**1. Introduction**

Adherence to medication is essential but challenging in the psychiatric profession [1,2]. A meta-analysis including 35 studies that reported a pooled estimate of medication nonadherence found that the non-adherence rate in schizophrenia, major depression, and bipolar disorder was 56%, 50%, and 44%, respectively [3]. Antipsychotic medications are effective in successfully preventing relapses if taken regularly [4,5]. Schizophrenia is a lifelong disease with the lowest adherence to medication.

Non-adherence to medication in schizophrenia is a multifaceted issue. Previous studies have found that this non-adherence is associated with first onset, young age, lack of insight, negative attitude to medication, side effects of the medication, social support, medication alliance, alcohol, and substance abuse, among others [6,7]. In addition, a poorly planned discharge, post-discharge environment, and poor therapeutic alliances, among others, can also contribute to non-adherence [8–10].

Antipsychotic adverse effects may also occur more in compliant patients because patients with poor adherence are not regularly taking their medications and do not, therefore, experience side effects [5,11]. A study interviewed pharmacists, psychiatrists, and

**Citation:** Lin, Y.-Y.; Yen, W.-J.; Hou, W.-L.; Liao, W.-C.; Lin, M.-L. Mental Health Nurses' Tacit Knowledge of Strategies for Improving Medication Adherence for Schizophrenia: A Qualitative Study. *Healthcare* **2022**, *10*, 492. https://doi.org/10.3390/ healthcare10030492

Academic Editors: Athanassios Tselebis and Argyro Pachi

Received: 27 January 2022 Accepted: 4 March 2022 Published: 7 March 2022

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nurses to explore how they help patients manage their medication and found that the topmost concerns were understanding patients' beliefs about medication and systematically monitoring side effects [12]. The findings indicate the need for a regular follow-up evaluation to simplify medication treatment and reduce the problem of patients taking complex medications to increase adherence [13].

Building a good relationship with the patient is very important in improving medication adherence. A good therapeutic alliance or therapeutic interpersonal relationship between mental health professionals and patients is positively related to improved adherence [5,14,15]. The connotation of a therapeutic alliance includes cooperation, an emotional connection between the therapist and the patient, and common goal setting [16]. Building a trusting relationship with the patient is also the most commonly used strategy used by nurses, which involves listening to and interpreting their needs and concerns [17]. However, many patients with schizophrenia are not hospitalized voluntarily, and their relationship with medical professionals is not spontaneously established, which makes implementing measures to enhance adherence with medications difficult for nurses. Furthermore, no relevant studies have been conducted.

In order to improve medication adherence among patients with schizophrenia, MHNs (mental health nurses) provide psychological education to increase patients' understanding of the characteristics of the disease and recognition of medications [18], cognitive behavior therapy [19], and adopted motivation interviewing to increase motivation to take medications [20] in the clinical setting. Otherwise, long-acting antipsychotic injections can be administered to assist oral medication to decrease relapse [21]. Healthcare professionals encourage patient involvement in shared decision making with their physician to express their preference and opinion in treatment selection to increase their adherence to medication [22]. Inviting family caregivers involved in the treatment of patients with schizophrenia is one strategy to increase adherence to medication [9]. Some studies suggest that social support is also related to medication adherence [5,9,11], but some studies report that it is unrelated [14]. Nurses have frequently conducted psychoeducation for families in practice [23], which means that social networks can support patients and encourage them to adhere to their treatment. Involving family for social support may vary with culture. Therefore, the patient's condition or preference during the intervention should be considered before involving the family.

Nurses have a positive influence and can help patients change their attitudes toward disease and enhance their insights to increase medication adherence [24]. Previous studies aimed to clarify the factors that influence medication adherence in psychiatric patients. However, there are two problematic aspects in clinical practice. First, the quantitative study separates the variables into a part of medication adherence that cannot be understood in the whole view context of increasing medication adherence. Second, previous studies rarely demonstrated the "how" aspect; specifically, how the influences on medication adherence embody nurses' experiences. The 3D creativity management theory considers the within-discipline expertise, out-of-discipline knowledge, and a disciplined creative process to explain how creativity and innovation are manifested throughout information processes [25,26]. Nurses have the longest and most frequent contact with patients. Moreover, patients' adherence to medicine must consider the overall context in clinical practice. The experiences of MHNs may embody the tacit knowledge gained in actual practice; however, these experiences have not been highlighted and consolidated in previous studies.

#### *Aim*

This study has two goals. First, it sought to explore the strategies employed by MHNs to improve medication adherence in clinical practice. Second, it aimed to describe MHNs' knowledge of facilitation strategies in medication.

### **2. Methods**

This study was based on qualitative exploratory methodology and used in-depth interviews to collect information on nursing experiences and strategies for medication adherence in mental illness. Ethical approval was obtained from the research ethics committee (TTPC 108026) and the administrative committee of a psychiatric hospital in Taiwan. All participants provided signed informed consent on their understanding of the study and to the audio recording of their interviews.

#### *2.1. Sample*

All participants were selected from a psychiatric hospital in central Taiwan. The corresponding author conducted all interviews. The participants were accompanied by MHNs who were over the age of 20 years and had at least 1 year of nursing experience. One-on-one interviews were conducted for data collection. The interview began with questions on the participant's recognition and experience of non-adherence, followed by questions that elucidated how they dealt with those situations.

#### *2.2. Data Collection*

Purposeful sampling was conducted on 25 MHNs in this study. The researcher kept the interview questions in mind and used them flexibly to avoid interfering with the interview process. The interviews were conducted from February to July 2020. An in-depth interview included questions focusing on the strategies employed by MHNs to improve medication adherence and describe the knowledge of facilitation strategies in medication. These interviews used an interview guide with questions that were developed a priori by the authors based on their review of the literature and clinical experience: "Could you describe care experience about non-adherence medication of schizophrenia?", "Based on your clinical experience, could you describe the reasons for the non-adherence medication for schizophrenia?", and "Could you give me some examples of how to increase nonadherence medication for schizophrenia?". Additionally, the following questions were asked about the context, in order to elicit tacit knowledge of medication adherence in nurses' experiences: "How does this happen?" or "What causes this to happen?".

Each participant was interviewed one to two times. The interviews lasted for 45–65 min. All interviews were audio-recorded and transcribed verbatim. Possible identifying information was deleted from the data, and codes were used to replace the names of participants. Data were kept anonymous, and coding numbers were used during analysis to ensure they could not be linked to any personal information.

#### *2.3. Data Analysis*

A 7-step inductive qualitative content analysis was performed [27]. Data analysis began after the first interview and simultaneously continued with subsequent interviews until data saturation was reached for the purpose of this research and no new relevant information could be obtained [28,29]. The data were saved in Word files before being uploaded to NVivo 12 Pro software (QSR International, Melbourne Australia) for analysis.

Each unit of analysis was given meaning units from the text. Descriptions of participants who used strategies to increase medication adherence for mental illness were as detailed as possible. Preliminary labels were given to the meaning units and were grouped based on similarities and differences. The codes from the data were divided into subthemes, and these themes were labeled according to the content. The subthemes were further compared and grouped based on similarities and differences. The themes were named based on content characteristics. The researchers continued to analyze the data until data saturation had been reached.

#### *2.4. Rigor and Credibility*

To ensure rigor [30], purposive sampling was conducted, and the participants enrolled all had experience of promoting medication adherence in psychiatric mental illness. The researcher (M.L.L.) had a background in phenomenology and experience in qualitative research in the field of mental health nursing. The researcher established a relationship of respect and trust with each participant and maintained intersubjectivity. All participants provided rich, diverse perspectives of the phenomena in this study. To enhance transferability, interview questions were used to assist the researcher to encourage the participants to recall their caring experience of medication non-adherence with detailed descriptions to obtain extensive data. Regular research meetings among researchers were held to examine the verbatim transcriptions to ensure the quality of the interviews. The text was preliminarily coded and categorized independently and manually (MLL). The codes, subthemes, and themes were checked and discussed (WCL). If the subthemes or themes varied, the authors modified the list and read the transcripts to confirm the participants' views until an agreement of categorization among researchers was achieved. The participants provided their comments after reviewing the summary of the theme, sub-theme, and summary of the final results. Regular meetings with the authors were held. To ensure confirmability, peer debriefings among researchers were adopted to discuss the findings, emerging themes, and interpretations of data. Reflective diaries were kept to assist the researcher to maintain neutrality during the data analysis process.

#### **3. Results**

The demographic characteristics of the 25 MHNs are presented in Table 1. The following were identified as the strategies MHNs used to promote medication among patients with schizophrenia: establishing a conversational relationship, overall assessment of non-adherence to medication, understanding the disease and adjusting the concept of medication, incorporating interpersonal connection feedback, and building supportive resources (Table 2).
