Recently, I had the opportunity to give a talk to a group of psychiatric nurses about the environment of care. This group worked in public sector acute care psychiatric hospitals where the treatment goal is stabilization. In years gone by, these same institutions might have worked to develop the nurse-patient relationship and the patients’ sense of belonging. However, with the shortened lengths of stay and other factors inherent in the healthcare system, the focus has shifted to managing behaviors, biomedical stabilization and discharge.
One of the concepts that continues to be a part of the vernacular of psychiatric hospitals is the “milieu,” or environment. Historically, in psychiatric hospitals and therapeutic communities, the framework for a therapeutic milieu has included containment, support, structure, involvement and validation. In today’s acute care environment, the milieu focus is often on containment alone. The result is that nurses in these settings often feel like control officers because of the urgent need to maintain safety, and the nurse-patient relationship takes a back seat.
The talk I gave that day was focused on how to re-conceptualize the milieu from management, containment and control to one of a healing environment in psychiatric inpatient care. In both ways of thinking, safety is a priority. After all, how can anyone heal if they don’t feel safe? I talked about how the issue of safety becomes a point of contention when those charged with maintaining the safety of the patient view this as “being the bad guy” and patients feel like they are “being punished.” The question was raised: Do you want to be a jailer or a healer?
I suggested that these views are the result of how we frame safety situations. Reframed, maintaining safety is a healing activity. In the early stages of engagement, nurses who view safety as a prerequisite for healing orient the patient by explaining,
“You have come to us for help with some life difficulty. We will partner with you on this journey of recovery as we discover new ways to improve your situation. One of the first things we will do is create a safe place for you to do your work. It is often very challenging for people who enter treatment to build a safe environment. When this challenge is not met, therapy is sabotaged. We have learned how to create a safe environment to support treatment. There may be times when you do not agree with the structure we have in place. At those times, we should talk about the importance of safety in your life so that you can develop mastery in creating your own safe environment after you go home.”
That day, we talked about a healing environment based on our relationships with patients as well as each other and our other colleagues and how all are equally important. We talked about the need for healing places and spaces, self-reflection and intentionality, personal wholeness and healthy lifestyles; all are components of an optimal healing environment and the need to create a sanctuary for healing.
At the end of the discussion, every nurse in the room enthusiastically identified concrete ways they would apply the principles of a healing environment into their practice. They said they thought this mattered because thinking like this was energizing, not energy depleting as was the “control” model of care. To quote one participant,
“I love the idea of a healing environment. This puts me in touch with the heart of nursing and the reason I started doing this work in the first place, to help my patients.”
Benefits for the spirit
In a June 26, 2011, editorial published in the Houston Chronicle, Rabbi Samuel Karff called our attention to the time-honored principle of the doctor-patient relationship. He contended that the doctor-patient relationship is a part of the spiritual dimension of care. I believe he would extend this to include the nurse-patient relationship and the relationships that all clinicians have with their patients. He suggested that relational practice is good for the spirit – both for patients and clinicians. It was evident to me that the nurse who spoke up about the “heart of nursing” was talking about what is good for her spirit and the spirit of those for whom she provides care.
Editor’s note: To read one of Dr. Mahoney’s more recent blog posts, check out “Honor, grace and courage: a tribute to Betty Ford.”