Elder Abuse: Ethics, Nursing Roles, and Prevention

Introduction: What Is Known About Elder Abuse

Elder abuse occurs at an alarming rate—around one million incidents a year, and perhaps more due to under-reporting and inconsistencies in defining what constitutes elder abuse (Falk, Baigis, & Kopac, 2012). Roberto (2016) estimates that as many as one in every ten American elders experiences some form of abuse. Unfortunately, "there is no uniform term or agreed-upon definition used among state governments, researchers, health care and service providers, and advocates" (Roberto, 2016, p. 302). Cultural and religious diversity further impedes the development of a comprehensive and universally applicable definition of elder abuse, in spite of the fact that some forms of abuse and certain instances can be considered unequivocal (Saghafi, Bahramnezhad, Poormollamirza, et al., 2019).

Some types of abuse may go undetected, such as financial abuse or identity theft, which could go unnoticed for years. Healthcare workers often feel powerless to intervene in instances of financial abuse perpetrated by family members, particularly when those family members are also primary caregivers, and there may be little or no legal recourse to investigate the problem (Falk, Baigis, & Kopac, 2012). Other than the fact that it is "highly prevalent," and is perpetrated by healthcare workers, caregivers, and other elders in assisted living and nursing home communities, not much is known about elder abuse because there are no established means of reporting it or assessing for risk factors (Lachs, Teresi, Ramirez, et al., 2016, p. 229).

Elder abuse encompasses various forms and degrees of physical, sexual, psychological, and financial abuse. It is also important to include self-neglect and general neglect as forms of elder abuse. Furthermore, both men and women can be victims and perpetrators, but research shows that men are by far more likely to be the perpetrators of sexual abuse against elders (Malmedal, Iversen, & Kilvik, 2015).

Ethical Dimensions of Elder Abuse

Why Is Elder Abuse an Ethical Issue?

On the surface, elder abuse appears to be a straightforward ethical issue. However, the different phenomena comprising elder abuse are far more complex than they first appear. Not all cases of elder abuse involve physical or sexual assault, or overt instances of verbal abuse and aggression. Financial abuse and psychological abuse vary in their severity; moreover, cultural differences may shape perceptions of what constitutes abuse. Competency creates ethical dilemmas, particularly when it comes to the decision-making capacity of elders experiencing cognitive decline and the legal role that family members play in healthcare decisions (Forum on Global Violence Prevention; Board on Global Health, 2014).

Healthcare workers and caregivers are not always the perpetrators of elder abuse. The fact that other residents of senior care facilities can be perpetrators of verbal, emotional, physical, and sexual abuse makes it even more challenging to respond to and identify elder abuse (Lachs, Teresi, Ramirez, et al., 2016). Nurses have a responsibility to protect their patients from abuse, but may encounter conflicts when they suspect family members, other residents, or colleagues are perpetrating some form of elder abuse. Misreading cues, misunderstanding cultural communication or elder care norms, and being overly intrusive into residents' affairs are also major challenges to preventing or mitigating elder abuse in healthcare institutions.

Sexual abuse is a surprisingly common form of elder abuse. In a review of literature by Malmedal, Iversen, & Kilvik (2015), findings "show that sexual abuse occurs in nursing homes and that both older women and men are victims of sexual abuse. Perpetrators appear mainly to be staff and other residents and mainly to be men, but also women abuse both older men and older women" (p. 7). Even sexual abuse, however, is not always easy to define, and matters related to mental competency serve as important mediating factors.

Relevance to Nursing and Health Professionals

Elder abuse is of extreme importance to all healthcare professionals, including those whose work does not otherwise focus on the geriatric population. An aging population and the growing numbers of seniors in healthcare institutions means that almost all health professionals will encounter elder abuse issues at some point in their careers. Elder abuse issues are of special concern to healthcare administrators and those working directly in elder care. For example, administrators and care providers in nursing homes, assisted living facilities, and home health care settings can be considered primary stakeholders.

Nurses and other care providers need a supportive workplace environment and organizational culture within which to effectively report elder abuse. Healthcare providers and administrators need improved reporting systems that offer staff the means to make anonymous reports or suggestions for internal investigations. The organizational culture and environmental factors of care settings can be designed in ways that minimize some forms of elder abuse. For instance, ensuring that patients have greater access to information and the outside world, and creating better means of monitoring patients and observing their interactions with other residents or healthcare workers, are ways administrators can reduce instances of elder abuse in their facilities.

Protocols may also allow healthcare workers to confront possible perpetrators—whether they are staff members, residents of the care facility, or family caregivers. Wangmo, Nordstrom, & Kressig (2017) recommend that healthcare institutions provide "proper education and training, better management of nursing care provider responsibilities and timely intervention to address abuse and neglect, as well as rotating care providers" (p. 385). Information booklets and workshops may also help residents, caregivers, and family members better understand how their actions could adversely affect elders, since some forms of abuse may be more unconscious or rooted in ignorance than in actual malice.

Due to situational variables and the cultural complexities surrounding elder abuse definitions, it would be impossible to create a fully standardized set of protocols for identifying and responding to reported incidents. At the same time, all suspected incidents should be taken seriously, given that elder abuse can lead to fatalities, litigation, and other severely harmful outcomes.

When it comes to financial abuse, competency can be assessed using established, evidence-based methods. One researcher developed a system for evaluating financial competency across four main domains: basic monetary skills, cash transaction competency, banking competency, and financial judgment (Forum on Global Violence Prevention; Board on Global Health, 2014). The capacity to live independently likewise presents care providers with the opportunity to develop checklists that allow for maximum independence and autonomy without enabling self-neglect. Elder abuse that takes place within care facilities can be easier to identify and address than elder abuse occurring in the home. Nurses and healthcare professionals—particularly home health aides—should be trained to recognize the signs and symptoms of various types of abuse, including psychological, physical, financial, and sexual abuse. Similarly, caregivers should be given information about how to identify those same signs and symptoms.

Conclusion

All healthcare workers need to become more aware of and concerned about elder abuse. Elder abuse is commonplace, but it frequently goes ignored or undetected. Some nurses or healthcare providers might worry that raising concerns about elder abuse infringes on the rights of the patient or caregivers, while others may fear losing their jobs by whistleblowing on a colleague. To reduce the severity and prevalence of elder abuse, all nurses can arm themselves with information about the laws that protect them and their patients. Likewise, nurses can empower patients with information about how to recognize abuse, helping patients understand and exercise their legal rights when necessary. Creating a supportive and safe environment in eldercare facilities, training personnel and caregivers, and remaining mindful of the various types of abuse—including financial abuse—will all be key components in reducing instances of elder abuse.

References

Falk, N. L., Baigis, J., & Kopac, C. (2012, August 14). Elder mistreatment and the Elder Justice Act. OJIN: The Online Journal of Issues in Nursing, 17(3).

Forum on Global Violence Prevention; Board on Global Health; Institute of Medicine; National Research Council. (2014). Ethical considerations. National Academies Press.

Lacher, S., Wettstein, A., Senn, O., et al. (2016). Types of abuse and risk factors associated with elder abuse. Swiss Medical Weekly, 146, 1–10.

Lachs, M. S., Teresi, J. A., Ramirez, M., et al. (2016). The prevalence of resident-to-resident elder mistreatment in nursing homes. Annals of Internal Medicine, 165(4), 229–236.

Malmedal, W., Iversen, M. H., & Kilvik, A. (2015). Sexual abuse of older nursing home residents: A literature review. Nursing Research and Practice, 2015(Article 902515). http://dx.doi.org/10.1155/2015/902515

Roberto, K. A. (2016). The complexities of elder abuse. American Psychologist, 71(4), 302–311.

Saghafi, A., Bahramnezhad, F., Poormollamirza, A., et al. (2019). Examining the ethical challenges in managing elder abuse: A systematic review. Journal of Medical Ethics and History of Medicine, 12.

Wangmo, T., Nordstrom, K., & Kressig, R. W. (2017). Preventing elder abuse and neglect in geriatric institutions: Solutions from nursing care providers. Geriatric Nursing, 38(5), 385–392.