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The combination of two theoretical paradigms aided in understanding the decisions made by staff to mistreat elderly nursing home residents. These paradigms included: a theoretical model for predicting causes of maltreatment of elderly residents developed by Pillemer (1988) and the Theory of Reasoned Action developed by Ajzen & Fishbein (1980) – a theory that deals with human behavior and the factors that motivate human decisions. Based on these models, maltreatment of elderly nursing home residents may be predicted based on characteristics of the facility, the resident, and the staff (demographic traits, professional experience, and training); in addition, maltreatment of elderly residents by staff is influenced by behavioral beliefs – attitudes about elderly people, views and knowledge about maltreatment of elderly nursing home residents, as well as by subjective norms – the manner in which staff members perceive the institution’s social policy towards this phenomenon. In other words, to what degree staff members sense that maltreatment is a customary social norm at the facility. People behave when such behavior is evaluated as positive and when they perceive an organizational reality that dictates pressure in such direction.
In addition, the qualitative study consisted of an attempt to access the experiential world of elderly long-term nursing home residents who experienced some sort of maltreatment and to understand their experience and the subjective meanings that each resident attributes to such an experience and its causes. The phenomenological research added another dimension by discussing the causality of awareness-dependent meanings rather than only linear causality derived from quantitative findings.
The population included in the quantitative study consisted of the staff of 24 long-term nursing homes in Israel. Six hundred questionnaires were distributed in these facilities and 510 of them were completed and returned (N=510). In addition, 24 questionnaires were distributed among the directors of the facilities, and 22 of them were returned. The questionnaires were structured questionnaires constructed specifically for the present study in order to answer the research questions and its hypotheses, based on the two theoretical foundations. In addition, data on the characteristics of each facility were collected individually.
The qualitative study sampled 23 elderly residents who suffered from various types of maltreatment, through systematic sampling. The criteria for identifying and selecting the residents were: men and women aged 60 and older who were mistreated while living at a long-term nursing home and who are capable of expressing themselves on a level that would enable in-depth interviews. The respondents were interviewed individually by in-depth semi-structured interviews using an interview guide, throughout the year 2007. Each interview lasted two to three hours and the interviews were recorded and transcribed.
The quantitative research findings indicate that slightly more than half of the staff sampled reported abuse of elderly residents over the past year, involving one or more of the types of maltreatment investigated. The findings indicate that the total number of various types of maltreatment reported was 513. About two-thirds of the cases were incidents of neglect (physical neglect and mental neglect). About 70% of the respondents reported that they had been present at an incident/s in which another staff member abused an elderly resident in one or more types of maltreatment, while in such situations mental abuse and mental neglect were the most prevalent forms of maltreatment.
The research findings indicate that of all the variables consisting of behavioral views only attitudes regarding the elderly serve as partial mediators between staff characteristics and mental abuse, while the variable of subjective norms is a partial mediator in cases of mental abuse, mental neglect and total number of maltreatment cases. In addition, there is a combined effect of behavioral views and subjective norms on physical and mental abuse of the elderly.
The independent variables which have a unique effect on maltreatment of elderly nursing home residents and which were found to be significant predictors of the various types of maltreatment are: Physical abuse – two variables: mental fatigue of the caregiver and the resident’s cognitive state. Mental abuse – two variables: depersonalization of the caregiver and the resident’s cognitive state. Mental neglect – two variables: staff turnover rate and mental fatigue of the caregiver. Physical neglect – the variable of staff turnover rate. The total number of maltreatment cases was affected by the resident’s cognitive state.
All the above proves that staff attributes, i.e., the degree of emotional burnout and the degree of depersonalization; and resident traits, i.e., their cognitive state (dementia) affect the chance of physical abuse and mental abuse; while institutional characteristics, i.e., staff turnover rate and staff traits – their level of emotional fatigue – affect the chance of physical neglect and mental neglect. Finally, resident traits, i.e., their cognitive state (dementia), are the most significant variable influencing the total number of maltreatment cases
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Analysis of the qualitative findings enables categorization of the coping methods of elderly residents who experienced maltreatment according to three major themes in which the relationship between the “self” and the maltreatment is manipulated. The first theme is the form of coping employed by “combative elderly” – those who try to change the situation and to cope with external factors. The second theme, “passivity,” and the third theme, “construction of new realities,” both involve transfer of the self to another situation which consists of internal coping.
The first theme – the “combative elderly” – forms a pattern of combative coping by elderly people who encounter maltreatment. When this group of people encounter a situation that threatens their self-respect or their life they do whatever they can to overcome it, both in relation to life events in the past and the present. They do not expect anything from others, particularly not from the institution; rather they trust and believe only in themselves. They believe that they have the power to change the situation. Previous and present reality has taught them not to trust others to effect changes. They are the only ones who know what needs to be changed.
The common denominator of all respondents subsumed under this theme is the combative response, i.e., to respond to offense and not remain silent. However, there are two separate groups that employ the combative response: one group of elderly people report isolated incidents of abuse, however they believe that in general life at the nursing home is good and that the facility tries to care for them, while the second group of elders report lasting maltreatment and neglect at the nursing home. The solitary incidents group perceives the maltreatment as unique events that usually stem from the staff’s personal traits: ethnic group, staff burnout, professional training of caregivers/nursing assistants, while the group suffering from lasting neglect believe that they are not abused by a specific person rather by the facility and its manner of caring for the elderly.
The second theme – the passive elderly – presents a coping pattern characterized by lack of response, disregard. This group attempts to noticeably conceal their identity and embrace a passive identity. This tendency stems from conformity, submission. They perceive their reaction to their maltreatment as stemming from lack of choice. They believe that they do not have much choice in life. Most of their life is perceived as a cruel and uncontrollable fate. All these elders responded to their maltreatment passively. They were passive towards their predestined fate and the abuse they experienced. They believed that they have no choice but to accept their fate in order to avoid a worse situation. This group was divided, again, into two sub-groups. One included those mistreated by family members while living at the facility. The second group included those mistreated and neglected by the nursing home and its staff. The population of passive elderly – victims of family maltreatment – identify their abusers as family members however they do not blame them. They blame themselves and the social circumstances (drug abuse, battered women, financial pressures, fate, etc.). In contrast, victims of abuse and neglect of the nursing home and its staff tie the basic cause of their maltreatment to their personal traits and dementia.
The third theme – new reality constructions – presents a coping pattern in which a new reality is constructed. These elderly people completely ignored the situation. This coping method is similar to the avoidance characteristic of passive behavior, but it is much more extreme in its self-detachment from the maltreatment. This manner of coping is intended to define the maltreatment as unconnected and irrelevant, and therefore all the problems connected to it are also ostensibly insignificant. Thus, it is difficult to understand what they perceive as its causes.
The research findings have theoretical and practice implications. Theoretically, this is the first study that examines maltreatment of the elderly population in residential settings in Israel within a conceptual framework which combines the theoretical model for predicting causes of maltreatment of elderly nursing home residents developed by Pillemer (1988) and the Theory of Reasoned Action developed by Ajzen & Fishbein (1980). These models and the present research findings lead to an expanded and improved research model for investigating the maltreatment of elderly long-term nursing home residents. Similar to the theoretical premises of the Theory of Reasoned Action regarding the connection between subjective norms and behavioral views as affecting behavior – in the present study, only attitudes about the elderly had an effect on staff traits and the decisions they made in incidents of physical and mental abuse.
Among the factors described in the theoretical model developed by Pillemer (1988), the chance that elderly people will suffer from (physical and mental) abuse and (physical and mental) neglect is greatly affected by their cognitive state. Among the factors described in the theoretical model developed by Pillemer (1988), the chance that elderly people will suffer from (physical and mental) abuse and (physical and mental) neglect is greatly affected by their cognitive state. In addition, it must be emphasized that the institution’s features were found to be the most significant factors influencing resident neglect while staff traits are the major factors influencing mental and physical abuse against residents. Thus the present study illuminates the different effects of the factors presented by Pillemer on the types of maltreatment. These findings are compatible with the factors described as causes of maltreatment in qualitative interviews with elderly victims of maltreatment in nursing homes. Accordingly, this study contributes to expansion of the theoretical and practical knowledge base and to comprehension of the hierarchy of factors that affect abuse in nursing homes.
From an applied point of view, the research findings indicate the need to conduct periodical, structured and regular training for staff, particularly practical nurses and nursing assistants, unrelated to their professional seniority, concerning difficulties that might arise while caring for demented residents, difficulties in coping with heavy work loads, attitudes about the elderly, and managing their feelings towards residents. In addition, it is recommended to hold support groups for staff in which they can share with each other their difficulties in coping with aggressive events involving demented residents and personal inability to cope with stressful situations that lead them to abuse residents. In such meetings they can learn from the experience of other staff members how to cope with these difficulties. It is very important to establish an internal and external government regulatory system that will examine the orientation of institutions towards the prevention of maltreatment, the satisfaction of elderly residents, and reach clear policy conclusions to close facilities that are not up to standards.
In cases of residents identified as victims of maltreatment, methods of intervention must be adjusted to residents’ needs, creating a therapeutic environment that will sanction different coping patterns with stressful events without personal judgment. However, such intervention also requires the imparting of knowledge regarding rights, appealing to organizations to help enforce the law, encouraging residents to seek assistance, and awareness of the option of transferring to other nursing homes. In addition, it is important to construct support systems for elderly residents who have been victims of maltreatment.
This abstract is based on a doctoral thesis, supervised by Prof. Ariela Lowenstein, Dept. of Gerontology, Faculty of Welfare & Health Studies, The University of Haifa, Haifa, Israel. The thesis was approved in August 2008.
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