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PROFESSIONAL EXPERIENCE PRACTICE ANALYSIS ESSAY

Professional Experience Practice Analysis

Schizophrenia affects about 1% of the world’s population. It is a severe and incurable

mental disorder, which can have a profound impact on people’s lives (Nucifora, Woznica,

Cascella & Sawa, in press). Roughly one third of people diagnosed with schizophrenia do not

respond to standard anti-psychotic drug treatments, and are therefore referred to as having

‘Treatment Resistant Schizophrenia’ (TRS) (Gillespie, Samanaite, Egerton & MacCabe,

2017; Nucifora et al., in press). People diagnosed with TRS have significantly poorer

outcomes across a range of functional and health measures (Nucifora et al., in press). The

only evidence-based pharmacotherapy for TRS is the atypical antipsychotic Clozapine

(Gillespie et al., 2017).

John (pseudonym) is a middle-aged man who enjoys films and playing chess with his

friends. He was diagnosed with TRS in his early 20s and has been unable to work since. He

has been on Clozapine for more than a decade, which is moderately effective at controlling

his psychotic symptoms, however John remains prone to relapses, with several hospital

admissions over the past decade. His current admission occurred when he became unwell

with increased auditory command hallucinations and suicidal ideation, resulting from poor

medication management and a stressful home environment. This essay will use the nursing

process (Orlando, 1961) to explore the role of the nurse in caring for someone like John, in

the context of the recovery model of mental health care.

Assessment

At the time of Mental State Examination, John was clean, well groomed, relaxed and

appropriately dressed. His cognition and behaviour were normal; he was alert to time, place

and person, cooperative and engaged, pleasant and polite, with sustained eye contact. His
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affect was restricted and guarded, and anxiety was evident. His attention was limited, his

mood was dysphoric and affect restricted. His speech was loud and monotonous, normal in

rate and appropriate in content, showing no signs of formal thought disorder. John reported

perceptual disturbances in the form of auditory hallucinations, stating that ‘the voices’ were

talking to him throughout the interview. He denied thoughts of self-harm, suicidal ideation or

thoughts of harming others. He reported a good appetite but had trouble getting to sleep due

to anxiety. John demonstrated insight into his condition and showed no signs of impaired

judgement.

On the basis of this assessment, John was deemed low risk, however a number of risk

factors make him vulnerable to deterioration in his mental health. Predisposing factors

include a history of trauma, self-harm, suicide attempts and cannabis use. He reports drinking

alcohol socially, ‘occasionally’. Sometimes John does not take his medication, claiming it

makes him unable to sleep, confused, nauseous, lethargic, constipated, and gain weight. In

addition to anti-psychotic medications, John is on a daily regimen of anti-depressants,

anxiolytics, an anticholinergic drug to counteract the extra-pyramidal side-effects of the anti-

psychotics, and an anti-convulsive drug to prevent Clozapine-induced seizures.

Precipitating and perpetuating factors include John’s ongoing struggle to take his

medication consistently and strained relations with his exploitative drug-dependant brother,

who is reliant on John’s disability pension for his rent. Tensions in his home environment, a

common trigger for the onset or exacerbation of psychotic symptoms (Townsend, 2014,

p.112), contributed to John’s recent relapse.

Protective factors, which help to mitigate these risks, include John’s ability to attend

to his activities of daily living independently, as well as his community connections. He

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PROFESSIONAL EXPERIENCE PRACTICE ANALYSIS ESSAY

regularly attends his local neighbourhood house for meals and chess games. He is connected

with local mental health services and has a nominated person.

John’s physical health has been affected by his mental illness, in particular his anti-

psychotic medication. He has hypertension and has developed hypercholesterolaemia and

hyperlipidaemia as side-effects of his Clozapine treatment. He takes hypertensive and statins

to manage these conditions. As a result of all his medications, John is a risk of a range of

physical and psychological side-effects associated with polypharmacy.

Diagnosis

John’s psychiatric diagnosis is chronic TRS. John’s presentation is consistent with the

DSM-5 diagnostic criteria for schizophrenia, on account of his positive and negative

symptoms, their long duration, and the resulting significant degree of distress and disability

(5th ed.; DSM–5; American Psychiatric Association, 2013). His chief symptom is psychosis,

in the form of auditory hallucinations, which he claims he has experienced since he was a

child. He exhibits diminished emotional expression and complains of a lack of energy,

potentially a negative symptom of schizophrenia (Townsend, 2014 p. 116), or a side-effect of

his medication. He also struggles with depression and anxiety, mood symptoms commonly

associated with schizophrenia.

Living independently and being more active are John’s recovery goals. These goals

inform a priority nursing diagnosis determined by John and his primary nurse: Ineffective

self-health management (Townsend, 2014, p. 619), related to medication, evidenced by lack

of consistent adherence to prescribed medication.

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Planning and Implementation

In response to John’s primary goal and nursing diagnosis, two appropriate nursing

interventions are identified:

1. Support John to transition to self-administration of medications.

2. Arrange a referral to a dietician and exercise physiologist to assist John with his

physical health, especially in relation to the side-effects of his anti-psychotic

medication.

The first intervention, independent medication administration, is a multi-stage

process. The first step will be to request a medication review from John’s psychiatrist and GP

to ensure that all his prescriptions are appropriate to his conditions and circumstances. The

second step will be to ensure that John understands what his medications are for, their side

effects, and strategies for managing them. The final step in the process will be to initiate a

staged transition from nurse-administration to consumer-administration. John stands to

benefit from medication review and education, a clear and practised administration routine

and increased autonomy.

The promotion of medication self-administration is a ‘guiding principle’ of Australian

mental health care policy (Department of Health, Australian Government, 2006). However, a

recent systematic review of studies of self-administration medication (SAM) in psychiatric

and other hospital settings, found that the evidence for the effectiveness of the practice is

limited and mixed (Richardson, Brooks, Bramley & Coleman, 2014). Moreover, a 2008 study

(Stewart, Anthony & Chesson) cautioned against assuming that in-patients with

schizophrenia will want to take responsibility for their own medication, underscoring the

need for nurses to remain focussed on consumer-driven care.

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Staged medication self-administration will be supported by connecting John with a

dietician and exercise physiologist, aligning with John’s second goal of becoming more

active. Poor physical health among people living with severe mental illness is a major public

health challenge that psychiatric nurses can play a powerful role in addressing (De Hert,

Correll, Bobes, Cetkovich, Bakmas,…& Leucht, 2011; Scott & Happell, 2011; Thornicroft,

2011). The side-effects of John’s antipsychotic medication are multiple and systemic.

Physical activity is vital for preventing the chronic conditions strongly associated with anti-

psychotic medication, such as diabetes, cardiovascular disease and stroke, (Korsavva &

Dhadesugur, 2018), as well as providing a positive coping strategy for anxiety and stress.

Evaluation

According to the recovery model of mental health, ‘recovery’ can mean many things.

It may be usefully understood as ‘being able to create and live a meaningful and contributing

life in a community of choice with or without the presence of mental health issues’

(Department of Health and Ageing, 2013, p.2), but above all, it is defined by the consumer

(MIND, 2012; Slade, Amering, Farkas, Hamilton, O'Hagan, Panther, ... & Whitley, 2014).

Hence the success of the proposed interventions will be determined by John. Grounded in

John’s own goals, the interventions accord with the recovery-focused model of mental health

care, which emphasises consumers’ autonomy, empowerment and investment in their own

treatment and care (Department of Health and Ageing, 2013; MIND, 2012).

The interventions also address three out of four key aspects of holistic well-being,

according to the ‘Biopsychopharmacosocial’ model of psychiatric nursing (Clark & Clarke,

2014). This model, which emphasises a holistic approach to recovery, builds on the more

familiar ‘biopsychosocial’ model of mental health (Engel, 1977). The new term ‘pharmaco’ is

intended to reflect the significant and multivalent role that pharmaceuticals often play in the
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PROFESSIONAL EXPERIENCE PRACTICE ANALYSIS ESSAY

daily lives and subjective experiences of people living with mental illness (Clark & Clarke,

2014), as this case study highlights.

Together, by promoting achievable and sustainable change through education and

practice, these interventions have the potential to help John overcome a significant barrier to

achieving his chief goal of living independently. The interventions directly address two of the

nine essential components of recovery (Davidson, Rowe, O'Connell & Lawless, 2008),

‘assuming control’ and ‘managing symptoms’, thereby helping to lay the foundation for the

remaining components.

Outcome Assessment

At the time of assessment, John completed a questionnaire (STORI-30) designed to

help clinicians establish his subjective stage of recovery across five stages: moratorium,

awareness, preparation, rebuilding and growth, and four process components: hope, identity,

meaning and responsibility (Andreson, Oades & Caputi, 2003). This indicative measure will

need to be supported by ongoing discussions between John and his treating team, together

with the participation of John’s nominated person and any other support people.

Objective observations of John’s participation and progress in the interventions will

be supported by measurable data collected by the nurse in collaboration with the dietician,

exercise physiologist and GP. Metabolic monitoring of blood pressure, BMI and other

biometrics, blood sugar, cholesterol and lipid levels has become standard care protocol for

consumers on antipsychotic drugs, (Mitchell, Delaffon, Vancampfort, Correll & De Hert,

2012). Recognising that consumer’s goals may change as progress is made or new priorities

emerge, a revised Recovery Action Plan is prepared every three months, offering an

opportunity for the treating team and John to review the continuing relevance of the proposed

interventions to John’s evolving goals.

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PROFESSIONAL EXPERIENCE PRACTICE ANALYSIS ESSAY

Conclusion

The preceding discussion has outlined the application of the nursing process in the

context of care of a consumer recovering from an exacerbation of a chronic mental health

condition within the framework of contemporary models and theories of recovery.

Proceeding from the consumer’s self-identified goals of living independently and increasing

his physical activity, the proposed nursing diagnosis and interventions are responsive and

mutually reinforcing, assisting the consumer in transitioning to a safe and effective

medication self-administration, and enhancing the consumer’s capacity to manage his holistic

health, including medication side-effects, thereby supporting his ability to maintain his

medication regimen. By focussing not on the consumer’s psychiatric diagnosis, but rather on

his subjective goals, this case study has highlighted the role of the mental health nurse in

recognising the consumer as a person first and foremost, and supporting them on their

recovery journey (Australian College of Mental Health Nurses, 2013, p.30). At the same

time, it has pointed to the profound impact that poorly managed psychiatric symptoms and

medication side-effects can have on people’s lives, demonstrating that complex and holistic

problems require complex and holistic solutions.

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PROFESSIONAL EXPERIENCE PRACTICE ANALYSIS ESSAY

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