3.1.1. Concerning Daily Life

Nurses interact with patients in their daily lives to reduce the sensitivity of patients and to create a starting point for interactions. Only by gaining trust can MHNs further discuss the core problems of the disease. Participant 17 thinks that providing care in daily life is not intrusive and avoids the patient's symptoms. She said:

"If his (patient) symptoms are really bad, or he has delusions, don't be too deliberate. Continue providing routine care every day. You can ask: How are you (patient) sleeping lately or how are you eating? He may feel that this is just a common concern. The patient may be willing to talk about why he doesn't (want to) take his medication further."

MHNs start with normal contact, and only after establishing trust can they talk to the patient about problems with their disease and medication status.

#### 3.1.2. Express Care Nonverbally

Non-verbal communication of care acknowledges that patients are more sensitive to non-verbal expressions of care. MHNs can convey their concern for patients through non-verbal communication, which helps to build relationships. Participant 9 discusses this as follows:

"Actually, language is a secondary form of communication. What's more important is the nurse's attitude, expression in the nurse's eyes, tone of voice, and spending time with them. That can help the patient feel safe to talk about their illness."

Given the importance of non-verbal communication in relationship building, MHNs thus try to communicate nonverbally.

#### 3.1.3. Lenience and Being-With

Containment and being-with mean that nurses respond to the patient's negative emotions through listening and empathy to convey understanding and acceptance to the patient. Participant 9 recalled facing psychiatric patients complaining about medication problems:

"When he (patient) may have some complaints, I just comfort him. He was complaining about the discomfort of taking medicine. First, I listened to his complaints. After he complained, he talked about taking medicine slowly."

Participant 10 thought that, given enough time, the patient will gradually vent out their emotions, which will help to establish the relationship. He said:

"You should give the patient plenty of time to talk nonsense or complain and vent the accumulated emotions and pressure. He (the patient), in this way, will more likely develop trust in you."

Nurses can show empathy, listen, and accept behaviors to deal with patient's negative emotions and earn the patient's trust in order to talk about medications.

#### 3.1.4. Handling Patients' Characters

Handling patients' characters means nurses should appropriately adjust the interaction according to the different personalities and situations with the patients to maintain a friendly interaction. At the beginning of the interaction between Participant 11 and a patient, an adjustment of the interaction according to the patient's characteristics facilitated the patient's cooperation in therapeutic activities after the relationship was established. She said:

"There are some patients who are more perceptive. It is better to give him a little flexibility rather than confront him. Then, he will be more willing to accept and cooperate in the follow-up. We learn how to use the patient's traits to take care of him."

Nurses should have sensitivity during the interaction. Participant 17 thought that they should not talk about medication too directly. She said:

"At the beginning, you can't directly talk about medicine. No! Otherwise, you will not be received well. The patient may instead say that they don't use it anymore. Patients will disagree with you. You will be rejected."

The nurse is unable to carry out the follow-up treatment plan if it triggers negative emotions in this case.

#### *3.2. Overall Assessment of Non-Adherence to Medication*

Non-adherence to medication involves various factors, and the nurse should assess the medication status and difficulties. The subthemes of this include evaluating beliefs about taking medication from the context, tactfully confirming side effects, and assessing the ability of the family to support medication.

#### 3.2.1. Evaluating Beliefs about Taking Medication from the Context

Evaluating the beliefs about taking medication from the context means that the nurses evaluate the reasons why the patient is disinclined to take medication to use as a reference for intervention. Participant 21 described a clear reason:

"The patient's lack of desire to take medicine must be based on reasons. If the patient can specify his reasons, we can assist him in eliminating them to improve his motivation to take medicines."

The nurse should also confirm the medication status from the patient's relatives and friends. In this regard, Participant 12 said:

"I listened to the patients and the family members to see if there are any points of fit because they actually live together."

In addition to assessing medication, the nurse should also confirm from their relatives observervations whether patients take medication. The assessment status is used as the basis for interventional medication by understanding the context.

## 3.2.2. Tactfully Confirm Side Effects

Nurses know that side effects are one of the reasons for non-adherence to medication. They take indirect or tactful methods to clarify the side effects experienced by patients. Participant 6 described an example using postural hypotension:

"If the patient is taking medicine that causes postural hypotension, we will ask: 'Do you usually have it?' or 'In addition to the uncomfortable things you said, do you still feel dizzy?' We will not directly say that this is a side effect of the medicine."

#### Participant 19 also mentioned:

"We will avoid saying we notice the patient's worry, such as tremor of hands. I will not ask him directly, 'Do your hands tremor?' Instead, I will ask, 'Do you feel uncomfortable after taking the medicine?"

MHNs use euphemistic methods to clarify and evaluate to prevent patients from hesitating or ceasing to take medicine due to side effects.

#### 3.2.3. Assessing Ability to Support Medication from Family

To determine the knowledge of family members in supporting medication adherence, the family's ability and individual problems of the family members as medication supervisors are assessed to confirm the patient's medication problems. Participant 16 described the assessment of the family members' ability and concern about medication adherence:

"Sometimes family members have to work and can only prepare medicines for him to take. Sometimes family members are afraid of the patient's anger, fearing that the patient will be upset by being urged to take the medicine. Nurses need to evaluate the abilities and attitudes of family in supervising the patient in adhering to medication."

The family members are the main caregivers of patients with mental illness, and nurses need to evaluate the ability of a family as a resource in medication adherence.

#### *3.3. Understanding Disease and Adjusting the Concept of Medication*

Nurses use different viewpoints to help patients understand disease, explain the pros and cons of medication, and improve patients' willingness to take medication. Subthemes include an analogy to an acceptable disease, the pros and cons of taking medication, identifying and managing medications, and reducing influence from side effects.

#### 3.3.1. Analogy to an Acceptable Disease

Creating an analogy to an acceptable disease means that the nurse compares the treatment of psychiatric medication to a generalized disease that can be accepted to increase the patient's willingness to take medicines. Participant 3 explained that taking psychiatric drugs is similar to taking medication for a general physical illness to increase motivation in taking medication:

"Some patients have no insight. I use analogy to physical diseases. I will tell patients: 'Taking this medicine (antipsychotic) is just like taking medications if you have high blood pressure or heart disease.' I also tell the patient, 'Even us nurses have to take medicines when we are sick."

Participant 12 used acceptable generalized symptoms as a starting point for the explanation:

"I think that discussing symptoms of the disease that are acceptable to the patient, such as insomnia, and asking them to confirm with continued treatment whether the symptoms improve can persuade him to take the medicine."

MHNs can help improve the patient's acceptance of symptoms and medications by comparing the treatment process to those of general illnesses.

#### 3.3.2. The Pros and Cons of Taking Medication

The nurse discusses the pros and cons of taking medication to emphasize that failure to do so will cause the return of symptoms and relapse. The nurse reminds the client of the consequences and losses of not taking medication. Participant 9 positively reminded a patient of the changes after the medication:

"Let the patient compare the results of adherence and non-adherence, and ask them to think about what is good for them."

To encourage continuous medication treatment, Participants 21 said:

"Let the patient know that with treatment, their situation would be more stable. Without treatment, they may be sick or hospitalized all the time, unable to work, unable to maintain their marriage, and the family will eventually be affected."

The nurse can enumerate the benefits of taking the medicine to avoid losing one's well-being due to the influence of symptoms.

#### 3.3.3. Identifying and Managing Medications

Identifying and managing medications refers to improving motivation to take medications by understanding the benefits of drugs for disease control. The improvement in symptoms after patients administer the medicine is used as the premise to increase their awareness regarding medications. Participant 20 stated:

"I will inform patients about the effects and side effects of medications. The main purpose is to let the patients know how medicine can help stabilize the disease."

MHNs can also assist in the administration of medicines so that patients can take medicines conveniently. Participant 12 said:

"There are some patients who will still be unable to identify their medicines clearly. I can help them concentrate the medicine and tell them: 'this package is your after-breakfast medication."

MHNs can assist patients in organizing medications to improve medication adherence behaviors and convenience.

#### 3.3.4. Reducing Influence from Side Effects

Side effects are one of the reasons that cause patients to stop adhering. One of the strategies used by nurses to improve patients' medication adherence is to help reduce the side effects via providing information or assisting the physicians to adjust the medications that affect patients' confidence in taking the medication. Participant 5 provided suggestions to alleviate side effects after speaking with the patient:

"I will provide nursing knowledge and inform patients that if side effects are present, the medication can be adjusted to relieve discomfort."

MHNs can act as agents for the patient. Nurses can communicate with the physician the need to adjust medication and reduce the impact of side effects. Participant 2 said:

"Some patients need to work, and the drugs make them groggy and sleepy. I can ask the doctor to make some adjustments in the medication regimen."

MHNs can provide information on reducing side effects and also serve as a communication bridge between patients and physicians to increase patient willingness to take medication while helping decrease the influence of side effects.

#### *3.4. Incorporate Interpersonal Connection Feedback*

Incorporating interpersonal connection feedback means helping patients perceive the benefits and responsibilities of taking medications through feedback of the wellness associated with taking medications as prescribed. Subthemes include positive affirmations for taking medication, describing illness anecdotes from peers, and consideration of the burden on their loved ones.

#### 3.4.1. Positive Affirmations for Taking Medication

Positive affirmations for taking medication means providing encouragement to the patient to boost the patient's willingness to continue taking medication. Participant 4 provided patients with feedback on taking medication through affirmation cards:

"The patient likes the star. I made cards and wrote blessings on the back of the cards. After the patient takes the medicine, I give them the card as positive affirmation for adhering to medication."

Positive feedback improves the motivation of patients to adhere to medication, thereby enhancing medication compliance.

#### 3.4.2. Describing Illness Anecdotes from Peers

The nurse invites the patient's peers to describe their experiences of the benefits of taking the medicine to enhance the patient's motivation to do the same. Participant 12 described her experience:

"I invited patients with the same disease to talk about their experiences of taking the medicine. The invitees told the hesitant patient, 'You must take it! I can sleep better and I don't have a bee in my bonnet.' Hearing anecdotes from peers has a significant effect on persuading patients to do the same."

Hearing the experiences of peers with the same can increase motivation for adherence to medication.

#### 3.4.3. Consideration of the Burden on Their Loved Ones

Consideration of the burden of the disease on their loved ones entails the nurse reminding the patient to pay attention to the effort of their caregivers in helping them manage their illness. Participant 7 recalled:

"Tell the patient that if they take their medicine, they will be less likely to be hospitalized and that they can also make their mother feel more at ease."

Participant 16 further reminded patients to value the hard work of their family members in helping them manage their illnesses. Only stabilizing their symptoms can reduce the burden on their family. She said:

"I tell the patient: 'Your mother is worried about your health, but she is also getting older. If you are willing to take the medicine and to manage your symptoms, then you will be also helping unburden you mother."

MHNs can remind patients that their illness not only affects themselves, but also increases the burden on their family. Taking medications as directed helps to stabilize symptoms and reduce caregiver burden.

#### *3.5. Building Supportive Resources*

The nurse evaluates how to help the patient comply with the medication regimen by changing the patient's participation in medical care and/or oral medication status or using family and community resources. The subthemes of this intervention include encouraging shared decision making, using long-acting antipsychotics, inviting family to monitor symptoms and promote medication adherence, and referral to related resources.

#### 3.5.1. Encourage Shared Decision-Making

MHNs encourage patients to communicate with their physicians in order to talk about medicine and fight for their best interests. Participant 19 said:

"You can adjust the medication during the hospitalization, and you can talk to the attending doctor. You can also communicate with your doctor and make adjustments during outpatient visits."

Nurses can encourage patients to express their thoughts on the medications prescribed to them and to get involved in consultation with doctors to find the most suitable medical treatments for themselves.

#### 3.5.2. Using Long-Acting Antipsychotics

The use of long-acting antipsychotic injections can help stabilize the illness and its symptoms for a longer duration. Participant 1 mentioned that changing the drug dosage form is one of the strategies to improve medication:

"I will tell the patient during the hospitalization: 'Long-acting antipsychotics can be injected once a month. If you forget to take the oral medicine, you will not relapse too quickly which can cause you to be hospitalized.' Oral medications are more prone to non-adherence. Long-acting injections help remedy this and/or increase compliance."

3.5.3. Inviting Family to Monitor Symptoms and Promote Medication Adherence

Families can help to monitor the patient's symptoms and medication adherence at home. Therefore, improving family members' knowledge of symptoms and drugs is helpful. The nurse can remind and assist family members in this. Participant 16 let the family members know about the symptoms and medication status:

"I will tell the family to pay attention to the signs of the patient's illness, for example, to see if the patient is starting to suffer from insomnia or emotional instability, and to pay attention to his medication status."

Family members confirm that medication and illness status contribute to adjuvant treatment. Participant 22 said:

"I will mention to the family that you have to observe the patient's medication status and confirm the remaining amount of medication to prevent any disruptions."

Family members have an important supporting role in enhancing medication compliance. Nurses can teach family members to identify the signs of onset and confirm medication.

#### 3.5.4. Referral to Related Resources

A pre-hospital search for related resources can help stabilize the patient's condition and improve compliance with medications. Participant 2 mentioned that when assessing patients for poor drug compliance, follow-up resources should be considered to continue care. She said:

"If the patient does not cooperate with the medication, he may prepare for referral to a home care, daycare, or another sheltered environment and find a place that can help them supervise medication adherence before leaving the hospital."

From the perspective of resource linking, patients can continue to take medication after discharge from the hospital.

#### **4. Discussion**

This study explored the strategies of MHNs that incorporated tacit knowledge in managing treatment adherence in patients with schizophrenia in clinical work. MHNs choose medication adherence strategies based on a judgement that considers patient attitude, side effects, and related resources. The first conditions need to be fulfilled in building a trusting relationship between nurses and patients. There is a complex process based on the patient's response in the next step. Nurses consider "act" to be a viable and preferable option in terms of the patient's response that is similar to 3D creativity management theory

to explain how creativity and innovations from nurses are involved in promoting adherence to medication in patients with schizophrenia [25]. Nurses nonverbally express sincerity and safety, provide psychoeducation, and go on to build a trustworthy relationship with patients. The core tenet of medication adherence strategies is to avoid ruining relationships with patients. The results indicate that nurses will often select strategies from patients' feedback, which is a dynamic process, and consider the best benefits for patients. Nurses euphemistically and thoughtfully adjust their behavior to the attitude of the patient, make sure the information is available, evaluate information, and provide related resources to increase medication adherence.

#### *4.1. Trust Building*

A high level of trust helps facilitate information reception and acceptance. A previous study promoted medication adherence and acknowledged that patients' beliefs about medications play an important role [12]. The authors agree with this opinion. MHNs, as the first-line psychiatric professionals in the management of mental illness, are well aware that the relationship with the patient can constitute the basis of drug beliefs. It is critical for psychiatric patients to take medications as prescribed. Research has shown that establishing therapeutic alliances with patients can increase the benefit of medications [16]. However, in the early stages of the treatment relationship, few patients are voluntarily hospitalized, and the positions of nurses and patients tend to differ. The key to the role of nurses in enhancing compliance with medications depends on whether the patient can trust the nurse as a starting point for cooperation that maintains dialog and interaction with patients.

MHNs' "tacit knowledge" is different from "explicit knowledge" of improving mediation adherence in patients with schizophrenia. Explicit knowledge can be easily expressed, written, and transferred from one person to another. In this study, nurses accumulate tacit knowledge that is obtained from the experience and intuition gained during interpersonal interaction based on hands-on experience and in-depth practice analysis, observation, etc. The term "tacit knowledge" was coined by Michael Polanyi [31] to refer to the knowledge that cannot be transferred through formalization (writing or verbalization). Similar to previous research, MHNs also think that good interpersonal relationships between mental health professionals and patients can improve adherence [5,14,15]. Moreover, MHNs strive for cooperation and alliance with patients and avoid triggering negative emotions in the patient that may cause the patient to distance themselves from or reject the nurse in clinical practice. It could be based on the concept of the disease, and the cognition of medications is different between the patient and the nurse at the beginning of the contact. In this regard, the MHNs used a careful probing attitude to confirm the problem of the patient's adherence to the prescribed medication. Establishing an interpersonal strategy for maintaining conversational relationships to improve compliance with medications cannot be applied as a whole. Given the wide variety of patient personalities, nurses need to flexibly use their experience to slowly grasp the essentials in an interaction.

#### *4.2. Information Availability*

Nurses help patients identify what information is needed and to deal with side effects to increase medication adherence. MHNs know that patients encounter side effects and this may cause them to stop taking the medication [5,11]. The nurses use tactful methods to assess the patient's feelings about the side effects in the identification process. They express a caring attitude to ask generalizing questions for the assessment of side effects and symptoms, but they avoid directly mentioning the side effect to the patients. Nurses are concerned about highlighting the side effects that may cause patients to stop taking the medication. Nurses try to lead patients to receive medication and improve medication compliance, but nurses using their knowledge as power should maintain a high degree of self-awareness and caution while using this "invisible" power in professional roles [32]. The MHNs assess side effects in indirect ways to avoid worsening the patient's apprehension and reluctance to take medication. However, MHNs may neglect to inform patients about side effects.

#### *4.3. Information Evaluation*

Nurses understand that the patients' perceptions of medication depend on what subjective values they attach to that concept. Generalization of the disease and making analogies can help the patient to understand the purpose of adhering to medication and help soften or change the patient's perceptions of antipsychotic medications due to the social stigma of mental illness [33,34]. MHNs can provide positive affirmations and invite family members to support medication adherence, as also suggested in previous studies [5,11]. The authors found that nurses can enlist the help of peers with similar illnesses and more insight to share positive experiences of medication adherence and provide anecdotes that are relevant to the patient. Research plans previously proposed to improve medication adherence are similar [35,36]. However, nurses who have accumulated experience and information through interpersonal exchange can persuade patients to willingly take medication as prescribed by doctors.

The nurse reminds the patient that disease stability can reduce the burden on their loved ones to motivate them to take their medication. This has not been mentioned in previous studies. Even good support from relatives and professionals also motivates patients to continue taking medication [37]. It may be because Confucianism is deeply rooted in Taiwanese society and has expectations of the relationships between people in society [38]. Although this approach may increase the patient's awareness of taking medicine for others, how long can the effect last? What is the benefit to the patient? Further research is still needed to explore these questions.

### *4.4. Resource Management*

A patient's willingness to adhere to medication is based on a complex system of interlocking. The patient can best understand his body and the improvement of symptoms after taking the medicine, as well as his preferences. The nurse encourages the patient to discuss their treatment with the doctor for shared decision making [39]. The patient advocates for their needs, which can positively affect compliance with medication. Medication management can facilitate patient recovery. Nurses will consider relevant resources for promoting patient adherence to medication. There are several resources available to support patients' adherence to medication, including inviting family members to monitor symptoms and promote medication adherence, discussing with the physician the provision of long-acting antipsychotics as an injection, and the referral to related community systems. MHNs' cognition of adherence to medication is not the patient's business, but needs a system for support.

This study expects to gather information relevant to an increase in medication adherence strategies from MHNs, which can serve as a reference for new colleagues and psychiatric nurses to continue education. Additionally, considering the positive impacts of medical research on not only the patients but also the whole society, MHNs' strategies for medication adherence need to further comprehensively consider the role of the institution in assisting patients to adhere to medication. The value of this study as a scientific enterprise brings integrity and self-correction in social evolution [40]. Furthermore, it is necessary to provide nurses with sufficient education, training, and counseling. It should be ensured that nurses can receive adequate support. The related systems should also be sufficient for supporting patient adherence medication tracking after discharge, thereby preventing patients from constantly swinging through the revolving door of hospitalization.

The advantage of this study is that way in which samples were selected was a fair and adequate reflection of the study purpose, which maximizes the potential transferability of the study. More qualitative research needs to be undertaken in various contexts and among patients with similar economic statuses to widen the current understanding of the factors that influence medication adherence. While the analysis attempted to remain as close to the interview data as possible, the selection of extracts and analyses inevitably involved subjective interpretation; thus, other interpretations may also exist concurrently.

#### **5. Conclusions**

This study has responded to how nurses increase medication adherence in patients with schizophrenia from the internalized experiences and practice of nurses through practical exercises. Because there are diverse reasons for nonadherence in patients with schizophrenia, nurses cannot use the same methods in the increased medication adherence process, and need to consider patients' situations in order to adopt fitting strategies. The establishment of a conversational relationship is the starting point in the overall assessment of the causes of non-compliance with medications, the adjustment of attitudes toward disease and medication, and the promotion of participation with medication. This method of connecting with patients with schizophrenia allows them to better understand their symptoms and achieve medication compliance, which in turn will help stabilize their symptoms and reduce the burden on loved ones. Side effects are an important factor affecting patients' willingness to take medications. MHNs can actively intervene in reducing side effects and thus reduce non-compliance with medications.

#### **6. Relevance for Clinical Practice**

This study discusses the strategies used by experienced nurses to improve medication compliance in patients with schizophrenia. The use of seminars and problem-based learning contributed to the rich experience of nurses in medication adherence. To enable nurses to exchange experience, they should be encouraged to continue learning and use their accumulated knowledge when interacting with patients to complement the static clinical guidelines.

**Author Contributions:** Y.-Y.L., M.-L.L. and W.-L.H. contributed to the design and implementation of the research. W.-J.Y., W.-C.L. and M.-L.L. contributed to the analysis of the results and to the writing of the manuscript. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was supported by the Ministry of Health and Welfare of Taiwan funding for independent analysis of the data (grant number 10956).

**Institutional Review Board Statement:** The study was conducted in accordance with the guidelines of the Declaration of Helsinki and was approved by the Institutional Review Board of Tsaotun Psychiatric Center (protocol code 108026).

**Informed Consent Statement:** Written informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** All data were generated at the Tsao Psychiatric Center, Taiwan. The derived data supporting the findings of this study are available from the corresponding author Lin, M.-L. on request.

**Acknowledgments:** The authors thank all participants for their contributions to these data.

**Conflicts of Interest:** The authors declare that they received no financial or relationship support that could pose a conflict of interest with this manuscript.

#### **References**

