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This presentation explains milieu management oriented toward nursing.
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MILIEU MANAGEMENT
Chapters 24, 25, 26
Key Terms
Therapeutic milieu The context in which treatment occurs
Therapeutic community In-patient setting with a patient-led
government to establish and enforce community rules
Milieu Management
Purposeful manipulation of the environment to promote a therapeutic atmosphere
Essential Features of the Therapeutic Environment
Share responsibility and decision-making
High levels of interaction between patients and staff
Clarity of the program’s role and leadership
Milieu Elements
Safety Structure Norms Limit-setting Balance Environmental modification
Psychotherapeutic Manager Roles Working with patients Leading groups Participating in community meetings Coordination medical care Dispensing medications Making discharge arrangements Working with families Leading interdisciplinary team meetings Teaching patients and families
Variables affecting the Therapeutic Environment
Unit model of care Staff relationships Management practices Organizational structures Staff burnout Physical layout of unit
Variables affecting the Therapeutic Environment
JCAHO standards Dealing with aggression/violence Dealing with suicidal behavior Consumer movement Clinical supervision
JCAHO Environment of Care Standards
Ongoing assessment and maintenance of equipment
Hazard surveillance Reporting and investigating safety
issues Monitoring safety management
technique/procedures Orientation programs that address
safety
JCAHO Environment of Care Standards
Security is ensured through: Mechanisms to address security issues Appropriate identification of staff,
patients, visitors Mechanisms for handling emergencies Mechanisms for interacting with media
JCAHO Environment of Care Standards
The social environment must provide: Storage space for grooming and hygiene
articles Closet and drawer space for personal
property Suitable clothing
JCAHO Environment of Care Standards
The physical setting must provide: Adequate privacy Door locks consistent with program goals Telephones for private conversations Sleeping rooms with doors Suitable furnishing Access to outdoors, unless
contraindicated
De-escalation Interventions Separate the patient from others Listen, empathize Calm voice, appropriate body language Set clear, specific limits Allow patient to verbalize concerns Show respect and interest in well-being Stay connected with patient Point out problematic behavior
De-escalation Interventions
State what will happen if behavior continues
Offer alternatives; avoid ultimatums Don’t argue Use show of force judiciously
Inpatient Therapeutic Activities
Occupational therapy Recreational therapy Exercise therapy Patient education Group psychotherapy Spirituality groups Living skills groups
Therapeutic Community
Fundamental Themes: Reality confrontation Learning social skills Group cohesion/community
Utilize: Community meetings Step systems
Inpatient Settings
Open adult unit Intensive/acute care Child-adolescent unit Medical-psychiatric unit Substance abuse unit Dual diagnosis unit Psychogeriatric unit
Community Treatment Settings Day treatment Partial hospitalization Residential treatment homes