Improving Long-Term Care through Abuse Prevention and Ethics Training

Many of us look forward to our older years as a time to enjoy ourselves by starting a second career, volunteering, or spending time with our families and friends. Unfortunately, this is not the case for everyone as some grow increasingly frail, have cognitive problems, and may not have the family and social support they need. A variety of vulnerabilities can be a factor in elder abuse, a critical problem throughout the USA and beyond. For older adults in long-term care, physical functioning problems, limitations with regard to being able to carry out activities of daily living, and behavioral problems mean they have a significantly increased risk of abuse. This is coupled with the “loss of self” for those who become the “cared for,” who not only lose their independence but their life story.

We are known through our work, our faith, and our family relationships, and we maintain our identity while our life changes (Gridley et al., 2016). When a person who has been Kosher all his/her life is offered ham for dinner, or when a person who has always worshipped at sundown is now forced to bathe at that hour, we lose the concept of who that person is. Depending on the person’s resistance and the staff’s response to it, these circumstances are ripe for abusive behavior to take place.

Pastoral care and mental health professionals can benefit by using the film and curriculum described below for professional development when providing counseling, or when caring for elder clients on a long-term basis.

The film is intended primarily for staff of congregate nursing facilities and other long-term care providers and is aimed at preventing elder abuse; however, it can also be a useful resource for non-staff who counsel families, visit, consult, or serve on boards or committees associated with long-term care.

This curriculum and film are guided by life stories. Take the story of Dr. M., a leading surgeon who suffers from dementia and is in a nursing home. His daughter receives a call to inform her that he was found in another resident’s room during the night. The nursing home is familiar to Dr. M. in several ways: there are nurses around who are writing on charts, there are “patients” in bed, and there is a lot of activity. Who could blame him for thinking he was making his rounds? When the nursing home learns about his story, they engage him by giving him “charts” to look at and welcoming him to sit at the nurses’ station, a much better approach than trying to force him out of another person’s room. Care providers must consider what is important, sustaining, meaningful, and valued by each care recipient. Berry (2005) suggests one way of doing this is through the development of a “spiritual care plan,” carefully thought out for every person based on learning their faith background and essential needs.

As many as 24.3% of residents experienced at least one instance of physical abuse while in a nursing home. Among older adults living at home who are often isolated, the picture is even bleaker. One study reported that each year one in ten community-dwelling adults aged over sixty experience mistreatment and almost 50% of those with dementia are abused (Ben Natan & Lowenstein, 2010). Even this does not provide a full picture of the problem because it is estimated that only one in 23.5 cases of abuse are reported. In a study consisting of 2,000 interviews carried out with nursing home residents, 44% said they had been abused and 95% said they had been neglected or had seen another resident neglected (Broyles, 2000). In one study, more than 50% of nursing home staff admitted to mistreating (e.g., physical violence, mental abuse, neglect) older residents and two-thirds of those incidents involved neglect (Ben Natan & Lowenstein, 2010).

In response to these issues, the Center for Advocacy for the Rights and Interests of the Elderly (CARIE) developed an interactive training program entitled Competence with Compassion: An Abuse Prevention Training Program for Long-Term Care Staff, and an accompanying film, At the End of the Day. Before the training was tested, an evidence-based survey found that 17% of nurse’s aides had pushed, grabbed, or shoved a nursing home resident, 51% had yelled at a resident, and 23% had insulted or sworn at a resident (Pillemer & Hudson, 1993). In a post-test three months later, several positive changes had been made. The percentage of staff agreeing that nursing home residents are like children and in need of discipline dropped from 56% to 37% and all the individual conflict items had a significantly lower percentage. In addition, staff reported reductions in resident aggression, and self-reported abusive actions by staff declined significantly.

Research pointed to the need for enhanced training for staff to enable them to recognize abuse and neglect both in their own behaviors and those of others. To respond to this need, CARIE created a five-module curriculum with an introduction and conclusion written in an informal, non-technical style. Trainers are expected to modify the sessions to accommodate the education level of the participants and to individualize events or issues arising within a specific facility. The following is a list of topics covered in the program:

Module I: Introduction

History and philosophy of training

Module II: A Look at the Work We Do

$10,000 pyramid game: encourages open discussion, group interaction, and reflection on the experiences of being a professional caregiver

Module III: What is Abuse?

Definitions of abuse

Module IV: Why Abuse?

Residents at risk of abuse

Module V: Case Scenario At the End of the Day

Show and discuss the film

Module VI: Conflict Management

RETHINK—a conflict management technique

Module VII: Wrap Up and Evaluation

Review topics covered in workshop

An integral component of this dynamic curriculum is the use of the film, At the End of the Day. This twenty-minute film depicts an abuse scenario from the different perspectives of the staff involved, the resident, and family members. The provocative story highlights the complex, multilayered problems that influence every aspect of caregiving. For spiritual and mental health providers, the film can augment awareness about the nuanced nature of abuse and empower them to provide support to staff, residents, and family. The film serves as an example for staff with regard to exploring both the role of stress and the utilization of conflict management as an abuse prevention technique. In the film, Alice, who is a nurse, has been working a long shift and is worried about not getting home in time to see to her young son. As a result, she is rushing to finish her work and go home. She is depicted as a caring person who is visibly stressed. In an activity room, she encounters Lillian who says she wants to go back to her room and then she wants to go home. Lillian shows signs of mild cognitive decline and like many residents would rather be at home. When Lillian is back in her room, Alice comes in to administer her medication. Lillian is still distressed and asking to go home; however, Alice is focused on the task of giving her the medication. We learn later that Lillian’s family has decided to sell her home and she will not be going back. Lillian strikes Alice and scratches her face. Alice then holds Lillian’s arm down on the chair rest. In the encounter, Lillian’s arm is also injured. This scenario is then seen from a variety of perspectives and becomes a valuable training tool as trainees examine the dynamics of the situation and ways in which they might diffuse a similar one. The curriculum and the film are available by calling CARIE at 800-356-3606 or emailing mathes@carie.org.

While conducting and evaluating this program, it became obvious that there was confusion about legal and ethical issues. Too often, when conflict happens in a nursing home, an attorney is contacted whether the issue is clearly a legal one or not. Take the example of Dr. M., who if forcefully removed from a resident’s room may have been harmed or harmed someone else. By learning his life story, staff used an ethical approach to help him have a meaningful life while his life story was changing. Helping staff think through conflict is the goal of the subsequent Competence with Compassion training program, “Ethical Decision-Making in the Changing Culture of Long-Term Care”.

This train the trainer package examines the ethical issues that come into play while caring for elder clients in a long-term care setting. It uses two three- to five-minute video excerpts to document many of the concerns and ethical responsibilities that are integral to providing quality care. One video excerpt involves a “minor” struggle between a staff member and an elderly woman, and the other involves a well-intentioned independent living resident whose “forceful” actions toward his wife, a resident in a nursing home, are perceived as abusive. The extensive training package includes a four-module curriculum, two video excerpts, a PowerPoint presentation, reproducible handouts, and supplementary reading on responsibility and commitment to ethics in long-term caregiving. This field-tested package will provide a realistic approach to understanding and making decisions about care issues that pose ethical dilemmas. The curriculum, including the video excerpts, is available by calling CARIE at 800-356-3606 or emailing mathes@carie.org.