The Case of Sam: Multidisciplinary Perspectives

The problems presented by Sam's mental health history are challenging for any professional, and the psychiatric nurse is no exception. Sam is clearly a patient who has received a wide array of mental health services over a number of years. Initial questions that come to mind: What is the optimum level of functioning that Sam is capable of? What does Sam regard as his best and most desirable adjustment, and how does that compare with the ambitions his caregivers have for him?

It is reasonable to assume that Sam allows only selective intrusions of the outside world into his personal world, and therefore there is limited opportunity for reality testing. It is evident, however, that he does not have a favorable attitude toward psychiatric medications, because he denies having a psychiatric disorder and possibly because of the side effects of the many medications he has taken. It also seems reasonable to assume that Sam's care providers do not have a clear understanding of whether or not he has been consistently compliant with prescribed medications throughout his illness.

Certainly, nurses have participated in implementing Sam's treatment plan during his many inpatient stays. However, the case summary does not mention how nurses have been involved in Sam's care in community-based programs. Although this case presents many issues for discussion, from the psychiatric nurse's point of view the most pertinent considerations are medication compliance and the provision of a supportive and structured environment in which Sam can engage in reality-testing activities.

The proper administration of medication and compliance with the medication regimen are critical to the stabilization and rehabilitation of patients like Sam. However, it cannot be assumed that proper administration and compliance are occurring in Sam's case. Medication management for such patients can best be accomplished within a supportive and structured therapeutic relationship.

Careful tracking of medication administration and monitoring of compliance may alleviate the need for medication switches or increases in dosages that are based on the assumption that a certain medication is not working. It is important to deliberately incorporate the elements of medication management in the plan of care for all psychiatric patients who are on medication, and particularly for patients who have difficulty adhering to the prescribed medication regimen and who, like Sam, are poorly motivated, marginally compliant, in denial of illness, and cognitively impaired.

Medication management involves more than administering medication. It involves a set of activities beginning with assessment. The most important aspect of assessment in terms of medication management is evaluation of the patient's beliefs about his or her psychiatric illness and its severity and the patient's perception of the benefits and challenges of prescribed medications or other treatment regimens (1). Assessment also involves the investigation of gaps in the patient's knowledge and factual information. The information obtained from such assessments can be used in teaching the patient and clarifying misconceptions.

Other crucial steps in medication management for a patient with a psychiatric illness include administration of medication; monitoring of the physiological, psychological, behavioral, and social changes in response to medication; and documentation of the process and changes. In some community-based mental health settings, medication administration and monitoring activities are either nonexistent or are delegated to unlicensed health workers, which is likely in Sam's case. Assessing a medication's effects and teaching and monitoring the patient is a continual process, and it needs to be carried out by experienced and trained professionals. Medication management is a collaborative effort between the members of the health team, the patient, and the family.

Nurses are members of the interdisciplinary team in various psychiatric settings, including inpatient settings, partial hospital facilities, community mental health centers, and home-based care settings. By virtue of their biopsychosocial training and the amount of time they spend with the patient, nurses assume substantial responsibility in managing medication-taking behavior. Therefore, the role of the nurse in community-based mental health settings needs to be further clarified and developed.

Sam needs further functional assessment, medication management, and monitoring of the side effects of medication. He also needs more interpersonal contact in a structured environment. Thus Sam might benefit from a stay in a short-term, full-time partial hospital program—from four to six weeks, five days a week. Some investigators have suggested that the prescribed length of stay in a partial hospital program negatively influences attendance—that is, the longer the stay, the lower the rate of attendance (2,3). Studies also suggest that the number of prescribed days per week is positively related to attendance (2,4). A patient who attends on a full-time basis—that is, five days a week—and for a relatively short time may have a better attendance record.

To obtain the benefits of a partial hospital program, a patient must adhere to the prescribed schedule of attendance, which is based on the goals and objectives of the treatment plan. It is significant that Sam has refused to enroll in a partial hospital program, a clubhouse, or a vocational rehabilitation program. These programs tend to be more demanding and structured and require more interpersonal involvement. Therefore, if Sam's treatment plan were to involve partial hospitalization, the treatment team may be faced with an attendance problem.

In addition to Sam's denial of his psychiatric illness, other issues and concerns may influence his enrollment and regular attendance. For example, Sam's perception of barriers to attending the program may influence his enrollment and attendance. Previous studies have indicated that change of lifestyle, interpersonal involvement, daily structure, and practical inconveniences may be perceived barriers (2). Sam's perceptions of barriers to attending a partial hospital program must be addressed and incorporated in negotiations about enrollment.

Sam's enrollment in the partial hospital program should be considered as an initial phase in his long-term plan of care. Observations of his functional level in the program can help caregivers plan and organize a transition to vocational rehabilitation or other structured activities. Such observations are invaluable in ascertaining the best methods of enlisting Sam in a treatment plan that is realistic, that has achievable goals, and that takes into account his interests and his tolerance of stress.

Dr. Evans is a consultant in psychiatric mental health nursing. Send correspondence to her at 9608 Carterwood Road, Richmond, Virginia 23229 (e-mail, [email protected]).