Medication Compliance among Male Schizophrenics - Essay Example

Change Management and Evaluation: Medication Compliance among Male Schizophrenics Introduction Evidence-based approach in healthcare services delivery has become the current trend in the healthcare system. The delivery of care is no longer based on standard forms of treatment, but is now based on effective interventions supported by evidence from the clinical practice and research or clinical studies. Such evidence supports best and most appropriate care for individual patients. The importance of patient-centered care is also highlighted by evidence-based approach, especially in terms of what the patient would actually prefer among different types of interventions. Working with the patient and making them active participants in their care is therefore a necessary part of evidence-based practice. This paper shall discuss change how evidence-based practice can change professional practice, specifically in relation to medication compliance among male schizophrenic patients. This study would utilize the Care Pathway Model in order to describe how evidence-based practice can be implemented to professional practice. This study shall also explain how I would undertake an audit process to establish if the change in professional practice has influenced health outcomes. Body I would utilize the evidence-based approach to change professional practice in schizophrenia care by applying evidence from the different lessons learned in the professional practice. These lessons shall be based on research studies, compiled and systematically assessed, specific to issues and remedies for schizophrenia. These studies would have to relate to medication practices, psychosocial interventions, information technology, as well as state and federal-level interventions. Recommendations for future directions of practice can be secured from such lessons and from such studies supporting evidence-based care. I would use the integrated care pathway model in order to implemented changes in the care of male schizophrenia patients. Integrated care pathway is an express agreement between local staff members and workers, within multi-disciplinary and multi-agency settings, with the goal of establishing comprehensive service for clinical or care groups on the basis of current perspectives of good practice as well as available evidence or guidelines (Goodwin, et.al., 2012). It is crucial for the group to agree to the communication, the record keeping as well as the audit. There must also be systems set in order to note when service users have not received any care input indicated by the pathway in order to remedy omission. Local groups must therefore be committed to consistent improvements in the integrated care pathways supported by new evidence on service developments and problems in implementation (Goodwin, et.al., 2012). The essence of the integrated care pathway in this case is for the team working well with each other in order to promote change (Cheng, et.al., 2012). Within the team, components like communication, record-keeping, and auditing are important in order to provide evidence-based outcomes for the care of schizophrenia patients, especially in relation to better compliance with medications. For majority of mental health patients, including schizophrenia patients, compliance with medication intake can sometimes be difficult (Cheng, et.al., 2012). The side-effects and adverse effects of psychopharmacologic drugs can be very undesirable for patients, and sometimes, inevitable. These side-effects may include drooling, dizziness, lack of appetite, erectile dysfunction, insomnia, and other adverse effects which often decrease the quality of life of patients (Rungruangsiripan,, et.al., 2011). Hence, some patients often choose not to take their medications because they simply do not want to go through the side-effects of the medications. Low compliance with medication intake is therefore common among those mentally ill. Some institutionalized patients have actually been known to use various tricks in order to make it appear that they did indeed take their medications (Rungruangsiripan,, et.al., 2011). Some hide it under their tongue and spit it out after their nurses have left them, and others become violent whenever their medications are due, often forcing nurses to use physical restraints on these patients. The care model can provide suggestions on how change can be implemented in the care of schizophrenia patients. The integrated pathway suggests the importance of working with a mental health team (Insel, 2010). This team would include the attending mental health physician who is likely a psychiatrist, a nurse sufficiently trained in mental health care, and a social worker who can work with the affected families on how they can assist in the management of the patient. This team would then assist each other in establishing a plan of care for the schizophrenia patient. Given the patient’s compromised state of mind, including the patient in planning for his care may not be viable, nevertheless, efforts to discuss with the patient about his care must be made in order to ensure patient cooperation and improved compliance with medication intake (Schottle, et.al., 2013). In case the patient can effectively participate in his care, his preference on patient intake must be included in the plan. Some patients may want to spread out their medication intake within several hours, and not to take multiple medications at one single time. Others may also need to take other medications which would counter the medication and its side-effects. All of these details have to be integrated within the care pathways for the schizophrenia patient (Schottle, et.al., 2013). Evidence-based approach to changing professional practice In recent years, Mental Health reports as well as other projects for mental health patients, including systematic studies have established various evidence-based treatments for patients with schizophrenia. Examples relating to effective interventions include specific approaches to medication management, including assertive community management, relapse prevention systems, including supported employment (Seddon, et.al., 2001). Even with much evidence on effective remedies, epidemiologic as well as clinical surveys have indicated that individuals suffering from schizophrenia in Canada are not likely to receive such effective interventions. Epidemiologic data from the Vanasse, et.al., (2012) study indicated that 60% of individuals suffering from serious mental illnesses received no treatment in the previous year with about 25% of them not receiving adequate treatment and 15% having minimal treatment. The study by Vanasse, et.al., (2012) also established that patients in public mental health programs were not likely to receive a good majority of their evidence-based practices. In recent years, the Canadian Mental Health Association (Picard, 2013) found that 1.2 million children have mental issues, but only 1 in 4 are actually receiving mental healthcare. Some recent studies also indicate how quality of care may actually be getting worse instead of actually improving (Gould, et.al., 2010; Durbin, et.al., 2012). In effect, researchers are still trying to secure effective interventions in the management of schizophrenia, including the number of individuals suffering from this disorder, are actually not receiving any or are having less than quality care for their diseases. Previous studies in this concern have assessed the epidemiology of services as well as the issues of engagement and retention (Gould, et.al., 2010; Vanasse, et.al., 2012). Within this article, it is important to evaluate efforts being made to carry out effective interventions for schizophrenia in mental health care settings and provide suggestions in lessening the gap between science and practice. General medical literature on quality management efforts includes several conclusions. First is that the standard remedy of passive diffusion of research including release of findings on effective treatment options have little effect on routine practice (Whitley, et.al., 2009). Second is that more intricate efforts to organize research evidence in relation to systematic reviews and disseminated guidelines do not have much impact on practice. Third, is that using total quality management and quality improvement measures from industry have good but inadequate results. Quality improvement which has been advocated by Deming (1986) involves a process which highlights training, education, and the utilization of information to improve the performance of organizations. Within the mental health treatment settings, quality improvement has become more field-based in its supervision; the systematic review of patient outcomes has also emerged as an important aspect (Shojania and Grimshaw, 2005). The current effects towards completing systems towards reworking information technology has provided mixed outcomes, some more successful than others, and the rest calling for more detail and understanding. Drake, Bond, and Essock (2009) discuss that the Schizophrenia PORT study was carried out during the 1990s and efforts have been made to implement effective treatments, including evidence-based practices for schizophrenia patients over a large scale population. In changing medication practices, there is a need to consider different providers as well as mechanisms from changes in the psychosocial practice, including the implementation of medication guidelines. Antipsychotic interventions are a major element of treatment in schizophrenia, and most people having schizophrenia and undergoing treatment have sufficient access to antipsychotic medications (Drake, et.al., 2009). In the PORT study on adherence to recommendations within routine practice, the possibility of having a schizophrenia patient hospitalized, and receiving antipsychotic medications was very high; however the quality of frequently prescribing antipsychotics deviated from the recommendations from evidence (Drake, et.al., 2009). Since prescribing medications is an important element in the management of schizophrenia and is easy enough to implement, the administrators and researchers have focused more on efforts to improve adherence to treatment specifications. Change management for schizophrenia patients The change management in this case would involve improvements on medication compliance of schizophrenia patients. The use of electronic reminders and nurse monitoring can serve the purpose of improved medical compliance (Grol, 1997). Various studies have been undertaken in order to establish the efficacy of using SMS messages sent to phones of patients and the primary caregiver of schizophrenia patients. These studies indicate higher compliance with medication intake for these patients. These SMS also reduce the need for field monitoring for patients, especially those within the outpatient setting (Pijnenborg, et.al., 2007). Shortage of personnel can make the monitoring process of schizophrenia patients difficult. However, with SMS reminders, the primary caregivers or the patients themselves can be reminded when they are supposed to take their medications (Pijnenborg, et.al., 2007). In change management, it is always important to engage others in the improvement. In this case, it is important to establish how the stakeholders would be personally affected by the changes. The stakeholders in this case would include the schizophrenia patient, the family or the primary caregiver, the attending nurse, the social worker assigned to the patient, and the patient’s psychiatrist. The change management process would require these stakeholders to carry out specific functions (Smerud and Rosenfarb, 2011). The patient has to be motivated to comply with the medication regimen. The family members or the primary caregiver would also have to take an active interest in the patient’s care, specifically his medication regimen. The nurse would also have to monitor the patient, and send the SMS messages when the patient’s medications are due. The psychiatrist would prescribe the pertinent medications for the patient, consider its side-effects and options in relation to reducing or eliminating such side-effects (Spaniel et.al., 2008). The social worker would serve as counselor for the patient and his family, helping them manage their daily activities, securing financial assistance where necessary, and counseling family members who are experiencing difficulties in caring for the patient (Bentley and Walsh, 2013). It is important to acknowledge that people are often personally affected by change because it usually calls for them to do something which they have not done before (Galvin, 2003). People are considered the most critical resource but also the most significant barrier in implementing change. The uncertainties which often come with change can often prompt strong feelings, with majority of individuals going through the process of letting go of the old and moving on to the new. Various emotions may be seen from those affected by change, including frustration, anger, despair, acceptance, and elation (Galvin, 2003). The emotion encountered would likely be based on whether staff members would implement change willingly or unwillingly. The awareness of various reactions to change would likely help leaders for the change process react to the concerns indicated. Comprehending why these feelings may manifest would help leaders and also stakeholders respond to the concerns expressed. In some instances, the stakeholders may not be aware of the need for change, and may sometimes feel that there are bigger issues which have to be managed first (Lin, et.al., 2012). Objecting to the change is often expected, especially if they also feel that there are better ways to secure better outcomes. In order to effectively secure changes and improvements in medication compliance among schizophrenia patients, it is important to secure a plan in the implementation of the change. Under these conditions, it is important to include specific preparations which would adapt the change in cases where the outcomes from different stages indicate the need for adjustments (Reiss, 2012). It is also important to secure executive or senior support in order to secure successful change. The stakeholders also have to recognize the fact that the change would come from the ground up, or from the implementers of change and then into the wider health care system (Reiss, 2012). Establishing objectives and supporting the team and the stakeholders when the objectives are achieved is also important in order to successfully implement each stage or aspect of the change or improvement (Steinacher, et.al., 2012). Acknowledging that the plan for change and monitoring is very much crucial, it is also important to secure the commitment of the people in order to ensure that the original plan for change would be successful. Another essential aspect of successful change management is communication (Free, et.al., 2013). It is an aspect which must be seen in some form among those affected by the proposed change, in this case, all the stakeholders in the care of the schizophrenia patient. Early communication and consultation is essential during the planning stage is also very much important in order to assist the stakeholders in developing interest for the change and to prepare for their participation in the change process (Free, et.al., 2013). Under these conditions, the stakeholders would develop an ownership for the new plan or the change, and therefore develop more interest in promoting its success. The stakeholders would also have various levels of involvement. At different stages in the implementation, there needs to be consultation and collaboration with these stakeholders (Nakanishi, et.al., 2006). They must also be given as much data as possible, including baseline information, objectives for change, and they must take part in considering and anticipating issues as well as promoting solutions for possible emerging issues. Implementing change for healthcare would call for major commitment from the stakeholders affected by the changes. Some may be motivated by it, and others may simply resist such change (Nakanishi, et.al., 2006). Changes would likely be more successful with more stakeholders committed to the change, especially if these stakeholders believe that the change would help improve the patient’s outcomes as well as the practice in general. Ensuring debate and discussion on the need for change via data presentation can also present a sense of urgency. Individuals usually veer away from issues and gravitate towards better conditions (Jones, et.al., 2006). The leaders in the clinical setting can affect the change process and secure positive planning settings as well as encourage staff members to ensure creativity as well as innovation to change. Audit plan This audit would be undertaken on the conduct of medication compliance among schizophrenia patients. The objectives of this audit would be to review available evidence on electronic SMS reminders in improving medication compliance. The role of the nurse in sending the SMS would also be audited. Based on these objectives, possible evidence of standards can be services, upon which current practice will be evaluated. Based on this audit, a possible strategy would be considered. A pilot audit would also be carried out in order to evaluate the plan in terms of the objectives being sought. As the results of the pilot would be assessed, the actual practice would be evaluated, observed, with more information collected. Such data would then be further assessed, with the findings discussed in relation to relevant stakeholders, alongside quality improvement identified and implemented and a re-audit undertaken. Several cycles shall also be carried out in order to determine efficacy. The medication compliance for schizophrenia patients is the area of my practice which would undergo this clinical audit. Specifically, the compliance with the medication intake would be audited. At present, schizophrenia patients are suffering through a debilitating disease which has a lifetime prevalence of about 1% of the Canadian population (Canadian Mental Health Association, 2012). In general, it manifests during late adolescence or early adulthood, often affecting perception, cognition, feelings, as well as behavior. The families are also affected by the schizophrenia diagnosis, often affecting their social and economic life. Various antipsychotic medications are being indicated for schizophrenia. These medications often help reduce the symptoms of schizophrenia, improving patient well-being, as well as helping ensure productive and quality lives for these patients (Addington, et.al., 2011). However, the adherence to these medications is an essential aspect of reaching maximum efficacy in treatment. An evaluation of dropout rates for clinical trials established that about 28 to 55% of schizophrenia patients dropped out of their clinical trials even before the study was completed (DiBonaventura, et.al., 2012). The rate of dropouts was significantly higher for the classic medications when compared to second generation drugs because of side effects. In the CATIE or the Clinical Antipsychotic Trial of Interventional Effectiveness study, there were about 74% mental health patients who stopped their treatment within 18 months of the study. About half of patients with schizophrenia were taking 70% or less of their actual medications. There was therefore inadequate adherence to the intake of antipsychotic medications with dangers of relapse being observed alongside associated costs. The review by Sun and colleagues (2007) indicated that antipsychotic non-adherence in the US was to blame for increased rates for rehospitalization. Studies indicate that antipsychotic medication side effects are also related to issues in adherence. The ratings from clinicians of the side effects are also linked with treatment and its discontinuation (Messias, et.al., 2007). Moreover, the side effects including medication-related obesity, stress over weight gain, and cognitive impairment, have been linked with higher rates of non-adherence. While other studies have evaluated adherence within the actual world conditions, not many studies have evaluated the relationship between the specific side-effects and non-adherence. Also, there are limited studies evaluating the link between patient-associated side effects as well as self-reported adherence. Such patient perspective is important especially as it indicates insights into the perception of side-effects and how they relate to specific non-adherent behaviors, elements which cannot be taken using objective assessments in adherence (Goldner, et.al., 2002). Factors affecting the decision to audit a specific issue or topic relate to the elements relating to evidence-based practice, and whether or not there is sufficient evidence which can be used to implement changes in the practice (Johnston, et.al., 2000). Where the interventions in place are not producing improvements in the condition of the patients, there is a need to audit the interventions being applied. Auditing the interventions would involve a reassessment of the elements involved in the interventions, alongside the objectives being sought. Clinical audit plays a significant role in the evidence-based practice. Measuring quality performance in the healthcare system has often been a challenging task (Patel, 2011). New techniques in measuring and reporting has to support data on the service’s overall approach if it would consider reporting in order to adequately secure excellence in healthcare. The healthcare system has to reconsider its quality assurance elements and how it assesses patient experience, safety, as well as clinical effectiveness in care (Naismith, et.al., 2001). Nurses who have closer relationships with patients and those who understand their needs have to inform the quality objectives and form part of the quality management structure. This is mostly supported by government reports which highlight the fact that nurses have to take part in the decisions of organizations and their operations (Edwards, et.al., 2006). Moreover, if the nurses are ever to gain success, there is a need to reduce bureaucracy which may pose barriers in the promotion of quality care for schizophrenia patients. Clinical audit has become an important element of integrated governance in the healthcare system. With the expansion of clinical governance during the late 1990s, the elements of clinical audit have been raised. Clinical audit basically refers to quality improvement processes which function to ensure improvements in patient care via systematic review using explicit criteria and implementation of change (Harrington, et.al., 2002). Elements involve the knowledge of the topic, selection of the fitting criteria in standards to be measured against, assessing current practice, comparing results with standards, changing the practice, and re-auditing in order to ensure improvements in the practice. There are various changes in the clinical audit process, and they all involve similar basic elements. Where the cycle would persist, the patient care would likely improve. Within the mental healthcare system, nurses makeup the majority of the healthcare staff (Sim, et.al., 2004). It is therefore important to include them in the planning stages of care, especially as they would be the personnel would deliver majority of the patient care. They are key elements in ensuring that the outcomes of the clinical audit would be accurate. Moreover, clinical audits are clinically initiated in order to ensure improved patient outcomes, ensuring collaborative tools for medical staff in the conduct of the audit (Patel, 2011). Quality has been based on safety, efficacy of care, as well as patient experience. While planning to audit, it is important to consider audit triggers. Under these conditions, evaluating whether the audit would be clinical or non-clinical, also assessing for possible untoward incidents and whether they have been complaints and if the current practice has to be changed in order to meet the change requirements and objectives (Bowie, et.al., 2012). Differences between the actual audit and the research are often seen and have to be understood. Research relates to gaining more knowledge and establishing which types of treatment would be most efficient. Clinical audit relates to quality and determining if the best practice is actually being carried out (Hyde, et.al., 2012). In order to undertake audits, standard needs have to be identified and the pertinent criteria must be chosen in order to determine the type of compliance level is being applied. In planning audits, the application of quality assurance resources have been considered as one of the ways by which members of the nursing and other health professions can provide a clear focus on the basic and important elements of care (Badham, et.al. 2006). In the end, better patient experiences can be secured. The important aspect of the care toolkit is based on the stakeholders involved. For instance, schizophrenia patients, nurses, social workers, and psychiatrists mention the importance of nurse monitoring of patients during the administration of medications (Humberstone, et.al., 2004). Through the monitoring process, the patient adherence to medication can be secured. Stages of care often include agreement on best practice, assessment of clinical area relating to best practice, producing and implementing action plans seeking to ensure best practice, reviewing achievements relating to best practice, dissemination of improvements and review action plans, and agreements on best practice once again (Power, et.al., 2003). Clinical audit is the primary driver for the government’s vision on healthcare services. The application of national frameworks including the essence of care would help support the vision and ensure effective patient-related outcome measures (Volavka, et.al., 2002). Nurses have to be a major part of the audit process; they also have to support the practice which challenges present in the current practice, especially relating to openness, transparency, as well as patient engagement. Within the evidence-based process, it is revealed that there are major gaps in the delivery of care for schizophrenia patients, especially in relation to their medication compliance (Halligan and Donaldson, 2001). The audit highlighted such gap and through such audit, improvements in the mental health care can be implemented. The audit has provided a picture of what evidence would be needed in order to secure changes and improvements in the care of schizophrenia patients. Clinical governance in this case covers various initiatives taken by the Health agencies supporting quality services for their patients. Clinical efficacy has become a major foundation for the nursing profession and is crucial to medicine and other related health professions (Rowlands, 2001). Clinical efficacy has been considered as a basis for different terms, including evidence-based practice, clinical audit and clinical governance. All these terms support monitoring for effectiveness within medical and nursing interventions in order to ensure quality patient care. Measuring the quality of care is important towards ensuring improvements in the clinical practice, and is also a basic aspect of clinical governance. Quality healthcare can be assessed in relation to patient safety, patient experience, and efficacy of care (Leucht and Heres, 2005). For the schizophrenia patient in this case, his safety is a major consideration with safety interventions secured using prescribed medications and by administering medications to counter side effects. Assessments made in relation to drug interactions are also part of the patient’s safety, especially where the patient may not often be aware of the adverse drug interactions which may pose a danger to the patient’s life (Brown and Crawford, 2003). The schizophrenia patient’s specific experience in relation to medication compliance must also form part of the audit. Some patients react in different ways to psychopharmacological drugs. The patient’s individual experience and reaction to the drug must be determined during the clinical audit (Kane, 2002). His reaction to the drug must be considered specifically and then addressed. Some patients may not have problems with side-effects but may not like the frequency of intake of their medications. Hence, they may have poor medication compliance. Some also do not like going through insomnia, vomiting, or dizziness as side-effects. Each patient experience is different; hence, the interventions and remedies must consider these different reactions (Barnes, et.al., 2007). Clinical audit can lead to improvements in patient care, helping ensure improvements in the professionalism of staff as well as the efficient application of resources. The discussion on appropriate methods for audit is very much complicated and various studies on audit have considered the examination, interpretation, and dissemination of principles of audit or criteria for good practice in audit for doctors and nurses (Barnes, et.al., 2007). As soon as a topic would be chosen, it is important to consider the feasibility of the audit. Nurses have the responsibility of practicing based on the codes of conduct, and to ensure that patient data would stay confidential. Clinical audits must protect data and clinical principles, ensuring patient confidentiality. The patients must be made aware that the data may be recorded, and also shared in order to ensure care and for clinical audits to provide monitoring in the quality of care. Such ethical considerations support the elements relating to the clinical audit and the monitoring of improvements in quality care. Conclusion It is important for the nurse to work with colleagues in order to monitor the schizophrenic patient, assessing also the quality of the clinical care and ensuring the safety of such patient. Following the collection of the audit data, analysis follows. It is important at this time to secure a plan of action which would specify how and by whom the issues would be managed, including the time frame of implementing solutions. Following the implementation of good practice, another audit cycle would have to follow in order to consider and determine if improvements have been made and sufficiently sustained. The auditors in this case must spend a lot of time verifying the data gathered and the standards applied. Explaining the elements of the audit to the staff is therefore very much important. As nurses actively participate in securing standards, they are then able to better recognize their function in the care of schizophrenia patients. 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