viously the two physicians in charge had attempted to supervise the entire 30-bed unit, and to “know everything” about the unit, but they now divided the unit staff into two smaller teams, including psychiatric residents, students, patients, and nursing personnel. This approach allowed each physician to concentrate his efforts more effectively. Team meetings were more informative, as there was time for detailed discussion of patients’ behavior and treatment planning. With more effective supervision of patients, treatment became easier and more effective. Finally, the department chairman brought together all the administrators involved and insisted that they begin to communicate with each other. Although the disturbances did not clear up rapidly, there was a gradual resumption of working, teaching, and patient care, and the number of meetings devoted to solving the problem began to decrease. After successful interventions, mass symptoms tend
to subside undramatically. Problems recede from the foreground of attention without ever being clearly “solved.” Energies freed from pseudo-problems gradually become available for work. After some time there may be a surge of new enthusiasm in the organization. It is not uncommon for new projects and innovative approaches to emerge at these times. Problems that remain tend to be realistic problems that are susceptible to further clarification or solution. As old realistic problems are solved, new ones continue to emerge. Although the wounds of such disturbances do heal, deep scars may remain. Trust that is destroyed may be long in returning. Ultimately the same lesson always seems to be learned. Communication is hard work and has nothing to do with good will or enthusiasm. Communication pathways must be structured so that they support the work of the organization, and they must be continually brought up to date as the organization changes.U
Egalitarianism in a Mental Health Center: An Experiment That Failed MARINA
CHAPMAN
DOYLE,
Senior Outpatient Therapist South Pinellas Mental Health St. Petersburg, Florida
R,N. Center
A core group of staff hired to open a new community mental health center attempted to employ the concepts of egalitarianism and role-blurring to avoid the rigidity and the strictly hierarchical approach to decision-making that existed in the state hospital where they formerly worked. The new structure permitted no authority figures, and decisions were made by the staff as a group. All staff, including the unit chief-a physicianand the psychologist, social workers, nurses, and attendants, were expected to rotate shifts and interchange jobs. The author discusses the inefficiencies and the lack of direction that resulted, and describes the evolution of a more traditional authoritative structure that enabled staff to proceed toward the goal of quality patient care.
Ms.
Doyle
paper.
Her
burg,
Florida
was
psychiatric
mailing 33704.
address
supervisor is 2031
at Locust
the
center
discussed
Street,
N.E.,
in St.
this
Peters-
Sin some areas of medicine, specialization of staff functions is the rule. It offers a streamlined method of communication and an assurance that someone is directly responsible for meeting a patient’s needs. However, such a system may become codified, rigid, and inflexible. Patients whose needs do not fit the specialist functions are often forced to adapt to the system or simply to go with their needs unmet. It is in reaction to such rigidity that the concept of blurred roles, equality of functioning, and the principle of the generalist worker was conceived. Generalization and a kind of egalitarianism seem especially attractive possibilities in the mental health field. It seems, on first viewing, that the medical model of the general hospital need not be followed in a psychiatric setting since most jobs can be performed by most workers if they are properly trained. However, while a blurred-role concept may be valid and useful when superimposed over an already existing structural framework, total equality without the underpinnings of a delineation of authority can have a deleterious effect on the very excellence of patient care that is sought. A total commitment to egalitarianism can impede actualization of a new facil-
VOLUME
28
NUMBER
7 JULY
1977
521
ity’s potential in its crucial early stages of growth. One mental health center attempted to employ the fascinating concept of egalitarianism when it was first established but eventually had to modify that approach as staff became aware of the organizational realities in a health-care facility. The Innercity Mental Health Center (a pseudonym) was created in a large downtown sector of a major northeastern metropolitan area. It was established there to provide inpatient and outpatient psychiatric treatment in the community in lieu of the more traditional treatment and the accompanying physical displacement that takes place at a state facility. The center served three culturally distinct catchment areas totaling approximately 100,000 people. The center was housed in its own newly erected building, three blocks from a large general hospital. Primary planning permitted newly formed staff a one-month organizational period before small numbers of patients would be introduced into the center. Later additional wards would be activated and filled. The initial staff of the center were a core group of employees from an eastern state hospital. The ward setting at the state hospital had epitomized the backward stereotype. There were reactionary personnel, a strict hierarchical approach to decision-making, and much passive-aggressive acting out by those staff lowest in the pyramid. Group meetings or team approaches were met with indifference or near sabotage. Specialists such as occupational therapists, social workers, and psychologists appeared relegated to work in their respective fields, with communications from members of other fields nearly nonexistent. Even the approach to supportive therapy had been cursory and patients were often given simple custodial care. Within this structure, however, were a few enthusiastic workers who, when the chief of the ward was called to head the new Innercity Center inpatient unit, chose to accompany him there and institute some changes that they had been unable to make on the old ward. The seven core group members were a nurse, two social workers, an occupational therapist, two counselors, and the psychiatrist. This group believed that staff lethargy and uninvolvement and the resulting poor patient care could be eliminated if the staff devised their own administrative regulations, were responsible for initiating progressive patient care, and if they accomplished those goals in a setting of equality, where even those with the least prestigious jobs could feel actively involved in helping patients. The fledgling philosophy was articulated as 80 per cent generalist functioning and 20 per cent specialist. That meant everyone-counselors, nurses, social workers, and doctors-would share 80 per cent of the work and that only the remaining 20 per cent would be done by the various specialists. INITIAL
PROBLEMS
Several factors at the outset led to future difficulties. One was a lack of knowledge of other organizational models. As Glasscote points out, “It is necessary before
522
HOSPITAL
& COMMUNITY
PSYCHIATRY
embarking upon any kind of restructuring of an organtzation or program to have studied other facilities, models and While the changes the core group hoped to implement were ambitious, they had not studied other models, consulted with experts, or received reflective feedback outside the core circle. Talk among the group members tended to be mostly supportive of each other and, although vague, bravely optimistic regarding the new mental health center. As one member of the initial group stated, We were full of enthusiasm, but weren’t sure where to start.” A second important factor was the personality of the hospital administrator. The physician chosen to head the unit was a psychoanalytically oriented therapist, extremely efficient in his field, but without administrative expertise. He had little knowledge of the organization involved in a hospital’s functioning and was admittedly uncomfortable with the decision-making nature of his new role. This latter element, perhaps more than any other, made for confusion as the mental health center evolved. A third difficulty present in the initial phase of development was a generalized lack of hospital experience among the heads of supporting services: pharmacy, purchasing, building services, and laboratory. These persons had previous experience in industry, retail sales, and the military but had never worked within a medical organization. Lines of authority, standards of professional practice, and interdepartmental relationships were not specified or considered important. Apparently frustrated by the pressure to perform outside of their previous vocational orientations and the need to establish a functioning hospital environment relatively quickly, the department heads often made well-intentioned errors or vascillated widely in enforcing vanous rules. The business manager occasionally turned away much-sought job applicants because he was unsure about what educational requirements were needed. He also refused to issue more than two ward keys for a staff that ultimately neared 40 because he was afraid they would either be lost or abused. In another case, the pharmacy relied solely upon ward nurses to account for narcotics supplies because of the physical disorganization and lack of adequate record-keeping in that department. With little preplanning, with an inexperienced administrating physician, and a variety of poorly oriented department heads, the core group of seven made its move to the new mental health center. Patients were to arrive on an overnight basis one month later. It was at this point that the working philosophy of the new facility began to grow. One of the dominant themes was that of the group. The group mechanism was adopted as the sole decision-making body in an effort to avoid the factions and cliques that had developed at the state hospital. New employees were to be hired following a “
“
R.
Analysis D.C.,
Glasscote
et a!., The
of Existing 1964.
Models,
Community Joint
Information
Mental
Health Service,
Center: Washington,
An
group interview rather than arbitrarily through the personnel office. All issues pertaining to ward structure, function, and role assignment were to be dealt with at a daily staff meeting. However, as the staff swelled to 30 then 40, that method became cumbersome and less effective. Often the two hours designated for staff meetings would be spent in heated discussion of issues such as designation of parking and office spaces. Major issues of organizational structure or policy were not dealt with. In striving for a communal investment of mental and physical input, group design was expanded to a kind of egalitanianism whereby, with support, staff would be expected to perform any task. The group decided that the unit chief, a physician, and the psychologist, social workers, nurses, and attendants would rotate shifts and interchange jobs. Initially all ward decisions were made by a charge administrator of the day who was an inexperienced or experienced person who had volunteered that morning. Patient work was to be accomplished by a three-team approach, delineated by the three culturally different catchment areas the center served. Each patient would be assigned a therapist for one-to-one sessions and a privileges-administrator who would determine passes, bedtimes, and off-ward responsibilities. While the treatment team could offer input, the patient’s administrator retained final decision-making authority whether he was experienced or not. The inexperienced personnel were to receive onthe-job training through observation of the more expenienced and knowledgeable staff.
ROLE-BLURRING Many of the attendant staff were hired from a statesponsored public service career program for persons who had previous poor job performance, were undertrained, or over a work-marketable age. None of the program participants had ever worked in a mental health setting before. They were hired by the group on the basis of their enthusiasm, motivation, and residence in one of the catchment areas served by the center. Theoretically, such indigenous, inexperienced workers may have much to offer in terms of empathy and a down-to-earth approach to the emotionally ill. However, the ratio of untrained personnel from the program to those with experience was disproportionate. Of an early total of 32 inpatient staff, ten had more than one year’s experience; eight had just one year, and 14 had never worked in a mental health setting before. Although Ellsworth has pointed out that “Trained nonprofessionals with a warm, genuine approach often show more patient progress, fewer readmissions, than do formally trained psychiatric professionals,”2 it should be stressed that the difference between “trained” and “untrained” nonprofessionals is great. 2 R.
The
Ellsworth,
Notes
on Professionals
Psychiatric
Aide
and
Century-Crofts,
New
York
the City,
In
Psychiatric
Schizophrenic 1968,
p. 634.
The new center itself had no training program although an outside, separate teaching consultant was retained to train the public-program workers in psychodynamics and interviewing techniques. However, by the fifth month of operation, a curriculum had not yet been formulated and the inexperienced personnel were experiencing a closure in their willingness to learn. In addition, many of the expectations were unreasonable and overwhelming. The public-program workers came from low socioeconomic cultural backgrounds and had limited vocabularies, poor spelling, poor reading skills, and concrete rather than abstract abilities to observe. Nevertheless, these individuals conducted one-to-one therapy, led family therapy groups, charted patients, and had final decision-making responsibility for determining whether a patient should be on medication. One semiexpenienced staff member believed that You learn social work by doing it and you learn psychotherapy the same way.” Authority conflicts between inexperienced staff and experienced staff began to occur. While the public-program worker believed he was qualified to give therapy by having been dubbed therapist, experienced professionals often perceived him as being permissive, overreactive, or simply oblivious to important behavioral cues. The public-program personnel began to respond to the hostility and pressure by absenteeism, tardiness, and occasional outbursts of anger directed toward patients. Four of those attendants were subsequently dismissed within the first five months. The role of the physicians was equally blurred. Most of the doctors were first-year residents with little experience in actual therapy; under the existing philosophy there was little chance for them to practice their own skills in formal therapy sessions. Physicians were used more as consultants, to advise on medicines primarily, but with no particular decision-making authority. The occasional rotating resident with two or three years experience was usually frustrated and irritated with the generalized lack of expertise on the part of the therapists’ and even more concerned that few people gave much weight to his observations. The resident was exclusively a team member. He had no more right to exert his influence than anyone else even though legally he had the responsibility for care. Fischer explains the dilemma as a situation whereby the “Team concept may be carried to the point where professional distinctions are blurred and treatment decisions are made in such a way that medical people seem to be abandoning their essential responsibilities.”3 ‘ ‘
“
‘
POLICIES
Appleton-
PROCEDURES
Torbert suggests that an important organizational development is the specific goals within a communications
Rehabilitation:
Patient,
AND
$ A.
Fischer
the Image 25,
July
VOLUME
and of
1971,
28
M.
R. Weinstein,
Enlightenment,” pp.
‘
Mental
Archives
characteristic determination framework.
Hospitals,
of General
Prestige,
Psychiatry,
of of In
and Vol.
41-47.
NUMBER
7 JULY
1977
523
practical terms, an organization’s policy and stated procedures form a requisite scaffolding for the actual performance of a task.4 When some experienced personnel outside the core group posed questions about the organizational policies for the pharmacy, laboratory, laundry, cafeteria, and ward administrative functions, the core group protested that these issues would resolve themselves once patients actually arrived on an overnight basis. However, once again, the premise of egalitarianism proved encumbering. Because no individual had been given the authority to contact other departments to establish a working procedure to serve patient needs, these issues were not dealt with up to the time patients actually arrived on the ward. Due to the lack of a laundry franchise, patients slept without sheets for the first several nights. At this time, one registered nurse with some administrative experience but no delegated authority wrote up a policies and procedures handbook for each of the above services. The handbook was to be used as a working model on which the group could build its policies. It was presented at a staff meeting, but little interest in it was shown. Nine months later, no additions had been made to the original plan, and few staff members had even read over the text. Although the policy and procedures book explicitly dealt with many interdepartmental issues, those same issues were brought up and went unresolved because few persons were aware of the existence of the book. Staff were so preoccupied with defining their philosophical and therapeutic position that little actual planfling was done for daily patient involvement. Although day-care patients were expected to appear daily and spend six therapeutic hours on the ward, only one hour had been programmed. That was for a team grouptherapy meeting. Patients bitterly complained of boredom and of “getting worse just sitting here” and said that staff seemed interested only when they spoke of their sickness-not of their healthy endeavors. The trained activities therapist, one of the initial core group, was reluctant to initiate an activities program for fear that he would get stuck with all the responsibility of activities and never involved in therapy.” There was no one who could or would assert the authority to stipulate that such programs were necessary. Staff discussed having activities groups for exercising, photography, and psychodrama, but impetus for these were expected to be generated by the inexperienced attendant staff. However, without any real leadership, supervision, or support, these good ideas were never implemented. Indicative of a basic flaw in the staff’s orientation was the fact that the one extra-therapy group that did find fruition was a psychodrama group for staff. Patients who inquired about participation were told that staff too needed to “work out their feelings,” and that a similar group for patients “may be developed at a later date.” “
W.
Torbert,
Organization January
524
‘
Pre-Bureaucratic
Development,”
1974,
pp.
and Post-Bureaucratic Interpersonal Development,
Stages
of
Vol.
5,
1-25.
HOSPITAL
& COMMUNITY
PSYCHIATRY
Although many staff members began to recognize the inadequacies of a system that permitted no authority figures, that held to a somewhat sketchy philosophy, and that seemed to be structured entirely for staff needs, occasional attempts to modify the horizontal structure or define specific approaches to problems were met with group procrastination and an administrative wait-and-see attitude. As awareness of the need for direction grew, increased pleas were made to the physician who was acting as ward administrator. As yet no nursing director had been hired. Registered nurses in supervisory positions frequently demanded role definitions or job descriptions that would identify exactly what authority they had to assist in the functioning of the unit. However, their requests were met with vague answers about the basic equality of personnel and a definition of their supervisory roles by the degree of personal magnetism each could generate. This absence of executive responsibility left the more experienced staff essentially powerless to alter poor work habits and therapy and led to administrative errors that bordered on illegality. One attendant staff member refused to learn how to take blood pressures because he did not see the job as part of his responsibility; several junior nurses rebelled at having to count narcotics each shift; others got angry if asked to complete forgotten charts. The lack of an appointed nurse responsible for maintaining routine hospital standards in gathering and recording vital information nearly resulted in the death of a patient, later diagnosed as having acute malignant hypertension. No vital signs had been taken at admission and no physical examination had been conducted since the patient’s presence had not been called to the physician’s attention. Nursing staff who had proposed a list of basic medical examinations to be conducted upon admission were told that mental health centers differed radically from general hospitals and that the line between medical and psychiatric care was firmly -drawn. As a result, no admission vital signs were taken and physical examinations were conducted days after admission or forgotten all together. The supervisory nurses received no support in their efforts from the administrative physician; he told them that assertion of authority was counter to the center’s philosophy. All the while, however, the administrative physician was only occasionally present on the ward to observe its functioning.
EVOLUTION
OF AUTHORITY
Although the model of a democratically governed ward continued to be propagandized, especially to job applicants, the reality of poor organization, poor representation, and the absence of defined leadership made it increasingly clear that change was needed. After frequent urgings by supervisory personnel, the administrative physician appointed an executive staff chosen from each of the disciplines and including a senior member of each of the three teams. Prior to this selection, each of the members had worked independently,
feeling little cooperation or empathy with co-workers. The executive staff began meeting twice weekly in a feelings meeting” during which they began to honestly appraise the egalitarian system and the high pitch of anxiety and inefficiency it seemed to generate. They decided that it was time to alter the old 80-per-cent generalist, 20-per-cent specialist philosophy. The executive staff delegated to itself the decisionmaking authority to hire and fire and to modify existing policies. They generally removed themselves from the quagmire of total democracy. The acknowledgment of their special skills and experience freed the executive staff from performing time-consuming tasks such as day-room coverage, outing planning, and bus driving that could be easily handled by personnel with less training. They were then able to begin developing some of their neglected specialties. Even so, among the executive staff there was a reluctance to abandon the attractive concept of total equality. Some expressed guilt feelings about assuming new powers. Yet the psychologist, who had previously been unavailable for psychological testing, pulled away from her ward team responsibilities and began to establish a schedule for conducting and interpreting tests. With much peer pressure from other members of the executive staff, the occupational therapist who had been reluctant to separate himself from what he considered the locus of patient care began to provide materials for crafts and to set up time schedules for activities therapies. Registered nurses who had previously been reprimanded by the administrative physician for exerting authority over junior nurses were now delegated responsibility for auditing charts and at times questioning techniques employed by the nursing and attendant staff. As the personnel with special skills withdrew from strict team responsibilities, time-consuming ward-coyerage assignments, and charge duties, a new echelon evolved to fill the void created. Experienced attendants were assigned on a weekly basis to learn the chargeduty role while registered nurses acted as resource persons. The assignment was repeated for several weeks before the attendant was placed solely in charge. The transition was not totally smooth, however. As specialists pulled away from routine ward duties, many junior staff felt “dumped on” and abandoned. Attendants met surreptitiously to discuss those feelings. Only late in the transition did the executive staff decide to ask for attendant representation at the executive staff meetings and to permit any real ventilation of junior staff’s feelings of isolation. Gradually the roles of the junior staff members were clearly defined for them and, with support from experienced staff, they began to feel that they occupied a position of true value on the ward. At the same time, the administrative physician became more assertive and self-assured. He gained confidence in his abilities to deal with and direct a large group of staff when he found that his authority was not met by insurrection as he had feared. He was soon able to firmly assert his position as executive chief of the unit “
and authoritative head. This evolution, perhaps more than any other factor, was responsible for a new cornmon sense of identity on the unit and the gradual release from the unrealistic attempts at total equality. There were other changes as well. A director of nurses was hired in the eighth month of operation. Although she initiated no sweeping innovations immediately, her presence was reassuring to the staff who had been searching for an authority figure to give direction to their multitude of creative ideas. Shortly thereafter, a clinical director was appointed. This ambitious leader gave a genuine credibility to the executive hierarchy in that he firmly and explicitly spelled out specifled goals. With a full executive staff who assumed responsibility and published directives now intact, the general staff were relieved of their pervasive anxiety and morale was improved. Finding themselves freed to carry out the jobs they had been trained to do, staff members began to function more effectively. Although staff generally believed that if allowed to evolve slowly, the ward philosophy and goals would probably have come close to those proposed by the new leaders, the abandonment of egalitarianism allowed those goals to be realized more quickly and with less waste of valuable staff expertise. Under the guiding influence of experienced hospital administrators, concrete plans were developed for day care, rehabilitation, community services, and outpatient and inpatient programs. The executive staff proposed a more traditional model for providing inpatient services. The model included a head nurse, clinical supervision for each of the therapeutic disciplines, and a consistent level of professionalism that no longer depended on personal tastes. The actualization of a mental health center was finally being carried out.
THE
NEED
FOR
LEADERSHIP
Two elements must be present in the successful operation of a health facility: a well-thought-out and forrnalized philosophy and an authoritative leadership. Lack of leadership creates a fluid shifting of power that is disorganizing and undermining to the philosophy. Lack of a pre-shaped philosophy prevents or negates true responsible leadership. It has often been demonstrated that a strict vertical hierarchy can impinge upon staff creativeness and innovation and prevent executive figureheads from meeting the true needs of the patients they serve. However, it is necessary to have a basic structure and discipline upon which to anchor creativity and allow freedom to explore new methods. Given an option for evolution and change, the Innercity Mental Health Center staff moved toward the standard concept of chain of command. Total freedom was uncomfortable and inefficient. The evolution forced a leadership to emerge to establish guidelines. With the delineation of concrete rather than vague goals, and through increased specialization and selectivity, the staff were able to effectively proceed toward the delivery of excellent patient care.U
VOLUME
28
NUMBER
7 JULY
1977
525
to subside undramatically. Problems recede from the foreground of attention without ever being clearly “solved.” Energies freed from pseudo-problems gradually become available for work. After some time there may be a surge of new enthusiasm in the organization. It is not uncommon for new projects and innovative approaches to emerge at these times. Problems that remain tend to be realistic problems that are susceptible to further clarification or solution. As old realistic problems are solved, new ones continue to emerge. Although the wounds of such disturbances do heal, deep scars may remain. Trust that is destroyed may be long in returning. Ultimately the same lesson always seems to be learned. Communication is hard work and has nothing to do with good will or enthusiasm. Communication pathways must be structured so that they support the work of the organization, and they must be continually brought up to date as the organization changes.U
Egalitarianism in a Mental Health Center: An Experiment That Failed MARINA
CHAPMAN
DOYLE,
Senior Outpatient Therapist South Pinellas Mental Health St. Petersburg, Florida
R,N. Center
A core group of staff hired to open a new community mental health center attempted to employ the concepts of egalitarianism and role-blurring to avoid the rigidity and the strictly hierarchical approach to decision-making that existed in the state hospital where they formerly worked. The new structure permitted no authority figures, and decisions were made by the staff as a group. All staff, including the unit chief-a physicianand the psychologist, social workers, nurses, and attendants, were expected to rotate shifts and interchange jobs. The author discusses the inefficiencies and the lack of direction that resulted, and describes the evolution of a more traditional authoritative structure that enabled staff to proceed toward the goal of quality patient care.
Ms.
Doyle
paper.
Her
burg,
Florida
was
psychiatric
mailing 33704.
address
supervisor is 2031
at Locust
the
center
discussed
Street,
N.E.,
in St.
this
Peters-
Sin some areas of medicine, specialization of staff functions is the rule. It offers a streamlined method of communication and an assurance that someone is directly responsible for meeting a patient’s needs. However, such a system may become codified, rigid, and inflexible. Patients whose needs do not fit the specialist functions are often forced to adapt to the system or simply to go with their needs unmet. It is in reaction to such rigidity that the concept of blurred roles, equality of functioning, and the principle of the generalist worker was conceived. Generalization and a kind of egalitarianism seem especially attractive possibilities in the mental health field. It seems, on first viewing, that the medical model of the general hospital need not be followed in a psychiatric setting since most jobs can be performed by most workers if they are properly trained. However, while a blurred-role concept may be valid and useful when superimposed over an already existing structural framework, total equality without the underpinnings of a delineation of authority can have a deleterious effect on the very excellence of patient care that is sought. A total commitment to egalitarianism can impede actualization of a new facil-
VOLUME
28
NUMBER
7 JULY
1977
521
ity’s potential in its crucial early stages of growth. One mental health center attempted to employ the fascinating concept of egalitarianism when it was first established but eventually had to modify that approach as staff became aware of the organizational realities in a health-care facility. The Innercity Mental Health Center (a pseudonym) was created in a large downtown sector of a major northeastern metropolitan area. It was established there to provide inpatient and outpatient psychiatric treatment in the community in lieu of the more traditional treatment and the accompanying physical displacement that takes place at a state facility. The center served three culturally distinct catchment areas totaling approximately 100,000 people. The center was housed in its own newly erected building, three blocks from a large general hospital. Primary planning permitted newly formed staff a one-month organizational period before small numbers of patients would be introduced into the center. Later additional wards would be activated and filled. The initial staff of the center were a core group of employees from an eastern state hospital. The ward setting at the state hospital had epitomized the backward stereotype. There were reactionary personnel, a strict hierarchical approach to decision-making, and much passive-aggressive acting out by those staff lowest in the pyramid. Group meetings or team approaches were met with indifference or near sabotage. Specialists such as occupational therapists, social workers, and psychologists appeared relegated to work in their respective fields, with communications from members of other fields nearly nonexistent. Even the approach to supportive therapy had been cursory and patients were often given simple custodial care. Within this structure, however, were a few enthusiastic workers who, when the chief of the ward was called to head the new Innercity Center inpatient unit, chose to accompany him there and institute some changes that they had been unable to make on the old ward. The seven core group members were a nurse, two social workers, an occupational therapist, two counselors, and the psychiatrist. This group believed that staff lethargy and uninvolvement and the resulting poor patient care could be eliminated if the staff devised their own administrative regulations, were responsible for initiating progressive patient care, and if they accomplished those goals in a setting of equality, where even those with the least prestigious jobs could feel actively involved in helping patients. The fledgling philosophy was articulated as 80 per cent generalist functioning and 20 per cent specialist. That meant everyone-counselors, nurses, social workers, and doctors-would share 80 per cent of the work and that only the remaining 20 per cent would be done by the various specialists. INITIAL
PROBLEMS
Several factors at the outset led to future difficulties. One was a lack of knowledge of other organizational models. As Glasscote points out, “It is necessary before
522
HOSPITAL
& COMMUNITY
PSYCHIATRY
embarking upon any kind of restructuring of an organtzation or program to have studied other facilities, models and While the changes the core group hoped to implement were ambitious, they had not studied other models, consulted with experts, or received reflective feedback outside the core circle. Talk among the group members tended to be mostly supportive of each other and, although vague, bravely optimistic regarding the new mental health center. As one member of the initial group stated, We were full of enthusiasm, but weren’t sure where to start.” A second important factor was the personality of the hospital administrator. The physician chosen to head the unit was a psychoanalytically oriented therapist, extremely efficient in his field, but without administrative expertise. He had little knowledge of the organization involved in a hospital’s functioning and was admittedly uncomfortable with the decision-making nature of his new role. This latter element, perhaps more than any other, made for confusion as the mental health center evolved. A third difficulty present in the initial phase of development was a generalized lack of hospital experience among the heads of supporting services: pharmacy, purchasing, building services, and laboratory. These persons had previous experience in industry, retail sales, and the military but had never worked within a medical organization. Lines of authority, standards of professional practice, and interdepartmental relationships were not specified or considered important. Apparently frustrated by the pressure to perform outside of their previous vocational orientations and the need to establish a functioning hospital environment relatively quickly, the department heads often made well-intentioned errors or vascillated widely in enforcing vanous rules. The business manager occasionally turned away much-sought job applicants because he was unsure about what educational requirements were needed. He also refused to issue more than two ward keys for a staff that ultimately neared 40 because he was afraid they would either be lost or abused. In another case, the pharmacy relied solely upon ward nurses to account for narcotics supplies because of the physical disorganization and lack of adequate record-keeping in that department. With little preplanning, with an inexperienced administrating physician, and a variety of poorly oriented department heads, the core group of seven made its move to the new mental health center. Patients were to arrive on an overnight basis one month later. It was at this point that the working philosophy of the new facility began to grow. One of the dominant themes was that of the group. The group mechanism was adopted as the sole decision-making body in an effort to avoid the factions and cliques that had developed at the state hospital. New employees were to be hired following a “
“
R.
Analysis D.C.,
Glasscote
et a!., The
of Existing 1964.
Models,
Community Joint
Information
Mental
Health Service,
Center: Washington,
An
group interview rather than arbitrarily through the personnel office. All issues pertaining to ward structure, function, and role assignment were to be dealt with at a daily staff meeting. However, as the staff swelled to 30 then 40, that method became cumbersome and less effective. Often the two hours designated for staff meetings would be spent in heated discussion of issues such as designation of parking and office spaces. Major issues of organizational structure or policy were not dealt with. In striving for a communal investment of mental and physical input, group design was expanded to a kind of egalitanianism whereby, with support, staff would be expected to perform any task. The group decided that the unit chief, a physician, and the psychologist, social workers, nurses, and attendants would rotate shifts and interchange jobs. Initially all ward decisions were made by a charge administrator of the day who was an inexperienced or experienced person who had volunteered that morning. Patient work was to be accomplished by a three-team approach, delineated by the three culturally different catchment areas the center served. Each patient would be assigned a therapist for one-to-one sessions and a privileges-administrator who would determine passes, bedtimes, and off-ward responsibilities. While the treatment team could offer input, the patient’s administrator retained final decision-making authority whether he was experienced or not. The inexperienced personnel were to receive onthe-job training through observation of the more expenienced and knowledgeable staff.
ROLE-BLURRING Many of the attendant staff were hired from a statesponsored public service career program for persons who had previous poor job performance, were undertrained, or over a work-marketable age. None of the program participants had ever worked in a mental health setting before. They were hired by the group on the basis of their enthusiasm, motivation, and residence in one of the catchment areas served by the center. Theoretically, such indigenous, inexperienced workers may have much to offer in terms of empathy and a down-to-earth approach to the emotionally ill. However, the ratio of untrained personnel from the program to those with experience was disproportionate. Of an early total of 32 inpatient staff, ten had more than one year’s experience; eight had just one year, and 14 had never worked in a mental health setting before. Although Ellsworth has pointed out that “Trained nonprofessionals with a warm, genuine approach often show more patient progress, fewer readmissions, than do formally trained psychiatric professionals,”2 it should be stressed that the difference between “trained” and “untrained” nonprofessionals is great. 2 R.
The
Ellsworth,
Notes
on Professionals
Psychiatric
Aide
and
Century-Crofts,
New
York
the City,
In
Psychiatric
Schizophrenic 1968,
p. 634.
The new center itself had no training program although an outside, separate teaching consultant was retained to train the public-program workers in psychodynamics and interviewing techniques. However, by the fifth month of operation, a curriculum had not yet been formulated and the inexperienced personnel were experiencing a closure in their willingness to learn. In addition, many of the expectations were unreasonable and overwhelming. The public-program workers came from low socioeconomic cultural backgrounds and had limited vocabularies, poor spelling, poor reading skills, and concrete rather than abstract abilities to observe. Nevertheless, these individuals conducted one-to-one therapy, led family therapy groups, charted patients, and had final decision-making responsibility for determining whether a patient should be on medication. One semiexpenienced staff member believed that You learn social work by doing it and you learn psychotherapy the same way.” Authority conflicts between inexperienced staff and experienced staff began to occur. While the public-program worker believed he was qualified to give therapy by having been dubbed therapist, experienced professionals often perceived him as being permissive, overreactive, or simply oblivious to important behavioral cues. The public-program personnel began to respond to the hostility and pressure by absenteeism, tardiness, and occasional outbursts of anger directed toward patients. Four of those attendants were subsequently dismissed within the first five months. The role of the physicians was equally blurred. Most of the doctors were first-year residents with little experience in actual therapy; under the existing philosophy there was little chance for them to practice their own skills in formal therapy sessions. Physicians were used more as consultants, to advise on medicines primarily, but with no particular decision-making authority. The occasional rotating resident with two or three years experience was usually frustrated and irritated with the generalized lack of expertise on the part of the therapists’ and even more concerned that few people gave much weight to his observations. The resident was exclusively a team member. He had no more right to exert his influence than anyone else even though legally he had the responsibility for care. Fischer explains the dilemma as a situation whereby the “Team concept may be carried to the point where professional distinctions are blurred and treatment decisions are made in such a way that medical people seem to be abandoning their essential responsibilities.”3 ‘ ‘
“
‘
POLICIES
Appleton-
PROCEDURES
Torbert suggests that an important organizational development is the specific goals within a communications
Rehabilitation:
Patient,
AND
$ A.
Fischer
the Image 25,
July
VOLUME
and of
1971,
28
M.
R. Weinstein,
Enlightenment,” pp.
‘
Mental
Archives
characteristic determination framework.
Hospitals,
of General
Prestige,
Psychiatry,
of of In
and Vol.
41-47.
NUMBER
7 JULY
1977
523
practical terms, an organization’s policy and stated procedures form a requisite scaffolding for the actual performance of a task.4 When some experienced personnel outside the core group posed questions about the organizational policies for the pharmacy, laboratory, laundry, cafeteria, and ward administrative functions, the core group protested that these issues would resolve themselves once patients actually arrived on an overnight basis. However, once again, the premise of egalitarianism proved encumbering. Because no individual had been given the authority to contact other departments to establish a working procedure to serve patient needs, these issues were not dealt with up to the time patients actually arrived on the ward. Due to the lack of a laundry franchise, patients slept without sheets for the first several nights. At this time, one registered nurse with some administrative experience but no delegated authority wrote up a policies and procedures handbook for each of the above services. The handbook was to be used as a working model on which the group could build its policies. It was presented at a staff meeting, but little interest in it was shown. Nine months later, no additions had been made to the original plan, and few staff members had even read over the text. Although the policy and procedures book explicitly dealt with many interdepartmental issues, those same issues were brought up and went unresolved because few persons were aware of the existence of the book. Staff were so preoccupied with defining their philosophical and therapeutic position that little actual planfling was done for daily patient involvement. Although day-care patients were expected to appear daily and spend six therapeutic hours on the ward, only one hour had been programmed. That was for a team grouptherapy meeting. Patients bitterly complained of boredom and of “getting worse just sitting here” and said that staff seemed interested only when they spoke of their sickness-not of their healthy endeavors. The trained activities therapist, one of the initial core group, was reluctant to initiate an activities program for fear that he would get stuck with all the responsibility of activities and never involved in therapy.” There was no one who could or would assert the authority to stipulate that such programs were necessary. Staff discussed having activities groups for exercising, photography, and psychodrama, but impetus for these were expected to be generated by the inexperienced attendant staff. However, without any real leadership, supervision, or support, these good ideas were never implemented. Indicative of a basic flaw in the staff’s orientation was the fact that the one extra-therapy group that did find fruition was a psychodrama group for staff. Patients who inquired about participation were told that staff too needed to “work out their feelings,” and that a similar group for patients “may be developed at a later date.” “
W.
Torbert,
Organization January
524
‘
Pre-Bureaucratic
Development,”
1974,
pp.
and Post-Bureaucratic Interpersonal Development,
Stages
of
Vol.
5,
1-25.
HOSPITAL
& COMMUNITY
PSYCHIATRY
Although many staff members began to recognize the inadequacies of a system that permitted no authority figures, that held to a somewhat sketchy philosophy, and that seemed to be structured entirely for staff needs, occasional attempts to modify the horizontal structure or define specific approaches to problems were met with group procrastination and an administrative wait-and-see attitude. As awareness of the need for direction grew, increased pleas were made to the physician who was acting as ward administrator. As yet no nursing director had been hired. Registered nurses in supervisory positions frequently demanded role definitions or job descriptions that would identify exactly what authority they had to assist in the functioning of the unit. However, their requests were met with vague answers about the basic equality of personnel and a definition of their supervisory roles by the degree of personal magnetism each could generate. This absence of executive responsibility left the more experienced staff essentially powerless to alter poor work habits and therapy and led to administrative errors that bordered on illegality. One attendant staff member refused to learn how to take blood pressures because he did not see the job as part of his responsibility; several junior nurses rebelled at having to count narcotics each shift; others got angry if asked to complete forgotten charts. The lack of an appointed nurse responsible for maintaining routine hospital standards in gathering and recording vital information nearly resulted in the death of a patient, later diagnosed as having acute malignant hypertension. No vital signs had been taken at admission and no physical examination had been conducted since the patient’s presence had not been called to the physician’s attention. Nursing staff who had proposed a list of basic medical examinations to be conducted upon admission were told that mental health centers differed radically from general hospitals and that the line between medical and psychiatric care was firmly -drawn. As a result, no admission vital signs were taken and physical examinations were conducted days after admission or forgotten all together. The supervisory nurses received no support in their efforts from the administrative physician; he told them that assertion of authority was counter to the center’s philosophy. All the while, however, the administrative physician was only occasionally present on the ward to observe its functioning.
EVOLUTION
OF AUTHORITY
Although the model of a democratically governed ward continued to be propagandized, especially to job applicants, the reality of poor organization, poor representation, and the absence of defined leadership made it increasingly clear that change was needed. After frequent urgings by supervisory personnel, the administrative physician appointed an executive staff chosen from each of the disciplines and including a senior member of each of the three teams. Prior to this selection, each of the members had worked independently,
feeling little cooperation or empathy with co-workers. The executive staff began meeting twice weekly in a feelings meeting” during which they began to honestly appraise the egalitarian system and the high pitch of anxiety and inefficiency it seemed to generate. They decided that it was time to alter the old 80-per-cent generalist, 20-per-cent specialist philosophy. The executive staff delegated to itself the decisionmaking authority to hire and fire and to modify existing policies. They generally removed themselves from the quagmire of total democracy. The acknowledgment of their special skills and experience freed the executive staff from performing time-consuming tasks such as day-room coverage, outing planning, and bus driving that could be easily handled by personnel with less training. They were then able to begin developing some of their neglected specialties. Even so, among the executive staff there was a reluctance to abandon the attractive concept of total equality. Some expressed guilt feelings about assuming new powers. Yet the psychologist, who had previously been unavailable for psychological testing, pulled away from her ward team responsibilities and began to establish a schedule for conducting and interpreting tests. With much peer pressure from other members of the executive staff, the occupational therapist who had been reluctant to separate himself from what he considered the locus of patient care began to provide materials for crafts and to set up time schedules for activities therapies. Registered nurses who had previously been reprimanded by the administrative physician for exerting authority over junior nurses were now delegated responsibility for auditing charts and at times questioning techniques employed by the nursing and attendant staff. As the personnel with special skills withdrew from strict team responsibilities, time-consuming ward-coyerage assignments, and charge duties, a new echelon evolved to fill the void created. Experienced attendants were assigned on a weekly basis to learn the chargeduty role while registered nurses acted as resource persons. The assignment was repeated for several weeks before the attendant was placed solely in charge. The transition was not totally smooth, however. As specialists pulled away from routine ward duties, many junior staff felt “dumped on” and abandoned. Attendants met surreptitiously to discuss those feelings. Only late in the transition did the executive staff decide to ask for attendant representation at the executive staff meetings and to permit any real ventilation of junior staff’s feelings of isolation. Gradually the roles of the junior staff members were clearly defined for them and, with support from experienced staff, they began to feel that they occupied a position of true value on the ward. At the same time, the administrative physician became more assertive and self-assured. He gained confidence in his abilities to deal with and direct a large group of staff when he found that his authority was not met by insurrection as he had feared. He was soon able to firmly assert his position as executive chief of the unit “
and authoritative head. This evolution, perhaps more than any other factor, was responsible for a new cornmon sense of identity on the unit and the gradual release from the unrealistic attempts at total equality. There were other changes as well. A director of nurses was hired in the eighth month of operation. Although she initiated no sweeping innovations immediately, her presence was reassuring to the staff who had been searching for an authority figure to give direction to their multitude of creative ideas. Shortly thereafter, a clinical director was appointed. This ambitious leader gave a genuine credibility to the executive hierarchy in that he firmly and explicitly spelled out specifled goals. With a full executive staff who assumed responsibility and published directives now intact, the general staff were relieved of their pervasive anxiety and morale was improved. Finding themselves freed to carry out the jobs they had been trained to do, staff members began to function more effectively. Although staff generally believed that if allowed to evolve slowly, the ward philosophy and goals would probably have come close to those proposed by the new leaders, the abandonment of egalitarianism allowed those goals to be realized more quickly and with less waste of valuable staff expertise. Under the guiding influence of experienced hospital administrators, concrete plans were developed for day care, rehabilitation, community services, and outpatient and inpatient programs. The executive staff proposed a more traditional model for providing inpatient services. The model included a head nurse, clinical supervision for each of the therapeutic disciplines, and a consistent level of professionalism that no longer depended on personal tastes. The actualization of a mental health center was finally being carried out.
THE
NEED
FOR
LEADERSHIP
Two elements must be present in the successful operation of a health facility: a well-thought-out and forrnalized philosophy and an authoritative leadership. Lack of leadership creates a fluid shifting of power that is disorganizing and undermining to the philosophy. Lack of a pre-shaped philosophy prevents or negates true responsible leadership. It has often been demonstrated that a strict vertical hierarchy can impinge upon staff creativeness and innovation and prevent executive figureheads from meeting the true needs of the patients they serve. However, it is necessary to have a basic structure and discipline upon which to anchor creativity and allow freedom to explore new methods. Given an option for evolution and change, the Innercity Mental Health Center staff moved toward the standard concept of chain of command. Total freedom was uncomfortable and inefficient. The evolution forced a leadership to emerge to establish guidelines. With the delineation of concrete rather than vague goals, and through increased specialization and selectivity, the staff were able to effectively proceed toward the delivery of excellent patient care.U
VOLUME
28
NUMBER
7 JULY
1977
525
