Retraining Hospital Staff for Work in Community Programs in California JAMES
M.
KARLS,
A.C.S.W.
ChiefofProgram Planning and Development Health Training Center California Department of Health Los Angeles, California In 1972 the California Department of Mental Hygiene offered special courses to retrain for community work those state hospital employees who might lose their jobs when the hospitals were closed. The courses were conducted by the Centers for Training in Community Psychiatnj. The author describes the development, implementation, and structure of the Los Angeles course. He also presents findings that show that while participants considered the course valuable, most opted to return to the state hospital instead of taking jobs they had been offered at community mental health centers. Participants who did take community jobs tended to be slightly younger and better educated and had fewer years of experience in state hospital service than did those who returned to the hospital. #{149}In1972, against the backdrop of a growing national trend toward moving mental patients out of large institutions and into community mental health centers, the California Department of Mental Hygiene made two options available to employees who might lose their jobs when state hospital facilities were closed. The employees could move to facilities such as prisons or other hospitals not threatened by cutbacks, or they could obtain training that might make them better candidates for employment in the burgeoning community mental health centers. The task of providing that training was assigned to the Center for Training in Community Psychiatry in Berkeley and in Los Angeles. (As a result of a state government reorganization, the centers have been renamed the Health Training Centers and are now under the California Department of Health. ) The Department of Mental Hygiene funded a training program to be conducted from 1972 to 1974. The project was originally intended to train 500 employees, 250 at each Mr.
Karls’s
Boulevard,
mailing address at the center Angeles, California 90064.
LOS
is 11665
West
Olympic
center. But because of logistical and other problems, 82 were actually trained at the Berkeley center, and 122 were trained at the Los Angeles center. The first step in setting up the training program at the Los Angeles center was the establishment of an advisory committee that would help project staff design and implement the course. The committee consisted of about 20 administrators or their representatives from local mental health agency programs and those with prior experience in training nursing personnel and cornmunity workers. The course was then developed and advertised in a newsletter published by the state for its employees. There were more than 400 applications to the Los Angeles center. But because of the previously agreed-upon admission quota, only 250 applicants could be accepted. Therefore, a subcommittee of the advisory group was formed to help develop guidelines for selection of participants. Working on the assumption that the most recently hired employees would be the first dismissed when cutbacks occurred, the subcommittee recommended that group be given priority. Among the other criteria were an interest in further education, community affairs, and employment in the community. The first class admitted to the program reflected those criteria. But state hospital administrators complained that the program was draining off their most capable staff members. Subsequent participants were selected by the same criteria, but only after prior approval of hospital management. That change resulted in a marked increase in the participants’ mean age and length of hospital experience. Seventy-six per cent of the participants were women. Sixty-seven per cent were white, 25 per cent were black, and 8 per cent were Chicano. The average age was 42.3 years, the average years of hospital experience was 9.6, and the average amount of college education was one year. Thus the typical participant was a woman psychiatric technician in her early forties, with a little more than one year of college and approximately ten years of experience in a state hospital. She was likely to be active in a community group or a political or fraternal organization. The participants were selected from seven state hospitals in southern California. The first group had an
VOLUME
27 NUMBER
4 APRIL
1976
263
enrollment
of 15 instead of the 25 planned, partly as a delay by hospital personnel officers in notifying candidates. The officers had complained to project staff that allowing so many personnel to attend the cnirse at one time would cause staffing problems. Therefore, subsequent groups were limited to about 15 participants, with each hospital agreeing to release a fixed number for each course. The structure of the course required a great deal of travel. To reduce transportation expenses for participants, the project provided funds to cover costs for one car from each hospital, and car pooling was encouraged.
The training consisted of six elements: a five-day conference providing an orientation to basic community mental health history, legislation, and policies; onthe-job training three days a week for 11 weeks in a community mental health program under the supervision of a preceptor; an agency site-visitation program covering at least ten community facilities; a day-long didactic session once a week on various mental health methods used in general practice, with emphasis Ofl crisis control; a weekly three-hour seminar; and an ongoing discussion of readings assigned from several texts and journals. Participants went on site visits either individually or
COURSE
in pairs
result
of
some
STRUCTURE
and,
whenever
possible,
to agencies
within
their
communities. Each participant was required to write a weekly report on the agency he visited, cr1tiquing the agency and its relationship to other community services. Those reports were then used in class discussions on the nature of community-care systems. The project director held regular conferences with each community preceptor to monitor the participant’s dm1cal experience. Also, participants were asked to prepare a report at the end of the training period, describing by case example how they had applied their knowledge of treatment methods in the community. Project staff realized that the process of starting clinical work in the community agencies would be the most trying phase of training for the participants. To make that adjustment easier, they attempted to match the participants’ backgrounds and interests as closely as possible to the characteristics of the training sites. Despite the stress on the participants during the initial training phase, only four placement changes had to be made during the entire project, and only two participants withdrew from the course. Shortly after the project started, center staff secured accreditation for the courses from a local community college. Since most of the participants had completed less than two years of college, the credit was both a reward and an incentive to further their education, which many did after completing the course. The academic credits gained in the course also helped some participants advance their civil-service status. Achievement of program goals and objectives was measured in several ways. An evaluation scheme was designed to allow participants to estimate their OWfl growth in knowledge and skill development. Participants were also evaluated by the preceptors with whom they had worked in the community agencies. Finally, in order tO test the participants’ attitudes toward community mental health, the Baker-Schulberg Community Mental Health Ideology Scale was administered both before and after the course.’ Following completion of the course, 90 per cent of the participants showed a markedly more positive attitude toward community care for patients, as measured by the ideology scale, and could demonstrate a good deal OWfl
State
administrators
agreed
to release
each
participant
from hospital assignments for 90 days. Therefore the curriculum was developed within that time frame. The coUrse objectives were to provide participants with an awareness of basic community mental health concepts and philosophies and to give them a working knowledge of the community-care system. Another priority was the enhancement of crisis intervention techniques; project staff believed that community agencies would expect former state hospital personnel to have special abilities
in dealing
Community were
taught
with
mental because
the
acting-out
health
concepts
project
staff
patient.
and
philosophies
assumed
that
state
hospital employees would have a different orientation than community workers. They assumed that state hospital employees tended to follow the medical disease model in which the patient is seen as being sick and in need of a cure before he can be returned to normal life. The ideal community worker, on the other hand, was perceived as following a social adjustment model, in which the patient is helped to lead a life as close to normal as possible within the confines of his handicap. More than 25 community agencies agreed to provide on-the-job training or accept site visits from the trainees; they included several county mental health agencies in the southern part of the state and a variety of
private
agencies,
including
board-and-care
agencies
and family service agencies. A group of preceptors, selected from the participating community agencies, were assigned the task of teaching specific treatment techniques appropriate to the community setting.
Following completion of the course, 90 per cent of the participants showed a markedly more positive attitude toward community care for patients and could demonstrate a good deal of knowledge about community mental health concepts and issues.
264
HOSPITAL
& COMMUNITY
I
City,
PSYCHIATRY
F. Baker and 1967.
H. C. Schulberg,
Behavioral
Publications,
New
York
The typical participant was likely to have impressed the community agency enough either to have been offered a job or considered a strong candidate if an opening occurred. She was likely to decline the offer, however. of knowledge about community mental health concepts and issues. A score of 266 indicated the greatest possible orientation to community care; the participants’ scores increased from an average of 204.9 before the course to an average of 222.7 after, an average increase of 17.7 points. Participants with high scores tended to be slightly younger; the 20 highest scorers had a mean age of 40.3 years, compared with a mean age of 47.4 years for the 20 lowest scorers. They also tended to have slightly less experience at the state hospital, with the 20 highest scorers having a mean length of employment of 8.6 years, and the 20 lowest a mean of 9.95. And they tended to have slightly more education; the 20 highest scorers
had
a
mean
of
13.8
years,
compared
with
a
mean of 13. 1 years for the lowest scorers. The typical participant, as described earlier, was likely to have impressed the community agency enough either to have been offered a job or to be considered a strong candidate if an opening occurred. She was likely to decline the offer, however, as long as there was still a position for her in the state hospital, since moving to a community agency would in most cases involve a salary cut. The typical participant, then, returned to her job at the state hospital, usually to the position she had previously held. Despite that, she was likely to have considered the experience extremely useful to her professional
career
by
increasing
her
awareness
of the
mainly descriptive of the group and not legitimately generalizable. However, from the data we did conclude that if one were to make a concerted effort to move state hospital personnel into the community, the most likely candidates would be the younger, better-educated technicians with less institutional experience. There is also some evidence that involvement in community affairs, one of the selection criteria, is a useful indicator that the candidate will make a successful adjustment to the community mental health role. The major reason for not accepting community employment appeared to be the lower salaries offered by community agencies. There was also a reluctance by state hospital personnel, most of whom were in their mid-forties, to risk a job change unless forced to. A major positive finding was the willingness of most community agencies to hire the program participants. That willingness seemed to reflect the growth of a more positive attitude on the part of community agencies toward state hospital employees. During
the
course
of the
program,
the
political
and
economic climate in California changed, lessening the pressure to reduce the number of personnel in state hospitals. As a result of that change, there was less need to encourage state employees to move to community jobs. However, those who participated in the program were so enthusiastic about it that the state realized there was a demand for a similar form of continuing education.
Therefore,
although
the
center
terminated
the full 90-day program on June 30, 1974, it still conducts a shortened form of the course in collaboration with hospital training officers. Its operation has been transferred to various state hospital sites, both to reduce the amount of time employees are away from their unit assignments and to lessen state and individual costs, such
as transportation
expenses.U
patient’s
options for treatment and help in the community. Only 37 per cent of the participants actually did leave the state hospital system for jobs in the community upon completion of the course. Those who took community jobs generally tended to be slightly younger, to have a bit more formal education, and to have had considerably less time in state service. The mean age of those taking community jobs was 37.7 years, compared with a mean of 42.3 years for all participants. They had a mean education level of 13.4 years, compared with a mean of 13 years for all participants. Their mean length of employment in a state hospital was 6.48 years, compared with a mean of 9.58 years for all participants. However, the attitudes measured on the community mental health ideology scale did not vary significantly between the group who stayed in state hospital service and the group who left. Partly because the program was not designed with a rigid research component, the results reported here are
VOLUME
27
NUMBER
4 APRIL
1976
265
M.
KARLS,
A.C.S.W.
ChiefofProgram Planning and Development Health Training Center California Department of Health Los Angeles, California In 1972 the California Department of Mental Hygiene offered special courses to retrain for community work those state hospital employees who might lose their jobs when the hospitals were closed. The courses were conducted by the Centers for Training in Community Psychiatnj. The author describes the development, implementation, and structure of the Los Angeles course. He also presents findings that show that while participants considered the course valuable, most opted to return to the state hospital instead of taking jobs they had been offered at community mental health centers. Participants who did take community jobs tended to be slightly younger and better educated and had fewer years of experience in state hospital service than did those who returned to the hospital. #{149}In1972, against the backdrop of a growing national trend toward moving mental patients out of large institutions and into community mental health centers, the California Department of Mental Hygiene made two options available to employees who might lose their jobs when state hospital facilities were closed. The employees could move to facilities such as prisons or other hospitals not threatened by cutbacks, or they could obtain training that might make them better candidates for employment in the burgeoning community mental health centers. The task of providing that training was assigned to the Center for Training in Community Psychiatry in Berkeley and in Los Angeles. (As a result of a state government reorganization, the centers have been renamed the Health Training Centers and are now under the California Department of Health. ) The Department of Mental Hygiene funded a training program to be conducted from 1972 to 1974. The project was originally intended to train 500 employees, 250 at each Mr.
Karls’s
Boulevard,
mailing address at the center Angeles, California 90064.
LOS
is 11665
West
Olympic
center. But because of logistical and other problems, 82 were actually trained at the Berkeley center, and 122 were trained at the Los Angeles center. The first step in setting up the training program at the Los Angeles center was the establishment of an advisory committee that would help project staff design and implement the course. The committee consisted of about 20 administrators or their representatives from local mental health agency programs and those with prior experience in training nursing personnel and cornmunity workers. The course was then developed and advertised in a newsletter published by the state for its employees. There were more than 400 applications to the Los Angeles center. But because of the previously agreed-upon admission quota, only 250 applicants could be accepted. Therefore, a subcommittee of the advisory group was formed to help develop guidelines for selection of participants. Working on the assumption that the most recently hired employees would be the first dismissed when cutbacks occurred, the subcommittee recommended that group be given priority. Among the other criteria were an interest in further education, community affairs, and employment in the community. The first class admitted to the program reflected those criteria. But state hospital administrators complained that the program was draining off their most capable staff members. Subsequent participants were selected by the same criteria, but only after prior approval of hospital management. That change resulted in a marked increase in the participants’ mean age and length of hospital experience. Seventy-six per cent of the participants were women. Sixty-seven per cent were white, 25 per cent were black, and 8 per cent were Chicano. The average age was 42.3 years, the average years of hospital experience was 9.6, and the average amount of college education was one year. Thus the typical participant was a woman psychiatric technician in her early forties, with a little more than one year of college and approximately ten years of experience in a state hospital. She was likely to be active in a community group or a political or fraternal organization. The participants were selected from seven state hospitals in southern California. The first group had an
VOLUME
27 NUMBER
4 APRIL
1976
263
enrollment
of 15 instead of the 25 planned, partly as a delay by hospital personnel officers in notifying candidates. The officers had complained to project staff that allowing so many personnel to attend the cnirse at one time would cause staffing problems. Therefore, subsequent groups were limited to about 15 participants, with each hospital agreeing to release a fixed number for each course. The structure of the course required a great deal of travel. To reduce transportation expenses for participants, the project provided funds to cover costs for one car from each hospital, and car pooling was encouraged.
The training consisted of six elements: a five-day conference providing an orientation to basic community mental health history, legislation, and policies; onthe-job training three days a week for 11 weeks in a community mental health program under the supervision of a preceptor; an agency site-visitation program covering at least ten community facilities; a day-long didactic session once a week on various mental health methods used in general practice, with emphasis Ofl crisis control; a weekly three-hour seminar; and an ongoing discussion of readings assigned from several texts and journals. Participants went on site visits either individually or
COURSE
in pairs
result
of
some
STRUCTURE
and,
whenever
possible,
to agencies
within
their
communities. Each participant was required to write a weekly report on the agency he visited, cr1tiquing the agency and its relationship to other community services. Those reports were then used in class discussions on the nature of community-care systems. The project director held regular conferences with each community preceptor to monitor the participant’s dm1cal experience. Also, participants were asked to prepare a report at the end of the training period, describing by case example how they had applied their knowledge of treatment methods in the community. Project staff realized that the process of starting clinical work in the community agencies would be the most trying phase of training for the participants. To make that adjustment easier, they attempted to match the participants’ backgrounds and interests as closely as possible to the characteristics of the training sites. Despite the stress on the participants during the initial training phase, only four placement changes had to be made during the entire project, and only two participants withdrew from the course. Shortly after the project started, center staff secured accreditation for the courses from a local community college. Since most of the participants had completed less than two years of college, the credit was both a reward and an incentive to further their education, which many did after completing the course. The academic credits gained in the course also helped some participants advance their civil-service status. Achievement of program goals and objectives was measured in several ways. An evaluation scheme was designed to allow participants to estimate their OWfl growth in knowledge and skill development. Participants were also evaluated by the preceptors with whom they had worked in the community agencies. Finally, in order tO test the participants’ attitudes toward community mental health, the Baker-Schulberg Community Mental Health Ideology Scale was administered both before and after the course.’ Following completion of the course, 90 per cent of the participants showed a markedly more positive attitude toward community care for patients, as measured by the ideology scale, and could demonstrate a good deal OWfl
State
administrators
agreed
to release
each
participant
from hospital assignments for 90 days. Therefore the curriculum was developed within that time frame. The coUrse objectives were to provide participants with an awareness of basic community mental health concepts and philosophies and to give them a working knowledge of the community-care system. Another priority was the enhancement of crisis intervention techniques; project staff believed that community agencies would expect former state hospital personnel to have special abilities
in dealing
Community were
taught
with
mental because
the
acting-out
health
concepts
project
staff
patient.
and
philosophies
assumed
that
state
hospital employees would have a different orientation than community workers. They assumed that state hospital employees tended to follow the medical disease model in which the patient is seen as being sick and in need of a cure before he can be returned to normal life. The ideal community worker, on the other hand, was perceived as following a social adjustment model, in which the patient is helped to lead a life as close to normal as possible within the confines of his handicap. More than 25 community agencies agreed to provide on-the-job training or accept site visits from the trainees; they included several county mental health agencies in the southern part of the state and a variety of
private
agencies,
including
board-and-care
agencies
and family service agencies. A group of preceptors, selected from the participating community agencies, were assigned the task of teaching specific treatment techniques appropriate to the community setting.
Following completion of the course, 90 per cent of the participants showed a markedly more positive attitude toward community care for patients and could demonstrate a good deal of knowledge about community mental health concepts and issues.
264
HOSPITAL
& COMMUNITY
I
City,
PSYCHIATRY
F. Baker and 1967.
H. C. Schulberg,
Behavioral
Publications,
New
York
The typical participant was likely to have impressed the community agency enough either to have been offered a job or considered a strong candidate if an opening occurred. She was likely to decline the offer, however. of knowledge about community mental health concepts and issues. A score of 266 indicated the greatest possible orientation to community care; the participants’ scores increased from an average of 204.9 before the course to an average of 222.7 after, an average increase of 17.7 points. Participants with high scores tended to be slightly younger; the 20 highest scorers had a mean age of 40.3 years, compared with a mean age of 47.4 years for the 20 lowest scorers. They also tended to have slightly less experience at the state hospital, with the 20 highest scorers having a mean length of employment of 8.6 years, and the 20 lowest a mean of 9.95. And they tended to have slightly more education; the 20 highest scorers
had
a
mean
of
13.8
years,
compared
with
a
mean of 13. 1 years for the lowest scorers. The typical participant, as described earlier, was likely to have impressed the community agency enough either to have been offered a job or to be considered a strong candidate if an opening occurred. She was likely to decline the offer, however, as long as there was still a position for her in the state hospital, since moving to a community agency would in most cases involve a salary cut. The typical participant, then, returned to her job at the state hospital, usually to the position she had previously held. Despite that, she was likely to have considered the experience extremely useful to her professional
career
by
increasing
her
awareness
of the
mainly descriptive of the group and not legitimately generalizable. However, from the data we did conclude that if one were to make a concerted effort to move state hospital personnel into the community, the most likely candidates would be the younger, better-educated technicians with less institutional experience. There is also some evidence that involvement in community affairs, one of the selection criteria, is a useful indicator that the candidate will make a successful adjustment to the community mental health role. The major reason for not accepting community employment appeared to be the lower salaries offered by community agencies. There was also a reluctance by state hospital personnel, most of whom were in their mid-forties, to risk a job change unless forced to. A major positive finding was the willingness of most community agencies to hire the program participants. That willingness seemed to reflect the growth of a more positive attitude on the part of community agencies toward state hospital employees. During
the
course
of the
program,
the
political
and
economic climate in California changed, lessening the pressure to reduce the number of personnel in state hospitals. As a result of that change, there was less need to encourage state employees to move to community jobs. However, those who participated in the program were so enthusiastic about it that the state realized there was a demand for a similar form of continuing education.
Therefore,
although
the
center
terminated
the full 90-day program on June 30, 1974, it still conducts a shortened form of the course in collaboration with hospital training officers. Its operation has been transferred to various state hospital sites, both to reduce the amount of time employees are away from their unit assignments and to lessen state and individual costs, such
as transportation
expenses.U
patient’s
options for treatment and help in the community. Only 37 per cent of the participants actually did leave the state hospital system for jobs in the community upon completion of the course. Those who took community jobs generally tended to be slightly younger, to have a bit more formal education, and to have had considerably less time in state service. The mean age of those taking community jobs was 37.7 years, compared with a mean of 42.3 years for all participants. They had a mean education level of 13.4 years, compared with a mean of 13 years for all participants. Their mean length of employment in a state hospital was 6.48 years, compared with a mean of 9.58 years for all participants. However, the attitudes measured on the community mental health ideology scale did not vary significantly between the group who stayed in state hospital service and the group who left. Partly because the program was not designed with a rigid research component, the results reported here are
VOLUME
27
NUMBER
4 APRIL
1976
265
