Nursing Care for Schizophrenic Clients: Recent Advances and Client-Centred Nursing Care Perspectives

Abstract

Schizophrenia is one of the leading causes of disability worldwide; psychiatric disorders can result in impairments of perception, poor self-care, and decreased performance in activities of daily living. Treatment and nursing care are vital options for clients to improve their signs and symptoms, especially during the COVID-19 pandemic. The planning of nursing care for individual schizophrenic clients is essential and will help them have a satisfactory quality of life. Current nursing should be provided according to the client’s needs and particular problems, such as the presence of comorbidities, amidst the state quarantine. The current nursing care focuses on telenursing, with nurses implementing information technology to provide the necessary care. Despite the physical distancing, clients can access nursing services efficiently, with nurses being flexible enough to continue their care provision during the COVID-19 pandemic.

1. Introduction

The most common impairments of schizophrenic patients include delusions, illusions, hallucinations, anger, hostility, and aggression. Nursing care for this population should focus on patient-centered needs and individual problems. In addition, during the coronavirus pandemic, telenursing should be provided to prevent infection and adhere to social distancing rules. The practical nursing process application will reflect the effective nursing outcomes.

When the global coronavirus SARS-CoV-2 (COVID-19) epidemic hit, nursing care was pressed to switch to telenursing. Telenursing is primarily performed by the nurses using a cell phone, computer, audio and video technology, or advanced digital and optical communications, in order to deliver health care and provide remote, synchronous (e.g., via live interactive videoconference) or asynchronous (e.g., the information is stored electronically) care. This type of health care usually falls within care management for emergent situations, coordination of care, and health maintenance services. It is considered beneficial for both the patient and nurse; the patient benefits from increased access to health care services, while the nurse benefits from a more flexible and less physically stressful work environment.

Telenursing is increasingly prevalent in the nursing domain because of a preoccupation with cutting down on health care costs, an increase in the number of aging and chronically ill individuals, and a rise in the coverage of health care to distant, rural, minor, or sparsely populated regions. Telenursing, providing nursing care at a distance using new technologies, is identified as one alternative. Among its many benefits, telenursing may help prevent a shortage of nurses, reduce distance and save travel time, and keep patients out of the hospital. A greater degree of job satisfaction has also been registered among telenurses.

Telenursing has been considered a potential solution to service delivery challenges during the COVID-19 pandemic, mainly due to its compliance with physical distancing measures and stay-at-home orders implemented by several governments to curb the spread of infection. Additionally, telenursing is benefit for the nurse to providing telenursing care for victims in disasters in a simulated study for introducing of possibility nursing interventions, telenursing education on nurses’ compliance with standard precautions during the COVID-19 pandemic [1], telenursing training based on family-centered empowerment pattern on compliance with diet regimen in patients with diabetes mellitus, education through telenursing can increase the quality of life of COVID-19 patients [2], telenursing in COVID-19 times and maternal health: whatsapp® as a support tool, telenursing on attachment and stress in mothers of preterm infants, telephone-based telenursing on perceived stressors among older adults receiving hemodialysis, telenursing on levels of depression and anxiety in caregivers of patients with stroke, Treatment of Obesity Among Youth With Intellectual and Developmental Disabilities: An Emerging Role for Telenursing [3], Telenursing intervention increases psychiatric medication adherence in schizophrenia outpatients [4]. Telenursing are ongoing to increase both nationally and internationally. A primary role of telenursing is to channel clients towards appropriate levels of nursing care thereby reducing healthcare costs and freeing up resources [5, 6].

The purpose of this chapter is two-fold. First, it describes the principle of caring for a person with schizophrenia during the COVID-19 pandemic. Second, it aims to describe the processes behind understanding the facilitators and barriers to telenursing during the pandemic.

The principle of caring for a person with schizophrenia during the COVID-19 pandemic.

This chapter provides an overview of telenursing and its application to nurses’ daily practical challenges. The principle of caring for a person with schizophrenia during the COVID-19 pandemic is as below:

2. Cognitive and perceptive disorders (delusions, illusions, and hallucinations)

2.1 Delusions

A delusion refers to a fixed false belief with no basis in reality in the psychotic phase of an illness. A common characteristic of schizophrenic delusions includes the direct, immediate, and total certainty with which the client holds these beliefs. A person with schizophrenia is probably suspicious, mistrustful, and guarded about disclosing personal information. They may examine a room periodically or speak in hushed, secretive tones due to delusions.

2.2 Illusions

An illusion distorts one’s senses by misinterpreting true sensory stimuli, as in visual illusions. Some misconceptions are based on general assumptions that the brain makes by using organizational principles, the client’s perceptual ability and motion perception, and perceptual dependability. The causes of illusions are biological, psychological, and physical. For example, hearing voices regardless of the background would be a hallucination, whereas hearing voices instead of the sound of running water would be an illusion; individuals watching a ventriloquist will perceive that the voice is coming from the dummy since they can see the dummy’s mouth moving (Table 1).

Types of delusions	Description
Persecutory delusions	The conviction of a person with schizophrenia regarding others wanting to harm, spy on, follow, ridicule, or belittle them. Sometimes, they cannot name who these “others” are. They may think that their food has been poisoned, and their bedroom has been bugged with listening devices. Occasionally, specific individuals, including family members, may be named as the “persecutor.” Sometimes, the “persecutor” is the government, the Federal Bureau of Investigation, or any other powerful organization.
Grandiose delusions	The client believes that they are famous or capable of incredible feats.; Examples: The client may claim to be engaged to a famous movie star or related to some public figure, such as claiming to be the daughter of the president of the United States, or they may claim to have found a cure for cancer.
Religious delusions	The client believes that they center around the second coming of Christ or another significant religious figure or prophet. These religious delusions appear suddenly as part of the client’s psychosis and are not part of their or others’ religious faith.; Examples: The client claims to be the Messiah or some prophet sent from God; they believe that God communicates directly with them, or they have an extraordinary religious task or special spiritual powers.
Somatic delusions	They believe that they have an illness, but it is not valid. Even though they are healthy, it does not change these beliefs.; Examples: A male client may say he is pregnant, or a client may report having decaying intestines or worms in the brain.
Delusions of reference	The conviction of a person with schizophrenia about television broadcasts, music, or newspaper articles has a special meaning for them.; Examples: The client may report that the president was speaking directly to them on a news broadcast or sent particular messages through newspaper articles.

Table 1.

Five types of delusions.

2.3 Applying the nursing process for clients with delusion

2.3.1 Nursing diagnosis

Risk for self-harm/other harmful activities related to disturbed thought processes

2.3.2 Assessment data

• Thinking not based on reality

• Disorientation

• Labile affect

• Short attention span

• Impaired judgment

• Distractibility

2.3.3 Goals

• Build a relationship with the client based on empathy and trust.

• Encourage an understanding of the features and appropriate management of delusions.

• Promote coping strategies.

• Promote medication compliance and healthy lifestyle choices (diet, exercise, no smoking, and substance abuse).

• Promote social skills and support networks.

• Promote effective working relationships and communication.

2.3.4 Outcomes

Immediate: The client will

• Experience safety

• Have decreased anxiety levels

• Respond to reality-based interactions

Stabilization: The client will

• Respond to reality-based interactions

• Have increased concentration to complete tasks

Community: The client will

• Verbalize recognition of delusional thoughts

• Experience safety (Table 2)

Nursing interventions (* Apply telenursing)	Rationale
Assessment of the level of; Thinking not based on reality Disorientation Labile affect Short attention span Impaired judgment Distractibility	To plan for the care of specific symptoms.
Communicating with sincerity and honesty.*	The person with schizophrenia and delusions is susceptible to others and can recognize insincerity. Evasive comments or hesitation reinforce mistrust.
Be consistent in setting expectations, rules, and so forth.	May decrease anxiety, which leads to severe delusion.
Do not make promises that you cannot keep.	Broken promises lead to the client’s mistrust of others.
Encourage the client to start small talk with another client.	To promote social skills.
Formulating procedures and ensuring the client understands the procedures before providing nursing care.	When clients have full knowledge of the procedures, they are more likely to feel safe and have no anxiety.
Give positive feedback.	Positive feedback for genuine success enhances them to maintain positive behavior.
Use unconditional positive regard.	Recognizing the client’s perceptions can help nurses understand their feelings and provide more chances to talk with them to know about their needs.
Avoid vague or evasive remarks and do not convince the client that their delusions are false or unreal.	An argument can interfere with the development of trust.
Interact with the client based on the present reality technique.	Interacting with reality can enhance the perception of the client’s actual situation.
Promote one-on-one activities, then in small groups, and gradually in larger groups for the person with schizophrenia.	A suspicious client can best deal with one person at first. The steady introduction of others is enforced as the client tolerates less hostility.
Support the client’s accomplishments, such as completing projects, tasks fulfilled and initiating interactions.	Recognizing the client’s accomplishments can decrease anxiety and promote self-esteem.
Use empathy regarding the client’s feelings; reassure the client of your presence and recognition.*	Empathy conveys your caring, interest, and acceptance of the client.
Avoid being judgmental, belittling, or joking about the client's beliefs.	The client may not appreciate or feel rejected by attempts at humor.
Directly interject doubt about delusions when the client is ready to accept, with this sentence, “I find that hard to believe.” Avoid disagreeing but give information about the actual situation as you see it.	Once the client trusts you, they may become willing to doubt the delusion if you express your doubt.
Ask the client if they can see that the delusions interfere with or cause problems in their lives.	The question may help the nurse in planning care and can decrease the client’s anxiety from delusion
Provide medication as a prescription and educate them about the drug and positive benefits of medication adherence [7].	The medication will balance neurotransmitters and decrease psychotic symptoms, such as delusions.
Record vital signs and monitor medication-induced movement disorders and adverse effects.	To record signs and symptoms during medication treatment and plan a client-centered nursing intervention.
Provide cognitive compensatory interventions and cognitive remediation according to the client’s needs [8].	Cognitive compensatory interventions aim to ease psychosocial disability by targeting straight-line functioning using aids and strategies, thereby minimizing cognitive impairment.
Encourage clients to join the group of internal self-management strategies, such as self-talk during task completion, paraphrasing instructions, and using mental imagery [9, 10, 11]	Internal self-management strategies facilitate more efficient cognitive processing during task performance regarding categorical relationships to aid memory.

Table 2.

Nursing interventions.

2.4 Sensorium and intellectual processes: Hallucinations

The main psychotic symptom of people with schizophrenia is hallucinations. A hallucination refers to false sensory perceptions that appear real. Hallucinations are related to five senses and bodily sensations. They can be both threatening and pleasant (Table 3).

Types	Description
Auditory hallucinations	These comprise voices demanding that the client take action, often to harm the self or others, and are considered dangerous. The most common type involves hearing sounds, most often voices, talking to or about the client. There may be one or multiple agents; a familiar or unfamiliar person’s voice may be speaking.
Visual hallucinations	They comprise visual images that do not exist at all.
Olfactory hallucinations	These involve a specific olfactory sense that smells something wrong, such as urine, feces, or the body.
Tactile hallucinations	Tactile hallucinations are most frequently found in clients undergoing alcohol withdrawal; they rarely occur in clients with schizophrenia. The client will feel like a bug on their skin and try to eliminate it.
Gustatory hallucinations	These hallucinations feel like a client’s taste is lingering in the mouth or the fact that food tastes like something else. The taste may be metallic, bitter, or represented as a specific taste.
Synesthetic hallucinations	The client reports feeling like bodily functions are usually unnoticeable. Examples would be the sensation of urine forming or impulses being transmitted through the brain.
Kinaesthetic hallucinations	The client is immobile but reports the sensation of bodily movement. Physical activity is odd, such as floating.

Table 3.

Types of hallucinations [12].

In psychotic episodes, disorientation of time and place, as well as depersonalization, are common in Cl. Although clients can state their name correctly, they think that their body belongs to someone else or that their spirit is separated from the body. They may also demonstrate poor intellectual functioning. The client cannot pay sufficient attention to display their academic abilities accurately. The nurse is more likely to obtain accurate assessments of the client’s intellectual abilities when their thought processes are more transparent. They often have obscurity with abstract thinking and may respond literally to other public situations and the environment.

2.5 Applying the nursing process for clients with hallucinations

2.5.1 Nursing diagnosis

Change in the amount or patterns of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli related to disturbed sensory perception

2.5.2 Related factors

• Altered sensory perception.

• Altered sensory reception: transmission or integration.

• Neurological/biochemical changes/stress.

2.5.3 Defining characteristics

• It has altered communication patterns.

• Hallucinations/auditory distortions/disorientation to person/place/time.

• Change in problem-solving patterns.

• Frequent blinking of the eyes and grimacing/inappropriate responses.

• Mumbling to self, talking or laughing/tilting the head as if listening to someone.

• A reported or measured change in sensory acuity.

2.5.4 Desired outcomes

The clients will

• State the symptoms they recognize when their stress levels are high.

• State that the voices are no longer intimidating, nor do they obstruct their life.

• State, using a scale from 1–10, that “the voices” are less frequent and intimidating when aided by medication and nursing care.

• Maintain role performance and social relationships/monitor their intensity of anxiety.

• Identify the stressful life events that trigger hallucinations, and personal interventions that decrease or lower the intensity or frequency of hallucinations (e.g., listening to music, wearing headphones, reading aloud, jogging, socializing).

• Demonstrate a stress reduction technique that distracts them from the voices (Table 4).

Nursing interventions (* Apply telenursing)	Rationale
Assessment of the level of: Altered sensory perception. Altered sensory reception: transmission or integration. Biochemical factors, such as those manifested by an inability to concentrate. Chemical alterations (e.g., medications, electrolyte imbalances). Neurological/biochemical changes/psychological stress. Or use the scale to screen the sign and symptoms [13].	To assess the client’s needs and problems and plan for nursing intervention.
Give details and accept that you do not hear the voices using the present reality technique. *	Validating that your truth does not include voices can help the client cast “doubt” on the validity of their voices.
Monitor signs of increasing fear, anxiety, or agitation.*	Fear, anxiety, or agitation is the warning sign of hallucinations and can decrease them.
Explore how the client experiences the hallucinations, such as content, frequency, influencing factors, and coping with delusion [7].	Exploring the hallucinations and sharing the experience can help give the person a sense of power that they might be able to manage the hallucinatory voices.
Help the client to identify the needs that might underlie the hallucination. In what other ways can these needs be met.	Hallucinations might reflect the need for anger, power, self-esteem, and sexuality.
Help the client recognize times when the hallucinations are most rife and fearsome.	The helps both the nurse and client to recognize the situations and times that might be most anxiety-provoking and intimidating.
Provide environmental precautions when the delusion or hallucination commands them to harm the self.; Notify the health care team and administration according to unit protocol. Document what the client says, and if they are a threat to others, document who was contacted and notified (use agency protocol as a guide).	People often obey hallucinatory commands to kill themselves or others. Early assessment and intervention might save lives.
When clients start to hallucinate, stay with them and tell the voices they “hear” to go away. Repeat often in a matter-of-fact manner.	The client can sometimes learn to push voices aside when given repeated instructions, especially within a trusting relationship.
Decrease environmental stimuli when possible (low noise, minimal activity).	Decrease the potential for anxiety that might trigger hallucinations. This helps calm the client down.
Intervene through one-on-one interaction, seclusion, or PRN medication (as ordered) when appropriate.	Use chemical or physical restraints following unit protocols in case of uncontrol.
Keep to simple, essential, reality-based topics of talk and support the client in focusing on one thought at a time.	The client’s thoughts might be confused and muddled; this caring helps the client focus on and comprehend reality-based issues.
Find which activities can reduce anxiety and distract the client from a hallucination, and perform training with the client, such as relaxation techniques [14].	Anxiety and stress lead to hallucinations, and relaxation techniques can reduce stress and anxiety, which will decrease hallucination.
Keep clients in reality-based activities, such as group activities.	Redirecting the client’s energy to acceptable activities can decrease and distract them from hallucinations.
Provide flexible services, such as tele counseling and medication delivery.*	This would support the client in receiving continuous treatment.

Table 4.

Nursing interventions and rationale.

2.6 Conclusion

There is a variety of nursing care that can be provided for a person with cognitive impairment, such as schizophrenic clients in the schizophrenia disorder spectrum. Holistic care is always the go-to approach for decreasing the negative signs and symptoms. Psychosocial and compensatory interventions for cognitive impairment in psychotic disorders are famous and influential in improving functioning as well as decreasing the negative and general symptoms. Continuous compensatory interventions are associated with more significant improvements in functioning. Additionally, medication adherence, social function, and social support are critical factors that nurses should be concerned about, training the clients and caregivers accordingly.

3. Behavioural problems (anger, hostility, and aggression)

Anger, hostility, and aggression are common behavioral problems in schizophrenic clients. When handled appropriately and expressed assertively, anger can be a positive force that helps resolve conflicts, solve problems, and make decisions; anger results from a person being frustrated, hurt, or afraid. Anger energizes the body physically for self-defense by activating the “fight-or-flight” response mechanism. However, it can cause physical or emotional problems and interfere with relationships when expressed inappropriately or suppressed. Anger is perceived as a negative feeling. People who are uncomfortable reveal their anger directly. However, anger can be a normal response when situations are inequitable or undue, personal rights are not respected, or realistic expectations are not met. If the person can express their anger energetically, problem-solving or conflict resolution is possible. Anger becomes negative when someone rejects or suppresses it if they are uncomfortable expressing it. Examples of the consequences of anger include migraine, headaches, ulcers, coronary artery disease, depression, and low self-esteem.

Inappropriately expressed anger can lead to hostility and aggression. Some people express their angry feelings through safe activities, such as hitting a punching bag or yelling. Such actions, called catharsis, are supposed to provide a release for anger. However, catharsis can increase rather than alleviate anger. Practical methods of anger expression, such as assertive communication, should replace angry, aggressive outbursts of temper, such as yelling or throwing things. Controlling one's temper or managing anger effectively should not be confused with suppressing angry feelings, leading to the problems described earlier.

3.1 Hostility and aggression

Hostility, also called verbal assault, is an emotion expressed through negative verbal outbursts, uncooperative rules or norms, or hostile behavior. It occurs when individuals feel threatened or have no power. Hostile behavior causes emotional harm and leads to physical aggression. Verbal and physical aggression is meant to harm another person to experience fulfillment, caused by delusions and/or hallucinations in the schizophrenia spectrum. Some clients with psychiatric disorders display hostile or physically aggressive behavior that challenges the professional nurses.

Hostile and aggressive behavior can be sudden and unexpected. Clients with psychotic illnesses are much more likely to harm themselves than others. In contrast, clients with paranoid delusions may believe others are out to get them, assuming they are protecting themselves; they retaliate with aggression or hostility. Some clients have auditory hallucinations that dominate them to hurt others. Overall, violent clients are more symptomatic, have poorer functioning, and lack insight. Some clients with depression have anger attacks. These sudden intense spells of anger typically occur in situations where the depressed person feels emotionally trapped. Anger attacks engage verbal expressions of anger or rage but no physical aggression. Clients identify these anger attacks as uncharacteristic behavior unsuitable for the situation. The anger in some depressed clients is related to irritable mood, overreaction to minor annoyances, and decreased coping abilities (Table 5).

Phase of aggression	Description	Behavioral expression
Triggering phase	A situation initiates the client’s expression of anger/ hostility.	Restlessness, anxiety, tetchiness, pacing, muscle tension, tachypnoea, speaking loudly, anger.
Escalation phase	Loss of control.	Pale or flushed face, yelling, swearing, being agitated, threatening, demanding, having clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly.
Crisis phase	Loss of control.	Loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, and poor communication.
Recovery phase	Regains physical and emotional control.	Lowering the tone of voice; decreased power tension; clearer, more rational message; bodily relaxation
Post-crisis	Reconciliation with others proceeds to the execution level before the aggressive occurrence and its antecedents.	Regret, apologies, crying, calming down, separation

Table 5.

Five-phase aggression cycle [15].

3.2 Application of the nursing process

3.2.1 Nursing diagnoses

The risk for other-directed forms of violence related to ineffective coping

Risk factors
Potential violence Destruction of property Homicidal/suicidal ideation Harm to self or others Assaultive behavior Neurologically disordered Substance abuse	Agitation or restlessness Out of control Psychotic symptoms (delusions/ hallucinations) Personality disorder/ conduct disorder Manic episode Posttraumatic stress disorder (PTSD)

3.2.2 Expected outcomes

Immediate: The client will

• Be free of self-harm.

• Decrease violence/aggressive behavior

Stabilization: The client will

• Demonstrate the ability to exercise internal control over their behavior.

• Show no psychotic behavior.

• Identify strategies to deal with tension and aggressive feelings in a non-destructive manner.

• State feelings of anxiety, fear, anger, or hostility verbally or in a non-destructive manner.

• Express an understanding of aggressive behavior, associated disorder(s), and medications, if any.

Community: The client will

• Contribute to treatment-associated psychiatric problems.

• Show internal control of behavior when faced with stress (Table 6).

Implementation (* Apply telenursing)	Rationale
Build a trusting relationship and keep calm.	Trust can reduce the client’s fears and aid effective communication. Your behavior provides a role model for the client and communicates that you can and will provide control.
The nurse should be assessing: Risk factors that influence aggression in the psychiatric environment. A history of violent or aggressive behavior. Determination of how the client with a history of aggression handles anger and what the client believes is helpful in assisting them in controlling or non-aggressively managing angry feelings. Clients who are angry and frustrated and think that no one is listening to them are more prone to behave hostile or aggressive. History Violence A history of being personally victimized Substance abuse Which phase of the aggression cycle they are in to implement appropriate intervention. Individual cues, such as what the client is saying, changes in the client’s voice—volume, pitch, speed; changes in the client’s facial expression and behavior can help the nurse identify when aggressive behavior is coming up.	Assessment and effective interventions with angry or hostile clients can often prevent aggressive episodes. Early assessment, judicious use of medications, and verbal interaction with an angry client can often prevent anger from escalating into physical aggression.; The data from the interview will help the nursing plan for nursing intervention to prevent harmful situations.
Be aware of factors that boost violent behavior and utilize verbal communication or PRN medication, restraint, and legal requirement.	Decide and act quickly. Warning signs of agitation include restlessness, verbal cues, motor activity pacing, speaking louder, verbal cues, threats, decreased frustration tolerance, and frowning or clenching fists. If the client is severely agitated, medication may be necessary to decrease the agitation.
Reduce external stimulation by turning the stereo or television off or lowering the volume, dropping the lights, and asking other clients, visitors, or others to leave the area.	The client is not capable of dealing with stimuli overload when agitated.
If the client communicates with you (verbally or nonverbally) that they feel hostile or destructive, try to help them express these feelings in non-destructive ways (e.g., use communication techniques or take the client to the gym for physical exercise).	The client can try performing positive behaviors with you in a nonthreatening environment and learn to focus on conveying emotions rather than acting out.
Serenely and deferentially assure the client that you will provide control if they cannot control themself, but do not threaten the client.	The client may fear the loss of control and be afraid of what they may do if they begin to express anger. Showing that you are in control without competing with the client can reassure them without lowering their self-esteem.
Encourage clients to state anger appropriately as a model and use roleplaying assertive communication techniques. Use “I” statements that speak of feelings and are specific to the situation, for example, “I feel angry when you interrupt me,” or “I am angry that you changed the work schedule without talking to me.” *	The ‘I’ statements are a suitable expression of anger and can lead to creative problem-solving discussions and reduced anger.
Enable weapon removal; try to kick it out of the client’s hand.	Having a weapon increases your physical vulnerability.
The nurse needs to call outside assistance (especially if the client has a gun). When this is done, total accountability is delegated to the external authorities.	Exceeding the nurse’s abilities may place you in grave danger. It is unnecessary to deal with a situation beyond your control or assume personal risk.
Report the in-charge nurse and supervisor in a (potentially) aggressive situation; convey to them your appraisal of the case and the requirement for help, the client’s name, care plan, and orders for injection, seclusion, or restraint.	You may need support from staff members who are unfamiliar with this client. They will be able to help you more successfully and safely if they are aware of this information.
Follow the hospital staff guideline (e.g., use an intercom system to page “Code, [area]”); then, if needed, have one staff member meet the additional staff at the unit door to provide them with the client’s name, situation, goal, plan, and so forth.	The need for help may be instant in a crisis. Any detail given to the arriving staff will ensure safety and helpfulness in dealing with this client.
Be aware of physical restraints or techniques with indication.	The client has a right to the least limits possible for safety and prevention of destructive behavior.
Remain aware of the client’s body space or territory; do not trap the client.	Potentially violent people have a body space zone up to four times larger than that of other people. It would help if you stayed farther away from them for them not to feel trapped or threatened.
Talk with the client in a low, calm voice. Call the client by their name; tell the client your name and where you are.	Using a low voice may help prevent increasing agitation.
Tell the client what you will do and what you are doing. Use simple, straightforward, direct speech; repeat if necessary. Do not threaten the client, but state limits and expectations.	The client may be disoriented or unaware of what is happening.
When a decision has been made to subdue or restrain, the client acts quickly and cooperatively with other staff members. Tell the client that they will be controlled, suppressed, or secluded; allow 110 bargaining after the decision has been made. Reassure the client that they will not be hurt, and that restraint or seclusion is to ensure safety.	The client’s ability to understand the situation and process information is impaired. Clear limits let the client know what is expected of them.
While subduing or restraining the client, talk with other staff members to ensure coordination of effort (e.g., do not attempt to carry the client until you are sure that everyone is ready).	Firm limits must be set and maintained. Bargaining interjects doubt and will undermine the limit.
Do not strike the client.	Direct verbal communication will promote cooperation and safety.
Do not help to restrain or subdue the client if you are angry (if enough other staff members are present).	The physical safety of the client is a priority.
Develop and practice consistent restraint techniques as part of nursing orientation and continue education.	Consistent techniques let each staff person know what is expected and will increase safety and effectiveness.
Develop instructions on safe techniques for carrying out with clients. Obtain additional staff assistance when needed. Have someone clear furniture and so forth from the area where you will be taking the client.	Consistent techniques increase safety and effectiveness. Transporting an agitated client can be unsafe if attempted without enough help and sufficient space.
When placing the client in restraint or seclusion, tell them what you are doing and why (e.g., to regain control or protect the client from injuring themself or others). Use simple, concise language in a non-judgmental manner.	The client’s ability to understand what is happening to them may be impaired.
Give information to the client about where they are, that they will be safe, and the staff members that will take care of them. Tell the client how to summon the staff. Reorient the client or repeat to them the reason for restraint, as necessary.	Being placed in seclusion or restraint can be frightening for a client. Your assurance may aid in alleviating their fears.
Cautiously observe the client and promptly complete documentation regarding the hospital policy. Bear in mind the likely legal implications.	Correct, complete documentation is essential, as restraint, seclusion, assault, and so forth are events that may result in legal action.
Administer medication safely; prepare correct dosage, identify suitable sites for administration, withdraw plunger to aspirate for blood, and so forth.	When you are under stressful events and pressure to move fast, the risk of errors in dosage or administration of medication increases.
Keep away from needlestick injury and other injuries that may expose the client’s blood/body fluids.	Hepatitis A or C, HIV, and other diseases are transmitted by blood or body fluids contact.
Monitor the client for medications’ side effects and side effects and provide care as appropriate [14].	Medication treatment can have adverse effects, such as allergic reactions, hypotension, and pseudo-parkinsonian symptoms.
Talk with other clients after the situation is resolved; allow them to express feelings about the situation.*	The other clients have their own needs and problems. Be careful not to give attention only to the client acting out.

Table 6.

Implementation and rationale.

3.3 The facilitators and barriers to telenursing during the pandemic

Nurses play a pivotal role in the provision of mental and physical healthcare. Telenursing, the use of information and communication technologies to deliver and support healthcare directly to the setting, is emerging as an essential application for nurses. The empirical evidence supports its use in specific areas and guides those thinking of implementing telehealth in their practice. The future of home telehealth lies in carefully considered and designed research, ongoing education and training, and a multidisciplinary approach. This chapter aims to stimulate the consideration of home telehealth as an application that may improve nursing care and patient outcomes.

There is massive potential for technology such as telenursing to transform people's experience, including assisting with chronic disease management, coordinated care, and guided self-care for consumers. Innovative technologies are increasingly available to assist in maintaining health and independent living.

The beginning of 2020 has been characterized by the pandemic outbreak of a novel human Coronavirus named SARS-Cov-2. This virus is responsible for causing a disease, COVID-19, that often causes only mild illness but can also make some people very ill. More rarely, the disease can be fatal, especially among older people and those with pre-existing medical conditions who spread the virus.

That allowed to contain the spread of the virus, helping the health system to face the demands of thousands of people needing hospital advanced care. On the other hand, it resulted in worse health among people not affected by the virus. Recently, a review investigated the relationships between telenursing and health. The authors identified health problems (musculoskeletal problems, psychological problems, overwork, and others) and benefits (stress reduction, greater flexibility, better work-life balance/control, and enhanced job satisfaction).

At the end of March 2020, Italy was the world’s most affected country by the novel coronavirus spread. The advanced average age of the population, together with a particular social structure, has also contributed to making the death rate of this country among the highest in the world.

The pandemic forced Governments to establish lockdown measures such as the closing of schools, universities, banks, parks, supermarkets, and non-essential businesses, limiting movements and transport, and promoting social distancing, to slow down the and a lower risk of burnout but on the other hand, the responders think that working from home diminishes their promotion opportunities and weakens ties with their colleagues and employer

Integrating technology into health care has created both advantages and disadvantages for patients, providers, and healthcare systems alike. Overall, the benefits of technology in health care outweigh the risks; however, proper measures must be taken to ensure successful implementation and integration. Accuracy, validity, confidentiality, and privacy of health data and information are key issues that must be addressed for successful technology implementation. This chapter examines the risks and benefits of technology in health care, the availability of health information online, and how technology affects relationships within the healthcare setting.

3.4 The advantage of telenursing during the pandemic

The COVID-19 pandemic has forced most countries to implement social distancing measures, also known as “lockdown,” to reduce the virus transmission through respiratory droplets and contact routes by increasing physical distance or social distance aggregations19. The adoption and development of telenursing helped reduce some of the consequences of the current health crisis on the economy. It allowed continuing business even if workplaces were inaccessible, and telenursing has a significant emotional impact on nurses and patients, with the appearance of negative emotions such as loneliness, irritation, worry, and guilt. Telenursing overall was also found to experience more mental health support than usual care. The correlation may have been influenced by the current pandemic situation, which can feel that receiving information from nurses via telephone can be much safer than going to the hospital and taking public transport. People with lower educational levels had a lower risk of psychological distress than those with higher education. That assumption contrasts with solid evidence that low socioeconomic position is often associated with severe mental health disorders, such as depression.

What emerged about lifestyle habits is the rise of unhealthy behaviors among the responders who reported higher levels of psychological distress and lowered perceived well-being. Half of the responders reported to be smokers have increased the number of daily cigarettes during the lockdown. Tobacco smoking is a well-known coping strategy against psychological stress 26. Many studies 27,29 have also reported that those who smoke or drink alcohol usually increase their consumption in stressful conditions. Eating habits changed for almost half of the participants, and most of them increased food consumption. It is known that psychological stress can alter both the quantity (there is usually an increased food intake) and quality (typically with high sugar or carbohydrate content) of food. Besides, stress-induced alterations in food intake can, in turn, influence mood 30,31. The literature has also demonstrated concern about food (often unhealthy) intake as a mechanism to cope with stress. It can be considered valid also in the context of this research. People who reported not “feeling sheltered at home” felt more psychological distress and poorer well-being. This is consistent with the evidence about the health benefits of cohabiting and the adverse effects of isolation (i.e., the state quarantine).

3.5 The barriers to telenursing during the pandemic

Implementing existing healthcare systems poses some potentially deterring and serious risks, such as confidentiality breaches, identity theft, technological breakdowns, and incompatibilities. Therefore, electronic records should not be hastily integrated into healthcare systems without proper precautions.

4. Conclusion

Telenursing, increasing diffusion and adoption of this type of work organization. The consequences of the COVID-19 pandemic and lockdown impact well-being and psychological distress experienced and are at risk of unhealthy eating behaviors and increased cigarette smoking or substance abuse, especially among those with higher education levels who live alone. Occupational physicians may play a central role in that process even through health promotion campaigns (healthy diets, tobacco smoking cessation) and supporting nurses in the risk assessment.

In order to provide nursing care to angry, hostile, or aggressive clients, nurses should identify the strategies to manage angry feelings, assessing assertive communication and conflict resolution. Enhancing these skills in dealing with behavioral problems in schizophrenic client will help nurses work more effectively with clients; the care of potentially aggressive clients should be discussed with experienced nurses, and nurses should be trained not to take the client’s anger or aggressive behavior personally. Moreover, telenursing is a low-cost and free resource that will be the strategy for considering while providing care for the COVID-19 pandemic.

Conflict of interest

The authors declare no conflict of interest.