the Beck Anxiety Inventory [BAI] by Beck (1987), to measure both psychological and cognitive component of anxiety (University of Pennsylvania, 2008), and also used the Beck Depression Inventory (BDI -1) Beck (1961) to determine the severity of depression. The BDI-1 and BAI are both self rating scale consisting of 21 items, in which patients rates the existence and severity of their presenting symptoms (Norman and Ryrie, 2005). The patient rates from 0-3, how best describes the way they have been feeling over the past few weeks and later summed up between 0-63. The author decided to use these scales on John to identify the severity of his anxiety and depression and was completed by him; it aims at promoting him as partner in his own care (NMC, 2008). It was also felt that both tools would enable the author to discuss problematic areas of John's life rather than just engage in general conservation and additionally giving scope for appropriate intervention (Barker, 2003). Going through these assessment tools after the appropriate time scale will give him and the whole nursing team a report of the progress that has been achieved or any changes that can be worked on. The outcome of the screening tools used shows an indication of moderate anxiety and depression. During time spent with John, it was believed that his immediate needs in connection with these concerns were being met by the involvement of the staff and the support he receives from his mother (carer). Negative attitude by his carer about John's diagnosis may be linked to lack of knowledge, skill or judgement (Duffin, 2003). This was not an issue for the staff providing him with professional support as all performed to a high standard offering him empowerment and informed choice, ensuring best practice in care delivery in John's life (Department of Health, 2006). Psychosis has an enormous impact on the sufferers' family and carers particularly in the first episode (Reed, 2008). Families are often distressed, confused, anxious and fearful of the patient's behaviour, and what the future may hold for them as a family. The author's observation is that John was distressed and stigmatisedby his family, their member's presentation and behaviour and other people's judgement about him and the family as a whole. The physical and emotional burden of care always falls on the family which may adds stress and anxiety, and attempt to come to terms with their own feelings of mental illness (Patterson et al, 2005). Families may often tackle the guilt for not recognising their beloved family member's symptoms and distress earlier, while also recognising that the illness itself might procure financial burdens to the entire family. They also feel the burden of stigma of mental illness to deal with and Patterson (2005) hypothesises that families often perceive the patient as displaying odd behaviours deliberately and therefore become less empathetic, and feel that they have less control over the situation. The Department of Health (1999) recognised the importance of caring for carers and the National Strategy aimed to support people who chose to be carers, and the National Service Framework (NSF) for mental health reported levels of services to involve service users and their carers in planning and delivery of care. By considering this patient in his own terms during the care planning process, he came to terms with his psychotic experience by promising to accept his medications and keeping to appointments with the professionals, began to understand it and acknowledge ways of coping with it. This is in - line with evidence based practice which sees the patient as central to all care packages with individualise care plans and multidisciplinary teamwork at the heart of care delivery (DoH, 1999 and NICE, 2002). The National Institute of Clinical Excellent (NICE, 2002) further emphasise the need for family intervention to be available to the families of patients diagnosed as being schizophrenic. Norman and Ryrie (2005) recognise families as a valuable resource for individuals that have symptoms; however if the family reacts to symptoms by being critical or by doing too much for the patient, this can equally have a negative effect on the individual. Education regarding his illness and medication was given to both John and his carer. This was undertaken in his homein an interactive, question and answer format and took several days to complete. Updates and recaps of information were given at regular intervals and they were encouraged to introduce difficulties, questions and queries as they arose. It was an interactive session as it enabled John to give consent for treatment and he contributed his own version. Educating the families / carers of a schizophrenic patient is aimed to lower the expectation of patients and may reduce the presenting symptoms. Leff (1994) and McDonagh (2005) note that one of the main contributions of stress in psychological disorder is expressed emotion from families. Having a mental illness may place limitations on patients' lives; in any case, it is the negative attitudes of the other people that may help disable people with mental illness and not the mental illness itself (Seggie, 2007). The expressed emotion from formal carers such as the support workers and nurses can equally have an effect on patient as high and low expressed emotion can be present in the relationship between the nursing staff and patients resulting in possible negative effects on patient's outcome (Tattan and Tainer, 2000). Expressed emotion is the critical, hostile and emotionally over involved attitude that carers have towards patients. The carer may influence the outcome of the diagnosis through negative comments and nonverbal actions. This negative attitude from carers does not always help the patient to improve the state of his health. Carers with “high expressed emotion” are said to cause stress in psychological disorders such as schizophrenia. The stress from negative criticism and pity becomes a burden on the person with a disorder, and may relapse. Expressed emotion may be a direct factor in the relapse of a patient with a diagnosis of schizophrenia (Leff and Vaughn, 1985). Patients are more likely to relapse when there is high expressed emotion present in their living environment as was noted with John (Lopez et al. 1985). When the patient can no longer live with this kind of stress from pity, s/he may fall back into his/her illness using drugs as a way of coping. The stress from the remarks, attitudes and behaviour of the carer maybe over-whelming, because she may feel that she is the cause of the problems. The patient may fall into bad habits and forms a circle of relapse and rehabilitation. One way to escape this circle of behaviour is for the carer to be involved in behaviour family therapy together with the patient it aims to improve the health of the family with less stress and aggravation. The carer is able to learn to accept that John has an illness and may need her help to improve and remain stable hence family therapy. Educating the carer and patient about mental illness is one way that expressed emotion can become lower and no longer be an issue (McDonagh, 2005). When considering family interventions in the care of John, it was important that this includes many others relevant in his life (Berkeet al., 2002). A multidisciplinary meeting of all those involved in John's care was called, aimed at educating them that crisis can be a turning point and the start of something new. Information about the devastating cause of mental illness can take, and exacerbations of symptoms and remissions to patients and carers were given to them. All aimed at stabilising the family's environment by increasing knowledge, coping skills, and the level of support for the carer and John. Most of the therapeutic interventions offered to John's carer involved communication - training, problem solving skills, and education. The style of therapy emphasises the positive aspects of the family's coping style and avoids judgemental or blaming remarks. The aim is for collaboration between the carer and the nursing team over goals for change and a greater emphasis on the needs of John. However, Fadden (1998) criticised the narrow focus on relapse prevention at the expense of addressing the carer is widen needs. There have also been strong criticisms noted about family intervention based on beliefs that it blames families for schizophrenia, thus some family therapists have moved away from a position of trying to reduce expressed emotion by offering a message that stress exacerbates psychosis rather than causes it (Harris et al, 2002). There is contradiction that teaching family that reducing criticism lessens the chance of relapse, yet educating families that schizophrenia is an illness not caused by the family. Family intervention has been noted to improve a number of aspects of this patient's social well being such as taking part in activities. John believes that voices from people who were walking closely were planning an imminent attack against him. By getting angry and shouting back at them, he believes that he had prevented a potential attack. In this case, distraction was unlikely to be successful unless this belief is challenged in a calm and friendly way. John and the author agreed to put this belief to a test and he was later convinced that this was part of his illness. John was told to remove his mind from that thinking and belief that people were talking about him. One of John's main obstacles in life is lack of motivation; he quiet understands that his mood would lift if he spent more time doing activities to occupy his mind. However, he finds it difficult to motivate himself into taking any form of activity but he had accepted going to his carer (mother) most weekends and to pay regular visit to the communal centre. These will enable him to think less about his delusions. According to Hogston and Simpson (2002) reflection is a process of reviewing an experience of practice in order to better describe, analyse and evaluate, and so inform learning about practice. Wolverson (2000) includes that this is an important process for all nurses wishing to improve their practice. This will be investigated using the Gibbs (1988) model of reflection. On reflection on the care and interventions that John received, a person centred approach appears to be fore-most. He was at the centre of his care, his personal feelings, beliefs and values were appreciated and he was able to exercise informed choices throughout (Callaghan and Waldock, 2006). Engaging John in discussion about his illness and care, and how it is best dealt with was highly appreciated by him; and this was highly regarded by him and his carer, and it leads to improved ability to cope, improved compliance and better outcomes (Kemp et al., 1996). Relaxation techniques were taught to John as a coping strategy for his anxiety; however, although relaxation can be effective, Frisch and Frisch (1998) recognise that relaxation alone is not beneficial therefore it should be used as complimentary intervention with other therapy. Kirby et. al. (2004) acknowledge that mixed skills of staff is important, this works in conjunction with the Essence of Care Document (Department of Health, 2006) which states that training programmes and materials should be accessible and used for patients. John was supported by staff with a combination of experience and knowledge with training on Family interventions and cognitive behavioural therapy (CBT). CBT is a short term, problem solving based psychological treatment aimed at finding solutions to problems in every day life (Forsythe, 2008). Standard two of the National Service Framework for Mental Health (1999) specifies that clients should have their mental health needs assessed and be offered effective treatment if they require it. It is hoped that John will benefit from CBT in the future along with continuation of family intervention. Throughout the care of my chosen patient, the relationship between the author, the patient and the carer was crucial and recognised as an aspect of service effectiveness (DoH, 2001a) and that active collaboration with the family is a requirement rather than an optional extra whilst delivering care to people with enduring mental health problems. John and carer were happy with the sort of help, support and service the author gave to them when they really needed it most. this assignment will be based on collaborative working, it will be in two sections, section one will look at definition of collaboration and will then address the highlighted issues within collaboration such as a need for and applying inter professional collaboration between mental health service providers and the way they collaborate with service users and their families which is required by the Department of Health (DoH 1990/91 to 1999/1999a). Within this section will be a brief outline of issues that are relevant to the DoH such as policy initiatives that advocate collaboration within and between teams as well as other service providers. Section one will also look at the barriers, difficulties and challenges that has been highlighted with the usage of effective collaboration workings between both multi professionals and service users. Section two will hopefully show my own personal experience of collaboration through the critical summary of my reflections which i have used The Gibb’s (1998) model of reflection (see appendices 1-3) this has been based on my learning experiences during the course involved client assessment and the implementation of their care and treatment packages. Within this section the critical scrutiny will involve re-examining my skills in working collaboratively with both clients and multi-disciplinary team (MDT), within the framework of mental health care, identifying areas for additional development. It must be prominent that the names of all persons contained within this part of the assignment are illusory due to confidentiality which remains in accordance with the Nursing & Midwifery Council (NMC 2008) The Code. Part 1: Defining collaboration & outline of issues

The literal translation of collaboration from the Latin is ‘together in labour’, whilst the dictionary definition of ‘to collaborate’ is ‘to work with another or others on a project’ (Chambers 1999). However, Clifford (2000 pp103) in re-iterating Henneman et al‘s. (1995) earlier argument stated that, in practice, the process of defining collaboration remained a “complex, sophisticated, vague and highly variable phenomenon”, which often resulted in inappropriate usage of the term, as issues relating to collaboration were (and still are) referred to using a range of terms, all intended to indicate broadly similar processes e.g.: ‘inter-professional/multidisciplinary’, ‘inter-agency/multi-agency’, ‘intersectional’, ‘teamwork’ & ‘co-operation‘. However, Hall & Weaver’s (2001) conclusion that although both require people to work together (sharing information, knowledge & skills) in achieving common goals, inter-agency partnerships are created at a formal organisational level (service planning), whilst multi/inter-professional collaboration involves different professionals working directly to achieve service-user care/treatment, seems to sum up differences in concept/process & Barret et al. (2005) have concluded that in practice even if the composition of team(s) or group(s) varies, these indicate similar ideas of collaborative effort, which Hall & Weaver (2001) stressed required co-ordination in order to ensure that each professional’s effort is acted upon and that each is aware of what the others are doing. The move towards interagency (across health & social care boundaries), & multidisciplinary (within & between teams) collaboration, began with the shift in emphasis from institutional to community-based care, when it was felt that the demarcations and hierarchical relations between professions were neither sustainable nor appropriate (Barr et al. 1999 & Sibbald, 2000) & new ways of working that crossed professional boundaries, had to be found, to facilitate a more flexible approach to care delivery (Malin et al., 2002). Thus the promotion of inter-professional working in the delivery of healthcare has long been regarded by the DOH, theorists & practitioners as of great importance, in providing a better quality of service, as highlighted by the NMC (2008) and in UK government policy over the last two decades, at least. However Whitehead (2000), also highlighted the fact that one example of team working that was surprisingly neglected in the nursing literature of the time, was the partnership between client and nurse, which she argued should be regarded as part of the collaborative framework as well as in a team context. Although, Whitehead (2000) highlighted the fact that client-professional collaboration was neglected in the (nursing) literature of the time, which she argued was an important element, it should be noted that this was not neglected by the DOH in their policy & guidance documents for all mental health workers & the DOH has consistently highlighted the need to collaborate with service-users &/or their family/carer. For example the Care Program Approach (CPA), its’ up-date Effective Care-coordination (ECC) & the National Service Framework for Mental Health ({NSFMH}: DOH; 1990/1991, 1997, 1999/1999a) all specified the need for all service providers to work with their clients, highlighting the belief that such collaboration increased client satisfaction and improved client engagement. However, research by e.g. the Sainsbury Centre for Mental Health (SCMH 1998, 2003) & the DOH (e.g. 2006a) identified that neither the CPA or the ECC initiatives where working & there has now been a return to the original principles of the CPA (DOH 2008/9) in an effort to address problems & further emphasise the need for collaboration between service-providers & with service-users in providing evidence-based & agreed care/treatment packages. The rationale for such policy stems from the recognized need to break-down organizational barriers between health & social-care services in particular to ensure that service-users received adequate care/support/treatment through integrated services (DOH 1997, 1998/1998a) & that they were involved in the planning & delivery of care (DOH 1998b). However, as the SCMH (2001/2002) identified in their ‘Keys to Engagement’, such changes/initiatives required specific skills for mental health workers (see appendix 4), particularly if the targets of the NSF for Mental Health were to be achieved. Based in this document the DOH (2004) identified core skills/competencies required by all mental health workers to work with each other & with service-users in achieving evidence-based outcomes & for nurses the ‘Values-to-action’ document (DOH 2006b) further emphasised the need for such knowledge & skills/competencies in the application of an holistic approach based in the ‘Recovery Model’. This document is further supported by the NMC’s (2008) revised code which reiterates their consistent requirement that nurses should not only work with their peers, but also with other professionals and importantly with clients in developing their care-package & in relation to community mental health nurses (CMHN’s) one role that was introduced through the NSFMH and ECC guidelines (DOH 1999/1999a) was that of the care-coordinator (previously key-worker), for the DOH acknowledged the CMHN’s central position & suitability for this role (O’Carroll & Park 2007). Effective care-coordinator’s, & all nurses, as with other professionals, must appreciate the roles of the other members of the MDT, and possess excellent communication & collaborative skills (Bonney. in Davis & O’Connor 1999, Hadland 2004, Stuart 2005), as emphasised by the DOH (2004, 2006), SCMH (2001) & NMC (2008). However, as e.g. Hudson (2002), Hadland (2004) & Whitehead (2001) identified besides the benefits of collaboration, a variety of barriers exist, in relation to service-providers, hindering the developments of close collaborative relationships (see appendix 5) However, given the above changes have been proposed to implement across professional common foundation programme of training of all healthcare workers to enhance inter-disciplinary communication (NHS Plan: in Lilley. 2001) & although these have been introduced (to varying degrees) within approved educational institutions, the DOH (2008) have now acknowledged that simply providing definitions & guidelines regarding the skills required for collaboration &/or for a particular role (e.g. the care-coordinator-Nb1) within the collaborative process, although it remains to be seen if their initiatives to address this will have a positive effect. Relating to the role of the nurse as care-coordinator/key-worker, as long ago as 1984 Benner considered that, nurses played an essential role in the management of care of patients both as coordinators and educators, which in line with NMC requirements means that they e.g.: - Keep-up-to-date with the latest developments in care and local and National policies to ensure their practice conform to the standards of clinical governance Be central to the MDT to ensure that the patient is the focus of that care This also means that nurses are required to persist in their attempts to actively engage all clients in the shared development or their care-packages, even when clients may be unable or unwilling (at least initially) to become involved (Thurgood 2004) for as the SCMH (2005) argued by 2015, not only should every patient have a comprehensive, tailored care plan, they should have taken the lead in determining how they want their needs to be met according to the NHS plan (1998). --------------------------------------------------------------------------------------------------------------- Nb1:It should be noted that s/he is not one who simply follows an established ‘pathway’ but someone who challenges existing practice and leads the way in developing new evidence-based clinically effective care (Seaman in Smith M: 1999:1998). Part 2: Collaborative Skills (see appendices 1-3 for full reflections) The following summarises my insights into my learning/learning needs regarding collaborative skills use relating to firstly my involvement in the collaborative assessment, planning & implementation of the treatment/care provided for ‘Jane’, a patient within an acute forensic inpatient psychiatric unit (reflections 1-2) & secondly the collaboration between my mentor, the team & myself to achieve my set & mutually agreed learning outcomes whilst on placement. Reflections regarding Jane’s assessment & care plan implementation. Before conducting the initial assessment with ‘Jane’, under supervision, I was conscious of the requirements of the NSFMH & the then ECC guidelines (DOH 1999/1999a/b) that the assessment must be comprehensive in order for the MDT to develop an appropriate care package. I was also conscious that this required not only my use of effective communication skills with Jane, but also with the nursing and multidisciplinary team members (SCMH 2001, DOH 2004, 2006b). in order for the assessment data to be used as a basis for Jane’s initial care-plan, which would allow for further assessment data to be gathered prior to her MDT review. While both Barker (2003 & Stuart (2005) stated that psychiatric care requires the completion of an assessment of the client’s bio-psycho-social status, Barker also asserted that the way in which an assessment is carried out and the methods used in the process make it a worthwhile exercise or largely a waste of time. Therefore I was conscious of the need to not only adhere to the ECC framework but also to the ‘Best practice competencies’ guidelines for pre-registration mental health nurses (DOH 2006) and those of the NMC (2008) & guidelines for students. NMC (2009) I also found that the experience afforded me the opportunity of using in-depth & specialist assessment tools like the ‘START’ Short-Term Assessment of Risk and Treatability (Mental health and addiction services online 2010) in further enhancing the basic ECC assessment framework a guide to areas requiring further discussion and as the START (see appendix 6) focused on risk pertinent to mentally ill offenders I found it useful & also discovered that it’s use was being researched by this & other ‘special hospitals’, for validity & reliability. This I realised was important an assessment & management of risk (to the patient &/or others) can never be 100% (Morgan & Wetherell 2004) & therefore valid assessment tools & collaborative in-put by the team & the patient should be fundamental to risk-management strategies, which should also involve positive risk-taking (DOH 2007, 2008). Even in the absence of identified risk this need for collaboration is further supported by specific National Institute of Clinical Excellence guidelines (NICE 2009) on care provision &/or treatment for a variety of client groups & specific disorders including: Schizophrenia which applied to Jane. As indicated, the NMC (2008) also requires nurses to work with clients as partners; and there is widespread agreement that mental health service-users and their carers should be fully involved in care planning as this increases their satisfaction and engagement with services (Warner 2005, Rose 2003, SCMH 2009) This involves identifying their preference regarding care & the START facilitated this by identifying Jane’s needs, as Jane’s key-coordinator it was my (supervised) role to ensure that all due procedure was carried out regarding recording of the outcomes which also included the planning of therapeutic engagement. Record keeping, if accurate, topical & comprehensive facilitates collaboration with the team (NMC 2005) Any assessment also requires that the nurse use her observation skills (Barker, 2003, O’Carroll & Park 2007, Stuart 2005b), which I feel also facilitated my engagement with Jane in the process of deciding together and with the team the best potential strategies to facilitate development of her on-going care-package. Further, although I was aware of Jane’s history & apparent paranoia, & despite an aggressive incident during this time (see appendices 1-2) I also realised that to work effectively with Jane that I needed to put my personal feelings aside (Stuart 2005b) and on further reflection, I feel that I was eventually able to therapeutically work with Jane in her on-going assessment & care-planning Theoretical knowledge and experience are required to make informed decisions in deciding a plan of action for patients (Stuart 2005a, NMC 2007/8, DOH 2004, 2006) Further although we no-longer utilise the nursing process in statutory mental health services I realised that the ECC/CPA framework is based in the same principles & Wilkinson’s (2007) argument that the nursing process promotes collaboration, remains pertinent, for when team members have an organised approach, communication is good, and patient problems are prevented. Similarly the ability to transfer/adapt knowledge and skills, especially communication skills, based in self-awareness, mutual-trust and understanding of each other’s roles facilitates effective collaboration with different people in different situations (Hadland 2004, NMC 2008, Onyett 2004, Stuart 2005a/b) and are required competencies by the DOH (2004 2006). The (NMC, 2008) also make it clear that nurses must always act on what they believe to be the service-users best interests, and the Healthcare Commission’s (2005b) core standards emphasise the need for employers to ensure that employees follow their professional codes. As indicated MDT collaboration regarding Jane, began before the formal review meeting, however when I formally presented my initial and on-going assessment findings to the team, using guidelines from ‘The New Ways of Working programme’ (DOH, 2005b), I encountered barriers to collaboration with Jane in this process, which were primarily due to legal and safety requirements of the environment (Mersey Care Risk Management Policy and Strategy, 2007 DOH 2007) & I found that Jane was prevented from attending because the review was held in a non-secure area of the hospital. Although I understand the rationale behind this & although an advocacy service is provided for patients to overcome this, none was made available for Jane & I still feel that other strategies to overcome the problem should be developed, for as the SCMH (1998) & Rose (2003) identified this lack of patient involvement by services was an area of complaint by service-users. Reflections on support for my learning: I feel that I was effective in utilising the skills outlined above in respect of gaining Jane’s positive and collaborative engagement with me and the strategies agreed by the MDT. To help me develop my self-awareness and skills in relation to such issues, and those outlined above I found that keeping a reflective diary at this placement, was a crucial way of ensuring critical events that needed further review, to benefit my practice, would not be forgotten. Keeping a structured reflective diary facilitates further review (either alone or with a supervisor) of experiences from which the practitioner can learn & improve his/her practice (Gibbs 1998, Kirby & Hart 2004, Norman & Ryrie 2004) & throughout my experiences my mentor has proven to be a valuable resource, without whose support I feel collaboration with both Jane and the MDT would have been significantly more difficult. It is the responsibility of the student & mentor to work together in identifying learning needs & strategies to achieve them (NMC 2008 & 2009) Conclusion:

In addition to my personal reflections and supervised experiences, which gave me the opportunity to better understand the roles of other team members and helped create a collaborative partnership between people with varying knowledge, skills and perspectives (Hornby & Atkins 2000, Nancarrow 2004), I feel that the opportunity for clinical supervision with my mentor has played an important part in my role development. Finally one specific criticism of the collaborative process I have concerns the lack of collaboration with families and carers, as their involvement I feel was actively discouraged, unless clients gave their permission for this (which I have found is not unique to this placement), with the only information given being visiting arrangements and telephone numbers. Although confidentiality & patient rights have to be considered (NMC 2008) (Mental health act 2009), I have found that they are never invited to the MDT meetings, Yet the DOH (e.g. 2005) state that to work effectively in partnership with service-users and carers, it is essential that we are able to form and sustain relationships and offer meaningful choice.

The focus of this assignment is to show an understanding of the assessment process. A brief description of the patients profile and practice setting will be outlined. The setting’s name, location and patient’s name are not disclosed for confidentiality according to the Nursing and Midwifery Council, (NMC2008) hence the name will be fictitious. The patient has consented to the use of their personal information in this assignment. A consent form has been signed by the mentor. The patient’s name will be referred to as Jane. The assignment will discuss the importance of assessment and how the contribution of patient, family, or carer and multi professionals assist the process of assessment. The Mini Mental State Examination, (MMSE) tool will be used in the assessment of a patient and the rationale for using the tool will be discussed. The outcome of the assessment will determine the patient’s needs and future care plan and will therefore be highlighted. An analysis of the efficiency of the assessment tool, its advantages and disadvantages as well as my overall view on my experience of using the tool will conclude the assignment. Maria is an 81 years old lady who was referred by the Emergency General Hospital to an elderly acute Mental Health hospital for patients with dementia. She was in the Emergency general hospital for treatment of a chest infection following a chest drain. The referral was made after she became uncommunicative and had stopped feeding orally. Whilst she was in the General hospital she had been put on a nasogastric feeding machine and had been bed bound for four months. She was admitted on an informal basis for assessment and treatment with the hope to discharge her back home with a full package of care or into a nursing home with a continuing package of care. Jane’s past medical and non medical history confirmed that she suffered from anxiety and mild agoraphobia and has over the past few years had Cognitive Behavioral Therapy. She was reported by her son to have been forgetful over the past 3 years and had forgotten him. She has recurrent urinary tract infections. She mobilizes by use of a hoist and needs total nursing intervention. On admission she was found to be withdrawn and uncommunicative, she was diagnosed with depression and psychomotor agitation or pseudo dementia and acute confusion due to infection. Alongside nursing care and support, she was offered specialist expertise intervention which involved the contribution from nutritionists, Doctors, physiotherapists and other multi professionals and multi agencies. According to Phillip Barker, (2004), page 7, “An assessment is described as the process of making a decision, based upon the collection of relevant information, using a formal set of ethical criteria that contributes to an overall estimation of a person and circumstances, while Mosby’s Medical Dictionary (2009), defines assessment as identification of needs, preferences, and abilities of a patient. Phillip Barker, (2004, p6) says that it was suggested by most psychologists that a definition relevant to psychiatric and mental health nursing should focus on estimation of character or person’s worth and what they may become. An assessment is very important because it provides the scientific basis for a complete care plan. It is considered to be the first step towards treatment of a patient. An assessment has to be precise and accurate because it determines patient’s diagnosis and prescription of medication. An assessment involves an interview and observation of a patient by the nurse and considers the symptoms and signs of the condition, the patient’s verbal and non verbal communication, the patient’s medical and social history and any other information available. The physical aspects assessed are vital signs, skin color and condition, motor and sensory nerve function, brain function, nutrition, rest, sleep, activity, elimination, and consciousness. The social and emotional factors included in assessment are religion, occupation, attitude towards hospital and health care, mood, emotional tone, and family ties and responsibilities. Medical Dictionary, Mosby, 8th edition, (2009). There are two forms of assessment methods, which are informal assessment, where information is collected by less structured questions even haphazard methods and formal assessment where structure to questions is emphasized and has been planned and studied carefully through research. However different kinds of assessment tools in form of questionnaires or guidelines where designed in order to assist nurses in carrying out a formal assessment and collect information about the nature and scale of a patient’s problem. A tool is selected and used if the questions meet the individuals assessment needs. The MMSE was first published in a Journal in 1975 as an appendix in an article written by Dr. Marshal Folstein , Dr Susan E. Folstein, and Dr.Paul R McHugh with the aim to separate individuals with cognitive functions from those without such disturbances. It was found to be highly reliable in detecting cognitive impairment and is now widely used around the world and in many clinical settings, and by General Practioners. The MMSE is a structured questionnaire that includes such categories as orientation to time and place, registration, attention, calculation, recall, language, ability to follow a three step command and visual construction. It contains standard wording and a total score of thirty points. Any score greater than or equal to 25 points (out of 30) is normal, 9 points and below indicate severity, 10-20 points indicate moderate and 21-24 points indicate mild cognitive decline. According to Folstein, a score below twenty was found in patients with dementia, delirium, schizophrenia, or affective disorder, and not in normal elderly people. He also states that an abnormal score on the MMSE is not diagnostic of dementia or delirium but does reflect the severity of cognitive impairment. Thirty seven studies were carried out over ten years using the MMSE to show progress of patients with dementia and an average change of score was3.3 points, Tom burgh and McIntyre (1992). The MMSE has its limitations , it is found that cognitive performance as measured by the MMSE varies within population by age and education, with lower scores for oldest age groups and those with less education and it is insensitive to very mild cognitive decline particularly in highly educated individuals, Miller et al: (August 1997). The MMSE was also found to be brief and can be easily administered in ten minutes. The rationale for using this assessment tool is that it is found to be appropriate for assessing elderly people with Dementia by the practice placement. The multi professional team also found the tool reliable and considered it to meet the patient’s needs and ensured clinical effectiveness and evaluation. In order to prepare for Jane’s assessment, her medical and non medical history was accessed through Rio. Mary received specialist care of a nutritionist for diet intake, and a physiotherapist for aiding with walking since the tendons of the back of her feet have shortened from being bed bound for four months. Weekly meetings are held by the Multi professional team in order to discuss her progress and review her care. Relatives are involved because they are considered to have an important role in planning of care and helping to evaluate the service and also in consenting for the patient if they do not have an advanced directive or capacity to consent. Jane’s history explains why she is low in mood and tired most of the time. Therefore, it was important to be very sensitive when building a rapport with her. A professional relationship was built everyday for a period of two weeks during assisting her with personal care, by initiating conversation with her during the day, by assisting her with feeding, and getting involved in her physiotherapy sessions. A lot of empathy and encouragement was demonstrated. A therapeutic relationship built on trust and respect was developed. When Jane seemed relaxed and less tired, she was asked if she would mind completing an MMSE and she consented. She was taken to a quiet room where an MMSE was administered. A quiet room was selected in order to reserve her privacy and to maintain concentration. Interview skills such as sitting squarely, maintaining eye contact, active listening and having an open posture and pleasant attitude where maintained (SOLAR). The questions were spoken clearly and softly and repeated for clarity when necessary. Jane remained calm, content and pleasant during the assessment and engaged appropriately throughout. Mary’s overall score was 13 out of 30. Jane’s results reflected poor orientation in time and place with a score of 4 out of 10, in registration test she was hesitant of repeating the three objects but mentioned all 3 very quickly, on attention she could not subtract, she became very confused. On recall she could not remember any of the three objects which is a sign of short term memory. Jane was found not to be very clear in speech but could follow instructions of folding a paper, closing eyes and so on without much confidence. Her drawing and writing was much affected by shaking; she scored 6 out of 9 points. Jane’s MMSE result is lower than 20 so it reflects poor cognitive function, memory problems, lack of insight and understanding possibly caused by dementia, urinary infections and maybe depression. Total nursing intervention is required. Her care plan requires a holistic approach based on physical, psychological, social, and spiritual needs. Jane was involved in preparing her care plan. Her care plan outlines, -Regular physical activities such as walking. Exercise is known to slow down decline in mobility associated with dementia. This will be achieved with the help of a physiotherapist. -Imply cognitive stimulation by talking to Jane and allowing her to discuss her feelings and thoughts, and introduce recreational activities such as problem solving activities that may enhance quality of life and wellbeing. -Reality orientation, by giving regular information about times, dates, season, places, or people to keep her oriented. - Cognitive behavioral therapy known to treat people with depression associated with dementia. This can be achieved with the help of an Occupational Therapist. -Reminiscence therapy by initiating discussions about her past so she can use her long term memory. This is known to be good in people with mild to moderate dementia. -Sensory stimulation by use of music, lights, massage, sounds to stimulate the brain; this is known to improve restlessness and lift moods. -A risk assessment with regular baseline observations to monitor self neglect and poor dietary intake and poor personal hygiene caused by poor cognitive function. -General observations to be maintained by monitoring improvement or deterioration of mental or physical state. -Two weekly MMSE’s to be carried out to monitor progress.

-Her son to be involved in weekly care reviews and in deciding her care. This is important because problems such as hearing, illiteracy, late onset of depression, urinary tract infections, underactive thyroid, drugs such as sedatives and pain killers can cause memory lose and confusion so they can interfere with interpretation of the MMSE, if not properly noted. Patient UK leaflet Print, page 1, Alzheimer’s society, In this essay the process of building a therapeutic relationship and assessing clients' own circumstances within the inpatient admission and the framework found in practice will be uses analysed and criticized by using Johns (1994) model of reflection. The framework that has been used in mental health services is the Care Program Approach (CPA), which it has been profoundly criticised since it was introduced. Therefore the reflection will look into other model of nursing, Tidal Model, which offers a different philosophy of care. The reflection will also explore the interpersonal interactions theories which the nursed used during the assessment and how these aided to engage the client in the biopsychosocial assessing process. It also will be discussed other intervention models and the possible usage in similar situations. In order to begin the analysis of the above points, engagement needs to be defined. Thurgood (cited by Norman and Ryrie (2004) p.650) described it as: 'can be broadly defined as providing a service that is experienced by service users (including carers) as acceptable, accessible, positive and empowering'. Although this definition gives an idea of the concept, it lacks to define the key elements of engagement, which Cutcliffe and Barker (2002) identified as forming a human to human relationship, expressing tolerance and acceptance, and hearing and understanding. Both definitions gather the professional values of the service and the interaction itself. Yet, Cutcliffe and Barker (2002) definition can be considered more practical when holistically assessing clients. However, these definitions do not acknowledge factors of engagement that are behind the interpersonal relationship, such as personal or organizational perspectives of engagement. The personal perspective for the nurses practice is underpinned by poor structural organization, occupational cultures and stress, bureaucratic constrains, lack of time and nursing culture driven by measurable targets (Hosany et al (2007) and Addis and Gamble (2004)). On the other hand, clients and their families are conditioned by the mental illness, their past experiences with other services, the trust in the service and the relevance of it. Additionally, the organizational issues effect upon engagement and care by reducing services budgets, by not providing resources and also by politics. Engagement has been recognized as an important part of mental health services users' care. The National Service Framework (NSF), the National Institute for Clinical Excellence (NICE) and the Department of Health (DoH) appoint that users under CPA should be provided with resources to build a therapeutic relationship, optimise engagement and reduce risks. These documents also highlight the need to provide a therapeutic environment in order to provide best care and to engage the clients and their families with the service. Taking into account all the above information a reflective account will be taking place in the following pages by using Johns' model of reflection (1994). 1. Description of the experience

The clinical environment where this assessment took place was in an acute adult ward. The ward is based in an old mental health hospital, which has old and pilling off wooden windows, untidy roofs and old fashioned flooring. The ward had untidy carpets, the curtains did not draw appropriately and the painting on the walls was peeling off. These are the organisational barriers affecting engagement. This particular client was known by the service already, to protect his right to confidentiality he will be referred as John (NMC code of practice 2008). John had been stable for 10 years, but in the past few months his mental state had worsened. His psychosis and levels of anxiety increased; he distrusted neighbours and other acquaintances as well as strangers. Consequently, he stopped going out of his house and began to self medicate with over the counter sedatives. Crisis and Resolution Home Treatment Team (CRHTT) was involved and as they felt that John was not able to cope at home, they decided that an inpatient admission would be beneficial. Before the admission the CRHTT forwarded the CPA form 1A, which updated the ward staff about the latest assessment of the client's biopsychosocial needs. Once John arrived to the ward, he fully understood the situation where he was in. He was able to consent and had capacity to agree with treatment and, thus, he was admitted as an informal client. This facilitated the initial interaction and the initial grounding for the nurse/client relationship. Before the beginning of the assessment Tom (John's named nurse) introduced everyone to John, roles were explained, a welcome pack with the ward information and a CPA booklet were given and Tom provided all the information in an oral and written manner. The nurse started the assessment by formulating open questions. However John gave single direct answers (yes, not, not sure ...). Consequently, the nurse decided to change to more direct questioning. After that the client was very co-operative and was answering all the questions. He reported to be very anxious, which also was noticeable by looking to his body language (he was sweaty, clenching his fingers, rubbing his hands on the chair's arms and removing his spectacles several times during the interview). At this stage the nurse decided to undertake an anxiety assessment by using the scales tools available on the ward - the Beck's Anxiety Inventory (BAI, see Appendix 1). Following this assessment, John began to answer the questions more in depth and he appeared more eased, stating several times that he was in hospital for help and was going to do everything that was available for his recovery. Following the local trust policies and NICE guidelines, the CPA 1A assessment was concluded (as it must to be completed within 72 hours of the admission); the Integrated Care Pathway for Inpatient Safety and the Patient Property Liability Disclaimer were filled in and signed by nurse and client. 2. Reflection

The whole assessment was intended to gather as much information as possible about John in order to understand the client's actual biopsychosocial situation (holistic assessment) and the context that led to the admission, which would highlight the needs and strengths of the client. However, inpatient admissions are more likely to focus on a more medical approach to health, mainly because social interventions cannot be implemented until the client's mental state has stabilized and he is ready to move on to community settings. Along this process the multi-disciplinary team organizes care to build up the grounds to enable recovery (Simpson 2009). This particular ward was focus on treatment and stabilizing, working on one to one interventions (nurse-client), building a therapeutic relationship through structured and unstructured interventions, and used CPA as a nursing intervention framework. Alongside these individual interactions, the activity nurses and the occupational therapist offered daily social and leisure activities. These groups provided skills and entertainment to the clients on the ward, but did not follow a particular model of nursing, such as the Tidal Model, and they offered activities to spare the free time on the ward without promoting recovery. The Tidal Model provides structured group-work centred on recovery (Barker and Buchanan-Barker 2005). This model centres its assessment on a holistic approach for the short and long term needs, viewing the mental illness as a unique experience of each individual, their families and social environment. It looks into the lowest point of the illness (such as an inpatient admission like John's) as the point where the recovery begins with a positive approach to the illness. There are three working groups recommended in this model: discovery, solutions and information (see appendix 3), where therapeutic relationship is built and issues common to the individual and others are discussed and explored. As mentioned above, the ward nurses had more structured interventions with clients, and the issues discussed in these interviews were correlated to the Tidal's Model theme groups. In these interviews the clients engage with their primary nurses and they discuss their concerns in relation to their care or other personal matters. These interventions or interviews were intended to happen at least twice weekly for at least an hour. However, for organizational issues (usually low number of staffing) not all the clients had the opportunity to benefit from these one to one interventions on a regular basis. Initially, the Tidal Model research was criticised for being bias, for lacking to fully describe clients' pre and post intervention with the model, not taking into account 'Hawthorne effect' and most of physiological factors and by not reasoning the need for a new model in mental health care (Noak 2001). However, further research and analysis showed that the Tidal Model provides tools and structure to improve care in acute ward admissions filling the gaps in care pointed in the NSF and The Sainsbury Centre for Mental Health (Gordon et al 2005). One could say that this model has been shown to improve mental health services, fulfil the historical gaps within nursing practice and to be grounded on evidence-based practice. However, the author of this essay believes, after reading the relevant literature, that for the implementation of the Tidal Model the levels of staffing (and therefore the service budget) should be increased and nursing practice cultures must be changed by re-educating the workforce. Arguably both implementations are very difficult to achieve as the health service has seen budgets cut downs in the recent years and nurses' practiced has been subject to negative ward cultures towards nursing models. On the other hand CPA, which is the framework used on the ward, was first designed after a series of fatal incidents which involved mentally ill people. It was aimed to be introduced in Wales by 2004 (in England was done by 1991). CPA is person centred focus which promotes social inclusion and recovery, through assessment and planning of individualized needs and strengths, working with the clients and their families or carers (Care Programme Approach Association (CPAA) 2008). Despite the initial intention that the CPA was brought to improve service users' quality of care, to increase inter agencies communication and to be a case management tool, some critiques appeared. Simpson et al (2003a) researched showed CPA was thought to be an over-bureaucratic duty within the professionals. The author of this paper has observed in practice, not in this particular assessment, that some professional do not reassess clients' when they are admitted. Instead the latest CPA 1A form (usually filled in by the CRHTT) is photocopied or copied-pasted and re-used to speed up the process. This would be acceptable if the client was assessed the day or night before the admission, because the social, psychological or biological needs would have not changed in that period of time. When older assessments are used, changes in circumstances might have not been updated. In the worst case scenario a health professional could have misunderstood the client's needs and have documented them wrongly. This misunderstanding could be carried over, therefore care would be affected. This hypothetical scenario shows that CPA assessments should be done every time when needed. CPA as a case management tool fails to compile the most important features which promote therapeutic relationship. In contrast with other case managements models the role of the care co-ordinator is more of an administrative and as an alternative service prescriber (Simpson et al 2003a). This means that there is no need for a specific training or skills related to therapeutic relationship, partly because other services (or service providers) will engage with the client, and the care co-ordinator just oversees the process of care. Moreover, CPA also lacks a nursing model background and fails to define specific roles within the multi-disciplinary team. These factors reduce the teamness feeling between the health professional (Simpson et al 2003b). Although, it could be argued that the reason, why CPA is lacking nursing background, is that it was not designed as a mental health nursing framework but for the use of mental health services. In this particular reflexion the care co-ordinator was not present in the admission and never mention during the assessment. Whether it was a usual situation or not it is something that never was discussed, but it shows Simpson et al (2003a and 2003b) critiques of CPA as a case management were factual. CPA and Tidal Model are intended to provide holistic care for clients and their families. However, the Tidal Model is more client's centred than CPA, and it also looks into the more positive side of the clients' situation, foreseen the now and future as a whole. It explains the illness as an accumulation of life factors. The Tidal Model complements other health and social care professionals, as well as it searches to nurse by building a special relationship between health practitioner and client. Moreover, CPA always looks for risk signs in the short-term and from a psychiatric approach. As this assessment took place in an inpatient admission it is important to bear in mind that in this particular environment CPA forms (1A, 2, 2A and 4) were used for assessment, planning, implementing and evaluation of inpatient care and for the liaison with other health professional in tertiary care (such as physiotherapist, dietician or occupational therapist). Perhaps CPA would benefit from sharing some principles of a nursing model (like the Tidal Model), by using it as a tool more than as a paperwork and from a better staff training and promoting adherence to nursing models (Barker 2001). Whether the ward uses Tidal Model or CPA to structure care, an inpatient admission is always stressful and uncomfortable experience for clients and their families. John saw the nurse as a stranger in an unfamiliar place, however, Tom was there to guide the client throughout his care, to provide information and to be somebody he could relay on. This first encounter related to the orientation phase described by Peplau (1952) (cited by Sheldon (2005), see Appendix 2). In this phase John's past experiences, expectancies, culture and believes were to condition the initial interaction. Following this phase John went into the identification stage, where he sought assistance for anxiety relief techniques, shared needs and strengths when and co-designed care plans and began to have feelings of belonging and capability, therefore decreasing negative feelings. This exchange of feelings is going to lead to exploitation and resolution phases, where John will engaged with treatment (medical, physical and social), having different needs at different times, starting to be informed about all the help available towards the final stage, feeling as an important part of the whole nursing process and finally ending the professional relationship when discharged. The exploitation and resolution phases were not observe as at the time of writing John was still an inpatient. John had had previously one bad inpatient admission. He reported that he was very unhappy when he was in the other hospital 10 years ago. He explained that the bad experience was related to the other clients and organizational issues rather than staff. John stated that he was feeling anxious but happy that he was getting help. His positive attitude helped to engage him in the assessment process and on the ward activities, which were the first steps towards the identification phase. Therefore, John could begin to have professional input from other members of the multi-disciplinary team. Tom interacted in a way that John felt understood, respected and individualized. Tom did not appear to have preconceived ideas of the client after reading the CPA forma 1A. And certainly, Tom treated John respectfully and as an equal human being. He followed the NMC code of practice 2008, which states that: 'you must treat people as individuals' and 'not to discriminate in any way those in your care'. Tom tried to adapt the pace of the questioning to the client's needs, involving him and asking in a respectful manner. Tom also acknowledged John's anxiety feelings, and showed it when taking further (BAI see appendix 1) assessments to empathize more with John's situation. This reinforced the approachability and genuineness of the nurse and led John to open and engage with the assessment process and the health professional. 3. Influencing factors

John scored 45 points in the BAI (see appendix 1), which is a high scoring. This could have been influenced by the hospital admission and the assessment process. Despite these factors and John's actual mental state he engaged in the assessment actively. The BAI scales consist of 21 observable and self-rating symptoms of anxiety, rated from 0 to 3 (0 being the lowest score), which can also be easily transformed in direct questions or self rating. At the end of the assessment the scores are added up and compared against the scales. There are several assessment tools available such as Hospital Anxiety and Depression Scales (HADS) or Hamilton Anxiety Scales (a collection of them can be found in the Appendix 1 reference). The BAI is shown to be a quick and reliable when measuring clients' anxiety levels and it also differentiates General Anxiety Depression and depression (Fydrich et al 1992). Although, these characteristics appear to be positive, it could be argued that BAI is just a merely adaptation of the DSM-IV panic symptoms and therefore it could also be said that measures panic attacks rather than anxiety levels (Cox et al 1996 and de Beurs et al 1997). On the other hand, HADS which achieves good levels of anxiety and depression screening could have been more appropriate for hospital settings and more accurate (Bjelland et al 2002). It is important to point out that NICE clinical guideline for management of Anxiety (2004) does not recommend a specific tool for assessment of anxiety, which gives to the professional practitioner choice on the usage of available tools. This affects practice as these scales are not used as often as they should be. Most practitioners relay on their observations and experience to perform informal assessments, rather than using research based scales. It is perhaps understandable when dealing with clients unable to fully understand these assessments. But in practice it can be noticed that nurses do not tend to use anxiety inventory even with clients that could engage with the process. Tom designed care plans in partnership with John and made him realise which were more realistic goals in the short and long term. Tom had shown knowledge and understanding of the professional capabilities that the NSF defined in the documents "The Ten Essential Shared Capabilities" (2004) and "The Capable Practitioner" (2001). These documents set basic principles that underpin positive mental health practice as well as providing the basic grounding for service workers to continue developing and learning skills. Therefore, it was observed during the placement that along the whole admission the nursing team also guided care and practice as appointed by these documents. They provided patient-centred care, which is accountable for each client and respecting the individual. The team also had a broad knowledge of national legislations as well as local policies and services, and worked under the same professional and ethical principles recognizing the rights of the clients and their families. They promoted recovery and self-realisation by identifying people needs/strengths and empowering the individuals. Most of the team members were undertaking further training, to keep their skills up-to-date or be able to transfer their existing skills to new environments. They also worked in partnership with family, carers, lay people and external agencies, such as community care services, voluntary associations and vocational services. 4. Evaluation

In the interview Tom used a Rogerian approach (Roger (1961) cited by Sheldon (2005)). He also showed knowledge of Peplau's interpersonal theories and applied them in practice by creating a shared experience of care. However, it also would be appropriate to use the Heron's six-category intervention framework (Heron 1989). This framework was designed to enable a practitioner (nurse) taking the lead to facilitate the clients' specific needs or arising issues. Therefore this intervention could have been used in the admission's assessment and the following one to one sessions, which have been described in this essay. The framework is made off two categories, which are subdivided in three more. The first category is authoritative which it can be prescriptive, in which the nurse influences and directs behaviour, gives advice and prescribe goals. It also can be informative providing information or giving feedback for the client's behaviour. The third subcategory is confronting, in which the practitioner challenges the client's beliefs or actions. The second category is the facilitative which is divided into cathartic, in which the nurse tries to release the clients' painful feelings and talks about or express them with actions (tears, anger or shouts). Next subcategory is catalytic, where the nurse tries to help the client and encourage self-discovery and learning. Finally, supportive is the category

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