Schizophrenia is a mental illness characterized by perceptional impairments and impairments in expression of reality manifesting as auditory hallucinations, paranoid delusions in the context of significant social or occupational dysfunction (Castle et.al, 1991). Diagnosis is based on the patient's self-reported experiences and observed behavior. An increase in dopaminergic activity in the mesolimbic pathway of the brain has been found to be associated with the disease (American Psychiatric Association, 2004). Treatment by pharmacotherapy is done with antipsychotic drugs that suppress dopamine activity. Schizophrenia patients usually show comorbid conditions, including clinical depression and anxiety disorders (Parnas J et.al, 1989). Disorganized thinking, auditory hallucinations and delusions are common symptoms. Patients in advanced stages of schizophrenia exhibit frequent agitations and bizarre postures (Amminger et.al, 2006).
Psychiatric nurse care
Although psychiatric nursing practice has incorporated many aspects of the medical model and the attention has been on neuroscientific theories and models of serious mental illness, nursing theories and nursing models have been placed in a low profile within psychiatric and mental health nursing (Barker, 2001). Continuity of care seems to be a significant factor in psychiatric nurse care as documented by research studies (Backrush, 1981). Continuity of caregivers, where a single, continuous treatment team is responsible for patients in both inpatient and outpatient settings seem to complement improved cognitive function (Fuller Torrey, 1986). A study to investigate and compare mental health nurses’ beliefs about interventions for schizophrenia with those of psychiatrists has shown that the nurses usually agree with psychiatrists about the interventions most likely to be helpful, such as antipsychotic medication for schizophrenia. However, nurses have been shown to believe that certain non-standard interventions such as vitamins, minerals and visiting a naturopath would be helpful as well (Caldwell and Jorm, 2000).
The neo responsibilities of a mental health nurse include monitoring the physiological status after medications, establishing a communication bridge to establish patient’s self care, caring based on intimacy and decision making rather than just following physician’s instructions. In this context, the importance of reevaluation of Peplau's nursing theory that considers nursing as an interpersonal process between nurse and patient in mental health care has been well documented (Jones, 1996).Through the use of nursing models and theories for planning patient and health care, nurses will be able to offer a better service to the individual and the community (Brown, 2000). For example, the Tidal Model, which has emerged from a series of studies on the ‘need for psychiatric nursing’ extends and addresses some of the traditional assumptions concerning the centrality of interpersonal relations within nursing practice, emphasizing in particular the importance of perceived meanings within the lived-experience of the person-in-care and the role of the narrative in the development of person-centred care plans. The model also effectively integrates discrete processes for re-empowering the person who is in mental distress (Barker, 2001).
Drug and psychosocial interventions for the symptoms of schizophrenic disorders contribute to a lower incidence and prevalence of schizophrenia (Falloon et.al, 1996). Studies have also shown that psychiatric nurses are under pressure to concentrate more on those with a diagnosis of schizophrenia (Marland and Sharkey, 1999) and treatment services for many schizophrenia patients are inadequate (Lehman, 1999). Caring such patients undergoing therapy with antipsychotic drugs like clozapine and benzodiazepines involves careful monitoring of the patient’s physiological condition as well. Such drugs have marked side effects like sedation, hyper salivation, increase in transaminases, EEG changes, cardiovascular respiratory dysregulation, overweight, mild Parkinsonism, akathisia ,tardive dysakinesia, increase of liver enzymes, hypotension , fever ,ECG alterations , tachycardia, and delirious states. These drugs also pose the risk of seizures (Cochrane, 2006). The quality of life as an indicator of the outcomes of nurse interventions has been recommended to measure the impact of variables such as gender, ethnicity and duration of illness on the measurable quality of life of an individual diagnosed with schizophrenia (Pinikahana et.al, 2002). A study to investigate whether brief cognitive-behavioural therapy (CBT) produces clinically important outcomes in relation to recovery, symptom burden and readmission to hospital in people with schizophrenia at one year follow-up has shown that brief therapy protected such patients against depression and has highlighted the need for mental health nurses to be trained in brief CBT for schizophrenia to supplement case management, family interventions and expert therapy for treatment resistance (Turkington, 2006).Another study has also elucidated the application of cognitive behavioral therapy (CBT) in the treatment of clients with schizophrenia and the implications for mental health nursing practice showing that CBT has positive effects for clients reducing the relapse rate (Chi-Chan et.al,2002).
A grounded theory investigation has identified the importance of the nurse/patient relationship as the central concept for psychiatric nursing. This substantive theory has knowing as the core category of the theory and socializing, normalizing, and celebrating as subcategories (Dearing, 2004). A symptom self-regulation model has been evaluated recently to examine the characteristics and stability of indicators of illness identified by individuals with schizophrenia. Primary indicators of illness from 51 subjects categorized as anxiety-based, depressive, or psychotic indicators have been shown to enhance self-care through monitoring symptoms (Hamera et.al, 1992).Although the use of care pathways is recommended to enhance mental health care, little has been investigated about the development or implementation of care pathways for mental health conditions. A recent action research guided process of implementation has shown many problems in implementing the care pathway including poor levels of morale and engagement (Jones, 2000).A recent study has addressed three main factors for the development of care pathways for people suffering from schizophrenia, namely, predictability of the illness, nature of standardized care and role autonomy. A care pathway has also been shown to establish standardized care and a greater control over the delivery of care (Jones and Adrian, 2001). A study to investigate the use of reality orientation in mental health care has shown that nurses use reality orientation frequently in their nursing work, with reality orientation being most often used in the mornings and evenings (Patton, 2006).Reality orientation therapy has been shown to improve the cognitive capabilities of the Schizophrenics. Individuals with schizophrenia commonly do not know how to use time productively when not in therapeutic sessions, and are restless and bored spending a great deal of time in bed, focusing their waking activities on eating, and smoking. They are not adequately prepared in activities of daily living, social skills, and community awareness. Programs that train these residents on the primary Activities of Daily Living (ADLs) have been shown to enhance their social skills, motivation, and desire to change, simultaneously decreasing their lethargic and apathetic state (www.schizophrenia-help.com).
Drug and psychosocial interventions for the symptoms of schizophrenic disorders contribute to a lower incidence and prevalence of schizophrenia. Nurses will be able to offer better care through the use of nursing models and theories in the care of Schizophrenics. Protocol for assessing standards of care for people with a diagnosis of schizophrenia have major implications for nursing practice (Gournay, 1996). The theory-practice gap in psychiatric nurse care of Schizophrenics needs to be addressed as a matter of urgency.
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Agency San Francisco
San Francisco, California
Charles L. Berman
Liz Di Bernardo