Self-care program for inpatients in a mental hospital* G.
VoiNESKOS,f md; J.
A. Butler, ba; L. J. Bullock, rn; A. A. El-Gaaly,
Summary: A self-care program for selected inpatients in a mental hospital has been developed and has been in operation for more than a year. The 12-bed unit operates without any nursing or other professional staff during the night and weekend. Certain factors, including the mental hospital as an organization, tend to hamper the development of this type of program as well as the progress and growth of other programs in psychiatric hospitals. It is suggested that the much needed progress in the mental hospital would be facilitated by an open-systems approach to its organization. Mental hospitals should consider
the introduction of self-care programs for selected patients, mainly in view of their therapeutic potential, but also because of the financial savings such programs offer.
Resume:
Depuis plus d'un an les pied un programme visant a developper I'autonomie d'un certain nombre de patients psychiatriques dans un hdpital mental. auteurs on mis sur
Une section de 12 lits fonctionne pendant le weekend sans I'aide d'infiimieres ou d'autres membres de I'equipe psychiatrique. La mise sur pied de ce genre de programme toute la nuit et
et son
epanouissement,
tout comme
d'autres programmes psychiatriques innovateurs, sont rendus difficile par un nombre de facteurs parmi lesquels il faut citer I'hdpital psychiatrique en tant qu'organisation. Le developpement de cette derniere beneficierait d'une approche dite de "open-systems". ?Modification of paper presented at the Canadian Psychiatric Association annual meeting, Ottawa, Ont., October 1974 From the southwestern service, Queen Street Mental Health Centre, Toronto Reprint requests to: Dr. G. Voineskos, Southwestern service, Queen Street Mental Health Centre, 999 Queen St. W., Toronto, Ont. M6J 1H4
Les hopitaux psychiatriques devraient envisager serieusement I'adoption de ce genre de programme pour un certain nombre de malades choisis, principalement pour tirer parti de sa valeur therapeutique indeniable, mais aussi parce qu'un tel programme permet des economies financieres.
The literature on self-care programs in hospitals is characterized by pau-
md
patients, he goes to bed. A definition, therefore, of this self-care program is the responsibility by inpatients for their living situation and their treatment for at least 50% of their time on the ward in the absence of mental health pro¬ fessional staff. We are describing this program be¬ cause we believe the intrinsic thera¬ peutic benefits and financial savings of self-care programs could make a compelling case for consideration of devel¬ opment and evaluation of such pro¬ grams by mental hospitals.
city punctuated only occasionally by a description of a surgical or medical program. Reports on self-care pro¬ grams in mental hospitals have been even more infrequent. It could be sug¬ The setting, the program and gested that rules and regulations and the house advisers the role of the mental hospital as perceived by the staff and the community The self-care program is a com¬ may partly account for this poverty ponent of a day-care and inpatient selfof the literature. care unit that was developed as an There is a lack of definition as to integral part of a comprehensive clinical what constitutes a self-care program; service in an urban mental hospital in in using such a term no one seems to the spring of 1973. The unit is designed refer to factors in common or to provide for 30 day-care and 12 self-care pa¬ a definition at all. The term "self-care" tients. has been used to refer to the following: The unit is located in what was (a) the management by patients them¬ formerly an inpatient ward of 34 single selves of some aspects of their personal bedrooms clustered in three pods. The care, e.g. hygiene and bedmaking; (b) bedrooms of the self-care patients are the responsibility for decisions by pa¬ in one of these pods. Five days a week tients in the daily running of the ward, from 8 am to 8 pm the self-care pa¬ on readiness for discharge, ete; (c) the tients join the day-care patients in a obligation on the part of patients for day program that operates on therataking charge of their own medication peutic-community lines6,7 and includes and the associated educational role of a great variety of large- and small-group the staff; and (d) the diminution in the activities. The staff consists of eight number of regular staff employed, parti¬ nurses (RNs and RNAs), a psychologist, cularly when the unit is located outside a part-time psychiatrist, a part-time the hospital and usually adjacent to social worker and a recreational therit.15 apist. This paper describes the first year From 8 pm until 8 am and through¬ of operation of a self-care program out the weekend, when the unit for inpatients in a mental hospital unit. operates without any nursing or othex The unit operates without any nursing professional staff, the self-care patients or other professional staff from 8:00 organize and operate their own treat¬ every evening until 8:00 in the morning ment program activities. During this and throughout the weekend. During period the house adviser is present. this time a university student designated His role is "to be on the ward" and as house adviser is on the ward; someto facilitate contact with the staff if a time after 11:00 at night, like the major problem develops. CMA JOURNAL/JANUARY 25, 1975/VOL. 112 177
For the first 4 months of the opera¬ gram each patient receives a 2-week tion of the self-care program the house supply of medication and assumes re¬ adviser was a volunteer from the non- sponsibility for taking it. The medica¬ nursing clinical staff of the clinicai tion is individually packaged and sent service and other parts of the hospital. to the ward by the hospital pharmacist. (One day off in return for house adviser Criteria and contract of entry duty had been agreed upon by the hos¬ to the program pital administration, but many volunteers did not take it.) Since the The two criteria for a patient's program proved to be working without admission to the unit are, first, the any major problems, at the end of the to gain living4-month period a proposal for funding patient's requirementin learning experiences preparation for to hire house advisers was approved. to living in the community adjustment There are now four house advisers outside the hospital, or the need for who share the 108 hours of the week more intensive therapy than can be when the program operates without on an outpatient basis; and, given any professional staff. The house ad¬ second, the patient's willingness to visers are university students who have come to the unit. There are three consome experience in "helping" relation¬ traindications to admission: first, seri¬ ships. They are employed by the de¬ ous suicidal risk; second, severe psypartment of medicine as hospital at¬ chotic or organic illness; and third, is each and $31.17 tendants, paid per current abuse of alcohol or other adweek for 9 of the 27 hours each is on dictive substances. time is voluntheir the rest of duty; When a patient is considered for the teered (they are members of the Asso¬ program he is seen, along with ciation of Volunteers.) They are offered self-care the who referred him, by an as¬ person a free meals and accommodation if sessment committee consisting of a staff bedroom is provided in the unit and a patient from the pro¬ they wish; some take up this offer, member gram. During this meeting the problems others do not. When a problem arises in the unit of the patient and the goals of referral at night or on the weekend the patients are specified and the self-care program is outlined. If admission is agreed upon, ;an usually handle it. A "buddy" sys¬ a contract is drawn up between the tem has evolved whereby each patient assessment committee and the patient, has a fellow patient to contact and talk in which the goals of treatment, the to. If necessary a community meeting activities in which the pa¬ therapeutic is called. The house adviser may be tient will and a tentative participate, invited to join or his assistance may be time limit for the achievement of these requested. There is always a staff mem¬ goals and for his stay in the unit are ber the house adviser can contact by the admission After specified. clearly telephone for consultation. If a medical contract is reviewed and, if necessary, problem arises the physician on duty modified by the whole community of is calLed. The house adviser does staff and patients in the unit. Every not give "therapy"; he does, however, contract is reviewed at the patient's socialize and talk with patients. Both contract-review meeting. weekly he and the day staff attend the evening thus becoming The patients community meeting, aware of the mood of the group and In the first year 53 patients (36 men, of any ongoing problems. The house adviser writes in a logbook his im- 17 women) were treated in the self-care pressions and events that occurred dur¬ program. Only 1 patient was married; ing his tour of duty, which assists com¬ 31 were single, 11 were separated, 8 were divorced and 2 were widowed. munications. During their first week on the unit Only 4 had a job, 5 were students, 1 the self-care patients receive instruction was a housewife and the remaining 43 were unemployed. Fifteen patients on medication both individually and at medication seminars, which are part of (28%) had criminal records. Sixteen the psychiatric seminars attended by patients (30%) had attempted suicide the patients in the program. These on one or more occasions prior to ad¬ seminars start with an introductory talk mission to the self-care program. Fortyby one of the staff and are followed by eight patients (91%) had had one or more inpatient psychiatric admissions a group discussion in which staff and patients participate freely. Their dual before the present admission or transeducational purpose is to help the pa¬ fer to the self-care program. The pre¬ tient gain understanding about his med¬ senting diagnoses of the self-care pa¬ ication and develop self-reliance for tients are in keeping with the overall taking it, and to clarify some of the diagnostic distribution of the popula¬ issues involved in mental ill-health and tion of the clinical service, except that how they may affect postdischarge ad¬ organic disorders and alcoholism are a result of the justment to the community outside. under-represented After the first week in the self-care pro¬ self-care program admission policy. 178 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
Other pertinent details are set forth in Tables I to IV. In the first year of operation of the program the major problems encount¬ ered by house advisers were three seizures, a major drinking incident involv¬ ing three patients, one self-injury, and a physical attack on one patient by a patient from a different ward. During the same period of time the day staff made use of "guesting"8 in the crisis unit for 10 patients for an average of 3 nights per patient. "Guesting" is de¬ fined as the overnight accommodation of a patient in the crisis unit while he attends the program on the day-care and self-care unit during the day; it is used for any patient whose condition might become more serious. Four of these patients were finally transferred to an inpatient unit. Processes involved in the development of the program Two factors led to the approval, development and implementation of the program in the unusually short period of 2 weeks. First, mainly as a result of the introduction of a crisis interven¬ tion program,9 the 150-bed clinical service had decreased its occupancy rate to an average of 120 beds by the spring of 1973. Second, a budget cutback necessitated a reduction of 26 in the hospital's nursing staff. To implement this cutback the hospital decided that one of the clinical services with the lowest bed occupancy rate would have to convert an inpatient unit to a day-care unit. The staff of this service
Table II.Previous admissions*
No.of admissions Not known 0 1
psychiatric No. of
patients 1 4 7 9 7 3 7 2 4 2 7 53
2 3 4 5 6 7 8 9 Total ?Not including the inpatient admission (if any) as a continuation of which transfer to the self-care pro¬ gram took place.
objected to place, there
this decision. In the first
already a day hospital as part of the service, and the creation of yet another day-care program seemed superfluous. In the second place, all the programs of the service had been introduced in the previous 12 months and therefore each team wanted to preserve its own program.10 Lastly, the loss of the use of 34 beds of the inpatient ward caused real apprehension among the staff that at times the number of remaining beds would not be adequate. The insistence of the hospital admin¬ istration on converting a ward to a daycare unit and the objections of the clin¬ ical staff brought the situation to a point of crisis. When the idea of developing a self-care program to function alongside and in the same ward as the proposed day-care program was first raised the discussion was terminated immediately, the staff expressing their great disbelief that "rules and regula¬ tions" would ever permit them to obtain administrative approval for a self-care program in a mental hospital. The fol¬ lowing day the staff asked for more information on the proposed self-care program. The central concept was that patients would take care of themselves on the ward at night and on the week¬ end. If, as it happened, fire or other regulations did not permit patients to be on the ward without any staff, a house adviser might be considered. The staff became enthusiastic about the therapeutic potential of such a pro¬ gram, and a number of non-nursing clinical staff members volunteered for house adviser duty. Contrary to the staffs predictions, was
the administrative officers in the hosTable
III.Presenting diagnosis
pitai expressed a great deal of interest, and, once assured of the safety and potential therapeutic value of the pro¬ gram, approved it for an experimental period of 3 months and agreed to con¬ sider funding the house adviser posi¬ tion at the end of that period. The only major issue that needed further consideration was fire safety. The fire safety adviser for hospitals in the On¬ tario Ministry of Health stipulated the following conditions: 1. At least one staff member would always have to be present, since a patient could not be held legally responsible. 2. All self-care patients would have to receive fire safety training. 3. Fire-alarm key stations would have to be replaced with pull stations. 4. Smoke detectors of the ionization type would have to be installed in corridors of pods used in the pro¬ gram to provide early fire detection. 5. During night hours, when the house adviser would be in bed, a staff member would have to patrol the unit once every hour. The security guards agreed to fulfill this last condition by including the unit in their routine patrol of the hospital. The equipment was installed as speci¬ fied and the patients receive fire safety training. To meet the first condition, the position of house adviser was de¬
veloped.
Results
The self-care program for inpatients has been operating for more than a year. One of the essential factors for the successful functioning of this pro¬ gram has been the availability of
"guesting".8
Most of the patients treated in this program had dependency problems or were lacking in environmental supports or had both problems. The patient who is living far away from his family or who has no environmental supports faces a realistically difficult situation at the time of discharge from hospital. Lack of a job or accommodation may prevent him from giving up the pro¬
security offered by the staff hospital, thus prolonging his hospital stay.11 The self-care program, by permitting a gradual solution of these problems, can be more beneficial than total inpatient ward care for such a patient. The antitherapeutic effects of mental hospitals, resulting in institutionalism and deculturation,1214 undermine the patient's adaptive strengths and pro¬ mote passivity and dependence on the hospital. At times the anxiety provoked by impending discharge is so severe that it may jeopardize the results of the en¬ tection and and the
tire treatment effort.15 The self-care
patient to take responsibility and actively participate in his treatment program, thus discouraging dependency and the assumption of the sick role. Those patients who suffer from ina¬ dequate or faulty social learning often find it difficult to cope in the com¬ munity. The self-care program provides a therapeutic milieu that promotes ini¬ tiative and independence while the pa¬ tient is in hospital, and provides ample opportunities for living-learning experiences.6,7 In our program the "helper" therapy principle16 and therapeutic-community concepts are applied. The impact of these techniques and the resulting par¬ ticipation of the patients are reflected in their comments, for example, "It gives you more room to think for yourself and depend more on yourself." The patients feel proud of taking care of themselves at night and on the week¬ end; the ward community feeling, cohesion and spirit of cooperation with staff and fellow patients have been enhanced. As reported by Dukszta,17 fre¬ quently the patients "look after" the house adviser, trying to put him at ease, explaining the program and showing him the amenities on the ward, par¬ ticularly when he is new. Patients are usually capable of tak¬ ing much more responsibility than the staff think they can. Policies, rules, regulations and the bureaucratic outlook in mental hospitals engender staff attitudes that permit the patient little or no responsibility and often convey conflicting expectations. Frequently, for instance, the staff are at pains to ex¬ plain to the patient that he is to be trusted as an individual, and yet many aspects of mental hospital practice covertly transmit just the opposite. An obvious contradiction is the handling of medication during the inpatient and outpatient phases of treatment. The in¬ patient phase, with its meticulous staff control and recording of every single pill the patient takes, is followed by the outpatient phase, in which the pa¬ tient suddenly becomes responsible for the self-administration of more than 100 pills of two or more different kinds. In our program it has proved pos¬ sible for the patients to take charge of their medication; this not only prepares the patient for what he will have to be doing when he is discharged to the community, but also frees the nurses from the time-consuming job of distributing the medication. Self-administration of medication during the inpatient phase has been tried successfully in other hospitals with a variety of patients, including those suffering from neurologic, diabetic, psychiatric, arthritic, cerebrovascular program encourages the on
and other disorders.2^
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 179
The savings resulting from the introduction of the self-care program cannot be underestimated. To determine the economy of this type of unit it would be necessary to compare the present cost with the former cost when the unit had a full nursing staff. When all 34 beds were used for inpatients 12 more members of the nursing staff were required than at present, in order to provide round-the-clock nursing (three shifts). Elimination of those 12 salaries would produce an annual savings of $90 171 for a 34-bed unit, or $30 057 for a 12-bed unit.* This is a rather simplified cost analysis and is based on the assumption that if the self-care unit were extended to 34 beds, 12 house advisers would be required (three times as many as are required now; this number is, of course, too high). It also assumes that if the present 12-bed unit were to have a full nursing staff, 4 additional nurses would be required (one third of the 12 additional nurses when the unit was an inpatient ward of 34 beds). It is certain that more than four nurses would be required in view of the existing "policy" in mental hospitals in Ontario to staff each inpatient ward with at least 20 nursing staff members in order to operate the round-the-clock shift system. Furthermore, this cost analysis does not take into consideration the fact that the 34-bed inpatient unit had only 8 to 10 day-care patients, whereas there are now 20 to 25 day-care patients treated alongside the self-care patients. The financial savings, therefore, would be much higher if these points were taken into consideration. If each mental hospital in this country operated only one ward on a self-care basis the savings to the taxpayer would run into many millions of dollars. We suggest that with proper program development and selection of patients it is possible for any mental hospital to develop at least one self-care program. The insistence on having two or three nursing staff members on each inpatient ward at night, which is the "policy" in mental hospitals in Ontario, is questioned. Such a policy casts doubt on the optimum and prudent utilization of such highly trained and expensive individuals. However, when policies of this kind are questioned, anxiety - if not hostility - is provoked in many quarters in the mental hospital. The stereotyped responses to these questions (e.g. "They are needed for safety reasons" or "for accreditation" or even "the union") are only the tip of the iceberg beneath which lies a whole *. these calculations, salaries and meals for house advisers were assessed at $25 929, and salaries and fringe benefits for nurses were assessed at $116 100 with respect to a 34-bed unit.
variety of problems that beset the mental hospital as an organizational system. These problems, amply described in the literature of the last 2 decades,6'12'14'18-22 and the accompanying polarization20'. hamper the much-needed change in the mental hospital. As an organization the mental hospital has been largely characterized by rigidity and lack of growth. The mental hospital has a lot to learn from organizational development concepts and the whole field of systems theory, already applied to industry in the last decade.24-26 Bennis. describes organizational development as "a response to change, a complex educational strategy intended to change the beliefs, attitudes, values and structure of organizations so that they can better adapt to new technologies, markets, and challenges and the dizzying rate of change itself." Such a strategy, however, implies interference with the status quo and threatens the security of everyone within the system, particularly at the upper levels of the hierarchy, where power, decision-making, controls over behaviour, etc. are centralized.27 Furthermore, as Jones27 points out, in advocating an open-systems approach "psychiatry has remained strangely resistant in its awareness and application of the field of systems theory." Despite the problems that beset the mental hospital, it proved possible to introduce this self-care program, which has aspects fundamentally departing from traditional mental hospital practice. The self-care idea was seen as a positive solution by staff at all levels and was adopted very quickly. The approval and the short time it took to introduce this program can best be understood in the context of crisis theory, as the result of the openness and susceptibility to change characterizing states of crisis.2832 Conclusion In an era of much public debate about the future role of the mental hospital and of rising health care costs, the introduction of self-care programs for selected patients should be considered by mental hospitals, mainly in view of their therapeutic potential, but also because of the financial savings. The self-care program, as an integral part of a comprehensive mental health service, appears to have its place as one of a number of treatment modalities. This study has demonstrated that the development and operation of a selfcare program is feasible. However, comparative evaluative studies and long-term follow-up studies to determine the efficacy of such programs are required. Studies are also required to
180 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
delineate precisely the kind of patient who could be optimally treated in a self-care program. The authors would like to thank all those who have made the creation and continuing operation of this program possible: those who participated in the development of the program and the staff of the unit; those staff who volunteered to act as house advisers, and the current house advisers; Mr. W. Lopatto for providing us with the figures in the cost analysis; Mr. J. Menzies for his support on the admimstrative aspects; and Drs. H. B. Durost and A. L. Swanson for their continuing support. References I. Towarn AP: Self-care unit: some lessons in institutional power. J Consult Clin Psychol
33: 561, 1969 Self-medication. Hospitals 44: 57, 1970 LAUZEN E: Hotel becomes self-care unit in move to delay expansion. Mod Hosp 118: 56, 1972 Kaar.ta J: Hospital tells patients: "Take care of yourself". Mod Hosp 119: 91, 1972 BRADSHAW B, SmAKER M: A special unit to encourage giving up patienthood. Hosp Community Psychiatry 25: 164, 1974 CLARK DH: Administrative Therapy. London, Tavistock Pubi, 1964 Joe.as M: Beyond the Therapeutic Community. New Haven, Yale U Pr, 1968 ENGLE RP, SABIN J: Partial hospitalization, in Practice of Community Mental Health, edited by GRUNEBAUM H, Boston, Little, 1970 VoiNasicos G, MoJIRIsoN MF, JAIN R: The introduction of a crisis unit in a mental hospitaL Can Psychiair Assoc 1 19: 445 1974 DuitosT HB: Polarizing factors affecking decision-making in mental hospitals, in Psychiatry: Proceedings of the V World Congress of Psychiatry, part II, Amsterdam, Excerpla Med, 1973 BOYD WD, KENNEDY RI: Patterns of admissions to an acute psychiatric ward. Health Bull (Edinb) 26: 55, 1969 STANTON AH, SWARrZ M: The Menial Hospital. New York, Basic, 1954 CAUDILL W: The Psychiatric Hospital as a Small Society. Cambridge, Harvard U Pr, 1958 GOFFMAI-I E: Asylums. Garden City, New
2. COCKERHAM MF: 3.
4. 5. 6. 7. 8. 9.
10.
11. 12. 13. 14.
York, Doubleday, 1961 15. KiNoalt E, DANIELS RS: Day and night psychiatric treatment centres: description, organization and function. Am I Psychiatry
119: 415, 1962 16. RncssMAN F: The 'helper' therapy principle. coe 111, Free Pr, 1964 17. DUK5zTA J: Under self-care, patients are shown to be very capable. Parkdale Citizen, August 1973, p 4 18. STRAuss A, SCHALzMAN L, Bucuait R, et al: Psychiatric Ideologies and Institutions. Glencoe 111, Free Pr, 1964 19. .IuN¶-ut TD: Hierarchy or Arena? in New Aspects in the Mental Health Services, edited by FREEMAN H, FARNDALE J, London, Perganson, 1967 20. JACKSON J: Consensus and conflict in treatment institutions. Hosp Community Psychiatry 19: 165. 1968 21. ROBERTsON A: Organization control in remedial institutions. Br I Soc Psychiatry 3: 3, 1969 22. GREENBLA¶-r M: Administrative psychiatry. Am I Psychiatry 129: 373, 1972 23. GREENBLATF M, SHARAF MR, STONE EM: Dynamics of Institutional Change. Pittsburgh, U of Pittsburgh Pr, 1971 24. MILLER El, RICE AK: Systems of Organization. London, Tavistock Pubi, 1967 25. BENNIs WG: Organization Development. Series on Organization Development. Reading Mass, A-W, 1969 26. ARGYRIs C: Intervention Theory and Method. Reading Mass, A-W, 1970 27. JoNas M: Psychiatry, systems theory, education and change. Br I Psychiatry 124: 75, 1974 28. LINDEMANN E: Symptomatology and management of acute grief. Am I Psychiatry 101: 141, 1944 29. THOMAS WI: Social Behaviour and Personality. New York, Soc Sd Res, 1951 30. CAPLAN G: Principles of Preventive Psychiatry. New York, Basic, 1964
31. ScHuLsaRo HC, SHELTON A: The probability of crisis and strategies of preventive intervention. Arch Gen Psychiatry 18: 553, 1968 32. LINDENBERO RE: Social services. Hospitals
46: 52, 1972
VoiNESKOS,f md; J.
A. Butler, ba; L. J. Bullock, rn; A. A. El-Gaaly,
Summary: A self-care program for selected inpatients in a mental hospital has been developed and has been in operation for more than a year. The 12-bed unit operates without any nursing or other professional staff during the night and weekend. Certain factors, including the mental hospital as an organization, tend to hamper the development of this type of program as well as the progress and growth of other programs in psychiatric hospitals. It is suggested that the much needed progress in the mental hospital would be facilitated by an open-systems approach to its organization. Mental hospitals should consider
the introduction of self-care programs for selected patients, mainly in view of their therapeutic potential, but also because of the financial savings such programs offer.
Resume:
Depuis plus d'un an les pied un programme visant a developper I'autonomie d'un certain nombre de patients psychiatriques dans un hdpital mental. auteurs on mis sur
Une section de 12 lits fonctionne pendant le weekend sans I'aide d'infiimieres ou d'autres membres de I'equipe psychiatrique. La mise sur pied de ce genre de programme toute la nuit et
et son
epanouissement,
tout comme
d'autres programmes psychiatriques innovateurs, sont rendus difficile par un nombre de facteurs parmi lesquels il faut citer I'hdpital psychiatrique en tant qu'organisation. Le developpement de cette derniere beneficierait d'une approche dite de "open-systems". ?Modification of paper presented at the Canadian Psychiatric Association annual meeting, Ottawa, Ont., October 1974 From the southwestern service, Queen Street Mental Health Centre, Toronto Reprint requests to: Dr. G. Voineskos, Southwestern service, Queen Street Mental Health Centre, 999 Queen St. W., Toronto, Ont. M6J 1H4
Les hopitaux psychiatriques devraient envisager serieusement I'adoption de ce genre de programme pour un certain nombre de malades choisis, principalement pour tirer parti de sa valeur therapeutique indeniable, mais aussi parce qu'un tel programme permet des economies financieres.
The literature on self-care programs in hospitals is characterized by pau-
md
patients, he goes to bed. A definition, therefore, of this self-care program is the responsibility by inpatients for their living situation and their treatment for at least 50% of their time on the ward in the absence of mental health pro¬ fessional staff. We are describing this program be¬ cause we believe the intrinsic thera¬ peutic benefits and financial savings of self-care programs could make a compelling case for consideration of devel¬ opment and evaluation of such pro¬ grams by mental hospitals.
city punctuated only occasionally by a description of a surgical or medical program. Reports on self-care pro¬ grams in mental hospitals have been even more infrequent. It could be sug¬ The setting, the program and gested that rules and regulations and the house advisers the role of the mental hospital as perceived by the staff and the community The self-care program is a com¬ may partly account for this poverty ponent of a day-care and inpatient selfof the literature. care unit that was developed as an There is a lack of definition as to integral part of a comprehensive clinical what constitutes a self-care program; service in an urban mental hospital in in using such a term no one seems to the spring of 1973. The unit is designed refer to factors in common or to provide for 30 day-care and 12 self-care pa¬ a definition at all. The term "self-care" tients. has been used to refer to the following: The unit is located in what was (a) the management by patients them¬ formerly an inpatient ward of 34 single selves of some aspects of their personal bedrooms clustered in three pods. The care, e.g. hygiene and bedmaking; (b) bedrooms of the self-care patients are the responsibility for decisions by pa¬ in one of these pods. Five days a week tients in the daily running of the ward, from 8 am to 8 pm the self-care pa¬ on readiness for discharge, ete; (c) the tients join the day-care patients in a obligation on the part of patients for day program that operates on therataking charge of their own medication peutic-community lines6,7 and includes and the associated educational role of a great variety of large- and small-group the staff; and (d) the diminution in the activities. The staff consists of eight number of regular staff employed, parti¬ nurses (RNs and RNAs), a psychologist, cularly when the unit is located outside a part-time psychiatrist, a part-time the hospital and usually adjacent to social worker and a recreational therit.15 apist. This paper describes the first year From 8 pm until 8 am and through¬ of operation of a self-care program out the weekend, when the unit for inpatients in a mental hospital unit. operates without any nursing or othex The unit operates without any nursing professional staff, the self-care patients or other professional staff from 8:00 organize and operate their own treat¬ every evening until 8:00 in the morning ment program activities. During this and throughout the weekend. During period the house adviser is present. this time a university student designated His role is "to be on the ward" and as house adviser is on the ward; someto facilitate contact with the staff if a time after 11:00 at night, like the major problem develops. CMA JOURNAL/JANUARY 25, 1975/VOL. 112 177
For the first 4 months of the opera¬ gram each patient receives a 2-week tion of the self-care program the house supply of medication and assumes re¬ adviser was a volunteer from the non- sponsibility for taking it. The medica¬ nursing clinical staff of the clinicai tion is individually packaged and sent service and other parts of the hospital. to the ward by the hospital pharmacist. (One day off in return for house adviser Criteria and contract of entry duty had been agreed upon by the hos¬ to the program pital administration, but many volunteers did not take it.) Since the The two criteria for a patient's program proved to be working without admission to the unit are, first, the any major problems, at the end of the to gain living4-month period a proposal for funding patient's requirementin learning experiences preparation for to hire house advisers was approved. to living in the community adjustment There are now four house advisers outside the hospital, or the need for who share the 108 hours of the week more intensive therapy than can be when the program operates without on an outpatient basis; and, given any professional staff. The house ad¬ second, the patient's willingness to visers are university students who have come to the unit. There are three consome experience in "helping" relation¬ traindications to admission: first, seri¬ ships. They are employed by the de¬ ous suicidal risk; second, severe psypartment of medicine as hospital at¬ chotic or organic illness; and third, is each and $31.17 tendants, paid per current abuse of alcohol or other adweek for 9 of the 27 hours each is on dictive substances. time is voluntheir the rest of duty; When a patient is considered for the teered (they are members of the Asso¬ program he is seen, along with ciation of Volunteers.) They are offered self-care the who referred him, by an as¬ person a free meals and accommodation if sessment committee consisting of a staff bedroom is provided in the unit and a patient from the pro¬ they wish; some take up this offer, member gram. During this meeting the problems others do not. When a problem arises in the unit of the patient and the goals of referral at night or on the weekend the patients are specified and the self-care program is outlined. If admission is agreed upon, ;an usually handle it. A "buddy" sys¬ a contract is drawn up between the tem has evolved whereby each patient assessment committee and the patient, has a fellow patient to contact and talk in which the goals of treatment, the to. If necessary a community meeting activities in which the pa¬ therapeutic is called. The house adviser may be tient will and a tentative participate, invited to join or his assistance may be time limit for the achievement of these requested. There is always a staff mem¬ goals and for his stay in the unit are ber the house adviser can contact by the admission After specified. clearly telephone for consultation. If a medical contract is reviewed and, if necessary, problem arises the physician on duty modified by the whole community of is calLed. The house adviser does staff and patients in the unit. Every not give "therapy"; he does, however, contract is reviewed at the patient's socialize and talk with patients. Both contract-review meeting. weekly he and the day staff attend the evening thus becoming The patients community meeting, aware of the mood of the group and In the first year 53 patients (36 men, of any ongoing problems. The house adviser writes in a logbook his im- 17 women) were treated in the self-care pressions and events that occurred dur¬ program. Only 1 patient was married; ing his tour of duty, which assists com¬ 31 were single, 11 were separated, 8 were divorced and 2 were widowed. munications. During their first week on the unit Only 4 had a job, 5 were students, 1 the self-care patients receive instruction was a housewife and the remaining 43 were unemployed. Fifteen patients on medication both individually and at medication seminars, which are part of (28%) had criminal records. Sixteen the psychiatric seminars attended by patients (30%) had attempted suicide the patients in the program. These on one or more occasions prior to ad¬ seminars start with an introductory talk mission to the self-care program. Fortyby one of the staff and are followed by eight patients (91%) had had one or more inpatient psychiatric admissions a group discussion in which staff and patients participate freely. Their dual before the present admission or transeducational purpose is to help the pa¬ fer to the self-care program. The pre¬ tient gain understanding about his med¬ senting diagnoses of the self-care pa¬ ication and develop self-reliance for tients are in keeping with the overall taking it, and to clarify some of the diagnostic distribution of the popula¬ issues involved in mental ill-health and tion of the clinical service, except that how they may affect postdischarge ad¬ organic disorders and alcoholism are a result of the justment to the community outside. under-represented After the first week in the self-care pro¬ self-care program admission policy. 178 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
Other pertinent details are set forth in Tables I to IV. In the first year of operation of the program the major problems encount¬ ered by house advisers were three seizures, a major drinking incident involv¬ ing three patients, one self-injury, and a physical attack on one patient by a patient from a different ward. During the same period of time the day staff made use of "guesting"8 in the crisis unit for 10 patients for an average of 3 nights per patient. "Guesting" is de¬ fined as the overnight accommodation of a patient in the crisis unit while he attends the program on the day-care and self-care unit during the day; it is used for any patient whose condition might become more serious. Four of these patients were finally transferred to an inpatient unit. Processes involved in the development of the program Two factors led to the approval, development and implementation of the program in the unusually short period of 2 weeks. First, mainly as a result of the introduction of a crisis interven¬ tion program,9 the 150-bed clinical service had decreased its occupancy rate to an average of 120 beds by the spring of 1973. Second, a budget cutback necessitated a reduction of 26 in the hospital's nursing staff. To implement this cutback the hospital decided that one of the clinical services with the lowest bed occupancy rate would have to convert an inpatient unit to a day-care unit. The staff of this service
Table II.Previous admissions*
No.of admissions Not known 0 1
psychiatric No. of
patients 1 4 7 9 7 3 7 2 4 2 7 53
2 3 4 5 6 7 8 9 Total ?Not including the inpatient admission (if any) as a continuation of which transfer to the self-care pro¬ gram took place.
objected to place, there
this decision. In the first
already a day hospital as part of the service, and the creation of yet another day-care program seemed superfluous. In the second place, all the programs of the service had been introduced in the previous 12 months and therefore each team wanted to preserve its own program.10 Lastly, the loss of the use of 34 beds of the inpatient ward caused real apprehension among the staff that at times the number of remaining beds would not be adequate. The insistence of the hospital admin¬ istration on converting a ward to a daycare unit and the objections of the clin¬ ical staff brought the situation to a point of crisis. When the idea of developing a self-care program to function alongside and in the same ward as the proposed day-care program was first raised the discussion was terminated immediately, the staff expressing their great disbelief that "rules and regula¬ tions" would ever permit them to obtain administrative approval for a self-care program in a mental hospital. The fol¬ lowing day the staff asked for more information on the proposed self-care program. The central concept was that patients would take care of themselves on the ward at night and on the week¬ end. If, as it happened, fire or other regulations did not permit patients to be on the ward without any staff, a house adviser might be considered. The staff became enthusiastic about the therapeutic potential of such a pro¬ gram, and a number of non-nursing clinical staff members volunteered for house adviser duty. Contrary to the staffs predictions, was
the administrative officers in the hosTable
III.Presenting diagnosis
pitai expressed a great deal of interest, and, once assured of the safety and potential therapeutic value of the pro¬ gram, approved it for an experimental period of 3 months and agreed to con¬ sider funding the house adviser posi¬ tion at the end of that period. The only major issue that needed further consideration was fire safety. The fire safety adviser for hospitals in the On¬ tario Ministry of Health stipulated the following conditions: 1. At least one staff member would always have to be present, since a patient could not be held legally responsible. 2. All self-care patients would have to receive fire safety training. 3. Fire-alarm key stations would have to be replaced with pull stations. 4. Smoke detectors of the ionization type would have to be installed in corridors of pods used in the pro¬ gram to provide early fire detection. 5. During night hours, when the house adviser would be in bed, a staff member would have to patrol the unit once every hour. The security guards agreed to fulfill this last condition by including the unit in their routine patrol of the hospital. The equipment was installed as speci¬ fied and the patients receive fire safety training. To meet the first condition, the position of house adviser was de¬
veloped.
Results
The self-care program for inpatients has been operating for more than a year. One of the essential factors for the successful functioning of this pro¬ gram has been the availability of
"guesting".8
Most of the patients treated in this program had dependency problems or were lacking in environmental supports or had both problems. The patient who is living far away from his family or who has no environmental supports faces a realistically difficult situation at the time of discharge from hospital. Lack of a job or accommodation may prevent him from giving up the pro¬
security offered by the staff hospital, thus prolonging his hospital stay.11 The self-care program, by permitting a gradual solution of these problems, can be more beneficial than total inpatient ward care for such a patient. The antitherapeutic effects of mental hospitals, resulting in institutionalism and deculturation,1214 undermine the patient's adaptive strengths and pro¬ mote passivity and dependence on the hospital. At times the anxiety provoked by impending discharge is so severe that it may jeopardize the results of the en¬ tection and and the
tire treatment effort.15 The self-care
patient to take responsibility and actively participate in his treatment program, thus discouraging dependency and the assumption of the sick role. Those patients who suffer from ina¬ dequate or faulty social learning often find it difficult to cope in the com¬ munity. The self-care program provides a therapeutic milieu that promotes ini¬ tiative and independence while the pa¬ tient is in hospital, and provides ample opportunities for living-learning experiences.6,7 In our program the "helper" therapy principle16 and therapeutic-community concepts are applied. The impact of these techniques and the resulting par¬ ticipation of the patients are reflected in their comments, for example, "It gives you more room to think for yourself and depend more on yourself." The patients feel proud of taking care of themselves at night and on the week¬ end; the ward community feeling, cohesion and spirit of cooperation with staff and fellow patients have been enhanced. As reported by Dukszta,17 fre¬ quently the patients "look after" the house adviser, trying to put him at ease, explaining the program and showing him the amenities on the ward, par¬ ticularly when he is new. Patients are usually capable of tak¬ ing much more responsibility than the staff think they can. Policies, rules, regulations and the bureaucratic outlook in mental hospitals engender staff attitudes that permit the patient little or no responsibility and often convey conflicting expectations. Frequently, for instance, the staff are at pains to ex¬ plain to the patient that he is to be trusted as an individual, and yet many aspects of mental hospital practice covertly transmit just the opposite. An obvious contradiction is the handling of medication during the inpatient and outpatient phases of treatment. The in¬ patient phase, with its meticulous staff control and recording of every single pill the patient takes, is followed by the outpatient phase, in which the pa¬ tient suddenly becomes responsible for the self-administration of more than 100 pills of two or more different kinds. In our program it has proved pos¬ sible for the patients to take charge of their medication; this not only prepares the patient for what he will have to be doing when he is discharged to the community, but also frees the nurses from the time-consuming job of distributing the medication. Self-administration of medication during the inpatient phase has been tried successfully in other hospitals with a variety of patients, including those suffering from neurologic, diabetic, psychiatric, arthritic, cerebrovascular program encourages the on
and other disorders.2^
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 179
The savings resulting from the introduction of the self-care program cannot be underestimated. To determine the economy of this type of unit it would be necessary to compare the present cost with the former cost when the unit had a full nursing staff. When all 34 beds were used for inpatients 12 more members of the nursing staff were required than at present, in order to provide round-the-clock nursing (three shifts). Elimination of those 12 salaries would produce an annual savings of $90 171 for a 34-bed unit, or $30 057 for a 12-bed unit.* This is a rather simplified cost analysis and is based on the assumption that if the self-care unit were extended to 34 beds, 12 house advisers would be required (three times as many as are required now; this number is, of course, too high). It also assumes that if the present 12-bed unit were to have a full nursing staff, 4 additional nurses would be required (one third of the 12 additional nurses when the unit was an inpatient ward of 34 beds). It is certain that more than four nurses would be required in view of the existing "policy" in mental hospitals in Ontario to staff each inpatient ward with at least 20 nursing staff members in order to operate the round-the-clock shift system. Furthermore, this cost analysis does not take into consideration the fact that the 34-bed inpatient unit had only 8 to 10 day-care patients, whereas there are now 20 to 25 day-care patients treated alongside the self-care patients. The financial savings, therefore, would be much higher if these points were taken into consideration. If each mental hospital in this country operated only one ward on a self-care basis the savings to the taxpayer would run into many millions of dollars. We suggest that with proper program development and selection of patients it is possible for any mental hospital to develop at least one self-care program. The insistence on having two or three nursing staff members on each inpatient ward at night, which is the "policy" in mental hospitals in Ontario, is questioned. Such a policy casts doubt on the optimum and prudent utilization of such highly trained and expensive individuals. However, when policies of this kind are questioned, anxiety - if not hostility - is provoked in many quarters in the mental hospital. The stereotyped responses to these questions (e.g. "They are needed for safety reasons" or "for accreditation" or even "the union") are only the tip of the iceberg beneath which lies a whole *. these calculations, salaries and meals for house advisers were assessed at $25 929, and salaries and fringe benefits for nurses were assessed at $116 100 with respect to a 34-bed unit.
variety of problems that beset the mental hospital as an organizational system. These problems, amply described in the literature of the last 2 decades,6'12'14'18-22 and the accompanying polarization20'. hamper the much-needed change in the mental hospital. As an organization the mental hospital has been largely characterized by rigidity and lack of growth. The mental hospital has a lot to learn from organizational development concepts and the whole field of systems theory, already applied to industry in the last decade.24-26 Bennis. describes organizational development as "a response to change, a complex educational strategy intended to change the beliefs, attitudes, values and structure of organizations so that they can better adapt to new technologies, markets, and challenges and the dizzying rate of change itself." Such a strategy, however, implies interference with the status quo and threatens the security of everyone within the system, particularly at the upper levels of the hierarchy, where power, decision-making, controls over behaviour, etc. are centralized.27 Furthermore, as Jones27 points out, in advocating an open-systems approach "psychiatry has remained strangely resistant in its awareness and application of the field of systems theory." Despite the problems that beset the mental hospital, it proved possible to introduce this self-care program, which has aspects fundamentally departing from traditional mental hospital practice. The self-care idea was seen as a positive solution by staff at all levels and was adopted very quickly. The approval and the short time it took to introduce this program can best be understood in the context of crisis theory, as the result of the openness and susceptibility to change characterizing states of crisis.2832 Conclusion In an era of much public debate about the future role of the mental hospital and of rising health care costs, the introduction of self-care programs for selected patients should be considered by mental hospitals, mainly in view of their therapeutic potential, but also because of the financial savings. The self-care program, as an integral part of a comprehensive mental health service, appears to have its place as one of a number of treatment modalities. This study has demonstrated that the development and operation of a selfcare program is feasible. However, comparative evaluative studies and long-term follow-up studies to determine the efficacy of such programs are required. Studies are also required to
180 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
delineate precisely the kind of patient who could be optimally treated in a self-care program. The authors would like to thank all those who have made the creation and continuing operation of this program possible: those who participated in the development of the program and the staff of the unit; those staff who volunteered to act as house advisers, and the current house advisers; Mr. W. Lopatto for providing us with the figures in the cost analysis; Mr. J. Menzies for his support on the admimstrative aspects; and Drs. H. B. Durost and A. L. Swanson for their continuing support. References I. Towarn AP: Self-care unit: some lessons in institutional power. J Consult Clin Psychol
33: 561, 1969 Self-medication. Hospitals 44: 57, 1970 LAUZEN E: Hotel becomes self-care unit in move to delay expansion. Mod Hosp 118: 56, 1972 Kaar.ta J: Hospital tells patients: "Take care of yourself". Mod Hosp 119: 91, 1972 BRADSHAW B, SmAKER M: A special unit to encourage giving up patienthood. Hosp Community Psychiatry 25: 164, 1974 CLARK DH: Administrative Therapy. London, Tavistock Pubi, 1964 Joe.as M: Beyond the Therapeutic Community. New Haven, Yale U Pr, 1968 ENGLE RP, SABIN J: Partial hospitalization, in Practice of Community Mental Health, edited by GRUNEBAUM H, Boston, Little, 1970 VoiNasicos G, MoJIRIsoN MF, JAIN R: The introduction of a crisis unit in a mental hospitaL Can Psychiair Assoc 1 19: 445 1974 DuitosT HB: Polarizing factors affecking decision-making in mental hospitals, in Psychiatry: Proceedings of the V World Congress of Psychiatry, part II, Amsterdam, Excerpla Med, 1973 BOYD WD, KENNEDY RI: Patterns of admissions to an acute psychiatric ward. Health Bull (Edinb) 26: 55, 1969 STANTON AH, SWARrZ M: The Menial Hospital. New York, Basic, 1954 CAUDILL W: The Psychiatric Hospital as a Small Society. Cambridge, Harvard U Pr, 1958 GOFFMAI-I E: Asylums. Garden City, New
2. COCKERHAM MF: 3.
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York, Doubleday, 1961 15. KiNoalt E, DANIELS RS: Day and night psychiatric treatment centres: description, organization and function. Am I Psychiatry
119: 415, 1962 16. RncssMAN F: The 'helper' therapy principle. coe 111, Free Pr, 1964 17. DUK5zTA J: Under self-care, patients are shown to be very capable. Parkdale Citizen, August 1973, p 4 18. STRAuss A, SCHALzMAN L, Bucuait R, et al: Psychiatric Ideologies and Institutions. Glencoe 111, Free Pr, 1964 19. .IuN¶-ut TD: Hierarchy or Arena? in New Aspects in the Mental Health Services, edited by FREEMAN H, FARNDALE J, London, Perganson, 1967 20. JACKSON J: Consensus and conflict in treatment institutions. Hosp Community Psychiatry 19: 165. 1968 21. ROBERTsON A: Organization control in remedial institutions. Br I Soc Psychiatry 3: 3, 1969 22. GREENBLA¶-r M: Administrative psychiatry. Am I Psychiatry 129: 373, 1972 23. GREENBLATF M, SHARAF MR, STONE EM: Dynamics of Institutional Change. Pittsburgh, U of Pittsburgh Pr, 1971 24. MILLER El, RICE AK: Systems of Organization. London, Tavistock Pubi, 1967 25. BENNIs WG: Organization Development. Series on Organization Development. Reading Mass, A-W, 1969 26. ARGYRIs C: Intervention Theory and Method. Reading Mass, A-W, 1970 27. JoNas M: Psychiatry, systems theory, education and change. Br I Psychiatry 124: 75, 1974 28. LINDEMANN E: Symptomatology and management of acute grief. Am I Psychiatry 101: 141, 1944 29. THOMAS WI: Social Behaviour and Personality. New York, Soc Sd Res, 1951 30. CAPLAN G: Principles of Preventive Psychiatry. New York, Basic, 1964
31. ScHuLsaRo HC, SHELTON A: The probability of crisis and strategies of preventive intervention. Arch Gen Psychiatry 18: 553, 1968 32. LINDENBERO RE: Social services. Hospitals
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