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
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
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.
- A.F Lehman. (1999) Quality of care in mental health: the case of
schizophrenia. Health Affairs, 18(5): 52-65.
- American Psychiatric Association (2004) Diagnostic and Statistical Manual of
Mental Disorders DSM-IV-TR (Text Revision). American Psychiatric Association.
- Amminger GP; Leicester S, Yung AR, Phillips LJ, Berger GE, Francey SM, Yuen
HP, McGorry PD (2006). "Early-onset of symptoms predicts conversion to
non-affective psychosis in ultra-high risk individuals". Schizophrenia Research
84 (1): 67-76.
- Backrush (1981).Continuity of care for chronic mental patients: a conceptual
analysis. Am J Psychiatry 138:1449-1456.
- Barker PJ, Reynolds W, Stevenson C (1997). The human science basis of
psychiatric nursing: theory and practice. J Adv Nurs.25(4):660-7.
- Barker, P. (2001). The Tidal Model: developing an empowering, person-centred
approach to recovery within psychiatric and mental health nursing. Journal of
Psychiatric & Mental Health Nursing 8(3):233-240.
- Brown R (2000). Describing a model of nursing as a focus for psychiatric
nursing care. Int J Psychiatr Nurs Res. 6(1):670-82.
- Chan SW, Leung JK (2002). Cognitive behavioural therapy for clients with
schizophrenia: implications for mental health nursing practice. J Clin Nurs.
- Dearing (2004). Getting it, together: how the nurse patient relationship
influences treatment compliance for patients with schizophrenia. Arch Psychiatr
- Douglas Turkington, David Kingdon, Shanaya Rathod, Katie Hammond, Jeremy
Pelton, Raj Mehta (2006). Outcomes of an effectiveness trial of
cognitive-behavioural intervention by mental health nurses in schizophrenia. The
British Journal of Psychiatry 189: 36-40.
- Fuller Torrey (1986).Continuous Treatment Teams in the Care of the Chronic
Mentally Ill. Hosp Community Psychiatry 37:1243-1247.
- Gournay K (1996). Setting clinical standards for care in schizophrenia. Nurs
Times. 14-20; 92(7):36-7.
- Gournay K, Beadsmoore A (1995). The report of the clinical standard advisory
group: standards of care for people with schizophrenia in the UK and
implications for mental health nursing. J Psychiatr Ment Health
- Hall and Beverly (1996). The Psychiatric Model: A Critical Analysis of Its
Undermining Effects on Nursing in Chronic Mental Illness. Living With Chronic
Illness. Advances in Nursing Science. 18(3):16-26.
- Hamera EK, Peterson KA, Young LM, Schaumloffel MM.(1992). Symptom monitoring
in schizophrenia: potential for enhancing self-care. Arch Psychiatr
- Hellzén O.; Kristiansen L.; Norbergh K.G (2003). Nurses' attitudes towards
older residents with long-term schizophrenia. Journal of Advanced Nursing
- Hopton J (1996). Reconceptualizing the theory-practice gap in mental health
nursing. Nurse Educ Today.16(3):227-32.
- Jones A (1996). The value of Peplau's theory for mental health nursing. Br J
- P.J. Barker, W. Reynolds, C. Stevenson (1998).The Human Science Basis of
Psychiatric Nursing: Theory and Practice. Perspectives in Psychiatric Care. 34.
- Parnas J; Jorgensen A (1989). "Pre-morbid psychopathology in schizophrenia
spectrum". British Journal of Psychiatry 115: 623-7.
- Patton D.(2006). Reality orientation: its use and effectiveness within older
person mental health care. J Clin Nurs. 15(11):1440-9.
- Phil Barker (2001). The tidal model: the lived-experience in person-centred
mental health nursing care. Nursing Philosophy. 2(3); 213-223.
- Sally Wai-Chi Chan & Jessie Ka-Yi Leung (2002). Cognitive behavioural
therapy for clients with schizophrenia: implications for mental health nursing
practice. Journal of Clinical Nursing. 11(2):214-224.
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