69902 2Elder abuse and neglect is a critical health care issue that must be brought to the attention of health care providers and older adults family members. Adults older than 65 who live at home or in long-term care facilities may be at risk for abuse. Nurses should be aware of the causes, screening questions, symptoms of abuse, and resources in the community. Armed with information and a better understanding about the issue, nurses can minimize the devastating effects of abuse on older adults and their families.
Every man, woman, and child deserves to be treated with respect and caring. Individuals of all ages deserve to be protected from harm by caregivers (American Psychological Association, 2006). Significant policy developments during the past 20 years have focused on eliminating abuse. However, a deficit in health care providers’ knowledge and clinical skill application remains. The purpose of this article is to define and describe the kinds of abuse, their potential clinical presentations, and theoretical explanations for abuse to enhance nurses’ knowledge and understanding of their role in its assessment and management in older adults.
BACKGROUND
Abuse is defined as the infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish (Table 1). It can also be the willful deprivation by a caregiver of goods or services that are necessary to maintain physical or mental health (American Psychological Association, 2006). Elder abuse and neglect has plagued society for centuries but only recently has the issue come to the attention of health care providers, law enforcement agencies, and protective services. Fewer research studies exist about the maltreatment of older adults than about other forms of family violence, including child abuse, rape, and intimate partner violence. The earliest reports of elder abuse and neglect in the United Kingdom in the 1970s dramatized case reports of the phenomenon, termed “Granny battering.” The health care community and the public were shocked and appalled. A decade later, studies confirmed that the problem was common in the United States as well.
In the late 1970s, the U.S. Senate Special Committee on Aging issued a series of reports on abuse and neglect occurring in nursing homes. In 1981, the U.S. House of Representatives Select Committee on Aging conducted hearings in which victimized older adults gave firsthand testimony of their experiences with abuse. In 1986, the Institute of Medicine published recommendations for preventing the maltreatment of older adults in institutions, and several years later, the Elder Abuse Task Force was created by the Secretary of the U.S. Department of Health and Human Services. The task force developed an action plan for the identification and prevention of maltreatment of older adults in their own homes, health care facilities, and communities. The action plan included data collection, research, technical assistance, training, and public education. The National Center on Elder Abuse was established as part of the Administration on Aging’s Elder Care Campaign. Adult Protective Services programs now exist in every state to serve vulnerable adults, particularly older adults, who may be at risk for abuse and neglect. Many law enforcement agencies and Offices of the District Attorney have investigative staff specifically trained to address abuse of older adults and other vulnerable populations, in collaboration with health care and protective service professionals.
Such actions have led to increased public and health care provider awareness about elder abuse and neglect. Researchers have also sought to grasp the full scope and causes of maltreatment among older adults. Laws that require health care providers to report suspected cases have been instituted in nearly every state. The Joint Commission on Accreditation of Healthcare Organizations’ (2006) standards for emergency departments and ambulatory care centers call for improved identification and management of elder abuse, in addition to intimate partner violence and child abuse.
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As the U.S. population ages, demands placed on health care systems to care for older adults are increasing. More than 36 million people who live in the United States are older than age 65, and 600,000 older adults will require assisted living (U.S. Department of Health and Human Services, Administration on Aging, 2006). Currently, there are approximately 17,000 nursing homes in the United States, with 1.6 million residents (U.S. Department of Health and Human Services, Administration on Aging, 2004). Unfortunately, older adults are becoming victims of intentional abuse and neglect within their own homes, as well as in assisted living and long-term care facilities.
Each year in the United States, 1 to 2 million adults older than age 65 are injured, exploited, or mistreated by their caregivers (National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect, 2003). One community-based, cross-sectional survey reported that 32 of every 1,000 older adults reported that they had experienced some form of maltreatment at least once since reaching age 65 (Pillemer & Finkelhor, 1988). Underreporting is typical with all kinds of abuse, and it is estimated that only 1 in 14 elder maltreatment cases are reported. Health care providers can expect to see a steady increase in the number of cases of elder maltreatment as the older adult population rapidly increases.
THEORIES OF ELDER ABUSE
Elder abuse is a complex problem with multiple risks and causes. Dysfunctional family lives, cultural issues, and caregiver inadequacies have been implicated as contributing factors. Awareness of such factors may help nurses understand and anticipate situations where maltreatment may be preventable.
Several theories attempt to explain the existence and increasing occurrence of elder abuse. The transgenerational, or social learning, theory asserts that violence is a learned behavior. Individuals who have witnessed or been victims of family violence are more likely to try to resolve challenging and difficult life situations with violent tactics they learned in their formative growth. Although 90% of perpetrators of elder abuse are reported to be family members, this cannot account for all cases (Fulmer, Guadagno, Bitondo, Dyer, & Connolly, 2004).
Situational theory supports the idea that the greater the burden on caregivers, the more likely caregivers are to abuse. Exchange theory addresses the dependence of older adults on their caregivers as a risk of abuse, along with inadequate methods of problem solving as an established pattern of family behavior. Political economic theory addresses the changing roles of older adults. Their loss of independence and income may cause them to look to others for care and support (Fulmer et al., 2004).
Psychopathology of the caregiver theory studies caregivers with severe emotional or mental health problems or addictions that put the older adults for whom they care at risk of being abused. For example, a caregiver with a mental health problem who cares for a frail older adult with cognitive impairment is a dangerous combination and may lead to resistant behavior and maltreatment. Although theoretical frameworks cannot explain all cases of elder maltreatment, they can provide a foundation for nurses to begin to understand the combination of factors responsible for the occurrence of elder abuse and initiate a holistic plan of care.
NURSING ASSESSMENT & INTERVENTIONS
Nurses are in an ideal position to play a significant role in the detection, management, and prevention of elder maltreatment and may be the only individuals outside of the family who have regular contact with an older adult. Nurses are uniquely qualified to perform physical and psychological assessments, order confirmatory diagnostic tests (e.g., blood tests, x-rays), and collaborate with physicians and protective services. They may authorize services, such as home health care, or recommend hospital admission as they initiate further investigation by the appropriate local agencies.
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Opportunities for abuse detection and intervention occur daily in health care settings. In institutional settings, nurses may monitor patient health and perform health history interviews and physical, psychological, sexual, and financial abuse assessments that may be crucial to elicit reports, expose or prevent abuse, and intervene for patients’ safety (Wieland, 2000). Nurses and other health care providers are part of an interprofessional team collaborating to ensure appropriate, sensitive, and safe outcomes for older adult patients.
Institutional maltreatment occurs in long-term care facilities, board-and-care homes, and other assisted-living facilities. Institutional medical directors, private practitioners, nurses, and all health care workers in daily contact with older adults have a responsibility to identify, treat, and prevent abuse.
Abuse may be perpetrated by a staff member, another patient, an intruder or a visitor, or a family caregiver. Abuse may include failure to implement a plan of care or provide treatment, unauthorized use of physical or chemical restraints, and use of medication or isolation for punishment or staff convenience. Nurses must be aware of patient diagnoses, medical orders for care, and medications and their side effects to recognize what is suspicious and needs further evaluation or warrants a report to supervisors. However, most elder maltreatment does not occur in institutions but in the home at the hands of a caregiver, often a family member.
Unless nurses are educated about abuse and how to observe suspicious injuries, elder abuse may be difficult to detect. Definitions of the kinds of abuse and their signs and symptoms should be included in the training and education of family members and health care workers who care for older adults. Older adults experiencing abuse may be unable to communicate clearly, their bruises may be attributed to the aging process, or they may be fearful and hesitant to report abuse (Wieland, 2000). Indications of physical abuse should signal health care providers to evaluate for other kinds of abuse, such as sexual abuse.
In addition to inadequate information, training, and the caregiver’s experience of caring for older adults, older adults are at risk for maltreatment due to other vulnerabilities. Older adult residents in institutions are typically dependent and chronically ill and may have cognitive, visual, and auditory impairments. They are usually more frail than are younger patients and may not have regular visitors who monitor their mental status, physical condition, or health care. In older adults, each vulnerability increases their mortality risk (Fulmer et al., 2004).
Co-existing conditions and medical diagnoses may lead to worse outcomes for older adults who are abused. They may have a decreased ability to heal after injury and may experience greater trauma from physical injuries than do younger people. Their bones are more brittle and tissue more easily bruised, abraded, and lacerated with minimal trauma. Injured older adults differ from the younger population in terms of cause of injury, physical and psychological responses to abuse and injury, and outcomes.
Dementia is common in 50% of residents of long-term care facilities (National Center for Health Statistics, 1985), and cognitive impairments often cause older adults to behave in a more resistant manner toward caregivers. Impaired cognition, along with insufficient resources, staff shortages, high staff turnover, and inadequate supervision and training, may increase the risk of elder maltreatment. In addition, societal ignorance about required standards for quality care and victimized older adults’ acceptance of abusive or neglectful behavior can lead to exacerbation of elder abuse in institutions.
Routine questions related to elder abuse and neglect can be incorporated into daily nursing practice. Diminished cognitive capacity does not necessarily negate older adults’ ability to describe maltreatment. It is always reasonable for nurses to ask about abuse or neglect. A brief mental status examination can be helpful in evaluating patients’ cognitive status.
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Assessment for elder abuse should include caregiver, as well as victim, evaluation. Nurses should conduct interviews and examinations with the patient first, in a private setting separate from the caregiver.
Clinical settings should have a protocol for the detection and assessment of elder maltreatment. Protocols should consist of a narrative, checklist, or standardized forms that enable rapid screening for elder abuse and provide guidelines for sound documentation that may help disclose patterns of abuse over time and will withstand scrutiny in court. Basic demographic questions should be included and should allow the interviewer to determine the family composition and socioeconomic status. Interviews should proceed from general questions that assess the patient’s sense of well-being to those focusing on specific kinds of abuse. Common signs and symptoms of maltreatment should be evaluated (Table 2).
Elder abuse screening instruments are summarized by Fulmer et al. (2004). Questions recommended by Wieland (2000) for general abuse screening and assessment include:
* Do you feel safe where you are living?
* Who is responsible for your care?
* Do you often disagree with your caregiver(s)? If so, what happens?
* Does anyone scold or shout at you, slap or hit you, or leave you alone and make you wait for care or food?
After general screening questions, more specific questions about kinds of abuse may follow:
* Has anyone ever touched you without your consent?
* Has anyone ever made you do things you did not want to do?
* Has anyone ever taken something that was yours without asking?
* Have you ever signed any documents that you did not understand?
Health care providers do not have to prove that elder maltreatment has occurred. They need to screen and document suspicious verbal and physical findings, which may be as simple as stating that the patient seems to have health or personal problems and needs assistance. Sound documentation may include drawings of injuries on body diagrams or photographs to support written reports. Suspicious claims for abuse and neglect may be difficult to quantify. Diagnosis of elder maltreatment depends on education about abuse and application of that knowledge by the multidisciplinary team of health care providers, law enforcement agencies, advocates, and patients. Protocols for elder abuse screening, assessment of risk factors, and documentation should be posted in all health care facilities.
ABUSE AND THE LAW
National standards for care in nursing homes are based on the Nursing Home Reform Act of 1987. The law is part of the Consolidated Omnibus Budget Reconciliation Act of 1987, often referred to as OBRA 87. The intent of the law is to promote high-quality care and prevent substandard care. The law also seeks to ensure that the rights of nursing home residents are respected. These include:
* The right of protection against Medicaid discrimination.
* The right to participate in health care decisions and to give or withhold informed consent for particular interventions.
* The right to safeguards to reduce inappropriate use of physical and chemical restraints.
* The right for provisions to ensure proper transfers or discharges.
* The right to full access to a personal physician, long-term care ombudsman, and other advocates.
* The right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion.
* The right to be free The Legal Context Of Social Work Social Work Essayfrom physical restraints or psychoactive drugs administered for the purpose of discipline or convenience.
Nearly all states have mandatory reporting laws that require health care professionals and paraprofessionals to report suspected elder abuse and neglect to a designated authority. Some state laws specify that after authorities have been alerted to suspected elder abuse or neglect, an agent of the state must make an onsite investigation in an attempt to corroborate the report. Uniform reporting systems are established, and cases are assigned and investigated by protective services in a timely fashion. Cases are assigned and investigated by protective services in a timely fashion. Nurses may play an important role in preventing and identifying elder abuse, as well as in the subsequent investigation.
The primary mission of Social Work profession is to enhance wellbeing and help meet the basic needs of all people with particular attention to the needs and empowerment of people who are vulnerable, oppressed and those living in poverty (luc.edu). The first part of my assignment will be looking at, the importance of the legal context of social work, different types of law and courts that social workers mostly use when representing cases, the impact of the Human Right Act (1998) upon the legislation and how it links in with anti-oppressive practice as well as the powers and duties and their implications for social work practice.
The legal context of social work is important because it provides duties and powers for social work and it provides an understanding of the statutory and legal requirements for effective and fair social work practice (Brammer, 2010). Without an understanding of law, social workers may not be able to make decisions which may be complex for example, removals of children from their own home. Their professional conduct should be legal and ethical. The NASW code of ethics (naswdc.org)[online], statement that, “social workers should promote the general welfare of society from local to global levels and the development of people, their communities and their environments…..” It added that, the knowledge of the legal system help social workers to be aware of the conflicts that may arise between their personal and professional values and how to deal with them responsibly. The knowledge of law is essential to social work practice and failure to have it may leave social workers vulnerable to being sued by service users who feels their lives where affected by a failure to use their professional act (Stein, 1893).
The law supports social workers who wish to disclose concerns about unacceptable behaviour, for example, the guidance on protecting vulnerable adults through the Public Interest Disclosure Act (1998) (Scie.org). England consists of different types of law that social workers are mostly involved in and these are; criminal and civil law, private and public law. Brown and Rice (2007) stated that, criminal law deals with some forms of conduct, for example, murder, and the state reserves the punishment by prosecuting the offender whereas the civil law concerns the relationships between private persons, their rights and their duties.
Public law consists of three types of law which are; constitutional law; controls the method of the government for example who is allowed to work or whether there was a correct procedure which was taken during an election (Martin 2002). Administrative law; controls the operation of ministers of state and other public bodies for example the local authorities. Private law consists of many branches such as tort, family law, company law and employment law.
The hierarchy structure of court consists of the House of Lords which is the highest in the land and that is where civil and criminal appeals are heard. The court of appeal hears civil and criminal appeals and with divisional courts, two or more high court judges may convene to hear appeals from inferior courts in cases where points of law are referred from the magistrates court or county court. Magistrate court has an important jurisdiction in both criminal and family law. The approved social worker has a duty to make an application for admission to hospital or guardianship if necessary for continuity of care and family work.
Social workers are admonished to promote the right of service users to select their own goals but at times social workers uses their professional judgement to limit the service users right to self-determination when the service user’s actions can pose a serious risk to themselves and others (Stein, 1893). Anti-oppressive practice is based on an understanding of how the concepts of power, oppression and inequality determine personal and structural relations (Davies p14). The duty of a social worker is to make sure that people have access to their rights and those who have been oppressed are empowered to regain and are promoted to change as well as taking control of their lives. The HRA 1998 came into force in October (2000) and the focus of the Act is to promote and uphold rights and the act applies to public authorities only (Mandelstam 2009), however, the courts in the past argued that, independent care providers in the context of community care are not public authorities for the purposes of HRA (YL v Birmingham cc) (Mandelstam, 2009). Mandelstam (2009) also argued that, vulnerable people are being deprived of their rights they are entitled to for example their own protection under the HRA. There are a number of rights that are relevant to the Health and Social Care for example article 2 (right to life), It is a right under the European convention on human rights for an individual to have a right to life but the courts also argue that, if a person does not have a capacity to know what is right for them, if this is in their best interest, for example withdrawing artificial hydration and nutrition; it is regarded as a principle lawful not a breach of article 2 (Mandelstam 2009).
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Article 3; no one shall be subject to torture or to inhuman or degrading treatment or punishment. Article 5 is deprivation of liberty. Everyone has a right to liberty and security and nobody should be deprived to it except if it is in accordance with the law. This act was breached under ECOHR due to the absence of legal safeguards of mental health patients (jevde and surrey cc), by depriving a mentally incapacitated person by placing him in a care home and not allowing him to return to his own home. Article 6 says that everyone is entitled to a fair and public hearing within a reasonable timescale by an independant and impartial tribunal established by law (Ball and Mcdonald,2002).
Article 8 is a right to respect for his private and family life and the court held the act as it sometimes a positive obligation on the state to provide support for asylum seekers (Brammer,2010). The courts said that the LA failed to assess the physical and psychological needs of a 95yr old woman who was to be returned from the hospital to a care home, therefore it breached article 8. Article 14, “is the enjoyment of rights and freedoms set forth in this convention shall be secured without discrimination…” Ball and Mcdonald(2002).
The legal context of social work is important because it provides duties and powers for social work and it provides an understanding of the statutory and legal requirements for effective and fair social work practice (Brammer, 2010). Without an understanding of law, professionals would not be able to deal with certain situations and the majority of vulnerable people would be experiencing oppression and treated unfairly. A duty is usually indicated by shall or must and it is imposed by law therefore it is a mandatory to carry it, for example, a duty to investigate and carrying an assessment after suspicion of abuse (Brammer: 2010).
Power constitutes what may, but does not have to be done (Mandlestam: 2009; p97). It provides the authority to act in a particular way but there is a scope to decide how to act (Brammer:2010;p17). Not every country operate with social workers, others use police, relatives even the Mayor (Bean:1986). Some families use power structure to control the family and this could be due to cultural background for example male having power over women.
The second part of my assignment will be focusing on the National Assistance Act (1948), The National Health Service and Community Care Act (1990). The community Care Act 1990 was established to end the existing poor law in order to assist the person in need for example, the disabled, sick and the old age persons. This was done by the National Assistance board and the local authority. Compulsory removal from home outside the terms of the Mental Health Act 1983 can be affected. There is power of removal from home under section 47 of the National Assistance Act 1948 when a person is unable to look after themselves as well as if they are not receiving proper care and attention from their carers. The removal may be breaching that person’s human rights under article 6 of the European Convention. If people fail to cooperate and there is continuity of uncaring, the social worker would then have the power under section 48(2) of the NAA 1948 to enter the premises in order to carry out their duty.
Community Care Act 1990 governs the provision of community care services for vulnerable adults for example the older people and disable people. The National Assistance Act 1948 sec 29 defines disabled people as, “aged 18 or over who are blind, deaf or dumb or who suffer from mental disorder or any description, and other persons aged 18 or over who are substantially and permanently handicapped by illness, injury or congenital deformity os such other disabilities as may be described.” Ball et al 2002 said that, it is a duty to assess an individual need for community care services according to section 47 of the NHS and community care act.
The assessment that social workers carry out for Mr and Mrs Bertram is to make sure that an individualised package of care is provided. Assessing a service user is a way to gather relevant information inorder to make a care plan. Mrs Bertram has always want to live in her therefore the service that the social workers would be providing would have to allow her to live as independently as possible in her community rather than in a residential home. According to Davies (2000), the assessment will cover the service user’s health needs, physical, mental capacity, emotional needs, financial support, suitability of living environment and carer support. The resources provided should make the Bertram family feel enabled rather than feeling oppressed.
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The process should be client based. Working with older people is rewarding and challenging because it affects their social, spiritual and emotional wellbeing and at times it will be hard to understand their complex situations that is why they should be client based. Carl Rodgers ( ) listed the three core conditions pf person centered practice. He said that a social should have unconditional positive regard and congruence and being empathetic. He said that to understand someone’s situation is walking in their shoes, understanding the nature of their experience and their unique point of view. By putting the service user at the centre is also by making informed choices as well as working in partnership with Mr and Mrs Bertram and other agencies. Section 45 of the Health Services and Public health Act 1968 contains a power to promote the welfare of older people (Ball 2002:p111). Mr and Mrs Bertram would benefit to services like meals on wheels and domiciliary care. Section 47 (2) of the National Health Service and Community Care Act 1990 requires the Local Authority to identify people whom they are in the process of assessing as disabled (Ball, 2002;p112). The local authority’s duty to the Bertram is to provide an adaptation in their home by providing facilities that can suit them for the greater safety, comfort and convenience of the family.
Mr Bertram could be facing serious threat in his marriage by not understanding what his wife is going through. He is facing a gradual loss of the woman he has lived with and that could be distressing him. The service that social workers provide should not discriminate and the service provided should not contribute to it. Social workers need to help Mr Bertram understand the condition of his wife for example attending the user and carer support groups run by the alzheimers society. This will help him to understand the condition of his wife especially when it is coming from other people facing similar life changing experiences.
Social workers can also help the Bertram with benefits issues or even advising the family to contact the local neighbourhood or citizen advice bureau regarding the financial status. Mental capacity act has brought in a standard test for mental capacity and so long as Mrs Bertram retains capacity, she can under this act appoint someone such as Mr Bertram of one of her daughters with lasting power of attorney who could write an advance directive, both to be applicable should Mrs Bertram be assessed as having lost her mental capacity.
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CONCLUSION
Elder abuse is a significant problem in the United States and often goes unreported and unrecognized. Elder abuse may be physical, emotional, psychological, sexual, or financial. Immediate care, overnight housing, and care in a safe location, in addition to long-term care and home-delivered food, may be necessary. Elder abuse may be a minor issue that can be easily resolved or it can result in severe and life-threatening debilitation.
The more knowledge health care providers have, the more likely they are to institute strategies for abuse prevention and management. No matter how minor or severe the abuse, nurses have a duty to assess elderly patients according to recommended protocols and report suspected abuse to designated authorities. The multidisciplinary team then works together to help resolve the issue. The application of knowledge about elder abuse includes screening, assessment, and sound documentation in an attempt to enhance the quality of life and maximize the functional ability of older adults.
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