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Are nurses equipped to manage actual or suspected elder abuse?

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Ginnette Kitchen, MSc, RMN, RN.

Research Nurse Fellow, Camden and Islington NHS Mental Health and Social Care Trust, Department of Psychiatry and Behavioural Sciences, Whittington Hospital, London

Elder abuse is thought to be common in the UK, but we are reliant on figures generated in other countries such as the USA. A US study of nursing homes revealed high rates of abuse, with more than 81% of staff claiming to have witnessed psychological abuse and 36% witnessing physically abusive acts towards residents in their care (Pillemer and Moore, 1989).
Elder abuse is thought to be common in the UK, but we are reliant on figures generated in other countries such as the USA. A US study of nursing homes revealed high rates of abuse, with more than 81% of staff claiming to have witnessed psychological abuse and 36% witnessing physically abusive acts towards residents in their care (Pillemer and Moore, 1989).

The relatively high rate of abuse of older people nursed in institutional settings (Jenkins et al, 2000) has been addressed in the form of No Secrets (DoH, 2000), a White Paper that sets out good practice for care staff working with vulnerable adults. It defines abuse and advises health and social services on strategies and practice regarding its management.

Several studies show that a disproportionate number of victims of elder abuse are cognitively impaired (Dyer et al, 2000; Coyne et al, 1993). Many studies also show that carers are more likely to abuse in response to physical assault by a person with dementia (Coyne et al, 1993; Kurrle et al, 1997; Compton et al, 1997; Colin-Shaw, 2001).

Often, despite knowing that abuse is wrong, nurses empathise with the perpetrator and do not necessarily make a formal report (Dyer et al, 2000; Coyne et al, 1993). Empathy from colleagues tends to be more strongly expressed when the staff member has experienced abuse at the hands of a confused patient (Garner and Evans, 2000).

Other reasons for abuse going unreported include fear of recrimination, inability to recognise abuse and poor knowledge of procedures to deal with such situations (McCreadie, 1998; Garner and Evans, 2000).

The other side of this problem is that a high proportion of people with cognitive impairment are abusive towards their care-givers. One survey of formal care-givers reported that 89% had experienced aggression and 26% serious violence from those for whom they were caring (Cahill and Shapiro, 1993).

Aims of the study
This study aimed to investigate whether nurses working with older people would recognise two scenarios, one of suspected abuse and one of definite abuse, and respond appropriately to either.

Sampling frame - All participants were qualified nurses, either hospital or community based, and worked solely with older people. They worked for an inner-London NHS trust and at the time of the study had not yet attended a newly set up course on the recognition and management of abuse.

Data collection tool - Two previously validated vignettes were used (Box 1): one described suspected abuse, the other definite physical abuse (Richardson et al, 2002). The model answer used for scoring was derived from the No Secrets paper and is consistent with UKCC (1999) policy and trust policy on elder abuse. Seventeen core points were necessary for a safe answer, but a further seven points could be gained in a comprehensive and precise answer. The potential scores in each scenario were the same. Some core answers are outlined in Box 2.

Procedure - Nurses were approached and given an information sheet plus a verbal explanation of the study, and asked to give written consent. Those who agreed to take part were asked to treat the scenarios as if they were working in the area/ward where it happened. They were asked to be exact about whom they would contact or what they would do under such circumstances.

Data analysis - Data were entered into SPSS-PC for quantitative analysis and into a NUD*IST software program. The frequency of each answer, total score, and mean and standard deviation were calculated for each vignette. Paired t-tests with 95% confidence intervals (CI) of mean differences were performed to compare mean scores on the suspected abuse vignette with that on definite abuse.

Independent t-tests were performed to compare the mean scores according to the following:

- Gender

- Nursing grade (F and G versus D and E)

- Country of birth (British/Irish-born versus others)

- Place of work (community versus hospital).

Frequency of core responses was calculated. Chi-squared tests were performed with odds ratios and 95% CI to examine significant differences between the vignettes. Grade, area of work, gender, ethnicity and training specialty were entered into forward logistic regression to find independent predictors of high scores on each vignette.

A content analysis was carried out of generalised statements about actions and sentiments, which formed recurrent themes.

Participants - Forty of the 45 nurses (89%) approached participated. One ward nurse and four community psychiatric nurses refused.

Table 1 shows the grades of the participant nurses and their work/specialty area. The sample consisted of 14 (35%) men and 26 (65%) women. They fell broadly into two ethnic groups: British-born 23 (57%) and others 17 (42.5%).

Scores on vignettes - Scores on the definite abuse vignette ranged from 0 to 24 (mean=9.6; standard deviation=5.9). Scores on the suspected abuse vignette ranged from 3 to 21 (mean=12.4; SD=4.1). Nurses performed significantly less well in answering the definite abuse vignette than when abuse was suspected (p<0.001 95%;="" ci="1.3-4.4;" mean="" difference="">

Nurses at higher grade, F and G, had significantly higher scores on the definite abuse vignette compared with those at D and E grade (respectively mean=11.3, SD=6.1 and mean 6.7, SD=4.4, p< 0.01;="" mean="" difference="4.6," 95%="" ci="">

There were no significant differences in answers between nursing grades on the suspected abuse vignette. Scores did not differ by gender, country of birth or place of work. Analysis using forward logistic regression revealed that the only significant independent predictor of better performance was being of a higher grade (odds ratio=2.2; 95% CI=1.10-4.35; p<0.05). there="" were="" no="" significant="" independent="" predictors="" of="" suspicious="" injury="">

Frequency of core responses - On discovering a suspicious injury, 20 (50%) nurses would inform a senior colleague, 24 (60%) would report the injury to a doctor, 28 (70%) would document the injury, and 16 (40%) would check the patient's records for history of the injury.

On witnessing a senior staff member assault a patient, 32 (80%) of nurses indicated that they would inform their superior. Six (15%) indicated that disciplinary proceedings would be necessary. Four (10%) indicated that the nurse would need to be suspended from duty.

With the suspected abuse vignette, nurses were significantly more likely to inform a doctor than in the definite abuse vignette - 24 (60%) versus 16 (40%); p<0.05; odds="" ratio="" 9.8;="" 95%="" ci="1.8-53.1." similarly,="" they="" were="" significantly="" more="" likely="" to="" inform="" next="" of="" kin="" than="" with="" the="" definite="" abuse="" vignette="" -="" 23,="" 57.5%="" versus="" 12.3%;=""><0.05; odds="" ratio="" 14.7;="" 95%="" ci="1.7-129.7." there="" were="" no="" other="" significant="" differences="" between="" core="" answers="" between="" the="">

Theme analysis - Of the 13 G-grade participants, two stated that the nurse would need to be formally suspended. Four G-grades mentioned disciplining the nurse but then made statements that seemed to absolve them of responsibility for either making the ultimate decision to discipline the nurse or initiating the disciplinary process.

Examples of statements from G-grade nurses included:

- 'I would expect the senior staff to be disciplined'

- 'I would refer the case to my senior for investigation'

- 'I would inform the nurse that her/her behaviour was unacceptable and that she/he should receive disciplinary action'

- One F-grade nurse indicated that the disciplinary process needed to be put into operation but did not understand the mechanism fully and did not realise that the process operated differently in cases of gross professional misconduct.

Of the total sample, only one nurse working at F-grade gave a full account of the process required. Some of the lower grade nurses were frank about the fact that they felt ill-equipped to deal with the issue. The following quotes represent the responses of two E-grade nurses:

- 'This is a very difficult scenario and I am struggling to know what to do'

- 'Unfortunately, there is a lot of rhetoric about reporting violent acts towards patients but the framework for handling the issue is either poor, unfriendly, primitive or not there at all.'

In some cases the nurses indicated knowledge of what to do but made statements that indicated ambivalence about whether they would follow the procedure because of fear of recrimination.

While making it clear that they were not condoning the action respondents often showed empathy towards the perpetrator. Two indicated that they would offer the nurse a second chance and many more felt it appropriate to send the nurse for a coffee break or suggest a holiday instead of suspension.

This study involved a questionnaire survey of qualified nurses. The response rate was high and the sample represented nurses working with older people in inner-city areas. This is a maximum variation sample in that respondents included:

- Both genders

- All grades

- Community and hospital nurses

- Nurses working in mental health

- Nurses working in physical health

- Ethnic minority groupings.

Thus, the study can be taken to include the spectrum of likely responses. While the nurses' performance could be linked to the training strategies in their workplaces, we think the results can be extrapolated to similar settings, as the nursing population in UK inner cities is highly mobile.

There may be several reasons why nurses may not report abuse. In the first instance, some nurses made explicit empathic comments about a nurse who abused in retaliation for a patient hitting out. Some expressed the view that the nurse was in an impossible situation and required respite rather than disciplinary action. This perception may explain why nurses who performed better on the scenario of suspected abuse did not apply their knowledge with regard to the scenario of seeing a colleague abuse a patient.

The results suggest that most nurses are ill-equipped to deal with such a sensitive problem, particularly when it involves colleagues with whom they share a professional allegiance and often a personal and supportive relationship.

Nurses also experienced management of incidents as punitive or unsympathetic rather than fair and supportive. It might be useful if the procedure for dealing with such problems included explicit wording regarding the help staff might need. This might contribute to reducing the incidence and collusion in covering up abuse.

There was a clear and almost universal lack of knowledge about what should happen in these circumstances. This was particularly true of nurses at lower grades, suggesting that experience and training are contributing factors. In addition to adapting the working environment, there should be more emphasis on educating nurses and specific interventions to change knowledge and practice. Our findings showed that G-grade nurses lack confidence in dealing with issues such as disciplinary hearings, suggesting a lack of management skills despite the role's contractual responsibilities.

Some senior grade nurses also gave inappropriate responses and lacked knowledge about the disciplinary process. This again shows the value of training and the need to constantly update ward-based nurses to enable them to perform their duties effectively. Serious incidents such as assault are rare and require careful handling, so it may also be possible that senior managers do not feel it appropriate to allow ward managers to deal with this kind of conduct.

In reality, senior managers are not always readily available when an incident occurs and the nurse on duty may be uncertain about what to do. A solution to this problem might be to focus on teaching ward managers to perform the simple and neutral act of suspending the nurse from duty. They could subsequently allow the ward manager to follow the formal process of investigation, while being closely supervised. This would provide a productive learning experience for the nurse and empower the nurse to take the safest initial steps.

Another suggestion might be to examine where and how damaged and aggressive individuals are cared for. Simple but costly strategies such as increasing staffing levels could reduce the occurrence of abusive incidents. Increasing staff numbers may not only be an acknowledgement of the extra physical and emotional demands on those working with this client group but could also help reduce stress on staff, making them less likely to retaliate. In addition, the presence of colleagues can help diffuse a situation.

The Care Standards Act 2000 should make an impact on the incidence of abuse in care homes. It establishes a list held by the secretary of state of people judged unsuitable to work with vulnerable adults, emphasises the need to increase staffing levels and mandates minimum environmental standards.

Some nurses expressed reluctance to take any action for fear of recrimination. The study shows that it is naive to expect that the present protocols for reporting abuse will be effective for all nurses even when they have sufficient knowledge. It is important to consider the benefits of protection for the informant who may have misgivings about reporting what he or she has witnessed not only because of fear of recrimination but also feelings of loyalty and a belief that the results of an investigation would be punitive to his or her colleagues.

The present system often fails patients. Serious systematic abuse has been revealed in many hospital inquiries and demonstrates how the current system of preventing and managing abuse continues to lack efficacy. This could be dealt with by providing a means by which nurses could report abuse confidentially. This process could also offer the opportunity for discussion for nurses who are unsure as to whether an abusive act has taken place and would allow them to seek advice on what action to take.

Similar recommendations are contained in an NHS circular sent to trusts nationwide outlining the Public Interest Disclosure Act 1998, suggesting strategies for the protection from the victimisation of whistle-blowers. The authors believe that the disciplinary process could have the potential to be helpful by providing a rehabilitative function, focusing both on the individual and the factors in the working environment predisposing to abuse.

The study relied on nurses telling us what they would do in specified scenarios. It is impossible to know whether respondents would have reacted in exactly the same way had they been confronted with a real-life situation but we feel that their responses were plausible.

Future research
To date there has been no national study on the prevalence of abuse in UK hospitals. If one reason for not reporting abuse is fear of recrimination, this is a barrier to researching its prevalence. It is difficult to estimate the efficacy of interventions without first being able to measure the problem.

Research in the UK is hampered by the lack of a guarantee to protect informants. In the USA, participants are afforded protection when divulging information about abuse: the researcher obtains a special certificate that overrides the law.

The authors believe that the outcome of any future research into the issue could be used to inform the design of environments to make them safer, assist in the design of education of staff and provide a means for the Government to measure the impact of policy changes.

Cahill, S., Shapiro, M. (1993)'I think he might have hit me once': aggression towards caregivers in dementia care. Australian Journal on Ageing 12: 4, 10-15.

Colin-Shaw, M. (2001)Nursing home resident abuse by staff: explaining the dynamics. Journal of Elder Abuse 9: 4, 1-2.

Compton, S.A., Flanagan, P., Gregg, W. (1997)Elder abuse in people with dementia in Northern Ireland: prevalence and predictors in cases referred to psychiatry of old age service. International Journal of Psychiatry 12: 632-635.

Coyne, A., Reichman, W.E., Berbig, L.J. (1993)The relationship between dementia and elder abuse. American Journal of Psychiatry 150: 643-646.

Department of Health. (2000)No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse (White Paper). London: The Stationery Office. Available at:

Dyer, C.B., Pavlik, V.N., Murphy, K.P., Hyman, D.J. (2000)The high prevalence of depression and dementia in elder abuse or neglect. Journal of the American Geriatric Society 48: 2, 205-208.

Garner, J., Evans, S. (2000)Institutional Abuse of Older Adults (Council Report CR84). London: Royal College of Psychiatrists.

Jenkins, G., Asif, Z., Bennett, G. (2000)Listening is Not Enough: An analysis of calls to Elder Abuse Response - Action on Elder Abuse National Helpline. Brighton: Pavilion Publishing.

Kurrle, S.E., Sadler, P.M., Lockwood, K., Cameron, I.D. (1997)Elder abuse: prevalence, intervention and outcomes in patients referred to four aged care assessment teams. Medical Journal of Australia 166: 119-122.

McCreadie, C. (1998)Elder abuse: issues for nurses. Nursing Times 94: 45, 60-61.

Pillemer, K., Moore, D.W. (1989)Abuse of patients in nursing homes: finding from a survey of staff. Gerontologist 29: 3, 314-320.

Richardson, B., Livingston, G., Kitchen, G. (2002)The effect of education on management of elder abuse: a randomised controlled trial. Age and Ageing. In press.

UKCC. (1999)Practitioner-client Relationships and the Prevention of Abuse. London: UKCC.

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