nurses’ perceptions of mental health assessment in an acute inpatient setting in new zealand: a...

International Journal of Mental Health Nursing (2003) 12, 203–212

INTRODUCTION

Acute psychiatric care in Central Auckland is providedwithin a purpose built mental health unit with 58 beds. Theunit has two open wards and one closed ward.

A recent review of this unit indicated that the nurse’srole within the formal assessment process was minimalstating that nurses’ contribution to the initial assessmentwas their presence and that no active role was expected(D. Mcleod, unpubl. data, 2001). Nurses were rarely askedtheir points of view during and after formal assessments.The predominantly medical model operating on the unitplaced most legal and professional accountability withdoctors during the assessment phase of treatment. One ofthe outcomes of the review was that the acute unit neededto redevelop nursing skills that were once the ‘bread andbutter of mental health care’ which had been lost in asetting of ‘medically orientated care’. On the other hand,

nurses have been identified as being central in the assess-ment process because of their unique role and holistic per-spective (Barker 1997), particularly in inpatient settingswith the added factor of 24-hour nursing care. Given this,it is surprising that mental health nurses have not estab-lished a clear role in the formal assessment process.

Nursing assessment skills are core skills and thereforeidentified as an important part of the professional develop-ment of mental health nurses in New Zealand. AucklandDistrict Health Board set up a steering committee toidentify key areas of training needed to ensure ongoingdevelopment of local mental health nurses’ skills.

This committee highlighted the need for a trainingpackage focusing on mental health nursing assessment dueto lack of conceptual framework and models of practicewith regards to assessments.

The present study set out to explore the perceptions ofthe nurses working in the Central Auckland acute unitabout their role and skills in both formal and informalassessment. The study aimed to show how the nurse’s rolecould be developed to meet the recommendations of bothlocal review of inpatient care and also national and inter-national directives for professional skill development.

FEATURE ARTICLE

Nurses’ perceptions of mental health assessmentin an acute inpatient setting in New Zealand: A qualitative study

Correspondence: Darryl Bishop, Kari Centre, 76 Grafton Road,Grafton, Auckland, New Zealand. Email: [email protected]

Darryl Bishop, RMN, BA (Hons), BSc (Hons).Ines Ford-Bruins, RN Comp, MA Soc.Accepted June 2003.

Darryl Bishop1 and Ines Ford-Bruins2

1Kari Centre, Grafton and 2Auckland University of Technology, School of Nursing and Midwifery, Northcote,Auckland, New Zealand

ABSTRACT: This qualitative study explores the perceptions of mental health nurses regarding assess-ment in an acute adult inpatient setting in Central Auckland. Fourteen mental health nurses took partin semistructured interviews answering five open-ended questions. The analysis of data involved ageneral inductive approach, with key themes drawn out and grouped into four categories (roles, atti-tudes, skills and knowledge) in order to explore the meaning of information gathered. The outcome ofthe study acknowledged the importance of contextual factors such as the physical environment andbureaucratic systems, as well as values and beliefs present within the unit. The participants expressedconcern that their input to assessment processes was limited, despite belief that 24-hour care and thenature of mental health nursing generally suggested that a crucial role should exist for nurses. In orderfor nurses to be established as central in the assessment process on the unit the study concludes that anursing theoretical framework appropriate for this acute inpatient setting needs to be developed.

KEY WORDS: acute mental health nursing, assessment, qualitative study.

LITERATURE REVIEW

Assessment may be seen as collecting information about awhole person in order to make a judgement. Barker (1997)defined assessment simply as ‘estimating of the characterof something or someone’. The primary function ofassessment has been referred to as ‘the description of theindividual’s behaviour and resources’ (Savage 1991) byobtaining as much information as possible about theperson. Assessments are done for diagnostic functions andto assist in the process of planning an appropriate and effec-tive care package.

A recent study by Hummelvoll and Severinsson (2001)in Ireland described two categories of assessment. Theyidentified the first category as the ‘independent assessmentand evaluation of nurse’, which means the collection of datathrough many informal sources such as observation, dis-cussion and written information. The other category iscalled ‘interdependent assessment and evaluation withother members of the health care team’. This refers to theassessments done in collaboration with other professionals.

Most assessments in psychiatric nursing are doneinformally on a day-to-day basis, with information aboutthe client gathered in a less structured, more haphazardmanner (Barker 1997). Formal assessments or inter-dependent assessments like the initial admission assess-ment is more structured and planned.

Mental health nurses, to aid judgement and decisionmaking, now also use standardized assessment tools.Examples of standardized assessment tools available andused by nurses in the setting of this study are the Positiveand Negative Syndrome Scale (PANSS), the Chamberwellassessment of needs, Health of the Nation Outcome Scale(HONOS), Hamilton and Beck Depression inventoriesand risk assessment tools (Perdue & Piotrowski 2000).

In reality, both informal and formal assessmentscomprise part of nursing practice, with informal assess-ment providing information about the nature of theproblem and more formal standardized assessment toolsassisting in testing efficacy of treatment (Barker 1997).

MEDICAL MODEL

Historically it has been argued that the only function ofnursing assessments was data collection in order to aidmedical diagnosis (Savage 1991). More recently nursinghas moved away from the collection of quantifiable data inthis fashion, and can be seen as gathering and analysinginformation from a holistic perspective about individualsand their environment, working towards a nursing diag-nosis. Mulhearn (1989) states that although a number ofmodels and theories have been developed since the shiftfrom the medical model, research suggests that psychiatric

nurses still plan their care based on the dominant psychi-atric ideology of their workplace instead of their ownnursing theories and models. Therefore, the role of nursescannot be seen without considering the context of theirworkplace. More recently research in Norway has shownthat the culture in the acute psychiatric setting is slowlychanging. Hummelvoll and Severinsson (2001) investi-gated the everyday reality of an inpatient psychiatric unitand stated that the medical model still dominates practicebut not on the ideological level.

Shortness of time to spend with clients in order tocomplete a holistic assessment was given as one of thereasons that the medical model still dominated. There is atension between the ideal of wanting to spend more timewith the client and engage in a more holistic assessment,and the reality of not having enough time. Models such asthe Tidal Model (Barker 2001) have attempted to give theclient a central role in the assessment and planning of care.

Within the Tidal Model the role of the nurse is to col-laborate with the client in exploring the client’s needs.Doctors are there to diagnose and prescribe medication.The Tidal Model has been introduced in acute psychiatricunits in the UK since 1997 attempting to change the med-ically dominated culture. Antonovosky (1996) developed asimilar movement towards a more holistic assessmentcalled ‘the salutogenetic model’ (Antonovosky 1996).Through this model nurses are trying to interpret themeaning of suffering, to treat in both a sensitive andrational way, and being open to a range of problems likelyto be associated with mental disorder (Hummelvoll andSeverinsson 2001).

In New Zealand, no research could be found examiningthe culture and the role of nurses with regards to assess-ment in inpatient psychiatric units.

Assessment as part of the nursing processAssessment is an integral component of the nursingprocess, which is an interactive, problem-solving processwhereby on a systematic and individualized way outcomesof nursing care are achieved (Stuart & Laraia 2001).Assessment in this light is part of a formalized process andthe first phase of the nursing process, followed by nursingdiagnosis, planning, implementation and evaluation.Barker (1997) stated, ‘nurses cannot offer valid and reliableforms of nursing care without valid and effective assess-ment’. Ongoing care planning, implementation of inter-ventions and evaluation of care in mental health is thusdependant on the information gained from assessment(Neilson et al. 1996).

Without a process of nursing, the nursing processbecomes more a series of tasks (Savage 1991) than thefunction nursing assessment can result to aid medical diag-nosis and nurses are likely to repeat procedures performed

204 D. BISHOP AND I. FORD-BRUINS

by doctors. Savage (1991) concluded in his research thatnurses needed to improve their understanding and prac-tice in the art of assessment in order to achieve a promi-nent place in the acute psychiatric assessment.

Mental health nurses face new challenges in their workas a result of a greater emphasis on involving consumersand their carers in the planning, delivery and evaluation ofmental health services (Cowan 2000). In order to supportthese changes mental health nurses will need to adopt newknowledge and skills.

Auckland District Health BoardA Professional Development Program for mental healthnurses at Auckland Health Care was developed as part ofthe above developments. Workshops are now offered toimprove nurses’ understanding and skills with regards toassessment. It was identified that the skills involved inassessment were not being used optimally and that a con-ceptual framework around psychiatric nursing assessmentwas missing. In addition, the nurse’s role was unclear withregards to assessment within the multidisciplinary team(MDT); with nurses tending to rely on doctors’ initialassessments (D. Mcleod, unpubl. data, 2001).

METHODOLOGY

This qualitative study explores and attempts to understandthe perception of mental health nurses towards assess-ment. Qualitative research is founded upon a number ofwider assumptions. One important assumption is the sig-nificance of the social context of people (Cormack 1996).The social context is crucial because through our inter-actions with others we create our reality.

This is not a static process but variable, fluid andchanging over time and place depending on the interactionswith each other which is a two-way process (Cutcliffe 2000).The social reality consists thus of the experiences andunderstandings of people.

The practice of mental health nurses and the conceptsof qualitative research appear to have similarities andlinkages as Cutcliffe (2000) outlined in three themes: theuse of self, the creation of interpersonal relationship and theability to accept and embrace ambiguity and uncertainty.

The role of the researcher in qualitative research is totry to discover and understand the world of the participants(Bowers 1988) as this method relates to specific beliefsconcerning epistemological and methodological issues.

This means that the researchers’ knowledge consists ofshared understanding between individuals and groups andthe researcher’s own beliefs will influence the research.Both researchers have worked in acute mental healthsetting. The assumptions, experiences and perspectives ofthe researchers have therefore influenced the findings ofthe research (Denzin & Lincoln 1994).

ETHICAL CONSIDERATIONS

Both Auckland District Health Board Ethics Committeeand the University Ethics Committee approved thisresearch process. Participants were given a brief overviewabout the nature and conduct of the research and confi-dentiality was discussed.

ParticipantsWe interviewed 14 mental health nurses working in anacute adult inpatient setting who were asked to describehow their world is constructed with regards to mentalhealth nursing assessment. The participants were workingin the open and closed wards of the unit and two partic-ipants were in the position of clinical nurse specialist. Theparticipants were selected on the basis of their knowledgeof the topic (Bowers 1988) and are all experienced inmental health nursing assessment.

Data collectionThe interviews were semi-structured as each participantwas asked five questions (Appendix 1) about mental healthnursing assessment. They were open-ended questions andparticipants were able to talk freely about the topic. Theinterviews were taped and transcribed.

Data analysisBoth research objectives and multiple reading andinterpretations of the data (Thomas 2000) determined dataanalysis. The research objective was to explore the per-ceptions and understandings of the mental health nursesin an acute setting about nursing assessments. The generalinductive approach was used to analyse qualitative data(Thomas 2000). Inductive approaches aid an understand-ing of meaning in complex data through the developmentof categories of data. The general inductive approachallows the researchers to investigate the world of theparticipants rather than having a basis in literature. Theunderlying assumptions of the general inductive approachare that both research objective (deductive) andinterpretations of the data (inductive) determine dataanalysis. The findings try to describe data within a socialsetting and also try to conceptualize the underlying socialprocess (Pandit 1996).

The model of analysis involved the development of cate-gories into a framework that summarizes the data andconveys key themes and processes. Cutcliffe (1997) devel-oped the framework utilized within the present study, inresearch that utilized a grounded theory approach toexamine the nature of expert nursing. In his study, Cutcliffe(1997) describes the nature of expert psychiatric nursingworking in an inpatient setting through four categories:attitudes, skills, knowledge and philosophies with 20 keycomponents. In order to analyse the findings in this

NURSES’ PERCEPTIONS OF MENTAL HEALTH ASSESSMENT 205

research, Cutcliffe’s four categories were adopted to deter-mine the key components within the participants’ views ofmental health nursing assessment in a similar setting.

The analysis of the data began with close reading of thetext to lift out key themes and processes, according to theframework determined applicable. After systematicreading and rereading, major themes/key competenciesemerged from the text. The next step was to assign thethemes/key competencies into the four categories ofCutcliffe’s model (Appendix 2). This process is called‘inductive coding’ (Thomas 2000).

The reliability and validity of the data analysis includedthe so-called ‘consistency check’ that means having theresearcher going through the interviews of the otherresearcher, take the four categories and find the text thatbelongs to those categories. Then compare the outcomeswith the original researcher findings. We have includedquotes from the participants to illustrate the meaning ofthe different themes.

RESULTS

Examination of data in this inductive study began by util-izing the categories of Cutcliffe (1997). The final break-down of how the results transferred to the categories areshown in Appendix 2. Similarly to Cutcliffe (1997) the inte-grated nature of the competencies, involved in expertnursing practice, is shown by the presence of overlappingcircles. For example, while holism primarily belongs to theattitude category it is also an influence on the roles, skillsand knowledge involved in assessments.

This inductive study further developed the model byacknowledging the external influences identified byparticipants as major factors impinging on assessmentprocess (Appendix 1).

Before exploring the competencies identified in thestudy, it was important to examine what statements weremade by the participants regarding assessment generally.All participants saw assessment as the most important taskand primary focus in their job because of their 24 hour care.

Everybody else comes and goes but you’ve got thatcontinuation of care.

Many statements reflected the importance placed onassessment by the literature in New Zealand and inter-nationally.

Nursing assessments go way beyond just a patient assess-ment too. There is the ward environment, doctors neverassess that.

The participants also engaged in the debate present inliterature about the move away from biomedical assess-ment towards a more holistic biopsychosocial model, andalso the importance of the therapeutic relationship.

It is funny but as the years have gone by my role hasbecome more assertive and the assessment has becomemore holistic because of that.

All the participants expanded their views on assessmentand their role within it well beyond general statements andtheir interviews can be broken down into core compe-tencies identified in the categories outlined by Cutcliffe(1997). In order to discuss the competencies found andexplore their meaning, it is important to outline them inmore depth.

KnowledgeThe first debate that emerged from the participants wasthe issue of experience versus theory as a base for theknowledge involved in performing an assessment in anacute setting. The interviews produced a balance ofopinions on this subject with participants discussing therole both types of knowledge have in their assessment situ-ations. Most participants concluded that experience(including observing colleagues performing assessments),‘gut feeling’ and knowing the client were the dominantfactors in their assessments.

Generally I have already made up my mind about what isgoing to happen by how that person behaved rather thanwhat they say. I have got to this stage by watching otherpeople go through that process since I have been here andchecked what works for other people and what hasn’tworked.

This tends to be further enhanced in this acute unit bya high ratio of ‘revolving door’ clients, meaning that nursesdevelop ongoing relationships with high numbers of clientsadmitted (D. Mcleod, unpubl. data, 2001). Most partici-pants stated that theory in their practice is never forgotten.

Like hopelessness is a major indicator for suicidality, so ifsomeone is mentioning suicidal ideation then I always kindof ask questions about hopelessness or whatever.

All participants indicated the medical model dominanceby the fact that knowledge around signs and symptoms offormally diagnosed disorders (DSM IV) was identified asa crucial element of the assessment. Participants usedBATOMI as an assessment tool (McEvoy 2000). This wasfurther supported by the suggestion that the knowledgebase of nurses was inferior to that of doctors.

We’re entrenched in the medical model, so I see us as sortof the step for doctors, we feed information on to thedoctors, with our perceptions and they perhaps take thatlevel higher.

Again the integrated nature of the medical model beingutilized is important, as this influences greatly both theskills and roles perceived as important by interviewees.

Finally, another key issue raised was the importance of


‘knowing all aspects’ of the client. Nurses tend to have anoverview of all aspects of the client while other disciplineshave specific aims in assessment covered.

We are sort of ‘jack-of-all-trades’ in some respects: thereisn’t some pure science of nursing, so we tend to draw onall the other disciplines for our nursing assessments.

SkillsObservation was seen by a number of participants as oneof the core skills of mental health nursing assessment,which was supported by their role of secondary, more silentpartners in initial assessments on the unit. While being inthis secondary position often, the nurses saw this as anopportunity to gather information.

We don’t play a part at all in the initial assessment, thedoctor will sit and then ask questions, all of which are usefulin a kind of biopsychosocial stuff but with a medical focus,what’s your diagnosis. While I am going through a check-list in my mind what’s been going on with this person, whathas happened in their lives?

The participants also reported that level of experienceinfluences their role in the assessment process.

Furthermore, participants talked about taking advan-tage of the low expectations of them in terms of verbalinput to focus on utilizing their listening skills to enhancetheir information gathering process.

My role within the formal assessment of a client isabsolutely nothing, it’s useful for me because what I cando is sit back and on the strength of the question asked, Ican draw my own conclusion.

Participants mentioned that documentation skills arevery important with assessment.

It’s very rare for a psychiatrist to actually document whatthey are seeing, where as a nurse it is very important tocontinually document and assess what you are seeing andwhat’s going on.

It was surprising that even though nurses had donetraining in formal assessment tools (usually the Positive andNegative Syndrome Scale – PANNS), they tended to basetheir assessments on informal tools/models. A lot of partici-pants discussed the importance of practical skills such asbasic communication skills.

The doctor takes the interview and I always sit down after-wards with the clients and do my own kind of assessment,I don’t use formal assessment tools.

The more active part in the process of assessmentsinvolved skills around engagement. This was discussed asan ongoing process, which was not necessarily done in theinitial assessment, but over time, and supported by thenurse’s ongoing contact with the client, and crucial toongoing assessment of need.

When you try to engage with clients they are more willingto tell you things, especially when you could ask themspecific assessment questions and not just observing causeyou know what you are looking for.

Furthermore the participants pointed to the impor-tance of intuition in the process of assessment. Again, thissupported the perception of experience and informalassessments being of equal if not superior value toresearched and formal tools. Finally, there was discussionabout the skill of negotiation, particularly with colleaguesaround the nature of treatment plans, which were identi-fied as important to nurses in facilitating assessment andongoing evaluation of care.

I spend a lot of time negotiating with the medical team andbasically giving them my opinion.

RolesWhen examining the participants’ perceived role in theassessment process, the main responses indicated it asbeing very important because nurses spend 24 hours a daywith the clients.

So there is a lot of reliance on nurses’ ability to assess andto basically translate that information into somethingsensible that is going to be useful in the clinical picture.

Because of 24 hour care, their role involves triaging allthe different assessment areas. Nurses stated that oftenother disciplines would not be involved unless nurses hadthought about specific issues such as benefits or living skillsassessments and asked for involvement.

You are the one who is really triaging the need for partic-ular assessments and if you’re at that level I think where Iam at like you are fairly experienced, you are able to makethat triage decision.

Participants reported that the doctors would usually dothe initial assessments and nurses would have a secondaryrole or sometimes even no role at all. Some participantsstated that they were too busy to do the initial assessmentsand were happy doctors were doing them.

The role of the nurse, statements supported as com-prehensive with regards to assessment because nurses haveto assess the safety of the individual clients as well as theward environment.

As I said before, nursing assessment goes beyond just apatient assessment, there is the ward environment, thesafety of the ward as well, and doctors never assess thingslike that.

Some participants saw the role of the nurse in morehumanitarian terms, as a partner or friend to the client.For some this seemed to reflect an understanding that theprocess of admission and ensuing treatment in an acuteunit was a very difficult one, and the most important role


the nurse could play was as a support or advocate in theprocess.

I see the role mainly as staying with that person and pro-viding that support and reassurance and gaining thatreport.

AttitudeThe interviewees discussed their attitudes and beliefsabout the nature of a nursing assessment in mental health,and the important features of a good admission stage of aninpatient treatment plan. Many nurses talked aboutempowerment as being the key to assessment. The impor-tance of helping the clients help themselves was stressedand a rejection of old fashioned paternalistic approachesto assessment. Similarly, interviewees were keen to discussthe influence of the recovery model and consumer-focusedtreatment in general to their approach to assessment onthe unit. There was discussion in most interviews about thecrucial nature of being client centred.

I hold in my head the client’s perceptions and what theybelieve is best for them, I tend to be consumer and recoveryfocused.

At times this was difficult to achieve within thedominant medical environment of the unit whereby diag-nosis was at times more important than what was going onfor the client. The participants stated that the unit lacks aclear nursing assessment package for admissions.

I do my own admission notes but sometimes you mightcome on and another nurse might not have documentedmuch and it varies from nurse to nurse how comprehen-sive that is as well.

There is a lack of participation of nurses in most initialassessments but most of the nurses stated that their attitudeis changing and they feel they are the ones who should askthe questions, as one clinical nurse specialist in the studystated:

I try to change and encourage nurses to get more involvedin the questions telling people, you are confident, you askthe questions.

Many pointed out that nursing assessments in mentalhealth should be proactive and not reactive, which they feltcould only be achieved by being client centred and gaininga true sense of realistic interventions and goals. This wasfurther covered in statements, which reflected a caring andsupportive attitude to mental health nursing assessment inacute settings, again emerging from beliefs around thetraumatic nature of inpatient admission.

People being dragged through the main reception wailingand upset, I think that doesn’t do anything for dignity andrespect.

The nurses that were interviewed felt that nursingassessments were unique in that they were holistic asopposed to the more reductionist nature of the medicaldiagnostic interview. This reflected a belief in a biopsycho-social model of care in general as underpinning theirapproach to mental health nursing.

Critically, some participants discussed the time-consuming nature of assessments and in particular outlineda belief that clients should not have to undergo the processmore than once – a concern should a nursing assessmentbe introduced which merely repeated the process cur-rently undertaken by the medical staff.

They’ve already been assessed in the community by a reg-istrar or the consultant and they come here, and doctorsdo it all again, sometimes they have been assessed all daylong. I can’t see the point in this.

EnvironmentAs well as the original four domains outlined by Cutcliffe(1997) it became clear as the interviews progressed thatthe participants were indicating other important environ-mental influences on the structure and nature of the assess-ment process on the unit.

The environment can be described in two subgroups:systems and values/beliefs. Systems is explained as the waythe work processes in the unit is structured as well thephysical environment of the unit while with values andbeliefs is explained as the way the participants experiencedthis environment in terms of its systems. (See figure one)

Systems

Much reference was made to the physical environmentespecially with regards to the admission process and theinitial assessment.

It would be good to have a nicer environment, especiallyif it’s the first time coming to the unit and it’s much nicerwhen the ward is not so busy because you can take timewith the client.

The unit is just about to undergo a complete rebuildingphase and most of the interviewees indicated that the setup of the current unit and particularly the ‘run down’ feelof the building played a part in the difficulties aroundassessment.

The bureaucracy on the unit was seen as a negative influ-ence on the nurse’s role in the assessment process, partic-ularly referring to the difficulty of installing any change inthis process. The fact that clients have to be assessed by somany different people before entering the ward is one ofthe main reasons that nurses tend to have a minimal inputin the assessment process. Questions that were asked atthe initial assessments tended to be repetitive and a lot ofpaperwork is involved. Therefore, the process was seen as


time consuming by some nurses and nurses did not mindthat doctors did the initial assessments because it savedtime.

The medical staff was the subject of much discussion inthe interviews, with both positive and negative influenceson the nurse’s role in assessment identified. Positively, aconsultant was singled out as being consistently support-ive of nursing contributions in all stages of the treatmentprocess from admission to discharge. Many of the partici-pants explained that nurse’s involvement in the assess-ments depends on the type of doctor.

Occasionally the doctor will ask you what you think, butonly if they are not a complete medical imperialist, so in away it depends on the doctor you are dealing with.

It also depends on the level of experience, the confi-dence and the rapport that a nurse has with a client. Thefact that the unit was predominantly still perceived as oper-ating a medical model of care was viewed as responsiblefor the limited role of the nurse in assessment and otheraspects of care involving decision-making. One of thereasons is that the initial assessment tool has a strongmedical focus and was developed by doctors. Attempts todevelop a nursing assessment package have been difficultdue to the lack of clear theoretical base for one to be usedon the unit. The questions asked in assessments are there-fore more focused on signs and symptoms of the illness, sothe role of nursing perspectives in this process is minimal.

Similarly, participants indicated that while the unit wasseen as a training unit for medical staff the developmentof the nurse’s role in the assessment process was unlikely.

It’s all about doctors training other doctors in training andtherefore our role is limited.

The registrar moves off into the sunset and you have tostart the process all over again to establish rapport withclient.

Values and beliefs

There was a lot of discussion around the changing cultureof the unit. Participants discussed the feeling that positivechanges were happening and that along with a new buildingwould be new ideas, models and thinking. The main changethat was identified by some as already happening was asense of encouragement to do more, which was discussedin the context of assessment and nursing on the ward ingeneral. All participants wanted change in the assessmentprocess of the unit and they all saw their role as very impor-tant because nurse provide 24 hour care and ‘know theclient the best’. Doctors were seen as needing a betterunderstanding of what nurses do to create a culture ofparticipation and collaboration in the assessment process,rather than the current medical dominance. Clients canhave feelings of failure associated with the stigma of mental

illness and therefore the input of the nurses is of great valueat that first contact.

It is very important that a nurse is at the initial assessmentbecause they usually have a good rapport with clientsbecause they have been in the unit before and the nursescan diminish that feeling of failure.

Work was described as being performed under incred-ible pressure of admissions and shortfall of resources,which left little time to reflect on the role and to makechange.

It was mentioned by a number of participants that thepredominant culture was one of managing safety and risk.Some saw this as inevitable, and a key part of inpatient carebut others also saw this as negative and negating the prin-ciples of consumer model, which is about empowermentand encouragement.

I feel my role here is very much a bureaucratic nursingrole, do the rounds, all ritualized instead of being with theclient and having more a counseling role to support clients.

The values and beliefs on the unit could change whenthe new building opens. Most of the participants werepositive about this and felt they will have more input in theassessment and work in partnership with the MDT.

DISCUSSION AND CONCLUSION

The present study demonstrates the assertion that nurseson acute units perform informal assessments indepen-dently while their role in formal assessments is minimalwith medical staff taking the majority of the responsibility.Examining the accounts of the participants allows us toexplore their perceptions of nursing contribution to bothformal and informal assessment.

Clearly it is not merely the system, medical staff orhistory of the unit that dictates the role of the nurse inassessments but the nurses themselves also determinewhether that role is active or inactive. Factors influencingthis determination include confidence, training and expe-rience.

The nurses in this study have indicated that there is aneed for change with regard to their role in assessment.The current situation described, involves over-reliance onthe assessment of pathology and the ignorance of widersocial and psychological factors that may give better insightinto the clients’ suffering and lead to more effective careplanning. Similarly to findings of a study by Hummelvolland Severinsson (2001), nurses have suggested that whilethey are the best people to perform this wider, more holisticsort of assessment, the time constraints around formalassessment and their exclusion from the process are crucialto it not happening. Nurses on this unit, as researchers haveindicated is often the case, could be seen to ‘waste’ a lot of


time because of the bureaucracy inherent to inpatientsettings, taking them away from direct client care(Whittington & McLaughlin 2000). Nurses need theirenvironment to value their contribution to the assessmentprocess by allowing them to be part of the process.

The importance of maintaining a safe environment inacute settings also supports the role of the nurse in assess-ing safety and risk, with all participants discussing thiscrucial element of assessment. Nurses tend to balanceclients’ unpredictability with the safety of staff and otherclients (Higgins et al. 1999) and determine acceptable andunacceptable risk.

It is clear that the participants believe the role of thenurse in the formal assessment should include the assess-ment of risk, but despite this and the increasing availabilityof formal nursing risk assessment tools their role remainsminimal. However, our participants have clear ideas aboutthe change needed and expressed positive feelings that thischange was already happening.

Senior appointments, both nursing and medical, haveled to changing attitudes, with there being movement awayfrom medically dominated thinking. The unit is about toundergo major rebuilding and the new physical environ-ment is perceived as heralding a new type of care. Allparticipants discussed the influence of the recovery model(Curtis 1997) and collaborative care.

The success of such approaches dictates holistic assess-ment. Similarly, the units increasing focus on clients’cultural needs means that assessment needs to be morethan a diagnostic interview.

The unit is making moves to introduce formal assess-ment tools, which may serve to give the nurse a formal rolewithin the assessment interview. However, many of thetools introduced may still support medical rather thanbiopsychosocial frameworks. Currently the medical modelis still dominant on the unit, with nurses feeling uncertainabout their role and the boundaries between nursing andmedical treatment. Nurses have become preoccupied withchecking for signs and symptoms of medical diagnoses,instead of examining the whole person, which has beensuggested is a result of nurses adopting the dominantideology (Barker & Walker 2000).

The medical model remains dominant due to the under-development of nursing models and interventions(Hummelvoll & Severinsson 2001). It was clear that mostof the nurses’ contributions to informal and formal assess-ment were not based on theory-guided reflective practicebut on experience, intuition, ‘gut feelings’ and ‘knowingthe client’.

Experience is vital to holistic assessment, which relieson more than formal reductionist tools (Crook 2001), asis the nurses’ self-confidence to trust intuitive feelings(Gilje & Klose 2000). Change occurs on many levels. The

participants seem determined to change, and are beingsupported by training offered around conceptual frame-works as well as formal tools of assessment. There is anacknowledgement that it is difficult for individuals tochange their world without change in systems and widerattitudes. As discussed previously not only are therechanges afoot to the physical environment but also an indi-cation from participants that attitudes around them arechanging. Furthermore, mental health nursing has movedaway from reliance on medical models of assessment(Savage 1991) and nursing policy and training in NewZealand is beginning to reflect this (Cowan 2000). Nursesneed to adapt new skills, attitudes, knowledge and roles inthe light of a growing body of evidence regarding the natureof effective practice in an inpatient unit (Heath 1998). Thehigh number of revolving door clients in this particular unit(D. Mcleod, unpubl. data, 2001), which may reflect thepaucity of community services supporting the unit, under-lines the need for long-term effective care plans based oncomprehensive holistic assessment. Psychiatric nurses playa vital role within the MDT working on an acute unit. Inorder that the 24 hour care involved in nursing, the increas-ing focus of nursing training on biopsychosocial modelsand the changing attitudes of the nurses on this unit bemaximized to produce these desired holistic and compre-hensive assessments many changes need also to occur. Thedevelopment of theoretical framework appropriate topsychiatric nursing in the setting, increased collaborationbetween all members of the MDT and a long-term com-mitment to ongoing training would seem to be crucialamong these changes.

From a wider perspective the present study has impli-cations for future nursing research and the direction ofnursing theory in mental health settings. Nursing hasbecome reliant on the medical constructions inherent inpsychiatric diagnoses, and future research needs to focuson the usefulness of other constructions in contributing toholistic care provision in mental health settings such as theone described in the present research.

This study has limitations. First, the final phase ofgrounded theory is to develop a theory about the under-lying structure or processes that were evident in the text.We have not done this due to shortness of time. Second,the study involves a limited sample from one inpatientsetting; further research could investigate comparison withmental health nurses from other acute services. A thirdlimitation is the reliability and validity of the data analysis.The interviews took place during working hours with alimited timeframe.

The researchers are well known to the participants andalso hold opinions and beliefs concerning the unit, whichcould influence the honesty of the answers and the objec-tivity of the researchers. Fourth, the specific cultural


context and influences on nursing assessment is acknowl-edged but not specifically addressed in the present researchas this is an area that needs to be explored on its own.

ACKNOWLEDGEMENTS

We would like to acknowledge the participants for theirreflections and perspectives on assessment, as well theirtime they have put aside to be part of this research.

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APPENDIX 1: Mental health nursing assessment in an acute psychiatric ward

KNOWLEDGE

Experience vs. theory, signs and symptoms, inferior to doctors, “knowing” the client. Generic/“Jack of all trades”.

ROLES

Secondary/none, educator, partner/friend, resource person, advocate, professional, triage

ATTITUDES

Empowerment, proactive treatment, holism/bio psychosocial model, time consuming, recovery/consumer focus, caring, confident/competent

SKILLS

Observation, information gathering (informal/formal tools), reassurance, intuition, listening, negotiating, engagement, time management, documentation

SYSTEMS

Physical environment + consultant support

SYSTEMSBureaucratic, medical, Dr training school

VALUES ANDBELIEFS

Failure, fear, hopelessness, pressure, expectation

VALUES AND

BELIEFSChange, safety

+ risk, encouraging,

stigma


APPENDIX 2: The five questions asked of each participant

1. How do you see your role as a nurse with regards to assessment in mental health?2. How does your role differ to other members of the multidisciplinary team such as doctors, social workers and occupational therapist?3. What frameworks, structures, tools or models, both informal and formal, do you base your assessments on?4. How do you see your role within the initial assessment of the client admitted to the unit?5. Would you like to change anything about your role within the initial assessment process in the unit?

nurses’ perceptions of mental health assessment in an acute inpatient setting in new zealand: a...

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