In partial fulfillment of NUR 700

Doctor of Nursing Practice

Chatham University


It’s common for people with mental health conditions to suddenly stop taking their medication, or to altogether avoid seeking a prescription. This choice can be profoundly frustrating for loved ones and clinicians alike, particularly when the disorder is one that is often easily treated with the right medication. (Garcia-Cabrera, I., Diaz-Caneja, C.M., Ovejero, M, & de-Portugal, E, 2018). While the decision to avoid medication isn’t always a wise one, understanding the motives behind patients’ decisions to stop taking medication can help clinicians, community organizations, friends, and family work together to encourage healthy choices without undermining the autonomy of people struggling with mental illness (Garcia-Cabrera et al., 2018). The purpose of this assignment is to explore noncompliance as a significant issue that could impact patient outcomes and analyze ways of knowing that pertain to my professional experience and how they will direct my choice of actions to take in the future. NUR 700 ways of knowing essay


Personal Experience

I was debriefed by the RN on shift that a patient was refusing vital signs. Patient presented today with her caregiver. Patient was mute upon presentation, which was noted not to be her baseline. Caregiver was available to give collateral information. Caregiver was visibly anxious, almost in tears while describing patient’s behavior in the past month. Caregiver stated that the patient had been refusing all her medications, which included her psychotropic and blood pressure medications. Caregiver added that patient was exhibiting some bizarre behaviors and had been disappearing from home for several days, sometimes hiding in the garage for hours at a time. Caregiver reports patient has been paranoid about eating food she prepared and has resorted to eating only packaged meals she purchased by herself.  Caregiver reports she became concerned few days ago when patient stopped talking and refused to eat. Caregiver stated patient was suspicious about coming to the clinic today but was able to convince her to come with her today. Prior to approaching the patient, I had reviewed her chart.  I noted she had her last refills in September of the previous year and had not followed up at the clinic for several months. Patient has a diagnosis of paranoid schizophrenia, which is a serious mental illness (SMI) NUR 700 ways of knowing essay.  Paranoid schizophrenia is the most common form of schizophrenia, a type of brain disorder that can make it difficult for you to tell the difference between reality and fantasy. In turn, the symptoms can significantly affect the way you perceive and interact with the world. (Legg, 2017). Before inviting patient and caregiver into my office, I discussed my concerns with the RN. Patient had not been on blood pressure medications (patient has history of elevated blood pressure readings at previous follow ups and has history of non- compliance). I realize she might need to be medically stabilized in our Emergency Department (ED) prior to restarting any psychotropics. I acknowledged the caregiver’s collateral information and requested consent from patient at this time to continue interview with caregiver in the room. Patient nodded in agreement at this time and motioned for her caregiver to sit close to her.  Patient refused to speak to me during much of the interview. I was able to elicit whispered words from the patient. It was clear to me that this patient had poor insight and judgement and was not safe to return home. In that instance, it was significant to make the call to transfer the patient to a higher level of care. A detention warrant was written up by our hospital police personnel at this time and patient calmly left my office with the officers who presented to transport her to the ED.

This experience was perceived as significant because patients with schizophrenia who stop taking their medication are at increased risk of relapse, which can lead to multiple psychiatric hospitalization and poor outcomes. In addition to focusing on the patient, it is important to encourage family support as studies have also shown that family involvement decreases rehospitalization and improves social functioning. Family members can be taught how to monitor the patient and when to report adverse effects of treatment to the clinician (Patel, Cherian, Gohil, & Adkinson, 2014). NUR 700 ways of knowing essay

My perception and intervention in the above professional experience requires deliberate development of who you are and requires one to understand their actions and relationships when caring for others (Chinn & Kramer, 2018). Personal knowledge involves awareness of your inner experiences in each situation, recognition of the ways you are interacting in the moment and bringing together in the moment your understanding and insights (Chinn & Kramer, 2018). The questions, “Is this right?” and “Is this responsible?” sets the motion of the creative processes of clarifying values and exploring alternatives for my professional experience. .The ethical way of knowing is a fundamental pattern of knowing that focuses on the moral obligations, guiding what needs to be done (Chinn & Kramer, 2018). This pattern offers guidance for the choices to be made in the event of complex situations. Through this pattern, nurses are directed into doing what’s right and what’s expected under any circumstance.

Ways of knowing

Personal Knowledge

Personal knowledge could be observed from my initial encounter with the patient and caregiver. I approached the situation knowing that this would require time and dedication to achieve any intervention due to patient’s present state of paranoia. I also tapped into my personal knowledge of past experiences with dealing with similar situations where patients have presented to the clinic and have had similar presentation.  I have also learned that it is important to obtain collateral information from caregivers, review the chart for additional history, obtain any additional information, consult with my supervising physician and the attending at the ED if needed in order to derive at the best possible option for the clinical experience. I was able to gain the trust of the patient and caregiver due to my composure, sincerity and dedication to help. My willingness to listen to the patient allowed her time to express her feelings and concerns as much as she could during our encounter, which somewhat allowed her to trust the clinician despite her current state of suspicion and paranoia. The patient was trusting enough to understand that she needed a higher level of care and was able to cooperate with the police department for safe transport to the ED.

Ethical Knowledge

The ethical knowledge was applied when I was assigned to assess the patient.  Reviewing her chart and listening to her caregiver allowed me to understand the complexity of the case.  Following my own values, my moral obligation to advocate for our patient population, I was prepared to find the appropriate intervention that was suitable for this patient. I realize her mental well-being was important, but I wanted her to also get medically cleared due to her history of hypertension, elevated blood pressure readings, and medication noncompliance. Sending the patient home with a distressed caregiver who is unable to safely care for the patient was not acceptable. On the other hand, I struggled with the decision to obtain a detention warrant to commit the patient against her will as the patient did not see the reason to go to the ED at this time NUR 700 ways of knowing essay. As a nurse, it is my moral duty to advocate for my patient and my decision to transfer the patient to a higher level of care was the right thing to do. To protect the patient, it was necessary to file a detention warrant for a temporary involuntary hold to allow clinicians in the psychiatric ED to care for the patient in a secure and safe environment.

Future Actions

The main aspect of personal knowledge is the encountering, knowing and actualizing of the individual self (Chinn & Kramer, 2018) Nurses use personal knowledge daily, thereby gaining experience and perfecting our skills.  Future actions would involve the exchange of experiences like my professional experience discussed in this paper between practicing professionals for collaborative care.  This action will enable the development of professional knowledge and skills. An example will be the implementation of weekly grand round case conferences where patient cases are presented to different departments in my organization. This case conferences are recorded and made available on the organization’s intranet for future viewing.  Collaborating with the primary care provider (PCP) in the above scenario would be important for coordinating care for this patient with behavioral disorder and chronic condition. A check in or follow up phone call by an assigned case manager would also be important to follow up with patient and family to provide support as needed because noncompliance with patients with SMI can lead to worsening clinical status, emergency department visits and hospitalization. Better clinical surveillance would improve this patient’s outcome in the future. Furthermore, developing a problem-based learning instructional model for nurses with less clinical experience and judgement will be helpful in developing personal knowledge (McEwen & Willis, 2014).

According to Sederer, (2013), an individual with a mental illness that interferes with his judgment, self-interest, self-preservation and safety represents a profound challenge for families and clinicians. Doctors have remarked that when patient rights exceed truly necessary protections, individuals with mental illness can “die with their rights on” and sometimes they may harm others along the way NUR 700 ways of knowing essay. As noted in my professional experience, it was with good intention and as a result of wanting the best outcome for the patient that warranted a temporary hold to be filed. Most of the time, the family members are left helpless due to state laws that limit them filing for involuntary hospitalization. Advocating for patients and their families by engaging our law makers to reform the laws will help clinicians provide timely and necessary care to patients with SMI. The author proposed that we ask the families of people with SMI what changes in law and clinical practices could better help their family members (Sederer, 2013).


A professional experience was detailed which involved issues with mental health and treatment noncompliance. My involvement was thorough with the intention for a positive patient outcome. My knowledge of this patient’s history, collateral information, patient interview, collaboration with other clinicians and chart review were required for a thorough investigation of the situation and for an appropriate intervention suited for the patient. Working with patients with similar presentation influenced by my personal beliefs, experiences and my moral obligations as a nurse guided my decision. Safety and positive outcome were the basis for my intervention. As a nurse, it is important to build up on my experiences as this helps develop professional knowledge and skills NUR 700 ways of knowing essay.  Ethical knowledge helps us to tackle dilemmas and make morally sound decisions based on patient’s presentation.


Chinn, P.L., & Kramer, M.K. (2018). Knowledge development in Nursing (10th ed). St. Louis. MO: Elsevier/Mosby

Garcia-Cabrera, I., Diaz-Caneja, C.M., Ovejero, M, & de-Portugal, E. (2018). Adherence, insight and disability in paranoid schizophrenia. Psychiatry Direct, 270, 274-280. Retrieved from

Legg, T.J. (2017). What is Paranoid Schizophrenia. Healthline Media. Retrieved from

McEwen, M., & Willis, E. M. (2014). Theoretical basis for nursing. (4th ed). Philadelphia: Lippincott.

Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: overview and treatment options. Pharmacy and Therapeutics: a peer-reviewed journal for formulary management, 39(9), 638–645.

Sederer, L. I. (2013). The tragedy of mental health law. Missouri State Medical Association. 110(2), 104-105. NUR 700 ways of knowing essay

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