Clinical Nurse Specialist Lynne Gray – Holistic Needs Assessment: Tick box or Pandora’s Box?


As a Clinical Nurse Specialist within the colorectal team in NHS Tayside I was involved in introducing the Holistic Needs Assessment as part of the Transforming Care after Treatment (TCAT) project.

When I was approached to complete a baseline assessment score of my skills in assessing patients, I immediately gave myself as high a score as possible.

Why not? I have been nursing for decades and had been in the specialist nurse role for ten years. I considered myself to be extremely skilled and experienced in the assessment of patients.

Perusing the form, I was dismayed and insulted; this looked like another ‘tick box’ exercise. Firstly, I didn’t need a form with numerous boxes ticked.

During the patients’ consultation I had my agenda which was to utilise a cancer surveillance protocol and ensure that all of the patients received all of the investigations and treatment that they required.

This was of paramount importance as I did not want to put the patient at risk if I missed anything, and this what the patient expects.

Secondly, there was no way I had the time to incorporate this huge form and the ‘Pandora’s Box” it could potentially open. Anyway, I felt that I covered all of those concerns; I just didn’t document all of it.

My first experiences within the clinics involving the use of the HNA’s was met with feelings of dread and uncertainty, but the HNA was already being given to the patients in the waiting area and they were all completing them prior to their consultation.

In my experience most of the patient’s were ticking the physical concerns which I thought was fantastic. I remained in my comfort zone, why not? Physical concerns are within my area of clinical expertise. An HNA was making very little difference to my consultations.

Then, it happened; I glanced at a completed HNA form and carried out the consultation with my usual agenda, and then I addressed the HNA. It became apparent that most of the concerns that the patient had were addressed but, the patient’s main concern was very different to what I had anticipated.

I thought that the patient’s main concern would be the results of recent blood tests and CT scans. I was wrong; this patient’s main concern was about transport to and from the hospital, as fatigue was an issue, causing problems in attending appointments. Housing was another concern, as was loneliness and isolation.

There was my fear! I had to acknowledge that I actually did not know about transport or housing, and my knowledge of dealing with loneliness and isolation was limited. In fact upon further scrutiny there were a few things I did not have a clue about.

I would have been able to direct patients to the Macmillan website for most things but, I did not know what was available within the local community. This really concerned me. However, I wanted to signpost patients appropriately I therefore actively set out to find out what was available by looking at the local authority website and networking with colleagues.

I accepted that I could not take huge amounts of time during consultations to address every concern, however, this was managed by contacting the patient after the consultation to discuss their concerns and give them information and signpost them appropriately.

Despite my initial cynicism, I now realised, that although I was experienced in assessing patients I did not always address their concerns, as I did not know what their concerns were. Pandora’s Box had opened for me, and revealed that I did not know everything.

The HNA has became business as usual for me, especially within my role as Macmillan Project Manager for the TCAT Phase two project, which has involved the setting up of a service for patients with the late effects of pelvic radiation.

Within my role the HNA has proven to be an essential, valuable assessment tool and has facilitated a documented individualised care plan for patients. Another important aspect is that the data collected from the HNA can be used to evaluate the care given to patients and influence the commissioning of future services.

The cynicism that I had towards the use of the HNA no longer prevails, as experience of utilising the HNA within my clinical practice has converted me.

I now vigorously support the use of this tool, particularly to specialist teams who do not use them on a regular basis.

I am no longer worried about opening the Pandora’s Box to patients concerns, as the learning and knowledge gained through engaging with local authority and other third sector partners has given me the confidence to deal with social concerns by referring on or sign posting on to other agencies.

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