Milieu Process

How do inpatient nursing staff keep units safe and why does safety involve the milieu they maintain? In the broadest context, the manner in which patients experience the milieu or inpatient environment is dependent on the cumulative actions and practices of the nursing staff. In his seminal framework, Gunderson (1978) conceptualized these staff-driven influences into five critical milieu elements, safety, structure, support, involvement, and validation. The milieu should embody these processes as qualities of the environment available to all patients.

Recent investigations, referenced below, have identified specific nursing activities that ensure the milieu reflects the essential process of safety—both physical and psychological. To understand the experience of safety from the patient’s perspective, studies have explored how patients’ perceptions of feeling safe are affected by attendant nursing interactions. In addition to safety, nursing staff contribute to the milieu process of structure by establishing routines, implementing daily schedules, and clearly communicating expectations (Voogt et al., 2016). This milieu process (structure) is tied to safety in several ways which is evidenced by multiple studies. Organizational culture, including leadership practices, team dynamics, and institutional values, also influences how staff maintain safety, as detailed in select reviews highlighted here.

References

Reducing violence by patients against healthcare workers at inpatient psychiatric hospitals: An integrative review.
Amara, S. S., & Hansen, B. R. (2024). Reducing violence by patients against healthcare workers at inpatient psychiatric hospitals: An integrative review. Issues in Mental Health Nursing, 45(11), 1185–1193. https://doi.org/10.1080/01612840.2024.2386419

De-escalating aggression in acute inpatient mental health settings: A behaviour change theory-informed, secondary qualitative analysis of staff and patient perspectives.
Price, O., Armitage, C. J., Bee, P., Brooks, H., Lovell, K., Butler, D., … & Papastavrou Brooks, C. (2024). De-escalating aggression in acute inpatient mental health settings: A behaviour change theory-informed, secondary qualitative analysis of staff and patient perspectives. BMC Psychiatry, 24(1), 548. https://doi.org/10.1186/s12888-024-05920-y

Exploring safety culture within inpatient mental health units: The results from participant observation across three mental health services.
Molloy, L., Wilson, V., O’Connor, M., Merrick, T. T., Guha, M., Eason, M., & Roche, M. (2024). Exploring safety culture within inpatient mental health units: The results from participant observation across three mental health services. International Journal of Mental Health Nursing, 33(4), 1073–1081. https://doi.org/10.1111/inm.1332

‘Safer, not safe’: Service users’ experiences of psychological safety in inpatient mental health wards in the United Kingdom.
Vogt, K. S., Baker, J., Kendal, S., Griffin, B. L., Mizen, E., Sharp, H., & Johnson, J. (2024). ‘Safer, not safe’: Service users’ experiences of psychological safety in inpatient mental health wards in the United Kingdom. International Journal of Mental Health Nursing, 33(6), 2227–2238. https://doi.org/10.1111/inm.13381

No safety without emotional safety.
Veale, D., Robins, E., Thomson, A. B., & Gilbert, P. (2023). No safety without emotional safety. The Lancet Psychiatry, 10(1), 65–70. https://doi.org/10.1016/S2215-0366(22)00373-X

Development of “The Safe Psychiatric Ward Battery.”
Vahidi, M., Namdar Areshtanab, H., Ebrahimi, H., & Asghari Jafarabadi, M. (2023). Development of “The Safe Psychiatric Ward Battery.” Clinical Nursing Research, 32(2), 375–383. https://doi.org/10.1177/10547738221085614

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: A scoping review.
Svensson, J. (2022). Patient safety strategies in psychiatry and how they construct the notion of preventable harm: A scoping review. Journal of Patient Safety, 18(3), 245. https://doi.org/10.1097/PTS.0000000000000885

Comparison of patients’ and staff’s perspectives on the causes of violence and aggression in psychiatric inpatient settings: An integrative review.
Fletcher, A., Crowe, M., Manuel, J., & Foulds, J. (2021). Comparison of patients’ and staff’s perspectives on the causes of violence and aggression in psychiatric inpatient settings: An integrative review. Journal of Psychiatric and Mental Health Nursing, 28(5), 924–939. https://doi.org/10.1111/jpm.12758

Hospital work environments affect the patient safety climate: A longitudinal follow-up using a logistic regression analysis model.
Cutler, N. A., Halcomb, E., Sim, J., Stephens, M., & Moxham, L. (2021). How does the environment influence consumers’ perceptions of safety in acute mental health units? A qualitative study. Journal of Clinical Nursing, 30(5–6), 765–772. https://doi.org/10.1111/jocn.15614

Hospital work environments affect the patient safety climate: A longitudinal follow-up using a logistic regression analysis model.
Brubakk, K., Svendsen, M. V., Deilkås, E. T., Hofoss, D., Barach, P., & Tjomsland, O. (2021). Hospital work environments affect the patient safety climate: A longitudinal follow-up using a logistic regression analysis model. PLOS ONE, 16(10), e0258471. https://doi.org/10.1371/journal.pone.0258471

Nurses’ influence on consumers’ experience of safety in acute mental health units: A qualitative study.
Cutler, N. A., Sim, J., Halcomb, E., Moxham, L., & Stephens, M. (2020). Nurses’ influence on consumers’ experience of safety in acute mental health units: A qualitative study. Journal of Clinical Nursing, 29(21–22), 4379–4386. https://doi.org/10.1111/jocn.15480

Feeling safe or unsafe in psychiatric inpatient care: A hospital-based qualitative interview study with inpatients in Sweden.
Pelto-Piri, V., Wallsten, T., Hylén, U., Nikban, I., & Kjellin, L. (2019). Feeling safe or unsafe in psychiatric inpatient care: A hospital-based qualitative interview study with inpatients in Sweden. International Journal of Mental Health Systems, 13, 1–10. https://doi.org/10.1186/s13033-019-0282-y

Development of the Psychiatric Nursing Intervention Providing Structure: An International Delphi Study.
Voogt, L. A., Nugter, A., van Achterberg, T., & Goossens, P. J. (2016). Journal of the American Psychiatric Nurses Association, 22(2), 100-111. https://doi.org/10.1177/1078390316637049

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