The Intervention and Relapse Prevention Plan
THE DEVELOPMENT and testing of evidence-based interventions in health care have attracted increasing attention in recent years, in part because of the need to provide high-quality and effective care that contributes to health benefits for the patient. The scarce resources available for health care must be used cost-effectively, which means maximum yield at an acceptable cost.
In nursing too, evidence-based practice is necessary. Nurses are trying to specify what they do or should be able to do in the form of nursing interventions that can then be examined for its effectiveness and efficiency. The present study is seen to be in line with this development.
The research project of which the present study is a part is focused on the development and testing of a nursing intervention protocol geared to the prevention of psychotic relapses in patients with schizophrenia and related disorders. It was developed on the basis of a review of the literature. The effects of the application of the protocol are investigated in a randomized controlled trial (RCT) with the occurrence of psychotic relapses and rehospitalization being the most important measures of outcome.
This article presents the results of a survey conducted among nurses who applied the protocol within the experimental condition of the RCT. The objective was to obtain an understanding of the manner in which the protocol was actually used in the RCT and of the experiences and evaluation of the nurses with it.
The protocol is intended for patients who are diagnosed as having schizophrenia, schizophreniform disorder, or schizoaffective disorder. The intervention protocol instructs nurses in how to draw up, together with these patients and members of their social network, a relapse prevention plan in function of the individual situation and how they can then work with it.
The relapse prevention plan contains a detailed description of early warning signs of a psychosis: changes in feelings, thoughts, and behavior of the patient that can be considered early warning signs of an impending psychosis on the basis of previous experience. When these signs are noted in an early stage (early recognition), one can intervene preventively (early intervention) to contribute to the recovery of the equilibrium of the patient. The preventive actions are listed in an action plan, which is part of the relapse prevention plan.
The intervention protocol consists of four phases: (1) The preparatory phase; (2) The listing of early warning signs; (3) The monitoring of the early signs; (4) The preparation of an action plan.
The intervention protocol is so devised that the nurses are offered a good deal of structure in the execution of the intervention but still sufficient space for adapting the method to the individual characteristics of the patient, of the members of the patient’s social network, and of the specific context within which care is provided.
The present study was conducted during the RCT in which the effects of the intervention were examined. The nurses in the experimental condition received instruction in the application of the intervention protocol. They then executed the protocol with one or more patients. The nurses in the control group offered “care as usual.” In a follow-up period of 1 year, the psychotic relapses and rehospitalizations were noted. The central research question within the RCT was whether the patients in the experimental group had fewer psychotic relapses and needed fewer readmissions than did the patients in the control group.
When the relapse prevention plan was ready in the experimental condition and the follow-up year could start, the nurses were given a survey form. A number of questions and statements about the execution of the interventions were presented. Three research questions were central:
- • How did the nurses actually execute the intervention protocol?
- • How did the nurses experience working with the intervention protocol?
- • What value do the nurses assign to the execution of the intervention protocol?
The responses to these questions are important for an understanding of the process of the execution of the intervention. The results of the RCT can then be related to the results of the process study.
The structure of the intervention protocol was mirrored in the design of the survey. The nurses used structured questions to determine the actual application of the intervention. Open questions offered the opportunity to make qualitative comments. In addition, positively and negatively formulated statements were presented to obtain an understanding of the experiences of the nurses with the intervention protocol and the value they assign to the intervention. Finally, in the last part of the survey, a number of statements were presented to gauge the appreciation of the nurses of the intervention protocol as a whole. A 5-point Likert scale ranging from “strongly agree” to “strongly disagree” was used for the scoring.
The instructions for the survey emphasized that there were no “correct” or “incorrect” answers to reduce the tendency to give socially desirable replies. It was stressed that the intervention protocol had to be adapted to the specific characteristics of the patient, the social network, and the social context. This inevitably leads to divergent methods. The nurses were thus encouraged to report on the actual method used, to describe the experiences encountered, and to make an evaluation.
Fifty-one stabilized patients were included in the experimental condition of the study. Thirty-six of them were receiving outpatient care, six were in day care, and nine were hospitalized. Eleven patients dropped out for various reasons during the preparation of the relapse prevention plan: early discharge of the patient (n = 1), the stress caused by the preparation of the relapse prevention plan (n = 2), psychotic relapse (n = 1), lack of motivation (n = 5), and lack of time on the part of the nurse (n = 2).
Ultimately, a complete relapse prevention plan was prepared with 40 patients involving 26 nurses. Of the 40 survey forms, 35 were returned. Two forms were not returned because the nurse was on sick leave, and the other three were simply never returned without reason given, despite repeated reminders.
The data were entered in an SPSS database and analyzed with descriptive techniques.
Before a relapse prevention plan can be prepared, an introduction to “working with a relapse prevention plan” is required for the patient and, if appropriate, for the members of the social network. The objective is to provide information, to create a basis for collaboration, and to make concrete agreements about the involvement of various people in the preparation of the plan.
All of the nurses conducted one or more introductory discussions with the patient and, if appropriate, the members of the social network. In half of the cases, this introductory discussion was held only with the patient; in the other half, one or more members of the social network were also involved.
In 85% of the cases, concrete agreements were made about the involvement of members of the social network in the preparation of, and working with the relapse prevention plan. In most of the cases (57%), one opted to invite network members a number of times during the preparation of the plan to inform them of the progress and to exchange information about the relapse prevention plan. In 2 of the 30 cases, an even more intensive form was chosen whereby members of the social network were permanently present during the preparation of the plan.
Some of the patients, however, opted for less intensive involvement of their social network. A fourth of them considered it sufficient that members of the social network be informed about the content of the relapse prevention plan after it was completed. Ten percent of the patients wanted no involvement at all of outsiders. For them, the relapse prevention plan was a matter between themselves and the nurses.
Virtually all of the nurses (94%) considered the introductory discussions with the patient to be an important or very important part of the protocol to achieve good cooperation in the preparation of a relapse prevention plan. This judgment applied to a somewhat lesser degree to the introductory discussions with members of the social network (77%).
Tags: relapse prevention