Recognizing Abuse: An Assessment Tool for Nurses

Michael Davies

This chapter is intended principally, but not exclusively, for nurses, both hospital and community-based. It will explore the implications associated with elder abuse from this perspective. It will also incorporate the development of an assessment tool, which could help all health care professionals to recognize early signs and actual incidences of abuse in elderly people.
Specific reference to community psychiatric nurses and social workers will not be made, as strategies for their intervention are explored elsewhere in this volume. However, it is hoped that the possible outcomes highlighted could well be adapted for use by others in the field, and including practice nurses, when carrying out their screening role of the over-75s, which now forms part of the new General Practitioners (GP) contract in Britain.

A cause for concern?

There is no doubt that the abuse of elderly people occurs both in the community and in health care institutions. This chapter will look at the evidence regarding the prevalence of abuse in hospitals and elderly care units. In so doing, it is hoped that a measurement can be ascertained concerning the overall existence and identification of abuse in all areas of health care where nurses are involved.
Nurses, whether based in hospital or in the community, are in an ideal position to identify possible abuse. However, to be able to carry out this role, they will need specific education, training and guidance to heighten their awareness:

The abuse of vulnerable elderly people is usually assumed to be either physical or psychological ill treatment by unpaid carers – most frequently by members of the victim’s family. However, it is not necessarily confined to those living at home, in the community. Deliberate ill treatment may also involve paid staff (Age Concern England, 1986: 35).

Perhaps the best-known exposé for nursing staff is the book Sans Everything: A Case to Answer in which Robb (1967) exposed the frightening conditions endured by patients in some state psychiatric institutions, in the hope of raising public and professional awareness of the need for reform. Robb concentrated on the conditions within the geriatric and psychiatric wards and, for a while, some improvements were perceived, but several inquiry reports have followed (see Chapter 1), often instigated by distraught relatives and occasionally by staff.
A. King’s Fund report (Glouberman, 1990) further compounds this evidence. Twelve monologues were selected from 60 interviews with workers from 27 different institutions, including prisons, long-stay hospitals, a long-stay geriatric unit, wards for mentally handicapped adults and so on. This should perhaps be compulsory reading material for policy-makers, particularly in the light of the impending community care reforms in Britain.
What is not so obvious, possibly due to the preoccupation with large psychiatric establishments and their gradual reduction in size and eventual closure, is the amount of possible abuse occurring in those hospital wards caring for elderly patients, either in purpose-built units or in the large Victorian establishments scattered around the majority of health districts and National Health Service (NHS) Trusts. This does not, of course, preclude the need to question the possibility of abuse in other health care settings, specifically in the so-called acute care wards, and in medicine, surgery, orthopedics, etc.

Old people today make greater use of hospitals than ever before. Roughly half of all occupied hospital beds are used by people aged 65 and over; nearly a third of such beds are occupied by people over 75. Departments of Geriatric Medicine and the Psychiatry of Old Age contribute massively to the hospital care of older people, particularly those over 75, and have special knowledge of their needs. But to be able to look after older patients effectively is now a need in virtually every hospital ward and department. (Royal College of Nursing. 1987:5)

There is, therefore, an urgent need to develop educations/training programs which may, in the long term, help to change a negative approach to nursing and/or caring for elderly people. “Being a nurse or social worker, does not in itself create a immunity against being an abuser, neither does it prevent the possibility that, as we become older, and perhaps dependent on our own adult children, we too may become victims” (Eastman, 1988: 16).

Attitudes towards elderly people

The way that older people are perceived can be important indicators of care-giving.

There is a prevalence of ageist attitudes and inherent in such attitudes is the denigration of older people, where they are regarded as less than fully human and therefore not deserving of equal respect. This may be exacerbated by their mental frailty, by their neglected appearance, or by sensory defects, for example, dearness or some other impairment. (Stevenson, 1989: 23)

The vast majority of patients admitted for care into our hospitals and elderly care units are in a poor state of health, whether physically, psychologically or socially, but very often due to all three factors. The majority are especially prone to multiple losses, which is associated with the gradual process of ageing as Green (1985) describes. Loss of:

income
body function
health
independence and home
sexual attraction
company (spouse, friends, pets)
life

and in addition, reduced mobility, physical handicap and often the living bereavement of dementia. Demographic trends indicate that the flow of these particular patients will probably increase. However, the quality of life that these people can expect is not guaranteed, and the provision for their care will still be, on the whole, hospital-based, as the services they require are not adequately provided for in the community.
The general attitude towards elderly people, particularly in the health care setting, is invariably a negative one. This view is held by staff working within such units, as well as by those outside. These negative attitudes are brought about by:

perceived dead-end professional progression;
low-level staffing and inappropriate skill mix, causing staff constantly to choose procedures of care, which are sometimes incompatible with the ideal of good practice or their Code of Professional Conduct;
finances perceived as always going to the high tech areas, at the expense of elderly care;
low sponsorship potential.

Student nurses have no more positive attitudes towards elderly people than secondary school pupils (Hope, 1992). General practitioners may present in a similar way:

Does your heart sink when the request comes in for a visit to an 80-year old patient with dizzy spells? On your way in the car do you have a mental picture of a confused, deaf, octogenarian with multiple pathology and chronic disease? Do your expectations make you ageist? (Grace, 1991: Il)

Grace goes on to say that, although one may dislike the word, it is clear that ‘ageism’ exists and that it has important consequences in health care, particularly in a world of finite medical resources. Dangers arise, however, when age assumes an inappropriate importance in decision-making, to the detriment of the patient and therapeutic options are withheld. This is a serious issue that will become increasingly apparent as the population ages, especially if the National Health Service continues to move in the direction of the market place. Hope (1992) argues that the negative attitudes of students are a prime factor in the delivery of sub-standard care and that society has allowed sub-standard services to become the norm for this client group. We are now reaping the consequences, having to deal with problems that should never have arisen.

Ageist attitudes, it is argued, are a contributory factor in cases of abuse.

As elderly people lose mental and physical capacities they are marginalized by society and by individuals and looked upon with contempt. They may come to accept this low evaluation of themselves and learn to be helpless. When people are considered to be of little value to society there will be less restraint on treating them with abuse and neglect. (Johnson et al., 1985, citing Block and Sinnott, 1979).

In hospital, in many instances the specialty of geriatrics, elderly care or elderly mentally infirm, still retains a poor image. ‘Geriatric medicine is a second-rate specialty, looking after third rate patients, in fourth rate facilities’ (Lye, 1982: 129). Although one might feel this to be an overstatement, and in several places to be outdated, there is little doubt that attitudes to nursing elderly people are still negative and are seen by many young, as well as mature, nursing staff as being less than glamorous and certainly not their first choice of elective placement.

The way forward

The importance of raising the profile of the care of elderly people cannot be over-emphasized; but professional education alone does not provide the panacea, changes in social attitudes are also required.
Patients’ quality of life is closely associated with that of the staff who share with them the human need for recognition of worth and for self-esteem. All staff working with elderly people need to be skilled and confident and should be given every opportunity to initiate better methods of care and ways of working.
Supporting patients with their family and friends to come to terms with irreversible disability, or to accept death, can be rewarding. Staff need to understand and believe in what they are doing and above all to know that their contribution is valued. Staff also have a right to effective management and leadership, an efficient communication system, a meaningful working environment and continuing professional education opportunities.
Caring for elderly people, though rewarding, is nevertheless physically and emotionally demanding. Professional carers are under ever-increasing pressure in their daily work. At times, they all may feel anger, frustration and hostility. We should realize that this is a natural response to pressure.

[But] What is totally unacceptable is to vent those feelings on those in our care. The dependent elderly in hospital are often unpopular patients. They demand a lot of nursing time and attention: the skills required to care for them are not seen as important or specialized. (Williams, 1989: 23).

Podnieks (1985) identified key areas which contributed to possible neglect and abuse of elderly people by staff as: negative attitudes towards ageing, a lack of understanding of the ageing process, inadequate staff preparation and opportunity for professional growth.
The basic education/training of nurses in the Project 2000 program has been under review and, it is to be hoped, will change radically in the next few years as more programs are designed and taught. But the Project has elected to keep elderly care nursing within the generic adult branch. Despite specific topics which must be addressed within the holistic approach to care of the individual, greater emphasis should be placed on the specialty of elderly care nursing.
Opportunities for qualified staff to attend English National Board post-basic courses on the care of elderly people must be made available. They are equally relevant to both specialist and generalist nurses. Care of elderly people demands skills which are of a very high standard. In all disciplines there is a continual need for further training, and it is vital for Health Authorities and NHS Trusts to allow time and finance for staff to attend course and study days.

Each unit needs to explore what provisions are made for:

newly appointed staff orientation programs;
continuous in-service education;
post-basic course, leading to certificate, diploma and degree.

We need to ask:

are all the multidisciplinary teams involved, including night staff?
are opportunities available for staff to share knowledge and skills and express feelings and attitudes in their day-to-day work?
are there adequate learning resources available?

(adapted from the Royal College of Nursing Project, 1987)

These educational innovations should involve all staff who have any dealings with elderly patients in any setting. Once implemented, they would begin to raise the profile of the nursing of elderly people.
Nurses are ideally placed to identify possible cases of elder abuse. However, to carry out this role they need training and guidance, as already said, particularly in interviewing and assessment skills. The approach should be multidisciplinary, involving social work, psychological, medical and nursing staff, both hospital and community-based. The involvement of other professions, such as occupational therapists and physiotherapists, could also be included. Together, they can form supportive teams to collaborate in producing a package of care for any elderly person who may be suspected of being at risk of abuse.

Assessment

The assessment tool will be primarily concerned with the identification of potential abuse of patients when they are admitted to hospital from their home or other residential setting, and how these indicators may be recognized by nursing staff.

Implications for Nursing Practice

The need to improve the detection and prevention of the abuse of elderly people has direct implications for nursing practice. Nurses need to be aware of the importance of a comprehensive nursing history. Meticulous attention, using the nursing process in identifying the elderly person’s individual needs and problems, should be employed to help nurses identify the elderly at risk. There is clearly also a need to formulate and implement a valid and reliable tool which will assist practitioners to detect neglect and abuse. This should be the focus of a sound knowledge of ‘high risk’ indicators and an awareness of the available support systems that can be used in the case of intervention.
Perhaps the biggest problem in assessing the extent of abuse is that the abused person is reluctant to report the incident for fear of retaliation (Ross, 1985). This could also account for the reluctance on the part of health care workers to report cases where they have witnessed abuse of elderly clients by their colleagues. However, the United Kingdom Central Council for Nursing’s Code of Professional Conduct (1984) leaves us in no doubt of our responsibility to our clients. The Code states that nurses should ‘act always in such a way as to promote and safeguard the well-being and interests of patients/clients’. If nurses are to maintain their role as the patient’s advocate, they must be willing to act to prevent abuse to one of the most vulnerable groups in our society.

Detection

Detection is often problematic because of the victim’s reluctance to admit that abuse is taking place. This may be because of pride, shame, fear, bewilderment or confusion, or because of heavy dependence on the abuser, blaming themselves for the situation.
The nurse’s assessment role in cases of physical abuse begins at the initial contact with the elderly person and continues with each subsequent interaction. During routine physical assessment, the nurse must be alert for clinical symptoms that are inconsistent with the information collected from the patient’s history. This becomes difficult when the elderly individual has cognitive defects and exhibits confusion and disorientation. In such cases it is advisable to locate the primary carer or, where appropriate, other workers who have been involved in the care of the patient, to confirm details. Often neighbors and relatives have additional information that may clarify the nature of the injury and its cause.
The nurse’s observational skills are paramount in all cases whether or not the patient’s mental state is functional or organic. Indicators of abuse should be considered in clusters because, although while not proving the existence of abuse, they certainly indicate a risk (see Chapter 2). Part of the detection process is the importance of observing if the ‘symptoms’ disappear in hospital or residential care and reappear at home or in cases of ‘respite admission’, when the patient is re-admitted. It is therefore essential that close liaison exists between the multidisciplinary elderly support group.
Signs of physical abuse and neglect are often not evident, and therefore the psychological and material features of abuse are not so easy to detect and there may be very little overt evidence to raise suspicion. However, nurses should be aware of possible indicators which may denote the presence of such abuse. These include:

undue anxiety or aggression displayed by the elderly person;
depression, helplessness, hopelessness;
fearfulness, ‘what are you going to do to me?’ or being left alone;
ribbons in hair, toys, baby talk;
cowering;
expression of ambivalent feeling towards family;
excessively tired, confused, experiencing insomnia, tearful;
unusual interest being shown by others in the elderly person’s possessions, especially money;
necessities not being provided by carers, for example, money for soap, sweets, newspapers, despite holding the pension/bank books;
patient being distressed by being ‘forced’ to sign unexplained documents etc.

In cases where these indicators are present, it would be advisable to involve other health care professionals, for example, district nurses, health visitors or social workers, where they have been involved in the care of the individual, as they will he in a better position to confirm any suspicions, having possibly observed relevant factors in the home/residential environment.

Carers

When nurses are carrying out their patients’ assessment, they need to be aware of the vital part that carers play. In any case where there may be reason to believe that abuse has taken place, the assessment must involve the primary carer(s). This must be conducted with great sensitivity. In cases that ‘appear’ to indicate neglect, it is important to assess the carer’s level of understanding, the resources that they have available to them and the elderly person’s willingness to accept care. Older people have the right to self-determination and may knowingly refuse the care necessary to sustain health. Many carers themselves are elderly and nurses have an obligation to ‘care for the carer’, as well as those being cared for. Many carers find themselves in an overburdened situation with other family and employment commitments making considerable demands upon their time, energy and loyalties.
It is important not to jump to conclusions that relatives are being cruel and heartless to frail old people. Old age abuse is a significant problem but it also includes the abuse of relatives by old people, perhaps using emotional blackmail and sometimes physical aggression effectively to keep the relative under control. Indeed we have come across probably more instances of the caring relative being attacked by the patient than vice-versa. (Matthews and Woods, 1980: 37).
Observing carers for signs of physical abuse will not be easy, as they too may well be reluctant to volunteer information, but nevertheless a carer assessment is important if we are to be in a position of building up a complete picture which could lead towards a resolution of the situation.
Perhaps the best indicator that all is not well with the carer will be signs of stress, but most carers will exhibit these signs, and the role of the nurse will be to attempt to measure the intensity of feeling associated with the common signals that might be expected. These could include:

frequent requests for help (self or patient), which includes admission to care;
aggression: frustration or despair often towards staff;
obvious signs of physical or mental illness, exhaustion;
non-visiting or telephone enquiry;
non-participation in discharge planning;
anxiety and worry, feeling isolated, lonely, low self-esteem, depression;
indifferent relationship with patient;
obvious alcohol/drug dependence;
over-critical regarding aspects of care towards patient.

A carer will often express a lack of time for self, of not being able to see an end to the situation and no future – that all has gone beyond control. These signals are not necessarily an indicator that abuse is/has taken place. But assessment and recording of these indicators are important pointers towards collating the most appropriate package of care for both the patient and the carer and may well help to stop an abuse situation occurring.
Precise, informed detection skills on the part of nurses, and the completion of the necessary assessment protocols, though perceived as lengthy and time-consuming, will provide definitive information regarding suspected cases of abuse. This in itself may be sufficient to instigate action or at least to alert medical colleagues to the need for further investigation.
The assessment protocols (Appendix 6.1 and 6.2), one for use with patients and the other for use with carers are designed to complement the existing history-taking documentation that exists within the nursing process procedure. Initially, both could be used in cases where abuse/neglect is suspected but, once adopted, they could in the long-term be incorporated within the documentation used during the ‘normal’ assessment of all elderly people admitted to hospital, thus performing universal screening mechanisms, including identification of possible abuse, as a matter of routine.

Training

Before attempting to implement these protocols, it will be essential for all staff to receive training and guidance in their use. This will ensure that staff are made aware of the specific terminology employed and that the assessment tools are used in a uniform and objective way. A glossary of terms, particularly for use with Appendix 6.2 might be helpful.
Elder abuse assessment protocol (Appendix 6.1)
If a nurse suspects that the patient is a victim of abuse or neglect, this assessment tool may be employed. The process may take several days to complete and should involve both day and night staff. Many of the more obvious ‘signals’ which may alert a nurse to the possibility of physical abuse will be observed during routine admission procedures. Examples of these are:

general appearance, nutritional stale, mental attitude, awareness;
condition of skin, ulcers, pressure sores, need for aids, dentures, hearing aid, glasses;
activities of daily living, including mobility.

Cognizance can be taken of these general areas during the physical examination, while accompanying the admitting doctor. Further observations can be made during either bed or general baths. The patient may well be reluctant to answer direct questions. They are more likely to respond to indirect conversation. Too many questions will often deter compliance.
Other aspects, for example psychological abuse, will need to be handled very sensitively and again may need to be carried out in several stages, once the nurse has gained the patient’s trust and confidence. Learner nurses may participate in this procedure, but they must be accompanied by a qualified practitioner, and the patient’s consent to the observer should be sought prior to the assessment.
Carer’s abuse assessment protocol (Appendix 6.2)
This is designed to be used to obtain indications of possible stress and its intensity. It could be used usefully to assess any carer where staff feel stress is apparent and need not only be used in cases of suspected abuse.
The assessment will need to be carried out in stages, in order to allow the carer to build up a sense of trust and confidence in the staff. The nurse’s approach needs to be supportive and at all times sensitive and never judgmental.

Valid assessment

‘People who ask questions must expect to be told lies’, whether deliberately, inadvertently or unconsciously. Clients are often ‘too close’ to evaluate their own needs and their ability to articulate may vary from day to day (Wilkin and Thompson, 1989).

Conclusion

It is reasonable to assume that elder abuse is a significant problem that nurses who work with old people can expect to encounter. They also face major problems when caring for the victims of elder abuse. As Ross (1985: 11) argues: “Knowledge on the topic is limited and nurses cannot locate quality research to guide their practice.” Furthermore, since elder abuse has only recently been identified as a family and social problem, there are few established resources, services and treatment programs available which can be used in an attempt to solve the problem. The data collection tools discussed here are intended to serve as a guide in the detection of neglect and abuse of elderly clients. But this can only be part of the process. However, they may alert nurses to a possible diagnosis of neglect and/or abuse.
Nurses should continue to make inroads towards becoming more sensitive and responsive to the issue of actual and potential abuse, by acknowledging that the problem does exist among elderly members of the population. They must be willing to ask difficult and sensitive questions surrounding the appearance of bruises, fractures or other untoward injuries to an elderly patient.

Appendix 6.1: Assessment Protocol for Elder Abuse

(adapted from Fulmer, 1984; Ross, 1985)

Initial guidance for use

Before attempting to carry out the assessment, reference should be made to the section on ‘detection’ above.
The assessment is meant to serve as a screening procedure and to document cases of suspicion of abuse or neglect. You are not asked to ‘rate’ any particular section but rather to use your powers of observation, instinct and ‘gut feeling’. Remember, seldom will you find isolated symptoms, but a ‘cluster’ of symptoms may give rise to suspicion, and should not be ignored. Any suspicion will need to be fully explained in the Assessor’s summary and general opinion’ section.
A tick (V) should be placed against the applicable description and, where appropriate, expanded upon in the summary section. For example, if you tick Physical Assessment I. Bruising: shoulders / left; color: purple/yellow 2’, in the summary section, you will need to expand, for example: bruise left shoulder, approximately 2’ in diameter, purple in center with yellow tinged edge.
In cases where the patient is not able to communicate or cooperate, this fact should be indicated in the summary.