By Catia Malaquias
“Boss on floor.”
I can’t get this phrase out of my head.
Two weeks ago the South Australian Government released a report prepared by the South Australian Chief Psychiatrist into the government-run Oakden mental health facility – a facility that “specialised” in the care of older persons, particularly with severe dementia and other intellectual and cognitive disabilities. The South Australian Government responded by announcing the closure of the facility and where possible the transitioning of residents to appropriate mainstream residential aged-care facilities.
Three incidents that have occurred in the past eight months at Oakden have been referred to police, eight staff members have been stood down pending investigations and twenty-one reported to the national health regulator for action.
In relation to the culture of the facility and its staff, the Report states:
“There are exceptional people and … they did well, they did their best and they made things better, but they are not the dominant culture of Oakden.
Early on in the Review, we came across the use of the phrase ‘boss on floor’ as a distinctive form of insider communication. As a cultural practice, ‘boss on floor’ is a phrase used by nursing staff to communicate to each other that a[n external] person in authority (for example, an external assessor, official visitor, protected person’s guardian or senior SA Health employee) was in the building and/or on the ward. Upon hearing the phrase the staff would be expected to act in ways that would reduce the likelihood of being scrutinised. The phrase is telling in terms of reducing external scrutiny. It has specific meaning largely known only to those who use it.” [pp. 93-94]
After noting amongst other cultural concerns, “seclusion, restraint and rough handling practices transported from the mid-late 20th Century Glenside Hospital” and rejected as appropriate 200 hundred years ago in the United Kingdom, the Report recommended:
“the significant introduction of people in senior leadership positions at Oakden that can drive the change in culture required to one that has as its core principles the values of dignity, respect, care and kindness for both consumers and the staff that work there.”
In essence, the Report found a dominant culture at Oakden that devalued vulnerable people with significant intellectual and cognitive disabilities entrusted to their care. A finding that resonates with the findings in November 2015 of the Community Affairs Reference Committee of the federal Senate in its report on “Violence, Abuse and Neglect against People with Disability in Institutional and Residential Settings”:
“Throughout the inquiry, the evidence presented from people with disability, their families and advocates, showed that a root cause of violence, abuse and neglect of people with disability begins with the de-valuing of people with disability. This de-valuing permeates the attitudes of individual disability workers, service delivery organisations and most disturbingly, government systems designed to protect the rights of individuals.” [p. xxvi]
The importance of a positive culture is emphasised in the Report – quoting Professor Don Berwick in a recent landmark report on the safety of patients in England:
“culture will trump rules, standards and control strategies every single time, and achieving a vastly safer [National Health Service] will depend far more on major cultural change than on a new regulatory regime.” [p.71]
The Chief Psychiatrist reportedly told The Advertiser that “patient abuse and the rotten culture amongst staff at the Oakden mental health facility would likely have continued without a comprehensive review.” That review having involved 17 days at Oakden itself, including two weekends. When asked why many previous audits and investigations into Oakden had failed to uncover the “shocking” deficiencies and cause the necessary change, he answered that they “did not have the ‘degree of scrutiny’ his review was able to achieve.”
In the meantime, the Chief Executive of the federal Australian Aged Care Quality Agency has initiated “an urgent review of how we could have found that service compliant”.
Earlier this year the federal Government rejected the primary recommendation of the federal Senate inquiry – namely for a Royal Commission into violence, abuse and neglect of people with disability to be initiated. That recommendation was advanced on the basis that “only … a Royal Commission with investigative powers, funded and empowered to visit institutions [and to speak to people with disability that cannot reasonably access an external forum], could properly conduct an inquiry, and give full weight to the seriousness of this issue.” [para 10.9, p.268]
Oakden has been described by the Chief Psychiatrist as an enduring relic from the past. The Chief Executive of the federal inspection agency, following a recent visit, described Oakden as one of the “poorest examples” he had experienced.
But is Oakden a rare animal? Is the dominant culture it bred a rare culture? Rarity is sometimes more about concealing from human observation, than whether it exists. Ask an Iberian wolf – they are out there – just hard to spot.
How many institutions spend more time monitoring whether “the boss is on the floor” than the adequacy of the services they provide to vulnerable people?
It is suggested that institutions like Oakden usually receive up to 1 month’s notice of audits and inspections – and usually during normal working hours when staffing levels are higher.
The factors that led to the “toxic culture” at Oakden are not specific to Oakden, mental health facilities or facilities for people with severe mental, intellectual or cognitive disabilities.
Poor management and leadership, under-resourcing, inadequate staff training, challenging “customers”, low staff morale, low staff wages, poor complaint processes and weak regulatory oversight are factors that are far from rare – they may well be found in combination in health care institutions, aged care institutions and education institutions. The dangers of consequent abuse, violence and neglect against “customers” is magnified when the institution or a part of it provides services to vulnerable people who cannot adequately protect themselves, avail themselves of sound complaint channels or arrange transfer to an alternate setting. People with mental, intellectual or cognitive disabilities are most at risk – whether young or elderly.
The concentration and segregation of people with disabilities in discrete residential, health care, employment and educational settings increases the opportunity for abuse, whether as isolated incidents or systemically. Providing the same services in more “mainstream” environments, as is now being proposed for most Oakden residents, provides greater scope for peer review of staff and peer support amongst customers – patients looking out for patients with disabilities, residents looking out for residents with disabilities and students looking out for other students with disabilities.
The Oakden Report looks at a particular institution with a particular history – but the picture it paints and the lessons it teaches should be heeded more broadly.
In the meantime, the federal inspection agency has undertaken to visit Oakden “daily” and wants its residents moved out as soon as possible.
The “boss will now always be on the floor” until the floor is closed.
[Cover photo © Christian Langballe]