Intervention development in protocal patients
THE PREVENTION of psychotic relapse has high priority in the treatment of patients with schizophrenia. To achieve this goal, joint effort is needed on the part of the patient, the members of his or her social network, and professionals. Nurses can contribute in several ways to this preventive objective. They have the opportunity to offer the patient and the people in his or her environment education about schizophrenia and about its implications for daily life; they can support the patient in adequate use of medication; and, because of their regular contact with the patient, they can monitor his or her condition and take measures if the condition requires it. This article concerns the last possibility.
Research has shown that psychosis in most cases arises gradually during a period from a few days to weeks [Herz ]. Often, cognitive-perceptual changes and dysphoric symptoms first occur in the process of relapse, followed by prepsychotic or psychotic symptoms [Birchwood and Spencer 2001]. These changes in feeling, thinking, and acting that precede a psychosis are also called early warning signs or prodromal symptoms. The gradual development of psychosis offers opportunities for preventive intervention. When early warning signs of psychosis occur and are reported (early recognition), appropriate measures can be taken that promote the recovery of balance (early intervention).
The evaluation of the condition of the patient is an activity that is often routinely done during the contacts between the nurse and the patient. However, an inventory study in The Netherlands indicated that there is a need for further systematization of the knowledge about early recognition and early intervention [Mierlo van 1997].
This study attempts to respond to this need. We describe the development of a nursing intervention protocol oriented to the prevention of psychotic relapse in patients with schizophrenia.
Method
In the development of complex nursing interventions, a careful procedure should be followed. [van Meijel et al 2002c] have designed a model for the development of evidence-based nursing interventions. The essence of this model is that a number of steps have to be followed for the intervention development that have the objective of providing the building blocks for the design of the intervention. These building blocks can be assembled by means of the literature, analysis of the problem for which the intervention is intended, research into the needs of patients and the social system and the resulting demand for care, and research into already existing intervention practices. The review of the literature is an obligatory component of the process of intervention development. The use of the other research possibilities depends on the state of the knowledge and the concrete research opportunities within the intervention area concerned.
The following two studies preceded the intervention development described in this article: a review of the literature [van Meijel et al 2002d]; and a qualitative study of present intervention practices of early recognition and early intervention in The Netherlands [van Meijel et al 2002a and van Meijel et al 2002b]. This study provides an understanding of various methods and procedures that are presently already applied. It also offers insight into the experiences and needs of patients, family members, and care providers with these methods. The results of these substudies constitute the basis for an initial design of the intervention protocol. This design was presented to eight experts in the area of schizophrenia care: two psychiatric nurses, two psychiatrists, two clinical psychologists, and two family members of schizophrenic patients. They studied the protocol and participated in a semistructured interview. Their judgments led to further adaptation of the protocol.
The protocol was then tested in nursing practice. Four nurses who work in a teaching hospital and who have expert knowledge in the field of the care of patients with schizophrenia received instructions on the background and application of the protocol. Then, they applied the protocol with six patients. The first author also applied the protocol with two patients. Patient selection was done by purposive sampling to have variation of the patient characteristics regarding sex, age, illness duration, treatment setting (clinic, day clinic, outpatient treatment), severity of symptoms, and level of social functioning. The nurses kept a log in which they noted their experiences, questions, and comments. The first author was available as a consultant for coaching the nurses while the protocol was being applied.
During the implementation of the protocol, the nurses were interviewed at the following two times: halfway through the implementation of the protocol, that is, after the inventorying of early warning signs; and after the protocol was completed in its entirety, ie, when all the relevant data for the patient and the family were entered in a symptom recognition plan. The results of the case studies were used to improve the protocol.
First, we briefly discuss the theoretical model that underlies the intervention. Second we present the structure and the procedure of the protocol; and third, we summarize the judgments of the experts and describe a number of experiences from the case studies.
Tags: Protocol Intervention