“Single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress including physical, emotional, verbal, financial, sexual, racial abuse, neglect and abuse through misapplication of drugs.”
Abuse can happen to anyone, anywhere, at any time. However, it is so alarming that more and more elderly people suffer from abuse everyday. Many elderly adults are being abused in their homes and even in care facilities such as nursing homes responsible for their care. How can elderly groups be vulnerable to abuse and/or harm to self and others? And how do nursing homes which are supposed to deliver utmost care and support become one of the major contributing factors of abuse?
1.1As people gets old, many physical changes takes place on the process. They become weaker and fragile, thus unable to stand up and fight back if bullying occurs. Their eyesight and hearing become less sensitive, thus, they are prone to more wicked people taking advantage of them. Physical and mental disorders that elderly people may have may be the factor of abuse in the home or at the residential home. This could also lead to any forms of abuse. People with dementia, for example are very much susceptible to abuse because of the conditions (loss of memory, mood changes and communication difficulties) that they suffer (The RCN Learning Zone, 2011). People around them such as care providers who are aware of their condition can take advantage of that because they think that the service user is powerless or have no knowledge of the medical consequence and might not be able to defend themselves when they are being abused or might not be able to identify the type and kind of abuse.
This could also be related to “Power” and or “authority” which affects the existence of abuse between the care provider and the service user. Whoever has the power can become the abuser and the the other party who can not defend them selves tends to be the abused. Due to the conditions of the age of the service user, they are classified as vulnerable and may need help and assistance from other people especially their carers or family members to support them to maintain their independence or promote well being. This in effect tends to be seen as burdensome to the carer or family member and is is then formed in the minds of these elderly people that they are weak and powerless and therefore should be submissive to carers in order to gain assistance from them. If carers, on the other hand, perceive this weakness from their clients and that they have the power over them, then, they can use that power to abuse them. In this essay, the author will use false names of people and establishments to respect the privacy and confidentiality of all concerned. Terms such as resident, client, patient and service user will be used interchangeably.
In the nursing home where I work, we have one resident called Mrs. M, who is bed ridden for many years now. She can only utter certain words such as Bryan (son’s name), Yes or No and some swear words. She has dementia, speech impairment and mobility issues. This service user can not speak out or stand up to defend herself. She needs turning every two hours to prevent bedsore. She needs assistance in feeding and it is very hard to do it because she always chews cloths from either the sleeves of her clothes or the bed sheets and even her arms. Referring to Valuing People White Paper (for England) which states that people with learning disabilities and/or mental health problem have the right, choice, independence and inclusion for opportunities to lead a full and active life (Fyson, 2005).
This service user’s needs are still within the context definition and aim and therefore have the right to be treated fairly. Carers must not be put off by her inability to respond to commands or speak out her view. They must look at the medical condition and health care working ethos. This service user must also not be discriminated in spite of the condition. she has rights and deserves some respect and humane treatment. Article 14 of Human Rights Act of 2008 states that “everyone has the right to be treated fairly regardless of gender, race, religion, sex, age, political views, disability or anything else” (Ministry of Justice, 2008). But if the care provider doesn’t know how to respect these rights, then he/she is likely to abuse the client.
1.2There are other risk factors that may lead to incidence of abuse or harm to self and others. Lack of appropriate training and supervision can put not only the client at risk for physical injury but the carer as well. As for Mrs. M, she needs careful moving and handling method and appropriate equipment to avoid non-accidental use of force in turning her. Moreover, lack of staffs and poor working conditions can put the carer and client at risk for abuse as well. Mrs. M being attended by only one carer is not a good practice and must not accepted in the home and tolerated by the service user. This is always the norm in most care home who do not have enough resources especially staff due to lack of funds of qualified staff . Assessing and reviewing the risk involved in moving and handling the service user it is recommended that the service user will need two staffs to assist her in feeding and moving, otherwise she will be left hurting and bruised from rough handling and risk of fall.
The responsibilities and demands for caring the elderly can become very stressful and make care givers burned out and unable to keep themselves from hitting or lashing on the residents. But if the carer has the right working attitude and mindset of respect and passion for his/her work, appropriate communication, good sense of humour then, most likely, the service user will not be abused and the risk involved will be minimised or if possible avoided. Under Regulation 3 of the Management of Health and Safety at Work Regulations 1999, risk assessments are a legal requirement for employers to carry out to eliminate or reduce risks. Employers with 5 or more employees need to record the significant findings of the risk assessment. ( Health and Safety, 2003).
A risk assessment will be undertaken by a trained and qualified person, of the potential risks to service users and carers. The risk for service users in maintaining their independence and daily living within the home must be assessed and must be based on the appropriate needs of the individual service user. As part of risk assessment, enough precautions to prevent harm should include practical control measures, providing information and training, and carrying out monitoring and health surveillance where necessary. The main benefit of risk assessment is in helping achieve a health and safety culture which have an impact on the reduction of accidents/incidents to a minimum, creation of a working environment which values health and safety and improvement of staff morale due to increased job satisfaction and feeling more valued.
1.3Culture can be simply defined as people’s “way of life”. It is a learned pattern of behaviour and ways in which a person lives his or her life. It is something that a person learns from his family and surroundings (Buzzle, 2012). Culture can be be practised in the home or at the work place, but in this assignment, I will write about how culture is practised in the care home. Most of the time staff form into a habit working as a team and demonstrating attributes which can be referred to as culture amongst the team but as individuals culture can also be demonstrated through our belief or perception. Culture that has been build up in the nursing home and the care provider’s own culture as an individual can also become a medium to different forms of abuse.
Creating a culture within a home wherein every resident who ask for something or complains only receives a response of shouting or being ignored by caregivers creates an environment that is abusive and where residents feel powerless. However, it is also identified that service users who shouts for help and attention gets the best services as compared to the ones that are quite and do not disturb or shout for attention. A culture that attends to the needs and respects the rights, choices and individualities of each residents can lead to a successful delivery of health care. Understanding and balancing your own culture with the culture of the nursing home and applying the policies of the home as well can avoid the occurrence of abuse to oneself and others.
Social factors such as the staffs, the community or the service and/or the family can affect the service user’s life. These social factors, can, sometimes lead to abuse. Studies have shown that residents who rarely receive visitors are at greater risk of being mistreated, physically neglected or harmed. Being lonely and isolated can increased the risk. Residents depend on family members and friends to keep watch. This usually happens with the case of Mrs. M. She is completely isolated and alone in her room and seldom visited by family members. Added to this, she lacks the capacity and is completely dependent due to complex care needs, therefore, she can be neglected by busy staff members who don’t always have the time to provide all the individualized care they need.
However, too much family involvement can also be problematic, especially when a family member is always present and controls how and when care is provided. We have one resident called Mrs. E, who is always being visited by her daughter, every tea time of everyday. The daughter is very demanding not only to the carers but to the mother as well. She forces her mother to eat all her meal even if Mrs. E is almost gagging from too much eating. She asks her mother to be toileted even if Mrs. E doesn’t need to. The daughter always makes unreasonable demands to staffs and she always has complaints. In this case, both the service user and care provider are being abused.
Poor relationship between staffs and service users can present a risk factor of abuse. Caring for residents who are extremely physically and cognitively dependent is a demanding job. Some residents may have behavioural symptoms that staffs and other residents may find intolerable. Sexual acting out, screaming, wandering, hitting and cursing, can cause an already overstressed caregivers to lose patience and even strike back. However, if a good relationship can be built between the residents and caregivers, risk of injuries and abuse can be reduced. These can only happen if there is a manageable workload for staffs wherein they can have time to sit and talk with the residents and get to know them. If the relationship is good, staff will respect residents’ choices and desires for control over their lives (National Association of States Units on Aging, 2005).
2.1Any form of abuse is unacceptable, no matter what justification or reason may be given for it. It is also very important that we are aware of this and know that help is available. A number of legislations and policies has been created and formulated which helps protect vulnerable adults from harm and any forms of abuse. Human Rights Act of 1998, for example, acknowledges that all vulnerable adults have a right, and should be enabled to achieve that right, to live and receive services in an environment which is free from prejudice and safe from abuse. The Disability Discrimination Act 2003 extends the right of the disabled people. It promotes the equality of opportunities in terms of education, employment, access to goods, facilities and services; and buying or renting land or property, including making it easier for disabled people to rent property and for tenants to make disability-related adaptations. The Mental Capacity Act 2005 provides a legal framework for acting and making decisions on behalf of adults who lack the capacity to make particular decisions for themselves.
Safeguarding Adults – National Framework of Standards 2005 provides safeguarding practice and sets it within 11 good practice standards which are to be used as an audit tool and guide for those implementing adult protection work. In recognition of the changing context, previous references to the protection of “vulnerable adults” and to “adult protection” work are now replaced by the new term: ‘Safeguarding Adults’. This phrase means all work which enables an adult “who is or may be eligible for community care services” to retain independence, well-being and choice and to access their human right to live a life that is free from abuse and neglect. This definition specifically includes those people who are assessed as being able to purchase all or part of their community care services, as well as those who are eligible for community care services but whose need – in relation to safeguarding – is for access to mainstream services such as the police (Fiennes, et. al, 2005).
The Public Interest Disclosure Act 1998 (Whistle blowing) on the other hand, gives significant protection to employees who disclose information reasonably and responsibly in the public interest and are victimised as a result. The fear of being labelled a trouble-maker, the fear of appearing disloyal and the fear of victimisation by managers and colleagues are powerful disincentives against speaking up about genuine concerns staff have about criminal activity, failure to comply with a legal duty, danger to health and safety or the environment and the cover up of any of these in the workplace (Health Service Circular, 2002). However, with this Act, any employee who had been victimised in breech of the Act, can bring a claim and can be fully compensated from his losses. These are only some of the legislations and policies that can help as a guide in protecting vulnerable adults from any form of abuse.
For the past two years that I have been working in a nursing home, I have witnessed several forms of abuse. We had a resident called Mrs. N. She was 88 years old and had dementia. She was a small woman but overweight. She had mobility problems and she requires the assistance of two carers in standing her up and moving her from one place to another. She only speaks when she wants to and can still understand simple instructions and phrases. However, she becomes very aggressive every time she sees this one carer called Hafsta. Her mood changes and starts to become resistant whenever Hafsta assist her in getting up or going to bed for example. One morning, a very big bruise was seen on the leg of Mrs. N. Nobody knows how she got it. They assumed, she must have hit her leg on the side rails of the bed. But that night when I and Hafsta put her to bed, Mrs. M was very aggressive towards her.
She suddenly pointed at Hafsta and said that she hit her on her leg. Hafsta denied the accusation of Mrs. N and said that she doesn’t know what she is saying. I have a strong feeling that Hafsta has something to do with Mrs. N’s bruise based but I don’t have any strong evidence to prove my suspicion. I was afraid that if I report this incident to the management, it will just give them trouble and they might just ignore it. And if this happens, then I will just create an animosity between me and Hafsta. I told to my other colleague about this incident and he tried to report this to the manager. However, they just ignored it. I didn’t do anything about it because of some confusions and fears. But this action has left Mrs. N defenceless, powerless and an easy victim of abuse.
Creating ‘safe care’ or support for vulnerable people involves a holistic approach, which is centred upon the needs of the cared-for/supported person. It can be recognized that this will only be achieved through effective recruitment, induction, support, training and management of staff. More so, effective protection of vulnerable adults is achieved through a multidisciplinary approach with consultation and the sharing of information. The legislations, policies and procedures that exist to protect vulnerable adults from abuse provide a reasonable framework to support practice and decision-making. The Public Disclosure Act for example does not only protect “whistleblowers” from victimisation or dismissal if they raise concerns about serious fraud or malpractice in their workplace. Protecting the whistleblowers is like protecting the service users at the same time from further abuse.
Trainings are also available to support the implementation of legislations, policies and procedures, like, for example, a training for staffs in Safe Moving and Handling Operations to support the Health and Safety Act. However, the weakness in these legislations and policies is that they are not consistently implemented and do not always adequately promote effective practice. The management of a care home should not only have policies and procedures in place for safeguarding vulnerable adults but should also make sure that there is an awareness and a full understanding of such policies by the staffs. This can be made possible during the recruitment and induction process of newly hired staffs. A right recruitment and induction process plays a vital role in ensuring that the new employee becomes effective caregiver in the shortest time. In my experience, abuse happens because there is a failure by the management of the nursing home to provide staff the knowledge and understanding of its policies and procedures in acknowledging and respecting the rights of service users to be free from harm.
I started working in a nursing home without any knowledge on the existence of its policies nor the knowledge of certain legislations such as the whistle blowing policy that could protect me from reporting serious incidence of malpractice such as the case of Mrs. N. A weakness arises when there is a lack of will by the care institution to implement existing framework. The home where I am working didn’t provide clear internal procedures for identifying and dealing with concerns about possible abuse. However, it is not enough that there is an awareness regarding legislations and policies to avoid abuse. Staff should also adopt a proper code of conduct, promote a value for real care. This can be achieved through trainings in this policies and procedures and code of behaviour, as part of the induction process. At this point, there was a failure by my home to promote this value to their employees as evidenced by some of their carers being aggressive to their residents.
The home should make every effort to ensure that staffs receive adequate training in, for example, Safeguarding Adults within their probationary period and then a refresher training and more advanced training thereafter as part of their appraisal. If a staff has the right skills, values, knowledge and abilities in protecting vulnerable adults, then the incidence of abuse can be minimised if not totally avoided. Another weakness of the policies and procedures is that they do not adequately promote effective practice, recording of investigation assessment, risk assessment and decision-making process. As for the case of Mrs. N, the home didn’t bother to make any risk assessment as to how Mrs. N could have actually got her bruise. They even ignored when a suspicion was raised about a possible physical abuse by a carer. They didn’t make any prompt action regarding the report and didn’t make any further investigation. There was no clear policy and a proper reporting system about cases of abuse that was in place.
2.2All people who work with vulnerable adults have a duty to protect them from abuse and report all incidents, concerns or suspicions of abuse or neglect. In every nursing home, there is a single mission: to enhance the abilities rather than the disabilities of the service user while providing a comprehensive care that upholds his quality of life. To accomplish this, each staff member must work together as a team to see that high standards of care are met. The manager in a nursing home assumes several roles in the protection of adults vulnerable to abuse. He must ensure safe recruitment practices are fully employed in the recruitment of both staff and volunteers and that they have the necessary skills and experience in safeguarding, appropriate to the role. This means that supervision is given to staffs and a continuous training specially in safeguarding and support commensurate with their need must be provided. Safeguarding practice must regularly be discussed in supervision to identify any training needs and is included within the staff appraisal process.
The manager must also ensure that there is a written policy on safeguarding in place and that safeguarding is a standing item on every team meeting agendas. He should also ensure that the risk assessment framework for any case of abuse is regularly reviewed and an action process implemented as necessary. The carers are the frontline workers in the nursing home because they work directly with the service users. They are directly responsible for the delivery of care. The qualities of frontline workers, their personal abilities and the training and support they are offered affect the care and support they provide and their ability to promote independence for the service user (Henwood and Waddington, 2002). Thus, carers have the responsibility to make sure that they undertake trainings and appraisals as necessary and should be alert to safeguarding issues in all aspects of their work. They should keep accurate and timely records which are signed and dated and comply with their company’s procedures and policies.
Attending regular staff meetings and regular supervision to discuss and learn about care practices which could be abusive should also be assumed by carers. Finally, carers has the professional and moral duty to report any suspected abuse of a vulnerable adult. Other key professionals involved in the protection of vulnerable adults against abuse includes the General Practitioners, Social workers, Specialist Nurse, Nutritionist, Physiotherapist, Occupational Therapist, Clinical Psychologist, Advocate group and the family as well. These people must all work together as a team to effectively support the service user. Working as team can improve the quality of patient care, enhance patient safety, and reduce workload issues that cause burnout among healthcare professionals. Teams work most effectively when they have a clear purpose and a common goal; good communication; active listening to the service user’s views; co-ordination; protocols and procedure. The active participation of all members is another key feature.
However, promoting an effective delivery of heath care best work through a “person-centred care” approach, which involves the service user and his/her family in all the decision making concerning his health and social care. It should promote autonomy and independence for the service users to have a choice and control over their own life despite any disabilities they may have. Working as a team to discuss the care plan of the service user must and should always involve the service user in any decisions made. Key professionals can also work successfully to minimize cases of abuse by discussing and writing down the needs of the service users in their care plan and monitoring or checking that they are being met.
3.1Despite the fact that many nursing facilities in United Kingdom provide good care to frail and vulnerable elders, almost everyday incidents of abuse and neglect of nursing home residents are reported in the newspapers. In truth protecting residents is complicated, particularly since the effects of negligent care, abuse, or mistreatment are not always visible. Abuse is always there, the question is how to minimise it. Nursing homes must have a step by step process on how to provide quality care to the service users. They must clearly identify what are their mission, vision and goal . And they must have procedures and strategies which complements and supports the guidelines and legislations. There are still some good working practices being practised to minimise abuse in the nursing home where I work. There is one service user called, Mrs. T who goes to the nursing home once a week for day care service.
She suffers from right sided paralysis and speech difficulties due to stroke. She was on the lounge that day sitting on a normal chair, with other residents and two staffs who were watching the floor. Mrs. T was very agitated and wanted to go to the toilet, however, the carers could not attend to her needs because one was also looking after a resident who is at risk of falls and was wandering around and it needs two people to assist Mrs. T. One carer saw Mrs. T leaning forward on one side and pushing herself out of the chair so the carer ask her not to do that and helped her sit back properly. However, just for a few seconds when the carer was attending to another resident, she suddenly heard a heavy thud and saw Mrs. T on the floor, lying on her right side. Immediately, the carer, ask her colleague to watch Mrs. T as she ran quickly to the office to report the incident to the nurse and the manager. The nurse and the manager, then, went to the lounge to see how Mrs. T’s condition is and made an assessment of any injury.
After making sure that she is safe and didn’t suffer any major injury, the carers lifted her up using a hoist and sat her back to her wheelchair with her seat belt on. Proper documentation was made by the carer, making note of the date, time, setting when the incident happened and who was there at that time. The report was dated an signed by the carer as the document may be required as part of any legal action or disciplinary proceedings in the future. The nurse, on the other hand, made the proper documentation and also informed the family of Mrs. T about the incident. Mrs. T suffered a small bruise on her right cheek from the fall later that afternoon. One week after, Mrs. T’s daughter brought her in the nursing home for her daycare service but she is making an allegation that her mother is being hit and abused by carers as she found a bruise on Mrs. T’s left hand. She said that her mother was very agitated and doesn’t want to get out of bed that morning to go for her day care. The manager dealt the issue with the daughter, providing the documentation of the incident and also ask the presence of the carer who has witnessed the fall. At the end of the day, the issue was resolved.
Elder abuse prevention must be an all out team effort. While policies encourage individual action initiatives to assess risks, enhance protections, and intervene for residents, collaboration is vitally important. Many of the actions for reducing nursing home abuse risk can only be initiated in cooperation. From the case above, there was a team work being practised between the carers, the nurse and the manager. Immediate reporting of the incident, quick response and proper documentation has been made which in the end has proved to be crucially important in dealing with allegations of abuse.
Employees must also be able to recognize the signs and symptoms of abuse and believe that they can report allegations to management without suffering negative consequences themselves. The carer, at this point, was aware of what abuse is. He has the information on how to recognise abuse and so he realized the importance of proper reporting and documentation for future use if any allegations of abuse will be raised. Appropriate and prompt steps by management to stop the abuse, investigate, and report abuse to appropriate agencies when it occurs is also an important strategy to minimise abuse in health and social care.
3.2From the case of Mrs. T, strategies of collaboration, awareness, proper reporting of abuse and immediate response from the management to investigate incidence of abuse are existing working practices and strategies in the home that has been found out to be effective in minimising abuse. However, there are still some loopholes that can be identified, factors that prevents the nursing homes to provide and support effective measures of protecting and safeguarding adults to its fullest. There was a failure by the management to provide a good staffing level. Numerous studies have shown that the chance of an abuse or neglect is more likely in a facility where there is a low staff ratio. Inadequate staffing means each staff person will have too many residents to care for. Labor shortages affect not only staff, but also residents. When caregivers have to work double shifts, they are more likely to be overtired and stressed, and less able to handle difficult situations.
Over-reliance on nursing pool or temporary staffing, coupled with rapid turnover, makes it impossible for staff to get to know the residents. They end up not knowing residents’ care needs, preferences, likes or dislikes. Consistency of staffing is especially important for residents who have dementia. Staff must have enough time to provide needed care. A good communication and relationship can be built if there is enough staff. Caregivers who do not have ongoing personal relationships with residents are more likely to maltreat those in their care. If supervision is inadequate, there may be more instances of abuse (including residents striking one another, as well as staff abuse of residents) and less chance that incidents will be reported.
The effectiveness of working practices and strategies can also be achieved through staff education and training. To assure resident safety, staff training is crucial. Training should be frequent, not a one-time intervention, and trainers must be well educated and provide consistent information. Besides improving competence and knowledge, training also offers a vehicle for building self-esteem, which also may help to reduce stress and burnout. Training can also prepare staff to respond appropriately to difficult situations, such as dealing with physically combative residents, which have the potential to trigger abuse. As well, it can provide them with conflict resolution and other coping skills, and increase staff empathy and competence.
3.3 Based on my experience in a Nursing home, it is important that every nursing facility has a clear policy on abuse prevention in place and is widely communicated with all the staffs. Awareness on legislations, policies and procedures about safeguarding adults from abuse can be made possible through staff education. Recruitment and induction of newly hired staffs prove to be most beneficial in taking one measure to prevent abuse. At the very start of the recruitment process of staffs, measures to prevent abuse can already be implemented. Preemployment screening – including checking references and conducting criminal background checks – is essential to ensure that applicants who are not suited to care for vulnerable elders are not hired. People who would be inappropriate are people who lack empathy, who have no real interest in the welfare of the residents for whom they care, who are disrespectful or controlling, who have known substance abuse, domestic violence or criminal histories (National Association of States Units on Ageing, 2005).
The stress of work can lead to inappropriate behavior management. This, therefore, implies the need for staff screening. It is important that management in nursing homes should include in the screening process questions about the applicant’s feelings about caring for elders, how they handle anger and stress, their reaction to an abusive situation and if they have any history of substance abuse and alcohol. This is to test the applicant’s suitability to the job, if they can become an effective care provider. Education of staffs regarding how to recognize abuse, neglect and exploitation should take place during the induction process. Trainings must also include communication skills, proper management of people with dementia, mental illness or behavioural symptoms and should emphasize witnessing and reporting abuse. Staffing issues such as staff shortages must also be addressed by nursing care facilities.
All of these issues has proven to have direct impact with the quality of care being provided. If these are all implemented, it follows that a good communication and a good relationship between the carers and services users can be founded. Moreover, management of nursing homes must not only be aware of the need to promote adult protection and safeguarding but must need to do more to build on the progress made to implement a coherent vision, and strategy to support adult protection. Their performance should be constantly monitored, reviewed and improved. They should review and assess the effectiveness of their arrangements for risk assessment and risk management in adult protection to know if they have to make several changes or revisions to their own policies.