418094 tle and BeachJournal of Applied Gerontology
JAG32210.1177/0733464811418094Cas
Article
Elder Abuse in Assisted Living
Journal of Applied Gerontology 32(2) 248–267 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464811418094 jag.sagepub.com
Nicholas Castle1 and Scott Beach1 Abstract Assisted Living (AL) currently represents one of the most numerous institutional care settings for elders. Very little information exists on abuse in AL. Descriptive information on elder abuse reported by nurse aides working in AL is presented from a survey sent to nurse aides. The questionnaire had items addressing verbal, physical, psychological, caregiving, medication, material, and sexual abuse. The responses to the questions included in the verbal abuse, physical abuse, psychological abuse, caregiving abuse, medication abuse, and material exploitation abuse sections (28 questions) show that suspected abuse is not uncommon. We could not objectively verify the cases of abuse described in the survey, still, they give a first indication that staff abuse may occur in AL. This may be significant given the large number of ALs in the United States and may influence the health, quality of life, and safety of many residents. Keywords abuse, assisted living, survey Assisted Living (AL) has experienced rapid growth over the past decade. An estimated 36,000 facilities exist in the United States with approximately 1 million residents (Assisted Living Federation of America [ALFA], 2009) compared with an estimated 17,000 nursing homes with approximately 1.5 million residents (National Nursing Home Survey; National Center for Health Statistics, 2004b). Elders living in AL may be particularly vulnerable to abuse because many suffer Manuscript received: February 11, 2011; final revision received: June 28, 2011; accepted: July 1, 2011. 1
University of Pittsburgh, Pittsburgh, PA, USA
Corresponding Author: Nicholas Castle, University of Pittsburgh, A610 Crabtree Hall, Pittsburgh, PA 15261, USA. Email: [email protected]
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from cognitive impairment, behavioral symptoms, or physical limitations—factors that have been reported as risk factors associated with elder abuse (Dyer, Connoly, & McFeeley, 2002; Pillemer, 1988). In this research, descriptive information on abuse (observed, second-hand, and suspected) by staff on elders living in AL is presented. AL consists of long-term care (LTC) settings that typically provide residents with support for activities of daily living (ADLs) and instrumental activities of daily living (IADLs; ALFA, 2009). Following the view of the American Medical Association (AMA, 1990), elder abuse was defined in this research as “an act of commission or omission that results in harm or threatened harm to the health or welfare of an older adult” (Stiles, Koren, & Walsh, 2002, p. 34). Moreover, based on a review of the abuse literature and interviews with AL caregivers, seven categories of elder abuse from staff were examined in this research (i.e., verbal, physical, psychological, caregiving, medication, material, and sexual abuse [definitions are given in Table 1]).
Prior Research Many scholars have acknowledged that little is known about resident abuse in long-term care settings (e.g., Cooper, Selwood, & Livingston, 2008). For example, a recent review of the literature identified only seven empirical studies addressing abuse in nursing homes (Lindbloom, Brandt, Hough, & Meadows, 2007). In this prior review, no empirical studies were identified examining elder abuse in AL. A few reported descriptive and observational statistics indicate that elder abuse may be an issue of concern in AL. Hawes (2002) has reported to Congress that in her data, 15% of staff had witnessed verbal abuse of AL residents. The long-term care ombudsman program (LTCOP) has reported that abuse in AL is commonly reported, but no figures were given (Administration on Aging [AoA], 2005). In addition, states have reported abuse statistics coming from licensing inspections. For example, in 2009 Pennsylvania reported that 8% (i.e., 116) of 1,441 complaints received and 6% (i.e., 1,231) of 20,550 incident reports were for resident abuse in AL (Pennsylvania Department of Public Welfare, 2010). A few authors have also presented the opinion that elder abuse may be problematic in these settings. One study concluded that “residents of assisted living facilities are poorly informed about protective services and uncertain about options if care were not optimal” (Wood & Stephens, 2003, p. 753). However, empirical evidence to substantiate issues regarding abuse were not provided. The paucity of information on abuse in AL led us to report information from this descriptive study. In addition, we believe there are several characteristics of
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Intentional infliction of anguish, pain, or distress through verbal interactions (Clarke & Pierson, 1999, p. 635) Acts done with the intention of causing physical pain or injury (Lachs & Pillemer, 2004, p. 1264) Acts done with the intention of causing emotional pain or injury (Lachs & Pillemer, 2004, p. 1264) Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness (Centers for Medicare & Medicaid Services, 2004, 42 C.F.R. §488.301) Elders purposely deprived of their correct medication or given inappropriate medication (Chambers, 1999, p. 80) The improper use of an older person’s assets (Rabiner, O’Keeffe, & Brown, 2006, p. 51) Nonconsenting sexual contact of any kind (National Center on Elder Abuse [NCEA], 1998, p. 1)
Verbal abuse from staff
Sexual abuse from staff
Material exploitation from staff
Medication abuse from staff
Caregiving abuse from staff
Psychological abuse from staff
Physical abuse from staff
Definition
Category of abuse
Have you seen any staff member pull the hair of a resident?
Pushing, grabbing, pinching, pulling hair, kicking, other physical violence Intimidation, aggressive behavior, threatening remarks, critical remarks Halting care, withholding food, withholding water
Unwelcome sexualized kissing, unwelcome fondling, unwelcome discussion of sexual activity, exposure of private body-parts, oral-genital contact, digital penetration, vaginal rape
Preventing access, excessive medications, delay in medications Taking possessions, taking assets
Have you heard any staff member curse at a resident?
Yelling, insulting remarks, cursing
Have seen a staff member delay giving meds to a resident on purpose? Have you seen a staff member take cash belonging to a resident? Have you seen a staff member involved in unwelcome discussion of sexual activity with a resident?
Have you seen any staff member not provide water to a resident on purpose?
Have you any staff member threaten a resident?
Example item
Specific areas examined
Table 1. Categories of Abuse Examined, Definitions, and Example Items.
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the AL industry (given below) that could potentially lead to situations of elder abuse. This augments the importance of this study.
Significance of Abuse in AL The AL industry is not regulated by federal legislation but is regulated by the states. State regulations, standards, and oversight are often designated to a Department of Health, Public Welfare, Aging, or Senior Services (Carlson, 2007; Hawes & Phillips, 2007). The scale and scope of regulations is highly variable across states; but for the most part, the industry does not have a high degree of oversight. In this relatively unregulated environment, AL has clearly flourished. Programs and services of value and importance to elders have developed. Not surprisingly, AL is favored by elders above other institutional long-term care settings (Carlson, 2007). Still, in this relatively unregulated environment, staffing levels and staff qualifications are thereby also often not precisely stipulated. This does not necessarily mean that staffing levels and staff qualifications are insufficient in all AL in all states. However, evidence would suggest that quality of care is not high in some facilities, and this includes problems with staffing (Castle, 2008a; General Accounting Office, 1999; Zimmerman et al., 2003). Inadequate staffing levels and training have been shown to increase the risk of abuse in other long-term care settings (Pillemer & Hudson, 1993). AL provides services for physically and mentally impaired elders. For example, 64% of residents have moderate to severe cognitive impairment (ALFA, 2009). A reported 9% of residents also have a mental disorder (ALFA, 2009). Elders with these characteristics are more likely to be abused (Burgess, Dowdell, & Prentky, 2000; Dyer et al., 2002; Pinsker, McFarland, & Pachana, 2010).
Method Source of Data Information on resident abuse in AL came from nurse aides included in the Pennsylvania nurse aide registry. As part of a research project examining nursing home abuse, in 2010 a mail survey was sent to a random sample of approximately 20% (N = 7,000) of nurse aides in this registry. The survey was sent once to nurse aides with a follow-up post-card reminder. The survey was anonymous and had an estimated completion time of less than 20 min. Our institutional review board approved this research.
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A total of 855 nurse aides indicated that their prior place of employment was in AL, and they completed the questionnaire items. The rationale for choosing to use the prior place of employment rather than current place of employment in designing the survey was to reduce potential underreporting of abuse. The information from these nurse aides who self-identified their prior place of employment in AL is reported in this research and represents a data source of convenience. This clearly represents a limitation of this research. A second limitation is the survey was designed to examine nursing home abuse. However, given the paucity of information on abuse in AL, we believe the information is relevant and a significant first step in examining resident abuse in this setting. The Pennsylvania nurse aide registry was also a data source of convenience. It was used for this research because the authors had access to this resource. All states are required by the Centers for Medicare and Medicaid Services (CMS) to maintain a nurse aide registry (Elvidge & Buechlein, 1992). The purpose of these registries is to “ensure that nurse aides have education, practical knowledge, and skills needed to care for residents of facilities participating in the Medicare and Medicaid programs” (Federal Register, 1991, p. 48880). Nursing homes are required by federal and state regulations (42 CFR 483.75[e][5] and 10 NYCRR 415.13[c] [2][i]) to check this registry prior to hiring nurse aides. Nurse aides can only be employed if they are both certified and included in the registry. For example, in Pennsylvania, published instructions to nursing homes stipulate, “A nurse aide who is not enrolled or in good standing on the registry may not be employed in a nursing care facility that receives Medicare or Medicaid reimbursement” (www. dsf.health.state.pa.us/health/cwp/view.asp). In 2009, Pennsylvania had 1,470 AL facilities and served 50,000 residents. Approximately 30,000 direct-care staff (which includes nurse aides) were employed by the Pennsylvania AL industry (Pennsylvania Department of Public Welfare, 2010). The registry used by nursing homes (described above) is not required to be used by AL. The staffing requirement in Pennsylvania for AL is that all direct care staff in AL who provide unsupervised activities of daily living (ADLs) services must successfully complete a course and pass the competency test (www.dpw.state.pa.us).
Abuse Questionnaire Development Seven categories of elder abuse were considered most relevant to this research (i.e., verbal, physical, psychological, caregiving, medication, material, and sexual abuse; see Table 1), based on the following: first, the research teams experience in nursing homes; second, a review of the literature; third, interviews with directors of nursing; and, fourth, interviews with nurse aides.
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Several questionnaires exist addressing elder abuse (Cooper et al., 2008), but few were developed specifically for use in long-term care settings. Also, few questionnaires have used nurse aides as respondents (an exception is Pillemer & Moore, 1990). This is important, as it may influence both face validity and content validity. Nurse aides often do not have high education levels, which may limit understanding of items in existing questionnaires. Thus, we developed a questionnaire for this research. The questionnaire was developed to examine abuse in nursing homes (and not necessarily AL). Therefore, to develop items for the questionnaire, interviews with 37 nurse aides from 10 different nursing homes were used. This included using open-ended questions regarding resident abuse. For example, the openended questions asked nurse aides the following: (a) their opinions on existing items from previously published instruments; (b) examples of resident abuse; and (c) their opinions on wording items in general. This approach was intended to improve the content-related validity of the questionnaire (Berk, 1990). The questions used by the research team included items from previously published instruments (n = 144) and specific comments provided by nurse aides in the interviews described above (n = 58). Based on this experience with nurse aides, this pool of questions was modified by the research team. All questions were written to be relevant to nurse aides (i.e., face validity), to be relevant to the nursing home context (i.e., content validity), and to be easily understood. Specifically, to facilitate understanding of the questions by nurse aides the items were written such that Flesch–Kincaid scores ranged from 8.0 to 12.9 (Kincaid, Fishburne, Rogers, & Chissom, 1975). These scores correspond to an equivalent U.S. school grade level. The resulting modified pool of questions was then reduced using three methods. First, duplicate/similar question were eliminated. Second, items that did not address the specific areas of abuse of interest were eliminated. Third, four researchers rated each item for importance in addressing each area of abuse. The highest rated items in each area of abuse were retained. Cognitive testing was used with an additional 15 nurse aides as part of the validation of the pilot instrument. Cognitive testing is an interview process used to examine whether respondents fully understand questions and whether they respond to the questions as intended (Levine, Fowler, & Brown, 2005). Minor wording changes to the pilot questionnaire were made as a result of cognitive testing. The resulting questionnaire had 46 items addressing verbal, physical, psychological, caregiving, medication, material exploitation, and sexual abuse. Additional items included questions addressing nurse aide demographics and employment characteristics (questionnaire is available from the authors).
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Abuse Questionnaire Response Format As part of the questionnaire development the issues of observing abuse and the reference period of interest were addressed. Some types of abuse can happen quickly, thereby reducing the likelihood of observation. Therefore, questions were asked using four formats: (a) observed or have evidence that this happened; (b) the resident told you this happened; (c) someone other than the resident told you this happened; and (d) you suspect that this happened. To gain some insight into the degree of reported abuse, a time period is needed. No single time period was optimal for this research. Short periods may be most accurate but may miss infrequent events, whereas the opposite issues arise for longer periods. Based on our questionnaire development process, 3 months was chosen as a reference period. Nurse aides believed they could reliably report abuse using this time frame. As many nurse aides told us, resident abuse is memorable; so most respondents should be able to recall when the abuse occurred. Thus, the questionnaire items specifically asked nurse aides to recall abuse that had occurred in the last 3 months of employment. As part of the response format, employment status was also addressed. To circumvent the potential barrier of reporting on a sensitive topic, with perceived implications for their current employment status, we asked nurse aides about abuse in their prior place of employment. All sections of the questionnaire used the questionnaire stem wording: “in your prior place of employment.” This approach was considered feasible due to the documented very high turnover of nurse aides in long-term care. For example, Castle (2008b) reported that in 2008, the average nurse aide turnover rate in PA nursing homes was 42% per year. As we describe above, this was fortuitous, as several nurse aides indicated their prior place of employment was in AL (although we do note that one limitation of this approach is recall bias from nurse aides with long tenure, and thus we exclude some nurse aides from the sample).
Analyses Descriptive analyses are presented. First, the percentages and means for the sample of nurse aides and AL is provided. Second, the percentage of nurse aides responding to each questionnaire item is provided. This provides information on the nurse aides opinion of whether the abuse in question had occurred. In addition, nurse aides were asked to give a value judgment on the impact of abuse in facilities. Specifically, we asked whether, in their opinion, the abuse created an unpleasant atmosphere for other residents (with respect to verbal, physical, psychological, caregiving, medication, material, and sexual abuse). The percentage
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Castle and Beach Table 2. Characteristics of Nurse Aides and Assisted Living Facilities. Characteristic
%
Personal characteristics of nurse aides (N = 832) Gender (female) 94 Age (years) Race (minority) 41 Marital status (single) 32 77 Highest level of education (high school) Facility characteristics of assisted living facilities (N = 832)a Facility size (number of beds) 72 For-profit ownership Chain membership 39 85 Average occupancy (estimated)
M (SD) 31.4 (8.1) 78 (72)
a. Information was reported by nurse aides, not from a facility survey.
of nurse aides responses to each item in the scale used (i.e., strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree) is presented.
Results Table 2 presents descriptive statistics of the nurse aide sample, along with selfreported characteristics of the AL facilities in which they worked. Most characteristics of the sample were not significantly different from equivalent characteristics recorded in national samples of AL (e.g., Hawes, Phillips, Rose, Holan, & Sherman, 2003). Also, most nurse aide characteristics of the sample were not significantly different from equivalent characteristics recorded in the 2004 National Nursing Assistant Survey (NNAS; National Center for Health Statistics, 2004a). The NNAS was conducted as a supplement to the 2004 National Nursing Home Survey (National Center for Health Statistics, 2004b). Nurse aides on average were 31 years old, female, and had a high school diploma. In addition, nurse aides reported that they had worked in AL on average 4 months prior (not shown in the table). Of the 4,451 surveys returned (giving a response rate of 64%) 895 were from nurse aides whose previous place of employment was in AL. Some nurse aides (i.e., 23) indicated that they had not worked in AL for 3 months and 40 indicated that they had worked in AL more than 1 year prior to the survey. The responses for these nurse aides were not included, giving an analytic sample of 832. Most
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(i.e., 63%) of the questionnaires were returned by mail within 1 month, and few items had missing information. Table 3 presents descriptive statistics of the questions in each of the abuse categories of interest. A total of 34 questions and 4 response categories are presented in this table, so for parsimony here we simply highlight the highest and lowest values reported for items in each abuse category. In the verbal abuse from staff category, 59% of nurse aides observed or had evidence of staff cursing at residents, whereas 6% had someone other than the resident tell them about staff making humiliating remarks. Overall, for all of the items included in the verbal abuse from staff category the highest scores were from the section addressing residents telling the nurse aides of abuse. In the physical abuse by staff category, 52% of nurse aides suspected other staff of pulling the hair of residents, whereas 6% had observed or had evidence of other physical violence from staff. Overall, for all of these items included in the physical abuse by staff category, the highest scores were from the section addressing nurse aides suspecting abuse. In the psychological abuse by staff category, 49% of nurse aides reported that a resident had told them about staff intimidation, whereas 16% had observed or had evidence of staff making critical remarks. Overall, for all of these items included in the psychological abuse by staff category, the highest scores were from the section addressing that a resident had told them about the abuse. In the caregiving abuse from staff category, 38% of nurse aides reported a resident told them that a staff member had deliberately withheld food, whereas 19% reported someone other than the resident had told them that food was deliberately withheld by staff. Overall, for all of these items included in the caregiving abuse from staff category, the highest scores were from the section addressing residents telling the nurse aides of abuse. In the medication abuse from staff category, 32% of nurse aides reported that they suspected staff had inappropriately delayed giving medications to residents, whereas 7% suspected that staff had denied access. Overall, for all of these items included in the medication abuse from staff category, the highest scores were from the section addressing residents telling the nurse aides of abuse. In the material exploitation from staff category, 26% of nurse aides reported they had observed or had evidence that staff had destroyed residents belonging, whereas 3% reported they had suspected staff tampering with residents’ savings. Overall, for all of these items in the material exploitation from staff category, the scores were low and no one reporting source seemed to give higher or lower scores. In the sexual abuse from staff category, 11% of nurse aides reported the resident had told them that staff had exposed their private body parts to embarrass
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Verbal abuse from staff Yelling Insulting remarks Cursing Humiliating remarks Argumentative with resident Physical abuse from staff Pushing Grabbing Pinching Pulling hair Kicking Deliberately hurt resident Throw things at resident Other physical violence Psychological abuse from staff Intimidation Aggressive behavior Threatening remarks Critical remarks Caregiving abuse from staff Threaten to stop taking care of resident Deliberately withheld food Deliberately withheld water
Category and item
319 366 492 104 426 116 245 311 410 125 164 169 51 217 243 199 137 175 167 179
14 29 37 49 15 20 20 6 26 29 24 16 21 20 22
N
38 44 59 13 51
%
Observed or have evidence
38 38 32
49 38 47 42
38 32 29 19 16 26 37 39
50 49 49 37 36
% N
314 317 266
411 318 389 351
312 266 245 160 133 217 310 322
417 410 406 307 302
The resident told you
Table 3. Nurse Aides Opinions of Staff Abuse in Assisted Living Facilities.
25 19 33
26 30 33 30
15 16 14 15 17 29 31 28
13 13 11 6 9
%
211 156 277
217 249 271 250
126 134 113 122 138 242 256 231
112 111 93 47 79
N
Someone other than resident told you
31 29 28
38 43 32 42
50 47 49 52 43 38 37 39
44 37 36 32 31
%
N
(continued)
261 241 233
314 358 269 353
414 389 410 429 356 313 307 326
365 310 302 267 255
You suspect
258
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100 119 183 114 93 39 67 220 21 26 61 10 9 3
14 11 5 8 26 3 3 7 1 1
JAG32210.1177/0733464811418094Cas
Article
Elder Abuse in Assisted Living
Journal of Applied Gerontology 32(2) 248–267 © The Author(s) 2011 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464811418094 jag.sagepub.com
Nicholas Castle1 and Scott Beach1 Abstract Assisted Living (AL) currently represents one of the most numerous institutional care settings for elders. Very little information exists on abuse in AL. Descriptive information on elder abuse reported by nurse aides working in AL is presented from a survey sent to nurse aides. The questionnaire had items addressing verbal, physical, psychological, caregiving, medication, material, and sexual abuse. The responses to the questions included in the verbal abuse, physical abuse, psychological abuse, caregiving abuse, medication abuse, and material exploitation abuse sections (28 questions) show that suspected abuse is not uncommon. We could not objectively verify the cases of abuse described in the survey, still, they give a first indication that staff abuse may occur in AL. This may be significant given the large number of ALs in the United States and may influence the health, quality of life, and safety of many residents. Keywords abuse, assisted living, survey Assisted Living (AL) has experienced rapid growth over the past decade. An estimated 36,000 facilities exist in the United States with approximately 1 million residents (Assisted Living Federation of America [ALFA], 2009) compared with an estimated 17,000 nursing homes with approximately 1.5 million residents (National Nursing Home Survey; National Center for Health Statistics, 2004b). Elders living in AL may be particularly vulnerable to abuse because many suffer Manuscript received: February 11, 2011; final revision received: June 28, 2011; accepted: July 1, 2011. 1
University of Pittsburgh, Pittsburgh, PA, USA
Corresponding Author: Nicholas Castle, University of Pittsburgh, A610 Crabtree Hall, Pittsburgh, PA 15261, USA. Email: [email protected]
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from cognitive impairment, behavioral symptoms, or physical limitations—factors that have been reported as risk factors associated with elder abuse (Dyer, Connoly, & McFeeley, 2002; Pillemer, 1988). In this research, descriptive information on abuse (observed, second-hand, and suspected) by staff on elders living in AL is presented. AL consists of long-term care (LTC) settings that typically provide residents with support for activities of daily living (ADLs) and instrumental activities of daily living (IADLs; ALFA, 2009). Following the view of the American Medical Association (AMA, 1990), elder abuse was defined in this research as “an act of commission or omission that results in harm or threatened harm to the health or welfare of an older adult” (Stiles, Koren, & Walsh, 2002, p. 34). Moreover, based on a review of the abuse literature and interviews with AL caregivers, seven categories of elder abuse from staff were examined in this research (i.e., verbal, physical, psychological, caregiving, medication, material, and sexual abuse [definitions are given in Table 1]).
Prior Research Many scholars have acknowledged that little is known about resident abuse in long-term care settings (e.g., Cooper, Selwood, & Livingston, 2008). For example, a recent review of the literature identified only seven empirical studies addressing abuse in nursing homes (Lindbloom, Brandt, Hough, & Meadows, 2007). In this prior review, no empirical studies were identified examining elder abuse in AL. A few reported descriptive and observational statistics indicate that elder abuse may be an issue of concern in AL. Hawes (2002) has reported to Congress that in her data, 15% of staff had witnessed verbal abuse of AL residents. The long-term care ombudsman program (LTCOP) has reported that abuse in AL is commonly reported, but no figures were given (Administration on Aging [AoA], 2005). In addition, states have reported abuse statistics coming from licensing inspections. For example, in 2009 Pennsylvania reported that 8% (i.e., 116) of 1,441 complaints received and 6% (i.e., 1,231) of 20,550 incident reports were for resident abuse in AL (Pennsylvania Department of Public Welfare, 2010). A few authors have also presented the opinion that elder abuse may be problematic in these settings. One study concluded that “residents of assisted living facilities are poorly informed about protective services and uncertain about options if care were not optimal” (Wood & Stephens, 2003, p. 753). However, empirical evidence to substantiate issues regarding abuse were not provided. The paucity of information on abuse in AL led us to report information from this descriptive study. In addition, we believe there are several characteristics of
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Intentional infliction of anguish, pain, or distress through verbal interactions (Clarke & Pierson, 1999, p. 635) Acts done with the intention of causing physical pain or injury (Lachs & Pillemer, 2004, p. 1264) Acts done with the intention of causing emotional pain or injury (Lachs & Pillemer, 2004, p. 1264) Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness (Centers for Medicare & Medicaid Services, 2004, 42 C.F.R. §488.301) Elders purposely deprived of their correct medication or given inappropriate medication (Chambers, 1999, p. 80) The improper use of an older person’s assets (Rabiner, O’Keeffe, & Brown, 2006, p. 51) Nonconsenting sexual contact of any kind (National Center on Elder Abuse [NCEA], 1998, p. 1)
Verbal abuse from staff
Sexual abuse from staff
Material exploitation from staff
Medication abuse from staff
Caregiving abuse from staff
Psychological abuse from staff
Physical abuse from staff
Definition
Category of abuse
Have you seen any staff member pull the hair of a resident?
Pushing, grabbing, pinching, pulling hair, kicking, other physical violence Intimidation, aggressive behavior, threatening remarks, critical remarks Halting care, withholding food, withholding water
Unwelcome sexualized kissing, unwelcome fondling, unwelcome discussion of sexual activity, exposure of private body-parts, oral-genital contact, digital penetration, vaginal rape
Preventing access, excessive medications, delay in medications Taking possessions, taking assets
Have you heard any staff member curse at a resident?
Yelling, insulting remarks, cursing
Have seen a staff member delay giving meds to a resident on purpose? Have you seen a staff member take cash belonging to a resident? Have you seen a staff member involved in unwelcome discussion of sexual activity with a resident?
Have you seen any staff member not provide water to a resident on purpose?
Have you any staff member threaten a resident?
Example item
Specific areas examined
Table 1. Categories of Abuse Examined, Definitions, and Example Items.
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the AL industry (given below) that could potentially lead to situations of elder abuse. This augments the importance of this study.
Significance of Abuse in AL The AL industry is not regulated by federal legislation but is regulated by the states. State regulations, standards, and oversight are often designated to a Department of Health, Public Welfare, Aging, or Senior Services (Carlson, 2007; Hawes & Phillips, 2007). The scale and scope of regulations is highly variable across states; but for the most part, the industry does not have a high degree of oversight. In this relatively unregulated environment, AL has clearly flourished. Programs and services of value and importance to elders have developed. Not surprisingly, AL is favored by elders above other institutional long-term care settings (Carlson, 2007). Still, in this relatively unregulated environment, staffing levels and staff qualifications are thereby also often not precisely stipulated. This does not necessarily mean that staffing levels and staff qualifications are insufficient in all AL in all states. However, evidence would suggest that quality of care is not high in some facilities, and this includes problems with staffing (Castle, 2008a; General Accounting Office, 1999; Zimmerman et al., 2003). Inadequate staffing levels and training have been shown to increase the risk of abuse in other long-term care settings (Pillemer & Hudson, 1993). AL provides services for physically and mentally impaired elders. For example, 64% of residents have moderate to severe cognitive impairment (ALFA, 2009). A reported 9% of residents also have a mental disorder (ALFA, 2009). Elders with these characteristics are more likely to be abused (Burgess, Dowdell, & Prentky, 2000; Dyer et al., 2002; Pinsker, McFarland, & Pachana, 2010).
Method Source of Data Information on resident abuse in AL came from nurse aides included in the Pennsylvania nurse aide registry. As part of a research project examining nursing home abuse, in 2010 a mail survey was sent to a random sample of approximately 20% (N = 7,000) of nurse aides in this registry. The survey was sent once to nurse aides with a follow-up post-card reminder. The survey was anonymous and had an estimated completion time of less than 20 min. Our institutional review board approved this research.
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A total of 855 nurse aides indicated that their prior place of employment was in AL, and they completed the questionnaire items. The rationale for choosing to use the prior place of employment rather than current place of employment in designing the survey was to reduce potential underreporting of abuse. The information from these nurse aides who self-identified their prior place of employment in AL is reported in this research and represents a data source of convenience. This clearly represents a limitation of this research. A second limitation is the survey was designed to examine nursing home abuse. However, given the paucity of information on abuse in AL, we believe the information is relevant and a significant first step in examining resident abuse in this setting. The Pennsylvania nurse aide registry was also a data source of convenience. It was used for this research because the authors had access to this resource. All states are required by the Centers for Medicare and Medicaid Services (CMS) to maintain a nurse aide registry (Elvidge & Buechlein, 1992). The purpose of these registries is to “ensure that nurse aides have education, practical knowledge, and skills needed to care for residents of facilities participating in the Medicare and Medicaid programs” (Federal Register, 1991, p. 48880). Nursing homes are required by federal and state regulations (42 CFR 483.75[e][5] and 10 NYCRR 415.13[c] [2][i]) to check this registry prior to hiring nurse aides. Nurse aides can only be employed if they are both certified and included in the registry. For example, in Pennsylvania, published instructions to nursing homes stipulate, “A nurse aide who is not enrolled or in good standing on the registry may not be employed in a nursing care facility that receives Medicare or Medicaid reimbursement” (www. dsf.health.state.pa.us/health/cwp/view.asp). In 2009, Pennsylvania had 1,470 AL facilities and served 50,000 residents. Approximately 30,000 direct-care staff (which includes nurse aides) were employed by the Pennsylvania AL industry (Pennsylvania Department of Public Welfare, 2010). The registry used by nursing homes (described above) is not required to be used by AL. The staffing requirement in Pennsylvania for AL is that all direct care staff in AL who provide unsupervised activities of daily living (ADLs) services must successfully complete a course and pass the competency test (www.dpw.state.pa.us).
Abuse Questionnaire Development Seven categories of elder abuse were considered most relevant to this research (i.e., verbal, physical, psychological, caregiving, medication, material, and sexual abuse; see Table 1), based on the following: first, the research teams experience in nursing homes; second, a review of the literature; third, interviews with directors of nursing; and, fourth, interviews with nurse aides.
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Several questionnaires exist addressing elder abuse (Cooper et al., 2008), but few were developed specifically for use in long-term care settings. Also, few questionnaires have used nurse aides as respondents (an exception is Pillemer & Moore, 1990). This is important, as it may influence both face validity and content validity. Nurse aides often do not have high education levels, which may limit understanding of items in existing questionnaires. Thus, we developed a questionnaire for this research. The questionnaire was developed to examine abuse in nursing homes (and not necessarily AL). Therefore, to develop items for the questionnaire, interviews with 37 nurse aides from 10 different nursing homes were used. This included using open-ended questions regarding resident abuse. For example, the openended questions asked nurse aides the following: (a) their opinions on existing items from previously published instruments; (b) examples of resident abuse; and (c) their opinions on wording items in general. This approach was intended to improve the content-related validity of the questionnaire (Berk, 1990). The questions used by the research team included items from previously published instruments (n = 144) and specific comments provided by nurse aides in the interviews described above (n = 58). Based on this experience with nurse aides, this pool of questions was modified by the research team. All questions were written to be relevant to nurse aides (i.e., face validity), to be relevant to the nursing home context (i.e., content validity), and to be easily understood. Specifically, to facilitate understanding of the questions by nurse aides the items were written such that Flesch–Kincaid scores ranged from 8.0 to 12.9 (Kincaid, Fishburne, Rogers, & Chissom, 1975). These scores correspond to an equivalent U.S. school grade level. The resulting modified pool of questions was then reduced using three methods. First, duplicate/similar question were eliminated. Second, items that did not address the specific areas of abuse of interest were eliminated. Third, four researchers rated each item for importance in addressing each area of abuse. The highest rated items in each area of abuse were retained. Cognitive testing was used with an additional 15 nurse aides as part of the validation of the pilot instrument. Cognitive testing is an interview process used to examine whether respondents fully understand questions and whether they respond to the questions as intended (Levine, Fowler, & Brown, 2005). Minor wording changes to the pilot questionnaire were made as a result of cognitive testing. The resulting questionnaire had 46 items addressing verbal, physical, psychological, caregiving, medication, material exploitation, and sexual abuse. Additional items included questions addressing nurse aide demographics and employment characteristics (questionnaire is available from the authors).
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Journal of Applied Gerontology 32(2)
Abuse Questionnaire Response Format As part of the questionnaire development the issues of observing abuse and the reference period of interest were addressed. Some types of abuse can happen quickly, thereby reducing the likelihood of observation. Therefore, questions were asked using four formats: (a) observed or have evidence that this happened; (b) the resident told you this happened; (c) someone other than the resident told you this happened; and (d) you suspect that this happened. To gain some insight into the degree of reported abuse, a time period is needed. No single time period was optimal for this research. Short periods may be most accurate but may miss infrequent events, whereas the opposite issues arise for longer periods. Based on our questionnaire development process, 3 months was chosen as a reference period. Nurse aides believed they could reliably report abuse using this time frame. As many nurse aides told us, resident abuse is memorable; so most respondents should be able to recall when the abuse occurred. Thus, the questionnaire items specifically asked nurse aides to recall abuse that had occurred in the last 3 months of employment. As part of the response format, employment status was also addressed. To circumvent the potential barrier of reporting on a sensitive topic, with perceived implications for their current employment status, we asked nurse aides about abuse in their prior place of employment. All sections of the questionnaire used the questionnaire stem wording: “in your prior place of employment.” This approach was considered feasible due to the documented very high turnover of nurse aides in long-term care. For example, Castle (2008b) reported that in 2008, the average nurse aide turnover rate in PA nursing homes was 42% per year. As we describe above, this was fortuitous, as several nurse aides indicated their prior place of employment was in AL (although we do note that one limitation of this approach is recall bias from nurse aides with long tenure, and thus we exclude some nurse aides from the sample).
Analyses Descriptive analyses are presented. First, the percentages and means for the sample of nurse aides and AL is provided. Second, the percentage of nurse aides responding to each questionnaire item is provided. This provides information on the nurse aides opinion of whether the abuse in question had occurred. In addition, nurse aides were asked to give a value judgment on the impact of abuse in facilities. Specifically, we asked whether, in their opinion, the abuse created an unpleasant atmosphere for other residents (with respect to verbal, physical, psychological, caregiving, medication, material, and sexual abuse). The percentage
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Castle and Beach Table 2. Characteristics of Nurse Aides and Assisted Living Facilities. Characteristic
%
Personal characteristics of nurse aides (N = 832) Gender (female) 94 Age (years) Race (minority) 41 Marital status (single) 32 77 Highest level of education (high school) Facility characteristics of assisted living facilities (N = 832)a Facility size (number of beds) 72 For-profit ownership Chain membership 39 85 Average occupancy (estimated)
M (SD) 31.4 (8.1) 78 (72)
a. Information was reported by nurse aides, not from a facility survey.
of nurse aides responses to each item in the scale used (i.e., strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree) is presented.
Results Table 2 presents descriptive statistics of the nurse aide sample, along with selfreported characteristics of the AL facilities in which they worked. Most characteristics of the sample were not significantly different from equivalent characteristics recorded in national samples of AL (e.g., Hawes, Phillips, Rose, Holan, & Sherman, 2003). Also, most nurse aide characteristics of the sample were not significantly different from equivalent characteristics recorded in the 2004 National Nursing Assistant Survey (NNAS; National Center for Health Statistics, 2004a). The NNAS was conducted as a supplement to the 2004 National Nursing Home Survey (National Center for Health Statistics, 2004b). Nurse aides on average were 31 years old, female, and had a high school diploma. In addition, nurse aides reported that they had worked in AL on average 4 months prior (not shown in the table). Of the 4,451 surveys returned (giving a response rate of 64%) 895 were from nurse aides whose previous place of employment was in AL. Some nurse aides (i.e., 23) indicated that they had not worked in AL for 3 months and 40 indicated that they had worked in AL more than 1 year prior to the survey. The responses for these nurse aides were not included, giving an analytic sample of 832. Most
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Journal of Applied Gerontology 32(2)
(i.e., 63%) of the questionnaires were returned by mail within 1 month, and few items had missing information. Table 3 presents descriptive statistics of the questions in each of the abuse categories of interest. A total of 34 questions and 4 response categories are presented in this table, so for parsimony here we simply highlight the highest and lowest values reported for items in each abuse category. In the verbal abuse from staff category, 59% of nurse aides observed or had evidence of staff cursing at residents, whereas 6% had someone other than the resident tell them about staff making humiliating remarks. Overall, for all of the items included in the verbal abuse from staff category the highest scores were from the section addressing residents telling the nurse aides of abuse. In the physical abuse by staff category, 52% of nurse aides suspected other staff of pulling the hair of residents, whereas 6% had observed or had evidence of other physical violence from staff. Overall, for all of these items included in the physical abuse by staff category, the highest scores were from the section addressing nurse aides suspecting abuse. In the psychological abuse by staff category, 49% of nurse aides reported that a resident had told them about staff intimidation, whereas 16% had observed or had evidence of staff making critical remarks. Overall, for all of these items included in the psychological abuse by staff category, the highest scores were from the section addressing that a resident had told them about the abuse. In the caregiving abuse from staff category, 38% of nurse aides reported a resident told them that a staff member had deliberately withheld food, whereas 19% reported someone other than the resident had told them that food was deliberately withheld by staff. Overall, for all of these items included in the caregiving abuse from staff category, the highest scores were from the section addressing residents telling the nurse aides of abuse. In the medication abuse from staff category, 32% of nurse aides reported that they suspected staff had inappropriately delayed giving medications to residents, whereas 7% suspected that staff had denied access. Overall, for all of these items included in the medication abuse from staff category, the highest scores were from the section addressing residents telling the nurse aides of abuse. In the material exploitation from staff category, 26% of nurse aides reported they had observed or had evidence that staff had destroyed residents belonging, whereas 3% reported they had suspected staff tampering with residents’ savings. Overall, for all of these items in the material exploitation from staff category, the scores were low and no one reporting source seemed to give higher or lower scores. In the sexual abuse from staff category, 11% of nurse aides reported the resident had told them that staff had exposed their private body parts to embarrass
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Verbal abuse from staff Yelling Insulting remarks Cursing Humiliating remarks Argumentative with resident Physical abuse from staff Pushing Grabbing Pinching Pulling hair Kicking Deliberately hurt resident Throw things at resident Other physical violence Psychological abuse from staff Intimidation Aggressive behavior Threatening remarks Critical remarks Caregiving abuse from staff Threaten to stop taking care of resident Deliberately withheld food Deliberately withheld water
Category and item
319 366 492 104 426 116 245 311 410 125 164 169 51 217 243 199 137 175 167 179
14 29 37 49 15 20 20 6 26 29 24 16 21 20 22
N
38 44 59 13 51
%
Observed or have evidence
38 38 32
49 38 47 42
38 32 29 19 16 26 37 39
50 49 49 37 36
% N
314 317 266
411 318 389 351
312 266 245 160 133 217 310 322
417 410 406 307 302
The resident told you
Table 3. Nurse Aides Opinions of Staff Abuse in Assisted Living Facilities.
25 19 33
26 30 33 30
15 16 14 15 17 29 31 28
13 13 11 6 9
%
211 156 277
217 249 271 250
126 134 113 122 138 242 256 231
112 111 93 47 79
N
Someone other than resident told you
31 29 28
38 43 32 42
50 47 49 52 43 38 37 39
44 37 36 32 31
%
N
(continued)
261 241 233
314 358 269 353
414 389 410 429 356 313 307 326
365 310 302 267 255
You suspect
258
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100 119 183 114 93 39 67 220 21 26 61 10 9 3
14 11 5 8 26 3 3 7 1 1
