Treatment compliance with schizophrenia
THE TREATMENT OF schizophrenia has been a major area for research worldwide. For the past 30 years, one of the foremost concerns in schizophrenia research is patient treatment compliance. Researchers have found low compliance rates, both medical and psychosocial therapies, with prescribed treatment. Patient compliance with treatment continues to be a major challenge for patients, their families, clinicians, researchers, and administrators.
McPhillips and Sensky (1998) related that it is impossible to abandon the term treatment compliance for patients with schizophrenia. Compliance is an encompassing term for an approach to a serious, chronic, and frequently disabling illness that generally lacks a significant degree of insight or acceptance by the patient. The approach to patient treatment compliance is complex and has many medical and psychosocial variables. A trusting relationship between nurses and their patient’s is based on cooperation and support and is the foundation of compliance (Evangelista, 1999).
Compliance with treatment is defined as attendance at scheduled individual therapy, medication clinics, group therapy, partial day care, psychosocial rehabilitation programs, and taking medications as prescribed. Estimates are from 25% to 94% of patients in outpatient clinics do not take their medications as prescribed (Corrigan et al., 1990; Davidhizar, 1982). Problems that occur with medication compliance include taking nonprescription drugs, making mistakes in dosage, making self-changes in dosage, omitting a particular medication, or stopping medication ( Kane, 1985; McPhillips, M. and Sensky, T., 1998. Coercion, adherence or collaboration?. In: Wykes, T., Tarrier, N. and Lewis, S., Editors, 1998. Outcome and innovation in psychological treatment of schizophrenia, John Wiley & Sons Ltd, New York, pp. 161–177.McPhillips & Sensky, 1998). Studies have identified compliance rates for patients with schizophrenia in treatment in the community are low. Estimates are that from 15% to 48% of patients with schizophrenia will become noncompliant with any aspect of care within the first year ( Corrigan et al., 1990; Kissling, 1997).
No single treatment intervention for schizophrenia has been effective in improving the multiple symptoms and disabilities associated with schizophrenia. However, researchers have found that the relationship developed by clinicians working with patients with schizophrenia has the greatest value in influencing treatment compliance (Fenton, 2000). They also agree there is a need for a strong positive individual relationship with patients. Most notably, Streicker, Amdur, and Dincin (1986) concluded that, of all the factors analyzed and benefits gained from educational interventions used to enhance treatment compliance, all could be eclipsed by poor provider/patient relations.
The therapeutic relationship, developed by the nurse/patient interaction, has been the domain of psychiatric nursing and was first identified and introduced by Peplau (1952). Peplau wrote that nurses have an instrumental role in their patients’ processes of changing health-related behaviors through the formation of therapeutic relationships in which common goals are developed. However, little research has targeted provider/patient relationships, treatment interventions, and the impact on patient treatment compliance (McPhillips & Sensky, 1998). Lego (1999) reported that the number of unanswered questions with regard to what does or should take place in the nurse/patient relationship is staggering.
Purpose
The study of the nurse/patient relationship as it relates to patient compliance in the outpatient setting needs to be evaluated and effectively interpreted. The analysis needs to include a description of (1) how nurses decide to provide care in an effective manner to enhance treatment compliance and (2) what problems nurses encounter to provide care and their efforts to solve these problems. Therefore, the purpose of this study was to understand the social processes used by nurses in an outpatient community mental health clinic to develop a nurse/patient relationship that promotes treatment compliance for patients with schizophrenia.
Methodology
Grounded theory
Grounded theory was chosen as the methodology for this study. Lowenberg (1993) suggested that grounded theory is Glaser and Strauss’s (1967) version of the broader sociological school of symbolic interactionism. Grounded theory is a method of inquiry that explores social processes and social interactions. This research methodology explores the richness and variety of being human ( Glaser & Strauss, 1967; Strauss & Corbin, 1998; Streubert & Carpenter, 1999). The philosophical underpinnings of grounded theory are based on the assumptions that individuals learn about and define their world through interactions with others. The grounded theory method portrays the process of health care promotion.
Participants
Two groups of participants were recruited for this study: (1) nurses in outpatient clinics and (2) patients in nurses’ caseloads. Nurse participants were approached first. Five expert nurses (Benner, Tanner, & Chesla, 1996), four bachelor prepared and one with an associate degree, were selected using purposive and theoretical sampling, for direct participant observation with their patients (see Table 1). The first two nurses were selected from outpatient units, using purposive sampling based on the selection criteria, the number of years of employment experience with the mentally ill population, and the number of patients with schizophrenia on their caseloads. Three other nurses were selected through theoretical sampling to gain sampling diversity. Nurse participants as dyads with patient participants were added until saturation of the data occurred. Informed consent from the participants was obtained and their confidentiality assured.
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