Part 1: Maori Principles
The Maori principles of kawanatanga (governance), tino rangatiratanga (self-determination), and oritetanga (maintaining mana between health professionals and the Maori) provide a basis for reducing the need for the administration of second-generation antipsychotics (SGAs) through coercive means. The Maori of New Zealand believe in a holistic and traditional healing system. The healing system includes the usage of incantations, massage, and plant use. The Maori are in tune with their traditions and often exhibit perceived resistance to modern medicinal practices (Came et al., 2021). Subsequently, Maori people with mental health challenges have long been provided with compulsory treatment orders. These orders compose coercive medicinal practices and have encouraged the administration of SGAs to community members through coercive means. Application of least coercive practice in mental healthcare advocates against forced administration of medicines, including SGAs (Rae et al., 2022). Consequently, healthcare interventions should be implemented in line with most minor coercive practices. Among the Maori, the principles of kawanatanga, tino rangatiratanga, and oritetanga provide a basis for the least coercive practice in mental health treatment.
Kawanatanga is a Maori principle meaning governance. The principle requires healthcare providers to recognize the importance of self-governance among the Maori. Consequently, healthcare providers are encouraged to partner with the Maori and embrace shared decision-making in the healthcare process (Rae et al., 2022). Adherence to the principle of kawanatanga encourages a least coercive approach by requiring healthcare providers to involve Maori patients in their treatment processes actively. Through kawanatanga, healthcare providers provide Maori with appropriate healthcare sensitization. Healthcare sensitization provides Maori patients with sufficient competency in making decisions concerning their healthcare. Health education increases patients’ perception of the importance of mental health medication for positive health outcomes. Subsequently, more Maori can realize the importance of SGAs and voluntarily accept their administration in mental health management.
The Tino rangatiranga principle implies self-determination among the Maori. Colonization in New Zealand created a culture where the Maori were deprived of the power to rule themselves. The power of self-determination is crucial in the Maori way of life, indicating that they are a people in themselves, not just colonies. The Maori prefer independent living to adapt and survive changes in the world (Lawson-Te Aho et al., 2019). Since the Maori ought to be provided with support in making decisions regarding the direction of their healthcare, the patients should make the final decisionsetermination results in patients accepting the administration of SGAs if deemed necessary, hence reducing coercive practice.
The principle of Oritetanga requires equitable treatment of Maori and other citizens of New Zealand. As such, the principle requires healthcare professionals to treat the Maori as they would also be treated in similar circumstances (Oetzel et al., 2021). Usually, healthcare professionals or non-Maori New Zealanders would have the autonomy to make decisions regarding their healthcare services. Oritetanga requires healthcare professionals to provide equitable treatment to the Maori. Increased autonomy for the Maori encourages their decision-making in the administration of SGAs. Health promotion education is an efficient resource to assist patients in making decisions that improve their physical and mental wellbeing.
Part 1: Clinical Examples
The three principles above are applicable in various nursing practice scenarios involving the Maori. In one nursing practice case, an elderly Maori patient in a community setting working with older people diagnosed with psychosis was prescribed appropriate medication. In alignment with the principle of tangata whaiora, the patient will be referred by a pseudonym, Kahu, in this section. Kahu was brought to the community treatment center by his son. Initially, he had refused to come to the facility, citing his lack of belief in the system. Kahu believed that the Maori approach to healthcare was sufficient for his wellbeing. He stated that the modern medicine provision ignored the importance of religious beliefs and practices in the healing process. Additionally, the patient lacked sufficient understanding of the importance of the prescribed medication, hence refusing to consent to its administration.
Kahu was encouraged that Maori healing beliefs and principles could be applied in the treatment process. He was informed that the healthcare process recognized the importance of all the critical elements in Maori beliefs: spiritual, psychological, and physical wellbeing (Came et al., 2021). The patient was also informed that his son and other family members would participate in the decision-making process. Additionally, the patient was told about the nature of his diagnosis and the need to administer the prescribed medication. Failure to take the medication would have resulted in declining psychological and potentially physical and spiritual health. Despite these efforts, the patients still refused to consent to the administration of the drug. Subsequently, Compulsory Treatment Orders (CTOs) were invoked, and the patient was administered the medication without his consent (Beaglehole et al., 2021). Subsequently, the patient exhibited improvements from his initial symptoms.
The application of CTOs proved a practical decision in the nursing case scenario above. CTOs are generally applied to reduce cases of readmissions among patients (Beaglehole et al., 2021). In the case above, the policy facilitated the administration of essential medication to offset symptoms of psychosis. A fortnight after the commencement of the administration, the patient had already demonstrated improvements in his mental health status. The patient’s extended family was involved during the treatment process to adhere to the principle of whanau in Maori healing practices. The effects of medication administration were one thing that went well in the nursing practice case of Kahu.
Despite the success in providing treatment to Kahu, there was still room for improvement in the treatment process. The patient’s failure to consent to the treatment resulted in forced administration. Adopting a less coercive approach would have improved the patient’s experience with the healthcare system. The healthcare professionals in the case would have provided more sensitization to encourage the patient to consent before giving the medication. The treatment process could also be improved by providing comprehensive care considering Maori beliefs (Rae et al., 2022). Despite consideration of Maori culture, relevant principles were not applied comprehensively. In future practice scenarios, I would encourage the comprehensive application of Mori principles in treatment and improved health sensitization to encourage resistant patients to consent to appropriate treatment, achieving the least coercive healthcare practice.
Part 2: Scenario – Non-pharmacological Options
Non-pharmacological options may be implemented before medication to improve disease symptoms in patients. Additionally, non-pharmacological options provide a solid basis for implementing medication interventions in various healthcare scenarios (Chang et al., 2021). The in-patient nursing scenario is best suited to my nursing practice. Practical non-pharmacological approaches to this scenario include building therapeutic relationships and providing access to cultural and peer support. These two options align with providing holistic nursing care to patients from diverse backgrounds.
Building Therapeutic Relationships
Building therapeutic relationships is a crucial non-pharmacological practice before the provision of medication. A therapeutic relationship between patients and healthcare professionals fosters better patient commitment to prescribed medication interventions. A therapeutic relationship between healthcare providers and patients creates a bond of trust and warmth between both parties (Michel et al., 2023). Therapeutic relationships increase feelings of patient support and foster deep connections in healthcare. Improvement in trust levels during the building of therapeutic relationships encourages the patients to follow through with prescribed medications. Patients from cultural minority backgrounds often lack trust in the healthcare system. Healthcare professionals should institute appropriate measures to build therapeutic relationships and encourage patients to trust the medication process.
Healthcare professionals may use various techniques to build therapeutic relationships with their patients. Counseling sessions provide an appropriate setting for building these relationships. Healthcare providers use goal-setting strategies and provide areas for collaboration with patients to encourage the formation of therapeutic relationships. Goal-setting and collaboration assist patients in developing increased confidence in their healthcare providers (Chang et al., 2021). The professional uses empathy to show understanding of the patient’s situation, thereby increasing trust. The relationship-building process requires therapists to seek and act on client feedback. Feedback gives the healthcare professional insight into what works best for the patient (Michel et al., 2023). Additionally, the patient becomes more involved in the therapeutic process, develops a sense of ownership, and develops trust in the healthcare provider.
Access to Cultural and Peer Support
Access to cultural and peer support is crucial in the treatment process, especially for culturally minority groups. Consequently, healthcare providers should consider providing cultural and peer support to their patients. Cultural groups such as the Maori exhibit high reverence for the culture. Patients from this community require the adoption of cultural principles such as hinengaro (mental), wairua (spiritual), tinana (physical), and whanau (family) (Oetzel et al., 2021). Adoption of these principles increases the community members’ commitment to the healthcare process. Consequently, the members are more willing to consent and adhere to prescribed medications.
Peer support initiatives provide supportive communities to patients. Interacting with individuals facing similar issues and showing progress amidst potential adversity offers hope to the patients. The patients realize they can improve their healthcare status by adhering to medications like their peers. Additionally, peer support groups provide patients with insight into effectively managing their condition scenarios (Chang et al., 2021). Support groups inform patients about existing outpatient health services and their appropriate utilization for positive health outcomes. Among the Maori, the principle of whanau relates to peer support as it calls for family involvement in the treatment process. Like peer support groups, the family provides patients guidance, strength, and health resources.
Part 2: Scenario – Social and Political Influences
Social determinants of health and political factors impact the tangata whaiora’s experience of mental distress in inpatient nursing. The tangata whaiora in New Zealand face various social and political factors affecting their quality and experiences in healthcare. One of the leading social factors of health impacting the Tangata whaiorea is alcohol and drug use in Aotearoa. Structural racism is one of the main political issues affecting the experience of mental distress in inpatient nursing.
Alcohol and Drug Use
Alcohol and drug use present one of the leading social problems affecting the Maori in the Aotearoa. The Maori are twice as likely as non-Maori to consume large amounts of alcohol in New Zealand. The lifetime prevalence of substance abuse in the Maori is close to 30%. High alcohol and drug consumption negatively influence the experience of mental distress in the community. Alcohol and drug consumption increases the likelihood of the Maori having employment and financial problems compared to other New Zealanders (Smye et al., 2023). Financial challenges negatively impact the ability of the Maori to access quality addiction treatment and other healthcare services. Consequently, mental health patients with alcohol and drug use problems experience increased challenges in access to quality treatment.
The interrelation between mental distress and substance abuse creates a compounding effect of poor outcomes among the tangata whaiora. Alcohol and drug abuse are risk factors in the development of mental health diseases (Cunningham et al., 2023). Furthermore, high consumption of alcohol and drugs is likely to increase the severity of existing mental health conditions. Conversely, the presence of mental health ailments is expected to drive individuals into alcohol and drug abuse. Mental health stigma, still prevalent among the Maori, predisposes diagnosed individuals to escape mechanisms such as drug and alcohol abuse.
Alcohol and drug abuse negatively impact decision-making concerning access to mental health treatment services. Substance abuse results in poor decision-making, increasing the probability of mental health patients refusing to seek appropriate care and hence experiencing increased mental distress. Additionally, substance abuse increases the likelihood of refusing prescribed medication among mental health patients (Cunningham et al., 2023). Societal stigmatization associated with substance abuse and mental health diagnosis further increases the levels of mental distress among affected tangata whaiora. Furthermore, the stigmatization discourages alcoholics from seeking mental healthcare, resulting in increased levels of mental distress (Smye et al., 2023). The interaction between mental health challenges and substance abuse calls for increased efforts in the provision of relevant therapy services. Health promotion campaigns are necessary to inform affected persons about the importance of seeking professional help for improved mental, physical, and social wellbeing.
Structural Racism
Structural racism presents one of the most impactful challenges influencing the experiences of mental distress among tangata whaiora in in-patient nursing. The Maori have been subject to structural racism since their colonization. Structural racism in Aotearoa is directly associated with poor access to healthcare, low-quality healthcare services, and hence poor health outcomes. Structural racism has resulted in health inequities that restrict access to mental healthcare among the Maori (Came et al., 2021). Subsequently, the population faces increased mental distress as a result of inadequate access to mental health services. Lack of access to mental health services exacerbates the symptoms of mental health ailments.
Racism results in poor economic outcomes for the Maori, who face challenges accessing resources such as education, employment, and public utilities. Lack of adequate education is associated with poor health literacy, meaning that lack of access to education discourages the Maori from seeking appropriate care for various mental health ailments (Talamaivao et al., 2020). Consequently, lack of education worsens the tangata whaiora’s experience of mental distress. Structural racism has also driven the Maori to a high prevalence of alcohol and drug abuse. As described in the previous section, high alcohol and drug abuse coupled with mental health ailments worsen the experience of mental distress.
Structural racism has also resulted in the development of healthcare policies that disproportionately affect the Maori. One of such policies is the Mental Health (Compulsory Assessment and Treatment) Act 1992. The policy provides a legal framework for compulsory mental health assessment and treatment (Muir et al., 2023). The policy provides healthcare providers with an avenue to provide treatment without consent from patients to avoid future readmissions. The Maori cultural practices are different from the treatment discussed in the policy. Consequently, the Maori are more likely to refuse mental health treatment compared to other citizens. The one-size-fits-all policy adopted by the act puts the Maori in increasing distress despite existing mental health ailments in the population.
Part 3: Advocating for Change – Physical Health Risks and Interventions
Administration of second-generation antipsychotics (SGAs) results in side effects that encompass physical health risks. These physical health risks include weight gain, constipation, sedation, metabolic disease, increased blood and cholesterol levels, and dry mouth.
Weight Gain and Metabolic Irregularities
Administration of SGAs results in metabolic dysregulation, which predisposes patients to weight gain, perturbation of blood lipids, cardiovascular diseases, and diabetes. If left unchecked, the effects of metabolic dysregulation may result in increased morbidity and mortality in mental-health patients. SGAs cause changes in the central nervous system’s ability to regulate intake and homeostasis (Doane et al., 2022). Additionally, SGAs such as olanzapine and aripiprazole induce insulin resistance. Subsequently, patients administered with the disease experience elevated hunger levels, eating more foods, and experiencing weight gain.
Metabolic irregularities as a result of administration of SGAs result in abnormal blood glucose levels. Abnormal glucose metabolism results in insulin resistance, which may advance and cause type 2 diabetes (Grajales et al., 2019). Antipsychotic medications bind and block M3 receptors, reducing the secretion of insulin. This disruption in insulin secretion and its subsequent effect on glucose homeostasis are the causes of diabetes. Chronic medication using SGAs causes insulin resistance and, subsequently, diabetes.
Various nursing interventions may be implemented to mitigate the physical health risks associated with the administration of SGAs. Considering the physical health risk of weight gain, providing SGAs with metformin has shown increased control of weight changes in patients (Doane et al., 2022). Other drugs which prevent or treat weight gain in patients taking SGAs include reboxetine, sibutramine, and topiramate. Additionally, patients may be encouraged to engage in increased physical activities to reduce weight gain during medication further (Doane et al., 2022). The administration of antihyperlipidemic medicines may correct hyperlipidemia and high cholesterol levels. Increased exercise may also help reduce cholesterol levels in patients receiving antipsychotic medications (Grajales et al., 2019). Similarly, lifestyle modifications may be used to prevent diabetes. Additionally, physicians may recommend insulin supplementation to correct imbalances caused by blockage of M3 receptors.
Constipation
The medication’s anticholinergic effects cause constipation due to the administration of SGAs. These effects disrupt prophylaxis development and gut motility. SGAs inhibit the action of neurotransmitters such as histamine, serotonin, and acetylcholine, which promote gut peristalsis. Inhibition of these hormones results in prolonged gastrointestinal time and constipation (Lin et al., 2022). Low physical activity, limited fluid intake, and poor dietary habits are risk factors for drug-induced constipation. Constipation due to the administration of SGAs is mitigated through the consumption of stool softeners, lactulose, lubricant laxatives, and polyethylene glycol.
Conversely, the patient’s medication may be switched to ones with a low risk of constipation. Additionally, the physician may recommend reducing the dosage of drugs with anticholinergic properties. Increasing fluid intake, physical activity and healthy dietary habits may relieve constipation.
Sedation
Sedation due to administration of SGAs is more prevalent when patients are administered high doses of the medication. Long-term sedation interferes with the patient’s ability to engage in normal daily activities such as work or school. Additionally, sedation may impair arousal levels during the day and hence cause an increased number of falls (Fabrazzo et al., 2022). Sedation may also reduce the efficacy of rehabilitation, psychosocial training, and other forms of transport—elevated levels of sedation prompt physicians to remove other sedative agents from a patient’s list of medications.
Consequently, other sedation-inducing drugs, such as antidepressantsantidepressants and mood-stabilizing medications, may be stopped. Additionally, the physician may reduce the dosage of the SGAs and instruct most of the dosage to be taken before bedtime. Another option is changing the type of medication to less-sedative options.
Dry Mouth
Administration of antipsychotic drugs may result in the development of a dry mouth. SGAs may interfere with the parasympathetic nervous system. The medications bind and block muscarinic cholinergic receptors of the salivary grounds (Nuchit et al., 2020). Blockage of these receptors reduces saliva output, hence resulting in dry mouth. The severity and frequency of dry mouth depends on the type, dosage, and number of drugs taken. Dry mouth effects are more likely in elderly patients with salivary hypofunction and decreased drug metabolizing ability. A dry mouth due to the administration of SGAs may be controlled by changing the drugs in preference to ones with less anticholinergic properties.
Conversely, physicians may recommend reducing drug dosages (Fabrazzo et al., 2022). Additionally, the physicians may encourage patients to include foods that promote saliva production. These foods include sugarless gums, candies, apples, carrots, and celery.
Part 3: Advocating for Change – Nursing Role
Nurses are tasked with ensuring the welfare of patients is protected at times. In a scenario where a senior nurse fails to address the need for a change of medication for a patient experiencing several unwanted effects, the concerned nurse ought to take appropriate measures to ascertain the patient’s safety. Nurses are required to provide sufficient help and support to patients and their families during the recovery process (Hallett et al., 2023). Nurses must respect their seniors to create harmony and organization in their practice. However, nursing codes of ethics also require nurses to show respect for the individual dignity of patients. Ignorance of a patient’s plea of adverse medication effects contradicts nursing ethics and practice. The patient’s cultural identity further reinforces the need for timely interventions for the experienced side effects. Being of a Maori background, the patient and his community are used to experiencing health inequities in the public health system (Hurley et al., 2022). Refusal to provide timely interventions to the patient may constitute further discrimination against the patient due to his culture. Additionally, refusal to provide timely interventions may result in increased severity of the side effects, resulting in adverse events and resultant morbidity or mortality.
If the senior nurse fails to act on the patient’s plight, an appropriate action is to seek counsel from the nurse in charge of the floor or the nursing supervisor. A nurse should take caution and prevent using language that paints the senior nurse in a bad light (Hallett et al., 2023). Instead, the nurse should present the case to the nurse supervisor and stress the need for timely interventions. Liaising with other healthcare professionals is a critical role in nursing care. Once the issue is presented to the nurse supervisor, the nurse supervisor may recommend conducting more assessments on the patient to assess the extent of the side effects. A clearer picture of the patient’s condition potentially averts crisis, which would have resulted in poor physical and mental health status (Hurley et al., 2022). Subsequently, the nurse may coordinate with other professionals to effectively address the side effects experienced by the patient. This scenario’s case management process may include addressing physical and mental health factors.
Once the nurse supervisor accepts conducting a thorough analysis of the patient’s status in collaboration with colleagues, the next step would be administering and monitoring treatment regimes. There are multiple reasons why the patient may be experiencing adverse effects (Hurley et al., 2022). Once the drugs responsible for the adverse effects are identified, the nurse may recommend changes in dosages or provision of substitute drugs. Additionally, the nurse may prescribe additional medications to offset the adverse side effects. Also, the nurse may prescribe additional lifestyle modifications to effectively address the adverse effects of the drug (Hallett et al., 2023). Finally, the nurse is required to monitor the effects of the prescribed interventions to assess their efficacy. Positive effects would indicate successful implementation of the intervention and may thus be used in future treatment. If the effects are undesirable, additional interventions may be proposed.
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