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C I. .. . I .o...t . ...-.. ...... ... .. . . I .. I. . . O. Ix .7 . . ... ... . .I O . .a 3 . . . D . ... ' . . . . . . . v . . . .0 I. . v a . .t . . . . . . . a . .. r I. 00 OD I .. . . . I I 0 .OI'I.. . 09¢ . This is to certify that the thesis entitled PAT 13M MID EIIPLOYEE LABOn IN A STAIE P-EII‘L‘AL HOSPITAL £001) SEnVICE presented by KATHLEEN xtU'i‘H UmbH has been accepted towards fulfillment of the requirements for Master of Science degree inmon Administration Major professor 0-169 0 PATIENT AND EMPLOYEE LABOR IN A STATE MENTAL HOSPITAL FOOD SERVICE BY KATHLEEN RUTH CREECH A THESIS Submitted to the School of Graduate Studies of Michigan State College of Agriculture and Applied Science in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Institution Administration 1955 ABSTRACT The purpose of this study was to analyze in terms of labor hours both patient and employee labor assigned to the Food Service at Kalamazoo State Hospital. The hospital had a census of 3,500 patients and 900 employees. The Food Service was operated on a decentralized basis with fourteen kitchens located in thirteen differ- ent buildings without connecting rampways. The first objective was to obtain information concerning the histories of the patients assigned to Food Service and Food Supply (extra-departmental). Accordingly, factors which might have pointed out their work capacity, sex, category of freedom, and age, were investigated. The second objective was to compare patient and em- ployee labor hours and to determine the distribution between the two groups. The final objective was to determine the distribution of labor hours between three large and ten small kitchens and to compare the number of meals produced per labor hour. During the time of the study, there were 87 employees, 55. women and 32 men; and 151 patient helpers, 117 men and 34 women, assigned to Food Service. The average age of patients who were ii 354768 on duty in Food Service and Food Supply (extra-departmental) was 49 years; the age range was from 14 to 82 years. Twenty-seven patients were assigned to Food Supply. The kitchens were grouped according to function as well as location to facilitate the interpretation of data. In the function clas- sification, the kitchens were three large, ten small, and one diet; in addition, there were four cafeterias and one bakery. Ninety-three per cent of the labor hours was in the three large kitchens, ten small kitchens, and four cafeterias. Seventy-five per cent of the patient labor hours was accrued in the four cafeterias and ten small kitchens. Seventy-three per cent of the employee labor hours was in the three large and ten small kitchens. The average number of meals produced per labor hour in the large kitchens was 18.19, in the small kitchens the corresponding number was 10.23. Sixty-two per cent of the food or an average of 6,930 meals per day was prepared in the large kitchens, the com- parative number for the small kitchens was 3,964 or 35 per cent of the food. iii ACKNOWLEDGMENTS The author wishes to express her sincere appreciation to Miss Katherine Hart for her encouragement, patience, advice, and guidance in the execution of this study, and to Dr. Pearl Aldrich for her sug- gestions and constructive criticisms. The author desires to express her gratitude to Miss Grace B. Murray, Chief Budget Examiner, Department of Mental Health; to Dr. R. A. Morter, Medical Superintendent, Kalamazoo State Hospital; and to Mrs. Marie Lemmer, Dietitian, Kalamazoo State Hospital. The study was made possible through their cooperation. Appreciation is also extended to Major General Harry G. Arm- strong, former Surgeon General, United States Air Force, and to Colonel Miriam E. Perry, Chief, Women's Medical Specialist Corps, United States Air Force, for their encouragement. iv TABLE OF CONTENTS INTRODUCTION ............................... REVIEW OF LITERATURE ....................... Treatment of Mental Disorders .................. Psychiatric Occupational Therapy ................. State Care ................................. Hospital Labor Hours ......................... METHOD OF PROCEDURE ....................... Physical Plant .............................. Food Service Operation ........................ - Assignment of Patients ........................ Employee Labor ............................. Collection of Data ............................ Interviews ............................... Compilation .............................. DISCUSSION .................................. Patient Labor ............................... Distribution of men and women ................ Page Category of freedom ........................ 51 Age distribution ........................... 53 Employee Labor ............................. 56 Patient and Employee Labor Hours ................ 60 Comparison .............................. 60 Distribution .............................. 62 Comparison of Kitchen Production ................ 65 SUMMARY ................................... 67 LITERATURE CITED ........................... 69 APPENDIX ................................. , . . 75 vi LIST OF TABLES TABLE Page 1. Distribution of men and women patients assigned to Food Service according to location classification ...................... 48 '2. Distribution of male patients assigned to Food Supply ............................. 50 3. Classification of Food Service kitchens according to location and function .............. 50 4. Age range and average age of patients assigned to Food Service and Food Supply according to location classification ........ i ..... 54 5. Distribution of men.and women employees in Food Service according to function classification ............................ 59 6. Comparison of patient and employee labor hours in Food service according to function classification ...................... 61 7. Comparison of average labor hours per patient and per employee assigned to Food Service ............................ 64 8. Distribution of patient and employee labor hours in Food Service according to function classification ............................ 64 vii LIST OF FIGURES FIGURE Page 1. Schematic map of Kalamazoo State HOSpital ................................ 30 2. Distribution of men and women patients in Food Service and Food Supply accord— ing to function classification ................. 52 3. Age distribution of patients assigned to Food Service and Food Supply . ............... 55 4. Kalamazoo State Hospital Table of Organization for Food Service ................ 58 5. Percentage comparison of patient and employee labor hours in Food Service according to function classification ............. 63 6. Percentage distribution of patient and employee labor hours in Food Service according to function classification ............. 66 viii INTRODUC TION At no time in history has there been greater public concern about mental hospital care than in the mid-twentieth century. Each year almost as many people are admitted to our mental institutions as are graduated from our colleges (32). The numerous problems encountered in the treatment of mental illness have created a grow- ing demand for more effective programs. Currently, one-half of all our hospital beds are occupied by those who are mentally ill. Hos- pitals are fourth in the list of expenditures of state governments, surpassed only by schools, social welfare, and highways (12). State governments are faced with insistent demands both for increased facilities and for higher standards of care for mental patients. The mentally ill need pleasant surroundings, proper hous- ing, and comfortable beds. These individuals require well-prepared, nutritious food, adequate provisions for personal care, and therapeutic work assignments. The State of Michigan maintains eleven mental hospitals with a capacity for 27,000 patients. In addition, Wayne County General hosPital had facilities for 3,800 and Wayne County Training School for 600 patients on a state contractual basis. Six of the state hos- pitals are for the mentally ill, one for the criminally insane, one for the epileptic, and three for the mentally deficient. Kalamazoo State Hospital, founded in 1859, is the oldest; Northville State HosPital, founded in 1952, is the newest. Both of these institutions are for the mentally ill. To insure the wisest use of hOSpital appropriations, far—sighted business judgment is imperative. Ideally, this business judgment should be tempered with a keen sense of social obligation. In any institution the cost of food and food production are large items of expense. Food is one of the factors conducive to the well-being of mental patients. The food budget for State Mental Hospitals in Mich- igan has been stabilized on a relatively satisfactory basis. With the adoption of the Recommended Dietary Standard in 1949, the basis for control of the cost and poundage of .Specific food classifications was established. To formulate the standard, food commodities were di- vided into seven basic groups recommended by the Council of Foods and Nitrition of the American Medical Association. Serving portions were established on the basis of pounds within each food group. Bud— get allocations have since been allotted on the basis of this standard. One avenue for more effective food service operation is the maximum utilization of labor. In mental hospitals, throughout the ages, the policy of having the patient contribute his services has been sanctioned. During the nineteenth century, this procedure was advo- cated with the idea of offsetting a portion of the expense for the patient. Medical observations have shown that mentally ill persons were more content when they were allowed to work. During the twentieth century, work has been extensively used as a part of therapy for mental disorders. Since the primary motive is the improvement of the patient, state mental hOSpitals do not mea- sure labor in terms of cost and production alone. Patients are en- couraged to perform duties in the areas related to their basic needs for food and clothing. Working conditions must be adapted to the special requirements of these individuals. The purpose of the study was to analyze in terms of labor hours both patient and employee labor assigned to the Food Service at Kalamazoo State Hospital. At the time of this study, this hOSpital had a census of 3,500 patients and 900 employees. The operation of the Food Service Department was decentral- ized with fourteen kitchens located in thirteen different buildings. The first objective of the study was to obtain information concerning the histories of assigned patients. Accordingly, factors which might point out their work capacities were investigated; these included sex, category of freedom, and age. The second objective was to compare patient and employee labor hours and to determine the distribution be- tween the two groups. The final objective was to determine the labor hours between three large kitchens and ten small kitchens and to com- pare the number of meals produced per labor hour. This analysis will show a food service labor picture typical of a state mental hospital which was established prior to the Civil War. In addition, the study might prove valuable for further investi- gation of the relative merits of Operating with centralized or decen- tralized kitchens on the basis of labor productivity. REVIEW OF LITERATURE Until recently people with mental disorders were stigmatized by society for their weaknesses or spiritual and moral offenses. As outcasts, they were faced with discouragement, failure, and a lost battle. Eventually these individuals were committed to state mental hospitals where they had to begin life anew with a childlike emotion in search of love and encouragement. Treatment of Mental Disorders During ancient times, persons who showed major signs of melancholic insanity were driven out of the, cities as outcasts or they were confined to dark cells. In contrast to this, those who were in- sane but showed signs of gaiety and sociability were treated with reSpect and kindness. Asclepiades, a Greek physician born in 124 B. C., changed the tradition and ordered well-lighted rooms for his melancholic patients (7). He advocated activity for the mentally ill and was the first man in history to use music therapy (41). In Rome a hundred years later, Celsus, an important medical author, revived the teachings of Asclepiades. However, for the mentally ill he prescribed labor to the point of fatigue (8). In addition, he advocated chains, flogging, and a semi—starvation diet (17). Galen, a remarkable physician who settled in Rome a century after the death of Celsus, stressed exercise in preference to employ- ment for persons afflicted with mental disorders (24). During the next two hundred years, several writers discussed insanity but made no contributions to existing theories. In 332 B. C. in Egypt, the men- tally ill were provided with pleasant surroundings, occupation, enter- tainment, and exercise (10). From the fourth century B. C. until the eighteenth century, practically no progressive methods were re- corded for treatment of mental disorders, except the recommendation made by Caelius Aurelianus. He advocated sun baths for the insane, recommending that the head of the patient be covered during the first few treatments (19). From the time of Aurelianus until the founding of the medical school at Salerno, Italy in the tenth century, most of the important medical writings originated with the Arabs. Johannes Actuaries, a Byzantine author, devoted considerable time to the study of the mind and its diseases (41). Historically, his work was an important link between the past and the Renaissance. Many thousands of insane persons were executed between the fourteenth and eighteenth centuries; most of these deaths were ordered by the Courts of Justice. Other lunatics were subjected to torture in the hope of expelling the possessing demon; it was believed that a foul remedy would force the demon to leave the body (27). Nowhere during the medieval period did the mentally ill find understanding except from the Moslems (17). The savage treatment of the insane continued, but religious leaders made some advancement toward more humane care. By 1547, the English Monastery, St. Mary of Bethlehem, had admitted some lunatics and as a result became known as ”Bedlam" (40). Spain was more progressive in the care of those who had mental discrders than the other countries (58). The first European asylum devoted exclusively to the treatment of the insane was established in the Iberian Peninsula toward the end of the Middle Ages by Father Gila- bert Jofre (17). Subsequently, other asylums were built in Spain dur- ing the fifteenth century. In 1723, Miguel Escartin, Bishop of Lerida, encouraged the inmates at the Spanish Insane Asylum of Saragossa to perform tasks. Patients were classified into work groups according to their abilities, and an attendant was in charge of each group. The duties of the attendant were to allocate work assignments and to act as overseer for the restless individuals who were more content when they were occupied (52). In 1772 William Cullen, a British Professor of Medicine at the University of Edinburgh, told his students that some maniacs had been cured by performing constant and hard labor. Cullen further stated that for all hypochondriac patients there was nothing more pernicious than absolute idleness or an absence of all earnest labor (41). During the same year, Benjamin Franklin recommended to the Pennsylvania Hospital that inmates capable of manual labor should be supplied spinning wheels, wool, and flax. In America the first hospital, provided to care exclusively for the mentally ill, was erected in 1769 in Williamsburg, Virginia. The Eastern Lunatic Asylum had the distinction of being the only such hOSpital in America for twenty years. PrOposals for constructing a similar institution had been discussed in several colonies, but the plans never progressed beyond the embryonic stage (17). The influence of the Quaker Society of Friends was reSpon- sible for the acceptance of occupational therapy as a part of mental treatment at the Pennsylvania Hospital. The Quakers were convinced that work would strengthen character and health (17). In 1873 Dr. Benjamin Rush joined the staff of the hospital and centered his atten- tion on patients who had mental disorders. Dr. Rush (56) stressed the importance of good care for the mentally ill. Phillippe Pinel, a friend of the French revolutionaries, started an occupational therapy program in Paris mental hospitals in 1786. Pinel based his policy for the treatment of the insane on "three legs", medical care, kindness, and justice (41). He was insistent that bru- tality to the mentally ill was useless; and, in the midst of opposition, he went to the great Common Council in Paris to plead the cause of the unfortunates (40). In addition, Pinel (52) recommended and proved from his experiences at two large asylums in Paris that manual labor resulted in good morale and discipline among patients. The operation of farms by the insane was initiated by Pinel, ‘who has been called the “Father of Occupational Therapy” (39). His progressive exam- ples were followed in Germany by Reil and in England by Tuke (41). Although Pinel influenced the psychiatric practice in many European countries, the accomplishments of Tuke in England set the precedent in America (17). William Tuke was a Quaker and, like so many of his sect, a practical idealist. In 1796 he was instrumental in establishing the Retreat at York for persons with mental disorders. The principles formulated for patient care were: to provide a family 10 atmOSphere, to emphasize employment and exercise, and to consider the hospitalized persons as guests rather than inmates (17). The fame of the capable English doctor and his philosophy of mental care rapidly spread to America. Thomas Scattergood, a Quaker Minister from Philadelphia, visited the Retreat in 1800 and was impressed with the management of the insane. When Scattergood returned to Pennsylvania, he zeal- ously pleaded with his friends to establish a similar retreat. His efforts materialized with the opening of Friends Asylum at Frankfort, and the treatment of patients was based on the policy of non-restraint and occupation recommended by Tuke (41). In Germany in 1805 Dr. Reil devoted most of his time to im- proving conditions for the insane; and he also founded the first jour- nal devoted to psychiatric problems. With evangelistic appeal, he persuaded the peeple to accept more progressive methods for treat- ing mental illness (17). At the beginning of the nineteenth century, William Hallaran of Cork Island wrote that abundant proofs were continually occurring in favor of employment for the insane (31). He commented that pa- tients who worked had a happy state of oblivion from their real or imaginary grievances. Hallaran further advocated work for incurable 11 persons in good physical condition because he felt their labor might offset a portion of the maintenance expense. In 1815 Thomas Eddy, a member of the Board of Governors of the Society of New York Hospital, studied the value of employment for mental patients. He read a paper to the Board setting forth his theories concerning the care of the insane in which he advised a balanced program of exercise, entertainment, and employment. Eddy recommended that the types of employment prescribed for patients should prove agreeable, on both a moral and physical basis, to the individual concerned (30). The McLean Asylum which opened in Boston in 1818 developed a philosophy of treatment that- emphasized kindness and humanity rather than severity and cruelty towards the patients (17). Dr. Rufus Wyman, the resident superintendent of this asylum, was the first med- ical man in America to be appointed to such a position. Being fully aware of the use of patient labor in Europe, he established a program of occupational therapy. As a department of the New York Hospital, the Bloomingdale Asylum was opened in 1821. The main building, with accommodations for 200 patients, stood on the site now occupied by the Columbia University Library. The philosophy of treatment in this establishment was moral management (17). 12 Jean Esquirol, the successor of Pinel, stressed the use of agricultural facilities in conjunction with the French asylums. He advocated organized work at stated periods during the day for his patients (55). According to Leuret (39), in his book published in 1840, there were some physicians in France who resisted the use of manual labor for private patients. The relatives of the inmates contended that persons who paid for their room and care should not work, and their objections undoubtedly influenced the attitudes of the doctors toward work therapy. Leuret insisted the antagonism would soon disappear if the people who were concerned could witness the advantages of keeping the patient occupied with useful work. Dorthea Lynde Dix was a crusader for the mentally ill. In 1834 she pleaded with the members of the Massachusetts Legislature to correct the miserable, desolate, and unfortunate condition of these outcasts. The results from her efforts were outstanding and far- reaching (18). Dr. Thomas Kirkbride, Superintendent of the Pennsylvania Hos- pital for Insane, embarked on a program of mental care which stressed patient labor. In 1842 he wrote that the value of employment was so universally acknowledged that no arguments were required in its favor-- (1). Kirkbride was convinced that since the primary objective of 13 employment was to restore mental health of the patients, the merits of work could not be measured in dollars and cents. However, his principles were not widely accepted, and occupational therapy did not make gains comparable to those in Europe (41). Pliny Earle conducted a survey of the insane asylums in Prussia, Austria, and Germany in 1844 and was favorably impressed with the advancement of occupational therapy. He found the Charity Asylum in Prague to be the most humanely conducted of all those he surveyed. The minds of the patients at Charity were occupied by moderate labor, household duties, and entertainment; and the patients were financially rewarded for their services. Dr. Reidel, the Super- intendent of Charity, was a firm believer in the therapeutic value of labor. He asserted that work often effected a cure when all other measures, both moral and physical, had failed (41). The observations of Dr. Wilson at the Bloomingdale Asylum in New York convinced him that important advantages were derived from regular and systematic employment of patients. In 1845 Dr. Pliny Earle organized a school of instruction for inmates at Bloom- ingdale. At that time more hoSpitalized females than males were employed voluntarily, because sewing was available and popular with the women. Areas where the men worked were the farm, carpenter shop, kitchens, and laundry (30). 14 The oldest continuous program of work therapy in history re- ceived official recognition from the Belgian government in 1855. Then, 1500 families were participating in a home care project for 1800 insane persons. The mentally ill were treated as household members (41). During the middle of the nineteenth century, work therapy pro- gressed slowly in America because of the independent spirit of the patients. They associated labor with pecuniary profits and refused to work without pay. In several European institutions, the inmates were given compensation, usually in the form of an extra allowance of beer or tobacco, for their labor. American physicians, feeling the practice too extreme for the severe simplicity of our national tastes, objected to the idea (41). Edward Jarvis, on his visit to the British Asylums in 1860, discovered occupational therapy to be the accepted policy. The man- agers of the public hospitals were encouraging patients to work. Dr. Cleaton of Liverpool, in his annual report to the Lunacy Commission in 1862, stated that the two major improvements in the treatment of the insane were the increased use of work therapy and the discontin- uance of mechanical restraint. By 1875 occupational therapy had spread to Portugal, Norway, and other European countries (41). 15 The final quarter of the nineteenth century was the least auSpicious for occupational therapy because of the increased respon- sibilities of physicians. At the turn of the twentieth century, work as a therapeutic agent for neurosis was introduced in Switzerland. Sev- eral establishments for occupation treatment were opened within a few years by Swiss people. One of the outstanding institutes of this kind was organized in 1894 by an engineer, Grohman. From his survey of patients who were treated at the institute, Dr. Henri Mon- nier concluded that work which aroused attention and interest of the patients had therapeutic value (41). In 1894 Miss Susan Tracy organized the first student course in invalid occupation at the Adams Nervine in Boston. The program was specially designed to prepare instructors to supervise patient activities. In the spring of 1911 the first course for nurses in Occu- pation Treatment was offered at the Massachusetts General Hospital (41). Harvard University became interested in work as a form of treatment for the insane and in 1906, through the Proctor Fund, granted $1,000 to Dr. Herbert Hall for research. Dr. Hall assisted with the study for the care of neurasthenic persons by progressive and graded manual occupation. He established a craft center at 16 Marblehead, Massachusetts, for industrial therapy. Here craftsmen, working with the neurotics, attempted to help in readjusting their emotional conflicts. After four years of observation, Dr. Hall con— cluded that the results obtained were favorable. He felt that the nor- malizing effect of suitable manual work or even of well-chosen intel- lectual work for neurotics needed only to be seen to be profoundly appreciated (41). For many centuries, public attitudes toward mental illnesses were based on misconceptions and prejudices. Throughout the greater part of history, occupational therapy has been recognized by the medi- cal profession as an aid in the treatment of mental diseases (54). This method of therapy has received varying degrees of acceptance. Psychiatric Occupational Therapy Since mental patients are occupied only a small portion of the day with medical treatment, the balance of their time needs to have a definite plan. Constructive use of free hours has aided in alleviat- ing the discontent which results from prolonged idleness (62). A mental hospital has many characteristics of a self-sustaining community with diversified occupations which furnish an ideal solution for selected employment of patients (12). Although the welfare of 17 the hospitalized person has been the primary factor in all work as- signments, the practical and economic considerations have not been neglected (37). According to Alexander (1), occupational therapy is one of the most potent auxiliary forces for the rehabilitation of the mentally ill. Among the modern psychological concepts of work, Karl Menninger has depicted a most progressive and provocative point of view. He asserted that work was one of the best available methods for absorbing the aggressive energies of mankind in a useful direction (15). The primary aims of psychiatric occupational therapy as re- lated by Franciscus are: to arouse interest and to restore confidence, to establish work patterns, to develop concentration, to release exces- sive energy and tension, to exchange destructive habits for construc- tive ones, to socialize by group work, and to develop habit training (22). Licht (42) classified the different modalities of occupational therapy into six groups: agriculture, arts, crafts, education, industry and maintenance, and recreation. The sub-divisions of industry and maintenance are industrial therapy and hospital industries. The term, industrial therapy, has been used for more than a decade, but con- flicting interpretations have obscured the precise meaning. Bryan (6) 18 explained the nomenclature to include patient labor in the industries which were responsible for hospital maintenance. The more recent interpretation has referred to that category of patients who were paid for work. To eliminate the confused terminology, Licht (42) recom- mended that unpaid labor be designated ”hoSpital industries". Inch (35) defined hOSpital industries as patient activities within the institution for the production of articles or for the performance of work useful to the institution but not for outside exploitation. He stated that inside industrial work included the laundry, kitchens, wards, and shops. Inch stressed that the proper choice of work for patients was beneficial to boththe institution and the individual concerned. Franciscus (22) emphasized that the patient should be placed in his duty assignment in accordance with his mental and physical needs, his interests and abilities. He stressed that the hospitalized person was not to replace a full-time employee; he further suggested that the work day range from eight to two hours and that the length of activity be planned according to the capacity of the individual. Bryan (6) advised that each job which was available for pa- tients be analyzed. Points he suggested for consideration were: description of work, attitude of industrial therapist, environment, supervision, industrial hazards, psychological requirements, physical 19 requirements, social opportunities, hours of work, and an additional notation by the therapist of her impressions of the job. The interview of each patient by the psychiatrist is one of the important phases of the hospital industry program in preparing the patient for his assignment. In the majority of cases, the person concerned is encouraged to state his work preferences. The work prescription for each patient is usually discovered by trial and error (34). Worchel (67) felt that industrial therapy or hOSpital industries should be considered as guidance and not as a prescription. He ex- plained that guidance inferred a continual process which assisted a patient in becoming a socially and vocationally useful citizen. Wor- chel added that, by implication, prescription was a static process denoting external compulsion to a certain extent. Menninger (46) stated that although some mental patients are apathetic and inattentive, sometimes satisfactory forms of occupation may be discovered for them. He further asserted that work for this category of persons had proved to be a factor in stimulating their interest. Foley (23) advised a pre—industrial or graded system of employment for patients who were too deteriorated to work in various departments of the hospital. He recommended that types of work 20 which were beneficial both mentally and physically should be planned for this class of individuals. The Occupational Therapy Department has become an integral part of most state mental hOSpitals. The trained therapists have co— operated with the psychiatrists in directing and coordinating the em- ployment of patients. In the smaller hOSpitals the department has been extended to include either the recreational or industrial pro- grams, and sometimes the three programs have been consolidated (12) . State Care Tradition has established the policy that the care of the men- tally ill is the responsibility of the state. At the begimiing of the' nineteenth century, Horace Mann made the statement to the Massa- chusetts Legislature that the insane were wards of the state, implying that it was the duty of the state to hospitalize all the insane who re- quired treatment. Throughout the years, the original assertion has been interpreted to have a broader meaning which included the build— ing, maintaining, and supervising of the institutions as well as caring for the patients (12). 21 The evolution of state care followed a long, tortuous path and was begun in 1751, when the Pennsylvania Legislature appropriated several thousand pounds for the erection of the Pennsylvania Hospital in Philadelphia. The next major event occurred in 1769 when the Lunatic Hospital at Williamsburg, Virginia, was built entirely at state exPense. Iri' 1822 Kentucky established the Lunatic Asylum at Lexing- ton, and the cost of this project was borne by the state. Between 1830 and 1840 the Utica Asylum in New York and the Worchester Lunatic HOSpital in Massachusetts charged maintenance of dependent patients to the counties in which the patients had previously resided. Both of these states paid only for the alien and non-resident insane (17). A controversy arose concerning the reSponsibility of the indi- gent insane. Was the state or the county to assume the expense? Over a half century elapsed before an agreeable solution was reached; within each state a decision was enacted. The majority of the states favored state reSponsibility. During the third decade of the nineteenth century there was an extensive asylum-building movement throughout the country. Since the belief prevailed that 90 per cent of the mentally ill could be cured, it was assumed that one hospital, centrally located, would provide adequate facilities in each state. In the sparsely settled 22 states of the West, one asylum was sufficient. However, in the East, where hospitals were filled to capacity soon after they were opened, authorities were faced immediately with problems of overcrowding. To counterbalance this unforseen predicament, the managers of the asylums adhered to the policy of admitting only acute or re— cently developed cases of mental disorders. Those persons who were mentally ill but were diagnosed as chronic or incurable were rejected and designated the "surplus insane". Since no provisions were made for the incurables, those who were not cared for in the homes of relatives or friends had to be confined to jails or poorhouses (17). A half century elapsed before a satisfactory solution was reached concerning the diSposition of the two distinct classes of the insane, chronic and acute. In the interim, state authorities were faced with new and more complex situations in the care of the men- tally ill. By 1850 it became apparent that a single state hospital could not meet the requirements of a growing population. Proposals were offered which recalled the former controversy about the respon- sibilities of state and county for the care of patients. During this interval two distinct patterns emerged with New York and Wisconsin taking the opposite viewpoint about their responsibility: New York advocated state care and Wisconsin favored county care (17). 23 Between 1863 and 1873 a State Board of Charities was estab- lished in eleven states, including Massachusetts, Ohio, New York, Illinois, North Carolina, Pennsylvania, Rhode Island, Wisconsin, Michigan, Kansas, and Connecticut. The members appointed to the different boards accepted their assignments with a dynamic attitude and worked incessantly to improve conditions for the insane. Some of the progressive members of the boards were Samuel Howe, Frank- lin Sanborn, Fredrick Wines, General Brinkerhoff, and William Letch- worth (17). Eventually, a satisfactory solution was developed for the care of both chronic and acute cases of mental illness. The "cottage" or "colony" system of institutionalism was introduced to provide facilities for the chronic patients. In this type of operationra tract of farm land was purchased, and housing was provided in the imme- diate vicinity for the long-term patients. These individuals maintained the farm and performed other essential duties. In America the colony system began in 1855, when 250 acres of farm land was purchased as a part of the facilities of the Kalamazoo State HOSpital in Michigan (17). New York was more progressive in the treatment of the insane than the other states. By the final decade of the nineteenth century, 24 three important reform measures were proposed by this state. These were: to remove all insane from the almshouses; to discontinue the maintenance of separate establishments for the chronic and acute cases of insanity; and to create a state office to supervise and con- trol the operation of all mental institutions. The Office of the Com- missioner in Lunacy was created-to enforce the proposed measures. The Association of Medical Superintendents waged a long and acrimonious fight to block the creation of Commissions in Lunacy. Medical men were anxious to maintain independent authority over their institutions and felt that the authorization of another agency would be injurious to the existing efficient system of control. The protests of the Association were not effective, and other states adopted the plan established in New York (17). In some of the states, the responsibility for the indigent insane was accepted at county level, and a hosPital was constructed in the local vicinity for their care. Within a few years, the shortcomings 0f the county-care system were obvious; the hospitals were not ade- quately supervised, uniformly constructed, or standardized in methods 0f treatment. By the latter half of the nineteenth century, the defects of the county-care plan had become more evident. As a corrective measure, legislative bodies recommended larger hospitals constructed at state expense (68). 25 By the beginning of the twentieth century the state-care System for the insane was functioning in all the states except Wisconsin and Iowa. In those two states the county-care plan still persisted (17). According to Davis and Rorem (16), by 1932 the states had accepted the major responsibility for the hospitalization of mental patients. At that time there were 223 state and 53 county hOSpitals; of the county institutions, 33 were located in Wisconsin. For the fiscal year 1949, the states varied widely in their annual maintenance expenditures per resident patient. Wisconsin had the highest per capita cost, $1,089; Tennessee had the lowest, $324. Among the forty-eight states, Michigan ranked third with a per capita cost of $917.94 (12). In 1951 the National Association of Mental Health reported that 82 per cent of all mental hospital beds were state maintained. Sixty per cent of the mentally ill patients in the state-operated insti- tutions were reported to have been hospitalized from five to forty- five years or longer (50). The introduction of the state-care policy marked a great milestone in the treatment of mental disorders. 26 HOSpital Labor Hours The successful operation of any industrial, government, or medical organization is largely determined by the caliber of personnel. Efficiency of the operation is impaired if employees are inadequately trained, insufficient in number, or incompetent. State mental institu- tions have a three-fold function: to treat and give humane care to the patient,-to teach medical personnel, and to conduct research (12). According to a publication by the Council of State Govern- ments, in 1949 all state mental hospitals were using patient labor in addition to employees. One-third of the institutions were paying pa- tients who performed useful work. A larger percentage of the mental hOSpitals were permitting more patients to assist in the Food Service Department than in the other available hospital activities (12). Owens and White (51) agreed that food could have therapeutic value for patients. They recommended that the Food Service Depart- ment have an adequate number of trained and understanding personnel for the performance of this function. Hospital administration is a growing profession. Hospitals are unlike industry, for they do not have profit as a primary motive. Many of the services rendered must be on an individual basis, be- cause there is no substitute for the intelligent use of hands, feet, 27 head, and heart. Mental institutions operate twenty-four hours a day, every day of the year. Time schedules must be flexible so that emergencies can be adequately handled. The personnel turnover in state hosPitals is high in comparison with other types of public employment. From the standpoint of the care and treatment of patients, this is an unfortunate circumstance. Salaries in medical institutions have increased substantially, but they still are too low to attract well qualified personnel (12). Until recently hospital employment was relatively undesirable, because the labor hours per week exceeded the number required in other occupations. The former two-shift work policy in each twenty— four hours has been replaced by a three—shift system. Hospitals have found it necessary to pay a 10 per cent bonus to employees who work at night (60). 28 METHOD OF PROCEDURE Since state mental hospital agencies do not follow any discern- ible general pattern of organization, there is a wide divergence in administrative structures, responsibilities, functions, and services. In Michigan the responsibility of the State Mental Hospitals is dele- gated to the Department of Mental Health, which was created in 1945. Physical Plant The Kalamazoo State HOSpital is located south of the city of Kalamazoo, Michigan. The hospital Operation includes 1,402 acres with a dairy herd and farm. The buildings are constructed of red brick and range in height from two to four stories; the grounds are beautifully maintained and landscaped. Figure 1 shows a schematic map of the principal hospital buildings. The central and largest building of the hOSpital is desig- nated Receiving Hospital. This structure houses the acutely ill, some of the convalescent patients, and the administrative offices: The buildings which house the female patients are situated on the north side of Receiving Heapital, and the arrangement is similar on the south side for male patients. The oldest and largest structure Z9 Hmfimm om mpudsppm : micron 838m 2. 338m “£33m S Hdfiamom unaduuohsrfi .332 >334 h unofiuudmofl 3.32 o 8502326632 Humanoo 032 13.9“»:de hopcmpumo magnum om maggouom 01“..th m Hmfiamom Gonna Gd> ma taumEHSdH 0?th v ommfioO uofiom N; wcfipfidm 30:52 3304 m owmfioO 00.332 A: faudEuMde 362 N unmfiuudaofl @3th ma magmooom 3.32 H ”poucoo wade—pom ”Hdfimmom wcgwoomm assess .oz . magnum . oz ZOHH 30m mafia 130 m THQLUHEM m aduoaoU ZOHHfl0u0m HU9’ /)/7’ Name Pay- Wed. ThurlFri. Sat. Sun. Mon. Tues. of roll 15 16 17 18 19 20 21 Total Employee No . Sept . C- H- 12 OFF 0;; 1/ z/ / / / é/fl W. C. 83 / OFF éFF l/ V x/ l/ {/0 J- A- 38 / 1/ / 1/ AW. of? a»: 3; Supply 1/ <2 Total M 4 4 W // M /é /)»0 Figure 11. Employees' time schedule. ROOM USE ONLY ROOM USE ONLY. ‘ O .- “...... MICHIGAN STAT R ITY E E 3 1293 “III 0 3 0 LIBRARIES 46 984 S