Risk assessment in mental health nursing

This paper will discuss the role of a mental health nurse in risk assessment and risk management and strategies for the risks identified in the scenario for Peter during his stay on the ward and in preparation for discharge. Definition of terms will be given. It will go on to critically discuss a discharge package and community support services available to peter and a discussion of a carer or relative’s involvement in and its impact on Peter’s care

Wellman (2005) defines risk as the probality of something happening in practice it is refers to the probability of something harmful or undesirable happening to a patient while risk assessment involves assessing the safety of a client and the risk the client poses to others (Newel & Gournay, 2000) (Boyles 2005) this can be achieved by having as much information about the patient’s background their past and present mental state, social functioning and behaviour. According to Department of health (2003) risk management is an active and systematic process to identify, evaluate, manage and monitor potential and actual risk

According to Snowden (1997) risk assessment will form the basis for development of treatment strategies and plan identified to manage risk. Risk assessment is an essential and on-going part of the Care Program Approach process. In order for the healthcare team to get as much information as possible they need to use one or risk assessment tools. According to the royal college of psychiatry (RCP) risk assessment tools have undoubtedly improved predictive assessment, particularly when used in combination with clinical evaluations.

The Violence Risk Appraisal Guide (VRAG) is an actuarial tool used for the prediction of violent recidivism. VRAG tool give the probability (from zero to 100%) that an offender will commit a new violent offense within a specified period of community access. The tool say how one offender’s risk compares to others. VRAG is for men who have committed serious, violent or sexual offenses. Another tool which could be used for Peter is the FACE is a 12 scales used to rate mental health service users of working age adults, it covers different aspects of mental and social health, each on a scale of 0-4.

They are designed to be used before and after interventions, so that changes attributable to the interventions can be measured. (RCP, 1998) Due to Peter’s complex needs he is subject to an enhanced Care Programme Approach (CPA). A CPA is a government requirement for all mental health patients who get into contact with mental health service under the Mental Health. Peter was brought onto the ward by police under section 136 of the Mental Health Act(1983) one would assume that he was initially placed on section 2 for assessment then section three for treatment. (Mental Health Act 1983)

Peter presents as a vulnerable young man who is floridly psychotic from the description of his presentation Peter appears to be suffering from a psychotic illness which resembles schizophrenia as according to DSMIV (1994). There is need to nurse Peter in a safe and therapeutic environment. According to Longan ; Lindow (2004) a good relationship with the service user and knowledge of them including their strengths and weakness and abilities gained over time can help in assessing what risk they pose. The risk that individuals pose alters with time (Newell ; Gournay, 2000).

Gamble ; Brennan (2006) therefore suggest that risk assessment should form part of an ongoing process rather than a one off decision. A fundamental aspect of nursing care is building a therapeutic relationship. According to Foster (2001) users of mental health services require stable relationships with staff to have any hope for recovery. Lowenburg (1994) further supports this idea of developing a therapeutic relationship when he states that trust, caring and compassion have been rated highest in terms of qualities of the nurse client relationship.

Engagement is concerned with the development and maintenance of a therapeutic alliance between staff and client This can be enhanced by the style of interaction, which should be non-confrontational, empathic and respectful of the client’s subjective experiences of substance misuse. The therapeutic alliance will also benefit from meeting a client’s immediate needs rather than focusing on the cessation of substance misuse. Peter seems to have established a rapport with the student, the student nurse will need the support from her mentor to further develop and maintain the relationship that has developed.

Miller ; Rollick (2002) and Repper (2002) suggest that the relationship that a nurse establishes with a client affects the quality and amount of information that the nurse can get from the patient and this will impact on the care the patient will receive. According to RCP (1998) high morale among staff and interactive collaboration with patients are key factors in the creation and maintenance of an effective care environment. Royal college of psychiatry() states that A management plan must be based on an accurate and thorough assessment and follow the principle of negotiating safety.

This entails paying close attention to the interaction between the patient and the clinician, aimed at reducing the risk of dangerous behaviour and making the patient feel as safe as possible. According to Nolan and Crawford (1997), the mental health nurse is in a unique position to develop an interpersonal relationship with the client, by accepting the client and helping him or her to increase confidence and self-esteem. The nurse is best placed to explore the effects of clients’ substance misusing behaviour on their life.

Peter poses a risk of self neglect both on the ward and in the community. According to Shephard (2002) patients suffering from schizophrenia tend to behave in a characteristic manner neglecting their appearance, some times abusing illegal drugs withdrawal and inertia therefore the nurse need to talk to Peter and attempt to encourage him to find ways of improving his activities of daily living, the nurse also need to draw up a care plan together with peter and encourage or prompt him to attend to his activities of daily living.

A lot of patients suffering from schizophrenia often neglect their appearance but with a lot of encouragement and prompting they attend to their personal hygiene. The fact that Peter continues to present with schizophrenic symptoms there maybe a possibility that he is abusing drugs (cannabis) and there is a correlation between the chemical effects of cannabis and the symptoms of schizophrenia. The dopamine hypothesis suggest that schizophrenia results from too much dopamine activity in the brain (Sadock et al 2003).

Cannabis is said to have the ability to raise dopamine levels within the nucleus accumbens which in turn cause alterations in cognition, euphoria and mood change as with schizophrenia (Blows,2003). According to Chick & Cantwell (2001) some psychiatry disorders occur as direct result of drug abuse and this can be considered as drug induced disorder or drug precipitated disorder. Sainsbury centre for mental health (1998) states that substance misuse is associated with exacerbation of symptoms such as violence and aggression and causing hallucinations.

To clarify wether or not Peter is getting access to drugs a urine drug screen must be done to determine if he is under the influence of drugs however it is important to not note that drug screen for cannabis can be misleading this is supported by Chick and Cantwell (2001) who states that cannabis is a fat-soluble and is only slowly eliminated so that urine test after a high dose of cannabis can remain positive for several weeks.

Antipsychotic drugs have proven to be crucial in relieving the psychotic symptoms of schizophrenia such as hallucinations, delusions and incoherence but they are not consistence in relieving the negative symptoms of the disorder ( Puri et al ) If it is found that Peter’s drug test is positive for cannabis a new care plan has to be written and a search policy will be introduced on the ward because there might be a risk of supplying drugs to other patients on the ward.

This will involve routine searches of people and property including visitors, use of drug testing kits, cancelling or restricting leave. Sandford (1995) supports the idea of searching patient and visitors he goes on to state that the use of police sniffer dogs will protect patients who do not use drugs from exposure to them by curtailing the sale and consumption of drugs.. There is need to work in liaison with the substance misuse team so that Peter can get help with the cannabis abuse this idea is supported by (…….. who advocate for Integration of mental health and substance use services results in improved detection, assessment and management of co morbidity. In practice the author has encountered such type of situation where searching patients regularly helped reduce the incidence of drug being brought onto the ward. Another factor which could explain why Peter is not showing any progress in his mental state could be misdiagnosis.

Peter could be suffering from an organic brain damage and could explain why he is not getting any therapeutic effect from medication (Blow 2002 ) according to Saddock ; Saddock(2005) apathetic withdrawal, agitation and severe delirium are some of the symptoms displayed by someone who has had a brain injury. There seems to be a risk of non compliance, Peter is said to have been on the ward for sixteen weeks but there is no signs of improvement in his mental state

Psychological therapies have an important role to play in helping people with mental health problems, who should have access to effective treatment, both physical and psychological (National Service Framework for Mental Health, Department of Health, 1999). According to NICE medication should be the first form of treatment given to patients with the first episode of schizophrenia NICE strongly recommend the use of atypical antipsychotic as they are believed to have less side effects so the nurse need to educate Peter and his family about the importance of taking medication.

This is in a situation where the patient refuse his medication family members can be incorporated into the therapeutic process. It will be ideal to nurse Peter on increased engagement observation (IEO) this is a form of observation where Peter has a nurse looking after on a one to one basis everyday until this has been reviewed by the multidisciplinary team considering Peter’s progress (. ) The author has had an experience of this kind of observation and it proves to be an effective way of nursing patients during the time they are most vulnerable.

While on the ward the nurse may consider giving Peter rapid or acute tranquilisers such as benzodiazepines medication this will help to calm him down in times when he is seriously disturbed (RCP, 2002) care should be taken when administering benzodiazepines as these may cause sudden death, after administering any benzodiazepines the patient should be kept under constant observations with attention to respiration , pulse and blood pressure. nice guidelines recomend the use of rapid tranquilisers.

During an acute illness, some service users can become behaviourally disturbed and may need help to calm down; for the majority of service users, however, rapid tranquillisation is unnecessary and should not be resorted to routinely. It is important to ensure that the environment is properly adapted for the needs of the acutely ill, and that communication between staff and service users is clear and therapeutic to minimise frustration and misunderstandings.

Due to the nature of Peter’s illness his behaviour can fluctuate sometimes causing disturbances on the ward if this situation arise It is recommended that the nurse use some methods to de-escalate the situation as a last resort Peter may need seclusion to calm him down( ) during this process the therapeutic engagement need to be maintained. The initial response should be to provide structure, to reduce stimulation and to try to verbally reassure and calm the person (Osser ; Sigadel, 2001).

The National Institute for Mental Health in England (2001) encourages the involvement of both Peter and his family to have a greater sense of control and to be a participants, rather than recipients of care. According to Doh, (2000), user involvement is integral to service evaluation and development in the modern NHS. Tilley (1997), supports the idea of user involvement as he argues that the care programme approach (CPA) should be implemented so that the service users are empowered in such a way as to ensure that their needs can be better expressed and met.

The Care Programme Approach (CPA) is the framework set out by the government for the delivery of effective mental health care. Clinical governance is about changing the way people work, demonstrating that effective teamwork is as important to high-quality care as risk management and clinical effectiveness (Doh, 1997). Carers also need support and education to improve their understanding of mental health and this according to Kuipers (2000) this can reduce relapse rates in service users.

Carers play a vital role in helping to look after service users of mental health services, particularly those with severe mental illness. Providing help, advice and service to carers can be one of the best ways of helping people with mental health problems ( ). While caring can be rewarding, the strains and responsibilities of caring can also have an impact on carers’ own mental and physical health, and these needs must also be addressed by health and social services( ).

Care and consideration must be given to the carer’s role in that their degree of coping and caring can change depending on the demands of the service user. Standard seven of the NSF local the healthcare team need to pay greater attention to the needs of carers and to the specific needs of those who care from someone with a mental health problem (DoH). This should include the assessment of each carer’s needs, the agreement of a care plan which is reviewed regularly and the development of local networks to support carers.

Anecdote evidence indicate that a lot of middle aged people are looking after an older relative or a child as well as an adolescent suffering from a chronic mental illness according to ( )Parents of people with schizophrenia often feel to blame, either because they have ‘passed on the genes’ causing schizophrenia, or because they are ‘bad parents Clear and intelligible information should be made available to service users and their families about schizophrenia and its possible causes, and about the possible role families can have in promoting recovery and reducing relapse.

According to Gamble and Brennan(2006. )Living with a patient suffering from long-term mental illness, the majority of family members experience stigma-related phenomena, affecting roles, causing, isolation and denial of illness in many cases. (……. ) suggest that Educational group programmes for carers are an effective way of providing both education and support, this can assist in reducing some of the distress and difficulties inherent in caring for someone with a mental illness. One of the main contributors to relapse in psychological disorders is expressed emotion.

Expressed emotion is the critical, hostile, and emotionally over-involved attitude that relatives have toward a family member with a disorder Camberwell Family Interview. This interview is a way to watch verbal and nonverbal answers to make an accurate assessment. High expressed emotion involves more criticism, hostility, and emotional over-involvement than low expressed emotion. Family members high in expressed emotion cause relapse in psychological disorders such as schizophrenia The nurse will need to assess the family dynamics and educate them about schizophrenia.

Using the RAI or Kasi the nurse can detect what information the family need. These are some of the tools used in order to access what knowledge the family have about schizophrenia. Most importatantly is the issue of expressed emotions. Patients discharged to a family with high expressed emotion often relapse within weeks after discharge( )Expressed emotion is a measure of how well relatives of a psychological patient express their attitude towards them while they are not present (Hooley ; Hoffman, 1999).

In order to measure this expressed emotion, the family is interviewed to carefully watch their expressions and comments while answering questions. This interview is known as the Camberwell Family Interview. according to ( )Therapy is used to educate the family on the psychological disorder, the understanding that the family has for the disorder will lessen high expressed emotion exhibited by hostility and criticism towards the patient.

The guilt or sympathy that the family may feel that could lead to the low expressed emotion of emotional over-involvement is also addressed and reduced. According to (Lopez et al. , 2004 ) Family interventions for people with schizophrenia and their families effectively reducerelapse rates during treatment and after treatment at follow-up, and reduce hospital admissions during the treatment programmes, when compared with all other interventions . The family is more educated and accepting of the disorder than those of high expressed emotion (Weisman et al. 1998).

In anticipation of Peter’s discharge the nurse may look at his discharge package as recommended by standard 4 of the NSF (DoH) which encorages the intergration of care with other agencies and crisis resolution and early intervention team. According to the government CPA document (DoH… ) Care plans for severely mentally ill service users should include urgent follow-up within one week of hospital discharge so prior to discharge the nurse need to send Peter’s information to his general practitioner who will continue to see Peter in the community.

Peter will also benefit from regular visits from a Community Psychiatric Nurse (CPN) or a care co ordinator ( ) The Care -Coordinator should inform the carer of their right to request an assessment. According to the royal college of psychiatry if responsibility for implementation of a management plan is passed on to another clinician or service it must be handed over effectively and accepted explicitly.

Information passed on under such circumstances must be comprehensive, and include all information known to the informant likely to be relevant to the assessment and management plan, i. e. covering the points above as a minimum. this is in line with standard three of the NSF (dH, 2004) which states that all service users should be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care;

While in the community Peter may benefit from depot antipsychotic this is to ensure compliance because he pose a risk of disengaging with the services as pointed out by (Petersen ; Mcbride, 2002) who states that people with dual diagnosis often disengages with the services after discharge. To compound these difficulties this group of users frequently distances themselves from professionals and is described as ‘hard to engange’ or ‘difficult to manage'(Chrome et al 2004).

The author has witnessed this in practice and it is a big problem. t can therefore be concluded that the risk an individual pose remains unpredictable but continious assessment of patients can reduce harm. it is recomended that nurse develop a thearapeutic relationship with patient and get to know them better so that they identify triggers and find ways of managing the situation. it is also recommended that health care professional work in collaboration in order to give good quality care to patient. nurses should also have knowledge of currect risk assessment tools and intervention for patients who are of high risk to themselves and others.