Milieu improvement in psychiatry using evidence-based practices: the long and winding road of culture change.

BACKGROUND: Shorter inpatient stays have resulted in greater patient acuity, making it difficult for patients to heal and challenging for staff to manage.

OBJECTIVE: To improve the milieu for psychiatric inpatients using evidence-based practices.

DESIGN: A thorough literature review suggested 18 basic principles to improve patient outcomes while reducing violence, seclusion, restraint, and 1:1 observation. Interventions were multiple, including intensive multi-modal staff education based on the literature review and starting in orientation, introduction of comfort rooms, changes in debriefing practices, careful review of all seclusion and restraint episodes, introduction of integrative modalities, and careful review of all 1:1 observation and review of unit structure.

RESULTS: Multiple interventions resulted in favorable outcomes in the following: rates of seclusion and restraints; time devoted to 1:1 observation, patient and staff satisfaction; violent incidents; and staff and patient injury.

CONCLUSIONS: Long-term culture change toward a more therapeutic milieu can occur as a result implementing evidence-based practices.