Multidisciplinary Reports of Nursing Home Mistreatment

Article Outline

• Abstract
• Methods
  • Instruments
  • Data Analyses
• Results
  • Survey Results
  • Interview Results
• Discussion
• Conclusion
• Appendix 1
  • Example Protocol
• References
• Copyright

Objectives

The purpose of this research was to learn about nursing home employees' knowledge and perspectives on mandatory reporting of elder abuse.

Design

Mailed questionnaire and personal interviews.

Setting

Two nursing facilities in Iowa.

Participants

All employees of the two nursing facilities.

Measurements

A 28-item questionnaire that included questions on demographics, personal experiences with suspected elder abuse and reporting, legislation, facility protocols, and opinions on mandatory reporting was mailed to participants. An interview composed of 11 open-ended questions was conducted in the nursing facilities.

Results

Forty-nine (15%) of the 335 employees who were sent the mailing returned the questionnaire and 22 (7%) participated in the interview. Over half (53%) of those who returned questionnaires reported suspecting a case of abuse in the facility where they currently work. Of these, 35% stated that they had not reported all the cases they suspected. Interviews of the 22 employees were about 15 minutes in length and took place at the nursing facility. Four themes emerged from these interviews, including the need for more staff education/training on the subject of elder abuse, difficulty in making judgments about whether the situation needs to be reported, barriers to reporting, and a sense that some abuse situations may occur because the staff is overworked, inexperienced, and/or frustrated from dealing with difficult residents.

Conclusion

Nursing home employees are knowledgeable about the mandatory reporter laws, but many remain hesitant to report suspected abuse for various reasons.

Keywords: Elder abuse, mandatory reporter, nursing home, education

The number of elderly people in the United States has been increasing dramatically and is expected to continue to increase. In 2006, an estimated 37.3 million people in the United States were older than 65 and the population of this age group is projected to be near 86.7 million people by the year 2050. The Census Bureau has projected a 147% population increase for this age group between 2000 and 2050, while the population as a whole is expected to increase by only 49%.¹

An aging population, along with a longer life expectancy,² suggests that more and more people will live in a nursing facility at one time or another. The 2006 Census Bureau survey revealed that approximately 4% (1.6 million) of those 37.3 million people ages 65 and older lived in a nursing facility in that year alone.¹

This expanding nursing home population has brought issues of the quality of nursing home care to the forefront, especially the issue of elder abuse. Forty-four states and the District of Columbia have laws designating certain professionals as mandatory reporters. Iowa is included and is the only state to require education for its mandatory reporters.³

Previous research that has concerned elder abuse in nursing homes has gathered information from nursing staff, administrators, and directors of nursing, demonstrating that abuse in the nursing home setting is common,⁴, ⁵, ⁶ with administrators and directors of nursing reporting 20.7 abusive events per 1000 nursing home residents.⁷, ⁸ However, there are more staff members that come into contact with residents than just the nursing staff, administrators, and directors of nursing. These employees are also considered to be mandatory reporters according to Iowa Code 235B.3, which states that “a mandatory reporter includes any member of the staff or employee of a public or private health care facility as defined in section 135C.1.”

A review of the literature found that perceptions from all of the employees in a nursing facility on the subject of mandatory reporting of elder abuse have not been widely explored. The purposes of this research are twofold; one quantitative and the other qualitative: (1) to learn about nursing home employees' knowledge and perspectives on mandatory reporting of adult abuse and (2) to determine the themes that represent the perceptions of nursing home employees about mandatory reporting of elder abuse in Iowa.

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Methods 

Two nursing facilities, one in western and one in eastern Iowa, were contacted and the administrators were asked permission to conduct this research. Facilities were known to the researchers, which facilitated cooperation by the nursing home administrators. Names and addresses of all facility employees were sought to begin the project. After University of Iowa Institutional Review Board approval, packets were mailed to each employee's home address that included a cover letter, a questionnaire, a postage-paid envelope for the questionnaire return, an interview consent form, a postage-paid envelope for the consent form return, and a list of interview questions. Employees were assured their responses would remain anonymous. Facility 1 had 178 employees and Facility 2 had 157 employees at the time of the mailing. Five envelopes were returned for incorrect address and then given to the respective human resources director for delivery to those employees.

Information about each nursing home was obtained through the Medicare Nursing Home Compare Web site and also through both facilities' human resources directors. Both nursing facilities are Medicare and Medicaid participants, not for profit, and have approximately 240 and 280 residents, respectively, between skilled nursing, assisted living, and independent living apartments.⁹ Further information about each facility is not provided to maintain anonymity.

Mandatory education for dependent adult abuse is required in Iowa and is provided by each facility. Employees are required to attend an education session within 6 months of being hired and every 5 years thereafter. The content of the education session includes prevalence of abuse, definitions, indicators, recognizing abuse, reporting requirements and procedures, assessment protocol, mandatory reporter classifications, legal rights and responsibilities, victim relations, intervention, prevention, and resources. The education mandate is by state law and is the same at each facility.

Instruments 

Two instruments were used for this project: a questionnaire entitled “The Nursing Home Questionnaire” and an interview form with 11 open-ended questions.

The “Nursing Home Questionnaire” that was sent is based on an elder abuse questionnaire that was sent to physicians and nurses in Alabama.¹⁰ The questionnaire was revised for nursing home employees and for Iowa laws.¹¹ The questionnaire included 28 items: 5 questions asked for demographic data (age, gender, race, level of education, and position of employment), 5 questions on personal experiences with suspected adult abuse and reporting, and 17 questions inquired about laws, facility protocols, and opinions on mandatory reporting. Participants were advised in the cover letter that they could leave questions blank if they did not want to answer them. The final question inquired about the employees' willingness to participate in a 15-minute interview about elder abuse. The employees were informed that the return of the questionnaire indicated their willingness to participate in that portion of the project.

The interview questions were adapted to fit nursing home employees from an interview guide developed by Rodriguez and colleagues.¹² Eleven open-ended questions were designed to allow employees to discuss their understanding and opinions of mandatory reporting of elder abuse. The employees were asked to sign a consent form indicating their willingness to participate in the interview and were contacted by the interviewer to set up an interview at the facility. The interviews were approximately 15 minutes in length and were conducted in a private room at each facility. Before the interview began the employees were asked if the interview could be recorded; they were reminded that they should not include any identifying information about themselves, coworkers, or residents.

Two return envelopes were included in the mailing: one envelope for the questionnaire and one for the participation form for an interview. Questionnaires and participation forms were received in separate envelopes. It is unknown if the person completing the questionnaire was interviewed or if the person completing the interview returned a questionnaire.

Data Analyses 

Analyses included both quantitative and qualitative methods. Data from the questionnaires were coded and entered into SPSS (SPSS for Windows, SPSS, Inc., Chicago, IL) where descriptive analysis was carried out for the questionnaire responses. Fisher's Exact tests were conducted to compare questionnaire responses between the 2 nursing homes, respondents who have seen abuse and those who have not, and 2 different job category groups.

Two categories were created for job positions: the nursing and administrative staff in group 1 and all other staff in group 2. Nursing staff was defined as certified nursing assistants (CNAs), certified medication aides, licensed practical nurses, and registered nurses. Administrative staff included administrators, human resources directors, social workers, and an in-service coordinator. Nursing and administrative staff were grouped together for this analysis because they are the employees who have been queried for this type of research in the past. They are also the employees who have the most one-on-one interaction with the residents and the administrative staff is heavily involved in the reporting process. Group 2 included maintenance, activities, dietary, transportation, and all other job categories that did not fit in the nursing or administrative staff category. Group 2 has not been queried in past research directly regarding elder abuse.

Interviews were coded by 1 investigator using N'Vivo, a qualitative software program, and themes were chosen based on the coding. Two thirds of the interviews were coded by the other 2 investigators and the 3 team members then agreed on the themes that were coded.

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Results 

Forty-nine employees returned the questionnaire, 21(12%) from Facility 1 and 28 (18%) from Facility 2, yielding a response rate of 15%, a nonsignificant difference in response rates. Overall, ages of survey participants ranged between 18 and 71 with a mean of 45 years of age. The majority of respondents were white (89.4%) and female (83%) with the majority (79%) having some college experience or having graduated from college. No significant differences in reporting abuse were noted for all participant demographic characteristics. More abuse was suspected by group 1 employees than by group 2 (Table 1). Information was not gathered on nonrespondents. Twenty-two (7%) employees agreed to participate in the interview, 10 from Facility 1 and 12 from Facility 2.

Table 1. Demographic Characteristics of Total Survey Respondents and of Those Who Suspect Abuse^⁎

Demographic Category	Total Respondents N (%)	Respondents Who Suspected Abuse N (%)
Age group, n = 48
18–45	25(52.1)	15(60)
46–71	23(47.9)	10(43.5)
Gender
Male	9(18.4)	2(22.2)
Female	40(81.6)	24(60.0)
Race
White	44(89.8)	22(50)
Non-white	5(10.2)	4(80)
Education
Some HS or HS graduate	10(20.4)	5(50)
Some college or College graduate	39(79.6)	21(53.8)
Position
Nursing & administrative staff (Group 1)	29(59.2)	22(75.9)†
Other staff (Group II)	20(40.8)	4(20)

Survey Results 

Fifty-three percent of the respondents reported that they have suspected a case of elder abuse in their current facility; 35% of those respondents indicated that they did not report all the cases of abuse they have suspected. Most of the respondents answered correctly the questions about reporting abuse (#7) and consent not necessary for reporting (#10) according to the Iowa law (Iowa Code Ann. §235B.1) (Table 2). Opinions varied about other aspects of reporting abuse, such as whether mandatory reporting is effective in dealing with the abuse problem (#16) (Table 2). There were no significant differences in the responses between employees from the 2 nursing homes.

Table 2. Respondents' Knowledge and Perception of Elder Abuse and Its Legislation^⁎

Questions	Answer Choices
	Yes	No	Unsure
	N (%)	N (%)	N (%)
1. Are you familiar with the laws pertaining to elder abuse in the state of Iowa?	48(98.0)	0(0)	1(2.0)
2. Do you have a written protocol for the reporting of elder abuse in your facility?	45(91.8)	0(0)	4(8.2)
3. Do you know to whom you should report cases of elder abuse?	49(100)	0(0)	0(0)
4. Do you attend mandatory education training for mandatory dependent adult reporters?	4(98.0)	0(0)	1(2.0)
5. Was it helpful for you to attend the mandatory dependent adult abuse training session? (n = 48)	46(95.8)	1(2.1)	1(2.1)
6. Do you think that reporting an elder abuse case benefits the person being abused?	46(93.9)	0(0)	3(6.1)

	True	Uncertain	Not True
7. Reporting elder abuse is not my responsibility.	0(0)	0(0)	49(100)
8. I am protected from litigation if I report unfounded cases of elder abuse. (n = 48)	33(68.8)	13(27.1)	2(4.1)
9. I believe that if I do report adult abuse, my identity will eventually be disclosed. (n = 48)	6(12.5)	19(39.6)	23(47.9)
10. The abuse victim must consent before a report of abuse is made. (n = 48)	1(2.1)	1(2.1)	46(95.8)
11. Very few older adults are abused or neglected in nursing homes.	6(12.2)	19(38.8)	24(49.0)
12. There are clear-cut definitions of elder abuse/mistreatment.	30(61.2)	5(10.2)	14(28.6)
13. Iowa has sufficient resources to meet the needs of mistreated elders. (n = 47)	14(29.8)	22(46.8)	11(23.4)
14. Prompt action will be taken if I report elder abuse. (n = 48)	32(66.7)	12(25.0)	4(8.3)
15. Reporting of elder mistreatment is a violation of the victim's rights.	4(8.2)	0(0)	45(91.8)
16. Mandatory reporting of suspected elder abuse is effective in dealing with the problem.	33(67.3)	11(22.4)	5(10.2)

Bolded response indicates correct answer.

When comparing the 2 job category groups, it was found that a higher percentage of group 1 employees had witnessed each type of abuse, with financial exploitation and neglect being seen significantly more by group 1. No employees from either category reported witnessing sexual abuse, but did report seeing the other abuse types (Table 3). The 2 job categories were also compared based on answers to the survey question about prompt action being taken once a report is made. The majority (85%) of group 2 employees responded that they believe prompt action will be taken once an elder abuse report is made, while only 53.6% of the members of group 1 agree (P = .031).

Table 3. Comparison of Groups Witnessing Abuse by Type in the Nursing Home

Type of Abuse Seen	Nursing and Administrative Staff Who Have Seen Abuse, n (%)	Other Staff Members Who Have Seen Abuse, n (%)	P Value⁎
Physical abuse	6(21.4)	2(10)	.440
Sexual abuse	0(0)	0(0)
Emotional abuse	9(32.1)	2(10)	.092
Neglect	9(32.1)	1(5)	.031
Financial exploitation	8(28.6)	0(0)	.014

The answer to this same question on prompt action was analyzed between employees who have suspected abuse and those who have not suspected abuse. Only 48% of employees who suspected abuse in the past believe prompt action will be taken if they report suspected abuse, while the majority (87%) of employees who had not suspected abuse believe their reports lead to prompt action (P = .006). Four respondents (17.4%) who had not suspected abuse in the past were unsure of the existence of a protocol for their facility, while all of the respondents who have suspected abuse in the past were aware of their facility's protocol (P = .042).

Interview Results 

After analyzing the interviews 4 themes emerged, including the need for more staff education/training on the subject of elder abuse; difficulty in making judgments about whether the situation needs to be reported or not; barriers to reporting; and a sense that some abuse situations may occur because the staff is overworked, inexperienced, and/or frustrated from dealing with difficult residents (Table 4).

Table 4. Quotations from Interviews by Theme

Theme	Job Title of Interviewee	Quote
Education/training	In-service coordinator	“And then what could be done to improve is giving more examples of dependent adult abuse. Not the broad examples in the current curriculum. Give me something that I may encounter just in every day working, that I might think I'm doing the right thing but it's not. Those fine line kind of things. Or other things that I might not think about that would be dependent adult abuse.”
	Activities staff	“Maybe if someone from the State came in. Everybody really respects State. They know…they're like ‘State’…they're the ones that get us in trouble. Maybe if someone from State did a mini in-service and said what exactly the steps were. You know, people might take that really seriously and realize that it is serious.”
Stress/frustration	Licensed practical nurse	“I've seen situations where I need to tell somebody to step out, step away and cool off for 5 minutes. Things on a smaller scale, nothing that would be consider abuse. People get frustrated…you can only get hit so many times.”
	Registered nurse	“I think that there are lots of times that staff get frustrated or have a bad day. They need the chance to just walk away. I think that people could always have more training. Staff needs more training on understanding and dealing with residents who have dementia.”
Barriers to reporting	Administrator	“The unfortunate thing is that in Iowa when the Department of Inspections and Appeals comes out to investigate possible abuse situations they look at a lot of other things. If they can't nail you on the abuse situation then they'll look for something else. It's almost like they're trying to justify their job. I think very rarely have I called the state to come out and investigate an abuse situation where the facility didn't end up with some kind of deficiency. Even in an abuse situation where they can't find enough evidence that it occurred or they decide that it didn't occur they will look for something else.”
	Transportation staff	“Retaliation probably. Or I think some of them would say it's not their business to step up and say something like that. Or they don't always want to get involved with it and they just don't want to mess with it.”
Suspicion/judgment	Activities staff	“Probably that some people may be afraid that they perceived it wrong. That it wasn't abuse and they might second guess themselves. If it's somebody they work with and they are friends with that person I could see them not wanting to report their friends. If they perceived it as not really hurting the resident. I think there are probably different levels of severity where somebody would try to talk themselves out of reporting it. And I think there are certain things that would be obvious and you would have to report it no matter what. I think that those things can stop people.”
	Social worker	“I feel like the more information you have…sometimes there are situations that seem really, really gray or you weren't personally part of witnessing what might have happened. I know it's not our purpose to determine whether or not something actually took place, but to report and then that can be determined later. But I think that there are times where people are deciding whether or not it's reportable. That can be hard for some people to figure out. So I think that for people who don't do it very often or the fact they have never done it before, it's good for them to talk to a supervisor about it…but yet to encourage people to call directly if they feel that it's necessary.”

The most common type of abuse participants discussed when asked, “Tell me about the kinds of elder abuse that might be encountered in the nursing home setting” were physical and verbal abuse. Less than half of the participants mentioned sexual abuse or financial exploitation. Of those who did, most were people who are involved in training other employees on the topic of dependent adult abuse. About half of the participants identified neglect as a possible type of abuse that might occur. One person mentioned that self-neglect is the only type of abuse that does not occur in the nursing home setting.

All the participants knew they were to report abuse and where to report in their institution and at the state level. The protocol for reporting in both of the nursing homes requires that the employee report to their direct supervisor, the charge nurse, the director of nursing, the administrator, and the Department of Inspections and Appeals (DIA); the state agency responsible for investigating nursing home abuse reports. All of the participants felt the protocol for their facility was adequate (see Appendix 1 for a Sample Protocol).

Eleven of the 22 participants mentioned a need for more education and expanded training. Employees expressed the need to have the dependent adult abuse class more frequently and to include better, real-life examples of abusive situations (Table 4).

Thirteen of the participants discussed reasons why it may be difficult for employees to decide to make a report. They expressed concern with the “gray areas” where it is difficult to decide whether a situation is severe enough to qualify as abuse or whether they perceived it in the correct way or in the correct context. Six of these 13 people were among those who mentioned a need for more education regarding abuse.

Half of the participants discussed how issues like frustration from dealing with difficult residents and fatigue from being overworked might lead to situations of “rough handling” and verbal abuse. Eight employees mentioned that they see people get frustrated when dealing with difficult residents, especially residents with dementia. Three participants mentioned that staff members need to have the ability to take a “time-out.” There were also 2 participants, an administrator and a CNA, from the same facility who expressed their concern about the young age and inexperience of staff.

When asked why they think nursing home employees might not report abuse, all of the participants mentioned that there is a fear of reporting. Seventeen of the 22 participants explained how they thought employees might not report abuse because of fear of retaliation from coworkers and even from employers. There is a sense among some of the employees that anonymity will not be maintained; therefore, their names will be told to other employees and they will be retaliated against for making the report. Other reasons discussed were that people are afraid of the DIA and they also don't want to “tell” on their friends or coworkers. Three members of the administrative staff discussed the staff's overall fear of DIA. The administrator of one facility stated that he doesn't like the fact that staff who are not well educated are required to be mandatory reporters. In his opinion the staff should report suspected abuse to administration first so that there can be an internal investigation to determine if the situation needs to be reported to state. Some situations, he felt, are in a gray area or may be misconstrued and need to be discussed internally first before a report to DIA is made.

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Discussion 

Of the respondents surveyed, 53% admitted suspicions of abuse but only 35% surveyed reported abuse, suggesting abuse is underreported even in a state with mandatory reporting. The interviews suggest that reasons for underreporting may include the feeling that they are not qualified to judge an abusive situation, or fear of retaliation following the report. Staff expressed the need for better training and better, more clear-cut definitions of abuse, which is quite interesting considering that Iowa is the only state that requires training for its mandatory reporters.

There is also hesitance by employees to report a suspected case of abuse before doing some personal investigation. Employees feel they need to understand the context of a situation before making a report. There is a sense that the majority of abuse situations occur because staff are inexperienced in dealing with difficult residents, such as those with dementia. This can lead to situations where staff get frustrated and may handle a patient roughly or speak to the patient in an abusive tone.

The results of the quantitative analysis show that most cases of abuse reported from the respondents are seen by nursing and administrative staff. The staff members who witness abuse stated that they are not confident that prompt action will be taken once they report abuse. Many staff members do not feel comfortable communicating with the DIA. Personnel from the DIA are viewed as part of a government agency that comes to the facility to investigate an abuse report, but also are looking for deficiencies within the facility.

Although this study identifies several issues that nursing home employees face, all of the interview participants expressed their dedication to the residents in their care. All reported that they would report any suspected abuse. This study may not be representative of the people who do not report abuse since they are most likely to not participate in a study on this particular topic.

A limitation of this study is the low response rate; however, it is not uncommon for nursing home questionnaire response rates to be low, especially because of the nature of the topic.¹³, ¹⁴, ¹⁵ Some studies done on the subject of elder abuse have yielded higher response rates, but they included follow-up methods.⁷, ¹¹ These earlier studies were not directed to the target population of this study; one study was done involving administrators and directors of nursing and the other physicians. The planned mailing at only one time with no follow-up was intentional because of the sensitive nature of the information solicited. Another concern was that nursing home administrators had given employees' names and home addresses to the researchers and we did not want employees to fear their employment could be in jeopardy by either choosing to participate or choosing not to participate in this study.

This study's participants were primarily Caucasian and about 80% had some college education. Generalizability may not be relevant for nursing facilities that have a different staff race and educational mix. Also, the facilities were both continuing care facilities, which may be different from skilled or intermediate care facilities.

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Conclusion 

Even with required education and training, nursing home employees who are suspicious of abuse are reluctant to follow the law and report their suspicions. Staff did have good knowledge of elder abuse reporting requirements. Knowledge may not necessarily translate into action of reporting abuse when it is suspected, as in 35% of our responders. Improving the educational process regarding elder abuse reporting and establishing a separate investigating entity other than the nursing home licensing agency may improve the likelihood that abuse in nursing homes will be reported.

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Appendix 1 

Example Protocol 

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References 

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