Evaluation of an Individual with Complex Health Needs

Globally, millions of people have complex health needs. According to Goodwin et al.
(2014), individuals with complex needs usually experience more than one health
challenge in their lives, thus impacting their physical, mental, and social well-being.
The complexity may have resulted from interactions of biological, psychological, and
social factors (Barton et.al., 2017). To address complex health needs effectively,
complex care therefore becomes a critical necessity (Miller et.al., 2015). Complex care
seeks to improve health and well-being for people with complex health, physical, and
social needs by coordinating and reshaping care delivery at the individual, community,
and system levels (National Institute for Health and Care Excellence (NICE); 2015).
However, this essay focuses on the critical evaluation of a service user with a complex
need during clinical practice of the author (self). In compliance with the Nursing and
Midwifery Council Code for Professional Practice (NMC), 2018), confidentiality of the
service user will be maintained throughout this essay. Therefore, the service user is
referred to as Hamza (pseudonym) for easy identification. This essay further analyses
the mental and physical health interaction of the service user (Hamza). It further
presents the impact of collaborative working with members of the inter-professional
teams on the health and well-being of Hamza as well as the influence of regulations,
legislations, and recommendations to support Hamza’s delivery of care. Effective
leadership plays significant roles in quality care delivery. This essay therefore
discusses the influence of leadership concepts/theories on the author’s roles in
delivering Hamza’s health care needs. Reflective practice helps healthcare
professionals to examine own strength and weaknesses during and after an episode
of care; the overall aim is learning from experience. This essay presents reflection of
personal (author) roles in the delivery of Hamza’s complex care health needs.

Hamza, a 59-year-old retired teacher who lives with his wife, two children and a
grandson in a Council House receiving benefits was referred by his GP for more
support, having experienced first episode of schizophrenia; he was withdrawing from
friends and families, and was experiencing sleeplessness. He was assessed by the
consultant psychiatrist and was diagnosed with paranoid schizophrenia. According to
Cagliostro (2019), Paranoid schizophrenia is characterised by mainly positive
symptoms of schizophrenia, including delusions and hallucinations which are less
likely to go unnoticed. These devastating symptoms blur the line between what is real
and what is not, thus, making it difficult for the person to live a normal life. After the
early signs and symptoms stage, Hamza entered the active phase of schizophrenia,
during which he exhibited debilitating thoughts and perceptual distortions. He also
experienced impaired cognitive functions, including catatonic behaviour and
disorganised speech.

The paranoia in paranoid schizophrenia stems from delusions—decisively held beliefs

that persist despite evidence to the contrary — and hallucinations — seeing or hearing
things that others do not (NHS, 2017). Both of these experiences can be threatening
in nature. A patient may hear voices in his/her head that do not recognise as own
thoughts. These voices can be hostile, driving a person to do things they would not do
otherwise. However, the negative symptoms might include an increasing lack of
motivation, decreasing inability to pay attention, or social isolation (NICE,2015). In
addition to Hamza’s mental health, his medical history shows other physical health
challenges such as Type 2 Diabetes Mellitus, and acute coronary syndrome thus
requiring complex care needs for him (Mamakou et. al., 2018). Hamza has complex
care needs, but this essay limits the discussion to paranoid schizophrenia related
needs, and Type 2 Diabetes as physical health condition. Type 2 diabetes is the more
common kind of diabetes, causing the level of sugar (blood glucose) to become
excessively high (NHS, 2017). Hamza’s history shows that he has been living with
Type 2 diabetes since 2012. According to Tabak et. al., (2012), prolonged exposure
to increased blood glucose can damage the small blood vessels that can lead to
serious health consequences such as heart disease, blindness, tiredness, and
overweight. It can be simply described as a lifelong condition that can affect everyday
life. Storm et. al., (2020) affirmed that there exists an interplay between mental and
physical health illnesses.

After the assessment by the Consultant Psychiatrist, Hamza was referred to the acute
ward for treatment under section 3 of the Mental Health Act (1983) as amended 2007.
Hamza’s health condition improved, and the adult Community Mental Health Team
(CMHT) continued the follow-up care after his discharge from acute care. The CHMT
consists of Community Psychiatrist Nurses to coordinate his care plan, psychiatrists
for diagnosis, psychologists for counselling, occupational therapist to take care of his
fall needs, pharmacists for drugs delivery, social health worker to take care of his
benefit needs, support workers for daily care, dietician for healthy eating, and the
author to observe and contribute to Hamza’s intervention process. As recommended
by the Department of Health and Social Care (2018), individuals with complex care
needs under specialist mental health teams such as CHMT be monitored under the
Care Programme Approach (CPA). The Care Programme Approach (CPA) is a
package of care for people with mental health problems (NHS, 2017). This ensures
that the right treatment is given to Hamza based on his health care needs. The goal
of the CHMT is to provide day-to-day support and treatment to ensure Hamza’s
independence as much as possible. The author (on placement) is among the CHMT.
This will assist own skills development towards effective care delivery to service users,
and in practice.

The care coordinator (a Community Psychiatrist Nurse) alongside student nurse

through conversation further assessed Hamza to identify his health care needs.
Through his medical history, and behavioural pattern, it was observed that Hamza had
entered the active phase of schizophrenia - a dramatic disruption in his life and the
lives of his family members; initial treatment is recommended at this point (Casarella,
2020). She added, when schizophrenia is diagnosed, antipsychotic medication is
most typically prescribed. Thus, the Psychiatrist prescribed the following: clozapine
100mg, 100mg nocte, lorazepam 1mg tablets BD, aripiprazole15mg tablets to be
taken daily in the morning, and gliclazide 80mg tablets, two to be taken daily.
Antipsychotic drugs can have unwanted side effects including weight gain,
drowsiness, restlessness, low blood pressure, dry mouth, and lowered white blood cell
count (Lord et. al., 2017). The care coordinator reviews his medication regularly, for
example, he attends clozapine clinic monthly to check his white blood cell through
blood test. Vitamins B-12 was prescribed after the result shows lowered blood cell
count of 3249 against 4000 microliters of blood. Levine (2020) discovered that people
who took high-dose B-vitamins such as B6, B8, and B12 in addition to their
medications significantly reduced symptoms of schizophrenia, compared with those
who took medicines alone. The CHMT ensured strict adherence to the medication
plan. To take care of the pain on his leg due to the fall, paracetamol 500mg tablets
was prescribed, and two to be taken four times daily.

In additional to his mental health care needs, the author shadowed the CHMT, and
conducted some assessments for his physical care needs. An Oral Glucose Tolerance
Test was carried out by the author to determine the blood sugar level, the results
showed a reading of more than 210 mg/dL (11.1 mmol/L). According to NICE (2014),
a blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal; however, a reading
of more than 200 mg/dL (11.1 mmol/L) in the presence of symptoms indicates
diabetes. This implies that Hamza suffers from Type 2 diabetes. Metformin 500mg
tablets was prescribed for the treatment of Type 2 diabetes; two tablets to be taken
with breakfast, and two tablets to be taken with evening meal. Hamza complained of
watery and itchy eyes, and latanoprost 50 microgram/ml eye drops was prescribed;
one drop into each eye at night. The student nurse built a rapport with Hamza using
appropriate person-centred communication (NICE, 2018). This was aimed at
monitoring Hamza’s condition and to prevent further complications. Hamza’s mental
care needs in additional to his physical health condition make monitoring a high priority
(Charity Diabetes, UK, 2017).

To continually meet Hamza’s health and social needs, the care Coordinator, and the
author, in partnership with Hamza developed a workable and realistic care plan (Barret
et.al., 2012); he was allowed to identify his health needs in order of preferences as
recommended by NICE (2014); the care and support patients receive should be based
on their needs and what matters most to them. For quality delivery of care to Hamza,
a careful attention was paid to the interplay between mental (schizophrenia), physical
(Type 2 diabetes) health interactions. According to Cagliostro (2017), schizophrenia
itself is proposed as causal factor for diabetes, given the observed higher prevalence
of diabetes in newly diagnosed patients with schizophrenia and unexposed to
antipsychotics. Engel (1977) postulated that an individuals’ health needs cannot be
predetermined through biological standpoint only, rather, it requires other health
determinants such as psychosocial and environmental factors to be considered.
Hamza’s mental health has impacted his social life via diabetes, and the adverse
effects of lorazepam and clozapine contributed to his excessive weight gain. Evidence
suggests that individuals’ biopsychosocial needs may vary across lifespan, thus,
health and social care professionals need to be vigilant and adapt to these changes
accordingly (Reeve and Cooper, 2014). Similarly, excessive sedentary lifestyle, social
determinants, adverse effects of antipsychotic drugs are considered aggravating
factors for diabetes onset and low quality of diabetes management (NHS, 2017).
Furthermore, studies support genetic predisposition to diabetes among people with
schizophrenia, suggesting shared genetic risk and disclosing a number of overlapped
risk points. As a result, CHMT paid special attention to Hamza, through intervention in
all possible modifiable risk factors. They also ensured careful implementation of
antipsychotic prescription, provision of adequate motivation for balanced diet and
physical activity. In the care plan, a combination of dietary and physical activities
interventions was recommended as recommended by NICE (2018).

During the development of the care plan under PCA, shared decision-making
approach was deployed by the care professionals and Hamza to negotiate a plan that
both parties agree is ethical, consistent with the evidence, and compatible with
Hamza’s preferences (Connor et.al., 2007). Furthermore, Drake et. al., (2009)
revealed that shared decision making can improve the participation of mental health
patients and the quality of decisions in terms of knowledge and values. The author
ensured that Hamza’s family particularly the wife, who remains the primary carer are
involved to support the decision-making process about care needs and treatment. This
is in agreement with the recommendation made by NICE (2018) that people are
supported to make decisions for themselves when they have the mental capacity to
do so. The author explained the frequency and dosage of the prescribed medication
to Hamza’s wife to enable him maintain a healthy lifestyle.

While antipsychotic medication is effective in treating the positive symptoms of

schizophrenia, it does not address negative symptoms such as decrease in goal-
directed behaviour and motivation, poor hygiene, and social withdrawal (Rethink
Mental Illness, 2017). People with schizophrenia sometimes quit their medications
because of side effects or not understanding their illness. This raises the risk of serious
symptoms returning, which can lead to a psychotic episode (in which someone loses
touch with reality). This was the case of Hamza, at some point, he was not following
the medication plan. The pain from fall caused him depression, and he withdrew
completely from his friends.

During one of the regular professional team review meetings, the author conducted
the review meeting using Situation, Background history, Assessment, and
Recommendation (SBAR) as directed by the care coordinator. As a result, a collective
decision was reached for a referral to a psychologist for counselling to help him stick
with his treatment plan. All physical conditions have a psychological implication
especially when a patient is isolated socially like Hamza (Norman and Ryrie, 2013).
NICE (2018), recommends Cognitive Behavioural Therapy (CBT) for adults with
schizophrenia. Cognitive behaviour therapy (CBT) has emerged as a widely used and
efficacious treatment approach for a variety of psychological conditions (Dobson and
Khatri, 2000), including depression, anxiety disorders, personality disorders, and
eating disorders. Similarly, NICE (2016) recommended psychosocial interventions to
address issues related to patients’ psychosocial factors. The Psychologist then
recommended CBT treatment for Hamza. Through CBT, Hamza was able to examine
his thoughts, and was able to recognise negative thoughts, and then countered those
negative thoughts and emotions.

Furthermore, communication plays a vital role in health care delivery; the information
can be used to recommend medication or treatment options. For effective
communication, openness, honesty and paying attention is highly encouraged as
recommended by the Trust policy of the care unit where the author did her placement.
It is essential that effective communication takes place regularly between the care-
givers, and the patient including the family; this will offer valuable information that will
guide decision making relation to care and treatment. Health and Social Act (2012)
stated that health care providers are established to diagnose, treat, and improve
mental and physical health and well-being of people. The CHMT followed the CBT
process in line with NICE Guidance (NICE, 2015) on psychological treatment. Goal
setting is step one of this process and it is to be set collaboratively with Hamza and
his wife in order to meet their needs (Fitzgerald, 2017). Hamza was still on his
antipsychotic medications; evidence shows that when medication is combined with
CBT, result has proved more effective than either treatment option (National Institute
for Health and Clinical Excellence, 2009). It is the policy of National Trust policy (2019)
to put mental health on a par with physical health. Nice (2018) recommends
psychological therapies for treating mental health disorders such as schizophrenia.
The author was involved in clinical supervision which is an integral part of CBT; this
provides additional information and knowledge, aids continual professional
development, and ensures quality control in CBT practice (Milne and Reiser, 2017).
After six weeks of CBT, Hamza recorded measurable improvement in both his physical
and mental health conditions.
For quality delivery of care to Hamza, effective management of the CHMT is
fundamental. This can drive the team’s performance and motivation to meet the care
needs of service users including Hamza. In addition, healthcare professionals with
understanding of their own leadership style, and that of their colleagues will be more
successful in managing their team for an improved patient care. Leadership is an
important function of management, and it plays a vital role in effective quality care
delivery. In the context of healthcare, Schyve (2009) defined leadership as the process
of influencing others to understand and agree on what needs to be done, and how to
do it as well as facilitating individual and collective efforts to accomplish shared
objectives. It is therefore recommended for healthcare professionals to understand the
leadership styles and theories that are relevant to their practice. This will also help the
CHMT and the author to develop skills to become better leaders for effective
healthcare delivery management. From observation, the CHMT demonstrated
Participative leadership, also called democratic style of leadership where the care
team members share knowledge, and make informed decision for effective care
delivery. One of such events was during the development of the care plan where
psychologist, the psychiatrist, the dietician, and the author deliberated on care based
on Hamza’s needs, and the care plan was developed accordingly. The democratic
style of leadership within CHMT gave the author the opportunity to contribute to the
development of the care plan, and this experience will be helpful in future practice. In
terms of democratic/participative leadership, the leader engages the followers in the
decision-making process by consulting team members, while still maintaining control.
According to the guidelines for democratic leadership, the first step is diagnosing
decision situations, which includes evaluating the importance of the decision,
identifying people with relevant knowledge, and evaluating whether it is feasible to
hold a meeting (Schyve, 2009). The second step is to inspire participation, which
includes encouraging people to express their concerns, and looking for ways to build
on ideas and suggestions. However, it is worth noting that there is no single leadership
style that fits all situations, for example, under emergency where decision needs to be
taken quickly, autocratic style of leadership is mostly preferred. It is therefore
suggested for the author and other healthcare professionals to understand different
leadership theories/style for effective care delivery.
The benefits of reflection on personal roles in nursing practice cannot be overstated.
Bout et.al (1985) defined reflection as the process of learning from experience or
activity to gain new understanding of practice and/or self. This implies that reflection
is associated with learning from experience which in turn can assist healthcare
professionals to identify areas for further learning and improvement as well as sharing,
supporting, and learning from colleagues (NMC, 2017). Reflectively, collaborative
working among the CHMT assisted timely delivery of quality care to Hamza, and this
should be promoted in healthcare. The collaboration reduced the workload of health
care providers as put forward by Leape et. al., (1999) that teamwork has shown to
provide benefits to healthcare providers which include reducing workload and
increasing job satisfaction. Furthermore, during Hamza’s assessment by the
Community Psychiatrist nurse to identify his care needs, the author felt emotional due
to the disruption in Hamza’s life and the lives of his family members. According to
Thorsteinsson (2002), empathy is of great importance in effective patient-centred care.
The author assessed Hamza to identify his physical health needs under the
supervision of the care coordinator; an Oral Glucose Tolerance Test was carried out
to determine the blood sugar level. At the start of the test, there was an internal anxiety,
but the care coordinator guided the author and this further built the confidence of the
author in patient diagnosis. The author also observed through assessment that there
is a substantial body of evidence relating psychosocial factors to physical illness such
as diabetes (Macleod and Davey, 2003); a causal effect of Hamza’s physical condition
(Type 2 diabetes) on his mental condition (Schizophrenia). During the assessment,
substantial information was gathered through therapeutic relationship, which in turn
was used for counselling to improve his physical health. Trust policy on confidentiality,
respect, and dignity of Hamza was adhered to accordingly. Communication plays
major roles in the delivery of quality care as observed in CHMT, and this skill will be
added to own development needs. The author was also involved in Hamza’s care
plan development, and this was done according to his health care needs (Milne and
Reiser, 2011). Conclusively, the CPA presents a great opportunity for the author to
learn the CPA process, how the CHMT works together to address the psychosocial
needs of service users. It is recommended that collaborative working among inter-
professional healthcare team members be promoted to improve to meet the care
needs of service users.
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