Many of us will relate the question of what is a therapeutic environment to the field of nursing in which we are engaged. We are familiar with the environments in which we deliver care. Treatment regimens, clinical protocols, and nursing policies are available to us. Most of us are part of multidisciplinary teams where the complex needs of patients are discussed; the knowledge and skills of the respective health professionals are considered; and treatment and care plans are adjusted to ensure the continuous meeting of patients' care needs.
Familiarity with particular working arrangements and team working are persistent features of care environments. However, familiarity with the patterns and routines of a local working environment does not necessarily equate with competence, defined as:
‘The ability to do something successfully or efficiently. Competence indicates sufficiency of knowledge and skills to enable someone to act in a wide variety of situations. Each level of responsibility has its own competence requirements …’
This definition resonates with the need for a preceptorship period for registrants new to the register, facilitating the transition from that of a student nurse to a functioning staff nurse, or for registrants transferring from a generic field of care to a specialised one. The Nursing and Midwifery Council's Code (NMC) (2018) requires registrants to commit to continuous professional development and to demonstrate current competencies through 3-yearly revalidation of professional registration. Otherwise the risk of being compliant with ‘how things are done here’ could lead to poor practice, leading to neglect (Francis, 2013).
Competence is directly linked to the availability of current evidence-based policies. This is reliant on healthcare organisations having a clear system of clinical governance (under the umbrella of corporate governance), for the production and regular revision of evidence-based policies, thereby ensuring that patients receive optimum clinical care. NMC registrants are required to deliver current evidence-based practice (NMC, 2018).
Effective teamwork, ranging from the executive board to the day-to-day running of a ward, enables the identification and meeting of patients' needs. An organisation's leadership on the establishment of effective communication systems is demonstrated by all staff having: a shared understanding of team goals and tasks and a willingness to listen to and support each other (Ellis and Bach, 2015).
So far, we have considered the delivery of care to a patient from the health professionals' perspective. After all, health professionals possess the knowledge regarding the patient's physical condition. Moreover, due to staffing shortages and the associated pressure of work there could be a tendency to fall back on task-oriented duties. However, the essence of a therapeutic environment is that the conscious patient be placed at the centre of healthcare delivery, and not just as a passive recipient of care.
A 2010 Department of Health White Paper stated the philosophy of ‘No decision about me without me’. Coulter and Collins (2012) emphasised the importance of shared decision making between clinicians and patients. I think it is timely that we ask ourselves about our interactions with patients. Do we merely inform them about their nursing care plans, or invite them to share with us their thoughts and suggestions? Undertaking reflection on this would allow us to further develop our communication and negotiation skills. Recently, when considering what makes a therapeutic environment, one of my students, Sabrina Robinson, reminded me that ‘nurses dispense comfort, compassion and care without even a prescription’. These fundamental skills are the bedrock on which more complex rapport-building and negotiations can be built.