I work in a ward where there are two to three hours of group activities a day, but we have well over 600 admissions a year through a sixteen bed unit. I agree with this editorial: I have seen what happens when enquiries and bean counters increase the forms overmuch.
Since it takes about an hour to do the admission paperwork at present, our risk of being preoccupied with bureaucracy may be harming patients.
For at least a century it has been known that dramatic failures and hospital scandals occur when staff are too preoccupied by bureaucracy, and too burnt out or detached from their patients and other members of the care team to be able to feel and show appropriate compassion and care. While mercifully such dramatic failures are rare, there is realistic concern that the staff working in overcrowded “pressure-cooker” environments can become demoralized and feel swamped fire-fighting behavioural problems and attending to paperwork, leaving little time for therapeutic activities with their patients. While international standards recommend a variety of group and individual therapeutic activities that together come to an average of at least 2.5 hours daily over and above the time spent in one-to-one contact, these standards are seldom met. In a recent survey of acute inpatient wards, we found that structured activity and one-to-one contacts amounted to only 4.5 hours per week
Does this happen? Here I am referring to a new document, from the NZ health quality improvement service, who have audited our suicide data including a detailed review of 20 such cases. This is taken from their summary report, and I have removed some formatting and headings.
DHB means district health board. The relevant quote is on page 59 of the report.
There was little evidence that service providers were hopeful their clients would recover. This may be because the reports were written retrospectively after events had occurred. Statements were made that the person died as a result of their mental illness without full consideration of potential contributing factors at the service provision level (eg, service quality issues) or other missed opportunities for preventing the death.
Such statements may reflect service providers’ preferred paradigms of mental health/illness (and associated models of care), or their general understanding of suicide and what could be done to prevent it.
DHBs that recognised their services weren’t working appeared to respond by providing more of the same treatments. This included more medication (or trying a different type), offering more inpatient stays, more assessments, more management plans and more respite. There did not seem to be any long-term view, and few responses were tailored to the individual.
Some DHBs tried to address communication issues within and between services by increasing documentation of all interactions. However, trying to address communication issues by documenting the minute details of every phone call or interaction may only make the problem worse, as this may reduce staff interactions further as people concentrate on written communication.
There is a culture of accountability and challenge of health services in New Zealand. Some of this may be justified: but there is a cost. If you are doing one thing, you are not doing other things. The most important thing a doctor or nurse can do is be with a person and deliver tailored treatment with some evidence base to back it up.
We are writing more. We are probably doing less. And over a hundred years, this has never ended well.
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