Assessment in Mental Health Nursing

Author: Mandy ReedEdited by Rachel Munton.

IntroductionThe term assessment has different perceptions within mental health nursing. In the past mental health nurses have seen assessment as part of the medical model, in order to diagnose a client’s illness (Barker, 1985). This approach can be said to be reductionist, in that problems are listed in order to fit a client into a category of mental disorder (World Health Organisation, 1992). Although it is important for mental health nurses to have a good working knowledge of medical approaches to mental illness and pharmacology, the focus for nurses when assessing is on gaining understanding of how clients perceive and cope with their difficulties (Altchul, 1997).The adaptation of the nursing process in the UK was generally limited to a concentration on problems or assessment of needs. In contrast, the nursing process in America including a nursing diagnosis and awareness of the client as an individual (Shannon et al, 1984). Mental health nursing in recent years has promoted holistic assessment of client needs, taking into account strengths as well as weaknesses (Barker, 1985; Beck et al, 1988; Savage, 1991; Ward, 1992). Government legislation and the trends towards multidisciplinary working (Department of Health, 1993 & 1995) have broadened the remit for nurses undertaking mental health assessments. The current challenge is to adapt to these demands whilst maintaining core nursing assessment skills.

Measurement of riskThe Care Programme Approach (Department of Health, 1990) calls for assessment of risk in all clients using mental health services. Following high profile investigations into homicide by people with a diagnosed mental health problem (eg Richie, 1994) and government initiatives to reduce suicides (Department of Health, 1993), priority has increasingly been given to this area of mental health assessment. Blowers and Munton (1998) have reviews and summarised the key issues for Community Mental Health Nurses in their recent article for the CPNA Handbook.

DefinitionsDefinitions of assessment with regard to mental health nurses have generally been either norm or criteria referenced. For example: “the measurement of the patient’s ability to function independently and the comparison of that ability with the level of behaviour he must achieve to bring about true self-sufficiency” (Ward, 1992).“estimating the character of something or someone” which “emphasises the collection of the information with the intention of making judgement” (Barker, 1985).Whatever the definition used, a value is applied to different aspects of a clients behaviour (Savage, 1991). As placing a value is tantamount to making a judgement, the assessment should be structured and unbiased as possible (Barker, 1985; Barneff, 1992). Increasing involvement of users in their care has highlighted the damaging effect of being labelled with a psychiatric diagnosis (lindow, 1994; Rogers et al, 1993). One approach to nursing assessment, which focuses on strengths as well as difficulties and avoids a disempowering diagnosis, is to encompass a holistic perspective.

Holistic assessmentThe beliefs of holistic philosophy (which incorporated humanism, existentialism and a range of eastern beliefs), are that physical, emotional, intellectual, social and spiritual dimensions constantly interact with each other and the environment (Beck et al, 1988). Illness exists when a dimension is not in balance; individuals having personal responsibility in developing conditions which either encourage illness or enhance health. Equally, individuals will have unique ways of meeting their needs in each dimension, whilst recognition of unmet needs can help in redressing the balance. By adopting this

approach it can be argued that assessment should take place in each of the five dimensions, presented under their different headings.

Areas to be covered in assessmentThe following are suggested headings or guidelines for questioning when undertaking an initial mental health nursing assessment. They can also be used when undertaking joint assessments with other professionals from Community Mental Health Teams (CMHTs).? Reason for referral (who from, why now, any known previous history)? Client’s perception (why they think they have been referred/are being assessed; what they hope to gain from the meeting)? Emotional health (mental health state, coping styles etc)? Social health (accommodation, finances, relationships, genogram, employment status, ethnic back ground, support networks etc)? Physical health (general health, illnesses, previous history, appetite, weight, sleep pattern, diurinal variations, alcohol, tobacco, street drugs; list any prescribed medication with comments on effectiveness)? Spiritual health (is religion important? If so, in what way? What/who provides a sense of purpose?)? Intellectual health (cognitive functioning, hallucinations, delusions, concentration, interests, hobbies etc)? Risk assessment (self harm, suicidal ideation, history/treats of violence, environment/relationship abuse)? Summary/Formulation of difficulties (to include nursing diagnosis where possible? Action plan (outcome of assessment, who else involved or to be contacted, follow up appointment etc)

SummaryAssessment is a fundamental skill for all mental health nurses. Mental health nurses working in the community are often the initial point of contact for users of mental health services. As value judgements are inherent in the process of assessment they should be as structured and unbiased as possible (Barker, 1985; Barneff, 1992). This article proposes one example of a holistic format providing the basis of a nursing assessment that can be applied to all clients who come into contact with mental health services. Whatever method chosen, it is important for community mental health and/or CPN teams to provide a standardised approach to assessment and documentation for the benfit of service users and purchasers.

ReferencesAltschul A (1997) A Personal View of Psychiatric Nursing in Tilley S (ed) The Mental Health Nurse; Views of Practice and Education Blackwell Science OxfordBarker P (1985) Patient Assessment in Psychiatric Nursing Croom Helm LondonBarneff N (1992) Assessing the Client’s problem: A cognitive-bahvioural approach Community Psychiatric Nursing Journal April 11-15Blowers E J & Munton R A (1998) Risk Assessment and Community Psychiatric nursing: An Introduction The CPNA Members Handbook CPNA Publications College Hill PressBeck C K, Rawlins R O & Williams S R (eds) (1988) Mental Health Psychiatric Nursing: A Holistic Life Cycle Apporach C V Mosby St. Louis