The context of health assessment, however, can subtly change its focus directly due to nurses adopting new roles in practice. This can be seen when the term ‘patient consultation’ is introduced into contemporary nursing along with details of consultation models which have found their way into nursing literature (Hastings, 2006; Young et al., 2009; Harper and Ajao, 2010; Young and Duggan, 2010). The aforementioned authors analysed the history-taking process in relation to a patient consultation, and it is clear that this reflects advanced skills in comparison to assessment of need by current community nurses. Among other things, these skills include clarifying the complaint and identifying any red flags (Young et al., 2009;
Young and Duggan, 2010), and for those with a prescribing background these terms in relation to risk assessment will no doubt be familiar. Although current consultation models clearly have an assessment component drawn from nursing, along with recognition of interpersonal skills, this does introduce advanced clinical proficiencies that nurses moving into these roles need to develop and maintain (Young et al., 2009), while simultaneously continuing to advocate person-centred care. Advanced physical examination and interpretation of diagnostic tests are developing skills for nurses
139
Adopting New Roles
particularly within the home setting, and this highlights the continued development of advanced level of assessment, although this advanced stage of nursing is linked to a level of expertise well beyond initial registration and would be undertaken only by those practitioners who had additional education and expertise.
Retrieving guidance in the form of a model or framework that assists the practitioner to undertake a holistic assessment however is not straightforward. Some years ago, in an attempt to provide novice prescribers with guidance for assessment, Gough (2008) developed a holistic assessment model based on relevant theoretical perspectives. Although a limitation of this holistic framework is that it has not been formally validated to determine its inter-rater reliability, the content can guide practitioners and help them evaluate the assessment and consultation models that they currently use. Developing an assessment tool for a group of patients is not a new phenomenon, although failure to disseminate it through nursing literature perhaps is.
The holistic assessment tool created by Gough (2008), which can be viewed in Box 7.3, was developed with a prescribing focus in mind. That said, the tool is arguably useful for guiding community nurses to engage in a partnership approach when assessing people who have an identified health need within a community setting.
Drawing on the dimensions of health (adapted from Aggleton and Homans, 1987;
Ewles and Simnett, 1999), the Determinants of Health (Dahlgren and Whitehead, 1991; Bickley and Szilagyi, 2016) physical examination and history taking along with the prescribing pyramid (National Prescribing Centre [NPC], 1999), which includes the Mnemonic WWHAM used in pharmacies for advising about over-the-counter treatments (Box 7.4), a flexible assessment tool emerged. The tool provides guidance for community nurses to undertake a holistic assessment and although every aspect may not be assessed at the first visit, the assessment tool allows community nurses to respond to the needs determined by both the patient and nurse thus implementing a partnership approach.
While the flexibility of the assessment tool developed by Gough (2008) promotes the identification of priorities and provides an opportunity to include additional information at a later date, it can only be used to guide or prompt practitioners. This is because Trusts and NHS organisations have their own discrete documentation which is increasingly electronic, that must be completed. Developments in relation to mobile technology have promoted agile working across the United Kingdom and as a result electronic assessment forms are frequently used. While some of these electronic forms may sustain the tick box approach, the holistic tool detailed below can act as a prompt to enhance a holistic approach that involves the patient in an authentic partnership.
Box 7.3 Holistic assessment tool for community practitioner nurse prescribers (Gough, 2008)
Name and address DOB
Occupation
(hazards, working conditions, risks)
Reason for assessment/presenting complaint Physical health
Onset, duration and severity of condition
Previous history of complaint, treatment and results Previous medical history
Family history
Current health status and appearance Medication
Prescription-only medication (POM), pharmacy medication (P), general sales list (GSL) and other
Herbal/homeopathic
Known allergies (drugs and substances)
Alcohol history (can include family if client a child) Smoking history (can include family if client a child) Diet and fluids
Mobility (aids and adaptations) Dexterity (aids and adaptations) Visual acuity (aids and adaptations)
Additional physical findings specific to complaint (e.g. bowel habit, oral hygiene, broken skin)
Clinical findings (if examination required)
Additional specific assessment tool required (pain, wound, depression, nutritional assessment tool)
Emotional and psychological health Emotional effects of condition
Cognitive (ability, disability, memory)
Mental health (anxiety, worry, confusion, depression, dementia) Social/environmental health
Home occupants Dependents
Carers (statutory and voluntary)
Living conditions (housing, access, safety) Financial (needs, allowances, exemptions) Local amenities (shops, transport, sanitation) Sexual health
Impact of condition on sexuality and sexual health Spiritual health
Impact of condition on religion, beliefs, faith and culture Additional information
Box 7.4 Mnemonic WWHAM W Who is it for?
W What are the symptoms?