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Analysing the role of assessment in planning nursing care for a client that requires mental health interventions.

Using the given scenario discuss the importance of assessment highlighting the key contextual elements and process of mental health assessment that ensure a quality, holistic and individualised approach to care.

Provide a rationale for the prioritisation of care highlighting the key factors that ensure holistic provision.

Using relevant literature, critically analyse the role of the nurse in the assessment process, making relevant links to practice in understanding the needs of the person and their family. 

Critically reflect upon your analysis and discuss how it may be used to enhance the assessment process. 

Scenario:

Tom is a 64-year-old who retired from BT 2 years ago.  He was an engineer who worked exclusively on repairing and maintaining telegraph poles in Northumberland.  He is married to Liz and they recently celebrated their Ruby wedding anniversary.  They have no children.

Tom has been referred to you following an assessment from the Crisis Intervention Service.  He had recently taken an overdose of citalopram which had been prescribed by his GP.  His PHQ9 score was 19 and his GAD score was 14.

He states he was overwhelmed by recent events, retirement, the death of his work colleague, and recent issues with his right knee which has made working as a part time delivery man for a supermarket more difficult.

He describes himself as a proud man, particularly of his working-class roots, and is somewhat traditional in his views believing he needs to be strong and the man’s role is to be the provider through hard work.  He is ex-army and is passionate about the need to adapt, overcome and survive, you don’t give in you get on.

He has been referred to you as the Crisis Team believe his mental health issues can be managed at home.  Tom states he has no intention of killing himself and is embarrassed by having previously given into those thoughts and letting everyone down.

Rationale for the Prioritization of mental Care and Factors that Ensure Holistic Provision

Mental health assessment is the process that involves gathering information about an individual who is suspected to be mentally ill or who shows symptoms associated with psychological sickness with the purpose of diagnosis, reference and care provision. (Ungar 2012, p. 14). Usually, this is the initial stage of the diagnosis. According to Becker and Kleinman (2013, p. 68), the intention of doing an assessment is to create a picture with the precision of the patient's needs. In ensuring that assessment is done with success, five interconnected nurse’s themes are considered. The themes include; patient focus which entails giving services based on the patient’s need, information focus that puts emphasis on how information about the patient is used, improvement of quality that sees how standards are met and attained, staff development which focuses on the improvement of the staff and its coordination in meeting patient needs and lastly leadership which focuses on how the improvement efforts are organized (Cunningham and Kitson 2000, p. 36). Further, Francis (2013) suggests that the five key themes are closely interconnected in forming a framework that seeks to improve the quality of health care provision. Also, in performing the assessment, the patients might encounter multi-disciplinary personnel in a mental health facility. Hence, a nurse, social worker, psychologist, psychiatrist, specialist pharmacist and other professional or a combination of all these in some circumstances may conduct the assessment.

Since ensuring the condition of the mentally ill patient improves is always the priority, the information gathered should be exclusively correct to guarantee an accurate diagnosis. In getting right and helpful information, Elder, Evans and Nizette (2008) points that using Neuman’s Systems Model in assessment will provide desirable results. This is so because the model focuses in the provision of a holistic and system-based approach to nursing that has an element of flexibility. In addition, considering Tom’s case, Neuman’s system model is most appropriate since its major concept is content which focuses on an individual’s interaction with the environment (Neuman and Fawcett 2002). Further, the model’s primary intervention is prevention which focuses in suppressing stress responses from affecting the patent. This will be fundamental in improving Tom’s case since one of his concerns is his injured foot and loss of colleague hence leading to stress. Also, (Crisp et al 2000, p. 4) suggests an inclusive guideline and points to consider. The points include; psychiatric well-being symptoms and experiences, patients thoughts, emotions and actions, financial state of the patient, family and social relations, gender and sexuality, whether there is anyone who depends on the patient, past experiences and hopes and future aspirations. From the scenario at hand, Tom's situation can well be assessed by considering points like his experience having in mind him serving in the military and the death of his colleague, his wife Liz depending on him and in his state he is physically inactive and lastly his hopes and future aspirations.

In addition to having the right information, holistic care provision is imperative. Grundberg (2014, p. 189) suggests that holistic care is an all-encompassing design of caring that is believed to be the focal point of the science of nursing. The foundation of holistic care is holism which stresses view that whole is superior to the sum of parts in human beings (Zamanzadeh 2015, p. 189). In this manner, it recognizes an individual's wholeness and avows one's relationship of biological, social, psychological and spiritual aspects. Further, holistic care incorporates medication, communication, awareness or education, self-help and treatment in line with factoring in all aspects of patients conditions that influence treatment. The patient element may include; thoughts, emotions, cultures, opinions, and attitudes which are the contributing factors to Tom’s current condition which if factored in will act as a contributing factor to recovery and satisfaction hence ensuring respect for Tom’s dignity satisfying the objective of holistic care (Voigt and Laing 2013, pp. 38-43).

Available Data on Psychological Ailment in the UK

The holistic provision will ensure that a right rapport between the nurse and Tom is created giving room for respect, openness and his participation in decision making (McDevitt and Melby 2015, p. 532) hence help in increasing the scope of health care providers' understanding of Tom and meeting his needs. Several factors ensure holistic provision as documented by Valizadeh et al. (2015, p. 25). Among them is educating patients in this case Tom on personal care and assisting him in performing his daily tasks exclusive of others help. In regard to this, Tom’s' self-confidence, self-awareness, an accord between cognitive, body, emotions and spirit in a dynamic environment will increase. The holistic provision also will improve health care providers since it betters their understanding on the effects of Tom’s illness, how it affects his life and how to meet his needs (Morgan and Yoder 2012, p. 10). With consideration of holistic care inclusivity in health care provision, the British Holistic Medical Association has put its support behind the belief that holistic nursing is inclusive of all nursing activities that heals a person wholly (Pietroni 1990, p. 1)

Available data on psychological ailment in the UK  shows that one out of four people will experience mental health problems in the United Kingdom in any given year the leading being North East England where Tom is based registering 71% of people who have been reported suffering from a mental health problem (Tomlinson 2011, p. 42). Further, Gray (2016, p. 74) reveals that in 2012, 21 British soldiers together with 29 veterans committed suicide after being diagnosed with post-traumatic stress disorder (PTSD). Linking the statistics and Tom’s former job, more light is shed on his suicidal intents. Additionally, an estimated world cost of 1.6 trillion Euros is used yearly for mental diseases. This value is higher than that of cancer, diabetes, cardiovascular diseases respiratory diseases. In the UK the cost stands between 70 and 100 billion yearly accounting for 4.5% of GDP (Fundamental Facts About Mental Health 2015). Considering the overwhelming data on mental health problems, the introduction and coming up with crisis teams such as Crisis Intervention Services is essential in lessening the burden on the mental health hospitals and facilities which solely have borne the burden of admitting and caring for psychiatric ill patients hence ensuring giving health care for mentally ill is a priority. Globally, there is a limitation of mental health facilities; therefore, providing the best care for overwhelming numbers coming in daily poses a challenge to health care providers. Thus, crisis teams in conjunction with hospitals have taken a broad stride in providing care and treatment for those living with mental health problems (Crisis Intervention Service n.d).

As earlier mentioned, assessment is crucial in giving the correct diagnosis and care for mental health patients. To ensure this is a success, nurses play a major role in the process. Since assessment will involve sourcing information from the patient and the family in the history of the patient (Crisp et al 2000, p. 7), communication is vital. According to Pazargadi et al. (2015, p. 551) communication is an important aspect of all nursing practices and actions for example prevention, treatment, therapy, education, rehabilitation and health promotion just to mention a few. Nursing practice requires not only scientific knowledge in meeting the needs of the patients but also technical abilities and interpersonal skills. This means having the knowledge, clinical work skills and interpersonal communication makes a complete nurse who can meet patient's medical, emotional and spiritual needs (Kourkouta and Papathanasiou 2014, p. 65). Additionally, the implementation of nursing is attained through conversation, interpersonal surrounding and explicit skills expressed verbally hence insinuating the fact that communication is not only from Tom to the nurse and vice versa in the scenario but a composition of all nursing activities in meeting his needs and improving the nurse relation with him (Bello 2017).

Through communication, Tom will express his fears and concerns to the nurse who in turn makes a correct medical diagnosis. Further, the physician takes the data and channels it to Tom and Liz accordingly with secrecy and respect as to the nature of Tom’s condition and gives advice on treatment and care with the aim of promoting health (Abbaszadeh and Ehsani 2014, n.d). In respect to Tom's case, the nurse will better understand what leads to his suicidal action through communication. Verbal interaction will also help in the rehabilitation of Tom since the nurse understands the situation as supported by Henderson, Barker, and Mak (2016, p. 75) who indicates that ‘effective communication asks for an understanding of the patient and the experiences they depict.' For success in assessment and all nursing practices, communication remains to be crucial (Wikström and Svidén 2011, p. 7) hence a significant role of the nurse in the evaluation.

Another nurse’s role during mental health assessment is the assessment of physical illness. The research is done shows that physical disease occurs in over 45% of psychologically ill patients and in most cases it goes undetected (Pietroni 1990, p. 1) resulting in lowered quality life, decreased levels of body functioning and eventually, untimely death (Webb et al. 2012, p. 261). To add to the already mentioned research fact, it is observed that people with serious mental ailment die earlier than the general populace due to side effects from medication, poor health practices, limited preventive and medical care (Hartz et al. 2014, p. 254). Albeit psychologist and nurses handling mentally ill patients are not trained to do assessment in the physical state of the patient, they are encourage to give holistic approach to the psychological problem which will involve assessing the patient's physical illness which is usually as a result of mental illness (Wu et al 2013, p. 600). Also, nurses' competence is viewed from a wide range of practices attentiveness to the physical signs of sickness being one of them including other actions like monitoring side effects of medication and making clinical referrals (Thomas n.d, p. 146). To ensure the physical status of mental patients is taken into consideration, nurses dealing with mental health should be trained on physical health areas or specialists in the area should be factored in during assessment.

From the scenario in Tom's case, it's clear that the crisis team has done the commendable job in assessing the physical state of Tom as seen from there report. This is unlikely in some mental health care providers as suggested in (Assessment of Physical Illness by Mental Health Clinicians During Intake Visits, n.d.) that physical illness assessment is usually a common occurrence for psychological health providers but lacks in a third of the cases in research done. For effective care on Tom, physical illness should be monitored continually to ensure inclusivity in his treatment and his wellbeing. It's also easy to note that his physical condition is among the factors that are overwhelming to him leading to his mental state.   

Linking the patient and the family together with counseling the family is another role that the nurse needs to undertake in the mental health assessment. The report in Tom's case registering the Patient Health Questionnaire-9 (PHQ-9) of 19 and a Generalized Anxiety Disorder (GAD) of 14 shows a severity in depression and anxiety which needs active treatment with psychotherapy and medication (Manea, Gilbody and McMillan 2012, p. 195). The findings and the steps that might be taken should be communicated to Liz. Since Liz might also be required to take care of Tom, counseling on how to cope with the situation is imperative. Although this is done best by specialist counselors, nurses have a role to play since they are in close contact with the patient. According to Lilly, Robinson, Holtzman and Bottorff (2012, p. 110) families which give care to mentally ill patients express a varied range of both positive and negative emotions in their role of providing care to their loved ones or rather family members for example concern, confusion, grief, frustrations, resentment and anger, accompanied with caring, compassion, sympathy and love.

The study also shows that many mental health caregivers experience financial strains related to the caring for the family members who are mentally ill. Facts from the research coupled with the family information of Tom such as, him being the family breadwinner and lacking children who may be available for help will change Liz's way of life. Therefore the nurse should prepare her psychologically and advice her accordingly on the way to go about different situations in ensuring interventions of Tom's mental illness is correctly applied. Albeit most a time giving care to mentally ill patients is done by professionals in mental health facilities hence limited contact with the family, their state of mind may be affected by the condition of their relative thus counseling should not be neglected.

Lastly, diagnosis and treatment of the mentally ill is another vital role of the nurse in collaboration with other mental health care providers such as psychiatrist. Since mental health problems are the leading cause of disability and disease burden in the world (World Health Organization 2014), early and precise discovery of the ailment, accompanied by appropriate intervention and care will prove helpful in the reduction of the burden caused by mental illnesses on social and healthcare facilities. Huge steps have been made in bettering the working environment of the health care providers which directly also improves on the diagnosis and treatment of the mentally ill. The Global Mentally Assessment Tool- Primary Version (GMHAT/PV) is one of the crucial developments in helping health caregivers in making quick and conclusive mental health assessment. Further, it has been prompt in task performance hence valid and reliable (Hilty 2013, p. 454). This is followed by quick treatment since the assessment is standard and comprehensive leading to curbing the mental disorders whose statistics are alarming due to escalations associated with it. In relation to Tom's case, the severity of depression and anxiety as shown in the (PHQ-9) and (GAD) (Manea, Gilbody and McMillan 2012, p. 195) together with citalopram side-effects should be countered through the application of correct medication to improve his condition.

Having indicated earlier that mental disorder is responsible for the largest disease burden in the world (World Health Organization 2014), it appears to me impressive steps have been taken in the curbing of the malady. Firstly is the development of the Global Mental Health Assessment Tool- Primary Care Version. I think it has ensured there is quick mental health assessment hence reliable and valid tool in use by the general practitioner (Jenkins et al 1998). The general practitioners and other primary care providers are expected to detect and assess the mental well being of their patients and manage the disorder accordingly (Dixon-Woods 2013). I also believe this has been made easier by the advanced technological developments in the assessment and treatment of the mental ailments. I have observed too that together with the computerized systems in mental health assessment, the department of health in the UK introduced new workers in the line of mental health to help already available workers in providing help to the increasing number of individual with mental health problems (Department of Health 2002) which is an additional welcoming move in ensuring there is a success in assessing and treatment of the psychological cases.

In enhancing the assessment and treatment of mental health cases, I have noted that effectiveness must be availed to all in need. According to World Health Organization (2017), effective treatment is available for several common mental health problems, but according to my view, few individuals suffering this disorder access the procedures. I have further observed that there are increased cases of mental health problems associated with those serving in the military (Gray 2016, p. 74) and due to the attitude developed in the service, most soldiers and ex-soldiers fail to admit their need of psychiatric help. Thus, I concur with the thought that most soldiers and ex-soldiers fail to access mental health care. However, in helping those who access mental health care, two integrated programs have been put in place. First is the integrated program which health care providers assess and treat patients holistically. This approach is patient-centered and usually more effective. The second integrated care program addresses the patient's mental health needs in a more general context which includes providing a specialized setting which offers care for people with severe psychiatric disorders (Community Preventive Services Task Force 2012). I agree that these two approaches have been a big step in improving the mental health assessment and general care provision.

In addition, I have read multiple studies by different researchers who have highlighted factors and steps to be taken in enhancing mental health assessment and as discussed earlier, the aspect of holistic care has proved useful where application has been done. According to Nouri (2013, p. 140) nurse lack freedom in conducting their tasks due to close supervision by doctors but I think through the application of holistic care,  the framework of the treatment process changes hence, provision of a free working environment.  Unfortunately, most mental health specialists and health care providers do not apply holistic care in patient assessment, therapy and rehabilitation (Jasemi 2017, p. 71). Furthermore, I agree with suggestions documented that mental health care providers don't have the holistic care knowhow hence neglecting the style of caring and only consider the patient's physical needs. Thus spiritual, cognitive and social needs of the patient which makes them whole are ignored (McKie and Naysmith 2014, p. 135).  I would prefer the use of holistic model together with other common models in seeking to improve mental health assessment to the use of typical models without supplement since it exposes the patient to more severe threats, increases the period in hospital hence elevating treatment costs (Navarro 2014).

Conclusion:

Mental health has become a concern in the environment that is ever changing and posing a challenge to the ones directly affected; the patients and those who are indirectly affected; the families, the community and the government which helps in their care. Commendable steps have been taken in preventing and reducing the ever-increasing sufferers as a result of mental disorders, but in some instances, the threshold is far off from being met by some specialists and nurses who provide psychiatric health care. Vital skills like communication and holistic care which have proved to be useful in mental health assessment, diagnosis, and treatment which involve therapy and rehabilitation have not been embraced yet by many physicians. This has been the case due to lack of knowledge and information hence only the scientific part of the care is applied consequently leading to the experienced stagnation and deterioration in mental health cases. To improve the status quo, the physicians and respective stakeholders should step up and take on the challenge by creating awareness and training mental health providers to reduce the ever increasing negative statistics of the ailment.

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