Assessment - mental health and wellbeing

Mental health assessment is an essential aspect of effective nursing care. Assessment is part of a process composed of planning, implementing, and reviewing care. Assessment can take two forms: comparative, where data is collected using validated tools or exploratory, by gaining further information via exploration about a specific problem (Thomas and Drake, 2012). A mental health assessment aims to establish an understanding of a service user's mental health needs at the time of the assessment. Relevant information is gathered to make up a picture of the service user's mental health from a biopsychosocial context. This allows for a shared understanding of the service user's experiences, strengths, capabilities, and coping strategies. Once collated, the information derived from the assessment is used to inform treatment.

Mental health assessments are often biopsychosocial to allow a holistic view of a service user. These assessments cover the nature and degree of the mental health problem, psychological strengths, what is vital to the service user, their personal beliefs, values and rules for living, quality of life, cultural and spiritual aspects, support networks, family history and upbringing, financial and educational attainment, mood, motivation, mental state, risk, physical health and past experiences of any involvement in psychological and physical health services (Wrycraft, 2015).

Assessment requires the exploration of a broad range of areas. Biopsychosocial issues overlap and are not assessed in isolation; it is vital to understand the interrelationship between needs and problems to enable the nurse to prioritise and create an effective care plan (Moon and Trenoweth, 2018).

The service users must know why this information is being asked of them and what will happen to the information once collected.

To conduct a thorough and effective assessment, a range of skills and attributes that all fall under the umbrella of effective communication are required. These include:

• An understanding of the rationale of the assessment

Before conducting an assessment, the nurse must understand why it is required and be aware of what each question is looking to explore and what will happen following the assessment. The nurse must also articulate this to the person being assessed.

• Effective interpersonal skills

A nurse needs to be an effective communicator. The therapeutic relationship needs to be established quickly and is done so via the art of communication. Both verbal and non-verbal skills are required. Verbal communication includes questioning; direct closed questions allow for short answers, whereas open-ended questions are helpful if you want the service user to describe and elaborate on the answer. Appropriate use of silence is also essential during assessments; allowing time

The assessment procedure includes:

1. Before approaching the service user, ensure enough time to conduct a thorough assessment. You also need to be aware of what assessment you are conducting and read any history available on the service user.
2. Be prepared; if you are recording on an electronic device, ensure it is working and you have logged on before meeting with the service user. Having a pen and paper is also helpful if any technical faults arise. It is also beneficial to provide a glass of water and to have some tissues available.
3. Once the room and surrounding environment are ready, the service user should be approached with a warm welcome and invited into the room. Ensure you have the right person and inquire if any additional people are there with the service user. If carers or family members accompany the service user, be clear to check that they are happy

With any interaction, there will always be the possibility of risk. When conducting a mental health assessment with a service user, this could be the first time you have met each other and so have no experience on how they will feel and react when questioned about their mental health. It is essential to be aware of your exits and to be able to clarify any miscommunications and use de-escalation skills if the service user becomes distressed or agitated.

Language, physical or cognitive barriers can also lead to complications; these can be overcome by exploring if there are any of these barriers before the assessment is scheduled. Asking if there are any language or physical issues beforehand allows you to prepare an interpreter or an alternative setting.

Ensure you understand all the questions you will ask before starting the assessment. Follow your workplace guidance and policies on assessment tools they want you to use, but also collect any assessment tools you find to build up your catalogue of tools that can be used to fit different assessments. Upon completing a thorough assessment, a collaborative care plan should be made.

References

Bach S, Grant A, Bach S. Communication & interpersonal skills in nursing (3rd edn). SAGE Publications Inc; 2015

Moon N, Trenoweth S. Mental health assessment. In: Wright, KM, McKeown M (eds.). Essentials of mental health nursing. 2018. SAGE; 2018.

Nursing and Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018. https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf (accessed 23 November 2022)

Thomas M, Drake M. (Eds.). Cognitive behaviour therapy case studies. SAGE; 2012.

Wrycraft, N. Assessment and care planning in mental health nursing. Open University Press; 2015.