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Therapeutic Environment

by Anne Vanderputten
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    00:01 Hi, I am Anne Vanderputten and welcome to the Therapeutic Environment and Security.

    00:06 I wanted to start with an overview of the environment for the patient and therapeutic environment.

    00:11 Florence Nightingale: - put forth the environmental theory which stressed the use of environment to assist in patient recovery.

    00:18 So this is one of the nursing paradise is including the environment in the care of the patient.

    00:24 So what are the goals of therapeutic environment? Firstly and in foremost is to facilitate the promotion of healing.

    00:32 It supports the psycho-social needs of the patient and family.

    00:37 And then thirdly it provides and promotes safety of the patient.

    00:42 It seem like very basic things.

    00:45 When a patient comes into a healthcare system they have the number of concerns and no. 1 is their health and their safety.

    00:56 And again when they are isolated from their family or their support systems this is create anxiety.

    01:02 And then the lack of control of their own environment. When they in their home they can do as they choose. But now they are in different environment and it can create anxiety for the patient.

    01:14 So some of the stressors that are included in the environment. These non-therapeutic environmental stressors include: Excess of bright lighting which disrupts sleep cycles or underlying disease process such as excessive stimulation.

    01:31 Again equipment alarms things in the healthcare environment that we all may be become use to.

    01:38 and absorb the [inaudible 0:01:39.080] because it's just part of our day.

    01:42 But you can image for a patient to have an IV just beep beep beep beeping next you. It's constantly distracting them and they don't know if it's an alarm or should they be concerned. So we wanna be aware of the perception of the patient of their environment.

    01:58 Other non-therapeutic environmental stressors include: the staff himself. If they are coming in we know the patient has just managed to fall asleep and in comes, you know, our equipment and we are banging walls or banging doors.

    02:13 So we have to be mindful of as we do our work that how do we sound to the patient.

    02:21 So these are all things that we want to try to avoid.

    02:25 What is our response to these stressors? We want to avoid excessive lighting but especially at night. If it's day time you wanna give the patient especially in some of these darker may be buildings.

    02:39 You do want to give them some bright light to indicate yes this is day time.

    02:44 But as the day goes on you don't wanna disrupt their perception of circadian rhythm or their a psycho. So you generally avoid excessive lighting especially at night.

    02:58 And be cognizant of their needs prior to the alarm settings. This is what I was speaking too earlier.

    03:03 Your IV you see that you only have 200ml left in the bag. Don't wait to the alarm be to "I will be come back".

    03:12 Be prepared to check on that and change the bag before it alarms and you know has the patient worried what's going on next to them And again you wanna coordinate your care needs to include the patient preference when possible. What do we mean by this? What we were talking about is that if the patient says "Hey can you get my vital signs at 3 o'clock rather than 10 o'clock?" Or you know understand where there sleep patterns may be falling you want to try to do as much care as possible create in one visit with the patient without coming in disorganized and "Oh I forget to get your vital signs" "Oh now here is your medications". You you want to be prepared and organized when you enter the patient's environment.

    04:04 And include them in when is the best time for them to get some tasks done.

    04:11 And again be aware of your staff conversations and disruptive movements in the patient environment.

    04:18 The patient environment is not just their room. Just remember this; because, out in the hole if you are sharing information you really have to be award that the patient can hear this and to that fact you also wanna be aware of people around you.

    04:35 So we have to be very cautious about what we say, where we say and how we say it.

    04:41 A lot of times at night, I worked night for many years and having is that staff may be carrying on their conversation for night staff. This is their day and they end up not really realizing that how kind of loud they are speaking and laughing and things like that.

    05:02 This really reflex on the patients. It's very disturbing to them and they also feel like nobody is doing anything.

    05:10 If they hear all this laughter and things. So take it to break room.

    05:14 But really the patient should feel a very calm and safe environment.

    05:21 So continuing this nursing and therapeutic environment which you can't avoid safety. And safety is part of a therapeutic environment; because, it's one of the patient's concerns. So of-course as nurses we need to respond and have a goal for safety at the environment.

    05:38 So from the patient's perspective they are now in an unfamiliar environment.

    05:45 And they may have mobility impairment or overestimate their condition and their strains.

    05:54 So you wanna be aware of that you know that they just inst to the restroom.

    05:59 Aware of obstacles. Sometimes we end up leaving a lot of our own supplies in the patient environment in their room which can become a safety issue. So also, the patient is able to kind of loose orientation at times due to their illness.

    06:18 May be their medications, their length of stay and they get a loss of circadian rhythm.

    06:24 So it's always good to be aware of this.

    06:28 And in response to some of these patient potential problems you want to provide an orientation of the environment and the surroundings.

    06:36 This is actually, mostly part of almost everyone's regulations in nursing.

    06:43 and initially the patient comes in you wanna make sure that they oriented to the room that they are aware of where the restroom is where is their call light. You wanna make sure that their call light is very near them.

    06:54 And be mind for that all patients are at risk for fallen and you want to provide side rails as needed.

    07:03 And ensure that the room is free of clutter.

    07:05 Again I mention here that Psychosis can develop in the intensive care unit to a patient who is a critically ill.

    07:14 Spending time often in the intensive care unit, they are you know the lights are on 24/7 and these patients can develop basically a Psychosis because of an extended length of stay.

    07:30 So keep that in mind because a lot of nursing interventions if you would see this developing in some of your patients.

    07:37 You may suggest to the doctor, "You know may be we can find room that has a brighter view within the patient's eye sight".

    07:46 And that helps the patient see the sunrise, you know, darkness and it helps them maintain orientation.

    07:54 So for the patient you want to provide or mimic natural lighting, as mentioned earlier, and clocks and calendar are always good to have in a patient room.

    08:04 If you notice that in your organization you don't have may be clocks often you will see may be a board. So you want to introduce it with the day, the date and keep the patient in the aligns of their line of view. So they can read these and maintain their orientation as days, and especially length of stay days can run together and they can kind of get out of sort on that.

    08:30 So when we moving forward on social support and control of the environment. Remember, that there are barriers to that feeling that the patient has some control.

    08:40 Space/staff restrictions to visitors: Remember the patient is concerned about their social isolation.

    08:48 You know "How is my family gonna visit if there any room filled with clutter?" They are concerned and they may be not even be concerned about themselves at this point than he be concerned about their spouse "Where can my spouse be?". So you wanna keep your environment and your the patient's environment clear and calming and free of these kind of barriers.

    09:10 So it also can lack for the patient to have input in their care.

    09:16 Those are also a barrier to an environment.

    09:21 So again you wanna include the patient in their care "What is the best time if you can adjust a treatment plan and make it conducive to the patient?" and this offers the patient some control of what's going on around them. They are not just subjective to who every walks in the door and says "Now it's time for this.

    09:38 Right?" So you can say to the patient "You know this is what your treatments are? Do you have a preference?".

    09:44 And that offer you enough control really promotes healing and wellness for the patient.

    09:50 Again uncertainty of staff response to their needs.

    09:54 This is a chronic problem in any institution where the patient says, "Well, okay I need something". They ring your bell and gosh someone says "Oh, I will be in there in a minute" and what may seems five minutes to you I would just tell you, to the patient is much longer.

    10:17 And when someone is in pain or they need something. May be they need to restroom you have to be mindful that when the patient calls and uses that call light that they need that security that someone is coming.

    10:33 A good tip is that when you enter a room and say to a patient. You give them a ton of expectation when they will return so even if the patient calls and they need something you say "I can get you this right now it may take me 5 minutes but I will be back in 5 minutes". This is a reassurance to the patient.

    10:52 So they have the information. They know what to expect and then they can trust that people are there to help them if they need it.

    11:00 Again continuing the therapeutic responses that is you want to ensure the patient environment supports the social needs as I discussed.

    11:08 You know having a space for spouse and family to visit.

    11:12 Allow the patient that input into when their treatments occur.

    11:17 Sometimes you can't because it's the schedule scan or something like that you can help them the patient by saying, "Your scan is scheduled for 10:30 tomorrow morning".

    11:27 This information is very helpful to the patient.

    11:30 Providing the call light and the prompt response and provide the information at the level for the patient understanding.

    11:38 So when we talk about security of the patient This is an overlap. Let's look at the definition and there is 3 that I have listed here.

    11:46 The first 1 is a freedom for danger, or risk and safety.

    11:51 This is a basic human need, you have to remember that. This is very basic.

    11:58 Every other aspect of the patient's life is compromised This becomes a very huge need.

    12:05 They also defines as it "Freedom from care or anxiety or doubt and well-founded confidence." The 3 definition is "Something that secures or makes safe; protection or defense." So in essence you are saying that you as the nurse can provide security for the patient.

    12:31 Most organizations have security personnel but you as the nurse are responsible for everything around your patient.

    12:38 So you also are a level of security to that patient.

    12:42 So what does security affect? It affects the individual, the patient.

    12:46 It affects the environment and again emergency preparedness would be included in security.

    12:53 Because it affects everything around the patient.

    12:57 So some of the principles of security for the individual.

    13:01 It includes their personal information. This is really very important special with laws and regulations now surrounding patient privacy and their information.

    13:14 So again if you are out the hall and your talking really gotta be aware of sharing their information.

    13:21 And again the individual creates a vulnerability and their ability to care for themselves.

    13:27 And safety of others, it affects this and the developmental risk factors. What are we mean by this? What we mean is a child you would not leave them near the top of the stairs; because their developmental age is a risk factor. So I hope that makes sense.

    13:43 And then elderly person may be with a weaken sight or few health patient who may be has recently injured their legs.

    13:52 You have to be aware of these risk factors as well.

    13:56 So some principles of security in the environment. A security of access.

    14:02 Almost everyone is aware of this know but your organization will have you know locked doors so that only certain people can pass through.

    14:12 The environment again includes this confidentiality.

    14:15 I can't stress that enough and their patient privacy.

    14:19 So if the patient is waving in the morning, you know, be aware. Close the door.

    14:23 This environmental privacy is very important to human dignity.

    14:29 And really again where the patient can trust you.

    14:32 So if you may be getting your patient a bass you don't wanna leave the door open and everybody walking by the hall, you know.

    14:43 So these are the things you have to be aware of in regard to the security of environment.

    14:47 Now emergency management. Every organization has their own plan of emergency management. But there are some underline principles.

    14:55 When we talk about emergency management we want to remember that in a true emergency if you have an evacuation going on or something.

    15:04 That the principles are the same as if you in an airline and they say, "You put your oxygen masks first and then assist someone who might need you next to you".

    15:15 You have to remember that you are not helping anyone if you if you pass out or you are injured. So the able bodied evacuate first in a healthcare environment.

    15:26 And then of-course the immobile would be a transported out next.

    15:33 In emergency management communication is very important.

    15:37 All lines of communication have to be open and you need to be aware of that as well.

    15:44 Organizational policies and procedure really drive the individual organizations plan. But these are the principles. So if you working in a institution you should review you organizations policies on the emergency management so that you are prepared.

    16:03 This also includes multiple trainings as well.

    16:06 So in summary when we look at the therapeutic environment it should be patient focused.

    16:13 It of-course should promote healing so if the environment is dirty and things like that, you know there is potential for nosocomial infections.

    16:21 You want to be aware of that and use your organizations resources to support that patient environment.

    16:29 You wanna support their human needs which again is their social needs. What are the family needs? We say you should be therapeutic as a nurse and try to get them what they need.

    16:40 Again providing safety, this is can be stress enough actually in nursing and then promote trust and therapeutic relationships in the environment.

    16:54 So in nursing summary of security You want to make sure you remember that.

    17:00 It includes the patient privacy and confidentiality.

    17:03 And it is very individualized to the patient and the safety of the environment includes that security.

    17:11 This is a very overlapping principle. And emergency preparedness is all part of security.

    17:19 Your organizations security department you should become familiar with that and rely on them.

    17:26 If you have patient's family that may be is becoming disruptive.

    17:30 You as the nurse are not indented to be the sole security for the environment. So use your hospital or organization resources to support the nurse. So that the nurse can support the patient.

    17:47 And some tips for success as you take your test and get ready for this.

    17:51 You wanna make sure that you think assessment when you cut your choices of answer. You think assessment before taking action or implementation.

    18:00 So even if you were to find a patient not breathing you answer would not be begin CPR before you did an assessment. Right? Because it will make sense. But just keep that in mind.

    18:13 Use your critical thinking skills to choose the best answer.

    18:17 Almost invariably the answers would be correct but for that situation based on most principles of nursing you wanna choose the best answer.

    18:28 You can reduce your choices if you are not sure which would be the best answer just kinda rule out the choices by eliminating the may be obvious Incorrect choices.

    18:40 And then prioritize your choices by safety if you are down to the last 2.

    18:46 Think about that assessment and safety and then do a double check. When you read your question your answer should make sense. It should make sense to you.

    18:56 So Thank you this is Anne Vanderputten for therapeutic environment and security and Good Luck.


    About the Lecture

    The lecture Therapeutic Environment by Anne Vanderputten is from the course Psychosocial Integrity. It contains the following chapters:

    • Therapeutic Environment and Safety
    • Stressors
    • Safety
    • Social support and control
    • Definition of Security
    • Definition of Security
    • Principles of Security
    • Nursing Summary

    Included Quiz Questions

    1. Provide reorientation to the patient, lower TV volume, dim lighting to promote less stimulation of the environment
    2. Contact the physician for an order for medication
    3. Determine if the patient is hard of hearing
    4. Sit with the patient for one hour and allow patient time to verbalize anxiety
    1. Assess the immediate environment for safety risk, keep the patient in close proximity for observation, follow institution policy and procedure
    2. Restrain the patient
    3. Contact security officer to watch the patient
    4. Allow family members to stay with the patient
    1. Discuss with the physician and suggest moving the patient to a room with a window view.
    2. Ensure a family member is with the patient 24 hours a day
    3. Reorient the patient and provide pain medication
    4. Turn on all the lights and television to keep the patient in touch with reality.
    1. Assess the patient’s need for extra warmth, educate the patient and family about fall risks, and ask family to bring home items not needed by the patient
    2. Requesting the family to leave and return during regular visiting hours
    3. Contact security to remove items
    4. Inform the patient’s spouse the rules of the hospital
    1. Safety is the highest concern in providing nursing care.
    2. Safety is an important need but self-actualization is higher.
    3. Safety is a basic human need provided outside the healthcare environment.
    4. Security is responsible for all safety in the hospital.
    1. Discuss fall risk education with the patient and suggest area rugs be removed.
    2. Tell the family it is better to have smooth clean floors.
    3. Look for other environmental hazards.
    4. Request an occupational therapist consult to provide the patient with a walker.
    1. “It is stressful to have so many interruptions to your sleep. If you would like, we can discuss with your doctor about ordering testing and labs during the day time hours.”
    2. “If you do not want care, it is your patient right to refuse.”
    3. “You could have died from your heart attack and we have to monitor your heart condition.”
    4. “I understand but we are here to do our job.”
    1. Reorient the patient to date and be sure to have a calendar posted in patient view
    2. Suggest the physician discharge the patient
    3. Ask the patient if they are frequently confused
    4. Adjust plan of care to include frequent reorientation for the patient
    1. Reassure the patient, staff will answer the call light and the nurse will check on the patient every hour or sooner if needed.
    2. Tell the patient the unit is short staffed and it is difficult to answer the call light so frequently.
    3. Consult respiratory therapy
    4. Dim the lights in the room
    1. Able bodied patients will evacuate first
    2. Nursing should secure windows
    3. Community providers will evacuate patients.
    4. Nursing staff should check in at home to ensure their family is safe.

    Author of lecture Therapeutic Environment

     Anne Vanderputten

    Anne Vanderputten


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