rnjbanner
 
Home > RNJ > 2010 > May/June > Nurses Create a Rehabilitative Milieu

Nurses Create a Rehabilitative Milieu
Julie Pryor, PhD MN BA RN RM

Despite the recognition of milieu therapy as a nursing intervention, nursing’s contribution to the creation of inpatient environments that facilitate patient rehabilitation has been underresearched. A large study conducted in five inpatient rehabilitation units in Australia that sought to develop a grounded theory of nursing’s contribution to inpatient rehabilitation has begun to address this gap in the literature. Analysis of data collected from 53 nurses during interviews and observations of their everyday practice revealed that nurses act purposefully to create a milieu conducive to rehabilitation. In doing so, they target all patients using a range of strategies that include allowing time, keeping patients’ spirits up, protecting patients from embarrassment, and making hospitals more homelike than is typically experienced in acute-care environments. As a consequence, rehabilitative milieu therapy is proposed as a subset of milieu therapy.

Purposeful manipulation of a patient’s environment is an intervention that nurses refer to as milieu therapy. This therapy is defined as the “use of people, resources, and events in the patient’s immediate environment to promote optimal psychosocial functioning” (Dotterman & Bulechek, 2004, p. 500). The literature base for milieu therapy comes from psychology’s interest in ward atmosphere. Moos’s (1974) seminal work focused on the development of the Ward Atmosphere Scale to study this phenomenon in inpatient psychiatric settings. The three dimensions of this scale related to patients’ relationships with other patients and staff, personal growth in patients, and organizational factors such as program clarity (Moos, 1989). Milne’s (1986, p. 203) comment that “the ‘personalities’ of wards now merit more attention than do those of individual nurses” is reflected in a study by Smith, Gross, and Roberts (1996), in which attention was paid to creating therapeutic communities in inpatient units that were more homelike. The focus in these communities was on encouraging patients to develop “supportive relationships with each other” and assuming “some responsibility for themselves and the ward” (Smith et al., p. 352).

It is not surprising that within nursing milieu therapy, the most interest has been generated in mental health, for which “the function of milieu is to provide conditions which support change” (Geanellos, 2000, p. 640); in addition, several decades of commentary on the topic exist. According to Echternacht (2001), nursing’s interest in milieu therapy in inpatient psychiatric settings was influenced by the work of Peplau (O’Toole & Welt, 1989), who believed that milieu comprised structured and unstructured components. Unlike structured components that are more system based (e.g., client meetings and groups; Thomas, Shattell, & Martin, 2002), unstructured components, which are about interactions between people (Echternacht), seem to be dependent upon individual staff for their therapeutic effectiveness. Delaney’s (2006) explication of three categories of interpersonal interventions (targeting changes in behavior, thinking and responding, and regulating feelings and responses) relate to the unstructured aspects of milieu therapy. Although interactions between people are classified as unstructured, the importance of specific education to prepare staff for their role in encouraging and guiding the creation of therapeutic relationships and environments is highlighted by Milne (1986). The “disciplined application of psychotherapy principles, knowledge, and skills to brief, unplanned clinical encounters,” known as fluid group work (Echternacht, p. 39), is one example of knowledge and skills that may need to be taught to nurses.

Nursing’s interest in the purposeful manipulation of inpatient settings in which rehabilitation following injury, illness, or surgery is provided appears to be limited. Pryor (2000) introduced the notion of purposefully creating a rehabilitative milieu and suggested that the participants (typically clients, families, and staff), the activities they undertake, and the physical and social aspects of the setting contribute to the rehabilitative potential of the inpatient milieu. This includes music, noise, and human voices (Pryor, 2008). Pryor’s (2000) rehabilitative milieu fits with Falconer’s (1997) description of physical and social dimensions of the treatment environment that can be manipulated to enhance patient rehabilitation.

Evidence supporting Pryor’s (2000) suggestion that nursing contributes to the creation of a rehabilitative milieu is emerging. In one Norwegian study of nursing on stroke units, nurses were found to create “a context conducive to rehabilitation (Kirkevold, 1997, p. 56).” In a similar study conducted in the United Kingdom, O’Connor (2000b) reported a friendly, relaxed unit atmosphere in which nurses had the time needed to work with patients. Nurses interviewed in Pryor and Smith’s (2000) Australian study talked about creating and immersing patients in an environment that was persuasive and encouraged patients to work hard. However, only one of the three studies (Kirkevold) used observation to validate nurses’ self-reports.

This article reports on one aspect of a large observational Australian study that sought to develop a grounded theory of nursing’s contribution to inpatient rehabilitation. Specifically, it describes how nurses create a rehabilitative milieu.

Methodology

Data for this grounded-theory (Glaser, 1978; Strauss & Corbin, 1998) study were collected through interviews with and observation of nurses working in five inpatient rehabilitation units in regional New South Wales, Australia, following approval from the relevant (two university and two clinical) human-ethics committees. The number of nurses providing data at each site ranged from 5 to 18 (mean = 11). See Table 1 for characteristics of informants.

Table 1

Data were collected using purposive and theoretical sampling procedures (Strauss & Corbin, 1998) for 3½ years on all days of the week and during morning, evening, and night shifts to capture the 24-hour nature of nursing. Initial interview questions were broad, typically asking informants to explain what they understood rehabilitation to be and talk about what they did at work. They also were encouraged to provide examples of their practice. Subsequent interview questions sought more information about specific aspects emerging from the concurrent data analysis. For example, participants were asked to provide examples of instances during which they intentionally used humor to engage with patients. The concept of unit atmosphere also was introduced to participants, who (once the term had been explained) were able to provide several examples of how nurses intentionally created an enabling environment.

Data also included field notes, which were recorded during observation of the nurses’ everyday practice. These notes were verified with nurses being observed, as well as nurses being asked to explain the observed practice, especially the information that was taken into account during the clinical decision-making process.

Constant comparative analysis involved concurrent data collection, coding, analysis, and memoing (Glaser, 1978). Analysis involved open coding, axial coding, and selective coding (Strauss & Corbin, 1998). In line with advice from Morse (2001), in the final stages of the analysis the emerging categories were compared with concepts already reported in the literature, and commentary regarding these comparisons was incorporated into the findings.

The rigor of the study was maintained using audit trails (Rodgers & Cowles, 1993), member checks that solicited feedback from informants about findings and the researcher’s interpretations of findings (Guba, 1981; Sandelowski, 2002), data analysis trails as recommended by O’Connell and Irurita (2000), and reflexive self-awareness as described by Hall and Callery (2001).

Findings

Nurses in this study understood the purposes of rehabilitation to be facilitating patient self-care and independence, helping patients cope with and adjust to their situation, and preventing patients’ hospital readmission. They also believed rehabilitation was a distinctive type of health service that required patients and staff to behave differently from the way they did in acute-care units.

To create a milieu conducive to patient rehabilitation, nurses used strategies that targeted both the physical and psychosocial environments of the inpatient unit. These strategies targeted all patients by creating an enabling environment that encouraged active participation in rehabilitation. Nurses achieved this by allowing time for patients to do for themselves, keeping patients’ spirits up, protecting patients from embarrassment, and making hospitalization more homelike than typically experienced in acute care. These strategies complemented and reinforced strategies nurses used to ease individual patients into rehabilitation (see Pryor, 2005 and 2007 for detailed discussions of strategies used with individual patients).

Allowing Time

Allowing time was the single most important strategy to create a rehabilitative milieu. Allowing time meant that nurses did not rush to help patients, but instead stood back to allow patients the time needed to do things for themselves. Allowing time validated a core principle of rehabilitation: Rehabilitation cannot be rushed. As one nurse commented, “It’s a different way of thinking” (RN 4). Implicit in this concept is the fact that rehabilitation demands a different way of interacting as patients and nurses. Allowing time by standing back instead of rushing in to help was recognized by O’Connor (2000a, 2000b); Pryor and Smith (2000, 2002); and Long, Kneafsey, Ryan, and Berry (2002) as essential to the rehabilitation approach nurses must take.

In this study, allowing time for patients to provide self-care was central to the way in which nurses interacted with patients. It required that nurses be patient, but, like nurses in Singleton’s (2000) study, nurses spoke of making time and organizing their work so they had time to support patients’ efforts for self-care. Promoting patient self-care was far more important to nurses than making their own work easier. Patients who could feed and dress themselves took more time to complete these activities. Several nurses stressed that working with patients toward independence needed to happen at the patient’s pace; this often meant information had to be repeated several times.

A range of factors reduced nurses’ available time to work at their patients’ pace. For example, from time to time nurses were called away to attend to patients who had more pressing physiological needs. At one site, surgical patients regularly were returning from the operating room. In all instances, registered nurses (RNs) were more likely than enrolled nurses (ENs; licensed pratical nurses are known as ENs in Australia and New Zealand) to cut their time short with rehabilitation patients. When there was an unusually high number of heavily dependent patients on the unit, each of whom required significant nursing assistance (particularly if cognitively impaired), nurses also reported cutting corners.

Keeping Patients’ Spirits Up by Creating a Light-Hearted Atmosphere

Nurse informants believed that keeping patients’ spirits up enhanced their rehabilitation. Many described the ways in which they contributed to creating a unit atmosphere that engaged patients and encouraged them to be positive and happy. Nurses described using a range of strategies to get patients laughing. ENs seemed to engage in these activities more so than RNs. The use of humor, banter, and everyday chat by nurses was common in Long and colleagues’ study (2001). Nurses in the current study understood laughter to be an important adjuvant to the healing process because it encouraged patients to look beyond their own situations. Rehabilitation patients (n = 35) in a study by Schmitt (1990) also reported humor to be therapeutic. In addition to recognizing laughter as a coping strategy, the patients in Schmitt’s study reported the use of laughter by rehabilitation nurses as appropriate. Not only did laughter provide opportunities for patients “to distance themselves from a source of stress,” it also was viewed as “a catalyst for a sense of well-being” (Schmitt, p. 144).

Keeping patients’ spirits up was important at all times of the day and evening. Many nurses were observed to be bright and cheerful on morning and evening shifts, especially when they first came on duty. They seemed to create and communicate to patients the atmosphere for the shift. Nurses also were observed to continue keeping patients’ spirits up well into the evening. One nurse explained that it helped settle patients for the night if a nurse was good tempered and the unit atmosphere was pleasant. Patients in Lucke’s (1999) study described interactions with staff whom they perceived as caring as “lifting my spirits” (p. 249). This helped patients “through the rough times, helped to motivate them, and helped them to move forward” (p. 249).

Some nurse informants reported deliberately “act[ing] the fool” (EN 1) to get patients’ attention and draw them out of themselves. Although some nurses were unable to articulate a deliberative approach, one nurse described the way in which she tried to engage all patients on the unit by making eye contact with them and including them all in a conversation. Another nurse described how she successfully engaged a group of men through an impromptu karaoke session based upon songs that were playing on a patient’s radio at the time:

“We had a karaoke morning when I was working up there with the men. One of the fellows had his radio on and we had a karaoke. We each had to have a turn at singing the song, and the guys did very well and I got Blue Bayou, and I did the whole song, and they just loved it. Laughing at it just makes them happy and I think that making a person happy is half the cure of getting them better.” (EN 5)

Schmitt (1990) recommends this inclusive form of humor in rehabilitation. Similarly to the nurses in Long and colleagues’ (2001) study, nurses in the current study actively encouraged patients to interact with and support one another. As part of creating a rehabilitative milieu, nurses valued patients’ encouragement of one another. A nurse clapping in response to a patient’s achievement sometimes initiated peer encouragement. But patient camaraderie, an important aspect of rehabilitation for patients with spinal-cord injury (SCI) in Laskiwski and Morse’s (1993) study, seemed to take on a life of its own with nurses in the current study reporting some patients perpetuating camaraderie in their absence. It appeared that after nurses showed patients that active support and encouragement was acceptable and desirable, they assumed some responsibility for keeping other patients’ spirits up.

“They do encourage each other a lot. You can hear them calling out from one bed to the next, ‘Come on, you know you can do it.’ They’re amazing.” (RN 3)

This particularly was evident when a new patient came to the unit. Existing patients were reported to initiate contact with new patients and “look after and look out” for newcomers (EN 10).

Protecting Patients

Nurses reported that encouraging patients to provide self-care sometimes was marked by limited success. Several nurses said they did not want these experiences to be negative for patients, so they used strategies to protect them from negative feelings, especially embarrassment. Specific examples related to patients with speech impairment. Nurses laughed with patients when they made mistakes. One nurse made a joke out of a patient’s mistake to encourage the patient to laugh at her awkward attempt to communicate with the nurse. This decision was based on knowing that this patient sometimes needed help to deal with the frustration she experienced at these times.

Nurses also reported using other, less direct strategies to protect patients. Several nurses talked about making bodily impairments seem as if they were ordinary and acceptable. RN 10 explained that she encouraged patients to talk about their impairments, particularly bladder and bowel dysfunction. EN 12 said she used touch to indicate acceptance of patients’ impaired body parts.

Another strategy a nurse spoke about using to protect patients related to maintaining a harmonious unit atmosphere. She monitored patients’ interactions and “pounced” on patients who were thought to be insensitive or hurtful to other patients, then encouraged them to be more considerate of others in a “short and sweet” encounter (RN 15).

Protection of patients is captured in aspects of Nelson’s (1990) notion of buffering. Buffering generally refers to “the nurturing and protective process of helping patients to gather physical and emotional strength” (p. 46). Buffering specifically includes supporting patients until they have mobilized the coping resources needed to facilitate their adjustment to disability and its associated limitations and protecting patients at times of high vulnerability.

Making Hospitalization More Homelike Than Acute Care

To help move patients to greater independence, nurses tried to create a homelike atmosphere by encouraging them to dress in day clothes, eat meals at a dining table, and resume desired activities, such as listening to the radio or watching sports on television.

A number of nurses stressed the importance of socializing with other patients. One nurse captured a belief shared by many others in saying, “Social activities get the people back onto normal life” (Nurse unit manager 3). Nurses in Long and colleagues’ study (2001) also shared this belief. At some sites in the current study, social activities were so highly valued that they were a well-planned and organized part of patient rehabilitation. Nurses often were the organizers of these events, which were mostly held in the afternoons and, to a lesser extent, during weekends. If not acting as the organizers, nurses always were heavily involved in the activities. The following field note captured a regular monthly social event at one of the sites:

“Thursday 3 pm—it’s happy hour and it is very, very happy, loud, and lively. The social worker is playing the keyboard and is leading the singing. Patients have been given song books and request songs. Several nurses are present and joining in. There is food (snacks), alcohol, and soft drink. Male and female patients are there…Family members are coming and going. EN 11 is serving drinks and snacks…She appears to have everyone under surveillance and is very quick to follow-up cues from patients. Sometimes she is sitting and sometimes standing on the edge of the group. I discuss happy hour with EN 11. She says it is about life. She is very happy that the patients participate. She identifies several patients and comments individually about their participation in the singing and says how surprised and happy she is that they are singing. She explains that families are always included in whatever is going on. As they will become the primary carers they need to be included to see what happens and what needs to be done.” (field note)

Nurses at other sites also reported hosting similar events on special occasions, and if patients had a skill or interest, they were invited to briefly discuss it with the other patients.

Marked variations in the rehabilitative environment were observed between sites regarding normalcy of dress and recreation and staff mealtime practices. These variations included an observed situation that raised concerns about patient self-image and compromised safety in relation to feeding and swallowing. At other sites, nurses were observed making fresh toast, encouraging patients to sit at tables with tablecloths, and scanning rooms for potential or actual problems. In summary, not all rehabilitation units have created a consistent rehabilitative milieu.

Discussion

The finding that nurses intentionally seek to create a milieu conducive to rehabilitation to help patients ease into inpatient rehabilitation provides evidence missing from Pryor’s (2000) earlier theoretical discussion of the topic. In that discussion, Pryor proposed that factors contributing to the creation of a rehabilitative milieu include patients, families and staff, activities undertaken on the unit, and the physical and social settings in which rehabilitation takes place. In this study, nurses initiated and participated in activities with the purpose of engineering a social setting that would enhance inpatient rehabilitation.

Strategies used by nurses in this study to create a rehabilitative milieu fit with Dotterman and Bulechek’s (2004) definition of milieu therapy. They used people (themselves, other patients, and families), resources (radio, music, food, and drinks) and events (patient achievements and special occasions) to promote optimal psychosocial functioning. When creating a rehabilitative milieu, nurses were cultivating a particular unit atmosphere. Similarly to mental health, in rehabilitation the purpose of this unit atmosphere “is to provide conditions which support change” (Geanellos, 2000, p. 640), namely the transition from acute hospital patient to rehabilitation patient.

By allowing time, nurses were communicating to patients that the pace of nursing work in rehabilitation is set by patients. However, working in this way was not always possible because of nurse-to-patient ratios and the physiological needs of sick patients. To maximize the use of this strategy, the additional nursing time required to work at the pace of patients reclaiming their self-care must be taken into account when calculating nursing hours per patient day.

Nurses who are comfortable incorporating humor into their interactions with patients identify and seize opportunities to do so. They use humor to help patients cope with and adjust to their situation as well as to engage them in the activities of rehabilitation. The use of humor is not unique to rehabilitation, as noted by McCance (2003) in her discussion of the process of nursing. She cited “being humorous…having ‘a bit of fun’ and ‘bantering’ with the patients” as part of providing for patients’ psychological needs due to humor’s positive effect on “ward atmosphere and on patients’ morale” (McCance, p. 109). Because, as Geanellos (2000, p. 644) suggests, “humour is a valued characteristic in the discipline of nursing,” further understanding of when, where, how, and with whom it can be used therapeutically to enhance patient rehabilitation is needed. Given that in the current study ENs were more likely than RNs to engage in keeping patients’ spirits up, further research in this area would help illuminate the valuable EN contribution to inpatient rehabilitation.

A particularly important finding is the marked differences between units. The conditions that allow nurses on one unit to more effectively create a rehabilitative milieu than nurses on another unit seem to be related to the extent to which nurses on a unit collectively embrace rehabilitation. Further research is required to test this relationship.

Limitations

By relying solely on nurses’ reports of their contributions to patient rehabilitation and on observation of that practice, the views of patients, their families, and non-nursing staff have been excluded. In particular, because patients were not studied, their experiences and perceptions of nurses as they attempted to create a rehabilitative milieu are not known. Further research in this area is required. So too, are studies of the clinical decision-making processes of nurses who purposefully use strategies to manipulate the inpatient rehabilitation environment and those who do not.

Conclusion

The findings of this study suggest that the term rehabilitative milieu therapy can be used to refer to various strategies nurses use when creating a rehabilitative milieu. These nursing strategies include those identified in this study and others, with primary strategies being allowing time, using humor, protecting patients, and encouraging patients to socialize with each other. As such, rehabilitative milieu therapy would be a subset of milieu therapy as described by Dotterman and Bulechek (2004).

Acknowledgments

This study was undertaken as a PhD student. The guidance and support of my supervisors, Jennifer Greenwood, Beverley O’Connell, Linda Worrall-Carter, and Rene Geanellos and my critical friend Annette Walker throughout the conduct of the study is acknowledged. Support from Royal Rehabilitation Centre Sydney, University of Western Sydney, and Deakin University is also acknowledged.

About the Author

Julie Pryor, PhD MN BA RN RM, is a researcher and consultant at Royal Rehabilitation Centre Sydney; an associate professor at Clinical Rehabilitation, Flinders University in Sydney, Australia; and an adjunct professor at Charles Sturt University. Address correspondence to her at julie.pryor@royalrehab.com.au.

References

Delaney, K. R. (2006). Top 10 milieu interventions for inpatient child/adolescent treatment. Journal of Child and Adolescent Psychiatric Nursing, 19(4), 203–214.

Dotterman, J. M., & G. M. Bulechek (Eds.). (2004). Nursing interventions classification (NIC) (4th ed.). St Louis, MO: Mosby.

Echternacht, M. R. (2001). Fluid group: Concept and clinical application in the therapeutic milieu. Journal of the American Psychiatric Nurses Association, 7(2), 39–44.

Falconer, J. A. (1997). Team process and outcome: Components of treatment. Topics in Stroke Rehabilitation, 4(2), 12–20.

Geanellos, R. (2000). The milieu and milieu therapy in adolescent mental health nursing. The International Journal of Psychiatric Nursing Research, 5(3), 638–648.

Glaser, B. G. (1978). Theoretical sensitivity: Advances in the methodology of grounded theory. Mill Valley, CA: The Sociology Press.

Guba, E. G. (1981). Criteria for assessing the trustworthiness of naturalistic inquiry. Educational Communication and Technology Journal, 29(2), 75–91.

Hall, W. A., & Callery, P. (2001). Enhancing the rigor of grounded theory: Incorporating reflexivity and relationality. Qualitative Health Research, 11(2), 257–272.

Kirkevold, M. (1997). The role of nursing in the rehabilitation of acute stroke patients: Towards a unified theoretical perspective. Advances in Nursing Science, 19(4), 55–64.

Laskiwski, S., & Morse, J. M. (1993). The patient with spinal cord injury: The modification of hope and expressions of despair. Canadian Journal of Rehabilitation, 6(3), 143–153.

Long, A., Kneafsey, R., Berry, J., Ryan, J., & Howard, R. (2001). Teamworking in rehabilitation: Exploring the role of the nurse. London: The English Board for Nursing, Midwifery and Health.

Long, A. F., Kneafsey, R., Ryan, J., & Berry, J. (2002). The role of the nurse within the multi-professional rehabilitation team. Journal of Advanced Nursing, 37, 70–78.

Lucke, K. T. (1999). Outcomes of nurse caring as perceived by individuals with spinal cord injury during rehabilitation. Rehabilitation Nursing, 24(6), 247–253.

McCance, T. V. (2003). Caring in nursing practice: The development of a conceptual framework. Research and Theory for Nursing Practice, 17(2), 101–116.

Milne, D. (1986). Planning and evaluating innovations in nursing practice by measuring the ward atmosphere. Journal of Advanced Nursing, 11, 203–210.

Moos, R. H. (1974). Evaluating treatment environments: A social ecological approach. New York: John Wiley & Sons.

Moos, R. H. (1989). Ward Atmosphere Scale manual (2nd ed.). Palo Alto, CA: Consulting Psychologists Press.

Morse, J. M. (2001). Situating grounded theory within qualitative inquiry. In R. S. Schreiber & P. N. Stern (Eds.), Using grounded theory in nursing (pp. 1–15). New York: Springer.

Nelson, A. L. (1990). Patients’ perspective’s of a spinal cord injury unit. SCI Nursing, 7(3), 44–62.

O’Connell, B., & Irurita, V. F. (2000). Facilitating the process of theory development by creating a visual data analogue trail. Graduate Research Nursing, 2(1), 1–7.

O’Connor, S. E. (2000a). Mode of care delivery in stroke rehabilitation nursing: A development of Kirkevold’s unified theoretical perspective of the role of the nurse. Clinical Effectiveness in Nursing, 4, 180–188.

O’Connor, S. E. (2000b). Nursing interventions in stroke rehabilitation: A study of nurses’ views of their pattern of care in stroke units. Rehabilitation Nursing, 25(6), 224–230.

O’Toole, A. W., & Welt, S. R. (Eds.). (1989). Interpersonal theory in nursing practice: Selected works of Hildegard E. Peplau. New York: Springer.

Pryor, J. (2000). Creating a rehabilitative milieu. Rehabilitation Nursing, 25(4), 141–144.

Pryor, J. (2005). A grounded theory of nursing’s contribution to inpatient rehabilitation. Unpublished PhD thesis, Deakin University, Melbourne, Australia.

Pryor, J. (2007). Coaching patients to self-care (Royal Rehabilitation Centre Sydney Monograph Series No. 10). Ryde, New South Wales, Australia: Royal Rehabilitation Centre.

Pryor, J. (2008). Family and client coping. In S. Hoeman (Ed.), Rehabilitation nursing: Prevention, intervention and outcomes (4th ed., pp. 448–474). St. Louis, MO: Mosby Elsevier.

Pryor, J., & Smith, C. (2000). A framework for the specialty practice of rehabilitation nursing. (Rehabilitation Nursing Research and Development Unit Monograph Series No. 4). Ryde, New South Wales, Australia: Rehabilitation Nursing Research and Development Unit.

Pryor, J., & Smith, C. (2002). A framework for the role of registered nurses in the specialty practice of rehabilitation nursing in Australia. Journal of Advanced Nursing, 39(2), 249–257.

Rodgers, B., & Cowles, K. (1993). The qualitative research audit trail: A complex collection of documentation. Research in Nursing and Health, 16, 219–226.

Sandelowski, M. (2002). Reembodying qualitative inquiry. Qualitative Health Research, 12(1), 104–115.

Schmitt, N. (1990). Patients’ perception of laughter in a rehabilitation hospital. Rehabilitation Nursing, 15(3), 143–146.

Singleton, J. K. (2000). Nurses’ perspectives of encouraging clients’ care-of-self in a short-term rehabilitation unit within a long-term care facility. Rehabilitation Nursing, 25(1), 23–35.

Smith, J., Gross, C., & Roberts, J. (1996). The evolution of a therapeutic environment for patients with long-term mental illness as measured by the Ward Atmosphere Scale. Journal of Mental Health, 5(4), 349–360.

Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedure for developing grounded theory (2nd ed.). Thousand Oaks, CA: Sage.

Thomas, S. P., Shattell, M., & Martin, T. (2002). What’s therapeutic about the therapeutic milieu? Archives of Psychiatric Nursing, 16(3), 99–107.