The Therapeutic Environment: NCLEX-RN

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of the therapeutic environment in order to:

• Identify external factors that may interfere with client recovery (e.g., stressors, family dynamics)
• Make client room assignments that support the therapeutic milieu
• Provide a therapeutic environment for clients with emotional/behavioral issues

Identifying External Factors That May Interfere with Client Recovery

Client recovery is negatively and positively impacted by a wide variety of intrinsic and internal client related factors and also with extrinsic and external forces and factors. For example, physical recovery from a biological illness or disease can be delayed, interrupted and otherwise negatively impacted when the client has a comorbidity such as diabetes which is an intrinsic factor; and physical recovery from a biological illness or disease can be facilitated when the patient has the support of the family and resources in the community which are extrinsic factors external to the client. Similarly, psychological recovery can be facilitated and enhanced when the client has a strong support system and psychological recovery can be impeded and interfered with when the patient is not compliant and adherent to their medication regimen.

Other factors that can interfere with the psychological recovery and psychosocial integrity include disrupted family dynamics, the inaccessibility and the lack of affordability of health care services and resources, levels of stress, social stigma, and the lack of culturally competent care.

Psychological recovery is enhanced when patients and significant others participate in group meetings for professional and peer support. For example, community meetings can help the client in terms of socialization skills enhancement, self care promotion groups, group therapy, and psychosocial peer support groups; and community group meetings are available to also facilitate psychological recovery for those affect with a common disease or disorder such as depression, and there are also peer support groups like Alcoholics Anonymous and Narcotics Anonymous meetings.

Making Client Room Assignments that Support the Therapeutic Milieu

As much as possible, client room assignments should support the therapeutic milieu. For example, a client with violent and, or otherwise, disruptive behavior should not share a room with a client who triggers a client's inappropriate and/or violent dangerous behaviors, and a client at risk for suicide should have a room close to nursing station so that the client can be observed and monitored more closely and more frequently than would occur in a less trafficked and remote area.

Providing a Therapeutic Environment for Clients with Emotional/Behavioral Issues

Nurses establish, provide and maintain a therapeutically safe and supportive environment, which is referred to as a therapeutic milieu. Environments must be free of all physical safety hazards and also free of any hazards that could potentially jeopardize psychological wellbeing and safety. A therapeutic milieu eliminates as many stressors from the environment as possible. The goal of this environment is to facilitate the client's coping and recovery without the need to cope with these extraneous and avoidable stressors.

Some of the elements of a therapeutic milieu environment include consistency, client rules, limitations and boundaries, and client expectations, including contracts, relating to appropriate behavior.

RELATED CONTENT:

• Abuse and Neglect
• Behavioral Interventions
• Chemical and Other Dependencies/Substance Abuse Disorders 
• Coping Mechanisms
• Crisis Intervention
• Cultural Awareness and Influences on Health
• End of Life Care
• Family Dynamics
• Grief and Loss
• Mental Health Concepts
• Religious and Spiritual Influences on Health
• Sensory/Perceptual Alterations
• Stress Management
• Support Systems
• Therapeutic Communication
• The Therapeutic Environment (Currently here)

SEE – Psychosocial Integrity Practice Test Questions

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Alene Burke, RN, MSN

Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.