Relapse prevention in patients with schizophrenia: the application of an intervention protocol in nursing practice☆

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Abstract

This article describes the results of a survey conducted among nurses who work in psychiatric care. Within the experimental condition of a randomized controlled trial, they executed an intervention protocol to prevent psychotic relapses among patients with schizophrenia. The central objective of this protocol was early recognition of the warning signs of psychosis and timely performance of actions intended to re-establish the equilibrium of the patient. The nurses were asked about the execution of the intervention, their experiences with it, and their evaluation. The nurses actually did execute the protocol in large measure and also made use of opportunities to tailor it to the individual patient. For the most part, the nurses judged that the intervention protocol contributed significantly to the treatment of the patient. The survey also revealed a number of difficulties in the execution of the protocol that deserve attention in the future.

Section snippets

The intervention protocal

The protocol is intended for patients who are diagnosed as having schizophrenia, schizophreniform disorder, or schizoaffective disorder (APA 2000). The intervention protocol (van Meijel et al. 2000; van Meijel et al. 2002d) 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

Methods

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

Results

The results are given for each phase of the intervention protocol and then the total protocol will be evaluated.

The preparatory phase

The results are discussed in function of the four-part objective of the introductory phase.

The listing of early signs

In this phase of the intervention protocol, the nurse, the patient and members of the social network looked back at previous psychotic relapses. Together, a judgment was made about what the most important early signs were during these previous relapses. The assumption is that certain of those early signs would also occur in the future in the early phase of a psychosis. Their early recognition would make early intervention possible. To enhance clarity, the intervention protocol instructed the

Monitoring early signs

In this phase, the nurse monitors possible early signs at least once a week with the patients and, if possible, with the members of the social network. As to the number of people actively involved in the monitoring, in almost a third of the cases the monitoring remained a matter between the patient and the primary nurse. Nobody else was involved. In half of the cases, another person was involved, and in the remaining cases (20%) a fourth person also participated in monitoring. Parents occupied

The action plan

In this part of the intervention protocol, the nurse, the patient, and the members of the social network together prepared an extensive action plan with the aim of contributing to the recovery of the patient’s equilibrium in periods of impending relapse. Attention is given to the use of medication, the prevention of stress, the enhancement of coping, and the use of protection from the environment. Practical agreements were also made about the 24-hour availability of professional assistance.

The

General evaluation

All of the nurses, with one exception, considered the preparation of the relapse prevention plan to be a meaningful activity. In their judgment, the relapse prevention plan contributes significantly to the treatment of the patient. More concretely, the relapse prevention plan was a useful instrument for the patient for controlling the course of the disorder. In two-thirds of the cases, the nurses succeeded in clearly establishing the responsibilities of the patient, the nurse, psychiatrist, and

Conclusions

In general the nurses considered that the intervention contributed meaningfully and significantly to the treatment and care. The various components of the intervention protocol were implemented, and they were considered necessary in arriving at a good relapse prevention plan.

Even though the nurses followed the structure of the intervention protocol quite faithfully, they still succeeded in harmonizing their approach with the specific characteristics of the patient and of the members of the

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Supported by a grant from Eli Lilly, The Netherlands.

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