PROFESSIONAL VANDALISM: Part One (Internal Issues)
By Mickey Skidmore, AMHSW, ACSW, MACSW
“It ain’t what you don’t know that gets you in trouble. It’s what you know for sure that just ain’t so.” -MARK TWAIN
In recent months I have written about disturbing examples reflecting the broken institution of the mental health service of Liverpool Hospital, touching on topics of institutionalisation; fraudulent practices regarding drug treatment; “precious” programming services; and the deplorable treatment of the Social Work profession to mention a few.
This month’s “Perspective” will further examine many levels of internal organisational and policy dysfunction that underscore the bureaucratic mental health service that adversely impacts clinical practice. Perhaps it is an oxymoronic fantasy to expect large and complex hospital departments and systems to be well adjusted, functional and efficient. Beyond a review of these practices however, this article also offers proposed suggestions and ideas to address these concerns. However, I will emphasise clinical acumen, common sense and offer direct evidence as the primary lens from which to consider these viewpoints.
Let’s begin with a seemingly simple inquiry. Is Liverpool Hospital a smoke-free facility, or not? While this would seem to be a simple and straight-forward question, the complexity of the answer suggests otherwise. In fact, the response to this inquiry is often unclear, muddled, contradictory and ultimately, unsatisfying. At the front/main entrance to Liverpool Hospital there are large no smoking banners and signs at the top and bottom of the light poles. There are huge no smoking signs on the wall near the entrance to the hospital. Yet daily there are people sitting underneath these signs, near or around the light post, in open defiance, puffing away on cigarettes while security staff strolls by saying and doing little or nothing at all.
In the psychiatric wards of Liverpool hospital the patients openly smoke cigarettes in the courtyard routinely in defiance of the staff who have all but given up and resigned themselves to this. Additionally, prior to COVID doctors routinely granted leave to patients for the sole purpose to smoke — on the grounds of a non-smoking facility.
Personally, I am generally indifferent about the smoking issue per se, other than the obvious poor optics of a health facility condoning conduct that is one of the largest contributors to poor health outcomes. What infuriates me is the inconsistency and hypocrisy of an organisation that has engages in a scenario where they cannot or will not enforce the policy that was mandated to them by the NSW government and the havoc that cascades down to the psychiatric wards who are already tasked with managing challenging and difficult patients.
Solution: if the hospital is unwilling to consider an exception to psychiatric patients who’s admissions are often lengthy, then they need to seriously re-evaluate how they intend to realistically enforce such a policy.
Prior to the COVID pandemic, perhaps the single most contentious issue, that impacted what was done on any given day is directly related to the issue of leave. Isn’t it interesting that we have patients that cajole, exaggerate, manipulate, or otherwise lie in order to be admitted the hospital, and then their first order of business once they’ve gotten out of the wheelchair on the unit is to begin asking when they can see the doctor to ask for leave? I find the issue of leave — in particular, unescorted leave to be a most baffling practice which in my view underscores numerous problems that adversely impacts the units systemically, and compromises the quality of care provided to our patients.
To further support this view, I’d like to frame the narrative in this manner: the way in which the practice of leave was employed on the inpatient units was largely indiscriminate; arbitrary; inconsistent; ill-conceived; counter-productive; frequently unnecessary; and quite honestly more often that not, to subvert the hospital and NSW smoking policy or other various reasons of expedience. (Please note: rarely was leave considered for clinical reasons, as state protocols intended). Furthermore, it exposes the hospital’s increased and unnecessary liability and overall contributed to more problems and difficulties that it offers in contrast to only minimal therapeutic benefit. The servic touts itself as being “evidenced-based”, but I have yet to see any empirical evidence to support this practice. Instead, what I heard was tired, shallow and unconvincing rhetoric, coupled with an appeal to tradition and history that implies “this is the way we’ve always done it”. I heard vague justifications of how getting fresh air can be beneficial or therapeutic. I submit that an exorbitant amount of time, effort and resources were devoted to the issue of leave beyond treatment or anything else that occurs during a psychiatric admission.
My clinical rationale is based on the following context. If someone is suitable for mental health admission in one of the acute wards (especially if they are under the Mental Health Act), then they are in the midst of an extreme or unusual event (developmental; life circumstance; drug-induced; or otherwise). When such patients are admitted to our facility, their overall ability of functioning in their families or society have deteriorated beyond the point of any definition of normalcy. In fact, it is more reasonable to describe their life or their circumstances as being in a state of crisis. I also recognise that being hospitalised (often involuntarily) is many things — mostly negative: unpleasant, unenjoyable, and stressful — and most importantly, that many of their rights and privileges as a result are temporarily suspended, adversely compounding this experience.
When patients are (involuntarily) admitted to an acute care inpatient unit and then they are granted unescorted leave within hours or a few days thereafter, it begs the question of why they are in the hospital in the first place? If they can function or manage in the community, then doesn’t it follow rationally (the least restrictive care tenet) that they don’t need to be hospitalised? If they meet the criteria for admission to the most intensive, acute level of psychiatric care in the medical continuum … and we acknowledge the previous premise, that their life is for the moment far from normal, or in a state of crisis — why would they be granted (unescorted) leave? Why would we pretend (Skidmore, 2020) that they are capable of functioning normally in the community after they have been scheduled? This level of care is in no way similar to receiving or residing in the community.
Now factor in the issue of drugs. I have conservatively estimate that 50% of the patients admitted present with primary or co-morbid drug-related issues, conditions or disorders. In particular with patients who are admitted with drug-induced psychosis, or known to have a significant psychoactive substance abuse condition, why do we even consider giving them unescorted leave? It significantly and unnecessarily risks undermining the treatment that was initiated; it increases the risk of them bringing drugs back in the hospital and compromising other patient’s treatment; it increases lengths of hospital stays; it diverts valuable nursing care to tasks of policing the unit for contraband; it sets up potential issues of inconsistency with other patients; and in short, underscores a range of problematic behaviours on the ward. Yet, in the face of all this evidence, this outdated and incompatible practice remained the norm until the recent COVID reality.
When patients are admitted to inpatient units, they are searched, as well as their belongings for contraband that might pose a risk to themselves or others on the unit. It is not clear to me that anything like this occurs consistently when patients return back to our units from leave. And if we are doing something along these lines, it is clearly are not being done well, or consistently. On a nearly daily basis patients are spotted with contraband (i.e. cigarettes; lighters; etc). And it is increasingly apparent that with so many patients coming and going on leave, that this is the likely source of illicit drugs making their way back onto the unit, and thereby compromising the medical treatment and care of other patients.
Additionally, with so many patients coming and going back and forth from leave, it reduces the nursing staff to being traffic police. A disproportionate amount of time, energy and effort is focused to keeping up with patients leaving and returning to the unit that they have considerably less time to tend to more important and pressing nursing care duties/responsibilities. And how many times are special diagnostics or services ordered or scheduled, only for them to come to the ward and a patient not be available due to being on leave?
I find that the previous leave practice sends an inconsistent and confusing mixed message to our patients as well that unwittingly undermines therapeutic intent. On one hand we say that they meet criteria for the highest, most intensive level of care in psychiatry (to the point that many of their basic rights/privileges are suspended) and that their lives are in crisis. Yet, extending (unescorted) leave to them contradicts this message, instead reinforcing the false premise that they can be managed as if they were in the community and not in crisis. It could even be argued that this apparent contradiction has a “schizophrenic” feel or dynamic to it that unintentionally reinforces aspects of a psychotic illness. The unintended result for far too many chronic and persistently mental ill patients is they become increasingly comfortable and overly dependent on the hospital which in the end only serves to extend their length of stay.
If inpatient stays were based solely on clearly defined admission and discharge criterion, then patients would be (and should be) discharged once they’ve demonstrated enough improvement to warrant leave (and they confirm this with an appropriate successful leave towards the end of their treatment). The previous (inconsistent) practice of leave however, only served to interfere or undermine treatment, contribute to unnecessarily increased lengths of stay; and foster an undesirable attitudinal belief that we are more of a custodial concierge or psychiatric day care service where medical mental health treatment is a secondary or after thought.
ADMISSION & EXCLUSIONARY CRITERION
I have been told by several doctors that there is indeed criteria for patients to be admitted to the psychiatric units of Liverpool hospital. (Theoretically, this criteria would be the same for Bankstown and Campbelltown hospitals as well given they are part of the same SWSLHD. Yet, more than they would care to acknowledge patients are often discharged from one facility, and present to another within a hour’s time or so and curiously they are admitted). I confess however, that I have never seen such criteria in print. Nor has anyone ever enlighten me with what the criteria actually is. (My guess it is largely around risk-averse circumstances more than anything else).
I am fairly certain that Liverpool hospital is not accredited or certified to be; authorised to be; or intended to be an in-patient or hospital-based substance abuse treatment service. But considering the number of patients admitted where drugs are the primary and predominant issues at presentation you’d never know it. As far as I am aware, Liverpool hospital is also not recognised as a dual-diagnosis service either, yet neither of these facts seems to deter such admissions. I recognise that from the national level on down, there is no legal structure, framework, or mechanism in Australia compelling people to receive alcohol or drug treatment. Thus, this issue is far bigger than Liverpool hospital. As stated previously, I would estimate conservatively, that these admissions on any given day absorb up to 50% or more of the bed capacity of Liverpool’s “psychiatric” service. Any serious exploration of why so many people are waiting in the ED for hours or days at a time, need look no further than this clear disconnect with such admission practices.
And this is but one of several contradictory or inconsistent scenarios. Too often, Liverpool also admits patients who’s primary presenting issues are associated with Intellectual Disabilities — even though again, it is beyond the scope of the intended mandate or clinical practice to treat such patients. There is longstanding history, where time and again Liverpool hospital was manipulated and outmanoeuvred by ADHC, who’s primary responsibility it was to care for such patients. And the end result, that unfolded repeatedly was, once these patients make their way into Liverpool hospital wards, they literally become residents for years at a time, despite psychiatric patients waiting for a bed in the ED.
Yet another puzzling scenario is the increasing number of geriatric patients that find themselves on the acute psychiatric wards of Liverpool hospital, despite the fact that they have a dedicated specialty service designed and intended to care for this developmental cohort. Even the veiled attempt to change the age threshold from 65 to 70 has not seemed to greatly diminish the number of geriatric admissions significantly, which further competes with psychiatric patients waiting for a bed in the ED.
There is still another heterogeneous group of ED presenters that perhaps are the most challenging to deal with, and the most illusive in designing a policy around to address. These are the savvy patients who instinctively understand how to manipulate and cut through all the bureaucracy, managing to get admitted despite not meeting any clear criteria for psychiatric admission. Whether it be drugs, alcohol, intellectual disability, head injury or some co-morbid presentation, or homelessness — if these folks voice suicidal ideation or threaten harm to themselves or others, whether the services are designed to address their “treatment” issues notwithstanding, they are often admitted. Some have even advanced the argument that when admissions like this occur, it is suggestive that admission criteria is irrelevant. However, this seems counter-intuitive to me. In fact, if there were clear admission and exclusionary criteria, my view is that it would be easier to both manage these risks more consistently and cull such admissions as well.
A review of these issues prompts further inquiries. If none of Liverpool Hospital’s mental health wards are properly accredited, certified or appropriately sanctioned to provide in-patient substance abuse treatment, should we be detaining consumers who suffer from substance abuse disorders under the Mental Health Act in psychiatric wards? Are any of Liverpool’s acute mental health wards intended or clinically appropriate for geriatric admissions (given that they supposedly have a specialised service for the elderly)? If there is a specialised ward/unit for brain injuries, why are so many brain injured patients admitted to Liverpool mental health wards? Are any of the mental health wards at Liverpool hospital accredited, sanctioned or intended to provide in-patient treatment for intellectual disabilities? Is it appropriate to admit patients to the mental health wards because they are homeless and attempting to have their accommodation needs met via the healthcare system rather than the DOH?
In my view, Liverpool hospital should not be providing in-patient substance treatment in a psychiatric facility. However, it may be more palatable and frankly doable to establish a “Dual-Diagnosis” Unit for patients with co-morbid presentations — emphasising medical detox and amelioration of deliriums. Additionally, there is already acceptance of the established specialty services, who need to be allocated additional resources in some cases (geriatrics in particular) and step up and serve their cohort populations overall. Even the most recent strategic planning for NSW estimates an increase of at least 33% of aged-care related health care need. Thus, the peculiar preciousness (Skidmore, 2020) that currently drives these services is simply not adequate to the task at hand or acceptable.
Additionally, the executive needs to be far more realistic and take clear and decisive action regarding the issue of homelessness increasingly presenting to ED. First we need to be clear and honest. Homelessness is not something that is ever resolved in a hospital setting intended to provided treatment for medical or psychiatric conditions. The hospital has wisely decided not to invest in accommodation strategies (i.e. group homes; shared accommodation; etc). Thus, even if it wanted to — there are no houses, apartments, units or granny flats at Liverpool Hospital. Accommodation can only be resolved in coordination with their family or alternatively with DOH or a real estate agent. I have always been perplexed by presentations that would otherwise be discharged but for homelessness, why the professionals involved never seem to suggest that if they want accommodation, they need to present to DOH rather than the ED. Calling for a Social Worker to address this only colludes and validates their manipulation. Hospitals provide medical treatment, they do not provide accommodation (despite many who hold the view that it should).
These are but a few of the contradictions associated with the admission practices for the psychiatric service at Liverpool hospital. Many of these scenarios touch on sensitive and difficult political turf. But pretending (Skidmore, 2020) otherwise merely gives politicians a pass on these issues that desperately need addressing. In lieu of a genuine political solution (that is likely far from forthcoming), a practical step that the hospital can take (for their own protection if nothing else), is to establish and enforce clear admission and exclusionary criteria, that may also provide some cover for the politicians. To avoid or even refuse to develop admission and exclusionary criterion results in admission practices that default to an emphasis of risk averse criterion instead.
BED MANAGERS AND THE ABSENCE OF A THERAPEUTIC MILIEU
Beyond issues directly related to admission criteria, the psychiatric service of Liverpool hospital is increasingly admitting patients from other hospitals within their own catchment area (Campbelltown — despite millions of dollars in new renovations; and Bankstown) and in some cases well out of area. While there are certainly extenuating circumstances where this could occur now and again, the justification on a somewhat regular basis for this is that these other hospitals are “full” and have no beds, so they are diverted to Liverpool. I find this most perplexing, and it begs the question … when is Liverpool hospital considered full? While Liverpool hospital is indeed the largest hospital in the area, possessing the most amount of psychiatric beds (for simplicity’s sake, let’s just say 100) — it is still a finite number. Whether you have 30 beds, or 50 beds, or 100 beds, when you are full — you are full. Yet the prevailing attitude appears to be that any hospital in the SWSLHD or surrounding LHD’s can be at capacity — except Liverpool. Regardless of how many patients it has, is somehow beyond the limits of saturation.
This appears to be due (at least in part) the mischievous, after hours/bed flow managers. The bed flow managers are perhaps the predominant strategy and resource of the organisational structure in addressing the ED admission/overflow challenges. It has significant FTE resources allocated in order to move patients around and “create” beds in order to alleviate either the number of patients in ED or their wait time. In other words, Liverpool hospital employs an entire staff of professionals, who’s job it is to manage the flow of transfers, leaves and discharges in a manner that allows for the admission of additional patients into the hospital’s psychiatric units. This arrangement, along with leave have the most significant and profound adverse impact that ripples throughout the MHU services. I say this, because the rational of decisions made by bed managers is rarely (if at all) based any clinical acumen. The process of which the bed managers operate is beset with many red flags and blatant contradictions to the professed CORE values of the hospital and other basic policies and procedures of the psychiatric service that it is beyond hypocritical. In fact, the hypocrisy is so thick as to be almost darkly funny.
On a daily basis, the bed managers canvass the psychiatric wards looking for potential patients to “sleep out” on another unit (often a sub-acute unit — North; South — or even PECC), or go on leave in order to “create” a bed for a patient waiting in an ED somewhere. Before this used to be mostly in the Liverpool ED, but now also includes Campbelltown and Bankstown as well. (I’ve never been able to figure out how the bed managers always seem able to create beds in Liverpool hospital, but for some reason they are rarely able to do so in Campbelltown or Bankstown, even though one would think the process would be the same).
The negative impact this has on patients does not appear to be a consideration in such decisions. If a patient has not progressed well or enough with their treatment, and is being pushed into leave prematurely, this raises a number of ethical concerns and issues. Is it clinically appropriate (or ethical for that matter) for a bed manager to pressure for premature leave or to disrupt their therapeutic milieu and their treatment to move them to another ward — in order to create a bed for another patient waiting in the ED? At the very least, this contributes to the creation of the psychiatric equivalent of a bad retail customer service experience.
While there have been times when the bed managers ask the doctors which of their patients are suitable for sleep overs; they do not do so consistently. There have been long stretches when they have simply stopped asking at all. Or worse, they will ask — and the doctors will specify who may be suitable and who is not clinically suitable to be moved. And then after the doctors and the salaried staff go home, they move the patients they want to move anyway — regardless of the feedback provided to them by the physicians, or anyone else. This would seem to be the opposite of collaboration, or clearly not working as one team with patients as the CORE values stipulates. Nor does this seem to be open or transparent. This process is neither respectful to the patients nor the staff intended to care for them. And perhaps worst of all, there is zero accountability of the bed managers for the adverse effects and negative repercussions that result in the wake of these arbitrary decision that they make routinely.
These routine, unchecked and unchallenged practices too often result in an array of self-inflicted and unnecessary issues that culminate in a type of professional vandalism — to patients, and our own professional and ethical standards as well.
There is an abundance of evidence on how to establish and operate a psychiatric hospital service. Yet, it should be clear that it is virtually impossible for medical professionals to adequately address the increasing range of social issues that people are being admitted for — especially, if we are not receiving assistance from other services in the government or society. Attempting to apply the psychiatric medical model to address these mounting issues is woefully inadequate and frankly an impossible task.
That is not an excuse however, from examining these issues nor avoid making necessary systemic changes that would enhance the way we know psychiatric hospitals are suppose to operate. It’s not naive to strive for patient centred, best-practice (i.e. evidenced-based), professionally ethical standards, nor is it valid or preferable to have to choose political expedience over those positions. It is a reality that all medical resources (including psychiatry), are finite and limited, regardless of whether it is a free market model or a socialist/welfare model. It is neither realistic, viable or sustainable to continue with the notion that the hospital can assume the duty of care or responsibility of every agency, organisation, or individual because of a sense of entitlement. The powers that be can certainly force the MHU’s to be the doormat of the service but in the end, in its present trajectory, it will continue to result in poorer outcomes.
In my view, it is short-sighted to dismiss the professional vandalism and damage that undercuts the dysfunctional operation of the mental health service at Liverpool hospital. While it has long been the status quo, what is happening on a routine basis in the psychiatric service is not normal by any reasonable definition.
I do believe that when we explore how to tackle some of these vexing issues, that the discipline of Social Work is uniquely qualified to participate and contribute in this endeavour. We are trained to understand systems and how to better negotiate and navigate within them constructively. The inclusion of Social Workers in the development of policies and procedures within complex systems would be worthwhile contributions. There is a dearth of recognition of indirect Social Work practice in policy development and management in the mental health service, just as there is wide misconception about direct Social Work practice. I sometimes wonder about the level of awareness in interdisciplinary teams that much of what Social Workers are asked to do on the inpatient units has almost nothing to do with Social Work. And rarely, if at all, are Social Workers thought of or viewed as clinicians. In short, I would suggest that the hospital is not fully maximising one of the best resources it has in tapping into the effective use of Clinical Social Workers.
IMAGINE THE POSSIBILITIES
So … imagine … what would happen if during the admissions process we refused to admit someone to the psychiatric unit because their presenting circumstances were clearly related to drug use rather than any co-morbid psychiatric condition that they may also have? If the symptoms and behaviours are more about psychoactive substance use than depression or schizophrenia, then they need to be admitted to a facility or program that reflects this reality. In any genuine acute substance abuse condition/disorder there is likely to be mood and/or reality disturbance. But if the circumstances around the presentation are about drug use, then we should not allow them to be admitted to the psychiatric service — period. So, what would happen if we stopped admitting these types of presentations? To continue to do so only enables the current status quo to continue, and never shines a light on how to better acknowledge and address this problem.
What would happen if we stopped admitting geriatric patients to our psychiatric service? What would happen if we took the position that there is in fact a specialised geriatric service designed and intended to care and look after this cohort, and to admit them to the psychiatric ward is beyond our therapeutic framework, often risky, generally inappropriate, and counter to best practice standards that would advocate that their developmental issues would be better addressed by their own service?
How will we deal with the bed management debacle? I don’t think this should be left exclusively to nurses. I think it is counter to the ethos of multi-disciplinary practice. I think doctors should be more involved in this process in particular, and I think clinical doctrine and rationale followed by quality of care for patients should be the predominant factors in the decision-making process rather than politics. In short, this workforce staff should no longer operate like a gestapo, without consequence or accountability, but should endeavour to strike a balance of managing bed flow in clinically appropriate ways that were also patient centred and contributing to quality of care and allowing the staff to model the CORE principles that we aspire to.
The one thing that is clearly within our reach as a psychiatric service is to re-evaluate our current leave policy and practices. It is time to get rid of unescorted leave — once and for all — period. For all the reasons I’ve previously stated, it is time to let go of this antiquated, impractical and unproductive practice. It has been entrenched not only in our systems’ but even in the Tribunal’s far too long. All leave should be escorted. And as I alluded to previously, leave should be a clinical consideration and only be considered at all towards the end of treatment with the possibility of discharge being imminent, as a way to test or measure progress or risk for the purpose of returning to the community — not used early and/or through out the length of stay. We can leave room for exceptions being made for specific, one-off, therapeutic tasks. But when the exceptions become the rule, then the policy means nothing.
Imagine that we neutralised this issue, and after months (or perhaps years) of consistent efforts we were able to establish the mind-set that when patients are admitted to a psychiatric ward in Liverpool hospital that there will not be leave until they are ready to be discharged. Imagine your patients more motivated to working on improving and getting better quicker so that they could return to the freedoms that come with residing in the community. And if all this were to occur, would you imagine longer or shorter lengths of stay overall? Can you imagine the statement that NSW hospitals could make with such a sweeping gesture? NSW could be a trailblazer with such an innovative policy shift.
The danger in every organisation, especially one built around hierarchy, is that an environment is cultivated that cuts off dissenting views and discourages honest feedback. This can quickly lead to a culture of delusion and deception (Comey, 2018). An elitist and condescending attitude and conduct towards subordinate personnel has long existed from the leadership of the mental health service, and set the tone of professional vandalism from the top down that has reeked havoc throughout the system of the mental health service. While many examples have focused on the adverse impact of patient care, this dynamic has also underscored major issues of devastating morale among the mental health staff and a toxic, hostile working environment that also places it’s workers at risk of perpetual trauma and mental health issues of their own.
I have often heard people convey that they do not feel supported by the executive management, or that they are not really interested in hearing anything different from what they’ve already decided. I’m not convinced however, that casting them or anyone else as the “bad guys” will contribute to the kind of discussions and change management that will be required to address these challenges. We all experience discouragement and exasperation at times. However, I believe that there are many bright, smart and intelligent people within the Liverpool workforce. And if provided the proper framework, context or structural mechanisms, and political will to creatively work through these issues, the mental health service of Liverpool could rehabilitate its damaged and broken image.
However, it is simply wrong to stand idly by, or worse, to stay silent when you know better. Silence is complicity — it is a choice.