Nursing practice

The aims and objectives of this assignment are to identify a nursing skill observed by myself whilst I was on my practice placement. The skill which I will be focussing on is the first phase of the nursing process in the form of the initial assessment interview. The client had been referred to the mental health services by his consultant and social worker, in order to continue his care in the community, after his discharge from a psychiatric ward. I was introduced to the client, and his permission was given for me to use my nursing skill of observation and also for me to use this assessment for the purpose of my study. The client in this assignment will be referred to as ‘Davey’. This is a pseudonym, in order to protect his real identity and for the purpose of confidentiality, this is also a requirement of the Nursing and Midwifery Code of Professional Practice (2002).

A patient assessment according to Basford and Slevin (1995) is ‘a carefully thought out methodical approach to gathering information and making an intellectual analysis of the data’ in simple terms, it is building a picture of the patient.

There are a great deal of factors to be given consideration when assessing a client, the most important being that the client is the most valuable source of information. Crucial factors can be gleaned from the assessment, and there are several different techniques for doing so. Therefore, it is intrinsic to set the scene before beginning the therapeutic relationship by considering interpersonal skills (Sundeen, Stuart, Rankin & Cohen 1998). The type of assessment used here, was the semi-structured approach whereby information is gathered on a document which is designed for the specific purpose. The approach is called the Care Programme Approach.

The client Davey was referred by his consultant and social worker, to the community resource centre following his discharge into the community. The purpose of this assessment interview was to primarily determine Daveys’ needs and subsequent suitability for a place at the centre, and also to establish whether the community health care team could actually meet Daveys’ needs in turn. Section 117 of the Mental Health Act (1983) states that there must be provision for the discharged client until the multi-disciplinary team is satisfied that the client no longer requires its services.

Daveys’ initial assessment interview was carried out by a registered mental health nurse, with myself observing. The assessment took place in an empty games room which had a relaxed theme to it, and housed several easy chairs. The chairs were placed approximately 20 inches apart diagonally, this allowed both the nurse and Davey to have personal space and also to allow him to feel non-threatened and to enable eye contact as and when he required. The room was vacant of tables. This can have a significant factor on whether the client feels at ease or not. It is also a good indicator in the nurse client relationship that there would be no barriers right from the beginning ( Basford et al 1995 ). This was a good choice of a room, as the physical environment is very important and should not be overlooked. Although sometimes constraints make it impossible to choose a perfect setting, it is important to where possible consider privacy. Privacy is one of the keys to good communication, as the client is likely to be disclosing information of a confidential and sensitive nature (Tschudin 1994).

On entering the room the nurse introduced herself to Davey who in turn introduced himself to her. This is an important part of the nurse client relationship, in as much as when two people are offering their names to each other they are respectively also offering themselves, which indicates an openness and readiness to talk and share with each other (Sundeen et al 1998). The nurse then introduced me to Davey and asked for his consent that I observed the assessment, he agreed. Informed consent is also an important factor in the process, as this is allowing the patient autonomy (Thomas, Hardy ; Cutting 1997).

The nurse presented as being pleasant, smiling and relaxed. She sat slightly forward with her hands placed palm down on her lap. As she spoke to Davey, she made appropriate eye contact with him. These gestures of non-verbal behaviour, all indicate to the client that the nurse is interested in what is being said. Thomas et al (1997) states that non-verbal behaviour says a great deal without words and posture also transmits a straight forward message. Although Davey appeared relaxed, his eye contact with the nurse was not regular. This may be because at times he found certain subjects difficult to discuss with her.

The nurse began by explaining the assessment interview to Davey, she told him that the information was being collated in order to finalise an appropriate plan of care for him. She also made it clear that he was free to ask any question on issues which he was unsure of.

The assessment commenced with the nurse asking Davey how he was feeling, she spoke in clear, simple terms. Heron (2001) identifies the importance of pitching language appropriately and according to the clients background. This is because a client with limited knowledge may find it difficult to understand highly academic language, which could result in inaccurate information being gained.

The questions were a mixture of closed and open ended questions. Stuart ; Laraia (1998) states that closed questions are questions which only required a one worded response, usually ‘yes’ or ‘no’. These questions are useful for gaining objective data i.e name, address, health problems etc., The nurse appeared to allow Davey to be empowered by the situation, as she only guided the interview in the right direction by using open-ended questions, i.e “Do you know what your diagnosis is?”, “Can you tell me about your symptoms?”. Therefore, these questions are used when there is a need to build up an image of the patients thoughts and feelings. Open-ended questions allow the interview to proceed in a natural sequence. Direct questions may upset the client, hence allowing him to focus on sensitive issues in his life, too soon and inevitably invoke anxiety and cocooning. (Dexter and Wash 1999). Another benefit of open-ended questions was the opportunity which it gave to Davey to elaborate upon his answers.

During the course of the assessment, the nurse would often repeat to Davey what he had just discussed. She would condense his discussion into the main points. This is called paraphrasing and summarising. These are the equivalent of non-verbal positive posture which sends out the message to say “I am listening to you” (Basford et al 1995). She also seemed to be very articulate in gently probing into sensitive areas of discussion with Davey and obtaining relevant information. She appeared very empathetic and non-judgemental, and quickly developed a rapport with Davey. By generating empathy the nurse gained a more satisfactory picture of the patients world.

The Department of Health (2001) identified that communication is the most important part of nursing, building a therapeutic relationship and gaining the trust of the patient. At times there were periods of silence in the assessment, which the nurse would use to record what was being said in the interview. Moments of silence according to (Thomas et al) are seen as beneficial, as there is an opportunity for free thought and the initiative for the client if he requires, to add to the conversation.

When he appeared to decline from giving information, the nurse perceived this response as Davey needing to gain trust and confidence in her, so she did not force him to answer. The nurse client relationship can not progress unless the client trusts the nurse. Tschudin (1994) makes it clear that trust in a therapeutic relationship, where there is an exchange of information, needs to be earned.

After a while it appeared that Davey became a little unrestful and anxious. Observations made, indicated that Davey was sitting on the edge of his seat and rocking gently to himself, this is when the nurse decided to conclude the assessment.

It was perceived that Davey had become tired of the assessment interview scenario. The nurse therefore brought it to a close. Heron (2001) states that observation provides information which allows the nurse to then make a decision from. In this situation, the indicating information was that Davey had not been rocking previously, but towards the end of the assessment, it was clear that something was beginning to make him feel unsettled.

The nurse informed Davey that the interview was being concluded, she then summarised the assessment and ensured that Davey was happy with the conclusion. She asked him whether there was anything which he would like to ask or add. Davey was informed of the next step of the nursing process, finally she thanked him for his cooperation and ended the interview. This is all a very important part of the nursing process (Basford et al 1995)

The assessment, although rather unstructured, gave the nurse the ability to infer a great amount of information from Davey. It would appear that an assessment of this description would not benefit from having a structured format, because the patient leads as much as the nurse.

In conclusion, the initial assessment interview is one of the most crucial phases of the nursing process. The nurse must ensure that she creates a therapeutic relationship, right from the beginning, in order for her client to open up to her and trust her. This is done by using appropriate verbal and non-verbal behaviour, which are transmitted to the client, who in response will be either receptive or non-receptive, dependent on the message which is being relayed by the carer. The appropriateness of the communication was high because the content of the assessment was closely relevant to meeting the desired outcome.

It is important that the nurse uses a non-directive approach to the assessment, and allows the client to be empowered to talk about his thoughts and feelings, her role in the assessment is purely to guide the client in the right direction.

Accurate observation is needed during the assessment to ensure that the correct conclusions are arrived at, from the clients verbal and non verbal behaviour.

The assessment interview was successful in so far as it being both nurse and patient led, this made it relatively easy for the nurse to record the information necessary for her to create an appropriate plan of care.

The observations which were made by myself, will enable me to understand how to conduct a nursing assessment correctly. For future reference, I will remember that this phase of the nursing process is to enquire in relation to the needs of the client. It is therefore intrinsic, to consider all aspects of interpersonal skills and communication in order to transmit the correct messages to the client.

References

Code of Professional Practice (2002) London: Nursing and Midwifery Council.

Basford, L., and Slevin, O. (1995) Theory and Practice of Nursing. Edinburgh: Campion Press.

Patient Involvement – Public Confidence, CNO Conference November 2001. Department of Health Speech http://www.doh.gov.uk/speeches/mullallycnonovemberspeech.htm. Accessed 8 February 2003.

Dexter, G., and Wash, M. (1997) Psychiatric Nursing Skills: A Patient Centred Approach. London: Croom Helm.

Heron, J. (2001) Helping the Client: A Creative Practical guide. 5th Edition. London: Sage Publications.

Stuart, G., and Laraia, M. (1998) Psychiatric Nursing: Principles and Practice, 6th Edition. London: Mosby.

Sundeen, S., Stuart, G., Rankin, E., Cohen, S. (1998) Nurse Client Interaction: Implementing the Nursing Process. 6th Edition. London: Mosby.

The Mental Health Act 1983: An Outline Guide http:www.mind.org.uk/mindpdfs/outline.guide_to_MHA.pdf. accessed 12 February 2003.

Thomas, B., Hardy, S., Cutting, P. (1997) Mental Health Nursing: Principles and Practice. London: Mosby.