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Education and a multi-agency approach are key to addressing elder abuse

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Caroline Bond, RNA, BA (Hons) Eng Lang & Lit, BSc (Hons) Adult Nursing.

Staff Nurse, Trauma and Orthopaedics, at Swindon and Marlborough NHS Trust

Elder abuse has been given a higher public profile in recent years, prompted in part by the launch of the charity Action on Elder Abuse in 1993. Social policy, such as the National Service Framework for Older People (DH, 2001) and No Secrets guidance (DH, 1999) now show a concern for vulnerable older people that is also reflected by the NMC (2002).

Elder abuse has been given a higher public profile in recent years, prompted in part by the launch of the charity Action on Elder Abuse in 1993. Social policy, such as the National Service Framework for Older People (DH, 2001) and No Secrets guidance (DH, 1999) now show a concern for vulnerable older people that is also reflected by the NMC (2002).The definition of elder abuse used in this paper was developed in 1995 by Action on Elder Abuse. It defines elder abuse as ‘a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’ (Bennett et al, 2000).Abuse may be physical, psychological, financial, sexual or take the form of neglect. It may be carried out by anyone in a position of control or authority and may be the result of deliberate intent, negligence or ignorance (DH, 1999; Action on Elder Abuse, 2003).Publication of national research on the prevalence of elder abuse in domestic settings in the 1990s (Ogg and Bennett, 1992) prompted further research into the issue in the UK. However, many of these have been small-scale, locally based and the results cannot be generalised owing to methodological issues (Penhale, 1999). A few have focused on the effectiveness of education and interventions by health-care staff (Richardson et al, 2002). Action on Elder Abuse has also promoted research and education, but while government policy now confronts ageism and the marginalisation of older people, it does not specifically identify elder abuse as a social problem.There is wide variation in the definition of elder abuse, and a consensus is necessary for the accurate establishment of prevalence rates and recognition of abuse by professionals (Clarke and Ogg, 1994a). Current estimates have been extrapolated from Ogg and Bennett’s 1992 research. This applied a broad definition of elder abuse, but it has methodological problems such as the exclusion of the most frail elderly and its restriction to the domestic setting.This raises questions about the accuracy of the estimates since the frail elderly are at the highest risk of abuse, a significant proportion of which is believed to occur in institutional settings (Bennett et al, 2000). Until the true prevalence is established, and the circumstances of elder abuse understood, training programmes cannot be designed to effectively address the issue.The development of a coherent national strategy for research, intervention and prevention is necessary to establish the actions taken by professionals in practice, and the effectiveness of procedures and interventions.Nurses’ awareness
Nurses are ideally placed to identify elder abuse (Davies, 1997; Pullen, 1998) but, while research shows that they can identify abusive situations relatively accurately, they are reluctant to act on their observations (Trevitt and Gallagher, 1996; Davies, 1997; Kitchen et al, 2002).This raises serious moral, ethical and professional concerns. For example, problems may arise when professionals have differing views about what constitutes abuse; other reasons for under-reporting include professional loyalty, lack of knowledge of protocols and fear of management systems (Davies, 1997).Fear of repercussions if exposing institutional abuse (Kitchen et al, 2002) should have been addressed by the Public Interest Disclosure Act 1999, which aims to provide protection for whistleblowers. However, many NHS staff still fear and experience personal reprisal when reporting bad practice (CHI, 2002; Public Concern at Work, 2003). The characteristics of the victim and perpetrator also affect professionals’ judgement (Bennett et al, 1997; Kitchen et al, 2002). For example, if the abuse is perceived to be the result of carer stress, there is likely to be empathy and collusion with the perpetrator and its reporting less likely.When abuse is identified or suspected, nurses need to know what is expected of them, so protocols should be readily available. The US experience shows that a multidisciplinary approach is most effective (Pettee, 1997; White, 2000).McCreadie (2001) identifies considerable variation in training programmes and local protocols across the UK, highlighting the importance of collaboration, including holistic needs and risk assessments of both older people and carers. She points to the wide range of harmful behaviours included under the umbrella term ‘elder abuse’ as a reason for under-reporting, believing that the diversity of victims, perpetrators, causes and situations bring confusion.Education programmes
Richardson et al (2002) established that training courses are effective in improving knowledge. But it is often difficult to make a cost-benefit analysis in health and social care settings, as these aspects cannot be measured in purely monetary terms (Hyrkas et al, 2001).This is complicated in the field of elder abuse by the lack of research to underpin the evaluation of training outcomes. Cost-effectiveness rather than cost-benefit analysis would be required to evaluate non-monetary benefits such as quality of life. However, without a baseline indicator of rates it would be hard to assess the benefits of training and, without a fuller understanding of the social context, there can be no certainty that training courses are relevant.US studies have shown that training given to nursing assistants and auxiliaries reduces institutional abuse and improves detection of domestic abuse (Davies, 1997; Pettee, 1997). It may therefore be appropriate to offer training to all staff members. This could involve considerable cost to the NHS, but to reduce the financial burden information could be cascaded by a minority of staff designated to attend courses, the use of distance learning (Price, 2001) and regular study-day updates (Davies, 1997).Nurses’ response
The No Secrets guidance (DH, 1999) calls for a multi-agency code of practice for the protection of vulnerable adults, to ensure consistent and effective responses. In community settings, the identification of abuse may stem from the single assessment process - which aims to give a comprehensive needs assessment, encourage information sharing among professionals and avoid duplication (DH, 2002). In acute care, identification is likely to stem from holistic nursing assessment.If nurses are to fulfil their responsibility to protect vulnerable adults, they need to be alert to indicators of abuse; the introduction of assessment tools would support a multidisciplinary response, making the same information available to all agencies. Many such assessment tools exist, but care should be taken in opting for one (Penhale, 1999), as few have any claim to reliability and validity (Wolf, 2000). They must also be easy to use if nurses are to use them routinely (White, 2000).Interventions must strike an ethical balance between protection and the right to self-determination (Bennett et al, 1997; Pettee, 1997). Although many US states have adopted mandatory elder abuse reporting, this destroys confidentiality, differentiating older people from other adults (Brogden and Nijhar, 2000). Older people must retain the right to refuse interventions and it is important that professionals respect this right, despite their desire to resolve abusive situations (Bennett et al, 1997).Victims may fear that intervention will exacerbate the situation or provide a less desirable alternative (Baumhover and Beall, 1996). At the same time, there is a risk that professionals may avoid intervening because they lack knowledge. These feelings of inadequacy may lead to disingenuous use of the principle of choice or inappropriate intervention in the desire to help in some way (Bennett et al, 1997).These potential problems highlight the need for co-ordinated multidisciplinary guidelines that set out the responsibilities of all professionals and the options for intervention. Having a clear focus on prevention and empowerment (Pettee, 1997; McCreadie, 2001) will reduce risk of collusion with the perpetrator and the removal of choice from the victim. If victims believe their confidentiality and self-determination will be respected, they are more likely to disclose abuse and seek professional advice (Baumhover and Beall, 1996).Further work needed
Deterioration is seen as a normal part of ageing, making it less likely that nurses will suspect abuse. Slater and Eastman (1999) identify less vigilance and lower expectations among professionals for elder abuse than other types of abuse. Since the problem was highlighted in the 1970s, successive governments have failed to address it. While the Department of Health this year announced a funding boost of 431 000 to Action on Elder Abuse for its help-line and research into prevalence, it has not managed to estimate the extent of the problem.While changing ageist attitudes is key to combating elder abuse, multidisciplinary work that focuses on the needs of victims is also vital. Slater and Eastman (1999) believe this would transcend the different models of intervention that tend to apply to different health and social care professions (such as medical treatment, nursing care or social work protection). Multidisciplinary training would give all professionals the ability to take a more holistic approach, improving assessment of victims’ needs in considering resource and service provision.Clarification of the issues around nursing intervention in elder abuse cases is significant owing to recent legislation and guidance on protecting vulnerable adults (DH, 1999; 2001). As the prevalence of elder abuse in the UK has not been identified, and its definition remains flexible, further work is necessary to help match the nursing response to the needs of victims. While nurses clearly have a pivotal role in identifying abuse and initiating interventions, they are not currently fully equipped to fulfil their duty of care to vulnerable older people.- See page 54 for an interview with Deborah Sturdy, Nursing Officer for Older People, Department of Health, EnglandLatest policy
Policy relating to older peopleHOUSE OF COMMONS HEALTH SELECT COMMITTEE (ELDER ABUSE, 2004)- Calls for ‘mandatory training in the recognition, reporting and treatment of elder abuse for those professionals working and caring for older people’. Recommends multidisciplinary research into prevalence, and the development of performance indicators for intervention. Identifies the need for extensive professional educationNO SECRETS (DEPARTMENT OF HEALTH, 1999)- Demands a multi-agency code of practice for the protection of vulnerable adults, stating that this is essential to ensure consistent and effective responses. Defines abusive behaviours and situations, but does not specifically identify elder abuseNSF FOR OLDER PEOPLE (DEPARTMENT OF HEALTH, 2001)- Sets national standards of care, including specific areas of concern to older people (such as falls prevention). Aims to tackle institutional ageism within NHS. Fails to mention elder abuse WHAT WE KNOW
Indicators for action- Elder abuse is a significant social problem but its extent is unknown- There is a lack of cohesion in the response of health and social care to the problem- Nurses are not adequately prepared to identify abuse and respond appropriately- Further research into the prevalence of elder abuse in the UK is urgently required- Inter-agency working is needed to develop intervention strategies- Pre-registration education should incorporate training in recognising abuse.CAN YOU SPOT ELDER ABUSE?
- Could you recognise elder abuse in the home setting?- Could you recognise elder abuse if you were in a hospital setting?- What do you think amounts to elder abuse?- Why do staff and carers abuse the elderly?- Would you report a colleague for elder abuse?- Do you feel confident that your manager would deal with your concerns?- Do you feel that your confidentiality would be protected?- Do you know what to do if a member of staff is accused of elder abuse?- Do you have procedures in place for dealing with cases of elder abuse?- Have you had any formal training in elder abuse?Author’s contact details
Caroline Bond, Staff Nurse, Trauma and Orthopaedics, The Great Western Hospital, Marlborough Road, Swindon SN3 6BB.

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