The Therapeutic Milieu
The therapeutic milieu is the distinctive nurse-created, nurse-led healing culture and atmosphere of a ward, nursing unit or other nursing practice setting. We often talk about the environment in nursing. But the therapeutic milieu is more than an environment. It is a healing culture, rich in therapeutic inter-personal relationships and co-operative attentiveness to patients. Its physical features are soothing and provide for optimum safety and comfort.
Public health nurses and other nurses who attend to people in their home can think of the therapeutic milieu and its concepts as qualities they take with them in themselves when they enter a persons' home. To some extent the tone and quality of a therapeutic milieu is created by nurses' spiritual qualities as described in the previous Philosophy webpages; it is an expression of the spiritual in nursing as it is expressed in the attitudes and actions of nurses and their assistants.
The creation of a therapeutic milieu is a natural aspect of nursing practice and, thus, one of the four dimensions of the professional practice model of Careful Nursing. In the following diagram of Careful Nursing the therapeutic milieu with its six concepts is highlighted while the other dimensions remain in the background.
The purpose of the therapeutic milieu is three-fold
♦ to provide for patients' optimal safety and healing
♦ to provide nurses with a healing surrounding in which to practice, enabling them to care for themselves and help and support one another to practice together well
♦ to engage and support everyone concerned with patients' care; patients' family and friends, other health professionals, and assistive personnel.
A long-established nursing responsibility
The therapeutic milieu dimension of Careful Nursing reflects an historical fact that for centuries nurses have been primarily responsible for the management and quality of patient care areas in hospitals, traditionally called wards (and still called wards in most countries except the United States). The words ward and guard have the same origin and meaning (Partridge 1959) and until the 19th century were used synonymously in reference to protecting vulnerable people from harm. People in hospitals were guarded or warded by nurses, hence the inseparable relationship between nurses and their particular responsibility for the management and quality of a ward, or other nursing unit.
Naturally, all healthcare personnel in a given ward or unit contribute to its quality, but its quality is primarily created and sustained by professional nurses in co-operation with their care assistants and other assistive personnel; other health professionals come and go but nurses, in their 24/7 relational continuity with patients, are always present. The therapeutic milieu provides the co-operative healing context within which all multidisciplinary care takes place, as illustrated in the following diagram:
Making our responsibility visible
Our nursing role in creating this milieu is so fundamentally important that it is often taken-for-granted by others. As nurses we must be mindful not to take this important responsibility for granted ourselves. In creating a therapeutic milieu we make this responsibility visible to ourselves and others by naming how we create and sustain it, guided by the six therapeutic milieu concepts.
Most concepts concern the relational practice of nursing; the creation of healing nurse-patient relationships. These relationships draw mainly on our inward life of mind and spirit (recall from the philosophy section). Most concepts concern how we are in ourselves; how we practice nursing.
In the following six pages we will review each of the six therapeutic milieu concepts. Keep in mind that each concept is infused and informed by the philosophical principles.
Especially keep in mind that the practice of stillness for five minutes each day underpins implementation of all the therapeutic milieu concepts.
For each concept you will be encouraged to think of 'I will' statements (recall from previous professional practice model page) which you will be able to use to help you implement the concept in practice.
Partridge E. (1959) Origins: A Short Etymological Dictionary of Modern English. (2nd ed). The Macmillan Company, New York.
Therese C. Meehan©