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The purpose of mental health nursing assessment

We have emphasized two assessment stages, the collection of information and the use of that information to infer the need for nursing or other health care interventions. Though medical diagnosis is an important part of assessment, and one we fully acknowledge, mental health nursing is interested not in medical diagnoses per se, but in the way a person functions as a result of their condition. We need to comprehend their life problems (and strengths), and to understand the context within which these problems arise. Nursing diagnoses have been advocated for this purpose, which describe the nature of a person’s problem and the effect it has on their functioning (Ward 1992).

For example, ‘I feel under threat and am angry with everyone I encounter.’ This nursing diagnosis could be present in several medical diagnoses including paranoid schizophrenia or generalized anxiety disorder. Better then to deal with the nature of the problem and its implications, than with overlapping categories. We have to confess that neither of us have been strong advocates of the term ‘nursing diagnosis’, preferring to use other, non-medical, terms to describe nurses’ activity. But we agree fully with Ward (1992) and Barker (1997) that the exploration of relationships between a person’s thoughts, feelings and behaviour is a diagnostic process, and one that nurses perform. Whether this procedure is referred to as nursing diagnosis, problem identification or functional analysis may be less important to the person in care. Barker (1997) identifies four assessment objectives (summarized in Table 7.1), the products of which provide the basis for nursing diagnoses. The information provides an assessment overview; it tells us something about the quality, content and context of a person’s health concern, its relationship to contributing factors and its effect on the person’s and others’ functioning. These data allow us to make judgements about why a problem exists and the factors that seem to be associated with it. In turn we are able to identify areas of need and so plan interventions. As a simple example consider the following problem statement, ‘Arguments with my parents mean I don’t like to be at home, so I spend my time alone in public parks where I smoke cannabis to make the day more interesting.’ We can make several judgements about this person’s need for care. The relationship between family tensions and personal isolation represents one possible area of need, and the lack of meaningful daily activity another. We might consider an opportunity to reflect on the positive and negative consequences of cannabis smoking to be a further need. The concept of ‘needs led’ assessment is an underlying principle of the NHS and Community Care Act (1990) and the National Service Framework for Mental Health (NSF) (DH 1999). What is accepted as a need will vary across and within professional groups and, more importantly, between professionals and the people in their care. Bradshaw’s (1972) definitions of need are often cited to understand these differences:

Normative needs are defined by an expert or professional. This may involve a standard below which a person is considered to be ‘in need’. For example, a community nurse who deems an isolated person to be in need of social skills training is making a normative assessment of their need.

Comparative needs are identified by comparing the service provision received by one community or population, with the levels of provision received elsewhere. This approach may provide objective evidence for unmet needs in specific areas or localities.

Felt needs are identified by the users of services and their carers. They are subjective and specific to them, for example the felt needs of a family or user group.

Expressed needs represent the translation of felt needs into action. For example, an individual who feels isolated may attend a drop-in service, or the close family of a person who experiences a psychotic breakdown may attend a carers’ group.

These different needs can conflict, for example normative and felt need and there will be occasions where identified needs have to be balanced against available resources. Thus, as Pickin and St Leger (1993) point out, a need may only be considered to exist in health care terms if there are the necessary resources to meet it. The possible relationships between these types of need and between need and resource are therefore far from perfect. But this is not true only of health care, it seems a good metaphor for life in general if we consider our own felt needs against the resources we have at our disposal. As Barker states, ‘There is no obvious solution to this conflict. This is just one nettle of the assessment process that we must grasp without too much trepidation’ (1997: 95).

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