Training course reduces abuse in nursing homes

Aging, Spring, 1996 by Beth Hudson Keller

In dealing with the problem of abuse and neglect in nursing homes, it's easy to assume that it is committed by staff people who don't care about their elderly clients or who have poor work attitudes. That's not the case. My own experience can illustrate this point: When I was a nurse aide during college, I worked the 3-11 shift, which is considered a stressful one since it includes everything from helping the residents with dinner to getting them ready for bed. I started out cheerful and patient. By the end, I was impatient and couldn't wait to get out. I'd be stuffing food down the mouth of a woman and thinking, "Aren't I efficient?" I wasn't even thinking about her. I was thinking about the five residents down the hall I had yet to feed. The reality of most abuse in long-term care facilities is that it's not committed by mean or malicious people who intend to harm anybody. It's most often committed as the result of difficult and stressful work situations.

Although abuse in the nursing home setting is widely documented, little attention has been given to developing training programs for staff on how to identify and defuse potentially abusive situations. In 1989, with a grant from the Retirement Research Foundation, the Coalition of Advocates for the Rights of the Infirm Elderly (CARIE) began to explore how the frustrations and difficulties nursing home staff faced in their dealings with residents related to abusive practices.

The study focused on aides as a result of two reports, both of which showed that aides have the greatest opportunity to reduce incidents of abuse and neglect. According to a 1990 study of 250 nursing homes undertaken by the Office of the Inspector General, the primary abusers of nursing home residents are nurse aides and orderlies who have never received stress training and who are working in nursing homes that show evidence of administrative problems, such as high staff turnover. The report recommended that these staff members receive ongoing training in the aging process and abuse awareness.

This study amplified an earlier one done by Karl Pilemer of Cornell University in 1989, which showed that abuse against residents of nursing homes was related to the perceived low job status of their primary caregivers, the attitude that residents are childlike and need disciplining at times, high levels of conflict and burnout on the part of the nursing home staff, and nurse aides who are dealing with stressful personal lives in addition to the demands of their work. Pilemer's recommended interventions included increased attention to the quality of interactions between residents and care aides and training in conflict resolution, stress reduction, and managing difficult care situations.

Using the wealth of practical day-to-day information furnished by its ombudsman program and the Philadelphia Elder Abuse Task Force, CARIE developed an innovative training course, "Ensuring An Abuse-Free Environment: A Learning Program for Staff." This 8-hour program is designed specifically for nurse aides in long-term care facilities. The curriculum not only educates about abuse but also provides opportunities to practice conflict intervention strategies through role-playing, case discussion, and small group work. The program, which can be administered in separate one-hour sessions, two four-hour sessions, or preferably in one day-long session, is built around the following modules:

* Identification and recognition of types of abuse. The six types of abuse and neglect: physical, psychological, and sexual abuse, financial exploitation, and active and passive neglect;

* Possible causes of abuse. Understanding how residents' behavioral problems and communication deficits may trigger negative reactions by caregivers;

* Understanding personal feelings of caregivers. Anger, fear, and stress are often associated with caring for impaired elderly. Staff need to be aware of the danger signs of burn-out and to have opportunities to manage their stress. This model has turned out to be the most valuable aspect of the training program. It gives caregivers the chance to explore their feelings about caregiving. Many nurse aides are dealing with incredible adversity in their personal lives as well as being caught between unsupportive administrators and difficult patients at work;

* Cultural and ethical perspectives. Differences between residents and staff can lead to conflict, but an awareness and understanding of resident and staff cultures and backgrounds can lead to enrichment for both;

* Abuse of staff by residents. Causes of resident anger that may lead to verbal or physical aggression. Aides learn that this lashing out is often caused by pain, low self-esteem, incontinence, the lack of family or other visitors, and the loss of hope. Nonviolent approaches to defusing anger and minimizing resident aggression are presented through roleplay and group discussions;

* Ethical and legal issues of reporting suspected abuse. Ethical responsibility for reporting abuse, along with pressures against reporting are discussed. Aides are familiarized with the ombudsman program and learn how to report abuse. Emphasis is placed on possible consequences of not reporting abuse;