NU245CL Unit 4 Milieu Observation Example

One Phone, Four People Waiting and Yesterday's Schedule on the Wall: A Milieu Observation of a Composite Inpatient Dayroom at Midday, Tested Against Gunderson's Five Functions of a Therapeutic Milieu

[Student Name]

Purdue University Global

NU245CL: Mental Health Nursing Clinical

Unit 4 Milieu Observation

[Instructor Name]

[Date]

The unit, patients and staff are composite and carry no identifiers; the student observed during a midday period with the assigned nurse's knowledge.

The Room, Before Any Person

The dayroom is about [10] by [12] meters with a row of windows that do not open. Fourteen chairs, mostly along the walls; two small tables. One wall phone near the nursing station, no chair beside it. A television mounted high in the corner; the remote is kept behind the nursing station glass, and patients ask staff to change the channel. A whiteboard by the door, headed "Today," still listed yesterday's groups at [1130] and [1400]. The nursing station is enclosed by glass with a sliding window.

What Happened Between 1130 and 1300

At [1130], no group started, because yesterday's art group was not on today's schedule. Two patients asked a staff member at the window when art was; she said it was not today. One of them said, "The board says it is." The board was not changed. From [1145], four people waited for the phone. There was no sign-up list or time limit. The man using it talked for about twenty minutes. A woman waiting began to pace, then knocked on the station window to complain. A staff member told her to wait her turn. Two others gave up. At [1215], a patient asked for the television to be changed. A staff member did so through the window. Another patient objected. They argued until a staff member came out and turned the television off. Lunch arrived at [1230]. The room calmed. At [1300], a nurse wrote the correct schedule on the board.

Testing the Milieu Against Gunderson's Five Functions

Gunderson described five functions a therapeutic milieu should provide: containment, support, structure, involvement and validation (Gunderson, 1978). Containment, keeping people physically safe: present. The unit was locked, staff were nearby and no one was hurt. Support, helping people feel comfortable and less anxious: weak. There was no chair by the phone, and the woman waiting was told only to wait. Structure, a predictable organization of time and expectations: weak. The board showed the wrong day, and the phone had no rules. Without structure, waiting turned into conflict.

The phone queue had no rules, so the patients made their own, and their rules were loudness and persistence.

Involvement, patients taking part in the life of the unit: absent. Patients had no role in setting phone rules, choosing television programs or keeping the board current. Validation, recognizing each person as an individual: mixed. The staff member who came out to deal with the television argument spoke to both patients by name; the woman knocking on the window was not acknowledged.

What the Environment Did

Most of the conflict in the ninety minutes grew from three features of the room, not from patients' illnesses: a phone with no rules, a remote behind glass and an out-of-date board. The Safewards model describes how features of a ward, such as unclear rules and frustrations with routines, act as flashpoints for conflict, and that staff interventions addressing them can reduce conflict and containment (Bowers et al., 2015). Each of the three features was a flashpoint, and each could be changed without any patient changing.

How the Five Functions Interact

The functions are not independent. Strong containment, a locked door and staff close by, did not make up for weak structure and support; in fact, the locked unit made the phone more important, because it was the patients' only link to the outside. When structure failed, staff fell back on containment, turning the television off and telling people to wait, which kept the room safe but did nothing for involvement or validation. A milieu that leans on containment when other functions are weak can feel safe to staff and confining to patients.

Simple Changes Suggested to My Nurse

A phone sign-up sheet with a ten-minute limit and a chair. A community decision about television times, recorded on the board. The board updated at the start of each day shift. My nurse said the phone rule had been discussed before but never written down, and she would raise it at the community meeting.

The Writer Behind the Glass

For most of the period I was inside the nursing station, watching through the glass. It was a good place to see the whole room, which is what I learned to value as a sitter. But I was on the staff side of the window, and when the woman knocked, she knocked at me too. I did not go out. If I had sat in the dayroom, I might have helped organize the phone line or simply talked with her while she waited (Halter, 2022). Observing a milieu from behind glass is still taking a position in it.

Limits

One ninety-minute period on one day. A different day, or a different staff mix, could show the functions differently.

References

Bowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial. International Journal of Nursing Studies, 52(9), 1412-1422. https://doi.org/10.1016/j.ijnurstu.2015.05.001

Gunderson, J. G. (1978). Defining the therapeutic processes in psychiatric milieus. Psychiatry, 41(4), 327-335. https://doi.org/10.1080/00332747.1978.11023992

Halter, M. J. (2022). Varcarolis' foundations of psychiatric-mental health nursing: A clinical approach (9th ed.). Elsevier.