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English Language Page Wages It was revealed in the course of the monitoring, that the average wage of a doctor at psychiatric institutions makes up about 1800—2000 rubles which is below the survival minimum. While in some regions (Arkhangelsk region, for instance) the rate of wages is extremely low and equals 1200 rubles, and in other regions it reaches 4500 rubles (Khabarovsk territory) or 5500 rubles (Magadan region) a month or higher (Chukotka autonomous district). The regional differences in the wages of doctors are due to the size of regional additional payments which depend on the specifics and potential of the concrete region. These additional payments for the workers of the psychiatric service vary from 10% of the monthly salary in the Vladimir region to 50% in the Krasnodar territory. In the Chukotka autonomous district all the workers of the budget sphere, including the staff of the psychiatric service, receive an additional payment of 1500 rubles a month. The average wage of a nurse does not exceed 1500—1800 rubles, and of a medical attendant — 600—800 rubles a month. Evidently this level of payment makes staff members of psychiatric institutions take up more than one job at once increasing thus the load of work. It decreases the quality of aid and the safety of patients, doctors, and the personnel of these institutions. The heads of institutions work hard to find special forms of labor remuneration in order to improve the real income of their staff. Thus, some hospitals (Volgograd regional psychiatric clinic, Pskov regional psychiatric clinic #1) practice the so-called team work when a “team” of personnel receives money for certain work. When a member of the team is absent (for the reason of his or her illness or studies, etc.), his or her salary is distributed among other members of the team increasing their wages. Some hospitals pay bonus money on a regular basis. One extensively used method of increasing the level of labor remuneration for the staff of psychiatric clinics is the maximum increase in the size of the work load. Doctors, working on a daily basis, extend their working hours, take additional night work and increase the number of patients they treat. Nurses, who basically have shift work, sometimes perform the duties of medical attendants. It should be noted that there is an acute deficit of medical attendants at psychiatric clinics, so everywhere they have to work more than they should, sometimes for two or three people at once. Nevertheless, with all additional payments the real monthly income of a psychiatrist at several psychiatric clinics (9%) does not exceed 3000 rubles (Astrakhan regional psychiatric clinic, Belgorod regional psychiatric clinic, Bryansk regional psychiatric clinic #3, Nizhnii Novgorod city psychiatric clinic #1, Penza regional psychiatric clinic, Kuznetsk city psychiatric clinic of the Penza region, the neuro-psychiatric dispensary of the Udmurt Republic named after Votkin, Rostov city psychiatric clinic (Kovalevka settlement), Smolensk city psychiatric clinic, Stavropol territorial psychiatric clinic #1). The incomes of a nurse and a medical attendant are also unacceptable at a number of monitored hospitals (Bobrovo-Dvorsky psychiatric clinic of the Belgorod region, Kotelnichesky clinical psychiatric hospital of the Kirov region, Dankovsky psychiatric clinic of the Lipetsk region, Lipetsk regional neuro-psychiatric hospital, Pskov regional psychiatric clinic #1, Republican clinical neuro-psychiatric dispensary of Adygea, Tver regional psychiatric clinic #1 named after Litvinov, Yaroslavl regional psychiatric clinic “Afonino”). Here nurses earnings are not more than 2400 rubles and medical attendants earn not more than 1200 rubles a month. As for the country as a whole, the conducted monitoring revealed that the average monthly income of a doctor at psychiatric institutions made up 4740 rubles, of a nurse — 3070 rubles, and of a medical attendant — 1670 rubles. The biggest monthly payments were observed in the staff of the Irkutsk regional neuro-psychiatric dispensary, Krasnoyarsk territorial psychiatric clinic #1, Magadan regional neuro-psychiatric dispensary, Moscow psychiatric clinics #4 and #13, Vladivostok city psychiatric clinic of the Primorsky territory, Samara regional psychiatric clinic, St. Petersburg psychiatric clinic #1 named after Kaschenko, Khabarovsk territorial psychiatric clinic #2, Tyumen regional psychiatric clinic, Chita regional psychiatric clinic #2, Chukotka district neuro-psychiatric dispensary. Yet even here these payments are a little more than 6000 rubles which makes them 2—2.5 times lower than the average wage of a worker in the construction industry, for instance. Work Load Low standards of labor remuneration, despite local additional payments, force, as we have mentioned above, the increase in the work load of the staff of psychiatric clinics. Usually doctors work on a daily basis from 9 to 18, and have several night shifts, although the calculation for the rate of a doctor’s wage determines a six hours work day, i. e. from 9 to 15. One doctor is to serve 25 patients, while doctors actually treat 40, 50, and even 75 patients simultaneously: “At present our department has 57 patients, and I work alone, plus one nurse and 2 medical attendants;” “a doctor works from 8 to 16 or from 9 to 17, 1 doctor is to have 25 patients, but sometimes he or she has over 40, there are 35 patients per 1 nurse, and during night shift — 70, medical attendants work for 24 hours, and each of them cares for 25—30 patients. The situation at the Ulyanovsk regional psychiatric clinic #1 named after Karamzin is approximately the same: A doctor works every day from 8 to 16, plus night shifts on his or her demand, one doctor has from 30 to 60 patients, a nurse works either for 24 hours and has three free days, or from 8 to 16 every day, just as medical attendants, their load is from 30 to 40 patients. At the Khabarovsk city psychiatric clinic named after Professor Galant 2 doctors work in a 75-beds department, just as at the Republican psychiatric clinic of Bashkortostan. Working conditions of nurses and medical attendants are not less hard. They often have not only to care for a large number of patients, but also to cut the free periods between 24 hours shifts. Nurses work during day time (from 8 to 20), during the night (from 20 to 8 a.m. of the next day), then they have 2 free days. When our staff was full, they had 3 free days. Many people wanted to work here because the schedule was convenient. And now they have only 2 days of rest. The load is very large, and they can hardly endure it from one vacation to the other. There ought to be 2 nurses and 3 medical attendants in a shift. And we have 1 nurse and 2 medical attendants” (there are 75 patients in the department). In the Moscow psychiatric clinic #13 “nurses and medical attendants work for 24 hours with 2 days of rest, the load is very big, during the night shift 1 nurse and 2 medical attendants are left to care for 60 patients.” The same schedule of work is used at the Khabarovsk city psychiatric clinic named after Galant and some other hospitals. Delays in the payment of wages have been in acute problem for the workers of the budget sphere, which also covers the doctors and the personnel of psychiatric clinics. Thus, in the Kirov and Orenburg regions the wages of doctors and other personnel are sometimes delayed for 1 month. Privileges Privileges of the workers of psychiatric services are determined by the RF Labor Code enacted on February 1, 2002, and by Federal Law on Labor Pensions in the Russian Federation, which came into force on January 1, 2002. These documents provide for all the workers of psychiatric institutions and researchers who work with ill persons all day long a 6 hour working day and an additional paid vacation besides the annual vacation provisioned by the RF Labor Code (30 days for doctors, middle and junior medical staff, 12 days for dietologists, 18 — for laboratory assistants, etc.), and establish an increased rate of labor remuneration (the order of the RF Ministry of Health Care #377 of October 15, 1999) which positions the rate of wages 15—40% higher (depending on the concrete type of activity and conditions of labor). The privileges also provide for an earlier retirement age (55 years for men, 50 years for women) and a labor pension. Besides that, since many psychiatric clinics are situated in the countryside, their staff is covered by the additional privileges provided by the Russian legislation (50% coverage of the utility services rates, etc.) for these regions. Regional and local authorities can introduce additional privileges for improved housing, free stay at sanatoriums and health resorts, boarding houses, vacation homes, etc. for rehabilitation or treatment. The monitoring revealed that the staff of psychiatric clinics enjoys all the privileges provided for them by the Russian legislation (shorter working hours, additional vacations, increased labor remuneration, earlier retirement age). At the same time there are cases when the compensation of utility services rates for countryside residents which is guaranteed by the law is not made. Thus, the personnel of the Smolensk regional psychiatric clinic does not have the privileges in utility services rates due to the actions of the local authorities, and at the Rostov regional psychiatric clinic (the village of Peshkovo) the above mentioned privilege unjustly covers only those staff members who reside in state owned apartments. A permanent system to provide additional privileges for the workers of psychiatric clinics who work under permanent stress is absent. The set of existing privileges for the staff of psychiatric service revealed by the monitoring proved to be very meager and was determined, first and foremost, by the things necessary for the normal process of work. Psychiatric clinics do not receive the financing from local authorities to expand additional privileges, so the responsibility for the staff of the psychiatric service fully lies with the leadership of the corresponding institutions whose potential is very limited. Nevertheless, the leadership of hospitals finds the ways to provide, at least partially, for the additional privileges of their staff. First and foremost, the hospitals try to organize free transport to carry the staff to and off their workplace. For example, almost all the hospitals situated in the countryside use their own transport for it, and some psychiatric clinics fully or partially compensate the use of city transport by their staff (Moscow psychiatric clinic #13, Moscow regional psychiatric clinic #2). According to the information received from head doctors, only the Prokhladnensk district psychiatric clinic of Kabardino-Balkaria which is situated far from major towns, has serious problems with carrying its staff to and off the workplace. Other privileges are provided for only at some hospitals. At the Vladimir regional psychiatric clinic #4, Kurgan regional psychiatric clinic and some other hospitals fully or partially free food is provided for the staff. At the Chukotka district neuro-psychiatric dispensary and the Khabarovsk territorial psychiatric clinic the staff receives milk on a regular basis. The Smolensk municipal psychiatric clinic provides its staff with the right for an out of the queue installation of the telephone and free medical aid. The Chelyabinsk regional psychiatric clinic #1 provides its nurses with coal or money to pay for heating. Sometimes hospitals fully or partially cover the costs of trips to sanatoriums and rest homes (Moscow psychiatric clinic #4, Chelyabinsk regional psychiatric clinic #2). The most serious problems are associated with the housing for the staff. Earlier many hospitals were able to provide good housing for their staff and, therefore, attracted qualified people. Now their potential for it is dramatically reduced. For example, in 1994 the Moscow regional psychiatric clinic provided all its staff with free housing, but at present the queue to get lodgings or to improve housing conditions is more than 100 people long. The Shadrinsk regional psychiatric clinic of the Kurgan region provided its staff with good housing in 1996, but now it can only offer a hostel. The Tyumen regional psychiatric clinic needs finances (about 1 million rubles) to complete the construction of an apartment house for its staff. And the absence of housing near the hospital is especially damaging in the cases when hospitals are located far from towns and daily commutes to work take up too much time. To some extent such a disastrous housing situation is explained by the fact that local authorities place the staff of medical institutions at the end of the queue for new apartments, and the staff of the psychiatric service finds itself at the end of the list of medical workers. Thus, at the Chelyabinsk regional psychiatric clinic #2 only 5 people have got apartments on the money provided by the local budget since 1998, and at the Krasnodar city psychiatric clinic — only 2 people. In the Chita region only 1 one-room has been allocated for the Chita regional psychiatric clinic #1, and for the Chita regional psychiatric clinic #2 — only 2 apartments. The absence of municipal housing and low levels of labor remuneration sometimes result in the fact that the staff of hospitals is forced to live in inadequate conditions deprived of necessary conveniences. For example, the head doctor of the Kuznetsk city psychiatric clinic of the Penza region has been living in a hostel for 18 years, and several families of the staff of the Pskov regional psychiatric clinic #1 are still living on the premises of labor rehabilitation workshops which are utterly inadequate as housing. When the hospital was constructed, they were allowed to move in there, but the promised housing has not been provided for them. Safety In psychiatry especially great attention is to be paid to the issue of labor safety, to the elimination of harmful and dangerous factors, to safe organization of workplaces. In order to provide protection from the potential aggression on the part of the patients “the administration of the hospital is to equip all the doors of all departments with quality wagon locks. The keys are to be stored in the place to which patients have no access.” Some diseases which may occur in the staff of psychiatric institutions as a result of extensive contacts with mentally ill patients and work with psychotropic drugs are included into the List of Professional Illnesses adopted by the RF Ministry of Health Care and the State Committee for Sanitary and Epidemiological Surveillance in 1995, and when this disease results in the loss of the ability to work, the reasons for this loss are regarded as professional. Yet one often has to prove it in court, and that is not exactly simple. In the case when the court admits that the loss of the ability to work (complete or partial) was associated with the professional activity, health care authorities are obliged to pay this worker a disability pension which is substantially higher than the common one. It is understandable that the hospital administration makes everything in its power not to admit the professional characteristics of the disease, and the expert’s assessment is often evasive (“may be caused by…”), and in case of doubt the courts usually side with the organization, not with the individual citizen. According to the Supplement to the Order of the Minzdravmedprom #92 of April 11, 1995, “the administration is to provide the personnel of the hospital with sanitary clothes, special robes, and means of individual protection,” “every department is to have a personnel room, a cloak room, and a toilet room for the personnel,” “every department must be equipped with a shower room for the personnel,” “the toilet room of the personnel is isolated from the toilet room of the patients.” To reduce the risk of allergic diseases associated with the work with psychotropic drugs, “the treatment room for the injections of neuroleptic drugs is to be equipped with an exhaust hood.” There are many documented norms which must be used as guides in the work of a psychiatric clinic, ranging from the Decree on the Organization of Work to Promote the Safety of Labor in the Bodies, Institutions, Enterprises and Organizations in the System of the Ministry of Health Care of the USSR (1982), to the Rules for Construction and Maintenance of Steam Boilers and Water Heating Boilers (1988), and the Typical Instruction on the Protection of Labor in the Work of Food Catering of the Institutions of Health Care (1986). Everything is thoroughly worked out in these documents, but the financing of the hospitals prevents timely acquisition of the necessary means, equipment, etc. to provide the staff with everything that is necessary. Sometimes the financial deficit of hospitals causes the situation when staff members have to spend their own means to acquire special robes and instruments necessary for the normal organization of work and distract their attention from their professional activity to do things which are not associated with it. Thus, for instance, the Voronezh regional psychiatric clinic does not have enough means to acquire medical robes, and the personnel has to buy them themselves, and at the Stavropol territorial psychiatric clinic #2 and the Ulyanovsk regional psychiatric clinic #1 named after Karamzin staff members are involved in maintenance work, because the hospital does not have the money to spend on it. Financial difficulties which prevent the timely building maintenance and capital repairs of departments, the absence of equipped premises deprive the personnel of some hospitals of the right to the adequate conditions of labor. For example, at the Astrakhan regional psychiatric clinic the personnel rest room requires urgent repairs, and the examined departments of the Novokuznetsk city psychiatric clinic of the Kemerovo region, of the Rostov regional psychiatric clinic (the village of Peshkovo), Smolensk regional clinical psychiatric hospital #1, and Smolensk city psychiatric clinic had no rest rooms for the personnel at all. The Bobrovo-Dvorsky psychiatric clinic of the Belgorod region had a personnel toilet in the yard and a shower at the laundry, and at some departments of other psychiatric clinics (Novokuznetsk city psychiatric clinic of the Kemerovo region, Kurgan regional psychiatric clinic, Novgorod city psychiatric clinic #1, Kuznetsk city psychiatric clinic of the Penza region, Rostov regional psychiatric clinic (the village of Peshkovo), Prokhladnensk district psychiatric clinic of Kabardino-Balkaria, Smolensk regional clinical psychiatric hospital #1, Chelyabinsk regional psychiatric clinic #2) the personnel has no separate toilet room what creates considerable difficulties both for the staff, and for the patients. Medical treatment rooms are in most cases equipped according to the existing standards, but some of them do not have hot water (psychiatry and tuberculosis hospital of the Marii El Republic, Smolensk regional clinical psychiatric hospital, Rostov regional psychiatric clinic, Chelyabinsk psychiatric clinic #2, Yaroslavl regional psychiatric clinic Afonino), tiles (at 7 hospitals), ultraviolet lamps (Voronezh regional psychiatric clinic, Moscow regional psychiatric clinic #2, Chelyabinsk psychiatric clinic #2). The exhaust hood is absent at the medical treatment room of the Smolensk regional clinical psychiatric hospital, and that poses the danger of allergic diseases. But the situation with alarm systems and internal communication is particularly grim. This issue has been worked out in great detail in the Rules for the Construction and Maintenance of Psychiatric clinics adopted by the RF Ministry of Health Care since it is directly linked to the safety of the personnel. A hospital must have an internal communication system between its departments, administrative and maintenance services in the form of a local automatic telephone exchange or intercom telephony. Departments must be equipped with alarm systems. “The alarm systems must have light and sound signals… A mutual audio and light alarm system is to connect the office of the head of the department with the offices of doctors and chief nurse when intercom telephony is absent, the bath room is to be equipped with a buzzer for the urgent call of the personnel.” Up-to-date technology facilitates the use of mobile wireless alarm systems with remote control. Buzzers inside departments were found only at three examined psychiatric clinics: at the Krasnoyarsk territorial psychiatric clinic #2, Dankovsky psychiatric clinic of the Lipetsk region, and the Republican neuro-psychiatric dispensary of Buryatia. As for the rest of psychiatric clinics, any communication systems between different rooms of a department are absent, and the personnel has to cry out in case of need. This situation is inadmissible taking into consideration the absence of male medical attendants and staff deficit since it poses a real threat to the life and health of the personnel. Departments communicate with each other and administrative premises with the use of telephones, and in most urgent cases hospital security is called in. We should note that the security staff of a hospital guarding its premises is not responsible for the work inside the hospital. Security people are not trained to work with ill persons, and their actions may harm the health of patients. The police is called in when it is necessary. Everything that was said above makes it clear that the organization of safety measures among the staff of the examined hospitals contains blunders. It is confirmed by the cases of serious attacks of patients on the personnel which were revealed by the monitoring. Insurance The article of Federal Law “On Psychiatric Care and Guarantees and Privileges of the Experts Participating in the Providing of Psychiatric Care” (article 22) states, in particular, that these people are to be the subjects “of obligatory state insurance in case when their health is harmed or they die in fulfillment of their duty.” “When disability occurs, the insurance money is paid ranging from an annual to a five years salary… and in case of death the heirs of the deceased are paid a ten years salary.” According to the Decree of the Supreme Council of the Russian Federation, of December 1, 1992 (i.e. by the moment when Federal Law “On Psychiatric Care” came into force) the Russian government was to “develop and adopt the Decree on the procedure and the conditions of the state insurance of doctors, other experts, medical and other personnel involved in administering psychiatric care, and legal acts on the privileges for such persons.” More than ten years have passed since that time, but the special legislative act on the state individual insurance for the workers of the psychiatric service was not adopted. As a result, experts involved in psychiatric care are not insured from the potential damages to their health associated with their professional activities. Yet their life and health are in serious danger. It was revealed in the course of the monitoring that cases when grave damage was inflicted on the health of doctors or staff members were observed at many psychiatric clinics. Thus, at the Kaliningrad regional psychiatric clinic a patient broke a nurse’s lower jaw in 2001, at the Republican psychiatric clinic of the Komi Republic a military person who was under examination inflicted heavy physical damage on a medical attendant, at the Belgorod regional psychiatric clinic a patient pushed a staff member who broke his leg as a result, at the Irkutsk regional neuro-psychiatric dispensary a medical attendant was seriously wounded by a patient with a sharp object. At the Kirov regional clinical psychiatric hospital named after Bekhterev a female patient hit a doctor who suffered from retinal detachment as a result and was given second degree disability after 14 operations. In all these cases the state provided no compensation for damages inflicted on their health. In most of the examined psychiatric clinics staff members are not insured against the potential aggression of patients. From the formal point of view, in cases when damages are inflicted on their health, the decision concerning the payment of insurance money is to be taken in correspondence with the Decree of the Supreme Council of the Russian Federation #4214-1 of December 24, 1992 ”On the Adoption of the Rules of Compensating on the Part of Employers Damages Resulting from Injury, Professional Diseases or other Harm to the Health Associated with the Performance of Labor Duties.” Yet, in fact, to get the compensation for damages, the employee has to resort to a lengthy procedure in the court of justice. Thus, for instance, a doctor of the Magadan neuro-psychiatric dispensary who was seriously injured by a patient on his workplace was not able to make the administration of his institution compensate the inflicted damages. Now his case versus the administration of the neuro-psychiatric dispensary on the payment of insurance money is examined by the court. The administration understands that this person sustained injuries but tries to avoid responsibility for it as it does not have the means to pay adequate damages. Some hospitals (11 out of the examined 93), mainly those which had cases when their staff sustained injuries, had their personnel insured by private insurance companies against an accident on their workplace. At the Irkutsk regional neuro-psychiatric dispensary, for instance, 116 employers are insured by the Metallurgmedstrakh Insurance Company against any damages inflicted on their workplace. At the Irkutsk regional psychiatric clinic an individual insurance of the staff was introduced which depends on the size of their wages, and at the Magadan regional neuro-psychiatric dispensary all the staff is insured against industrial traumatism and accident on the workplace. Yet the overwhelming majority of the hospitals do not have the means for individual insurance of their staff. The head doctor of the Pskov regional psychiatric clinic #1 said that in the Saratov region the Regional Assembly allocated means to insure the staff of the psychiatric service from the local budget, but there is no practice of that kind in other regions. At the Vladimir regional psychiatric clinic #1 a staff member who sustained injuries from a patient receives financial aid and his treatment is covered. Other psychiatric clinics do not provide even that. Thus, one should admit that the right of the staff of psychiatric clinics to receive compensation of the injuries sustained or the loss of the ability to work which is guaranteed by the state is not realized. The staff is not insured against potential grave risk of its profession. |
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