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Created: May 15, 2003
Latest Update: May 20, 2003
jeannecurran@habermas.org
takata@uwp.edu
Elder Abuse in Nursing Homes: Concerns for the Nurse Practitioner
Abstract
Improved health care for older Americans will be one of the great challenges of the next several decades. By the year 2030, approximately 21% of the population will be 65 and older (Wilson and Trost, 1987).
Elder abuse is a behavior that is only beginning to gain the attention needed to apply remedies and recourse on an institutional basis. It is estimated that one in twenty people will experience elder abuse (Carluccio, 1991). Definitions of elder abuse must consider a variety of verbal and physical behaviors.
The following paper will consider verbal abuse. While seemingly more difficult to diagnose, verbal abuse is more prevalent. The lack of physical symptoms and a less than adequate understanding on the part of those who are victims of abusive behavior are of concern to the paper. Of importance to the investigation is a critical approach to understanding the recourse available to the nurse practitioner who recognizes potential and diagnosed elder abuse. The examination will limit itself to those suggestions for cases found in nursing homes.
A dramatic reversal of behavior can be witnessed after a therapeutic course has been attended to by those in proximity to the victim, as well as the perpetrator of the abuse. Theories are many, and the following examination will primarily concern itself with change theories and the expected realizations and goals resulting within the context of institutional care involving nurse practitioners. Definitions of a variety of abuses can be determined and a variety of therapeutic and change oriented approaches can be taken. The resulting examination makes prescription for the intervention of the nurse practitioner and the potential, subsequent consequences.
Introduction
Among people who seek the services of care facilities such as nursing homes are reported to have found that many circumstances in which elders are involved indicate abuse. In a study Bond, et al (1995) found that neglect was the most commonly reported category of elder abuse, followed by financial and psychological abuse. Physical abuse was the least frequently reported category. Another study conducted in 1988 as reported by Mahmiash (1995), financial abuse was the most commonly reported category, followed by chronic verbal aggression, physical abuse, and neglect.
Within the health care industry, it is a newly determined goal of many professionals to foster the changes within systems with a therapeutic and healing approach. Change theories can be employed for a structural application. Nurse practitioners have a vast potential to function within the diagnosing, treating and facilitating short term and long term plans for change in residential and support systems of elders.
The nurse practitioner faces the mounting problem of elder abuse as the population steadily ages. Valuable efforts to implement conscientious methods are crucial to the healthy functioning of care takers and nurse practitioners can maintain a professional attitude determined to facilitate the needs of the profession as well as the patient.
Of significant concern are the areas where abuse may have previously gone unnoticed or accepted. Verbal abuse results in the realization of emotional or psychological harm. Definitions, from a legal source are- emotional abuse includes ridiculing or demeaning, making a derogatory remark or cursing directly at a person who is a resident of a long term care facility. Threatening to inflict physical or emotional harm on a patient is also a crime, as long as the behavior is performed knowingly. The use of words to cause a response is a crucial criteria in determining abusive language. The recipients themselves may often allow abusive language, unable to recognize the long-term effects. To be abusive, speech must meet four criteria: as accountable speaker, unwarranted assumptions about relationships, unwarranted violations of rights. And a recipients who is harmed (Nandal and Wood, 1997).
Discussion
Theories of addressing recourse for the nurse practitioner includes a Nurse practitioners as a specialist who can have a significant role in the addressing of elder patient needs. A recent trend has been a movement away from a pathology to problem focused approach to identifying strengths and resources. While change is understood to be the goal, this valuation of change can be a guiding focus for any professional who has encountered systematic abuse and the resulting, underlying facilitate change. Neutrality is the guideline that holds the most promise for shifting the nurse from a former stance of expert, advice-giver to that facilitator in creating the context for change.
Residential Care for Elders
Currently only 5% of the population lives in residential are facilities (Smith & Maurer, 1995). Nursing homes provide an invaluable service to elders who are in need of around the clock care. Services often made available in nursing homes are continuous nursing care, rehabilitation, social activities, supervision, and room and board in state licensed facilities. Within the clinical staff of nursing homes an increase has been seen in the number of available nurse practitioners to residents.
Definition of Verbal Abuse
Verbal abuse is a demeaning and emotionally coercive dynamic present in many relationships of society. Residential care facilities for elders are no different than any other institution within society. Despite proximity to the proper mandated authorities, verbal abuse experienced by elder residents is rarely reported by the victim (Smith & Maurer, 1995). While often a result of isolation, the elder as a resident should be able to safely report the experience suffered by staff or family members. A key limitation of the information that is currently available is that it is not grounded in older person's understanding of elder abuse (Stones, 1995).
Survey of Elders Understanding of Abuse
Through interview with those over 65 a conclusion of the population perception of abuse determines methods of intervention. Penelope identifies at least five aspects of abuse: it involves illegal actions; it can take many forms; it involves particular intentions on the part of the perpetrator; it entails negative consequences for victims; and it violates ethical standards of conduct (the indicator of ethical standards in the study was the concept of good).
While perceiving the acts that may constitute physical abuse much more readily, it is concluded that elders can recognize the behavior as actions that can be abusive.
Abusive behavior can be measured through the consequences considered when attempting to define abuse. "Mental abuse can be seen as a consequence of someone's actions, rather than the actions of the person inflicting the abuse. Some participants who focus primarily on the consequence of actions also mentioned specific actions that could be abusive. Although the nature may serve to categorize the type of abuse involved, for example mental cruelty" (Nandal & Wood, 1997). Other criteria of the relationship a resident has to abuse:
Misuse of the term abusive
The study of the act of using language as a means to abuse results in elders interviewed recognizing that there are numerous and various speech acts that can be abusive: accusing, complaining, criticizing, demanding, ignoring, insulting, lying, ordering, refusing, reprimanding, swearing, and threatening.
Speech acts were often defined as abusive because of their consequences, the intention being to harm the victims. Consequences were able to help better clarify the meaning of abuse for the elder interviewees. The participants of the study determined four criteria for verbal abuse:
Possible Indicators of Psychological/Emotional Abuse
The nurse practitioner can look for a multiplicity of symptoms: helplessness; hesitation to talk openly; implausible stories; confusion or disorientation; anger; fear withdrawal; depression; and agitation. The determination by the interviewing nurse practitioner will suggest a series of interventions. The responsibilities of the victim should be to themselves. The nurse practitioner can be a facilitator in enabling the resident to recognize they can help themselves.
The nurse practitioner must address the circumstances that precipitated the relenting symptoms. The potential sources are large in a residential care facility: the support staff, other resident's visitors, the victims' own personal visitors.
Reports of Substantiated Abuse by Others
Family members of victims reported one-fifth of the 70,942 substantiated reports of domestic elder abuse and neglect in 1996. Hospitals (17.3 percent) and police/sheriff's departments (11.3 percent) followed. In addition, in-home service providers (9.6 percent), friends/neighbors (9.1 percent), victims (838 percent), and physicians, nurses, and clinics (834 percent) each accounted for slightly less than one tenth of the substantiated domestic elder abuse reports where elders were abused by perpetrators. Further, banks (0.4 percent) and public health departments (0.1 percent) were responsible for small percentages of the substantiated reports, but he numbers of their reports are negligible and may not be much greater than zero. After accounting for their larger proportion in the aging population, female elders are abused at a higher rate than males (OCV, 1999).
The nation's oldest elders (eighty years and older) are abused and neglected at two to three times their proportion of the elderly population. In almost 90% of the elder abuse and neglect incidents with a known perpetrator, the perpetrator is a family member, and two thirds of the perpetrators are adult children or spouses.
Legal Considerations
The nature of elders' sometimes vague representation of the encounters they have during the day, or with whom, can be a potential dead end for the nurse practitioner to find the means to prevent the abuse. However, many investigative sources are available, and often there are legal recourses.
In recent years, elder abuse has increasingly been addressed by the enactment of legislation. A loose web of federal and state laws, as well as private claims and lawsuits, now pertain to elder abuse. On the federal level, four laws form the bulwark of protection: the Older Americans Act; the Family Violence Prevention and Services Act; the Nursing Home Reform Act; and the Civil Rights of Institutionalized Persons Act. A fifth statute, which is part of the Nursing Home Reform Act, requires states to establish Medicaid fraud units in order to investigate patient abuse or maltreatment in institution receiving federal Medicaid funds (Buchanan, 1999).
The Older Americans Act creates federal programs designed to identify, prevent, and address elder abuse, neglect, and exploitation (Buchanan, 1999).
Grant programs to states are also authorized by the Older Americans Act to create a long-term care ombudsman program and establish adult protective services systems. Every state has some form of an adult protective services agency, although not all of them were formed in response to the Older Americans Act or depend entirely on federal funds. Most state adult protective services agencies provide a combination of social services, investigation units, and referrals that interact with other state and local agencies, law enforcement departments, and branches of the court system. The long term care ombudsman program has the responsibility to identify, investigate, and resolve complaints made by, or on behalf of, long term care residents that "relate to action, inaction, or decisions that may adversely affect the health, safety, welfare or rights of the residents" (OVC, 1999).
Nurse Practitioner Methods of Intervention
Upon the recognition of abuse as intentional and voluntary the recourse of the victim is to facilitate their own means of healing. Empowerment of the victim is a necessary step in providing them with the means to resolve the circumstances. To better enable the needs of those undergoing the circumstances of the continued verbal abuse experienced in their residential elder care facilities is a feature that a nurse practitioner could address while a member of a clinical staff, or potentially as a visiting health care provider.
Because of their round the clock surveillance of patients, nurse generalists also serve as the lynchpins of multidisciplinary teams, working closely with physicians. These teams may include attending physicians, house staff, social workers, physical therapists, and other health care professionals. Such teams are useful in hospitals, outpatient clinics, nursing homes, and hospice settings.
Model of Change
Models and theories of change are pertinent and readily dispersed. The nurse practitioner could provide clinical counseling or perhaps the establishment of a therapeutically trained staff member not on the clinical staff. An effective change agent must be a highly skilled communicator who is able to establish good interpersonal relationships; in addition change agents must be self aware and aware of others' attitudes about change and be able to handle disagreement and disappointments (Naetzberg, Dayton, and McMonagle, 1997).
Screening interviews are available as intended to diagnose the abuse. These screening interviews are brief and are practical for the practitioner.
The approach proposed for the needs of the elders within a residential care facility are comprised of a multidisciplinary team. A secondary method of response would e the determination of a "volunteer buddy scheme" which is applicable within a residential treatment facility. In essence a self monitoring strategy, the application of individual therapeutic techniques that would be administrated by the nurse practitioner and multidisciplinary team attending to the needs of individual residents. The methods to address the needs of the residents are able to suggest that understanding the definitions of what constitutes abuse. The determination that was suggested earlier is to enable the understanding that often what constitutes abuse is different for each person, may have generation connotations and may be a result of infirmities that are part of the victim's constitution that prevent them from making the obvious objections. The nurse practitioner, whose mandate is enable healing and health. To educate residents and staff concerning a significant, often unrecognized phenomenon is a professional response (Naetzberg, Dayton, and McMonagle, 1999).
The element which would bond the worker to an elder resident is an established trust. Nurse practitioners who are on staff are potentially invaluable sources of insight to facilitate the changes necessary in any typical residential care facility. The necessary professional maintenance of knowledge and research information about the ability to manage change should be a primary responsibility. Kurt Lewin's Theory of Change (Lewin, 1948) is a classic model of planned change.
Any proposed response to verbal abuse will follow a dynamic outlined by Lewin the recognition of the circumstance by a nurse practitioner can encompass. Initially the response of the part of the resident would predictably be 'unfreezing' as defined by Lewin "during this stage the motivations to establish some sort of change occurs. The client becomes aware of the need to change. This stage is a cognitive process in which the person becomes aware of a problem, and of a better method of accomplishing a task and hence a need for change. Having identified the need the client must also identify restraining and driving forces. The restraining forces are those that inhibit change, and the driving forces are those that support change." The nurse practitioner who is involved in the initial recognition of the abuse could face a circumstance potentially present in many elders. The ability to communicate is sometimes impaired and sometimes difficult to determine as fact. This presents a definite constraint of the abilities of the nurse practitioner to intervene at the source of the abuse. This possibility also emphasizes the potential success of the "buddy team" intervention propositions. If the residents are aware of what constitutes verbal abuse, verbal abuse can be addressed by the general population.
The second phase of the Change Theory presented by Lewin is referred to as Moving: "in this second stage the actual change is planned in detail and started. Information about the problem is gathered from one of several sources. At this stage, it is important that the people involved agree that the status quo is undesirable. In the previous example, the nurse practitioner to see the disadvantages of not recognizing the situation of verbal abuse and to view the problem form another perspective: how to accomplish recognition. The nurse practitioner could also guide the multidisciplinary task in their search for information about the problem. The nurse practitioner, as the agent of change, should provide an environment that is conducive to the change. Rewards may need to be provided to reinforce desired behaviors. An environment that fosters change should be supportive, non threatening, and educational.
The third stage of the Change Theory is the phase in which the changes are integrated by the resident and the changes are stabilized. According to Welch (1979), the individuals involved in the change integrate the idea into their own value systems. Thus, in the previous example, the nurses in the unit would come to value the recognition of the clinical excellence and would integrate this idea into their own value system.
Conclusion
Each method of intervention will be met with resistance. The goal is to address even that circumstance. The following are goals for the nurse practitioner to attend to:
The most crucial factor for the nurse practitioner is the attendance to the methodical approach and consistency with the staff. Resistance to change is endemic and has brought the health care profession to a point where a science of change encompasses understanding that change is a continual process.