As a psychiatric mental health nurse practitioner (PMHNP), I’m challenged to continually learn—evolving my approach to nursing care and growing my knowledge base to ensure I am meeting the needs of those I am treating. I often think of someone who was ahead of her time, Hildegard Peplau, as she prioritized the patient and revolutionized what it means to be a nurse practitioner (NP). Peplau is often thought of as the “mother of psychiatric nursing” as she was a true pioneer in the development of the theory and practice of psychiatric and mental health nursing. Peplau introduced the “nurse-patient relationship” in her Theory of Interpersonal Relations, which she developed in 1952, a time when patients did not actively participate in their own care.¹ Peplau proposed that the therapeutic relationship established between the nurse and the patient forms the basis of nursing care, a concept now weaved into virtually all nursing specialties, which can be broken down into 3 phases: orientation, working, and resolution.¹

Communication is a key component of the nurse-patient relationship. As a PMNHP, I see the vital role each member of the treatment team plays. For nurse practitioners (NPs), our greatest power is prioritizing the patient and fostering strong relationships, rooted in caring, to champion for their management and care to ensure it’s the best possible treatment plan for them, based on their goals and aspirations. However, in my experience, it is especially critical in the relationships we have with our adult patients who have a diagnosis of schizophrenia. In my opinion, adults living with schizophrenia require individualized treatment plans to meet their unique symptom needs and individual priorities. While clinicians are experts of the illness, our adult patients are experts of themselves, and the contributions that they bring to the decision-making process should be recognized and considered. To construct a strong therapeutic alliance, open conversations, trust, and respect play fundamental roles, with the ultimate goal being to establish a partnership to optimize patient outcomes.²

Orientation Phase

During the orientation phase of the nurse-patient relationship, the psychiatric nurse begins to gain essential information, establish rapport, and develop trust, while also helping the patient living with schizophrenia to recognize and understand their diagnosis.¹ Here we define the purpose, roles, and framework for assessing a patient’s needs.¹

When working with adults living with schizophrenia, establishing the right treatment plan, including medication, is very important. Adults living with schizophrenia tend to have the lowest rates of adherence to medication compared to other major psychiatric illnesses.³ Research has consistently found a link between poor adherence and relapse. ^4,5 Fortunately, other studies have demonstrated significantly increased adherence in patients who receive their medication by way of a long-acting injectable (LAI) antipsychotic and less-frequent relapses than in patients receiving oral medications. ^{6, 7, 8, 9}

Given the pervasive problem of nonadherence or partial adherence, it is imperative, in my view, to establish early on and maintain open communication around an adult’s faithfulness to their treatment regimen.¹⁰ In the orientation phase, I assess levels of adherence and insight to determine an adult’s understanding of their condition, the importance of medication, and how often they have forgotten medications or how often they can take medications regularly without being prompted. I also find it’s necessary to consider values, beliefs, culture, past experiences, expectations, and preconceived ideas to understand where the patient comes from and what informs their knowledge base and views.

The answers tend to give me a solid baseline understanding of the patient’s insight, helping me provide relevant and appropriate care based on the individual’s beliefs, views, and aspects of identity. Not knowing what the medication is for or describing only taking it when they are symptomatic is a strong indicator of limited insight.

Working Phase

The working phase is the problem-solving phase, when nurses and adults with lived experience take the problems and issues that are identified and put the plans created to address these into action.¹ During the working phase, the patient attempts to cope with their diagnosis, and is encouraged to participate in care to promote personal acceptance and satisfaction, while also setting goals for the future.¹ This is a time when the adult living with schizophrenia begins to feel capable and empowered to acknowledge and address their symptoms, thereby decreasing their feelings of helplessness and hopelessness.¹

Motivational interviewing and shared decision making are modalities that promote effective communication, collaboration, choice, and empowerment.² I find my patients are less hesitant and more agreeable to considering an LAI during the working phase, when we are working together to implement the plans we’ve established, including therapeutic goals. I have also found adults are open to considering an LAI when it is offered in the company of a family member or trusted team member, as it can be helpful for them to have a secondary (and perhaps more trusted opinion) to take into consideration.

Treatment conversations should occur throughout the management and care journey. The use of motivational interviewing and shared decision making can be effective in evoking and increasing the patient’s motivation over time, especially as the therapeutic relationship strengthens and we learn more about the patient’s unique motivating factors.² These factors can be rooted in the importance of adherence and can showcase to patients the possibilities that may be open to them with their symptoms managed, including improved relationships with family members, opportunities to have more freedom, and ownership over the things that are important to them.

These techniques can be effective when suggesting treatment evolutions, like LAIs.

Resolution Phase

During the resolution phase, the patient reviews what has been learned and plans for the future, adopting new goals.¹

Peplau defined health as “a word symbol that implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal and community living.”¹¹ Within this phase, we can plan for the future, revisiting the goals and aspirations a patient had established, like going back to school, starting a job, volunteering, or maintaining relationships with friends and family, because of the symptom stability they’ve achieved.¹¹

Education on the importance of medication adherence is a key part of planning for the lifelong trajectory of schizophrenia. LAIs can be a compelling intervention as they provide greater assurance that patients will receive their medication continuously, since LAIs are professionally administered. With symptoms under control, the adult patient is able to focus on new goals that previously seemed like longshots due to unmanaged symptoms and subsequent relapses.

For additional PMHNP perspectives on the management and care of schizophrenia, visit PEERspectives on TalkingLAIs.com.

This article reflects my own experience and opinions and was developed in joint collaboration by Janssen Pharmaceuticals, Inc., and myself. I have been paid an honorarium for my time.

References

¹ Peplau HE. Interpersonal relations: a theoretical framework for application in nursing practice. Nurs Sci Q. 1992;5:13-8.

² Mucci A, Kawohl W, Maria C et al. Treating schizophrenia: open conversations and stronger relationships through psychoeducation and shared decision-making. Front Psychiatry. 2020;11:761. doi:10.3389/fpsyt.2020.00761

³ Semahegn A, Torpey K, Manu A, et al. Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis. Syst Rev. 2020;9:17. doi.10.1186/s13643-020-1274-3

⁴ National Council for Mental Wellbeing. Guide to Long-acting Medications. National Council for Mental Wellbeing website. Accessed September 28, 2022. Available at: https://www.thenationalcouncil.org/topics/long-acting-medications/

⁵ Morken G, Widen JH, Grawe RW. Non-adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia. BMC Psychiatry. 2008;8:32. doi:10.1186/1471-244X-8-32

⁶ Greene M, Yan T, Chang E et al. Medication adherence and discontinuation of long-acting injectable
versus oral antipshoticis in patients with schizophrenia or bipolar disorder. J Med Econ. 2018;21(2):127-134. doi:10.1080/13696998.2017.1379412

⁷ Marcus S, Zummo J, Pettit A et al. Antipsychotic adherence and rehospitalization in schizophrenia
patients receiving oral versus long-acting injectable antipsychotics following hospital discharge. J Manag Care Spec Pharm. 2015 Sep;21(9):754-68. doi:10.18553/jmcp.2015.21.9.754

⁸ Offord S, Wong B, Mirski D, et al. Healthcare resource usage of schizophrenia patients initiating long-acting injectable antipsychotics vs oral. J Med Econ. 2013;16(2):231-239. doi:10.3111/13696998.2012.751025

⁹ Joshi K, Muser E, Xu Y, et al. Adherence and economic impact of paliperidone palmitate versus oral atypical antipsychotics in a Medicare population. J Comp Eff Res. 2018;7(8):723-735. doi:10.2217/cer-2018-0003

¹⁰ Bright CE. Measuring medication adherence in patients with schizophrenia: an integrative review. Arch Psychiatr Nurs. 2017;31:99-110.

¹¹ Martin P. Peplau’s interpersonal model: clinical applications. In: Reynolds W, ed. Psychiatric and Mental Health Nursing. Boston, MA: Springer Science+Business Media Dordrecht; 1990:261-278.