Enhancing Care in Mental Health Practice

CHAPTER ONE

INTRODUCTION

The practice improvement is regarded as an essential part in the job activities of any healthcare practitioner (Janes and Mullan, 2007). In healthcare, practice improvement is regarded as a systematic approach which uses certain techniques for delivering and measuring sustained quality improvements (The health foundation, 2010). Bosanac and Castle, (2015) and Achim et al., (2009) informs that anxiety is increasingly prevalent throughout each phases of schizophrenia but its clinical significance often remains unidentified. Thus, for people who are suffering from anxiety disorders or schizophrenia presence of adequate data is required for supporting specific treatment need to resolve the mental issue such as anxiety faced in this nature of disease (Bosanac and Castle, 2015; Norman and Ryrie, 2013; Kiran, and Chaudhury, 2016). The psychological treatment like Cognitive Behaviour Therapy (CBT) is found to be effective if properly targeted and primary data informs that progressive muscle relaxation and mindfulness based intervention approaches may be are beneficial in nature (Mackenzie and Kocovski, 2016). National Institutes of Clinical Excellence (NICE), (2014) recommend pharmacological and psychological intervention to treatment for anxiety in schizophrenia. However, evidence suggest that most often pharmacological interventions are widely use with limited psychological intervention (Amato et al., 2011);(Dennis and Dowswell, 2013);(Bushby et al., 2010). Patient often became dependant on these medications and find it difficult to come off it which often delay recovery (Guerlaise et al., 2015) ;(Voyer et al., 2010). The evidence gathered informs that mindfulness based intervention (MBI) are at an increasing gaining support in the form of adjunctive treatments for different nature of mental health condition such as depression, anxiety and others (Khoury et al., 2013a; Samson and Mallindine, 2014). Mackenzie and Kocovski, (2016), added that, psychological treatments such as cognitive behavioural therapy (CBT) appear effective if targeted carefully, and preliminary data suggest that mindfulness base intervention approaches and progressive muscle relaxation may be beneficial. Evidence suggest that, mindfulness base intervention (MBI) are gaining empirical support adjunctive treatments for variety of mental health conditions, including anxiety, depression and others (Khoury et al., 2013a; Samson and Mallindine, 2014). Research highlights that, MBI reduces rehospitalizations rates on acute-inpatients hospital for the minimization of national cost and enhances clinical improvement (Tabak and Granholm, 2014; Shawyer et al, 2012; Chadwick et al., 2009).

The Pharmacological interventions are required to be related according to the nature of specific health condition and need of the schizophrenia patients with anxiety (Medalia et al, 2018). In this regard, it is seen that there is an increasing evidence that are reflecting the detailed neurobiology of schizophrenia along with concurrent anxiety disorders with the hope that they would be able to improve the options of treatment which can be available by the patients. This PIP will therefore explore the use of mindfulness Base Intervention (MBI) to reduce the intake of benzodiazepines in an acute inpatient ward in schizophrenic patient experiencing anxiety. The project will be presented in form of a dissertation and will consist of the following parts: title, introduction/ rationale, background information, the expected improvement, research methods to be used, ethical issues, data analysis and presentation of results, dissemination of the results, recommendations, time frame, references and appendices.

CHAPTER TWO BACKKGROND

Introduction

This chapter will explore schizophrenia anxiety in schizophrenia in a wider contest through a discussion of its prevalence; reason for chosen of focusing on anxiety, common presentation problems, aetiology and theory of causations. It will also look at treatment recommended and policies. It will also look at the integration of mindfulness based interventions in the daily routine practice of a mental health nurse working within an inpatient mental health unit.

Concept of Anxiety in Schizophrenia

Anxiety is referred to the feeling of unease such as fear or worry that may be severe or mild at time. The symptoms of anxiety can be split into two component that is physical and emotional component. Anxiety can affect any part of the body physically and the most common ones are sweating, shaking, feeling the heart pound, feeling difficult to breath, muscle pain, headache, feeling tension and many others. The emotional symptoms are often feelings of impending dooms, lost of control, a fear of going to do something inappropriate. (Steel et al. 2017). The schizophrenia patients are often seen to frequently face anxiety may be due to medication effect, underlying organic condition or any symptom that is resulting to co-occur anxiety disorder (Gastambide et al. 2015). This is evident from the study of Temmingh and Stein (2015) where it is mentioned that anxiety symptoms occur in 65% of the schizophrenia patients and is able to reach the threshold for being diagnosed with different comorbid anxiety disorder such as post-traumatic stress disorder and obsessive-compulsive disorder. The study also informed that anxiety of the schizophrenic patients leads them to have internalising symptoms regarding their health compared to externalising symptoms. The anxiety in schizophrenia is often associated to increase suicidality, depression, cognitive impairment and utilisation of medical service among the patients (Temmingh and Stein, 2015). This nature of hyperemotional status is experienced by the schizophrenic patients in anxiety because they increase to mistrust their person responses provided to the world and develop the feeling that their body may give way at any time. Thus, it positions the schizophrenia patients to lose control over self-making them be psychologically vulnerable to cause harm to themselves and show hyper emotions (Gallagher and Trigg, 2016). Schizophrenia is one of the common mental health disorders and it is regarded as one of the most disabling illness in the field of psychiatry (WHO, 2018; Norman and Ryrie, 2013). In global context, Schizophrenia is considered among the top most common health disorder (Ganguly, 2018). Ryrie (2013) and NIMH (2014) assert that schizophrenia is considered as a chronic, disabling disorder and complex illness that affect one percent of national population. This disabling disease has impact not only on has negative impact on the health and well-being of the patient bust also on the surrounding environment and social factors (Ganguly, 2018; Ryrie, 2013). According to American Psychiatric Association (APA) schizophrenia is characterized by episodes where patients have distorted thoughts or loss of reality which is able to negatively affect their social life (Keefe and Harvey 2010). Various researches shows that the course of the mental illness results individuals to face frequent hospital admission that makes them incapable to properly manage social life (Awad and Voruganti, 2008; Ganguly, Soliman, and Moustafa, 2018). The factors influencing the conditions diverges from each individual with the conditions, yet, common among them include psychological stressors, misuse of recreational substances such as cannabis, genetic factors including with affected relatives and environmental factors such as early childhood trauma (Cunning and Peters, 2014; Van Os, 2009). This means that the development of the condition can be influence by both genetic and environmental factors. These assertions agrees with researchers who point out that genetic factors are involved in the aetiology of schizophrenia (Siris and Braga, 2013; Hall et al. 2015; Birnbaum, and Weinberger, 2017). Instead of various methodological difficulties, all the independent studies indicate in a common direction that individuals with presence of schizophrenia in the genes of the parents are likely to suffer more from the disease compared to others (Dempter et al., 2011);(Ettinger et al., 2010). Additionally, there is 10% chance of a child developing the illness if one of the parents suffers from schizophrenia (Dempter et al., 2011). “The Family, twin and adoption studies have suggested that genetics play a major role in the transmission of schizophrenia”

A twin study was conducted by Irwing Gottesman and the study complied by over 40 studies to identify the risk of schizophrenia development in individuals with different family relationship with the person who is suffering from schizophrenia. It was identified that an offspring with both the parents having schizophrenia and a monozygotic co-twin of a schizophrenic individual has increased risk of developing the disease. It was apparent that people are more likely to develop schizophrenia who shares most genes from the previous generation (Mistry et al., 2018). Although, environmental factor is regarded to have influence on developing schizophrenia but the studies related to adoption indicates rise of schizophrenia is due to genetic theory (Suh et al., 2019).

Reason of focusing on anxiety in Schizophrenia

Anxiety is frequently observed among individual who are suffering from schizophrenia (Baylé et al, 2011). The study by Hall (2017) informs that in the prodormal phase of schizophrenia as well as in preceding phases of psychotic relapses affective symptoms and anxiety is key features of the disease. Although, few studies has indicate the risk of rise of the symptom is related to use of anti-psychotic medication but greater number of studies indicates that the genetic risk related to the illness may be related with greater anxiety long before the rise of the symptoms (Lin et al. 2017). Thus, targeting the anxiety symptoms may be regarded as important strategy for primary as well as secondary prevention of the disease (Hall, 2017). In 2017, research conducted by UK council for Psychotherapy revealed that the rate of anxiety in schizophrenia among British citizens had increased by 30.5% from what it was in the year 2013 (NHS, 2018). Anxiety has become the most common in schizophrenia which needs urgent intervention as it is a cost burden to the society and National Health Services (NHS) (NHS, 2018). A study conducted by Kiran and Chaudhury in 2016 on an inpatients hospital using techniques such as prospective and purposive sampling. In this study, 93 schizophrenia patients are involved with similar number of participants present in the control group who are normal. It was seen that the prevalence of anxiety disorder was far more in schizophrenia patients (45.16%) compared to the control group (16.12%). Moreover, it was seen that the prevalence of social anxiety disorder, panic disorder and obsessive compulsive disorder have higher prevalence of occurrence in schizophrenia patients compared to the normal individuals in the control group. This indicates that the prevalence of anxiety is high among the schizophrenia patients compared to the normal individuals (Kiran and Chaudhury, 2016). Baylé et al., (2011) informs that anxiety is regarded as frequent and key indicator of schizophrenia that is commonly related with high risk of relapse, low life quality, impaired functioning and increased incidence of executing attempts of suicide. However, it is still seen that even after the key risk is highlighted in clinical environment anxiety in schizophrenia patients are still not properly understood. Anxiety indicates a progression towards psychotic decomposition in the prodromic stage. It is seen that nearly 65% of the patients with schizophrenia can have anxiety symptoms which may lead them to reach the threshold to be later diagnosed with different co-morbid anxiety disorders later (Temmingh, and Stein, 2015). Importantly, the aim of treating this disorders is to enhance quality of life and engage patients in everyday life and not only decreasing some of the symptoms (Garcia-Portilla et al. 2015).

Pharmacological challenges in controlling anxiety in schizophrenia patients

According to Heideman et al. (2017), anxiety in schizophrenia is treated with both pharmacological and psychological intervention and the condition likely to become chronic if not treated and managed. However, the number of people with anxiety disorder who are not being treated remains at a higher percentage. A figure provided by the world Health Organization study highlights about 27% of people with anxiety in schizophrenia in the United Kingdom get treated (Alonso et al, 2018). Nevertheless, according to the Mental Health Foundation (MHF) (2016) these figures are higher at 48% for Generalised Anxiety Disorder (GAD). This means that over 50% of people with GAD are not receiving or not being treated, whiles the treatment of comorbid such as anxiety disorder and other mental health conditions varied at over 88%, the use of pharmacological medication remains best option (Mental Health Foundation, 2016). The study of Katzman et al., (2014) informs that more than 35 million drugs are being prescribed each year for management and treatment of mental illness. Among these, higher proportion of them are believed to be used to resolve anxiety disorder. The benzodiazepines like lorazepam, diazepam and clonazepam are among few medicines that are highly used for management of anxiety disorder (Royal College of Psychiatrists, 2018). NICE ,(2016) recommends treatment of anxiety to be pharmacological and psychological. However, primarily it appears involves pharmacological intervention, holistic management also offers the management of issues related to the symptoms (Norman and Ryrie, 2013). There is enough information and awareness however only a third of persons with anxiety in United Kingdom receive treatment (Gournay et al., 2011). Furthermore, most people seeking help from general practitioners are offered medications which are anti-depressant in nature. The number is so large than more than 35 million prescriptions for antidepressants are given annually is been reported. The main medication to treat anxiety according to NIMH, (2016) is anxiolytics that have benzodiazepines. Commonly used in the group are Clonazepam, Lorazepam and Diazepam. It is significant to mention that use of benzodiazepines has to be controlled and keenly handled with care because it causes addiction hence offering a dangerous withdrawal period that include gaining weight, increased tolerance to medication leading to higher dosages prescriptions it is why prescription dosages for the drug are always increasing with increase in age. At high dosage, patients have a risk of impaired cognition, mobility and risks of fall.

Impact of Mindfulness techniques in managing anxiety in Schizophrenia

Mindfulness technique is referred as the meta-cognitive process that includes mainly two components that are personal regulation of attention that include switching attention, sustaining attention and inhibiting the elaborative process by orienting openness, curiosity and acceptance for all aspects of immediate experience that involves feeling, thoughts and sensation. This indicates that mindfulness technique has a multifaceted construction which is intricately linked for improving self-regulation through its impact on emotion regulation, self-awareness and attention control (Tang et al. 2015). In the study of Chadwick et al. (2016), it is mentioned that the mindfulness technique has a great impact on managing anxiety faced by individuals in schizophrenia. This is because the technique leads schizophrenic individuals to be aware and accept unpleasant experiences that drive them to be anxious in such a way so that they can shift their attention to be able to open up to welcome it rather than being bothered to avoid anxiety. The impact can be proved through the study of Langer et al. (2012) where the researcher uses mindfulness practices such as mindfulness breathing, body scan and meditation along with metaphors and poetry to assists the individuals with schizophrenia to illustrate the meaning of them. The implementation of such mindfulness techniques on the individuals led them to show better ability to respond to stressful conditions and thoughts without getting anxious regarding the way to deal with the situation. The denial to accept a negative situation often acts as risky for individuals because unwilling to accept certain negative thoughts or feeling or sensation are regarded as initial link with the mental chain that leads to critical negative pattern building in mind (Çetin and Aylaz, 2018). However, in such situations, the mindfulness technique is implemented as it offers concrete ways in which people are able to develop the stance of letting the situation be even in the middle of difficult experience. This helps the schizophrenia patients to control their emotions in difficult situation and remain calm in turn avoiding them to be anxious (López-Navarro et al. 2015). It is evident as in the study of Davis et al. (2015) where it is reported that with implication of mindfulness technique schizophrenic people are able to motivate them in life in negative situations. It made them reduce their negative thoughts and feelings like anxiety and stress or depression in difficult situation. This is because mindfulness technique improves self-awareness helping schizophrenic individuals to reject avoidance strategy that produces anxiety and distress and develop acceptance strategy to be at ease in difficult situation. The fact can also be supported from the study of Rayan (2017) where mindfulness techniques were reported to act as mediators in case of schizophrenia patients to help them learn to see and develop a tolerance for unpleasant internal sensations without responding to it as per their habit. Thus, it leads the schizophrenic patients to avoid being bothered to negative situation or feelings such as hallucinations and other signs even though they are not eliminated. In the study of Sathyanarayanan, Vengadavaradan and Bharadwaj (2019), it is reported that a strong negative correlation is found between the mindfulness technique and any nature of dysfunctional attitude among schizophrenic patients. Moreover, in the study, a similar relationship was found between mindfulness activities and the requirement of approval for the technique in control groups. Thus, it indicated that the techniques are able to show their efficacy in reducing relapse of their depression and anxiety. The mechanism of the effect explained in the study is that mindfulness techniques help patients to view depression and negative thoughts as events that are passed by and do not necessarily require their attention to be reflected in reality. Thus, facilitation of the detached view among the patients of schizophrenia is able to lower the negative symptoms in patients and produce better functional outcomes.

Meditation is referred as one of the techniques of mindfulness that is used in controlling anxiety of the schizophrenic patients. In the study of Gotink et al. (2015), it is informed that brief time of meditation is able to improve the mood. This is because such process is seen to show improved electrical activity in the left frontal part of the brain that acts as a key area in controlling the mood of the individuals. The extended hours of meditation are seen to develop neuroplasticity which is the brain’s ability to create change in their function and structure (Li et al. 2018). Thus, such changes in the brain lead individuals with schizophrenia to develop control on their thoughts, responses and feeling regarding the situation they are facing that may have previously made them anxious if the mindfulness activity was not performed. In another study by Chien et al. (2017), the researchers took a total of 138 patients who are suffering from schizophrenia or schizophrenia-spectrum disorder out of which 52% were male. The mindfulness technique was applied to the patients to increase their awareness regarding their thoughts, bodily functions, control of negative perception and thoughts and others. Apart from that, the CPG (Conventional Psycho-education Group) and Tau (Treatment as-usual) were applied. The outcomes were measured 1 week 6 months after the implementation of the technique. The results showed that patients who are treated with mindfulness techniques showed greater improvement in recovery from their illness, psychosocial functioning, perception of negative and positive facts and others compared to the TAU ort CPG techniques. It was reported that 37% of the patients who received TAU intervention, 27% who received CPG intervention were readmitted to the hospital for their anxiety and other psychological issues due to schizophrenia compared to 11% re-admission rates in patients who received mindfulness intervention. This indicates that mindfulness techniques are more effective and operation compared to other intervention in controlling anxiety in schizophrenia patients.

Disadvantages of Mindfulness techniques implemented to manage anxiety in schizophrenia

In most of the studies, it is seen that the mindfulness technique has a positive impact on controlling anxiety in people with schizophrenia. However, mindfulness technique is seen to face challenges and various disadvantages while implementing it to manage anxiety in schizophrenia. In the study of Wilson et al. (2015), it is reported that implementing mindfulness technique leads schizophrenic individuals to develop false memories. This is because meditation which is one of the activities of mindfulness in schizophrenia encourages patients to develop judgement free feelings and thoughts which leads them to develop recollection of an event that may not have actually occurred but they have felt it has occurred at some point of time. The fact is also supported by the study of Rosenstreich (2016) where the researcher performed experiments and found out that mindfulness ion resolving anxiety in schizophrenia patients improved the cognition of true memories but they have no effect on the spontaneous false memories even though the provoked false memories are seen to be increased. However, the perspective was contradicted by the study of Baranski and Was (2017) where the researchers informed that they did not found many false memories to have built by schizophrenic individuals when mindfulness technique was implemented for them to reduce anxiety. The study of Matthews (2017) informs that mindless techniques though have been effective to help resolve problems that raise anxiety by clearing the mind yet they are associated with lowering the creative state of the individuals. This is evident as the techniques do not allow the person to resolve the problem in a creative way to avoid is it bother them further but makes the person with schizophrenia develop coping strategy to deal with the problem each day. In another study Mehta, Keshavan and Gangadhar (2016) it was reported that meditation which is one of the activities of mindfulness used in managing anxiety in schizophrenic individuals has a negative side as it increases the feeling of disconnection and dissociation of a person from their own body. This is vulnerable because such an act may lead individuals more maniac, anxious as well as show psychosis in turn deteriorating the mental health of the individuals. Another study by Xiao et al. (2017) reported that mindfulness leads schizophrenic individuals to develop better feeling about themselves in controlling anxiety and personal problem making them have higher self-esteem. However, the high self-esteem may make the schizophrenic individuals be aggressive even though they are not anxious making them to develop a feeling of superiority over others that may make them to face difficulty in getting accepted in the society out of their ego towards others.

Mindfulness and Anxiety Management

The schizophrenia patients who are experiencing anxiety require quality life and be in a healthy relationship with their friends and family which due to the disease they are unable to attain at the present (Ganguly, Soliman and Moustafa, 2018; NMC, 2015). The Mindfulness Based Intervention (MBI) is able to contribute in managing anxiety issues through various techniques such as meditation, yoga, drawing, analysing images and others (Fabrice et al., 2019). According to Duarte et al., (2018), MBIs are developed for resolving the negative psychological impact which arises from any psychological disorder or illness. Thus, it can be use as an effective framework for creating holistic management of anxiety in schizophrenia patients in an effective way. There is a well documented literature on the direct effectiveness of mindfulness interventions in anxiety management such as Askey-Jones, (2018) ;Duarte et al., (2018);( Hofmann et al., 2010) Pearson et al., (2012); Greener, Singh, (2012); Krusche et al., (2013); Greener,(2014); Banks et al., (2015). These reports identify significant reduction in anxiety and depression levels for all participants in different evidence based experiments and programmes. Hofmann et al., (2010) shows the improvements made on management of anxiety conditions and asserts that evidence has indicated that anxiety is reduced by 46%. Greener, (2014) cites that, the improvements associated with mindfulness are a result of flexibility in thinking resulting in an ability to regulate behaviours, seconding the suggestion is Cavanagh et al., (2014) who argues that mindfulness allows patients to engage in beneficial activities. In mindfulness as indicated by McGrandle (2010), relaxation exercises play a key role in reducing anxiety. Major causes of anxiety are multifactor that include emotional, social, cognitive and physical hence treatment should be non-judgmental and a form of supportive process. It is to say that good therapeutic treatment relationship offers vital advantage in management and treatment. In the study of Christopher et al., (2013), it is informed that mindfulness technique has an effective role for creating satisfaction in life by raising self-esteem of people. The study mentioned that self-esteem of people is a significant construct of life which helps in creating overall positive emotion, social confidence, psychological adjustment to intense situations, pro-social behaviour and life satisfaction. In the view of Atkinson and wade (2012) it is postulated that by implementing mindfulness activities greater satisfaction in life can be achieved in constraining situation and the study of Worth and Robins (2014) indicates that mindfulness is able to improve self-esteem of individuals. Since high self-esteem helps to improve work relationship with others therefore practices which enhance the self-esteem would be effective for reduction of anxiety (Worth and Robins, 2014). In another study () informs that mindfulness activities may actually improve the acceptance of thoughts that in other case would have been fixate or avoided resulting to minimise the negative emotional reactions from negative coping strategies. (Refer to Appendix 1)

CHAPTER THREE Improvements

This chapter will discuss the proposal improvement plan and outline in details all intended outcome. Improvement Promote patient’s health and is important to health care professionals as it promote continuity of care. Evidence suggest that, the improvement of quality is about making healthcare effective and safe along with patient-centred with equitable, efficient and timely (Johnson, and Sollecito, 2018; Craig, 2018). However, on its own it may not be enough for improvement in patient outcomes and quality of care. According to Suhonen et al, (2012) highlighted that, Patient health improvement and experiences of the care received in a health service are recognized as a key maker of the quality of those services and a source of information for quality improvement. The UK government through the department of health is committed to improve experiences of the patients as an essential element to attaining quality care and for this purpose they have set up different policies and reviews (DOH, 2008). These include The NHS outcomes framework and the NHS mandate (Department of Health, 2014). Other national drivers that have been very instrumental in reinforcing improved patient’s experience in an inpatient mental health settings include the Care Quality Commission (CQC) which is a health care watchdog that carries out regular inspection to find out the state of care within inpatient mental health services, the Royal College of Psychiatrists which has set up standards for inpatient mental health services and the National Institute for Health and Care Excellence (NICE) guidance on inpatient mental health setting ( NICE, 2014). Despite the above mentioned government initiatives to reinforce improved patient experiences as a key determinant of quality care, a recent inspection conducted by the care quality commission on patients experiences and outcomes in the mental health units revealed low levels of patient satisfaction and experiences of the care being given by the staff ( CQC, 2015). Additionally the Francis report ( Francis, 2013) highlighted a lot of shortcomings in inpatient mental health care and raised concerns over the poor quality of mental health services across the country. This could be attributed to a number of factors that occurs throughout the entire patients journey. Among other things a good service improvement is one in which patient care and safety remains paramount . This Practice Improvement Plan proposed the use of mindfulness -based interventions to manged anxiety in schizophrenia on acute inpatients ward. Mindfulness is a psychological intervention which aims in changing negative ways or pattern of processing ideas into positive thoughts. This assertion agress with Norman and Ryrie, (2013) who argue that, these positive thoughts results in positive behavioural change especially in difficult times in patients presentations.

According to Christopher Shea, (2019) in 2013, Kabat-Zinn came up with the definition of mindfulness stated that, “Mindfulness is as the psychological process of bringing individual attention to the internal and external experiences occurring in the present moment, which can be developed through the practice of meditation and other training.” Other researchers define mindfulness as a state of paying attention to being aware of experience at it occurs in the present moment” (Brazier, 2013);(Brown and Ryan, 2003). Similar explanation state that, Mindfulness is a psychological intervention which aimed to regulates emotions, decrease distress, anxiety and depression (Marchand, 2014) ;(Ives-Deliperi, 2013). It also help changed negative thoughts into positive thinking. This assertion agreed by Tabak Horan and Green, (2015) who added that, mindfulness helps to focus on our attention, as well as to observe our thoughts and sensations without being judgemental. Thus “what is what we actually do when we are practicing mindfulness. Tang et al., (2015) argue that, although specific definitions diverge, it is clear that mindfulness is a multifaceted construct that is strongly linked to improved self-regulation through its effects on attentional control, emotion regulation, and self-awareness. Many literature provides evidence of how mindfulness contributes in managing a wide range of problems which includes, sleeping disturbances, anxiety and depression and psychosis.

ORIGIN OF MINDFULLNESS

According to Groves, (2016), the concept of mindfulness is a form of meditation which has existed in Buddhist traditions for over 2,500 years. They inform that it is a nature of attitude as well a method for reduction of personal suffering and develop insight along with wisdom and compassion to deal with extremities in life. In contemporary psychology, the activity of mindfulness is regarded as optimal method of responding to mental process that contribute to maladaptive behaviour as well as give rise to emotional distress (Maex, E. (2011). In addition to this, Historically, mindfulness originated from the USA by Jon Kabat-Zinn in 1960. In 1976, it was being used as an intervention in a clinical setting for psychological wellbeing (Groves 2016). Evidence suggest that, Scientific investigation discovered that, mindfulness was being use by Buddhist communities and spiritual to help calm down the mind before it was discovered to be implemented (Groves, 2016);(Maex, 2011). Kabat- Zinn in 1979 introduced to the world what would become Mindfulness-Based Stress Reduction (MBSR), where he highlighted that it will would have a tremendous impact when its clinically accepted (Groves, 2016) According to the Mental Health Foundation Trust, (2014), Mindfulness can be beneficial for people from all diverse faces of life and the number of areas that mindfulness is being applied to is growing. These include, schools, criminal justice, workplace and in pregnancy.Mindfulness All-Party Parliamentary Group (MAPPG) (2015) release a publication on the Mindful Nation UK (MNUK) which is a report that culminates the year long research and inquiry into effect of mindfulness technique along with eight hearing done in the parliament. This report provide review of the scientific evidence related to current practices and mindfulness and provide concrete policy recommendations to the government related to four area of public policy that are healthcare, criminal justice, education and the workplace. They added that increased time spending at work without the family are regarded on an average as the least happy time of a person’s life. A huge proportion of absence at a workplace caused huge loss to the government that accounts for endemic stress in knowledge-based industries. (Mindfulness All-Party Parliamentary Group. (2015). Mindful Nation UK. Mindfulness Initiative.) Although mindfulness originated in Buddhist spiritual practices., practicing this skills will not compel or induce one to become a Buddhist(While, 2010). However, a standardised method have been developed for clinical setting thus are Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT). Mindfulness works in number of ways which promotes continuity of care. Practicing mindfulness involves non-judgment of current internal issues at the exact moment went it happens (Groves, 2016). Bohlmeijer et al., (2010) argues that mindfulness regulates emotions, sensations and thoughts hence acting as a distraction from thoughts of the past. Bohlmeijer et al., (2010) cites that absence of mindfulness in case the individual is caught in distressing thoughts about a moment will cause mindless attitudes. Mindful Attention Awareness Scale result in doing activities in hurry without paying attention to details, spillage or even forgetting the person’s name as soon as it is mentioned. Anxious persons stray from the present and remain afraid of the past and future. This PIP proposes adoption of two mindfulness exercises, i.e. Progressive Muscle Relaxation (PMR) and Body Scan (BC) exercises as intervention for management of anxiety for patients suffering from schizophrenia. Among all things, the availability of the two component will give the patients a chance to choice from , which best suits them.(Nursing and Midwifery Council (NMC), (2015). Involving patient in their own care and allowing them to make a choice is paramount and cannot be under estimated. It will offer them a satisfaction and concordance with their treatment as argued by Karazivan et al., (2015). A study conducted in America about theses exercise reveals that, participants involve in the brain scan exercise showed a thicker cortical walls than than those of the general public. Science associated thicker cortical walls with age. Older people have thicker walls and hence the idea is practicing ways that will reduce aging of their brains. Systematic reviews by Cavanagh et al., (2014) and Meta analysis show that there is a clinically significant benefit in mindfulness when it comes to achieving self help. The advantage is that mindfulness can be applied in groups or to individuals and outcome be observed within eight to twelve weeks of practice. (Refer to Appendix 4)

CHAPTER FOUR: Research Methods

2.0 Introduction to Methodology

The chapter is going to discuss in details the type of research methods being selected by the researcher in executing the study. The choices of each of the methods are made on the basis of study nature is followed by the researcher. The choice of appropriate research methods is mandatory for the study so that the researcher is able to properly check the hypothesis developed in the study whether it is true or not. The justification of each of the methods for executing the study is to be provided to inform about the cause of using the chosen one in the particular study. Therefore, a proper research methodology is to be framed so that the researcher has an effective plan to understand which way the study is to be progressed to examine the hypothesis developed in the study.

2.1 Research Paradigm

In this study, mixed research paradigm will be followed which means that both qualitative and quantitative research methods are to be used. As asserted by Ben-Zeev et al. (2018), in mixed research method the researcher collects data through quantitative mode and then through qualitative data instrument collects further explanation regarding the quantitative data. This is done to provide details information and develop through an understanding of the collected results. Moreover, in mixed research paradigm, the researcher may use qualitative data instrument to explore information regarding the topic and based on the collected information the researcher develops a better strategy of collecting quantitative data by using quantitative data instruments (Nemoto et al. 2018). In this study, the researcher will be going to use the quantitative instrument to examine the impact of mindfulness techniques over PRN Anxiolytics medicine in managing anxiety in patients with schizophrenia. The qualitative instruments will be used to ensure whether or not the mindfulness techniques are more effective compared to PRN Anxiolytics medicine in managing anxiety in patients with schizophrenia. The mixed paradigm is planned for being used in the study for its various advantages. It is seen that both qualitative and quantitative research paradigm has own weakness. This is evident as quantitative research has the weakness of failure to understand in which setting the data is to be collected whereas qualitative research has weakness of involving biases in the study as well as do not allow generalisation and statistical representation of data. In this condition, using the mixed method paradigm helps to offset each other’s weakness by allowing analysis as well as exploration of collected data at the same time (Flick, 2018). Thus, mixed method paradigm is planned for being used as it would help in enriched collection of data in both statistical and descriptive format to generalise the results as well as avoid bias in the study. As mentioned by Firth et al. (2017), mixed research paradigm provides benefit to the researcher to use all nature of tools available for them for collective comprehensive data regarding the study. This will provides opportunity for the researcher in this study to have broader perspective to understand the reason behind mindfulness techniques are more effective than PRN Anxiolytics medicine in managing anxiety in patients with schizophrenia. The other benefit of using mixed research paradigm is that the final results collected include observational as well as statistical analysis (Teigset, Mohn and Rund, 2018). This will help the researcher in providing better validation of the study as using both the approaches in a single study provide development of additional evidence as well as support for the findings made in the study. Moreover, mixed research paradigm will be used in the study as it allows the researcher to have the benefit of using both words as well as numbers in communicating the findings. This offers the advantage of creating a wider audience for the study. The use of mixed research paradigm is beneficial as helps to reduce the personal biases of the researcher (Kim and Jun, 2016). This means that the personal biases of the researcher in interpreting the data in the study to be faced that will create error will be able to be avoided through the help of the mixed paradigm.

The challenges or limitation to be faced by using mixed paradigm is that the study will require increased amount of time (Grant, 2015). This is evident as both qualitative, as well as quantitative data regarding the effects of mindfulness techniques over PRN Anxiolytics medicine in managing anxiety in patients with schizophrenia, is required to be collected in executing the study. Thus, to avoid this limitation the researcher will try collecting both qualitative and quantitative data in minimum amount of time so that no time constraints are faced as hindrance that may lead to collect incomplete data. The study is also going to require increased resources in collecting both nature of nature which will act as limitation in implementing the method. This is because the budget for conducting the study is low and all the resources required for the purpose may not be able to be presented. The research process in mixed research paradigm is complex in nature which acts as a limitation as the researcher require to have the professional capability in executing each of the complex methods in an appropriate manner (Schneider and Schwarz, 2017). However, the researcher in this study has effective knowledge regarding the use of each qualitative and quantitative instrument in the study and has expert assistance from other researchers who have previously used such tool in executing similar studies. Thus, this limitation will not be faced by the researcher in executing this study.

2.2 Research Approach

There are mainly two types of research approaches which are inductive research approach and deductive research approach. As stated by Springham and Whitaker (2015), inductive research approach initiates with observation and in the end, theories are proposed which are developed as a result of the made observation. This indicates that in inductive approach the researcher begins their search for a pattern of data by executing observation and gradually develops explanations or theories for the pattern with a series of hypothesis. Thus, no theories are being applied at the initiation of the research. However, this does not mean that inductive research does not imply to disregard theories while formulating the research questions and objectives of the study. The limitations to be faced while using the inductive approach is that it offer limited scope to the researcher and inaccurate inferences for the study (Leavy, 2017). This may lead the researcher to fail in creating a fair judgement and inference of the collected data related to the study. The deductive research approach is referred to the process in which a hypothesis is developed based on the existing theories and designs a research strategy for testing the hypothesis (Nunez et al. 2018). In this study, already a hypothesis by evaluating the existing theories and literature are created that mindfulness techniques have greater impact in managing anxiety in schizophrenic patients and reduce the use of PRN Anxiolytics medication among the patients. The advantage of using deductive approach is that it allows the researcher to effectively explain the causal relationship between concepts and the variables (Krupchanka et al. 2018). This means that by using deductive approach in the study the researcher will be benefited to identify the relationship of mindfulness techniques in comparison to PRN Anxiolytics medicine to manage anxiety in schizophrenic patients. The deductive approach helps the researcher to develop statistical data for explanation of concepts in a quantitative manner (Grácio, Gonçalves‐Pereira and Leff, 2018). This indicates the researcher will be able to mention with the support of numeric data regarding what amount of patients are benefited by using mindfulness techniques to lower the use of PRN Anxiolytics medicine to control anxiety faced as a result of schizophrenia. The deductive approach helps to generalise the results to some extent (Springham and Whitaker, 2015). This means that the developed findings regarding mindfulness technique in the study can be used in some aspects in controlling anxiety among other mentally-ill patients. The limitation of deductive approach is that the researcher develops conclusions from the probability which are assumed to be true in the initial condition but may not true in certain cases at the end (Rose et al. 2015). Thus, this indicates that if the researcher is unable to develop a proper statement at the beginning the whole data collected may be wrong creating an intense error in the study.

2.3 Research Design

The research designs are of three types that include exploratory research, explanatory research and descriptive research design. As asserted by Hashimoto and Tensho (2016), descriptive research design is referred to the method which includes description and observation of a subject’s behaviour without influencing it. This design also considers both the negative as well as positive perspective related to any study for critically analysing the problem encountered in the research. As mentioned by Forsyth et al. (2017), exploratory design is the method which studies the problem identified in the research that is not clear and has limited information. This nature of design is often regarded as unstructured as the research has no valid reference data available to solve the problem. In this study, wide amount of data are available regarding the impact of mindfulness techniques in managing anxiety in schizophrenic patients. Thus, the exploratory design will not be valid to be used for the study. As commented by Bryl (2018), explanatory design involves connecting ideas for identifying and understanding extent and kind of cause-effect relationship of variables identified in the study. This indicates that the use of such design leads to develop a new hypothesis in the study by analysing the cause-effect relationship. In this study, already a hypothesis is developed and so the implementation of explanatory design will not be valid. In this study, descriptive research design will be used because it helps in executing the study by considering the aims and objectives determined in the research. This will allow the study to be executed in a structured format which provides scope for the researcher to perform an enriched analysis to gather relevant and vital information needed by the study (Del Bello et al. 2016). The benefit of using descriptive design is that it offers opportunity to the researcher to collect in-depth data within minimum time span. Thus, better information in studying the impact of mindfulness techniques over PRN Anxiolytics medication can be understood by planning to implement descriptive research design. The explanatory and exploratory research design are used in studies that do not any format set of objectives or where the research problem is not being identified (Beauchaine and Cicchetti, 2016). In this study, clear declaration of the study objectives, aim and research problem is mentioned so the explanatory and exploratory research designs will not be required to be used in the study.

2.4 Sampling Method

The Sampling methods are of two types that are probability sampling and non-probability sampling. As asserted by Albrecht et al. (2016), probability sampling performs selection and identification of the participants to be used in performing the study in a random manner. The participants selected through this method are regarded as representative of the whole population. The benefit of using probability sampling is that it is cost-effective in manner and includes less judgement as well as is easier to be performed as it involver less complex method while implementing it (Treadway et al. 2015). Thus, the probability sampling will be used in collecting quantitative data as it is an easier process through which huge amount of information regarding the impact of mindfulness over PRN Anxiolytics medication can be identified in controlling anxiety in schizophrenia patients. The limitation may be faced while using probability sampling is that it may make the researcher select specific participants for the study (Axelsen, Jepsen and Bak, 2018). In order to avoid the limitation, the researcher will select the participants of all age groups with schizophrenia who are suffering from anxiety. The non-probability sampling includes selection of the participants where each of the individuals is not provided equal opportunity of getting selected. The sampling is used in studies where it is required to demonstrate that a particular trait exists among the individuals in the population (Hussein, Jacoob and Sharour, 2016). In this study, the particular trait that anxiety is better relieved through mindfulness technique over PRN Anxiolytics medication will be analysed in individuals suffering from schizophrenia. Thus, this sampling method will suitable for the study and it will be used in collecting qualitative data as it regarded as most suitable form of method for gathering such nature of data. The limitation to be faced while planning to use this method is that the researcher will be unable to know how well the selected participants are representing the population (Ebrahem and Alam, 2016). In order to collect qualitative data, total of 12 schizophrenia patients will be selected who are suffering from anxiety through convenient sampling technique. In order to collect quantitative data, the researcher will use the health report, care charts and medical reports of 60 schizophrenia patients.

2.5 Research Strategy

The survey research strategy will be chosen for collecting quantitative data. The benefit of survey is that it helps to collect information which is close to appropriate attributes mentioned by the participants. In addition, survey strategy allows collection of increased amount of data within less amount of time (Gay et al. 2016). Thus, the researcher by surveying medical reports of the schizophrenia patients will be able to collect increased amount of data required for explaining the impact of mindfulness techniques over PRN Anxiolytics medication in anxiety. The survey assists the researcher to present statistical data and avoid implementing any personal biases in the study. Moreover, it helps in generalisation of the collected data (Speerforck et al. 2017). Thus, the survey research strategy will be used in executing this study. The interview research strategy will be used in collecting qualitative data related to the study. The benefit of using interview strategy is that it helps the researcher to investigate the raised issue in the study by exploring the expressions and feelings of the participants (Blanchard et al. 2017). Thus, it will be used in the study as it would help to execute detailed analysis of the collected information to present vital data that may not have been able to be provided by using survey strategy. Moreover, interview helps in providing in-depth explanations for the collected quantitative data (Østergaard, Opler and Correll, 2017). Thus, it will be used in the study to provide better explanation of the collected statistical data.

2.6 Data Collection Method

The quantitative data collection method will be used in the study as it offers greater scope to include increased number of participants for creating enhanced results (van den Heuvel et al. 2016). The quantitative data collection method allows the researcher to objectify answers as well as helps in ensuring accuracy of the results. This method also allows summarization of vast amount of data from different sources, in turn, facilitating the researcher to compare various categories. Moreover, this method allows the researcher to avoid implement biases in the study due to influence of personal perception ensuring to lower error in studies (Sariaslan et al. 2016). Thus, the method will be used as it also allows the cost-effective collection of information. In order to collect quantitative data, survey closed-ended questions will be provided to the participants that are developed by the research through collection and analysis of clinical reports of the patients. The qualitative data collection method allows for detail examination and interpretation of the collected findings. Moreover, it allows the participants to openly inform about the research topic (Al-HadiHasan, Callaghan and Lymn, 2017). Thus, this method will be used as it would allow the participants to freely express their feeling and emotions to prove whether or not mindfulness technique is able to lower use of PRN Anxiolytics medication to manage anxiety in schizophrenia. The qualitative data collection method helps to explain in details the reason behind their reaction by analysing regarding the feeling and emotion of the participants (Lloyd et al. 2017). The qualitative data collection will be using semi-structured questionnaire for the participants to interview them. This is because the semi-structured questionnaire allows freedom to the participants to some extent to inform added information regarding the study topic that may not have been gathered by using only structured questionnaire.

2.7 Pre-test Data

• Retrospective data of the patient's health are to be collected before and after the application of Benzodiazepines or other anxiolytics such as PRN

• Total number of patients who were prescribed Benzodiazepines or other anxiolytics such as PRN in the past 8 weeks

• Amount of Benzodiazepines or PRN anxiolytics used in the past 8 weeks before implementing PIP (mindfulness techniques)

• Amount of Benzodiazepines and Anxiolytics used for PRN 8 weeks before PIP at least once

2.8 Prospective Data

• At the end of the implementation of PIP, observations are to be made on patients who are still prescribed to use anxiolytics PRNs and Benzodeipine

• Amount of anxiolytics PRNs and Benzodeipine cumulatively used by patients within 8 weeks of implementation of PIP

• Opinions of the patients after using anxiolytics PRNs and Benzodeipine in managing anxiety

• Opinions of the patients after using mindfulness techniques in managing anxiety

2.9 Reliability and Validity

Reliability is referred to as the quality to be regarded as trustworthy whereas validity refers to the quality of logically sound (Gomes et al. 2016). As mentioned by Blanchard et al. (2017), validity is important in the study as without valid results the findings are regarded as meaningless. This means that the evidence collected cannot be used as evidence to support the healthcare practitioners to resolve the raised problem for which the research is being developed. Moreover, validity is required to be ensured in research because if the findings do not help to measure what is the aim of the study is to be measured then the results are also unable to be used in proving the hypothesis of the study or the answering the raised research question in the study (Keefe et al. 2015). This mentions that the results developed are just a waste of time as it cannot be used in generalising the findings. One of the common reliability issue faced in studies is the selection biases of the participants. This mainly occurs when the chosen sample is not a proper reflection of the population. In this study, it is probable to happen as in probability sampling such nature of biases is the limitation of the method (Aubin, Béliveau and Klinger, 2018). The error often occurs when the research select the participants of certain nature from the population who do not represent the population as whole (Treadway et al. 2015). This means that the researcher may chose only elderly schizophrenia patients from the population and neglects the young or middle-aged schizophrenia patients while selecting the participants for the study which makes it an issue as the selected participants do not represent the population as a whole. Thus, the researcher would be unable to determine the impact of mindfulness over anti-depressant in young and middle-aged schizophrenic individuals who are suffering from anxiety. In order to avoid such biases in the PIP, the researcher requires choosing patients with different age group who are accessing PRN medication at least every week to manage anxiety. In the study, while executing data analysis biases may occur as a result of the development of some data to prove the hypothesis. In order to avoid such biases, raw data are to be mentioned in the appendix for allowing transparency. Moreover, the PIP is going to be executed based on primary research to avoid reliability and validity issue that may be caused as seen in cases of secondary research where the perception of the researcher creates biases. (Refer to Appendix 2)

CHAPTER FIVE Implementation:

In the beginning, the research ethic committee should approve the intension of carrying out the research process. Thus, this approval letter and its copy as offered by the research and ethics committee will be submitted to the managing body of the secure hospital for organizing and arranging a meeting with the manager and the chief clinicians of the said hospital with regard to the intent of carrying out PIP. during this meeting the objectives, details of PIP, resources required for instance rooms for exercises , quantity of sections, duration of sessions per week and favorable wards will be determined. The next meeting will involve team leaders and staff managers of the allocated wards who will be introduced to a summary on PIP. During the meeting, raising questions in regard to PIP will be addressed and the duties of the staff and any other participant will be thoroughly defined. Final objective of the meeting will be to set a date on which PIP will be introduced to patients. During the introductory session, participants will be educated about PIP as an investigation into assimilation of mindfulness exercises and its possibility as an alternative treatment to PRN medication in anxiety management for adults who suffer from severe mental illnesses. Setting of target date during which participant selection will take place and also formulation of care plans with these participants will be the next step (Gulanick and Myers, 2011). A care plan defines the aims of PIP, the time period for the entire PIP, estimated duration of sessions, type of data to be gathered, privacy and data protection, participants and staff roles, criteria to opt out of the programme and questions of confidentiality (NMC, 2015). This care plan also acts documentation and legal evidence that patients participated in the PIP. The role of the staff will mainly encompass encouraging participants to adopt mindfulness exercises when requesting prescription for Anxiolytics and Benzodiazepine medication drugs. A consensus on the starting date should then be determined. First step of the programme will be completion of Mindfulness Attention Awareness Scale questionnaire which is used to measure the level of mindfulness, and level of anxiety in each participant (Ostafin, 2015; Brown and Ryan, 2003; Appendix I). The same will be done at the end of PIP to measure change and acceptance levels of mindfulness.

According to the methodology, the Pip will take a period of 8 weeks in which the participants will effectively take part in progressive exercises specifically, muscle relaxation and body scans. These exercises will take place every week at an approximate of one hour sessions. Experiences of the participants after the sessions will be taken and discusses so that emphasis can be laid down to determine the effectiveness of the mindfulness exercises. It is important to reduce the pressures of these participants with the aim of achieving instant mindfulness. The PIP will use a minimum of twelve participants, 6 mal6 and 6 females who are already taking different amounts of PRN. More so, the participants will be offered assignments at the end of every session to go any carry out any of the preferred activities. The experiences that come with undertaking the homework will also be discussed at the beginning of every session I n attempt to create awareness of the minds behaviors and the normal way made part from wondering. The awareness made in every session will be built on in the next session and a progressive outcome report generated to understand how mindfulness is being adopted and its impact on the participants.

CHAPTER SIX Ethical Principles

Ethics in philosophy is defined as the part that deals with the dynamics of decision making in regards to what is wrong or right Fouka and Mantzorou (2011). They further argue that a person researching in most likely to come across three value systems that include social values of human rights; values of researcher with regards to scientific investigations and the nursing culture and code of conduct as defined in ethics of caring Norman and Ryrie (2013). They also affirm ethical tensions and dilemmas are created by confliction of these three values. Four ethical principles have been proposed by Beauchamp and Childress (2013) during medical practices which are respect for the autonomy, non-malfeasance, beneficence and justice.

Respect for autonomy

There is an argument that levels of autonomy can vary with the cognitive functioning of the patient which can create a dilemma in its definition. The participants of this PIP are considered to fall in the vulnerable group due to their diminished cognitive functioning. Vulnerable groups are defined as persons that are unable for one reason or another to protect their rights and welfare. There is a dilemma on determining whether carrying out experiments with these groups can still be considered ethical due to the lack of informed consent, coaxed participation or their abilities in keeping the confidentiality and privacy measures. The implication of this is that PIP must have measures in place that will help in safeguarding confidentiality and privacy however, it must be expected that breach of this is possible. Further, the research binds the research to legal obligation to disclose any form of information that may be seen as vital to protect property of life. Informed consent refers to the ability of a person to knowingly, intelligently and voluntarily with clear and sober mind manifest the consent, Roache, (2014). In the PIP, the vulnerable groups cannot be deemed intelligent, knowing or able to understand the idea of autonomy and their participation in the research. While some will offer their consent as conformity to group norms it does not mean that the rule of autonomy is upheld. (Refer to Appendix 3)

Beneficence

According to Parahoo, 2014, the PIP should be necessary plus beneficial to both participants and the whole society in order to attain the principle of beneficence which means that necessary measures should be taken in order to affirm that the PIP benefits and also promotes the objectives of the participants. It should be taken into consideration that the participants most probably overestimate the benefits of taking part in the PIP programme hence the optimum assessment should therefore be carried out to ascertain these benefits. This assessment basically makes an ethical dilemma because in normal circumstances not all participants directly benefit from this research study (Rossetto, 2014; Doody and Noonan, 2016). (Refer to Appendix 3)

Non- malfeasance

Non malfeasance basically means carrying out an activity with no intent of doing harm (Doody and Noonan, 2016). Therefore, while conducting the research, the staff should take into account balancing the potential benefits against the risks by safeguard participants (Parahoo, 2014). This is done by making an effort to reduce emotional, psychological and excessive physical demands on the participants (Polit and Beck, 2013). Psychological harm nevertheless might be less apparent hence complicated to handle as compared to the physical harm. Therefore, support mechanisms such as 1:1 sessions should be considered to curb issues that arise during PIP because normally there is not confirmed assurance that participants in this programme won’t encounter any physical or psychological torture.

Justice

This principle basically affirms that all participants in a given research activity must be treated fairly and equally. That is according to a survey conducted by Doody and Noonan (2016). According to them, this principle ensures that the researchers distribute risks and benefits equally. They came to an agreement with Alperovitch et al. (2009) that for this principle to attain equity, participants must be chosen randomly in relation to the phenomenon that’s being investigated. However, individuals must first of all agree to partake in this nursing research in accordance with the NMC (2016) code of professional conduct. Thus, choosing participants in regard to capacity to consent or equity will make a dilemma in accordance with the principle of justice vis-à-vis the NMC (2016) code. To a nurse, equity as based in the principle of justice (Lynch, 2016) won’t be more vivid compared to the NMC (2016) code of conduct.

CHAPTER SEVEN Data Analysis and Presentation

All information in the retrospective section and that which will have been collected by the end of implementing PIP must b analyzed and weighed out to determine the effectiveness. Analysis will be a series of comparing quantities in grams of PRN and Benzodeipine. Opinions of all participants before and after PIP will also be analyzed in the descriptive method. After the analysis, data collected and analyzed will be tabulated and graphs drawn to make interpretation easier (Lee et al. 2013; Bowling, 2014). Statistical methods will be applied in measuring amounts of medication that issued by the participants before and during the implementation phase of PIP for the period of eight weeks. The information will then be presented in pie charts (Klass, 2012; Griffiths, 2009). Basic working of a pie chart is that the larger the segment the more the amount of drugs was used. The aim of using these diagrams to ascertain if there is any change and specifically reduction in quantities of PR medication usage that occurs as a result of introducing PIP. Weekly data will also be estimated to show which weeks PIP was more significant. It is expected that some of the participants will not make it through the entre process and thus only those who complete the minimum six weeks will be used in the analysis and presentation.

CHAPTER EIGHT Dissemination Methods

Dissemination is the process of dispersing that information and knowledge that has been acquired in a research process. Without this step, the information that has been acquired is rendered useless because it becomes wasted (Macnee and McCabe, 2008). Similarly bowling (2014) argues that the effectiveness of a dissemination process in research is very important mainly in health services. The PIP intends to take the finds, generate and present them with clarity. A summary version of the entire research that include abstract, aims, hypothesis of the research, descriptive information on the design, research methods. Outcomes, analysis and conclusion must be presented. WHO (2014) offers a number of barriers to adoption of research evidence as being the perceptions about a research by practitioners who should adopt it, culture of some organizations, the perceived cost of change and the quality of skills among them. They thus advocate that researchers should find numerous ways to disseminate the information as a vital step in overcoming any foreseeable barriers (Fuller, 2013). The outcomes of the research will hence be disseminated through a number of ways. First, presentations of finds will be done to peers and scholars in nursing both in school and those under practice placement, press releases will be made, social media pages on mental health and websites will be used to publish the information, involving medical journals such as British Journal of psychiatry and NICE journal will also be called upon among others. The outcomes of the research will also be shared with the hospital involved, the participants, local Medias as well as sending it to the parliamentary health committee.

Conclusion

It has been established through evidence offered by secondary materials that using pharmacological treatments for anxiety both in SMI and general patients has resulted in problems mainly because of the severe side effects. A number of recommendations including those by NICE on the need to utilize non-phrenology as a treatment method for anxiety have been made. Unfortunately patients have not been offered options o which methods of treatment to undertake they either have to take medication or get no treatment. This PIP comes in to propose using two different mindfulness exercises together with medication as a progress in attempting to reduce the impact of medication on patients. It specifically narrows down to body and brain scan exercise and progressive muscle relaxation techniques that will be applied in treating anxiety among adults who already suffer from severe mental illnesses. The objective is to offer an alternative hoping that the outcome will show reduced use of medication, reduce the span of time required for treatment and recover, empower the patients to self manage using these skills, reduce the cost of treatment among other benefits. It is important that the challenge of the proposal is that outcomes to be realized from the project may offer data that varies from the expectation of the PIP, further, PIP may not be applicable with SMI patients due to their inability to follow instructions fully. Using a sample space of ten to twelve patients, from the capacity of a local hospital the sample space will be a proper representation of the population and hope that should positive results is made, they can be adopted for large scale implementations.

References

National Institute for Health and Care Excellence, 2014, Costing statement: Psychosis and schizophrenia in adults: treatment and management.

Palmer B, Pankratz V, Bostwick J, 2005, The Lifetime Risk of Suicide in Schizophrenia: A Re- examination.

Warner R, 2000, The Environment of Schizophrenia, Brunner Routledge.

Caldwell C, Gottesman I, 1992, Depression, Suicide and Suicide Prevention in Schizophrenia, Schizophrenics Kill Themselves Too, Published in Schizophrenia Bulletin.

Atkinson, M. and Wade, T. (2012) "Impact of metacognitive acceptance on body dissatisfaction and negative affect: Engagement and efficacy.", Journal of Consulting and Clinical Psychology, 80(3), pp. 416-425.

Bashford, S. (2011) "Using ‘mindfulness’ to help treat anxiety and depression", Independent Nurse, 2011(4).

Baxter, A., Scott, K., Vos, T. and Whiteford, H. (2012) Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychological Medicine, 43(05), pp.897-910. Beauchamp, T. and Childress, J. (2013) Principles of biomedical ethics. 7th ed. USA: Oxford University Press.

Brown K W & Ryan R M (2003) The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology 2003; 84(4): 822-848.

Burch, V. and Duff, C. (2012) "The mindful way to living well", British Journal of Cardiac Nursing, 7(3), pp. 134-136.

Carlson, L. and Garland, S. (2005) "Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients", International Journal of Behavioural Medicine, 12(4), pp. 278-285..

Cavanagh, K., Strauss, C., Forder, L. and Jones, F. (2014) "Can mindfulness and acceptance be learnt by self-help?: A systematic review and meta-analysis of mindfulness and acceptance-based self-help interventions", Clinical Psychology Review, 34(2), pp. 118- 129. Chadwick, P., Taylor, K. and Abba, N. (2005) "Mindfulness Groups for People with Psychosis", Behavioural and Cognitive Psychotherapy, 33(3), pp. 351-359.

Cronin, P., Coughlan, M. and Smith, V. (2015) Understanding nursing and healthcare research. 1st ed. London [u.a.]: Sage Publishers. DH (2012) liberating the NHS: No decision about me without me.

Fitch C, Simpson A, Collard S, Teasdale M (2007) Mental health and debt: challenges for knowledge, practice and identity Journal of Psychiatric and Mental Health Nursing 14: 128–33

Greaney, A., Sheehy, A., Heffernan, C., Murphy, J., Mhaolrúnaigh, S., Heffernan, E. and Brown, G. (2012) "Research ethics application: a guide for the novice researcher", British Journal of Nursing, 21(1), pp. 38-43.

Gregg, J., Callaghan, G., Hayes, S. and Glenn-Lawson, J. (2007) "Improving diabetes self- management through acceptance, mindfulness, and values: A randomized controlled trial.” Journal of Consulting and Clinical Psychology, 75(2), pp. 336-343.

Gum, A., King-Kallimanis, B. and Kohn, R. (2009). Prevalence of Mood, Anxiety, and Substance-Abuse Disorders for Older Americans in the National Comorbility Survey- Replication. The American Journal of Geriatric Psychiatry, 17(9), pp.769- 781.

Hoge, E., Ivkovic, A. and Fricchione, G. (2012) "Generalized anxiety disorder: diagnosis and treatment", British Medical Journal, 345(nov27 2), pp. e7500- e7500.

Keng, S., Smoski, M. and Robins, C. (2011) "Effects of mindfulness on psychological health: A review of empirical studies", Clinical Psychology Review, 31(6), pp. 1041-1056.

Koch, H. (2016) "Everyday mindfulness: A review of recent publications", British Journal of Mental Health Nursing, 5(2), pp. 78-80.

Lee, C., Lee, J. and Lee, A. (2013) Statistics for business and financial economics. 1st ed. New York: Springer.

Majumdar, M., Grossman, P., Dietz-Waschkowski, B., Kersig, S. and Walach, H. (2002) "Does Mindfulness Meditation Contribute to Health? Outcome Evaluation of a German Sample", The Journal of Alternative and Complementary Medicine, 8(6), pp. 719-730.

Mendes, A. and Palmer, S. (2016) "The value of mindfulness in people with longterm conditions", British Journal of Community Nursing, 21(10), pp. 532-532.

Morone, N., Lynch, C., Losasso, V., Liebe, K. and Greco, C. (2011) "Mindfulness to Reduce Psychosocial Stress", Mindfulness, 3(1), pp. 22-29.

Nezlek, J., Holas, P., Rusanowska, M. and Krejtz, I. (2016) "Being present in the moment: Event-level relationships between mindfulness and stress, positivity, and importance", Personality and Individual Differences, 93, pp. 1-5.

NMC (2015) The Code Professional standards of practice and behaviour for nurses and midwives. [online]

Orth, U. and Robins, R. (2014) "The Development of Self-Esteem", Current Directions in Psychological Science, 23(5), pp. 381-387.

Petrie A, Sabin C (2010) Medical Statistics at a Glance. 3rd edn. WileyBlackwell, Singapore Polit DF, Beck CT (2013) Essentials of Nursing Research: Appraising Evidence for Nursing Practice. 8th edn. Wolters Kluwer/Lippincott Williams and Wilkins, Philadelphia

Roemer, L. (2009) Mindfulness- and Acceptance-Based Behavioral Therapies in practice. 1st ed. New York: Guilford Press.

Smith, S. (2014) "Mindfulness-Based Stress Reduction: An Intervention to Enhance the Effectiveness of Nurses' Coping With Work-Related Stress", International Journal of Nursing Knowledge, 25(2), pp. 119-130.

Vøllestad, J., Sivertsen, B. and Nielsen, G. (2011) "Mindfulness-based stress reduction for patients with anxiety disorders: Evaluation in a randomized controlled trial", Behaviour Research and Therapy, 49(4), pp. 281-288

Williams, J., Alatiq, Y., Crane, C., Barnhofer, T., Fennell, M., Duggan, D., Hepburn, S. and Goodwin, G. (2008) "Mindfulness-based Cognitive Therapy (MBCT) in bipolar disorder: Preliminary evaluation of immediate effects on between-episode functioning", Journal of Affective Disorders, 107(1-3), pp. 275-279.

Yusainy, C. and Lawrence, C. (2014) "Relating mindfulness and self-control to harm to the self and to others", Personality and Individual Differences, 64, pp. 78- 83.

Baranski, M. and Was, C.A., 2017. Mindfulness meditation may not increase false-memory and may instead protect from false-memory susceptibility. Mindfulness, 8(6), pp.1569-1579.

Chien, W.T., Bressington, D., Yip, A. and Karatzias, T., 2017. An international multi-site, randomized controlled trial of a mindfulness-based psychoeducation group programme for people with schizophrenia. Psychological medicine, 47(12), pp.2081-2096.

Chadwick, P., Strauss, C., Jones, A.M., Kingdon, D., Ellett, L., Dannahy, L. and Hayward, M., 2016. Group mindfulness-based intervention for distressing voices: a pragmatic randomised controlled trial. Schizophrenia Research, 175(1-3), pp.168-173.

Davis, L.W., Lysaker, P.H., Kristeller, J.L., Salyers, M.P., Kovach, A.C. and Woller, S., 2015. Effect of mindfulness on vocational rehabilitation outcomes in stable phase schizophrenia. Psychological Services, 12(3), p.303.

Gotink, R.A., Chu, P., Busschbach, J.J., Benson, H., Fricchione, G.L. and Hunink, M.M., 2015. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PloS one, 10(4), p.e0124344.

Matthews, C.F., 2017. Exploring body image. Working Across Modalities in the Arts Therapies: Creative Collaborations, p.152.

Nemoto, T., Uchino, T., Aikawa, S., Funatogawa, T., Matsumoto, H., Yamaguchi, T., Katagiri, N., Tsujino, N., Sakuma, K. and Mizuno, M., 2018. Competence-Performance Discrepancy In Social Functioning In Patients With Schizophrenia: The Impact Of Social Anxiety. Schizophrenia Bulletin, 44(suppl_1), pp.S315-S315.

Teigset, C., Mohn, C. and Rund, B., 2018. F66. Do Clinical Variables During The Early Illness Period Predict The Cognitive Course In Early-onset Schizophrenia?. Schizophrenia Bulletin, 44(suppl_1), pp.S245-S245.

Springham, N. and Whitaker, R., 2015. How do art therapists structure their approach to borderline personality disorder?. The Arts in Psychotherapy, 43, pp.31-39.

Nunez, D., Fresno, A., van Borkulo, C., Courtet, P., Arias, V., Garrido, V. and Wigman, J., 2018. Examining Relationships Between Psychotic Experiences And Suicidal Ideation In Adolescents Using A Network Approach. Schizophrenia Bulletin, 44(suppl_1), pp.S96-S96.

Grácio, J., Gonçalves‐Pereira, M. and Leff, J., 2018. Key elements of a family intervention for schizophrenia: a qualitative analysis of an RCT. Family process, 57(1), pp.100-112.

Beauchaine, T.P. and Cicchetti, D., 2016. A new generation of comorbidity research in the era of neuroscience and Research Domain Criteria. Development and psychopathology, 28(4pt1), pp.891-894.

Bryl, K., 2018. F239. The Role Of Dance/movement Therapy In The Treatment Of Negative Syndrome And Psychosocial Functioning Of Patients With Schizophrenia: Result From A Pilot Mixed Methods Intervention Study With Explanatory Intent. Schizophrenia Bulletin, 44(Suppl 1), p.S315.

Ebrahem, S.M. and Alam, F.H., 2016. Effectiveness of Psychiatric Nursing Intervention on Adherence to Medications and Quality of Life of Schizophrenic Patients. American Journal of Nursing, 5(6), pp.232-239.

Østergaard, S.D., Opler, M.G. and Correll, C.U., 2017. Bridging the measurement gap between research and clinical care in schizophrenia: positive and negative syndrome scale-6 (PANSS-6) and other assessments based on the simplified negative and positive symptoms interview (SNAPSI). Innovations in clinical neuroscience, 14(11-12), p.68.

Al-HadiHasan, A., Callaghan, P. and Lymn, J.S., 2017. Qualitative process evaluation of a psycho-educational intervention targeted at people diagnosed with schizophrenia and their primary caregivers in Jordan. BMC psychiatry, 17(1), p.68.

Keefe, R.S., Davis, V.G., Spagnola, N.B., Hilt, D., Dgetluck, N., Ruse, S., Patterson, T.D., Narasimhan, M. and Harvey, P.D., 2015. Reliability, validity and treatment sensitivity of the Schizophrenia Cognition Rating Scale. European Neuropsychopharmacology, 25(2), pp.176-184.

Lin, G.H., Wu, C.T., Huang, Y.J., Lin, P., Chou, C.Y., Lee, S.C. and Hsieh, C.L., 2017. A Reliable and Valid Assessment of Sustained Attention for Patients With Schizophrenia: The Computerized Digit Vigilance Test. Archives of Clinical Neuropsychology, 33(2), pp.227-237.

Allgulander, C. (2012) "Generalized Anxiety Disorder: A Review of Recent Findings", Journal of Experimental & Clinical Medicine, 4(2), pp. 88-91.

Bullis, J., Bøe, H., Asnaani, A. and Hofmann, S. (2014) "The benefits of being mindful: Trait mindfulness predicts less stress reactivity to suppression", Journal of Behavior Therapy and Experimental Psychiatry, 45(1), pp. 57-66.

Deckersbach, T., Hölzel, B., Eisner, L., Lazar, S. and Nierenberg, A. (2014.) Mindfulness-based cognitive therapy for bipolar disorder. 1st ed. New York: Guilford Publications.

Eastman, N. (2012) Forensic psychiatry. 1st ed. Oxford: Oxford University Press.

Hofmann, S., Sawyer, A., Fang, A. and Asnaani, A. (2012) "Emotion dysregulation model of mood and anxiety DISORDERS", Depression and Anxiety, 29(5), pp. 409- 416.

Kristeller, J. and Hallett, C. (1999) "An Exploratory Study of a Meditation-based Intervention for Binge Eating Disorder", Journal of Health Psychology, 4(3), pp. 357-363.

Long, J., Briggs, M., Long, A. and Astin, F. (2016) "Starting where I am: a grounded theory exploration of mindfulness as a facilitator of transition in living with a long-term condition", Journal of Advanced Nursing, 72(10), pp. 2445-2456.

Neumark-Sztainer, D., Paxton, S., Hannan, P., Haines, J. and Story, M. (2006) "Does Body Satisfaction Matter? Five-year Longitudinal Associations between Body Satisfaction and Health Behaviors in Adolescent Females and Males", Journal of Adolescent Health, 39(2), pp. 244-251.