DNRS 6630 Week 11 Reflection Example

From Justifying a Choice to Committing to a Check: A Reflection Built on Three of My Own Sentences

Student Name

College of Nursing, Walden University

DNRS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology

Instructor Name

Month Day, Year

From Justifying a Choice to Committing to a Check: A Reflection Built on Three of My Own Sentences

What I Thought a Rationale Was For

When this course began, my view was that a prescribing rationale existed to justify a choice I had already made. I would decide on a class, and then write sentences that made the decision look inevitable: a mechanism, a guideline, a line about tolerability. The rationale was an argument for the defense. It never occurred to me that a colleague would pick it up and act on it, and I did not expect it to be checked against what happened afterward. Looking back at my early assignments, I can see this belief in almost every paragraph, and three sentences show it most clearly.

The belief had a practical cost I did not see at the time. Because my rationales were arguments for decisions already made, they rarely told the next reader what to watch for or when to change course. A covering clinician reading my early plans would have learned why I chose a class but not how to tell whether the choice was working. The rationale protected the decision; it did nothing for the patient between visits.

Three Sentences, Then and Now

The first concerns a delayed response. In week 1, I wrote: "The patient has not responded because the medication has not yet built up in his system." I would now write: "By week 3 he has been at steady state for about 2 weeks; the delay reflects the time needed for adaptation downstream of the target, so the dose is unchanged and response is reassessed at week 6." What moved was my grasp of the two timelines, the body's handling of the compound and the compound's action at its target; my first sentence blamed the wrong timeline and would have led to a dose increase.

The second concerns adherence. In week 3, I wrote: "The patient is noncompliant with his medication and requires further education." I would now write: "He reports missing 5 of the last 7 days because of nausea; the nausea is addressed first, and the missed-days question is repeated in the same words at the 2-week call." What moved was treating a report as data with a method behind it, asked the same way each time (Stirratt et al., 2015), instead of a verdict that ends the inquiry.

The third, and the clearest, concerns monitoring. In week 4, I wrote: "The patient will be monitored for response and side effects." I would now write: "The clinic nurse calls at week 2 to ask about side effects and missed days; I repeat the PHQ-9 at weeks 4 and 8; a fall of under 20% at week 4 triggers a review of adherence first." What moved was the difference between an intention and a commitment. My first sentence could never be shown to have been broken. The second names who does what and when, with a score that anyone can check (Kroenke et al., 2001).

What the Pairs Have in Common

Read together, the three replacements share one feature: each could be audited by someone who was not in the room. The early sentences were written to be agreed with; the later ones are written to be checked. That change came less from any single reading than from the appraisal work in week 8, when I had to ask whether a large trial's participants resembled one specific woman (Rush et al., 2004). Marking rows as unknown taught me that a document's honesty about what it does not know is part of what makes it useful, and I began to write my own plans as if someone would later compare them with what happened.

The change also altered how I read other people's notes. I now look first for the sentence that could be checked, the score, the date, the named person, and when I cannot find one, I treat the plan as unfinished rather than as complete.

What Still Feels Unsettled

I am not sure how much uncertainty a document can admit before it stops helping the next reader. A plan that lists every unknown may leave a covering clinician unable to act, while a plan that hides them repeats my week 1 habit. I have begun to handle this by stating the one or two unknowns that would change the decision and leaving the rest out, but I do not yet know whether that line is drawn in the right place, and I expect to learn it from the plans that go wrong.

References

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Rush, A. J., Fava, M., Wisniewski, S. R., Lavori, P. W., Trivedi, M. H., Sackeim, H. A., Thase, M. E., Nierenberg, A. A., Quitkin, F. M., Kashner, T. M., Kupfer, D. J., Rosenbaum, J. F., Alpert, J., Stewart, J. W., McGrath, P. J., Biggs, M. M., Shores-Wilson, K., Lebowitz, B. D., Ritz, L., . . . STAR*D Investigators Group. (2004). Sequenced treatment alternatives to relieve depression (STAR*D): Rationale and design. Controlled Clinical Trials, 25(1), 119-142. https://doi.org/10.1016/S0197-2456(03)00112-0

Stirratt, M. J., Dunbar-Jacob, J., Crane, H. M., Simoni, J. M., Czajkowski, S., Hilliard, M. E., Aikens, J. E., Hunter, C. M., Velligan, D. I., Huntley, K., Ogedegbe, G., Rand, C. S., Schron, E., & Nilsen, W. J. (2015). Self-report measures of medication adherence behavior: Recommendations on optimal use. Translational Behavioral Medicine, 5(4), 470-482. https://doi.org/10.1007/s13142-015-0315-2