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English Language Page One of the main responsibilities of the administration and medical personnel of a psychiatric institution is to ensure the safety of patients (Part 1, Paragraph 6 of Article 39). In a number of circumstances, it is for the safety of patients and the people surrounding them that hospitalization is resorted to. In order to guarantee safety, the administration of the psychiatric institution has the right to significantly restrict the freedom of resident patients. One of such restrictions is the placement of the patient in an observation ward, which differs from a regular ward in that the monitoring of patients in it is more intensified. It is better provided with junior medical personnel, it has a round-the-clock medical nurse station, and patients are forbidden to leave its premises of their own accord. The patient is allowed to leave the premises of the observation ward only if accompanied by a representative of medical personnel, even if for the purpose of satisfying their physiological needs. In addition, such wards often contain agitated patients; therefore measures of physical restraint may be applied there. Practically all surveyed departments have observation wards that are equipped with supplementary safety features: window bars, unbreakable window glass, and round-the-clock medical nurse stations. Many did not have any furniture other than beds. In several institutions, observation wards are equipped with alarm systems in the form of an internal telephone or bell network (Orenburg regional psychiatric clinic #1, Neuro-Psychiatric department of the Nenetsky autonomous district hospital). When asked by an interviewer, “What do you do when you require urgent assistance?” one of the medical nurses responded, “We just cry out.” Apparently, lack of alarm systems jeopardizes not only lives of patients but also those of the medical personnel. Limited financial and human resources prevent psychiatric institutions from equipping observation wards with the necessary equipment. In some departments suffering from a lack of beds and personnel, patients that require special observation are placed not in wards but in hallways that are easily seen-through (Kostroma regional psychiatric clinic, Nikolskoye settlement). A similar practice exists in the men’s subdivision of the psychiatric department of the Altai republican clinic which is also filled to such a degree that, as the head of the department put it, “if a new patient arrives, we urgently release one of the tenured patients. If it is children, we can even have two of them share the same bed.” Speaking of safety in such circumstances becomes inappropriate. In the women’s subdivision of the psychiatric department of the Altai republican clinic, all the wards are organized as a series of corridors (3—7—28 beds), and the last one serves as an observation ward. In the departments that are designed for the treatment of marginal conditions (St. Petersburg psychiatric clinic #7 named after Pavlov, rehabilitation department of the St. Petersburg psychiatric clinic #1 named after Kaschenko) or on the contrary for lengthy treatment of chronic patients (Yaroslavl regional psychiatric clinic “Afonino”), there were no observation wards. The ratio of the number of patients contained in observation wards and the overall number of patients in the department varied within a very wide range: from 1:2 in the Smolensk municipal psychiatric clinic to 1:44 in the Kotelnicheskaya psychiatric clinic in the Kirov region, and 1:43 in the Tver regional psychiatric clinic #2. Monitors did not find a single patient in one of the departments of the Novgorod Psychiatric Clinic designed for 60 patients, although there was an observation ward for three beds, or in the 30-bed neuro-psychiatric department of the Nenetsky autonomous district clinic in which there was an observation ward with two beds. It appears that in the last two cases, heads of departments used a more justified approach to the restriction of patients’ freedom. In 22 (24%) general-psychiatry departments providing all kinds of psychiatric care, every third or fourth patient was contained in an observation ward and consequently unnecessarily restricted in their freedom. Those were departments of the following psychiatric institutions (see Table 1).
In this respect there are grounds to state that the practice of placing newly arrived patients in observation wards has been preserved, regardless of the degree of severity of their condition. On the other hand, during the monitoring, 20 (21%) Common-Psychiatry Departments were identified in which only one out of 10 or more patients were placed in an observation ward (see Table 2). The 1:10 ratio appears to be more adequate from the viewpoint of the balance between safety and the right to freedom.
The rest of the departments demonstrated an average ratio of 1:6, i.e. additional freedom restriction was applied to every sixth patient of these departments. Undoubtedly, this indicator depends on a variety of factors, first and foremost on the initial severity of the patients’ condition, on the degree to which the department is provided with medications, and the qualification of psychiatrists and medical personnel. However, it also reflects the attitude of the head of the department and attending medical doctors towards the fundamental rights of their patients. For some of them safety is more important than all other rights. Others tend to respect the freedom and dignity of the human being on a par with ensuring safety, which is an optimal combination from the viewpoint of the rights of patients. The lack of medical personnel in observation wards is directly connected with the general deficit of medium- and junior-level medical personnel of psychiatric departments. According to the National Psychiatric Association, some departments have still preserved a once ubiquitous practice of placing, at least for a short term, all newly institutionalized patients in observation wards. It appears that the indiscriminate placement of all newly institutionalized patients in observation wards is an excessive measure that often times results in the unjustified restriction of rights. Disinfection, isolation chambers, and disposable medical instruments Protection of patients from physical aggression and self-aggression is not confined to the contents of safety requirements for psychiatric institutions. Patients should also be protected from adverse environmental factors, first and foremost from infections of different kinds. Unsatisfactory conditions in psychiatric institutions, overcrowded wards, and risks associated with the conduct of medical procedures brought about special requirements regarding the disinfection of departments, the availability of disposable medical instruments, and isolators for infected patients. According to the rules of the Organization of Psychiatric Institutions approved by the Ministry of Health Care of the Russian Federation, each institution must be equipped with a disinfection department, a laundry facility with a disinfection chamber, and a central sterilizing facility. Data received in the course of monitoring indicate that a great number of psychiatric institutions lack the means necessary for disinfection: less than half of psychiatric clinics have functioning disinfection departments. Oftentimes clinics use only one or several disinfection chambers, which are not always in working order. For example, in 12.7% of cases disinfection chambers did not allow for quality disinfection. Some clinics experience an acute lack of equipment, while the equipment in others is significantly or completely worn out. The same applies to clinics’ central sterilization facilities: less than half of the clinics surveyed (43 clinics) dispose of sterilization rooms. Information collected during monitoring allows one to conclude that clinics fully equipped with all the necessary means of disinfection remain a minority. But even in these scarce cases, the availability of equipment is rather nominal due to a lack of spare parts, and other reasons, most frequently accounted for by the financial status of clinics (i.e. equipment is out of order, outdated, non-effective). Cases were registered during the monitoring when clinics totally lacked any disinfection tools and facilities. For example, the Kuznetsk city psychiatric clinic (city of Penza) has no means to acquire disinfection equipment, therefore one of the clinic’s bathrooms is used as a disinfection facility. In the Prokhladnensk district psychiatric clinic (Republic of Kabardino-Balkaria), clothes are disinfected in open-fire boilers due to the lack of a digester. The effectiveness of such primitive methods of disinfection is rather questionable. Isolation chambers for infected patients have been put together in 38 of the monitored mental institutions (41%). In some clinics each department is equipped with an isolation chambers, in others there are centralized isolation wards (for example, in the Nizhnii Novgorod City Psychiatric Clinic there is only one isolation ward serving the 250-bed clinic) which however cannot always meet existing needs. Six of the surveyed institutions have specialized infection departments which infected patients are transferred to whenever needed. The other 49 clinics solve this issue at the expense of internal recourses as they transfer patients with acute conditions to other health care institutions. Some of the clinics reported that they allocated one of the department’s wards to use as an isolator, but such a possibility is not always there. For example, the North Ossetia Republican Psychiatric Clinic uses its recreation room as an isolation chamber. At the same time, according to head physicians, infectious diseases are very common in psychiatric clinics and large institutions have to resort to quarantine many times a year. The situation with availability of disposable medical instruments in psychiatric clinics has significantly improved over the past two years and currently the majority of institutions do not experience any difficulties in that respect. Some of them however do complain about disruptions in the supply of disposable instruments (Republican Psychiatric Clinic of Komi), and nine institutions (10%) still experience an acute deficit of disposable instruments, therefore patients or their relatives must acquire them at their own expense. Compliance with disinfection requirements is a guarantee of patients’ safety. The monitoring indicates that disinfection rules are grossly violated, many institutions have limited or no means to conduct effective disinfection. At the same time, the issue of compliance with disinfection requirements in contemporary psychiatric institutions has become even more important due to a large number of hygienically neglected patients. Junior Personnel Lack of junior personnel is the most acute problem currently faced by psychiatric institutions. Extremely low salaries (600-800 rubles) and hard working conditions combined with the lack of prestige associated with this type of work have resulted in a lack of orderly personnel which has reached a catastrophic scale. In compliance with legislation and safety requirements, individuals under 18 years of age, as well as those suffering mental disorders and chronic alcoholism, are not allowed to work with mental patients. These requirements are not always complied with. At its best, employees are selected on the basis of clearance certificates from neuro-psychiatric and narcological dispensaries indicating that candidates have no contraindications to work in a mental institution (for example, in the Psychiatric Clinic #13, Moscow). At its worst, in order to fill in their orderly vacancies institutions hire alcoholics and individuals previously convicted by a court of law. This results in a situation where the orderly personnel of psychiatric institutions become a source of danger for patients. The situation with orderly personnel may be recognized as satisfactory in only eight (9%) of the surveyed psychiatric institutions. This is observed in those regions of the country where the level of unemployment is high and vacancies in psychiatric clinics are in demand: Shadrinsk neuro-psychiatric dispensary of the Kurgan Region, Buryat republican neuro-psychiatric dispensary, Troitsk psychiatric clinic of Buryatia, Kalmyk republican neuro-psychiatric dispensary, Marii El republican psychiatric and tuberculosis clinic, Republican psychiatric clinic of Mordovia, Votkinsk neuro-psychiatric dispensary of the Udmurt republic, Chita regional psychiatric clinic #2. 47 institutions (i.e., half of the clinics surveyed) are understaffed with orderlies by over 50%. At the same time, doctors of clinics whose orderly personnel staffing exceeds 50% complain about absenteeism and drunkeness (Central Moscow regional psychiatric clinic #1, Penza regional psychiatric clinic, Republican psychiatric clinic of Komi, Smolensk municipal psychiatric clinic, and many others), which forces administrations of these institutions to dismiss such employees. The situation is aggravated by hard working conditions and an extremely low level of pay that result in orderly personnel promptly quitting their jobs. The turnover of orderly personnel amounts to 30-40% per year and more. The number of orderlies holding more than one job is impossible to estimate since a whole variety of gimmicks are used to attract people and raise their pay. For example, the orderly personnel staffing of the Moscow psychiatric clinic #13 is only 28%, but 96% of orderly jobs available at the clinic are filled. In some institutions (Kostroma regional psychiatric clinic [Nikolskoye settlement], Krasnodar city psychiatric clinic, Moscow regional psychiatric clinic #2, and others) medical nurses carry out orderly functions. This of course results in a lower quality of the treatment of patients, and a lower level of safety. For example, at night, the 120-bed women’s department of the Moscow regional psychiatric clinic #2 is monitored by just two medical nurses, and no orderlies at all. Many doctors especially complain about the lack of male orderlies whose physical strength is sometimes absolutely required (Krasnoyarsk territorial psychiatric clinic #3, Moscow psychiatric clinic #4, Vladivostok city psychiatric clinic of the Primorsky territory, Pskov regional psychiatric clinic #1, etc.). The head physician of the Novgorod regional psychiatric clinic sees the solution of this problem in the recruitment of alternative service soldiers. Some head physicians view positively the fact that the orderly personnel of their clinics consists entirely of women, predominantly of senior age, who have spent many years working in psychiatry. They think that this ensures more humane treatment of patients. Cases of aggressive treatment of patients by personnel were not reported by a single physician or medical nurse. At the same time, according to the National Psychiatry Association, such cases are not rare. This is a logical consequence of the acute deficit of orderly personnel, and accordingly, the induced recruitment of unchecked people who sometimes have a criminal background and/or are mentally disturbed. At best such orderlies are dismissed; at worst, they are reprimanded and transferred to another department. Due to the deficit of orderly personnel, patients are frequently employed as departmental assistants which is often viewed as an adequate substitute of labor. But to the question of whether or not patients are ever employed as orderlies, all physicians and nurses responded in the negative. Many physicians do not even realize that employment of patients as departmental assistants, even with their consent, is a form of exploitation. Protection of patients from external aggression Adequate treatment, sufficient staffing with well-trained personnel, isolation of agitated patients in observation wards, and special equipment in departments are conditions required to protect patients from external aggression. At the same time there is dissent as to what should be considered aggression. On one hand, aggression at the interpersonal level that does not result in any serious consequence is frequent. On the other hand the majority of physicians consider one’s conduct to be aggressive only if it results in physical harm of an individual. The Vladimir Regional Psychiatric Clinic #1, the Regional psychiatric clinic of the Jewish autonomous district, and the Orenburg regional psychiatric clinic #2 register all cases of aggression among patients, with 58, 102 and 107 cases of aggression among patients a year respectively. But the majority of head physicians do not pay much attention to petty skirmishes among patients (“they fight quietly”), leaving the regulation of such types of conflicts at the level of interpersonal everyday communications among patients. It is logical then, that such an approach by head physicians does not result in the necessary registration of cases of aggression. As a rule, only cases of clear aggression resulting in physical harm are registered. Thus, what is registered is not the aggression itself but the fact of physical injuries. Such practice cannot be regarded as satisfactory because in order to improve protection and preventive measures, a permanent analysis of cases of aggression of patients with respect to each other is necessary, as well as correction of existing errors and drawbacks. Disregard of petty cases of aggression results in the fact that control measures undertaken to ensure the safety of patients prove insufficient. Sometimes this may become one of the reasons causing aggression that results in the death of a patient. Although serious cases of aggression were denied by the majority of physicians and personnel members, it is known that last year aggression of patients with respect to each other at the Bashkortostan republican psychiatric clinic of and the Voronezh regional psychiatric clinic #1 resulted in deaths of patients. Administration of a psychiatric institution is responsible to ensure the safety of patients. However, the factual lack of a permanent practice of registering cases of aggression among patients and with respect to personnel, differing approaches towards the understanding of what aggression is — creates a situation in which patients turn out to be legally unprotected, since cases of aggression are not registered and are therefore unable to be proved. Sexual safety Medical legislation in Russia does not regulate sexual relations within health care institutions in any fashion. The problem of sexual violence within closed communities is an important one. It is known however that patients in therapy have a significantly lower level of sexual activity and sexual claims of various kinds with respect to each other or personnel members are not frequent. Medical personnel pay close attention to the conduct of patients and register their “behavioral patterns” in observation journals. Whenever a danger of sexual actions with respect to one of the patients appears, the patient is transferred to another ward. The question of sexual aggression and of the sexual safety of patients left the majority of physicians and nurses in bewilderment: “there is no such problem,” “there was not a single case,” “orderlies are exclusively women and of senior age at that.” Representatives of the Vladimir regional psychiatric clinic #1 reported that “manifestations of one being attracted to somebody” do occur. The head physician of Krasnoyarsk territorial psychiatric clinic #1 reports that he does take into account this issue: “we have sexually anxious patients in the women’s department, therefore we do not hire men to work as orderlies there.” It was only the Stavropol territorial psychiatric clinic #1 specializing in examining military personnel that acknowledged the existence of this problem: “soldiers do show interest for women,” but made a reservation that this is kept under strict control and no cases of violence have been registered. Nevertheless, the issue of sexual safety is not a priority for administrations of psychiatric institutions; it is not paid the attention it deserves. Potential sexual intentions of personnel toward patients are also peripheral — it is assumed that gender homogeneity within the department is sufficient enough an obstacle to prevent anyone from sexual actions. This results in the fact that the majority of head physicians do not take into account the danger of homosexual aggression. Withdrawal of dangerous objects To ensure the safety of patients and personnel, the rules of psychiatric institutions account for withdrawal of all objects from patients that can be used to harm oneself or others. Such objects include all sharp, prickly, or objects used to cut (razors, scissors, knives, forks, glass dishes, etc.). At the same time personnel of all psychiatric institutions take away patients’ waist belts to be on the safe side, which is not always justified and in many cases humiliates patients. Withdrawal of forbidden objects occurs in the admission room at the time of a patient’s admission. This is followed by a subsequent examination of parcels and packages delivered to patients, as well as occasional examination of bedside tables and other places where patients keep their personal belongings. Withdrawn objects may be passed over to patients’ relatives or returned to patients themselves at the time of discharge. All patients and their relatives are well aware of this practice — as a rule, entrance doors of psychiatric institutions carry notices to that effect which does not usually cause any complaints. |
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