Mental health unit staff work collectively to solve ongoing overcrowding problems: overcrowding and understaffing continue to beset Wellington Hospital's acute inpatient mental health unit Te Whare o Matairangi. The solution--increased care in the community--will not be found overnight.

Up to 40 patients sleeping in an acute mental health unit funded for 29 and originally designed for just 24. Clients having to sleep in lounges, the library and on thin mattresses on the floor. Noise revels and the rate of serious incidents increasing. A tack of food and dirty facilities. Patient safety compromised.

Such descriptions paint an alarming picture of conditions at Capital and Coast District Health Board's (DHB) acute mental health unit, ward 27/Te Whare o Matairangi. Yet, despite continuing overcrowding and the ongoing challenge of finding sufficient qualified mental health staff to fill the rosters, staff morale and relationships between senior and staff nurses are improving, claims staff nurse and NZNO delegate Grant Brookes.

Brookes has worked at the unit since 2002. He has also been appointed to the new Acute Response Taskforce, a group comprising senior managers, union delegates and non-government organisations (NGOs). The taskforce has been set up by the DHB to come up with immediate solutions to some of the worst of the overcrowding problems. Its timeframe is only three months, as longer term solutions and a five-year plan for mental health services in the region are expected to emerge from a project called "The Journey Forward".

Brookes readily admits the issues facing the unit and finding solutions to them are complex. However, he is grateful that management now seems more willing to listen to the nurses and is more open in its approach. "The acute unit is only funded for 29 beds and that is unlikely to change," he said. "The agreed direction for mental health services is to fund and establish an array of services in the community. Nurses support the concept of people being cared for in the least restrictive environment. However, at the moment, patients cannot be discharged in a timely way, as there is a blockage in the system. There are simply not enough community supports to complete their recovery at home, and not enough facilities to take people needing respite or rehabilitative care, rather than acute care.

"The ongoing problems mean nurses can't deliver the quality of care they want to or provide an environment that fosters recovery. For the last 12 months, there has been only a handful of days when we have been at or below our 29-bed limit. In June, for instance, average occupancy was 35.4 clients. Add to this the numbers of people "on leave", who return to the ward during the day for nursing and medical care, and we can have more than 50 people under our care. This can mean a nurse to patient ratio of one to ten during the day, and up to one to 20 at night. These ratios are far from safe.

"The effect of overcrowding on our clients means they lack space, peace and quiet, areas in which to socialise, to do activities and to attend gender specific activities. With our seclusion rooms and tow stimulus areas often used as bedrooms, there is decreased scope to defuse conflict. Incidents of violence towards other clients and staff are way up. Incidents nurses are having to deal with regularly include self-harm, assaults on clients and AWOLs. Some of the newer nurses find these incidents pretty stressful to cope with.

"People need choices of where to go during the day. They don't want to be forced to congregate in just one lounge or to retreat to their bedrooms to escape the overcrowding. If these conditions continue, the likelihood of a sentinel event occurring grows that much stronger." Brookes puts the root of the problems mostly down to government underfunding and past management decisions. The issue of overcrowding was also greatly exacerbated when the second acute unit for the Wellington region, Te Whare o Rangatuhi in Porirua, closed in 2002. "Last year was particularly difficult at ward 27 and one third of our staff left. Some of our managers also refused to admit the problem was as bad as it was. This year, things have improved. One of the reasons for this is that staff have come together collectively to take the issues to management and find some solutions for themselves. NZNO members wrote a collective letter to the DHB's chief operating officer Meng Cheong in June, outlining the problems as we saw them and suggesting solutions.

"NZNO delegates and members now work together daily to support each other. We take the lead in organising our own debriefs after traumatic events and arrange community meetings with clients to hear what they would like. For example, our clients recently asked whether they could have a weekend barbecue. The staff agreed and helped make this happen. As a result of these sorts of initiatives, there is now a better feeling on the ward and staff turnover is down."

For Brookes, the solutions are quite dear. Respite services in the community need to be expanded and liaison between the NGOs and the ward needs to improve. Intensive community support needs to be expanded and information about clients should be shared more openly between the ward and the NGOs. "The DHB appears to be willing to offer more money to expand NGO services and this would certainly take a lot of pressure off the ward. My hope is that the Acute Response Taskforce will result in better relations between the ward and the NGOs, and that this will lead to a freeing up of inpatient beds."

Staff nurse and former team leader Roy de Groot has had a ten-year association with ward 27. He, too, is supportive of the philosophy of deinstitutionalisation but believes the overall service configuration is now inadequate, especially following the closure of Te Whare o Rangatuhi. "Te Whare o Matairangi is now being asked to provide more services to more people," he said. "Some of the people being cared for at the unit don't really need to be there. Some are sub-acute or in need of rehabilitation. The unit is not designed to give them that kind of care and it undermines our key function to have these sorts of clients remaining with us. The DHB does have a rehabilitation unit in Porirua which is designed to help people integrate back into the community, but they don't have the space. Basically, we are having trouble getting people into appropriate care. The DHB needs to purchase more community-based services, so people are not kept in acute services when they should be discharged. My concern is for people with longer-term needs who are missing out on the level of care they need."

Health care assistant Kerry Borewicz, who has been at the unit 15 months after working for 15 years in mental health in Australia, agrees there are people in the ward now who shouldn't be there. However, she is concerned that a lot of expectations are put on the NGOs who do not always have the skills to cope with some of the long-term clients. "We need people with a real understanding of mental illness caring for these clients. People who are mentally unwell are not always treated very well, as society often regards them as the bottom of the barrel. When there's nowhere else for them to go, we just have to keep them in the ward. We can't discharge people onto the street." Describing herself as "an optimistic cynic", Borewicz says she has been quite impressed with recent efforts to relieve the problems and hopes the new crisis taskforce will come up with some immediate solutions. "Management needs to be upfront and honest about the issues, then you'll get co-operation across all services. I know how dedicated the nurses are and I think a bit of affirmation and appreciation would go a long way to boosting morale."

NZNO organiser Christin Watson's patch comprises Capital and Coast and Hurt Valley DHBs. Ward 27 is by far the most difficult area he has to deal with, he says. His main priority is ensuring the safe staffing clauses in the DHB and multi-employer collective agreement are honoured. "My task is to ensure the required number of staff is on the roster. Unfortunately, there is a high reliance on casual staff, which is not a sustainable solution. High use of casual staff can put increased pressure on permanent staff. The afternoon shifts can be particularly hard to fill. Nurses want a say in how the ward is run, especially how to manage the overcrowding. They believe that if a bed is required for an acutely unwell and at-risk client, then the person authorising the admission must find a placement for the least unwell and lowest risk client among the current inpatients.

"It's been a rocky road trying to maintain meetings between managers and union members, but comforting to see that the big divide between managers, senior nurses and staff nurses I observed last year has changed. The DHB doesn't want to provide more inpatient beds, so the answer lies in opening up more community beds and securing the funding for that. "The other key is to encourage the private providers to move people on once their needs have been met. At present, some private providers have little motivation to move people on when all they want to do is fill the beds. This is something over which the DHB has little control. One of the answers might be for the DHB to provide some of that community care itself." Watson has enormous respect for the nurses and health care assistants who work in Te Whare o Mataurangi. "Our members are committed to making the ward work better. In my opinion, anyone who works there deserves a medal. The staff are always being asked to work late and do extra shifts and the work is so demanding, yet so important. These people are heroes."