Explore the assessment process and how it informs the assessment of a patient.
Introduction
The admission into hospital of a patient is routine for hospital staff, but forms a major event in people's lives. It is suggested often as being a source of anxiety and stress (Scrambler 2002). The aim of this essay is to explore the assessment process and how it informs the assessment of a patient. I aim to effectively assess a patient on my most recent clinical placement, using evidence-based practice. The ethical issue of consent needs consideration. I explaining to the patient the purpose of my assessment. That all the work would be confidential, and a pseudonym would be used in the essay to protect her identity, as stated in NMC (2002) section 5. By doing this I gained valid, informed consent NMC (2002) section 3.
I aim to discuss effective communication, by reviewing and reflecting on my interviewing techniques and interpersonal skills. I will introduce the patient and give a brief social, biological and personal history. From this assessment I will highlight one patient problem and discuss the biological, sociological and psychological perspective, which influences and informed the care given. During the assessment I used the Roper- Logan-Tierney model for nursing. I aim to discuss the advantages and disadvantages of using this nursing framework, and compare it to a more appropriate nursing model in relation to the individual patient problem.
Introduction of Patient
The patient I have chosen for the purpose of the assessment will be referred to as Janet.
Janet is an 84 years old independent widow admitted into hospital via GP referral. It was during Janet's admission that nursing assessment took place. Janet is an intelligent woman and very aware of her surroundings, she was happy to be involved in the assessment. She has two children both who live close to her and give her a great deal of social support. Janet is a retired personnel manager and worked full time until her retirement. She was admitted into hospital due to exacerbation of her chronic obstructive pulmonary disease. This is her first admission into hospital due to this disease. Janet was a smoker, she smoked 10 cigarettes a day for 40 years and gave up two years ago when she was first diagnosed. Janet has help at home from home care services, to perform tasks such as housework and general maintenance of the house and garden. Janet manages to cook for herself and attend to her own personal care. She is an affluent lady and lives alone in a four-bedroom house, and is use to her own personal space.
Process of assessment
The use of nursing models developed initially in the USA ''to provide a basis for nursing practice that went beyond following medical instructions'' (Walsh 1998). During the assessment process the Roper-Logan-Tierney model of nursing was used, in relation to the Gloucester Patient Profile, which was adapted from this model. There is little evidence written on the Gloucester Patient Profile, but it is being used as a derivative of Roper, Logan, and Tierney model for nursing.
The Roper model of nursing, which is based on Virginia Henderson's 'Human Needs' based on Maslow's analysis of Human motivation, emphasises the importance of considering factors such as age, culture, education and environment, as well as psychological and social factors. All of which influence health and an individuals potential for health (Hinchliff 1994). This model uses the nursing process as a system to deliver nursing care, and is based on the 12 activities of daily living. Maintaining a safe environment, Communication, breathing, eating and drinking, eliminating, personal cleansing and dressing, control of body temperature, mobilising, working and playing, expressing sexuality, sleeping, dying, (Roper, Logan and Tierney 1996).
The use of nursing model is a way to inform assessment by establishing the kind of information required (Aggleton and Chalmers 2000). It gives a guideline to the nursing assessment, by collecting baseline information, assessing patient needs, and helps to plan, implement and evaluate their care.therefore nursing models help us to underpin and direct the care of the individual, and provide an individualised holistic approach to nursing care.
Assessment should be done continuously throughout the hospital stay as this will help provide continuity and quality care. Aggleton and Chalmers (2000) discuss how individualized care should be given according to the patient's individual needs, such as culture, age and ethnic origin. This is also highlighted in the NMC (2002) in section 2 where it states ''as a registered nurse you must respect the patient as an individual''. Ogden (2000) and Brown (1996) discuss how assessment of patients will help the nurse identify the patient's own perception of their health and needs. I believe this can be achieved during the assessment by hearing the patient own story, gaining an insight to the person's life. This will help identify problems; needs and concerns of the patient (Hincliff 1994). I feel it will also give a clear picture to the nurse, of the patients understanding of what is happening to them and any psychosocial problems they may face. This knowledge can then help plan evidence based care with clear rationals, which are patient centred (Kagan and Evans1998). Balzer-Riley (2000) agree with this and believe communication is also fundamental to the assessment process (Communication will be discussed further on page 5). Enabling the patient to form a connection to someone, and build a relationship will enable effective communication throughout there hospital stay.
Janet had arrived on the ward one hour prior to her assessment, she was allowed time to settle in and familiarise herself with her surroundings. During this time her stress levels had become increased. Contributed by the sociological factor of having to share a room with a patient, which she felt was from a different social class and culture. Janet arrived at visiting time so had met the ladies son. She found him scruffy and unpleasant and explained to me that she thinks he is a drug dealer. Being in a hospital environment often throws people together of ...
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Janet had arrived on the ward one hour prior to her assessment, she was allowed time to settle in and familiarise herself with her surroundings. During this time her stress levels had become increased. Contributed by the sociological factor of having to share a room with a patient, which she felt was from a different social class and culture. Janet arrived at visiting time so had met the ladies son. She found him scruffy and unpleasant and explained to me that she thinks he is a drug dealer. Being in a hospital environment often throws people together of all cultures and social classes, some patients find it difficult to adjust (Scrambler 2002). This sociological aspect had influenced and informed the assessment. Ogden (2001) suggest that giving the patient information on their illness and surroundings will enable them to feel in control of the situation and reduce psychological stress. Lazarus and Folkman (1973) discuss the way in which, if patients can predict and control the situation then they can cope better.
The assessment process helps identify psychological perspectives that influence the assessment of patients. Some patients may need psychological care when admitted into hospital with a physical illness ( Nichols 1993).The response-based model by Selye (1976) suggest that encountering a stressful event, such as a hospital admission can lead to arousal. Being in an unfamiliar environment with unfamiliar staff and patients had caused Janet to become over sensitive towards the other patient. Janet felt the psychological affects of this by displaying anger towards the other patient. The general routine of the ward is different to Janet's at home, and felt she has no control over her situation. This raised ethical issues as the NMC (2002) section (2.2); state that nurses should promote and protect the interest and dignity of patients. There were no private rooms available.
Privacy, during an assessment, is difficult to achieve in a shared hospital bay; a quite private room is not always available. Drawing the curtains around the bed help create a safe, private environment (Ogden 2001). Although not sound proof, Brown (1994) suggests this can help the patient feel secure and disclose any problems and concerns. I aimed to prevent interruptions, which Kagan and Evans (1998) suggest can be distracting to the patient, by informing other staff an interview is taking place.
When assessing Janet I collected data by looking at the physical well being of the patient, the patient's normal routine, anxiety levels, social needs, whether she had, or needed, social support. To enable me to do this I took notes during the assessment. This was distracting Janet's concentration, she asked me if I was busy today and did I have time for her. Falkner (1996) sees taking notes as a distraction from the nurse patient interaction. I was aware that I had been so busy taking notes that my body language had shown a lack of interest. By reflecting on my lack of eye contact and input into the conversation, I could see I had given Janet the message that I was very busy. I had been passive during the assessment. Burnard (1995) states "when listening passively in a non- verbal way the patient may be unsure if they have been understood". I changed my sitting position and sat squarely in relation to Janet. Burnard (1995) suggest slightly
leaning towards the patient will give the patient the message that they are important to you and their conversation is interesting. I found by maintain eye contact and changing my sitting position, allowed Janet to openly communicate. Burnard (1995) would agree with this and suggests, it is crucial that patients are given the nurses full attention on admission, so any anxieties can be dealt with as effectively as possible.
Communication is vital during an assessment. Nichols (1993) state that ''effective communication makes a positive contribution to a patient's recovery, by acting as a buffer to fear and confusion''. Faulkner (1992) believes, listening to patient's attitudes and values in an active way, and giving a verbal contribution in a conversational style enables patients to feel understood. Reflecting on my communication skills I was able to begin to use open questions that did not restrict the interaction from Janet. This gives control of the conversation to the patient (Falkner 1992). Mishler (1994) also believes this interviewing style allows the conversation to be centred on the patient's own experience, interpretation and concerns. This enabled Janet to relax, Faulkner (1992) agrees with this and suggest by creating a relaxed and informal approach that will help the patient feel at ease. This also enabled Janet to start trusting me, which Ogden (2001) sees as vital to encourage the patient to talk.
During the assessment it was identified that the lack of privacy was a concern for Janet and was causing her stress. Further exploration of Janet's concern was needed; this was possible by paraphrasing. Burnard (1995) states ''clarification, and reflection to the feelings of the patient, deepen the understanding of the problem, and help in the expression of hidden emotions''. This also enabled me to feel empathy for the patient, and gain an insight into the potential needs. Reynolds and Scott (2000) believe using
prolonged eye contact, touch and a calm soothing voice, which are all part of empathy can help the patient openly express there worries.
With the use of non-verbal behaviours, such as touch, gives non verbal signs that its ok to be upset, and the patient doesn't need to feel embarrassed or stop communicating (Edwards 1992). Just touching Janet's hand was a comforting to. I was aware that research done by McClann and McKenna (1993) suggest the only touch perceived as comfortable to the elderly is on the arm or shoulder by a female nurse. By interacting with the patient and reading body language, I found signs of stress and anxiety can be picked up during assessment (Ogden 2001). Walsh (1989) suggest that during the assessment it is important to look for the physical changes in the patient, as an indicator of the biological effects of anxiety and stress. Janet sat clenching her hands together, her body language was very closed, and she looked drawn in her face and had a worried expression. Pearson (1996) warns nurses that patient may say there are fine, while their facial expressions indicate something is wrong. Marsden (2002) discusses how if these signs are not considered, serious omission to the care planning process may occur.
Janet's stress was physically visible, her breathing had become increased and her pupils were dilated. While Janet was talking I noticed her skin became pale, due to the blood diverting from non-essential organs towards the skeletal muscles (Rutishauser 2001). This is due to more light reaching the eye in the fight and flight response (Wilson 1993). Research by Donovan (1988) suggests that the release of stress hormones such as adrenaline can impair the immune system, and that alterations here are thought to be the basis for the increase susceptibility to infections. It was important that any further stress was avoided, as stress may also accelerate the ageing process (Selye and Tuncweber 1976), as older organisms, even when in good health will not tolerate stress as well as younger ones.
During the assessment the Roper-Logan-Tierney model of nursing was used, in relation to the Gloucester Patient profile, which concentrates on the 12 activities of daily living.
I found it gave a good basis for collecting information, and recording daily on the patient's progress. Carke (1982), Pearson et al (1996) suggest the advantages of adopting a nursing model for practice, include assisting the nurse to organize their thinking about nursing, giving direction to practice. Kenny (1993) believes nursing models also enhance the standard of care. However there is debate as discussed by Tierney (1998), on whether nursing models are relevant within practice today. A Research study in Northern Ireland suggests that care plans have little effect on patient outcomes, unless they are customised by those who use them (Mason 1999). However I feel the assessment process needs some form of guideline and framework to collect information, and found the Gloucester Patient Profile was a useful guideline during the assessment. However, Reed et al (1991) argue that the kind of information the Roper model was centred around was restrictive and could be viewed as a checklist. Reed (1991) points out when using nursing models it is vital to treat all patients as individuals and not as a series of questions. The way the Gloucester Patient Profile is presented could result in closed questions being asked and boxes being ticked with little interaction with the patient. Pearson (1996) agrees with this, and feels there is a danger that a series of closed question may be asked to tick the boxes. I would agree it could be used like this, but found I could use the patient profile based on the Roper model in an interactive way to enhance and guild my assessment.
According to Roper et al (1990) the model draws on sociological and psychological work, including the work of Maslow (Hincliff 1994). Walsh (1989) disagrees and believes the emphasis is on the physical aspects of patient care, and doesn't take into account the psychological and sociological aspects of the patient, and believes the Roper model focuses on the physical state of health and highlights the failings. Rake (1990) is also critical of the Roper model and feels it uses a reductionism approach and dehumanises people, putting them into a system of biological systems. Rake (1990) warns this could lead to labelling and ignoring the psychological and social aspects of the patient. Information gained about psychosocial factors would have to be passed to other staff verbally, as there is no were to document them on the patient profile.
Macleod-Clark (1984) warns this could result in vital information being missed. This model is useful systematic and thorough (Hincliff 1994), but I believe it would need to be implemented in a holistic, interactive way. The assessment is updated daily, the danger of this can be when staff follow the same answers as the day before, and do not assess the patient properly on a daily basis.
In this patient assessment, I feel the use of Roy (1984) nursing model would have provided a comprehensive assessment model, one that focuses equally on bio- psychosocial approach. Using the Roy (1984) adaptation model, would enable a useful insight into how the knowledge of the patients adaptation level, coping abilities, life history and beliefs provide a comprehensive base from which to plan care. Hincliff (1994) discusses how Roy's (1984) model may be considered where patients are found to have problems coping or adapting, whether these are generated from within the patient or from the environment. In relation to this I feel this model would have been more appropriate for Janet.
Conclusion
When assessing a patient it is important to pick out clues during the interview, and skilfully control the interview using open and closed questions. This will create an environment where the patient can open up, and the nurse can get all the relevant information from the patient, still allow the interview to explore any psychosocial and biological issues that arise.
Stress was identified as a problem for Janet; it was crucial this was picked up during nursing assessment. Carey et al (1993) reported that people who experience high levels of stress are more likely to start smoking again, compared to those who experience less stress. Reducing Janet's stress was important as she had recently given up smoking and suffered from chronic obstructive pulmonary disease.
Evaluation
During the assessment process, reflective practice played a key role for me. By
reflecting on my practice. I developed an insight to my own behaviours and the effect these can have on patients. This has made me aware of how to improve my assessment skills, as nurse's play an enormous part in the lives of those we care for. Looking at the Health Commissioner Report (2001-2002) I have found strong links between effective communication and overall satisfaction with patient care, so much so that it has been suggested by Health Service Commissioner Report (2001-2002), that complaints would dramatically fall without these failures in communication. The manager on my clinical placement agrees with this, and informed me that 80% of all complaints received by her are due to poor communication by nursing staff.
From the evidence in this essay, I would recommend that during a patient assessment a conversational approach be used. Edwards (1995) discusses that communication in hospitals can be superficial and task orientated. If nursing tools such as the Gloucester patient profile were used interactively, this would allow a comprehensive, accurate interaction and gathering of information about the patient to take place.
I also recommend the Gloucester Patient Profile is redesigned to allow for room to write on the psycho- social elements of patient's needs. I have discussed this with my ward manager, and was reassured that a new version was in the process of being produced, allowing for the recording of this information. Nurses should be able to use a model, which suit the individual patients and not the one the ward stocks. The patient and their environment are central to trying to apply nursing theories, a point elaborated by Roy (1995). With so many tools available to enhance interaction between nurse and patients, I feel the restriction in the hospital setting unacceptable and frustrating, and as Tierney (1998) elaborated, if the nursing models used are inappropriate, the information collected may be less effective.
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