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Keywords:

  • judicial;
  • Grounded Theory;
  • nursing assessment;
  • mixed-method review

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. BACKGROUND
  5. METHODS
  6. DISCUSSION
  7. IMPLICATIONS FOR PRACTICE
  8. CONCLUSIONS
  9. References

Background: Much skilled nursing practice is described by words that at face value appear low-tech and self-explanatory. Despite being intrinsic to practice, the term “nursing assessment” has few operational definitions. Evidence-based practice and the quality agenda makes it imperative that this term is well understood.

Objectives: To contribute to the evidence base and facilitate a greater understanding of assessment of patients as carried out by nurses through exploring the research question: How is the term “nursing assessment” used in the current health care literature?

Design: The review process, synthesised from the work of Greenhalgh et al. (2005), Clancy (2002), Egger et al. (2001), identified and assessed the quality of articles, text books, the grey literature, policy documents and databases. Glaser's Grounded Theory (GT) method was utilised to analyse the concept of “assessment” as exemplified within the included studies.

Methods: The focus for this mixed-method review is the health care literature between 1990 and 2005. Studies were identified, screened and assessed for methodological quality and data were extracted and recorded. Analysis of the included studies was facilitated using a GT approach. Possible tensions when using a mixed-method research design are acknowledged and briefly discussed.

Results: Of the 32,602 instances initially identified, 329 articles, policy documents and book extracts were closely read and after further screening, 120 articles and 12 policy documents and book extracts were analysed. Seven overlapping categories were identified, with “judicial” or “judgement making” identified as the core category.

Conclusions: Hierarchies of nursing practice, government policies and inter-professional agendas cause barriers to meaningful assessment. Informal and formal assessments and screening processes are often conflated, resulting in confusion regarding the scope and nature of the process. Differences between the rhetoric of placing the patient at the heart of the assessment process and practice have been identified.


INTRODUCTION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. BACKGROUND
  5. METHODS
  6. DISCUSSION
  7. IMPLICATIONS FOR PRACTICE
  8. CONCLUSIONS
  9. References

The purpose of this review is to better understand and contribute to the evidence base regarding the assessment of patients as carried out by nurses. Despite assertions that assessments are intrinsic to all health care practice (Elstein et al. 1978; Milner & O'Byrne 2002; Houston & Cowley 2003), carried out daily in health care settings and “a cornerstone of high quality care” (Challis 1999, p. 69), the nursing literature revealed few operational definitions for the term. For example, of six United Kingdom (UK) government policy documents referring to assessment (Department of Health [DH] 2000, 2001a, 2001b, 2002a, 2002b, 2004), only two offer operational definitions (DH 2001a, 2002a).

Etymologically in English, “assess” was noted in the 1420 Rolls of Parliament. From the Medieval Latin “assessare” or to fix a tax on, via the Anglo-French “assesser.” It is a derivative of the frequentive Latin form “assidére” (“to sit and assist a judge or assessor”), literally to “sit beside another.” Use of “assess”+“ment” has been found in documents dating from 1548 (Barnhart & Steinmetz 2001). Interestingly, these roots are echoed in this analysis of nursing assessment.

This paper describes the mixed-method review process undertaken to identify and evaluate examples of the term “assessment” in the health care literature (1990–2005) and the analysis of the review findings using Glaser's (1978) general Grounded Theory (GT) approach.

BACKGROUND

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. BACKGROUND
  5. METHODS
  6. DISCUSSION
  7. IMPLICATIONS FOR PRACTICE
  8. CONCLUSIONS
  9. References

Internationally nursing faces challenges from both within and without (Dal & Hatipoğlu 1996; Donley 2005), as much skilled practice is described by words that seem self-explanatory, appearing at face value, to be low-tech and therefore of little worth. For example, Kane's (1995) discussion of “home care” in the United States articulates the complex consequences, for patients, caused by variations in interpretation of that seemingly well-understood term. Similarly, there is a lack of consensus regarding the meaning of assessment, resulting in blurring of the term and hampering attempts to measure or monitor the process. Yet nursing is rising to the challenge of incorporating evidence, founded on clarity of concepts and theories coupled with appropriate measurement techniques, into practice (Mulhall 1998; Rycroft-Malone et al. 2002). Lord Darzi's report, “High Quality of Care for All,” emphasises the need “to measure and understand exactly what we do” (Darzi 2008, p. 48). Before undertaking evaluative exercises, it is necessary to better articulate the processes that comprise nursing assessment.

The late 20th century brought fundamental changes in health care delivery influenced by the World Health Organisation's ([WHO] 1978) emphasis of good health resulting from good primary care delivery. This has prompted a shift in investment and practice from secondary to primary care. Jarvis (2001) describing U.S. practice notes, “a revolution in health care delivery over the preceding two decades” (p. 170). Similar situations are echoed across Europe (Council of Europe 2000) with specific fundamental changes in the UK engendered by: the National Health Service and Community Care Act (DH 1990), Patients' Charter (DH 1991), fund holding practices (DH 1990) and their abolition, the thrust towards partnership working outlined within the NSF for Older People (DH 2001b) and introduced as the Single Assessment Process (DH 2002b).

WHOs focus on global demands for equitable and effective primary health care strategies and delivery remain current (WHO 2008). Additionally, the UK's new medical contracts and alterations in the health professional workforce (DH 1996, 2000, 2003; Wanless 2002) have resulted in challenges to traditional professional boundaries (Nancarrow & Borthwick 2005). Nurses in Switzerland, Germany, Thailand, Malaysia, Puerto Rico, and the UK (International Council of Nurses [ICN] 2004), noted extensions of their role in response to demographic and economic changes.

Implications for the process of nursing assessment have resulted as UK nurses now undertake formal and informal assessments alone, jointly, or as part of a team. The Single Assessment Process (SAP) (DH 2002a) was designed to curtail needless information duplication, collection, and storage. The SAP requires that health professionals from different agencies assess for needs previously outside their role and share the information they collect. The intention is to ensure a patient-centred approach to care delivery by addressing dissonances resulting from competing agendas between the narratives of health professionals and patients (McKinley & Middleton 1999; Gillespie et al. 2002; Skelton et al. 2002). However, the combination of poorly delineated boundaries between UK acute and primary health care sectors and social care (Nancarrow & Borthwick 2005), coupled with their conflicting philosophical and implementation care delivery positions, have led to the exposure of unresolved tensions within the SAP (Dickinson 2006).

METHODS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. BACKGROUND
  5. METHODS
  6. DISCUSSION
  7. IMPLICATIONS FOR PRACTICE
  8. CONCLUSIONS
  9. References

Foucault (1977) and Levine et al. (1994) note alterations in the use of terminology at times of upheaval as particularly revealing as accepted understandings are thrown into flux. Therefore, the period chosen for this review, 1990–2005, included the radical changes and challenges to nursing practice outlined above.

The identification of papers for review was facilitated by a seven-step process synthesised from the works of Clancy (2002), Egger et al. (2005) and Greenhalgh et al. (2005).

Step 1. Formulate a research question to focus the studyHow is the term “nursing assessment” used in the current health care literature?

Step 2. Eligibility criteria Eligibility, quality criteria, and data retrieval forms were based on information from http://www.policyhub.gov.uk, and the criteria included qualitative or quantitative studies of assessments made throughout Scandinavia and western Europe:

  • • 
    On health care premises.
  • • 
    In the patient's own home/care homes.

Papers referring to assessment made by American, Australian, or Chinese nurses were excluded as Pang (2003) and Pang et al. (2004) have shown the influence of role interpretation and practice brought about by cultural differences. Further, the lack of universal health care in the U.S. impacts the assessment experiences of nurses.

Step 3. Location of studies The 17 databases searched and the search terms used to identify journal publications between 1990 and 2005 are listed in Table 1. A fingertip search of relevant policy documents, and nursing textbooks and conference publications since 1990 was also made.

Table 1.  Databases and search terms
DATABASES SEARCHED 12.04.06 TO 02.05.06SEARCH TERMS USEDNUMBERS OBTAINED AFTER SCREENING FOR DUPLICATES
○ Web of science & Social Services citation index1. Nurs*“and” assess*Assess*24,862
○ Allied and Complimentary medicine (AMED)2. Patient “and” nurs*“and” assess*    731
○ ASSIA via illumine3. Nurs*“and”appraisal    22
○ Age Concern     64
○ BIDS4. Nurs*“and” evaluation* 
○ British Nursing Index (BNI)  
○ Cumulative Index for Nursing, Allied health literature (CINAHL)5. Nurs*“and” judgement    31
○ Database of Reviews effectiveness (DARE)6. Nurs*“and” review 6,467
○ Diabetes UK7. Nurs*“and” measure*   191
○ Economic evaluations  
○ Expert patient programme  
○ Health Technology Assessment (HTA)  
○ HMIC  
○ Ingenta  
○ Kings fund database  
○ LexisNexis European papers  
○ Medline  
○ National Research data base  
○ National Research register  
○ PROQUEST  
○ PsycINFO  
○ Pub Med  
○ RCN included in OVID  
○ Sigle  
○ Zetoc  
○ Grey literature searchedUsing the SIGLE and DISSABS databases, conference proceedings, abstracts and papers    22
○ Key policy documents and text booksTextbooks identified from current HEI reading lists and policy documents were finger tip searched   101

Step 4. Select studies All identified papers, nursing textbooks, the grey literature, and policy documents published between 1990 and 2005, meeting the inclusion criteria were reviewed. Examples using “assessment” with regard to nurse education, training, or referring to nurse's or patient's assessment of the workplace, colleagues or environment, were excluded during screening.

Step 5. Assess study quality Evaluation of the quality of each included study was undertaken and tabulated using the criteria presented in Table 2.

Table 2.  Adapted from Egger et al. (2001)
QUALITY APPRAISAL 
Methodological qualityNoting for discussion whether:
○ The aims and objectives of study are clearly stated.
○ A clear and answerable question was asked.
○ There was clarity in exposition of a theoretical framework.
○ There was a clear description and justification of the methods, settings and participants chosen.
○ There is sufficient information to assess the data collection process.
○ There is rigour in documentation and process.
○ There is a clear ethical basis.
○ Possible sources of bias are acknowledged.
○ The researcher's perspective is acknowledged.
○ There is a demonstration of analytical precision.
○ Any deviant cases are included and discussed.
○ The conclusions are justified by the findings.
○ Applicability and representativeness are discussed.

Step 6. Extract data A total of 32,602 records, including duplicates, were screened by title, abstract, and finally full text. Papers were excluded at each stage, leaving 329 articles, policy documents and book extracts that were closely read. A critical analysis of their research quality was made and recorded on data collection forms. Additional articles identified from reference lists which met the inclusion criteria were added to the study. Following further screening and a full text review, 120 articles and policy documents and 12 extracts from books (0.4% of the total number of hits, 40.1% of those read in full) were analysed.

Step 7. Analyse and present results Each citation's methodological quality was tabulated and all excluded studies logged. An inductive GT approach (Glaser 1978), was chosen for this exploratory study as it avoids verification of a preconceived hypothesis that forces the data into the binary of accepted or unaccepted. Wittgenstein (1992) criticises inductive methods, as it is difficult to know when they are complete. However, GT involves identification of instances at the conceptual level allowing for:

  • • 
    Transferability between incompatible studies (Glaser 1978).
  • • 
    Context determined concepts remaining contextually bound.
  • • 
    Limitation of researcher bias as concepts rather than theories are identified and challenged within the process.
  • • 
    Confounding data included and explored.

This was seen as advantageous for the analysis of a portmanteau word like assessment.

As comparisons are made at the conceptual level in GT, classification of the different types of study is unnecessary (Glaser 1978). Assessment examples covered the broadest possible spectrum. Each was read and categorised using the sensitising question of how assessment was portrayed within the study. Comparisons between the similarities and differences of the representation of assessment resulted in the creation of initial open codes. Following textual deconstruction in the theoretical sorting stage, the final stage, “selective coding,” requires that the accumulated memos and networks be explored and the researcher returns to their data producing a general theory from instances of the identified prototypes (the basic unit of a category or concept [Rosch & Lloyd 1978]) until a core category emerges. For example, the data exemplified assessments as based on predictions of how patients would respond to anticipated outcomes. At the axial coding stage, the concept of prediction was differentiated from others, using comparison across memos. Prediction was then located within the category, which comprised the methods nurses used to make decisions regarding assessment. Coding lists, diagrams and memos were then scrutinised and the central or core category “judicial” was identified at this selective coding stage. Competing methods by which nurses make assessments were identified, categorised, and are presented in Table 3.

Table 3.  Competing and core category
CATEGORYCONCEPTEXAMPLES OF MEMOS
CoreJudicial• a process of evaluation
 • concerning knowing
 • dependent on the nurses' ability
 • linked with formal processes such as diagnosis
 • often reliant on intuition or gut feeling
CompetingInfluenced by• process, participant
 • expectations
 • perceptions
 • culture
 • first impressions
 • face saving
 • flattery
 • arbitrary skill mix
 • prognosis
CompetingDependent upon• prestige
 • status
 • professional knowledge and skills
 • experience
 • intuition
 • attention
 • being there for the patient
 • rapport
 • empathy
 • power balance
CompetingTheoretically• philosophical stance
 • methodological process
 • nurse experience
 • a descriptive process
 • non-evaluative
CompetingReliant on cue identificationPsychological cues:
 • loneliness
 • well being
 • fear
 • anxiety
 • depression
 • physical distress,
 • tone of voice
 • body language
 • pain
 • spiritual distress
 Social/functional cues
 • social relationships
 • sexuality
 • safety
 • suitability of home environment
 • ability to cope
 • cognition
 • hearing
 • sight
 • oral hygiene
 • sleep
CompetingReliant on indicator identificationClinical/physical manifestations:
 • changes in blood pressure
 • pulse
 • sleep patterns
CompetingIntrinsic to the nursing process• holistic process
 • first-stage decision making
 • followed by advising
 • recommending
 • negotiating
 • asking questions

Glaser (1978) acknowledges the emergence of competing categories but recommends researchers “promote one core variable to the centre and demote others to sub-core variables” (p. 122). The core category/variable is identified as the one that best fits the narrative presented through coding of the data. Böhm (2004) notes that “core category is characterised by its formal relationship with the other important categories” (p. 274; see Figure 1 and Table 3).

image

Figure 1. Diagrammatic representation of the conceptual categories.

Download figure to PowerPoint

This paper will focus on the evidence provided by studies that consider the types of judgements nurses make when undertaking assessments.

Judicial activities based on sound professional knowledge emerged at the selective coding stage and were fundamental to all the other categories. For example:

  • • 
    Experience and knowledge that “influence” the process of judgement making are core to nursing practice (categories A and F).
  • • 
    Cues and indicators (categories D and E) that allow the patient's condition and needs to be identified are reliant on judgement making.
  • • 
    Skills, professionalism required to make assessments are influenced by and predicated upon judgements (categories A and B).

Findings

The Judicial was core to 19 papers and represented in all categories identified and can be understood in terms of the mental processes which enable judgements to be made.

Judgements—ways of knowingHarbison (1991) described two decision-making approaches:

  • • 
    The rationalist, based on
    • ○ 
      observation;
    • ○ 
      analysis;
    • ○ 
      logical response to data.
  • • 
    A phenomenological perspective, where data is
    • ○ 
      interpreted;
    • ○ 
      contextualised within the arbiter's experience (Benner 1984).

Crow and Spicer (1995) and Schmidt and Boshuizen (1993) note the concept of “illness scripts,” causally linked categories that correspond to one particular illness. Both papers suggest nurses remember an exemplar or prototype of any illness or condition and match the patient's cues and indicators, observed in practice, to this memory. Crow, Chase & Lamond (1995) refer to nurses forming “perceptual patterns which guide their internal search” (p. 210). These enable the recognition of disease.

The recognition of “illness scripts” and pattern matching imply a mechanistic approach that does not allow for the diversity and complexity of manifestations of disease processes, illness, health, or lack of well-being that require observation as part of an assessment. It may, however, be the process required for the interpretation of diagnostic cues and biomedical findings, such as blood results, X-rays and ECGs.

Appleton and Cowley (2004) found that guidelines based on causative mechanistic assumptions of this kind are used only if found to have a value and are often actively resisted. Both they and Niven and Scott (2003) describe the use of professional judgement to identify those for whom such guidelines are appropriate. Similarly Lake and John (2001) identify “practice wisdom” as underpinning judgements.

Latimer (1998) sees assessment as a cognitive process combining information gathering, problem identification, and diagnostic reasoning. This implies a metaphysical stance with patient's needs “out in the ether” waiting for identification by the nurse.

Hamers et al. (1994) and Crow, Chase & Lamond (1995) also link assessment with medical diagnosis suggesting assessment as a combination of surveillance, driven by the search for evidence to support a particular model of illness, that is synthesised with experiential knowledge. Sainfort and Booske (2000) describe this process as “constructing preferences and applying them” (p. 51).

Diagnostic reasoning comprises a search for evidence to support the hypothesised medical diagnosis and is akin to the concept of “illness scripts” (Benner 1984; Schmidt et al. 1990; Crow & Spicer 1995). Crow, Chase & Lamond (1995) note that diagnostic reasoning is an integral part of Elstein et al's (1978)“nursing process,” concluding that assessment is based on diagnostic reasoning. However, their examples of assessments have more in common with evaluation or appraisal of a patient, falling short of a medical diagnosis.

Crow and Spicer (1995) refer to “domain-specific cognitive structures” (p. 414) that are similar to “illness scripts” and enable the information gathered to be categorised. Sainfort and Booske (2000) note that in medicine, these domains equate with the medical specialties and are experientially developed. This contrasts with Luker et al.'s (1998) suggestion that a nursing diagnosis, or assessment, is a synthesis of both scientific and analytical judgements.

Thommessen et al. (1991) identify assessment as part of a screening tool. Green and Watson (2005) note that screening and assessment are often used interchangeably, as in the Essence of Care (DH 2001a). However, Green and Watson assert that nutritional assessment is a more complex process than nutritional screening, suggesting these two processes are not in this instance synonymous. Bazian Ltd.'s (2005) systematic review of nurses' pre-operative assessments identified from one study of 60 children prior to orthopaedic surgery (Rushforth et al. 2000) showed that nurses were “better” at history taking than senior house officers (SHOs). “Better” indicated that nurses identified 94% of the detectable problems identified by a senior specialist registrar in anaesthetics. Comparison revealed SHOs detected 42% of these problems in the same cases.

Bazian Ltd.'s (2005) review included a study, undertaken by Stables et al. (2004), who found more people reporting they were “very satisfied” when assessed by a nurse, than those assessed by a house officer. Differences in these findings highlight a disparity between medical and nursing assessments in these instances.

Luker et al. (1998) and Lake and John (2001) note the paucity of precise information available for nurses to evidence their judgements. Lake and John's (2001) work using fuzzy logic defines assessment as “an intuitive process in that the expert uses inexact or imprecise information to make judgements based on nursing knowledge and practice wisdom” (p. 10).

Luker et al. (1998) suggest nurses develop an implicit “risk benefit analysis” to overcome these information deficits. Conversely, Crow, Chase & Lamond (1995) conclude the accuracy of decision-making depends on the quality of information gathered. Additionally, Jordan (2002) notes that categorisation is required to facilitate clinical assessment, which imposes “artificial assumptions and boundaries” (p. 422) on the nurse patient interaction.

Nurses deliberately or unwittingly obscure the process of assessment because, as McIntosh (1996) notes, their thought processes cannot be directly observed. When asked, district nurses find these processes hard to articulate. Further, Meerabeau (1992) notes, when questioned regarding their thinking, nurses often re-interpreted their activities to make them appear rational.

IntuitionCrow and Spicer (1995) see intuition as a nursing explanation of the cognitive skill of nursing assessment. Six other studies refer to the importance of empathetic feeling to intuitive decision-making. Morse et al. (1994) explore the practice of nurse assessment, including sensing or “reading the patient” in need, and list five metaphysical concepts to “describe the process of sensing;

  • • 
    intuition;
  • • 
    knowing;
  • • 
    countertransference;
  • • 
    embodiment;
  • • 
    empathy” (p. 234).

Both Morse et al. (1994) and Meerabeau (1992) acknowledge that uncovering information regarding intuition by interviewing nurses is difficult. Paley (1996) challenges Benner's (1984) assertions regarding “expert” decision making as the conscious “highly intellectual analysis” of the novice that is replaced by “intuition.” Stating that Benner's notion of intuition is just something that experts do, Paley asks, what do non-experts do when carrying out the same functions and in what ways do their actions differ from intuition?

Gut feelingGodin's (2004) research demonstrates the importance of “gut feeling” in risk assessment for community psychiatric nurses, although he questions the exact nature of intuition and asks whether if it can be discerned from “whim or prejudice” (p. 353).

Pyles and Stern (1983) define their term “nursing gestalt” as a matrix, linking knowledge, past experience with cue identification and “gut feeling.” They described this as noting if the patient's observable, but not necessarily clinical, condition falls significantly outside their usual pattern. Nurses interviewed based this feeling on their intuition; one noted that despite the stability of monitor readings, “everything about the patient looks the same yet I just have the feeling something is going to happen” (Pyles & Stern 1983, p. 54).

Intuition a “subconscious” responseWalker (2003) categorises aspects of assessment, which cannot be verbalised as events, as examples of intuition. Manias et al. (2004) refer to this as happening at an “unconscious” level. In their study of 12 graduate nurses, each observed for two hours on a busy acute ward, they observed two instances of decisions attributed to intuition. Each occurrence was in connection with possible interpretations of a patient's behaviour. Intuition is included in Cader et al.'s (2005) Cognition Continuum theory of judgement making, referred to as a rapid “unconscious” form of data processing. Eraut (1994) contends that professional deliberations consist of both intuition and analysis. Benner and Tanner (1987) describe intuition as “understanding without rationale” (p.23), while Rew (1986) asserts that intuition is “knowledge acquisition without a linear reasoning process” (p. 37).

Predictive Quality of Assessment

Benner (1984), Yates (1990), Molony and Mags (1999) and Kennedy (2002) note that assessments contain a predictive quality. For example, when a patient's condition is assessed to decide what help they will need, decisions are based on predictions of patient's responses to the potential models of help available. Crow and Spicer's (1995) study analysing nursing judgement showed these anticipated outcomes of interventions or “recovery” were a core deciding factor in how nurses view a patient's “hold on life” (p. 419).

Yates refers to this predictive quality as “a likelihood judgement” of the patient's future performance with the identified need resolved. This predictive aspect was noted in 26 studies that directly referred to intuitive assumptions.

Experience and Expertise

Thirteen studies listed expertise and experience as necessary assessment pre-requisites. Luker and Kenrick (1995) and Kennedy (2002) refer to an experiential knowledgebase that underpins assessment judgements made by nurses. However, they do not differentiate between knowledge, science and experience. Crow and Spicer (1995), Hovi and Lauri (1999) and Richards et al. (2004) note that expert assessments differ from novice assessments and Crow, Chase & Lamond (1995) state that experts solve problems faster than novices. Schraeder and Fischer (1987) describe intuition as expert knowledge that is “acquired and refined with experience” (p. 239).

Marks et al.'s (1991) study of nurses' and doctor's subjective predictions of patient death noted that nurses were more accurate than doctors in these predictions, and further that experts zeroed in on what was important. This, they suggest, was the cognitive response of “seen it before; recognise it;” however, this seems to be the same mechanistic process that Sainfort and Booske (2000) described underpinning medical diagnosis. Therefore, if doctors and nurses are both using the same cognitive process, what might explain the nurses' greater accuracy in predicting death?Pyles and Stern (1983) noted the emphasis critical care nurses put on experience when developing “gut feelings” and intuition. They identify the nursing gestalt as a process that the “neophyte nurse” learns from experienced nurses.

Clough (2002) tracked 39 referrals for community care assessment and compared the different process and content when made by social care professionals and service users or carers. The results were found to be “indistinguishable from assessment for a limited range of social care services” (p. 2). Outcomes were discipline orientated and directed by service resources rather than identified needs. This type of assessment would fit into the pattern recognition noted by Marks. By implication, Clough sees it as being less than ideal, concluding social services departments were not translating assessment and care management into practice.

Lake and John (2001) note the “complexity of context and degree of acuity of nurse patient interaction” (p. 10). They identify aspects of “holistic assessment” whilst addressing a primary focus on “physical/medical conditions or diagnosis” (p. 10), further noting the ability of nurses to gather imprecise information that they translate into “recognisable fragments of knowledge” (p. 10).

Lake and John (2001) also note the specific use of types of language used by nurses for assessment and handover. Their example, “stable,” when used as a descriptor is not measurable in the same way as “tallness,” and yet it has a precision when used in this context.

Nine additional studies referred to familiarity with the patient or their prognosis, or having nursed others with the condition, as concepts that enable decision making. The importance of the context of care is highlighted by Sbaih's (1998) research where first impressions of the patient played an important part in judgement-making in triage for accident and emergency treatment.

Diagnosis—A combination of Inductive and Deductive Reasoning

The literature (Elstein et al. 1978; Latimer 1998) indicates that both inductive and deductive reasoning were required to make a diagnosis. They identified four stages in hypothetic-deductive reasoning, firstly cue recognition, which they described as collecting information regarding the patient's signs and symptoms. This was followed by hypothesis generation and cue interpretation where possible matches between the hypothesis and the assessed signs and symptoms were made. This process culminated in hypothesis evaluation.

DISCUSSION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. BACKGROUND
  5. METHODS
  6. DISCUSSION
  7. IMPLICATIONS FOR PRACTICE
  8. CONCLUSIONS
  9. References

Mixed-Method Approach

This study borrows from the systematic review process, a quantitative research method, to locate, retrieve, select, and screen examples from the literature that are then analysed using the qualitative approach of grounded theory. Much has been written regarding the integration of qualitative and quantitative studies within the same review (Thomas et al. 2004; Dixon-Woods et al. 2005; Harden & Thomas 2005) or the “phase method,” (Barton & Lazersfled 1952), where qualitative studies are used for hypothesis generation then verified by quantitative procedures. Creswell's (1998) discussion of the combination of paradigmatically different research methods in the same study describes a shift from a qualitative versus quantitative debate to consideration of the research process as a continuum between these two poles. Hammersley (1992) argues the “process of inquiry is the same whatever method is used” (p. 182).

The searching, identification, screening, and quality assessment processes of this study was rigorous and replicable (Egger et al. 2001). However, Egger et al.'s systematic review analysis is predicated on the assumption, inappropriate for an exploratory study, that studies are outcome orientated. Compromises regarding the quality assessment of studies were needed as not all published studies, with stringent word limits, explicitly state all components of quality (Table 2) and omission, in the publication, need not indicate absence in the original research.

Limitations

Ideally, more than one reviewer is used in order to reduce personal subjectivity and bias. However, bias may be partially ameliorated when using GT as it requires the researcher to challenge all the memos generated as every converse case is considered.

Implication of Findings

We have found that assessment has a multiplicity of meanings and nuances. The question remaining is how better to understand the term and create a matrix of these meanings that will have relevance to practice? Studies have shown that when assessing, nurse's judgements are “influenced by” (category A) a patient's prognosis (Hamers et al. 1994; Lake & John 2001) and the severity of their condition (Crow & Spicer 1995). Kratz (1978), Hamers et al. (1994), Crow & Spicer (1995) and Thompson et al. (2005) suggest that nurses focus on alleviating the needs of critically or terminally ill patients. However, patients with chronic or stable conditions receive a less needs-focused assessment.

Analysis of the literature has identified the following features across the various assessment types. Assessment is:

  • • 
    a dynamic process (category F);
  • • 
    requires nurses to “attend” to patients (category B);
  • • 
    requires the establishment of rapport and trust (category B);
  • • 
    has consequences for a patient's future (category G);
  • • 
    gathers information (category F);
  • • 
    is undertaken by nurses who have received post-qualification training (category B);
  • • 
    involves expertise and domain-specific knowledge (category G).   It is influenced by:
  • • 
    ethical considerations (e.g., nursing professional code of conduct) (category C);
  • • 
    government policies (category A);
  • • 
    resource allocation (category A);
  • • 
    culture and agenda of the employing organisation, the assessor and those assessed (category B);
  • • 
    by nurse's and patient's own life experiences (category B).

The literature suggests assessment combines processes of induction, deduction, and analytical reasoning, linked with intuition and practical, theoretical and experiential knowledge. Screening and assessment are often incorrectly conflated as screening requires only cue recognition and inductive reasoning using the binary of, is it A, or not A. In contrast, the following factors were used by nurses as part of the judicial process of assessment:

  • • 
    cue recognition (categories D and G);
  • • 
    observation classification and prioritisation (categories F and G);
  • • 
    predictive estimation of probable outcomes (category G);
  • • 
    intuition (category B).

Additionally, Lake and John (2001) note assessment involves clarification of imprecise and obscure information, although they do not identify processes used.

IMPLICATIONS FOR PRACTICE

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. BACKGROUND
  5. METHODS
  6. DISCUSSION
  7. IMPLICATIONS FOR PRACTICE
  8. CONCLUSIONS
  9. References

Department of Health (1992) policies in the UK have led to changes in composition and skill-mix of community and acute nursing teams for policy, demographic, and managerial reasons. These changes have resulted in the intimate caring practice previously carried out by UK registered nurses being devolved to unregistered staff. The literature suggests rapport and trust are established while sensitively carrying out such intimate tasks (Twigg 2000; Niven & Scott 2003; Appleton & Cowley 2004) and that rapport and trust between nurse and patient are essential for effective assessment (Maher & Hemmings 2005; Dickinson et al. 2006).

Many papers note differences in the quality of expert and novice assessments with newly qualified nurses learning from the experiences of their established colleagues (Pyles & Stern 1983; Crow & Spicer 1995; Hovi & Lauri 1999; Richards et al. 2004; Darzi 2008). Changes in skill mix and the devolution of core practice to unregistered colleagues militate against both optimal assessment conditions and the preceptorship needed for expertise to develop. Therefore, nurse managers need to consider the importance of mentorship and the retention of experienced nurses. Additionally, although the intimate aspects of care delivery appear to be low-tech and suitable for untrained staff, they are the interactions that facilitate the establishment of trust and rapport (Kennedy 2002) between nurses and patients (category B).

Resource allocation further constrains assessment with practitioners reluctant either to discuss or record unmet needs with service users for fear of legal ramifications (Bryans & McIntosh 1996; Ellis 2000; Kennedy 2002; Niven & Scott 2003; Appleton & Cowley 2004). Assessment must reflect the identification of genuine need and not consist of a process of distributing available resources.

Additionally, financial and staffing constraints have led to limitations being imposed on the number, length, and frequency of home visits to patients by staff. These restrictions constrain the dynamic process of assessment that may require frequent reviews and contacts (Crow, Chase & Lamond 2005; Appleton & Cowley 2004) and can impose target-led limitations on assessment practice.

Kennedy's (2002) study records a community nurse's observation: “once you start chatting with them, they start to give you information you need without even asking” (p. 716). This begs two questions: firstly, why are these patients not self-assessing? Secondly, how aware are patients that the information they give when “chatting” may be used in ways they may not anticipate or desire?

Griffiths et al. (2005) noted the absence of research into or working definitions of self-assessment, indicating three core elements:

  • • 
    self-reporting;
  • • 
    self-completion;
  • • 
    self as potential beneficiary.

Kennedy's (2002) study of nursing practice provides evidence of gate-keeping, paternalism, and clandestine judging of patients, factors that limit self-assessment opportunities.

Whilst evaluating congruency between nurse's and patient's assessments, Nekolaichuk et al. (1999) conclude that nurses are able to assess as accurately as patients. Conversely, therefore, patients can assess as accurately as nurses. Self-assessment would seem a more desirable practice than imposing opinions constructed by others and reflecting their experiential, cultural, and institutional agendas. Further consideration is required as to the effect on both patient and nurse of co-assessment and the cultural agendas that health care professionals from different backgrounds bring to this task.

Nursing theory, policy and practice guidelines indicate the centrality of translating patient's decisions into care delivery. However, representation of the unique quality of individual experiences and symptoms appear diluted in assessment practice. Sbaih's (1998) study of accident and emergency nurse's assessments, found if a mismatch between the patient's narrative and the nurse's assessment was apparent, the patient's motives were questioned.

CONCLUSIONS

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. BACKGROUND
  5. METHODS
  6. DISCUSSION
  7. IMPLICATIONS FOR PRACTICE
  8. CONCLUSIONS
  9. References

The literature relevant to the analysis of assessment has been identified and evaluated using a mixed-method process in answer to the question: “How is the term ‘nursing assessment’ used in the current health care literature?” Overall, this study has demonstrated the complexity of ideas, practices, and presumptions that are encapsulated in the everyday term “assessment.” The themes identified by the analysis (Figure 1) indicate that “judicial/decision making” is at the core of nursing assessment.

Areas for further research include the exploration of the conflation of “formal” and “informal” assessments and screening that has led to confusion regarding the scope and sophistication of the process under review.

This review raises the need for further exploration of efficacy of the current delegation of intimate care to unregistered staff and the effect this may have on trust and rapport building, which is so vital for meaningful assessment.

Discrepancies between rhetoric and practice regarding assessment have been recognised. These may be addressed by repositioning the patient as central to the process by focusing on their embodiment of the experience of illness rather than its medical or nursing construct. Patient self-assessment should be considered wherever possible.

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