In this essay, I will discuss my experience with an acute mental health service user which occurred while I was on clinical placement in this care setting. Medication concordance in major depression is an important part of illness management and will be the emphasis of this paper. First will be a discussion of the service user’s profile including her background, history, and social status which aims to generate an understanding of the factors contributing to non-concordance. Consistent with the Code of Conduct of the Nursing and Midwifery Council (2015), care will be taken to uphold the privacy of the service user and the confidentiality of health information. Towards this end, a pseudonym is used in this paper to refer to her and other information that may lead to her identification is omitted.
Second, theoretical frameworks supporting the approach to care are discussed. One is the nursing process that gave rise to a personalised care plan in collaboration with other disciplines involved in the service user’s care. Specifically, the nursing process involves assessing the client, identifying problems and needs, planning how to address these problems and needs, and implementing and evaluating the plan (Castledine, 2011). Another is patient engagement as an approach that promotes optimal treatment outcomes. A third framework is holistic care embodied by the biopsychosocial approach which promotes a perspective of the health as influenced by the biological, psychological, and social factors (Ryan & Carr, 2010).
Third, I will reflect on this experience in order to learn from it and enhance my future practice. Gibb’s Reflective Model enables a systematic approach to reflection and is employed in this paper. In using this model, I will describe the experience, explore my thoughts and feelings, evaluate the positive and negative aspects, and analyse further what had happened (Burzotta & Noble, 2011). Subsequently, I will conclude about alternative or additional actions that could have been taken and create an action plan on how I will approach a similar situation further in my practice (Burzotta & Noble, 2011).
Lastly, I will briefly summarise my experience and draw conclusions in regards to working with service users to promote medication concordance.
Service User’s Profile
Maria is a 33-year-old female diagnosed with moderate depression that has recurred 7 months ago. She was born to an Asian mother and a British father and had immigrated to the UK before she began primary school. Her parents divorced when she was young and had been in the care of her mother. She has a degree and used to work as a sound engineering technician but lost her job and is now unemployed. She is divorced from a physically abusive husband and has an only child aged 10 years. Following her divorce more than a year ago, Maria and her daughter moved back to her mother in a community that has ranked in the top ten most deprived areas in England. However, she had many friends and relatives there.
The divorce and her experience of physical abuse had led to moderate depression with one suicidal attempt. At the time, she could not function and such impairment even in self-care and the care of her daughter led to her losing her job and her cousin stepping in to help. Maria was brought in by her mother for treatment. Selective serotonin reuptake inhibitors (SSRIs) combined with psychotherapy was recommended. Medications will initially be for 6 months and then reviewed if another 6 months, at the maximum, is appropriate consistent with guidelines (Allison, Flowerdew & Elmslie, 2012).
Maria was non-concordant with her medications and follow-up visits during the initial trial of pharmacotherapy but her mother’s unwavering support eventually led to optimal concordance and remission of symptoms. The side effects and forgetting to take her pills were her primary reasons for non-concordance. She had experienced constipation and dry mouth as side effects which she had not expected. Furthermore, continuing medications and psychotherapy was recommended after 6 months but she refused. She cited not understanding why continued therapy is warranted as the reason for her refusal. Maria had 5 months of remission but then her mother died of a longstanding heart disease. Shortly thereafter, Maria was admitted again for moderate depression this time brought in by a cousin. She did not report any suicidal ideations.
Engagement of Service User and Family
Engagement entails the collaboration between the service user, family members, and health professionals in the development of a care plan (Cree et al., 2015). Collaboration requires open communication in that information is openly relayed to the client and family (Wilson & Kenkre, 2009). It further requires actively listening to questions and concerns and addressing them appropriately (Wilson & Kenkre, 2009). Collaboration is also allowing the client and family to make informed decisions regarding their care based on their values, needs, and preferences (Burns et al., 2014; Cree et al., 2015). It departs from the traditional paternalistic point of view wherein it is the health care professional who makes decisions on behalf of the client who only follows what he or she is told. Giving the client and family control over the care plan promotes ownership of it and in its implementation (Burns et al., 2014; Wilson & Kenkre, 2009).
Engagement was achieved through warm, emphatic, and respectful communication with Maria and her cousin and the use of layman language to promote understanding (Brown & Gray, 2015; Taylor et al., 2013). More importantly, communication was non-judgmental in order to be therapeutic as opposed to pointing out the recurrence of depression as a weakness or failure on the client’s part. This communication strategy has been pointed out in a study of carers’ thoughts about engagement (Burns et al., 2014). The psychiatrist amply explained the treatment options, with non-treatment also an option, as well as the benefits, risks, and expected outcomes of each and what behaviors the client would need to enact to achieve the best outcomes. Questions were also encouraged. As such, communication regarding treatment adhered to current practice guidelines (NICE, 2013; Tacchi et al., 2012).
Furthermore, the NICE (2013) highlights the need to obtain the client’s informed consent prior to treatment initiation and was secured in orally and in writing. Informed consent upholds client right to autonomy (Selinger, 2009). The goal of the care plan, the steps needed to achieve the goal, and the responsibilities of the health care team, client, and relative were jointly decided upon. This demonstrates how power is effectively shared with the client in a partnership rather than a hierarchical relationship where health experts make decisions for clients (Mostow et al., 2014). Engagement in this manner has been shown to be effective because it promotes collective ownership of the plan and its outcomes (Cree et al., 2015) as well as upholds the self-worth and dignity of the client (Burns et al., 2014). Engagement also builds client trust in service providers thereby enabling continued utilisation of care which is vital especially in chronic mental health conditions (NICE, 2013).
The nursing process permits a scientific approach to meeting client needs (Castledine, 2011). Given that the current admission is a recurrence of depression, the factors that gave rise to recurrence requires an assessment in order for such to be modified thereby preventing a similar outcome. The client has a history of non-concordance with medications and psychotherapy because of side effects, unintentionally forgetting, and inadequate understanding of her treatment. As such, non-concordance validates the literature which states that this behaviour arises from patient-related and service provider-related factors thereby requiring a multifaceted solution (Brown & Bussell, 2011). A proactive approach to preventing non-concordance is warranted given that this is often overlooked in patients with mental health problems (Kane, Kishimoto & Correll, 2013). The goal is concordance characterised by the client taking the recommended medication dose at the right time and for the agreed upon duration (Horne et al., 2013). Another goal was concordance with agreed-upon visits and lifestyle change.
Planning of Care
The plan of care was developed by a multidisciplinary team consisting of a psychiatrist, nurse, psychologist, care and support worker, and a community mental health nurse together with the client and her support person. The multidisciplinary biopsychosocial approach is warranted given the mental health, social, and psychological needs of the client that must be addressed concurrently in order to achieve the goal of remission. The plan was to initiate SSRI therapy and high-intensity psychotherapy consistent with guidelines (NICE, 2013). The dose of SSRI was reduced compared to her previous dose to minimise the occurrence of side effects. Psychotherapy will include interventions for bereavement-related grief. The client preferred cognitive-behavioural therapy.
In addition, the client also had gained much weight so that she is now borderline obese. As such, lifestyle change in terms of nutrition and physical activity is also an important intervention to reduce the risk of diabetes and cardiovascular disease. At the same time, exercise has been found to be helpful in the management of depression (Berk et al., 2013; Linden, 2011). Moreover, the client’s need for social support was addressed by letting her know of groups and other resources in the community that she can turn to. To ensure the acceptability and effectiveness of care, service user and family engagement was secured.
Furthermore, Brown and Gray (2015) highlighted that medication concordance is vital to improving symptoms but interventions should be based on evidence and not on service providers’ beliefs. An evidence-based intervention considers the results of research, professional experience, the context of service delivery, and client preferences (Pearson et al., 2005). Meanwhile, Mackay, Taylor and Patel (2011) recommend the use of multiple interventions that address specific client barriers. There are several interventions to increase medication concordance identified in the literature. These were discussed with the client to identify the most appropriate strategies in consideration of her preferences and situation.
One strategy is education on the management of the side effects of SSRIs. Client education included the importance of medication adherence given the progressive manner in which antidepressant effects are achieved. In addition, it was emphasised that constipation and dry mouth are often experienced initially but that these side effects go away over time. Sugarless sweets or gum and acid-tasting fruits or drinks were recommended to stimulate salivation and help alleviate dry mouth (Virdi, 2012). Adding fruits and vegetables and ensuring sufficient fluid intake were recommended to prevent constipation with psyllium to be taken as a bulking agent if constipation continues despite dietary changes (Goroll & Mulley, 2011). Exercise was also recommended. As such, constipation management also addressed the lifestyle change needed to manage her weight. However, it was also emphasised that the client can request for a review of her current medication if side effects do not abate over time and despite self-management.
Implementing and Reviewing of Care
The plan indicated who was responsible for accomplishing the different tasks. The client’s and support person’s responsibilities were also delineated. The client’s progress was followed-up via telephone and home visits were done to provide additional education and support. Furthermore, reinforcement was given to positive behaviors enacted by the client in terms of lifestyle change, self-management of SSRI side effects, and medication and psychotherapy concordance. Review of treatment was conducted every 3 months as preferred by the client.
Reflective Account Using Gibb’s Reflective Model
Reflective learning is an effective way to improve individual practice (Morrow, 2010). Given how medication non-concordance negatively affects client outcomes and that service providers have a role to play in improving concordance, this reflective account relates to the client’s medication management.
The experience pertained to a client who suffered multiple losses and a past experience of intimate partner violence and who was readmitted for relapse of moderate depression. Non-concordance played a role in the relapse as she refused to continue antidepressant medications and psychotherapy after 4 months of treatment and initial reduction of symptoms. Lack of knowledge of the treatment, medication side effects, and forgetting were the reasons for non-concordance.
Thoughts and Feelings
It was nice to know that the client’s care improved the second time around. Non-concordance and the service-providers’ role in it was recognised as a factor contributing to the relapse. This led to improvements such as better client engagement, providing information sufficient for genuine informed consent, and health education pertaining to medications management including the management of side-effects and forgetting. That the client herself expressed appreciation and greater satisfaction with the assessment, care planning, and implementation of her care during my placement as compared to her previous admission reflects a significant change in practice. This corresponded to the recent implementation of new guidelines. It reinforced the belief that change aimed at practice improvement represents ethical practice as it prevents harm and promotes what is best for clients. I felt positive that client outcomes would certainly be better this time around.
The only negative aspect about the experience was the knowledge that the unfavourable outcome in the client was something service providers were accountable for. Overall, the experience was mostly positive given that guidelines, holistic care, and evidence-based practice were considered and the client was satisfied with her care where satisfaction is one indicator of quality service.
The experience demonstrates the importance of continually assessing practice, identifying gaps between current and ideal practice, and implementing change for improvement. It also demonstrates the utility of employing patient engagement (positive communication and collaborative decision-making), the nursing process, and the biopsychosocial approach in providing care to patients with depression. Specifically in relation to medication non-concordance, utilising evidence-based practices ensure that appropriate and effective strategies are employed to increase concordance. Asking the client if he/she is satisfied with the care received can be a good way to gauge whether an evaluation of practice and practice change are necessary.
Nurses should be knowledgeable and skilled in engaging patients, providing holistic care, implementing evidence-based practice change, and evaluating the quality of care with the intent of improvement. Concordance should be recognised as an important aspect of medication management in patients with chronic or relapsing depression.
Specifically in relation to medication management, I will make sure to address concordance when caring for patients with mental health conditions such as depression. Using the nursing process, I will assess for biopsychosocial factors that can negatively impact concordance and engage the patient and carer to plan ways to ensure optimum medication management. The plan will address client knowledge about medications, coping with side effects, and preventing unintentional missed doses.
The assignment reinforces the importance of reflective practice in order to improve the care one provides. A structured reflection is best because it facilitates progression to a higher order of learning beginning with a description of the experience and then analysing, evaluation, and concluding about it. Eventually, it is patients who will benefit from nurses’ reflective practice.
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