Nursing Care for Schizophrenic Clients: Recent Advances and Client-Centred Nursing Care Perspectives

*Ek-Uma Imkome*

#### **Abstract**

Schizophrenia is one of the leading causes of disability worldwide; psychiatric disorders can result in impairments of perception, poor self-care, and decreased performance in activities of daily living. Treatment and nursing care are vital options for clients to improve their signs and symptoms, especially during the COVID-19 pandemic. The planning of nursing care for individual schizophrenic clients is essential and will help them have a satisfactory quality of life. Current nursing should be provided according to the client's needs and particular problems, such as the presence of comorbidities, amidst the state quarantine. The current nursing care focuses on telenursing, with nurses implementing information technology to provide the necessary care. Despite the physical distancing, clients can access nursing services efficiently, with nurses being flexible enough to continue their care provision during the COVID-19 pandemic.

**Keywords:** schizophrenia, telenursing, nursing care, client-centered, psychiatric disorder

#### **1. Introduction**

The most common impairments of schizophrenic patients include delusions, illusions, hallucinations, anger, hostility, and aggression. Nursing care for this population should focus on patient-centered needs and individual problems. In addition, during the coronavirus pandemic, telenursing should be provided to prevent infection and adhere to social distancing rules. The practical nursing process application will reflect the effective nursing outcomes.

When the global coronavirus SARS-CoV-2 (COVID-19) epidemic hit, nursing care was pressed to switch to telenursing. Telenursing is primarily performed by the nurses using a cell phone, computer, audio and video technology, or advanced digital and optical communications, in order to deliver health care and provide remote, synchronous (e.g., via live interactive videoconference) or asynchronous (e.g., the information is stored electronically) care. This type of health care usually falls within care management for emergent situations, coordination of care, and health maintenance services. It is considered beneficial for both the patient and nurse; the patient benefits from increased access to health care services, while the nurse benefits from a more flexible and less physically stressful work environment.

Telenursing is increasingly prevalent in the nursing domain because of a preoccupation with cutting down on health care costs, an increase in the number of aging and chronically ill individuals, and a rise in the coverage of health care to distant, rural, minor, or sparsely populated regions. Telenursing, providing nursing care at a distance using new technologies, is identified as one alternative. Among its many benefits, telenursing may help prevent a shortage of nurses, reduce distance and save travel time, and keep patients out of the hospital. A greater degree of job satisfaction has also been registered among telenurses.

Telenursing has been considered a potential solution to service delivery challenges during the COVID-19 pandemic, mainly due to its compliance with physical distancing measures and stay-at-home orders implemented by several governments to curb the spread of infection. Additionally, telenursing is benefit for the nurse to providing telenursing care for victims in disasters in a simulated study for introducing of possibility nursing interventions, telenursing education on nurses' compliance with standard precautions during the COVID-19 pandemic [1], telenursing training based on family-centered empowerment pattern on compliance with diet regimen in patients with diabetes mellitus, education through telenursing can increase the quality of life of COVID-19 patients [2], telenursing in COVID-19 times and maternal health: whatsapp® as a support tool, telenursing on attachment and stress in mothers of preterm infants, telephone-based telenursing on perceived stressors among older adults receiving hemodialysis, telenursing on levels of depression and anxiety in caregivers of patients with stroke, Treatment of Obesity Among Youth With Intellectual and Developmental Disabilities: An Emerging Role for Telenursing [3], Telenursing intervention increases psychiatric medication adherence in schizophrenia outpatients [4]. Telenursing are ongoing to increase both nationally and internationally. A primary role of telenursing is to channel clients towards appropriate levels of nursing care thereby reducing healthcare costs and freeing up resources [5, 6].

The purpose of this chapter is two-fold. First, it describes the principle of caring for a person with schizophrenia during the COVID-19 pandemic. Second, it aims to describe the processes behind understanding the facilitators and barriers to telenursing during the pandemic.

**The principle of caring for a person with schizophrenia during the COVID-19 pandemic**.

This chapter provides an overview of telenursing and its application to nurses' daily practical challenges. The principle of caring for a person with schizophrenia during the COVID-19 pandemic is as below:

#### **2. Cognitive and perceptive disorders (delusions, illusions, and hallucinations)**

#### **2.1 Delusions**

A delusion refers to a fixed false belief with no basis in reality in the psychotic phase of an illness. A common characteristic of schizophrenic delusions includes the direct, immediate, and total certainty with which the client holds these beliefs. A person with schizophrenia is probably suspicious, mistrustful, and guarded about

*Nursing Care for Schizophrenic Clients: Recent Advances and Client-Centred Nursing Care… DOI: http://dx.doi.org/10.5772/intechopen.106911*

disclosing personal information. They may examine a room periodically or speak in hushed, secretive tones due to delusions.

#### **2.2 Illusions**

An illusion distorts one's senses by misinterpreting true sensory stimuli, as in visual illusions. Some misconceptions are based on general assumptions that the brain makes by using organizational principles, the client's perceptual ability and motion perception, and perceptual dependability. The causes of illusions are biological, psychological, and physical. For example, hearing voices regardless of the background would be a hallucination, whereas hearing voices instead of the sound of running water would be an illusion; individuals watching a ventriloquist will perceive that the voice is coming from the dummy since they can see the dummy's mouth moving (**Table 1**).

#### **2.3 Applying the nursing process for clients with delusion**

#### *2.3.1 Nursing diagnosis*

Risk for self-harm/other harmful activities related to disturbed thought processes


**Table 1.** *Five types of delusions.*

#### *2.3.2 Assessment data*


#### *2.3.3 Goals*


#### *2.3.4 Outcomes*

#### **Immediate:** The client will


#### **Stabilization:** The client will


#### **Community:** The client will




#### **Table 2.**

*Nursing interventions.*

#### **2.4 Sensorium and intellectual processes: Hallucinations**

The main psychotic symptom of people with schizophrenia is hallucinations. A hallucination refers to false sensory perceptions that appear real. Hallucinations are related to five senses and bodily sensations. They can be both threatening and pleasant (**Table 3**).

In psychotic episodes, disorientation of time and place, as well as depersonalization, are common in Cl. Although clients can state their name correctly, they think that their body belongs to someone else or that their spirit is separated from the body. They may also demonstrate poor intellectual functioning. The client cannot pay sufficient attention to display their academic abilities accurately. The nurse is more likely to obtain accurate assessments of the client's intellectual abilities when their thought


#### **Table 3.** *Types of hallucinations [12].*

processes are more transparent. They often have obscurity with abstract thinking and may respond literally to other public situations and the environment.

#### **2.5 Applying the nursing process for clients with hallucinations**

#### *2.5.1 Nursing diagnosis*

Change in the amount or patterns of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli related to disturbed sensory perception

#### *2.5.2 Related factors*


#### *2.5.3 Defining characteristics*


#### *2.5.4 Desired outcomes*

The clients will


• Demonstrate a stress reduction technique that distracts them from the voices (**Table 4**).

#### **2.6 Conclusion**

There is a variety of nursing care that can be provided for a person with cognitive impairment, such as schizophrenic clients in the schizophrenia disorder spectrum. Holistic care is always the go-to approach for decreasing the negative signs and symptoms. Psychosocial and compensatory interventions for cognitive impairment in psychotic disorders are famous and influential in improving functioning as well as decreasing the negative and general symptoms. Continuous compensatory interventions are associated with more significant improvements in functioning. Additionally, medication adherence, social function, and social support are critical factors that nurses should be concerned about, training the clients and caregivers accordingly.

#### **3. Behavioural problems (anger, hostility, and aggression)**

Anger, hostility, and aggression are common behavioral problems in schizophrenic clients. When handled appropriately and expressed assertively, anger can be a positive force that helps resolve conflicts, solve problems, and make decisions; anger results from a person being frustrated, hurt, or afraid. Anger energizes the body physically for self-defense by activating the "fight-or-flight" response mechanism. However, it can cause physical or emotional problems and interfere with relationships when expressed inappropriately or suppressed. Anger is perceived as a negative feeling. People who are uncomfortable reveal their anger directly. However, anger can be a normal response when situations are inequitable or undue, personal rights are not respected, or realistic expectations are not met. If the person can express their anger energetically, problem-solving or conflict resolution is possible. Anger becomes negative when someone rejects or suppresses it if they are uncomfortable expressing it. Examples of the consequences of anger include migraine, headaches, ulcers, coronary artery disease, depression, and low self-esteem.

Inappropriately expressed anger can lead to hostility and aggression. Some people express their angry feelings through safe activities, such as hitting a punching bag or yelling. Such actions, called catharsis, are supposed to provide a release for anger. However, catharsis can increase rather than alleviate anger. Practical methods of anger expression, such as assertive communication, should replace angry, aggressive outbursts of temper, such as yelling or throwing things. Controlling one's temper or managing anger effectively should not be confused with suppressing angry feelings, leading to the problems described earlier.

#### **3.1 Hostility and aggression**

Hostility, also called verbal assault, is an emotion expressed through negative verbal outbursts, uncooperative rules or norms, or hostile behavior. It occurs when individuals feel threatened or have no power. Hostile behavior causes emotional harm and leads to physical aggression. Verbal and physical aggression is meant to harm another person to experience fulfillment, caused by delusions and/or hallucinations in the schizophrenia spectrum. Some clients with psychiatric disorders display hostile or physically aggressive behavior that challenges the professional nurses.

*Nursing Care for Schizophrenic Clients: Recent Advances and Client-Centred Nursing Care… DOI: http://dx.doi.org/10.5772/intechopen.106911*


**Table 4.** *Nursing interventions and rationale.*


**Table 5.**

*Five-phase aggression cycle [15].*

Hostile and aggressive behavior can be sudden and unexpected. Clients with psychotic illnesses are much more likely to harm themselves than others. In contrast, clients with paranoid delusions may believe others are out to get them, assuming they are protecting themselves; they retaliate with aggression or hostility. Some clients have auditory hallucinations that dominate them to hurt others. Overall, violent clients are more symptomatic, have poorer functioning, and lack insight. Some clients with depression have anger attacks. These sudden intense spells of anger typically occur in situations where the depressed person feels emotionally trapped. Anger attacks engage verbal expressions of anger or rage but no physical aggression. Clients identify these anger attacks as uncharacteristic behavior unsuitable for the situation. The anger in some depressed clients is related to irritable mood, overreaction to minor annoyances, and decreased coping abilities (**Table 5**).

#### **3.2 Application of the nursing process**

#### *3.2.1 Nursing diagnoses*

The risk for other-directed forms of violence related to ineffective coping


*Nursing Care for Schizophrenic Clients: Recent Advances and Client-Centred Nursing Care… DOI: http://dx.doi.org/10.5772/intechopen.106911*

#### *3.2.2 Expected outcomes*

#### **Immediate: The client will**


#### **Stabilization: The client will**


#### **Community: The client will**


#### **3.3 The facilitators and barriers to telenursing during the pandemic**

Nurses play a pivotal role in the provision of mental and physical healthcare. Telenursing, the use of information and communication technologies to deliver and support healthcare directly to the setting, is emerging as an essential application for nurses. The empirical evidence supports its use in specific areas and guides those thinking of implementing telehealth in their practice. The future of home telehealth lies in carefully considered and designed research, ongoing education and training, and a multidisciplinary approach. This chapter aims to stimulate the consideration of home telehealth as an application that may improve nursing care and patient outcomes.

There is massive potential for technology such as telenursing to transform people's experience, including assisting with chronic disease management, coordinated care, and guided self-care for consumers. Innovative technologies are increasingly available to assist in maintaining health and independent living.

The beginning of 2020 has been characterized by the pandemic outbreak of a novel human Coronavirus named SARS-Cov-2. This virus is responsible for causing a disease, COVID-19, that often causes only mild illness but can also make some people very ill. More rarely, the disease can be fatal, especially among older people and those with pre-existing medical conditions who spread the virus.

That allowed to contain the spread of the virus, helping the health system to face the demands of thousands of people needing hospital advanced care. On the other hand, it resulted in worse health among people not affected by the virus. Recently, a review investigated the relationships between telenursing and health. The authors identified health problems (musculoskeletal problems, psychological problems, overwork, and others) and benefits (stress reduction, greater flexibility, better work-life balance/control, and enhanced job satisfaction).

At the end of March 2020, Italy was the world's most affected country by the novel coronavirus spread. The advanced average age of the population, together with a particular social structure, has also contributed to making the death rate of this country among the highest in the world.

The pandemic forced Governments to establish lockdown measures such as the closing of schools, universities, banks, parks, supermarkets, and non-essential businesses, limiting movements and transport, and promoting social distancing, to slow down the and a lower risk of burnout but on the other hand, the responders think that working from home diminishes their promotion opportunities and weakens ties with their colleagues and employer

Integrating technology into health care has created both advantages and disadvantages for patients, providers, and healthcare systems alike. Overall, the benefits of technology in health care outweigh the risks; however, proper measures must be taken to ensure successful implementation and integration. Accuracy, validity, confidentiality, and privacy of health data and information are key issues that must be addressed for successful technology implementation. This chapter examines the risks and benefits of technology in health care, the availability of health information online, and how technology affects relationships within the healthcare setting.

#### **3.4 The advantage of telenursing during the pandemic**

The COVID-19 pandemic has forced most countries to implement social distancing measures, also known as "lockdown," to reduce the virus transmission through respiratory droplets and contact routes by increasing physical distance or social distance aggregations19. The adoption and development of telenursing helped reduce some of the consequences of the current health crisis on the economy. It allowed continuing business even if workplaces were inaccessible, and telenursing has a significant emotional impact on nurses and patients, with the appearance of negative emotions such as loneliness, irritation, worry, and guilt. Telenursing overall was also found to experience more mental health support than usual care. The correlation may have been influenced by the current pandemic situation, which can feel that receiving information from nurses via telephone can be much safer than going to the hospital and taking public transport. People with lower educational levels had a lower risk of psychological distress than those with higher education. That assumption contrasts with solid evidence that low socioeconomic position is often associated with severe mental health disorders, such as depression.

What emerged about lifestyle habits is the rise of unhealthy behaviors among the responders who reported higher levels of psychological distress and lowered perceived well-being. Half of the responders reported to be smokers have increased the number of daily cigarettes during the lockdown. Tobacco smoking is a well-known coping strategy against psychological stress 26. Many studies 27,29 have also reported that those who smoke or drink alcohol usually increase their consumption in stressful conditions. Eating habits changed for almost half of the participants, and most of them




#### **Table 6.**

*Implementation and rationale.*

increased food consumption. It is known that psychological stress can alter both the quantity (there is usually an increased food intake) and quality (typically with high sugar or carbohydrate content) of food. Besides, stress-induced alterations in food intake can, in turn, influence mood 30,31. The literature has also demonstrated concern about food (often unhealthy) intake as a mechanism to cope with stress. It can be considered valid also in the context of this research. People who reported not "feeling sheltered at home" felt more psychological distress and poorer well-being. This is consistent with the evidence about the health benefits of cohabiting and the adverse effects of isolation (i.e., the state quarantine).

#### **3.5 The barriers to telenursing during the pandemic**

Implementing existing healthcare systems poses some potentially deterring and serious risks, such as confidentiality breaches, identity theft, technological

breakdowns, and incompatibilities. Therefore, electronic records should not be hastily integrated into healthcare systems without proper precautions.

#### **4. Conclusion**

Telenursing, increasing diffusion and adoption of this type of work organization. The consequences of the COVID-19 pandemic and lockdown impact well-being and psychological distress experienced and are at risk of unhealthy eating behaviors and increased cigarette smoking or substance abuse, especially among those with higher education levels who live alone. Occupational physicians may play a central role in that process even through health promotion campaigns (healthy diets, tobacco smoking cessation) and supporting nurses in the risk assessment.

In order to provide nursing care to angry, hostile, or aggressive clients, nurses should identify the strategies to manage angry feelings, assessing assertive communication and conflict resolution. Enhancing these skills in dealing with behavioral problems in schizophrenic client will help nurses work more effectively with clients; the care of potentially aggressive clients should be discussed with experienced nurses, and nurses should be trained not to take the client's anger or aggressive behavior personally. Moreover, telenursing is a low-cost and free resource that will be the strategy for considering while providing care for the COVID-19 pandemic.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Ek-Uma Imkome Faculty of Nursing, Thammasat University, Pratumtane, Thailand

\*Address all correspondence to: ek-uma@nurse.tu.ac

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Nursing Care for Schizophrenic Clients: Recent Advances and Client-Centred Nursing Care… DOI: http://dx.doi.org/10.5772/intechopen.106911*

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#### **Chapter 4**
