The underreporting of abuse

Victims of elder abuse have traditionally been somewhat reluctant to report that they have been abused, especially if the perpetrator is a family member or other perceived authority figure (Jordan, 2001, p. 149). This silence is has contributed to an historic underreporting of elder abuse. Although reports of elder abuse have increased over the past decade, it is still believed that many cases of abuse or potential abuse go unreported.

All fifty states and the District of Columbia have laws that require doctors and other professionals who work with the elderly to report suspected cases of abuse; however, research indicates that doctors, social workers, and other care providers, along with their aging patients and clients, tend to downplay suspected signs and symptoms of abuse (Levine, 2003, p. 37). Nursing home administrators have also been reluctant to report cases of elder abuse that occur within their facilities (GAO, 2002).

The GAO found that residents and family members were encouraged to report charges of abuse to the administrator of the facility and not to report the abuse to the police. In many cases, nursing home policies prevent residents from contacting the police until the resident has first reported the incident to the administration of the facility (GAO, 2002). This practice may have caused an underreporting of abuse at residential care facilities. When reports of suspected or actual abuse are made, it is often not in a timely manner. The GAO (2002, p.

10), found that in two-thirds of the cases, abuse reports, when they were reported, were filed with local law enforcement agencies two or more days after the incident had been reported to the manager for the facilities. This delay in reporting and a lack of credible witnesses that could testify that they saw abuse as it occurred have been linked to the degradation of evidence and faulty memories of older patients; consequently, relatively few prosecutions and even fewer convictions result from reports of abuse from a nursing home facility (GAO, 2002, p 14).

Detecting abuse In some cases, there may be visible evidence of abuse, especially physical abuse. In other cases, abuse is harder to detect and to substantiate. Some nursing homes have installed video surveillance systems to monitor patient-employee interactions and for safety and security reasons, although nursing home managers as a group have been opposed to video surveillance, citing privacy concerns for residents (Kohl, 2003).

For the residents of a residential care facility, the facility is their home. Installing a camera could violate the 4th amendment guarantees against unreasonable search and other violations of privacy. Administrators of residential care facilities would need to weigh the advantages of monitoring against the loss of privacy that would accompany the practice. In the absence of credible witnesses or surveillance cameras, other means have been used to detect possible abuse.

Several instruments have been developed to help social workers and healthcare providers detect abuse and to screen for suspected abuse. In addition to these studies, the American Medical Association and the American College of Obstetricians and Gynecologists recommend that physicians routinely ask their elderly patients direct and specific questions about how they are being treated by their caregivers and about any potential abuse (Berg, 2004, p. 158-159).

More formal assessments may be conducted with the Vulnerability to Abuse Screening Scale (VASS), a 12-item self-report measure that determines the patient’s risk of abuse based: Vulnerability, Dependence, Dejection, and Coercion (Schofield & Mishra, 2003), the Brief Abuse Screen for the Elderly [BASE] and the Hwalek-Senstock Elder Abuse Screening Test [HSEAST], and the Caregiver Abuse Screen [Reis-Nahmiash CASE] (National Guidelines Clearinghouse, 2004).

The Conflict Tactics Scale [CTS], although not specifically designed to be used with the elderly, has been shown to be effective in determining whether individuals have been threatened or assaulted and is considered to be a valid assessment for physical and verbal abuse, but it does not address the issue of neglect (Fulmer, Guadangno, Dyer, Connolly, 2004, p. 300). In addition to these formal assessments, nursing home administrators may benefit from checking in on their patients and performing an informal assessment of their treatment and attitude.

Main Thesis: TQM Could Reduce Elder Abuse in Residential Facilities Total Quality Management (TQM) is a philosophy of management that emphasizes the improvement of quality at all stages of an organization’s operations (Ryan & Hurley, 2004). In the health care setting, TQM would be characterized by efforts to improve the quality of the interactions between staff and residents as well as efforts to improve all of the operational aspects of the organization that contributed to the overall quality of the services delivered.

TQM emphasizes the importance of breaking down the supply chain into smaller components, analyzing each, and checking for quality throughout the system. The TQM philosophy also maintains that the overwhelming majority of quality failures are the result of faulty systems and not faulty people. When viewed through the lens of TQM, elder abuse may be seen as a systemic breakdown in the quality of services that are delivered to the consumer. Using TQM to identify where problems occur TQM emphasizes identifying problems at the granular level.

TQM organizations would not be satisfied with simply stating that an organization has a problem with the delivery of services or a high number of allegations of abuse, but would endeavor to discover where the breakdown of services occurred and what can be done to repair it. In the case of elder abuse, the TQM organization would identify the factors that could possibly contribute to elder abuse. For example, it is possible that abuse is the result of having an understaffed, overworked workforce.

In this scenario, nurses and other employees would be prone to abuse because they were exhausted or overstressed to the point that they would lash out at patients in an inappropriate manner. This does not excuse the behavior, but identifying the cause of the behavior would allow the organization to take concrete steps towards correcting the problem. Conversely, the facility may have an acceptable number of qualified workers on staff but those workers may be unaware of what constitutes abuse or the rights of elderly patients.

If this is the case, then more training would be an appropriate response, since adding additional staff members would not correct the problem. Using TQM to correct the identified problems TQM is not a one-time response, but should be viewed as an ongoing process in which problems are identified and corrected. This ongoing nature of TQM is sometimes referred to as continuous quality improvement, or CQI. CQI uses an ongoing four-step process in which solutions for identified problems are planned, enabled, checked, and the results acted upon.

Managers who are familiar with TQM and CQI refer to this as the PDCA cycle, in which P stands for Plan, D represents Do, C stands for Check, and A for Act. (Source: Minkoff & Cline, 2004) TQM and CQI rely heavily on data, including industry benchmarks and assessments. Objectives and results are based on data, not hunches, and quality outcomes are achieved by deliberate and planned interventions over time. Because CQI is an ongoing process, the goals of TQM and CQI organization are always moving forward as the system learns and advances (Minkoff & Cline, 2004).

Thus, plans are subject to change as targets are reached. All plans, however, point towards the ultimate objective of improving quality in the product and in the organization’s interactions with customers. The first phase of CQI implementation involves establishing benchmarks. Internal benchmarks are based on the production that already occurs within the organization. Benchmarks provide a starting point for future reference. To be useful, these measurements must be as accurate as possible, and should reflect what is actually happening, not what managers or stakeholders might wish is happening.

In the case of elder abuse, these benchmarks might include the number of positive interactions that staff members have with patients, the nature of patient-staff interactions, the number of abuse allegations, and how abuse cases are handled. Once the benchmarks have been established, plans for improvement may be developed. In this case, appropriate plans might include plans for increasing or training the staff, working with patients, or other strategies to help reduce the potential for abuse. CQI focuses on systemic change; the focus of the resulting improvement plan should be on improving the system.

Once the plan is established, it must be put into action. Managers need to understand the plan, how to implement it, and the expected results. Once the plan is in place, it must be checked with objective measurements. After the changes have been checked, then the organization may act on what has been learned. Appropriate actions may include additional training about the new procedures, the development of more materials, or other steps that can bring the outcomes more inline with benchmarks or established goals. Continuous quality improvement is an ongoing process.

After the new plan has been implemented, checked, and acted upon, it is time to start the planning process over again, using the revised data as a starting point. Using TQM to protect patient-residents Finally, TQM relies heavily on the feedback of end users. As the GAO found, nursing homes and other residential care facilities tend to prefer to handle charges of abuse in-house without informing the appropriate social service agencies and law enforcement agencies. A TQM philosophy would place a greater emphasis on the reports of victimization.

Rather than viewing law enforcement and social service agencies as potential threats, the TQM organization would view these agencies within the context of the overall organizational structure. This change in perception of the roles of the various agencies could increase the number of instances of abuse by residential care employees and could reduce the amount of time that lapses between the initial reports of abuse and the facility notifying the appropriate agencies. Recommendations for Business Practice Residential care facilities should implement TQM to develop systems that will reduce the likelihood of elder abuse.

Facility managers should create open, honest organizational cultures within which abuse cannot be hidden, and managers should work with law enforcement and other appropriate agencies to discourage abuse. Previous researchers have concluded that TQM could have “profound consequences on the delivery of health care services” (Kaluzny, McLaughlin, & Jaeger, 1993). If elder abuse in nursing homes and other residential facilities are viewed from a quality control perspective, then it becomes evident that TQM has the potential to reduce elder abuse in these settings.

In a TQM model of elder abuse, the abuse would represent a symptom of a larger systemic problem that would need to be addressed. While this does not negate the personal responsibility of the individual abuser, the TQM model would recognize the institution’s role in creating and contributing to an environment in which abuse could occur. Residential care facilities could use TQM to identify potential problems, to make necessary corrections, to work with patients to ensure that abuse or the perception of abuse does not occur. Recommendation 1: Make systemic changes

Although specific incidences of abuse may be committed by individual employees, abuse does not occur within a vacuum. In some cases, the hiring policies and other practices of residential facilities leave the patients who live there more vulnerable to abuse (GAO, 2002). This problem is no doubt exacerbated by the twin swords of increased patient numbers and a decreasing of qualified caregivers. TQM can help organizations to identify their potential vulnerabilities and may suggest appropriate remedies that could be implemented. Recommendation 2: Change the organizational culture

Adopting a TQM philosophy would require a cultural change for residential care facilities. Currently, the culture of many residential care facilities can be best described as a culture of self-preservation, or, in less polite terms, a culture that is best described by the familiar business term of “CYA”. In such a culture, incidents are not reported to outside agencies and the patients are placed in an adversarial position against the facility. Unfortunately, abuse thrives in secret and relies on the inaction of others who are unwilling to intervene.

TQM emphasizes relationships between the departments and individuals within an organization and is characterized by increased communication within the organization and greater involvement of all employees in the quality improvement process (Daily & Bishop, 2003). Organizations that use TQM tend to be less hierarchal and to have flatter organizational structures. Daily and Bishop (2003) found that teamwork success in the TQM environment was associated with greater employee involvement in the decision making process.

Employees that feel empowered to make decisions are more likely to conform to the organizational culture and to cooperate with other employees in achieving organizational objectives. Employee empowerment has also been associated to increased employee commitment. TQM emphasizes the relationship between the consumer and the organization. In the residential care setting, nurses and other staff members function as a surrogate family for the residents. In addition to performing their duties as described in their job description; i. e.

, bathing, feeding, and otherwise assisting patients and meeting other specified needs, nurses and staff members are also in a position to help meet some of the socialization needs of the residents, providing conversation or even just a friendly face to whom the patient can turn. This positive relationship is reciprocated, to some extent, when nurses are allowed or encouraged to get to know their patients beyond their physical ailments or disabilities (Clarke, Hanson, & Ross, 2003). The patient’s quality of life improves when nurses are allowed to view their patients as people (Tonuma & Winbolt, 2000).

Patients also appear to benefit from the development of appropriate social, nonsexual physical, and intellectual intimacy with caregivers (Bullard-Poe, Mulligan & Powell, 1994). To be beneficial, these relationships must be kept within appropriate boundaries, yet nurses and other caregivers can develop significant personal relationships within the boundaries of a professional context. Just as worker empowerment leads to greater commitment to the organization, a sense of patient empowerment also helps patients and their families as they work with the residential care facility (Ingersoll-Dayton, Schroepfer, Pryce, & Waarala, 2003).

This empowerment could be achieved through a TQM design and the appropriate interactions with resident-patients. Recommendation 3: Work with and not against outside agencies The culture of self-preservation that permeates many residential facilities has created a barrier that prevents these organizations from soliciting and receiving help from outside agencies. Given the potential for litigation and other forms of punishment for elder abuse cases, this is not an unexpected response. Ultimately, however, this strategy puts the organization and the public that it serves at a greater risk.

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