Recent research shows that abuse in nursing homes for older people is not always reported and sometimes deliberately concealed. What can be done to tackle under-reporting?
Abuse in nursing homes for older people is not always reported, and sometimes it is deliberately concealed – this is one of the key findings from recent research conducted in nursing homes in four local authority areas in England. Data on the extent and nature of residents’ abuse was published by Nursing Times earlier this year. This article presents more data from the same study, but focuses on the reporting of abuse. The outcomes suggest that the safeguarding responses from local authorities need to be changed so that all those working in nursing homes are encouraged to, and not afraid of, reporting abuse.
Citation: Moore S (2017) Reasons for staff failure to report abuse of residents in nursing homes. Nursing Times [online]; 113: 7, 53-57.
Author: Steve Moore is commissioner of care and nursing home services, Dudley Metropolitan Borough Council.
To what extent is the abuse of nursing home residents reported, acted on and investigated? How much of it is silenced, stifled and kept secret? The outcomes of an empirical research study (Moore, 2017) indicate that abuse is far from being always reported, internally or externally, and that it is sometimes deliberately concealed from outsiders such as relatives and external agencies.
An article published earlier this year gave an indication of the extent and nature of the continuing abuse of older people in private-sector nursing homes (Moore, 2017). The findings came from a mixed-method study in which I distributed anonymous questionnaires to staff in five recently opened nursing homes for older people. This article presents more data from the study, this time focusing on the reporting of abuse. The data was obtained from the questionnaires and semi-structured interviews with nursing home owners, nurses working as home managers, and nursing or care staff from 12 further care homes for older people.
Evidence from the literature
What little is known about the prevalence of abuse in nursing homes derives largely from research undertaken outside of the UK; it suggests that such abuse is a common occurrence (Cambridge et al, 2011; Joint Committee on Human Rights, 2007; Goergen, 2004; Saveman et al, 1999; Pillemer and Hudson, 1993; Pillemer and Moore, 1989). A meta-analysis of prevalence studies in both domiciliary settings and care and nursing home settings determined that, overall:
- 16% of staff admitted having committed psychological abuse;
- 10% admitted to physical abuse;
- 80% reported witnessing others committing abuse in their workplace (Cooper et al, 2008).
Bennett et al (2000) showed that almost 30% of calls made to the Action on Elder Abuse helpline between 1997 and 1999 related to abuse in care and nursing homes or hospitals; 29% of abusers were paid care workers, and 362 calls reported abuse in formal care settings, compared with 148 in people’s own homes. Action on Elder Abuse (2006) later determined that, during a six-month period in 2005, 29.4% of alerts across nine local authority areas came from nursing and care homes.
More recently, based on national surveys of all local authorities in England, the Health and Social Care Information Centre has produced reports on the abuse of adults in all settings in 2011-12, 2012-13 and 2013-14. The reports showed that 34% of all referrals to safeguarding teams concerned abuse that was alleged to have occurred in nursing or care homes (Health and Social Care Information Centre, 2014a; 2014b; 2013).
However, it is likely that only a fraction of the abuse that occurs is brought to the attention of safeguarding authorities such as local authority social services departments or the Care Quality Commission. A number of researchers maintain that as few as one in every four or five cases are reported (Cooper et al, 2008; Bonnie and Wallace, 2003; Wolf, 2000), while the World Health Organization (2008) estimates it is one in every 15. Nursing home staff sometimes fear the personal consequences of reporting abuse, which could include: victimisation; intimidation; ostracism; reprisal from peers, managers or employers; and loss of employment (Carvel, 2009; Taylor and Dodd, 2003).
Between 2011 and 2015, I conducted semi-structured face-to-face interviews in 12 private nursing homes in four local authority areas in England, with:
- 12 owners, two of whom had previously been registered nurses;
- 12 nursing home managers, 10 of whom were registered nurses;
- 12 nursing or care staff.
In parallel, questionnaires were given to 207 newly appointed nursing and care staff in five recently opened nursing homes in the same local authority areas. The questionnaires were anonymous – neither personal details nor details of previous employment were required – and were returned directly to me using a supplied pre-paid envelope. This data collection method aimed to avoid staff under-reporting abuse for fear of the consequences they might face.
The study design had its limitations, as the anonymous questionnaires could reveal instances of abuse but not allow action to be taken in response. However, nursing homes are difficult to penetrate for research purposes (Davies et al, 2009), so the method was deemed acceptable from an ethical perspective, as it might reveal data that would otherwise remain hidden. I also hoped the study would improve how abuse in nursing homes is tackled by placing greater emphasis on prevention. Currently, action on abuse occurs mainly at a secondary, reactive level, rather than at a primary, preventive level (Kalaga and Kingston, 2007).
The data from the questionnaires is relatively recent: the questionnaires were sent to nursing homes that had opened between 2011 and 2015 and, among the 109 respondents who had witnessed abuse, a large majority had witnessed it in the 12 months before completing the questionnaire. The definition and typology of abuse used in the interview schedules and explanatory notes accompanying the questionnaires were those used in the Department of Health’s No Secrets guidance (DH, 2000).
Reporting of abuse
The nurses and care staff interviewed were aware that abuse was sometimes not reported to the appropriate people, whether internally or externally:
“In nursing homes you only see a piece of what is going on and lots goes on behind closed doors that is never reported – you know, in bedrooms, bathrooms and toilets. I’ve seen it happen and it’s not been reported […] I’ve not reported it, no. I’ve got to work with these people you know.” [Nurse 1]
“No, no, you can’t trust the staff here. Believe me, you need to be on your toes. These people are supposed to care but they can be very cruel to [residents] and no one is ever told, and the ones with dementia can’t tell, can they?” [Nurse 2]
“I’ve reported people to management level [for abusive behaviour] and they said: ‘We didn’t expect that of you’. They didn’t want to know what I said, they wouldn’t act. They made me feel I was in the wrong for reporting abuse!” [Care staff member 3]
“Abuse often isn’t reported. If you report stuff like that you are in trouble, aren’t you? You’ve still got to work with the same people.” [Care staff member 6]
“Abuse is tainted so it’s ignored by the manager because it makes people at the top look bad, so brush it under the carpet, it will go away, let’s pretend we are doing a good job. We’re not, but nobody will ever know.” [Nurse 4]
The managers were particularly voluble when explaining that staff did not always report abuse and that owners sometimes discouraged reporting:
“I constantly have to check up on what staff are doing. I need eyes and ears everywhere because they just don’t tell of the abuse that goes on here.” [Nurse manager 7]
“When these staff are working together, a code of loyalty seems to develop and a blind eye is turned to abuse. I know it happens here. In homes, they [staff] are a law to themselves, a little clique, and they protect each other’s backs.” [Nurse manager 2]
“Well I have to say … this is all confidential isn’t it? Well the owner really doesn’t like it if a safeguarding referral is made. It looks bad, bad on the business.” [Nurse manager 8]
“It wouldn’t be possible to report all instances of abuse, it happens so frequently and the owner doesn’t like it at all. It would mean too many empty beds.” [Nurse manager 6]
The owners generally spoke less about the under-reporting of abuse, but they did recognise that not all instances of abuse were being reported:
“I do worry about this home, sometimes I think staff can’t be trusted. Abuse has happened here, yes, unfortunately, but it’s the relatives who have reported it after the fact – and sometimes I know two staff were present, but neither have reported it and the relative has reported it later.” [Owner 6]
“My manager knows that any and all abuse must be reported, but I do know that this is not always the case. I’ve told her and told her, but she has said that what occurred wasn’t abuse, but the powers that be said it definitely was … But what can you do? I run a business here, and even half-decent managers are hard to come by.” [Owner 1]
Participants from all three groups said that safeguarding responses from local authorities were “negative”, ‘intimidating” and “awful”, and that they generated “fear” or even “terror” among those required to attend multi-agency safeguarding meetings. Owners, managers and care staff also believed that, in the safeguarding process, there was a strong tendency to presume guilt before it could be proven.
Owners and managers thought these two characteristics of safeguarding responses deterred people from reporting incidents and were driving abuse further “underground”. They thought this was leading to people turning a “blind eye” or trying to deal with cases of abuse “in house”, rather than involving external agencies.
Managers and owners spoke mostly from personal experience, while care staff’s perceptions were informed by what they had heard from their managers:
“I’ve been to safeguarding meetings. I was terrified! That process is upsetting and frightening. A horrendous experience[…] You expect us to bare all and then you give us a hard time. To be honest, I would only report something that was serious.” [Owner 2]
“Absolutely, there is a temptation not to report. The providers are the ones who are made to feel guilty and this stifles openness in the culture of the home. If providers were not assumed to be guilty before they were proven innocent, there would be a lot more openness.” [Owner 6]
“You feel like you are the accused, even when nothing is proven. Small wonder some staff – managers especially – are reluctant to report, turn a blind eye. I know it goes on from other managers of homes in this group.” [Nurse manager 4]
“It is very daunting – bloody horrible, I would say. You feel you are in a court of law and you have done something wrong. You are made to feel guilty.” [Nurse manager 5]
Among the 156 nursing and care staff who returned the anonymous questionnaire, 109 had witnessed abuse (Moore, 2017). Table 1 shows data regarding whether the witnessed abuse was reported internally, whether action was subsequently taken, and whether external agencies were involved in investigating the abuse. One of the most telling results is that 45.9% of the 109 respondents said that, in some cases, abuse had deliberately not been reported to external agencies.
Table 2 lists the methods respondents said were used to conceal abuse from visitors and external agencies, and how many respondents had witnessed each method being used.
At the end of the questionnaires, respondents had the opportunity to make additional comments; one care staff member explained:
“In my second experience in care, they had four staff on duty for 20 dependent residents but one was permanently in the kitchen… [Because] the staff were struggling they were hoisting alone; they all ganged up on me one day and said ‘We know it’s wrong but we have to do it’ and said ‘Could you not just [hoist alone] too?’. I refused and said ‘No, I’d rather leave here’. I was in tears because I’d not been taught this way and felt isolated. I did leave, as this place caused me to be off with depression.” [Care staff member 2]
Another care staff member wrote:
“The nurse in charge and the owner called me into the office [after I had reported abuse] and the owner asked me if I had a mortgage. I said I did, and he said, ‘If you don’t shut up about what happened I’ll have your house off you.’ I was scared he might, so I said nothing.” [Care staff member 9]
This research confirms that figures on the extent of abuse in nursing homes in the literature, which are already sparse and unreliable, are likely to be underestimates because of under-reporting and concealment. It also confirms a significant fear of reporting abuse, expressed by all respondents and occurring at two levels:
- At the interface between staff and their peers, managers and the nursing home owners;
- At the interface between the nursing homes and the local authorities.
Interface between staff and peers, managers and owners
The research highlights a number of internal factors that can deter staff from reporting abuse, including:
- Fear of losing their jobs ;
- Fear of being ostracised by their peers.
These factors are barely considered in current safeguarding and whistleblowing policies, which calls into the question their effectiveness. Policies should ensure staff do not experience negative consequences as a result of speaking out, but the reality seems to be at odds with the theory.
Similarly, the effectiveness of current management and governance regimes is called into question by respondents’ descriptions of:
- The lack of trustworthiness of staff;
- Abusive practices happening behind the closed doors;
- “Codes of loyalty” and “cliques” among staff members.
These management regimes, largely unchanged since the 1990s, focus on readily observable organisational artefacts (such as care plans, fluid and food intake charts, staff training records and turn charts) and fail to penetrate the facade of nursing-home life to reveal the tacit assumptions – the unspoken, organisationally ingrained ways of working described by Schein (2004) – that may contribute to abuse.
A report from the Association of Directors of Social Services recommends that: “each partner agency has a clear, well-published policy of zero tolerance of abuse within the organisation” (ADSS, 2005).
This is simple enough to achieve in terms of writing a policy for the nursing home, but it is naive to believe that all staff will consequently adhere to the policy – which could be nothing but another ‘organisational artefact’.
In nursing homes, as this research reveals, there is a degree of tolerance towards abuse, for a number of reasons including codes of loyalty among staff and fear of reprisals, punishment or bullying. Policies that are intended to protect whistleblowers – as advocated by, among others, the DH (2000) and the ADSS (2005) – will likely be less effective if staff who report abuse are ignored or threatened by those above them within the organisation.
Interface between nursing homes and local authorities
The predominant reason why nursing homes can be reluctant to report abuse externally seems to be the fear-inducing nature of the safeguarding response. Interviewees explained how this response tends to presume guilt, and assume allegations of abuse are true before anything is proven. Respondents perceived the environment in which they are required to report abuse as antagonistic and intimidating.
Owners and managers said they wished to see safeguarding authorities display attitudes of common purpose and effective collaboration between agencies, rather than current attitudes of attributing blame and punitive reactions.
Simic et al (2012) determined that safeguarding responses are sometimes “inquisitorial and quasi-judicial” with respect to private-sector providers. There is nothing fundamentally wrong with a quasi-judicial approach, as long as care providers and staff are presumed innocent until proven guilty. This research makes clear that some owners and managers do not think this is the case. This view was shared by the Care Standards Tribunal in one specific case brought to its attention (Hall-Turner versus the Secretary of State, EWCST 972, 2007), in which it ruled against the secretary of state and in favour of the petitioning care organisation. It stated that:
“The adult protection strategy meetings lacked focus on the reasons for concern or any structured assessment of the risk allegedly posed by the applicant […] Decisions were made on the basis of ‘feelings’ and ‘felt fear’ [and] not linked to any formal process of structured risk assessment.”
A process that is supposed to encourage the reporting of abuse has, at least among some nursing homes’ personnel, become something to fear. All nurse managers who were interviewed unanimously stated that, from their personal experience, the nature of the safeguarding response was a deterrent to open disclosures of abuse. Although it is not likely to cause abuse in itself, it may well contribute to its concealment and perpetuation, thereby driving abuse further ‘underground’.
Addressing the problem
The current safeguarding regulations, including whistleblowing policies, are failing to protect nursing home residents who experience abuse, as it is either not reported, or reported internally but ignored or stifled. Under-reporting must be tackled at all levels, including through revisiting the nature of the safe-guarding response, and remodelling the value frameworks of staff who witness or are aware of abuse but allow, or participate in, its concealment. Box 1 lists some recommendations for nurse managers in nursing homes and nurses working as safeguarding leads.
Box 1. Recommendations for practice
Nurses managing nursing homes:
- Mediate between owners, management and staff so that reporting abuse is not discouraged
- Encourage a culture of openness, in which reporting abuse is viewed as an opportunity for improvement
- Ensure whistleblowing policies are clear, accessible and include guidance on how to report directly to external agencies
Nurses working as safeguarding leads:
- Critically examine their own approaches, and those of partner agencies, to safeguarding enquiries
The interviews showed a desire, on the part of the nursing home sector, to avoid stigmatisation, work collaboratively with local authorities to remedy abuse, and learn from occurrences of abuse. In their safeguarding responses, local authorities need to manage the tension between finding fault and apportioning responsibility, and determine a way forward that facilitates the effective scrutiny of abuse allegations while encouraging openness among providers. If they achieve this, it may reduce the likelihood of reports of abuse being ignored or concealed.
- The sparse literature on the subject suggests the abuse of residents is a common occurrence in nursing homes
- An empirical research study found that abuse in nursing homes is not always reported, and sometimes it is deliberately concealed
- Nursing and care staff replying anonymously to a questionnaire revealed that they were often under pressure to keep quiet about abuse
- How authorities that are responsible for safeguarding respond to alleged abuse can deter people from reporting incidents
- Safeguarding and whistleblowing policies must be reviewed and a culture of openness promoted
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