Answer

Recovery and Psychosocial Interventions

Nursing in the mental healthcare can be described as an extensive process of caring. The scope of people who require nursing is large and this makes the process generally complex. It should employ principles of critical thinking with a focus on case-specific/person focused methods. Goal-oriented tasks and evidence-based practice (EBP) principles should be applied appropriately with respect to a specific case. Effective nursing outcome can be achieved through appropriate planning for care delivery. The most important point to understand in the recovery and psychosocial intervention is the care delivery phases, which include assessment, care planning, implementing and evaluating (APIE) (Chang & Chang, 2010).

A demonstration of a clear understanding of the nursing process by application of theory to practice is the main focus of this paper. The paper explores the recovery of a patient with respect to applied person-centered care delivery principles. Essentially, the paper is laid out from a reflective point of view of work placement experiences of the case with a sufficient theoretical knowledge of the nursing principles. Evident in the paper is a review of the assessment methods used to care for a patient with severe mental health problem. The review is thus applied hand in hand with the placement experiences to support the evidence-based practice. As an important part of nursing, the impact of practice values and principles sustaining recovery approach to an individual’s ownership, and responsibility for recovery are explored. Use of psychosocial interventions are also explored as an important part of the case. A review of the recovery tools used is given with a focus to improving the recovery tools.

With due respect to the patient, and in accordance with the Nursing and Midwifery Council (2015) code of conduct, the name of identity of the patient is concealed and only noted as ‘M’ for purpose of confidentiality. M’s recovery and support plan is attached in appendix 1.

Background

M is a 32 year old man who was referred to the Individual Package Care (IPC) recovery team by the ACUTE team. The IPC team is a community based Mental Health facility committed to supporting individuals with severe mental condition in accordance with Section 117 aftercare after leaving hospital. In accordance with the Section 117, the facility offers aftercare to reduce the risk of mental health becoming worse after leaving hospital (Oxton, 2015). The care is collaboratively done with other caregivers to integrate the patient into the community. The main responsibility of IPC to be an effective reconstruction of the individual’s life through the Recovery Model of Care. One of the best strategies to maintain stability to help the patient find a friendship group (Oxton, 2015). In line with this fact, IPC helps with such help as, finding college, employment or any activity that help find/get involved in a friendship group. From a scientific point of approach, the IPC employs such psychosocial recovery interventions as support plans to prevent relapse, individual support plans and the Safety plans and Recovery. All these principles were dully applied in accordance with assessment of M’s case.

A record of M reveals that he was living with his girlfriend but the relationship was breaking down and he was at risk of homelessness. He was diagnosed with schizophrenia and had problems with substance misuse. He had diabetes, which was not under control, had HIV and Hepatitis B. M’s substance misuse and health problems were the factors that put him most at risk. He was also having to leave his girlfriend’s home, with no alternative place to stay and was too vulnerable to sustain a tenancy of his own. Moving into Forest Road in itself addressed the immediate issue of him having a safe place to stay. M did not understand how to budget and the choices he made about how to spend his money often left him without the basics. Additionally, M did not have support.

Diagnosis

Understanding the diagnosis ensures evidence-based pharmacological and psychosocial intervention. Once at the facility, M’s history was looked into and determined as above described. Just as a matter of reiteration as part of diagnosis, M was living with his girlfriend but the relationship was breaking down and he was at risk of homelessness. He was diagnosed with schizophrenia and had problems with substance misuse. Schizophrenia is characterized by delusions, hallucinations, depression, and suspicion. A combination of these schizophrenic behaviors could have been a major factor for strained relationship with the girlfriend. He had diabetes, which was not under control, had HIV and Hepatitis B. M’s substance misuse and health problems were the factors that put him most at risk. Substance misuse has multiple aspects that could worsen M, given his case. First, drugs worsen schizophrenic conditions, and second, substance abuse aggravates HIV impacts (Butterworth et al., 1999).

In psychiatry, the diagnostic assessment of schizophrenia involves Positive and Negative Syndrome Scale (PANSS) test to determine the level of the problem. There are no standard diagnostic tool for schizophrenia and thus the doctor assesses the patient on an interactive basis.  6-factor PANSS model known as PANSS-6 which was used for the case of M. the tool considers delusions, conceptual disorganization, hallucinations, blunted affect, social withdrawal, and lack of spontaneity. Semachew (2018) determines PANNS-6 to be 99% accurate in symptom remission, thus more appropriate and effective than PANNS-30 which would have almost similar outcome but consume a lot of resources (Semachew, 2018).

Assessments routine

Nursing is a continuous logical, deliberative, systematic, and interactive nursing process. Assessment is a very important part of nursing. Nursing initiates the nursing process, permeates the caring process, and most importantly, it starts the problem solving cycle (Stanghellini, Bolton & Fulford, 2013).

Upon receiving M, an assessment of M’s needs were assessed. The assessment was done with respect to ascertaining wellness, illness, periods of stability through collaborative sources and shared with the caregivers. Through conferences, IPC reached consensus on such key issues that arose during the assessment. Key issues assessed included the risk level, strengths, functioning level, and the goals. The SMART concept (Specific, Measurable, Attainable, Realistic, and Timely) is routed in the appropriate assessment of the key issues with regards to the case. The first to be assessed was M’s care needs. The assessment was accomplished by use of Mental Health Clustering Tool (MHCT). MHCT is a needs assessment tool designed to assess the care needs of adult patients on a series of 18 rating scales. The importance of using clusters was so as to allow for a variation in the combination and severity of rated patient needs (Bobes, Rejas & Arango, 2013). As guided by Bobes et al. (2013), MHTC would later be used to reflect differing levels of input that were provided throughout changing and unpredictable episodes of care. Not only is clustering done at the point of referral but a periodic reassessment and re-clustering should be done. It was always clarified on who was responsible for clustering since more than one professional was involved. The MHCT tool was, thus, used at the end of the initial assessment, during formal care reviews, and where a significant change in planned care was deemed necessary (Ferraz & Wellman, 2018).

From MHTC results, M was determined to be in need of a full-time support living in the community. Additionally, clinical and social needs were assessed by use of the Camberwell Assessment and Social Questionnaire tools respectively. Integration into society required a measurement M’s impairment, behavior, symptoms as well as the social functioning. To achieve this, a Health of the Nation outcome scales (HoNOS) was used. HoNOS is a 1993 12-scale tool developed by the Royal College of Psychiatrists useful for promoting the social functioning of severe mentally ill persons 18-64 years of age. Ganeshan et al. (2018) explains that it is routine to have a Mental State Examination. The MSE was carried out to determine the depression and anxiety for M. This was done by use of Brief Psychiatric Rating Scales (BPRS). Ganeshan et al. (2018) describes BPRS as the most appropriate tool for studying people with schizophrenia. In the respect of M, 1-7 score scale was used to determine the level of depression, hallucinations, anxiety and unusual behavior. M was determined to show low levels of anxiety and hallucinations but moderate levels depression.

Over 70 studies reveal that HIV is often associated with poor nutrition (Chaudhari, Saldanha, Kadiani & Shahani, 2017). The nutritional status of M was assessed by use of modified version of Subjective Global Assessment (SGA) tool specific for HIV (SGA-HIV). SGA-HIV was important in determining if the patient needs referral to a dietician for nutritional intervention, education, and follow-up. As Chaudhari et al. (2017) describes, the results of SGA-HIV for M presented an opportunity for the IPC nurse to work collaboratively with a dietician because M’s SGA-HIV outcome showed need for nutritional support. In order to assess the substance use, the National Institute on Drug Abuse (NIDA) drug use screening tool developed by WHO was used. This is a 1-to-7 question tool used to assess the patient’s level of use and readiness to abstain (Ishii et al., 2017). The readiness assessment is used to determine the level of assistance. M was determined to be ready for help towards withdrawal from substance abuse. Tsuji et al. (2017) explain that although people with schizophrenia are not violent, violence could arise from hallucinations and delusion on their thinking. M’s violence was assessed to be low. This was determined by use of Short-Term Assessment of Risk and Treatability (START) tool. K-6 and K-29 were used to determine the imminent and long term violence risk factors. K-6 implies 6 factor and K-29 is a 29 factor version. For both the cases, M had low scores of 2. START score between 0-3 is low risk of violence. Additionally, START considers strengths as well as risk (Tsuji et al., 2017). The Strengths Scale on the START tool revealed that was good at making jokes. By evaluation, thus, M was considered to be a highly sociable person and could easily integrate within the community. The Specific Risk Estimate (SRE) did not describe M as being at any specific risk. From the Strengths Scale outcome, it was determined that M would be less stigmatized if well integrated into society, for example college. From this assessment, other strengths were discussed and suggested for M including leadership skills.

Once all the above assessments were completed, it was time to assess one of the most important parts which is psychological distress. Psychological distress was assessed using the Kessler Screening Scale for Psychological Distress (K6) whose outcome indicated that M had low psychological distress. K6 version of the Kessler tool for either screening or severity of distress. The recommended Kessler tool cut-off low is 13. The score for M was 10 implying he was at a low distress status. Kylma (2001) research reveals that at least 8/10 HIV patients have the tendency to develop hopelessness. Consequently, M’s hopelessness status was assessed using the commonly used tool Beck Hopelessness Scale (BHS). M scored 5/20 indicative of low risk of hopelessness.

IPC assessment team concluded that M was stable and less vulnerable to fall and hydration. The M’s ability to carry out activities daily living (DLAs) was assessed. At the time of referral M was determined to be able to perform ADL. This was arrived at when M scored high, on Katz Activities of Daily Living Scale, where M was considered able to attend to himself in matters of toilet including bathing himself, continence, and eating by himself. Although not a daily activity, M was found to be unable to inject himself with the drugs. Once the illness and PANSS was determined, adherence was determined by use Morisky Medication Adherence Scale-8 (MMAS), from which it was learnt that M needed someone to monitor adherence to therapy after a low score of 4/8. For this kind of score for a HIV patient, Kathryn McHugh (2010) explains that a necessary nursing care was important to monitor the intensive therapy that was designed for M.

The support system for M was assessed. M only had his girlfriend who was in fact not ready to live with him. Although the girlfriend was aware of M’s medical situation, she was initially unwilling to take full care of M. In this way, it would be difficult to ensure adherence monitoring. Extra assistance was necessary. The family functioning support conclusion was an outcome of the family assessment device (FAD). Besides the nursing support, Penas (2017) explains that understanding the social support is important for schizophrenics. This was achieved by use of multidimensional Scale of Perceived Social Support (MSPSS) scale from which M scored low.

Being a major decision maker in his life, M’s budgeting skills were assessed. This assessment was in line with Penas (2017), which explains about person-centered care.  It was determined that M needed training on budgeting skills.

Care Planning and Goal

One of the most important nursing care planning in the mental health care system is the Person-Centered Care Planning (PCCP), a collaborative process between the caregivers and the patient in the development of a suitable action plan to achieve his/her personal goals along the recovery journey (Brisch et al., 2014). The first and very important goal for M was the stoppage of substance abuse, which were considered as the biggest problem and barrier against achieving other healthcare goals. For poor financial planning, M would be assisted with budgeting skills. M first accepted the fact that he had poor budgeting skills, which the IPC staff would take the responsibility to train him on budgeting skills. Mr. M was interested in attending college. This was, in fact, a very important goal from the perspective of community integration (Brisch, 2014). The IPC facility took the responsibility of looking for college for Mr. M. Since it was necessary for M to use needles for insulin injection to improve of the care process, it was planned that the Dual Diagnosis team and local council on needle exchanges would help M with learning on how to use the needles as well as arrangements for collection of sharps boxes. As part of the care process and community integration process, M was advised to use his joking skills to attract friends and develop a social life, which was necessary and in line with Dickens advice (2012) on social integration as part of person-centered care. Additionally, it was considered necessary to have M back into the community rather than inpatient despite the family care having been assessed as not very promising. It was arranged that the IPC facility engage M’s girlfriend, and talk to her in depth about it. During the first few days, IPC considered it safer to provide 24 hour nursing care.

Following M’s abuse of substance as well the perceived inability for people with schizophrenia to make informed decisions (Koshy, 2017), it was planned that although he will be mostly informed of all the procedures and therapy, he will not be left alone in making critical decisions. It was planned that M would be allowed to contribute to a larger extent on minor clinical issues but major ones would be relayed to him, but he would not have the final decision on the type of medication or therapy to undertake particularly where criticality was considered. Some of the clinical decisions such as when to administer insulin were left upon him after a state of stability was attained.

Since M’s care was determined to be a community based/integration process rather than facility centered, it was considered worthwhile to plan for how to measure progress. This was particularly a necessary way of realizing the well-progressed areas such as self-care. For Mr. M the first critical areas to track progress were self-care, addictive behavior to substance use, relationship especially with his girlfriend, social networks, identity and self-esteem, responsibilities, living skills, and managing the mental health. This kind of tracking progress was particularly important since it would support the person-centered care plan. Balla et al. (2009) describe this kind of care as Recovery Star care. However, at all stages, although Mr. M was considered generally not in a critical condition, it was planned that particularly during the early days of being released, the triggers for such problems as violence such as M’s suspicion of his girlfriend were designed to be avoided by talking to both parties about it so as to make his girlfriend understand that she should try not to create such triggers and that M should also try to understand in scenarios that could trigger and wait for explanations. Changes in behavior could be regarded as possible onset of hallucinations. At this moment, appropriate decisions such as talking to him were proposed and if within medication appropriateness, it relevant drugs such as prescribed antipsychotics be administered. Mr. M was also advised that if notes himself being anxious and feeling confused, he should consider injecting himself with insulin. However, although it was predicted that M was at low risk of collapsing and falling, or becoming very violent, the nurses were advised to make sure they always carry out activities with another person around, especially M’s girlfriend. The girlfriend was advised to always call for assistance from the IPC facility whenever he noted a crisis such as collapse, violence or extreme change of behavior. This was in accordance with Dickens’ explanation (2012) about crisis handling of a psychotic patient. If very critical, it was advised to expressly call a medical help and hospitalization if deemed so under the circumstance. It was agreed upon that after the crisis, M shall be closely monitored and cared after by an IPC nurse. Balla et al. (2009) describe this whole process of care plan as Wellness Recovery Action Plan (WRAP), which had been successfully applied to over 10 cases of schizophrenia (Brisch et al., 2014). The process of recovery should involve a measure of the enhancement of a recovery environment. In order to do this, IPC facility involved M in the process of developing a plan of measuring the recovery environment progress. The recovery environment enhancement (REE) measurement was developed by IPC in which M was to answer such questions as where he currently was, how he feels about the service, how appreciated he currently felt. The REE was designed such that it captured such information as what M thought should be changed or done better, how well M’s potential for resilience and recovery was supported, the recovery services that M felt IPC should include, and what M thought to have been best delivered to him. Bella et al (2009) describe this process as Development of Recovery Enhanced Environment Measurement (DREEM). DREEM would be very useful to IPC in assessing its service delivery to the service users such as M.

Evidence-Based Implementation

Although the overactivity of M was seen to be low at time of referral, Penas (2017) recommends that even if there’s low evidence of predicted risk of overactivity, it should be put in place sufficient measures to handle hyperactivity which could arise spontaneously based on 14 studies. Antipsychotic drugs are often useful to have in order to take care of such problems as hyperactivity, hallucinations and delusions. Penas (2017) recommends that patients with schizophrenia should have an Improved Access to Psychological Therapies (IAPT). For the case of Mr. M, this was done by offering 24 hour monitoring and nursing services at his residence during the first few days. Since the assessment indicated stability in self-care, after the first three days, M had full responsibility of self-care except when there was risk. From the assessment, several problems were designated for a hands-on solution. First, M was trained on how to inject himself with insulin as an additional act of self-care under different circumstances. Secondly, from M’s inability to budget, he was taught trained on how to do it so that he could take the responsible role of financial management. These were short-term trainings to help solve basic problems that M had. This kind of management is best described as the Cognitive behavioral Therapy (CBT). Additionally, M was trained on the importance of not overthinking about his girlfriend because it was unnecessarily ruining their relationship. A psychotherapy was carried out to reduce the overthinking and psychosis, which was the potential for breaking down their relationship. Still, this fell under CBT.  As an extension of CBD, M was trained on accepting his situation as having the challenges. He was trained on how to relate with his girlfriend when he felt extremely suspicious. M was also trained to value his nurses and see them as people helping him with the recovery process and thus respect them. This short-term therapy is referred to as Dialectical behavioral therapy (DBT) to help people with personality but extended to other mental health areas such as schizophrenia.  During the nursing care process, WRAP was used to understand how well the patient was doing at any time. The Recovery Star was also used to capture information on how IPC was contributing towards M’s recovery process. Tsuji et al., (2017) describes this as Solution Focused Therapy (SFT). There have been two meta-analyses () of Solution Focused Therapy. Additionally, there are 77 empirical studies on the effectiveness of Solution Focused Therapy (Tsuji et al., 2017). Mr. M was determined to be stable to inject himself with insulin for diabetes when need arose. However, during the early days, M’s medication was monitored by the nurse from the IPC facility since the girlfriend was considered as still under training. Antipsychotics are the first-line treatment against schizophrenia. In some cases, some drugs could be ineffective. Penas (2017) explains that evidence suggests that if patients show only a minimal response to an antipsychotic drug during the first two weeks, it is unlikely that the individual will have a robust response. Patients should be observed on stable dose for up to six weeks before concluding that the drug is unstable. M was monitored closely during the first two weeks and the response was fair.  The medication management concluded the evidence-based implementation of the care plan.

Evaluating Care

Care Program Approach (CPA)

The IPC facility applied a framework developed for use on the clients such as M. The framework included a keyworker whose main objective was to foster a continuous relationship and coordinated care. Other features included in the framework are assessment and intervention over a range of needs, involvement of user and carer, and a multidisciplinary working in the community. The main objective was to ensure continuity of care and avoid rehospitalization. From this respect, it can be said that the outcome was attained. M managed to desist from substance abuse which was the major problem that could cause rehospitalization. Having been applied on other patients before, it can be said that the CPA is effective. The similar approach has been commonly practiced by other facilities and known to be effective (Ganeshan et al., 2018).

Case Management

The expected specific case management outcomes for M was the probability of being rehospitalised within 30 days, adherence to treatment, and getting a college admission. To assess the case management satisfaction, WRAP and Recovery Star were partly used to evaluate the M’s satisfaction in accordance with Ganeshan et al. (2018). In the regard of the expected outcome, real outcome and the case management can be said to have been successful because M was not hospitalized within 30 days, he was adherent to treatment, got a college admission and stopped smoking. Additionally, M felt satisfied for with the care. The main source of evaluation of evaluation was through survey