Introduction

The essay’s objective is to develop an evidence-based care plan for a patient with psychosis demonstrating co-creation with the patient and parents. I will be critically evaluating the evidence base for various recommended interventions and explore their suitability for the patient in question. The information which is not limited to name, but also any data that expressly makes the patient identifiable has been changed in compliance with GDPR 2018 and NMC code of conduct (NMC, 2017).

Description

Alimi is a black Caribbean 18 years old male. He was born and lived in the UK all his life. He has been recently seen by my mentor and me in the community, following distressing early episodes of auditory hallucinations with paranoia.

Alimi pathway into care started from an involuntary hospitalisation because of an increase in paranoia. Alimi was found by police roaming aimlessly around a local parking lot. He was acting erratic and mumbling to himself. He attempted to run when approached by the police, but he got apprehended and transported to a place of safety under section 136 of the mental health act. The police reported that Alimi appeared to be experiencing episodes of auditory hallucinations. After mental health act assessment was initiated, Alimi was placed under section 2 which means he can be kept in the hospital for up to 28 days for assessment or (and) treatment (Berry and Haddock, 2008).

Following this experience, Alimi has become wary of mental health professionals and its services, but he has agreed to work in partnership with us on his parent’s request. When my mentor and I visited, Alimi told us he believes that the people on the TV are sending him messages and when he told his friends in the past, they told him that he’s crazy if he hears voices.

His parents are afraid that Alimi’s condition will affect his way of life. The auditory hallucinations are having a significant effect on his functioning hence having a negative impact on his quality of life. They believe that with proper treatment and care, he can attain a higher quality of life despite this having a probability of being a lifelong disorder. The parents wanted to stay with him at home so that they can assess and provide the best support that they can.

The relevant nursing issues in Alimi’s case are hearing voices and paranoia. Hearing voices has been chosen since it is preventing him from leading a quality life.  He is having problems sleeping and interacting with other people as a result. My mentor and I intend to ensure that Alimi is able to work whether the voices are coming from outside or inside his head. There will also be an introduction of coping strategies to help resist the compulsion of engaging in these voices. Paranoia on the other hand might be attributed to the aspect of hearing voices due to fear that comes with it.

There are various nursing needs that ought to be incorporated to help Alimi actualize a higher quality of life. Among them is establishing a positive therapeutic relationship with him. Whoever….. asserts that this is a critical step towards the recovery process. The patient ought to trust the care giver in that he/she has the desired skill set, knowledge and desired to provide care. He/she also ought to trust that everything confidential that they tell the care giver will remain that way, and there is no exploitation or harm likely to arise as a result. In the case of Alimi, it will help him to open up emotionally and provide further details on his aspect of hearing voices.

This will be very important, more so given how he has become wary of mental health professionals. It is very important to appeal to the parents and other significant people in his life, coupled with clinical records if they exist. Establishing these relations will make it easy to collect data in case Alimi is not in a condition of providing reliable information (Rogers et al., 2012). There is also the need for always showing the patient the necessary understanding of his condition and empathy. To establish a therapeutic relationship, there is a need to initiate short and frequent conversations. This is because, with Alimi’s condition, he is likely not to tolerate long assessments and conversations (Rogers et al., 2012). There is also the need of putting Alimi under medication and counselling. The medication will be useful for putting the hallucinations and paranoia under control. This will pave the way for counselling, which will help Alimi improve at school, take care of himself, get along with others and make friends.

Critical Analysis

In order to develop a comprehensive and appropriate care plan, it becomes important to enhance shared decision making with the relevant patients. This helps to put the patients at the centre of decisions regarding their own care and treatment. Co-creation helps in fully exploring the treatment or care options, along with the inherent benefits and risks. Involvement of the patient in their own care helps to promote increased willingness and confidence to take control of their health, which is likely to result in improved outcomes and healthier behaviours.  Patients end up showcasing increased levels of health literacy and empowerment (NICE,…..). This is why I found it to be important in establishing co-creation for Alimi’s care plan. It has helped in establishing that Alimi feels that the issue of hearing voices should be given priority since it is affecting numerous aspects of his life. His parents also believe that the paranoia he is experiencing could be triggered by the voices he is hearing.

Psychosis represents a notable psychiatric disorder, and this is when a person’s thoughts, mood, behaviour, and perception are altered significantly. The symptoms of psychosis include delusions and hallucinations and a review in 2012 about incidences of psychosis discovered that 31.7 percent of 100,000 people suffer from psychosis (Morrison, 2017).

Involvement of family in the healthcare process brings in additional value to the whole care experience. This is why when one is focusing on the patient’s recovery goals, it is important to include the patient’s family in the formulation of the appropriate care plan for both the short-term and long-term basis (Boyle, 2015). The patient’s family members may not have the necessary healthcare background, but their presence and voice matters in the entire care process. It is the family that helps in identifying the precipitants and history of the patient’s problems, coupled with potential future problems when it comes to the treatment and management of psychosis related issues. The family can offer valuable information on how the patient is functioning while at home and also aid in his/her compliance with treatment recommendations, while at the same time keeping track of any medication side effects (Boyle, 2015). As a result, clinicians ought to establish favourable relations with family members. The relations can be improved by way of establishing good communication, favourable problem solving skills, the achievement of family development tasks, clear roles, adaptability, open expression of appreciation, and mutual support among others. In the case of Alimi, he trusts his parents as they are the ultimate reason why he agreed to work with us. He has become wary of mental health professionals after his last admission in the hospital. As a result, it is very important to involve the parents in the co-creation of the care plan. Though it is important to put the needs of the parents into consideration, the essay will focus on Alimi’s needs.

Family support alone will not be sufficient to help Alimi lead a quality life. There will be a need for medication to put his delusions and hallucinations under control. Community settings and hospitals use neuroleptic medication as the primary psychosis treatment, and there’s a body of evidence for its efficacy in treating acute episodes of psychosis and relapse alongside various psychological interventions. Gabalda (2017) argued that neuroleptic drugs are the major tranquilisers and showed to have been effective in the treatment of psychosis symptoms in some patients due to sedative effects instead of any action in specific symptom. This is because they work by altering the brain chemistry in order to reduce psychotic symptoms such as delusions, disordered thinking and hallucinations. Neuroleptic drugs are normally designed to serve a similar purpose, but they tend to affect people in different ways. The experiences that people derive from their usage are unique (Morrison et al., 2013). This is why some people end up developing side effects upon their usage.

Using medication will help reduce Alimi’s positive symptoms of hearing voices to tolerable levels. Once the psychosis recedes, while still continuing with medication, psychosocial and psychological interventions will also come in handy. A favourable psychological intervention that can be integrated into Alimi’s care plan is cognitive behavioural therapy. Cognitive Behavioural Therapy (CBTp) is tailored for individuals, and it’s a talking therapy that aims to improve the coping ability of people with specific psychotic experiences. CBTp does this by modifying the physical sensations, associated thoughts, emotions, and behaviour (Morrison, 2017). CBTp is grounded on the idea that how people think, how they feel, and how they act tend to interact together. Simply put, people’s thoughts, determine their feelings and behaviour. As a result, unrealistic and negative thoughts are likely to cause people distress that results in problems. This results to skewed interpretation of situations that has a negative impact on the actions likely to be taken (Hutton and Morrison, 2013). In Alimi’s case, CBTp will help him to become aware of when he is making negative interpretations and behavioural patterns that reinforce his distorted thinking. It will work in the way of providing alternative ways of behaving and thinking that aims to reduce his psychological distress.  I will work together with Alimi to explore how he is experiencing the aspect of hearing voices. This exploration can help him get a sense of power that he has the ability to manage the inherent voices. This coupled by helping him to identify needs that tend to underline the voices. Chaudhury (2010) asserts that hearing voices might reflect needs for power, sexuality, self-esteem and anger. The aspect can help us in identifying other ways that these needs can be met. Helping Alimi to identify when the voices are most frightening and prevalent will be vital in identifying the situations and periods that are more threatening and anxiety-producing for Alimi.

Ray and Tort (2019) just concluded Census research shows that the main aspects of CBTp entails formulation, collaboration, change strategies and normalisation. These processes were reported by patients to reduce stigma and improve engagement. Attestation of sample-controlled trials shows that CBTp reduces positive symptoms alongside comorbid (Ochoa, 2015). Further evidence also suggests that CBTp prevents the onset of psychosis in individuals at risk (Ray and Tort, 2019). The APA (American Psychiatric Association) 2006 guidelines of practice also recommend CBT intervention for psychosis.

CBT provides an opportunity to challenge the beliefs that people might have. Whoever……asserts that patients enter into CBT believing in things that they deem to be true. They will rarely question these beliefs. As a result, instead of trying to change the belief, CBT’s goal should be to try to help the patient question the accuracy and value of what he/she believes. In Alimi’s case, he has acknowledged that he is hearing voices. Given that the voices are real to Alimi, I will accept the fact that the voices are real to him, but explain that I do not hear the voices myself. Validating that my reality does not include these voices might help Alimi to cast some “doubt” or questions on their validity (Chaudhury, 2010). I will also take the initiative of trying to inquire if he recognises the voices and what they are saying to him.  This will help to determine whether he is having command hallucinations that direct him to indulge in certain behaviours like harming others or himself (Chaudhury, 2010). If the voices are telling him to harm others, I will take the initiative of informing the people around him, and the police so that necessary environmental precautions can be taken. In case the voices are directing him to harm himself, I might recommend that he is transferred to a psychiatric unit.

When subjecting CBTp on Alimi, there needs to be caution put into place. This comes in based on an EDIE trial conducted on 54 participants with the objective of assessing whether CBT can prevent or ameliorate among individuals at risk (Sims et al., 2014). An interesting part of this trial is Morrison (2017) requested the group’s ethnicity breakdown, and the Black Caribbean manifested significantly low change in their insights when compared to White counterparts. Our patient Alimi is from a black Caribbean ethnicity, and this is why that part of the study caught our attention. This research highlights problems of generalisability by studies and NICE guidelines of CBT for psychosis across ethnic minorities.

There are assumptions why CBTp does not favourably work for ethnic minority compared to whites, and some of the factors that have been identified included communication barrier, where English isn’t the first language. The patients may end up with imprecise diagnosis as a result of being misunderstood (Jolley et al., 2012). The good thing is that language barrier will not be an issue when it comes to Alimi’s case since he is fluent in the English language. Previous research has also demonstrated that poor results of ethnic minority groups are due to professional attitudes and perceptions of therapists/clinicians that BME’s individual are a difficult group to engage in. For this reason, secondary and primary care professionals are reluctant to refer these individuals for psychological therapies (Michie et al., 2007). Earlier studies accounted that the Black Caribbean group is stereotyped as impulsive, not psychologically mindful and hostile (Switzer, Harper and Peck, 2019). Comparably is another recent research by Prins et al. (1993) titled ‘big black and dangerous,’ pointed out the extent of misconceptions about blacks. He argued that these misperceptions are exacerbated by cultural, prejudices, racism and misunderstanding; however, National guideline has intensified CBTp recommendation over the years which has led to an increase in awareness of professionals about the advantage of CBTp (Nice.or.uk, 2019). Having an idea of such information will be helpful to my mentor and me as we deal with Alimi since it will help in not being judgemental, and keeping an open mind at all times.

CBT entails an integral part referred to as psycho education. It works to help patients to develop strategies likely to change their negative thought patterns. Through psycho education, I will help Alimi to better understand, accept and cope with the issue of hearing voices. This is the point where I will introduce coping strategies during periods when he is hearing the voices. I will provide him with several options so that he can choose the ones that he feels to be more appropriate for him. They will include singing or humming, reading (forwards and backwards), exercise, listening to music, ignoring the voices, or talking to others. This will be part of enhancing co-creation of the care plan with Alimi.

I will also involve the family in this process to ensure that Alimi is taking his medication appropriately. His parents will help to assess any side effects that they might notice or progress for that matter. They will work as his support system at all times.

Proposed Care plan

Nursing Diagnosis: Alimi is experiencing distressing early episodes of auditory hallucinations with paranoia. It is characterised by hearing voices and delusions.

Short-term goals

 

 

Evaluation

The study evidence, clinical guidance, and policies outlined above show the importance of the involvement of service users in their own care. By doing this, one will be able to eliminate various assumptions that are causing a barrier to the most appropriate care pathway for patients. In mental health, multiple shreds of evidence suggest that patients who feel isolated about their care often report low self-esteem and slower recovery (Gray-Burrows et al., 2018).

For Alimi who’s wary of mental health services and staff, by recognising him as partners we will be able to improve his choices, health outcome and autonomy. One of the challenges of creating care plans is about how “caring” is understood and what constitutes caring by patients and professionals. Research has shown that talking therapies will help me as a professional to become proficient in integrating theories of co-creation of care plans into practice.

Talking therapies have also shown to address these gaps (understanding care) between professionals and patients, and it also facilitates acceptance, understanding, and implementation of co-creation of nursing care plans (Jolley et al., 2012). This research has also shown me the importance of looking at my patients as individuals and to always reflect back on evidence-base interventions that identify them in a person-centred way.

Furthermore, I will like to raise awareness around prejudice and various massive assumptions that influence clinicians attitudes towards some ethnic minorities. In addition, I have now realised the importance of family-centred care. Alimi’s case shows that integrating patients families as part of the care process is highly important because parents opinions and involvement usually guides patients.

 Conclusion

Dealing with a patient experiencing auditory hallucinations with paranoia can be problematic due to the onset of the inherent symptoms. When providing care for such patients, there is a need for involving family members since they understand a range of aspects regarding the patient. Alimi, in this case, was wary of mental health professionals and only became cooperative upon the parents’ request. Using neuroleptic medication will help reduce Alimi’s positive symptoms such as hallucinations and paranoia to tolerable levels. Once his symptoms recede, then there will be the use of cognitive behavioural therapy as the preferred psychological therapy.

Nursing Problem	Goal	Intervention	Evidence
Parent’s Involvement
	Ensuring there are familiar faces so that Alimi can respond positively to the entire care process.	Given that Alimi has become wary of mental health professionals , his parents will play a significant role in ensuring that he cooperates appropriately	(Lawlor, Hall and Ellet, 2014)
Auditory Hallucinations
	Putting Alimi’s delusions and hallucinations under control.	Using neuroleptic medication to reduce the symtoms to tolerable levels. Parents will play a significant part in assessing whether there are inherent side effects.	(Morrison et al., 2013)
	Improve Alimi’s coping ability in light of prevailing psychotic experiences.	Using CBTp to modify his physical sensations, associated thoughts, emotions, and behaviour	(Morrison, 2017)

 

 

 

 

 

 

 

 

 

 

 

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