A RESEARCH STUDY ON ATTITUDE OF NURSES TOWARDS

RELAPSE PREVENTION AMONG PSYCHIATRIC PATIENTS IN

BY

BALA IBRAHIM
balaibrahim872@gmail.com

BSC. PUBLIC HEALTH

DEPARTMENT OF PUBLIC HEALTH

A TERM PAPER WRITE-UP

SUBMITTED
TO

JOIN PROFESSIONALS TRAINING AND SUPPORT

JULY, 2021
 ABSTRACT

The problem of every hospital when the targeted objective is not achieved is that
there is something wring either with health care givers, the patients or the
general public. In order to improve the standard of health of the patients and
keep them progressively fit. The reason why such lapse are present here to be
sought and the remedy met in order to achieve the set objective of the hospital.
This study is based on the Attitude of Nurses towards Relapse Prevention among
Psychiatric Patients in Federal neuropsychiatric hospital. The aim and objective
of this study are all directed towards bringing out lasting solutions to curtail
this menace. It also intends to actively involve the management of the hospital
especially on employing new and scientific approach to holistic patient care. All
these can be prevented through adequate Education, Family oriented therapies,
good social support, compliance and keep the follow-up appointment.

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 TABLE OF CONTENT

Title page
Abstract
Table of Content
1. INTRODUCTION
1.1 Background of Study
1.2 Statement of Problem
1.3 Objective of the Study
1.4 Significance of the Study
2. REVIEW OF LITERATURE
2.0 Introduction
2.1 Conceptual Framework
2.1.1 Background of the Study
2.1.2 Concept of Attitude
2.1.3 Causes of Relapse
2.1.4 Phases of Psychiatric Illness
2.1.5 Types of Relapse
2.1.6 Prevention of Relapse among Psychiatric Patients
2.2 Theoretical Framework
2.2.1 Cognitive Behavioral Chain
2.2.2 Problem of Immediate Gratification (P.I.G)
2.2.3 Abstinence Violation effect (A.V.E)
3. CONCLUSION
4. RECOMMENDATIONS
5. REFERENCES

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 CHAPTER ONE

1.1 Background of Study

Psychiatric illness has fascinated and confounded healers, scientist and

philosopher for centuries, it symptoms have been attributed to possession by

demons considered to be punishment by the gods for the evil done or

accepted as evidence of the inhumanity of its sufferers victims. Thus

explanation resulted in enduring stigma for those whose were diagnosed

with such disorders. Even today, much of the sigma persist although it has

less to do with demonic possession than with society’s unwillingness to

shoulder the tremendous cost associated with mental illness.

Relapse is one of the most severe problem of mental health care givers. It is

common in about 1.3% of the already treated cases of mental illness or more

than two million people (U.S. Department of Health and Human Services

[USDHHS] 1999). Its economic cost is envious. Direct cost of relapse

treatment expenses of most psychiatric illness were estimated 2.5% of the

total treatment of first hand mental illness care budget in 1998 (American

Psychiatric Association [APA] 2000).

The last year for which these data were available (USDHHS, 1999). In 1997,

this accountant for $23.6 billion of mental health care dollar spent. The

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indirect cost such as lost of wages, premature death and incarceration were

estimated to be $46 billion in the first half of 1998 (APA, 2000).

Further unemployment among permanent disability is 10% (APA 1998). The

cost relapse in terms of individuals and family suffering are probably

inestimable.

Despite the current trend in modern treatment, there is still an alarming rate

of relapse and the reoccurrence of psychiatric illness globally. Individual

who ought to be productive and responsible in life are wasting away on daily

basis.

Today patients are required to stay for a short period of time in the hospital

admission and discharge to home environment to help reduce dependency on

the hospital care and reducing relapse. Also this helps to reduce

stigmatization and prevent complications (Feyinsayo, A. 2009). This study

will attempt an overview of Nurse and also to show how proper utilization of

psychiatric Nursing service will go a long way in reducing and eradicating

the ever growing cases of relapse among psychiatric patients in Federal

Neuropsychiatric Hospital Barnawa, Kaduna.

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1.2 Statement of Problem

The frequency of patients having readmission into the hospital over the last

few years has become a problem. This has made the achievement of good

control of patients’ symptoms and cure impossible.

Nursing Staff and the Hospital has suffered frustration seeing the

readmission of patients, whom were recently discharged home after being

stabilized on admission. Some patient relapse as soon as they are discharged

home. Other on trials discharge relapse while other still relapse while on

admission. Various factors ranging from financial problems, lack of

adequate staff have contributed to the relapse of patients.

Some patients have about a day or two days journey distance to the hospital

resulting in poor monitoring and accessibility to the mental health services.

Other factors also include stigmatization and dependency on care giver. All

these have contributed in the frequency of relapse experienced in the care of

these groups of patient leading to the social disability.

Hence, resulting in the following:

a) Low manpower

b) Untold hardship

c) Financial constraints

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 d) Societal nuisance

If not properly handled and solutions found, the economy may suffer and the

society will be at a loss apart from the untold hardship. This is what

motivated the researcher to investigate the cause, give suggestions, remedy

the situation and also reduce the high rate of relapse.

1.3 Objective of the Study

1. To evaluate the relationship between the educational

background of the Nurses and their attitude towards prevention

of relapse.

2. To ascertain the relationship between the status of the Nurse

and her ability to prevent relapse among psychiatric patients.

3. To determine the relationship between the experience of the

Nurse and their ability to identify symptoms of relapse.

4. To find out whether poverty can predispose psychiatric patient

to relapse.

5. To determine the relationship between drug compliance among

psychiatric patient and relapse prevention.

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1.4 Significance of the Study

The significance of this study is to help Nurses develop a positive

attitude towards the care to the psychiatric patient thereby reducing

the incidence of relapse.

2. REVIEW OF LITERATURE

2.1 Conceptual Framework

2.1.1 Background of the Study

Psychiatric illness comprises of various disorder with some common

features. These common features include disturbances in thinking and

occupation with self and inner fantasies. The person with a psychiatric

disorder may live in a private world. A world inhabited by voices that

condemns or accuses the person vile acts and by vision of frightening. The

person may be totally withdrawn from external environment and may be

preoccupied with an internal fantasy life.

Mary Ann Boyd (2001) defined relapse as a return of the illness symptom

which are severe enough to disrupt daily activities or require unscheduled in

patient or outpatient intervention.

Herz (1999) outlined five phases, relapse for psychosis, these are:

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 1. Over Extension: In this phase, patients feel estranged from self and

the environment. He/She no longer understands himself

(depersonification).

2. Boredom and Apathy: Patients become easily tired and withdrawn,

there is a bit of clouding of consciousness here.

3. Disinhibition: There is return of consciousness, patients has paranoid

idea, accuses others etc.

4. Disorganization: Patients becomes chaotic sees, hears and believes in

all manner of things.

5. Resolution: He no longer question beliefs but act on them.

According to Barbara Schoen Johnson (2000), Non-compliance with

medications, indulging in alcohol and drug abuses are commonly related to

the frequency of rehospitalizations. Clients education about the importance

of the following medication regimes and abstaining from alcohol and other

substances have been shown to lengthen the time between hospitalization.

Denzin (1996) described four stages of relapse as it affect drug. They are:

1. The person engages in perssimissive thinking, feeling that it is alright

to quiet old haunts.

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 2. Engaging in substance use in a situation where one feels compelled to

use it.

3. Realizing the need for help and getting it.

Sadock and Sadock (2003) suggest that the term of chronic mental illness,

which historically has been associated with long hospitalizations that

resulted in loss of social skills and increased dependency. These individuals

may never have experienced hospitalization but they still do not possess

adequate skill to live productive lives with the society.

In 1955, the joint commission on mental health and illness was established

by congress to identify the nations mental health needs and to make

recommendations for improvement in psychiatric care.

2.1.2 Concept of Attitude

Attitude is a positive or negative evaluation of people, objects, event,

activities, ideas or just about anything in the environment. Attitude is also

defined as psychological tendency expressed by evaluating a particular

entity with the same degree of favour or disfavor (Eagle and Chaiten, 2012).

Attitude can also be said to be an expression of favour or dis-favour towards

a person, place, thing or event (the attitude object). Prominent Psychologist

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Gordon Allpoit (2012) further said that the distinctive and indispensable

concept in contemporary social psychology is attitude.

The concept of attitude does not adequately distinguish between attitude and

factual beliefs on the one hand or between attitude and preference on the

other hand. To hold an attitude is to ascribe an objective moral property to

the attitude objective, however, the concept of such properties rests on

incoherent theory of relations as constitutive of their term and the belief in

them has also pseudo-cognitive content. Moralism or th1e maintaining of

attitude is a special technique for distinguishing and promoting interest.

Attitude serves as rationalizations for concealed or unconscious impulses

and the themselves defensive by further rationalization.

Attitude formation occurs through classical conditioning, operant

conditioning and modeling as it occur to Nurse who is psychologically,

socially, culturally bound to his to her community, family and the society

they live, this will invariably affect the way they care for their patients.

According to Mary Ann Boyd (2001) defined relapse as a return of the

illness symptom which are severe enough to disrupt daily activities or

required unscheduled in patient or outpatient intervention.

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2.1.3 Causes of Relapse

 Patient may not be getting enough rest;

 The patient may not be taking their medications properly as

prescribed;

 The patients may be under more stress than usual;

 They may have started another drug form a different health

problem which may interfere with the existing drugs;

 In some cases availability of drug in the case of drug abuse can

predispose a patient to relapse;

 Social influence is a cause due to pressure exerted by peers who

influence or force their friends to abuse drugs so as to

demonstrate status or superiority;

 Lack of follow-up care-in most cases patient get relapsed due to

lack of follow-up care to keep to their appo0itnment for review

and constant check-up;

 Lack of support from relations/significant others: In some

cases, patient do not get enough care, concern and

encouragement from their relations/significant others and so

they tend to lose confidence in themselves and these can lead to

relapse;

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  Lack of drug compliance – is one of the major cause of relapse

as most patients get tired of taking their medications as at when

due;

 Existing disease conditions – some infection like HIV/AIDS

tend to complicate psychiatric condition as the body immune

system is being destroyed in the process of such disease

condition.

2.1.4 Phases of Psychiatric Illness

The natural progression of psychiatric illness is usually described as

deteriorating over time. There is usually external plateau in the symptoms.

Only in some cases has it has been suggested that improvement might occur.

In reality, no one knows what the course of psychiatric illness would be if

patients were able to adhere to a treatment regime throughout their lives.

Only recently have their medications been relatively effective with

manageable side effects. At this point, it is understood that the symptoms of

psychiatric illness combine in various numbers and degree they differ from

each other and the experience for a single individual may be different from

episode to episode, the typical course of the illness appears to have phases.

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 i) Phase I: Initial Diagnosis and Early Psychiatric Illness

Here, the behavior may be both confusing and frightening to the patient and

family. Often the changes are subtle. However, at some point, the changes in

thoughts and behavior become so disruptive or bizarre that they can no

longer be overlooked.

They might include episode of staying up all night for several nights.

Incoherent conservations, aggressive act against self and others, as the

symptom progress, the patient is less and less able to care for basic needs

such as eating, sleeping and bathing. Usually, the person may not be able to

function at school or a job resulting in dependency on family and friends.

Because delusions and hallucinations seem so real, the individual is

generally unable to recognize the need for treatment. Usually Hospitalization

or some type of intensive outpatient treatment must be initiated by family

and friends.

ii) Phase II (Adaptation)

After the initial diagnosis of psychiatric illness and the successful initiation

of treatment, the patient enters a period in which symptoms may be less

acute and require less drastic measures to control. This however, is not a

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period of quiescence and the symptoms actually become worse (Brere et al,

2006).

iii) Phase III (Relapse)

Relapse is a return of the illness symptom which are severe enough to

disrupt daily activities or require unscheduled inpatient or outpatient

intervention (Murphy and Moller, 2002).

Relapse is not inevitable however, it occurs with sufficient regularity to be a

major concern in the treatment of psychiatric illness.

Reported relapse rates vary from 25% to 90% and relapse affects both those

who are being treated and those who are not. The lower relapse rate, is for

the most part, among groups who are following a treatment regimen.

2.1.5 Types of Relapse

treatment.

2. Secondary Relapse
In this type of relapse, the patient is discharged home but gradually relapses

as a result of some stressor around the environment.

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3. Tertiary Relapse

This is where a patient breaks down after being discharged home and

accepted in the community where he belongs and eventually resumes his/her

normal life and responsibilities and is settled for some time but suddenly or

gradually relapses due to some conditions around him/her.

4. Partial Relapse

This is type relapse where the patient breaks down in measure and not

completely and is still able to manage himself or herself to a certain extent.

5. Total Relapse

This is when the patient totally disintegrates mentally, socially and

physically to an extent that she/she cannot cope or manage him/herself and

is completely dependent on others for total care for activities of daily living

and psychological support to meet his needs and medical intervention.

2.1.6 Prevention of Relapse among Psychiatric Patients

i. Health Education:

It is very crucial and a part of a Nurse’s or Doctor’s responsibility to

properly health education the patients on the rules guiding hospital care both

as in and outpatients.

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It is very vital for the patients to keep to appointment dates as it enhances

continuity of care and allows for assessment especially of eminent signs of

relapse. The patient is also instructed on drug compliance taking the drugs as

at when due and to report any hypersensitivity to drugs.

Proper information is given especially about his condition, to give the

patient insight to his condition and to alert him of factors that can precipitate

a relapse.

If patients conditions are related to self imposed stressor such as overwork,

unduly complicated social relationships, the patient should be encouraged to

change to a lifestyle less likely to lead to further episode of illness.

An alcoholic who works in a brewery might be asked to change occupation

ii. Also efforts should be made to detect early signs of relapse in patients

in order to issue prompt and adequate treatment, usually done in the

outpatients units and wards in general. It is also important to have in mind

that efforts should be made to discharge the patients home as soon as he is

well enough because prolonged hospitalization precipitates relapse.

Relatives should be encourage to visit client regularly to make the patients

have a sense of belonging and not to loose touch with the family.

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iii. While on admission, patients are given holistic and individualistic

care. The Nurses and other health care givers should establish a good rapport

with the patient creating a very conducive and therapeutic environment for

recovery and prevention of relapse. The social worker is informed to keep in

touch with relations of patients and to inform them when bills are due to be

paid in the hospitals. That will enhance the care given to patients.

There must be sufficient drugs and not only sufficient, the drugs must be

proved and useful and effective in the treatment of the condition. Other

amenities in the ward must be in place to keep the patient occupied and

minds off the problem.

Examples of such are television or other indoor games.

iv. Family Oriented Therapies

Family oriented therapies are useful and helpful in treating psychiatric

condition because most times, patients are often discharged in an only

partially remitted state in parole.

Families to which a patient returns can often benefit from a brief but

intensive course of family therapy. The therapy should focus and the

immediate solution and should include identifying and avoiding potentially

troublesome situations (stressors).

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Problems from within the family must also be resolved immediately.

After the immediate post discharge period, the recovery period, the recovery

process, its length and its rate are important subjects to cover in family

therapy.

Above all, patients family must accept him back as a member and learn to

help him reintegrate back into the family. The family must help the family to

avoid disability and redundancy.

v. Relapse Prevention Therapy (RPT)

This therapy is mostly used for drug dependents patients. It is a therapy that

relies on cognitive and behavioural techniques in addition to hospitalization

on outpatients basis to achieve the goal of abstinence.

The psychological intervention usually involves individuals, group and

family modalities. It also focuses on the future and on changes in the family

activities. They may help the patient stay off the drug. This approach can be

used on a one patient basis.

vi. Milieu Therapies and Rehabilitation

The general impression from experimental studies is that vigorous

aggressive outpatients after care programmes after discharge from the

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hospital combined with drug treatments are effective in maintaining patients

in the community and wading off deterioration. Rehabilitation therefore

starts from admission when the patient develop in sight.

For either case, daycares are alternative to hospital care. The evidence for

inpatient activity programme is more circumscribed and less impressive.

Their main usefulness may come from possible prevention of

institutionalization and the secondary de-socializing and deteriorative effects

of a barren environment and form better discharge.

Employment planning and their effects on primary psychology may be

relatively small. In some chronic cases, push and intrusive interventions

have been found to aggravate symptoms. Therefore, these programmes

should be regulated and critically evaluated.

Readmission rates are as high for chronic patients who have participated

intensively in hospital experimental programmes as they are for control

patients who have been involved in less innovative programmes. Evaluation

of such programmes leaves little doubt that they are useful in preventing

relapse, suggesting that treatment and support in the society precisely where

the patient needs help in adjusting in the appropriate direction or the future

work with chronic patients.

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vii. Respite Care

It is a treatment approach designed to decrease the rate of relapse or

exacerbation of psychiatric symptoms and to afford families relief from their

care given responsibilities.

Respite care programmes (Greise, Honcho and King, 1999), provide mini

hospitalization for a few days every 6 – 8 weeks to reinforce patient’s

growth and to intervene in the early stages of relapse. Evidence suggests that

overall time in the hospital can be reduced with respite care.

viii. Follow up Care

This is essential for preventing relapse. The Patient and Nurse need to be

aware that recovery has began when an inpatient or outpatient programme is

complete. The few months immediately following completion of a treatment

programme are dangerous for the patient. This is when relapse is not

uncommon. The Nurse should confirm that arrangements for care and

outpatient counseling are made before discharge. There should be good

following up care by the psychiatric social workers to serve as a link

between the relations of patient and the hospital.

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viii. Mass Education

The awareness of mental illness should be made public through public

enlightenment regular seminars, radio programmes on the causes, prevention

and on misconception about mental illness.

ix. Government Involvement

The government should active role in the care of the mentally ill. They

should subsidize the cost of drugs for the patient in order to ensure that all

patient no matter their social status should be able to afford their drugs. The

government can also through foreign aid import drugs and distribute to

various psychiatric units where they are given free to less privileged

patients. All government hospitals must have provision for psychiatric units

render psychiatric services at the grass root level. There should also be

provision of employment opportunities for patient soon after discharge in

order to make them useful and a contributing member of the society. To the

frequency of re – hospitalizations client education about the importance of

the following medication regimes and abstaining from alcohol and other

substances have been shown to lengthen the time between hospitalizations.

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2.2 Theoretical Framework

2.2.1 Cognitive Behavioral Chain

Pither (1990) looked at relapse process as a of the length sequences of the

thought and action. The behavioural chain generally consists of four distinct

stages.

First there is life style, personality or situational event which firms the

background to the addictive behavior.

 The individual becomes dysphonic (experience negative mood

Once the person is the high risk situation ten their anticipation of the

pleasurable and positive effect of the addictive behaviour create a situation

of cognitive dissonance with their desire to avoid the negative

consequences. This is called problem of immediate gratification and

facilitate the chances of lapse occurring. This theory described that when

there is a problem with immediate gratification relapse can occur (G.ALAN

MARLATT 2004).

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2.2.3 Abstinence Violation effect (A.V.E)

Failure to deal adaptively with the high risk situation lead to decrease self

efficacy relapse and the abstinence violation effect, essential awareness that

the person commitment to abstinence has been violated depending on how

the abstinence violation effect is manually managed, a relapse may or may

not occur. This theory explain that high risk situation leads to decrease self

efficacy relapse (Katie Witkiewitze 2004).

5.3 Implication for Nursing

The nurse should advise patient on the importance of compliance and

follow-up for continuity of care. The relatives should be encouraged to show

love to the patients and they should be told the importance of incorporating

the patients back into the family and community.

The patients should be advised to keep self occupied and stay away from the

company that may influence them negatively especially if the relapse was as

a result of drug abuse. Family therapy should be advised in order to prevent

relapse because when the family is involve in the care of the patient, it

reduce the rate to zero level.

The nurse should encourage rehabilitation from admission to discharge. This

enables the patient to be engaged and productive in life and also help in the

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prevention of relapse.

3. CONCLUSION

In the course of the study, it was discovered that there are five (5) types of

relapse namely primary, secondary, tertiary, partial and total relapse all of

which have devastating effect on patients. It was shown in the study that the

families and the hospital should be fully involved in the care of the patient in

order to prevent relapse. It was also discovered that with frequent relapse

rate the might be thrown out of jobs, be divorced.

Attitude of nurses towards relapse prevention plays a vital role in preventing

relapse to occur. "prevention they say is better than cure "in line with this

statement relapse like any other condition is preventable. Alongside drug

therapy, avoidance of stressful situations and good family support systems

are good preventive measures. Drug compliance also tremendously assists in

the stability of the patient mental state. To this extent, the patient is health

educated on the need to comply with drugs.

With proper management and care, the possible complication that may result

from frequent relapse, can be reduce as much as possible.

4. RECOMMENDATIONS

1. Nurse and other healthcare giver should enlighten the public on the

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 causes and preventive methods of mental illness. This will help them

know what to do and when to act when they come into contact with

relapsed patient/patients with mental illness.

2. The nurse should at every level of contact with patients relative should

health educate them on the importance of active participation in the care

of psychiatric patients taught the need of visiting psychiatric hospitals.

3. Long hospitalization of patients should also be avoided in order not to

make patient lose contact with home environment, community, friends

and colleagues as this also trigger relapse.

4. The government should formulate a policy to subsidize for drugs given

to psychiatric patient as the prices of the drugs are on the increase and

some of the patients are unable to buy them.

5. The national mental health act should receive reviewed and proper

implementation by the government agencies involved.

6. Nurses should be send for training so as to be up to date and

empowerment of more man power should be made.

7. The occupational therapy departments should be well equipped with

modernized equipments necessary for the rehabilitation of patients

where some of them can learn new trades to practice when discharged

from the hospital.

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5. REFERENCES

Ademola, A. (2002). Basic Psychiatric Nursing, 2nd Edition. Nigeria:

Manisha Printing Press, Ibadan.

Boyd, M.N. (2001).Psychiatric Nursing: Contemporary Practice. 2nd

edition, Lippincott.

Burgess, A.W. (1997). Psychiatric Nursing Promoting Mental Illness, 3rd

Edition. USA: Cappleton and Large Standford, Connecticut.

Kaplan & Saddock (2005). Synopsis of Psychiatric Behavioral Science,

Chemical Psychiatry. 9th edition, USA: Lippincott William and

Wilkin, New York.

Townsend, M.C. (2006). Psychiatric Mental Nursing, 5th edition.

Philadelphia: F.A. Davis Company.

www.currentnursing.com

www.google/theoriesofattitude.com

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