This assignment is a client-focused study based on the four stage nursing process- assessment, planning, implementation and evaluation.
Introduction
This assignment is a client-focused study based on the four stage nursing process- assessment, planning, implementation and evaluation. After a brief introduction to the client and clinical setting I shall provide evidence of a comprehensive mental health assessment, discussing both the formal and informal techniques employed. Through this assessment and in collaboration with the client a specific need was identified and highlighted for intervention. After justifying my choice of intervention, based on the current evidence available, I shall move on to the application of the intervention itself, paying particular emphasis to the skills needed by the nurse for an effective working. The principle area covered by this assignment is the use and efficacy of Cognitive Behavioural Therapy (CBT) when applied to the positive symptoms of psychosis. In particular I shall be concentrating on coping strategies aimed at reducing the negative impact that some of the clients auditory hallucinations created. Finally I shall evaluate the intervention discussing whether it was efficacious or not. Throughout the assignment I have placed particular emphasis on collaborative working with the client, and have as far as possible attempted to respect and incorporate their views and opinions. Confidentiality has been maintained at all times in deference to the NMC Code of Professional Conduct (2002).
The Client
The client is a forty-two year old male with a diagnosis of schizophrenia. Schizophrenia is a condition characterised by both positive and negative symptoms. Positive symptoms include delusions, hallucinations, disorganised speech/thought, and grossly disorganised behaviour. Negative symptoms include affective flattening, alogia and avolition (Fortinash & Holoday Worret 2003). The DSM IV Diagnostic criteria for Schizophrenia states that two (or more) of the above must be present for a 'significant period of time' during a one month period for a diagnosis to be made. The client under study experiences auditory hallucinations, hearing both benevolent and malevolent voices at differing times, and possesses little insight into the nature of his condition, 'I'm not ill it's just chemicals in my brain'. As a consequence his compliance with taking his medication is poor. His current admission is due to an increase in symptomology caused principally by a reduction in the effectiveness of his prescribed medication. As a result he has been started on a regime of the anti-psychotic drug Clozapine. The client has been known to local services for around six years when he was forced to leave his job due to the increasing severity of his illness. Apart from an initial assessment on admission the client had recently undergone a KGVM assessment by the Psychology department, and was awaiting the results.
The Environment
The ward on which the client is based is a twenty-one bedded all male acute psychiatric unit converted some years previously from its initial function as a ward for the elderly. It consists of three dormitories- two six bedded and one seven, and two single bedded side-rooms, primarily used by clients who are deemed most unwell. The dormitories and side-rooms occupy three sides of a wide communal area which also doubles as the dining room. A television room and smoking lounge complete the picture along with a small 'quiet' room for therapeutic usage. Along with the physical environment it is also important to understand the milieu or social surroundings that impact on staff and clients alike. The unit in question has a full complement of staff of varying degrees of experience from 'D' to 'H' grades. The clients themselves also have a mix of illnesses, bi-polar disorder, depression, personality disorder and schizophrenia. The atmosphere is generally pleasant and clients are allowed the freedom to express themselves openly within certain boundaries concerning safety, both their own and that of others. I shall discuss the environment and its possible impact on therapy more fully in the section on evaluation.
Assessment
During this section of the assignment I shall be addressing the following: - What is assessment and what is its purpose? How do we assess and what tools do we use? I shall then provide evidence of a comprehensive mental health assessment of a client in practice before prioritising and highlighting a specific need and giving my rationale for this. Due to constrictions of space I have not gone too deeply into the evidence base behind the formal assessment tools used in practice. I am however fully aware of the importance of a tool being valid and reliable in order for it to be of any real use. The client had already undergone a complete bio/psycho/social assessment on admission and his physical health in particular was being closely monitored due to the possible unpleasant side-effects of Clozapine i.e. a destruction of white blood cells resulting in possible death. As a matter of Trust policy all clients on the unit undergo a weekly 'risk assessment review' along with continuing informal daily assessment and as such I have concentrated almost exclusively in this section on the psychological and social aspects affecting the client's condition.
What then, is assessment? Mosby's Nurse's Pocket Dictionary defines it as '1. An appraisal or judgement made about a particular situation or circumstances. A stage of the nursing process involving the collection of information and data relating to patients and their healthcare needs. 2. A test of measurement or competence' (Mosby 2002,p.31). Thompson and Mathias (2000) confirm this definition and add that assessment must not be seen as just the initial stage of a process but should be an ongoing and integral part of its entirety. Fortinash and Holoday Worret (2003) see assessment as the means by which the nurse gathers the relevant information from a myriad of sources. The most important source of all being the client themselves (Wilson & Kneisl, 1996).
Why though, do we assess? The purpose of assessment is manifold but is essentially undertaken to identify risk and highlight general problem areas in order to provide a platform for possible future intervention (Hinchliff et al, 1998). Assessment should be comprehensive and cover the biological, psychological and social spheres of an individual's life. Apart from identifying negative areas such as problem and risk, a good assessment should also highlight a clients strengths and motivation. This knowledge is of particular importance when applying cognitive and behavioural interventions (Thompson & Mathias, 2000). The therapist can utilise the client's strengths to ...
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Why though, do we assess? The purpose of assessment is manifold but is essentially undertaken to identify risk and highlight general problem areas in order to provide a platform for possible future intervention (Hinchliff et al, 1998). Assessment should be comprehensive and cover the biological, psychological and social spheres of an individual's life. Apart from identifying negative areas such as problem and risk, a good assessment should also highlight a clients strengths and motivation. This knowledge is of particular importance when applying cognitive and behavioural interventions (Thompson & Mathias, 2000). The therapist can utilise the client's strengths to motivate them and increase their self-worth. Ultimately, assessment allows us to determine appropriate intervention strategies to meet the client's needs and provide a baseline against which future assessment may be gauged (Wilson & Kneisl, 1996). Perhaps a more cynical but nevertheless very real reason for assessing clients is that the nurse is obligated to. Mental Health Trusts unquestionably view assessment as a legal requirement, and at all costs wish to avoid any litigation. The government through the NHS have also emphasised the importance of assessment in Mental Health services. Consequently, assessment forms an integral part of Standards four and five of the National Service Framework: Mental Health (1999), that deals with people with severe mental illness.
How then do we assess? There are a number of ways in which the nurse may assess the client. Formal assessment tools are widely used and can range from a Trusts and wide in scope admission form to more specific and highly detailed tools which may only cover a particular symptom or aspect of a clients illness e.g. PSYRATS - Psychotic Rating Symptom Scale (Haddock et al 1999), which focuses on the delusions and hallucinations of people experiencing psychosis. Why use these standardised assessment tools? Apart from the more general reasons for assessment outlined above standardised tools provide additional aid to those connected with the process. Thompson and Mathias (2000) state that assessment tools may be used for a variety of reasons and it is important for both the nurse and client to be aware of there usage in order to make the process effective. Apart from clinical audit and quality monitoring the tools can also be useful in the collection of research data and as a focal point for therapeutic interaction, providing the client and members of the MDT with a base reference useful to both (Thompson & Mathias 2000). Assessment tools provide a structure for both questioning/interviews for the nurse and the client. This can often be helpful where difficult or awkward questions may be embarrassing for either the client or nurse e.g. questions around the issue of sexuality. Also the fact that the questions are written down gives the client some indication that this is standard procedure and not something personalised (Fortinash & Holoday Worret 2003). On an equally practicable level standardised tools also assist the nurse by acting as a reminder to ask all the relevant questions, some of which, if there are many, they might otherwise forget. The omission of an important question at this stage of a clients care could have serious ramifications further down the line when an intervention package is being formulated (Wilson & Kneisl 1996).
Formal interviews are another useful method of assessment. This type of interview usually takes place when the client is first admitted to the unit and is comprehensively broad in scope. Hinchliff et al (1998) claims that the inherent flexibility of this type of assessment is more meaningful and useful to both the client and nurse than is often the case with standardised tools. Through the therapeutic use of self and interpersonal techniques the nurse may be able to encourage the client to discuss areas that a more formal tool might miss.
An equally important area of assessment is the constant day-to-day, minute-by-minute assessment that takes place on an informal basis. This includes such things as simply observing the client, their posture, gait, speech etc, but always in an unobtrusive manner so as to respect the client's privacy.
Assessment in practice
During this section I have concentrated almost exclusively on my own role in the assessment process, and as a result have made scant reference to standardised assessment tools. As a student nurse I was not in a position to implement either the KGVM or the PSYRATS scale, as both of these require a high degree of skill and training to implement and interpret effectively. I was however able to discuss the results with the psychologist who performed them and, in conjunction with my mentor it was agreed that I should conduct my own 'semi-formal' assessment of the client.
Having met the client previously basic introductions were unnecessary so I began by explaining what exactly the session would entail. I placed particular emphasis on the opinions of the client and stressed that it was not an interrogation but an opportunity for him to put his own views forward concerning his experiences. Using core nursing skills (discussed at length in the intervention section of the assignment) and in collaboration with the client I was able to accrue information relating to his current psycho-social status. The client lived on the seventeenth story of a tower block in an area fraught with crime and drug taking. Neighbours were often verbally abusive towards him, and he not surprisingly became frightened by this. It has been noted that the client experienced both malevolent and benevolent voices and it was the latter that the client was particularly concerned about in this situation. He was concerned that his 'new' medication would remove these 'helpful' voices and leave him terrified and at the mercy of his abusers. The 'good' voices he claimed calmed and reassured him, and he didn't want them taken away. Another major concern to emerge involved the clients malevolent voices and the effect the were having on his daily functioning. The client often had to make regular bus journeys but found on these occasions that the voices increased in intensity. He therefore became agitated and argued with the voices, the volume increasing until he found himself shouting loudly. This in turn made him angry and drew much unwelcome attention from other passengers. He stated that 'I feel irritable. I hear voices from afar. I feel aggressive but don't know why'. All this he claimed was affecting and lowering his self-confidence and self-esteem.
These then were the two main areas highlighted by the assessment process, but which was to take priority? In conjunction with the client it was decided that the malevolent voices were the cause of most immediate concern. The client felt that could he gain some control over them he would be able to live 'a more fulfilling life.' Although he stressed that he would not like to lose his benevolent voices he would rather sacrifice them if it meant controlling or ridding himself of the more unpleasant ones. The goal of the assessment therefore was to enhance the clients coping strategies in the hope of reducing the negative effects the malevolent voices were having upon him.
Intervention
Having now identified the area of prime concern to the client I shall endeavour to justify and explain the application of the selected intervention. Following discussions based around the evidence provided by the assessment procedure it was decided collaboratively by the MDT that the client could possibly benefit from a course of Cognitive Behavioural Therapy (CBT) to run in conjunction with his use of anti-psychotic medication. During this section I shall therefore initially look at what CBT is, followed by a review of the evidence concerning its effectiveness when applied to psychosis. Finally I shall discuss the necessary skills for the successful application of the intervention and attempt to link it to my own approach with the client. As with the assessment tools used previously my student status and lack of specialised training in the area of CBT meant that I could not actively engage in the therapy itself. It was therefore decided in collaboration with the psychologist and my mentor that I spend time with the client to a) reaffirm and reflect with the client on his CBT sessions and b) attempt to explain any problems the client may have, and encourage him in the upkeep of his coping strategies.
What then is CBT? CBT is not a single therapy in itself, but is an umbrella term for a variety of interventions (Cormac et al 2004). Each of these interventions aim to reduce dysfunctional emotions and behaviour by altering behaviour and by altering thinking patterns, based on the assumption that prior learning is currently having adverse consequences. The purpose of therapy is to reduce this distress or unwanted behaviour by undoing this learning or by providing new more adaptive learning (Thompson & Mathias 2000). CBT therapists believe that a change in symptoms follows a change in thinking (or cognitive change) which is brought about by a variety of possible interventions, including the practice of new behaviours, analysis of faulty thinking patterns and the teaching of more adaptive self-talk (NACBT 2004).
Much of contemporary CBT is based on the work of two men- Albert Ellis' Rational Emotive Therapy (RET) and Aaron Becks Cognitive Restructuring Therapy. Ellis (1962) argues that many emotional difficulties are due to the irrational beliefs people bring to bear on their experiences and the reinforcement these receive through being repeated. For Ellis (1991), irrational beliefs can be understood as part of the A-B-C model. According to this a significant activating event (A) is followed by a highly charged emotional consequence (C). However to say that A is the cause of C is not always correct, even though it may seem to be as far as a person is concerned. Rather, Ellis sees C occurring because of a persons belief system (B). Inappropriate emotions therefore can only be abolished if a change occurs in beliefs and perceptions. Like Ellis' RET, Beck's therapy also assumes that disorders stem primarily from irrational beliefs that cause people to behave in maladaptive ways (Beck et al 1979).
Having now looked briefly at what CBT is I shall attempt to justify its use with psychotic clients. It has only been in the last decade that the cognitive behavioural approach has been considered to be potentially useful in psychosis (Martindale et al 2000). Most studies into the efficacy of CBT and psychosis acknowledge that the therapy should be an adjunct to the first line treatment- neuroleptic medication (Drury 1996, Grech 2002, Cormac et al 2004). In cases where drugs are ineffective (25% - 50% of clients will still experience persisting and distressing symptoms (Grech 2002)) or non-compliance high CBT may still be effective even if used in isolation. Even with drug compliant clients follow up studies suggest that 40% - 60% would relapse following discharge over the first two years, and that many others would continue to experience hallucinations and delusions even at a reduced or residual level (Barrowclough & Tarrier 1997). In relation to psychosis CBT works on the assumption that illnesses such as schizophrenia are not just caused by chemical imbalances in the brain but are often the result of excessive stress. Zubin and Spring (1977) developed their Stress Vulnerability Model based on this assumption. They claimed that people with schizophrenia are liable to a relapse of their illness when exposed to increasing levels of stress in their daily lives. Acute symptoms therefore develop as the client's coping strategies fail, and perceived stress increases (Baguley & Baguley 1999). CBT aims to correct these imbalances in the client's perception. Originally psychosis was not thought to respond to CBT but evidence now shows that even previously unresponsive and medication-resistant psychotic symptoms can be modified (Grech 2002).
In this next section I have attempted to describe the skills necessary for an effective working of CBT with reference to my own therapeutic engagements with the client. I shall not be discussing the more detailed aspects of CBT such as Core Beliefs, Intermediate Beliefs or Automatic Thoughts or how the therapist identifies them. Instead in order to follow the assignment guidelines more closely I have concentrated on my own skills whilst developing a therapeutic relationship with the client, although most often these, and the skills required in CBT are one and the same.
It was arranged that I spend two half-hourly sessions each week with the client on a semi-structured basis. Initially boundaries were set, including duration of sessions, acceptable behaviour, language and so on. The setting of boundaries is important as they clearly define the nature of the relationship and aid in the development of trust between nurse and client (Fortinash & Holoday Worret 2003). Also from the outset I emphasised the importance of collaboration to the client, that our relationship was to be a two-way process. I made it clear that I was not there to tell the client what to do, but to merely provide options to enable him to empower himself and take responsibility for his own actions. This was important as Thompson and Mathias (2000) state, for CBT to be effective it must be a collaborative process.
Each of our sessions took the following form: - Firstly the agenda was set out, followed by a resume of our previous meeting. Next we identified any problems the client may have and prioritised them. Finally we suggested possible solutions and alternatives. Throughout this time with the client I attempted to adopt and utilise the core features of Carl Rogers' Client-Centred Therapy. There are three major elements in the 'therapeutic atmosphere' which Rogers believed would encourage personal growth in his clients - genuineness, unconditional positive regard and empathy (Rogers 1951, 1986). Genuineness (or congruence) refers to real human relationships in which the therapists honestly express their own feelings. Rogers (1951) believed it would be harmful to the client if the therapist manufactured a fake concern or hid his own beliefs. This would stifle the client's personal growth. Unconditional positive regard essentially means respecting clients as human beings with values and goals, and accepting people for what they are. Rogers (1951) states that a persons worth should not be judged by their behaviour and that therapists should attempt to respect the client and show them that positive regard is not dependent on what the client says or does. Empathy is the process of perceiving the world from the client's perspective and understanding what they are experiencing (Fortinash & Holoday Worret 2003). In addition to Rogers' ideal skills I also attempted to employ a number of core nursing skills in my relationship with the client e.g. communication skills such as restating to demonstrate understanding and listening; focusing - concentrating on a particular point the client has made and exploring it further, and the use of silence - appropriate pauses in conversation to allow both the client and myself to reflect and gather our thoughts. Perhaps an important skill that I overlooked at the time, but undoubtedly used was my ability to draw on my learned knowledge and experience. By being more confident within myself I realise that the client was more at ease than would have been the case had I attempted the intervention earlier in my training.
Before going on to the evaluation stage of the nursing process I will give brief mention to the intervention proposed by the psychologist enacting the CBT sessions with the client. As already highlighted in the assessment section the clients main concern were his malevolent voices that resulted in his discomfiture in public when arguing with them. A series of coping strategies were discussed which the client applied with varying degrees of success. Firstly he was advised to lower the tone of his own voice when addressing his voices to see if they in turn would respond in a like manner. Secondly to use the simple device of a mobile phone when speaking to his voices in public. My task had been to encourage and discuss the use of these techniques in a general ongoing assessment role. So, were these coping strategies successful and how would I evaluate my own role in the process?
Evaluation
The final stage of the nursing process is evaluation. The nurse compares the current status of the client's health with the expected outcome criteria (Wilson & Kneisl 1996). In regards to the client under study this would translate as, does he now have a greater feeling of self-confidence and self-esteem due to the interventions proposed? Does he have more control over his malevolent voices? The first stage of the evaluation involved the client being reassessed with the PSYRATS auditory hallucination scale (Haddock et al 1999). The three most important areas that the scale addresses are frequency of voices, loudness and clarity. Once again I was unable to participate in the actual assessment but was later informed by the psychologist that the clients 'score' had much improved particularly regarding loudness and frequency of voices. According to the formal assessment tool there appeared to be a significant improvement in the client's condition. From my own purely subjective point of view I also noticed a considerable change in both the client's attitude to the intervention (which he was at first unconvinced would work), and in his overall 'cheeriness' which seemed to increase as the sessions moved on and the application of his coping strategies progressed. However, I could not help but wonder if this change had been as much due to his new medication regime taking effect as it had been to his cognitive therapy.
Undoubtedly though the most reliable evaluation 'tool' is the opinion of the client themselves. No amount of subjective or objective evaluation by others can truly tell us how the client really feels. In this instance the client claimed to have noticed a marked improvement and stated that he felt much more confident now in public, 'I don't feel everyone is staring at me anymore, but I'm afraid someone might steal my phone.'
How though would I evaluate my own role in the proceedings and was it of any real use to the client? The client claimed to find our sessions helpful from a reinforcement point of view i.e. it did help him focus on the real therapy he was receiving elsewhere, whereas I felt although it was a useful learning experience my presence was merely tokenistic. I have however come to the important realisation that training is a key aspect of effective therapy. Bradshaw et al (2003) claims that psycho-social interventions such as CBT are implemented very rarely in clinical settings for this very reason i.e. a 'lack of appropriately trained clinicians.'
Conclusion
During this assignment I have been following the nursing process with a client with schizophrenia. I chose as my intervention aspects of CBT and have attempted to provide evidence of its efficacy. I soon began to realise what a vast and growing area this topic covers and have therefore been somewhat selective with the material. Although I recognise the importance of intervention in the early onset of psychosis and the apparent effect that high expressed emotion can have on people experiencing psychosis I chose not to include them due to restrictions of space and their inapplicability to my chosen client. Ultimately I believe that any intervention (or assessment) can only be as good as the individual applying it. No matter how comprehensive a tool may be it is still ultimately reliant on effective interpretation, which is essential for equally effective application. If clinicians are therefore not adequately trained in their usage and are stumbling along only 'one-page' ahead of the client then very little benefit can possibly be gained, and indeed more harm may be done than good.
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