Emotional Abuse of Older Adults by Nursing Home Staff: An Ecological Perspective

Lawrence B. Schiamberg Ph.D. Ji Hyun Lee MA Michigan State University

Levente von Heydrich Ph.D. Baker College

American Society on Aging (ASA)March 26, 2015

Acknowledgements This research was supported by a grant from the Centers for Medicaid/Medicare Service

# CFDA 93.778 to Michigan State University.

INTRODUCTIONEmpirical research on prevalence and risk factors of elder abuse in nursing home care, including emotional/psychological abuse is limited. Definition of the emotional/psychological abuse oA caregiver act carried out with the intention of causing psychological distress or

emotional pain; including treating an older adult disrespectfully or like a child, not allowing contact with family or friends, giving the silent treatment or not providing appropriate support when an older adult appears anxious, depressed, or fearful (NCEA definition).

This study presents the analysis of risk factors and incidence of emotional/psychological abuse of older adults in nursing home care using a random-digit-dial telephone survey of 452 adults with an elderly family member, ≥65 years, in a nursing home.

REVIEW OF RESEARCHPrevalence estimates and types of reporting nursing home abuse

Institutional reportingo The reporting of elder abuse in nursing homes has typically been accomplished through

institutional reporting, often in collaboration with Medicaid Fraud Control Units, Adult Protective Services (APS), law enforcement officials and, in some states, through long-term care ombudsman programs.

o The shortcomings of institutional reporting are the developmental status of the older adult, older adult fear of institutional retaliation, underestimates based on reports of institutional caregivers or police reports.

Family reporting of institutional elder abuse oThis study explores an alternative reporting methodological strategy involving the

estimation of prevalence and identification of risk from random-digit-dialing telephone interviews of an individual (typically a family member) who is “responsible” for the older adult nursing home resident (Hawes, 2002; Brandl et al., 2007).

REVIEW OF RESEARCH Selected/relatively recent research on conceptual models and self-report measures of psychological abuse Pioneering studies of Conrad, et al.(2011) in mapping conceptual clusters of

psychological abuse characteristics ( e.g. physical intimidation, isolation, insensitivity and disrespect) and levels of severity in predicting Psychological abuse.

Development of self report measures (Conrad et al., 2011)

REVIEW OF RESEARCH Risk factors

Promising theoretical perspectives for identifying risk factors of elder abuse in nursing homesoEcological framework, as originally applied to domestic abuse of older adults by adult

child caregivers (Schiamberg and Gans, 1998, 1999, 2000) oMore recently extended to elder abuse in nursing homes (Schiamberg, Barboza,

Oehmke, et al., 2011).

Contextual frames for institutional elder abuse oOlder adult/institutional caregiver relationship as the bi-focal and immediate context

for identifying and organizing risk factors, oAlso including distal contexts such as family-older adult relationships, family-

institution interactions, and the broader institutional environment (e.g. the relationship between nursing home residents, including resident-on-resident abuse).

METHODS: subjectsSurvey respondents The analytical sample (N=452) for this

study included respondents with relatives 65 years of age and older living in a nursing home, who answered questions about emotional/ psychological abuse.

Study respondents were overwhelmingly family members (97%), with an adult child being the most frequent category of family member (41.6%).

See table 1.

Table 1. Characteristics of respondentsVariable Frequency PercentageSpouse 34 7.5Sibling 29 6.4Child 188 41.6Parent 2 0.4Grandchild 67 14.8Daughter / Son-in-Law 34 7.5Niece / Nephew 31 6.9Mother /Father-in-Law 14 3.1Self 1 0.2Friend 7 1.5Other Relative 40 8.8Attorney 5 1.1TOTAL 452 100

METHODS: subjectsCharacteristics of the Older Adults (see Table 2) Demographics

o Some 73% of nursing home residents were females and almost two-thirds (64.8%) of all nursing home residents were widowed.

oNursing home residents whose relatives completed the questionnaire was largely Caucasian (91.4%).

Health/functional statuso Every resident suffered from at least one physical, cognitive, and psychiatric disability, and a

significant number had more than one disability or disease (e.g. 38% were diagnosed with Alzheimer’s disease and 78.8% suffered from one or multiple forms of cognitive illnesses).

oOver 83% of elderly nursing home residents suffered from one or multiple ADL limitations. oA significant proportion of nursing home residents (21.7%) exhibited behavior problems.

Table 2.Characteristics of older adults (nursing home residents)Variable Frequency Percentage

GenderMale 121 26.8Female 331 73.2

EthnicityCaucasian 413 91.4African American 29 6.4Asian American 1 0.2Hispanic / Latino 1 1.3Native American 1 0.2Middle Eastern 1 0.2Other 1 0.2

Education LevelNo formal schooling 3 0.7High school or less 324 85.8Bachelor degree or less 77 8.8Graduate degree 26 4.7

Marital StatusSingle-never-married 31 6.9Married 100 22.1Widowed 293 64.8Divorced 28 6.2

Variable Frequency Percentage

Age65 – 74 52 11.575 – 84 185 40.985+ 215 47.6

Health/Functional StatusAlzheimer’s Disease 169 38Psychiatric diagnoses 57 12.8Cognitive problems 354 78.8ADL limitations (at least one) 344 83.7Behavior problems 97 21.7

METHODS: measures and variables (Table 3) Immediate bi-focal context variables: older adult & institutional caregiver

Older adult demographic characteristicso age, gender, education

Older adult physical/performance factorsoADL/IADL limitations and dependencies

Older adult cognitive health factorsoDiagnosis of Alzheimer’s Disease, or cognitive impairments (e.g. dementia, memory problems,

mental confusion) Institutional Caregiver Abusive behaviors o Physical abuse (e.g. striking, hitting, pushing, slapping) o Sexual abuse (e.g. forced sexual contact, sexual coercion, unwanted touching) o Caretaking abuse/restraint (e.g. over-administration of drugs, unjustified forced feeding,

inappropriate use of physical restraints)

Distal contextual variables Resident-on-resident abuse (RRA), as an indicator of… o Institutional relationships of the older adult beyond the caregiver/older adult relationship oQuality of the institutional social climate

Outcome variable Incidents of emotional/psychological abuse

METHODS: measures and variables

PREDICTOR VARIABLES1. Older Adult/Caregiver ContextsOlder Adult Demographics Age (year) Age of the nursing home resident Gender Female=1 if the nursing home resident is female; Male=0 if nursing home resident is male

Education What is this person’s highest level of education: 1= No formal schooling, 2= First through 7 th grade, 3= 8th grade, 4= Some high school, 5= High school graduate, 6= Some college, 7= Four year college graduate , 8= Some graduate school, 9= Graduate degree.

Older Adult Cognitive Health

Dementia Has this person been diagnosed as having dementias; A binary variable taking the value of 1 if the respondent reported that the resident has “Dementia” and 0 otherwise.

Alzheimers Has this person been diagnosed as having Alzheimer's disease; A binary variable taking the value of 1 if the respondent reported that the resident has Alzheimer's disease, and 0 otherwise.

Older Adult Health and Behavior

ADL Limitations The number of ADLs (i.e., bathing, dressing, getting around inside, toileting, getting in or out of bed or a chair, and eating) that the nursing home resident cannot perform independently based on the family respondent’s report.

Caregiver Abusive Behaviors

Physical abuseLet's start with incidents of physical mistreatment by staff or other care givers such as striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, or burning: A binary variable taking the value of 1 if the respondent reported that the resident was “physically abused” and 0 otherwise.

Sexual abuse Now, we want to discuss incidents of sexual misconduct by staff or other care givers such as forced sex, sexual contact without consent, sexual coercion, and unwanted touching; A binary variable taking the value of 1 if the respondent reported that the resident was “sexually abused” and 0 otherwise.

Caretaking abuseNow, I am interested in other types of caretaking mistreatment by staff or caregivers such as over-administration of drugs, withholding or delaying of drugs, inappropriate use of physical restraints, unjustified force feeding, inappropriate toileting; A binary variable taking the value of 1 if the respondent reported that the resident was “caretaker abused” and 0 otherwise.

2. Distal ContextsBroader Institutional Climate: Resident Relationships in the Nursing Home

Resident-to-resident abuse (RRA)A binary variable was constructed to measure whether or not the nursing home resident was mistreated in the nursing home by an individual who was not a caregiver or member of the nursing home staff in the past 12 months (most probably another resident). The variable takes the value of 1 if there has been at least one such incident and 0 otherwise.

OUTCOME VARIABLE

Emotional Abuse A binary variable was constructed to measure whether or not the nursing home resident was emotionally/psychologically mistreated by a caregiver or member of the nursing home staff in the past 12 months. The variable takes the value of 1 if there has been at least one such incident and 0 otherwise.

Table 3. Descriptions of variables

SEM with LISREL modeling provided estimates of contextual risk factors contributing to emotional abuse, including:

1. Older adult resident characteristics: a)demographic factors (age, gender, education); b)behavioral/health factors (ADL/IADL limitations, cognitive health issues)

2. Older adult/staff relationship factors: other types of staff abuse (e.g. physical abuse, restraint abuse, and sexual abuse)

3. Contextual factors beyond the older adult resident/staff caregiver relationship: Resident-on-Resident Abuse

METHODS: analysis

ADL/ IADL

Cogni.Health

Staff Abuse

Non-Staff Abuse

Emot. Abuse

Age

Gender

Education

Y11

Y2 Y2

Y3

Y4

Y5

Y6

Y7

Y8

Y9Y10Y11

Y12Y12Y13Y14Y15Y16Y17Y18Y19Y20Y21

RESULTS AND DISCUSSION Incidence of emotional/psychological abuse

18.6% of the family member respondents reported that that their older adult relative experienced one or more incidents of emotional abuse by nursing home staff over the course of their residence.

The immediate bi-focal context: caregiver/older adult relationship Older adult resident characteristics: demographic variables of the nursing home resident such as

age (γ= -.005, t-value=-2.017, p=.044) and education level (γ= -.027, t-value= 1.99, p= .047) were strongly associated with emotional abuse of nursing home residents.

ImplicationsoNegative relationship of age to emotional abuse may reflect separation of progressively older

adults with provocative behaviors (e.g. Alzheimer’s victims) into separate units. o Relationship of education to emotional abuse may reflect a greater sensitivity to, and awareness

of, insulting or degrading situations.

RESULTS AND DISCUSSION The immediate bi-focal context: caregiver/older adult relationship

Older adult/staff relationship factors: Other forms of staff abuse (i.e. physical abuse, restraint abuse, and sexual abuse) (γ= .291, t-value=7.143, p<.000) were strongly associated with emotional abuse of nursing home residents.

Implicationso The contribution of staff behavior to emotional abuse is a particularly relevant factor in the quality

of the older resident/staff relationship which underlies negative outcomes such as abuse and positive outcomes.

Distal Contextual factors : Quality of resident-on-resident relationships A history of older adult victimization by other residents (RRA) is significantly correlated with staff

emotional/psychological abuse (γ=.179, t-value=4.132, p<.000). Implicationso Individuals who are chronic victims of abuse likely display some behaviors that may provoke

abusive responses, such as behavioral problems (e.g verbal or physical provocations) which may be common triggers for staff abuse (e.g. emotional abuse, as in this investigation) and resident-on-resident abuse (Barboza, Schiamberg, Oehmke, et al., 2011).

RESULTS AND DISCUSSION

Limitations of the Study Given that nursing home residents of Caucasian ancestry composed the main sample body (91%),

findings should not be taken as accurate reflections of experiences in more multicultural contexts.

While data collected in this study reflect the knowledge of family respondents about their older adult relatives in nursing homes, additional research is needed to compare the results of this study with research using other elder abuse reporting formats (e.g. institutional self report, criminal justice reports and government/ agency data collection).

Extensive data (beyond incidents of abusive behavior) was not collected on the characteristics and contexts of the institutional caregiver, which is an important dimension of the bi-focal older adult/institutional caregiver context.

RESULTS AND DISCUSSION

Conclusions and Policy RecommendationsIncreased attention to a contextual or ecological framework of nursing home abuse is essential.

Staff emotional/physical abuse in nursing homes occurs in the context of the delivery of caregiving efforts suggesting the value of focusing on the relational context of the older adult /institutional caregiver as an initial context for framing the key features of the relationship, including characteristics of the older adult and the staff caregiver.

Interactional contexts more distal to the older adult/ institutional caregiver relationship such as the institutional climate (measured here as resident-on-resident relationship) are essential to a full understanding of emotional/psychological abuse in nursing homes.

Finally, effective interventions for addressing staff emotional/psychological abuse in nursing homes are best informed by, and directed at, the multiple levels of the risk factors identified in this investigation, including those in immediate and more distal contexts.

ReferencesBarboza,G., Schiamberg,L., Oehmke,J., Korzeniewski,S., Post, L., and Hereaux,C. (2009). Individual Characteristics and the Multiple

Contexts of Adolescent Bullying: an ecological perspective. Journal of Youth and Adolescence 38, 101-121.

Brandl, B., Dyer, C.B., Heisler, C.J., Otto, J.M., Steigel, L.A., and Thomas, R.W. (2007). Elder Abuse Detection and Prevention. NY: Springer Publishing Company.

Donohue, W.A., Dibble, J.L., & Schiamberg, L.(2008). A social capital approach to the prevention of elder abuse. Journal of Elder Abuse and Neglect, vol. 20(1), 1-23.

Griffore, R., Barboza, G., Mastin, T., Oehmke, J. Schiamberg, L, & Post, L. (2009). Abuse in Michigan nursing homes. Journal of Elder Abuse and Neglect.

Hawes, C. (2002). Elder abuse in residential long-term care settings: what is known and what information is needed? In R. J. Bonnie and R. B. Wallage (Eds.), Elder mistreatment: abuse, neglect, and exploitation in an aging America. Washington, D.C.: National Academies Press.

Hawes, C., Blevins, D., & Shanley, L. (2001). Preventing Abuse and Neglect in Nursing Homes: The Role of the Nurse Aide Registries. Report to the Centers for Medicare and Medicaid Services. Texas A & M System, College Station Texas.

Schiamberg, L.B., Barboza, G.E.,Oehmke,J., Zhang,Z., Griffore, R., Weatherill,R. & Post, L.(2011, in press). Elder abuse in nursing homes: An ecological perspective, Journal of Elder Abuse and Neglect.

Schiamberg, L. & Gans, D. (2000). Elder abuse by adult children: An applied ecological framework for understanding contextual risk factors and the intergenerational character of quality of life. The International Journal of Aging and Human Development, 50(4), 329 - 359.

Schiamberg, L. & Gans, D. (1999). An ecological framework for contextual risk factors in elder abuse by adult children. Journal of Elder Abuse and Neglect,11(1), 79 - 105.

Schiamberg, L. & Gans, D. (1998). An ecological perspective to elder abuse by adult children. Paper presented at the World Conference on Family Violence, Singapore.

Workshop Discussion Questions/Top-ics

Self introduction of the workshop participants Current roles/positions

Interest in elder abuse

Incidence/prevalence/scenes of Emotional Abuse in nursing homes

o 18.6% of the family respondents reported that an older adult relative experienced one or more incidents of emotional abuse over the course of residence.

1. From your perspective as a professional in the field, do you think this rate is an accurate representation of your obser-vation of emotional abuse toward nursing home residents?

2. Could you describe specific context (location, time, activity, service types etc.) in the nursing home that emotional abuse is more likely to occur?

Workshop Discussion Questions/Top-ics

Predictors/risk factors of emotional abuse 1. Although this study found demographic characteristics of the resident as

a significant predictor of emotional abuse, do you feel that there are other characteristics of the resident that maybe relevant (e.g. behavioral problems, ADL/IADL dependencies)?

2. While other types of staff abuse (e.g. physical abuse, restraint abuse, and sexual abuse) were found to be significant predictors of emotional abuse, what other caregiver characteristics do you think might contrib-ute to emotional abuse?

3. Are you familiar with a type of resident-on-resident abuse (RRA) that might be characterized as resident bullying?

4. Do you think that resident-on-resident abuse could contribute to an in-stitutional culture of violence, if ignored or ineffectively controlled?

5. What are the contextual factors beyond the nursing home, including res-ident-family relationships and family-nursing home communication, that you consider relevant for both understanding and addressing emotional abuse?

Workshop Discussion Questions/Top-ics

Practical implications for interventions and policies

1. What are the current practices and policies for addressing elder abuse in nursing homes, including emotional abuse?

2. What are the strategies have you found to be most useful in ad-dressing this problem?

3. What are the institutional issues that need to be addressed in re-lation to reducing emotional abuse toward residents?

4. Is there a significant incorporation of the family of the residents in core caregiving decisions, including prevention of elder abuse?

5. What are the implications this research and your professional experiences for the training of nursing home staff?