The nurse’s role in assessment has evolved and become a key aspect of the multidisciplinary team’s findings when formulating a care plan. A nursing assessment can be defined as ‘collecting subjective and objective data’ (Weber and Kelley, 2014). This essay will focus on assessment tools used in an acute community mental health setting for a particular case study. The mental state examination (MSE), activities of daily living model and the biopsychosocial history are the aspects of assessment used with the aim to meet the patient’s physical, social and psychological needs. In mental health, assessment tools like the MSE are usually verbal interviews and rely on a therapeutic interview technique and rapport between nurse and patient while maintaining a clinical and professional environment (Trzepacz and Baker, 1993). Assessments are valuable when updated regularly because it allows baseline to observe change in the patient over time thus their care plan is adapted to the current situation and perceived risk. Formal assessments are used by nurses for example the Mental Health Act (Legislation.gov.uk, 1983) where patients can be detained and admitted for assessments. In contrast, aspects of the MSE are used informally in nursing reviews and can be linked to risk assessments in local NHS Trust policy surrounding suicide, supervision and environment.
Mary, who has been renamed to protect her confidentiality (NMC 2015), is a 52 year old woman with schizophrenia and psychosis in the form of auditory and visual hallucinations. She has been well known to the secondary mental health services since the age of 16 and has had frequent formal inpatient admissions. She was referred to the home treatment team (HTT) because she was struggling to cope with the voices she was hearing and had expressed suicidal and homicidal intentions. Mary received home visits from members of the HTT including nurses, doctors and health care assistants based on her level of risk and also had access to a out-of-hours crisis support. During this period of medical responsibility the team completed frequent regular assessments involving the aforementioned tools to address Mary’s physical, social and psychological needs.
The MSE allows succinct structure to a clinician’s observations into categories for clear communication and documentation. On one occasion Mary’s mental state was observed at home on a Sunday afternoon. Her appearance was unkempt, dressed in nightclothes and overweight. Her behaviour was restless with limited eye contact and she was experiencing akathisia in her right leg, a known side effect of quetiapine (BNF, 2018). Mary’s mood was anxious and low and the affect, flat. Her speech was hesitant and often inaudible. Her thought content was disordered and she was constantly experiencing auditory hallucinations, multiple voices from outside telling her to harm herself and others and being very degrading about her. She had extremely low self worth and felt hopeless. Mary had visual hallucinations of figures that she knew of in reality but had hidden faces. Mary disclosed she had consistent suicidal thoughts and often homicidal thoughts towards anyone and she felt a risk to others. Mary however did have insight into her voices and recognised she had relapsed and wouldn’t usually have these intentions but lacked judgement because she had acted upon these thoughts by making attempts on her own life and assaulting members of the public. In this instance the MSE is a useful tool of assessment in monitoring Mary’s thought content and suicide risk as the team attempt to manage her in the community. Unfortunately her situation did become unsafe and medical recommendation for a Mental Health Act assessment under Section 3 was requested. This is a formal assessment citing Mary was a perceived danger to herself and others and implemented to protect her psychological needs. Mary was deemed not detainable and to have capacity under the Mental Capacity Act (Legislation.gov.uk, 2005) and was initially refusing admission. However with family input Mary agreed to an informal admission because she recognised that she needed to protect her own psychological needs by being in a safer inpatient environment. This was not a failure of the team as they managed to treat her effectively in the community which what Mary wanted thus meeting her social needs. Mary was happier at home where her family were supporting her but in trying to meet her social needs, her psychological safety was being compromised. Thus there are critical limitations to using MSE as a form of assessment. It is tempting to draw incorrect conclusions if a clinician uses MSE without considering the presenting complaint and history drawing from the biopsychosocial model. There is no classification to a MSE as it the clinician’s role to take subjective and objective opinion to deliver appropriate care and make clinical decisions. However this leads to another issue of interpretive bias . It can be argued that the usefulness of MSE directly relates the the interviewer’s skill and experience in articulating their opinions. Their relationship with the patient and awareness of their cultural and social situation makes the MSE more reflective in terms of a holistic assessment. Even if the outcome if focussing on meeting a patient’s psychological needs, it still recognises their physical and social needs. Continuation of care was an issue a student nurse could easily recognise, as the rapport between different members of staff creates slight variations in the conclusions drawn from each MSE assessment because of interpretive differences. In mental health nursing especially, a therapeutic relationship between the nurse and patient is a result of increased self-awareness on both parts, a key factor in a holistic assessment (Mirhaghi et al., 2017).
Another assessment tool used was taking a history using the biopsychosocial model. Mary has a particularly complex psychological and social history. In the biological aspect Mary suffers with hypothyroidism and her symptoms include weight gain, tiredness and depression (nhs.uk, 2018). Levothyroxine is her lifelong medication for the long term management of the condition which is managed by her GP. Mary also suffered from social anxiety and emotional disturbances which has a possible physical cause of hypothyroidism (Schildkrout, 2011). She experienced difficulty in engaging with primary healthcare which is a common barrier for people with mental illness trying to access physical healthcare (Happell, Scott and Platania-Phung, 2012). This part of the assessment tool meant we could liaise with her GP to take over the dispensing the thyroid medication whilst Mary was an inpatient and also arrange a home visit from the GP. The team worked collaboratively to bridge the barrier Mary faced in receiving physical healthcare and therefore the assessment met her physical health needs and reduced health inequalities in this case (Hallett and Rees, 2017).
Assessing Mary’s social needs will be addressed in the biopsychosocial model by taking a social history. Mary had a large network of extended family living close by that she was in close contact with. However she admitted to limited self disclosure and said she wouldn’t talk to her family about her mood or hallucinations. Her family give Mary her medication and usually there is always someone else in Mary’s house for company and safety. Mary was keen to disclose a traumatic rape event she experienced at 16 years old which resulted in an abortion. Her social history appeared to suggest that that event was the cause of Mary’s depression and anxiety. In terms of her psychosocial development at that age, it was significantly distorted from intimacy to isolation and therefore it impacted on her future intimate relationships (Erikson, 1995). For example, Mary has struggled to maintain a romantic partner and she admits she doesn’t have close contact with her children. This aspect of a social history means that the assessment can meet Mary’s social needs. Her care plan was updated to reflect this and her care is delivered by females wherever possible and careful language is used around her known triggers. Mary can therefore move forward from the event and members of the team are all fully aware of her complex social history because it has been updated on her electronic file. Assessment tools like the biopsychosocial model and history are extremely comprehensive and take time to extract from the patient. It is efficient if the history is updated on a patient’s electronic file so the clinical is always informed without the patient feeling like they have to keep repeating their situation. This is especially necessary in Mary’s case because she has experienced psychological trauma which she doesn’t want to re-live at every new assessment.