Abuse of Older Adults in Institutions

Table of Contents

1. What Is Abuse of Older Adults?
     
2. What Makes Older Adults Particularly Vulnerable to Abuse in Institutions?
     
3. How Widespread Is the Problem?
     
4. Recognition of Abuse of Older Adults in Institutions
     
5. Prevention of Abuse of Older Adults in Institutions
     
6. Reporting Abuse of Older Adults in Institutions
     
7. Tips for Older Adults in Preventing Abuse
     
8. Additional Readings
     
9. Suggested Audio-Visual Material
     
10.  References
      
11. Publishing Information

1. What Is Abuse of Older Adults?  

Abuse of older adults can be defined as any action that takes advantage of a relationship between the health care worker and the older adult. The abuse is used to the advantage of the user and to the disadvantage of the abused.¹

The National Clearinghouse on Family Violence (1998) identifies four broad categories of abuse of older adults:

• Physical Abuse involves inflicting physical discomfort, pain or injury. It includes behaviours such as slapping, hitting, punching, beating, burning, sexual assault and rough handling.
    
• Psychological abuse diminishes the identity, dignity and self-worth of the older person. Examples are name calling, yelling, insulting, threatening, imitating, swearing, ignoring, isolating, excluding from meaningful events and deprivation of rights.
    
• Financial abuse, also known as material or property abuse, involves the misuse of money or property. Examples include stealing money or possessions, forging a signature on pension cheques or legal documents, misusing a power of attorney, and forcing or tricking an older adult into selling or giving away his or her property.
    
• Neglect is the failure of a caregiver to meet the needs of an older adult who is unable to meet those needs alone. It includes behaviours such as denial of food, water, medication, medical treatment, therapy, nursing services, health aids, clothing and visitors.

Other forms of abuse include violating the older person's rights.² An example of this is providing treatment or procedures, or involving the older person in research, without consent.

The following are some examples of abuse that can occur in institutions:

• unnecessary use of physical force
    
• unnecessary use of restraints³
    
• hitting, pinching, shoving or pushing³
    
• handling roughly or administering a treatment roughly³
    
• talking to the older adult harshly
    
• making derogatory comments that can result in emotional damage or amount to mental cruelty³
    
• sexual harassment or molestation³
    
• verbal abuse that threatens the older adult, causes annoyance or discomfort³
    
• financial abuse such as theft³
    
• any form of punishment for the person's behaviour³
    
• providing care when the person does not wish it
    
• hurrying the person through care, when taking time would provoke less aggression from the person⁴
    
• neglect in any form such as not responding to an older adult's call, leaving the person in soiled linen and feeding too quickly³
    
• failing to review the care plan for each older adult on a regular basis³
    
• pushing the person in a wheelchair without telling him or her where he or she is going
    
• borrowing an older adult's belongings without permission
    
• not calling the older adult by the name he or she prefers, and
    
• seemingly innocent rules that affect older adults negatively. An example is a rule against unsupervised bathing. This rule would be made so that staff understand their responsibilities to supervise older adults while they are bathing. However, the rule would stop an older adult who is able and likes to shower alone from doing so without supervision.

2. What Makes Older Adults Particularly Vulnerable to Abuse in Institutions?  

Older adults who live in institutions can be vulnerable to abuse due to insufficient institutional resources and the difficulties encountered by health care workers.

Institutions

• Sometimes, institutions do not have enough registered nurses to provide supervision and role modelling for other health care workers who may not have any training in how to care for older adults.⁵
    
• An institution may not be giving a clear message about abuse. There may be no policies or guidelines to help the health care worker understand what is considered abusive and what the worker can do if he or she sees abuse.⁶
    
• The institution may not have the ability to provide a high level of care to the older adults who live there. The institution may not be a safe environment. Also, the institution may not be paying enough attention to the effects of the care it is able to provide.⁷

Health Care Workers

• Abuse can occur because much of the care is given by health care workers who are relatively powerless within the institution. These relatively powerless people then abuse the older adults who are even more powerless.¹
    
• Health care workers in institutions may see the older adult as needing only custodial care so that only basic physical needs are looked after. This can result in health care workers not caring for the whole person.¹ As a result, the older adults are not given a chance to care for themselves, to take on responsibilities or to have much control over their situations.⁸
    
• Health care workers may have too many older adults to look after each day, increasing job stress.⁶ This stress can sometimes result in mistreatment of older adults.
    
• A health care worker in institutions who has had little education or training about the care of older adults may display behaviours that are abusive.⁵
    
• A health care worker's cultural background may be different than that of the older adult, which can lead the worker to exhibit a lack of respect or understanding of the things that are important to the resident.⁹
    
• Some health care workers may not know that what they are doing is abusive. For example, a health care worker may think that taking an older adult to an activity is for the best, even when the person does not want to go. This is abuse because it takes away the older adult's right to choose how he or she wishes to spend the day.¹⁰

Older Adults

• Residents often have diseases or disabilities, such as Alzheimer's, which rob them of their memory and ability to carry on usual activities. Such residents sometimes act in ways that staff find frustrating. What makes the situation more dangerous for these older adults is that their illness may prevent them from being able to tell anyone that they have been abused.⁶
    
• Older adults who are able to say that they have been abused may not wish to inform on other health care staff because they are afraid of what the health care worker will do to them or because they think they do not have any rights.¹¹
    
• Older adults can sometimes be abusive and aggressive toward health care workers. Health care workers often find themselves being hit, scratched, bitten, called names and yelled at when they are providing care to the older adult.¹² If there is no one for the health care worker to talk to about this, the frustration is sometimes taken out on the older adult.

3. How Widespread Is the Problem?  

In 1994-95, more than five percent of adults older than 65 were living in institutions (Statistics Canada).

It is very difficult to estimate how much abuse actually goes on in institutions that are caring for older adults. The three identified studies that focus on the topic of abuse were all survey studies. While they are not strong scientifically because they do not indicate the incidence of abuse, they do confirm that the problem of abuse of older adults does exist.

The Ontario College of Nurses¹³ surveyed 804 nurses and 804 nursing assistants:

• 20 percent reported witnessing abuse of patients in nursing homes.
    
• 31 percent reported witnessing rough handling of patients.
    
• 28 percent reported witnessing workers yelling and swearing at patients.
    
• 28 percent reported witnessing embarrassing comments being said to patients.
    
• 10 percent reported witnessing other staff hitting or shoving patients.

In another survey conducted in Quebec,¹⁴ 140 professionals were asked about violence that they knew about in institutional or home settings:

• 974 acts of abuse were identified.
    
• Of these 974 acts, 35.5 percent were observed in residential centres or hospitals.
    
• Another 28.4 percent were observed in institutions, which included private institutions receiving government aid.

Two American researchers⁵ surveyed 577 nurses and nursing aides who were employed in 31 different nursing homes in New Hampshire. The staff reported that in the year before the study took place, the following behaviours were observed:

• Physical abuse had been witnessed by 36 percent of staff.
    
• Excessive use of restraints was witnessed by 21 percent of staff.
    
• Pushing, grabbing, shoving or pinching was witnessed by 17 percent of staff.
    
• Slapping or hitting was witnessed by 15 percent of staff.
    
• Psychological abuse was observed by 81 percent of staff and included yelling at the resident in anger, insulting or swearing at the resident, and isolating the resident inappropriately.

4. Recognition of Abuse of Older Adults in Institutions  

The following is a list of signs that will indicate that an older adult may be being abused by a health care worker:

• The resident's account of what happened in a situation is different than the health care worker's account.
    
• The worker's account does not seem credible in light of the degree of injury suffered by the resident.
    
• The health care worker gives a bizarre or vague explanation of the injury suffered by the resident.¹⁵
    
• The resident is afraid, seems paranoid, is depressed, withdrawn, angry and/or agitated.
    
• The resident's behaviour changes when the health care worker enters or leaves the room.¹⁵
    
• Older adults who have dementia will sometimes talk about what has happened to them. The health care worker should also listen to what the older adult says even if he or she appears to be confused. Often, kernels of truth can be found in what seems to be senseless rambling.¹⁶

If physical abuse is suspected, a physical examination should look for the following:

• injuries around the mouth, face and eyes;
    
• clumps of missing hair and/or haemorrhaging beneath the scalp, which suggests hairpulling;
    
• bruises (especially any in the shape of hand or finger marks) in unexplainable places; and
    
• injuries around thighs and perineum if sexual abuse is suspected.

5. Prevention of Abuse of Older Adults in Institutions  

There are two levels of responsibility for preventing abuse.

At the first level, the institution has a responsibility to ensure that there are ways and means in place that reduce the risk of abuse to the older adult. An institution can do this by employing the following methods:

• Develop a mission statement that is resident-focussed and stresses a commitment to quality of care and quality of life.¹⁷
    
• Post a residents' bill of rights.¹⁷
    
• Ensure that all staff are familiar with what is considered to be abuse of residents.
    
• Have a policy of zero tolerance for abuse. (This may vary depending on labour standards in different provinces.)
   
• Ensure that comprehensive investigation procedures are developed and initiated promptly, whenever there is suspected or actual occurrence of resident abuse.¹⁷
    
• Provide regular in-service education for all staff about the aging process to increase sensitivity to the needs of older adults.
    
• Encourage and help all staff to take courses in gerontology to increase their knowledge of the aging process.
   
• Provide conflict-resolution training for all staff.¹⁷
    
• Institute regular multidisciplinary care planning meetings to discuss care approaches with specific directions for the management of hard-to-care-for residents.
    
• Encourage staff to bring their concerns and frustrations regarding hard-to-care-for residents to the attention of their supervisor, because regular, open discussion will help to diffuse tensions, and will help staff to view the situation without being overly influenced by their emotional reaction to the situation.
    
• Encourage staff to take five-minute cool-down breaks when tension and frustration affect their ability to deal compassionately with residents.
    
• Ensure a regular rotation of staff off heavy or difficult resident assignment groups to reduce the chance for burnout and the potential for abusive situations to occur.
    
• Alternatively, have a health care worker assigned consistently to give care to a heavy or aggressive resident. This may help the health care worker and resident to develop a relationship that may reduce the risk of abuse in either direction.
    
• Promote a strong resident's council to ensure that concerns are addressed.

At the second level of responsibility, each individual health care worker has a responsibility to ensure that his or her own behaviour toward residents is not abusive. Strategies include the following:

• Insist that care of difficult and aggressive residents be discussed in staff meetings.
    
• Talk to your co-workers about difficult-to-handle situations, and find out what they would have done if or what they did when the same thing happened to them.
    
• If a resident is fighting or resisting care, leave for a while if the resident is not able to reason with you. If the resident is able to reason, then negotiate another time or ask the resident for alternate solutions.
    
• Take a time out if you find yourself beginning to lose your temper.
    
• Apologize to the resident if you have said something that is hurtful.
    
• Ensure that you know your institution's policies and procedures about abuse. Know what abuse is and what to do about it.
    
• If your institution has no policies, find out what your supervisor thinks about abuse of residents, what this person considers abusive and how he or she would handle abuse.
    
• If you belong to a professional association, ensure that you are familiar with its standards regarding abuse of older adults.
    
• If you do not belong to a professional association, talk to a co-worker who is to find out about the association's standards.
    
• Treat the resident with all the respect that you would like to receive.
    
• Report all witnessed or suspected abuse.

6. Reporting Abuse of Older Adults in Institutions 

There are two levels of responsibility for reporting abuse.

The institution must have procedures in place so that health care workers know what to report and to whom to report it. Health care workers must feel that they can report with reasonable assurance that retaliation will not result. Health care workers must also trust that a proper investigation will occur. Residents also should be encouraged so that they feel safe when reporting abuse. A way for the institution to encourage reporting is to discuss abuse at team meetings, so that staff begin to feel comfortable talking openly about the subject.

Health care workers themselves must also report abuse. In fact, in several provinces, it is mandatory for health care workers who witness abuse to report it.¹⁸

There are many reasons for not reporting abuse when it is observed. The health care worker may feel powerless. It may be that abuse seems to be an accepted part of care at a particular institution. Also, the health care worker may not realize that what he or she is seeing can be considered abusive to the resident. A health care worker may be reluctant to inform on a co-worker for fear of being labelled a "rat" or a "squealer," or may fear how other co-workers will treat him or her when they find out. However, to avoid reporting is to say that you think it is all right for a staff member to keep abusing the older adult.

7. Tips for Older Adults in Preventing Abuse 

Older adults living in institutions do not often report abuse when they are experiencing it. This occurs for several reasons, including the following:

• Older adults may not be aware of their rights.
    
• Older adults may be afraid that they will not be believed when they report the abuse, or they feel that there is no one they can trust enough.
    
• Older adults may think that if they report the abuse the staff member will treat them even more abusively.

There are several steps that family members, friends and older adults who live in institutions can take to prevent abuse:

• Tell a trusted staff member about how you, your loved one or another older adult is being treated.
    
• Be aware of resident rights. Most institutions have a Resident's Bill of Rights, which often promotes the right to be treated with dignity. Also, in many cases abuse can be a criminal act.
    
• Do not be afraid to tell a health care worker that you do not like how you are now or another resident is being treated or touched. Write down what happened, so that you will remember the details when you report it to someone in administration.

8. Additional Readings

Beaulieu, M. & Tremblay, M. (1995). Abuse and Neglect of Older Adults in Institutional Settings: Building from French-language Resources. Ottawa: Public Health Agency of Canada, Health Canada.

MacLean, Michael J. (1995). Abuse and Neglect of Older Canadians: Strategies for Change. Ottawa; Toronto: Canadian Association on Gerontology, Thompson Educational Publishing.

Murphy, N. (1994). Resource and Training Kit for Service Providers: Abuse and Neglect of Older Adults. Ottawa: Health Programs and Services Branch, Health Canada.

National Clearinghouse on Family Violence (1994). Abuse and Neglect of Older Adults in Institutional Settings. Ottawa: Health Programs and Services Branch, Health Canada.

Pillemer, K. & Hudson, B. (1993). A Model Abuse-Prevention Program for Nursing Assistants. Gerontologist 33(1), 128-131.

9. Suggested Audio-Visual Material  

Sisters of Charity of Ottawa Health Services (1997). Abuse Prevention in Long-term Care. This educational package consists of two videos: The first is "Abuse and Prevention in Long-term Care - Intervention and Prevention"; the second is "Fostering a Supportive and Respectful Environment in Long-term Care." Included are a facilitator's guide and overheads. The package consists of nine modules which cover a wide variety of issues, including abuse, intervention, residents' rights and responsibilities, advocacy in long-term care, prevention of abuse, loss and grieving, and decision-making.

Baycrest Centre for Geriatric Care (1996). Institutional Abuse: Everyone's Problem. This educational package consists of the video of the same title and a facilitator's guide. Included in the appendices are sample forms and Baycrest abuse policies. The video is based on the premise that abuse in institutions is systemic. Various scenarios of abuse are presented with suggested strategies for avoiding or preventing the situation. The types of abuse presented include staff to resident, resident to volunteer and family member to staff.

College of Nurses of Ontario (1995). One Is One Too Many: A Program for Learning About Prevention of Abuse of Clients. This educational package consists of a video, a facilitator's guide and a self-directed learning guide. The package is aimed at nurses and addresses a variety of abusive situations, including elder abuse. The video uses a variety of techniques to present experiences and situations that may trigger abuse, and it suggests strategies for preventing or mitigating the potentially abusive situation.

10. References

1. Cassell, E.J. (1989). Abuse of the Elderly: Misuses of Power. New York State Journal of Medicine, 89(3), 159-162.
     
2. Spencer, C. (1994). Abuse and Neglect of Older Adults in Institutional Settings: A Discussion Paper Building from English-language Resources. Ottawa: Health Programs and Services Branch, Health Canada.
     
3. Ontario Hospital Association (1984). Guidelines for the Protection of Patients and Residents in Healthcare Facilities. Toronto: Author.
     
4. Meddaugh, D.I. (1993). Covert Elder Abuse in the Nursing Home. Journal of Elder Abuse and Neglect, 5(3), 21-37.
     
5. Pillemer, K. & Moore, D.W. (1989). Abuse of Patients in Nursing Homes: Findings from a Survey of Staff. Gerontologist, 29(3), 314-320.
     
6. College of Nurses of Ontario (1995). One Is One Too Many: A Program for Learning About Prevention of Abuse of Clients.
     
7. Pillemer, K. & Bachman-Prehn, R. (1991). Helping and Hurting: Predictors of Maltreatment of Patients in Nursing Homes. Research on Aging, 13(1), 74-95.
     
8. Goodridge, D.M., Johnston, P. & Thomson, M. (1996). Conflict and Aggression as Stressors in the Work Environment of Nursing Assistants: Implications for Institutional Elder Abuse. Journal of Elder Abuse and Neglect 8(1), 49-67.
     
9. Chappell, N.L. & Novak. M. (1992). The Role of Support in Alleviating Stress Among Nursing Assistants. The Gerontologist, 32(3), 351-359.
     
10. Hall, B.L. & Bocksnick, J.G. (1995). Therapeutic Recreation for the Institutionalized Elderly: Choice or Abuse. Journal of Elder Abuse and Neglect, 7(4), 49-61.
      
11. Kimsey, L., Tarbox, A., & Bragg, D. (1981). Abuse of the Elderly. The Hidden Agenda: The Caretakers and the Categories of Abuse. Journal of the American Geriatric Society, 29, 465-472.
      
12. Pillemer, K. & Moore. D.W. (1990). Highlights from a Study of Abuse of Patients in Nursing Homes. Journal of Elder Abuse and Neglect, 2, 5-29.
      
13. College of Nurses of Ontario (1993). Abuse of Clients by RNs and RNAs: Report to Council on Result of Canada Health Monitor Survey of Registrants. Toronto: Author, 1-11.
      
14. Belanger, L., Darche, T., de Ravinel, H., & Grenier, P. (1981) Violence et personnes âgées. (1) Montréal: Les cahiers de l'Association québécoise de gérontologie.
      
15. Patterson, C. & Podnieks, E. (1993). A Guide to the Diagnosis and Treatment of Elder Abuse. Ontario Medical Review, January, 11-17.
      
16. Mullan, C. (1995). It Doesn't Happen Here... Action on Elder Abuse. Elderly Care, 7(4), 3-6.
      
17. Health Horizons (1991). A Model for the Prevention of Elder Abuse in Longterm Care Facilities. Owen Sound, Ontario.
      
18. Robertson, G.B. (1995). Legal Approaches to Elder Abuse and Neglect in Canada. In Abuse and Neglect of Older Canadians: Strategies for Change, Michael J. MacLean (ed.). Ottawa; Toronto: Canadian Association on Gerontology. Thompson Educational Publishing, pp. 54-62.

This document was prepared by Irene Ens, Baycrest Centre for Geriatric Care, Toronto.