Twelve nurses who worked in intensive care units agreed to participate in the interviews. During the project 10 nurses were interviewed, for an overall interview rate of 83% and 2.7% of those initially contacted to participate. The nurses all worked in hospital-based critical care units in three Iowa counties. Interview responses are provided within the concepts of types of elder abuse, suspicions of elder abuse, reporting of elder abuse, barriers to reporting elder abuse, legislation, and improvement in practice.
Types of Elder Abuse
Nurses reported the kinds of abuse they may encounter as emotional abuse, financial exploitation, neglect, and physical abuse. None of the nurses reported sexual abuse, and one nurse stated: “I’m trying to think…I don’t think we’ve ever seen sexual…not to my knowledge.” Another nurse stated, “I’ve worked in the surgical intensive care unit for over 20 years and I haven’t seen any signs of any physical abuse, partly because as a nurse in the ICU, you’re usually so busy you don’t have time to scratch your nose.”
Neglect issues were frequently mentioned and described as the patient having many sores on the body, bruises, needing hygiene care, and looking malnourished. One nurse reported, “They will be very filthy. They’ll have sores. It’s obvious they haven’t been bathed or shampooed for a long time. So we see a lot of that type of thing.”
An example of financial exploitation was provided. “The patient was on a ventilator, controlled life support, and the family wanted us to wake him up to sign his social security check. And that was kind of like a red flag right there. And the patient was in for 3 months, and the only time we saw the family was the first of the month when the check came in.”
A report of actual abuse occurring in the intensive care unit was depicted by a nurse. “I had one case where the wife would come in every day and sat for 3 hours next to her husband’s bed, and shortly after she left the ventilator alarm would always go off, and we could never figure out why, and we always ended up changing the tubing. Well, we sat and watched her one day, and she sat there with her sewing needles and was poking all these holes in the ventilator tubing. And she’d called in later, asking, “Oh, is he still alive?” So, that was something we did report.”
Suspicions of Elder Abuse
Nurses report being suspicious of elder abuse if the patient 1) depicts being malnourished and unkempt; 2) has bruising or other marks on the body with no reasonable explanation, 3) has burn marks in places where the patient can’t reach, 4) can’t provide a clear explanation/reluctance to answer questions, or 5) if a family member hovers or appears uncomfortable with health care professionals present. Many reported suspicions because of evidence such as sores on their body and the patient being hungry.
Two nurses reported their admission questionnaire asks about their care at home and if they are safe. One reported, “The joint commission standards have mandated that we ask people, you know, have you been sexually abused, have you ever been physically abused, and that sort of thing. So, my particular situation, it’s rare…we ask those questions to an awake and oriented person. Well, most of our people come to us completely anesthetized from the operating room, and by the time they do wake up they’re pretty disoriented.”
A nurse described one situation as, “an elderly gentleman came in with cigarette burns on his back, and he did not smoke, and a step-son who was a primary care giver did. We just kind of figured that had to be the son. There was no logical explanation for it [other] than that. And it wasn’t a single burn; it was multiple burns on his back.”
An example of establishing rapport to confirm suspicions was provided. “Ultimately my goal is to be able to have time alone with that patient. If we have a good rapport going on, the family will leave. If we force them to leave, a lot of times that really frightens the patient and that puts up more defenses because then they really think they are going to get in trouble.” Thus, suspicions of elder abuse lead to the reporting of an allegation of abuse.
Reporting of Elder Abuse
Similar themes were found from all the nurses where reporting of abuse is conducted in the hospital setting according to hospital policy. In most instances, the nurses reported suspected abuse to the patient’s physician or the unit’s social worker. And in a VA hospital, one nurse reported, “I know in the hospital I work in right now that we aren’t supposed to report it directly to the Department of Human Services. We are supposed to go to the federal before we go to state, as this is a federal hospital. We have to report it to the manager and then the social worker, and then she takes it further.”
One nurse said, “I would report, because there’s not a penalty to reporting, unless you are doing it to be malicious. There’s no penalty and there’s no harm to the patient by me saying, something doesn’t seem right here.” Stressing the importance of physical injuries, one nurse would “find the physician probably first, so that the physical conditions can be dealt with, and then we have our nurse managers, and the nurse managers’ then are required to notify appropriate people.”
Nurses generally seemed to let someone else do the actual reporting to the state’s adult protective services agency. “No, I’ve never reported the abuse. I’ve told them what I’ve noticed, and then the social worker does the report.” And another similar response, “We’ve got the chain of command: our charge nurses, or supervisor, and so on. It’s always worked. We have an excellent social worker.”
Another similar theme to reporting was that the nurses didn’t know what happens after the allegation is reported to the social worker. A nurse described, “I’m not sure how the system works as far as reporting up past the social worker…where it’s supposed to go, but I’d always go to the social worker.” Similarly, nurses did not know the end result of the case, if it was founded or not. A nurse conveyed, “I don’t really know whatever happens afterwards. It goes to the manager, it goes to the social worker, and then it goes to…I don’t know, like a safety officer or something and then it goes…I don’t know where it goes. It goes to some federal officer and then state gets notified. So, it’s like, where does it go? It’s like out there in virtual space or something.” Another nurse said, “We never find out a result.”
In emergency situations, a nurse reported, “If it was severe enough you would have to call the authorities. Absolutely, call the police and make sure whoever the perpetrator was had no access to the patient.” And because of the shift changes and staffing, another nurse conveyed, “…because we do 12-hour shifts, but there are a lot of nurses that take care of these patients, so you always want to make sure to give your thoughts and your feedback to give it to the next nurse to be sure it doesn’t fall through the cracks. Because you’re not going to come back a week later and be like, Well you know I thought there could potentially be… You don’t want that.”
Barriers to Reporting Elder Abuse
Reasons provided by the nurses why patients are reluctant to report being abused include being scared, feeling they deserve the abuse, it may get worse when they get home, fear of being relocated to a nursing home or different institution, fear of abandonment, or they don’t want to get their children in trouble. One nurse stated, “You have an inverse ratio of power in that relationship, whether it’s with a spouse, or a neighbor, or a child, or whoever the perpetrator is. These people are older. They are dependent on who ever or at least their perception is that they are dependent on that person for whatever, shelter, food, clothing, care, money, or whatever. I think they are afraid to disrupt it.” Another nurse reiterated the same thought, “people that are co-dependent on other people tend to need that other person and tend to justify [the abuse].”
A similar thread across interviews was that the perpetrator was a relative and they didn’t want to get them in trouble. The nurse felt the patient thinks, “Oh, I brought this child up, this is how I brought them up to be. They get real touchy when it’s their kid.”
Nurses provided mixed responses about the state’s legislation, including the following: we don’t need a law, the law should be better enforced, and healthcare professionals’ education should be more frequent and content expanded. A nurse responded about Iowa legislation that, “I don’t really think we even need the law, because we do it anyway.” And another nurse provided a different opinion, “Oh, I think it definitely needs to be there, because, you know, without that, some people when they notice it, well, that’s too bad, but it’s not me.”
Healthcare professionals in Iowa are required to report allegations of elder abuse. A nurse’s perception about this reporting was, “I think that if people feel like its mandatory, they have to, they are more likely to do it than if they think, Oh, I don’t really have to do it. I know it’s wrong, but I don’t really want to get involved.” Whereas, another said, “the nurses that I know anyway take that seriously and realize that they have made an oath, so that if they feel that something is going on with someone that it is their moral and ethical duty to step up and say, This isn’t right and I’m not going to let it continue.”
Completion of a dependent adult abuse curriculum is required for healthcare professionals, beginning when they enter a healthcare profession and every five years thereafter. Additional content to this curriculum was suggested, as “more education about it [reporting abuse], what we can and cannot do. And our legal liability, are we putting ourselves up for a lawsuit.” Another complaint about the law was “the law doesn’t lay out the signs and symptoms [of abuse], doesn’t tell you when you see it. It doesn’t give you that way of noticing the abuse. It just gives you a way of contacting the law enforcement. It doesn’t give you a way of recognizing the abuse or…how to recognize the symptoms.” I think it’s adequate, but like I said I’d like to have something on elderly abuse and just abuse in general annually. Because I don’t think every three years is enough.”
In response to the law needing to be better enforced, one nurse stated, “we don’t have investigators out there,” Indicating that the law should provide for additional investigators for conducting investigations of alleged abuse. Another final thought on the law was, “in the best of all worlds, we wouldn’t have abuse [and then wouldn’t need the law].”
Improvement in Practice
Various ideas were suggested for improving nursing practice for elder abuse in critical care. Suggestions included the following: conduct health history in private, ask safety questions on admission assessment, readdress the issue of elder abuse at discharge from the unit, establish the reporting of elder abuse as a priority for the unit, and offer elder abuse education in addition to that required by law.
One nurse reports, “On admissions, we ask questions like, Are you in a relationship where you feel unsafe? Are you in a relationship where you are being harmed by someone? Do you want to harm yourself?” Those kinds of things. We ask those questions, and that gives them an opportunity to say, Yes.” Emphasizing the need for admission assessment, another nurse responded, “You know, I think probably…, you have to identify that there is truly a problem, and for example, a problem there. Epidemiology comes up, documents transmission of one bacteria from one patient to another that can be stopped by washing your hands. And they show that there is a problem. And if there is problem that it can be changed by doing this. So, I think that if you could document that there is some type of abuse going on, then I think there is more motivation, and maybe that’s how to change.”
Additional education was suggested by providing information about the seriousness of elder abuse. A nurse suggested, “I think it should almost be like an annual thing that they cover in the hospital. Because, I don’t know, I think with the way the economic situation is out there....I just think things are going to get worse instead of better and I think we need to be more aware of that.” Another nurse stated, “Just keeping the education going.”
In conclusion to the interviews, one nurse stated, “I just really think we’re on top of it. Not to toot our own horn, but I really do, I really think that we’re on top of it… any admission, I mean, we’re really looking at those things whether you realize it or not.”