Memorandum by the Community and District
Nursing Association (EA18)
1. SUMMARY
This inquiry is necessary and urgent because
of four straightforward facts:
1.1 We are increasingly an elderly population.
With age may come a greater dependency on others, which in turn
can lead to an increased risk of elder abuse.
1.1.1 The numbers of older people in the
population of the UK are increasing dramatically. Since the 1930s,
the number of people aged over 65 has more than doubled. Today,
a fifth of the population is over sixty. By 2025, the number of
people over the age of 80 is set to increase by almost a half
and the number of people over 90 will double.[98]
1.1.2 Elder abuse is only just becoming
recognised as a specific problem within the whole context of abuse,
and as yet it is given less credence than it deserves. Though
there have been no recent quantitative research studies that give
an accurate picture of the numbers and characteristics of older
abused people, Ogg and Bennett[99]
in 1992 set the probable figure of 5-9%. Even at a conservative
estimate this works out to over 500,000 people over 65 years.
1.1.3 More recently—and more alarmingly—a
survey of community and district nurses commissioned by CDNA[100]
last year indicated that the vast majority of respondents encountered
elder abuse at work (88%) and in 12% this was on a monthly, or
more frequent basis.
1.2 The Nurse has Responsibilities to the
Patient
1.2.1 All registered nurses are responsible
for ensuring that they safeguard the interests of patients at
all times.[101]
Community and district nurses are particularly well placed to
recognise and prevent elder abuse.
Community nurses often find themselves uniquely
placed to gain access to those areas of community life that they
are so often viewed by others as taking place "behind closed
doors".
1.3 Specific training on elder abuse is not
a mandatory part of nurses' training curriculum
1.3.1 Although 88% of respondents in the
CDNA survey had encountered elder abuse at work, only around a
third (35%) felt equipped to deal with the problem. Though nurses
are aware that elder abuse exists, they are often not aware of
the forms it takes. They are often unable to recognise it or know
how to deal with the situation when it has been identified. This
is why the CDNA has decided to take a lead in giving its members
the necessary knowledge, skills and guidance.[102]
1.4 Nurses who have had specific training
on how to deal with suspected cases of elder abuse are more likely
to recognise instances of abuse, report it, and help to stop it.
1.4.1 Where training had been provided,
respondents were more likely to recognise elder abuse. Almost
all respondents felt that training in elder abuse would be beneficial
(99%), and would be willing to undertake training in elderly abuse
(98%).
1.5 Recommendation
1.5.1 The Community and District Nursing
Association is therefore calling for mandatory training for all
those within the nursing profession, and also training for all
staff who work with older people in the prevention, recognition
and the management of elder abuse.
2. INTRODUCTION
2.1 For thirty-three years the Community
and District Nursing Association (CDNA) has been caring for those
who care. We are a specialist trade union affiliated to both the
TUC and STUC and represent 5,000 nurses who work in the community,
making highly skilled decisions on a daily basis in primary care.
Our members are experienced clinicians from various senior nursing
backgrounds who strive to give clients the best possible care.
2.2 The modernisation of the NHS has instigated
the modernisation of community nursing and this has been reflected
throughout our membership. We have a positive, forward thinking
mixture of professionals who are always open to learning and cascading
their knowledge and skills.
2.3 The breadth of our membership includes
District Nurses and their teams, Practice Nurses, those working
in Nursing Homes, Schools, Health Visitors, indeed, any nurses
who do not work in the hospital environment.
2.4 Our members, particularly those in District
Nursing, deal on a daily basis with the subject of this inquiry.
District nurses are in very privileged position: they hold a great
deal of personal and often private information on their patients
and their families. They may also be the only professional person
invited into people's homes and see what goes on behind closed
doors.
3. HOW PREVALENT
IS ELDER
ABUSE?
3.1 As there is no statutory demand to report
cases of elder abuse consequently many of the figures must be
estimated. Action on Elder Abuse's help line reports over 90 calls
per week[103].
3.2 Current research on the prevalence of
abuse in the community is inadequate. The total number of abused
in the community can only be estimated. The CDNA survey covers
only the older people known to District Nurses within the CDNA.
3.3 The CDNA survey in 2002 had a one in
six response from our members (457 of those responding were District
Nursing Sisters—experienced nurses). Reports were of abuse
that had taken place in the person's home.
3.4 88% of all nurses responding were encountering
abuse on a regular basis.
3.5 Types of abuse encountered in order
of numbers of incidents:
3.6 In 1992 it was estimated that between
5% and 9% of older people were subject to abuse which would give
a figure of around half a million people at that time. The Department
of Health predict that the number of people over 80 years of age
will have doubled between 1995 and 2025 and so the estimated number
of abused will also rise pro rata.
3.7 There is no evidence of Elder Abuse
that is robust, it is known that where there is one type of abuse,
including cruelty to animals, then other categories of abuse are
probable. The elderly and vulnerable are known to be less likely
to report abuse, they are ashamed, feel that they are in some
way to blame for the incidents or frightened of being institutionalised
as they rely on the abuser to maintain their level of independence.
They also frequently lack the opportunity to report abuse, even
if they are aware of how or to whom to report the abuse. In many
instances the abused person may not see the "situation"
as abuse—but that does not stop it being abuse.
3.8 The CDNA would recommend further research
that could give greater detail into elder abuse:
— the exact number of abusive incidents;
— the type of abusive incident;
— the outcome of the incident;
— the consequence to the abused person;
— the incidence of abuse areas of the
UK, also rural urban inner city; and
— Abusive incidents in ethnic/minority
communities.
3.9 Current thinking suggests that there
are no cultural, religious, ethnic or sexual orientation differences
to the incidence of elder abuse in the community. There is an
obvious need for staff to be aware of the wider context within
which an individual from a differing culture may suffer abuse,
and staff should be aware of how and where to get specialist help.
4. WHAT ARE
THE CAUSES
OF ELDER
ABUSE?
4.1 There are several explanations[104]
about why abuse occurs but not every incident fits into a neat
box!
4.1.1 Abuser psychopathology or dependency,
which suggests it is the characteristics of the abuser and not
those of the victim which makes mistreatment more likely. It appears
that the abuser is likely to be dependent in some way on the victim
for housing, money or emotionally or to have a history of mental
ill health or alcohol or substance misuse.
4.1.2 Transgenerational violence
in which abusive behaviour is learned in early life and becomes
the norm across generations. The abuser may have been abused as
a child or problems commonly solved by violence within the social
setup.
4.1.3 Stressed carer in which the
stress of caring combined with other factors such as behavioural
difficulties in the abused person leads to violence.
4.1.4 Exchange theory in which a
long-term situation develops so long as the abuser gains from
the situation.
4.1.5 Social isolation in which perpetrators
may break down social support systems and friends and neighbours
be discouraged from visiting.
4.1.6 Revenge for real or imagined
acts.
4.2 Degenerative and pathological changes
that may occur in the older person can create a dependence on
others for survival and so make them more vulnerable to abuse.
— neurological conditions such as Parkinson's
disease;
— skeletal conditions causing poor
mobility such as arthritis;
— sight and hearing impairment;
4.3 WHO ABUSES—Abuse can be carried
out any where by any one who comes into contact with a vulnerable
or older person. Statistically these are:
4.4 The perpetrators are usually male and
it should be noted that the main carer is not usually the abuser
leading to doubt placed on carer stress as the main cause of elder
abuse by family member.
4.5 SOME TRIGGERS THAT CAN LEAD TO ABUSE:
— people with an illness such as Parkinson's
disease or dementia which can affect memory, ability to reason,
reduce predictability, produce repetitive or aggressive behaviour;
— people with communication problems
of any kind (hearing, visual, speech);
— people who are physically dependent
on others in any way;
— people with a history of alcohol,
drug abuse (patient or carers);
— people with mental ill health/incapacity
of any kind;
— people with learning disabilities;
— patients and carers who are socially
isolated;
— people with history of family violence;
— people who have poor relationships
with family or their carers;
— people who lack support services;
— people whose carer receives inadequate
support (physical or emotional), or has had to change his/her
lifestyle, is experiencing financial difficulties, or has other
conflicting interests;
— cultural difference and language
barriers;
— non-qualified staff undertaking nursing
tasks and/or inappropriate care;
— staff shortages leading to lack of
supervision; and
— lack of training for all levels of
staff.
4.6 INDICATIONS SUGGESTIVE OF ABUSE:
— difficulty gaining access to patient,
inability to speak to them alone;
— history of unexplained or repeated
falls or injuries;
— refusal by patient or carer to accept
any help or support;
— frequent transfer from one agency
to another; and
— repeated visits to nurse, GP or A&E
department with no obvious medical problem.
It is essential that nurses and other staff
involved in care of the older person be aware of all the triggers,
indicators and signs of abuse.
5. THE SETTINGS
OF ELDER
ABUSE?
5.1 Auditing of the Action on Elder Abuse
Help Line suggests that abuse takes place as follows:
| % |
| Person's own home | 66.7 |
| Sheltered housing | 4.2 |
| Residential care | 10.1 |
| Nursing home | 11.6 |
| Hospital | 5 |
| Other locations | 2.4 |
| |
5.2 Although the total amount of abuse in residential/nursing
home settings appears a small number, 25.09% in total, only 5%
of those over 65 years actually live in this setting making the
actual incidents of abuse in these settings high.
5.3 All types of abuse occur in all the different settings.
It is known that some factors can help to prevent abuse:
— training for all staff in the recognition and
management of abuse.
— good communication channels for staff;
— no secrecy—open door policy;
— good working practices with clear guidelines and
stated procedures;
— good supervisory practices;
— support for staff who "whistleblow";
— insistence on general courtesy, politeness and
respect for others; and
— adherence to patient privacy and dignity.
5.4 The vulnerable and elderly are subjected to a higher
risk of abuse when care of any kind is given by a "lone worker".
As the title suggests the "lone worker" works unaided
and unsupervised, the one to one relationship occurring between
the worker and elderly person can lead to abuse.
6. WHAT CAN
BE DONE
ABOUT IT?
6.1 It is known that incidents of abuse are less if staff
are:
— in an environment free of secrecy; and
— maintain the patients' respect and dignity and
choice.
These working practices must be encouraged.
6.2 People buying in private care by direct payment could
open up a new avenue of opportunity for abuse. These people, many
vulnerable, must be given guidance and assistance, with police
checks and register for these employees compulsory.
7. INFORMAL CARERS
7.1 Reduction of stress by increase in day care and respite
facilities from both statutory and voluntary sectors.
7.2 Training for carers on handling/dealing with people
with mental/physical problems provided with support from both
carers associations and voluntary agencies.
7.3 Detailed information supplied and explained about
where help and support can be obtained locally and nationally
this supplied by all staff visiting vulnerable/older people and
carers.
8. FORMAL CARERS
8.1 In the case of private care, a register for all workers
in the private sector working in both residential facilities and
domiciliary agencies.
8.2 The reason for any dismissal/resignation of employment
recorded on the register, thus preventing people suspected of
abuse moving from agency to agency.
8.3 Compulsory approved induction programmes with training
of all private sector staff on recognition and response of abuse
and moving and handling of patients prior to patient contact.
8.4 Enforced police checks for all new private sector
staff prior to taking up duties.
8.5 A "whistleblowing" policy in place with
all employers, with support network for those who do whistleblow.
8.6 Training
8.6.1 Mandatory training on the recognition and response
to elder abuse for all staff, qualified and unqualified who work
with vulnerable and elderly people. It is only with knowledge
and understanding that potential abusive situations can be recognised.
It is only with training that appropriate action can be taken,
inappropriate intervention can cause more harm. Training provided
by qualified trainers in the recommended time allowed.
8.7 Multidisciplinary working
8.7.1 Must be encouraged—a more open and closer
working relationship between social services and health professionals,
agreed sharing of information—joint training to foster appreciation
of each others' roles and skills and the awareness that no one
profession can or should deal with abuse alone.
8.7.2 Multi agency working encouraged with voluntary
agencies, the police, housing departments etc joining health and
social service staff. Dealing with abuse is multi agency, each
individual case requiring differing solutions.
9. RECOMMENDATIONS FOR
NATIONAL AND
LOCAL STRATEGY
9.1 National
9.1.1 Training in the recognition and management of elder
abuse included in all nurse training, both pre registration and
on post registration courses that involve elderly care.
9.1.2 Mandatory training in recognition and management
of elder abuse for all staff working in statutory health or social
care.
9.1.3 Government Policies should lay down statutory procedures—not
guidance—on the prevention of abuse of vulnerable/abused
people. (No Secrets—guidance only document has still not
been implemented in all areas).
9.1.4 Abuse of the Elderly to be an addition to The National
Service Framework for Older People. This policy is being implemented
throughout the Health and Social Services.
9.1.5 The Government has brought forth the Mental Incapacity
Bill this year (2003). While this Bill does protect those with
mental incapacity, many vulnerable adults and older people in
the community do not have mental incapacity and so fall outside
the remit of the Bill's protection. The Domestic Violence Bill
currently going through Parliament does not cover abuse of the
vulnerable and elderly. The CDNA would recommend that provision
for elder abuse is made within these Bills.
9.1.6 National Care Standards Commission must revise
their visiting policies for residential homes and should also
be given more power to ensure that shortfalls identified are corrected.
9.1.7 More frequent inspections of homes with no formal
notice given prior to visit.
9.1.8 A swifter and more aggressive procedure for investing
complaints.
9.1.9 A Register for all unqualified staff working with
the older person.
9.1.10 Improved regulatory procedure for private domiciliary
care suppliers.
9.1.11 Increased supervision of staff obligatory and
training programme compulsory.
9.2 Local
9.2.1 Joint training programmes for health, social staff
and other agencies on prevention of abuse.
9.2.2 Improve risk assessment training with Health, Social
Services and the Police participating.
9.2.3 Efforts made to include the private sector in the
training programmes of local health and social statutory agencies.
9.2.4 Advice available from both health and social services
in developing training programmes for private homes.
9.2.5 Local Policies available for all staff—a
statutory policy preferable.
9.2.6 Adult Protection Officers in post in at least one
of the services (Health/Social) available for advice and support
in all areas of the UK.
10. CONCLUSIONS
10.1 Our understanding of family violence and its long
reaching consequences grows daily. Elder Abuse is a large part
of family violence but it is only just being given the acknowledgement
and credence that it deserves. Abuse of the older person is often
seen as less extreme than other forms of family violence but it
is not. It is occurring to the frail dependent elderly who must
wake each morning dreading the day ahead, it affects their mental
and physical well-being. Many nurses leave work worrying about
the safety of elderly patients fearing that they have left them
at risk, feeling unsupported and isolated with the responsibility.
10.2 Child abuse incidents hit news headlines on a regular
basis even though all health care professionals receive mandatory
training on recognition and response of child abuse—the
elderly and vulnerable in our society deserve no less.
10.3 Training for all staff caring for the elderly must
be only the start of prevention of this abhorrent practice. The
CDNA are calling for the inclusion of recognition on the management
of elder abuse on all pre registration nursing training. All post
registration courses connected with older people's care and for
its inclusion in all mandatory training for all levels of staff
working with elderly people[105].
98
Department of Health (2001), National Service Framework for older
people. Back
99
Ogg, J., Bennett, G (1992), Elder Abuse in Britain BMJ 1992 305;
998-9. Back
100
Community and District Nursing Association (2002), Survey of
members incidence of Elder Abuse. Back
101
Nursing and Midwifery Council (2000), Code of Professional Conduct. Back
102
Community and District Nursing Association (2003), Response to
Elder Abuse-A guide for nurses. Back
103
Action on Elder Abuse (2000), Listening is not Enough. Back
104
Bigg, S, Phillipson, C. and Kingston, P. (1995) Elder Abuse in
Perspective. Open University Press. Bucks. Back
105
Department of Health (2000), No Secrets. DoH London. Back
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