Consolidation of Mental Health Practice: The Decision-Making Process in Action
Introduction
The purpose of this paper was to analyse the role played by effective decision-making processes to promote patient-based care. To realize this objective, I explored a case study whereby the patient was living with his girlfriend and suffered schizophrenia and substance misuse. In addition to his financial management problems, he does not take his medication for schizophrenia and diabetes. Therefore, the decisions surrounding his health and mental capacity to ensure well-being were evaluated. The concepts of collaboration and interdisciplinary teaming to achieve patient-based care were examined. The conclusion which was a summary of the major findings was provided to show how the decision-making process played an integral role in improving the well-being and the living conditions of the patient.
Case Study
M is a 35-year-old man who lives with his girlfriend. He was referred to us because he needed help related to schizophrenia and substance misuse. He has been living with his girlfriend for the last 3 years, and the relationship between the two was breaking down. Subsequently, M is at risk of being homeless. He has been diagnosed with schizophrenia accompanied by problems of alcohol and substance misuse. In addition, he is diabetic, and he has not been under control and closer management. Notably, the health problems and substance abuse have put M at the most risk. He has been planning to leave his girlfriend's home. This is an issue because he has no alternative place to stay after leaving his girlfriend’s place. He is too vulnerable and affected to be in a position to sustain a tenancy on his own. He has, withdrawal symptoms, including difficulty concentrating, sleep disturbances, anxiety, hunger, anxiety, and irritability as well as drowsiness. In addition, the patient was not consistent with undertaking medications.
I with a team planned to undertake a needs and risk assessment to establish the areas that were at risk and the possible needs the patient has and ways which can be used to help him. A support plan was put into place and the team worked with Patient M. The aim was to provide him with the knowledge as well as the skills he required to look after himself. It was established that Patient M did not have medication for his diabetes. Thus, he was supported with medication and the way in which he would safely deal with needles for insulin. A Dual Diagnosis team accompanied by the local council planned ways in which they could supply and collect needles used on the client.
It was also established that patient M lacked basic understanding related to budgeting and making choices. As a result, he used to spend all his money and in most cases, he was left without money required for the purchase of the basics. I discussed this with a social worker on ways that can be used to help M improve his basic budgeting skills and reduce drug taking. I established that Patient M spent most of his money on substance abuse, which affected his financial position. We talked with his girlfriend to accept him because he needed care and medication, which could improve his life and well-being. Staying with his girlfriend was also helpful because the patient would have someone who could help him, especially when he experienced some episodes
In the beginning, the support team helps M to avoid any problems that could present health risks to him and to others. Nonetheless, after he was able to control the manner in which he took his medication, his health seemed to improve. It was concluded that close monitoring was necessary to ensure that M does not stop medication because his condition plus drug abuse could result in self-harm and to others.
Considerations in the Decision-Making Process
Evidence-based information is required to promote evidence-based care and to analyze the outcomes and risk-benefit in order to support patients in the decision-making process (Coulter et al 2013). It is imperative to ensure a patient is actively engaged in the management of long-term conditions. Thus, in this case, it was important to evaluate the capacity of the patient to strike a balance between autonomy and the principle of nonmaleficence and beneficence (Baillie, McGeehan, Garret & Garret, 2013). The principle of autonomy accompanied by the right to self-determination ensures that patients have the right to make decisions and choices are followed (Baillie et al., 2013). This aligns with the Mental Capacity Act 2005 which requires healthcare professionals to protect the rights of patients, especially those mentally challenged.
The Mental Capacity Act 2005 (the Act) is the center for making decisions that revolve around mentally challenged people. The Manchester City Council (2010) pointed out that the Act “provides the legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to make particular decisions for themselves” (p. 1). Thus, any person working with and caring for a person who could have limited capacity to make particular decisions must make the decisions based on the ethical framework provided by the Act. The underlying philosophy of the Mental Capacity Act 2005 is to make sure that any decision made, as well as the action taken, by someone else on behalf of one lacking the capacity to make a decision, is made in their best Interests. When making the decision, the MCA 2005 was considered because it protected the rights of the patient, individual values, attitudes, and beliefs (Coggon & Miola, 2011). Therefore to make decisions on behalf of Patient M, the team gave careful consideration of the MCA 2005 to establish his capacity in terms of understanding and making particular specific decisions by himself.
A shared decision-making process was applied whereby the patient, the social worker, and his girlfriend were involved. Shared decision-making is “A collaborative process through which a health care professional supports a patient to reach a decision about a specific course of action” (Health Foundation, 2014, p. 22). The process of decision-making involving patients with mental illness is important to promote patient-centered care. Person-based care played an integral role in helping address the health care demands of patient M and helping him take medication and reduce substance abuse. Shared decision-making was applied in the case because it “moves beyond the traditional model, in which the healthcare professional is viewed as the expert, to a collaborative relationship, in which the patient or service user is acknowledged as an expert in their condition” (Madsen & Fraser, 2015, p. 51). In the context of the patient, collaboration was necessary to make a shared decision. As such, the care team decided to meet at the home of patient M’s girlfriend because it was the only place where he felt comfortable (Health Foundation, 2012). A familiar environment is more comfortable and ensures that Patient M is not affected in any manner.
Patient M was diagnosed with schizophrenia and substance misuse. Thus, the patient had an impaired brain development, although this did not mean his incapacity to make crucial decisions. Patients suffering from schizophrenia, often struggle with recovery from recovery because they cannot fully take the necessary medications. Winklbaur, Ebner, Sachs, Thau, and Fischer (2006) pointed out that schizophrenic patients have impairment problems that may affect their ability to make specific decisions. Consequently, it was important to me and the care team to make sure that Patient M was equipped with all the relevant information related to his condition and the potential risks to himself and his girlfriend (Winklbaur et al., 2006). For instance, patient M was informed that his diabetic condition would worsen if medication was not provided. He was also informed that his schizophrenic condition could further be worsened by substance abuse.
The principles of shared decision making such as effective communication are important in an effective and collaborative- form of decision-making process. Thus communication was necessary to determine the risks and inform Patient M n the risks and dangers. Elwyn and Frosch et al. (2011) noted that effective communication was necessary to frame the risks in such a manner that the patient was able to make informed decisions. To ensure that the care team did not influence the decisions of the patient, the team was asked questions to establish his capacity. It was established that his decision-making process was partially impaired and his capacity affected. Therefore, his girlfriend played a major role in making some of the decisions. However, Patient M was able to make a decision about medicine taking at home and decisions about his lifestyle. Patient M was asked to decide if or not he wanted to embark on a specific course of action (Coulter & Collins, 2011). Adhering to the medication implies that patient M needed to take responsibility for his actions on a day-to-day basis.
The shared decision-making consultation supported patient M to work out his own adherence strategy (Coulter & Collins, 2011). The patient agreed to take medication with the support of his girlfriend and the care team. The recovery approach supported the decision-making process which was based on inclusion and autonomy. After the needs and assessment were completed, it was now time to provide the necessary support to Patient M. This was necessary to ensure that the patient succeeded in making health-related changes such as stopping substance abuse and to self-manage diabetes in a more effective manner (Coulter & Collins 2011). In this case, follow-up was also important to the patient. For example, a social worker was identified who was to provide support to Patient M to achieve the goal. The work setting was the home of the patient, where he could feel free and comfortable.
In clinical consultations, the principles of shared decision-making were followed. For instance, support was provided to patients so that they could articulate their understanding of his mental and diabetic condition (Madsen & Fraser, 2015). Also, Patient M was provided with the available treatment or self-management support options. In addition, we informed Patient M of his medical condition as well as the treatment or support alternatives available as well as the risks and benefits. I also ensured that a decision was arrived at based on a mutual understanding of the available information (Coulter & Collins 2011). A Dual Diagnosis team carried out the planning on ways to that could be used supply and collected needles used by Patient M. Shared decision-making played a major role in ensuring that different opinions were provided before the ultimate decision was made to promote the well-being and safety of Patient M.
The management processes facilitating the decisions were based on personalized care planning to support and manage Patient M his health and to share in decisions about his health care. Personalized care planning was chosen with the aim of supporting Patient M to manage the challenges of living (Madsen & Fraser, 2015). In reference to his medication, Patient M, his medicines were not changed, but he was supplied with a new diabetes injection kit that would help him curb his condition. The care package for the diabetes was to be provided by the nurse for medication three times a week. This was necessary for the carer to collect the used syringes so that the patient did not harm himself. A Community Psychiatric Nurse (CPN) was responsible for weekly visits to determine the patient’s progress. Additionally, this would allow the CPN to assess medication efficacy for diabetes prior to making any changes. The Social Work Team was responsible for establishing whether the conditions around his residence were suitable. Patient M was advised to wait and recover before planning out of his girlfriend’s homestead.
The Situated Clinical Decision-Making framework was applied in this paper. The framework “incorporates context, foundational knowledge, decision-making processes, and thinking processes “(Gillespie, 2010, p. 334). The framework was helpful in in process of analyzing nurses’ clinical decision-making (Gillespie & Paterson, 2009). The patient’s situation was helpful as it provided the foundational knowledge required for clinical decision-making. I depended on evidence-based analysis as a nurse student to process the information related to the case. On the other hand, the care team (CPN and social worker used previous knowledge, evidence, and intuition. As pointed out by Ebright et al. (2004) experienced nurses have the ability to have a total picture’ of a patient situation and use intuition in the clinical decision-making process. According to the Cognitive Continuum theory, human cognition has the capacity to undertake intuition and analysis of a situation and derive information required for decision-making (Cader, Campbell, & Watson, 2005). According to Cader et al (2005), the Quasi-rationality (as used by Hammond 1996,) is the center of the Cognitive Continuum theory and it entails components of both intuition and analysis. Accordingly, it was the core of the decision-making process in the case of Patient M as applied by CPN.
Standing (2007) and Pretz and Folse (2011) stated that intuition played some important value in clinical nursing, especially in decision-making. Nonetheless, evidence-based decision-making skills and also important and they should not be ignored at all (Thompson & Dowding 2009; Dowding, 2008). This is because the use of intuitive decisions alone could result in making mistakes related to lack of insight and this could affect the decision-making process. In this case, the use of intuition and evidence-based decision-making skills were applied to realize the decision made with reference to the help provided to Patient M. For example, the professional view was that Patient M could make some decisions even with his impairment. However, assistance was needed to ensure that he followed his medication to avoid any risks to his life and that of others. Judgment and decision-making were also explored via ethical decision-making whereby the MCA 2005 was applied (Dowding et al., 2011).
Individuals make judgments and decisions via a number of varied types of reasoning processes, such as intuition, analytical reasoning, and hypothetico-deductive reasoning (Thompson & Dowding, 2009; Dowding, 2008). In this case, cues were used to generate the hypothesis related to Patient M’s behavior (Dowding et al., 2011). For example, it was hypothesized that withdrawal symptoms such as difficulty concentrating, sleep disturbances, anxiety, and drowsiness were associated with schizophrenia and inconsistency with undertaking medications. Thus, substance abuse though a problem did not cause such symptoms. The cues collected combined with nurses’ recognition of patterns and trends within cues were used to establish that Patient M could improve his health and reduce substance abuse. Subsequently, he could live a good life and start to make better financial decisions.
In accordance with the Situated Clinical Decision-Making framework, the decision made focused on establishing if: (i) patient A had the capacity to take and manage his medication safely; and (ii) he could stay alone or with his girlfriend for the time being in order to control his drugs. The decisions were concerned about his health and the judgment made was that he needed help with his medication regime for at least three months, then he would safely take them. It was also decided that staying alone was not possible because (a) he did not have a place to stay other than his girlfriends, and (b) he needed to be at risk of self-harm and that of others. The opinion of the CPN and social worker was that Patient M could not manage his medication on a daily basis and some assistance could be helpful for him to recover. Ensuring that Patient M stayed with his girlfriend was necessary as it ensured that Patient M would be around familiar surroundings.
Conclusion
The case study is based on Patient M who suffers from schizophrenia and substance misuse. The decision-making process entailed the collection of evidence and information from the situation, followed by an analysis of it based on the MCA 2005, and the use of intuition and other modes to make the final decisions. Thus, decision-making process was continuous all through and it incorporated a shared-decision making between me, the CPN, the social worker, and others. The decision-making was guided by MCA 2005, whereby the process ensured that ethical principles of autonomy, and inclusion were considered. The decisions made have all been justified. The above case example indicated that Patient M experienced the symptoms and episodes not because he was abusing substances, but because he was schizophrenic. It has also demonstrated that clinical decision-making is a process that entails making judgments and choices based on available alternatives with the interests of a patient in mind.
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