elder abuse in nursing homes research paper

• Research article
• Open access
• Published: 12 March 2020

Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders’ perceptions of elder abuse and neglect

• Janne Myhre   ORCID: orcid.org/0000-0001-8983-7998 1 ,
• Susan Saga 1 ,
• Wenche Malmedal 1 ,
• Joan Ostaszkiewicz 2 &
• Sigrid Nakrem 1  

BMC Health Services Research volume  20 , Article number:  199 ( 2020 ) Cite this article

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The definition and understanding of elder abuse and neglect in nursing homes can vary in different jurisdictions as well as among health care staff, researchers, family members and residents themselves. Different understandings of what constitutes abuse and its severity make it difficult to compare findings in the literature on elder abuse in nursing homes and complicate identification, reporting, and managing the problem. Knowledge about nursing home leaders’ perceptions of elder abuse and neglect is of particular interest since their understanding of the phenomenon will affect what they signal to staff as important to report and how they investigate adverse events to ensure residents’ safety. The aim of the study was to explore nursing home leaders’ perceptions of elder abuse and neglect.

A qualitative exploratory study with six focus group interviews with 28 nursing home leaders in the role of care managers was conducted. Nursing home leaders’ perceptions of different types of abuse within different situations were explored. The constant comparative method was used to analyse the data.

The results of this study indicate that elder abuse and neglect are an overlooked patient safety issue. Three analytical categories emerged from the analyses: 1) Abuse from co-residents: ‘A normal part of nursing home life’; resident-to-resident aggression appeared to be so commonplace that care leaders perceived it as normal and had no strategy for handling it; 2) Abuse from relatives: ‘A private affair’; relatives with abusive behaviour visiting nursing homes residents was described as difficult and something that should be kept between the resident and the relatives; 3) Abuse from direct-care staff: ‘An unthinkable event’; staff-to-resident abuse was considered to be difficult to talk about and viewed as not being in accordance with the leaders’ trust in their employees.

Conclusions

Findings in the present study show that care managers lack awareness of elder abuse and neglect, and that elder abuse is an overlooked patient safety issue. The consequence is that nursing home residents are at risk of being harmed and distressed. Care managers lack knowledge and strategies to identify and adequately manage abuse and neglect in nursing homes.

Peer Review reports

Little is known about elder abuse in nursing homes, and compared to research on other forms of interpersonal abuse, research about elder abuse in nursing homes is still in its infancy [ 1 , 2 ]. Although no national prevalence data are available in any country internationally, high rates of elder abuse and neglect have been reported in nursing homes, including Norway [ 1 , 3 ]. According to the World Health Organisation (WHO), elder abuse has been identified in almost every country where these institutions exist [ 4 ]. In the Toronto Declaration, WHO 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 cause harm or distress to an older person’ [ 5 ] p:3. Prevention of harm is a core principle in health care services and a leadership responsibility [ 6 , 7 , 8 ]. Nursing home leaders are legally and morally responsible for ensuring that required quality and safety standards are met [ 6 , 9 , 10 ]. The National Patient Safety Foundation (United States) defines patient safety as ‘freedom from accidental or preventable injuries or harm produced by medical care’ [ 10 ], p,2. This includes preventing elder abuse and examining the factors that foster an unsafe environment for both residents and staff [ 6 , 7 , 11 ]. Furthermore, elder abuse can be categorized according to type of abuse. The definition from ‘Protecting Our Future: Report from the Working Group on Elder Abuse’ (Ireland) includes physical, psychological, financial and sexual abuse, and neglect (Table 2 ) [ 12 ]. Abuse in nursing homes may also be categorized according to type of relation [ 1 ]; staff-to-resident abuse [ 3 , 13 ], family-to-resident abuse [ 14 , 15 ] and resident-to-resident abuse, also called resident-to-resident aggression [ 16 , 17 ].

A recent meta-analysis of the prevalence of elder abuse in long-term care settings estimated a pooled prevalence of 64.2% of abuse perpetrated by staff in the past year, where psychological abuse and neglect had the highest prevalence [ 1 ]. A survey of 16 nursing homes in the central part of Norway found that 91% of staff had observed a colleague engaging in some form of inadequate care,

and 87% of staff reported that they themselves had perpetrated some form of inadequate care in the past [ 3 ]. Comparably, in a study from Ireland, Drennan et al. found that 57.5% of staff had observed one or more abusive behaviours from a colleague in the previous year [ 13 ]. Neglect and psychological abuse were the most commonly observed or perpetrated acts [ 3 , 13 ]. Living in a nursing home may also mean sharing room and space with co-residents, and in recent literature, resident-to-resident aggression has been identified as a common form of abuse in nursing homes [ 16 , 17 , 18 ]. Lachs and colleagues revealed that 407 of 2011 residents from ten facilities had experienced at least one resident-to-resident event over one month observation, showing a prevalence of 20.2%, and the most common form was verbal abuse [ 16 ]. The literature about elder abuse in domestic settings shows that close family and friends can be perpetrators of abuse [ 15 ], but few studies have investigated the role of family members as perpetrators of abuse in nursing homes. A study from the Czech Republic found that nursing home staff had observed relatives participating in financial exploitation combined with psychological pressure on residents in nursing homes [ 14 ]. However, comparing findings in the literature on elder abuse in nursing homes is challenging because definitions and understandings of abuse can vary in different cultures, jurisdictions, and among health care staff, researchers, family members, and residents themselves [ 1 , 2 , 11 , 19 , 20 , 21 ]. Different understandings of what constitutes abuse and its severity complicate detecting, reporting and managing the problem.

Nursing homes are complex social systems that consist of different participants, including staff, leaders, residents and relatives in constantly shifting interactions [ 22 , 23 ]. The aetiology of abuse in nursing home settings is described as complex, comprising varying associations between personal, social and organisational factors [ 2 , 24 ]. Nursing home residents often have complex care needs, dementia or other forms of cognitive impairment [ 25 ], display challenging behaviour [ 26 ], and depend on assistance in daily activities and care, all factors associated with a high risk of abuse and neglect [ 3 , 13 , 24 , 27 ]. In Norway, 80% of nursing home residents have dementia, and 75% have significant neuropsychiatric symptoms such as agitation, aggression, anxiety, depression, apathy and psychosis [ 25 ]. Residents who display aggressive behaviour toward staff are at greater risk of experiencing abuse [ 13 , 27 , 28 ]. Findings in Drennan et al.’s Irish study revealed that 85% of the nursing home staff had experienced a physical assault from a resident in the previous year [ 13 ]. Aggressive behaviour has also been found to trigger resident-to-resident aggression in nursing homes [ 16 , 17 ]. Related to organisational factors, there is an association between inappropriate environmental conditions for residents, low levels of staffing, and abuse and neglect [ 13 , 14 , 29 ]. As a result of this complexity, elder abuse in nursing homes is difficult to define precisely [ 11 ]. Within the literature, elder abuse in nursing homes is conceptualised as a specific form of institutional abuse [ 30 ] and a setting in which abuse and neglect take place [ 14 ], since rules and regulations in institutions can be abusive themselves, e.g., deciding residents’ sleeping and meal times, the use of restraint, and shared living spaces with other residents.

Good leadership plays a key role in developing staff’s understanding of residents’ needs [ 31 , 32 ] and creating a strong safety culture of respect, dignity, and quality [ 6 , 7 , 9 , 33 ]. The importance of leadership in developing a patient safety culture is highlighted in a report from the National Patient Safety Foundation [ 10 ]. In Norway, governmental strategies to improve leadership and safety culture have been launched, such as the Patient Safety Programme and a system for monitoring health services using quality indicators [ 34 ]. Leadership is defined as a process whereby a person influences a group of individuals to reach a common goal [ 35 ], such as a strong safety culture. The safety culture of an organisation is defined as ‘the product of individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management’ [ 10 , 36 ] p:23. This includes detecting situations that can be harmful to residents. However, several studies have shown that underreporting of abuse and neglect is a significant problem [ 1 , 37 , 38 ]. Residents’ own inability to communicate about the abuse or their fear of repercussions and retaliation are important factors of underreporting [ 1 , 2 ]. Therefore, staff should be able to recognise and report situations that can be perceived as harmful or distressful from the perspective of residents. However, a systematic review of staff’s conceptualisation of elder abuse in residential care found that staff were often uncertain about how to identify abuse, especially psychological abuse and caregiver abuse and neglect [ 39 ]. Despite the vast knowledge that exists about the importance of leadership, nursing home research has not yet paid much attention to the role leaders play regarding identifying elder abuse. Consequently, there is a gap in knowledge about elder abuse from the perspective of nursing home leaders. Knowledge about nursing home leaders’ perceptions of elder abuse and neglect are essential because their understanding of the phenomenon will affect what they signal to staff as important to report and what they investigate to create a safe and healthy environment. To our knowledge, this is the first study that seeks to understand the nature of elder abuse from the perspective of nursing home leaders.

Aim of the study

The aim of the study was to explore nursing home leaders’ perceptions of elder abuse and neglect.

The present study is part of a larger study funded by the Research Council of Norway (NFR), project number 262697. A qualitative exploratory design with focus group interviews was conducted to gain greater insight into this important but poorly understood topic. Qualitative methods provide knowledge about people’s experience of their situation and how they interpret, understand and link meaning to events [ 40 , 41 ]. In focus group interviews, group dynamics allow the questions to be discussed from several points of view, and the group’s dynamics can create new perspectives and opinions during the discussion [ 42 ]. This study follows The Consolidated Criteria For Reporting Qualitative Research (COREQ) (Additional file 1 ).

In Norway, approximately 39,600 residents live in nursing homes (12.9% of the population > 80 years), and their mean age is 85 years [ 43 ]. These nursing homes are mainly run by the municipalities and financed by taxes and service user fees. Residents pay an annual fee equal to 75% of the resident’s national age pension. In addition, residents may pay an additional fee if they have income of their assets, but with an upper limit decided by the government. However, the payment cannot exceed the actual expenses of the institutional stay [ 44 ].. Management of care in Norwegian nursing homes is regulated by ‘the regulation of management and quality improvement in health care services’ [ 45 ]. The regulation focusses on the leader’s responsibility to ensure that residents’ basic needs are satisfied. This includes the leader’s responsibility to ensure there is a system in place to monitor residents’ overall quality and safety and to create a safety culture that detects situations and factors that can cause harm to residents and staff [ 45 ].

Each nursing home is required to have an administrative manager, called the nursing home director, and some nursing home directors lead more than one facility. In addition, each nursing home has ward leaders and quality leaders, and in some municipalities, a service leader. Together, individuals in these leader roles form the leadership team in each nursing home [ 46 ]. The ward leader is a registered nurse (RN) who supervises and manages staff. Ward leaders are also responsible for budgets in their own wards and the quality of care for residents. There are often several wards and ward leaders in each nursing home. The quality leader is an RN who monitors the overall quality of care in the nursing home in collaboration with the ward leaders. The service leader supervises and manage service staff members who are in contact with nursing home residents (e.g., activity coordinators, cleaning staff and kitchen staff) and is also responsible for the budget related to his or her staff. Individuals employed in one of these leader positions provide the closest level of leadership to staff and residents but are not part of the daily direct hands-on care of residents. There is no national requirement regarding formal leader education to be employed in these leader positions, but leader education is a high priority in many municipalities. These individuals often have lengthy experience as RNs or have previous leader experience.

The study sample was recruited from 12 nursing homes in six municipalities in Norway. Inclusion criteria were a person who: (a) was employed in a leader position as ward leader, quality leader, or service leader in a nursing home, and (b) was employed full time in the leader position. The inclusion criteria were chosen because these individuals directly affect quality and safety in the nursing home, as they are the closest level of leadership to the staff and residents. Purposive sampling was initially used to ensure that participants recruited could see the phenomenon from the perspective of a leader. During the data collection, each municipality and its nursing home leaders were recruited using a step-wise approach, as we were seeking to get a theoretical sampling until saturation of data was achieved [ 40 , 41 ]. A total of 28 individuals participated in the study, 23 participants were ward leaders, two participants were quality leaders, and three participants were service leaders. However, in this study, all 28 participants are named ‘care managers’. Characteristics of the participants are presented in Table 1 .

Recruitment and data collection

Participants were recruited over a period of six months, from August 2018 through the end of January 2019. A recruitment email was sent to health care managers in 11 municipalities in both urban and rural areas. Health care managers from five municipalities stated that they could not find time to participate in the study, while six health care managers accepted the invitation. Thereafter, a second recruitment email was sent to all nursing home directors in these six municipalities. The email included an invitation letter, which the nursing home director forwarded to all individuals employed in a leader position at their nursing homes. Six focus group interviews were conducted, with three to six participants in each group. The focus groups were composed as follows: one focus group with three participants; two focus groups with four participants; one focus group with five participants; two focus groups with six participants.

All six focus group interviews took place in a meeting room in a nursing home in the participating municipalities. Each focus group interview lasted approximately 90 min. All participants gave informed written consent before the interviews started. Two researchers carried out the interviews. JM was the moderator in all six interviews, SN was co-moderator for two group interviews, and SS was co-moderator in one group interview. In the other three interviews, two researchers from the larger research team were co-moderators. During the introductory information about the focus group interview, we presented a figure (Fig. 1 ), and asked participants about their experience and thoughts on the topic of elder abuse from health care staff, co-residents or relatives. Participants were encouraged to speak freely. However, during the first interview, we experienced that participants were not familiar with the topic. To explore the topic in the ensuing interviews, the moderator gave the participants keywords from the categorization of abuse (e.g., abuse can be described as physical, psychological, sexual, financial, or neglect) (Table 2 ) [ 12 ]. We found that this helped the participants reflect, and they subsequently came up with examples of abusive situations they had heard about or witnessed. During the process of data collection, we further compared our experiences in interview one with interview two, which is in line with the constant comparative method [ 40 ]. This led to including keywords in the interview guide to ensure that all topics were covered (Additional fil 2). To ensure the credibility of an open thematic understanding of participants’ experiences and diminish bias by presenting the keywords, we were conscious about letting the participants speak freely about their experiences and thoughts on this topic. Moreover, they were not given any definition of abuse or examples related to these keywords (Table 2 ) [ 12 ]. The participants freely decided in which order they wanted to talk about different forms and situations of elder abuse. All interviews were recorded and transcribed verbatim, retaining pauses and emotional expressions.

Model of interactions where abuse can occur as used in the interviews

Data analysis

A constant comparative method with a grounded theory approach was used. This allowed us to generate a thematic understanding of elder abuse through an open exploration of the experience described by nursing home leaders [ 40 , 41 ]. The constant comparative method facilitated possible identification of themes and differences between individuals and cases within the data [ 40 ]. Our analysis started right after each interview, where the first author listened to the recorded interview. Memo writing was then used through the whole process of data collection and analysis and served as a record of emerging ideas, questions and categories [ 41 ]. Next, in line with the constant comparative method, open line-by-line coding of the transcribed interviews was performed [ 40 , 41 ], since we wanted to capture the meaning from the participants’ perspectives as they emerged from the interviews. The codes were compared for frequencies and commonalities and then clustered to organise data and develop sub-categories. The sub-categories were examined to construct the final categories and main theme. To add credibility and diminish researcher bias, two researchers (JM and SN) coded the transcribed interviews independently. During the analysis process, the authors held several meetings where codes and their connections were discussed until consensus was reached. To ensure that the emerging categories and themes fit the situations explored, the researchers went back and forth between contextualization, data analysis and memo writing [ 40 ]. An example of the analysis process is shown in Table 3 .

Ethical consideration

Ethical approval for this study was given by the Norwegian Centre for Research Data (NSD), Registration No: 60322. Each participant signed a written consent form after receiving oral and written information about the study. All identifiable characteristics are excluded from the presentation of data to ensure the anonymity of all individuals.

The main theme, ‘Elder abuse in nursing homes, an overlooked patient safety issue’, found in this study indicates an overall lack of awareness of elder abuse and its harm among care managers. Three analytical categories emerged from the analyses: 1) Abuse from co-residents – ‘A normal part of nursing-home life’ , 2) Abuse from relatives – ‘A private affair’ , and 3) Abuse from direct-care staff – ‘An unthinkable event’. Since there were no remarkable differences in care managers’ experiences, we present results without differentiating the participants. Below, we describe each category, together with examples of forms of abuse and neglect. These examples are used to describe the care managers’ perceptions of elder abuse and neglect (Table 4 ).

Abuse from co-residents – ‘A normal part of nursing-home life’

Resident-to-resident aggression was described as the biggest issue related to abuse in nursing homes and a daily challenge for the participants: ‘ That is what I also see, that co-residents are the biggest challenge regarding this topic’ (Group 2). The main cause of resident-to-resident aggression reported by care managers was symptoms of dementia, especially in the initiator, but also in the victim. The care managers expressed that they did not know how to address this problem. As one said, ‘ It happens because of the cognitive failure, so yes. But, at the same time, it is also difficult to do something about it’ (Group 2). Some care managers also stated that the risk of harm caused by resident-to-resident aggression was something residents must accept when living in a nursing home: ‘ There is a predictable risk, when living in nursing homes, [of] such incidents; there is a foreseeable risk that this will happen’ (Group 5) . This demonstrates that resident-to-resident abuse is normalized.

Care managers considered physical abuse to be the most serious form of resident-to-resident aggression, often leading to visible harm and despair. At the same time, all care managers had examples of residents who had been beaten, knocked down, or kicked by co-residents.

‘We have one resident now that is beaten a lot by the other residents. It’s a little extreme, but I think that such things can happen quite often in dementia care because, as in this case, the resident being beaten is not silent for a minute. She speaks and yells all day, and the other residents become annoyed since she disturbs them’ (Group 4).

Care managers described psychological abuse as acts of ‘everyday bullying’ and threats made among residents. They interpreted these situations as a normal consequence of the dementia disease in the individual resident. One care manager noted, ‘ What I think is the challenge is the everyday bullying. It is seen as normal behaviour for that group of residents’ (Group 1). When discussing psychological abuse connected to co-residents, all care managers provided examples of residents trespassing in other residents’ rooms. They interpreted this behaviour as a violation of residents’ privacy. At the same time, it was perceived as normal since it happened quite often. The care managers also reported that when residents trespassed and entered another resident’s room, the risk of other forms of abuse such as financial abuse increased. One care manager remarked , ‘We have some challenges related to residents who enter other residents’ rooms and destroy or take other residents’ possessions. It can be pictures and different things’ (Group 3).

Related to sexual abuse by co-residents, all care managers had examples of residents who had shown sexual interest in another resident. The care managers viewed this sexual interest as an ethical dilemma for them. On the one hand, they want residents to have a healthy sex life in the nursing home, but on the other hand, this is difficult when a resident has dementia and may not be competent to give consent. Several care managers experienced that what seemed to be voluntary sexual interest between residents could not be that, after all:

‘In that situation, she was very interested in him, and he was very interested in her. And it was like, yes, they were in the room together and so on. I remember it as very, very difficult because she often had a lot of pain. I do not know if there was penetration, but it was, in any case, an attempt, yes, it may as well have been that too. I had a lot of trouble because I was unsure whether she understood what happened and who it was happening with because it was often very difficult for her after they had been in the room together. I remember it as a huge ethical dilemma. But I never thought that it was a sexual . . . that it was an assault or something. But, right now, I think it was’ (Group 5).

During the focus group discussion, care managers reflected on the complexity of letting residents express themselves sexually and the risk of sexual assault. From their statements, it was clear that they had not reflected on this topic earlier. A summary of forms of harmful situations related to resident-to-resident aggression reported by participants is presented in Table 4 .

Abuse from relatives – ‘A private affair’

Abuse directed towards residents from their relatives was reported to be a particularly difficult problem. According to the care managers, relative-to-resident abuse was often hidden, occurring behind private closed doors when a relative was visiting the resident. Therefore, participants described it as difficult to discover and associated mainly with the private relationship between the resident and his or her relatives:

‘ It is very difficult. It is a relative who is going to visit her mother in the nursing home, she closes the door to the room and wants to be there alone with her mom, and we have very large rooms, so we thought they were having a nice time inside the rom. But then we discovered that the mom had some bruises, and then we understood that things were happening’ (Group 3).

Not all care managers had knowledge of or experience with relative-to-resident abuse, which highlights the private nature of these forms of abuse. Abuse from relatives was viewed as being linked to past family conflict, which continued inside the nursing home. The care managers deliberated over the extent to which they should interfere in the private relationship when they suspected this form of abuse. They reported that the problem was knowing what to do and when and how to interfere, especially when the resident has dementia or another form of cognitive impairment. One care manager remarked, ‘ It is very difficult. I have a patient who may not be competent to give consent. So, I have a responsibility I must take, but I think it’s challenging to know what to do’ (Group 2). Cases where the resident clearly did not want anyone in the nursing home to know about the abuse or to do anything about it and just wanted to maintain the relationship with his or her family member despite the abuse were reported to be particularly difficult. The care managers expressed that they lacked a strategy or authority in these situations, and harm to the resident being exposed was accepted.

‘ But it is not always that the resident wants us to do something, either. It may have been this way for a long time, and then, maybe it’s okay then. Well, I don’t know’ (Group 5).

Physical and sexual abuse from relatives was regarded as the most hidden form of abuse from relatives. Some care managers provided examples of physical abuse, but none had experienced sexual abuse. However, all care managers commented that when it happened, it took place behind private closed doors. In addition to past family conflict, abuse from relatives was often related to mental problems and/or drug abuse issues. One care manager said, ‘ I have experienced some older people who have children with drug issues and such things. And it is in those cases, I have experienced physical abuse towards residents from relatives’ (Group 4). Related to physical abuse from relatives, care managers also reported situations where a relative forced the resident to, for example, eat, get dressed, wash and groom, or exercise. These situations were linked to unrealistic expectations in relatives, and not trusting the staff is doing a good job.

‘After her husband had been there, we saw that she was so red around the cheek. We then found out that the husband squeezed her mouth open and poured cream into her’ (Group 3).

Care managers viewed psychological abuse from relatives as disrespectful communication with the resident. A participant stated, ‘We experience that relatives can be quite disrespectful to their loved ones. But, at the same time, it may have been this way their whole life’ (Group 6).

Care managers expressed that financial abuse from relatives was a common occurrence. They cited examples of stealing money from residents, threatening residents in order to get money from them, and unauthorized use of a resident’s finances. One participant stated, ‘ What I see most from the relative’s part is financial abuse. It is very common, actually’ (Group 1). Relatives’ economic problems were reported to be a causal factor related to financial abuse. At the same time, care managers indicated that financial problems and financial exploitation by relatives were private issues, and as such, they were reluctant to interfere.

Related to neglect, care managers described that some relatives made decisions on behalf of the resident without considering what the resident wanted and needed or would agree upon. Care managers stated that sometimes the health care staff also disagreed with the relative’s decision. One care manager noted, ‘ We have situations where relatives make decisions on behalf of the resident, which we do not agree upon, and which we might think the resident would not agree upon either’ (Group 3 ). Care managers also described experiences of relatives who refused to allow a resident to buy items the care managers considered necessary and not provided by a nursing home. These could be things such as clothes, hairdressing services, or podiatry, but it could also be related to taking part in activities that cost money. A care manager remarked:

‘ I have a resident who called her son to ask if she could go to a podiatrist because she really needed it, but her son refused and said she has no money for that’ (Group 5).

Thus, because of neglect by their relatives, residents might go without necessities of daily living and may not be able to participate in activities they would like to take part in. A summary of forms of harmful situations related to relative-to-resident abuse reported by participants is presented in Table 4 .

Abuse from direct-care staff – ‘An unthinkable event’

When care managers were prompted to talk about staff-to-resident abuse, they reframed the discussion to focus on the verbal and physical aggression they commonly experienced from nursing home residents. They interpreted aggression directed toward them as a risk to their health and safety. Moreover, they stated this phenomenon was a daily concern. One noted, ‘ We have the opposite focus in our units. We focus on staff being subjected to abuse by residents’ (Group 2). Several care managers also indicated that they understood that staff could become stressed and frustrated in their relationship with an aggressive resident:

‘We have a case that is extremely difficult, where there are many violations against staff by a resident. And then, to be in such a situation where you can quickly retaliate . . . this is difficult’ (Group 6).

Despite this, care managers expressed that elder abuse was not a topic they talked about in their daily work at the nursing home. They indicated that they wanted to trust the employees. Therefore, abuse from staff was difficult to talk about and almost unthinkable to them. One care manager said, ‘I think that no one who works in the nursing home started there just to be able to hurt someone, and that is perhaps why this is such a sensitive and difficult topic’ (Group 5) . The word ‘abuse’ was also reported to be a very strong term and mainly related to intentional physical acts. However, in the discussion, care managers also included unintentional acts in their examples of elder abuse and expressed that, to some degree, it could be difficult to know the full intention of a staff member’s actions. At the same time, they emphasised that staff’s intentions were mainly good, and therefore abuse was unthinkable:

‘Everyone who works in a nursing home is motivated by and has a desire to help someone. So, most of the [incidents] of abuse by staff . . . I think it may be those with a good intention at the heart of it. [For instance, thinking] “I thought he should have a shower, but I forgot to ask” (Group 5).

Care managers discussed examples of the use of physical and chemical forms of restraint and rough handling during care. Utilization of restraints and dilemmas related to their use was discussed in all focus groups, and care managers pointed out that the staff are sometimes compelled to use both physical and chemical restraints to help or protect the resident:

‘I think in relation to, well it is really both physical and psychological abuse. I think of cases, especially at night, where there is low staffing and many residents with aggressive behaviour, where it may be chosen to lock some residents into their rooms to prevent them from being exposed to abuse from co-residents so the staff can deal with the situation, but it is abuse to be locked inside’ (Group 2).

Rough handling was something that all care managers had experienced. This was thought to be mainly unintentional and something that could happen when caring for residents with aggression or those who resist care. Care managers expressed that, to define it as abuse, it had to be significant, or there needed to be visible signs of such handling, such as bruising. At the same time, the care managers also pointed out that residents in nursing homes often bruise easily, and it can be difficult to determine whether such marks are related to abuse:

‘Sometimes, we saw that she was so easy to bruise, and sometimes we clearly noticed hand marks on the bruises around her body. But it can be enough that you handle someone a little hard, and in the old ones, then they get bruises, although it can also indicate that there has been resistance, right. But then this happens all the time’ (Group 4).

Psychological abuse from staff members was linked to verbal abuse. Care managers cited examples of yelling at a resident in anger, speaking to a resident in a disrespectful tone, or being rude, which allegedly occurred in relation to resident-to-staff aggression. When discussing psychological abuse, some care managers also provided examples of violations of residents’ privacy by staff members, such as discussing residents’ health care issues and challenges in public areas in the nursing home:

‘If there has been a resident with a rejection of care responses, for example, that has been difficult to cooperate with, then that frustration can be expressed in public areas with other residents present. Without caution by staff, this is something other residents are going to hear’ (Group 5).

Financial abuse was thought to be related to stealing money or destroying a resident’s property. At the same time, care managers reported that their nursing home policies do not allow residents to keep much money in their rooms in order to protect residents from financial abuse by staff, visitors, or others, and hence, financial abuse from staff rarely happened. One said, ‘Financial abuse only happens if the residents have money laying around’ (Group 1).

When talking about sexual abuse, care managers offered examples of residents who stated that they were sexually assaulted by staff members. These were often female residents who expressed that male staff had sexual intentions towards them during care. At the same time, care managers reported that such statements from residents could be part of the dementia disease, and that resident could have hallucinated the abuse. Care managers indicated that sexual abuse by staff was unthinkable to them:

‘Sometimes, older people with cognitive impairment say things that we can become uncertain about. They say things, but we can’t be sure there has been an assault. Often, we think that it has not happened. It’s about us knowing them; they say a lot of these things and are very sexually oriented’ (Group 4).

Even so, a few care managers mentioned examples of sexual abuse by staff a long time ago that had been reported to the police, and the staff member was convicted.

Related to neglect, care managers reported that staff often did things for residents to save time instead of letting them do it independently. They also reported being aware that, in many situations, staff members do not pay attention to residents’ wishes and thereby neglect to include them in decisions concerning daily life in the nursing home. One care manager noted, ‘ It says on the duty list that you should shower today, so you should shower, even if you might say, “No, I don’t want to.” So, yes, it is your turn today’ (Group 3). Another form of neglect by staff was reported to be linked to health care neglect. Care managers referred to events such as not helping a resident with needed health care, giving a resident an incontinence product instead of helping them use the toilet, not calling for medical help when needed, and not following up on medical conditions:

‘To put on a pad instead of following the patient to the toilet, for those who still manage to use the toilet themselves . . . that can happen’ (Group 6).

The care managers reported that, because of low financial resources, staff must prioritize their work and tasks every day. For this reason, situations not specifically related to medical treatment and physical or health outcomes were given lower priority. This reprioritization was framed as acceptable and was not defined as neglect. One said, ‘ It is about our time. So, no, we don’t have time for you or that need is not important. It is about what we have to prioritize’ (Group 6). A summary of forms of harmful situations related to staff-to-resident abuse reported by participants is presented in Table 4 .

The aim of the study was to explore nursing home leaders’ perceptions of elder abuse and neglect. We found that most of the care managers were not explicitly aware of elder abuse in their daily work. However, when given keywords, they all came up with examples of situations they interpret as harmful or distressful to residents. This shows that care managers need time to reflect on complex aspects of care to become aware of abuse and neglect as a safety issue. At the same time, our findings revealed an ambiguity in the care managers’ examples. The situations, on the one hand, were described as harmful. On the other hand, they were rationalized as care managers attempted to excuse why it was happening. Three main categories are described in the finding: Abuse from co-residents – ‘A normal part of nursing-home life’, Abuse from relatives – ‘A private affair’, Abuse from direct care staff – ‘An unthinkable event’. These findings indicate that this cohort of nursing home care managers lack awareness of the abuse they observe or hear about. Particularly, these findings demonstrate that harm or distress to residents caused by abuse are an overlooked patient safety issue in these nursing homes.

Findings revealed that resident-to-resident aggression is a common form of abuse in nursing homes and a daily challenge. There is a high prevalence of residents with neuropsychiatric symptoms of dementia, including aggression, agitation and psychosis in nursing homes [ 25 , 26 ]. These symptoms impact on co-residents and staff safety, and resident-to-resident aggression is the most common form of abuse in nursing homes [ 16 , 17 ]. However, our findings revealed that harm resulting from resident-to-resident aggression was perceived as normal. This raises the question of whether care managers perceptions place the responsibility on the resident, without accounting for the complexity in the aggressive behaviour and the responsibility of the organization [ 22 ]. It is worth noting that in resident-to-resident aggression, both residents can suffer harm, since the initiator is likely to be confused and usually not responsible for the acts. For the victim, resident-to-resident aggression has both physical and psychological consequences [ 47 ]. However, previous research has also indicated that abusive behaviour can be understood as less abusive when the victim has dementia, and for that reason it is often not reported [ 17 , 48 ]. Recognising that aggressive behaviour has a multifactorial aetiology, best practice recommendations [ 49 ] and research evidence [ 50 , 51 ] call for a comprehensive biopsychosocial approach that investigates the resident’s unmet needs, medical conditions, environmental factors, and interactions between residents and caregivers and a tailored response [ 49 ]. Care managers’ perceptions of resident-to-resident aggression as normal and a foreseeable risk, places residents at risk and is also a failure to deliver much needed care to the initiator.

With respect to relative-to-resident abuse, findings demonstrate that care managers perceive negative events resulting in harm or distress as a private affair between the resident and his or her relatives, and that is difficult to intervene. Similarly, to resident-to-resident abuse, this indicates that the care managers place the responsibility of the observed abuse on the relationship between the resident and his or her relatives, without accounting for the complexity and their own responsibility in these situations. Care managers examples of relatives who force a resident to eat due to unrealistic expectations and distrust in nursing home staff’s care reveals that care managers find it difficult to interact with families. This finding points to potential communication difficulties between staff and resident’s relatives that could adversely affect the resident [ 52 , 53 ]. A Norwegian study that investigated quality of care from the perspective of families in long-term care found that family members saw themselves as an important link between staff and the resident, and an essential voice regarding the resident’s needs and wishes [ 53 ]. However, given the nature of the nursing home and the complexity of its organization and routines [ 22 , 23 ], it can be difficult for someone outside the organization to judge what is and is not adequate clinical practice. Collaboration and communication with the residents and their relatives depend on how the culture in the nursing home view these interactions; the relatives with right to an opinion, or professional as experts and in control [ 6 , 22 , 52 ]. This will in turn affect the quality and safety of the care that is delivered to the residents.

Although some care managers had experience of staff-to-resident abuse within all abuse categories, it was also difficult for them to admit to this form of abuse, and it was viewed as an ‘unthinkable event.’ Instead, care managers were mostly interested in talking about resident-to-staff aggression which they emphasised was a larger problem in their nursing homes. Resident- to-staff aggression can cause physical and psychological harm to staff, reduced job satisfaction, stress and burnout, emotional reactions including sadness, guilt and helplessness [ 28 ]. However, resident-to-staff aggression may also lead to reactive abuse and neglect, due to frustration in staff member being exposed to aggression [ 11 , 13 , 27 , 28 ]. Findings in the present study demonstrate that care managers lack awareness of the staff’s reactive responses to aggression from residents. This might raise the question if they perceive staff as victims in these situations and that abuse from staff is understandable. Unprovoked or intentional abuse towards a resident therefore is unthinkable with justification in their trust to the staff.

Difficulties in defining abuse in nursing home settings have been found in studies that include staff’s perceptions [ 39 , 54 ], where abusive situations are seen as normal in the nursing home culture [ 17 , 33 , 39 , 55 ]. However, these studies did not specifically focus on care managers’ or leaders’ understandings. Our study reveals important information related to detection and management of abuse in nursing homes, since care managers’ perception of abuse affects what they signal to staff as important to report. Care managers have the opportunity to influence the culture and care practice in the nursing home and are responsible for setting policies for the staff, it is therefore essential that they are aware of and able to face situations that constitute potential harm to the residents. But, to be able to define situations that can be experienced as harm and distress, it is essential to see situations from the perspective of the residents. Harm and distress are defined differently from the point of view of the one who causes the harm [ 39 , 54 ], the one observing or hearing about it [ 14 ], or the one who experiences a situation of harm or distress [ 20 , 21 ]. Our findings indicate that the care managers had difficulties in seeing potential harm caused by abuse and neglect from the perspective of the residents. Leaders’ abilities to promote a safety culture for both the resident and staff are linked to their leadership skills, knowledge of the resident’s needs and their capacity to implement effective safety care practices [ 6 , 31 , 32 ]. Care managers’ lack of awareness in identifying and following up on abuse will necessarily affect the safety culture in the organisation and, in the end, clinical outcomes such as quality and safe care for the residents [ 6 , 10 , 56 ].

A recent Norwegian study found that communication, openness and staffing were significant predictors of staff’s overall perception of patient safety in nursing homes, yet the nursing home staff scored low on these dimensions [ 56 ]. This finding aligns with our study, which revealed that care managers find it difficult to distinguish between prioritising and patient neglect. Low financial resources and low staffing can affect the perception of what constitutes harm and safety in the nursing home culture. Low finances, combined with the complexity of residents’ needs, the complex organisation, and demands for improved outcomes, puts great pressure on nursing home leaders [ 22 , 57 ]. The ambiguity in their examples can be understood as an attempt to rationalize abuse and diminish their personal and professional accountability. People in complex social systems will try to make sense of tasks and orders by adapting to internal and external demands [ 22 , 23 ]. Health care policies that mandate efficiency, cost saving, and nursing home care managers’ focus on prioritising contribute to lowering the limit for what is perceived as quality and safety, resulting in low quality and unsafe environment as the norm and accepted in nursing homes.

Strengths and limitations of the study

A strength of this study is that it involves participants who are in leader positions in different nursing homes and municipalities in Norway, which could increase the transferability of these findings. The research team consists of members from two countries, all with broad research experience, which contributed to multiple perspectives and discussions during analyses of the data. This strengthens the trustworthiness of our findings, and the credibility of the research. Three of the authors have worked several years in nursing homes as care managers, but none of those nursing homes participated in this study. The researchers’ backgrounds as care managers has both advantages and disadvantages. A variety of aspects of participants’ experiences was discovered by posing in-depth questions that might not have been possible without the background knowledge. However, the background knowledge can influence the type of follow-up questions that were asked. To counterbalance this possible bias, two researchers were always present during the interview, and the analyses were also independently coded by two researchers (JM and SN). Each focus group consisted of three to six participants, which can be perceived as small groups and a limitation. However, the participants gave a rich description of the phenomenon. Therefore, we decided to include data from the smallest groups.

The examples of abuse and neglect our participants described in the present study could be second-hand information because leaders are not always part of the direct hands-on care residents receive. At the same time, this study has sought to understand the nature of elder abuse from care managers’ perspective, which is of great importance due to their responsibility for creating a safe environment for both residents and staff. Even though the examples are second-hand information, the findings are representative of the care managers’ perceptions of the information and what we thought was important to study.

Many nursing home residents have dementia, neuropsychiatric symptoms, and complex needs, which increases the risk of their being exposed to abuse and neglect. At the same time, little is known about the nature of elder abuse in nursing homes and compared to research on other forms of interpersonal abuse, the study of elder abuse in nursing homes is still in its infancy. Care managers influence the culture and care practice in nursing homes and set policies for staff. Knowledge about their empirical understanding of the phenomenon is important to form more effective intervention and prevention strategies. The present study shows an ambiguity in the nursing home leaders’ examples of abuse and neglect. On the one hand, the situations were described as harmful. On the other hand, they were rationalized with an attempt to excuse their occurrence. Our study revealed that elder abuse and neglect is an overlooked patient safety issue in nursing homes. Care managers lack knowledge and strategies to identify and adequately manage abuse and neglect in nursing homes, and this warrants further research.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to format of the data not allowing for completely anonymizing data but are available from the corresponding author on reasonable request.

Abbreviations

Research Council of Norway

Registered Nurse

World Health Organization

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Acknowledgements

We would like to express our gratitude to our participants for sharing their experience and thoughts on the topic of elder abuse and neglect in nursing homes. Thanks to Anja Botngård and Stine Borgen Lund for contributing to data collection as co-moderators.

Ethical approval for this study was given by the Norwegian Center for Research Data (NSD), Registration No: 60322. All the participants were provided with written information about the study. They gave written consent to participate in the interviews and for the use of the data from the interviews.

Authors details

JM: RN, MSc, PhD candidate, at Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway.

SS: RN, MSc, PhD, Associate professor at Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway.

WM: RN, MSc, PhD, Associate professor at Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway.

JO: RN, GCert Cont Prom, GCertHE, MNurs-Res, PhD, Research Fellow, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Institute for Healthcare Transformation, Deakin University, Geelong, Australia.

SN: RN, MSc, PhD, Professor at Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway

The study is funded by the Research Council of Norway (NFR) project number: 262697.

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JM wrote the manuscript. JM, SS, WM, JO and SN developed the study design. JM transcribed the interviews, and JM and SN performed the analysis of the interviews, with discussion including all authors. SN supervised the project. All authors did critical revisions of the manuscript for important intellectual content and read and approved the final manuscript.

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COREQ checklist.

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Myhre, J., Saga, S., Malmedal, W. et al. Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders’ perceptions of elder abuse and neglect. BMC Health Serv Res 20 , 199 (2020). https://doi.org/10.1186/s12913-020-5047-4

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Strategies to build more effective interventions for elder abuse: a focus group study of nursing and social work professionals in Hong Kong

• Elsie Yan   ORCID: orcid.org/0000-0002-0604-6259 1 ,
• Louis To 1 ,
• Debby Wan 1 ,
• Xiaojing Xie 1 ,
• Frances Wong 2 &
• David Shum 3  

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One in six older adults living in communities experience abuse and neglect. Elder abuse has serious consequences for individuals, families, and society, including mortality, physical and psychological morbidities, and increased care requirements. Timely and effective interventions for elder abuse should therefore be a priority. This study used a qualitative focus group approach to address the following questions: What are the essential elements of elder abuse interventions? What can be done to improve current interventions?

The 32 participants in this focus group study included social workers, medical social workers, and nurses from seven organizations who shared their knowledge and insights. All sessions were conducted online, audio-recorded, and transcribed verbatim. Three researchers with backgrounds in social work and psychology independently coded the transcripts and agreed on the themes emerging from the focus groups.

Based on the experiences of frontline helping professionals in Hong Kong, we highlighted the key factors for effective elder abuse intervention: 1) identification and assessment; 2) essential skills and attitudes; 3) elements of effective interventions; 4) collaborative efforts across disciplines and agencies; and 5) raising awareness among professionals and the public.

Conclusions

Training can equip frontline professionals with the necessary skills to identify elder abuse cases and to assess the risk of abuse. Effective interventions should not only address clients’ safety and need for tangible support but also respect their autonomy and privacy. A client-centered, strength-based approach that involves supportive peers and addresses the complex family relationships involved can be useful. Interventions should also involve cross-discipline and cross-agency collaboration.

Peer Review reports

Elder abuse is “a single, or repeated act, or lack of appropriate action, occurring in any relationship where there is an expectation of trust, which causes harm or distress to an older person” [ 1 ]. It can occur in any socioeconomic and ethnic group. A review of 52 studies from 28 countries found an average prevalence rate of 15.7% [ 2 ]. Abuse has serious consequences for individuals, families, and society, including mortality, physical and psychological morbidities, and an increased need for care [ 3 ].

Due to its prevalence and detrimental consequences, efforts have been made to develop intervention strategies for elder abuse. These include community support for vulnerable older adults [ 4 ] and caregivers [ 5 6 ], telephone helplines [ 7 8 ], emergency shelters [ 9 ], and multidisciplinary case management [ 10 11 12 ].

Problems with current prevention and intervention efforts

Recruiting and retaining participants in elder abuse interventions has proven difficult [ 13 ], which may be due to various factors. Victims of abuse who depend on their abusers for care and companionship may accept mistreatment through “tactic exchange” [ 14 15 ]. The abusers may have larger social networks than their victims, who thus perceive them to have more power, which can reduce the likelihood of victims seeking assistance [ 14 15 ]. Older adults may also be unaware of the available community resources. Population-based research in the U.S. suggests that only between 4% and 14% of elder abuse victims are aware of the agencies through which they can make formal responses, such as adult protective services and law enforcement [ 14 15 16 ]. In addition to the lack of knowledge about available resources [ 17 ], traditional cultural values, the wish to protect family honor and maintain harmony, and a general lack of trust in third-party intervention represent barriers to elder abuse victims seeking assistance [ 17 ].

The perspectives of victims [ 18 ] and of professionals have been considered in the literature in terms of types of intervention [19] and the reporting of suspected elder abuse [ 20 ]. We aim to extend these studies by drawing on the experience of frontline professionals to identify the essential elements in a range of elder abuse intervention strategies.

The Hong Kong context

In 2004, the Hong Kong government first initiated a study on elder abuse, and the Social Welfare Department published guidelines for tackling elder abuse and established an online platform for reporting instances of abuse. Very few cases were reported between 2005 and 2022, ranging from 319 to 627 annually, with most being instances of physical abuse. However, a prevalence rate of 27.5% has been reported among community dwelling older adults [ 21 ], so the reported cases only represent the tip of the iceberg.

In terms of legislation, reporting elder abuse is not mandatory in Hong Kong, either for lay persons or professionals. Amendments to the Domestic Violence Ordinance (Cap. 189), originally aimed at protecting women and children in a marital relationship, were made in 2008. This was renamed the Domestic and Cohabitated Relationships Violence Ordinance (Cap. 189), and now is aimed at protecting all individuals living in the same household, including elderly victims.

The responsibilities of taking care of older people fall to a great extent on their families. The traditional cultural values of “filial piety” prescribe that adult offspring take care of their aged parents. The government also takes an “aging in place” approach, and encourages family care. Those providing care to a senior family member can apply for a tax reduction of around US$800, and Hong Kong citizens co-residing with a family member age 60 or above have priority when applying for public housing. In addition, only 8.5% of those aged 65 or above in Hong Kong live in long-term care facilities, as availability is limited [ 22 ]. Thus, some households in Hong Kong hire domestic help to assist with elder care. In 2019, 400,000 foreign domestic helpers worked in Hong Kong. Many receive a wage of around US$600 per month and are required by law to live in their employers’ residence. They perform caregiving tasks such as cooking, cleaning, transferring, bathing, and feeding. In addition to this heavy workload, many experience language barrier difficulties when communicating with care recipients.

This study attempted to identify essential elements of elder abuse interventions from a series of focus groups with social and health care professionals in Hong Kong.

Participants

We recruited a sample of 32 participants from seven local hospitals and governmental and nongovernmental organizations. They included social workers who focus on senior support ( n = 7), domestic violence intervention ( n = 4), shelters for elder abuse victims ( n = 9), medical support ( n = 3), and nurses in accident and emergency hospital units ( n = 9). The participants were first recruited through the research team’s professional networks. Community collaborators were invited to refer frontline colleagues with no less than five years’ experience in elder care, domestic violence, and elder abuse to our study. We took a snowballing approach to recruitment, and participants from the first round of focus groups were invited to refer colleagues concerned about elder abuse issues, again only if they had five years or more of experience. Participants’ work settings and backgrounds are summarized in Table 1 .

The research protocol was approved by the research ethics committee of the authors’ university. All participants provided verbal consent to participate before the focus group commenced.

Our qualitative approach of using focus groups had to be conducted online due to the social distancing requirements of the COVID-19 pandemic. The participants shared their experience and knowledge of elder abuse intervention through one of the eight group sessions, each of which was 120 to 180 minutes long with between 3 and 7 participants in each. Researchers in this study served the role of focus group facilitators and encouraged participants to share their views in the groups. Researchers did not actively shared their own views to avoid bias.

The sessions were all audio recorded and transcribed verbatim. All transcripts were reviewed by the team to ensure accuracy. Microsoft Excel was used for assigning codes and statements were compared across and within groups [ 23 ]. Three researchers read the transcripts and independently created preliminary code lists. Codes representing similar meanings were grouped into broader thematic categories to create a coding scheme. Any differences in the three researchers’ coding were resolved by discussing the context and meaning of the statement and agreeing on a final code. The authors then conducted a final review of the themes and subthemes.

We invited ten of the participants to comment on the themes generated from the focus groups, and they agreed that the themes accurately reflected their opinions.

Appendix I presents the focus group guides used in the present study.

The participants highlighted service gaps and areas requiring improvement in their discussions of elder abuse interventions. In the next section, we address the following key themes that emerged from the discussions: 1) identification and assessment; 2) essential skills and attitudes; 3) effective interventions; 4) collaborative efforts; and 5) raising elder abuse awareness. Table 2 summarizes the themes and subthemes generated from the focus groups. To protect participants’ identity, pseudonyms are used throughout this paper.

Identification and assessment

Timely and effective case identification is the first step in any elder abuse intervention. The participants suggested effective detection and identification approaches.

Avenues for case identification

Elder abuse victims may not proactively seek help, and thus professionals should inquire about issues relating to abuse when on routine service visits.

We always ask for additional information when [clients] apply for other services [unrelated to elder abuse]. We only learn about an abusive situation when they tell us more. Clients very rarely disclose that they are being abused when they first come to us. (Amelia, Social Worker, Elderly Services)

Many people do not come in seeking elder abuse services. They may need someone to escort them to medical appointments, need help with household chores, have financial difficulties, difficult relationships with family members, etc. It is only when we dig deeper that we realize it is an elder abuse case. Very few people will tell you spontaneously that someone in their family hit them. (Carmen, Social Worker, Elder Abuse Shelter)

Participants also noted that involving “knowledgeable others” in elder abuse detection is important. They suggested that those in close contact with older people, such as neighbors, janitors, security guards, and district councilors, can help in identifying cases of elder abuse. Most Hong Kong residents live in apartments, and hundreds of households are typically packed into the same building. This unique living environment means that neighbors and building security guards are in a very good position to detect and identify elder abuse cases, as they have frequent day-to-day contact with older residents.

Security guards in residential buildings have lots of opportunities to communicate with older residents. Workers on food delivery teams only contact them if they are using their services, and many would avoid mentioning suspected elder abuse for fear of getting themselves into trouble. If we could provide some training to security guards, they could easily keep an eye on older residents while they are on duty. (Amelia, Social Worker, Elderly Services)

The participants also observed that medical contexts offer an effective avenue for elder abuse identification. Older people often regularly visit their family doctors or hospitals. Frontline medical professionals must therefore be aware of and sensitive to elder abuse issues:

I once saw an old woman in the triage station with both hands scalded by hot water. It was pretty abnormal that it was both hands, so I suspected that someone had done it to her. When asked about the injuries, she eventually told me that her son had scalded her. We do that with unusual injuries, either nurses at the triage station or physicians in the examination rooms. (Iris, Nurse, Hospital Accident and Emergency Unit)

Awareness and readiness

Following this, the participants also noted that the readiness to address potential cases of elder abuse is critical for its detection.

A client may have many internal struggles; they may feel too ashamed to tell us what happened. Under such circumstances, social workers’ readiness is of critical importance. If a worker chooses to turn their back, the client will just continue to hide the abuse. If the worker is willing to listen, however, and is ready to dig deeper into the issue, clients will be more willing to share and positive change can happen. Social workers need to know themselves, to be ready all the time, and to continually reflect on the reasons why they might avoid addressing elder abuse issues. (Carmen, Social Worker, Elder Abuse Shelter)

Organizational culture and support

Participants suggested that organizational culture and policy may also influence the willingness and motivation to identify elder abuse:

When the attending doctor sees that an injury is in an uncommon location, he or she will always consult a more senior doctor who specializes in the study of suspected elder abuse. The Hospital Authority has specific guidelines requiring that every hospital has at least one medical doctor or nurse responsible for handling suspected elder abuse cases. We work with them very closely to determine whether the case is elder abuse or just a regular accidental injury. (Liz, Medical Social Worker, General Hospital)

Risk assessment

The primary goal of elder abuse intervention is to ensure client safety. The participants discussed the importance of risk assessment:

From the moment an older client contacts us, regardless of whether he or she comes in person or contacts us by phone, we always start with a thorough risk assessment to ensure his or her safety, and are alert to any potential danger. (Helen, Social Worker, Shelter for Domestic Violence Victims)

We assess the case severity, whether a hospital visit is required, whether there have been similar incidents in the past, etc. This indicates how risky the current situation is. Especially in cases of long-term domestic violence, it could be extremely dangerous for us to leave the client at home with the perpetrator. (Gloria, Social Worker, Shelter for Domestic Violence Victims)

Those we interviewed rely on a range of methods, including quantitative assessment tools, examining case histories and clinical judgment, and assessing the risk level in individual cases. A comprehensive assessment requires a combination of objective and subjective measures.

Comprehensive case assessment

After determining a client’s immediate risk and ensuring his or her safety, a comprehensive case assessment must be conducted:

All cases who use our shelter service complete the IMPACT scale assessment. We try to investigate how the abuse incident may have impacted the client: for example, sleep problems or their physical condition. We also provide older adults with Activities of Daily Living and Montreal Cognitive assessments to assess their physical and cognitive functions and basic self-care abilities. (Ofelia, Social Worker, Shelter for Elder Abuse Victims)

Essential skills and attitudes

Respecting client autonomy and privacy.

The participants acknowledge that elder abuse differs from other forms of domestic violence and that extra care is required in terms of clients’ autonomy and privacy. Studies focusing on Hong Kong have indicated that elder abuse victims prioritize family relationships, personal needs, and cultural considerations over their own physical and psychological safety [ 24 ]. This is supported by other studies suggesting that professionals should respect the autonomy of victims after giving them advice, even if their decisions are likely to expose them to unsafe situations [ 25 ].

Even if the client understands that he/she is being abused, we must still respect his or her wish as to whether any follow-up is needed, or whether we can bring legal action against the family member. (Wesley, Social Worker, Elderly Services)

Older persons really resent others knowing about their family problems. We take extra care to protect our clients’ privacy at our meetings. It is comforting for them to know that no one else will hear anything about our conversation. Without such reassurances, many would just leave. (Patty, Social Worker, Elder Abuse Shelter)

Rapport building

The importance of building trust and a rapport with clients was also highlighted. Engaging elder abuse victims is essential for effective interventions, and studies in the U.S. have suggested that a relationship of trust can be developed through the engagement process and that strong client–practitioner relationships are likely to lead to desirable intervention outcomes [ 25 ].

Some clients may maintain that “it’s better to keep the skeleton in the cupboard,” but then after several meetings they decide that you are trustworthy and are willing to listen, and then they start talking. (Scarlet, social worker, elderly services)

Some clients may have a long history of “building a wall between themselves and the rest of the world” and are wary of other people. We need extra time and effort to build a relationship of trust with them before moving on. I feel that everything starts with trust: without trust, clients will only tell you superficial things … one small step at a time, it takes time. (Scarlet, Social Worker, Elderly Services)

Active Listening

Active listening is the most commonly used therapeutic technique [ 26 ] in this area, and the participants identified active listening and patience as the two essential elements to support victims of abuse:

To build a rapport with a client, we need to put aside our presumptions and try to understand the person sitting in front of us as a unique individual with unique experience. (Patty, Social Worker, Elder Abuse Shelter)

It takes lots of courage to leave an abusive situation. Social workers should let clients know we are there to accompany them at every step. This would give them peace of mind about later changes. When a client finally opens up to share his or her stories, a story inevitably stirs up lots of tears, deep-seated feelings, and emotions. We need to provide clients with a safe space to tell their stories, both physically and psychologically. (Carmen, Social Worker, Elder Abuse Shelter)

Progressing at the client’s pace

Male abuse victims in particular may resist services if they initially perceive a “helping” attitude:

We assume the role of friends or neighbors, merely there to show care, and slowly build up a friendly relationship. If we start off showing that we are there to help, that social workers are there to help you, it can hurt their ego and lead them to turn away. This is especially true for older males: some of them have quite big egos. (Scarlet, Social Worker, Elderly Services)

Workers may be inclined to bombard cases with information, telling them what sort of assistance and services are available, rushing into clinical assessment, etc. and that can be scary for clients. From my own experience, the “hard sell” approach can be a real turn-off. (Ofelia, Social Worker, Elder Abuse Shelter)

Effective interventions

Providing tangible support.

The participants said that many elder abuse victims rapidly leave the abusive situation with little preparation. They may require tangible support such as financial assistance, clothes, and shelter. Shelter services can provide support to victims in the form of day-to-day assistance or community services, in addition to a physically and psychologically safe environment [ 26 7 ]

Tangible needs are of the utmost importance to clients. Many residents in our shelter suffer financial hardships. They may have left home abruptly. Some only have their personal identity card with them, no mobile phone, no money, no clothes…Tangible support, like food from food banks, a television to keep updated on the news, warm clothes and bedding, etc., increases their sense of security. Their acceptance of such tangible support is a huge step for them, helping them to accept the changing situation. (Carmen, Social Worker, Elder Abuse Shelter)

Many elder abuse victims may not have a clear plan as to where they will go after they leave [their home]. Those who are with us [at the shelter] may not have all the necessary resources, so it is imperative that we provide basic necessities to them. Tangible support shows that we care about them. (Carmen, Social Worker, Elder Abuse Shelter)

Strength-based approach and post-traumatic growth

A strength-based approach can also be taken, as suggested in various studies. Identifying victims’ strengths can help empower them and rebuild their identities, thus speeding up recovery [ 27 28 ], and the process of recovery may have a therapeutic effect and foster growth [ 29 ]. Our participants also observed post-traumatic growth in clients they have worked with:

Many clients who have left our shelters come back and visit every now and then. Apart from using our services, they actually want to contribute to society, to demonstrate their abilities. They volunteer to support the newcomers at the shelters and use their own experience to help other abuse victims. (Gloria, Social Worker, Shelter for Domestic Violence Victims)

To quote a client, “being abused at 60 years old is most unfortunate, but it’s just a phase.” There is still a long way ahead and he could still contribute to his family and society over the remainder of his life. (Florence, Center Director, Shelter for Domestic Violence Victims)

Many members of the Buddy Program1 share that they no longer feel ashamed about speaking of their experiences of abuse, and that they have transformed the feeling of shame into motivation to help other seniors who suffer abuse. (Patty, Social Worker, Elder Abuse Shelter)

Support and self-help groups

Those working in shelter services reported making use of peer support programs to help elder abuse victims cope and heal.

We have an ambassador program for recruiting domestic violence survivors who have successfully overcome their trauma. Our clients not only struggle to help themselves; once they have moved on, they can jump out of their shadow and support others in difficulty. (Florence, Center Director, Shelter for Domestic Violence Victims)

Every now and then a client will say, “Just because other people can succeed doesn’t mean I can,” and continue to discount his or her own ability. But then it’s always nice to be able to refer to successful cases. Our clients very seldom share their abuse history in community centers, but they open up to fellow residents in the shelter, knowing that everyone here more or less has the same experience. It gives them hope. (Carmen, Social Worker, Elder Abuse Shelter)

Addressing complicated family relations

The participants agreed that family dynamics in elder abuse cases are often complex, particularly when the abuser is a family member, and must thus be addressed in interventions. Older victims may value family relationships more than their own safety [ 25 17 ], particularly if they depend on the perpetrator in their daily lives [ 14 ]. They may also refuse to seek help from social services due to the traditional values that involve protecting the reputation of their family and thus their abuser [ 24 ].

They may have fought all the time; some [abusive2family members] may ignore the older person altogether. The older person is forced to roam the streets during the day and only return home late in the evening, just to avoid conflicts at home. This is psychological abuse if you ask me. Older persons react differently to situations like this. Some may avoid conflicts but still want to look out for the abusive family member. I have a case where the adult son is not taking care of the client in any way. The client goes out during the day to avoid his son but returns home to prepare meals for him day after day. The client didn’t want to leave and only came to us when it became unbearable. (Vicky, Center in Charge, Elderly Services)

Involving non-abusive family members in elder abuse interventions and providing education can help them recognize any issues. Other studies also demonstrate that supporting non-abusive family members can influence victims’ help-seeking behavior [ 14 ]

The abuser may not be easy to approach, so we can only start from other family members. (Denise, Social Worker, Elderly Services)

Families need to be educated about elder abuse, especially family members who are willing to offer help. We need to teach them about the serious impact of elder abuse and properly equip them with ways to handle it should it occur again. (Denise, Social Worker, Elderly Services)

Supporting caregivers

The participants noted that caregiver interventions can help prevent elder abuse as caregivers often suffer from stress, particularly when care services are inadequate.

I have met carers who are under great pressure, and many may be incapable of providing adequate care, especially in dual-elder families. With the long waiting time for services, many caregivers feel they are trapped in a lion’s cage. This is a common and serious problem. (Beatrice, Social Work, Elderly Services)

We do not provide round-the-clock services. Even if we provide home help, it is for one or two hours at most, whereas family members are there 24 hours a day. It is worse if the care recipient is suffering cognitive decline. Some sleep very little and wander around at night making lots of noise, and their family still need to go to work the next morning. It can be very stressful to be trapped in this vicious cycle … and family members apply for elder care services because it becomes urgent. How is it helping if the waiting time ranges from one to three years? (Amelia, Social Worker, Elderly Services)

As mentioned, some households in Hong Kong hire foreign domestic helpers, who can also assist in preventing elder abuse. The participants in this study suggested that adequate training and support should be provided to these helpers:

There are quite a few older couples with a live-in domestic helper in our district. In these families, the main caregiver is the domestic helper. We do observe cases of borderline neglect every now and then. Available training and education programs mainly target family caregivers, but in many households the caregiving tasks are carried out by foreign domestic helpers. It is especially important to help those who are new to Hong Kong and new to caregiving tasks to establish a good relationship with their care recipients. A good start will help avoid many unnecessary misunderstandings. (Ursula, Social Worker, Elderly Services)

In addition to the formal programs, we also introduce foreign domestic helpers who have recently come to Hong Kong to our members who have some experience working here. This helps foster informal social support. There was once a case where an older care recipient fell and hit his head. The helper was very worried but was too afraid to tell her employer for fear that he would terminate her contract. We asked a fellow helper to talk to her and managed to find a solution that was agreeable to everyone. (Beatrice, Social Work, Elderly Services)

Follow-up support

Elder abuse intervention should not end when the victim is discharged from hospital or leaves a shelter. The ultimate aim of such interventions is to enable the victim to lead a safe, meaningful, and sustainable life [ 24 ]. Some victims seek to maintain a relationship with their abuser [ 14 ]. The participants in our study outlined the follow-up support they provide to victims of elder abuse to ensure their safety, support them in their daily lives and, if required, help them to restore their relationships with their abusers:

Whether the older adult returns to his/her home or moves to a new community, we devise a safety plan. The plan covers their relationship with their abuser [and] managing emotional health, and includes the means to contact us at any time. They are fully informed that they can reach out to us any time should they have a problem or if they just want to have a casual chat with us. They may even choose to come back to the shelter. We follow up each case for a minimum of three months regardless of whether they are staying on their own, living in a nursing home, or have gone back to stay with their abuser. (Carmen, Social Worker, Elder Abuse Shelter)

We have a group therapy program catering for older adults who have left shelters. Most come to the shelter confused, there being simply too many things to manage, and they can spare very little time and energy for counseling, and some may not be psychologically ready for treatments. It is after we have settled all the practical issues such as housing and daily necessities that older adults have time to re-examine the abuse experience. (Carmen, Social Worker, Elder Abuse Shelter)

Collaborative efforts

Multidisciplinary and cross-agency collaboration.

The participants also highlighted the benefits of working with colleagues from other teams or disciplines. Such multidisciplinary approaches can enhance the efficiency of service delivery and improve intervention outcomes [ 25 7 ]. Our frontline practitioners agreed that no single profession can handle elder abuse cases alone and that input from a multidisciplinary team is helpful when delivering interventions.

Although there are social workers at the shelter to work on the case, we still see whether there is a family social worker from the community to follow up and make referrals if not. Social workers at shelters are responsible for client adjustment, daily necessities, [and] emotional and physical support. But when it comes to relationship and emotional problems with family members, we refer cases to social workers from the community for family counseling. (Rose, Social Worker, Elder Abuse Shelter)

In addition to those in social services, workers in healthcare, legal, and even financial services may encounter elder abuse victims [ 30 ]. Close collaboration and communication among such disciplines are thus essential. The participants in this study have experience of collaboration, but the process may not be smooth as points of view can differ. Reaching agreement is therefore essential for successful collaborations:

Our hospital community geriatric assessment team provides outreach services. We hold a multidisciplinary conference every few months and discuss how to manage cases. Professionals from different disciplines give opinions and suggestions. We also discuss whether we would need to report a case to the authorities if it was someone in a nursing home. (Liz, Medical Social Worker, General Hospital)

I think input from medical doctors and clinical psychologists is important. Their professional assessments can provide relevant information that will help us to confirm whether we have an elder abuse case. A medical doctor would guide the discussion most of the time. If we rule out a case of elder abuse, we work together to see how we can improve patient care. (Liz, Medical Social Worker, General Hospital)

Effective use of community resources

Intervention in and prevention of elder abuse often involve resource provision and service referrals. Connecting abuse victims with social resources may reduce the risk of further abuse [ 17 ]

Besides helping clients adapt and feel psychologically safe at the shelter, we also discuss practical issues. If he/she wants to leave his/her home, we ask integrated family services centers or other social service units to help them to apply to nursing homes or find alternative accommodation. If the client wishes to deal with their family members’ mental health problems, we refer them to mental health services. In addition to individual counseling, we also advise clients to join various activities during their stay with us. (Ofelia, Social Worker, Elder Abuse Shelter)

The hospital does not force older adults to return home after discharge. In cases where grown-up children refuse to take care of older patients, our medical social work team will help provide alternative solutions, private housing or government subsidized nursing homes, or alternative housing. The goal is to minimize the stress experienced by older adults. (Jenny, Nurse, Hospital Accident and Emergency Unit)

Raising elder abuse awareness

Professional training.

Awareness of elder abuse among frontline practitioners has been found to be limited [ 30 17 ]. Frontline practitioners are medical, social, and healthcare professionals, but also those working in legal domains, the judiciary, and care providers. Ideally, such professionals would have both the necessary knowledge and confidence to identify and intervene in suspected elder abuse cases:

Most frontline staff, such as receptionists, personal care workers, and healthcare workers, provide hands-on care to older persons. They are the first line of workers who are alert to the life circumstances of an older person. Say you visit a home and you can tell from the smell that it has been days since the older person has taken a bath. You can pick up lots of information from the living environment. Training should not be limited to social workers or health professionals; frontline staff, in particular those in supportive roles, should receive training. They spend the most time with clients and are in the best position to identify elder abuse cases. (Ursula, Social Worker, Elderly Services)

Most families eventually call the police. A police taskforce would be an effective way to refer clients to necessary resources if they could identify elder abuse cases. (Gloria, Social Worker, Shelter for Domestic Violence Victims)

Distinguishing the signs of abuse from accidental injuries, physiological changes due to aging, or chronic diseases can be difficult [ 24 30 ]. The medical social worker participants suggested that basic medical knowledge can help to differentiate elder abuse from accidental injuries:

Some elder abuse cases take place in nursing homes, among which drug-related incidents represent the majority. Say a resident with no history of diabetes was given diabetic medication and has low blood sugar as a result. It could be an honest mistake, or it could be someone playing a bad joke. At times we also see atypical bone fractures, but the nursing home reports no falls. How likely is it that a bed-bound patient was walking around and ended up falling and breaking a bone? You can’t help but wonder whether someone hit him. I consulted a geriatrician about this. I was told that long-term bed-bound status may result in a patient’s bone being more brittle and easily breakable if too much force is used in transferring a patient. Nurses would call that “rough handling.” As medical social workers, we need more knowledge of bone fractures and injuries. It would make it a lot easier for us to understand the situation, or to collect evidence. (Kate, Medical Social Worker, General Hospital)

Some medical knowledge would come in handy for social workers, in particular medical social workers. A colleague of mine received a case of suspected elder abuse in a nursing home. A family member spotted lots of bruises all over the patient’s body during her visit. The thing is, bruises can result from a host of different conditions. Some basic medical knowledge would be useful in a situation like that. (Xania, Medical Social Worker, General Hospital)

The participants also suggested that involving survivors of elder abuse in professional and community training can be beneficial:

Elder abuse survivors are very keen to share their experience with the police, medical staff, and younger people in the community. In doing so, they not only offer first-hand accounts to trainees but also empower other elder abuse survivors. (Patty, Social Worker, Elder Abuse Shelter)

Public education

Awareness campaigns can reduce the negative labeling effects of elder abuse and encourage victims to seek help [ 17 ]. In some countries, awareness campaigns are regarded as more important than interventions and prevention [ 7 ]. Promoting awareness of the rights of the elderly and the definitions, signs and symptoms, and consequences of elder abuse can be aimed at the elderly themselves, caregivers, service professionals, policymakers, stakeholders, and the general public.

Is the older victim aware that he or she is being abused? Not necessarily. This is exactly why we need to deliver more public education. (Wesley, social worker, Elderly Services)

An elder abuse victim may not be aware that he is being abused. Training would need to start by equipping older persons with this basic knowledge, so that they understand their own rights. (Emma, Social Worker, Elderly Services)

To quote domestic violence victims I have worked with: It is easy for physical injuries to heal and recover, much less so for psychological abuse. Being repeatedly told, “You are a useless creature,” “You are better off dead” has a long-term impact on victims in terms of cognition, emotions, etc. We utilize experiential learning in our training programs. For example, we invite participants to sit and have everyone scold him for a couple of minutes, so they can experience the strong feelings resulting from verbal abuse. This exercise is very useful for younger people. They begin to understand how a slip of the tongue can have lasting effects on the recipient. (Gloria, Social Worker, Shelter for Domestic Violence Victims)

Addressing “by-stander effects” and ambivalence

“Sweep the snow from your own doorstep, don’t worry about the frost on your neighbor’s roof.” This Chinese idiom reflects the entrenched cultural belief that one should not get involved in others’ family affairs. Many therefore refrain from providing advice or offering help to an acquaintance even if elder abuse is suspected [ 17 ]. A participant shared this experience:

I ran a community education program years ago. We recruited volunteers to do home visits and educate older persons about elder abuse, ways to communicate with suspected victims, etc. At the briefing session with volunteers, I asked them what they would do if they suspected that an older person was being abused. Some responded that they would ask them to tolerate it! And these volunteers were clients who had themselves used our elder abuse services! This reflects the deep-seated idea that it is wrong to tear families apart. Although it didn’t go as I had imagined, the program gave me a new perspective on how we should mobilize older persons to help their peers, how having a similar upbringing and values probably allows them to communicate better with each other. (Carmen, Social Worker, Elder Abuse Shelter)

As elder abuse can have extremely serious consequences, early detection, identification, and interventions are required. In this focus group study, 32 frontline nursing and social work professionals shared their knowledge and insights concerning elder abuse intervention. They identified the important elements in such interventions and suggested potential ways of improving current initiatives.

First, the participants highlighted the importance of timely detection and identification of abuse. They suggested that screening for abuse in routine services provided to the elderly and in medical settings can help case identification. They noted that it was often difficult to differentiate elder abuse from accidental injuries and suggested involving medical professionals in the screening process. The injury patterns common to abused older adults (Ziminski et al., 2013, [ 31 ] have been identified, which can be useful to frontline professionals. Most elder abuse victims choose not to seek help from individuals or formal support services [ 14 , 32 ] due to the influence of traditional Chinese culture, and they may prioritize family honor and harmony over their own safety [ 17 ]. Incorporating considerations of abuse in routine assessments can help to identify elder abuse cases.

The participants also noted the importance of engaging stakeholders in elder abuse detection, including health, social service and legal professionals and knowledgeable others in the community, such as neighbors, other family members, and friends. A previous study found that around a quarter of cases are referred by someone from the victim’s social network [ 17 ]. Studies outside of Hong Kong also indicate that non-abusing family members, friends, or significant others can encourage victims to seek professional help [ 14 ]. The level of organizational support also has a bearing on case identification. Social work in Hong Kong is characterized by inadequate resources and high job stress, caseloads, and turnover rates [ 33 ]. Thus, support from organizational management is thus extremely important. The willingness to devote time and effort to identifying elder abuse cases can be encouraged through official recognition that the issue is a priority, policies that support workers investigating such cases, and adequate resource allocation.

In terms of the intervention process, providing tangible support to abuse victims not only meets clients’ needs but has the added value of demonstrating care and support. Tangible support comes in various forms, from financial support to providing shelter, food, and clothing. The participants noted that accepting tangible support also has a symbolic meaning, as the clients are slowly accepting changes in their lives. Active listening and respecting clients’ autonomy and privacy were also identified as essential skills and approaches that help build a trusting, non-threatening relationship with clients that can lead to positive outcomes. The importance of progressing at the clients’ pace and recognizing the extent to which they are ready to change was an interesting point that came out of the discussions. This echoes the emphasis on the voluntary acceptance of intervention, which is critically important for successful outcomes [ 29 ]. Some victims suffer for a long time before they are willing to take steps to stop abuse [ 34 ], but it is important to consider the clients’ readiness for change and allow them to move at a pace they are comfortable with.

A strength-based approach to elder abuse intervention was emphasized, such as the example of a “buddy program” in which abuse survivors act as peer counsellors. Peer support groups are common and effective in interventions for abuse victims [ 27 ]. They can offer empowerment, a sense of safety, social support networks, effective coping methods, personal growth, and companionship [ 26 , 27 , 28 ]. Previous studies have indicated that the healthy relationships built in support groups are conducive to developing psychological resources and formal help-seeking behavior [ 14 , 15 , 35 , 17 ].

The participants also noted that it is important to support caregivers. Other studies have suggested that alleviating the burden experienced by caregivers can in some cases prevent elder abuse [ 36 , 7 ]. Measures including education about the concept of abuse, strategies to control it, and emotional management can be helpful. The broken relationship between victim and perpetrator can be restored if the caregiver is provided with sufficient support [ 24 ]. Many families in Hong Kong hire foreign domestic helpers to assist with elderly care, and they often take on day-to-day care such as cooking, cleaning, transferring, bathing, and feeding. Many also experience a language barrier when communicating with care recipients. Providing adequate support to this unique group of caregivers is essential.

Our participants agreed that no single profession should be solely responsible for elder abuse cases, and that multi-disciplinary and cross-agency collaboration is beneficial. Research has indicated that a multidisciplinary approach can enhance the efficiency of service delivery and improve intervention outcomes [ 25 , 7 ]. In addition to traditional human services professionals such as social workers, nurses, medical doctors, and psychologists, participants suggested that involving police officers, legal and judiciary professionals, building managers, housing authorities, and others would be helpful.

Finally, public awareness programs are required to educate senior citizens, caregivers, and families about senior rights and elder abuse, advise potential victims about how and where to seek help, and enable the general public to detect elder abuse. Prevention and intervention thus requires sustained and determined effort.

Our study has several limitations that should be considered when interpreting our findings. First, the participants in the study were referred by organizations that specialize in elder abuse, domestic violence, and emergency medicine. However, those who work in other sectors and may also have experience of working with elder abuse victims, such as occupational therapists, physiotherapists, and medical doctors, are not represented, nor are any other organizations that encounter elder abuse. Further studies should adopt broader inclusion criteria and consider professionals with different backgrounds. Furthermore, while focus groups allow participants to exchange their views and facilitate each other to share their experience in the process, the process could be clouded by social desirability and participants may be reluctant to share personal views that differ from the group norm. Moreover, all focus group in this study consisted of single profession. Further study should consider use of in-depth interviews or focus groups of mixed professions. Finally, our study was conducted online during the COVID-19 pandemic when social distancing measures were in place, rather than through face-to-face focus groups. The levels of participation and interaction may differ in physical meetings.

To conclude, tailored training is urgently needed to equip frontline professionals with the necessary skills to identify elder abuse cases and to assess the risk of abuse. While clients’ safety and need for tangible support remains a primary concern, frontline professionals should also respect clients’ autonomy and privacy. A client-centered, strength-based approach that involves supportive peers and addresses the complex family relationships involved can be useful. Interventions should also involve cross-discipline and cross-agency collaboration. The responsibility of preventing and intervening in elder abuse should not fall on any single profession or sector, and sustained and collaborative effort from all sectors of society is required to provide a safe environment for senior citizens.

Availability of data and materials

Data will be available upon request from the corresponding author.

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Acknowledgements

We are grateful to the Lee Hysan Foundation for supporting this project and to all who participated in this study.

This project was funded by the Lee Hysan Foundation. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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E.Y., F.W., and D.S. were responsible for the design and contemplation of study. E.Y., L.T., D.W., and X.X. conducted data collection. E.Y., F.W., and D.S. drafted the manuscript, which all authors have read and approved.

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Yan, E., To, L., Wan, D. et al. Strategies to build more effective interventions for elder abuse: a focus group study of nursing and social work professionals in Hong Kong. BMC Geriatr 22 , 978 (2022). https://doi.org/10.1186/s12877-022-03682-4

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Article publication date: 19 November 2021

Issue publication date: 23 February 2022

Reciprocal abuse inside care practices remain under-studied due to their invisibility and further research is required. The purpose of this paper is to explore different levels of conflicts inside organisations.

Design/methodology/approach

The paper is based on a self-administered questionnaire filled out by care workers (n = 150), in 16 Portuguese care homes.

Results indicated that, overall, 54.7% of care workers had observed abuse, in their daily practice, in the preceding 12 months: 48.7% psychological; 36.0% neglectful care practices; 14.0% physical and 3.3% financial abuse. The figures decreased significantly as regards abuse committed themselves, with 16.7% of those admitting to having committed at least one of these behaviours. The highest figures were also recorded for psychological abuse (13.3%) and neglect (6.7%). However, there is a statistically significant relationship between abuse committed by care workers and abuse committed by residents. Overall, 52.0% of care workers reported having been the target of at least one such behaviour by residents.

Research limitations/implications

This paper has its limitations as the sample consisted of only 16 nursing homes (12 not-for-profit and 4 for-profit nursing homes). The fact that only 4 of the 16 LTC homes were for-profit is a potential limitation both in general and in particular because research has shown that lower quality of care and elder abuse and neglect are more common in for-profit nursing homes at least in Portugal. The results were also based on self-reported measures.

Practical implications

A reactive behaviour, the risk of retaliation, after a complaint, the difficulty in dealing with dementia and the residents' aggressive behaviour, an absence of a training and support policy in an environment where difficult working conditions prevail, are factors enhancing a reciprocal process of abuse. The analysis followed by a discussion of potential implications to prevent institutional elder abuse and neglect, based on communication and social recognition, including better working conditions and training, and a cooperative work environment.

Social implications

Conflict is much more than reducing an interpersonal relationship problem between residents and staff (care workers, professional staff, managers) and extending to the whole organisation. Therefore, there are still uncertainties on how organisations, staff and residents interact between themselves, and affect care practises.

Originality/value

Reciprocal abuse in nursing homes is an important area of research and this paper enabled a discussion of potential implications concerning the quality of care, which required the identification of levels of conflict, in an organisational system, including interactions, the context where care is provided, difficult working conditions, lack of training and levels of support. All these factors are important when considering elder abuse and neglect and this calls for special attention by policymakers and researchers.

• Elder abuse
• Care workers
• Nursing homes
• Organisational conflict
• Older adults
• Reciprocal abuse

Acknowledgements

Funding: The first author disclosed receipt of the following financial support for the research: Foundation for Science and Technology (Fundação para a Ciência e Tecnologia) in Portugal (Grant SFRH/BPD/107722/2015).The first author would like to thank Irina Kislaya (INSA/DEP) and Ana João Santos (INSA/DEP) in statistical support of reliability tests of MBSM and GHQ12

Gil, A.P. and Capelas, M.L. (2022), "Elder abuse and neglect in nursing homes as a reciprocal process: the view from the perspective of care workers", The Journal of Adult Protection , Vol. 24 No. 1, pp. 22-42. https://doi.org/10.1108/JAP-06-2021-0021

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Elder abuse in Norwegian nursing homes: a cross-sectional exploratory study

Affiliations.

• 1 Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway. [email protected].
• 2 Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.
• 3 Department of Health Research, SINTEF Digital, Oslo, Norway.
• 4 Keck School of Medicine of University of Southern California, Los Angeles, USA.
• PMID: 31900138
• PMCID: PMC6942332
• DOI: 10.1186/s12913-019-4861-z

Background: Elder abuse is a global public health and human rights problem that is predicted to increase as many countries experience a rapid growth in their population of older adults. Elder abuse undermines an older person's well-being and is associated with a range of serious health consequences. In institutional care settings, older residents are particularly vulnerable and hence at higher risk of being abused, but few countries have explored the extent and nature of this phenomenon in national studies. The aim of this study is to estimate the prevalence of observed and perpetrated staff-to-resident abuse in Norwegian nursing homes.

Methods: We conducted a cross-sectional exploratory study of nursing staff in 100 randomly drawn Norwegian nursing homes. Nursing staff completed a pen and paper survey measuring how often during the past year they had observed staff commit acts of neglect and psychological, physical, financial/material, and sexual abuse towards residents. They also reported how often they had perpetrated acts of abuse themselves, and these rates were disaggregated by nursing staff's gender, age and education.

Results: Of 3693 nursing staff (response rate 60.1%), 76% had observed one or more incidents of elder abuse during the past year, and 60.3% reported they had perpetrated one or more incidents of abuse in the same period. Psychological abuse and neglect were most commonly reported. Male staff reported more acts of physical abuse, while female staff reported more acts of neglect. Higher education of staff was associated with higher rates of self-reported psychological abuse, physical abuse and neglect.

Conclusions: This first national survey of staff in Norwegian nursing homes is one of the largest studies globally estimating the prevalence of elder abuse in institutional settings. Overall, we found staff-to-resident abuse to be relatively common, and our findings propose a need for preventive strategies to improve the quality of life and safety of residents in Norwegian nursing homes.

Keywords: Elder abuse; Elder mistreatment; Nursing homes; Nursing staff; Observed abuse; Perpetrated abuse; Primary care.

• Aged, 80 and over
• Cross-Sectional Studies
• Elder Abuse / statistics & numerical data*
• Middle Aged
• Nurse-Patient Relations*
• Nursing Homes / statistics & numerical data*
• Nursing Staff / psychology*
• Nursing Staff / statistics & numerical data
• Surveys and Questionnaires
• Young Adult

Grants and funding

• ES571162 Project Number: -1/The Research Council of Norway

Elder abuse and neglect in nursing homes as a reciprocal process: the view from the perspective of care workers

Purpose Reciprocal abuse inside care practices remain under-studied due to their invisibility and further research is required. The purpose of this paper is to explore different levels of conflicts inside organisations. Design/methodology/approach The paper is based on a self-administered questionnaire filled out by care workers (n = 150), in 16 Portuguese care homes. Findings Results indicated that, overall, 54.7% of care workers had observed abuse, in their daily practice, in the preceding 12 months: 48.7% psychological; 36.0% neglectful care practices; 14.0% physical and 3.3% financial abuse. The figures decreased significantly as regards abuse committed themselves, with 16.7% of those admitting to having committed at least one of these behaviours. The highest figures were also recorded for psychological abuse (13.3%) and neglect (6.7%). However, there is a statistically significant relationship between abuse committed by care workers and abuse committed by residents. Overall, 52.0% of care workers reported having been the target of at least one such behaviour by residents. Research limitations/implications This paper has its limitations as the sample consisted of only 16 nursing homes (12 not-for-profit and 4 for-profit nursing homes). The fact that only 4 of the 16 LTC homes were for-profit is a potential limitation both in general and in particular because research has shown that lower quality of care and elder abuse and neglect are more common in for-profit nursing homes at least in Portugal. The results were also based on self-reported measures. Practical implications A reactive behaviour, the risk of retaliation, after a complaint, the difficulty in dealing with dementia and the residents' aggressive behaviour, an absence of a training and support policy in an environment where difficult working conditions prevail, are factors enhancing a reciprocal process of abuse. The analysis followed by a discussion of potential implications to prevent institutional elder abuse and neglect, based on communication and social recognition, including better working conditions and training, and a cooperative work environment. Social implications Conflict is much more than reducing an interpersonal relationship problem between residents and staff (care workers, professional staff, managers) and extending to the whole organisation. Therefore, there are still uncertainties on how organisations, staff and residents interact between themselves, and affect care practises. Originality/value Reciprocal abuse in nursing homes is an important area of research and this paper enabled a discussion of potential implications concerning the quality of care, which required the identification of levels of conflict, in an organisational system, including interactions, the context where care is provided, difficult working conditions, lack of training and levels of support. All these factors are important when considering elder abuse and neglect and this calls for special attention by policymakers and researchers.

• Related Documents

Nursing home leaders' perception of factors influencing the reporting of elder abuse and neglect: a qualitative study

PurposeThe purpose of this study is to explore the factors that influence the reporting of adverse events related to elder abuse and neglect in nursing homes from nursing home leaders' perspectives. Good leadership requires in-depth knowledge of the care and service provided and the ability to identify and address problems that can arise in clinical practice.Design/methodology/approachA qualitative explorative design with data triangulation was used. The sample consisted of 43 participants from two levels of nursing home leadership, representing six municipalities and 21 nursing homes in Norway. Focus group interviews were undertaken with 28 ward leaders and individual interviews with 15 nursing home directors. The constant comparative method was used for the analyses.FindingsBoth ward leaders and nursing home directors described formal and informal ways of obtaining information related to elder abuse and neglect. There were differences between their perceptions of the feasibility of obtaining formal reports about abuse in the nursing home. Three main categories of influencing factors emerged: (1) organisation structural factors, (2) cultural factors and (3) abuse severity factors. A main finding is that in its present form, the Norwegian adverse event reporting system is not designed to detect abuse and neglect.Originality/valueThis paper provides an in-depth understanding of patient safety and factors related to reporting elder abuse in nursing homes in Norway.

Elder abuse in Ghana – a qualitative exploratory study

Purpose The aim of this study was to explore how Ghanaian staff in nursing homes and hospitals perceive abuse and neglect of older adults as well as to explore the nature and scope of abuse and neglect of older adults as it exists in Ghana. Design/methodology/approach This exploratory study used a qualitative research methodology that sets out to explore staff’s perception of elder abuse in nursing homes and hospitals in Ghana. Five nursing assistants and two caregivers were interviewed in two nursing homes and four nurses were interviewed in one hospital. A semi-structured interview guide was used for data collection. Findings The findings showed that elder abuse occurs in both hospitals and nursing homes, which might be attributed to different personal, situational and institutional characteristics as well as cultural and traditional value systems. Various factors at the level of interpersonal relationships contributed to elder abuse. Situational characteristics such as aggressive exchanges between residents and health workers and institutional characteristics such as limited facilities and resources to care for residents are all factors that were implicated in elder abuse. Finally, culture and traditional views, beliefs system and socioeconomic factors seem to be implicated in elder abuse and neglect. Originality/value To the best of the authors’ knowledge, this is the first study that explores elder abuse and neglect in Ghanaian nursing homes and hospitals.

Elder Abuse in Nursing Homes: Do Special Care Units Make a Difference? A Secondary Data Analysis of the Swiss Nursing Homes Human Resources Project

Background: In special care units (SCUs) for residents with advanced dementia, both personnel and organizations are adapted to the needs of residents. However, whether these adaptations have a preventive effect on elder abuse has not yet been explored. Objective: To describe the prevalence of observed emotional abuse, neglect, and physical abuse in Swiss nursing homes, to compare SCUs with non-SCUs concerning the frequency of observed emotional abuse, neglect, and physical abuse, and to explore how resident-related characteristics, staff outcomes/characteristics, and organizational/environmental factors relate to observed elder abuse. Methods: This is a secondary data analysis of the Swiss Nursing Homes Human Resources Project (SHURP), a cross-sectional multicenter study. Data were collected from 2012 to 2013 and are based on observed rather than perpetrated elder abuse. We performed multilevel mixed-effects logistic regressions taking into account the hierarchical structure of the data with personnel nested within units and facilities. Results: Of 4,599 care workers in 400 units and 156 facilities, 50.8% observed emotional abuse, 23.7% neglect, and 1.4% physical abuse. There was no significant difference between SCUs and non-SCUs regarding observed emotional abuse and neglect. Higher scores for ‘workload' and sexual aggression towards care workers were associated with higher rates of emotional abuse and neglect. Verbal and physical resident aggression, however, were only associated with higher rates of emotional abuse. Negative associations were found between ‘teamwork and resident safety climate' and both forms of abuse. Conclusion: Improving teamwork and the safety climate and reducing work stressors might be promising points of intervention to reduce elder abuse. More specific research about elder abuse in SCUs and the interaction between work climate and elder abuse is required.

A Review on the Factors of Elder Abuse and Neglect in Nursing Homes

Abuse is in the eyes of the beholder: using multiple perspectives to evaluate elder mistreatment under round-the-clock foreign home carers in israel.

ABSTRACTThe overall goal of the study reported in this paper was to examine differences in the perceived occurrence of abuse and neglect as between older care recipients, their family carers, and foreign home-care workers in Israel. Overall, 148 matched family members and foreign home-care workers and 75 care recipients completed a survey of abuse and neglect. Significant discrepancies in their reports of neglect were found, with the foreign home-care workers more likely to identify neglect (66%) than the older adults (27.7%) or their family members (29.5%). Although the rates of reported abuse ranged between 16.4 and 20.7 per cent and the differences were not statistically significant, the different parties assigned the responsibility for the abuse to different perpetrators. The independent variables that significantly associated with abuse and neglect also varied by the three groups of participants. The findings suggest that even with round-the-clock home care, the basic needs of many older adults are not met, and that many experience substantial abuse. The study emphasises the subjective nature of abuse and neglect, and suggests that more education about what constitutes elder abuse and neglect may lead to more accurate and consistent reports across reporting sources. Incorporating data from the various stakeholders may enhance the early identification of elder abuse and neglect.

Elder abuse and neglect in nursing homes

A multi‐method study on elder abuse and neglect in nursing homes, stress, conflict, elder abuse and neglect in german nursing homes: a pilot study among professional caregivers, understanding elder abuse and neglect in aging chinese immigrants in canada.

Purpose – The purpose of this paper is to review and discuss existing literature and available research findings related to understanding elder abuse and neglect in culturally diverse communities, particularly the Chinese immigrant community in Canada. The conceptual understandings of elder abuse are examined, based upon the socio-cultural context and challenges faced by aging Chinese immigrants. Design/methodology/approach – Previous literature and research publications related to elder abuse and neglect related to Chinese in Canada were reviewed and synthesized. Statistical information and research findings were summarized to illustrate the socio-cultural context that defines elder abuse and neglect experienced by aging Chinese immigrants in Canada. Findings – From a culturally diverse perspective, influence of race, ethnicity, immigrant status, and cultural norms on the recognition, identification, prevention and intervention of elder abuse and neglect are important to consider. A key message for professionals working with the aging population, particularly older immigrants from ethno-cultural minority background, is that understanding the social cultural context in which elder abuse or neglect emerges is critical. For many of the aging Chinese immigrants in Canada, the socio-cultural circumstances that they have experienced, their social environment, and various barriers and challenges further prevent them from being aware of this emerging concern. Cultural norms and practices have played a critical role in their access to preventive and intervention services. Research limitations/implications – Although this paper is not based upon a particularly empirical research study, the research and literature synthesized are both empirically and conceptually based. As indicated in the review of previous research publications on the subjective matter of elder abuse and neglect in aging Chinese immigrants in Canada is limited. Research on various issues related to elder abuse and neglect in ethno-cultural minority communities is also relatively scant. Evaluation research on prevention and intervention programs is desperately needed so as to facilitate the further establishment of best practice prevention and intervention models that are culturally appropriate and effective. While research engagement with minority groups such as the aging Chinese immigrants who do not speak English or are not familiar with the research culture in the western civilization could be challenging, academic researchers and service providers in both the mainstream and ethno-cultural minority communities should further align themselves in practice-research partnership endeavors to ensure the safety and wellbeing of the aging vulnerable individuals could be better maintained. Practical implications – In order to provide culturally competent services, service providers should be aware of cultural differences in attitudes towards elder mistreatment, including the ways in which specific types of abuse (e.g. financial abuse) are defined within ethno-cultural communities, and the cultural values and experiences that shape these understandings and determine attitudes or barriers towards reporting, intervention, and service use. Originality/value – This paper is a first attempt in the research community to synthesize a few critical issues related to elder abuse and neglect in the aging Chinese immigrant community in Canada. The paper has connected previous empirical findings related to Chinese older adults as well as other culturally diverse aging populations to the conceptualization of elder abuse and neglect by considering the unique socio-cultural context faced by the ethnocultural older adults.

‘As if I just didn’t exist’ – elder abuse and neglect in nursing homes

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Examining the ethical challenges in managing elder abuse: a systematic review

Afsaneh saghafi.

1 M.S, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.

Fatemeh Bahramnezhad

2 Assistant Professor, Department of Critical Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.

Afsaneh Poormollamirza

3 M.S, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.

Ali Dadgari

4 Assistant Professor, Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran.

Elham Navab

5 Associate Professor, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran. 

Elder abuse is an increasingly intangible phenomenon that has created numerous ethical issues for care teams and caregivers. Although different studies have concentrated on various ethical issues regarding abuse, no study has arrived at a comprehensive conclusion. Therefore, the present study aimed to determine the existing ethical challenges in this context.

For this purpose, two researchers familiar with systematic search approach examined national and international journals on PubMed, Excerpta Medica Database (EMBASE), Scientific Information Database (SID) and similar databases between January and February 2017. They were able to find 116 articles that met the inclusion and exclusion criteria, and finally selected 15 articles based on the predesigned questions.

The findings were classified in five subtitles as follow: 1) the common definition of elder abuse, 2) a comprehensive legislation on elder abuse, 3) comprehensive ethical principles about elder abuse, 4) ethical considerations regarding patients without competency, and 5) reporting and sharing information about elder abuse. The study results revealed no common definition and no legislation about elder abuse, and also showed that health care providers’ observance of ethical principles depends on the ethical and legal conditions of the community.

Nowadays, elder abuse is a serious problem in many countries. Cultural and religious differences are the reasons for lack of a common definition and legislations, which comprises the biggest obstacle to protecting the rights of elderly people. It is clear that ethical principles should be respected as far as a person has competency. Furthermore, localization of clinical guidelines related to this issue leads to proper functioning of health care providers, especially nurses as the first line of treatment.

Introduction

Abuse is among the most common challenging issues in both developed and developing countries around the world ( 1 , 2 ). Presently, elder abuse is the most covert form of mistreatment that involves issues such as health, justice, ethics, and human rights ( 3 ). This phenomenon has been taken into consideration by World Health Organization (WHO) since 2002 ( 4 ).

Different definitions have been provided for abuse over time ( 5 ). Elder abuse may refer to an act or absence of a proper act that will cause harm or suffering to an older person, and it happens in a relationship that normally requires trust, and may be performed only once or several times ( 1 , 2 , 6 ).

While little information is available about elder abuse especially in developing nations, it is predicted to be on the rise in countries that experience the phenomenon of population aging. According to WHO estimations, one out of every six elderly people experiences abuse, and only 1 out of 24 abuse cases is reported ( 1 ). Since awareness of abuse is influenced by knowledge, expertise and preparedness of caregivers ( 3 , 7 ), the care team and nurses as the first line of treatment are responsible to identify and report mistreatments and support vulnerable populations such as the elderly ( 8 , 9 ). Elder abuse is an example of human rights and freedom violation ( 5 ) that leads to a serious loss of human dignity, independence and respect ( 6 ), and influences ethical principles such as autonomy, competency, beneficence, and non-maleficence  ( 10 ).

Intervention in case of abuse is accompanied by ambiguity and ethical challenges, because lack of professional principles leads to personal, legal and ethical concerns ( 11 ). However, it is difficult for nurses and other members of the care team to perform a successful intervention for an elderly who is willing to stay in the abusive situation ( 12 ). Also, this phenomenon causes challenges for nurses and other care team members when legal commitments are not consistent with ethical principles ( 11 ). Questions and challenges in this context include: Are there any comprehensive ethical principles and regulations? Is it illegal to share the information and secrets of patients with the care team in order to reach a diagnosis or choose the appropriate intervention? Which ethical principle is violated in elder abuse? When is respect for autonomy not consistent with ethical principles? In what cases are beneficence and non-maleficence in conflict with the other ethical principles? In cases where the patient suffers from a cognitive disorder, what are the ethical considerations that need to be taken into consideration by the nurse? Should reporting elder abuse be a legal requirement? What ethical challenges will nurses face when the elderly are not willing to share information with the authorities?

Abuse by a family member or intimate partner is complex, because the elderly may be struggling against social, cultural and religious aspects of life to live with abusive people ( 12 ). According to College of Nurses of Ontario (CNO), ethical conflicts and challenges emerge when two or several ethical values relevant to a particular situation necessitate conflicting measures ( 13 ). Elder abuse causes physical harm, depression, increased referral to hospitals, frequent hospitalizations, and increased mortality ( 1 , 2 , 14 , 15 ). It also creates problems such as job burnout and ethical distress for nurses and care team members ( 16 ), who should have a thorough and accurate understanding of the ethical concepts and challenges involved in elder abuse and decide on the best intervention ( 17 ). In view of the importance of this issue, this study aimed to examine the ethical challenges pertaining to elder abuse according to evidence-based ethical principles.

The present study was a systematic review to determine the ethical challenges involved in elder abuse and was conducted in 2017 by collecting related documents, articles, and sources.

Data sources and search method

To find articles, national and international journals from databases such as PubMed, EMBASE, ProQuest Central, Web of Science, SID, Magazine Iranian (Magiran) and Psychology Information (PsycINFO) were examined. For this purpose, journals were searched using Persian and English keywords according to MeSH. Important keywords included “elderly”, “aged”, “abuse”, “neglect”, “mistreatment”, “ethics”, “ethos”, “moral”, and “autonomy”. In order to increase sensitivity, general Persian and English keywords such as “violence” and “senior” were also used in the search process.

Article selection criteria

According to the inclusion and exclusion criteria, different articles available in the context of descriptive studies were examined. Since the nature of this issue is descriptive, articles with more evidence were selected.

The search was performed by two researchers familiar with systematic search approach between January and February 2017 according to the keywords and databases, and the details were documented. In this regard, 116 articles were found as seen in Figure 1 .

Article examination flowchart

Forty-nine articles were identified by EndNote to be duplicates and were therefore excluded from the study. According to the inclusion criteria, articles published after 2000 and those cases that had not been published were included in the initial examination. The abstracts were then studied by the two researchers in order to exclude unrelated articles, obtain the full texts for the ones that were related, and extract data for two of the articles whose full texts were not available. Finally, 15 articles were entered in the study to answer the following questions: Has a common definition been offered for elder abuse so far? Is there a comprehensive ethical set of regulations about elder abuse? What ethical principle is violated in elder abuse? When is the autonomy of elder people in conflict with ethical principles?

In order to minimize error, the required information was extracted according to the checklist ( Table 1 ) by the two researchers and the results were matched. Checklist variables included title, author, year, journal, place and objective, definition of elder abuse, method, concepts, ethical issues, and clinical points.

Characteristics of the reviewed articles on the ethical challenges in caring for elder abuse

After collecting the data based on the checklist, data quality was assessed by two experts. In order to prevent bogus, names of journals and authors were eliminated and the data were given to two experts. The publication years of 15 articles were between 2000 and 2012, 9 articles had been authored in the United States, 1 in Canada, 3 in the UK, 1 in France, and 1 was a Korean-American article. Articles were descriptive, cross-sectional, and case study. No Persian article was found by searching these keywords.

Along with the proposed questions, the findings of the present study were classified in five subtitles as follow:

1. The Common definition of elder abuse

Question: Has a common definition been offered for elder abuse so far?

The researchers did not find any specific definition for the term. A study conducted in 2012 stated that concepts related to elder abuse are abstract and there is no widely accepted definition for it. This lack of definition poses challenging questions. US laws recognize cases such as physical abuse, neglect and financial abuse, but the definitions are not the same in various states and to all researchers and doctors ( 5 ). Another American study declares that all 50 states in the Unites States have laws concerning abuse, but the definitions for elder abuse and those who are covered by these laws are different ( 18 ).

In this regard, another study stated that in most US laws, physical, sexual, financial, and psychological/emotional abuse pertain to elder abuse, as does self-neglect, which is in concordance with the Older Adult Welfare Law (OAWL) definition of abuse ( 19 ).

Adult Protective Services (APS) has identified three misconducts in connection with vulnerable elderly people: abuse, financial exploitation, and neglect. Abuse is defined as intentional harm to people. Financial exploitation is an illegal process of using vulnerable elderly people to obtain assets without their conscious consent. Neglect is the inability of an elderly person for self-care (self-neglect) or failure of a caregiver to provide appropriate care ( 20 ). Other studies have pointed to the definition provided by WHO that states “elder abuse consists of committing an inappropriate action in a trustful relationship that causes harm to an elderly person”, and four studies did not address the definition of abuse ( 21 , 22 , 23 , 24 ).

2. A comprehensive legislation on elder abuse

Question : Is there a comprehensive legislation about elder abuse?

Most US states combine elderly support laws and disabled adult laws. The laws are different in terms of classifications of abuse, but in general, elder abuse can be classified in five categories: physical abuse, psychological/emotional abuse, financial exploitation, neglect/self-neglect, and sexual abuse. Across the US, Elder Abuse Protection (EAP) laws share three common functions: 1) collecting the suspected abuse reports, statistical data management, and patients’ needs evaluation; 2) efforts to decrease or eliminate abuse risk for elderly people by providing instructions and interventions through referral to social services; 3) connection with courts and organizations that are responsible to execute the law in special cases ( 23 , 25 , 26 ).

The results of Bergeron and Gray’s study in 2003 revealed three major differences between the laws in different states of the US. First, in some states, it is mandatory to report suspected elder abuse. The second difference is the definition of “elderly” provided by law. In order to limit interventions in the private lives of citizens, some states have restricted their laws to vulnerable elderly people. The third difference is related to the authorization given to EAP staff in some states to conduct studies on abuse and make interventions in cases where abuse has been proved. For example, some states ask the EAP staff to receive permission from the victim in all research steps unless the victim lacks competency, while other states do not ( 23 ).

The National Association of Social Workers (NASW) and the Canadian Association of Social Workers (CASW) have specified values and principles as guidelines for the professional behavior of social services experts. These principles emphasize prioritization of the best interests of patients and protection of those who lack competency for decision-making. They also require that confidentiality of information be taken into consideration, which may be in conflict with abuse reporting responsibilities ( 11 ). Also in January 2004, OAWL established stable laws to offer protection services for elderly people such as 24-hour emergency phone lines to report abuse, standards to issue certificates for protective facilities, and professional standards to care for elderly people ( 19 ).

3. Comprehensive ethical principles about elder abuse

Question: Are there any comprehensive ethical principles about elder abuse?

A study conducted in the Unites States pointed out that when disclosing information, psychologists should use American Psychological Association (APA) codes ( 5 , 27 ). In this regard, another study proposed that psychologists consider ethical commitments in addition to the legal aspects of abuse reporting.

Reporting suspected cases according to APA ethical codes should be in line with beneficence, non-maleficence, and respect for human rights and dignity. Code 4/02 is related to privacy limitation and code 4/05 pertains to disclosure of information regarding elder abuse. If the elderly suffers from cognitive disorders, psychologists should try to maintain the confidentiality of their information and contact legal authorities. According to code 4/02, they are allowed to disclose information in suspected abuse cases even without the patient’s consent. According to code 4/05, psychologists are allowed to share the private information of patients with the latter’s families or with other experts to protect patients against harm ( 18 ).

In a 2009 study by Doe et al., similarities and differences between the protection systems of Korea and the United States were investigated. The two countries are similar in that they both have national laws to prohibit elder abuse, and legal definitions include abuse and neglect. In addition, laws necessitate mandatory reporting by experts. As for the differences, in the United States, federal laws are executed by different federal systems that implement both the methods of reporting abuse and referral. Emergency cases enter triage from the very beginning and a protection plan is designed for abuse cases and other forms of mistreatment. Laws prosecute the guilty person and punishments are specified for failure to report. However, in Korea, the law is enforced by a centralized system that only implements the reporting of abuse. Emergency cases are triaged within 12 hours and care plan only exists for abuse cases. These laws allow the patient to file a civil complaint about abuse, but they do not specify any punishment for failure to report ( 19 ).

Question: What ethical principle is violated in elder abuse?

Findings showed that the principle of respect (dignity and autonomy) is almost violated in psychological abuse, and the principle of non-maleficence in cases of neglect and physical or financial abuse ( 28 ). In most cases, autonomy may be violated because self-neglect, beneficence and non-maleficence may come before it, and as for self-neglect, caregivers can delay the required interventions as far as possible  ( 10 ).

Autonomy includes independent decision-making without any limitation, and respect for independence is a professional commitment ( 29 ). According to the American Nurses Association (ANA) autonomy not only means respect for patients’ decision-making, but also for the decision-making method ( 30 ), and patients have the right to participate in making decisions related to themselves ( 31 ). Another study stated that social workers are responsible for creating a balance between patients’ rights and the principle of autonomy, which aims to protect vulnerable populations. Nevertheless, in NASW, it is pointed out that social workers should have authority over patients’ right to autonomy when potential and actual actions of patients cause serious, predictable and unpredictable risks for themselves and others ( 11 , 32 ). Also, another was consistent with the above-mentioned points and stated that autonomy to maintain independence is acceptable only as far as it is reasonably and ethically possible  ( 10 ).

Negative autonomy emerges when the elderly prevents services and the caregivers accept this behavior, which is indeed a kind of neglect. Prevention is acceptable if the person has the capability for decision-making and his or her mental capacity is approved ( 33 ).

Beneficence and non-maleficence

Beneficence and non-maleficence are both based on ethical commitment toward others, and while the former focuses on the well-being of others, the function of the latter is to avoid harming them ( 29 ). Together, the two aspects provide more comprehensive principles to devise measures against elder abuse. For example, if a nurse considers a threat or damage serious and is convinced that measures are necessary to prevent harm, he or she will report the abuse to APS. Therefore, the nurse may use the principle of beneficence to promote health and ensure the best interests of the patient  ( 10 ).

In the 15 papers that were examined in this study, the principle of justice had not been mentioned.

4. Ethical considerations regarding patients without competency

Question: In cases where the patient lacks competency, what ethical considerations should be taken into account by the nurse or the care team?

A study entitled “Capacity for decision-making in Alzheimer's disease: selfhood, positioning and semiotic people” showed that capacity and competency are often used interchangeably. Capacity has dimensions such as decision-making, self-care, self-protection, and execution. According to experts, competency can fluctuate. In dementia, there is memory impairment, but personality, values and long-term memory stay intact. Dementia patients can be extremely vulnerable under undesirable conditions and their right of decision-making for different aspects of their life is unfairly influenced ( 34 ).

Dementia diagnosis is not the only criterion for lack of competency ( 35 , 36 ). For competent elderly people who expose themselves or others to harm, the caregiver may decide to work in support of beneficence, trying to achieve the best long-term results for the patient. It is noteworthy that one should consider interdisciplinary interventions, ethical principles, and cultural and gender differences when trying to determine decision-making capacity by means of valid and reliable measurements.

Dick suggests that nurses should note the cultural beliefs and patterns of adaptation of family members who neglect an elderly person’s personal and environmental health requirements rather than consider it a pathological finding ( 37 ). Nevertheless, according to most studies, when the elderly is incapable of decision-making due to cognitive impairment, the task can be left to another person. This person should support the patient and be aware of his/her needs. Most regional councils for elderly issues provide care services in which a group of competent people function as decision-makers for elderly people ( 5 ). In cases where decisions are related to the patient’s capacity, consultation with a group of interdisciplinary experts is necessary and the decisions should eventually be in favor of the elderly people  ( 10 ).

5. Reporting and sharing information about elder abuse

Question: Is it illegal to report abuse and share the information of elderly people?

Respect for confidentiality and trust is one of the most important ethical principles that has to be taken into consideration by caregivers. However, the results of one study indicate that in cases where a serious harm is caused, the care team can disclose information without obtaining consent ( 11 ). These findings were confirmed by another study, which presented statements with similar wording. For example, in the United States, if a therapist is suspicious about abuse, he/she should report it to authorities such as APS despite his/her concerns over the patient’s privacy ( 26 ). Also, according to code 4/05, psychologists are allowed to disclose patients’ private information to protect them against harm ( 17 ). However, they should try to engage the patient in the reporting process and only report relevant data to observe the privacy of the patient as far as possible ( 26 ).

Concepts related to elder abuse are complex and abstract, and therefore no common definition has been offered for this phenomenon ( 5 ). In most cases, the word abuse is replaced by maltreatment and mistreatment ( 41 ). One reason for lack of a common definition is related to cultural and religious differences among societies. Accordingly, people from different races have their own definition of abuse and its types based on their regional priorities ( 41 , 42 ).

Care team members need a clear definition to identify and prevent elder abuse ( 43 ). When a suitable definition does not exist for the phenomenon, accurate statistics cannot be obtained, which makes it impossible to identify and report abuse; consequently, the prevalence of this phenomenon will remain obscure. Therefore, measures related to elder abuse should be specific to each region where authorities function as the main foundations.

Another duty of governments includes establishment of regulations and ethical principles related to elder abuse. Since comprehensive ethical and legal regulations have not been developed and there are many ambiguities and conflicts, abuse cases are not reported due to the inability of the care team to interpret the ethical and legal codes ( 5 ).

Based on the existing evidence, elder abuse is a general issue in Italy where different policies and laws exist for the phenomenon and lack of a national and comprehensive strategy is tangible. While certain laws are in place for child protection, there are no specific regulations for elderly people.

Lack of legislation is the biggest obstacle to protecting the rights of elderly people in many countries. Constitutions normally emphasize rights, freedom, dignity and equality for all people, with the main emphasis on the latter. Elderly people may not be able to defend their rights. Therefore when they become dependent, they may be vulnerable to abuse and misconduct ( 44 ).

The first federal law on elder abuse was codified as “The Elder Justice Act” in March 2010 including the following main articles: (a) formation of the elder justice council to suggest recommendations related to federal, regional and private agencies involved in elder abuse; (b) formation of a council to plan strategic programs on elder justice; (c) budget provision; (d) founding and supporting legal centers; (e) provision of budget for long-term treatment programs; (f) financial assistance to improve long-term treatment programs for staff; and (g) budget provision for national institutes ( 45 , 46 ).

Moreover, laws related to APS aim to control elder abuse in home environments or institutes. Depending on the type of law, in each country there is a reporting system for elder abuse and social services provisions to support victims and change the conditions. Nevertheless, the aforementioned laws are mostly related to abuse of adults with disabilities and vulnerabilities rather than elder abuse ( 47 ).

Therefore, the availability of ethical principles and laws helps the care team deal with abuse. Ethical principles are laid down by experts to protect the profession, and social workers will be directed to implement the pertinent activities by standard establishment. This helps professionals defend themselves against Ethics Supervisory Boards as well ( 47 ).

Sometimes professionals deal with elderly people who experience conditions not directly specified by ethical standards, and this creates challenges ( 48 ). In such cases, members of the care team face controversial ethical and legal conditions in action. Ethical principles concentrate on rights and commitments against ethical challenges and specify what care team members should do in order to observe these principles. However, they may refrain from performing an ethical task for fear of the consequences, and may not implement any type of intervention in cases of abuse because they are concerned about violation of the patients’ rights ( 11 ).

Ethical principles are taught theoretically and when complications arise, care team members have a tendency to neglect ethical teachings, believing that theoretical teaching is one of the factors that complicate elder abuse ( 24 ). It is necessary for those who deal with elderly people to be aware of the professional, legal and ethical issues of elder abuse. In order to stay committed to caregiving values, the care team should have an effective performance and provide safety for elderly people and at the same time respect their dignity.

Important ethical principles that are violated in abuse are autonomy, beneficence, non-maleficence, and justice. This phenomenon not only involves elderly people, but also other vulnerable classes of the society such as women, children, people with disabilities, and people who suffer from mental disorders. Abuse creates challenges for the care team and puts them in dilemma. The question that now arises is: should the rights and freedom of an elderly person who has been abused be violated out of concern for his or her safety? In truth, the dual commitment of staff and other caregivers may violate the patient’s right to autonomy.

One study showed that professionals who are responsible for protecting patients should keep in mind that when an elderly person decides to reject services (autonomy) and continue to live in threatening conditions, logical thinking under critical circumstances will be a necessity ( 11 ). In a 2003 study by Healy the responses to a self-assessment by social services staff to ethical dilemmas concerning the decision-making capacity of elderly patients suffering from cognitive impairment are reported. In the section pertaining to house safety conditions, participants stated that they were faced with conflict when they had to force the person to go somewhere safe or respect his/her decision to continue in the existing conditions. In such cases, social workers face a decision-making challenge: to refrain from intervention and respect the person’s autonomy, or try to prevent harm to the person and introduce the culprit to the judiciary system ( 49 ).

However, discussion about ethical principles is complex, because they are based on the culture in each society. Autonomy should be respected as far as the person has competency and poses no risk for people and the community. The principles of beneficence and non-maleficence are no exception. When a patient’s decision jeopardizes individual and social interests, the two principles of beneficence and autonomy are in conflict, because respect for one principle violates the other. In these cases, the care team should select the best functional option according to regional interests, consultations and guidelines.

Another controversial issue relating to abuse is the principle of confidentiality. Confidentiality is one of the important principles ruling the relationship between patients and the care team, and one justification for it is respect for patient’s autonomy. The principle of autonomy emphasizes the patient’s right over all stages of life. Therefore, one’s personal information belongs to oneself and no one should be aware of it without permission. If confidentiality is violated, the patient’s autonomy will be violated too.

However, reporting abuse is another challenging issue. Discussion about elder abuse reporting is not limited to the social context, but it necessitates awareness about medication, law execution, and social services. All professionals who have relationships with elderly patients regarding treatment and law execution should assume the ethical responsibility to protect them against harm.

Rodriguez et al. conducted interviews in 2006 with primary health-care providers. They concluded that in Los Angles, physicians experience a conflicting relationship between life quality and obligatory reporting laws. Most respondents believed that the effects of abuse result in both improvement and harm for the patient, and experts’ tendency to promote patients’ life quality may decrease due to frequent reports ( 50 ).

The ethical principles of the American Counseling Association (ACA) emphasize the mandatory nature of consultation with other experts when counselors are not sure whether the case meets the reporting criteria or not. It should be mentioned that professionals should not only report suspected abuse, but they should be familiar with laws and regulations related to reporting, so that if a problem occurs, they can report it effectively ( 23 ).

Opponents of mandatory reporting argue that this type of reporting violates autonomy where the privacy of people is compromised ( 38 ). Evidence shows that social workers in Korea choose not to execute mandatory reporting because they feel that by modifying the conditions that cause abuse, family members can participate in providing care for the elderly at home. Social workers believe that providing care at home, improving the relationship between the elderly and their families and intermediation role provide a better cultural option for the elderly ( 19 ). There are concerns about receiving services from all ethnic groups. Studies on services showed that elderly people from various racial groups prefer to receive assistance from family members and friends to solve all types of problems except health and financial problems ( 23 , 51 ). However, the mandatory reporting law should observe the dignity and privacy of people.

Now, the question is, what is the objective of the care team in reporting suspected abuse cases? The objective should not be to obtain or complete the statistics of abuse cases, but the principles of beneficence and non-maleficence should be prioritized. The reporting system is unique in every country and follows the ethical principles and laws of that country. Mandatory reporting is valued when there are protective systems and laws to help the elderly and rescue them from trouble. In countries where these laws do not exist, however, mandatory reporting does not promote a person’s quality of life, and even increases the gap between that person and his/her family members who have committed abuse. Since a support system is non-existent in these countries, the elderly has to continue to live with the abusive family member(s), who may do more harm to the elderly, and even cause their death, because no education, reward or punishment system is in place.

As for the competency of the elderly, the obvious point is that despite the availability of instruments such as the Mini-Mental State Examination (MMSE) that examines cognitive capacity, researchers should fully examine the cultural concerns associated with environmental and lifestyle patterns    ( 52 ).

Finally, for decision-making the care team can benefit from the communication ethics approach, which is a participatory method comprising several stages: (a) the defense stage to clarify conditions and issues; (b) consultation; and (c) negotiation that leads to agreement ( 40 ).

Iranian Ethical Challenges

The definition of elder abuse varies in different societies. According to an Iranian study by Heravi et al. conducted in 2013, elder abuse may be defined as an act or absence of a proper action by family members or relatives, which may happen once or several times, and can cause harm or distress to an older person ( 53 ).

Comprehensive ethical and legal regulations have so far not been developed in Iran. According to investigations by a researcher in Iran, no specific law exists about reporting and handling elder abuse. The Secretariat National Council of the Elderly in Iran, established in 2004, is the only organization that is active in various fields related to the elderly, but it seems that no significant activity has been performed regarding elder abuse. Also, Social Emergency has been active in Iran since 2007 to prevent harms and also provide services in connection with elder abuse, but they have not mentioned any specific ethical principles for managing elder abuse, its identification and referral. It is clear that availability of ethical principles and laws can help the care team deal with abuse.

In chapter three of the Constitution of the Islamic Republic of Iran, the importance of autonomy and human dignity has been addressed. According to the constitution, respect for human dignity is a principle accepted by the Islamic Republic of Iran, obliging the government to provide care services to everyone ( 54 ). Accordingly, care services should be based on respect for rights and dignity of patients. Accordingly, the patient should choose and decide freely. Respect should be provided for the patient while receiving care services based on respect for patients’ privacy and confidentiality of information. In this regard, a study by Davis et al. showed that the possibility of decision-making is vital for elderly people, and lack of autonomy leads to depression ( 51 ).

Based on our Iranian-Islamic beliefs, confidentiality means trust, and it has to be protected. Sharing personal information with others indicates betrayal. Also, according to Article 648 of the Islamic Penal Code, disclosure of patients’ secrets is illegal except when personal or public interest is at risk ( 55 ).

In Iran, there is no particular penal code for elderly people, but according to Article 596 of the Islamic Penal Code on financial abuse, the abuser will be sentenced to 16 months to 2 years of imprisonment and payment of a fine. If the abuser is the guardian of the victim, in addition to the fine, the abuser will be sentenced to 3 to 7 years of imprisonment ( 56 ).

Thus, according to the above-mentioned points, elder abuse is a phenomenon that needs more attention from the government.

Abuse is a serious problem among elderly people. Although the care team is responsible for the support and promotion of the independence of elderly people, ethical challenges are the result of unsatisfactory performance of the care team and people who endanger themselves or the others.

In decision-making about measures related to elder abuse, ethical principles such as autonomy, beneficence, non-maleficence and competency should be taken into consideration. The care team should protect the autonomy of elderly people and consider their health and welfare. However, they should not impose their beliefs regarding living environments or social decision-making on the elderly.

As far as possible, the relationship between elderly people and family caregivers should be promoted. At the same time, protecting elderly people will not be possible unless the society can help them maintain their independence outside of the family system. This will allow the elderly to enjoy a positive relationship with members of their family who are also their caregivers. The achievement of these goals necessitates long-term coordination between services and institutes.

Some measures that can be effective in this context include: devising appropriate instructions for the care team, particularly nurses who deal with abuse issues; communication and consultation with other service providers while observing privacy and autonomy; commitment to follow instructions; observing ethical considerations regarding abuse; and conducting empirical studies.

Nurses as the first line of treatment and other care team members have an important role in this respect. Compilation or localization of clinical guidelines for the care team not only influences their perspectives into ethical issues, but also helps them perform properly and select the best functional option. Finally, clinical guidelines support the behavior and performance of the care team and serve as a criterion to assess the caregiving quality.

Acknowledgements

This article is part of a dissertation for a master's degree approved by Tehran University of Medical Sciences, Faculty of Nursing and Midwifery under the code of ethics 9411580003. The researcher declares her appreciation to the officials of the Nursing and Midwifery Faculty of Tehran University of Medical Sciences.

Citation to this article:

Saghafi A, Bahramnezhad F, Poormollamirza A, Dadgari A, Navab E. Examining the ethical challenges in managing elder abuse: a systematic review J Med Ethics Hist. 2019; 12: 7.

Conflict of Interests

Authors declare no conflict of interest.