Sydney hospital nurses impose work bans: not enough beds for the mentally ill

Nurses at Prince of Wales hospital in Sydney imposed work bans for the second time in two weeks on May 15 protesting the lack of adequate treatment for psychiatric patients in both the emergency department and the hospital’s mental health unit.

While the work bans have now been lifted, the situation for patients and staff remains unresolved.

The 50-bed mental health unit at Prince of Wales (PoW) has been running at capacity for several months, forcing nurses to place at least five patients a night on couches, on the floor or in seclusion rooms. Without enough specialist staff or ward beds to cope with the increased demand, nurses in the emergency department—not necessarily trained in mental health—have been left to deal with aggressive and psychotic patients, who pose a danger not only to themselves, but to staff and other patients.

Nurses in the emergency department commenced work bans on May 1. Staff anger had boiled over after PoW management and the Area Health Service failed to address any of the serious problems created by a surge of mental health patients at the hospital’s emergency department. In the ten days prior to May 1, five of the department’s staff were assaulted by psychiatric patients, with one nurse punched in the face.

Staff are concerned that their ability to treat a range of accident and emergency victims is severely compromised by the lack of specialist care for psychiatric patients. At the same time, because of the shortage of mental health beds and specialised staff, these patients are regularly sedated and restrained.

As work bans commenced on May 1, a Special Commission of Inquiry into Acute Care Services in New South Wales Public Hospitals convened at PoW. Among those testifying was the hospital’s head of emergency Dr Sally McCarthy. McCarthy revealed that the overload of mental health patients presenting at PoW emergency was so great that, on average, they occupied five out of the twelve acute care beds available. Since 2002 there had been an 80 percent increase in psychiatric patients presenting at PoW’s emergency department, with most cases occurring since 2005. “The prolonged stays these patients have is due predominantly to the lack of capacity of the mental health inpatient service to place them in appropriate beds,” said Dr McCarthy. “Our emergency department is not a suitable environment.”

The initial work bans by emergency nurses were lifted on May 5, following an interim agreement between the NSW Nurses Association (NSWNA), PoW management and the South Eastern Sydney & Illawarra Area Health Service. In a media release issued on May 6, the union’s general secretary Brett Holmes claimed that management “are as committed to solving the problem as the nurses are”.

According to Susan Pearce, manager of the Organising Division of NSWNA, hospital management agreed to all of the union’s demands including the hiring of security guards in the emergency department, alternative locations suitable for aggressive and psychotic patients, a capped length of stay for mental health patients of eight hours, transfer of mental health patients to a Psychiatric Emergency Care Centre, appropriate staffing levels as well as guarantees that no emergency department staff be forced to work overtime to cater for the mental health overload.

Yet the demands formulated by the NSWNA resolve none of the underlying problems. Some of them have been made simply to let off steam—as the NSWNA and PoW management are well aware. There are no “alternative locations” suitable for mentally ill and psychotic patients, which is why they are presenting at hospital emergency departments across the state.

Included in the NSWNA May 1 work bans were an eight-hour cap on length-of-stay for psychiatric patients in emergency and the enforcement of a Code Yellow, redirecting ambulances elsewhere once the department reached capacity. But one merely had to ask: where were mental health patients to go after their eight-hour stay? Where would ambulances be diverted, once PoW’s emergency department was full?

While nurses have demonstrated their willingness to fight, the thrust of the union’s demands have the effect of offloading the lack of services for the mentally ill onto other hospitals, and even onto other departments within the same hospital.

On May 15 a separate work ban was imposed by nurses in Kiloh, the hospital’s mental health unit, after a union meeting held the day before revealed there were more patients than available beds. The effect of the May 5 agreement at PoW, capping length-of-stay to eight hours, was to divert excess patients from the emergency department into Kiloh, but the lack of beds in that unit saw mentally ill patients relegated to couches and other makeshift accommodation.

The mental health nurses’ bans meant psychiatric patients would be turned away when the unit became full. However, the ban was lifted by noon that same day, after the NSWNA met with the Area Health Service which acceded to demands that the unit should never exceed capacity and that patients be placed in “appropriate care” when Kiloh was full. But management agreed to provide just four extra beds, far short of demand.

The NSWNA is working to isolate the struggle by nurses at PoW. The union did not involve mental health nurses in the May 1 work bans by emergency nurses, and when opposition erupted from the Kiloh nurses on May 15, it was rapidly hosed down.

Over more than two decades the NSWNA has betrayed countless struggles by its members against hospital closures and attacks on wages and conditions, and bears major responsibility for the situation in the public health system today. Any genuine campaign to address the mental health staff and capacity crisis would require extending it to nurses and hospital workers throughout the state, something the NSWNA has no intention of carrying out.

The impact of Labor’s Richmond report

Throughout NSW, public hospital emergency departments are unable to cope with the hundreds of mentally ill patients seeking crisis treatment. Twenty-five years after the Wran Labor government brought down the Richmond Report in 1983, and the policy of “deinstitutionalisation”, its results have proved disastrous. The report urged a reduction in the size of mental hospitals, with appropriate care to be provided by general hospitals and approved accommodation such as hostels and other service providers in the private sector. Public/private community-based support would be subsidised with government funding.

“Deinstitutionalisation” resulted in the closure of major psychiatric facilities including Gladesville Hospital, Rozelle Hospital and Parramatta Psychiatric Hospital. Psychiatric units were incorporated into general public hospitals such as Prince of Wales, Concord, Cumberland and Royal Prince Alfred Hospital. The limited capacity of these much smaller units has placed a greater burden on emergency departments in general hospitals. At the same time, the resources for “community based support” for the mentally ill never materialised.

People with a mental illness now constitute a substantial percentage of the homeless population. According to a 2004 report in the Australia and New Zealand Journal of Psychiatry (entitled “Psychiatric Disorders in homeless men and women in inner Sydney”) 73 percent of men and 81 percent of women who were homeless suffered at least one mental disorder in the preceding 12 months. The same study found 40 percent of homeless men and 50 percent of homeless women had two mental disorders. Men diagnosed with schizophrenia comprised 23 percent and women 46 percent.

Another outcome of the downsizing of psychiatric hospitals has been the swelling number of prison inmates with mental disorders, making jails de facto psychiatric facilities. A survey in 2003 by the Corrections Health Service “Mental Illness among NSW Prisoners” cites some alarming findings. These include the incidence of psychosis among NSW inmates in the 12 months prior to incarceration 30 times higher than the national average; the occurrence, in the same timeframe, of other disorders including psychosis, anxiety disorder, affective disorder, substance use disorder and personality disorder or neurasthenia as high as 74 percent among inmates compared to 22 percent in the general community. An estimated 4-7 percent of new inmates suffer from a functional psychotic mental illness.

Just as alarming are the suicide rates for patients who cannot access adequate care. Between 2005 and 2006, 137 recently discharged mental health patients committed suicide, according to the Patient Safety Report, produced by the Clinical Excellence Commission. Suicide rates among people receiving some form of care doubled between 1993 and 2001.

The reality of “private/public community care” is that mentally ill people are largely left to fend for themselves. A 2006 report called “Living with mental illness in Australia: Changes in policy and practice affecting mental health service consumers” published in the Australian Psychologist found that in 1994, eleven years after the Richmond recommendations, 50 percent of the 3,752 tenants in boarding houses licensed to cater for people with disabilities had a mental illness. The standards in these for-profit boarding houses varied widely, with many providing only the bare necessities, such as a bed and a meal, leaving the residents with little of their pensions to access other services, or engage in community activities or recreation.

The conditions at PoW are symptomatic of a far wider crisis. In the last two months, at least two psychiatric patients at Nepean hospital in western NSW have had to be handcuffed to their beds and sedated for up to 36 hours because of bed shortages. A Sydney Morning Herald report on May 7 revealed that nurses there were being assaulted at least twice a month and that duress alarms did not work.

One nurse told the newspaper, “The biggest problem is that we can’t get them into a secure area where they could function without being tied to the bed. They’re not animals, they’re people with mental illness and it’s terrible to see.” The nurse revealed that several patients a week absconded, adding to the psychological pressure on staff: “The enormous moral issues that it puts on you: has this person gone down to the train station and jumped under a train or have they hung themselves on a pole outside.”

As demand for psychiatric services increases, supply continues to diminish. The response of the Iemma state Labor government to the crisis is a proposal to sell off what remains of the Callan Park psychiatric facility in Sydney’s inner west to the University of Sydney, with services to be transferred to Concord Hospital, another under-resourced, under-funded public hospital. Meanwhile the Rudd Labor government’s first federal budget, handed down last week, slashes a further $9.7 million from mental health over the next two years.