The Milieu Enhancement Model:A Nursing Practice Model, Part I

Sandra Warner

The Milieu Enhancement Nursing Practice Model (MEM) served as the concep­tual framework for implementing a 3-year project funded by the Department ofHealth and Human Servicesthrough the Division of Nursing as a demonstrationgrant (No.1 010 NO 600013) from October 1987 through September 1990.The MEM is described and examples of Its use in developing health care forms,conducting research, guiding practice. and categorizing enhancements arepresented.Copyright © 1993 by W.B. Saunders Company

THE GOVERNMENT is seeking solutions fortoday's costly and often ineffective health

care. Vulnerable populations, such as childrenwho are orphaned, disadvantaged, or temporarilyremoved from poverty-stricken families, are espe­cially at risk. Alternative providers and innovativepractice models are potential solutions to the prob­lem of providing health care to such underservedpopulations. Popp (1988) suggested that nurses de­velop and test models that recognize the needs ofboth recipients and providers and then develop pol­icy to support these models. As nursing practicemodels prove effective in providing enhancedcare, alternatives to the current health care deliverysystem will become legitimized.

The Milieu Enhancement Model (MEM)*served as the conceptual framework for imple­menting a federal demonstration project funded bythe Department of Health and Human Servicesthrough the Division of Nursing (Grant No. I DlONU 600013, 1987 to 1990). Five broadly basedgoals offered nurses an opportunity to test thevalue of a nursing practice model, enhance the careprovided for orphaned and disadvantaged children,practice autonomously in a nontraditional setting,analyze the cost-benefit and the cost-effectivenessof project activities, and computerize existing andmodel-derived health care records. A descriptionof MEM and examples of its use in developing

* The development of the MEM was accomplished by con­tributions from Drs. Marie McGrath, Suellen Reed, and JeanJohnson, and from Professors Amy Perkins and Chris Kucin­kas.

health care forms, conducting research, guidingpractice, and categorizing enhancements are pre­sented here.

SETIING AND PROJECT PERSONNEL

The MEM project was implemented in a chil­dren's residential setting that provides care for 48orphaned, economically disadvantaged, neglected,abused, and predelinquent children (Hispanic,Afro-American, and Caucasian), aged 4 to 18years. The Home, located in a Southern state andadministered by a religious organization, has pro­vided care for more than 17 years. It is funded byUnited Way and private donations. The Homeworks closely with the Department of Human Ser­vices to provide care for children who, for variousreasons, are removed from their home, with thehope of returning them to their parents or relativesif possible, or placing them with adoptive parents.The Home's staff includes a nurse, four socialworkers, 12 child care workers (CCWs), and ninesupport personnel (secretaries, cooks, maintenancepersonnel). A boy's dormitory, a girl's dormitory,an administration building, and a chapel thathouses the cafeteria and study hall compose theHome's facilities. CCWs have apartments withineach of the dormitories.

From the Uniuersity of Texas Health Science Center atSan Antonio, School of Nursing, San Antonio, TX.

Address reprint requests to Sandra Warner, RN, PhD,University of TexasHealth Science Center at San AntonioSchool of Nursing, 7703 Floyd Curl Dr, San Antonio, rX78284-7948.

Copyright © ] 993 by W.B. Saunders Company0883·94] 7/93/0702-0002$3.00/0

Archives of Psychiatric Nursing, Vol. VII,No.2 (April), 1993: pp. 53-60 53

54

Project personnel consisted of four faculty mem­bers (Project Director, Clinical Specialist in Psy­chiatric Nursing, Pediatric Nurse Practitioner, andEvaluator), four social workers, and one nursefrom the Home, who functioned in their regularjobs as Executive Director, Program Director, So­cial Workers 1 and 2, and Campus Nurse. Each ofthe Home's professional staff gave a percentage oftheir time and effort in planning and implementingactivities funded by and/or related to the project.

Interdisciplinary cooperation between socialworkers and nurses in resolving practice issues re­lated to each discipline and in understanding thevocabulary unique to each was necessary for thesuccess of the many project activities. Eight con­sultants (a programmer, economist, social worker,psychiatric nurse, two psychologists, a systemsmanagement expert, and a psychiatrist/pediatri­cian) also contributed valuable guidance to projectpersonnel.

LITERATURE REVIEW

Webster (1989, p. 753) defined milieu as"midst, environment or setting." The link be­tween the milieu and human responses is well doc­umented. In 1948, Bett1eheim and Sylvester pro­posed the creation of a therapeutic milieu toreverse the effect of children's natural milieu(Tuck and Keels, 1992). Jones (1953) conceptual­ized a therapeutic milieu based on the premise thatinteraction between people and their environmentaffects behavior. LeCuyer (1992) defined milieutherapy as an interdisciplinary theoretical and clin­ical approach to psychiatric treatment in which thetotal environment is thought to have therapeuticpotential. She traced the history of milieu therapyfrom the l700s to present day, identified its goals(resocialization, ego development, and the preven­tion of the regressive effects of hospitalization),and explored basic milieu concepts (containment,support, validation, structured interaction, envi­ronmental arrangement, and open communica­tion). More importantly, she described the role ofthe nurse and changes in that role over time asmilieu therapy evolved in different settings. Tuckand Keels (1992) stated that nursing practice wasbased on two themes: one-to-one relationships andmanaging the milieu.

The interaction between environment and hu­man responses, such as coping, was studied byFolkman, Lazarus, Dunkel-Schetter, DeLongis,

SANDRA WARNER

and Gruen (1986) and Folkman, Lazarus, Gruen,and DeLongis (1986). Moos, Shelton, and Petty(1973) studied the interaction between the milieuand structured aspects of the environment such asschedules, physical environment, rules, regula­tions, and groups; Collins, Casey, Hickey, andTwemlow (1985) and Emrich (1989) studied un­structured aspects of the milieu, such as patient­staff interactions. Friedemann (1989, pp. 11-12)noted that the environment is the inescapable con­text in which humans live and "humans definetheir identity and the nature of their environmentby relationships they have with the human, mate­rial and other living systems in their environ­ment. "

In child psychiatry, the milieu concept was pri­marily a philosophical underpinning detailed inmodel treatment programs (Delaney, 1992b).Delaney (1992a) stated that certain aspects of thetherapeutic milieu were essential to the operationof child inpatient units (i.e., a safe, structured, andsupportive environment) and suggested that a sys­tem proposed by Gunderson (1978) allowed nursesto delineate just what they do in child psychiatricmilieus. The five therapeutic variables that nursesprovide for children included containment/safety,structure, support, involvement, and validation.

Friedemann (1989) noted the gap between grandtheory and practice models. Nursing theorists havebeen challenged to develop models that focus onnursing process, clinical applications, and measur­able outcomes (Brower & Baker, 1976; Chance,1982; Downs, 1982); yet Cox and Roghmann(1984) concluded that examples in the literature ofnursing practice models are limited. Loomis andWood (1983) identified cure as the outcome ofnursing care and used their model to representschematically the relationships among actual andpotential health problems, human response sys­tems, and clinical nursing decision-making. Saari(1992) considered the theoretical gap between per­son and environment and stated that an understand­ing of the child cannot be comprehended outside ofan appreciation of the milieu in which that personfunctions. The MEM, through its environmentalmodes, broadens the perspective of nursing's focusto include the milieu.

THE MEM

Milieu is a broad construct that captures the es­sence and interrelatedness of environment and its

MILIEU ENHANCEMENT MODEL 55

many subsets upon those within. The impact of themilieu can be experienced physically through theexternal effects of weather, earthquakes, anddrought, or through structure such as living quar­ters and decor. The impact of the milieu can alsobe experienced through personal-external interac­tions with people, family, and multiple systemsthat comprise the environment. These systems mayinclude social, organizational, religious, political,economical, and cultural overlays. Finally, the im­pact of the milieu can be experienced intraperson­ally, with interpretations unique to the individual.The MEM strives to capture the interrelatedness ofthese diverse systems in regard to nursing practice.

The MEM has three components (practice di­mensions, recipients, and environmental modes),12 elements, and many possible relationshipsamong each. The practice dimensions are actionsused to effect change, the environmental modesare approach avenues for achieving change, andthe recipients are individuals or groups who are thefocus of change.

Health care is organized through practice dimen­sions relative to human responses and/or targetedconditions within the milieu. An enhancement is apositive change within the milieu that is broughtabout through practice that approaches the recipi­ent through different environmental avenues. Themilieu is fluid and ever-changing; thus, the foci forpractice will vary with the needs of the recipients(individuals and/or groups) within a given milieu.

An "enhanced milieu" is the potential outcome ofnursing practice. Figure 1 provides a schematicrepresentation of the MEM.

The environmental modes and dimensions ofpractice remain constant across settings. Becausethe MEM was introduced in a residential setting,recipients of care included children, staff, family,group, and/or community. Were the model intro­duced in a different setting, recipients would bedefined to match the population of interest (i.e.,specific types of clients, consumers, etc.). Defini­tions for each element of the practice dimensionsand environmental modes are presented in Tables 1and 2.

MODEL USAGE

According to Pearson and Vaughan (1986),model usage will lead to consistency of care, whileproducing less conflict in the care providers. Rog­ers (1989) noted that when institutions began toimplement a conceptual framework, the processinvolved significant organizational and individualchange. Examples of how the MEM was used todevelop forms, guide research, and practice andcategorize milieu enhancements are presented.

Developing Health Care Forms

The MEM provided the framework to developvarious assessment forms. The Needs AssessmentForm was used to identify the dominant healthcare

Physical

I Prog amaticCs (lJ Educative

~ ~G Collaborative! ,..---+---+--~--....,

.,p .....~ Consultative~ Q. I-----:f---~~-_I_--., "

<zj ~

<S~ s§ AssessmenU

I ~ Evaluative

\ ~~}l

Children Family Staff Group!Community

• Recipients ~Fig 1. Child Milieu Enhance­

ment Model.

56

Table 1. Definition of Practice Dimension Elements: Actionsto Effect Changes

Assessment/Evaluative activities of detection, surveillance,analysis and measurement to indicate status of acondition, concern, or problem

ProgrammaticlEducative health teaching and guidanceInterventive activities promoting Insight and coping or

providing treatments directed toward alleviating orpreventing risk factors, early signs, and currentsymptoms

Coliaborative/Consultive intradlsciplinary andinterdisciplinary activities of informational exchange,coordination, advocacy, and refarral, which directly orindirectly influence the recipient

Adapted from the Omaha Project (1986). Client Manage­ment Inhumation System for Community Health NursingAgencies: An Implementation Manual: U.S. Department ofHealth & Human Services, Public Health Service, Health Re­sources and Services Administration, Division of Nursing(NTIS Accession No. HRP-0907023).

SANDRA WARNER

Table 3. Sample Page of the Revised Needs Assessment

Priority Ratingo= No longer a concern1 = Low priority; response needed in 6 to 9 months2 = Medium priority; response needed in 3 to 6 months3 = High priority; immediate response in ato 3 monthsM = Monitor; periodic evaluation

PriorityNeeds/Concerns Related to Children Rating

1. Children are from dysfunctionalfamilies 0 2 3 M

2. Children have history of abuse 0 2 3 M3. Children have behavioral andlor

emotional problems 0 2 3 M4. Adjustment of child to home 0 2 3 M5. Need for discharge planning 0 2 3 M6. Children frequently two grades

behind for age 0 2 3 M

were categorized broadly under the environmentalmodes (personal-internal or personal-external) andsubgrouped into categories such as general healthconcerns, emotions, education, and body systems.A partial listing of the CAT' s index is presented inTable 4 and a sample page of the CAT is listed inTable 5.

The Problem Rating Scale for Outcomes wasadapted from the Client Management InformationSystem for Community Health Nursing Agencies:An Implementation Manual (1986) as the ChildProblem Rating Scale (CPRS). This form allowedstaff to rate the severity of any problem identified

needs/concerns of the recipients (children andstaff) over the life of the project. Concerns such ashistory of child abuse, low morale, and CCW turn­over were given high-priority ratings and becamean immediate practice focus. Inservice offeringsrelated to child abuse were presented to all of thestaff. Support groups for adolescent children andCCWs were formed to address morale and CCWretention (Table 3).

An informational management system, whichwas developed by the Visiting Nurses' Associationof Omaha (Martin & Scheet, 1992) served as thefoundational springboard for The Clinical Assess­ment Tool (CAT). The Omaha System is an ex­haustive list of representative health problems orconcerns that was "pediatricized" to fit a childpopulation living in residential care. Since con­cerns unique to social workers and residential carealso needed representation, items related to educa­tion, dormitory environment, placement, and vis­itation were added. Health problems/concerns

Table:2. Definition of Environmental Mode Elements:Approach Avenues Used to Effect Change

Personal-Internal: physiological, psychological, andcognitive processesthat maintain and enhance life

Personal-External: interrelatedness from person outwardPhysical: natural, physical, structural, and material things

that influence lives such as grounds, buildings, decor,toys, supplies

Organizational: administrative decisions and supports suchas policy, rules, job descriptions, institutional service,and roles

Table 4. Index for the Clinical Assessment Tool

CAT Index

Personal-internal: Physiological processesGeneral health concerns

DentitionGrowth and developmentHealth care complianceNutrition

Personal-internal: Psychological processesEmotions

Dominate coping patternsEating disordersEmotional stabilityGrieflloss

Personal-external: Interrelatednessfrom Person Outward

IndividuationlseparationInterpersonal relationshipsSexuality

Partial listing of adaptation from US DHSS (1986).

Page

15161718

37383940

434445

MILIEU ENHANCEMENT MODEL

Table 5. Sample Page of the Clinical Assassment Tool

Education1. Speech and language:

AssessmentA. Risk factors

a. short frenulumb. family speaks for childc. history of cleft lip and/or palate

B. Impairment00. no impairment01. absent/abnormal ability to speak, mutism02. absent/abnormal ability to understand speech03. lacks alternative communication skills04. inappropriate sentence structure05. limited enunciation/clarity06. inappropriate word usage07. fear of speaking in front of groups08. stuttering

Rating scale: knowledge behavior status (1-4)

Adapted from the Omaha Project (1986).

on the CAT. Whether the problem related toknowledge, behavior, or physical status, changewas documented over time by evaluating the sameproblem at a later date (Table 6).

A coding fonn was devised that allowed staff tolocate, code, and quantify quickly by letter and/ornumber any child-specific problem for computerentry. Other computerized forms included theTelephone Screening Questionnaire, ScreeningProfile, Face Sheet, Admission Assessment, Ac­tion Plan, Plan of Service, Plan of Service Review,Discharge Summary, Educational Log, andNurse's Log. The Nurse's Log automaticallyflagged yearly dental, physical, and inoculationchecks for each child.

These forms were programmed in Basic (a com­puter language) for use on an IBM PC computerand the simple typing of a number caused the prob­lem and its rating to become a permanent part of

57

the child's record. Once data were entered, recordsbecame available for browsing, editing, or printingcopies and reports. The computerized record sys­tem enhanced the informational flow within theorganization, provided the means to print specificreports for various departments, and documentedthe care provided for a child from admission toplacement or discharge.

Guiding Research

Warner, McGrath, Perkins, and Kucinkas(1991) described how the MEM was used to con­ceptualize, conduct, and evaluate research relatedto CCW turnover. Results from The Needs Assess­ment identified low morale, children with historiesof abuse, and high turnover of CCWs as priorityconcerns. One way to address turnover was to de­crease work-related stress. Problems were concep­tualized using Staff, Organizational, and Interven­tive model elements.

The level of care (LOC) ratings for children inresidential care range from 1 to 3, while ratings fortreatment range from 4 to 6. It became obvious thatmany of the Home's children needed treatment,rather than residential care. Therefore, policychanges were implemented to screen admissionsmore stringently and transfer inappropriate place­ments.

The population profile became more congruentwith residential care; now children needing treat­ment were transferred to a more appropriate set­ting. During the project years, the number of LaCratings greater than 3 decreased from 15 to 5. Ananalysis of variance (ANOVA) on mean ratings byyear yielded a significant F value. Duncan's Mul­tiple Range test identified the means for years twoand three of the project as significantly lower thanmeans for the previous years (Table 7).

Table 6. Child Problem Rating Scale

K. Knowledge: ability of the child to remember and interpret information.B. Behavior: observable responses. actions. or activities fitting the occasion or purpose.S. Status: condition of the child in relation to objective and subjective defining characteristics.

2 3 4

Knowledge

1 = No knowledge2 = Minimal knowledge3 = Basic knowledge4 = Superior knowledge

Adapted from the Omaha Project (1986).

Behavior

1 = Not appropriate2 = Rarely appropriate3 = Frequently appropriate4 = Consistently appropriate

Status

1 = Extreme signs/symptoms2 = Moderate signs/symptoms3 = MinImal signs/symptoms4 = No signs/symptoms

58

Table 7. Mean Level of Care Rating by Year

N M SE

Preproject 72 2.85 1.04Year 1 71 2.72 0.85Year 2 60 2.48" 0.89Year 3 76 1.90" 1.36

NOTE. Overall ANOVA [F(3,275 ) = 11.62; p = .0001J; ttest[LSD t(275) = 1.97J . The mean LOC ratings for years 2 and 3were significantly lower than preproject mean.

.. p < .05.

Guiding Practice

The MEM provided the structure for helpingchildren . Each element was used to seek a solutionfor the problems each child presented . The indexof the model-based CAT provided a comprehen­sive review of the child 's strengths and weaknessesand the review process promoted feelings of re­spect and appreciation for staff roles and expertise.The child was discussed in relation to the sub­groupings listed in the CAT's index. The nursereported on health-related topics, the social work­ers on social work issues, and the CCWs on per­sonal observations related to sleep, eating, hygienepatterns , and dormitory -related behaviors and con­cerns.

The Practice Dimensions were used to meet thebiopsychosocial and educational needs of theCCWs, social workers, and children. The nurse­led support group (Interventive) provided an op­portunity to address psychological and social needsof the CCWs. A stress management workshopused both Interventive and Educative dimensionsto meet these, plus the biological and educationalneeds . Blood pressures were measured and infor­mation related to stress in terms of its multiplesources and typical effects was presented . Stress­ors identified by the CCWs included high turn­over, devalu ed role , inconsistent parenting, help­lessness in minimizing the negative effects ofhistory and environment, and an inability to dealeffectively with specific behaviors . A milieu ofsupport, trust, and ownership was fostered to pro­mote member-enhancement and, eventually , childenhancement.

Categorizing Enhancements

The MEM was used as an heuristic tool to iden­tify milieu enhancements. Enhancements (positive

SANDRAWARNER

change) were categorized using the elements of theEnvironmental Modes (avenues to effect thechange). The following is a limited listing of themany enhancements evolving from project activi­ties .

Personal-internal. Enhancements via the Per­sonal-Internal avenue were accomplished throughclasses, support groups, and therapy using the Ed­ucative and Interventive elements. Children whoreceived individual therapy made behavioral im­provements. Values, beliefs, and knowledge aboutsex-related issues were explored in the adolescentsupport groups . Cardiopulmonary resuscitation(CPR) classes were presented to the staff by certi­fied CPR faculty. Skilled staff maintain a protec­tive environment for the children and the Home isin compliance with state requirements. TheHome's nurse became certified as a CPR instruc­tor , which further enhanced the milieu by decreas­ing the Home's dependency on other agencies foryearly staff recertification.

Personal-external. Enhancements via the Per­sonal-External element approach occurred whencommunity networking allowed staff from anotherresidential setting to share consultants, inserviceofferings, media, lunches, and social fellowship.Evaluations of these services documented theirvalue in terms of educational, social, and econom­ical merit.

Positive change in children resulted from use ofthe Interventive and Educative elements via thePersonal-External avenue when increased opportu­nity to interact with adults and develop mastery ofsocial skills was provided. Faculty invited childrento their homes and to restaurants for socialization,cooking , and dining opportunities. These outingsprovided unstructured opportunities for the chil­dren to enjoy adult company and learn new skills.

Organizational. Usually , enhancements viathe Organ izational el ement were effected bychange in policies , rules, or administrative deci­sions. A few of the changes that occurred duringthe project included (1) CCWs now attend staff­ings during which each child is discussed by theprofessional team and a focused plan of care isdeveloped. They also attend psychological brief­ings on children living in their dormitories; (2)CCWs receive increased hours of inservice , work­shops , and community networking and attendweekly support groups; (3) the child population is

MILIEU ENHANCEMENT MODEL

more representative of residential care; and (4)new positions (Counselor, Dietary Analyst, FoodSupervisor, Secretary) were created.

Physical. Decisions affected through the Or­ganizational approach often preceded change im­plemented via the Physical mode. For example,focus on kitchen-related problems resulted in theadministrative approval (Organizational) for aFood Supervisor, the initiation of family-style din­ing on Sundays, calibration of the oven, and anutritional analysis of menus. Milieu enhance­ments (Physical) included family dining, more va­riety in menus, and hotter food, etc.

Other enhancements via the Physical mode in­cluded the jungle gym play equipment donated bythe police department; a swimming pool donatedby the Home Builders' Association; Saturdaybreakfast in the dorms rather than in the cafeteria;structured study halls; computers and educationalsoftware for the children; the separation of sexesby dormitory; pets allowed on grounds; therapeuticand educational toys; computers, educationalfilms, books, journals, and audiovisuals for thestaff; augmentation to the supply of over-the­counter medicines; fluoride tablets; medical equip­ment such as a treatment lamp, heating pads, ther­mometers, stethoscope, etc.; and computerizationof the health records.

SUMMARY

The impetus for development of the MEM oc­curred when the interplay of community, aca­demic, consumer, and state needs met with federalopportunity. The MEM offered a perspective fornursing care that was different from care offeredby traditional medical or institutional models. Itsheuristic value is noted, as the model provided theframework for implementing the Milieu Enhance­ment project, including the development of forms,the organization of records, the categorization ofenhancements, and the guidance for practice andresearch. Its acceptance across the disciplines ofsocial work and nursing speaks to its abstractness.The elements in the practice dimensions and envi­ronmental modes are abstract enough to addresshealth care problems, concerns, and situationsand, if recipient elements are named to match thepopulation served, the MEM should function in allsettings.

Questions such as those asked by Vander Ven

59

(1992) in a review of Wozner's (1992) work areoften asked by consumers and health care provid­ers when institutional care is discussed.

Can an organizational delivery model be createdto provide service that is truly therapeutic,rather than dehumanizing?

Is there a generic conceptual base valid for res­idential care across settings?

Can we mount the kind of systematic interven­tion process that is needed to enact real change?

Can we become knowledgeable about what wedo so that we attain the outcomes intended?

Initial evaluation suggests that the MEM modelhas merit. The model will likely undergo refine­ment with continued use in similar and differentsettings. While relationships within the MEM needempirical evaluation, this first application demon­strates its pragmatic potential. An enhanced mi­lieu, the potential outcome of nursing practice, be­came a reality in the Milieu Enhancement Projectusing this innovative nursing practice model.

REFERENCES

Brower, H., & Baker, B. (1976). Using the adaptation model ina practitioner curriculum. Nursing Outlook, 24, 686­689.

Chance, K. (1982). Nursing models: A requisite for profes­sional accountability. Advances in Nursing Science,4(2), 57-65.

Collins, 1., Casey, N., Hickey, R" & Twemlow, S. (1985),Treatment characteristics of psychiatric programs thatcorrelate with patient community adjustment. Journal ofClinical Psychology, 41(3), 299-308.

Cox, C., & Roghmann, K. (1984). Empirical test of the inter­action model of client behavior. Research in Nursingand Health, 7(4),275-285.

Delaney, K. (1992a). Nursing in child psychiatric milieus. Part1; What nurses do. Archives of Psychiatric Nursing,5(1), 10-14.

Delaney, K. (1992b). Nursing in child psychiatric milieus. PartII: Mapping conceptual footholds. Archives of Psychi­atric Nursing, 5(1), 15-19.

Downs, F. (1982). A theoretical question. Nursing Research,31(5),259.

Emrich, K. (1989). Helping or hurting? Interacting in the psy­chiatric milieu. Journal of Psychosocial Nursing,27(12),26-29.

Folkman, S., Lazarus, R., Dunkel-Schetter, C., Del.ongis, A.,& Gruen, R. (1986). Dynamics of a stressful encounter:Cognitive appraisal, coping and encounter outcomes,Journal of Personality and Social Psychology, 50(5),992-1003.

Folkman, S., Lazarus, R., Gruen, R., & Del.ongis, A. (1986).Appraisal, coping, health status, and psychological

60

symptoms. Journal of Personality and Social Psychol­ogy, 50(3), 571-579.

Friedernann, M. (1989). Closing the gap between grand theoryand mental health practice with families. Part 1: Theframework of systemic organization for nursing of fam­ilies and family members. Archives ofPsychiatric Nurs­ing, 3(1), 10-19.

Gunderson, J. (1978). Defining the therapeutic processes inpsychiatric milieus. Psychiatry, 41, 327-335.

Jones, M. (1953). The therapeutic communitY: A new treatmentmethod of psychiatry. New York, NY: Basic Books.

LeCuyer, E. (1992). Milieu therapy for short stay units: Atransformed practice theory. Archives of PsychiatricNursing. 1(2), 108-116.

Loomis, M., & Wood. D. (1983). Cure: The potential outcomeof nursing care. Image; The Journal ofNursing Schol­arship, 15(1), 4-7.

Martin, K., & Scheel, K. (1992). The Omaha system: Appli­cation for community health nursing. Philadelphia, PA:Saunders.

Moos, R., Shelton, R., & Petty, C. (1973). Perceived wardclimate and treatment outcome. Journal of AbnormalPsychology, 82(2), 291-298.

Pearson, A., & Vaughan, B. (1986). Nursing models for prac­tice. Rockville, MD: Aspen PUblication.

Popp, R. (1988). Health care for the poor: Where has all the

SANDRA WARNER

money gone? Journal of Nursing Administration. 18(1),8-12.

Rogers, M. (1989). Creating a climate for the implementationof a nursing conceptual framework. The Journal ofCon­tinuing Education in Nursing, 20(3), 112-116.

Saari, C. (1992). The person-in-environment reconsidered:New theoretical bridges. Child and Adolescent SocialWorkJournal, 9(3), 205·219.

Tuck, 1., & Keels, M. (1992). Milieu therapy: A review ofdevelopment of this concept and its implications forpsychiatric nursing. Issues in Mental Health Nursing,13, 51-58.

U.S. Department of Health and Human Services, Public HealthService, Health Resources and Services Administration,Division of Nursing (NTIS Accession No. HRP­0907023) Client management information system forcommunitY health nursing agencies: An implementationmanual (1986).

Vander Ven, K. (1992). Review of people care in institutions:A conceptual scheme and its application. In Wozner, Y.Child and Youth Care Forum. 21(2), 133-137.

Warner, S., McGrath, M., Perkins, A., & Kucinkas, C.(1991). A turnover prevention plan for child care work­ers: A failed project? Archives of Psychiatric Nursing,5(1), 10-16.

Webster's nimh new collegiate dictionary. (1989). Springfield,MA: Merriam-Webster, Inc.