Conditions of Providing Effective Structure

Our specialty understands that safety must be achieved without the use of coercive measures. We also understand that on inpatient units rigid rule and limit setting is a pathway to conflict and prompts escalating situations. Numerous approaches to this rule/limit setting issue have evolved, particularly with an aim of reducing coercive measures. Of particular emphasis in these strategies are the Six Core strategies, staff training and restructuring the social environment. Included here are staff training techniques deployed by Joy Duxbury as well as her team’s report on a version of the Six Core Strategies. Restructuring the social environment includes emphasis on culture and engagement which are outlined in the eight pillars. To deploy these liberating strategies demands one, adequate staff resources and two, a practice environment that supports staff efforts. Finally, a safe unit demands structure. The articles by Voogt and his team provide a review of the literature on providing structure and the development of the concept of rules as well as an updated definition of providing structure.

Baker J, Berzins K, Canvin K, Benson I, Kellar I, Wright J, Rocio Rodriguez Lopez, R.R., Duxbury, J. Kendall, T. & Stewart, D. (2021). Non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings: The COMPARE systematic mapping review. Health Services Delivery Research 9(5). https://www.ncbi.nlm.nih.gov/books/NBK568107/pdf/Bookshelf_NBK568107.pdf

“A report developed in the UK National Institute for Health Research, synthesizes literature searched from 1999 to 2009 on interventions to reduce restrictive practice used with adults in mental health services. Data summarizes 221 articles and 150 interventions-109 of which had sufficient evaluation data. The most common intervention target was seclusion and restraint reduction. The most common strategy was staff training. The majority of behavior change techniques mapped onto four clusters: goals and planning, antecedents, shaping knowledge and feedback and monitoring.” Open access

Berzins, K., Canvin, K., Kendal, S., Benson, I., Kellar, I., Wright, J., … & Baker, J. (2020). Establishing Components of Programmes to Reduce Restrictive Practices in Adult Mental Health Inpatient Services: A Behaviour Change Technique Analysis. Research Square.
https://assets.researchsquare.com/files/rs-99034/v1/871b989c-670a-4aa1-a7f5-c5b99ced9319.pdf

“A summary of the Baker et al. findings. Presents a useful table of the 13 behavioral techniques identified to reduce coercive measures”. Open Access

Duxbury, J., Baker, J., Downe, S., Jones, F., Greenwood, P., Thygesen, H., … & Whittington, R. (2019). Minimising the use of physical restraint in acute mental health services: The outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’). International Journal of Nursing Studies, 95, 40-48.

A UK adoption of the Six Core Strategies 9 REsTRAIN YOURSELF) which was put into a non-randomised controlled trial with 14 inpatient units (7 where intervention tested, 7 controls). Results demonstrate a significantly lower restraint rate on the intervention wards in the adoption phase versus baseline rate. Excellent review of the core principles as well as support for their use. Access through Science Direct.
Duxbury, J., Hahn, S., Needham, I., & Pulsford, D. (2008). The Management of Aggression and Violence Attitude Scale (MAVAS): a cross‐national comparative study. Journal of Advanced Nursing, 62(5), 596-606.

“Duxbury and her team have 20 years of research on staff training and the use of the MAVAS. This is an early article but provides data on the use of the MAVAS as well as a breakdown of items in the tool. Very strong theoretical support for training aimed at staff attitudes and beliefs around handling aggression.” Available at Wiley on-line and request from author via research gate.

McKeown, M., Thomson, G., Scholes, A., Jones, F., Baker, J., Downe, S., … & Duxbury, J. (2019). “Catching your tail and firefighting”: The impact of staffing levels on restraint minimization efforts. Journal of psychiatric and mental health nursing, 26(5-6), 131-141.

“Interviews were conducted with of staff (n = 130) and service users (n = 32) which focused on their experiences of participating in a large restraint reduction project; this report isolates the perceived influence and importance of staffing levels. Five themes were identified regarding how staffing levels complicate efforts to restraint minimization. They detail the impact of insufficient staff, the burden of non-clinical tasks and the detriment to staff and service users”. Open access

McKeown, M., Scholes, A., Jones, F., & Aindow, W. (2019). Coercive practices in mental health services: stories of recalcitrance, resistance and legitimation. In A Daley, L Costa, & P Beresford (Eds.) Madness, Violence, and Power: A Critical Collection (pp. 263). University of Toronto Press.

“There are numerous accounts of service users experience of coercive measures. This chapter by McKeown echoes several themes of the use of power and control on inpatient units. But also examines issues around the legitimacy of inpatient practice from the view of social justice and illustrates their points with service user, staff and researchers’ narrative account.” Manuscript available of research gate.

Van Bogaert, P., Peremans, L., Van Heusden, D., Verspuy, M., Kureckova, V., Van de Cruys, Z., & Franck, E. (2017). Predictors of burnout, work engagement and nurse reported job outcomes and quality of care: a mixed method study. BMC nursing, 16(1), 1-14.

“Research conducted in Belgium on inpatient psychiatric units over the last ten years on the impact of the practice environment on quality of care. This article tests their modeling of several variables including the practice environment and nurses burnout and engagement. The final model demonstrates the impact of nursing management/workload on outcomes”. Open Access

Voogt, L. A., Nugter, A., Goossens, P. J., & van Achterberg, T. (2013). “Providing structure” as a psychiatric nursing intervention: A review of the literature. Perspectives in psychiatric care, 49(4), 278-287.
This literature review aimed to clarify the definition of providing structure (PS) , its goals and effectiveness. Via synthesis of forty articles the authors arrive at elements of PS and the purposes it serves but little data on its effectiveness.

Voogt, L. A., Nugter, A., van Achterberg, T., & Goossens, P. J. (2016). Development of the Psychiatric Nursing Intervention Providing Structure: An International Delphi Study. Journal of the American Psychiatric Nurses Association, 22(2), 100-111.

“In a Delphi study the team gather opinions of 26 inpatient nursing experts is used to gather the opinions of experts on providing structure (PS). They arrived at a definition of PS, activities it entailed, and context variables.” Available to APNA members via JAPNA.