Summary and general discussion
This chapter summarizes the main findings in relation to the three research questions and adds a discussion about Providing Structure as a nursing intervention in mental health care. The methodological considerations are discussed, followed by a discussion of strengths and limitations. Finally, conclusions, practical implications for psychiatric nurses, and recommendations for future research are described.
The main objectives of this thesis were to define Providing Structure (PS) as a nursing intervention in mental health care, and to provide for a proper design of PS as an intervention according to the requirements described in the MRC framework for the development and evaluation of complex interventions (MRC 2008).
Three research questions were addressed throughout the research process:
1. What is the definition of PS?
2. Which activities are essential components of ‘providing structure’ as a nursing intervention in mental health care?
3. Which context-variables of PS are important for patients and nurses?
Answers to these research questions were given through the five studies, for which we summarize the main findings, following the research questions, below.
SUMMARY OF MAIN FINDINGS
The definition of Providing Structure
From our literature review (Chapter 2) suggested elements, goals, and effects of PS could be identified. Suggested elements of PS were the imposition and maintenance of rules and limits, the assessment of the condition of the patient, and interaction between nurse and patient. Goals of PS were formulated as the attainment of external security for the patient, making mutual expectations regarding the treatment relationship explicit, and promoting the experiences of better fitting into the world and recovery. However, no well-articulated studies about the effectiveness of PS could be found.
In the literature a continuum in the imposition and maintenance of rules and limits, seems of particular interest, namely the continuum that goes from general rules and limits up to very explicit rules and limits. On the basis of the literature the following provisional definition was formulated:
The aim of PS 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.
Based on our observational study (Chapter 3) the process of PS could be described. In each phase of this process activities of both nurse and patients could be depicted. In this study we described three phases of a PS-event: the start of the interaction, the intervention phase, and the end of an interaction. We learned that the first response of the patient to a nurse was often a turning point in the event, which then could either escalate or remain peaceful.
As expected, it was impossible to understand how patients and nurses experienced the PS-events from observations alone. Therefore, we decided not to change the provisional definition at this stage.
In the following two studies we interviewed the main stakeholders, both nurses and patients. The interview study with patients (Chapter 4) revealed that patients expected the nurse to be aware of their being a patient and feeling vulnerable, to take them seriously and to allow them to take responsibility for ward routines, to inform them of what to do, and to be aware of their need to maintain autonomy. Patients rather talked about a relationship of trust with the nurse, about how to maintain autonomy and about the importance of explicate mutual expectations. Patients mentioned several nursing activities as part of PS, such as: gaining knowledge of the patient’s situation; connecting with the patient; dealing with ward rules, times, and habits; applying the treatment plan; explaining and making the patient understand; and the moderation of the patient’s thinking. The patients' expectations became part of our working definition of PS.
The interview study with nurses (Chapter 5) focused on their description, use and explanation of PS. Nurses discerned three purposes of PS, namely 1) to firmly adhere to established structures, rules, regulations and agreements, 2) to achieve rest, routine and hygiene, and 3) to promote the patients’ personal control. Based on what nurses regarded important, the definition of PS was adapted with the addition of a working alliance between nurse and patient as an important element.
The fifth study (Chapter 6) was a Delphi-study with a panel of experts in the field of psychiatric nursing who were asked to rate statements about the de