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Self-care actions of chronic schizophrenics associated with meeting solitude and social interaction requisites
Self-Care Actions of Chronic Schizophrenics Associated With Meeting Solitude and Social Interaction Requisites James L. Harris
Solitude becomes a way of iife and social interaction a scarce commodity for many chronic schizophrenics who are in institutional settings. This article describes the self-care actions associated with meeting soiitude and social interaction requisites as reported by 10 institutionaiized chronic schizophrenics. Eighteen solitude self-care actions and 10 social interaction self-care actions emerged from the interview data. The solitude self-care actions clustered around two distinct categories: distancing and organizing. The social interaction seifcare actions clustered around one category, managing situations. The implications of this study extend to anyone who is in the position of providing care and support to an indiiduai diagnosed as a chronic schizophrenic. Additional research is suggested to increase the generaiizabiiity of the findings of this study and to isolate conditions related to Orem’s (1985) sets of actions for maintenance of a balance between soiitude and social interaction. 0 1990 bg W.B. Saunders Company.
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HRONIC MENTAL illness represents a significant problem for the health care system in the United States. The number of Americans estimated to be seriously mentally ill increased from 1.5 million in 1985 to 2.4 million in 1987, with predictions of a continued increase (Aiken, 1987). The increase is primarily due to larger cohorts of 18-to-44 year olds, the age group with the highest prevalence of chronic schizophrenia (Aiken, 1987; Wright, 1986). Although socioeconomic changes, policy changes, and public interest during the past 2 decades mandated reallocation of mental health treatment services from inpatient to community settings, inpatient treatment settings remain the major source of care for individuals diagnosed with chronic schizophrenia (Mechanic,
From Rush-Presbyterian-St Luke’s Medical Center, Chicago, lllinois. Address reprint requests to James L. Harris, D.S.N., R.N., C.S., 830 S. Leavitt St, #B, Chicago, IL 60612. 0 1990 by W.B. Saunders Company. 08s9417l90l0405-0003 $3.00/O
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1986). Observers attribute this continued high use of institutional care to the inability of chronic schizophrenics to maintain a balance between soiitude and social interaction (Aiken, 1987; Bachrach, 1988; Talbott, 1981). Solitude becomes a way of life and social interaction a scarce commodity for many chronic schizophrenics located in institutional settings (Manderino & Bzdek, 1987). Orem (1985) suggested that maintenance of a baiante between solitude and social interaction is essential both to the development of enduring social relationships and to continued development and adjustment in society. Psychiatric-mental health nursing is continually faced with the challenge of directing energy toward management of chronic psychiatric patients. Involvement of chronic schizophrenics in self-care emphasizes the individual’s initiation and performance of actions necessary to maintain a balance between solitude and social interaction and enhancement of well-being (Orem, 1985). Eliciting reports of self-care actions of chronic schizophrenics associated with meeting solitude and social in-
Archives of Psychiatric Nwsing, Vol. IV, No. 5 (October), 1990: pp. 298-307
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teraction is an initial step that must be taken as a basis for implementing measures to promote a desired balance. The challenge becomes one not only for nursing, but for other health-related disciplines as well. PURPOSE
The purpose of this study was to construct a unified description of self-care actions of chronic schizophrenics located in an inpatient treatment setting and specifically, to answer the following question: What self-care actions do chronic schizophrenics located in an inpatient treatment setting associate with meeting solitude and social interaction requisites? Definitions Self-care actions. Activities of chronic schizophrenics located in an inpatient treatment setting that are associated with meeting solitude and social interaction requisites. Chronic schizophrenics. Individuals, 18 to 44 years of age, who have been diagnosed with chronic schizophrenia according to the Diagnostic and statistical manual III, revised ([DSM III-R] American Psychiatric Association, 1987) and who are recipients of psychiatric treatment in an inpatient treatment unit. Solitude requisites. Requirements for purposive actions for reducing the number of social stimuli and reducing the demands for social interaction. Social interaction requisites. Requirements for purposive actions for the interchange of ideas, socialization, and the achievement of human potential. Inpatient treatment setting. A hospital-based treatment center that is located in the southeastern United States and funded as a state mental hospital. BACKGROUND
Orem’s (1985) theory of self-care provided the framework to describe the self-care actions of chronic schizophrenics associated with meeting solitude and social interaction self-care requisites, Self-care is the performance of actions for oneself that assists in the prevention of illness, the maintenance of health, or the recovery from illness
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(Orem, 1985). Further, self-care characterizes the actual proliferation of behaviors that regulate one’s functioning and well-being (Orem). Integral to self-care are self-care requisites. Orem (1985) defined self-care requisites as the purposes that are attained by individuals when they engage in self-care actions. Central to the purposes attained by individuals who engage in self-care actions is maintenance of a balance between solitude and social interaction. Both solitude and social interaction are required for normal human development (Orem, 1985). Loneliness, excessive social stimuli, noisy and crowded environments, and problems in forming and maintaining interpersonal relationships signal the need for action to meet the requisite for balancing solitude and social interaction. Individuals diagnosed with chronic schizophrenia experience problems in balancing solitude and social interaction (Wilson & Kneisel, 1988). Underwood (1980) advocated integration of self-care concepts in inpatient treatment settings as a way to promote chronic schizophrenic’s control over daily living, thus facilitating maintenance of a balance between solitude and social interaction. Findings reported in the nursing and mental health literature identified various treatment approaches and individual actions that promote the maintenance of solitude and social interaction. O’Sullivan and Brody (1986) noted that small group supportive therapy promotes actions for meeting solitude and social interaction needs among chronic schizophrenics located in inpatient treatment settings. Munich, Carsky, and Applebaum (1985) reported that the use of small group discussion provides opportunities for chronic schizophrenics to engage in activities that promote social relations. Further, Buckwalter and Kerfoot (1982) found that patients located in inpatient psychiatric units attained the skills necessary to balance solitude and social interaction needs through social skills training classes. Opportunities for coaching schizophrenics to balance solitude and social interaction requisites are numerous. Reviews of empirical studies showed that a wide range of skills for balancing solitude and social interaction can be learned by chronic schizophrenics; however, follow-up studies showed the inability of chronic schizophrenics to use the skills consistently in maintaining a balance between solitude and social interaction
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(Liberman et al., 1984; Wallace & Liberman, 1985; Wallace et al., 1980). Kuipers, Berkowitz, Ederlein-Friers, and Leff (1983) advocated consistent reinforcement of self-care actions associated with meeting solitude and social interaction requisites. Research by Serban (1975) evidenced a high correlation between the inability of chronic schizophrenics to balance solitude and social interaction behaviors and the incidence of rehospitalization. The primary contributing factor was the lack of opportunities to develop skills necessary for enduring social relationships and autonomy while hospitalized . Other studies have focused on behavioral symptoms among chronic schizophrenics as predictors of self-care actions necessary for meeting solitude and social interaction requisites (Carpenter, Bartko, & Strauss, 1986; Hertz & Melville, 1980). Carpenter et al. (1986) reported that chronic schizophrenics monitor symptoms of decompensation and engage in self-care actions to maintain health and well-being. The findings are similar to those of Hertz and Merville (1980) who reported that chronic schizophrenics located in inpatient and community settings monitor symptoms and engage in self-care actions necessary for meeting solitude and social interaction requisites. Results of investigations by Andorfer, Skimkunas, and Sciarini (1975) and Livesay (1981) suggested that chronic schizophrenics may be less consistent and less convinced of the accuracy of their interpersonal judgments than nonpsychiatric clients. Therefore, chronic schizophrenics are often reluctant to engage in social interaction with others (Cutting, 1981; Muzekari & Bates, 1977; Walker, Mar-wit, & Emory, 1980). Since solitude becomes a way of life and social interaction a scarce commodity for many chronic schizophrenics, eliciting reports of self-care actions associated with chronic schizophrenics meeting solitude and social interaction requisites is justified. Obtaining information from various patient populations partially fulfills recommendations from Orem (1979) and the Nursing Development Conference Group to derive knowledge about human functioning from a variety of sources. METHODOLOGY
Qualitative research methodologies, as used in this study, often have been selected as the research
strategy of choice when investigating and subsequently describing a given event or action at a particular time (Miles & Huberman, 1984). Characteristic of this approach is the process associated with the participant’s report of the event or action. Therefore, the “research and interview questions are framed to reflect the nature of [humans] and the connectedness of [humans] with the environment” (Parse, Coyne, & Smith, 1985, p. 91). Data are analyzed inductively, and themes emerge as the data are grouped and categorized. It was the emphasis on constructing a unified description of phenomenon that made a qualitative approach the most appropriate choice of methodology for this study. Sample
Ten persons who were diagnosed with chronic schizophrenia who could read, write, speak, and understand English and who received mental health services in a 30-bed unit of a state funded mental health inpatient facility in the southeastern United States agreed to participate in the study. Participants ranged in age from 18 to 43 (M = 28). There were six women and four men. Four participants were black; six were white. Each participant’s current hospitalization had exceeded 1 year (M = 2). The sample size was consistent with recommendations by Glasser and Strauss (1967) and Wilson (1977) that 10 to 12 participants are sufficient to identify and describe phenomenon. Moreover, the participant’s age was consistent with findings from the literature that indicate the highest prevalence for chronic schizophrenia is among individuals 18 to 44 years (Aiken, 1987). Method and Materials
An interview guide was constructed by the researcher after communication with D.E. Orem (personal communication, July 26, 1988) and used to collected data during semi-structured, audiotaped interviews. The interview guide was tested and refined in a pilot study (Harris, 1988). The interview guide consisted of two parts: (1) an introductory statement related to maintenance of a balance between solitude and social interaction, and (2) open-ended items for eliciting reports of self-care actions associated with meeting solitude and social interaction requisites from the partici-
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pants. The introductory statement and open-ended items are listed below: People do things every day in order to live and be healthy. Some of the things people do to live and be healthy is balancing activities such as: limiting the stimuli from people around them and spending some time away from others as well as spending time talking and being around others and doing things that they are able to do to meet personal goals. Think about a time during the last week that you limited the stimuli around you and spent time away from others. Tell me what you did to be able to limit the stimuli around you and to be able to spend time away from others. Think about a time during the last week that you were able to spend time talking and being with other people to help you accomplish something you wanted to accomplish. Tell me what you did to be able to spend time talking and being with other people so that you could accomplish what you wanted to accomplish. If more detailed response was required: You mentioned (use participant’s words); tell me more about that.
Procedures for Data Collection
Study participants were deemed not to be at risk, and approvals were granted by the appropriate institutional review boards to conduct the study. Each study participant was independently provided an overview of the purpose of the study, audiotaping procedures, confidentiality, and the option to withdraw from the study at any time during data collection. Further, an interview date and time was scheduled with each participant at his or her convenience, and interviews were conducted in a designated interview room. All interviews were tape recorded. Conduct of the interviews averaged 35 minutes and included the following sequence: reading and signing the informed consent, reading the introductory statement related to maintenance of solitude and social interaction of the participants, and asking the participant to report self-care actions associated with meeting solitude and social interaction requisites. Demographic data obtained to describe the sample were collected from the participants’ medical records at completion of the interview Procedure for Data Analysis The approach used in analyzing data from the audiotaped interviews was modeled after Turner (1981). Turner used seven steps to handle descriptive data. For the purposes of this study, Turner’s stages were adapted to form the following steps:
(1) transcribing the interviews upon completion of data collection; (2) reviewing the transcriptions, paragraph by paragraph, and asking the question, “What words and themes best describe the reported self-care actions of the study participants associated with meeting solitude and social interaction requisites?“; (3) entering the words and themes on an index card with a notation to indicate in which interview the words and themes were found; and (4) sorting and grouping the index cards and corresponding words and themes to establish a list of solitude self-care actions and a list of social interaction self-care actions. In order to establish interrater reliability, two certified psychiatric-mental health nurses familiar with Orem’s (1985) self-care theory reviewed a subset of 20% of the verbatim data transcriptions, the words and themes, and the solitude and social interaction self-care actions. The criterion for determining interrater reliability was whether the psychiatric-mental health nurses agreed with the researcher’s data transcriptions and the words, themes, and the solitude and social interaction selfcare actions. A rating of .92 was obtained by the researcher and was recognized as a valid measure of interrater reliability (Waltz, Strickland, & Lenz, 1984). FINDINGS
findings are presented in relation to the research questions, “What self-care actions do chronic schizophrenics located in an inpatient treatment setting associate with meeting solitude and social interaction requisites?” The solitude self-care actions are presented fmt, followed by the social interaction self-care actions. The
Solitude Self-Care Actions
Eighteen solitude self-care actions emerged from the interview data. The solitude self-care actions are presented in Table 1. Eight participants reported that following rules reduces social stimuli and the demands for social stimuli. As one participant stated, “I arrange it so I follow the rules and that cuts back on the social contacts with others and all the stuff they are putting out. Then I am in a world alone for a while.” Structuring self was reported by nine of the participants. According to one participant, “I set out to guide and organize my routine here to fit in. That way I can dilute the number of times I have to
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Table 1. Solitude S&f-Care Actions 1. Following rules
11. Reading
2. Structuring self
12. Completing a
3. Looking away
household chore
4. Sleeping
13. Waiting
5. Daydreaming
14. Silence
6. Hiding
15. Using available
7. Walking away 6. Watching lV alone 9. Drawing and painting pictures 10. Listening to the radio with headphones
resources 16. Avoiding situations and people
requisites. As one participant stated: “I get under my bed; it is safe and is quiet and lets me remove myself. There I do not have to talk with anyone because they cannot see me or even know where I am.” Another participant stated: I have been hiding for a long time. That gives me a lot of quiet time alone and space from people and all the demands to talk and do things I do not want to do. It is all the social pressure to move ahead that I hide from.
17. Positioning self 16. Sitting alone
talk with other people.” The description is representative of the participants’ statements that described ways for limiting social stimuli and interaction with others by ordering personal actions. Six participants reported looking away. As one participant stated: I do not have to look at all that is going on around me. I know how to fuc it to look away and that tells people that I am not interested in carrying on with them at that time. I really just want my space.
This action is descriptive of behaviors aimed at decreasing the number of social stimuli and reducing the demands for social interactions at a particular time. All 10 participants reported sleeping as a solitude self-care action. The participants’ reports were reflective of an independent activity that reduced social stimuli and demands for social interaction. As one participant stated: I get so tired of all the things I have to do here that I search for ways to remove myself from all the noise and demands to talk and be part of so much. I find that when I sleep, that is the key. Sleep helps me escape from demands and gives me distance from all that happens now in my life. Daydreaming was another solitude self-care action that was reported by nine of the participants. The reports described ways to reduce stimuli and interaction demands in order to experience solitude. According to one participant: removal from people, their talking and sharing, by just imagining myself floating on a big blue cloud high in the sky and being happy, with no need to be with others, cutting out all that I do not have to deal with and the demands here and everywhere to talk, share, and be around people. It is my way to distance. Lying in bed I get
Hiding also was reported by six of the participants as an action necessary for meeting solitude
Walking away was reported by nine of the participants. Walking away affords the participants with opportunities to limit stimuli associated with conflict; it also reduces demands for social interaction where one’s individuality and rights may be disregarded as evidenced by the participant statement: “I walk away from people that cause me extra conflict. If not, I may hurt them and not be thinking of their personhood. ” Watching TV alone was reported by seven of the participants as an action necessary for reducing social stimuli and interaction with others. As one participant stated: I watch TV alone and it is a way to focus on one thing without all the stuff that is happening around me and having to talk and deal with others. It is a time for me so I can get my distance.
Drawing and painting pictures was descriptive of another way of meeting solitude requisites as evidenced by reports from four of the participants. As one participant stated, “I draw and paint pictures so I can cut down on them telling me what to do and having to respond back and be totally involved.” Listening to the radio with headphones was used by seven of the participants to meet solitude requisites. According to one of the participants: I put on the headphones, turn on the radio, and that shows folks that I am doing something alone. What is so funny about it all is that I can learn about things around me from the radio, just listening, without having to talk with others.
Reading was another action associated with meeting solitude self-care requisites as evidenced by statements from five participants. As one participant stated, “Reading keeps me from having to talk and be socially involved. I can get by myself, get space, and keep up with the outside world without having to ask others about it. ” Completing a household chore was reported by four participants as another action associated with
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meeting solitude self-care requisites. According to one participant: Finishing a household chore here on the unit is one of the things that cuts back on the number of times I have to talk with others. It gives me a breather from all those I have to talk with daily.
Nine of the 10 participants identified waiting as another self-care action associated with meeting solitude requisites. According to one participant: I fix it to wait without jumping into things. That way the energy around me is cut back and I do not have to just jump in and talk when it may mean nothing. I can wait to see if I have to talk.
This action supports that waiting reduces social stimuli and demands in the form of self expectations for social interaction. Silence was another solitude self-care action as reported by nine participants. As one participant stated: By being quiet, I can lower tension that is on me at a particular time and not have to say a word. But I have to fix it to be that way, like going and getting in an empty room alone.
It was evident from participants’ statements that silence reduced social stimuli and demands for social interaction at a particular time. Silence, in combination with a quiet environment, facilitated the meeting of solitude requisites. Eight participants reported using available resources as a self-care action associated with meeting solitude requisites. One participant stated, “I fix it so that I can use the quiet room. It gives me time away from the chaos and I do not have to talk.” The report, similar to the other seven reports, validated that using available resources, such as a quiet room, reduces social stimuli and limits social interaction in order to meet solitude requisites. Avoiding situations and people was reported by all 10 participants as an action associated with meeting solitude requisites. As one participant stated:
ple purposefully reduced the number of negative social stimuli and interactions with individuals that presented as a threat; thus, solitude requisites were met. Positioning self and sitting alone were two other closely related actions that facilitated seven participants in meeting solitude requisites. According to one participant: I get so I can turn my back from commotion in a place and then I can sit alone and not have to talk with others. Also, when I do not know people, I fix it so that I can sit alone and do not talk. I just avoid them.
Both actions reduced social stimuli and demands for social interaction. Social Interaction Self-Care Actions Ten social interaction self-care requisites emerged during content analysis of the interview data. The social interaction self-care actions are presented in Table 2. Three participants reported that joking assisted in meeting social interaction requisites. Participants’ statements included: Joking helps me arrange myself to handle a situation and people. It breaks down the wall so I can share and ask others about their ideas. I can get more comfortable with them. It is important to talk with others and share ideas and listen to their ideas cause that is part of life and moving on to achieve leaving the hospital.
Statements from the three participants revealed that the demands for interchange of ideas and socialization are met by joking with others. Further, it is apparent from the statements that achievement of human potential is facilitated by using humor as a vehicle to communicate both socially and personally. Participating in groups was another social interaction reported by all 10 participants. As one participant stated: I find that attending and adding to the groups are setting it up so I can manage things and be a part of something I like Table 2. Social Interaction Self-Cam Actions
I organize it to avoid people, but I start by weaning off from them. I found it best to avoid people that are negative because I do not need to get all caught up in a bunch of nerves and badness.
1. Joking
6. Seeking and attempting
2. Participating in groups 3. Using available resources
7. Trusting others
to maintain relationships 6. Talking sensibly
It was evident from this report and reports from other participants that avoiding situations and peo-
4. Considering others 5. Conforming to norms
9. Acting normally 10. Structuring self
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and get my needs met to contribute here and learn how for the future. It is good to get others’ ideas, and a group seems to be that place right now.
As evidenced in the previous reply, participating in groups affords chronic schizophrenics opportunities for interchange of ideas, socialization, and the achievement of human potential; consequently, social interaction requisites are met. Using available resources also was reported by seven of the participants as a self-care action associated with meeting social interaction requisites. As one participant stated: I go to the group activities because there I can share my ideas, be with people and talk, learn things about myself, and learn what to do to move toward my goal of getting better and leaving here. I know that, like myself, other patients here use the nurses to try out how to talk with other folks. I do not think they know we use them like that. It helps in a way to try out things, share ideas, and end up doing what I am capable of doing.
The statements were reflective of an action associated with interchange of ideas, socialization, and achievement of personal goals and human potential that resulted in meeting social interaction requisites. Considering others was another action that was instrumental in eight participants meeting social interaction requisites. According to one participant: I find that if I consider others before myself, it makes it a lot easier to talk with them and in the same note gets my ideas across. I look at that as succeeding with my ability to be a good person that considers others.
Conforming to norms was reported by nine of the participants as a self-care action associated with meeting social interaction requisites. As one participant stated. I answer what is asked of me and follow the expectations. I find that that is the way to being able to grow and be able to talk with others and share my thoughts. You just have to follow all hints of advice and go along then with what is set up in places to do the right thing. Otherwise, life can be hard and there may not be a chance to share ideas and get what you want and deserve.
As evident in this statement, conforming to norms provided opportunities for socializing, exchanging ideas with others, and achieving a degree of one’s potential. Seeking and attempting to maintain relation-
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ships was reported by all 10 participants as a selfcare action associated with meeting social interaction requisites. Participants’ statements outlined ways for interchange of ideas, socialization, and achievement of human potential as evidenced by the following report: Important in life is to be able to meet the need to have someone to be with and share dreams. This is managing for now and later. You manage to sham ideas and dreams, get their ideas, and start getting close with them cause we all want to achieve having someone and keeping them.
Trusting others also was a self-care action associated with meeting social interaction requisites as noted by reports of six participants. As one participant stated, “When I trust someone, I can manage it so that I can share more with them and after a while get real close to them and have that relation be the kind that goes on.” Talking sensibly and acting normally also were actions that nine of the participants associated with meeting social interaction requisites. According to one participant: I have a handicap, schizophrenia, but that does not mean that if I work around it and try that I cannot talk in a sensible manner so that people can understand me and that I can manage it so I can act in a normal way as to lit in any place and have a lasting relationship with my girl and my buddies and make it so they can get close with me.
The preceding descriptive report outlined two actions necessary for the interchange of ideas, namely, socialization and achievement of human potential. Structuring self was another action reported by seven of the participants that was associated with meeting social interaction requisites. According to one participant: Structure is a big piece of the pie. It helps keep me on track and be able to talk with others and share my ideas and be close with them. But it is me that has to set up the structure.
Structuring self and the preceding descriptions of self-care actions associated with meeting social interaction requisites are consistent with the definition of social interaction requisites of this study. DISCUSSION
The findings of this study lend support to the assertion that both solitude and social interaction are required for human development and adjust-
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ment in society (Orem, 1985). Furthermore, the findings of this study support Underwood’s (1980) suggestion that self-care concepts be integrated in inpatient psychiatric treatment settings as a way to promote chronic schizophrenic’s control over daily living, thus facilitating maintenance of a balance between solitude and social interaction. Although this study is limited to a specific setting and sample, the finding that more solitude self-care actions are reported than social interaction self-care actions support that solitude is a way of life for many chronic schizophrenics in institutional settings and that chronic schizophrenics are often reluctant to engage in social interaction with others (Cutting, 1981; Manderino & Bzdek, 1987; Muzekari & Bates, 1977; Walker et al., 1980). In contrast, one could conclude that group living in an inpatient setting and lack of control over the environment could be directly related to the reporting of more solitude self-care actions than social interaction self-care actions. A myriad of empirical studies reported in the literature shows that chronic schizophrenics can learn the skills necessary for meeting solitude and social interaction requisites. Data from this study validate these findings of the earlier studies. The solitude self-care actions were consistent with skills necessary for distancing self from others and organizational skills that reduced the number of social stimuli and demands for social interaction. The social interaction self-care actions identified in this study also captured the variation among study participants’ skills necessary for managing situations that facilitate interchange of ideas, socialization, and achievement of human potential. Moreover, the findings of this study revealed that chronic schizophrenics located in inpatient treatment settings possess the skills for simultaneously engaging in more than one self-care action associated with meeting solitude and social interaction requisites. Hertz and Merville (1980) suggested that chronic schizophrenics monitor symptoms and engage in self-care actions necessary for meeting solitude and social interaction requisites, and O’Sullivan and Brody (1986) suggested that smallgroup supportive therapy promotes actions for meeting solitude and social interaction requisites among chronic schizophrenics in inpatient settings. Findings of this study suggest that it is within a structured milieu that individuals who are
diagnosed with chronic schizophrenia develop, master, and receive feedback on self-care actions associated with meeting solitude and social interaction requisites. IMPLICATIONS OF FINDINGS
The implications of the study extend across disciplines, and professional boundaries and involve anyone who is in the position of providing care and support to individuals diagnosed as chronic schizophrenic. Because of the limited generalizability of the findings, only tentative nursing implications are presented according to the categories of nursing practice, education, and research. Nursing Practice The findings expand areas of knowledge critical to the understanding of the self-care actions chronic schizophrenics associate with meeting solitude and social interaction requisites. The potential seems great for communication of this knowledge to nurses in each of the nursing practice specialty areas. More specifically, the availability of this knowledge to psychiatric nurses could underpin the creative development and structure of interventions that reinforce self-care actions by chronic schizophrenics that are associated with balancing solitude and social interaction. Nursing Education
Nurses must be prepared to facilitate movement of chronic schizophrenics toward maintenance of a balance between solitude and social interaction. Therefore, an educational emphasis that coaches novice students to recognize self-care actions chronic schizophrenic clients associate with meeting solitude and social interaction requisites is an essential part of basic nursing education. In particular, students should be helped to explore the meaning of the self-care actions associated with maintenance of a balance between solitude and social interaction. Analysis of intervention strategies that reinforce the maintenance of a balance between solitude and social interaction among chronic schizophrenic clients also should be encouraged by students and nursing peers. Moreover, the dangers and fallacies involved in stereotyping the chronic schizophrenic client as one who withdraws from others and seldom interacts with others should be explained and discussed.
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international pilot study of schizophrenia. American Journal of Psychiatry, 135, 940-944.
This study represents an initial attempt at describing the self-care actions chronic schizophrenics associate with meeting solitude and social interaction requisites. Additional research is needed to verify the findings of this study. Furthermore, a study should be attempted to examine if chronic schizophrenic clients living in community settings report similar or different self-care actions associated with meeting solitude and social interaction requisites. Also, conduct of research is needed to identify nursing interventions that reinforce chronic schizophrenics’ maintenance of a balance between solitude and social interaction and the efficacy of the interventions as reflected in established client outcome criteria. SUMMARY AND RECOMMENDATIONS
In summary, Orem’s (1985) theory of self-care and a qualitative approach proved useful in shaping and directing the study. Data emerged that were both interesting and useful for clinical practice and additional inquiry. Replication of the present study is suggested to increase the generalizability of the findings. Further, additional research is suggested to isolate conditions that are related to Orem’s (1985) sets of actions for maintenance of a balance between solitude and social interaction. Conduct of research by nurses will contribute to the extension of Orem’s work and assist in directing energies toward management of individuals diagnosed with chronic schizophrenia. REFERENCES Aiken, L. (1987). Unmet needs of the chronically mentally ill: Will nursing respond? Imuge, 19(3), 121-125. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders, (3rd ed., rev.). Washington, DC: Author. Andorfer, J., Shimkunas, A.M., & Sciarini, J.W. (1975). Neutralization of affective components in schizophrenia. Journal of Abnormal Psychology, 84, 772-775.
Bachrach, L.L. (1988). Defining chronic mental illness: A concept paper. Hospital and Community Psychiatry, 39,(4), 383-388.
Buckwalter, K.C., & Kerfoot, K.M. (1982). Teaching patients self-care: A critical aspect of psychiatric discharge planning. Journal of Psychosocial Nursing and Mental Health Services, 20, 15-20.
Carpenter, W., Bar&o, .I., & Strauss, J. (1986). Signs and symptoms as predictors of outcome: A report from the
Cutting, J. (1981). Judgement and emotional expressions in schizophrenia. British Journal of Psychiatry, 139, l-6. Glasser, B., & Strauss, A. (1967). The discovery of grounded theory: Strategiesfor qualitative research. Chicago, IL: Aldine. Harris, J.L. (1988). Solitude and social interaction self-care actions of chronic schizophrenics: A pilot study. Unpublished manuscript. Hertz, M.I., & Melville, C. (1980). Relapse in schizophrenia. American Journal of Psychiatry, 137. 801-805.
Kuipers, L., Berkowitz, R., Eberlein-Friers, R., & Leff, J. (1983). Chronic schizophrenia. Schizophrenia, 54, 139143. Liberman, R.P., Lillie, F., Falloon, I.R.H., Harpin, R.E., Hutchinson, W., & Stoute, T.M. (1984). Social skills training for relapsing schizophrenics: An experimental analysis. Behavior Modifications, 8, 155-179. Livesay, J.R. (1981). Inconsistent interpersonal judgement in thought-disordered schizophrenia. Psychological Bulletin, 49, 179-182.
Manderino, M.A., & Bzdek, V.M. (1987). Social skills building with chronic patients. Journal of Psychosocial Nursing and Mental Health Services, 25, 18-23.
Mechanic, D. (1986). The challenge of chronic mental illness. A retrospective and prospective view. Hospital and CommuniQ Psychiatry, 37(9), 891-896.
Miles, M.B., & Huberman, A.M. (1984). Qualitative data analysis. Beverly Hills, CA: Sage. Munich, R.L., Carsky, M., & Applebaum, A. (1985). The role and structure of long-term hospitalization: Chronic schizophrenia. The Psychiatric Hospital, 16, 161-169. Muzekari, L.H., &Bates, M.E. (1977). Judgement of emotion among chronic schizophrenics. Journal of Clinical Psychology, 33, 662-666. Orem, D.E. (1985). Nursing concepts of practice (3rd ed.).
New York, NY: McGraw-Hill. Orem, D.E. (Ed.) (1979). Concept formulation in nursing: Process and product (2nd ed.). Boston, MA: Little, Brown. O’Sullivan, A., & Brody, M. (1986, February). Discharge planning for the mentally disabled. Quality Review Bulletin, 55-67.
Parse, R.R., Coyne, A.B., & Smith, M.J. (1985). Nursing research. Qualitative methods. Bowie, MD: Brady. Serban, G. (1975). Functioning ability in schizophrenic and normal subjects: Short-term predictions of rehospitalization of schizophrenics. Comprehensive Psychiatry, 16, 447-456.
Talbott, J.A. (1981). The chronic mentally ill. Treatment, programs, systems. New York, NY: Human Science Press. Turner, B.A. (1981). Some practical aspects of qualitative data analysis: One way of organizing the cognitive processes associated with the generation of grounded theory. Qualitative and Quality, 15, 225-247.
Underwood, P. (1980). Facilitating self-care. In P. Pothier (Ed.), Psychiatric Nursing. Boston, MA: Little, Brown. Walker, E., Marwit, S.J., & Emory, E. (1980). A cross-
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sectional study of emotion recognition in schizophrenics. Journal of Abnormal Psychology, 89, 428-436. Wallace, C.J., & Liberman, R.P. (1985). Social skills training for patients with schizophrenia: A controlled clinical trail. Psychiatry Research, 15, 239-247. Wallace, C.J., Nelson, C., Liberman, R.P., Ferris, C., Lukoff, D., & Falloon, I.R.H. (1980). A review and critique of social skills training with chronic schizophrenics. Schizophrenia Bulletin, 6, 42-22.
Waltz, C.H., Strickland, O.L., & Lenz, E.R. (1984). Mea-
surement in nursing research. Philadelphia, PA: Davis. Wilson, H.A. (1977). Limiting intrusion-social control of outsiders in a healing community. Nursing Research, 26, 103-111. Wilson, H.S., & Kneisl, C.R. (1988). Psychiatric nursing (3rd ed.). Menlo Park, CA: Addison-Wesley. Wright, J. (1986). Unpublished statistics on the health care from the homeless program. Amherst, MA: Social and Demographic Research Institute, University of Massa-
chusetts
Solitude becomes a way of iife and social interaction a scarce commodity for many chronic schizophrenics who are in institutional settings. This article describes the self-care actions associated with meeting soiitude and social interaction requisites as reported by 10 institutionaiized chronic schizophrenics. Eighteen solitude self-care actions and 10 social interaction self-care actions emerged from the interview data. The solitude self-care actions clustered around two distinct categories: distancing and organizing. The social interaction seifcare actions clustered around one category, managing situations. The implications of this study extend to anyone who is in the position of providing care and support to an indiiduai diagnosed as a chronic schizophrenic. Additional research is suggested to increase the generaiizabiiity of the findings of this study and to isolate conditions related to Orem’s (1985) sets of actions for maintenance of a balance between soiitude and social interaction. 0 1990 bg W.B. Saunders Company.
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HRONIC MENTAL illness represents a significant problem for the health care system in the United States. The number of Americans estimated to be seriously mentally ill increased from 1.5 million in 1985 to 2.4 million in 1987, with predictions of a continued increase (Aiken, 1987). The increase is primarily due to larger cohorts of 18-to-44 year olds, the age group with the highest prevalence of chronic schizophrenia (Aiken, 1987; Wright, 1986). Although socioeconomic changes, policy changes, and public interest during the past 2 decades mandated reallocation of mental health treatment services from inpatient to community settings, inpatient treatment settings remain the major source of care for individuals diagnosed with chronic schizophrenia (Mechanic,
From Rush-Presbyterian-St Luke’s Medical Center, Chicago, lllinois. Address reprint requests to James L. Harris, D.S.N., R.N., C.S., 830 S. Leavitt St, #B, Chicago, IL 60612. 0 1990 by W.B. Saunders Company. 08s9417l90l0405-0003 $3.00/O
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1986). Observers attribute this continued high use of institutional care to the inability of chronic schizophrenics to maintain a balance between soiitude and social interaction (Aiken, 1987; Bachrach, 1988; Talbott, 1981). Solitude becomes a way of life and social interaction a scarce commodity for many chronic schizophrenics located in institutional settings (Manderino & Bzdek, 1987). Orem (1985) suggested that maintenance of a baiante between solitude and social interaction is essential both to the development of enduring social relationships and to continued development and adjustment in society. Psychiatric-mental health nursing is continually faced with the challenge of directing energy toward management of chronic psychiatric patients. Involvement of chronic schizophrenics in self-care emphasizes the individual’s initiation and performance of actions necessary to maintain a balance between solitude and social interaction and enhancement of well-being (Orem, 1985). Eliciting reports of self-care actions of chronic schizophrenics associated with meeting solitude and social in-
Archives of Psychiatric Nwsing, Vol. IV, No. 5 (October), 1990: pp. 298-307
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teraction is an initial step that must be taken as a basis for implementing measures to promote a desired balance. The challenge becomes one not only for nursing, but for other health-related disciplines as well. PURPOSE
The purpose of this study was to construct a unified description of self-care actions of chronic schizophrenics located in an inpatient treatment setting and specifically, to answer the following question: What self-care actions do chronic schizophrenics located in an inpatient treatment setting associate with meeting solitude and social interaction requisites? Definitions Self-care actions. Activities of chronic schizophrenics located in an inpatient treatment setting that are associated with meeting solitude and social interaction requisites. Chronic schizophrenics. Individuals, 18 to 44 years of age, who have been diagnosed with chronic schizophrenia according to the Diagnostic and statistical manual III, revised ([DSM III-R] American Psychiatric Association, 1987) and who are recipients of psychiatric treatment in an inpatient treatment unit. Solitude requisites. Requirements for purposive actions for reducing the number of social stimuli and reducing the demands for social interaction. Social interaction requisites. Requirements for purposive actions for the interchange of ideas, socialization, and the achievement of human potential. Inpatient treatment setting. A hospital-based treatment center that is located in the southeastern United States and funded as a state mental hospital. BACKGROUND
Orem’s (1985) theory of self-care provided the framework to describe the self-care actions of chronic schizophrenics associated with meeting solitude and social interaction self-care requisites, Self-care is the performance of actions for oneself that assists in the prevention of illness, the maintenance of health, or the recovery from illness
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(Orem, 1985). Further, self-care characterizes the actual proliferation of behaviors that regulate one’s functioning and well-being (Orem). Integral to self-care are self-care requisites. Orem (1985) defined self-care requisites as the purposes that are attained by individuals when they engage in self-care actions. Central to the purposes attained by individuals who engage in self-care actions is maintenance of a balance between solitude and social interaction. Both solitude and social interaction are required for normal human development (Orem, 1985). Loneliness, excessive social stimuli, noisy and crowded environments, and problems in forming and maintaining interpersonal relationships signal the need for action to meet the requisite for balancing solitude and social interaction. Individuals diagnosed with chronic schizophrenia experience problems in balancing solitude and social interaction (Wilson & Kneisel, 1988). Underwood (1980) advocated integration of self-care concepts in inpatient treatment settings as a way to promote chronic schizophrenic’s control over daily living, thus facilitating maintenance of a balance between solitude and social interaction. Findings reported in the nursing and mental health literature identified various treatment approaches and individual actions that promote the maintenance of solitude and social interaction. O’Sullivan and Brody (1986) noted that small group supportive therapy promotes actions for meeting solitude and social interaction needs among chronic schizophrenics located in inpatient treatment settings. Munich, Carsky, and Applebaum (1985) reported that the use of small group discussion provides opportunities for chronic schizophrenics to engage in activities that promote social relations. Further, Buckwalter and Kerfoot (1982) found that patients located in inpatient psychiatric units attained the skills necessary to balance solitude and social interaction needs through social skills training classes. Opportunities for coaching schizophrenics to balance solitude and social interaction requisites are numerous. Reviews of empirical studies showed that a wide range of skills for balancing solitude and social interaction can be learned by chronic schizophrenics; however, follow-up studies showed the inability of chronic schizophrenics to use the skills consistently in maintaining a balance between solitude and social interaction
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(Liberman et al., 1984; Wallace & Liberman, 1985; Wallace et al., 1980). Kuipers, Berkowitz, Ederlein-Friers, and Leff (1983) advocated consistent reinforcement of self-care actions associated with meeting solitude and social interaction requisites. Research by Serban (1975) evidenced a high correlation between the inability of chronic schizophrenics to balance solitude and social interaction behaviors and the incidence of rehospitalization. The primary contributing factor was the lack of opportunities to develop skills necessary for enduring social relationships and autonomy while hospitalized . Other studies have focused on behavioral symptoms among chronic schizophrenics as predictors of self-care actions necessary for meeting solitude and social interaction requisites (Carpenter, Bartko, & Strauss, 1986; Hertz & Melville, 1980). Carpenter et al. (1986) reported that chronic schizophrenics monitor symptoms of decompensation and engage in self-care actions to maintain health and well-being. The findings are similar to those of Hertz and Merville (1980) who reported that chronic schizophrenics located in inpatient and community settings monitor symptoms and engage in self-care actions necessary for meeting solitude and social interaction requisites. Results of investigations by Andorfer, Skimkunas, and Sciarini (1975) and Livesay (1981) suggested that chronic schizophrenics may be less consistent and less convinced of the accuracy of their interpersonal judgments than nonpsychiatric clients. Therefore, chronic schizophrenics are often reluctant to engage in social interaction with others (Cutting, 1981; Muzekari & Bates, 1977; Walker, Mar-wit, & Emory, 1980). Since solitude becomes a way of life and social interaction a scarce commodity for many chronic schizophrenics, eliciting reports of self-care actions associated with chronic schizophrenics meeting solitude and social interaction requisites is justified. Obtaining information from various patient populations partially fulfills recommendations from Orem (1979) and the Nursing Development Conference Group to derive knowledge about human functioning from a variety of sources. METHODOLOGY
Qualitative research methodologies, as used in this study, often have been selected as the research
strategy of choice when investigating and subsequently describing a given event or action at a particular time (Miles & Huberman, 1984). Characteristic of this approach is the process associated with the participant’s report of the event or action. Therefore, the “research and interview questions are framed to reflect the nature of [humans] and the connectedness of [humans] with the environment” (Parse, Coyne, & Smith, 1985, p. 91). Data are analyzed inductively, and themes emerge as the data are grouped and categorized. It was the emphasis on constructing a unified description of phenomenon that made a qualitative approach the most appropriate choice of methodology for this study. Sample
Ten persons who were diagnosed with chronic schizophrenia who could read, write, speak, and understand English and who received mental health services in a 30-bed unit of a state funded mental health inpatient facility in the southeastern United States agreed to participate in the study. Participants ranged in age from 18 to 43 (M = 28). There were six women and four men. Four participants were black; six were white. Each participant’s current hospitalization had exceeded 1 year (M = 2). The sample size was consistent with recommendations by Glasser and Strauss (1967) and Wilson (1977) that 10 to 12 participants are sufficient to identify and describe phenomenon. Moreover, the participant’s age was consistent with findings from the literature that indicate the highest prevalence for chronic schizophrenia is among individuals 18 to 44 years (Aiken, 1987). Method and Materials
An interview guide was constructed by the researcher after communication with D.E. Orem (personal communication, July 26, 1988) and used to collected data during semi-structured, audiotaped interviews. The interview guide was tested and refined in a pilot study (Harris, 1988). The interview guide consisted of two parts: (1) an introductory statement related to maintenance of a balance between solitude and social interaction, and (2) open-ended items for eliciting reports of self-care actions associated with meeting solitude and social interaction requisites from the partici-
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pants. The introductory statement and open-ended items are listed below: People do things every day in order to live and be healthy. Some of the things people do to live and be healthy is balancing activities such as: limiting the stimuli from people around them and spending some time away from others as well as spending time talking and being around others and doing things that they are able to do to meet personal goals. Think about a time during the last week that you limited the stimuli around you and spent time away from others. Tell me what you did to be able to limit the stimuli around you and to be able to spend time away from others. Think about a time during the last week that you were able to spend time talking and being with other people to help you accomplish something you wanted to accomplish. Tell me what you did to be able to spend time talking and being with other people so that you could accomplish what you wanted to accomplish. If more detailed response was required: You mentioned (use participant’s words); tell me more about that.
Procedures for Data Collection
Study participants were deemed not to be at risk, and approvals were granted by the appropriate institutional review boards to conduct the study. Each study participant was independently provided an overview of the purpose of the study, audiotaping procedures, confidentiality, and the option to withdraw from the study at any time during data collection. Further, an interview date and time was scheduled with each participant at his or her convenience, and interviews were conducted in a designated interview room. All interviews were tape recorded. Conduct of the interviews averaged 35 minutes and included the following sequence: reading and signing the informed consent, reading the introductory statement related to maintenance of solitude and social interaction of the participants, and asking the participant to report self-care actions associated with meeting solitude and social interaction requisites. Demographic data obtained to describe the sample were collected from the participants’ medical records at completion of the interview Procedure for Data Analysis The approach used in analyzing data from the audiotaped interviews was modeled after Turner (1981). Turner used seven steps to handle descriptive data. For the purposes of this study, Turner’s stages were adapted to form the following steps:
(1) transcribing the interviews upon completion of data collection; (2) reviewing the transcriptions, paragraph by paragraph, and asking the question, “What words and themes best describe the reported self-care actions of the study participants associated with meeting solitude and social interaction requisites?“; (3) entering the words and themes on an index card with a notation to indicate in which interview the words and themes were found; and (4) sorting and grouping the index cards and corresponding words and themes to establish a list of solitude self-care actions and a list of social interaction self-care actions. In order to establish interrater reliability, two certified psychiatric-mental health nurses familiar with Orem’s (1985) self-care theory reviewed a subset of 20% of the verbatim data transcriptions, the words and themes, and the solitude and social interaction self-care actions. The criterion for determining interrater reliability was whether the psychiatric-mental health nurses agreed with the researcher’s data transcriptions and the words, themes, and the solitude and social interaction selfcare actions. A rating of .92 was obtained by the researcher and was recognized as a valid measure of interrater reliability (Waltz, Strickland, & Lenz, 1984). FINDINGS
findings are presented in relation to the research questions, “What self-care actions do chronic schizophrenics located in an inpatient treatment setting associate with meeting solitude and social interaction requisites?” The solitude self-care actions are presented fmt, followed by the social interaction self-care actions. The
Solitude Self-Care Actions
Eighteen solitude self-care actions emerged from the interview data. The solitude self-care actions are presented in Table 1. Eight participants reported that following rules reduces social stimuli and the demands for social stimuli. As one participant stated, “I arrange it so I follow the rules and that cuts back on the social contacts with others and all the stuff they are putting out. Then I am in a world alone for a while.” Structuring self was reported by nine of the participants. According to one participant, “I set out to guide and organize my routine here to fit in. That way I can dilute the number of times I have to
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Table 1. Solitude S&f-Care Actions 1. Following rules
11. Reading
2. Structuring self
12. Completing a
3. Looking away
household chore
4. Sleeping
13. Waiting
5. Daydreaming
14. Silence
6. Hiding
15. Using available
7. Walking away 6. Watching lV alone 9. Drawing and painting pictures 10. Listening to the radio with headphones
resources 16. Avoiding situations and people
requisites. As one participant stated: “I get under my bed; it is safe and is quiet and lets me remove myself. There I do not have to talk with anyone because they cannot see me or even know where I am.” Another participant stated: I have been hiding for a long time. That gives me a lot of quiet time alone and space from people and all the demands to talk and do things I do not want to do. It is all the social pressure to move ahead that I hide from.
17. Positioning self 16. Sitting alone
talk with other people.” The description is representative of the participants’ statements that described ways for limiting social stimuli and interaction with others by ordering personal actions. Six participants reported looking away. As one participant stated: I do not have to look at all that is going on around me. I know how to fuc it to look away and that tells people that I am not interested in carrying on with them at that time. I really just want my space.
This action is descriptive of behaviors aimed at decreasing the number of social stimuli and reducing the demands for social interactions at a particular time. All 10 participants reported sleeping as a solitude self-care action. The participants’ reports were reflective of an independent activity that reduced social stimuli and demands for social interaction. As one participant stated: I get so tired of all the things I have to do here that I search for ways to remove myself from all the noise and demands to talk and be part of so much. I find that when I sleep, that is the key. Sleep helps me escape from demands and gives me distance from all that happens now in my life. Daydreaming was another solitude self-care action that was reported by nine of the participants. The reports described ways to reduce stimuli and interaction demands in order to experience solitude. According to one participant: removal from people, their talking and sharing, by just imagining myself floating on a big blue cloud high in the sky and being happy, with no need to be with others, cutting out all that I do not have to deal with and the demands here and everywhere to talk, share, and be around people. It is my way to distance. Lying in bed I get
Hiding also was reported by six of the participants as an action necessary for meeting solitude
Walking away was reported by nine of the participants. Walking away affords the participants with opportunities to limit stimuli associated with conflict; it also reduces demands for social interaction where one’s individuality and rights may be disregarded as evidenced by the participant statement: “I walk away from people that cause me extra conflict. If not, I may hurt them and not be thinking of their personhood. ” Watching TV alone was reported by seven of the participants as an action necessary for reducing social stimuli and interaction with others. As one participant stated: I watch TV alone and it is a way to focus on one thing without all the stuff that is happening around me and having to talk and deal with others. It is a time for me so I can get my distance.
Drawing and painting pictures was descriptive of another way of meeting solitude requisites as evidenced by reports from four of the participants. As one participant stated, “I draw and paint pictures so I can cut down on them telling me what to do and having to respond back and be totally involved.” Listening to the radio with headphones was used by seven of the participants to meet solitude requisites. According to one of the participants: I put on the headphones, turn on the radio, and that shows folks that I am doing something alone. What is so funny about it all is that I can learn about things around me from the radio, just listening, without having to talk with others.
Reading was another action associated with meeting solitude self-care requisites as evidenced by statements from five participants. As one participant stated, “Reading keeps me from having to talk and be socially involved. I can get by myself, get space, and keep up with the outside world without having to ask others about it. ” Completing a household chore was reported by four participants as another action associated with
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meeting solitude self-care requisites. According to one participant: Finishing a household chore here on the unit is one of the things that cuts back on the number of times I have to talk with others. It gives me a breather from all those I have to talk with daily.
Nine of the 10 participants identified waiting as another self-care action associated with meeting solitude requisites. According to one participant: I fix it to wait without jumping into things. That way the energy around me is cut back and I do not have to just jump in and talk when it may mean nothing. I can wait to see if I have to talk.
This action supports that waiting reduces social stimuli and demands in the form of self expectations for social interaction. Silence was another solitude self-care action as reported by nine participants. As one participant stated: By being quiet, I can lower tension that is on me at a particular time and not have to say a word. But I have to fix it to be that way, like going and getting in an empty room alone.
It was evident from participants’ statements that silence reduced social stimuli and demands for social interaction at a particular time. Silence, in combination with a quiet environment, facilitated the meeting of solitude requisites. Eight participants reported using available resources as a self-care action associated with meeting solitude requisites. One participant stated, “I fix it so that I can use the quiet room. It gives me time away from the chaos and I do not have to talk.” The report, similar to the other seven reports, validated that using available resources, such as a quiet room, reduces social stimuli and limits social interaction in order to meet solitude requisites. Avoiding situations and people was reported by all 10 participants as an action associated with meeting solitude requisites. As one participant stated:
ple purposefully reduced the number of negative social stimuli and interactions with individuals that presented as a threat; thus, solitude requisites were met. Positioning self and sitting alone were two other closely related actions that facilitated seven participants in meeting solitude requisites. According to one participant: I get so I can turn my back from commotion in a place and then I can sit alone and not have to talk with others. Also, when I do not know people, I fix it so that I can sit alone and do not talk. I just avoid them.
Both actions reduced social stimuli and demands for social interaction. Social Interaction Self-Care Actions Ten social interaction self-care requisites emerged during content analysis of the interview data. The social interaction self-care actions are presented in Table 2. Three participants reported that joking assisted in meeting social interaction requisites. Participants’ statements included: Joking helps me arrange myself to handle a situation and people. It breaks down the wall so I can share and ask others about their ideas. I can get more comfortable with them. It is important to talk with others and share ideas and listen to their ideas cause that is part of life and moving on to achieve leaving the hospital.
Statements from the three participants revealed that the demands for interchange of ideas and socialization are met by joking with others. Further, it is apparent from the statements that achievement of human potential is facilitated by using humor as a vehicle to communicate both socially and personally. Participating in groups was another social interaction reported by all 10 participants. As one participant stated: I find that attending and adding to the groups are setting it up so I can manage things and be a part of something I like Table 2. Social Interaction Self-Cam Actions
I organize it to avoid people, but I start by weaning off from them. I found it best to avoid people that are negative because I do not need to get all caught up in a bunch of nerves and badness.
1. Joking
6. Seeking and attempting
2. Participating in groups 3. Using available resources
7. Trusting others
to maintain relationships 6. Talking sensibly
It was evident from this report and reports from other participants that avoiding situations and peo-
4. Considering others 5. Conforming to norms
9. Acting normally 10. Structuring self
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and get my needs met to contribute here and learn how for the future. It is good to get others’ ideas, and a group seems to be that place right now.
As evidenced in the previous reply, participating in groups affords chronic schizophrenics opportunities for interchange of ideas, socialization, and the achievement of human potential; consequently, social interaction requisites are met. Using available resources also was reported by seven of the participants as a self-care action associated with meeting social interaction requisites. As one participant stated: I go to the group activities because there I can share my ideas, be with people and talk, learn things about myself, and learn what to do to move toward my goal of getting better and leaving here. I know that, like myself, other patients here use the nurses to try out how to talk with other folks. I do not think they know we use them like that. It helps in a way to try out things, share ideas, and end up doing what I am capable of doing.
The statements were reflective of an action associated with interchange of ideas, socialization, and achievement of personal goals and human potential that resulted in meeting social interaction requisites. Considering others was another action that was instrumental in eight participants meeting social interaction requisites. According to one participant: I find that if I consider others before myself, it makes it a lot easier to talk with them and in the same note gets my ideas across. I look at that as succeeding with my ability to be a good person that considers others.
Conforming to norms was reported by nine of the participants as a self-care action associated with meeting social interaction requisites. As one participant stated. I answer what is asked of me and follow the expectations. I find that that is the way to being able to grow and be able to talk with others and share my thoughts. You just have to follow all hints of advice and go along then with what is set up in places to do the right thing. Otherwise, life can be hard and there may not be a chance to share ideas and get what you want and deserve.
As evident in this statement, conforming to norms provided opportunities for socializing, exchanging ideas with others, and achieving a degree of one’s potential. Seeking and attempting to maintain relation-
L. HARRIS
ships was reported by all 10 participants as a selfcare action associated with meeting social interaction requisites. Participants’ statements outlined ways for interchange of ideas, socialization, and achievement of human potential as evidenced by the following report: Important in life is to be able to meet the need to have someone to be with and share dreams. This is managing for now and later. You manage to sham ideas and dreams, get their ideas, and start getting close with them cause we all want to achieve having someone and keeping them.
Trusting others also was a self-care action associated with meeting social interaction requisites as noted by reports of six participants. As one participant stated, “When I trust someone, I can manage it so that I can share more with them and after a while get real close to them and have that relation be the kind that goes on.” Talking sensibly and acting normally also were actions that nine of the participants associated with meeting social interaction requisites. According to one participant: I have a handicap, schizophrenia, but that does not mean that if I work around it and try that I cannot talk in a sensible manner so that people can understand me and that I can manage it so I can act in a normal way as to lit in any place and have a lasting relationship with my girl and my buddies and make it so they can get close with me.
The preceding descriptive report outlined two actions necessary for the interchange of ideas, namely, socialization and achievement of human potential. Structuring self was another action reported by seven of the participants that was associated with meeting social interaction requisites. According to one participant: Structure is a big piece of the pie. It helps keep me on track and be able to talk with others and share my ideas and be close with them. But it is me that has to set up the structure.
Structuring self and the preceding descriptions of self-care actions associated with meeting social interaction requisites are consistent with the definition of social interaction requisites of this study. DISCUSSION
The findings of this study lend support to the assertion that both solitude and social interaction are required for human development and adjust-
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ment in society (Orem, 1985). Furthermore, the findings of this study support Underwood’s (1980) suggestion that self-care concepts be integrated in inpatient psychiatric treatment settings as a way to promote chronic schizophrenic’s control over daily living, thus facilitating maintenance of a balance between solitude and social interaction. Although this study is limited to a specific setting and sample, the finding that more solitude self-care actions are reported than social interaction self-care actions support that solitude is a way of life for many chronic schizophrenics in institutional settings and that chronic schizophrenics are often reluctant to engage in social interaction with others (Cutting, 1981; Manderino & Bzdek, 1987; Muzekari & Bates, 1977; Walker et al., 1980). In contrast, one could conclude that group living in an inpatient setting and lack of control over the environment could be directly related to the reporting of more solitude self-care actions than social interaction self-care actions. A myriad of empirical studies reported in the literature shows that chronic schizophrenics can learn the skills necessary for meeting solitude and social interaction requisites. Data from this study validate these findings of the earlier studies. The solitude self-care actions were consistent with skills necessary for distancing self from others and organizational skills that reduced the number of social stimuli and demands for social interaction. The social interaction self-care actions identified in this study also captured the variation among study participants’ skills necessary for managing situations that facilitate interchange of ideas, socialization, and achievement of human potential. Moreover, the findings of this study revealed that chronic schizophrenics located in inpatient treatment settings possess the skills for simultaneously engaging in more than one self-care action associated with meeting solitude and social interaction requisites. Hertz and Merville (1980) suggested that chronic schizophrenics monitor symptoms and engage in self-care actions necessary for meeting solitude and social interaction requisites, and O’Sullivan and Brody (1986) suggested that smallgroup supportive therapy promotes actions for meeting solitude and social interaction requisites among chronic schizophrenics in inpatient settings. Findings of this study suggest that it is within a structured milieu that individuals who are
diagnosed with chronic schizophrenia develop, master, and receive feedback on self-care actions associated with meeting solitude and social interaction requisites. IMPLICATIONS OF FINDINGS
The implications of the study extend across disciplines, and professional boundaries and involve anyone who is in the position of providing care and support to individuals diagnosed as chronic schizophrenic. Because of the limited generalizability of the findings, only tentative nursing implications are presented according to the categories of nursing practice, education, and research. Nursing Practice The findings expand areas of knowledge critical to the understanding of the self-care actions chronic schizophrenics associate with meeting solitude and social interaction requisites. The potential seems great for communication of this knowledge to nurses in each of the nursing practice specialty areas. More specifically, the availability of this knowledge to psychiatric nurses could underpin the creative development and structure of interventions that reinforce self-care actions by chronic schizophrenics that are associated with balancing solitude and social interaction. Nursing Education
Nurses must be prepared to facilitate movement of chronic schizophrenics toward maintenance of a balance between solitude and social interaction. Therefore, an educational emphasis that coaches novice students to recognize self-care actions chronic schizophrenic clients associate with meeting solitude and social interaction requisites is an essential part of basic nursing education. In particular, students should be helped to explore the meaning of the self-care actions associated with maintenance of a balance between solitude and social interaction. Analysis of intervention strategies that reinforce the maintenance of a balance between solitude and social interaction among chronic schizophrenic clients also should be encouraged by students and nursing peers. Moreover, the dangers and fallacies involved in stereotyping the chronic schizophrenic client as one who withdraws from others and seldom interacts with others should be explained and discussed.
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international pilot study of schizophrenia. American Journal of Psychiatry, 135, 940-944.
This study represents an initial attempt at describing the self-care actions chronic schizophrenics associate with meeting solitude and social interaction requisites. Additional research is needed to verify the findings of this study. Furthermore, a study should be attempted to examine if chronic schizophrenic clients living in community settings report similar or different self-care actions associated with meeting solitude and social interaction requisites. Also, conduct of research is needed to identify nursing interventions that reinforce chronic schizophrenics’ maintenance of a balance between solitude and social interaction and the efficacy of the interventions as reflected in established client outcome criteria. SUMMARY AND RECOMMENDATIONS
In summary, Orem’s (1985) theory of self-care and a qualitative approach proved useful in shaping and directing the study. Data emerged that were both interesting and useful for clinical practice and additional inquiry. Replication of the present study is suggested to increase the generalizability of the findings. Further, additional research is suggested to isolate conditions that are related to Orem’s (1985) sets of actions for maintenance of a balance between solitude and social interaction. Conduct of research by nurses will contribute to the extension of Orem’s work and assist in directing energies toward management of individuals diagnosed with chronic schizophrenia. REFERENCES Aiken, L. (1987). Unmet needs of the chronically mentally ill: Will nursing respond? Imuge, 19(3), 121-125. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders, (3rd ed., rev.). Washington, DC: Author. Andorfer, J., Shimkunas, A.M., & Sciarini, J.W. (1975). Neutralization of affective components in schizophrenia. Journal of Abnormal Psychology, 84, 772-775.
Bachrach, L.L. (1988). Defining chronic mental illness: A concept paper. Hospital and Community Psychiatry, 39,(4), 383-388.
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