The Therapeutic Milieu
The Therapeutic Milieu is the distinctively nurse-created, nurse-led healing culture and atmosphere of a hospital ward, nursing unit or other nursing practice setting. 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 for patients, nurses and all who enter the milieu.
The Therapeutic Milieu is created primarily by how nurses are in themselves and by the manner in which they practice. Nurses' ability to create a Therapeutic Milieu depends on their practice of at least five minutes of 'stillness' every day, that is, any meditative practice that fosters their awareness of their inner being as human persons.
Nurses who practice in a community and attend to people in their home can think of the therapeutic milieu and its concepts (which are also values) as qualities they take with them in themselves when they enter a persons' home or other community setting. To some extent the tone and quality of a therapeutic milieu is created by nurses' spiritual qualities as described in the previous Philosophy web pages; 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The creation of a therapeutic milieu, with its concepts, emerged prominently from the historical documents from which Careful Nursing was developed, thus it is one of the four dimensions of the professional practice model. In the following diagram of Careful Nursing the therapeutic milieu is shown in the cream coloured section which is emphasised.
The purpose of the Therapeutic Milieu is four-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.
♦ to highlight that patient care environments in hospitals are traditionally and primarily the 24/7 domain of professional nurses and, thus, are properly nurse-led
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 or practice setting.
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©