Essay on Critically Appraise the Relationship Between the Nursing Process and Health Sector

The objective of this essay is to disseminate the nursing process and evaluate its contribution to the healthcare sector. The practical and theoretical aspects of the nursing process will be explored simultaneously. The nursing framework constitutes four stages: the actual assessment, planning, implementation and evaluation. This assignment is founded on a clinical placement which I undertook. The placement took place at mental health inpatient services that caters for patient with severe and enduring mental health difficulties. I will use a pseudonym, in substitution of the actual name of my client under the Nursing and Midwifery Council’s (NMC) (2002) jurisdiction to respect a patient’s confidentiality at all points. The communication and interpersonal skills that are essential in this particular sector will be examined in order to build therapeutic relationship with a patient, Bee et al (2008).

Nursing process is a problem-solving framework that allows the nurse to tailor the care they provide to suit a patient’s needs and condition (Hogston, 2011). Nurses are care givers and it is vital to establish the specific needs of a patient in order to supply effective provision (NMC, 2008). McKenna (1997) supports the use of nursing process in mental health as uncontroversial, stating that it is an unconventional process, although he does consider it relatively conducive to supply the right standard of care as it is a useful guideline for nurses to adhere to in their practice (McKenna, 1997).

Assessment is an ongoing cycle of activities that nurses should undertake to collect precise information and implement a care plan that is tailored for a client (Baker, 1997). The information collected must be meaningful and necessary to describe a person’s thoughts, feeling, status and environment they exist in. I will focus on one particular client, who shall be referred to as YZ and articulate the nursing process and stages which is known colloquially as APIE: Assessment, Planning, Implementation, and Evaluation. APIE is a nursing process whose use is prevalent in order to meet the needs of clients. The process is continuous and it centres on an individual to deliver the desired results. However in order to utilise the APIE framework appropriately, there is a demand for assessment tools that enables a nurse to collect information. Information can be obtained through various avenues. The most widely used methods of data collection are interviews, observations, listening, physical examination and the use of verbal and non-verbal communication and open and closed questions (Palgrave, 2011). Measurement of the patient’s ability to function is also an assessment method used in comparison of that ability with the level of behaviour a client must display in order to bring about true self-sufficiency (Ward, 1992). McKenna (1997) identifies that a deficiency of the four stages model is the gap between assessment and planning. This necessitates an interim stage where the assessment results are cemented in order to guide the planning. He elaborates further that elements in the assessment and evaluation stage are equally the same. It is more or less one stage not two. Evaluation can be logically be known as re-assessment. The fissure between assessment and planning can be filled by the concept of ‘specific problem identification’ or can be referred as diagnosis or formulation (McKenna, 2007). According to YZ, the diagnosis of the problems is clear and specific. YZ’s issues include mental health state, financial problems, low self-esteem and speech incoherency. All these diagnosed problems will be addressed in care planning in order to fulfil YZ’s specific needs.

On placement I had an opportunity to explore two types of assessments tools, one of which was ‘Camberwell assessment of need short appraisal schedule’, which focuses on clients’ feelings, thoughts, status and the environment. Camberwell represents its information through a scale of zero to nine to establish clients’ needs. A client will participate in the scoring and nursing staff ask questions about the met and unmet needs. It consists of twenty-two questions that collates everything involved in a clients’ lifestyle, making it a comprehensive assessment.

HONOS is a holistic assessment tool widely used in in the mental health field. It was developed in 1993 by the Royal College of Psychiatrist. Initially, the purpose of the “HONOS” was to distribute a mechanism of recording towards the health of the nation whilst aiming to improve the social and health of mentally ill people. Wing, Curtis and Beevor (1996) after a preliminary test, devised with the 12 items measuring behaviour, impairment symptoms and social functioning. The scales’ primary function is to test the acceptability, usability, sensitivity, reliability and validity of an individual, (RCP, 2011). The notion of holistic assessment is that physical, emotional, intellectual, social and spiritual dimensions constantly interact with each other and the environment (Beck et al., 1988).

Importance of assessment and planning care

The assessment of a patient is worthwhile because it intends to improve and facilitate nurses’ collection of information about patients. It is a sequence of stages that underpin an individual’s health needs and discover the appropriate help offered within the parameters of the health and social care. Assessment has been integral in the viewpoint of seeing the patient’s perspective. Jourard (1971) infers that it is difficult to know a person until steps are taken to establish who the person actually is. Banchik (1983) reinforced the idea of assessment by outlining the results expected in the assessment of a person. Every individual has their strengths and weaknesses. Banchik (1983) also argues that culture plays a vital role in formulating the values and beliefs of an individual such as the heuristic conditions that may influence the quality of life. Genetics can influence a particular behaviour or psychosis symptoms. So questions should be asked along these lines in order to determine the root cause of the problem and that will benefit the intervention procedure’s precision. In relation to YZ, they had a genetic disorder but, with the influence of the environment factors, such as interacting with people who use substances and engaging in these acts, will result in a mental state relapse. However medical intervention are necessary to be put in place to help YZ in his mental health difficulties. Such intervention techniques requires a holistic assessment of YZ.

A holistic assessment is a toolkit used to assess individuals’ mental health needs. Holistic applies a standard framework with guidance for a nursing team to complete the outcome of the assessment of a client (Garlick, 2011).The assessment area includes: empirical family mental health history, drug and alcohol history, current social circumstances, mental state examination and risk assessment. The holistic approach identifies everything about a clients’ life, whether it is physical or mental health, or status of an individual. A care plan can only be designed after the outcome of the assessment. It helps the nurses to draft clients’ needs and continue to monitor their progress sufficiently. There were certain arguments raised by prominent authors like Marks-Maran (1979) and Darcy (1982) conjecturing that the collection of information should be in a systematic and continuous manner. Schrock (1980) devised a nursing assessment form in practice. YZ’s assessment is comprehensive and holistic which considers a diaspora of physical, psychological, social and political strengths and needs in conjunction with full consideration of risks to self and others (Doyle and Dolan, 2007). Using the Campbell assessment tool after going through all the questions and scoring system, we established that YZ had an unmet need of physical health. He was developing acne all over his body. Acne is quite common and is an inflammatory disorder of the sebaceous glands. It affects the face, back and chest and it is quite visible. Symptoms of acne are blackheads with papules, and in most cases, scars and cysts visible on some parts of the body. A care plan was put in place after being referred to the doctor and being prescribed with Azelaic acid and antibiotics. He also had insufficient financial income, which was catered for in a care plan. This illustrates the way in which the holistic assessment approach works. It proved to be vital and accurate in meeting the patient’s needs.

YZ is a young person suffered a brain injury during a crash and in few months he started being agitating and hallucinating. He was taken to hospital acute unit and after assessment, the Consultant diagnosed the illness as code ICD~10 unspecified non-organic psychosis (F29). Prior to his illness, he admitted taking illegal substances on a daily basis. Psychosis disorders fall under a cluster of mental and behavioural disorders that are between F00 TO F99, ICD~10 (2010). Schizoaffective disorders are characterised by the distortion of thinking and perception. YZ experienced symptoms such as hallucinations, paranoia, typical auditory, perceptual distortions, episodic delusions, psychomotor disturbances and an abnormal affect, which may range from intense fear to ecstasy, ICD-10 (2010).He could stay in his room for long periods without interacting with his family. A definition of psychosis traditionally means the loss of touch with reality without clouding of consciousness that appears with symptoms such as delusion, delirium, confusion and memory disorder. There is also an extreme disparity in social and individual function which induces social seclusion and an inability to meet job responsibilities and family roles (Regier et al., 1993). Sometimes, YZ could become angry with no apparent triggers and threatening to kill his relatives. He was taken to an acute hospital as an informal patient, because he had accepted that he needed treatment from his violent behaviour towards his family members (MHA, 1983). The interventions process was put in place and after questions and history of a client obtained the illness fall under the category F19 to F29 (ICD, 2010).

Communication

Effective communication is regarded as the most vital element in the health sector. Communication is the transmission of information to others (John et al., 2008). According to Gregg (1963) and Maloney (1962), the capacity to understand clients’ own feelings influences the effectiveness of communication and helps nurses in the assessment process whether their actions help or hinder the client. The nurses’ role is to promote health and requires a prime tool which is a good rapport that he or she has with the patient. Hein (1980) suggested that therapeutic communication involves a planned approach that influences the patient to follow needs that are particularly tailored for an individual. Service users admitted in mental health services expect the nurse to be radically equipped with both therapeutic clinical skills and interpersonal skills (Bee et al., 2008). In relation to my placement, I had the opportunity to enhance and explore my core skills which cannot be learned by merely reading about them in a book. The therapeutic clinical skills and interpersonal skills requires theory learning but practising them consolidates them. As a learner I was doing most of the work under the supervision of my mentor and I would get constructive feedback. It is considered that generic interpersonal skills should come first in the initial stages of assessment because they involve therapeutic relationship from its establishment until it ends (Bee et al., 2008). In order to enhance and maintain the therapeutic relationship, interpersonal skills are underpinned by personal attributes and values such as compassion, empathy and respect. By observing and asking simple questions I managed to establish my client’s interests. I pursued engaging with my client in the area of their hobbies and I managed to build a rapport and some trust. Then I could ask any questions concerning physical health, mental health issues and getting specific answers that resulted in amending a care plan.

Care planning

This stage of nursing process can only be attainable after obtaining important information about a client. These are the individual needs of a client identified through the assessment process and which can be realistically met (Ward, 1992). In this stage, nurses adopt Ward’s theory called SMART, which stands for Specific, Measurable, Achievable, Realistic and Time limited goals. A SMART objective statement caters for the detailed information of what should be achieved on particular time. The goals can be short or long, but this is entirely based on the formulated goals that are agreed upon with the patient. The goals must reflect patients’ preferences and priorities (Ward 1992). Under the NMC act of (2010), respect for the autonomy and choices of a patient, nurses are there to guide in the nursing process. The nurse will give a patient a menu to choose from, and as a professional, only advises on the disadvantages and advantages of the option taken. YZ’s care plan consists of specific goals that needs to be adhered to in order to achieve optimum results. The main objective is for YZ to improve his mental health and live in the community and possibly search for employment. YZ’s care plan suggests that he need to be compliant with his medication which is Olanzapine 20mg daily. Olanzapine is an anti-psychotic drug used to treat schizophrenia, bipolar affective disorders and other assorted conditions (Mhra, 2014). YZ’s specific goals are to be able to get better and live independently. The other specific aim is able to engage in therapeutic sessions with staff and build his confidence. YZ is keen to learn to drive and also wants to practise cycling so that he can become a professional cyclist. This appears to be a long term goal. Short term goals set for YZ are to be compliant with medication every day and engage in communal activities with staff and fellow peers. To measure these goals is by observing and documenting daily activities that have been set for YZ. Achievable goals for YZ have been set based on the assessment plan. Nursing staff have to consider if YZ has the skills, knowledge, and abilities to achieve these goals. YZ’s realistic goals such as visiting his relative at least twice a week and if it goes well, the possibility of an overnight stay will be implemented. The time for these goals are reviewed every two weeks in the Multidisciplinary team where all allied health professionals meet and discuss the progress of the plan and if any amendments need to be done in relation to the measurable goals. YZ is considered to be underweight as he does not consume much food. Staff need to monitor his daily intake so that he will gain weight. His body mass index is below 18 and the normal index should range from 18.5 to 24.5 (Correct as of 28 January 2014). YZ is said that sometimes he is attempted to take substances, but staff should always advise him to refrain from taking drugs or alcohol as this would cause some serious ramifications towards his health. Activities have been put in place that will help YZ to cope with anxiety and stress. Playing a Wii game and engaging in communal activities such as daily meetings and group walks will help YZ to distract himself from any negative thoughts.

Implementation

The fourth stage is the tangible implementation of the nursing care. Implementation is defined as the stage of nursing process in which the patient’s individual care plans are utilised and put in place in collaboration of other healthcare team members (Oxford Dictionary, 2008). Despite the fact that implementation of the care involves other health care disciplines NMC (2008) state that each registered nurse is accountable for his or her actions in accordance with Code of Conduct. According to Standards of Psychiatrics – mental health clinical nursing 1994 define implementation as the actions being put in place by nursing staff in order to carry out the nursing measures identified in care plan. This criteria of implementation will enable the evaluation of expected outcome. I had an opportunity to participate in Multi-disciplinary team meeting which are held once a week. The purpose of the MDT is to measure the progress of the care plan implemented. YZ remain compliant with his medication and continue with his home visits twice a week as per care plan.

Evaluation

This is the final stage in nursing process, which will continuously be carried out throughout the care of patient. Evaluation means the act of determining or examining something in order to judge it value or importance, Encarta Concise Dictionary (2001). Evaluation is normally associated with the outcome in relation to certain goals implemented. In YZ case the care plan was reviewed and some patient needs were discovered to be unmet. Unmet needs were the limited time YZ allowed to visit his parents on weekly basis. As YZ is trying to rebuild the relationship with the family members he ought to visit regularly but at the same time not missing out on the daily activities within the unit. YZ has a strong bond with the family and despite the illness that cause a relationship breakdown YZ point of view was examined at this stage and appears to be benefiting a patient which is the primary goal. However the care plan was put in place for YZ to access overnight leave to his family. Objective measurement tools include ratings or questionnaires were implemented to determine whether YZ will be compliant with medication on overnight leave. The tool is called Self Medication Assessment tool that requires a patient to answer false or true questions. The score of false or true will determine if the patient will be compliant. This assessment tools is examined by the consultant who will give the final say on the outcome of the answers. Evaluation for YZ were carried out weekly at a pre-specified time. YZ evaluation compares the actual outcome of care with his goals. According to Lowe (1984) states that evaluation should be objective and facts need to be considered, rather than opinions. YZ care plan states that he should engage with family once a week and be compliant with medication. The strength and weakness of YZ were revealed on MDT. YZ was able to compliant with medication and home visits were all going well. The weakness were prolonging home visits and not able to engage fully on hospital activities. That was facts on the evaluation part of patient YZ.

Pharmacology and Assessment and Planning

Medication is a moral, ethical symptom reduction and its main purpose is to alleviate or improve and maintenance of patients’ quality of life (NPA, 1998). Prescribing of medication is a complex activity that requires patient concordance. Nurses play a key role in safe administration of medication to individuals with reference to best practice (Taylor et al., 2000). Systematic assessment of side effects is required to measure the reliability of medication (NICE, 2002). According to Day et al. (1995), outline that an in depth of knowledge of prescribed medication is vital to determine the pharmacokinetics, pharmacodynamics and pharmacogenetics. The medication YZ is currently prescribed is Olanzapine 20mg every night time. Olanzapine is an antipsychotic drug and are used to calm patients from the underlying psychopathology. The antipsychotic drug act primarily by blocking dopamine D-2 receptors in the brain. Dopamine are important neurotransmitter (messenger) in the brain. Olanzapine is referred as the second generation antipsychotic drug. It acts on a range of receptors in comparison to the first generation that work primarily on blocking dopamine D-2 receptors.

Dopamine is classified as a catecholamine (a class of molecules that serve as neurotransmitters and hormones). It is a monoamine (a compound containing nitrogen formed from ammonia by replacement of one or more of the hydrogen atoms by hydrocarbon radicals). Dopamine is a precursor (forerunner) of adrenaline and a closely related molecule, noradrenaline. Dopamine is formed by the decarboxylation (removal of a carboxyl group) from dopa. Patient YZ admitted that he used to get angry and agitating to an extent of not able to control himself. However since he started taking Olanzapine he no longer experiences such feelings of anger or negative thoughts. Side effects of Olanzapine are weight gain, blood clots in veins and feeling dizzy or faint (TEVA, 2012).

Pharmacokinetics refers to the biological function of medication in the body through the processes of absorption, distribution, metabolism and elimination. Olanzapine can be absorbed quite easily and reaches peak concentrations approximately 6 hours after an oral dose. It is eliminated extensively by first pass metabolism, with approximately 40% of the dose metabolised before reaching the systemic circulation (RxList, 2014).

Conclusion

In my experience as a care giver and observer, I found the sequence of care process beneficial to both service users and the nursing staff. The collaboration of the multidisciplinary team and patient YZ and their family yielded optimum results. I learnt the importance of building therapeutic relationships between healthcare professionals as it ascertains more information that will help in accentuates all areas of lifestyle of a patient. YZ was able to obtain help physically yet he was being his mental health needs were being attended to as well. The implication of person centred care, have proved to be at the foci of nursing practice. YZ’s person centred care has alleviated his family concerns and simultaneously rebuilt a remarkable relationship that had been lost because of YZ’s health deterioration. As the fourth principle of nursing practice, principle D, states that nursing staff are there to provide and promote care that puts patients at the centre, involving a patient, their carers and families (Manley et al., 2011), involving YZ’s family helped them make informed choices about the treatment and care.

Reference List

Garlick, D. and Rhodes, L. (2011) Holistic Adult Mental Health Assessment Toolkit: Separate Guide Format: Wirobound Manual with booklet of forms. South London and Maudsley NHS Foundation Pavilion Publishing.

European Medicines Agency (2012) 4 stages of care. [Online]. Available at: www.ema.europa.eu (Accessed: 26/01/2012).