“Care homes are understaffed, and the workers do not want to lose their jobs and/or be “black balled.” Mum and I witnessed as new eager workers with lovely dispositions started their employment. They had fresh ideas and wanted to do good for the families and residents and their employer and colleagues. Within literally a week or two, they had either left to try out another institution or had morphed to whatever extent they needed to in order to keep their job. Retaliation was swift and sure, and whistleblowers were not welcomed. It was a work culture of fear…” Daughter of a Canadian long-term care facility resident.
Frontline care workers are best positioned to identify and report neglect and abuse in long-term care facilities (LTCFs); they are the ones most frequently in close contact with residents. If care staff reported neglect and abuse, the issues could be addressed and the widespread mistreatment of elders in care could be reduced. One of the most obvious conundrums is that care workers, besides witnessing abuse and neglect, may also perpetrate it as hidden cameras planted by concerned family members have revealed time and again.
Here are some of the reasons care workers don’t report elder neglect and abuse in LTCFs:
1 ) Ignorance
Some care workers may not know what constitutes abuse. Long-time employees may not realize that previously approved practices are no longer acceptable. Newer employees may not be properly trained, and therefore lack understanding of what neglect and abuse are. In particular, workers may not know that, for example, speaking down to people who live with dementia, overmedicating them instead of meeting unmet needs, not providing them appropriate stimulation and activities, and other common practices are in fact considered abuse. If you can’t identify it, you certainly won’t be reporting it.
This ignorance extends beyond frontline staff; a 2009 systemic research review concluded that health and social care professionals in the United States “consistently underestimated the prevalence of elder abuse.”
On the other hand, many care workers clearly do understand what constitutes abuse and neglect. In a 2001 study, care workers identified twenty-five such practices. Normalization might be restated thus: “If everyone else does it, it must be okay,” and if something is “okay” there’s no need to report it. Over time, inappropriate behaviour, flawed procedures and poor practices become the norm, and when no one pauses to re-examine and re-evaluate we have what the military call SNAFU.
Consider these numbers:
A 1987 survey of 577 nursing home staff members from 31 facilities found that more than one-third (36 percent) had witnessed at least one incident of physical abuse during the preceding 12 months (Pillemer and Moore, 1989); and a total of 81 percent of the staff reported that they had observed and 40 percent had committed at least one incident of psychological abuse during the same 12-month period.
Ask yourself what’s wrong with this picture:
In 2000, the Atlanta Long-Term Care Ombudsman conducted a study in which it ninety-five percent of the residents who were interviewed reported that they had experienced neglect or witnessed other residents being neglected. Ninety-five percent!
Revisit this case that spanned thirteen years:
In 1999, a class action lawsuit detailing hundreds of cases of abuse was launched against the St-Charles Borromée hospital in Montreal. But it wasn’t until 2003, when family members of a patient there began secretly recording staff verbally and psychologically abusing their relative, that people began paying attention. The case was finally settled for 8.5 million in 2013.
Since then, little has changed:
In a 2015 report, the Canadian investigative journalism program W5 uncovered “at least 1,500 cases of staff-to-resident abuse and neglect in nursing homes across Canada in 2013. The program suggest the number of cases was likely higher “due to under-reporting of incidents.”
On October 20, 2016, a Canadian lawyer filed a statement of claim that raises 82 examples of neglect and abuse at a large North American eldercare provider.
The issues aren’t confined to Canada and the United States. A 2013 United Kingdom National Healthcare Services survey found that “one in three adults who are in residential care or receiving help at home fear abuse or physical harm – equivalent to about half a million people.”
3 ) Fear
Most people know that whistleblowers tend to be punished, not praised. Those workers who understand and witness neglect and abuse may not report it for fear of being censured, vilified, blamed, shunned by their co-workers or even of losing their jobs. They may be threatened and/or intimidated by supervisors, managers, administrators and/or facility owners who wish to maintain the status quo for various reasons including convenience or keeping costs down, or who simply don’t know what to do about it.
One former care worker shared this with me:
“As a former employee of long term care facilities my experience tells me there is a lack of education about elderly abuse within the health care facilities. I have reported abuse and lost my job – twice. It’s difficult to remain quiet…when you see something…say something!”
A novel three-year project to introduce an elder abuse policy in a long-term care facility in Quebec identified staff reluctance to report on their colleagues (who wants to snitch on someone they have to work with the next day?), and perceived lack of support from administration as major stumbling blocks. These and other observations were made in a Position Paper on Mandatory Reporting of Older Adult Victims of Abuse and Neglect in Residential Settings and presented to Quebec’s Minister of Health in 2014.
4 ) Privacy and confidentiality
Protective privacy laws in many jurisdictions are used to justify withholding important information with respect to an individual’s personal care. It’s ironic that instruments meant to protect them may in fact result in many elders being harmed by allowing neglect and abuse to remain hidden.
The Position Paper on Mandatory Reporting of Older Adult Victims of Abuse and Neglect in Residential Settings mentioned above concluded that “much needs to be done by the government (of Quebec) and by policymakers to stop and reduce the abuse and neglect experience by the most vulnerable people and our society.” The authors recommended that, among other things, “participants in the process should be exempt from restrictions of confidentiality.”
5 ) Complacency and cynicism
Advocates and pioneers tend to be outliers bucking the system, and systems are notoriously difficult to change. It takes vast reservoirs of courage and determination to maintain the levels of energy and commitment required to spark innovation let alone implement radical transformation. The stories and links above clearly show our eldercare systems and long-term care facilities are severely broken. Whistleblowers who speak out at great personal risk but to no avail may simply choose to give up.
6 ) A perpetrators’ paradise
While a good number of staff are compassionate and caring, the sad and sick truth is that LTCFs (and dementia care units in particular), are ideal stomping grounds for people who enjoy abusing the weak and vulnerable. Just as pedophiles enter the priesthood and other professions that make it easy to access victims while avoiding detection, elder abusers don’t want to report abuse, they want to continue abusing. That leaves it up to the rest of us to find out who the abusers are and to stop them. Not an easy task in the current UNcare environment where all five factors above are at work. I am not suggesting that LTCFs are crawling with serial abusers. But I think it’s important to be aware that the conditions are ideal for such perpetrators. On a related note, I think eldercare is extremely challenging work that is ill-suited to many who nevertheless remain employed in the field.
It’s time to take a closer look at the issue of elder abuse and neglect in long-term care facilities. The current state of affairs is completely unacceptable. We must educate, empower and encourage frontline staff to identify and report abuse and neglect whenever and wherever they see it. I also believe CCTV cameras should be required in long-term care facilities to protect both workers and residents moving forward. Change can’t come soon enough.
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