EVALUATION OF THE THERAPEUTIC MILIEU

The therapeutic milieu requires periodic evaluation to deter- mine its effectiveness. The Ward Atmosphere Scale (WAS) is an instrument that can be used to evaluate the effectiveness of a therapeutic milieu by contrasting client and staff views, comparing actual and preferred programs, planning and moni- toring changes in treatment programs, and promoting program

SELFAWARENESS PROMPT

Which type of behavior therapy do you think would be the hardest for you to implement when caring for a client in your age group: behavior mod- iﬁ cation, assertiveness training, or limit- setting?

Why? What resources or experiences do you think would help you to improve your ability to implement this speciﬁ c behavioral therapy intervention?

Critical Thinking Questions

1. Consider the WAS subscales identifi ed in the text as you evaluate the area of your current clinical assignment.

How many of the 10 subscales are evident on this unit?

What are your recommendations for improvement? How might you implement these recommendations?

2. Although assertiveness training is listed as a treatment modality under behavior therapy, it is also a useful method of communication for nurses. Explore assertive improvements. It encourages staff involvement in program planning and design (Moos, 2009). The WAS consists of 10 subscales. Each subscale is rated by staff and clients to provide information regarding what actually exists and what should exist in a therapeutic milieu. Subscale items focus on 1. staff control of rules, schedules, and client behavior;

2. program clarity of day-to-day routine;

3. measurement of client involvement in social functioning, attitudes, and general enthusiasm;

4. practical preparation of the client for discharge and tran- sition into the community;

5. supportive atmosphere of staff, doctors, and peers toward clients;

6. degree of spontaneity in the environment that allows the client to express feelings freely;

7. promotion of responsibility, self-direction, and indepen- dence, as well as staff response to client suggestions or criticisms;

8. order and organization of the unit, including staff and client responses;

9. encouragement of verbalization of personal problems by clients; and

10. encouragement of verbalization of feelings such as anger, and the channeling of feelings into appropriate behavior.

This instrument is appropriate for evaluating therapeutic mili- eus in inpatient settings, partial hospitalization programs, day-treatment centers, and community-based mental health programs.

KEY CONCEPTS

The therapeutic milieu, also called the therapeutic environ-

•

ment, is designed to meet the emotional and interpersonal needs of clients, help them control problematic behavior, and assist them in the development of coping skills.

Standards have been set forth by the JCAHO as a guide in

•

developing a therapeutic milieu.

The multidisciplinary psychiatric treatment team is com-

•

posed of members from several disciplines who discuss each client’s progress and review each client’s individu- alized plan of care. The psychiatric–mental health nurse manages and coordinates activities in the milieu.

Interventions in the milieu focus on client education, spiri-

•

tual needs, personal and sleep hygiene, pain management,

protective care, behavior therapy, and adjunctive or management therapies.

Adjunctive or management therapies are also provided to

•

promote personal change, to develop responsibility and accountability, to express creative needs, and to express feelings or confl icts that the client is unable to express verbally.

The WAS is an instrument that can be used to evaluate the

•

effectiveness of a therapeutic milieu in inpatient settings, partial hospitalization programs, day-treatment centers, and community-based mental health programs.

For additional study materials, please refer to the Student Resource DVD-ROM located in this textbook.

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CHAPTER 12 The Therapeutic Milieu 155

REFERENCES

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Andal, E. M. (2006). Compliance: Helping patients help themselves.

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Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2009). Provision of care, treatment, and services:

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communication—assess your communication skills and identify strategies for improving your own assertiveness.

Discuss how assertive behavior can help the nursing profession to come into its own.

Reﬂ ection

Review the quote at the beginning of the chapter and then interview three members of the staff who work with clients in your current clinical area (the staff members may represent different disciplines such as nursing, social services, or occupa- tional therapy). Ask each of them to describe his or her perceptions of a therapeutic milieu. Do they have similar perceptions?

If not, how do their perceptions differ?

NCLEX-Style Questions

1. The nurse is leading a group therapy session as part of the milieu therapy. During the session, the client has the freedom to do which of the following?

a. express feelings in a socially acceptable manner b. select daily schedule based on personal preferences c. revise rules according to individual needs

d. vote on policies and procedures of the unit

2. An adolescent client tells the evening-shift nurse that the day-shift nurse promised that she could stay up late to watch a special television program. No specifi c instructions/

alterations have been indicated anywhere on the patient’s chart regarding this issue. The evening nurse does which of the following to maintain the therapeutic milieu?

a. allows the client to stay up late to promote staff unity b. encourages client to express feelings about staff

disagreement on this issue

c. maintains the same rules for all clients, therefore refusing client request

d. uses staying up late as a reward for this client’s good behaviors

3. A 34-year-old female client with a dissociative disorder refuses to bathe or change her clothes. Which of the following interventions is congruent with the role of the nurse as a mother surrogate?

a. allow the client to make decisions about hygiene b. assist client to bathe and change clothes

c. encourage family member to talk to client

d. put client in private room to avoid offending others 4. The nurse assesses all of the following factors in a

56-year-old Asian American male complaining of insomnia. Which of the following does the nurse encourage the client to modify?

a. drinking coffee before midday

b. going to bed at the same time each night c. exercising 2 hours before bedtime d. reducing noise at bedtime

5. The use of virtual reality to treat a client’s phobic response can be catergorized as which of the following types of therapy or training? Select all that apply.

a. assertiveness training b. aversion therapy c. implosive therapy d. behavior modifi cation

6. The nurse–manager is preparing an orientation program for a group of new staff members at a community mental health center. As part of the program, the nurse–manager will be describing the therapeutic milieu. Which of the following would the nurse include? Select all that apply.

a. use of a multidisciplinary treatment team

b. participation of client’s family and support persons c. use of limit-setting

d. employment of behavioral interventions e. education of the client and family

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13

UNIT IV

Interactive Therapies

Crisis and

Disaster Intervention

LEARNING OBJECTIVES

After studying this chapter, you should be able to:

1. Understand the terms crisis and disaster.

2. Discuss the characteristics of a crisis.

3. Recognize the phases of a crisis.

4. Distinguish the fi ve periods of the disaster recovery process.

5. Articulate how the following balancing factors can infl uence the development of a crisis: realistic perception of the event, adequate situational support, and adequate defense and/or coping mechanisms.

6. Compare and contrast crisis intervention and disaster mental health nursing.

7. Interpret the goals of crisis intervention.

8. Analyze the role of the psychiatric–mental health nurse in crisis intervention and disaster nursing.

9. Apply the steps of crisis intervention.

10. Explain the issue of legal immunity for the crisis worker.

KEY TERMS

Crisis

Crisis forensics Crisis intervention Crisis response team Crisis situations Disaster

Disaster intervention

Disaster mental health nursing Disaster response team Maturational crisis

Paradigm of balancing factors Situational crisis

Any serious interruption in the steady state or equilibrium of a person, family, or group is considered a crisis. A crisis is a state of emotional turmoil. It is also considered an emotionally signifi - cant event which acts as a turning point for better or worse in a person’s life.

—MITCHELL & RESNIK, 1981

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158 UNIT IV Interactive Therapies

Dalam dokumen Basic Concepts of Psychiatric–Mental Health Nursing (Halaman 174-178)