Preventing Patient Abuse: Why Abuse Happens and How to Stop It

RISK FACTORS FOR PATIENT ABUSE

LaRocco (1985) states that the causes of abusive behavior can be divided into three categories: the staff member, the setting, and the patient. Some staff members involved in direct patient care are underpaid, poorly educated, and dealing with personal problems. All of these factors may play a role in how they deal with a demanding patient (LaRocco, 1985). Other factors that contribute to patient abuse by staff include caregiver stress when feeling overwhelmed by caring for the elderly patient, caregivers with a history of substance abuse or a history of abusing others, and caregivers who are emotionally or financially dependent on elderly patients (Hildreth et. al., 2011). The setting itself can also contribute to patient abuse. In institutional settings, the indiscriminate hiring of employees, lack of training for unskilled staff, insufficient staff, lack of managerial supervision, and tolerance of unacceptable behavior can lead to patients being cared for inadequately (LaRocco, 1985).

Health care settings that lack proper training for staff on how to care for, treat, and handle patients and that lack standard policies and procedures for reporting patient abuse also place their patients at risk for abuse by not holding their staff members accountable. Lastly, some characteristics of patients and/or their families may make abusive behavior more likely (LaRocco, 1985). As previously noted, there are several things that place elderly patients at risk for abuse. In addition to dementia, being a woman, and being older than 74 years old (Juklestad, 2001; World Health Organization, 2011; Yon et. al., 2019), elderly patients who are physically dependent on others and/or suffer from depression, loneliness, or a lack of social support are at higher risk (Hildreth et. al., 2011). Additionally, patients who are abusive toward staff members and cause distress or harm to staff members through physical or verbal abuse, including racial slurs, spitting, hitting or kicking, may be more likely to suffer abuse themselves (LaRocco, 1985). However, provocation does not excuse abusive behavior from staff members (LaRocco, 1985). Adults and patients who are in vulnerable groups, such as children and those with intellectual disabilities, as well as those in a vulnerable state (i.e., under the influence, sedated, etc.) are also at risk for abuse.

RECOMMENDATIONS

LaRocco (1985) recommended that institutions establish environments where there is concern for patients. Institutions can show concern by having nursing and hospital administration make frequent patient contacts to assess patient satisfaction (LaRocco, 1985). In addition to making patient contacts, establishing a patient centered environment where the patient advocate is a visible employee who has direct and immediate access to administration is another measure that can be taken to prevent patient abuse (LaRocco, 1985). Additionally, “all patient complaints should be thoroughly investigated and disciplinary action for staff initiated as necessary” (LaRocco, 1985, p.28). Efficiently responding to all patient abuse accusations and incidents and conducting thorough investigations will allow an institution to quickly clear up any misunderstanding related to the accusation or discipline or dismiss the accused staff member, if appropriate.

Feldman and colleagues (2001) designed a list of recommendations for institutions and staff members on how abuse incidents and accusations should be handled when they arise and how they can be prevented (Table 1). While Feldman and colleagues (2001) focused on child abuse and neglect, these recommendations can be applied to all patient groups, whether in institutional or community settings, to aid in properly handling accusations and preventing abuse by staff members and caregivers.

Table 1: Recommendations for Institutions and Staff Regarding Allegations of Abuse

Institutional Issues

  • Have an abuse accusation evaluation policy.
  • Train staff to be aware of their personal responsibility to report and how to activate the abuse evaluation.
  • Train employees to feel personally responsible for the safety of all children.
  • Screen prospective employees for a history of substance abuse or perpetration of past abuse or interpersonal violence.
  • Recognize staff stress and mental difficulties and act to relieve them.
  • Train staff, especially non-professional members, in patient “boundary” issues.
  • Have a patient restraint policy and staff training in its implementation.
  • Promptly notify the involved physicians, site supervisors, and hospital administrators that a complaint has occurred.
  • Brief and debrief the accused and his or her colleagues.

Individual Staff Issues

  • Conduct sensitive examinations in formal hospital settings, with an attendant.
  • Say what you are doing and why before you do it.
  • Recognize patient anxieties because of past abuse experiences. Chaperone in any questionable situation.
  • Use caution with mentally ill, sedated, or intoxicated patients. Recognize problem families and develop a hospital clinical safety plan. Handle fragile patients carefully.

may be overwhelmed by their responsibilities; using safe houses and emergency shelters to separate victims of abuse from abusive environments (i.e., residential homes and foster care); providing psychological programs for abusers; providing patients with the numbers of helplines to provide them with information and referrals; and providing caregiver support interventions.

PREVENTION STRATEGIES

Overall, the goal of the recommendations to institutions and staff regarding allegations of abuse (Table 1) is to prevent abuse in institutional and community settings and among all patient groups, rather than simply respond to accusations and incidents. According to the World Health Organization (2020), many strategies have been implemented, mainly in high-income countries, to take action against and prevent elder abuse. These strategies can be applied in all settings to prevent patient abuse among all groups. Some examples include public and professional awareness campaigns to educate the public on abuse; screening to identify potential abuse victims and abusers; providing respite care to caregivers when they are feeling overwhelmed; providing stress management programs to caregivers and staff members in institutional settings; providing caregivers with training on dementia; and requiring institutional facilities to define and improve their standards of care (World Health Organization, 2020). Establishing a system of checks and balances, providing proper training on patient care and handling, clearly communicating to staff members their responsibility to patients, instructing staff to clearly communicate procedures to patients and their families, having a standard policy on abuse and procedures to follow up on abuse accusations, and creating a patient-centered environment for institutional and community settings can work toward preventing patient abuse and strengthening the relationship between staff members, caregivers and patients.

An additional prevention strategy that should be explored involves hospital security and how they can be used to help prevent patient abuse. When reviewing “Security Personnel Practices and Policies in U.S. Hospitals: Findings From a National Survey,” Schoenfisch and Pompeii (2016) examined the characteristics and responsibilities of hospital security teams, components of hospitals’ workplace security policies, and hospitals’ security personnel training in workplace violence recognition and prevention. Of the 340 hospitals examined, more than half (55%) had all of the components for workplace violence policy that are recommended by the Occupational Safety and Health Administration, including recordkeeping, worksite analysis, management commitment, employee involvement, hazard prevention and control, and safety and health training (Schoenfisch & Pompeii, 2016). It is possible that if more hospitals included all of the recommended components, incidents of harm against patients could be reduced. While the details of hospital security personnel training were not specified, there needs to be a balance between employee health and safety and patient safety and satisfaction. In addition to training on employee safety, security personnel should be trained to recognize suspected instances of patient abuse and neglect. Although security personnel do not interact with patients in the same manner as health care professionals, they should be encouraged to report instances of suspected patient abuse or neglect and the health care professional involved.

PATIENT RESOURCES

If possible, patients and/or their families should first take abuse accusations to a managerial staff member at the institution where the incident took place. If they need additional help, there are many resources available, from the major organizations listed below in the United States and Canada to local groups that offer additional services and information.

  • Locator is a public service of the U.S. Administration on Aging connecting patients to services for elderly adults and their families.
  • The National Center on Elder Abuse through the Administration for Community Living offers information on how to report abuse and how to detect, stop and prevent abuse, as well as resources on training, awareness, where to get help, and federal and state abuse and neglect laws.
  • The National Adult Protective Services Association is an organization present in all 50 states that provides services to victims of maltreatment among the elderly and other vulnerable adult populations.
  • The National Domestic Violence Hotline assists victims and survivors of domestic violence by offering help to anyone who is a victim of abuse, providing information on where to get legal help, and offering resources for abusers looking to get help.
  • The U.S. Department of Justice provides information on U.S. law and enforces federal law.
  • Seniors Safety Line, a 24/7 resource that offers support in more than 150 languages for seniors who are experiencing abuse
  • Retirement Homes Regulatory Authority, an organization where elderly individuals or their family members can file a complaint if a complaint filed at a retirement home has not been resolved.
  • Seniors’ INFOline, a group that provides information on elder abuse
    • Phone: 1-888-910-1999
    • TTY: 1-800-387-5559
  • Kid’s Help Phone, an organization that allows children to call in and chat about anything and that will connect them to the proper resources for additional help.
  • Canadian Child Welfare Research Portal, a webpage to help individuals locate their local child welfare authority and the authority’s contact information.
  • Child Abuse Hotline, a 24/7 helpline to report child neglect, abuse or sexual exploitation.
    • Phone: 1-800-387-KIDS (5437)
  • Interior Health, an agency that responds to reports of Adult Abuse and Neglect