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Keywords:

  • Providing structure;
  • nursing intervention;
  • psychiatric nursing

Abstract

  1. Top of page
  2. Abstract
  3. Method
  4. Findings
  5. Discussion and Conclusions
  6. References

Purpose

To observe the actions of psychiatric nurses when providing structure and identify results in order to better understand providing structure as a complex nursing intervention.

Design and Method

Participant observation data were collected on a dual diagnosis ward and a crisis intervention ward in a mental healthcare organization. A total of 52 events were selected that involved providing structure.

Findings

Three phases in the processing of providing structure were identified: the start of the interaction, the interaction phase, and the end of the interaction. For each phase in the intervention, both critical nurse and patient responses were coded.

Practical Implications

The results of this observational study contribute to a formalization of the nursing intervention “providing structure” in the Nursing Interventions Classification.

Psychiatric nurses often write “provide structure” in their nursing plans, but without further description of nursing actions or achieved goals. The Nursing Interventions Classification (NIC) (Bulechek, Butcher, & McCloskey Dochterman, 2008) also does not mention an intervention called “provide structure” or “providing structure.” It is thus questionable whether nurses know exactly what to do to provide structure for psychiatric patients.

A recent review of the research literature using NIC keywords closely related to the concept of “providing structure” (e.g., use of structure, structure, restrictiveness, limit setting, setting limits, therapeutic milieu) revealed 40 research or opinion articles that were based on predominantly qualitative research. The methodological quality of these studies was assessed using the criteria of Van Tulder, Assendelft, Koes, Bouter, and the Editorial Board of the Cochrane Collaboration Back Review Group (1997) and, despite sufficient methodological quality, it proved difficult to compare the data on providing structure. Research designs and means for providing structure differed widely across the studies reviewed.

Based on the literature review and closer inspection of the included studies, three elements of providing structure could be discerned, namely to impose and maintain rules and limits, to assess the condition of the patient, and to interact with the patient (Voogt, Nugter, Goossens, & Van Achterberg, in press). With regard to the imposing and maintenance of rules and limits, two continua could be distinguished: (a) the continuum from general to specific structure (Garritson, 1983; Ransohoff, Zachary, Gaynor, & Hargreaves, 1982; Sebastian, Kuntz, & Shocks, 1990; Silver Curran, 2007; Vatne & Fagermoen, 2007; Yonge, 2002), and (b) the continuum from least to most restrictive forms of structure (Caplan, 1993; Delaney, 2006; Kozub & Skidmore, 2001; Morales & Duphorne, 1995; O'Brien, Woods, & Palmer, 2001; O'Brien, 2000; Vatne & Fagermoen, 2007).

In relation to the assessment of the patient's condition, four aspects were mentioned. These were the assessment of ego functions (Benfer & Schroder, 1985; Kerr, 1990a, 1990b), responses of the patient to being limited or supported (Delaney, Rogers Pitula, & Perraud, 2000; Garritson, 1983; Lancee, McCay, & Toner, 1995; Ransohoff et al., 1982), ability of the patient to adequately respond to redirection (Kozub & Skidmore, 2001), and the individual need of the patient for autonomy and self-control (Garritson, 1983; Lowe, 1992; Lowe, Wellman, & Taylor, 2003; Mohr, Mahon, & Noone, 1998; Morales & Duphorne, 1995).

Through the interaction nurses tried to relate to each patient, and nurses tried to put themselves in the patient's shoes to recognize the patient's individuality (Björkdahl, Palmstierna, & Hansebo, 2010). Nurses also tried to exchange mutual expectations about what to expect during treatment. This led to involvement of the patient in a process of cooperation with nurses and it led to the formulation of clear treatment goals (Caplan, 1993; Hopkins, Loeb, & Fick, 2009; Sebastian et al., 1990; Vatne & Fagermoen, 2007; Walker, 1994; Yonge, 2002). The three elements of providing structure appeared to be interrelated.

On the basis of literature review, three goals and several effects of providing structure could be identified, which ranged from most to least restrictive: to attain external security for the patient, to make mutual expectations within the treatment relationship explicit, and to attain the feeling that the patient better fits into the world and is recovering from illness (Voogt et al., in press).

The attainment of external security entailed the creation of a climate of trust, an intrapersonal feeling of safety at the same time (Lowe, 1992; Mohr et al., 1998; Puskar et al., 1990; Yonge, 2002), and a physically controlled environment to allow the patient to express tensions in a safe manner (Benfer & Schroder, 1985; Björkdahl et al., 2010; Vatne & Fagermoen, 2007; Vatne & Holmes, 2006; Vrale & Steen, 2005). Providing structure seemed most effective when psychiatric nurses respected the patient's autonomy, were sensitive and responsive to signs of fear and anxiety, and adapted their actions to the needs of the patient. If not, providing structure led to resistance, anger, fear, and incomprehension of treatment policy (Johansson & Lundman, 2002; Lancee et al., 1995; Mohr et al., 1998; Olsen, 2001; Silver Curran, 2007; Vatne & Fagermoen, 2007; Vatne & Holmes, 2006; Walker, 1994).

When mutual expectations were made explicit, barriers between nurses and patients lowered. This occurred as nurses tried to put themselves in the shoes of the patient (Björkdahl et al., 2010; Hopkins et al., 2009). In addition, the occurrence of unacceptable behavior could be avoided (Lowe, 1992). When inadequate communication between nurse and patient existed, expectations became unclear, mutual misunderstandings arose (Johansson & Lundman, 2002; Olsen, 2001; Walker, 1994), patients became insecure about the course of treatment, developed feelings of loneliness (Johansson & Lundman, 2002), and patients felt deceived, dissatisfied, and showed resistance to providing structure (D'Antonio, 2004; Olsen, 2001; Vatne & Fagermoen, 2007).

The final goal of achieving a better fit in the world meant that the nurse helped the patient to develop from a patient into a person in society, to live independently, and to allow the patient to have autonomy and responsibility, in order to enable the patient to shape his own recovery (O'Brien et al., 2001; O'Brien, 2000; Vatne & Fagermoen, 2007; Vatne & Holmes, 2006). Effects in relation to this final goal were that the patient felt supported, was able to function independently both inside and outside the hospital (Greig, Miller, Rollo, & McGillvray, 1985), and that he/she developed from a patient in the community to a person in the community (O'Brien et al., 2001; O'Brien, 2000).

Despite being able to identify critical elements of providing structure and three main goals for providing structure, no studies were found on the effectiveness of providing structure as a psychiatric nursing intervention.

The literature review led to the following provisional definition of providing structure as a psychiatric nursing intervention:

The aim of providing structure is to create a workable, well-organized situation between nurse and patient in which both can work purposefully and effectively towards the strengthening of ego-functions, towards the attainment of external security for the patient, towards explicit mutual expectations within the treatment relationship, towards participation in different life areas and recovery on the part of the patient. In order to do this, the nurse uses interaction, assesses the patient's condition, and imposes and maintains rules and limits in a balanced manner. (Voogt et al., in press)

Although in this provisional definition clear interrelations between the interaction between patient and nurse, the assessment of the patient's condition, and the imposing and maintenance of rules and limits existed, it remained unknown how these three elements interrelated, how nurses assessed the condition of the patient, and how nurses determined the amount of structure needed. For actual nursing practice, a balanced use of the different elements of providing structure appeared to be necessary. It was also difficult to decide if all of the goals related to providing structure were discerned and how nurses used the three key elements of providing structure to attain the aforementioned goals.

However, providing structure can also be construed as a complex intervention due to the number of components (i.e., nursing activities) that it involves. According to the Medical Research Council (MRC, 2008), many nursing interventions can be classified as a complex intervention, which they define as an activity that contains a number of components with the potential for interactions between them and which—when applied to the intended target population—can produce a range of possible outcomes and thus variable outcomes. For example: Providing structure applied in one situation can result in a calmed patient (or group of patients) but, applied in a different situation, it can result in an escalation of the situation (Kozub & Skidmore, 2001; Lancee et al., 1995; Lowe, 1992; Lowe et al., 2003; Sebastian et al., 1990). The complexity of an intervention can thus be defined in terms of the number of components and possible interactions between these components, and the degree of flexibility and tailoring possible for the intervention.

With that preceding in mind, an observational study of actual nursing practice was undertaken with an eye to developing a useful framework and an evidence base for the complex nursing intervention of providing structure, which would help nurses to underpin their interventions to provide structure. At this moment, the practice-based knowledge and experiences of nurses in combination with their personal styles seem to determine the application of providing structure.

The aim of this observation was 2-fold. First, we wanted to determine what nurses do when providing structure in actual practice and thus describe the content of various “providing structure” interventions in detail. Second, we wanted to identify the impact (i.e., results) of different forms of providing structure. The following research questions were thus formulated.

  • What do nurses do when providing structure in actual practice?
  • What are the observed results of providing structure?

Method

  1. Top of page
  2. Abstract
  3. Method
  4. Findings
  5. Discussion and Conclusions
  6. References

Based on the principles of grounded theory (Charmaz, 2006; Strauss & Corbin, 1998; Wester, 1995), a qualitative research design was adopted. Grounded theory aims to discover the perceptions and significance of people's behaviors, to reconstruct the ways in which people make sense of behavior, and to identify how people's interpretations of behavior influence their interactions. Grounded theory also aims to ground theory in empirical data, and thus the name.

To obtain a comprehensive description of behavior and interactions, we undertook participant observation. These observations resulted in an extensive set of field notes on the verbal and nonverbal behavior of nurses and patients during events in which structure was provided.

For the study of complex interventions, the MRC (2008) recommends a combined process of development, testing/piloting, evaluation, and implementation with a dynamic interchange between the different phases in the process. Each phase is important and can be quite lengthy in itself (see Figure 1).

figure

Figure 1. Key Steps in the Development and Evaluation Process (MRC, 2008)

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The present observational study can be considered part of the development phase for the creation of a complex “providing structure” intervention. First, we identified the evidence base for such an intervention via the aforementioned review and analysis of the literature (Voogt et al., in press). In the present study, we initiated the development of a framework and theory for providing structure as a psychiatric nursing intervention. A qualitative research design and a participant observation approach were chosen for this purpose. Furthermore, on the basis of the analyses of the qualitative data obtained in such a manner, the process and outcomes of providing structure for psychiatric patients were modeled.

With the use of purposive sampling (Morse & Field, 1996), we selected patients from two intensive care wards at a mental health hospital for observation. The expectation was that events that require providing structure would occur rather frequently on such wards with explicit boundaries. The patients on these wards could be characterized as patients with acute mental illness or a combination of acute mental illness and addiction problems, long-term care and chronic treatment needs, and a profound need for structure to meet these needs. Both wards were closed, and there were signed agreements with the patients in their treatment plans. Each ward had two separate units with 24 patients and 15 nurses in each unit.

The observed events had to meet one or more of the following criteria for consideration to be included:

  • The nurse had intervened because the patient had to participate more in certain life areas; the intervention was to ensure safety; or the intervention was to create a more habitable environment.
  • The nurse wanted the patient to do something that the patient initially did not want to do.
  • The patient wanted something the nurse could not provide immediately.

The end of an event was assumed to be reached when the nurse and patient parted and the verbal/nonverbal communication between them ceased. These criteria were developed in expert meetings with experienced psychiatric nurses. It took three meetings until consensus was reached.

Observations were conducted between August 2009 and January 2010. Intensive nurse–patient interactions were expected to occur at wake-up, breakfast, patient meetings (either group or individual), coffee breaks, lunch, evening meal, and bedtime. A total of 52 events met the aforementioned criteria and were included for analyses: 30 on the crisis ward and 22 on the ward for double diagnoses.

Procedures

The observations were performed by the first author. The observer had to be unobtrusive, so as not to disturb the usual ward routines (Polit, Beck, & Hungler, 2001). In one case, that meant to sit in the corner of the central living room with an eye on the nursing office, and in the other case the observer joined dinner with patients and nurses. The data from the first five observations were used to evaluate the initial observation format. The use of a standard observation format proved impossible because the observed events did not follow the order of the format or a standardized order. The use of a voice recorder to document the interaction also proved impossible because we could not get close enough to the participants without interfering. Thus, in the end, the observer simply made short notes on the nurse–patient interaction and providing structure process during the event. Immediately following the event, these notes were elaborated to record the event in as much detail as possible. After completion of the first 25 observations, the observation protocol was again evaluated to check that the written descriptions of the events met the inclusion criteria. No further adaptations were necessary.

The observer noted the date and time of the event, the number of patients and nurses present, the atmosphere on the ward at the time, the event itself, the initial reaction of the patient or nurse, the follow-up interaction, the verbal and nonverbal communication, how the interaction ended, and the outcomes of the interaction. The names of the patients and nurses were not noted and, in such a manner, the anonymity of the patients and nurses was assured.

Both the patients and the nurses were informed individually and in group meetings about the aims of the study, the methods, the use of the data, and the possibility of withdrawing from observation or the study any time. This information was also provided in a written document. Consents of patients and nurses were recorded in the minutes of group meetings. Prior to the start of each period of observation on a unit, the observer asked the nurses if the patients were stable enough to be observed and if there were any patients who did not want to be observed. When this proved to be the case, those patients were indeed excluded from observation. The medical ethics committee of the mental healthcare hospital approved the study and provided written consent.

Data Analysis

To develop a categorization scheme for the observed interactions and activities, we undertook open, selective, and axial coding (Charmaz, 2006; Strauss & Corbin, 1998; Wester, 1995). We used constant comparison to check the emerging codes and categories, to examine tentative ideas regarding the data, and to refine the categories.

After a detailed open coding of the events, a preliminary coding tree of categories and activities was developed with brief descriptions of the codes on memos by the researcher. Next, the initial coding tree was discussed with a research group, both individually and at a group meeting for which cases were selected at random to discuss. Among the initial activity codes were “Ask something from the patient” and “Confront the patient.” As a result of the constant comparison of the event data with the coding memos and the use of axial coding, the researcher decided the two codes of activities to become part of a new category code “Stop patient's current behaviour” because both activities were aimed to stop the patient's behavior. Furthermore, the former code “Ask something from the patient” transformed in “Request the patient to do something.” “To request to do something” specifies expected behavior better than “to ask something from the patient.” “Confront the patient” transformed in “Confront after action took place” because this emphasized the importance of reflection on activities the patient had performed.

With the use of selective coding, this resulted in the category code “Stop patient's current behaviour” together with the activity code “Request” being a less restrictive manner of stopping patient's behavior than together with the activity code “Confront” as a more restrictive way to respond.

Finally, a logbook was created to keep track of all discussions of the cases in the research group, the decisions made during the analysis of the data, and the changes made to the coding tree.

Data analysis was supported by the software tool for textual analysis, MaxQDA (Kuckartz, 2007). Data analysis stopped when no additional data, theoretical insights, or properties of the core categories were discovered (Charmaz, 2006).

Findings

  1. Top of page
  2. Abstract
  3. Method
  4. Findings
  5. Discussion and Conclusions
  6. References

With regard to the first research question, the data analysis led to the identification of an intervention process “providing structure,” which can be tentatively described as what nurses do to provide structure in actual practice. The following phases could be identified on the basis of our observations (see Figure 2).

  • Start of the interaction
  • Intervention phase
  • End of the interaction
figure

Figure 2. Diagram: Activities of Providing Structure

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Start of the Interaction

A providing structure event was assumed to start when either the patient or the nurse initiated contact in a situation that met the criteria outlined in the Method section (i.e., the nurse intervened to get the patient more involved, ensure safety, create a more habitable environment; the nurse wanted the patient to do something that the patient initially did not want to do; the patient wanted something that the nurse could not provide immediately). The atmosphere in the units could be generally characterized as relaxed during the events.

Initial Contact Initiated by the Patient

We identified four ways in which patients could initiate an interaction:

  • Draw attention by behaving conspicuously
  • Request something or indicate a desire to talk
  • Ask for medication or ask something about medication
  • Call a nurse to account for an agreement

In some of the events, the conspicuous behavior displayed by the patient created tension among the other patients. Examples of this were agitated talking, yelling, or walking away from the nurse without listening. The nurse would sometimes stop patient's behavior under such circumstances and otherwise ignore the conspicuous behavior of the patient (see nursing activities). In all other patient-initiated events, the patient talked calmly and slowly to the nurse. The patients rarely mentioned their expectations but, when they did, they used short sentences such as “I do not want you [the nurse] to act like this,” or patients reminded a nurse of something previously agreed upon, for example, that the nurse would give his medication an hour ago.

Initial Contact Initiated by the Nurse

We identified two ways in which the nurses could initiate an interaction:

  • Ask a patient or patients a general question or address a general remark to a patient or patients
  • Ask a patient a specific question

When the nurse posed a general question, it was usually relevant for a number of patients. For example, the nurse might inquire about the activities planned for the day while sitting at the breakfast table. When a nurse posed a specific question, her attention was usually focused on a certain patient. For example, the nurse might remind a patient of an agreement to take medication. Patients seldom refused to cooperate when the nurse initiated the contact; this only happened when the patient wanted to do something other than what the nurse asked or did not want to talk about what the nurse proposed.

The nurses only mentioned their expectations in 8 of the 52 events that were coded. An example is as follows: “You have been warned to not take drugs on the ward, and you know what the consequences of your doing this can be for your stay. So what I expect of you is that you not use drugs on the ward anymore. If you do use drugs, you will first be sent to your room. You may then be discharged depending on staff evaluation.” In this example, the nurse clearly connected the present behavior of the patient to the consequences of the behavior for the patient's treatment and used explicit sentences to do this.

Intervention Phase

After the start of an interaction, we next identified the first response of the patient to a nurse's attempt to make contact and the first response of the nurse to a patient's attempt to make contact.

First Responses of the Patient

The first responses of the patients to an initiation by a nurse could be classified along a continuum from most to least cooperative as depicted in Table 1.

Table 1. Continuum of First Responses of Patients From Most to Least Cooperative
Patient agrees to something or consents to a proposalPatient explains somethingPatient wants explanation or asks a follow-up questionPatient switches topicPatient does not agree to something and perseveres with undesirable behaviorPatient refuses explicitly

When a patient answered with a firm “yes,” it was clear that the patient was agreeing or consenting to the nurse's proposal. In other cases, the patient explicitly said he would cooperate with the nurse or do what the nurse proposed. The patient might also simply walk with the nurse, which also indicated agreement. Cooperation was further evident when the patient explained the reasons for his behavior. The reasons could involve a personal boundary; the verbal explicit wish to perform the activity; or the patient's feelings, needs, or judgments.

Lack of understanding was observed when the patient asked for an explanation, posed a follow-up question, or the patient switched subject. Then the patient seemed to indicate, also nonverbally, a hesitation to act as proposed by the nurse, and the patient appeared to be inhibited by a personal barrier. Some amount of cooperation nevertheless remained, however, because the patient stayed in contact with the nurse. Possibly, as a result of this conflict between verbal and nonverbal behaviors, the nurse often appeared to be caught by surprise. A fierce explicit and verbal reaction of the patient often indicated that the patient did not agree to what the nurse proposed in which no cooperation between patient and nurse existed.

First Responses of the Nurse (i.e., Nursing Activities)

The first responses of the nurses to a patient's attempt to make contact could be classified into four categories of nursing activities:

  • Ask the patient for more specific information
  • Explain something to the patient
  • Support and encourage the patient to follow treatment as planned
  • Stop a patient's current behavior

The first category of nursing activities in response to a patient-initiated interaction entailed asking for more specific information. The nurse could ask about specific personal subjects that mostly concerned medication, and the patient's day and night rhythm. For example, when a patient had red eyes and complained about fatigue during breakfast, the nurse could ask him if he can handle his planned activities for the day in relation to his fatigue. The nurse with her reaction, in this instance, appeared to help structure the patient's day. Questions could also be directed at individual responsibilities for group activities. For example, nurses could ask when a patient would do the grocery shopping that day, or what will happen if the grocery shopping is not done before noon. Finally, the nurses could ask questions that appeared to structure the group interaction, but in fact referred to an individual patient. At a ward meeting, for example, the effects of borrowing money from each other and lending money might be asked about.

The second category of nursing activities concerns explanation of something to the patient. Among other things, the nurse may explain the treatment process. Similarly, the nonverbal behavior of the nurses (e.g., give confirmation by nodding, look the patient in the eye) may indicate they are trying to understand the patient's behavior and/or trying to comfort the patient. The explanations provided by the nurses could thus range from general hospital-related issues to very patient-specific issues, as outlined in Table 2.

Table 2. Explanations Provided by Nurses From General to Specific Issues for the Patient
How things work on a ward in cases of involuntary admissionType of treatment, phases of treatment, speed of treatment planningWhat to expect with regard to treatment, goals of treatment, medication, therapies, discharge criteriaHow behaviors of patients can be perceived and affect the behavior of other patientsHow individual patient can perform new/desired behaviors and activities

The most general explanations concerned how things work on a ward in cases of involuntary admission, including closed-door policies and house rules. Less general explanations concern the type of treatment, phases in treatment, and speed of treatment planning. More individualized explanations concerned what to expect of treatment (i.e., medication and therapies), the goals of treatment, and the criteria for discharge. Even more specific were explanations of how the individual patient's behavior may be perceived and affect the behavior of other patients. Finally, the most specific explanations concerned just how the individual patient can perform new and desired behaviors and activities. During these—often repeated—explanations, the nurses spoke clearly and calmly, which provided support and comfort and was thus convincing.

The third category of nursing activities concerned the support and encouragement of the patient to follow treatment as planned. Three subtypes of this activity could be distinguished: support with the performance of agreed-upon tasks, the scheduling and management of activities, and support with the highlighting of the advantages for the patient to perform as suggested.

The first subtype of support and encouragement of the patient to follow treatment as planned involved help with the performance of agreed-upon tasks. This concerned the clarification of what the goals of task performance might be, and specification of what the expected outcomes of task performance might be. In doing this, the nurse did not question the intentions of the patient or the utility of performing the task at hand. The patient was complimented upon completion of the task. Moreover, when the nurse or a patient was not satisfied with the outcome, the nurse reflected on task performance and focused on the task as opposed to the patient when doing this. The nurse might therefore repeat the explanation of the task, provide more details on task performance, or reformulate the task. The nurse might also demonstrate task performance and thus act as a role model.

The second subtype of support and encouragement of the patient to follow treatment as planned involved help with the scheduling and management of activities. The support of the nurse might consist of formulating a time structure together with the patient to remind the patient of task performance and emphasize the importance of fulfilling tasks. The nurse might inform the patient with regard to the expected duration for an activity, the time remaining to perform a task, or when the nurse will come and help finish the activity.

The third subtype of support and encouragement provided to help the patient follow treatment as planned involved highlighting of the advantages for the patient to perform as suggested. In order to help the patient follow treatment as planned, the nurse could reflect on how the patient was doing relative to earlier or relative to other situations. The nurse might recall and emphasize the positive effects that occurred when performed as suggested, and emphasize positive effects expected to occur, for example, to regain the ability to solve a problem with another patient, or to become more independent in organizing groceries.

The fourth and final category of nursing activities occurring in response to a patient initiative was stopping the patient's current behavior. Four subtypes of stopping behavior were observed: requesting something, pointing out consequences of an action prior to the occurrence of the action, confronting the patient with the consequences of an action after occurrence of the action, and prohibition. The four subtypes of activities formed a continuum from least to most restrictive with regard to the boundaries imposed on the patient's behavior. In most cases, the stopping behavior concerned prior agreements such as undue taking liberties on the ward, failing to do something that was previously agreed upon, and reminders of house rules. The various nursing activities also often concerned the making of agreements to perform a specific task within a set time period.

The least restrictive and thus first subtype of stopping behavior is a simple request. The nurse requests that the patient perform a task that may have previously been agreed upon. A specific style of questioning was used for this purpose. The style could be characterized as friendly, positive, and assertive attitude of the nurse. The nurse sometimes had to remind the patient of an agreement that had been made between them and, in doing this, delivered the directive message as an inviting question or neutral question: “Could you come with me, please?”

The second subtype of stopping behavior is pointing out the consequences of an action on the part of the patient prior to the occurrence of the action. This is obviously aimed at the prevention of certain consequences. For example, a nurse was observed to tell a patient that he was not allowed to enter the nurses' office and mentioned that he [the nurse] would get angry if the patient did this. The patient immediately stopped and did not proceed to enter the nurses' office. The nurse continued talking to the patient and mentioned an alternative behavior such as “You could turn around now,” and the situation normalized. This specific activity borders on the following more restrictive subtype of stopping behavior, namely confronting the patient with his behavior.

The third subtype of stopping behavior is to confront the patient with the consequences of his or her action after its occurrence. Reference is often made to a mutually agreed-upon task that was nevertheless not performed. More specifically, the task can be a task that the patient should have known about or performed, a responsibility with respect to staff and/or other group members, or the consequence of not performing things as agreed upon. The confrontation subtype of stopping behavior is focused directly on the patient's behavior and quite detailed. Such confrontation can lead to situations that are more tense than other situations requiring stopping behavior.

The most restrictive and thus fourth subtype of stopping behavior is prohibition. This occurs when there is no room left for negotiation. Prohibition is typically a last resort and only turned to after several warnings have been issued but the patient's intolerable behavior persists: yelling or the damaging of goods on the ward. A critical boundary has been reached. The nurse voices disapproval of the patient's behavior, and the patient has to obey the nurse.

End of the Interaction

The findings with regard to how the interactions between the nurse and the patient end provide an answer to our second research question, namely: What are the observed results of providing structure? Similar to the interaction phase for providing structure, we examined the final responses of the patients and nurses' activities separately.

Final Patient Responses

The final responses of the patients could be classified along a continuum from most cooperative to least cooperative. Their final responses were observed to range from a clear statement of agreement to a refusal.

Patients were observed to acknowledge their behaviors, confirm their intentions to cooperate, or agree with a mutual solution using such clear statements as “okay” or “thank you.” Occasionally, the patients provided more information on what they intended to do and/or what the other patients needed to do in light of the division of tasks on the ward. In the interactions observed in this study, the patients generally acted as proposed by the nurse. The patient could also verbally or nonverbally show cooperation but, at the same time, restlessness or irritation. Such a final response was nevertheless still considered cooperation because the patient acted as mutually agreed upon. For example, when a patient was walking around restlessly on the ward and a nurse later turned him around and guided him to his room, the patient did not resist, although some irritation appeared the moment the patient was being touched. Further along the continuum is the patient initially verbally disagreeing with the nurse's proposal or walking away from the nurse but then reconsidering the nurse's proposal or request, returning to the nurse, and thus maintaining contact. This can be seen as a form of cooperation for which a mutually satisfying final result has yet to be made explicit. No cooperation was apparent when the patient walked away from the situation, indicated that he or she did not want to stay in contact with the nurse, and did not return soon thereafter. Alternatively, the patient might return but continue showing the same undesirable behavior as before, which then formed a provocation for the nurse. No cooperation was also obviously visible when the patient simply refused to act as the nurse proposed or previously agreed upon with the patient.

Final Nursing Activities

The final nursing activities during a providing structure intervention could be divided into the following four categories:

  • Reflect with the patient on what has happened between them
  • Act according to what has been agreed upon
  • Concede to the patient while staying in contact but without mutual agreement
  • Set a clear boundary in order to stop the patient's persistent behavior

In the first two ways of responding, cooperation between nurse and patient was obviously present and the atmosphere could be regarded as friendly. Both patient and nurse were relaxed and smiles appeared. Furthermore, equality between the nurse and the patient appeared to be present, both physically and psychologically. The nurse, for example, stood beside the patient; the nurse and the patient showed attention and interest in each other.

In the last two ways of responding, there was tension and a threat of escalation of the situation. In one situation, the nurse might concede to the patient's behavior and not demand anything more from the patient. For example, in the case that the patient had to clean the hallway on the ward, the nurse reminded him to do this on time, but the patient started to get more excited. At this stage, the nurse looked at the patient, did not remind the patient again, and went on doing other things. In another situation, the nurse just puts a firm stop at the patient's behavior, for example, when the patient was requested three times to leave the nursing office if he consisted swearing at one nurse, but refused to stop. Two nurses held the patient each on one side and guided him to his room. This refers to the aforementioned category in the intervention phase: “Stop a patient's behavior; prohibition.” At the end of these events, the reason for the nurse's (and the patient's) behavior could not always be discerned. The responses of the nurses in these two categories often occurred without explanation of why the nurse decided to concede to the patient or how the boundary for putting a stop to the patient's behavior was determined.

Discussion and Conclusions

  1. Top of page
  2. Abstract
  3. Method
  4. Findings
  5. Discussion and Conclusions
  6. References

The aim of this study was to describe, via participant observation, the complex nursing intervention of providing structure. In our search of the research literature, we found that the intervention label “providing structure” does not exist in the Nursing Interventions Classification (Bulechek et al., 2008) although psychiatric nurses in the Netherlands often use such an intervention (i.e., provide structure).

According to the guidelines of the MRC (2008), providing structure can be considered a complex intervention. Both an examination of the literature and observation should thus be part of the development phase for the study of this complex nursing intervention (MRC, 2008). In doing this, we asked the following two research questions:

  • What do nurses do when providing structure in actual practice?
  • What are the observed results of providing structure?

The answers to these research questions contribute to constructing a framework and theory for “providing structure.” With regard to the first research question, three phases could be distinguished which cover the beginning and end of an event, and also cover the range of activities of nurses during an event that required providing structure:

  • The start of the interaction
  • The intervention phase
  • The end of the interaction

A nurse or a patient initiated an interaction typically when they wanted something from the other party. The subsequent response of the patient or nurse then formed the start of the intervention phase. The first response of the patient to a nurse was often a turning point in the event, which could either escalate or remain peaceful. The initial responses of the patients could be categorized along a continuum from most to least cooperative. The first responses of the nurses to a patient initiative could be divided into four categories: ask the patient for more specific information, explain something to the patient, support and encourage the patient to follow treatment as planned, or stop a patient's current behavior.

With regard to the second research question concerning the end of an interaction and the observed results of providing structure, the last response of the patient could again be classified along a continuum from most to least cooperative. The last responses of the nurses could be divided into four categories: reflect with the patient on what has just happened, act according to what has been agreed upon, concede to the patient while staying in contact but without mutual agreement, or set a clear boundary in order to stop the patient's persistent behavior. Although the reason for the nurse to concede to the patient could not be discerned through observations, we assume that this was done to prevent further escalation.

The frequent call for providing structure in nursing plans suggests that providing structure is largely experience based rather than evidence based, and that providing structure thus depends upon the knowledge and experience of the nurses and nursing teams. The MRC (2008) has acknowledged these findings and therefore considers close examination of the experiences of nurses to be part of the development and evaluation phases for the establishment of complex interventions. In the introduction, it was mentioned that the outcomes of providing structure could vary dramatically. Some preliminary explanations for this variability can be derived from the continuum of possible patient's reactions, as described in Table 3.

Table 3. Continuum From Most to Least Cooperative Final Responses of Patients in Providing Structure Interactions
Patient verbally confirms cooperationPatient acts as nurse proposes or asks him to doPatient cooperates, but remains restless or shows irritationPatient seems not willing to cooperate, but stays in contact without an explicit and clear mutual satisfying resultThe patient does not cooperate, shows he does not want to stay in contact with the nurse, or returns and shows the same undesirable behavior as before and provokes the nursePatient refuses

Our observations showed the first response of the patient to a nurse initiative to stand out as a turning point in the interaction between nurse and patient. At this point in an interaction, the event can easily escalate or remain relatively stable. In only 8 of 52 events, nurses mention their expectations to patients which may itself influence a successful application of providing structure. This refers to the exchange of expectations we found in the literature review, that, for example, when inadequate communication between nurse and patient existed, expectations became unclear and misunderstandings arose (Johansson & Lundman, 2002; Olsen, 2001; Walker, 1994), which led to resistance (D'Antonio, 2004; Olsen, 2001; Vatne & Fagermoen, 2007).

It is also possible that following assessment of the patient's first response, the intuitive reasoning of the nurse, the personality of the nurse, and the experience of the nurse and the nursing team come to bear on the situation and shape the reactions of both patient and nurse during the subsequent interaction.

In our review of the literature, we discovered that the NIC (Bulechek et al., 2008) did not use the intervention label “providing structure” despite the frequent use of this term by psychiatric nurses. In this literature review, we further identified three elements of providing structure: to impose and maintain rules and limits, to assess the patient's condition, and to use interaction as patient and nurse.

In this observational study, we could discern the three elements of providing structure as distinguished in the literature review. During our observations, we recognized the continuum of general to specific agreements mentioned in the literature, in the continuum of explaining general to specific issues (see Table 2). But, it was impossible, with the use of observations, to understand just how the nurse assessed the condition of the patient, for example, in relation to the assessment of ego functions (Benfer & Schroder, 1985; Kerr, 1990a, 1990b), or the assessment of the patient's need for autonomy and self-control (Garritson, 1983; Lowe, 1992; Lowe et al., 2003; Mohr et al., 1998; Morales & Duphorne, 1995). On the basis of the observations, we assume the existence of a continuing assessment of the condition of the patient. The ability of the patient to adequately respond to redirection (Kozub & Skidmore, 2001) and the responses of the patient to being limited or supported (Delaney et al., 2000; Garritson, 1983; Lancee et al., 1995; Ransohoff et al., 1982) may be first assessed by using Table 1, and during following contacts by using Tables 2 and 3, which all contain a range of responses and nursing activities.

On the basis of our previous review of the literature and the present observational study, we conclude that a number of frequently mentioned and related concepts, keywords, and activities could be distinguished as part of providing structure as a psychiatric nursing intervention. The literature review yielded three elements, two continua, three goals, and a description of effects related to these goals. The observational study delivered a process of providing structure, where each phase of the three steps process activities of nurses and responses of patients are distinguished. On the basis of two studies, we might suggest that “providing structure” be introduced as a new intervention label within the NIC (Bulechek et al., 2008). To supplement this proposal, the nursing responses and activities described on the basis of our observations should be included as part of “providing structure” in the NIC.

We also conclude, on the basis of the present observations, that we can now elaborate upon the process of providing structure as a complex nursing intervention and identify a useful theoretical framework, model the process of providing structure, and evaluate the attained outcomes. In such a manner, we can better understand just why patients and nurses respond in a particular manner and make the decisions that they do during an interaction that calls for providing structure. And we can then try to gain further insight into their expectations with regard to their actions in future research.

Limitations

The first limitation on the present study was the position of the observer and the incomparability of the events we observed. The position of the observer on the two wards had to be unobtrusive in order not to disturb usual ward routines; this required a certain distance from events and may have led to the incomplete description of some events. Therefore, we made adjustment to record the nurse–patient interaction. This is described in the Method section.

The second limitation on the basis of this observational study is that the data were collected in one country and are therefore culturally specific.

Implications for Nursing Practice

The present observations and classifications of the interactions between patients and nurses during events requiring the provision of structure give us a provisional framework for reflection and feedback on the performance of nursing activities. Psychiatric nurses and nursing teams should be encouraged to reflect upon exactly what they do when providing structure for a patient and the results that this yields. Such reflection can provide insight into why providing structure may sometimes—but not always—result in an escalation of events. Moreover, the results of this observational study will contribute to a formalization of the nursing intervention in the NIC.

References

  1. Top of page
  2. Abstract
  3. Method
  4. Findings
  5. Discussion and Conclusions
  6. References
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