Introduction

Throughout this book we have written about approaches which encourage practice-based partnership and cooperation with the service user. The medical model has been criticised for contradicting this approach, due to the perception that decisions are often being made by medical practitioners about the best course of treatment based upon their professional expertise regardless of the service user's views. This approach is known as promoting ‘compliance’ and involves encouraging the person to adhere to a treatment regime which has been prescribed for them.

This chapter will discuss ways of working which support the service user to make choices about their treatment options based on knowledge and information given to them by the mental health practitioner. This is known as promoting ‘concordance’. The principles of concordance approaches apply to making decisions about all treatment options, however this chapter will focus primarily on how it can aid the management of medication.

Compliance

Compliance in the context of health care is defined as ‘The extent to which a person's behavior in terms of taking medications, following diets, or executing lifestyle changes, coincides with medical or health advice’ (Haynes et al 1979).

In a mental health setting, people are sometimes reluctant to adhere to medical advice for a number of reasons:

A number of service users have expressed their dissatisfaction with this approach to practice. It has been identified as disempowering as it doesn't acknowledge the person's perspective or take into consideration their knowledge of themselves (Perkins & Repper 1996). Furthermore, if the person does not agree with the treatment, they are unlikely to follow the plan as prescribed and therefore medication may be thrown away or appointments missed which can be a waste of resources.

In some circumstances a person may have been viewed as unable to contribute to a decision regarding their treatment due to the seriousness of their mental health problem. In these situations it would be appropriate for a Mental Health Act assessment to be undertaken or an assessment of the personal mental capacity. Parts of this legislation allow professionals to administer treatment against the person's will if it is deemed in their best interests (see Ch. 4). However, it is important to acknowledge that if this is not the case, the person has the right to make an autonomous decision about their treatment even if the mental health professional feels that they could be putting their health at risk. See the scenarios below for examples.

In these examples it is evident that the service users are not complying with their treatment plan for a range of reasons which is having a detrimental effect on both their mental health and their engagement with mental health services. In these types of circumstances it is proposed a concordance approach would be more beneficial.

Concordance

Weiss and Britten (2003) state that ‘concordance is fundamentally different from either compliance or adherence in two important areas: it focuses on the consultation process rather than on a specific patient behaviour, and it has an underlying ethos of a shared approach to decision making rather than paternalism … it is not possible to have a non-concordant patient’.

If we break this statement down, there are a range of skills and values which are required if we are to promote concordance.

In addition to these core elements, there are areas of knowledge and various tools which can aid this approach. The first of these is knowledge of the treatment options available.

In relation to medication management, it is beyond the scope of this book to provide you with a detailed explanation of each of the medications used in mental health services and how they work. Box 9.1 contains a brief explanation of the groups of medications commonly used in mental health services.

We recommend that in order to develop your knowledge base in this area, you complete and repeat the following activity. We suggest that this will enable you to relate the information regarding medication to people you meet, which is a helpful way of remembering this material. It also contributes to your learning in achieving your Nursing and Midwifery Council (NMC) competencies and essential skills (NMC 2010). We have recommended some texts which may be helpful in this area at the end of the chapter.

Activity

1. Consider a small number of service users you meet in practice on each placement.

2. Identify their diagnosis and the medications that they have been prescribed.

3. Use the British National Formulary (BNF), medication-focused texts, National Institute for Health and Clinical Excellence (NICE) guidelines and the person themselves to identify:

the type or classification of medication they have been prescribed

the dose and frequency that they take the medication

the side effects that they experience and how they manage them

their view of taking the medication and the impact it has on their mental health.

Once you have developed your knowledge of the medication options, it is then important to consider how you will present this information to the service user in a way in which they can understand the potential benefits and limitations. This aims to enable the service user to make an informed choice about their medication and is known as an educational intervention. Below you can see an example of how you might describe an atypical antipsychotic.

Example: describing an atypical antipsychotic

Nurse:

Hi Jenny. Last time we met we said we would have a chat about the medication you have been taking. You said you are having some doubts about continuing to take it. Is that still OK with you?

Jenny:

To be honest, I'm not sure I want to take anything. I've heard some really scary things about what these tablets can do to your mind and I would rather stick with my herbal stuff.

Nurse:

OK, I would be interested to hear what you have heard about the medication and the herbal remedies you mentioned. But before you make a decision, shall I tell you a bit more about the medication and you can see what you think.

Jenny:

Yeah, I don't suppose there is any harm in it.

Nurse:

Well, the medication that Dr Petal has prescribed for you is an atypical antipsychotic. This means it is one of the newer types of antipsychotic medications which work in a different way to the older types. The theory is that the voices that you hear are partly caused by a chemical in your brain called dopamine. This is a type of neurotransmitter which has been found to influence thoughts, emotions, mood and perceptions. It carries messages across the nervous system and sends signals which tell your brain how to respond. Some people have too much of the chemical and some people are very sensitive to it and so the medication works by blocking the chemical or reducing the amount that is produced. This doesn't fix the problem but can reduce the symptoms you might experience like your voices.

Jenny:

OK that makes sense.

Nurse:

Perhaps we can draw a diagram together of how this might look.

Jenny:

Yeah that might help.

Jenny:

So why have I being feeling all sleepy? I'm finding it really hard to concentrate on reading a book or watching TV. I've heard other people say they have had the shakes and that they might never go away.

Nurse:

This is because of the side effects of the medication. It can also disrupt how other chemicals in your brain work and everybody seems to respond differently. What Dr Petal has done is started you off on a small dose and he will gradually increase it until it makes a difference to your voices. At the same time we would be monitoring any side effects. If the side effects were causing you problems then we would try a different type of medication.

Jenny:

OK, I will have a think about what you have said and let you know.

Nurse:

That's fine, I will leave this information leaflet with you so you can have a read and we can talk through any questions you have next week.

Fig 9.1 Action of antipsychotics

Key features of the interaction

• Jenny has started taking the medication without a clear idea of how it works or how it might affect her. This was affecting her beliefs about her medication and her motivation to continue taking it.

• Jenny is considering stopping her medication but feels able to speak openly with the nurse about this. This illustrates the presence of a therapeutic relationship and allows the nurse to discuss Jenny's beliefs about her medication.

• Jenny has got some ideas about alternative treatment options. The nurse acknowledges this and is open to exploring her ambivalence and uncertainty about her treatment.

• Information about how the medication works is given in a clear and factual way.

• Different methods of presenting the information are used.

• Jenny is given the opportunity to ask questions and there is a focus on what is important to her (i.e. side effects, practical issues).

• Her perception about how the medication is affecting her is the central feature in the decision-making process illustrating a collaborative approach to decision making.

• The option to make changes based on her views of how her medication is affecting her is clearly given.

• The conversation is left open and plans are made to revisit it at the next session.

Other ways of promoting concordance are known as ‘behavioural interventions’ which aim to help service users think about how medication best fits with their daily routines. This might involve working with a person who finds it difficult to remember to take their medication. This may mean they are not getting a therapeutic dose or that they are taking extra to compensate when they have forgotten. Behavioural interventions would look at ways of reminding the service user and helping them to integrate taking medication into their daily routine. Alternatively the service user may be finding that the side effects of the medication are interfering with their day-to-day lives. In Jenny's case, a behavioural intervention might look like this:

Nurse:

At our last session I remember you telling me your new medication was making you sleepy and affecting your concentration. How are you finding that now?

Jenny:

It seems to have gotten worse now Dr Petal has increased the dose. The worst thing is I'm falling asleep during the day and then can't get to sleep at night. It's driving my boyfriend mad.

Nurse:

Perhaps we can have a think about how we might improve this for you?

Jenny:

Yeah that would be good. I have found my voices have got less intense but I'm not sure if that is just because I'm half asleep all the time.

Nurse:

OK, do you have ideas?

Jenny:

I'm not sure how much I'm allowed to mess around with it. At the moment I take the big dose in the morning and the smaller one at night. Is there any reason for that?

Nurse:

Well you used to hear your voices louder around midday

Jenny:

Yes but I haven't noticed that recently.

Nurse:

Well, Dr Petal was thinking the larger dose might help with that but what were you thinking about the dose?

Jenny:

Well I thought if I take the big one at night that might help me to sleep.

Nurse:

Good idea, and the smaller dose in the day is less likely to affect your concentration.

Jenny:

OK I will give it a go and let you know.

Nurse:

That's fine. Will you also jot down how your voices are at different times of the day? That way we can see if the time you take your meds has any impact on how they work for you.

Jenny:

Will do

Nurse:

I will let Dr Petal know what we have decided to do and see if he has any ideas.

Key features of this interaction

• The nurse revisits the area that is important to Jenny and explores her current views.

• The nurse uses language which reinforces that this is a partnership process.

• The nurse answers Jenny's questions with a simple and accurate answer.

• The problem is approached collaboratively. Jenny is encouraged to think of solutions and an action plan is made on how to implement the solution.

• Plans are put in place to evaluate the success of the solution.

The final element of concordance is around making longer term plans with the service user about how their medication fits with future goals. For some people, alternative coping skills will be developed and they may wish to reduce their medication and eventually stop taking it. By using the skills identified above, this can be a highly positive process whereby the person feels in control of their mental health and supported in developing their independence from mental health services. For others, the continuation of medication may be helpful and it is important to consider with them how it will continue to be an assistance rather than a hindrance to them reaching their desired future.