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Abuse in Nursing Homes
Special Research Review Section
National Center on Elder Abuse Newsletter, May 2002
by Lisa Nerenberg, MSW, MPH
Although the field of elder abuse prevention has historically focused on abuse in domestic settings, interest in abuse against residents of nursing homes has been rising. But as advocates call for aggressive action to ensure protection for this vulnerable population, they are discovering that little is actually known about the extent, nature and causes of nursing home abuse that could guide them in these efforts.
The forms of elder abuse found in nursing homes mirror those found in domestic settings; they include homicide, physical and sexual assault, neglect, inappropriate restraint, financial abuse, isolation, verbal threats and intimidation. In addition, nursing home abuse includes institutionalized practices that result in chronic neglect, sub-standard care, overcrowding, authoritarian practices, and failure to protect residents against untrained, troubled or predatory workers, or against abusive residents or visitors. Subtle forms of abuse that have been explored include denying residents the right to exercise personal choice in such matters as when they want to eat, get up or go to bed; pressuring residents to participate in activities; and "labeling" troublesome individuals, resulting in depersonalized treatment and exclusion (Meddaugh, 1993). It has been further been noted that facilities engage in discriminatory practices, such as emphasizing activities that favor more capable residents (Hall and Bocksnick, 1995).
What is known about the extent and nature of abuse has been drawn from a few scientific studies, surveys on the quality of care, and reports from governmental agencies that handle complaints about nursing homes, including the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration), Medicaid Fraud Control Units, and the Long Term Care Ombudsman Program (LTCOP). Several curriculum developers, in surveying workers about their information needs, have elicited information about workers' experience with abuse, further contributing to the knowledge base (Hudson, 1992; Braun et al, 1997).
Myriad problems with the research on nursing home abuse have been cited. These include variations in definitions and methodologies, which prevent researchers from comparing or aggregating results; difficulties in distinguishing abuse from substandard care or bad practice; and "contextual differences" that limit the usefulness of cross-country or cross-cultural comparisons. Perhaps the most consistent "finding" among researchers is that a national picture of abuse and neglect is not yet available.
Most of the research has focused on abuse by nurse aides. This does not suggest that other employees are less likely to abuse but, rather, reflects the fact that nurse aides comprise the largest number of employees and have the greatest opportunity to abuse. Most studies assume that abusive nursing home employees are not acting in a malicious, premeditated manner, but rather, are responding to the highly stressful nature of the work, which is attributed to insufficient staffing and time to complete tasks, interpersonal conflict and aggression by residents. One of the basic features of staff experience in nursing homes, in fact, appears to be the threat of verbal aggression and physical violence by residents. One investigator observed that within a single month, 84% of nursing aides surveyed had been sworn at or insulted and 70% had experienced some form of physical aggression, including being pushed, grabbed, shoved, pinched, hit, kicked, or hit by objects (Goodridge et al, 1996). Other sources of employees' stress include aggression by supervisors and residents' family members.
Despite the paucity of data, it is widely agreed that abuse and neglect is a common occurrence in nursing homes, and that it is significantly underreported. In the first random sample survey, Pillemer and Moore (1990) conducted confidential interviews with 577 nurses and aides, which revealed that 10% of the respondents had themselves committed one or more acts of physical abuse in the past year, and 40% admitted to psychologically abusing residents. The most common forms of physical abuse were restraining patients beyond what was needed to ensure their safety (6%); pushing, grabbing, shoving or punching (3%); hitting the patient with an object (2%); and throwing something at the patient (1%). The most common forms of psychological abuse were yelling, swearing or insulting residents, denying them privileges or threatening to hit or throw something. A full 36% of those interviewed indicated that they had witnessed other employees physically abuse residents, and 81% had observed at least one incident of psychological abuse in the last year. Braun et al (1997) reported that 14% of nurse aides surveyed had observed abuse and neglect daily, and a study of workers in Sweden (Saveman et al, 1999) revealed that 11% of the workers knew of at least one elder abuse incident in the last year (although this sample included home care workers as well as employees of long term care facilities, most worked in nursing homes).
Studies to explore causes or predictors of abuse typically define four categories of variables. "Structural variables" include societal, cultural or economic factors such as the low esteem in which the elderly are held and the insufficient labor force of workers. "Environmental factors" refer to the nursing home setting and include staffing levels, staff turnover, management, and ownership status.
Most studies of the causes of abuse in nursing homes have focused on characteristics of patients, workers or interactions between the two. Some have assumed that patients with cognitive and physical impairment, as well those who have infrequent visitors, are at greater risk for abuse and neglect (Menio, 1996), although these assumptions have not been substantiated. Patient aggression has been shown to be a particularly significant predictor of both physical and psychological abuse (Pillemer & Moore, 1990; Goodridge et al, 1996). Not only do staff strike back against aggressive residents, but severely confused and aggressive residents are more likely to be denied opportunities for personal choice (Meddaugh, 1993).
Perpetrators' characteristics that have been explored include age, gender and attitudes toward the elderly. In the case of psychological abuse, age has been shown to be a significant characteristic, with abusers being younger than non-abusers (Pillemer & Moore, 1990). Employees' negative attitudes toward residents are also a significant factor in psychological abuse. Psychologically abusive staff are more likely to view patients as "needing to have everything done for them," "waiting to die" and "like children who sometimes need to be disciplined" (Pillemer & Moore, 1990). Employees' "burnout," which is described as a progressive physical and emotional exhaustion resulting from prolonged involvement with people, has been found to be strongly associated with physical and psychological abuse. Burnout is believed to create negative job attitudes and perceptions and a loss of empathy for patients.
In a survey of nursing abuse cases prosecuted by Medicaid Fraud Control Units, 56% of the perpetrators were males; however, it should be noted that this study involved prosecuted cases, which are still relatively rare, suggesting that these abusers committed more serious acts of abuse or, perhaps, reflecting biases on the part of law enforcement (Payne & Cikovic, 1995). Abusers have been observed to be more aggressive, dominant, egoistical, sadistic and reactive, and some researchers have noted that abusers are more likely than others to lose their tempers and to have mental health problems (Shaw, 1998; Saveman et al, 1999).
Shaw (1998) suggests that workers' personality traits and circumstances influence their ability to cope with patients' aggression and determine whether they will respond negatively. According to Shaw, certain workers develop "immunity," or tolerance to aggression by residents; the ability to develop and sustain immunity is tied to such personality traits as resiliency, patience, and placing value on caring for others. Factors that undermine immunity include fatigue, financial stresses and substance abuse. Some workers never develop immunity.
Although abuse clearly has consequences for victims, abusers and society, little attention has been paid to abuse sequela. Saveman et al (1999) observed that abused residents become more fearful, aggressive, confused and withdrawn. The consequences for individual perpetrators have typically been termination from employment or disciplinary action. When individual workers are prosecuted, the sentence they are most likely to receive is probation (68%), with 23% serving time in jails or prison. Persons convicted of sexual abuse are more likely than other offenders to receive prison sentences. Abuse and neglect by facilities have typically been handled through regulatory and licensing agencies that fail to adequately maintain compliance with federal standards (USGAO, 2002).
Menio (1996) has shed light on what happens when a major corporate nursing home is criminally prosecuted. After the state's Attorney General issued the first of several indictments arising from the neglect of residents, it set in motion a series of events that had marked impact on the quality of care in the area. Sanctions were imposed by the state's Department of Health, which included temporary management and greater attention to applicants' quality of care histories when granting Certificates of Need (required to open new facilities). Fines from the criminal case were used to establish a "special ombudsman" program. Owing to special advocacy efforts, the displacement of residents was avoided.
A variety of impediments to protecting nursing home residents have been cited. A recent report by the General Accounting Office (USGAO, 2002) cites multiple gaps in protections for residents, including the inadequacies of state registries in tracking employees, inconsistencies by Medicaid Fraud Control Units in investigating abuse and neglect, the failure of local law enforcement to become involved, failure of states to inform consumers how to identify and report abuse, the failure of homes to notify state authorities of abuse allegations, lack of witnesses, and the failure of the Centers for Medicare and Medicaid Service to strengthen resident protections. Other factors that have been cited include employment practices designed to protect workers that compromise accountability such as expunging complaints of abuse from workers files if they can't be proven (Clough, 1999); lack of policies for preventing abuse; low worker pay and morale; lack of training and resources; low status of the work; lack of openness within institutions; lack of training; and poor communication between state agencies that review certificates of need (which must be submitted by providers and approved before they can open a new facility), and those that license and monitor homes, potentially permitting providers who are having trouble with their licensure to open new homes (Menio, 1996). It has further been noted that workers lack models to help them understand the authority, boundaries and intimacy issues posed by this type of work (Clough, 1999).
A variety of options have been proposed to reduce the risk of nursing home abuse:
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