VOL: 98, ISSUE: 01, PAGE NO: 42
Lois Dugmore, MBA, MSc, BA, RMN, is senior nurse manager, The Caludon Centre, Coventry Healthcare NHS TrustElder abuse is a problem that has been recognised relatively recently and health care professionals often find it difficult to identify and act upon. Although the prevalence of elder abuse is not easy to determine, it is thought to be only marginally lower than that of child abuse.
Elder abuse is a problem that has been recognised relatively recently and health care professionals often find it difficult to identify and act upon. Although the prevalence of elder abuse is not easy to determine, it is thought to be only marginally lower than that of child abuse.
A survey carried out in the UK by Ogg and Bennett (1992) showed that 5% of older people living in the community had been subjected to verbal abuse and up to 2% had been physically or financially abused.
No prevalence studies have been completed on abuse in UK care settings, although many lessons have been learnt from the inquiry into allegations of abuse at the former Garlands hospital in Carlisle, an institutional care setting run by North Lakeland Healthcare NHS Trust (Commission for Health Improvement, 2000).
Recognising the problem
The 1970s brought increasing awareness in the USA of what was then termed 'granny battering' (Bosanquet, 1978). This was seen as a domestic problem that involved physical abuse and was carried out by a caregiver (Eastman, 1982).
It was not until the 1990s that the problem of elder abuse received any real political recognition in the UK. In 1993 the Social Services Inspectorate and the Department of Health jointly published a guidance document, No Longer Afraid, which recommended that all social service departments, the police and hospitals developed interagency policies to combat elder abuse.
However, this document provided guidance only, rather than statutory requirements, so the issue was not considered a priority by all authorities.
By 1998 the need to protect vulnerable people from abuse had been recognised and 80% of local authorities and NHS trusts had policies on vulnerable adults. These aimed to provide protection for all vulnerable adults and did not concentrate specifically on older people.
The introduction of the National Health Service and Community Care Act 1990 heralded a commitment to providing choice for the users of social services when care packages were put together.
Elder abuse is a subject many people would prefer not to think about and have little experience of dealing with. However, it is a real problem and can occur in any setting: statutory or non-statutory, domestic, residential or voluntary.
Action on Elder Abuse (1995) defines this form of abuse as a 'single or repeated act, or lack of appropriate action, occurring within a relationship where there is an element of trust, which causes harm or distress to an elder person'.
This definition encompasses all those who are in a position of trust in relation to older people, including friends, relatives, informal carers and all health care staff.
Who is at risk?
The classic profile of a person at risk of elder abuse is a woman aged over 75 who has no role within the family but lives with her extended family. She may have an underlying physical or mental health problem and be unable to take part in the activities of daily living. However, abuse can be perpetrated against both men and women at any age and in any setting.
A number of types of abuse have been identified (see Box 1).
McCreadie (1998) highlights the covert nature of abuse in institutions, such as hospitals and nursing homes. It can often occur because of a lack of understanding among staff, inadequate management structures, low staff morale or inadequate training (Hudson, 1992).
The UKCC (1999) has published guidelines for staff and employers which aim to prevent abuse by tackling the circumstances under which it tends to occur. They focus on a number of areas, including:
- Staff attitudes;
- Policies and procedures;
- Staff support and management;
- Education and professional development.
Although the prevalence of elder abuse is still not clear, both nationally and locally, Action on Elder Abuse (1995) suggests that one elderly person in the UK is subjected to abuse every 10 minutes and one person dies every 40 minutes as a result of elder abuse. These statistics highlight the need to develop policies specifically for older people.
Developing a strategy
In Coventry, a collaborative strategy group was set up to tackle elder abuse by taking a multiagency approach to the issue. The group included the local community mental health trust, social services, the health authority, local police and an adjoining acute NHS trust.
The aim was to develop procedures and guidelines that would enable staff to recognise and deal with abuse in line with the joint recommendations of the Social Services Inspectorate and the Department of Health (1999), and the UKCC guidelines (1999).
For the policy to succeed, it was essential to include input from clinicians and professionals in each agency and to secure the support of senior management in implementing it.
The resource implications were as issue for all agencies and there were concerns about the amount of work that would be generated and who would pay the additional costs. Systems also needed to be put into place before staff awareness of the issues involved was raised.
The main concern on both counts was not the number of cases expected but the training implications for staff. All training must equip staff to develop their skills and knowledge in this area, ensuring that they are able to recognise abuse and know what monitoring systems are in place to protect this client group.
Although the provision of training has cost implications, the UKCC (1999) has highlighted the potential cost of ignoring abuse in terms of litigation being brought by those who have been subjected to it and staff who have witnessed it.
The lessons learned
Pritchard (1999) points out that communication is one of the keys to learning about collaborative working, which is essential to bring about changes in working practices. In adopting a multiagency approach, it was important to ensure that professional boundaries were pushed back so that the policy could be implemented. The agenda had to be about the client and not whose professional role was involved.
It also became clear that each agency needed to sign up to the policy document to ensure that it would work in practice. This was achieved by having representatives from each discipline on the strategy group, allowing all parties to present their side and share their experiences.
One of the most valuable lessons was that the policy could not succeed without the support of senior management in each organisation and the commitment of the police in particular, whose knowledge of the legal process and rules of evidence was invaluable.
The commitment of each organisation and the importance of ensuring that everybody involved felt that they retained ownership of the policy was also crucial.
The guidance document No Secrets (Social Services Inspectorate and the Department of Health, 1999) helped to move the strategy forward as it lists the agencies that should be involved in policy development. It points out that this should include all statutory and non-statutory agencies and that any policy that aims to protect vulnerable adults should not be developed solely by those that are government-financed and led.
No Secrets also recognises that agencies need a clear, nationally agreed framework to work from, so this is provided within its guidelines. The document also states that a lead person in each organisation should be responsible for ensuring that the policy is implemented.
Risk assessment is included in No Secrets, but the document falls short of giving clear guidelines. Although it protects people who are unable to provide informed consent by giving clinicians the power to advocate for them, it offers no guidance on what to do in cases where clients have the capacity to consent but refuse to say whether they have been abused.
If vulnerable older people are to be given the protection they need, it is essential that all areas of the UK institute a collaborative mandatory policy that focuses on preventing, recognising and tackling abuse. This must also address the needs of a multicultural society.
All agencies need to work together, following the guidelines laid down in No Secrets (Social Services Inspectorate and the Department of Health, 1999), to protect older and vulnerable people. However, the success of such policies depend on good coordination and the commitment of all organisations involved.