Issues in Mental Health Nursing, 35:872–882, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.908439

Building Collaboration in Caring for People with Schizophrenia Ratchaneekorn Kertchok, PhD Chulalongkorn University, Faculty of Nursing, Rama I Road, Pathumwam, Bangkok 10330, Thailand

People with schizophrenia, who have disturbances in mood, thought processes and behavior, experience impairment in day-today functioning. Primary caregivers have tried to become involved in caring for persons with schizophrenia by coordination with community psychiatric nurses. Community psychiatric nurses have an important role to play in supporting families in this care, especially primary caregivers. The purpose of the present study was to explore the relationship between Thai community psychiatric nurses and primary caregivers of people with schizophrenia. Grounded theory methodology was used to examine the process with which community psychiatric nurses work together with primary caregivers. Purposive sampling and theoretical sampling were used. Data were collected from 34 informants, including 17 community psychiatric nurses and 17 primary caregivers through in-depth interviews, observation, and field notes. Data was analyzed using constant and comparative methods by Glaser (1978). The study revealed that building collaboration in the care of people with schizophrenia involved coordinating both community psychiatric nurses and primary caregivers in a process that consists of five major stages. In the first stage, community psychiatric nurses and primary caregivers used strategies to establish trust in each other before the next stage, which engaged their concerns and needs. Later, the stages of mutual preparation for caregiving, cooperating on patient care and monitoring outcomes were jointly employed in order to promote a healthy family life for patients. The study concludes by suggesting guidelines and giving insights into ways of helping primary caregivers and their patients with schizophrenia.

INTRODUCTION Schizophrenia is a mental disorder in which patients exhibit abnormal emotions, thoughts and behavior (Austin, 2005; Eby & Brown, 2005; Morris, 2009). Hence, when a person suffers from schizophrenia, there will be inevitable effects on family members. In particular, this disease is a significant cause of family stress and leads to family members feeling burdened and/or encountering difficulty when acting as primary caregivers (Chan, 2011; Grandon, Jenaro, & Lemos, 2008). Primary caregivers spend a great deal of time looking after family members who Address correspondence to Ratchaneekorn Kertchok, Chulalongkorn University, Faculty of Nursing, Rama I Road, Pathumwam, Bangkok 10330, Thailand. E-mail: [email protected]

are ill with schizophrenia (Jeon, 2004; Madianos et al., 2004). In particular, they face the further challenge of having to control patients when those patients express psychotic symptoms, such as violent and bizarre behavior (Chan, 2011; Conn, 2003; Kung, 2003; Sawatzky & Fowler-Kerry, 2003). Moreover, primary caregivers also face difficulty in leading their own lives, through loss of income and loss of time for activities beyond their caregiving duties (Madianos et al., 2004; Rhoades, 2000). Primary caregivers seek the best way of caring for patients at home, so they have to make a number of decisions for relatives who are deficient in terms of their mental processes and behavior (Radden, 2002). This can cause primary caregivers to become stressed, think negatively about themselves and suffer in other ways because of the responsibility of caring for their family members who are living with this debilitating chronic illness (Chan, 2011; Grandon et al., 2008; Madianos et al., 2004). Psychiatric nurses play a major role in caring for persons with schizophrenia and their families, so that they are able to live together in the community under a policy that has been called ‘deinstitutionalization,’ with hospitalized psychiatric patients returning to live with their families (Townsend, 2000). Psychiatric nurses are prepared to learn new skills and expand these appropriately in-line with the emerging healthcare understanding and management of technology for families and patients. In addition, the psychiatric nurses combine scientific knowledge with critical thinking and clinical reasoning skills in helping patients and their families to live together; this includes providing psychoeducation, counseling, home health care, preparing readiness to care, and general assistance while providing care for the patients and families (Morris, 2009; Kertchok, Yunibhand, & Chaiyawat, 2011; Shives, 2005). In Thailand, most Thais, including primary caregivers, accept and trust any person who has more power or authority than themselves. When they have to work with such a person, they will do everything that they can do to understand and accept that person’s perspective (Kertchok et al., 2011; Petcharat, 2004; Vanaleesin, Chetchaovalit, Aowchareon, & Chiamongkol, 2003). Some primary caregivers have the understanding that the cause of their family member’s mental illness is from their doing the wrong thing in some way. Consequently, the patients

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are often punished for their mental illness (Petcharat, 2004; Lueponglukkana, 1992; Limvipaveanunt, 1991). Primary caregivers are not sure about, and do not know if there are, any strategies that will be able to help their patients, however, after they are educated by psychiatric nurses about the causes of schizophrenia, they both understand and believe the information. They try to collaborate and coordinate with health professionals in order to provide good care for people with schizophrenia (Dangdomyouth, Stern, Oumtanee, & Yunibhand, 2008; Kertchok et al., 2011; Petcharat, 2004; Lueponglukkana, 1992). A study conducted in Thailand (Dangdomyouth et al., 2008) found that the process of tactful monitoring has been employed by family caregivers in caring for persons with schizophrenia. The process has shown that the caregivers take their role of caring for their ill family members to be keeping an eye on their behavior, checking and reminding them of their medication intake, asking about symptoms, preventing the intake of strong beverages and helping their patients do daily activities with the guidance of psychiatric nurses. At the same time, caregivers often seek support resources for their own physical and mental health; resources which tend to come mainly from psychiatric nurses. These findings revealed that primary caregivers are able to work with psychiatric nurses through a relationship that involves learning how to manage physical, mental, social, and other problems that may arise in the course of caring for their patients. At the same time, psychiatric nurses relate with primary caregivers in order to obtain information (Macleod, Elliott, & Brown, 2011; Peplau, 1991, 1995), which will lead to better planning and care for patients (Gladstone & Wexler, 2002; Jeon, 2003). However, only one Thai study (Kertchok et al., 2011) has been published which demonstrates the existence of any relationship in terms of work between psychiatric nurses and family members of schizophrenic patients. This study focuses on perspectives of psychiatric nurses who have worked in psychiatric hospitals and have found that the relationship between psychiatric nurses and schizophrenic patients’ family members involves four stages: establishing trust, strengthening connections, preparing readiness to care, and providing support. However, no study has been done on the relationship or collaboration between psychiatric nurses and schizophrenic patients’ primary caregivers in the community, that takes into account the perspectives of both caregivers. Other Thai studies (Lueponglukkana, 1992; Limvipaveanunt, 1991; Sasichay, 2001) have focused on the perspectives of nurses regarding their patients. Primarily, they study the behavior of nurses when they interact with patients and are engaged in various nursing activities, such as asking patients about their symptoms, taking medicine and maintaining patients’ personal hygiene. These Thai studies have not been able to describe the nature of the relationship between psychiatric nurses who work in the community and the primary caregivers of people with schizophrenia. However, community psychiatric nurses may have ways to foster relationships and helping primary care-

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givers and other family members in an efficient manner within the Thai context. International studies have shown that the development of a relationship between community psychiatric nurses and primary caregivers is an ongoing process (Donovan & Dupuis, 2000; Friendemann, Montgomery, Maiberger, & Smith, 1997; Gladstone & Wexler, 2000; Jeon, 2004). The first phase is significant, in that nurses and primary caregivers need to form a relationship to obtain necessary and sufficient information to be able to diagnose and treat patients. If psychiatric nurses and primary caregivers establish cooperation together, help for schizophrenic patients will be continuous and this, in turn, will lead to continual and consistent holistic treatment for the patients (Astedt-Kurki, Paavilainen, Tammentie, & Paunonen-Ilmonen, 2001). In the second phase, the relationship takes the form of partial mutuality. Here, nurses and relatives start to share opinions on caring strategies. The last phase of the relationship is characterized by constructive mutuality. In this phase, nurses and relatives understand and accept each other’s perspectives, having come to understand how to look after their patients (Jeon, 2004). Having an understanding of the relationship between community psychiatric nurses and primary caregivers will help those who work in the community to be aware of the importance of having a relationship in terms of cooperation with the families of patients. Moreover, this study aims to help community psychiatric nurses and primary caregivers learn how to work together efficiently to promote the health of people with schizophrenia and will help community psychiatric nurses know how to develop their relationship skills with primary caregivers. Overall, hopefully, it will assist nurses to gain a better insight into the experiences of people with schizophrenia who are living in the community, and their family caregivers.

METHODS The purpose of the research was to develop a substantive theory of the processes community psychiatric nurses and primary caregivers use when they work together during the care of people with schizophrenia, in a Thai context. Glaser’s (1978) approach to grounded theory was used as the basis to collect and analyze data and generate substantive knowledge on how psychiatric nurses work with the primary caregivers of people with schizophrenia living in the community. The research question was, ‘What is the relationship between psychiatric nurses and primary caregivers of people with schizophrenia?’ Researcher Roles The relationship between the researcher and the participants profoundly influenced the nature of the data. The researcher was, for the most part, familiar with the participants. The researcher respected the participants as knowledgeable and for having experience in working with primary caregivers of people with schizophrenia. The participants’ facial expressions, gestures,

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and responses to the interview questions indicated genuine sincerity during the interviews. The researcher attentively listened to what the participants said, asked for clarification and explanations, and did not assume that the meaning of the participants’ words and statements was already known. The researcher also did not use leading questions that would prompt expected answers from the participants. Sample Selection and Participants The participants were registered nurses with Masters degrees in psychiatric and mental health nursing who work in community hospitals, or those with at least 2 years’ experience working with families of people with schizophrenia, as well as people who had acted as the primary caregivers for at least 6 months. Upon obtaining approval from the relevant research ethics committees, the author contacted the head nurses of the institutions involved, to inform them of the objectives and benefits of the study and provide them with a summary of the research protocol, as well as initial inclusion criteria. The head nurses then provided a list of names of community psychiatric nurses and primary caregivers who work together in caring for people with schizophrenia, who matched the initial inclusion criteria. During the analysis process, as tentative categories began to emerge, participants with experience that could help them refine and expand the emerging theory were sought. This theoretical sampling also allowed full saturation of categories. The final participants were 17 experienced community psychiatric nurses and 17 primary caregivers of people with schizophrenia. Details of the participants are shown as in Table 1. Data Collection Data collection took place in community hospitals in Thailand from June 2011 to May 2012. Potential participants were contacted by the author. The parameters including the purpose of the study, the research procedure, risks and benefits, the right to decline participation or later withdraw from the study, and the confidentiality of the data were communicated to the potential participants, and the names and the addresses of the contact people were collected. After written consent had been obtained, the author made an appointment with the potential participants and collected the data on the agreed date, according to participants’ availability. Data was collected by in-depth interviews in a private place selected by the participants. The main interview questions were used to reflect emerging categories, including: ‘How do you relate or work with the primary caregiver of people with schizophrenia?’ and ‘How do you relate or work with the psychiatric nurses for helping your family member who is diagnosed with schizophrenia?’ Each interview lasted approximately 45–60 min and was recorded by the author with an electronic recorder. At the same time, field notes regarding the participants’ behavior, tone of voice, and posture observed by the author, were noted. The data were confirmed and validated

TABLE 1 Demographic data of the 34 participants

Personal identification Sex Male Female Ages (years) 25–35 36–45 46–55 >56 Education level No study Grade 9 Grade 12 Master’s degree (psychiatric and mental nursing) Length for helping patients (years) 1–5 6–10 11–15 >16

Total psychiatric nurses

Total primary caregivers

1 16

3 14

– 10 7 –

1 2 6 8

– – – 17

2 11 4 –

8 6 3 –

4 5 1 7

by the participants to clarify some issues regarding transcription for the researcher. The researcher then reviewed the transcripts before analyzing the data. Data Analysis This research analyzed the data using the Constant Comparative Method (Glaser & Strauss, 1967; Glaser, 1978). The process of data analysis in this study simultaneously occurred with data collection throughout the research process. A category was considered saturated when there was no new information about the properties. The researcher started first, by transcribing every conversation in the interview in detail in the form of a memo and field note of participants, word-by-word. The researcher then read the conversations of each person many times to understand the context and, more importantly, to look for main points that corresponded to the objective(s) of the research. Second, three types of coding process, namely, open coding, selective coding, and theoretical coding, were determined. In open coding, the researcher read the conversations of each person line-by-line, word-by-word or phrase-by-phrase, many times. Then the researcher allocated substantive codes, such as data giving, greeting, paying attention, time giving, coming as promised, and listening. Each conversation were determined by these codes. If there were phrases or sentences similar to the codes already determined, they would be given the same codes.

BUILDING COLLABORATION IN CARING FOR PEOPLE WITH SCHIZOPHRENIA

The researcher determined the codes according to types of situation, activity and behavior that the data provider was facing at that time. At the same time, the researcher also comprehensively compared the data of each situation, activity and behavior for similarity or difference, before continuing to look for major categories. Selective coding is the process of cutting the length of codes to find variables or major categories that occur. In this research, once the researcher had given the codes, she/he would look for core categories and sub-categories. Coded data was grouped. If it had the same or similar meanings, the researcher put it in the same group and gave a name to that category, for instance: familiarise, pay attention and sympathetic, would be in the same group because they are properties or behavior that nurses and primary caregivers display towards each other, in order to achieve mutual trust. In theoretical coding, once the researcher had obtained the categories, sub-categories and properties of those sub-categories, she/he considered the relevance and connectedness of each category, sub-category and property. Then the researcher considered the order of occurrence of each aspect or whether they could simultaneously occur, for example establishing trust comes before engaging concerns and needs, though both aspects are related to each other. The third, and last step of data analysis, was the comparison of findings with existing theories. The researcher considered the findings from the study of grounded theories for similarities or conformity to existing ideas or theories, so that they could be used once the study was completed. Each step of the data analysis was completed by the researcher who wrote the ideas, questions, codes, categories, hypotheses, and relationship among categories in the form of memos. Rigor Regarding grounded theory, Glaser and Strauss (1967) stated that the proper criteria for judging the research are the credibility, fittingness, and stability of findings. These criteria of judgment should be based on the element of the actual strategies used for collecting data, and for coding, analyzing, and presenting that data. Credibility can be evaluated through the vividness and faithfulness of the description of a phenomenon. ‘Fittingness’ is judged based on a ‘thick description’ about the time and context of the findings provided by the researcher. ‘Dependability’ and ‘confirmability’ constitute the stability of findings (Rolfe, 2006). The evaluation of confirmability is based on the characteristics of the data, rather than on the researcher’s characteristics. A major technique of establishing the stability of data is through an ‘audit.’ Ethical Considerations The approved research proposal was submitted to the Institute of Review Boards on Human Subjects, of the selected hospitals: Chacheongchao Hospital, Samuthsongkhram Hospital, Phetchaburi Hospital and Suphanburi Hospital, in June 2011, before recruitment of the participants. All measures in this research

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were taken to protect the participants’ anonymity, confidentiality, and to ensure their voluntary participation.

FINDINGS Building Collaboration in Caring Building collaboration in caring is a basic social process that involves coordinating the behaviors of both community psychiatric nurses and primary caregivers for people with schizophrenia. This process is shaped by the community psychiatric nurses and the primary caregivers’ perspectives and reflects how they collaborate in helping people with schizophrenia live successfully in the community. The process has been found to consist of five stages: establishing trust, engaging concerns and needs, mutual preparation for caregiving, cooperating in patient care, and monitoring outcomes. Establishing Trust Establishing trust refers to behavior that demonstrates that community psychiatric nurses and primary caregivers have confidence in each other. It is the first step that occurs in the relationship between psychiatric nurses and primary caregivers. Trust, in this case, means believing each other, feeling comfortable with one another and feeling free to relate information to each other. This stage involves five strategies, namely: greeting, mutual familiarity, showing interest in each other’s perspective, being flexible, and having empathy. Greeting is a behavior that can be practised by community psychiatric nurses and primary caregivers every time they meet. It does not matter where the greeting takes place, whether it is at the hospital, or market, or elsewhere. It was found that community psychiatric nurses and primary caregivers of schizophrenic patients express greetings to each other consistently in the form of calling each other by name, saying hello, and smiling. As one community psychiatric nurse stated: Whenever I meet the primary caregiver, we always say hello to each other like ‘Hello, what have you been doing today?’ Then the primary caregiver will start talking with me.

Mutual familiarity is a relationship that fosters trust between community psychiatric nurses and primary caregivers. A feeling of familiarity is demonstrated when nurses and caregivers meet, whether at the home of the patient or at the hospital. Both community psychiatric nurses and primary caregivers will express their feelings of familiarity with each other, in such ways as by using informal language, familial titles of address, such as ‘auntie’ or ‘uncle,’ or even nicknames. They may also provide seating, sit and chat, and exchange phone numbers. As one community psychiatric nurse stated: We have to express our familiarity with relatives or primary caregivers as well as making them feel comfortable. We smile, ask them about things and talk to them in our workplace. When they need

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R. KERTCHOK help, they should be able to contact us anytime. We also give them our mobile numbers so that they can phone us at any time should any problem arise.

At the same time, primary caregivers also show a familiarity with the nurses. They smile as they welcome the nurses, and may prepare drinks and phone the nurses about the timing of visits. This is reflected in the comment of a primary caregiver: When the nurse visits our house, I prepare some welcome drinks. She has been very kind to our family. Sometimes if she/he cannot come or is going to be late, I will phone to ask her/him whether she/he is coming or about the time that she is coming. We can contact each other easily. She is friendly to me and I also have to be friendly in response. I follow whatever she suggests.

Showing interest in each other’s perspective is another way of fostering trust. The study found that community psychiatric nurses and most primary caregivers pay attention to each other’s point of view. They discuss various issues, such as living conditions. Community psychiatric nurses will express their concern for the primary caregivers’ own physical and mental health, as well as offering help in health-checking, performing routines and attending various activities in their community. They also communicate in a manner that directly expresses the concerns of community psychiatric nurses and primary caregivers. Being flexible refers to not being too attached to one’s own ideas. In other words, one has to be prepared to compromise on different aspects of care and others’ opinions. In this study, it was found that community psychiatric nurses and most primary caregivers are flexible with each other when taking care of schizophrenic patients, which helps patients to become healthier and improves their ability to live happily with their families. As one primary caregiver said: One day, my child’s condition was not good. The nurse informed another doctor who was not the doctor in charge. Because his condition was not good, I did not complain. Anything could change but I was also worried about my child. Yet, I left it to the discretion of the nurse. I was not too rigid that the person treating my child had to be the same doctor.

Having empathy is an expression of understanding. Community psychiatric nurses and most primary caregivers in this study expressed their care and concerns through verbal communication or gestures that revealed empathy. This occurred whenever they met, be it at the patient’s home or at the hospital when primary caregivers brought patients in for appointments. This attitude leads to mutual trust – as one psychiatric community nurse reported: I understand the feeling of every caregiver. I know that they are stressed out with a heavy burden. They also have a lot of expenses. Some days, he/she told me that he/she did not have anything to eat. I looked him/her in the face and gradually told him/her that I sympathized and understood. Some people even cried when I said this.

Engaging Concerns and Needs Once community psychiatric nurses and primary caregivers have established mutual trust, the next important step is engaging concerns and needs. Engaging concerns and needs refers to actions taken by both community psychiatric nurses and primary caregivers, in an effort to know one person as the whole person. This includes the addressing of problems at the time they come up, as well as the consideration of each other’s needs and ideas. It also means including giving and receiving of information while they collaborate in the care of the person with schizophrenia. Accessing concerns and needs cannot occur if community psychiatric nurses and primary caregivers do not have time for each other. Hence, allowing sufficient time is a strategy to help both community psychiatric nurses and primary caregivers to understand comprehensively the concerns and needs of schizophrenic patients. This entails spending enough time together. Allowing adequate time can be incorporated in any meeting, whether at the hospital or primary caregiver’s home. As one community psychiatric nurse said: The first time I asked [about this], the patient’s relative took time to think. So I gave him time to think so that his thoughts could flow. I also followed his thoughts as he expressed them to know what actually happened. Sometimes I allowed him/her to phone me back. I gave my mobile number so that he could phone me anytime he needed help or wanted to give any information.

One primary caregiver commented on giving time to the nurse saying that: I take leave whenever the nurse makes an appointment. I am working at a factory nearby so I can come. I have come to patient–relative meetings. I know a lot when I come because I talk to other people. I don’t normally talk to anyone a lot.

Sharing concerns and needs is an important step that helps community psychiatric nurses and primary caregivers achieve their mutual objectives. Sharing is expressing one’s opinions and feelings and includes giving details about one’s concerns, as well as needs in the care of schizophrenic patients. In this study, most community psychiatric nurses shared information about matters, such as patient symptoms, inappropriate community attitudes regarding patients and the monitoring of symptoms with primary caregivers. This is reflected in the comment of a psychiatric community nurse: There is the sharing of a variety of information, when we work together I have to understand patients as well as relatives who are primary caregivers. Previously, I would tell the primary caregivers about current symptoms or problems of patients, what the nurse had to do or care about. I had to tell them. I had to understand their symptoms and I had to ask them what they actually wanted. I really want the caregivers to understand.

Active listening is a strategy that helps both community psychiatric nurses and primary caregivers to access concerns and needs while taking care of schizophrenic patients. Whatever the

BUILDING COLLABORATION IN CARING FOR PEOPLE WITH SCHIZOPHRENIA

information given by the nurse, the caregiver listens carefully to what they have to say. If s/he does not understand, s/he will ask questions and more information will be given. Similarly, when the primary caregiver gives information about a patient, the community nurse will pay attention to what the primary caregiver says by listening carefully to every detail. Mutual identification of concerns and needs is another strategy pursued by the nurses and primary caregivers as a means of understanding the priority concerns and needs of each other. As one community psychiatric nurse stated: When we know the concerns of the caregiver, I will ask what she thinks and whether she thinks it is an important problem at the time as well as what their caregiver or relative needs.

Primary caregivers learn to express their needs in order of priority. This is shown in the comment of a primary caregiver: I tell the nurse what I want. Right now, what I want most is to have our child take the medicine. He will not take any at the moment despite all our efforts. Sometimes we have arguments. I am afraid that he/she will run to others’ homes.

Mutual Preparation for Caregiving Mutual preparation for caregiving refers to activities engaged in by community psychiatric nurses and primary caregivers to prepare to help the person with schizophrenia. This step occurs once trust has been established and involves several strategies. These strategies will help primary caregivers and community psychiatric nurses to suitably plan for the caring of the schizophrenic patient. Establishing understanding and acceptance is one of the most important strategies leading to good planning. Community psychiatric nurses try to establish more understanding and acceptance of patients by their primary caregivers and themselves. Methods used to achieve this goal were found to include giving information about the current disease, especially regarding symptoms and behavior of schizophrenic patients, so that primary caregivers could better understand them. As one informant said: I give most information as a basis for primary caregivers to understand patients better and accept patients as they are. The information given to relatives includes that regarding the disease, lesions of the disease, significant changes in symptoms and the side effects of medicines. Some relatives do not understand and they may reprimand patients and get emotional with patients.

Promoting a good attitude towards patients is a strategy used to help schizophrenic patients. The research found that community psychiatric nurses promote good attitudes towards patients in primary caregivers, by consistently pointing out the abilities and potential of patients to primary caregivers. Promotion can also be accomplished by asking primary caregivers to recognize and acknowledge the healthy behavior of patients. For instance, most nurses tell primary caregivers or families of schizophrenic patients that ‘patients can continue with their daily routine,’

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‘patients can do small chores, please look at the positive side,’ or ‘the patient can help the family conduct business, and relatives can help him/her do that.’ Once primary caregivers have observed examples of positive behavior in patients, they are better able to have a supportive attitude towards them. At the same time, although psychiatric nurses already have a caring attitude towards their patients, when they consistently help and inform patients and their families, they develop an even more affirming attitude towards their patients. Promoting health is one aspect of the preparation for caregiving. This study found that most community psychiatric nurses consistently promoted the health of primary caregivers physically, mentally and socially. They did so in ways, such as giving advice on lifestyle, suggesting ways of relaxing, and arranging health-checks when health problems arose. One primary caregiver said: ‘I have become more relaxed. I phone the nurse whenever a problem arises. I am happy that the nurse does not neglect me and helps me.’ Another primary caregiver spoke about the help of a psychiatric nurse with regard to his health, saying ‘I am happy to have such a nice person helping me, arranging medicines for me, like for my hypertension. The nurse also brings some medicines for me along the way.’ Mutual planning for caregiving is another strategy that helps the caregiver and the nurse to achieve predetermined objectives. This method includes holding meetings between nurses and primary caregivers to determine ways of planning for the care of schizophrenic patients together; the utilization of every meeting between both parties to plan or think about the care of patients, especially when patients have psychotic symptoms, or when they refuse to take medicines according to the treatment plan, and planning for the promotion of health and rehabilitation of patients. As one nurse stated: We think together what kind of work the patient can do and what relatives can do to encourage the patient to work. This can be done through something like asking the patient to buy something or asking the patient to help selling noodles.

Cooperating in Patient Care Cooperation in the care of patients refers to the behaviors of community psychiatric nurses and primary caregivers that decreases psychotic symptoms and improves healthy living in patients. It is an important step that follows the preparation phase in the care of patients. It is realized through cooperation, such as helping to stay safe in acute phase; giving continuous home health care; coordinating with networks in the community; providing general help. Helping to stay safe in the acute phase means focusing on keeping schizophrenic patients safe at home, in communities and at hospital in emergencies and, in particular, when patients develop serious symptoms that primary caregivers cannot manage by themselves. Methods that most community psychiatric nurses use to help patients to be safe include providing help at patients’ homes immediately after receiving information

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from health teams. This leads to cooperation with the primary caregivers. It also allows both to intervene for the good of schizophrenic patients. This is demonstrated in the comment of a psychiatric community nurse: We, I mean I and primary caregiver, help the patient to be safe first with mental support and care for the patient to take their medicine. Also, we explain what we should do.

Most primary caregivers of schizophrenic patients were successful in cooperating in helping schizophrenic patients to be safe in emergency situations. This included preparing the house to make it safe, for instance, by keeping sharp appliances away from patients and keeping the person’s bedroom unlocked. As one primary caregiver said: The nurse asked me to prepare and asked if he had access to any knife or wooden bat. I looked into that to help the nurse. When the nurse came with the police, they helped inject the patient.

Giving continuous home health care is a strategy used to help the patient. It is achieved by having a good relationship with the patient, providing a reminder to patients to do daily activities, managing medication for patients, and helping them to avoid addictive substances. As one community psychiatric nurse said: I visit her house regularly and sometimes if a relative asks me to see the patient, I will go to see him at the house. I will consider whether there are problems in the house. I will see if the patient can take the medication and help the relative to encourage the patient to perform his routine by himself. Sometimes, it is better to talk and the patient will get better.

As for the patient’s work, community psychiatric nurses suggest that primary caregivers look for some work for patients. This can be either paid employment, household chores, or hobbies that can be done at home. Caregivers can help their family member, as well, by reminding them to go to appointments and to help to arrange for them to be in a supportive environment. Coordinating with a network in the community is a strategy to assist the person with schizophrenia in the community. The purpose of coordination with a network in the community is to create a caring network to help and support patients living in the community. As stated by one nurse: We coordinate with various other agencies whether Sub-district Administrative Organizations or schools. Schools may be able to look at one aspect while the Sub-district Administrative Organizations may be able to help in others. These are the types of information we need from the network, so that we can go in and take action to provide care and help patients and their families.

Providing general help for patients refers to doing things not already mentioned but which are relevant to helping people with schizophrenia patients and their families. This includes protecting the legitimate rights of patients. In this research, it was found that community psychiatric nurses and most primary caregivers protected patients’ rights by various means, such as applying for disability patent cards together with senior cards for patients over 60, attempting to help poor patients who have

not applied for disability patent cards to apply for them in order that they may have medical or treatment expenses exempted or reduced. As one psychiatric community nurse said: With regards to patients’ patent card, I did not know that he had not got the card. I helped him get it by coordinating with his relative. I and the caregiver worked together to get the card, which he now has.

Monitoring Outcomes Monitoring outcomes is an important function of community psychiatric nurses and primary caregivers of schizophrenic patients. In this research, it was found that most community psychiatric nurses and primary caregivers observed and monitored behavior and activities, or the work of schizophrenic patients continuously at home and in the community. Monitoring outcomes consists of three important strategies: understanding patient assessment; continued monitoring of caregiving outcomes; discussing the patient’s progress. The first important step in monitoring outcomes is the strategy of understanding patient assessment. Nurses do this by providing information or teaching caregivers how to observe mental symptoms and various types of patient behavior. These include patients’ thoughts, emotions, feelings, sleeping patterns, medication, eating patterns and engagement in activities and work. This step is a significant aspect that will help primary caregivers become more aware of and be sensitive towards their family member’s illness. Importantly, primary caregivers learn how to monitor symptoms, so that their observations can inform continuous care. In this study, it was found that primary caregivers cooperated in establishing an understanding of patient assessment by listening to what community psychiatric nurses taught and suggested and then used what was learned at home and in the community. This is shown in the following statements from some primary caregivers: ‘I listen to what the nurse says,’ ‘The nurse tells me to observe everything even whether the patient takes a shower, trims her nails, or which clothes are left unwashed.’ After community psychiatric nurses have educated primary caregivers about what symptoms to assess and monitor, further outcomes can then be jointly monitored. Continued monitoring of caregiving outcomes refers to the strategy of monitoring outcomes in schizophrenic patients after care is undertaken. In this research, it was found that both the nurses and primary caregivers monitored both positive and negative outcomes in patient care. Nurses monitored outcomes in two ways: through direct communication and telephone communication, in order to check on patients’ symptoms. Most primary caregivers cooperated in monitoring the care of their family member in such ways as by checking that medication was taken and by determining whether the patient was able to take medication on his/her own, as well as monitoring the sideeffects of the medication, monitoring expressive behavior, the patient’s emotions, and any work done by the patient. This kind of monitoring is demonstrated in the comment of one primary caregiver:

BUILDING COLLABORATION IN CARING FOR PEOPLE WITH SCHIZOPHRENIA

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Establishing trust

Community psychiatric nurses

Building collaboration in caring

Primary caregivers

Engaging concerns and needs

Mutual preparation for caregiving

Cooperating on patient care

Monitoring outcomes

FIGURE 1. Building collaboration in caring for people with schizophrenia.

I observe whether he is going to get mad again. I always keep an eye on him, on everything about him. If he develops something, I will phone the nurse. If he seems to have a headache, I will take him to see the nurse. We can help the patient immediately.

Discussing the patient’s progress is a strategy in the stage of monitoring care outcomes. Once community psychiatric nurses and primary caregivers have information from monitoring activities, both parties seek the opportunity to discuss patients’ symptoms and behavior to determine the nature of any change, whether it is for the better or worse. This information will also be used to plan and help patients in the future. As one respondent said: We talk about the condition of the patient after the medication is taken or after the injection. Some patients develop problems. Should this happen, I will go to visit them at their houses. The patient may say that he does not want to take this medicine because he became dizzy after taking it.

Building Collaboration as a Dynamic Process This research demonstrates that there is a process to building collaboration in caregiving between community psychiatric nurses and the primary caregivers of schizophrenic patients. The process consists of five steps: establishing trust was the first strategy that the community psychiatric nurses employed with the primary caregivers to make them feel comfortable and accept the nurse as trustworthy. Later, the strategies engaging concerns and needs, mutual preparation for caregiving, coop-

erating on patient care and monitoring outcomes were also employed both by community psychiatric nurses and primary caregivers. When necessary, they would return to the strategy of re-establishing trust and then return to the later strategies. The strategies of engaging concerns and needs, mutual preparation for caregiving, and cooperating on patient care, continued to be used by both professional and primary caregivers. The end goal of this process of building collaboration in caregiving is the person with schizophrenia successfully joining life in the family and community. Throughout this process, the community psychiatric nurse–primary caregiver relationship is not linear. The nurses and primary caregivers may return to the stages necessary to help people with schizophrenia integrate and cope. The concept of building collaboration in caregiving for people with schizophrenia that emerged in this study is presented in Figure 1. DISCUSSION The research results reflect the mutual relationship between community psychiatric nurses and primary caregivers in the form of building collaboration in caring for people with schizophrenia under conditions of trust. The trust felt by community psychiatric nurses and primary caregivers is a result of using the cordial greetings by both parties, regardless of meeting place. In particular, in rural Thai society, people are more informal and they pay attention to each other. They inquire as to how each other has been. There must be flexibility and empathy given problematic or difficult circumstances. The results of this study

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also coincide with previous research (Lindhardt, Hallberg, & Poulsen, 2008; Gladstone & Wexler, 2000; Donovan & Dupuis, 2000). This shows that a good relationship between health professionals and the primary caregivers of patients is important for caregivers to be satisfied with the care and attention given by health professionals, nurses, or other staff. Health personnel, thus, greet primary caregivers and patients cordially and politely. Primary caregivers and patients should also be polite to relatives of patients (Gladstone & Wexler, 2000; Donovan & Dupuis, 2000; Roberts, 2004). Moreover, health personnel should greet visiting relatives politely, know names of visiting primary caregivers, and be ready to help primary caregivers (Donovan & Dupuis, 2000; Friendemann et al., 1997). This step is also found to correspond with the first orientation phase of interpersonal relationship of Peplau (1991). This step aims to establish trust and reduce the feeling of strangeness between professionals and caregivers. The findings also revealed that community psychiatric nurses and primary caregivers realized and understood each other’s needs and concerns. They gave as much time as possible to each other in meetings to discuss and exchange information, especially concerns and needs regarding patient care. They also had to provide time to mutually determine what needs and concerns exist among community psychiatric nurses and primary caregivers. These strategies will make it possible for community psychiatric nurses and primary caregivers to share necessary information and to be able to decide together how to achieve greater understanding. This is a significant aspect that promotes the establishment of good relationships between people. It also corresponds with the findings of several other studies (Gladstone & Wexler, 2000; Friendemann et al., 1997; Peplau, 1991; Salin, Kaunonen, & Astedt-Kurki, 2013). These studies have also found that a relationship between health professionals and primary caregivers has certain benefits, including nurses’ access to information about problems and the needs of patients and families that is necessary to efficiently plan care for the patients. Primary caregivers can provide important information about the symptoms and behavior of patients (Donovan & Dupuis, 2000). Primary caregivers will understand and be sympathetic with the health team, as well as having a good attitude when good relations exist between the two. They will be able to see that good patient care comes from a good relationship between them and health professionals. Most importantly, primary caregivers will realize that they can cope with complicated problems appropriately (Friendemann et al., 1997). Engagement in a mutual relationship is a significant component of ethical healthcare practice. In a study of healthcare ethics, Bergum and Dossetor (2005) found that engagement is an attempt of one party to access the thoughts, feelings, problems, and needs of the other by paying attention, trying to contact, and discuss issues, with the aim of providing mutual assistance or giving opinions. In this way, both parties learn of events and their impact on each other as well as realizing how to solve

problems together, leading to mutual respect in the execution of their duties. Mutual preparation for caregiving is a step discovered in the mutual relationship between community psychiatric nurses and primary caregivers of schizophrenic patients in the community. This discovery clearly shows that community psychiatric nurses and primary caregivers prepare the care program for schizophrenic patients together, that is, if both parties have come to understand the individual patient and his/her illness. Moreover, this may bring about more positive attitudes towards people with schizophrenia. This finding is consistent with the third stage of the relationship between healthcare staff and families of patients, which is that staff and patients’ families attain greater mutual understanding and acceptance and can together set a plan to care for the patients (Conn, 2003; Kertchok et al., 2011). Also important in the preparation is the health promotion of the primary caregivers. Most primary caregivers suffer from physical and mental health problems themselves, for instance, stress, headaches, and depression. These health problems add a further burden to the diseases that primary caregivers may already suffer from and affect, also, the outcome of the care of ill family members. Hence, community psychiatric nurses have to come in and help primary caregivers to be physically and mentally prepared before, during, and throughout the period of care of their family member with schizophrenia. This leads to a better quality of life for primary caregivers, which corresponds to the research of Chan and O’Brien (2011), in which it is clearly shown that primary caregivers of psychotic patients have to be encouraged to maintain a good quality of life. Moreover, community psychiatric nurses and primary caregivers have prepared by planning together for the care and assistance given to schizophrenic patients, to recover their physical, mental health and social integration. As a result, patients may be able to work at home or engage in other appropriate work to earn income, rather than simply living alone and isolated. Cooperating on patient care is a strategy in the process of collaboration in caring for people with schizophrenia. This step comes about when community psychiatric nurses and primary caregivers want to help schizophrenic patients and their families to remain safe from other illnesses that may occur. Patients and their families should have the supporting resources for their own health maintenance, and should be able to access health service centers when needed, as well as to be able to live in the community happily. This finding harmonizes with the third stage of interpersonal relationship of Peplau, referred to as the exploitation phase. This stage focuses on using competency or the resources of each person in problem-solving (Peplau, 1991). Similarly, the study by Macleod et al. (2011), which systematically analyzed various studies, found that most community psychiatric nurses support primary caregivers of schizophrenic patients by providing knowledge and understanding of schizophrenia, treatment methods, stress management, prevention of hazards that

BUILDING COLLABORATION IN CARING FOR PEOPLE WITH SCHIZOPHRENIA

may occur, as well as providing other general help for groups using various programs, such as the Mutual Support Group, Education Family Group, Crisis Intervention, and the Daycare Rehabilitation Program. With all strategies, the process of collaboration between community psychiatric nurses and primary caregivers establishes shared knowledge to help assess symptoms, thoughts, emotions, and the behavior of patients, monitor outcomes of the care and use the information received to discuss the patients’ progress. The collaboration can occur in-person directly or through communication over the telephone. This step facilitates the assessment of the care of schizophrenic patients, determines whether patients are improving or deteriorating, and considers various obstacles, while looking for new solutions. This outcome corresponds to the studies by Astedt-Kurki et al. (2001) and Raingruber (2003), which found that community psychiatric nurses discuss what happens in the care of mental patients, such as when patients have a reoccurrence of symptoms, or primary caregivers assess patients’ symptoms and find them to have improved, as well as changes in the treatment of patients. However, in this research, the step of monitoring outcomes mainly concerns community psychiatric nurses and primary caregivers trying to establish a knowledge and understanding of the care given and to determine further courses of action. IMPLICATIONS AND RECOMMENDATIONS Community psychiatric nurses may use the process of building collaboration in caring for schizophrenic patients as a conceptual framework in working with primary caregivers. This framework aims to provide comprehensive care of schizophrenic patients and respond to the needs of schizophrenic patients and their families. The framework will allow families, especially primary caregivers, to manage mental illnesses, as well as facilitate schizophrenic patients to live happily with their families in the community. Moreover, nurse educators may arrange for workshops that will encourage students to practice and work with primary caregivers of schizophrenic patients in the community, using the form of relationship fostered according to the outcomes of this research. Further quasi-experimental research is recommended to study the outcomes of the processes found in this research on ‘wellbeing’ or ‘relapse’ and other relevant variables. The development of an efficient system for helping families of schizophrenic patients to use this ‘process of collaboration’ in caring for schizophrenic patients is recommended. The process of collaboration in caring between community psychiatric nurses and primary caregivers of people with schizophrenia who live in the central part and other parts, such as the south of Thailand, where there is cultural diversity, is also recommended. Limitation of the Study The findings are limited by the fact that the research was performed by exploring community psychiatric nurses and primary caregivers of people with schizophrenia who live in the central

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part of Thailand. The result might not represent other regions in Thailand or other countries.

CONCLUSION The findings of this research show that the process of building collaboration in caring is a crucial guideline in working with families of people with schizophrenia in order to foster care of the patients and enable them to live in the community. Building collaboration in caring is a basic social process that is developed by exploring the community psychiatric nurses and primary caregivers’ perspectives upon the collaborative process. This process includes establishing trust, engaging concerns and needs, mutual preparation for care, providing general assistance to patients, and monitoring outcomes. Psychiatric nurses who work with families in the community can apply this process to help people with schizophrenia and their families.

ACKNOWLEDGEMENTS This research was completed with the assistance of some very special people. The author is especially grateful to the community psychiatric nurses and primary caregivers who participated in this study. The research was partially funded by the Asia Research Center, Chulalongkorn University. I also wish to acknowledge to Professor Dr. Wendy Austin, Faculty of Nursing, University of Alberta, Canada for giving suggestions to prepare this article. Declaration of Interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.

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