Developing Autonomous Practice in Mental Health Nursing Essay

Developing Autonomous Practice in Mental Health Nursing Essay

Assessment in mental health nursing is something that is most understood through its application in the case of a patient. In relation, this essay will then examine case of a patient with Paranoid Schizophrenia, who was the patient during my community placement. Developing Autonomous Practice in Mental Health Nursing Essay .Performed in a form of a case study, this essay will pay attention to the patient`s psychiatric and personal history. The current sociological, psychological and physiological needs of the patient will be also examined from the point of view of therapeutic approaches.

Moreover, this essay aims to demonstrate how the nursing therapeutic approaches work in practice and develop a deeper understanding of applying some therapeutic methods in the care of individuals suffering from paranoid schizophrenia. More specifically, this paper will utilize Maslow’s Hierarchy of Needs as the main guiding theory or theoretical perspective in the assessment and intervention processes. In addition, the goal of the paper is to examine the role of the nurse, especially as a health educator, in caring for the mentally ill patient. Finally, this paper will discuss therapeutic nursing interventions, assessment of needs, and patient`s progress, analyze the therapeutic efficacy of environment where the patient is being cared for. Case Study Patient’s Background and History As mentioned, the case to be studied involves schizophrenia. This condition is usually diagnosed in adolescents or young patients. In some cases, it can even manifest in the person’s earlier years of life. The peak incidence for the onset of the disease lies between 15 and 25 years for men and 25 to 35 years for women (America Psychiatric Association, 2004). More specifically, this case study will involve the case of Patrick Jones (pseudonym; the name of the patient is changed for confidentiality), a 25 years old who was diagnosed with paranoid schizophrenia last year. Paranoid schizophrenia is considered to be the most common type of schizophrenia all over the world. The clinical picture of this condition is characterized by delusions, paranoia. As with most paranoid schizophrenic patients, Patrick Jones usually has perceptual disturbances and hallucinations, generally of the auditory type.Developing Autonomous Practice in Mental Health Nursing Essay .  Two months before Patrick was diagnosed with paranoid schizophrenia, his girlfriend was killed by a gang committing acts of violence in the neighbourhood. Patrick`s relatives and friends were concerned about his constant complaints of abdominal pain and headache. He experienced severe appetite loss and as a result he lost a lot of weight in two and a half months – about 12 kg. Patrick stopped taking his showers and did not pay attention to personal hygiene. As a result, his body acquired an unbearable odour. Patrick also developed an ungrounded fear that he was about to be run over by a car, so he constantly stayed at home and refused to leave it even to go to the store to buy himself some food. His behaviour became utterly anti-social. He stayed locked in his bedroom for days. He also had episodes of outbursts of anger with elements of violence, which greatly terrified his family. Because of these different occurrences and observations, as well as the assumed cause of the patient’s condition (death of girlfriend), Patrick’s family opted to call for medical assistance. Thus, Patrick was brought in for assessment and evaluation. After a series of assessments and interactions with the patient


This essay will focus on a case study of a patient with Schizophrenia, whom I cared for during my recent clinical specialist placement in a medium secure unit. The patient personal and psychiatric history would be given. The patient current psychological, sociological and physiological needs will be looked at by using published therapeutic approaches. In this case study a demonstration of how the therapeutic approaches chosen provide or guidance of the nursing care provided in the assessment of needs, identification of goals/aims, therapeutic nursing intervention and clinical review of the patient progress will be discussed. Developing Autonomous Practice in Mental Health Nursing Essay .The therapeutic efficacy of the current environment where the care is being provided for the patient will be analysed in terms of possible alternative service provision where the patient could be nursed will also be considered. Finally a reflective conclusion would be drawn based on the previous care and interventions provided for the therapeutic efficacy of the model considered in improving the life of the patient’s suffering from schizophrenia.My patient will be referred to as Judy for patient confidentiality in accordance with the Nursing and Midwifery council code of professional conduct, (NMC, 2004). Which require nurses to protect all confidential information concerning patients obtained in the course of professional practice, Judy is a 17 years old she was born and raised in a deprived council estate.

Reports indicate that Judy had a normal birth with no obvious signs of problems during this milestone. Judy has one sibling, a brother who is the eldest her parents divorced when she was three years of age.Judy has a history of chronic bullying at school because of her excessive weight gain, abusive experiences within the home, and presented with mood instability, depressive mood, perceptual/ psychotic disturbances, aggressive behaviour, excessive alcohol intake, cannabis use, deliberate self harm and suicidal attempts. Judy has four years history of paranoid schizophrenia. She was first hospitalised at the age of 12 under section 2 of the Mental Health Act (1983) for mental state assessment and treatment.She has had five previous hospital admissions due to her disengagement from the services for a period of 18 months after a suggestion of increase family involvement and for non compliance with her prescribed anti-psychotic medication Resperidone 4mg twice daily and anti- depressant medication Fluoxetine 10mg. Judy is an occasional user of cannabis and alcohol and has a history of self harming and unpredictable aggressive behaviour when unwell. Developing Autonomous Practice in Mental Health Nursing Essay .

As a result of Judy’s disengagement from services and poor compliance of her medications, she suffered recurrent relapses.Due to Judy’s deterioration in her mental state led to her transfer and detention under section 3 of the Mental Health Act ((MHA) amended 2007) meaning compulsory admission for treatment from an open adolescent psychiatric unit to a medium secure unit. Judy has been observed to be hallucinating with command telling her to carry out self harming behaviour mainly by cutting.

She has been observed to be expressing delusional beliefs that people are against her that the Nurses on the ward are secret agent of the police wanting to pass information to the police for her to be arrested.Since she been on the ward she has been isolating herself for fear of being attacked by other patient. Judy has been racial and verbally abusive towards staff and has physically attacked ten members of staff by, head butting acting on her delusional beliefs, when approached by staff she stated she did it to protect herself because staffs are part of the police conspiracy; she has been observed to be talking loudly to herself of late. She has been sleeping a lot during the day in her bedroom and becomes verbally abusive and aggressive when encouraged to join in the ward based activities.In the past weeks she has been in good concordances with her prescribed medication with lots of prompting.

Judy has been neglecting her self care and has been suffering from poor sleep pattern, poor appetite and has a history of Asthma controlled by inhaler. Her current psychological difficulties include hallucination and delusional beliefs, feeling of worthlessness, hopelessness and anxiety as manifested by the symptoms of depression. Her current delusional beliefs have had an impact on her behaviour which includes suicidal thoughts, self harming and aggressive behaviour towards staff and poor adherence to her medication.Judy’s sociological problems includes low self esteem due to bullying at school and at home, loneliness due to self isolation, poor social skills as she does not trust anyone around her and poor coping strategy.Developing Autonomous Practice in Mental Health Nursing Essay .  Her physical problems include asthma, superficial cuts on arm, poor appetite and poor sleep pattern. There has no been any evidence of alcohol and cannabis use as the hospital is a medium secure unit. Schizophrenia is one of the terms used to describe a major psychiatric disorder (or cluster of disorders) that alters an individual’s perception, thoughts, affect and behaviour.

While a high proportion respond to initial treatment with antipsychotic medication, around 80% will relapse within 5 years of a treated first episode, which is partly explained by discontinuation of medication (Nadeem et al. , 2004; Robinson et al. , 1999a, 2002). Health professionals have used the term dual diagnosis to refer to individuals who were mentally retarded or had a learning disability and who also had a coexisting psychiatric disorder (Evans & Sullivan, 2001).

Abou-Saleh (2004) suggests that ‘co morbidity’ might be a better term, although he does not explain his reasons for his view. There is a conclusive evidence that dual diagnosis client suffer more psychotic symptoms, are admitted more frequently in hospital that other people with histories of mental disorder (Weaver et al. 2002).

Judy’s current history it appears as if her delusional beliefs are due to psychological and sociological factors, therefore the cognitive and social models would be considered with the aim of intervening to reduce Judy’s level of distress.The cognitive model lay emphasises on posits that people interpret their thoughts, which in turn are their main determinants of behaviour (Tyrer and Steinberg 1998). According to (Kingdon and Turkington 1993; Chadwick et al. 1996) the cognitive model is use to manage distressing delusions, hallucinations and feelings of paranoia that people may experience in the course of a mental disorder. Developing Autonomous Practice in Mental Health Nursing Essay .

The New York High Risk Project has shown that children who later developed schizophrenia show relatively specific deficits in verbal memory, attention, and motor skills (Erlenmeyer-Kimling et al. 000). The Diagnostic and Statistical Manual of Mental Disorders (also known as the DSM-IV-TR, 2002) defines auditory hallucination as the false perception of sound, music, noises, or voices. Her beliefs in the persecutory existence of the staffs are secret agent of the police might have resulted in Judy’s increased insecurity and anxiety as this could be a confirmatory evidence for assaulting.

Judy’s loneliness could be described as a result of self isolation in social relationship which could sometimes result in psychological distress.According to Freeman et al (2002) anxiety and depression play a part in the development of symptoms and maintenance of persecutory delusions. Judy’s insufficient coping mechanism to deal with her current psychological difficulties could be the result of her distressing life events which has contributed to her self developed strategy of avoiding patient and staff by isolating herself in her bedroom. According to Bowlby’s (1988) developmental and attachment theory states that interruption with the maternal figure at an early age could lead to an abnormal personality in life.Judy’s difficulty in maintaining long lasting relationships could link to the disruption in her maternal attachment. The social model focuses on the individual in relation to the society they live in according to Tyrer and Steinbery (1998). Judy’s deprived socio-economic circumstances could be the cause of her illness, research by Harrison et al. (2001) shows that people born in deprived area are 8.

1% more likely to be diagnosed with schizophrenia than people born in affluent areas.Judy’s difficulties in socialising with others indicate her lack of social skills. Developing Autonomous Practice in Mental Health Nursing Essay .Her relationships might have been formed in the past on the basis of trying to fit in her peers; resulted to her use of drug and alcohol as the western society’s expectations and value which maintained in certain accomplishments such as achieving independence and relationship but people with schizophrenia have difficulties in achieving these expectations. According to standard one of the National service framework for mental ealth (NSF) (DOH, 1999a) this might result in failures and social exclusions. Using the biological intervention on its own could be viewed as passive institutionalisation, since she is on section 3 (MHA, 1983) she is left with no choice but to comply with her treatment.

In Judy’ case Cognitive behavioural therapy (CBT) embodied in the psychosocial interventions will be considered as adjunct to Judy’s current pharmacological treatment in guiding the assessment of her needs, goals and interventions with the goal of gaining an effective outcome.CBT is a structured meaningful reliable time limited approach which aims to reduces distress, disturbance, disability, social exclusion, relapse rate and promote social inclusion for Judy. Judy consented for me to carry out the assessment in accordance with the NMC (2004). The assessment was carried out under the supervision of my mentor. The purpose of the assessment was explained to Judy I shook hands with Judy in an attempt to build therapeutic collaborative alliance with her Kingdon and Turkington (2005); the assessment was conducted in an informal manner, in a quiet room with a relaxed atmosphere to avoid anxiety.The needs identified and desirable goals and anticipated outcomes to be achieved in the plan of Judy care will be highlighted using (SMART) meaning specific, measurable, achievable, time realistic. According to Brewin et al. Developing Autonomous Practice in Mental Health Nursing Essay .

(1987) need is the concept that provides a link between a problem and an intervention of that problem. SMART goal will be considered depending on Judy’s preferences, priorities, skills, ability and strengths.In Judy’s care plan will reflect changes according to Judy’s day to day health, with her active participation and informed consent in the provision of her treatments and care needs and as long she has the capacity to make an informed decision (Mental Capacity Act, 2005). Roper and Tierney (2002) states that significant factors influencing Judy’s daily living activities will be identified and a collaborative working relationship between the patient, nurse and others professionals will be established in forming a reliable assessment and plan of care (McCray 2007).People with severe mental illness have been classified as being most in need of mental health services, this term covers people between the ages of 16-65 who have serious psychological disturbance so they are unable to live independently in the community without support due to limited social skills.

Judy’s auditory hallucination as expressed that the voices was approached in an empathetic and genuine manner, with the goal of alleviating the distressing feeling caused by the voices.Judy was advised to listen to music on her walkman with earphone since she is no longer at risk of self harm, to distract her from the voices as this as proved efficient in reducing hallucination (Birchwood ; Tarrier, 1994) and Romme ; Escher’s (1989) . Judy verbalised anxiety connected to feeling threatened by staff and patients. The aim was to overcome anxiety and promote environmental safety with clients and patients. Developing Autonomous Practice in Mental Health Nursing Essay .Research has shown that most people with personality disorders as well as schizophrenia often experience anxiety, depression, behaviour difficulty and delusional beliefs.These symptoms have been displayed in the past by Judy however there is the need to incorporate it into her care plan to minimise its reoccurrence in a supportive environment.

Using Beck et al. (1988) anxiety scale Judy scored a moderated 1 out of 3. Judy’s daily activities was assessed she was encouraged to participate in ward based activities to improve her social skills, this was provided by the occupational therapist and activity coordinator. According to NICE (2004) activity scheduling has proved to be an effective cognitive behavioural technique in treating depressive symptoms.Judy was also encouraged to utilise the ward based gym for gentle exercise to relieve physical symptoms, rebuild social confidence and alleviate her level of anxiety and depression.

It was identified by the Multi disciplinary team on the ward that to break Judy’s social barrier there is need to educate her carers more about Judy’s illness by so doing creating awareness among them for supportive way in caring for Judy. Meetings scheduled with her parents whom are her primary carers to meet up with her Primary Nurse and social worker on several occasions has proven to be productive.Her father showed lots of support to ensure her discharge back home to be a success. Developing Autonomous Practice in Mental Health Nursing Essay .

Judy’s poor compliance was explored during the assessment. She expressed that her main reason for non compliance with her medication was due to the sedative side effects and weight gain; she is currently on anti-psychotic medication Risperidone 4mg tablets and anti- depressant fluoxetine 10mg tablets. Motivational interviewing technique was used to promote compliance and resolve Judy’s doubts by educating her on the advantages and disadvantages of non compliance with her medication.Booklets and leaflets regarding her medication were given to her to read in her spare time. The motivational interviewing has shown significant improvement in compliance, by exploring and resolving ambivalence attitudes to treatment (Miller et al.

1991). During the assessment Judy did not verbalise suicidal thoughts which she had before. According to Becks et al. (1974) hopelessness scale Judy despairing feeling of hopeless and worthlessness is a predictor of suicide. Judy’s suicidal ideations and the intensity of her plan were monitored in order to protect safety of Judy and her risks to others Department of Health (2007).Judy was reassured by having a 1-1 session with her and allowing her to ventilate her feelings, thoughts, and concerns either with her primary nurse or her allocated nurse.

Judy’s physical needs were identified with the aim to educate her on the importance of healthy eating, physical activities and personal hygiene with given time to improve. There were several occasions that Judy wore the same clothing for weeks and refused to change them or have a bath. Developing Autonomous Practice in Mental Health Nursing Essay .Another major concern with regards to her physical health is that she is asthmatic and was encouraged to take her prescribed medication for her condition.Drug and alcohol misuse has been a key problem for Judy and precipitating factor to her illness. Relating current symptoms to this initial episode has proven valuable in understanding the phenomena and reattribution the psychotic experiences.

Her use of substances has discontinued been on the ward due to no access to them. Roper et al. (1996) defines the evaluation of care as a planned, ongoing, deliberate activity in which the nurse, patient and other professionals are involved in the care of the patient will determine the extent of the patient’s outcome of achievement and the effectiveness of the nursing care plan.Working with Judy for the past four weeks, I was asked to prepare her review report and present her to the multi disciplinary team which consist of consultant psychiatrist, social worker, the hospital occupational therapist (OT), the hospital teacher, psychologist and my mentor.

Making a Difference (Department of Health (DOH) 1999) suggests that effective care is the product of interagency working. Professionals working in collaboration provide care which is designed to meet the needs of the patient. Judy has been attending to her personal hygiene by taking a shower and changing her clothes every day.Judy showed enthusiasm in attending education on the. There has no been any evidence of physical or verbal abuse towards staff and patient. Judy’s anxiety and depression has subsided. She stated that the voices are under control as she appeared to have 100% conviction that the police and staff were there to protect and provide care for her and not to harm her.

Judy has stopped self harming behaviour. She has demonstrated self confidence and increased self esteem by increasing her support network with her family who visits and telephones her on a regular basis.The Joint Commission on Accreditation of Healthcare Organisation (2003) emphasise on the goal of the therapeutic environment to be safe, functional, supportive and effective to patients, staff and other individuals within the hospital and to minimise physical discomfort for patients and staff, all these could be either direct or indirect contributing factors to a therapeutic care. The environment plays a great deal in meeting patients treatment goal, therefore it should be organised in a way that will enable a atient to function and engage effectively with a committed multi disciplinary team in the provision of care and activities that will positively affects the patients psychological and social functioning. A research by (Drury et al, 1996b) states that cognitive therapy has been found to reduce time of recovery by 25–50%. Judy’s care is been provided in a medium secure unit with treatment goal of stabilisation rather than symptoms remission. Developing Autonomous Practice in Mental Health Nursing Essay .Cognitive behavioural techniques within this framework have been evaluated in Judy’s care and found to result in greater improvements in recovery (Garety et al, 1994; Drury et al, 1996a).The therapeutic efficacy of the current hospital environment is beneficial to Judy, psychologically, socially and physically because of her history of poor adherence to treatment and disengagement with services in the community; she needs twenty four hours nursing support with observation by specially trained personnel to gives her a sense of safety from threats from others and the monitoring of contra indications connected with their medication and signs of relapse.


To empower Judy and make it possible for her to live independently in a non secured environment, Judy could be discharged for follow up with the home treatment team in the community as an alternative environment; where Judy could live independently with an enhanced care programme Approach (DOH, 1991) which is a means of mental health services to provide care for either long term or short term patient with mental health difficulties.It is important for patient to change environment depending on the position of their illness. For Judy to be in the community will allow her the freedom of being in her own environment, alleviate the stigma attached for being in a psychiatric hospital, increase her prospect of furthering her education and eliminate social exclusion. In conclusion a consideration of the patient results in a comprehensive nursing care, Judy was assessed holistically. Developing Autonomous Practice in Mental Health Nursing Essay .

In the process I realised that communication is one of the most paramount nursing skills; this permitted me to gain the enlightenment of my patient needs. Judy’s case study has made me realised that a high individual care can be achieved by establishing a therapeutic relationship with patient. A reflection was done using Gibb’s (1998) model of reflection.Assessment process, the planning of care and the preparation of report which I found slightly daunting at first, because I was scared of missing out the vital information needed to feedback to the multi disciplinary team.

I managed to sail through with the support from my mentor. The patient was pleased with the assessment and later accepted a referral to a low support Unit. This whole process gave me an insight into the importance’s of communication skills as a vital tool for nurses in assessing patient needs and achieving their goals. Developing Autonomous Practice in Mental Health Nursing Essay.