Keeping the lines of communication open: a novel approach to schizophrenia
How one nurse’s idea contributed to a successful discharge for a man who was hearing voices
How one newly qualified nurse’s novel idea contributed to a successful discharge for a man with schizophrenia
During a placement on an acute mental health ward in the second year of my mental health nursing degree, I helped to care for a service user with schizophrenia, who I will call John.
John was in his mid-thirties and had lived with schizophrenia since he was a teenager. His condition had been diagnosed as treatment-resistant and he was taking clozapine – an atypical antipsychotic drug prescribed to patients with schizophrenia whose condition has not improved after using other antipsychotics.
John had frequently been admitted to the ward, usually because of his delusional beliefs. He would respond to his auditory and visual hallucinations when he was in public which would cause misunderstandings. He also became increasingly isolated and neglected his self-care.
After a three-month admission in the acute ward, John’s team discussed his discharge and arranged a suitable discharge plan.
He had engaged with nursing and occupational therapy staff and they developed a positive daily routine that involved John taking on his personal care without prompting.
John coped well when he was on leave from the ward under section 17 of the Mental Health Act 1983. He had gained insight into his delusional beliefs and no longer became distressed by visual hallucinations. The only symptom of schizophrenia that remained was what he called ‘her voice’.
John had previously talked about hearing multiple voices that no-one else could hear. Some were male, some female, some old and some young, some shouted while others whispered. Some of the voices made him miserable but ‘her voice’ motivated him and made him more willing to engage with the world.
When John was on leave from the ward, he would often talk to ‘her voice’. This could lead to difficult situations with members of the public who may have a limited understanding of mental health conditions.
This made John increasingly vulnerable and his family and friends were concerned for his welfare. The ward staff were also worried and some thought he should learn distraction techniques to help him ‘block out’ this voice.
Others, however, had learned that ‘her voice’ was John’s girlfriend who had died. He described how she would encourage him to get out of bed during difficult days and tell him to stop banging his head to get rid of the negative voices. She would also praise him when he achieved his desired goals.
Collaborative care plan
Despite having to cope with the voices he didn’t want hear, John’s biggest fear was that blocking out all the voices would mean this positive, inspiring voice would also disappear.
A collaborative care plan was created after listening closely to John’s wishes. He accepted the use of distraction techniques to manage negative hallucinations but said it would be detrimental to his mood if this daily motivating voice was no longer there.
A newly qualified nurse on the ward suggested that when John was out in public and wanted to reply to ‘her’, he could put his mobile phone to his ear and pretend to use it. That way he could openly respond but he wouldn’t get undesired attention from other people.
It took a lot of courage to suggest this unusual approach, particularly for a newly qualified nurse who was surrounded by experienced mental health professionals. But this simple suggestion ensured John had a successful discharge.
A successful discharge
He now had a robust care plan in place to manage all aspects of his schizophrenia and after graded exposure from the ward, he was discharged.
This experience not only highlighted the fresh approach that newly qualified nurses can bring to clinical practice and how important this can be to patient care, it showed how discharge plans are more successful when service users are involved in creating them.
It also showed that it is sometimes necessary to take positive risks and defer from normal therapeutic choices. We cannot assume that all symptoms of schizophrenia are detrimental and should embrace any positive aspects that can help people cope with the condition.
John’s case showed me what true person-centred care is. This is something I kept with me throughout the rest of my training and will continue to demonstrate in my practice as a registered nurse.
Kayleigh Rose McManus graduated from Edge Hill University in August. She now works as a registered mental health nurse for Cumbria Partnership NHS Foundation Trust