STANDARDS OF MENTAL HEALTH PSYCHIATRIC NURSING

A. STRUCTURE CRITERIA AND STANDARDS

Criterion I. Qualifications of the Nurse

The nurse shall have the professional qualification/preparation in nursing and in the area in which
she practices; and personal and other qualifications commensurate with her job responsibilities.

STANDARDS
● Professional - Graduate of BSN
Qualification - R.N.
● Preferably MS in Mental Health and Psychiatric Nursing for Leadership
and key positions
● Must have attended post graduate mental health pyschiatric nursing
programs consisting of the following major components: scope of mental
health psychiatric nursing practice, professional responsibilities of the
pyschiatric nurse, psychiatric nursing process, dynamics of behavior,
psychopathology, treatment modalities, and psychiatric nursing
intervention.
● Must have undergone structured orientation program in psychiatric
nursing
● Personal - Physically healthy
Professional - Possesses a well adjusted personality
Qualities and - Ability to:
Competence - Be patient and understanding in dealing with people
- Be flexible to differences in people and environment
- Relate effectively with different types of clients/members of the team
- Recognize and cope with one’s thoughts, feelings, reactions and attitude
- Maintain an objective attitude while emphatizing with clients
- Be continuously open to professional and personal growth
- Maintain ethical and safety standards for the clients’ welfare

- Possesses knowledge of:

- Man as an integral human person
- Concepts of mental health and mental illness, personality theories and
Psychopathology
- Scope of mental health and psychiatric nursing practice
- Mental health needs and problems of client
- Strategies/approaches in meeting/coping with mental health needs and
and problems
- Community resources
- National mental health programs and policies
- Trends in mental health psychiatric nursing
- Skills in
- Therapeutic use of self
- Effective therapeutic communication (verbal and non-verbal)
- Interpersonal relationships
- Assessment
- Analyzing dynamics of behavior
- Therapeutic interventions

Criterion II Functions of the Nurse

The nurse shall perform within the legal scope of nursing and in accordance with the needs and
resources for health care.

Nursing Care Functions and Activities

STANDARDS: The Nurse
● Professional - Is responsible and accountable to:
Accountability - One’s self, that is, possesses professional integrity by being honest and
sincere in nursing professional aims with the clients and acknowledge
one’s limitations.
 ● Clients with whom she works, for the efforts she makes in
working with clients and for the disclosure to the clients the purpose of
work to be done.
● Nurse colleagues in the work situation through periodic peer
review; and in the profession at large by being able to define and clarify
what nurses do in mental health psychiatric settings
● Nurse administrators for the best use of resources
● The public by applying nursing standards of practice

Provision of
Nursing Care - Analyzes the data in order to understand the meaning of the patient’s
behavior
- Identifies nursing needs and problems
- Formulates a plan of care considering patient’s needs, problems
- Implements nursing care plan
- Evaluating the progress of care and making whatever readjustments are
necessary to attain objectives

● Collaboration - Collaborates with other nurses in:

with the - Identifying the needs and problems
Nursing Staff - Planning and implementing nursing care
- Evaluating progress and outcomes of care
- Participates in nursing conferences noting the following:
- Client’s reaction to treatment plans
- Themes and patterns of clients behavior
- Observations and reports of others which are relevant to incorporate
in the nursing care plan
Participates in the orientation of new staff members
- Participates in the continuing education in the unit
- Participates in the supervisory process and continually develops and
improves clinical competence
- Assists in evaluating nursing care and performance of staff nurses

● Collaboration with members of the multi-disciplinary team in:

- Contributing to the comprehensive assessment in client’s behavior, needs,
and problems
- Interpreting dynamics of behavior
- Planning and implementing comprehensive treatment plan
- Evaluating the progress

● Research/Innovative functions and activities

Research: - Appreciates importance of research in the continuing development and
refinement of knowledge in the mental health field
- Initiates, conducts, participates, encourages others to participate in the
research projects
- Applies, observes, maintains responsible standards/ethics in conducting
Research
- Dissiminates research findings through presentation/or no publication

Innovations - Utilizes research findings when are pertinent to improving nursing

practice
- Experiments with new and creative approaches to practice
- Seeks expert consultation and or supervision as necessary
- Contributes to professional growth of others by sharing innovations in
theory and practice through presentations and/or publication

Criterion III Organization and Administration of Nursing Care Services

The nursing care services shall be organized and administered in a manner that is conducive to
decision-making and actions in order to meet the needs of clients as well as nurses are the care providers.

STANDARDS
● Conceptual - A conceptual framework for mental health nursing practice provides
 Framework statements of the beliefs regarding mental health/illness, mental health
psychiatric management and nurse’s responsibilities, which are the bases for
the nurses’ mode of practice
● Organization - Nursing care activities are organized within the context of framework for
of nursing mental health psychiatric nursing practice and the total system of health
care care within which care is given
- Nursing manpower needs are based on the conceptual framework for
practice, specific services rendered number and types of clients to be cared
for, and resources available.
- A system of communication is established and maintained for proper
collaboration with clients and relatives, co-nurses, members for the multi-
disciplinary team and community agencies
- Different needs and problems of client which require different levels of
nursing care and expertise are provided by nurses who are prepared
accordingly
● Staff - An orientation program is provided for every new staff nurse to acquaint
Development her with the responsibility for her role
- A staff development program is provided to assist the staff in becoming
increasingly knowledgeable and competent in fulfilling role expectations
and consequently, improving nursing care

Criterion IV Physical Facilities and Equipment

The physical facilities, lay-out, equipment and supplies required are provided and periodically
accounted for to insure safe and efficient delivery of nursing care.

STANDARDS
● Determination - In determining the physical facilities and equipment, lay-out and supplies
of physical for nursing care, the nursing staff considers the following:
inabilities and - Philosophy of care
Equipments - Framework for mental health pyschiatric nursing practice
- Setting of practice
- Nursing care services rendered
- Client’s needs and problems
- Number of clients to be cared for
- Resources available
- Recommendations and requests for facilities, equipments, and supplies are
determined by the nursing staff in consultation with the nursing service
administrator for approval of the agency

● Accountability - A system of checking, accounting, assessing, and supervision of the

maintenance of physical facilities, equipment and supplies is provided for
efficient delivery of care services

● General - The physical environment should:

Provisions of - Enhance a therapeutic climate to help the client develop a sense of self
Institutional esteem, improve his/her ability to relate with others, and to prepare him/her
Setting to be re-integrated into the community.
- Provide for safety, primary and basic needs for physical hygiene
- Enable the client to exercise initiative, make decisions and engage in self-
activity
- Provide for the following:
* Facilitate for clients to assume responsibility for their personal cleanliness
* Dining room facilities with seating arrangements that engage conversation
* Reception/visiting rooms to receive their visitors
* Living room to encourage clients to interact with one another
* Recreational space for diversional activities
* Treatment room/security for security risk clients
* Space for outdoor exercises and games
* Calendar and clock within sight for clients to be oriented to date and time
* Nursing station and lounge
* Conference room
* Clothes closet
 * Storage room

B. PROCESS CRITERIA AND STANDARDS

Criterion I Assessment
The data shall be relevant, accurate and comprehensive, recorded and available to proper persons or
groups. Data collection shall be systematic and continuous

STANDARDS:

● The nurse - Collects the following data from the client to determine level of
functioning and needs and problems that require nursing interventions

● Type of data Collected - Identifying characteristics such as name,

sex, age, marital status, address, ethnic and cultural origins, ordinal
position in the family,
religion, etc.
- Physical behavior
- Psychosocial data
- Mental status
- Mental health/psychiatric history
- Clients perception of his needs and problems
- Client’s motivation, objectives for seeking help, strengths and
resources
- Delineates raw data (data collected through the use of one’s senses
modalities i.e. what is seen, heard, smelled, etc) from personal
interpretations regarding the meaning of the data

● Confidentiality of - Respects client’s right to privacy, however sets limits to confidentiality

Information and states clearly and firmly what these limits are
- Makes data available only to proper persons and/or groups and in
accordance with policies and procedures.

● Sources of data - Collects data through:

and methods of - Constant observation
data collection - Interviews of clients, relatives and significant others
- Physical examination
- Mental status examination
- Regular interaction with clients
- Conferences with members of the team
- Records and reports
- Home visits

● Recording - Utilizes a system of data collection which provides for

- Systematic and accurate data recording
- Progress report
- Clear communications with members of the team

Criterion II Analysis of Data

Data are analyzed in order to draw nursing inferences and valid interpretations fo client behavior
based on knowledge of the arts and sciences with particular emphasis upon psychosocial and biophysical
sciences

STANDARDS

● The Nurse - Utilizes concepts and theories to explain the dynamics of human behavior

● Interpretation
and Validation - Validates with the clients and/or other observers interpretation of the
possible meaning of the client’s behavior and their relevance for nursing
intervention
 ● Needs and Problems - Defines client needs and problems that can be done through nursing
intervention
● Utilizes a systematic framework in defining client needs and problems

● Priority - Assists client in setting priority of identified needs and problems

Criterion III Planning

The nurse shall be responsible in planning and restructuring nursing intervention. Planning of
nursing intervention is based on adequate understanding of client behavior, identified needs and problems
and modes of nursing intervention.

STANDARDS:
● The Nurse - Establishes a therapeutic contract (client’s definition of personal
goals for treatment and nurse’s professional responsibilities) with
client

● Setting goals - Assists the client to set goals and objectives which are specific and
and objectives realistic and based on identified needs and problems

● Determining strategies – Utilizes supervisory process to explore plans for nursing intervention
- Explains to the client the corresponding activities/strategies necessary
to meet the goals and objectives

● Plan for - Determine criteria for evaluating effectiveness for nursing interventions
Evaluation

● Communicating - Develops and writes a nursing care plan which is discussed with other
the plan members of the staff and serves as guides for the care of the client

Criterion IV Implementation of Nursing Intervention

Nursing intervention is in accordance with the care plan

STANDARDS: The Nurse

● Scope of - Performs actions within the scope of mental health psychiatric nursing
Intervention practice and her professional qualification

● Use of self - Use self therapeutically in relating with clients

Examining - Utilizes available resources for care

● Resources - Maximizes participation of client/family, significant others and members

of the team to benefit the client

● Treatment - Carries out any of the following treatment modalities which are
Modalities appropriate for clients:
- Nurse patient relationship - Relaxation Therapy
- Group therapy - Play Therapy
- Family therapy - Other adjunctive therapies
- Milieu therapy - Counselling
- Crisis intervention - Health Teaching
- Behavior therapy
- Activity therapy
- Administers prescribed medication or supervise clients in taking their
own medications
● Assists clients in somatic treatments

Criterion V Evaluation
Evaluation is an ongoing process of assessing, estimating or judging the quality and efficacy of the
interventions
STANDARDS: The Nurse
Criteria - Evaluates effectiveness of nursing interventions according to defined
criteria and/or extent to which the nurse is able to achieve objectives
of care

Barriers to goal - Identifies factors that hinders the achievement of desired goals
Fulfillment

Modification - Modifies plan of care and makes alternatives courses of actions

C. OUTCOME CRITERIA AND STANDARDS

The outcomes of nursing intervention are reflected in the progress and effects of care
Short term care - The outcomes of nursing intervention on clients who require short term
intervention are reflected in the following:

● Progress of care - Increased participation and motivation in therapy

- Keeps regular appointments
- Adheres to the terms of contract
- Rapport with the nurse
- Develops trust as seen in the progress towards working stage of
relationships
- Ability to recognize/define one’s needs and problems, strengths,
weaknesses, limitations and resources
- Ability to meet one’s needs and cope with problems
- Ability to find meaning in one’s experiences

● Effect of Care - Changes towards coping behavior as seen in

- Resumption of activities in daily living
- Return to continued interest in work
- Ease in relating with others
- Integration in the community

● Long Term Care - The outcomes of nursing intervention on clients who require long term
intervention are reflected in the following:
- Maintenance of client’s basic needs
- Maintenance of client’s established daily routine
- Increased understanding of the client and/or the family on the nature of
the client’s illness
- Sustained interest and concern of the family on the welfare of the client
- Recognition and acceptance of the family on the welfare of the client
- Continued provision of opportunities for client to engage in therapeutic
Activities

● Progress of Care - Conservation of client’s energy, physical, personal and social integrity

DEFINITIONS OF TERMS

● CRITERIA – are attributes or variables believed or known to be relevant indicators of the quality of
nursing care

● STANDARDS – are desirables sets of conditions and performances considered essential in ensuring
the quality of nursing care/services which are acceptable to those instrumental/responsible in setting
and maintaining them

● STRUCTURE CRITERIA – are basic support components of nursing care which includes the
following: educational, personal and professional qualities and proficiencies of the nurse; functions
of the nurse; organization and administration of nursing care services; physical facilities and
equipments
● PROCESS CRITERIA – are the decisions and actions of nurse relative to the nursing process which
are necessary to provide nursing care. These include assessment, planning, intervention and
evaluation.

● OUTCOME CRITERIA – are the results of care provided and reflected in terms of progress and
effects of care.
 ATTITUDE THERAPY

An attitude is the way one feels toward the individual or experience. Our behavior is the result of all our
experiences. We learn to modify or change our behavior by the influence that other people have on us. The
attitude of other people toward us is one of the most important influences of our behavior. Nursing
personnel through the use of attitudes are able to structure interpersonal relationships to foster changes in
behavior of patients and co-workers. This maybe so, because attitudes maybe used to change behavior or
bring about desired behavior. A part of the changed behavior or bring about desired behavior. A part of the
changed behavior can be changes in attitudes of the patients and co-workers leading toward a more
adaptive and productive life.

Attitude therapy is the use of prescribed attitudes as a method of treating patients. The prescribed
attitude maybe used consistently by all personnel in order for the patients to receive maximum therapeutic
value.

Attitudes are prescribed according to the patient’s individual needs. Therefore, more than one
attitude maybe prescribed if the patient is subject to frequent changes in behavior. For example, a hostile,
impulsive patient may have an attitude of matter-of-fact to no demand prescribed. Matter-of-fact may be
used for his impulsive behavior and if he becomes agitated, no demand maybe used.

Code for attitudes:

MF – Matter-of-fact PF – Passive Friendliness ND – No demand

AF – Active friendliness KF – Kind firmness

Matter-of-fact
Patients for whom this attitude is necessary usually function on the pleasure principle. They may
have somatic complaints and complain about the hospital routines and assignments to gain sympathy,
attention, to satisfy their sick needs. Their real need is to learn that manipulation is unrewarding. If we
permit these patients to manipulates us, we are contributing to their illness. Relate to him in a friendly
manner when he is not attempting to manipulate. Positive attention is given when they demonstrate positive
behavior. Responses to patient’s please, apparent distress, manipulations or maneuvers, are made in a
consistent, casual and calm manner.

Do not let the patient know you are concerned about his somatic complaints but follow through on
their complaints.

We do not get angry, (negative attention) because if well fall into their trap by being angry, we are
being manipulated. Do not get into either verbal or physical power struggle.

A strict matter-of-fact is matter-of-fact with firmness. It should in no way denote sternness. Note the
difference in definition: Firmness denotes being steady not fluctuating; it markedly implies stability.
Sternness, denotes having a certain hardness or severity; hard or severe in dealing with others.

Example:

Mr. Complaint remarks about the food he has to eat, that it is not worth going for. Listen in a calm manner,
usually no comment is necessary but you may say, “The food is nourishing” or “All patients on a regular
diet have the same food”

Mr. Complaint: “This place is a prison. They make you work all the time” Make no comment or show
approval or disapproval. Just listen.

One patient frequently tries to change the plans of activity. He tries to play one team member against
another. Take every precaution to see that the plan for him is followed consistently by all concerned. Be
consistent and matter of fact in seeing that he follows his treatment plan. “Mr. Complaint you were due for
occupational therapy at 10:00 o’clock. It is not 10:15 now”

Patient, pointing towards the doctor. “I hate him, reminds me of my papa. “Listen in a matter of fact, as
much as to say, “Well so what. We are not going to pass judgement”
Mr. Complaint has many physical ailments for which no organic basis has been found. He is skillful in
crafts and today he is helping the unit in decorating for a party. He leaves the group, comes to you and say,
“I can’t work anymore. I have a headache, I think I’m sick.” You might respond, “Today is the deadline for
completing the decorations. Let’s give them all the help we can”

Mr. Touch puts his hand on your shoulders and says, “When do you give me a date?” Say to him,
“Mr.Touch, keep your hands to yourself. I’m not going to give a date now or later.”

Mr. Run says, “I’ve been in this locked ward for 3 months, and I’m well not. Why can’t you get me
privileges.” In a calm manner, “You will be granted privileges when the team feels you are well enough to
handle them” He replies, “I’m well now”. You may say, “There is no pint in discussing the matter any
further”

Active Friendliness

It is prescribed primarily for withdrawn or regressed patients, and those who have experienced very
few successes. It is usually the attitude prescribed for patients on the Reality Orientation Program.

Assume the initiative in showing a consistent, genuine interest in the patients, and their needs 24
hours a day. Seek patient out and spend extra time with him.

The basic principle in active friendliness is giving attention before the patient requests it. We do
“little things” that are important to him. We give sincere praise for accomplishment that show progress. The
therapist makes even the simplest decisions because the patient should not be allowed to fail.

Kind Firmness
This is perhaps the most difficult attitude to learn. It is very hard for us to be firm with depressed
patients and instead of sympathizing with their misery, we make them work. The first patient we worked
with had a suicidal depression. We started with him because everyone believe that he was hopeless and
there is nothing to loose if we failed. Three series of electroshock treatment had failed to bring lasting
improvement. He had active kindness, encouragement and anti-depressant drugs. We decided to try kind
firmness which has since become the basic of what we call not the Antidepressive Regimen (ADR). We
took the patient into small, rather drab room furnished with chairs, tables and told him to get to work
sending a small block of wood.

The purpose is to put a depressed patient to work in monotonous, ungratifying repetitive work, and
to criticize not the patient but the way he is doing the job. The work give him some muscle action and
something else to focus on besides his own miseries. We never let him do anything he wants to do. If he has
insomnia we make him dress and take him back to the workroom. If he talks to us, we reply, but we point
out that there he is here to work and not to talk.

A patient whose primary symptom is depression has a great deal of internalized hostility and the
purpose of Kind Firmness and the insistence of ungratifying work is to help him turn his hostility outward.
For instance, a man will be put to work counting seashells into a cigar box. He is easily distracted each time
he loses count, he is told to do it all over again. Finally, which usually takes 3 or 4 days or sometimes
longer, he will hungrily spill those shells on the floor. If he will not pick them up, he is already to come off
the anti depressive regime. The nursing assistant brings him out of the room to see their the staff physician.

The patient is usually very angry, he will stride up and down the hallways and may even become
quite verbally abusive. We take him outside to work off his excitement or let him workout on a punching
bag.

NO DEMAND
The last attitude is the no demand which is for patients who are in genuine, furious rages. We all
have a vivid recollection of a two barge operator who was brought to the hospital in a straight jacket. As
soon as we released him to flow into a rage and threatened us all. Such global rage is too much for one
person to take, so several staff members gathered wound him in a small circle, and he raged first at one of
us and then another. We gained strength from one another and prevented him from focusing his rage in one
particular person. After five or ten minutes he broke into tears and walked into the ward with his head on
the shoulder of William Patterson, Jr. Ph.d, the unit treatment team leader.
 We had promised this patient that he would see DR. FOLSOM, and when the patient met him with
the treatment team present, Dr. Folsom was admittedly afraid. “This was realistic” He said afterwards. “It is
even good for the patient to know that you fear him; you indicate that you are in contact, that you
understand his anger”.

“He was frightened to death of his own anger and would walk around the ward with his feast
clenched, threatening everybody, but we did know to commit him or put him in restraint. We continued the
no demand attitude. Within a very short period of time, this disturbed and potentially destructive patient
was on an open ward. He never hurt anybody in the hospital and within six weeks he was discharged.

Examples:
You may suggest “The weather is warm. Just right for a Coke”

Mr. Circle, your shoes surely do look good. I can almost see myself since you polish them”

Go with the patient to the occupational therapy or work with him. Accompany him on walks sit with him,
etc. When he hesitates to wash for working materials, get the materials he needs or go with him to get them.
Talk with him about the activities in which he participated.

Sit beside the patient, slowly leaf through a magazine and comment on certain pictures.

“Mr. Circle, here is a comb. Let us go over to the mirror and comb your hair,” Then walk with him and help
him if necessary.

Mr. Circle has just completed his bath and is dressed in clean clothes. You can make a remark by saying,
“My, you look good in those clean clothes. That is good looking shirt.

PASSIVE FRIENDLINESS
The attitude is prescribed who are suspicious. They are frightened by active friendliness or
closeness. Suspicious patients see their environment as being against them. They have feelings of distrust.

Real interest is shown by being available and alert, but not pushing. Wait for the patient to make the
first move and respond accordingly. There is little difficulty in implementing a program since these patients
usually follow their schedule

Examples:
“Mr Pass let us know if you want anything and we’ll get it for you. We won’t come too close
because we know you are frightened. We’ll be around when you need us.” And be really there when the
patient needs you. Be courteous and chat with him when he comes to you; but do not seek him out. If Mr.
Pass makes the first move, smile at him and need your head showing approval.

The patient brings to you a rag he has made in OT Admire the workmanship if it is desering and
encourages the patient to continue doing other things. Say, “This is a good job, maybe next time you can
use three colors”

“Good morning, Mr. Shine,” Do not stop to pass the time of day, without being courteous in everyday
matters.

A very suspicious patient expressed interest in finger painting and at the end of the evening proudly shows
you what he had done. Your response, “That looks to me like a very interesting combination of colors.
Thank you for showing it to me”

Mr. Pass says, “Miss Snow, I’m not sleepy. I want to finish this book.” You response, “You may if you
like”.

Mr. Pass says, “Miss May, I enjoyed the group sessions more than I thought I would”. Miss May smiles and
says, “That’s fine, we enjoyned having you”

Mr. Pass approaches the nurse and says, I’d like to look up a word. May I borrow your dictionary. The
nurse says, “Yes” and gives him one.
 Module on: Milieu Therapy

NARRATIVE

A Brief History of Milieu Therapy

Though the treatment potential of the environment was recognized long ago by the Egyptians,
Persians, Greeks and Romans, milieu treatment in general was not used until the early 19th century. It was
then that proponents of “moral treatment” led by Pinel, Tuke and Conolly sought to abolish the cruel
neglect and abuse of the asylums in favor of a healthy, supportive environment as a means to eliminate
undesirable behavior and promote restoration of health. Moral treatment, then, represents the first
systematic and widespread type of milieu therapy.

In the early 20th century, psychoanalysis, inspired by Freud and his followers, developed a type of
milieu therapy fashioned after psychoanalytic theory. According to this method, hospital activities and
specific staff interactions were prescribed for each patient by the psychoanalyst based on a formulation of
the patient’s unconscious needs. The influence of this practice is still felt in many inpatient Psychiatic units.

During this period between 1940 and 1950 another type of milieu therapy was developed largely
through the work of Maxwell Jones in England. This model, called the “Therapeutic Community”, stressed
the patient’s active responsibility for his own treatment and for the treatment of others. Patients were given
the responsibility of being primary treatment agents. The nursing staff and physicians functioned as role
models and treatment catalyst rather than as the sole source of treatment. The effort of Jone’s work has
been reaching in this country and abroad.

One common denominator of the different milieu therapy theories, then, what factors in the
treatment environment (e.g. activities, supportive, relationships, other patients, etc.) are used in manner that
is therapeutic the patient. To avoid confusion of the “Hodge Rodge Lodge” effect the present authors
suggest first looking at milieu therapy as others have seen it:

…..(as) a stable, coherent social organization which provides an integrated, extensive treatment context.
The aim…..is to make certain that a patient’s every social contact and his every treatment experience are
synergistically applied towards realistic, specific goals.

In order to achieve these goals, however, a conceptual framework of the milieu’s therapy mechanisms (i.e.,
social/psychological variables at play in the milieu) must be developed to insure that the institutional
treatment program maintains its stability as a therapeutic force.

Definition
A Model of the Therapeutic Milieu: Since Eysenck’s famous challenge to the efficacy of
psychotherapy, virtually every aspect of it has been examined. A resultant general model for psychotherapy
has developed which separates the many therapy variables into structural or content variables and dynamic
or process variables. Milieu therapy also discuss milieu therapy in terms of dynamic or process and
structure or content, yet theories and practices continue to differ. As some authorities suggest, a theory of
milieu therapy should be flexible enough to incorporate different specific psychiatric therapies to fit the
needs and goals of different treatment facilities.” A general theory of milieu therapy, however, should be
grounded in commonly accepted and salient psychotherapeutic dimensions facilitating discussion: within
and comparison access program. It is for this reason that we suggest subsuming all activities and
interactions in the milieu under three treatment dimensions: PROCESS, CONTENT AND TIME and
discussing them in relation to a fourth dimension, OUTCOME.

Process variables are interpersonal, intrapersonal or transactional characteristic and the overall
atmosphere of the unit permits or impedes therapeutic encounters between and among patients and staff.

Content variables are general social system variables such as structured program activities (e.g.,
group therapy, occupational therapy, structured time with staff or other patients), unstructured activities
(e.g., T.V. time, time alone, unstructured time with staff or patients), and specific content issues addressed
therapeutically (e.g. specific patient problems such as low self-esteem, social skills, depression, etc.)
Content may also refer to specific treatment regimes (e.g. medication, ECT, individual therapy) usually
administered by the individual patient’s physician but often an active milieu issue.
 Time variables include length of stay in the hospital, amount of treatment time, and when, in the
sequence from admission to discharge, a process or content variable occurs.

Outcome in general is the result – positive, negative or neutral – of treatment. Positive outcome may
be defined as personality growth and behavior change resulting in an increased capacity for post-hospital
community adaptation and adjustment. Specifically, outcome maybe thought of as the goal of the treatment
intervention.

_________________________________
An expert from-“Practical Implications
Of a Theory of the “Therapeutic Milieu”
For Psychiatric Nursing Practice” JPN
And Mental Health Service, May 1980
pp16-17

The Therapeutic Milieu

A therapeutic environment does not just happen. It must be build system atically and rebuilt daily,
the effort itself creating an atmosphere alive with growth in staff as well as patients.

The concept of milieu therapy as it is used in this article is both a method of treatment and a
philosophy. As a method of treatment, it is a scientific structuring of the environment in order to effect
behavioral changes and to improve the psychological health and functioning of the individual. As a
philosophy, it is a belief in the value of free self-expression and group process as a therapeutic approach.
All who work within the milieu must believe in the philosophy underlying milieu therapy and share a
common attitudinal set.

There are seven basic assumptions upon which every milieu program is based:
1. THAT HEALTH IN EACH INDIVIDUAL IS TO BE REALIZED AND ENCOURAGED TO
GROW. We begin by looking not for the psychopathology but for the health in the people who
come to us labelled “patients”. Every person, regardless of his degree of dysfunction, he has health
aspects to be used as foundation upon which to begin building a functional, productive personality.
2. EVERY INTERACTION IS AN OPPORTUNITY FOR THERAPEUTIC INTERVENTION.
One goal for every patient is to improve his communication skills. The mere fact that he is confined
to a community of others forces the formation of interpersonal relationships. Verbal
communications must be clear among staff as well as between staff and patient. Distortions in
manner and content will be dealt as they occur.
3. THE PATIENT OWNS HIS OWN ENVIRONMENT. As a member of the hospital community,
each patient is involved in the unit structure, its management and its activities. Each participates in
some form of organized patient government in which members make decisions and solve problems
related to their immediate surroundings. Not only does this satisfy the patient’s need for personal
autonomy, but is also allows the group as a whole to manipulate its environment to meet the group’s
needs.
4. EACH PATIENT OWNS HIS BEHAVIOR. Every one within the milieu is expected to be
accountable for himself and his behavior.
5. PEER PRESSURE IS A USEFUL AND A POWERFUL TOOL. When given the chance, a
community of patients will develop its own code of honor, and these self-governing group norms
are far more effective than any standard set by the staff. Confrontation is frequent. The therapeutic
milieu requires each not only to take responsibility for himself and his behavioral, but also to
become responsible for others within the system. How his behavior affect others is an ever-present
issue, and learning new patterns of behavior acceptable to others become essential.
6. INAPPROPRIATE BEHAVIORS ARE DEALT WITH AS THEY OCCUR. Patients are
required through here and now interventions to examine their behavior, its meaning, its effect on
others, and alternate ways of behaving in order to meet their needs.
7. RESTRICTIONS AND PUNISHMENT ARE TO BE AVOIDED. Group discussion is used to
control destructive behaviors. Whenever external controls are necessary.
The patient is always informed of the rationale. Generally, the group level of tolerance is high but in
instances in which the well being of others is endangered, it is easy for them to accept the need to isolate
one of their members until the individual can control his actions and once again profit from the milieu
experience.

Reference: JPN and Mental Health Services “The Therapeutic Milieu: Making It Work,
August 1979, pp 38-39
 Module on
ACTIVITY THERAPIES

Narrative on Activity: Therapies:

The discipline that comprise the activity therapies include occupational therapy, recreational
therapy, music therapy, vocational and industrial therapy, educational therapy, patient library services
(bibliotherapy). Within these specialities other services maybe provided, such as dance therapy; drama
therapy, art therapy and manual arts therapy. Close coordination must be maintained between the nursing
staff and the activity therapies if the patient is to receive optimum benefits these auxillary services. This is
especially are patient’s program of activity centers around activities of daily living since the nurse is in a
position to supervise and reinforce the use of those skills learned in activity therapy.

HISTORY OF ACTIVITY THERAPIES:

In the care of emotionally disturbed persons the activity therapies have, until recently, been
considered based peuchotherapeutic measures. This has been the case despite the fact that ancient Greek
and Egyptians civilization have left evidence of their use of music, games and dancing as forms of
treatment of the mentally ill.

By the turn of the 20th century two kinds of occupational therapy had developed and were
categorized by their purpose. The first kind \was designed to provide diverincry activities, primarily
through the use of arts and crafts, hospitalized persons were caught to make simple objects such as
ashtrays, leather slippers, and wallets. Other activities as painting and sculpturing were also available.
Some patients were quite talented in these areas and created objects that were not only aesthetically
pleasing but that also could be sold for profit. Many persons, however, used these activities merely as a
means of shiling away the hours in an effort so combat the medium of long-term hospitalization.

The second type of occupational therapy at that time involved the functional usefulness of the
activity. Large state mental hospitals, in particular carried on the centuries old conditions of silating the
mentally ill in rural settings that were designed to be as self-sufficient as possible. This means that the
hospital often includes a machine shop, heating plant, farm, kitchen, and laundry. These departments were
major enterprises since they had to meet the living needs of thousand of patients as well as many of the
staff who lived on his hospital’s grounds. Clients who were able to work were assigned task that included
farming, meal preparation and serving, cleaning, sewing, machine maintenance and repair, and grounds
maintenance. Although there is no doubt that many clients learned valuable skills as result of these
activities, economic factors played a large part in their use that did therapeutic factors. Clients who worked
in the hospital were not paid even a token salary; in fact it was seen as a privilege to be given a work
assignment. Therefore the hospital did not have to employ outside workers. Contributing to the overall
welfare of the institution and its inmates must certainly have created a sense of dependency on the hospital,
thereby increasing the syndrome of institutionalization.

Aside from these activities, the field of activity therapies was still very limited, since many
authorities believed that the best treatment for emotional illnesses was a strict regime of rest and inactivity.
This belief resulted on many persons spending their days sitting side-by-side on uncomfortable ward
benches not having sufficient ego strength to interact with each other or to structure their time in a
meaningful way. The trained nurses who worked in such settings must be given credit for seeing the lack of
therapeutic effect of idleness and for attempting to engage patients in diversionary or functional activities.
In fact, the first book written on the subject of occupational therapy was writte4n by a nurse, Miss Susan E.
Tracy. This book “Studies in Invalid Occupation”was published in 1910. Miss Tracy also give the first
course of instruction on the subject in 1906 at the Adams Nervine in Boston. As such, nurses were the first
occupational therapists, although the term was not used not until 1921.

Some physicians also saw the potential therapeutic benefit of a planned activities program. As early
as 1982, Dr. E.N. Brush wrote of his belief that even the most simple and routines task keep the mind
occupied, awaken new trains of thought and interest, and divert the patient from the delusions or
hallucinations that harass and annoy Dr. Brush particularly advocated the use of outdoor activities in the
belief that physical exertion had a beneficial affect on the emotional health of the patient. Since the nurse
staff was still seen as responsible for initiating and supervising all patient activities, a book titled,
“Occupation Therapy, A Manual for Nurses” was published in 1915. The author was one of the earliest
leaders in the field of occupational therapy. Dr. William Rush Bunton advised that the nurse “provide
herself with an armamontarium which should consist at least of the following: playing cards, dominoes, or
card dominoes, dibbage board, scrap board with puzzles and catches; and one or more picture puzzles…
She is also urged to cultivate a particular craft in order what she may herself have a hobby and also that she
may have special ability in instructing her patient.”

Activity programs for mentally ill patient were formerly called workoures and moral treatment.
These terms provide insight into both the way in which mental illness was conceptualized at the time as
well as the dominance of the word ethnic in activity, regardless of its purpose or outcome. It was not until
1921 that the term “occupational therapy” was coined and defined. After that time, activity programs for
the mentally ill increased, but their primary purpose was to keep the patient busy, with scant attention paid
to the therapeutic benefits that could be achieved. In recent decades, with advent of a greater number of
professionally trained activity therapists, there has been increased recognition for the positive role the
discipline can play in the diagnosis and treatment of emotional disturbances.

GOALS OF ACTIVITY THERAPIES

Although each form of activity therapy has a specific focus, they all share in the principle that is
helpful to the emotionally disturbed persons to be engaged in an activity that focuses on objects outside of
himself. The concept of “object relations: is a fundamental one in activity therapies. This concept includes
not only the materials utilized in the therapy but also the setting, the therapist, and the other participants.
These objects all have symbolic value, and through their use the individual expresses feelings, needs, and
impulses. In this sense, all activity therapies are creative and therefore can be used in varying ways and for
varied purposes. They are developed into the program based on psychodynamic insights but are highly
individualized to meet the needs of the person for whom they are designed. The nurse therefore may work
in mental health setting where most of the patients attend occupational therapy, but is must not be assume
that all are engaged in the same activity. The following four goals are common to all activity therapies in a
mental health setting:
1. To provide opportunities for structured normal activities of daily living. Activities are designed to
help the patients deal with their basic problems. In addition, the activities permit the maintenance as
well as reinforcement of the healthy aspects of the patient’s personality.
2. To assist in diagnostic and personality evaluation, activity therapists as trained members of the
health care team, can assist with diagnostic and personality evaluations through their observations
of patients while they are participating in the activities. In addition, the process of participations
such as the type of activity chosen and interaction that takes place between the client and other
participants gives the therapists valuable information about the personal structure of the patient.
3. To enhance psychotherapy and other psychotherapeutic measures. The activity prescribed for the
patient often provides a non verbal means for the patient to express and resolve the feelings that are
being discussed verbally in other settings. In addition, the interpersonal relationship established
between the patient and the therapist provides another vehicle for the provision of corrective
emotional experience.
4. To assist the client in making the transition from the sick role to becoming a contributing member of
society. Some activities provide opportunity for work experience, often utilizing community
resources. Through these activities the client is able to learn a skill that may be marketable. Other
activities in this category focus on the development of the client’s talents and interests so that he
might least to use his time in ways that are satisfying to him.

All activity therapies have in common the fact that they are purposely designed to achieve a specified
goal, and the role therapists is observe, direct and guide the client in the activity. The therapists
continuously assesses the client’s reactions to the activity both as a means of providing information to
the other memers of the treatment team and as a basis on which to alter the activity as the need of the
client change.

SPECIFIC ACTIVITY THERAPIES

Occupational Therapy
Occupational therapy is defined by the American Occupational Therapy Association as the art and
science of directing man’s response to selected activity to promote and maintain health, to prevent
disability to evaluate behavior, and to treat or train clients with physical of psychosocial dysfunction. This
bread definition compasses many activities, and thus the occupational therapy department is usually the
largest of the activity therapy departments is usually the largest of the activity therapy departments found in
mental health settings. Although all occupational therapists have an educational and experiential
background in the use of a wide variety of activities for many purposes, most develop particular expertise
in the use a few activities for many purposes, most develop particular expertise in the use of a few activities
for a specified purpose. For example, occupational therapists who work with the mentally ill have more
skill in the utilization of objects that help people identify, express, and resolve their feelings, than they do in
the utilization of objects that are designed physically handicapped in carrying out the activities of daily
living.

Although occupational therapy can be carried out in almost any setting, most mental health centers
have an occupational therapy departments to which clients go. This setting may be one or large, brightly
decorated rooms that contains types of equipment, which is organized into different section of the rooms.
For example, all the artistic supplies may be on one side of the room and the weaving and sewing
equipment on another. The advantage of this arrangements is more than organizational in that clients who
are engaged in similar kinds of activities will be working in physical proximity to another, which promotes
social interaction. Often persons who lack the social skills required to converse spontaneously with others
will be able to do so if they can focus their conversation on an object in which all are interested. An
individual’s self-esteem can be increased by the positive regard shown by others for a painting or other
project on which he’s working.

It is unusual for individuals who are emotionally disturbed to have difficulty in verbally expressing
or even identifying emotions they are currently feeling. Through the use of various objects, the
occupational therapist can help the individual discover and express those feelings. For example, the client
who is very angry but who has directed his anger inward and therefore feels depressed may not be able to
develop insight into those dynamics merely through talking with a psychotherapist, no matter how skilled
the psychotherapist maybe. The occupational therapist, however will take advantage of her observation
that the clients enjoys that require aggressive movement. The client is able to engage in these activities
because they provide a constructive, indirect outlet for his anger in contrast to the destructive direct
impulses he unconsciously harbors and fears. Whether or not the client and the occupational therapist
verbally discuss his feelings is highly dependent on the treatment goals and the client’s ability to tolerate
such an interpretation.

Although many examples could be given, it should be obvious that to achieve the optimum benefit
of occupational therapy, the individualized attention of the therapist is required. It is rarely possible to
provide one-to-one situations, but the group of clients participating in occupational therapy at any one time
is usually kept small. To achieve this, appointments are made with clients and the nursing staff frequently
has the responsibility of ensuring that the other activities of the unit do not interfere with these
appointments. If the members of the nursing staff are unaware of the purpose and value of occupational
therapy, they might view these sessions an unimportant and therefore feel free to schedule conflicting
activities. It is not sufficient to make sure that there are not conflicting activities schedule it is also
responsibility of the nursing staff to encourage the client to attend the occupational therapy sessions. Nurses
can be helpful to clients in this regard by inquiring about their projects and also expressing their interest in
the client’s activities.

RECREATIONAL ACTIVITY
Recreational therapy is described as the use of recreational activities, including but not limited to
games, sports, crafts and discussion groups, community functions for the purposes of aiding the client’s
recovery from illness and injury and assisting him in his adjustment to hospitalization. The latter purpose of
recreational therapy has been widely known and utilized in the past through the use of diversionary
activities. It has not been recently, however, that the therapeutic effects of recreational activities have been
recognized. A dramatic example occurs when a group of schizophrenic individuals who have probably
never achieve the developmental tasks of learning how to compete and compromise are successful in
engaging in a team sport such as basketball or football. Card games such as bridge that require the
cooperation between two players can accomplish the same objective in a less dramatic but equally effective
manner.

As Mental Health Centers have been gradually relocating in the community whose population they
serve, recreational therapists have been taking increasing advantage of community functions as therapeutic
activities for groups of clients. Activities such as concerts, plays, and lectures simultaneously provide
clients with an enjoyable activity as well as a focus for subsequent group discussion. For the client who has
been hospitalized for a period of time, attendance at community sponsored events is a relatively painless
means of re-entering community life. Despite enlightened treatment of persons with mental illness and the
trend to return them to the community as soon as possible, there is still a sizable number persons who have
been hospitalized for such a long period of time that they need to learn how to purchase a ticket to an event
or how to dress appropriately. Therefore, recreational therapists often aid and encourage clients to make
their own arrangements when they wish to attend a community sponsored event.
 One of the many values of recreational therapy is to help the client develop skill in diversionary
activity that he finds enjoyable that he can engage in by himself. Some emotionally disturbed individuals
become immobilized when left by themselves with nothing to do. This can result in a marked increase in
anxiety, causing the individual to retreat into a fantasy world or utilize other unhealthy defenses. The
person who is helped to develop an interest in such activities as stamp or coin collecting will be helped to
develop a socially constructive and emotionally healthy means of coping with unstructured time. This goal
is particularly appropriate for persons whose depression has been precipitated by such events as retirement
from an active career of the youngest child’s leaving home.

Recreational therapy, as all other therapies, attempts to build on existent interests and skills of the
client as well as to help the client develop new ones. The nurse can be particularly helpful as she works in
close collaboration with the recreational therapists if she is alert to the client’s expression of interest in
certain activities and conveys this information to the recreational therapist.

MUSIC THERAPY
For reasons that are not clearly known, many emotionally disturbed persons derive a great deal of
enjoyment from music. In fact it is not unusual for a several emotionally disturbed person who seems
unresponsive to everything else to respond to music. Music therapy is described simply as the purposeful
use of music as a participative or listening experience in the treatment of clients to improve their health.
Mental health centers with sufficient financial resources provide a music library for their clients. Clients are
encouraged to select records to play in soundproof rooms. The person’s selection is often an indication of
his emotional state at the time; persons who feel sad tend to select music that expresses sadness and the
client may even cry while listening. This emotional response may sometimes misinterpreted by the staff as
meaning that the client should be directed toward music that is more cheerful, rather than being recognized
as a therapeutic emotional release. Changes in the nature of the person’s selection of music overtime
provide some indication as to the progress he is making in the treatment. Group activities structured around
music are also a commonly used therapeutic endeavor. Clients discuss not only the history of the musical
selection and its composer but also can be helped to discuss the feelings the music but learn that others may
share these feelings, thereby decreasing his sense of aloneness.

VOCATIONAL THERAPY
Vocational therapy is sometimes termed industrial therapy. This form of activity therapy deals with
the development and provision of therapeutic work opportunities for clients under medical care, especially
for those who are emotionally disturbed. Many sick persons have never developed an occupational skill or
find themselves unable to engage in the occupation for which they are trained. Vocational therapy
recognizes that in American society the ability to earn a living is a major factor in enhancing a person’s
self-concept and thereby his mental health. Vocational therapists are often trained in the administration and
interpretation of vocational interests and aptitude tests. After the results have been interpreted by the
therapist, he head the client engage in the discussion about the results and mutually evolve a plan whereby
the client will improve an existent skill or develop a new one. Whenever possible the client is helped to
develop these skills in an on the job setting where he is paid as he learns.
The purpose of vocational therapy is not to find something for the client merely to pass the time or
to utilize his abilities to meet the needs of an institution but rather to place the client in a situation where he
will be able to develop skills that will be relevant and applicable in the future. Therefore it is important that
the client’s needs of the work situation be closely matched. This sometimes means that the client will work
in the mental health setting itself doing such jobs in the community since the community needs are wider in
scope that are the needs of the institution, thereby providing larger variety of appropriate work
opportunities. Positive relationships between the community and the mental health center are therefore
becoming increasingly important. Although many employees in the community have little, if any
understanding of the dynamics of mental illness, most have been found to be very cooperative when the
vocational therapist takes the time to elicit their help.
Some clients who are still hospitalized may progress to the point that they are working in the
community full time through the vocational department of the hospital then return to the unit in the
evening. If these instances, the most qualified nursing staff should be available during these times when the
clients are present rather than automatically working during the day, as is usually the case. Halfway houses
provide the best setting for such a client, but these are not always available.
It should be noted that vocational therapy not only provides the client with the opportunity to learn
and practice a marketable skill but also with the opportunity to interact with peers in a work situation. Some
clients quickly become skilled in the assigned tasks but have difficulty in relating with co-workers. The
sensitive vocational therapist will recognize these problems and either help the clients deal with the more
suggest that the interpersonal difficulties be discussed in psychotherapeutically oriented sessions.
EDUCATIONAL THERAPY
Educational therapy is closely related to vocational therapy but has as its specific focus the
gathering of information and providing the clients with credentials rather done the development of skills.
Some clients have never completed high school or may have begun but not completed their college
education, due to their emotional disturbance. This is not to say that all these persons are intellectually
incompetent but rather that their emotional problems have interfered with their intellectual achievement. In
American society, having the proper credentials is seen as a pre-requisite to many types of employment and
one of the goals of the educational therapist is to assist such an individual to complete his education usually
through non-traditional routes such as the High School Equivalency program or external degree programs.
The establishment of programs of this type many states has provided the emotionally disturbed individual
with an opportunity to obtain credentials without further lowering his self-esteem by forcing him to attend
classes with persons much younger than him.
Educational therapy is also utilized in instances where the client has problems that result from a
great deal of misinformation. Although this problems may be emotional, they may partially stem from
years of reinforcement of inaccurate information. The educational therapist has the opportunity to provide
the client with readings and learning experiences that can do a great deal to eliminate this misinformation
and resultant anxiety. The emotional conflict that this precipitates is usually explored in psychotherapeutic
sessions, but is sometimes dealt with by a skilled educational therapist.

PATIENT LIBRARY SERVICES (BIBLIOTHERAPY)

The patient library services are also referred to as bibliotherapy when it is described as the
prescription of reading materials that will help to develop emotional maturity and nourish and sustain
mental health.
Benefits of bibliotherapy
1. Some emotionally disturbed individuals are able to relate therapeutically to the experiences of
others when they read about them, rather than experiencing them directly. In other words, sufficient
distance between the individual and the situation is achieved by reading about is so that the person’s
level of anxiety may not increase. It is usually achieved by reading novels and bibliographies.
2. Increase in the individual’s fund of general information. Regardless of what is read, the person is
likely to pick up new ideas that can be used later in conversation with others, thereby enhancing the
person’s feelings of self-esteem. Some clients benefits greatly from reading of daily newspapers
which helps them to become re-oriented to the world around them. Not only are they belong to
become aware of local, national and world events, but they can gain a practical base of information
that will enable them to function more effectively within the community. The mere perusal of
grocery store advertisements gives the reader a knowledge of food prices, which is necessary in
planning a budget and show effectively. Some clients who have expressed interest in a particular
subject are encouraged to become familiar with the literature in that area. Not only can this form of
reading activity can be enjoyable, but it can also help him gain experience in the area.
3. Reading itself is usually a solitary activity. However, it is therapeutically desirable for small groups
to be formed to discuss a particular book or subject. The discussion is focused around the content
that was read, but the therapeutic benefit occurs as a result of the social interaction required for the
discussion.

IMPLICATIONS OF ACTIVITY THERAPIES FOR NURSING PRACTICE

The nurse has an important role in enhancing the therapeutic effects of activity therapies. The
activity in which a client is engaged elicits different feelings in which he will express not only to the
therapist but also to the nurse.

Close coordination between the nursing staff and the activity therapist is essential. The activity
therapist usually takes the initiative to establish and maintain this coordination, but the nursing staff
member should be receptive to the conference thereby acknowledging the therapeutic value of activity
therapies in the total treatment program.

The nurse’s interest in the client’s project enhances the therapeutic effects of the activity therapies.
This is particularly true if the client’s program of activities centers around the activities of daily living
because the nurse is in a position to supervise and reinforce the use of these skills learned in activity
therapy. It is, also the nurse who has often has the opportunity to gather clients together in formal groups.
The projects being worked on in the activity therapy program provide an excellence topic for discussion.
 Nursing staff sometimes participate in the activities planned as part of the recreational therapy
program. Such activities include dances, sport activities, and parties. By engaging in these activities, the
nurse not only has an opportunity to observe the client in a setting that is not only different from the one in
which she usually sees him in daily living. Through her observations of the client’s behavior during these
activities, the nurse will gain valuable information that she can subsequently utilize to therapeutic
advantage in the working phase of the nurse patient relationships.

REMOTIVATION-MODIFIED

Remotivation modified or Group Conversation Activity is a form of socializing activity. It is a

discussion about a topic of general interest by a group of patients with the nursing attendant as leader. This
is a modification of the Remotivation Technique Introduced at Philadelphia State Hospital in 1956

The purpose of Group Conversation Activity is to assist patient to socialize through group
interaction. To meet this purpose adequately the nursing attendant-leader should make the necessary
planning and preparation for the meeting with the assistance of the nurse instructor/charge nurse.

As leader, the nursing attendant select from ten to twelve patients with different behavior patterns
for each group. The nursing attendant-leader is responsible for asking the patients to join a group, for
telling them when and where the group will meet. Every effort should be made to have each patient
participate in at least six meetings in the receiving wards and twelve meetings in the continued treatment
wards. During the one-hour discussion period, the patients and the nursing attendant-leader are seated in a
circle or semi-circle.

These are five steps upon which Group Conversation Activity is based:

STEP ONE-CREATING A CLIMATE OF ASSISTANCE

The nursing attendant-leader opens the discussions by:
1. Greeting the group in general.
2. Expressing appreciation of the group’s discussion
After a few introductory remarks about the topic, the nursing attendant-leader gives his/her
name and then asks each of the patients to introduce themselves. The purpose of these introductory steps is
to create a relaxed and comfortable atmosphere in which the patients feel accepted and recognized as
individuals.

STEP TWO-BRIDGE OF REALITY

In step two, the nursing attendant-leader attempts to stimulate or help the patient get interested in
the reality-oriented topic. The following ways are used to meet this objective:
1. A poem appropriate to the topic may be used by reading the first lines, then asking each of the group
members read a line or two until everyone has participated.
2. At other times, the nursing attendant-leader reads a patient quotation or news item, and uses this as a
focus of group discussion.
3. A highly effective way and creating interest is by the use of related “props” such as actual objects,
picture, posters, drawing or maps
Steps two provide a starting point in the development of the topic, which is the purpose of step three

STEP THREE-SHARING THE WORLD WE LIVE IN

The nursing attendant-leader direct key questions to the group in general which he prepared in
advance. These questions should help to promote discussion and at the same time help the group focuses on
the topic. Since the patients display different behavior reactions the nursing attendant-leader has to use
some of patients and tact to give each patient the opportunity to participate in the group discussion.

STEP FOUR-SHARING AN APPRECIATION OF THE WORK OF THE WORLD

Step four is a continuation of step three, during which the group members exchange views and ideas
about the topic from their own personal experiences. By this time, communication and interaction are
taking place freely with lesser stimulation from the nursing attendant-leader. Quite often, the patient
becomes open to relate amusing personal experiences which make the discussion more interesting.
STEP FIVE-CREATING A CLIMATE OF APPRECIATION
The nursing attendant-leader leads up the fifth and last step by reminding the group that the time for
the discussion period is almost up. The nursing attendant-leader may ask the patients to give their opinion
about the discussion period, and asks suggestions for future discussion topics.
Finally, the nursing attendant-leader brings the discussion to a close by:
1. Thanking the patients for attending the group meeting.
2. Expressing appreciation of their participation

Chief therapeutic Value of Group Conversation Activity to Patients:

1. Being a part of the group meets the patient’s need for acceptance, belonging, support and approval.
2. Provides opportunities for social interaction to take place
3. Participation in group discussion helps the patients to put aside poor social habits, such as
withdrawal, preoccupation, fantasy, etc.
4. It allows patients to test the appropriateness of their social behavior in an accepting and friendly
atmosphere.
5. Participation in the group discussion periods also promotes a greater focus and acceptance of reality.
6. Members of the group are helped to develop feelings of worth and self-respect.
7. Group discussions help patients in renewing healthy interest as well as in stimulating new ones.
8. Group discussion provides opportunities for patients to get to know each other better to learn
something about each other’s beliefs and interests.