Abuse and Neglect of Older Adults in Institutional Settings: An Annotated Bibliography

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Les mauvais traitements el la négligence envers les personnes âgées en milieu institutionnel.Bibliographie commentée.

Foreword

Introduction

Section One: Introductory Issues

III. Specific Types of Abuse
A. Financial
B. Psychological
C. Inappropriate Use of Physical Restraints
D. Systemic Abuse

V. Guiding Principles
A. Right
B. Autonomy
C. Ethical Considerations
D. Cultural and Geographical Implications

Section Two: Causes, Identification and Assessment

II. Causes
A. Stress, Burnout
B. Lack of Training/Understanding
C. Exercise of Power
D. Resident Characteristics
E. Systemic Factors

Section Three: Intervention

Section Four: Prevention

V. Administrative Strategies
A. Development of Policies, Procedures & Protocols
B. Employment Practices
C. Collaborative Efforts
D. Seeking Alternatives

VI. External Strategies
A. Community Reviews
B. Ombudsman
C. Inspection/Regulation
D. Legislation

Appendix A - Members of Planning and Advisory Groups

Foreword

Since early 1992, the Mental Health Division has been working collaboratively with professional associations, educators, voluntary associations and others to develop and enhance resource materials dealing with abuse and neglect of older adults. While initial work focused on community settings, subsequent work included significant attention to institutional settings.

This work is part of the Federal Family Violence Initiative, which has been providing funding support to the Health Services Directorate over the four year period from April 1991 to March 1995. The Directorate's mandate has been to increase the awareness and sensitivity of health professionals to the issue of family violence, and promote the development of resource and training materials to enhance the capacity of health care providers to address this issue effectively.

Attention has been given to training materials, community guidelines, curriculum approaches and practice materials. Prevention and early intervention have been important aspects of all work, as well as attention to the needs of those who have been affected by violence in their lives. Our materials affirm the rights of older adults to self-determination, respect and dignity. Mental Health Division publications to date focused on abuse and neglect of older adults are:

Community Awareness and Response: Abuse and Neglect of Older Adults, published by Health Canada in 1993;
Resource and Training Kit for Service Providers: Abuse and Neglect of Older Adults, currently in press.

This current series on abuse and neglect of older adults in institutional settings includes the following publications:

Abuse and Neglect of Older Adults in Institutional Settings: Discussion Paper Building From English Language Resources
Abuse and Neglect of Older Adults in Institutional Settings: Discussion Paper Building From French Language Resources
Abuse and Neglect of Older Adults in Institutional Settings: Annotated Bibliography

This Annotated Bibliography provides an overview of selected English and French language materials published in Canada and North America. Some additional unpublished materials have also been referenced and are available through the sponsoring library and resource centre.

The Discussion Paper Building From English Language Resources is a reflection of English language literature on this issue, and focuses on implications for program and policy development.

The Discussion Paper Building From French Language Resources, available later in 1995, will provide a reflection on policy and practice issues building from French language literature and practice.

All publications in this series are available from the National Clearinghouse on Family Violence, Health Canada. Tel. (613) 957-2938 (Ottawa-Hull) or Toll free 1-800-267-1291 Fax (613) 941-8930 TDD (613) 952-6396 (Ottawa-Hull) or TDD toll free 1-800-561-5643

Work on these materials dealing with abuse and neglect of older adults living in institutional settings began in December 1993 with the assistance of a national planning group who considered priority needs and possible approaches for addressing these needs. These publications represent the work of the original planning group and the specific direction provided in June 1993 by a national advisory group who worked until June 1994 to oversee content development of the first products (see Appendix A for Members of Planning and Advisory Groups).

Charmaine Spencer from the Gerontology Research Centre, Simon Fraser University at Harbour Centre, undertook the collection and review of the English language materials for the annotated bibliography, as well as preparation of the first discussion paper. Marie Beaulieu from I'Université du Québec à Rimouski undertook the collection and review of the French language resources for the annotated bibliography and preparation of the next discussion paper.

Peer reviewers from across Canada examined draft versions of the first discussion paper over the spring of 1994, and provided constructive comments for the final text. Teresa Lukawlecki assisted in the early collection of bibliography resources, coordination of text development, and preparation of the final documents for publication. My colleague Pauline Chartrand, from the Health Service Systems Division, worked collaboratively with the Mental Health Division throughout the shaping and implementation of this initiative.

Our work on this series has benefited greatly from the expertise, contributions and commitment of the two advisory groups as well as the writers, and the many peer reviewers from all parts of Canada who helped shape the final text. We thank you for your attention to this important area and for sharing your perspectives and experience with us in this work.

Joan Simpson Coordinator, Family Violence Program Mental Health Division Health Services Directorate Health Programs and Services Branch Health Canada

Introduction

This annotated bibliography on abuse and neglect of older adults in institutional settings provides a resource and reference too] for service providers, policy makers, researchers and others in a position to enhance the lives of people who reside in institutions. "Institutions" in this context encompasses a wide range of facilities, from group homes and family care homes with three or four residents, to large scale facilities such as nursing homes or hospitals. Resources highlight abuse and neglect of older adults in institutional settings and note the similarities and differences with abuse and neglect in community settings.

Older adults may encounter abuse or neglect while residing in a facility; it may be a continuation of abuse or neglect experienced in the community or it may be a new problem that started upon entrance into an institution. As with mistreatment in the community, abuse and neglect of older adults in institutional settings involves an abuse of power and the violation of trust while the person is a resident of the facility. Mistreatment may be committed by staff, family, friends or neighbours, especially when the facility failed to safeguard residents.

The primary focus of material in this bibliography is on older adults in institutions. However, many issues of abuse or neglect with respect to an older institutional population may apply to the mistreatment of all people residing in facilities - including younger people with physical or mental disabilities.

This annotated bibliography has been developed to complement the two discussion papers on abuse and neglect of older adults in institutional settings. All of these documents are available from the National Clearinghouse on Family Violence.

The Scope of the Bibliography

Although the annotated bibliography has an extensive listing of books, articles and audiovisual materials on the subject of abuse and neglect in institutional settings, it is not intended to be inclusive. Only resources produced between 1981 and 1993 are considered, with several 1994 exceptions. Additional material on abuse and neglect of older adults in the community is not included here but can be found in such resources as the Elder Abuse Bibliography published by the National Clearinghouse on Family Violence or the annotated bibliography on abuse and neglect of older adults prepared by the Gerontology Research Centre at Simon Fraser University in 1994.

The English resources for this bibliography were compiled based on a framework identified by a national advisory committee and by an extensive search of all relevant indices and abstracts - both print and on-line. In recognition of the multidisciplinary nature of the literature related to abuse and neglect of older adults in institutional settings, the electronic reference databases searched included: Ageline, Psychinfo, Sociological Abstracts, Medline, Cumulative Index to Nursing an(] Allied Health, Health Planning and Administration and Microlog.

The French resources for this bibliography were compiled through a search of relevant indices and abstracts as well as through a written outreach to Quebec agencies and organizations responsible for institutional services for older adults for their most useful materials.

Both English and French language materials are included in this bibliography. The English language materials were prepared by the Gerontology Research Centre, Simon Fraser University at Harbour Centre, and are available there. The French language materials were prepared by le Département des sciences humaines, l'Université du Québec à Rimouski. They have been subsequently catalogued by the library at l'Université de Sherbrooke and incorporated in the collection there.

Canadian interest in the issues related to abuse and neglect of older adults in institutional settings has been gaining considerable momentum in the last two years; a number of facilities across the country have begun to formally address this concern. Activities in this area are ongoing and materials that are currently under development could not be included in this bibliography, e.g., the InterHospital Committee on Domestic Violence in Saskatchewan is developing an extensive set of training materials, Institutional Abuse Prevention Project, which will be available during 1995.

Format of the Bibliography

Introductory Issues
Causes, Identification and Assessment
Intervention
Prevention

Resources in the Introductory Issues section provide a general introduction to and context for the subject. In addition to articles that define specific types of abuse or neglect, this section covers issues such as quality of care/quality of life, guiding principles and ethical issues.

The Causes, Identification and Assessment section highlights articles that explore our current knowledge base of abuse and neglect in institutional settings, particularly its frequency and causes. Indicators, obstacles to identification and reporting, and ethical dilemmas associated with identifying the problem are described. The ethical dilemmas include issues such as potentially breaching confidentiality of residents and "blowing the whistle."

The Intervention section focuses on resources which discuss interventions and the problems specific to institutional settings. How the law relates to abuse and neglect in institutional settings is also covered, that is, either by establishing responsibilities for facilities, or by offering protection when abuse or neglect of residents by staff or family members is uncovered.

Resources in the Prevention section highlight strategies for preventing abuse and neglect. The section is organized into internal strategies (e.g., developing protocols and procedures, educating staff, and having resident or family councils), and external strategies aimed at increasing community involvement.

Citations and Annotations

Each journal citation includes the author, year of publication, title of article, journal title, volume, issue and page numbers in the style set by the American Psychological Association, Book citations include author, year of publication, title of book, place and publisher. Specific chapters in books that have been annotated, also include the title of the chapter and page numbers. Each entry provides an annotation summarizing the content of the article, book, or video and identifying the way in which the item relates to abuse and neglect of older adults in institutional settings.

Use of Key Words

At the bottom of each annotation is a list of key words indicating the major subject areas discussed. Key words may also give some geographic data (Canada, New Zealand), or indicate the type of resource (audiovisual). Individual documentation centres can be contacted for information on particular content areas.

Terminology

Throughout the bibliography, the term "abuse of older adults" is used, rather than such other commonly used terms such as "elder abuse." The term "abuse and neglect of older adults" has been gaining common acceptance in Canada over the last few years as the preferred term, because it does not carry the connotation of frail or very old adults. It also avoids confusion of the word "elder" as used in native or religious communities.

Abuse and neglect of older adults in institutional settings is defined as any act or omission directed at a resident of an institution that causes the person harm, or wrongfully violates the person's independence.

Location of Resources

Resources can be accessed by the public at the two centres listed below. Most of the references are also available through inter-library loan.

Section One: Introductory Issues

I. Quality of Care/Quality of Life

*124.Baril, M., M. Beaulieu, & Y. Brillon. (1988). La victimisation et les mauvais traitements chez les personnes âgées. Montréal: Centre International de Criminologie Comparée. Université de Montréal.

This research report presents two studies on older adults. The first is a Canada wide study on the fear of crime and attitudes toward the criminal justice system of older adults living at home. The second is an exploratory study on the lives of institutionalized older adults; they defined abuse in their own words with illustrations from their day-to-day lives. Information was provided on how residents evaluated staff, how safe they felt, and their views on justice and social problems. Older residents stressed the importance of the quality of life within an institution, and of their relationships with staff.

needs, definitions, abuse and neglect of older adults, abuse and neglect in institutional settings, health care providers, fear of crime, quality of life, Quebec

2. Bowers, B. (1990). "Family Perceptions of Care in a Nursing Home." In E.K. Abel, & M.K. Nelson (eds.), Circles of Care.- Work and Identity in Women's Lives. 278-289. New York: State University of New York Press.

In this study, 28 family members (primarily women and daughters) were asked to compare and contrast their roles in providing care to their relatives in nursing homes to care provided by staff, and to describe their strategies to improve the quality of their relatives' care. In general, family members described their care as "protective care" (maintaining family contacts, preserving their family member's dignity, bolstering relatives' hopes for recovery, and helping relatives assert control over their environment). Staff care was seen as instrumental (bathing, feeding). The two kinds of care were seen as closely linked, with good care resulting from family/staff collaboration. Families used a number of strategies to increase protective care by staff, by trying to personalize the care their family members received. This strategy included telling staff stories about the resident's life, revealing his or her likes and dislikes, and demonstrating how the resident liked some tasks to be done.

3. Committee on Nursing Home Regulation. (1986). Improving the Quality of Care in Nursing Homes. Washington: National Academy Press.

In this study the Committee on Nursing Home Regulation reviewed and recommended ways to improve the American government regulation of nursing homes. A variety of interested parties gave presentations (residents, families, staff, ombudsman programs) and research on quality of care/life was reviewed. Current regulations in related areas were considered, such as Medicaid, training and accreditation of staff, consumer and community involvement in nursing homes, and management styles and incentives. The book contains a detailed discussion of findings and recommendations. Two chapters are of particular interest: Chapter 2 considers the meaning of "quality of care" and "quality of life" in the context of nursing homes. Discussion focuses on the interrelationship of these concepts, techniques for assessing the two, and the ways in which the two should influence regulation of nursing homes to ensure proper standards of care. Chapter 6 discusses state regulatory practices undertaken to ensure high standards of quality of care and of life. These practices include encouraging the presence and involvement of consumer advocacy groups, fostering an active community to help protect more vulnerable older people, and developing sources of positive motivation for owners and managers of nursing homes. This will involve stressing professionalism, peer judgement and consultation, rather than relying on negative sanctions and punishment in response to inadequate care.

"Quality Care and Maltreatment In Israel's Institutions for the Elderly." R.S. Wolf, & S. Bergman (eds.), Stress, Conflict and Abuse of the Elderly. Jerusalem: JDC - Brookdale Institute of Gerontology and Adult Human Development. 33-49.

The authors begin by distinguishing between the terms "quality of care" and it maltreatment." "Quality of care" arises from therapeutic or medical contexts and refers to the broad concept of the "art" of care. Maltreatment, as a facet of quality of care, arises from a legal or social work context and refers to specific acts of omission or commission that result in mental or physical suffering for residents. The authors apply this framework to a specific study of quality of care in institutions. Using tracer methodology, indicators for quality of care are investigated to determine causes of poor quality of care and maltreatment. Factors within institutions (internal factors) and from beyond institutions (external factors) contributing to poor quality of care are identified. causes, Israel, abuse and neglect in institutional settings

5. Glass, A.P. (1988). "Improving Quality of Care and Life in Nursing Homes." Journal of Applied Gerontology., 7(3), 406-419.

The author suggests that while "quality of life" in nursing homes is affected by "quality of care," quality of care varies widely among nursing homes and is difficult to measure and ensure. Glass briefly discusses the problems of defining these two terms and regulating them in care facilities. He then suggests three ways to improve the situation: 1) develop a valid and reliable index of quality of care, based on a combination of structural criteria; 2) change the focus of resident care inspections from concentrating on structural criteria and resident charts to observing and interacting with residents, having unannounced visits and night visits, and eating the food served to residents; and 3) increase the involvement of the outside community to include volunteers, community advocacy groups, friends and family and by developing nursing home ombudsman programs.

*6. Grant, N.K. & M. Refflier. (1991). Indicator of Quality of Care Perceived by Residents, Significant Others and Nursing Staff in Long term Care Agencies. Calgary: University of Calgary.

This Study Sets Out to identify the indicators of quality of care as viewed by residents, significant others an(] nursing staff associated with five long term care facilities in Alberta. Data was collected using the critical incident technique, a method of focused interviewing which required respondents to describe incidents which signified the type of care they liked best and least. Identified indicators of quality of care include such factors as the nature of the facility, the nature of relationships, acknowledgement of the personhood of the resident, the nature of surveillance, presence of planning and judgment provision, use and attributes of resources, and the nature of space and environment. These indicators fall into three categories: neutral indicators, reflecting both an acceptable and unacceptable level of care; positive indicators, reflecting acceptable levels, the absence of which may not reflect an unacceptable level of care; and negative indicators, reflecting unacceptable levels, the absence of which may not indicate good levels of care. This study's findings suggest the need to expand the role of significant others as secondary providers of care and of their need for information and sensitivity from nursing staff within long term care facilities.

7. Mercer, S.O. (1983). "Consequences of Institutionalization of the Aged." In J.I. Kosberg (ed.), Abuse and Maltreatment of the Elderly. London: John Wright and Sons. 84-103.

This article focuses on the impact of institutionalization on older adults. A review shows long term care facilities to be a relatively new development, demonstrating an historical shift from housing diverse groups of disadvantaged people together to the current grouping of institutions serving the aged. Nursing home residents are most likely to be white, female widowed and alone, with one cited study showing the medium time of residence to be approximately two years. The major impact of institutionalization is loss of a sense of autonomy and control. The study identifies the "giving-up-given-up" complex characterized by feelings of hopelessness and impotence, poor self esteem, loss of gratification from roles or relationships, disruption of continuity between past, present and future, and reactivation of early memories. Loss of choices and control may lead to learned helplessness and indirect self-destructive behaviour. Programs, policies, and staff education are suggested ways to counter these effects, maximize residents' degree of choice and reduce institutional predictability.

Caring in the Clinical Setting: Patients' Descriptions." Topics in Clinical Nursing. 8(2), 30-36.

In this study, patients describe their interactions with nurses to provide insight into how patients perceive the care that they receive. Patients interpret nurses' behaviour as "noncaring"- being in a hurry, "just doing their job," and not responding to requests. The two behaviours that constitute the majority of patient perceptions about nursing care are being treating roughly or being belittled, and being treated as objects.

Patients consequently felt humiliated, frightened, out of control and essentially devalued as people. The author points out that these perceived "noncaring" behaviours may be encouraged by institutional imperatives for nurses to be "efficient" and by nurses' own feelings that their work is devalued. Nurses need to be truly "present" in thought, word and deed for patients to feel valued as human beings.

9. Williams, C.C. (1989). "The Experience of Long Term Care in the Future." Journal of Get-ontological Social Work. 14(1/2), 3-18.

This article looks at ways to improve the experience of residents in long term care facilities, noting the loss of dignity and freedom associated by such interventions as use of restraint. Williams notes that over a seven year period, 35 deaths by asphyxiation and strangulation due to restraints were reported by government agencies in the U.S. and Canada. By way of contrast, Denmark and Sweden have taken a significantly different approach in providing care. Both countries focus strongly on treating residents as individuals by: emphasizing nurses' knowledge of residents' needs and promoting an ongoing relationship; intentionally varying the physical environment, looking to both aesthetics and safety; offering choices to residents in key areas; individualizing activities; and providing effective responses to patients with dementia. Key factors observed in Scandinavian homes include a radical affirmation of full personhood regardless of health status, resulting in partnership rather than paternalism, and an enhancement of existing strengths, individualized environments and decision making by residents. Williams also

discusses the Skaevinge project where a nursing home was converted to sheltered flats. Both the nursing home and visiting nurse staff were merged into one organization capable of offering 24 hour services to residents.

II. Definitions

* 10.Beaulieu, M. (1992). "Les abus à l'endroit des personnes âgées en ressources d'hébergement." In G. Létourneau, Aider ses parents vieillissants. Un défi: personnel, familial, politique, communautaire. Montmagny: Marquis. 211-224.

Based on the results of a qualitative study on residential resources in Quebec, the author presents older adults' point of view on abuse. The article begins by situating the problem with five explanations documented in the scientific literature. A definition of abuse is proposed based on two components (abuse and neglect) and five forms are discussed (physical, psychological, material or financial, violation of rights, and social). Most older adults defined abuse by describing it in terms of harm to their well-being. The author's conclusion is that older adults clearly indicate that there is abuse in residential facilities in Quebec. She stresses the importance of empowering residents in such institutional settings by giving them a chance to be heard.

causes, definitions, empowerment, abuse and neglect in institutional settings, quality of life, Quebec

*11. Hétu, J. (1988). "Atteintes à l'intégrité de la personne âgée." In J. Hétu, Psychologie du vieillissement. Montréal: Éditions du Méridien. 257-276.

The author speaks of "encroachment on integrity" rather than abuse or mistreatment, since he sees this as a broader concept, encompassing physical, psychological, social and material aspects. Integrity may be affected both actively and passively. The author presents a model in which the various forms of attacks on integrity are inter-related. He focuses considerable attention on infantilization and the sometimes difficult relationship between natural caregiver and older person. He also presents some elements of the social exchange theory to explain encroachment on integrity. Finally, he proposes some approaches for prevention and intervention, in both natural and institutional settings.

definitions, ethics, infantilization, intervention, abuse and neglect of older adults, abuse and neglect in institutional settings, prevention, Quebec

12. Nebocat, S.A. (1990). "Elder Abuse and Neglect: Borderline Situations." In R. Roesch, D.G. Dutton, & V.F. Sacco (eds.), Family Violence: Perspectives on Treatment, Research, and Policy. Burnaby, British Columbia: British Columbia Institute on Family Violence.

The author argues that every day practices and a lack of sensitivity in care facilities create situations of abuse or neglect of older adults. Rather than dramatic examples of abuse and neglect, it is the "little" things that are done, often inadvertently, which become the "big" things in the life of impaired, semi-independent older adults, affecting their quality of life. Examples of the small, daily activities that may potentially be sources of neglect or abuse are provided. Aspects of staff orientation, staff development, and policy development are offered, along with examples of resources and suggestions to change care facility conditions. A checklist for the management of abuse of older adults in institutions and two case studies with suggested issues for discussion, are included.

training programs, policy, prevention, case studies, health care providers, nursing homes, quality of life

13. Valentine, D. & T. Cash. (1986). "A Definitional Discussion of Elder Maltreatment." Journal of Gerontological Social Work. 9(3), 17-28.

This article reviews the problem differing definitions for maltreatment and suggests new guidelines for definitions based on a social work perspective. Uniformity in definition is necessary for the development of a classification system capable of providing effective guidelines for reporting, for ensuring the use of consistent measuring criteria for research and for providing accurate tools to identify causal factors. Since legal definitions tend to limit the sphere of concern to issues requiring court intervention, a definition from a social work perspective is believed more effective in structuring services for use by adult protective service practitioners. Three categories of maltreatment are identified: 1) neglect, which constitutes the most common form and includes three subsidiary categories, passive, active and self neglect; 2) abuse, which is the second most prevalent form, constitutes approximately 20% of reported cases and includes physical and psychological abuse; and 3) violation of rights, including financial or other exploitation, which may involve criminal offenses.

III.Types of Abuse

A. Financial abuse

14. Beck, C.M. & L.R. Phillips. (1984). "The Unseen Abuse: Why Financial Maltreatment of the Elderly Goes Unrecognized." Journal of Gerontological Nursing. 10(12), 26-30.

In this interview, Beck and Phillips discuss financial abuse by families, financial abuse in institutions, and nursing assistants' working conditions which may lead to incidents of theft. They also respond to general questions about abuse of older adults. Included are discussions of the role of nurses as advocates when financial abuse is suspected, procedures for reporting suspected abuse, and the reasons why nurses sometimes do not report suspected cases of abuse.

B. Psychological abuse

15. Lusky, K. (1988). "Elder Abuse in LTC: Identification, Intervention." Contemporary Long Term Care. 11(9), 6-10.

Lusky addresses the subtle forms of psychological abuse and benign neglect older adults may encounter in institutional settings. Benign neglect may be unintentional and due to staff shortages or misunderstanding of patient needs. She suggests ways to identify abuse and to develop an environment in which abuse and potential abuse can be dealt with, through such measures as providing group sessions to deal with staff frustrations, building a team response to patient care, and developing nursing practices which can head off situations of benign neglect.

16. Tarbox, A.R. (1983). "The Elderly in Nursing Homes: Psychological Aspects of Neglect." Clinical Gerontologist. 1(4), 39-52.

This paper identifies various kinds of psychological neglect which occur in nursing homes, the impact on residents and possible interventions. Psychological neglect is subtle and not easily identified. The author provides six categories of psychological neglect, which can be assessed by examining the resident's physical appearance, the quality of the physical environment, and if nutritional and diet needs are being met. Infantilization, environmental deprivation and benign neglect are also indicators of psychological neglect. Suggested interventions include: enriching the environment, reducing infantilization, educating and training staff, and increasing community involvement in nursing homes.

17. Tulloch, G.J. (1987). "Subtle Psychological Abuse: A Resident's Perspective." Provider. 13(2), 47-48.

The author describes a form of psychological abuse in care facilities that is subtle, arises from insensitivity and is usually unintentional. Examples of "subtle psychological abuse" include not taking residents' statements about problems at face value, treating residents like children, ignoring calls or placing call bells out of reach, and blocking constructive criticism from residents about care. The identified causes of this form of abuse are 1) institutional attitudes which frame resident independence and self-reliability as a liability for caregivers, and 2) the stress of caregiving.

C. Inappropriate Use of Restraints

18. Bock, K. & E. Schilder. (1988). "Physical Restraints." Canadian Nurse. 84(7), 34-37.

This article presents a study of the use of physical restraints, by observing 82 patient participants in an American general teaching hospital. During the study period, an average of 10-15% of the patients were restrained at any given time. This phenomenon is examined in relationship to hospital policy which permits restraint for purposes of facilitating treatment or as a means of protecting patients and others from injury. The decision to restrain is often based on the number of demands placed on staff, the degree of behavioral and physical familiarity with patient type, the medical condition, or knowledge of hospital policy. Restraints are most likely to be used on residents with histories of seizures, weakness, short term memories deficits or brain damage. One crucial factor influencing the decision for restraint is the patient's own understanding of their medical condition and the treatment procedures. The authors conclude that since restraint use may deter recovery, it should be implemented as a last resort, with effective alternatives developed and provided.

19. Brower, H.T. (1992). "Physical Restraints: A Potential Form of Abuse." Journal of Elder Abuse and Neglect. 4(4), 47-58.

This article explores ethical and legal issues related to the use of physical restraints in care facilities. Use of restraints raises ethical concerns about basic human rights including quality of life, decision-making rights of residents, and the freedom to take risks. For care Providers, restraint issues are sometimes cast as "beneficence" versus autonomy": or balancing the provision of the "best care" for residents (including protection from falls) against the freedom of patients to make decisions (including those which might result in a fall). The issue is complicated by a number of deaths recently associated with use of restraints (e.g., due to strangulation), a lack of clarity for staff concerning when to use restraints, and philosophical or personal value conflicts for staff when restraints are used as a method of punishment. In spite of stricter legislative guidelines for the use of restraints in the United States, most states maintain an emphasis on safety over freedom. Ease of restraint use and lack of financial incentives to shift to less restrictive approaches have undermined federal legislation.

20. Evans L.K. & N.E. Strumpf. (1989). "Tying Down the Elderly: A Review of the Literature on Physical Restraint." Journal of the American Geriatric Society, 37(1), 65-74.

This literature review of the issue of physical restraint of older adults is followed by a discussion of the research and ethical implications of this practice. Increasingly criticized in recent decades for its negative effects on older adults, studies show the use of physical restraint to be positively correlated with increasing age and with the degree of cognitive impairment. Incidence of use ranges between 6% to 86% within various settings. Although the most frequently cited rationale for physical restraint use is prevention of injury to self or others, no scientific data supports this, with some evidence suggesting that the risk of injury from falls out of bed increases with restraint use. Studies also show that immobilization due to physical restraint may result in biochemical and physiological disturbances and that functional capacity diminishes with its use. The importance of interdisciplinary approaches to care of older adults, staff education regarding restraint selection and use, research into restraint alternatives and the development of ethical guidelines concerning physical restraint use are among the solutions suggested in this review.

D. Systemic Abuse

21. Diamond, T. (1990). "Nursing Homes as Trouble." In E.R. Abel & M.K. Nelson (eds.), Circles of Care: Work and Identity in Women's Lives. New York: State University of New York Press. 173-187.

In this analysis of nursing home culture, Diamond starts from an assumption that abuse of residents stems more from systemic and ideological factors than from interactive problems between individuals. Drawing from a participant/ observation study, the author describes four ways in which the medical model and capitalist ideology operate in ways that are counter productive to the care, health and well-being of residents. Medical tasks such as charting and dispensing medications have replaced caring work of social and emotional interaction with residents. Other systemic problems arise, such as nursing assistants facing personal and financial strain when required to become certified, but without gaining improved wages. Diamond argues that nursing homes have a vested interest in maintaining institutionalization, and that profit motives affect decisions made about staff wages and about the amount of resident allowances available from public funds for nursing home care. Finally, Diamond suggests that the presumption that mental illness is a part of every resident's diagnosis, results in the high use of drugs and in a tendency to see residents in terms of their diagnosis rather than as people with long and varied social histories. Examples are provided to demonstrate his analysis.

IV. Recognition of the Problem in Selected Countries

A. Canada

*22. Barabé-Langlois, J. (1994). "A l’attaque des mauvais traitements." Magazine FADOQ. 3(3), 18. This article in a seniors' federation magazine addresses abuse and neglect of older adults. During the sixties and seventies, legislation was passed on behalf of abused children and women. The time has now come to focus on older adults. Based on various study findings, the author discusses the various causes of abuse and neglect in industrialized countries, and lists indicators for detection of situations of abuse. She closes with a proposal for intervention procedures for those working with older adults in both home and institutional settings.

causes, detection, assessment, risk factors, abuse and neglect of older adults, consciousness-raising, caregivers, prevention, Quebec

*23. Baril, M. & M. Beaulieu. (1989). Vivre en résidence: les témoignages des personnes âgées. Montréal: Centre international de criminologie comparée. Université de Montréal.

This report of a qualitative research project on institutionalized older adults addresses abuse from their point of view. They describe the positive and negative aspects of their day-to-day lives. Theft, fraud and extortion were reported as the main types of mistreatment experienced in institutional settings. Physical abuse is reported very rarely. Older residents also report various forms of psychological abuse and violation of their rights.

needs, financial abuse, physical abuse, violation of human rights, psychological abuse, Quebec

*24. Beaulieu, M. (1993). Understanding Elder Abuse in an Institutional Setting. Presented at the XVth Congress of the International Association of Gerontology; Budapest, 1-5.

Thirty directors and mid-management practitioners of Quebec public nursing homes were interviewed to determine how they personally defined abuse of older adults in institutional settings. According to the study, definitions of abuse provided by respondents could be divided into two categories: abuse perceived as individual behaviour, and therefore individual responsibility, and abuse perceived as institutional responsibility. Psychological abuse was identified by the respondents as the most pervasive form of abuse; the existence of financial abuse was downplayed. Abuse perpetrated by individuals tended to be defined or based on the interviewee's own moral code. The respondents identified abuse and neglect in institutional settings in the context of laws, policies or practices which violated patients' rights or reduced their decision making abilities. Respondents showed stronger negative responses to abuse at the individual level than to systemic abuse. Directors and mid-management tended to react more strongly to abuses they defined as individual responsibility, responding with warnings, suspensions or dismissals of employees. Abuse defined as institutional responsibility was corrected more slowly. This study recommends further research on the subject.

*25. Beaulieu, M., & A. Vandal. (1990). Le rapport Vieillir... en toute liberté: éléments d'analyse critique. In J. Carette, & L. Plamondon, Vieillir sans violence. Montréal: Presses de l'Université du Québec. 341-35 1.

This chapter proposes a critical analysis of the report Vieillir... en toute liberté of the committee on abuse and neglect of older adults. It starts with a summary of the report, and goes on to address the main issues for the future of gerontology in Quebec. With respect to abuse in institutional settings, the authors stress the urgency of recognizing this social problem. This must be done by administrators, staff and patients' relatives, so that the campaign against abuse becomes a priority in the planning of each institution's activities.

administration, ethics, intervention, abuse and neglect of older adults, abuse and neglect in institutional settings, Quebec

*26. Bélanger, L., T. Darche, H. de Ravinel, & P. Grenier. (198 1). Violence et personnes âgées. (1). Montréal: Les cahiers de l'Association Québécoise de Gérontologie.

This report presents the findings of the first study carried out in Quebec on abuse and neglect of older adults. The data was collected by questionnaire from the members of the Quebec gerontology association. Respondents identified institutions as the location of most of the mistreatment. This report looks at such areas as characteristics of abused older adults, characteristics of abusers, and ways of counteracting mistreatment. It closes with recommendations focusing on prevention, services and legislation.

characteristics of abusers, characteristics of abused older adults, caregivers, legislation, abuse and neglect of older adults, abuse and neglect in institutional settings, prevention, Quebec

*27. Brillon, Y. (1987). "Neglect and Abuse of the Elderly." In Y. Brillon, Victimization and Fear of Crime Among the Elderly. Toronto: Butterworths. 69-86.

In this chapter, Brillon begins by pointing out that many forms of abuse and neglect are covert and harmful, but may not constitute legally criminal acts. He notes the problems associated with lack of agreement on definitions and outlines societal, family and individual causes for mistreatment and abuser/ abused person dynamics. Brillon's focus on abuse and neglect in institutional settings shows that residents tend to lose their autonomy and personality in institutions and are often treated as children rather than adults. Physical, psychological and financial abuse and neglect are an increasingly recognized problem. Belanger's 1981 study of Quebec professionals found that 7% of the respondents had never heard of abuse involving older adults, 36% were aware of the problem but did not know any specific incidents, while 57% knew of at least one case of maltreatment. Of the acts reported, 43. 1 % had been committed by institutional personnel, 23.5 % by relatives, 19. 1 % by strangers and 14.3% by other individuals taking care of older adults. This study reveals that older adults are mistreated in every milieu. The article concludes with a review of domestic violence towards older adults.

causes, definitions, characteristics of abusers, characteristics of abused older adults, study

Brief to the Interministerial Committee on Elder Abuse: Based on a Series of Six Follow-up Workshops on Different Aspects of Abuse of the Elderly. Available from Toronto: Canadian Pensioners Concerned.

Canadian Pensioners Concerned conducted six public workshops on abuse and neglect of older adults. The financial exploitation workshop distinguished between financial abuse and neglect, the latter often being linked to dependency. Identified risk factors included frailty, poor memory, required assistance with activities for daily living and insufficient social supports. The alcohol and abuse workshop discussed prevention and intervention strategies, and outlined education and service expansion needs. The workshop dealing with reaching out to older adults who are abused, vulnerable or neglected described casual and risk factors, noting that psychological abuse and neglect are difficult to detect due to the lack of external signs and reluctance to report due to fear of retaliation an(] embarrassment. The Institutional maltreatment of the older adults workshop pointed out that resident abuse is often subtle rather than blatant. Increase(] decision making power for residents and the dissemination of the handbook on legislated Bill of Rights for residents are recommended. The prevention workshop described the need for expanding services and the role of police in dealing with abuse. The workshop on community resources outlined considerations for the development of increased services. Issues and options are finally discussed and expectations for government action against abuse and neglect of older adults are outlined.

* 29. Carette, J. & L. Plamondon. ( 1990). Vieillir sans violence. Montréal: Presses de l'université du Québec.

This is one of the products of the "Vieillir sans violence" symposium organized at the Université du Québec Montréal in October 1990. It offers thirty-three previously unpublished texts authored by a variety of contributors from the health and social services network, the legal and paralegal field, the municipalities and researchers in university settings. The authors have analyzed various types of violence and proposed intervention approaches for home and institutional settings. A number of different aspects of abuse are touched upon, and various approaches to evaluation, prevention and intervention are proposed to administrators of institutions, and health and social service providers.

administration, legal aspects, causes, definitions, detection, risk factors, intervention, abuse and neglect of older adults, abuse and neglect in institutional settings, prevention, procedures, consciousness-raising, Quebec

*30. Caris, P. (1990). "La victimisation des personnes âgées." Plaidoyer-Victimes. 5(1), 44-47.

These proceedings of a symposium comprise six presentations, two of which address abuse and neglect of older adults in institutional settings. The first describes the current situation, pointing out that close to 11% of persons aged 65 or over in Quebec live in institutions. A number of them are virtually or totally abandoned and unvisited. Residents question the quality of service and certain aspects of the behaviour of their caregivers. The second paper deals with intervention, addressing the issues of detection and the use of intervention guidelines.

abandonment, detection, intervention, caregivers, abuse and neglect of older adults, abuse and neglect in institutional settings, quality of care, Quebec

*31.Caris, P. (1989). "Le comité sur les abus exercés à l'endroit des personnes âgées: éléments de réflexion." Plaidoyer-victimes. 4(1), 17-20.

This article is the report on the work of a committee on abuse and neglect of older adults, struck by the province of Quebec. It tabled its report Growing Old ... Remaining Free in 1989. The article defines abuse, describes the vulnerability of older adults to abuse, and the risk factors in the environment. It addresses elder abuse in all settings. Where institutions are concerned, it emphasizes staff behaviour, financial abuse, quality of service and standardization of living arrangements.

causes, definitions, abuse and neglect of older adults, abuse and neglect in institutional settings, quality of care, quality of life, Quebec

*32. Coalition "Vieillir sans violence." (1991). Mémoire présenté, au Groupe d'experts sur les personnes aînées du Québcc. Montréal: Coalition "Vieillir sans violence."

On May 3, 1991 the "Vieillir sans violence" coalition submitted a brief to an inquiry entitled "Le groupe d'experts sur les personnes aînées du Québec." It was comprised of thirteen different speeches, two of which deal with abuse in institutional settings. The first speech describes the future of seeking out abused residents in the institutional setting, describing the current state of knowledge and proposing four areas to be investigated with a view to an improved future (equal recognition of medical and psycho-social needs, improved quality of life, regulation of practices and care-givers' needs). The second speech gives the coalition's recommendations, particularly around quality of life, code of ethics and acknowledgement of volunteers.

volunteers, needs, caregivers' needs, ethics, abuse and neglect in institutional settings, procedures, Quebec

*33. Corporation professionnelle des travailleurs sociaux du Québec (CPTSQ). (1987). Mémoire présenté au Comité sur les abus exercés à l'endroit des personnes âgées. Montréal: Corporation professionnelle des travailleurs sociaux du Québec.

This brief to the committee on abuse and neglect of older adults is divided into two parts. The first part is devoted to the definitions of the two types of violence, anonymous and personalized, and the four types of abuse: physical, neglect, exploitation and psychological. There is also a brief presentation of the issue of abuse in homes and institutional settings. The second section presents the steps to be taken to prevent situations of abuse and violence. Finally, the corporation of social workers submits a series of recommendations for various groups of intervenors. They see the problem as rooted in relational difficulties between the abuser and the abused person.

definitions, intervention, abuse and neglect of older adults, abuse and neglect in institutional settings, prevention, consciousness-raising, Quebec

*34. Government of Canada. Standing Committee on Health, Welfare, Social Affairs, Seniors and Status of Women. (1993). Breaking the Silence on the Abuse of Older Canadians: Everyone's Concern/Rompre le silence sur les mauvais traitements infligés aux Canadiens âgés: la responsabilité de tous. Ottawa, Ontario: Supply and Services Canada.

This report of the Standing Committee on Health and Welfare, Social Affairs, Seniors and the Status of Women, highlights the issue of abuse and neglect of older adults, based on testimony gathered from witnesses throughout Canada. The report reiterates the problems associated with the lack of uniformity in definitions of abuse and neglect, and outlines incidence and risk factors associated with mistreated older adults. This document recommends a national survey to establish the scope of abuse and neglect, including an examination of the extent and nature of abuse and neglect in institutional settings. The report points out that the 1991 Family Violence Initiative was the first federal effort undertaken to specifically address the mistreatment of older adults. The report recommends improved multi-sectorial involvement between federal departments, government and community. The report reviews legal safeguards, as well as the general, advocacy and emergency services available to abused older persons. Further recommendations include the establishment of federal guidelines for evaluating current social, legal and health interventions, and the subsequent publication of these results. This document provides both English and French language versions of the report.

legal aspects, definitions, risk factors, legislation, adult protection laws, abuse and neglect of older adults, advocacy, Canada, United States

*35. Government of Quebec. Committee on Abuse of the Elderly. (1990). Growing Old ... And Remaining Free.- Report of the Committee on Abuse of the Elderly / Vieillir en toute liberté: rapport du comité sur les abus exercés à l’endroit des personnes âgées. Quebec City: Ministry of Health and Social Services.

This study by the Committee on Abuse of the Elderly examines abuse and neglect of older adults in the context of Quebec's social and legal environment. For the study, the Committee consulted with a wide variety of community and academic sources. The report defines abuse, notes situations of vulnerability for older adults, and identifies risk factors for abuse in the community and institutions. Included in the report is a discussion of the "underground accommodation network" (illegal and illicit rooming houses/foster family types of accommodation in Quebec communities which offer unaccredited services). For institutional settings, the Committee focused on issues of autonomy and the effects of day to day routine on quality of life for residents. Three chapters of recommendations are presented including suggestions to improve quality of service, ways to prevent and respond to abuse and measures to enhance the status of older adults in society. An underlying premise of the report is that one of the causes of abuse of older people is their low status in society.

Quebec, causes, autonomy, legislation, prevention, policy, quality of life, risk factors, services

*36. Hannah, F., H. Simmons, D. Goldstein, S. Hilditch, & H. Sheard. (199 1). Report Cardfor Ontario Nursing Homes, January '90 to March '91. Toronto, Ontario: Concerned Friends of Ontario Citizens in Care Facilities.

Concerned Friends, an Ontario advocacy group, presents an analysis of the Ontario Compliance Review Reports for nursing homes. These reports outline the government findings of yearly nursing home inspections for the purpose of re-licensing. Concerned Friends indicate that similar deficiencies are consistently found among nursing homes suggesting either improper inspections or a poorly functioning nursing home system. Of 263 homes reviewed, 146 showed evidence of serious violations of the Nursing Home Act and Regulations. Violations occurred in the general areas of facility management; nursing services; medical, pharmacy and other health services; activity programs; dietary services; environmental services; and in laundry services. Concerned Friends note that residents were not interviewed as part of the inspection process and food variety or preparation was not inspected, despite significant complaints concerning these factors. Among Concerned Friends' recommendations is replacing the current self-policing system with an independent enforcement department with the responsibility to investigate complaints, prosecute and enforce compliance with standards and legislation. Sample copies of Compliance Review reports and a copy of the Office of the Provincial Auditor, Ontario, 1990 report are included as appendices.

*37. Lévesque, M. (1990). "Les personnes âgées maltraitées: éléments de problématique et bibliographie sélective (1980-87). " In J. Carette, & L. Plamondon, Vieillir sans violence. Montréal: Presses de l'Université du Québec. 29-58.

Although abuse and neglect of older adults is not a new phenomenon, it is only since the 1980s that it has received any attention. Knowledge remains limited, however. According to the author it is difficult to obtain scientific data, given the inconsistency and scarcity of available information. She presents the characteristics of abused older adults, as well as the various concepts and definitions used, emphasizing the lack of consensus. She describes the causes and factors associated with abuse and presents strategies for intervention. A selective bibliography (1980-87) accompanied by various general references is provided.

characteristics of abused older adults, causes, definitions, assessment, risk factors, intervention, abuse and neglect of older adults, abuse and neglect in institutional settings, Quebec

*38. Massé, H. (1990). Rapport de consultation pour le Comité sur les abus exercés à l'endroit des personnes âgées. In J. Carette, & L. Plamondon, Vieillir sans violence. Montréal: Presses de l'Université du Québec. 59-85.

This product resulted from consultations with various organizations concerned with the issue of abuse and neglect of older adults, in home and institutional settings. Various themes were addressed during the consultation process, and each was discussed under three areas: the issue of abuse, the issue of aging, and the quality of services offered to older adults by the health and social services system both institutionally and in the home. The report offers a summary of the consultations, grouped under two separate headings. Under the first heading comments and perceptions on each of the three fundamental issues are reported. Under the second heading the point of view of the organizations is related to each issue, whether or not it is connected with one of the basic elements.

reporting, detection, intervention, abuse and neglect of older adults, abuse and neglect in institutional settings, prevention, quality of care, consciousness-raising, Quebec

*39. McDonald, P.L., J.P. Hornick, G.B. Robertson, & J.E. Wallace. (199 1). Elder Abuse and Neglect in Canada. Toronto: Butterworths.

This book analyzes the issues surrounding abuse and neglect of older adults in Canada, beginning with a critical examination of the definitions used for abuse and neglect. The authors review characteristics of abused older adults and abusers, noting the difficulties in generalizing from non-representative reports. The situational model, social exchange and symbolic interactionist theoretical perspectives are reviewed. Individual, structural and institutional factors associated with abuse/neglect are outlined. The authors review current laws (such as guardianship laws), legislation (such as adult protection legislation) an(] social services. Domestic violence, advocacy and adult protection models for intervention are examined and screening assessment problems and guidelines for abuse or neglect are discussed. Finally, the authors introduce policy issues, identify research needs, and make recommendations for the development of more effective program,,-,, policies, legislation and education to address the issue.

definitions, assessment, intervention, theory, adult protection laws, reporting, advocacy

B. United States

40. Attorney General's Family Violence Task Force. (1988). Violence Against Elders: A Report to LeRoy, S. Zimmerman, Attorney General of Pennsylvania. This report is an overview of information available on abuse of older adults in Pennsylvania. The report provides recommendations On issues of violence against older persons, and in particular the response,, of the criminal justice system. The report includes definitions of abuse (including a distinction between abuse and neglect in domestic and institutional settings), a discussion of causation, characteristics of abused older adults and abusers, legislative responses, and a discussion of criminal victimization of older persons. The report recommends improved interagency relationships, changes to social services and state laws, and amending criminal law to include specific reference to crimes against older people and crimes in institutions. The authors suggest training approaches and outline areas needing further research.

United States, causes, criminal justice system, legislation, definitions, characteristics of abusers, characteristics of abused older adults

41. Harrington, V. (1984). "Nursing Home Abuse: The Tragedy Continues." Nursing Fonim. 21(3), 102-108.

Over a four year period, four nursing, homes were studied revealing the plight of older adults in these homes Although the four homes examined are well reputed, psychological and financial abuse was found to be present in all four and involved both staff and residents. The author describes how aides dealt with budget cutbacks in one home by taking over the financial burden of juice provision themselves and recycled soiled towels for diapers. Evidence of mismanagement and theft in reputable homes indicates that the socioeconomic status of a home is no guarantee that mistreatment will not occur. Well-trained nurses tend to avoid working in nursing homes because of the lack of prestige for nursing home nurses that steins from understaffing and underpay. This article confirms studies which suggest that doctors see older nursing home residents less frequently than hospital patients, which may prevent the residents from receiving adequate medical treatment. Enforcement of regulations and a reversal of ageism is recommended.

United States, nursing homes, financial abuse, psychological abuse, case studies

42. National Committee for Prevention of Elder Abuse. (1986). The Hidden Sorrow: An Overview. Worcester, Massachusetts: The Committee [videocassette, no. 1 in series].

This videotape (the first in a series of three) provides an overview of issues related to abuse of older adults by family. Calling on the experiences of researchers, caseworkers and older victims and caretakers, this video clearly illustrates how older persons often hide their victimization due to shame, self blame and low self esteem, thus masking true prevalence rates. Reported cases of abuse and neglect involve all older adult categories, classes, races and educational backgrounds, with the most common age group being the 75+ category. Professionals note that widespread ageism is particularly onerous for older minority women. New research evidence indicates that while neglected adults are usually older, abuse may be associated more with abuser characteristics, such as mental illness or impairment than with victim characteristics such as old age or impairment. As well, more abusers are themselves dependent on older adults than was first believed. Factors such as social isolation and family cycles of violence make abuse more likely, with spousal violence often continuing into later years. Doctors may overlook signs and symptoms of abuse which mirror aging or medical conditions. Identification indicators and intervention strategies are briefly noted.

causes, identification instruments, intervention, ageism, family relations, audiovisual, United States

Note: Available through National Committee for Prevention of Elder Abuse c/o The Medical Center of Central Massachusetts, 119 Belmont Street, Worcester, Massachusetts, 0 1605.

43. Office of Evaluation and Inspections. (1990). Resident Abuse in Nursing Homes. Washington, D.C.: Office of Inspector General, Department of Health and Human Services.

This document is the first of two reports dealing with understanding and preventing abuse of older residents. Based on findings from 232 interviews with respondents from state, national and federal organizations, this study discovered seven categories of abuse: physical neglect, medical restraints, verbal/emotional abuse, physical neglect, medical neglect, verbal/emotional neglect and personal property abuse. Although respondents differed in their perception of the severity of abuse, at least 95% of them confirmed incidents of abuse from all categories, with physical neglect, verbal and emotional neglect and abuse viewed as the most prevalent types. Aides and orderlies were perceived as the primary abusers in all categories except medical neglect. Among the factors contributing to abuse are poor training, stress, staff turnover and personal problems. The report recommends improved training for both supervisors and nursing aide staff, additional research and the dissemination of information to nursing homes for the prevention of abuse and promotion of staff stability.

C. Great Britain

44. Glendenning, F. & P. Decalmer. (1993). "Looking to the Future." In P. Decalmer, & F. Glendenning (eds.), The Mistreatment of Elderly People. Newbury Park, New York: Sage. 159-173.

This chapter summarizes key findings about abuse of older people in England, and suggests the need for developing an effective response. In general, guidelines defining abuse are inadequate, policy development is difficult and scattered, and coordination among concerned parties and government departments is lacking. The authors note the need for policy development and interagency cooperation. They also recommend areas for further research and suggest using insights gained from the North American experience to improve conditions in both community and institutional settings. Separate attention is given to specific aspects of institutional settings such as complaints procedures, management audits and quality assurance programs. policy development

V. Guiding Principles

A. Rights

45. Brown, R.N. (1986). "Nursing Home Residents' Rights: An Overview and Brief Assessment." In M.B. Kapp, J. Harvey, E. Pies, & A.E. Doudera (eds.). Legal and Ethical Aspects of Health Care for the Elderly. Ann Arbor, Michigan: Health Administration Press. 151-172.

The author discusses various sources of "rights" for nursing home residents in the United States, suggesting not to ignore rights already embedded in other sources, such as the Constitution, Bill of Rights, and state legislation. Brown argues that it is time to move beyond simply listing rights to ensuring that rights are enforced. An overview of nursing home residents' rights, their meaning and how they are sometimes enforced is provided. Brown discusses the ways in which federal rights, such as those laid out in the American Constitution, have been applied to nursing home residents. He notes that some federally developed residents' rights have not been as effective because they are too vague or can be overruled by physicians. Examples of state based rights for nursing home residents are provided and the use of general civil rights laws and consumer protection laws to enforce rights are discussed. The author acknowledges the protection available from common law, and discusses, both, tort claims and the potential for liability.

*46. Carle, M. (l 990). "Un exemple de charte des droits en résidence." In J. Carette, & L. Plamondon, Vieillir sans violence. Montréal: Presses de l'Université du Québec. 323-33 1.

The author's experience working in an institution, le centre d'accueil Yvon Brunet, leads her to describe her thoughts about aging and older adults in today's society. She presents the charter of rights for institutions to re-empower older residents. It covers such areas as the right to information and freedom of expression, the right to privacy, respect and dignity, and the right to continuity, responsibility and participation. The Yvon Brunet charter dates back to 1984 and the Director has the mandate to implement the charter.

residents' bill of rights, ethics, policy development, abuse and neglect in institutional settings, quality of care, quality of life, Quebec

*47. Chernin, S., J. Jenkinson, & T. Lobu. (1990). Every Resident: Bill of Rights for People Who Live in Ontario Nursing Homes. Toronto: Community Legal Education.

In 1987 the Ontario government introduced a Bills of Rights for people who live in nursing homes. This illustrated handbook lists 19 distinct clauses of the Bill of Rights and expands each of the Bill's clauses with explanatory notes in accessible, layperson's language. The Bill covers a variety of issues such as residents' rights to: dignified treatment free from physical or mental abuse; proper shelter; privacy; information; active participation in decision making; confidentiality; and independence. Other rights include freedom of communication; pursuit of personal and social interests; and a safe, clean environment.

48. Cohen, E.S. (1986). "Nursing Homes and the Least-Restrictive Environment Doctrine." In M.B. Kapp, J. Harvey, E. Pies, & A.E. Doudera (eds.), Legal and Ethical Aspects of Health Care for the Elderly. Ann Arbour, Michigan: Health Administration Press. 171-184.

Cohen argues that the rights of older people are infringed during the process of being "committed" to a nursing home. This problem arises because "rights" are not automatic, individuals must claim benefits and entitlements by presenting their case, which assumes that claimants are assertive, independent and knowledgeable. Many older adults, especially those who are physically frail, mentally impaired or financially dependent, do not have these attributes and may not have anyone to advocate for them. Cohen argues that society needs to protect the rights of older adults to prevent their loss of rights, and then describes the development of a "least restrictive" environment to which older adults are entitled. Restrictions on resident autonomy in every day life are discussed, such as those limiting choice over clothing, food, preferred activities, and problems of competing interests within hospitals which can limit choice are noted. Cohen describes the relationship between the patient and the state in terms of cost, convenience and patient care, and outlines the need for due process in decisions made concerning an older person's placement in care.

49. Miller, B. (1988). "The Right to Health Care Free from Abuse." The Health Set-vice Journal. 1256-8.

Miller discusses the problems of abuse and neglect in health care institutions. The article affirms the typical silence associated with abuse situations and encourages "whistle-blowing" directed at both staff and management as part of an employee's professional responsibility to patients. One interviewed hospital official points out that inexcusable acts such as rough handling, kicking, slapping or badgering go against basic social values and do not require trained experts for assessment of their acceptability. If successfully implemented, whistle-blowing is expected to uncover an unsettling number and degree of abusive situations. Health authorities in one locale provided their staff with a handbook outlining patient rights in response to a report revealing the persuasiveness of abuse incidents.

50. Namara, R. D. (19 8 8). Freedom from Abuse in Organized Care Settings for the Elderly and Handicapped. Springfield, Illinois: Charles C. Thomas.

This text analyzes issues pertaining to the abuse and neglect of older adults and handicapped persons in organized care settings. The first major section of the book outlines the nature, signs and types of resident mistreatment and describes the attitudes and perceptions of caregivers towards this problem. This section emphasizes the complexity of abusive situations and notes that abuse can be situational or purposeful and may occur in either subtle or obvious ways. Section two focuses on prevention and examines the ways in which such factors as caregiver selection and hiring practices, diagnostic supervision, models of leadership and organizational policies affect the incidence of abuse. The text concludes with a list of 20 principles for developing an effective caregiving environment.

United States, prevention, health care providers, indicators, definitions, principles

B. Autonomy

51. Agich, G.J. (1993). Autonomy and Long-Term Care. New York: Oxford University Press.

Agich argues that long-term care has to move beyond viewing autonomy as independence, self-reliance, individual freedoms and freedom from intervention, to understanding autonomy within the concrete day-to-day experiences of older people in long-term care. The need for a new understanding of autonomy must recognize that while autonomy has traditionally assumed independence, being an older person in need of long-term care services assumes dependence. Agich calls this revised view of autonomy "actual autonomy." Conventional approaches for autonomy rely on abstract moral thought in the legal/political realm. In contrast, actual autonomy is developed in everyday life, relationships, and in concrete human actions in the world of long-term care. The author criticizes traditional approaches to autonomy, provides an analysis of the myths that surround long-term care (which affects the understanding of autonomy), and assesses the impact of the acute care model of care on concepts of long-term care. Key elements of actual autonomy in long-term care are suggested. long term care

52. Clark, P.G. (1988). "Autonomy, Personal Empowerment, and Quality of Life in Long-Term Care." Journal of Applied Gerontology, 7(3), 279-297.

This article outlines the influence of autonomy on programs aimed at improving quality of life for older people in long term care. The article explores how the concept of autonomy can be used to both improve our understanding of quality of life for older people in care facilities and to develop programs which enhance quality of life in long-term care settings. Clark describes the relationship between health and a sense of personal control. He discusses the definition of autonomy and the contradiction between autonomy and personal control (which suggest independence) and the need for services and supports (which suggests dependence). Programs which encourage advance planning for future long-term care needs and those which encourage independence (e.g. promoting self care, increasing options in daily life) contribute to increased autonomy and quality of life.

53. Erman, S. & A. Norberg. (1988). "Autonomy of Demented Patients: Interviews with Caregivers." Journal of Medical Ethics. 14(4), 184-187.

This article presents a study based on interviews with nurse aides and enrolled nurses in a geriatric clinic in Sweden. The study examines issues of autonomy through an investigation into variations in care provided for non-demented and demented patients, also exploring the ethical dimensions involved in care for the demented. Results of the interviews indicate that respondents spend more time caring for non-demented patients and have difficulty providing opportunities for autonomy for demented patients due to communication difficulties. Wishes expressed by demented patients are perceived of as being difficult to understand and often irrational. Lack of knowledge about patients' former lives and values interfere with the caregiver's ability to make decisions for or with them. Recommendations to improve autonomy of demented patients include improving education and training for caregivers, obtaining knowledge about previous patient beliefs, provision of individualized care and involvement in care by relatives.

C. Ethical Considerations

54. DeRenzo, E.G. (1989). "Elder Abuse: Ethical Theory in Everyday Practice." Caring: National Association for Home Care Magazine. 8, 10-12.

DeRenzo outlines four primary principles as a framework for dealing with suspected cases of abuse of older adults. These include non-maleficence (do no harm), beneficence (do good and prevent harm), autonomy (encourage self determination while maintaining one's integrity), and justice (balance benefits and burdens for all people involved). The author presents a case study of an older woman at risk of mistreatment and through discussion of potential intervention strategies, demonstrates how these principles can guide professional action in dealing with suspected cases of abuse. Ethical dilemmas such as those involved in questions of guardianship are not easily resolved, partly because these decisions are dependent on individual judgements and values. The author encourages preventive measures by urging home care providers to recognize danger signs and thus enable the implementation of interventions which are minimally disruptive. Inter-professional support networks are recommended which promote multidisciplinary teamwork and cooperation among health care workers.

55. Guccione, A. (1988). "Compliance and Patient Autonomy: Ethical and Legal Limits to Professional Dominance." Topics in Geriatric Rehabilitation. 3(3), 62-73.

Guccione examines ethical concepts and concerns facing professionals dealing with patients. The author recommends ethical decisions be based on a "moral point of view," reflecting on principles such as respecting individual autonomy, avoiding negative consequences, promoting good, maintaining professional fidelity and ensuring justice. Guccione notes that patients are typically expected to get well and resume productivity; this expectation is less relevant for older adults with chronic illness. Patients' and professionals' expectations about the "sick role" may differ, particularly when patients are non-compliant with physicians' orders. The combination of the patient's dependency on the physician and the physician's position of authority may result in paternalistic manipulation of the patient's situations. Advocacy is suggested as a tool to counter professional influence and promote patient self-determination.

Ethical Conflicts in the Management of Home Care: The Case Manager's Dilemma. New York: Springer.

This book helps readers identify and understand ethical issues confronting case managers working in community long term care. Many of these issues may also arise in institutional settings. The first chapter introduces case management and provides reasons why ethical issues and conflicts arise. Chapter 2 describes a study in which case workers report the kinds of ethical challenges confronting them. Chapters 3 to 13 present cases arising from this study, followed with commentaries by ethicists giving views on the case from their different disciplines and theoretical positions. Chapter 7 (concerning physical and financial abuse, guardianship and family members as caregivers) and chapter 8 (nursing home placement issues) are particularly relevant to abuse and neglect of older persons.

The authors explore the ethical issues arising in the everyday life of residents of nursing homes, that affect their quality of life/care and autonomy. The underlying premise is that attention should be given to the everyday routine and insensitivities which affect quality of life/care and autonomy, rather than only to overt acts of abuse or neglect. The introduction describes life in nursing homes and points to some of the ethical issues encountered. Part Two presents 18 cases, with commentaries by philosophers and ethicists on the ethical issues raised in each case. Topics of cases (derived from ail interview study with residents and nurses aides discussing resident autonomy) include such areas as guardianship; the impact of facility rules and regulations and programs such as Medicaid on resident life; use of restraints; roommates and tablemates; freedom to leave; and choice of television station. Each case ends with questions for further discussion. Part Three responds to the ethical issues raised, and outlines interventions and policy considerations which might reduce some of the problems.

autonomy, quality of life, quality of care, guardianship, restraints, case studies, definitions, causes

*58. Potter, P.A. &A.G. Perry. (1989). "L'éthique et les soins infirmiers." In P.A. Potter, & A.G. Perry, Soins Infirmiers: Théorie et Pratique (2nd edition). Montréal: Éditions du Renouveau Pédagogique inc. 459-472.

This chapter addresses professional ethics for nurses. It discusses the foundation for ethical decision-making, based on both personal values and professional ethics. Nurses play a lead role with residents, and their close contacts often require them to deal with such ethical dilemmas as who decides what is best for an older adult and what is the nurse's responsibility when a person's rights are threatened? Part of the chapter addresses the ethical dilemma of older people in institutions who are being abused by family members. Nursing actions are guided by personal and professional values, life philosophies, the philosophy of nursing care, and emotional and cultural factors. In order to facilitate decision-making, the authors suggest a process for resolving ethical problems which will make it possible for nurses to make the best possible decisions.

ethical dilemmas, nurses, abuse and neglect of older adults, abuse and neglect in institutional settings, Quebec

D. Cultural and Geographical Implications

*59. Levasseur, A. (l 993). Centre hospitalier de Charlevoix, Survol sur le phénomène de la violence en milieu rural et institutionnel. Baie-Saint-Paul: Centre hospitalier de Charlevoix.

This is a two-part lecture. The first section is devoted to a presentation of the issue of abuse and neglect of older adults in a rural environment (home and institution). According to the author, the geographical and economic context of the Charlevoix region may explain the high number of abuse cases reported. In a rural area, mistreatment may take place in a sort of vacuum where reporting is virtually impossible. The second section of the lecture deals with the definitions of the various types of abuse (psychological, verbal, physical, sexual). The dynamics of family violence are illustrated in diagram form, along with an explanation of the cycle of violence. Finally, the author proposes an explanation for the aggravation of abuse and neglect.

cycle of violence, definitions, abuse and neglect of older adults, abuse and neglect in institutional settings, rural, Quebec

60. Shomaker, D.M. (198 1). "Navajo Nursing Homes: Conflict of Philosophies." Journal of Gerontological Nursing. 7(9), 531-536.

Shomaker investigates the apparent conflict between the rise of nursing homes on a Navajo reservation and cultural understandings about the care of older adults and older adults' roles in Navajo homes, and death. As background, the historical development of nursing homes on Navajo reserves is described. Using anthropological research methods of interviews and observation, Shomaker argues that use of resources such as nursing homes does not equal rejection or disrespect for older adults. Acknowledgement of the need for skilled care, and the decision of the community to provide it, is a sign of respect. Navajo believe that the dead are a potential source of evil and in the past, the place where a person died was destroyed. In the case of the nursing homes, the dead person did not personally own the nursing home, and therefore it is not considered contaminated. Two nursing homes are described in detail, including the ways Navajo culture is maintained in each setting, and an analysis of how the western concept of skilled, institutional care has been adapted to Navajo cultural practices. culture, methodology, nursing homes

VI. Unregulated institutional settings

*61. Association des centres de services sociaux du Québec. (1990). "Les résidences d'hébergement privées non agréées: de la tolérance à l'intervention." In J. Carette, & L. Plamondon, Weillir sans violence. Montréal: Presses de l'Université du Québec. 365-394.

The association of Quebec social service centres (ACSSQ) examines non-accredited residences for older adults in Quebec. The first part offers a brief overview of the situation of non-accredited homes, while the second offers a profile of the residents. Reference is also made to the implicit official recognition of residences of this type and the reasons why the health and social system acknowledges them. The fourth part addresses the limited role of the municipalities when such residences are set up. After setting out the various issues at stake, the ACSSQ makes a number of proposals, including control of the quality of such services, universal accessibility to services regardless of place of residence, integrated regional planning and co-ordination between the municipal and provincial health and social services sectors.

family care, abuse and neglect of older adults in institutional settings, quality of care, quality of life, role of municipalities, Quebec

*62. Lightman, E. S. (1992). A Community of Interests: The Report of the Commission of Inquiry into Unregulated Residential Accommodation. Toronto, Ontario: Queen's Printer for Ontario.

This book presents the findings of an Ontario-based Commission of Inquiry into unregulated residential accommodations for vulnerable adults. The Commission focuses on daily problems and resident quality of life issues. One of the Commission's aims was to redress existing systemic imbalances; to empower vulnerable residents by assisting them in maximizing control over their lives; and to offer protection to rest home residents through the provision of rights. The Commission recommends mandatory registration of rest homes with the local municipality, the establishment of empowering resources such as a Bill of Rights for residents, rest home tribunals, mandatory reporting of abuse, criminal police record checks of operators, mandatory minimum staff-to-resident ratios and minimum competence standards for staff who dispense medications. The Commission also recommends that rest homes be covered under Part IV of the Landlord and Tenant Act and that the Rent Control Act be amended to accommodate nursing home needs. In the report appendix, the Commission also recommends deferral of the Ontario government's proposal to eliminate funding differences between nursing homes and other "homes for the aged", until effective accountability to residents can be established. The Commission favours an empowerment approach over extensive regulations, and makes 148 recommendations, listed at the conclusion of the book.

empowerment, regulations, Ontario, public inquiry, quality of life, recommendations, report

VII. Research

*63. Beaulieu, M. (1993). "Les abus à l'endroit des personnes âgées en centres d'accueil publics: une étude menée à l'aide d'une méthode qualitative." The Canadian Journal on AginglLa Revue canadienne du vieillissement. 12(2), 166-181.

This study on abuse and neglect of older adults in Quebec public institutions focuses on administrators. It shows how epistemological and paradigmatic concerns as well as specific research issues lead to the choice of a data gathering method. It addresses issues specific to the procedure for this research, which involve semi-directed interviews and presents results that are specific to this approach. It ends with a reflection on the contribution of qualitative methods to the advancement of knowledge on human aging.

caregivers' needs, intervention, abuse and neglect institutional settings, qualitative research, Quebec

*64. Beaulieu, M. (1992). "Elder Abuse: Levels of Scientific Knowledge in Quebec." Journal of Elder Abuse and Neglect. 4(1/2), 135-149.

Beaulieu critically examines research on abuse of older people, and describes Quebec's contribution to the field. Abuse in both community and institutional settings is considered. She outlines an understanding of abuse using a criminology framework of victimization, and then describes various approaches which have contributed to the development of definitions of abuse. These include definitions based on the Criminal Code of Canada, psychosocial factors, and practical and administrative considerations in institutional settings. Research needs to go beyond the use of the files of public and private agencies to better understand both the nature of abuse and its incidence and prevalence. Research and practice also need to be brought together by studying abuse resulting from public services management and manner of care of older people.

65. Pillemer, K. (1988). "Maltreatment of Patients in Nursing Homes: Overview and Research Agenda." Journal of Health and Social Behaviour. 29227-238.

After critically reviewing the literature available on "maltreatment" of residents in nursing homes, Pillemer presents a research agenda to address some of the gaps in knowledge. A definition of maltreatment of older people in institutions is provided based primarily on expectations for quality of care and staff-resident interactions, and a rationale for sociological study of maltreatment is developed. He emphasizes that the frequency of the problem demands concern, and a study of quality of care in nursing homes could provide valuable information not currently available. He also outlines a theoretical model that sets out potential predictors for patient maltreatment as a guide for future research. Pillemer suggests that: 1) exogenous factors (factors beyond the immediate environment of the nursing home such as the availability of beds in a geographical area); 2) nursing environment (such as size of institution, rates of pay, ownership status); 3) staff characteristics (education, age, experience); and 4) patient characteristics (health, social isolation, gender) are all possible predictors of maltreatment.

characteristics of abusers, definitions, predictors, characteristics of abused older adults, literature review, research

VIII. Reference Materials

*66. Alzheimer's Society of Canada. (1992). Guidelines for Care. Ottawa: The Society.

This handbook provides care guidelines for people with Alzheimer's disease and presents principles and ideas applicable for use with other institutionalized individuals. These guidelines are organized around such topics as education, caregiver training and support, assessment and care planning, programs and activities. Human resource expectations for staff dealing with this population are outlined. Environmental conditions, either at home or in institutions, are encouraged to meet safety needs, reduce confusion and to facilitate effective functioning, mobility and privacy. Specific decision making guidelines emphasize safety issues and family participation. Abuse prevention and intervention concerns are detailed and a guideline discussion on the use of physical restraints is included.

Family Violence: Clinical Guidelines for Nurses / Lignes directrices sur la violence familiale à l'intention des infirmières. Ottawa: Health and Welfare Canada.

This booklet is intended as a reference tool for those working to reduce family violence, including the abuse of children, women and older adults. For each group there is a description of the situation, the types of abuse involved and some intervention procedures. No distinction is made between abuse occurring in an institution and abuse occurring in the community. A lead role is attributed to nurses in preventing, detecting and addressing family violence.

assessment, intervention, abuse and neglect of older adults, prevention, procedures, nurses' role, consciousness raising, spousal abuse, Canada

*68. Government of Canada. Health and Welfare Canada. Mental Health Division. (1993). Community Awareness and Response: Abuse and Neglect of Older Adults / Sensibilisation et réaction de la collectivité: violence et négligence à l'égard des aînés. Ottawa: Health Services and Promotion Branch, Health and Welfare Canada.

Although this guidebook is focused predominantly on abuse or neglect occurring in the community, it offers a philosophic approach to the problem, based on a family violence perspective. It touches on a holistic approach and life span implications of abuse and neglect. The book offers principles to guide intervention. It also emphasizes strengthening or building informal social networks for older adults, advocating, training service providers, coordinating and developing services, and using preventive strategies that educate the public and empower older adults. Some of the legal issues around abuse and neglect are considered.

legal aspects, causes, advocacy, definitions, detection, reporting, intervention, abuse and neglect of older adults, prevention, Canada

*69. Government of Canada. National Advisory Council on Aging. (1991). Elder Abuse: Major Issues from a National Perspective / La violence faite aux aîné(e)s: une perspective nationale. Ottawa: Government of Canada.

This document offers an overview of abuse and neglect of older adults in Canada. It is difficult to accurately judge the nature and scope of the phenomenon, because there is a lack of consensus between authors as to what defines mistreatment and because the level of reporting is low. This document is divided into five parts. The first part is devoted to a definition of the various forms of abuse and neglect (physical, psycho-social, material exploitation, neglect). The second part deals with older adults' reactions to mistreatment. The third part presents characteristics of abused older adults and abusers, as well as mistreatment in institutional settings. The final two chapters address intervention and prevention strategies.

characteristics of abusers, characteristics of abused older adults, definitions, intervention, abuse and neglect of older adults, abuse and neglect in institutional settings, prevention, Canada

*70. Lukawiecki, T. (199 1). Elder Abuse Bibliography / Bibliographie sur les abus à l'égard des personnes âgées. Ottawa: National Clearinghouse on Family Violence, Family Violence Prevention Division.

This bibliography provides extensive reference material on abuse and neglect of older adults in community and institutional settings. The bibliography is divided into three sections: books, government documents and reports (1980-199 1); articles (1985-199 1); films (1980-1991). French and English Canadian material, including community resources are highlighted. This bibliography is available through the National Clearinghouse on Family Violence.

The Family Violence Audio-Visual Source Guide /Catalogue de documents audiovisuels sur la violence dans la Famille. Ottawa: National Film Board of Canada.

This bilingual audiovisual resource guide on family violence provides information concerning National Film Board as well as non National Film Board productions. The guide lists distributors and title descriptions, indexing material according to category and subject. A variety of films about older adults and issues concerning abuse and neglect are included; some films offer case studies. Films are available in such areas as family violence, causation of abuse or neglect, intervention and prevention strategies, reporting, emotional and financial abuse, caregiver stress, conservatorship, guardianship, abuse in nursing homes or other institutions, and abuse of older adults in native communities. The Source Guide lists 32 Canadian and American audiovisual references for abuse and neglect of older adults. These focus almost exclusively on abuse and neglect that occurs in community settings.

*72. Podnieks, E., K. Pillemer, J.P. Nicholson, T. Shillington, & A. Frizzel. (1990). National Survey on Abuse of the Elderly in Canada / Une enquête nationale sur le mauvais traitement des personnes âgées au Canada. Toronto, Ontario: Ryerson Polytechnical Institute.

This report presents the findings of a national study of 2000 older Canadians to identify the experiences, circumstances and incidence of abuse and neglect among older adults living in private dwellings. "Material abuse", "chronic verbal aggression", physical violence and neglect are examined. The study found approximately 4% of older Canadians reporting some form of mistreatment by a partner, relative or other person. Prevalence varied among regions, with material abuse constituting over half of reported abuse situations and chronic verbal aggression constituting about one-third. Risk factors varied among the types of abuse. Older adults reporting material abuse and neglect tended to be widowed and lived alone; older adults reporting verbal aggression and physical violence tended to be married or living with the abuser. Verbal abuse appears to be associated with other forms of abuse as well. The study also uncovered incidents of, and fear of crimes by strangers. Areas identified as requiring further consideration include education, services, legislation and research.

Canada, incidence, characteristics of abusers, characteristics of abused older adults, study

Section Two: Causes, Identification and Assessment

I. Prevalence/incidence

Abuse of Clients by RNS and RNAS: Report to Council on Results of Canada Health Monitor Survey of Registrants. Toronto: The College, I -11.

Registered nurses and registered nursing assistants in Ontario were surveyed to determine the extent, circumstances and nature of abuses they had witnessed or heard about. Almost half of the respondents reported witnessing abuse. Verbal abuse was the most common form, followed by physical abuse. Eighty-five percent of respondents reported hospitals as the setting of the abuse, with 29% reporting that the abuse occurred in nursing homes. The majority of alleged abusers were female and involved fulltime staff, with 40% of the respondents reporting multiple instances of abuse by the perpetrator. Abused older adults were typically female, in poor condition within long term stay environments, with limited mobility, and disoriented and stressed. Yelling, swearing and rough handling were the most frequent forms of abuse; physical abuse appeared to be associated with older people. The study found that many reported cases of abuse were not followed up nursing supervisors.

74. Pillemer, K. & D.W. Moore. (1990). "Highlights from a Study of Abuse of Patients in Nursing Homes." Journal of Elder Abuse and Neglect. 2(1/2), 5-29.

This article reports methodology, key findings and practical implications of a survey on the extent and nature of "inappropriate patient management practices." The study used focus groups and telephone interviews with 600 registered nurses, licensed practical nurses and nurses' aides to examine predictors of physical and psychological abuse in nursing homes. Based on their results, the authors suggest that recognizing the stressors in nursing home care, as well as the general context of providing care, is the key to understanding abuse and neglect in institutions such as nursing homes. They report that while most staff are motivated by humanistic concerns of helping others and having meaningful employment, approximately one third of their respondents fit the category of high burnout with many not viewing their patients in a favourable light. Levels of staff/patient conflict reported by respondents were high and staff reported experiencing both verbal and physical aggression from patients. Physical abuse was predicted by increased amounts of staff/patient conflict and the level of staff burnout. Psychological abuse was predicted by high levels of staff burnout, high patient aggression, young age of staff and negative attitudes toward patients. The authors discussed the implications of the results, emphasizing the need for improved responses to difficult patient care situations, the need to respond to highly stressful workplaces, and the need for staff training in conflict resolution and stress reduction techniques. The elements of a training program conducted by the authors and based on their findings are also described.

NOTE: This study is also detailed in the following articles in this bibliography:

a) Pillemer, K., & R. Bachman-Prehn. (1991). "Helping and Hurting: Predictors of Maltreatment of Patients in Nursing Homes." Research and Aging, 13(1), 74-95.

b) Pillemer, K. (1988). "Maltreatment of Patients in Nursing Homes: Overview and Research Agenda." Journal of Health and Social Behaviour, 29 227-238. c) Moore, D.W. & Pillemer, K. (1987) Final Report on "Inappropriate Patient Management Practices." Washington, D.C.: American Association of Retired People Andrus Foundation.

characteristics of abusers, causes, intervention, nurses, nursing homes, physical abuse, risk factors, psychological abuse, restraints, training programs, characteristics of abused older adults

II. Causes

A. Stress, Burnout

*75. Creedon, M. (1985). "Enhancing Worker Morale in Long Term Care." Ontario Association of Homes for the Aged Quarterly. 1-2.

An important determinant of quality care is staff morale. The author's suggestions to administrators on how to enhance worker morale in long term care facilities includes: meeting workers' basic needs; in-service education; skills training; and encouraging worker input. Sources of stress, indicators, and methods of alleviating stress are discussed.

76. Heine, C.A. (1986). "Burnout Among Nursing Home Personnel." Journal of Gerontological Nursing. 12, 14-18.

Too many confused residents, inadequate staffing patterns, and an unsuitable architectural design unsuited to the needs of older residents may contribute to burnout and job stress occurring among nursing home staff. Burnout affects the employee, the residents, the quality of work done, and the organization itself. Effects of burnout on residents include neglect (e.g. lack of response to residents' need for assistance), psychological abuse (e.g. not speaking to residents while giving care, ignoring resident's right to privacy, infantilizing residents), verbal abuse and physical abuse (including indiscriminate use of restraints). To deal with staff burnout, Heine stresses the need for policy development, education, and staff development strategies. Resident-centred responses to burnout should focus on improving care, developing structured therapeutic strategies for staff to work with residents, and changing staffs' current perceptions of residents as people without social backgrounds. Resident-centred responses can be accomplished by care planning sessions with staff, family and residents.

characteristics of abusers, intervention, nurses, quality of care, staff development

*77. Middleton, J. & E. Forbes. (1992). "Elder Abuse'? Nurse Abuse? Whose Problem is This Anyway?" Canadian Nurse. 20-21.

The twofold purpose of this article is to critique the study conducted by Pillemer and Moore (see reference #74) and to offer a summary of findings from a study conducted in Saskatoon, Saskatchewan. Pillemer and Moore's research on the incidence of resident abuse is often considered a pivotal study. It is based on the assumption that increased aggressive behaviour on the part of residents leads to increased stress for staff, which in turns results in increased abusive behaviour by staff. In the critique of Pillemer and Moore's work, the authors suggest the need to reconsider the assumption, and question the data collection methodology and the apparent lack of concern for context within which incidents of abuse were observed. The authors caution against the uncritical application of American data to Canadian situations, since differences such as education levels of caregivers need to be considered. Reporting on their own research, the authors tested the hypothesis that high levels of patient aggression would lead to high levels of staff stress. The hypothesis was not supported; staff working with cognitively alert residents were more distressed by aggressive behaviour than staff working with cognitively impaired residents, even though the latter group experienced higher levels of aggression from patients. Staff working with cognitively impaired residents appeared to expect patient aggression, while staff working with cognitively intact residents did not.

characteristics of abusers, characteristics of abused older adults, health care providers, resident aggression, study, Saskatchewan

Final Report on "Inappropriate Patient Management Practices in Nursing Homes." Washington, D.C.: American Association of Retired People Andrus Foundation.

The purpose of this study was to investigate the context of staff-patient interactions in nursing homes to determine the extent of inappropriate patient management practices, the most frequent forms of abuse, methods used by staff to handle conflict with residents, and the factors which contributed to inhuman and abusive situations. The groundwork for a model of factors that influence inappropriate patient management practices is presented. The authors argue that social science research on the sensitive topic of abuse of older persons is possible, and that a crucial topic missed in quality of care studies has been staff-patient interaction and conflict. An outline is provided for a training program for staff, focusing primarily on dealing with staff-patient conflict, managing problem patients, and ways to reduce job stress and burnout. Tables of results from the study are included, and the interview format, finding of focus groups, and the literature used to develop the survey, are presented in the appendices.

characteristics of abusers, causes, health care providers, incidence, intervention, training programs, characteristics of abused older adults, nursing homes, study

79. Pillemer, K. & R. Bachman-Prehn. (199 1). "Helping and Hurting: Predictors of Maltreatment of Patients in Nursing Homes." Research and Aging. 13(1), 74-95.

The authors report the results of a random survey of 577 registered nurses, licensed practical nurses, and nurses aides from 31 intermediate care facilities in an American state. Three sets of variables were investigated in order to determine factors which might lead to maltreatment of residents: 1) institutional characteristics (e.g., facility size, owner ship, rates); 2) staff characteristics (e.g., level of education, age, occupational position); and 3) situational characteristics (e.g., job stress, levels of burnout, staff-patient conflict). Staff were asked if they had engaged in actions in the past 12 months which the authors characterized as either physical abuse (e.g., excessive use of restraints, pushing, hitting) or psychological abuse (e.g., isolating, insulting, yelling or denying residents food). Situational variables were the most likely to predict both psychological and physical abuse. Staff burnout, patient aggression, negative attitudes of staff toward patients and younger staff were each positively related to the presence of psychological abuse. Staff burnout, patient aggression and staff/patient conflict were also positively related to the presence of physical abuse. The authors suggest proper responses to maltreatment include: increased numbers of staff, upgrading of the quality of staff and better salaries. They also suggest the need for improved public awareness of positive contribution of care facility staff. Finally, training needs to be undertaken to help staff deal with difficult patient care situations and to reduce staff-patient conflict.

characteristics of abusers, nurses, nursing homes, physical abuse, predictors, psychological abuse, risk factors, study

B. Lack of Training/Understanding

*80. Bourbonnais, J. (1987). "Réflexions sur les personnes âgées en besoin de services." The Social Worker / Le travailleur social. 55(3), 113-114.

The various characteristics specific to older adults are often given scant attention by those who work with them, either in a professional capacity or as natural caregivers. Many of these people are young, healthy and have difficulty judging the needs of older adults. Diminished or lost self-sufficiency, isolation and psychological abuse are three elements on which the author reflects. She emphasizes that older adults have specific needs which are not respected by natural caregivers and professionals in either home or institutional settings. This may result from caregivers being unable to distance themselves from their personal values or those who do not have the time to adapt their type of intervention to suit the older adults.

ethics, dependency, isolation, abuse and neglect of older adults, abuse and neglect in institutional settings, Canada

*81. Feldt, K. & M. Ryden. (1992). "Aggressive Behaviour: Education Nursing Assistants." Journal of Gerontological Nursing. 3-12.

Although nursing assistants are direct caregivers to residents, few have received training to prevent or reduce behavioral problems. The authors describe an education program that was part of a study testing the feasibility of an intervention to reduce or prevent aggressive behaviour in a sample of cognitively impaired residents. The educational program, which included content on such issues as communication techniques, preventing aggressive behaviour and understanding cognitive impairment, was followed by a 6 week caregiving phase to aggressive residents. Many nursing assistants report that the knowledge they gained changed their way of providing care, which in turn influenced the residents' behaviour.

*82. Kingdom, D. (1992). "Preventing Aggression." Canadian Nursing Home. 3(2), 14-16.

The aggressive behaviour of residents has to be properly handled by long-term care staff to create a caring environment. The article features a "hands-on" training program that focuses on practicing intervention techniques to handle aggressive behaviour, i.e. escape methods. This is supplemented with role playing and discussions on physical/mental loss and how to re-establish relationships. The necessity of staff support and improving professional skills is stressed.

83. Stilwell, E.M. (1991). "Nurses' Education Related to the Use of Restraints." Journal of Gerontological Nursing. 17(2), 23-26.

This article investigates education received by nurses about the use of physical restraints, and nurses' perceptions about the use of restraints. Most nurses had few (if any) hours of instruction, and most reported drugs or medications as the most common alternatives to physical restraints. While many identified the risks of using restraints as anxiety, confusion, and reduced ability to complete activities of daily living, few named death or major injury. The author concludes that nurses have little awareness of the alternatives to physical restraints, or of recent research findings on the risks. She recommends education in all clinical settings for nurses and proposes a syllabus for an education program.

C. Exercise of Power

84. Butler, B.M. (1986). "When Nurse and Patient Battle for Control." RN. 49(9), 67-68.

Butler considers how and why patients and nurses may get into a struggle for control. She argues that individuals identified as "problem patients" are, to some extent, created by nurses whose behaviours and attitudes influence the patient's response to them and result in the struggle. Some nurses have firm ideas about what a "good" patient is and feel threatened when patients ask questions. Butler's suggestions for overcoming the struggle for control include considering the patient's point of view and how to utilize strategies designed to respond to the patient's stress, such as showing concern or offering explanations for procedures.

85. Cassell, E.J. (1989). "Abuse of Elderly: Misuses of Power." New York State Journal of Medicine. 89(3), 159-162.

Cassell argues that abuse of older people occurs as a result of an improper exercise of power in which obligations or responsibilities normally associated with relationships are ignored. The author demonstrates the dynamics and nature of power, and the way in which failure to understand and accept the meaning of obligations and responsibilities in relationships with older people can result in abuse. Cassell focuses on use of power by doctors, medical therapy as a form of abuse, and legal considerations in patient care and treatment.

86. Diessenbacher, H. (1989). "Neglect, Abuse and the Taking of Life in Old People's Homes." Ageing and Society. 9(1), 61-71.

In this article, the author argues that abuse and neglect of older adults in institutions is not the result of lack of humanity (lack of love, affection or sympathy), but the result of lack of professional nursing routine in which all residents are treated the same, with no exceptions. For the author, "equality" means that residents should neither be ignored nor receive special treatment. Diessenbacher argues that abuse and neglect arise from power differentials between caregiver and resident, and from perceptions of older people as unproductive members of society, hopelessly approaching death. The author analyzes the "posture of caregiving" and the dynamics which result when the caregiver is usually standing while the resident is usually lying down. Case studies are used to demonstrate how personal psychological history of staff may be played out in situations in which a staff person is abusive to a resident. The author suggests that "regulators," built into the routine and life of the facility, are needed to counteract the effects of factors leading to abuse and neglect. Regulators include architectural design, appropriate diets, clear division of duties among staff, organized work/vacation rosters, ongoing staff education, and the introduction of the professional ethic that inner feelings about a resident come second to the proper execution of work.

characteristics of abusers, ethics, intervention, policy, protocols, risk factors, characteristics of abused older adults

D. Resident Characteristics

87. Dougherty, L.M., J.P. Bolger, D.G. Preston, S.S. Jones, & H.C. Payne. (1992). "Effects of Exposure to Aggressive Behaviours in Job Satisfaction of Health Care Staff." Journal of Applied Gerontology. 11(2), 160-172.

This study investigated the effect of physical and verbal aggression by institutionalized older residents on other residents and staff, and also studied the effect of disruptive behaviour on health care staff's job satisfaction. Twenty-eight health care staff (mental health workers, licensed practical nurses and registered nurses) were interviewed about job satisfaction and various types of aggressive behaviour they had experienced with residents in the previous month. Physical aggression was the most commonly reported form of aggressive behaviour. Three forms of aggressive behaviour were found to be correlated with decreased job satisfaction. Job satisfaction did not correlate with factors such as job category, length of employment, coping styles or staff demographics.

*88. Neault,S. &N. Poirier. (1991). La vulnérabilité psychique et la violence. Montréal: Fédération québécoise des Sociétés Alzheimer.

The authors describe the various forms of vulnerability related to the aging process (physical, emotional, social). Explanations for abuse involve three factors: the abuser, the abused person, and the environment. The abuser can be a family member or service provider, suffering from exhaustion, insufficient knowledge or problems of alcoholism or drug addiction. The deterioration of an older person's state of health, may increase the degree of dependency, leading the older person to be perceived as a burden for the service provider or natural caregiver. The environment may result in abuse, such as infantilization, ageism or no respect for dignity. The authors propose a number of interventions for service providers and institutions (continuing education, raising the prestige of their work and promotion of a code of ethics) and for relatives or foster families (training and self-help groups).

administration, characteristics of abused older adults, characteristics of abusers, ethics, risk factors, family, intervention, abuse and neglect of older adults, abuse and neglect in institutional settings, caregivers, vulnerability, Quebec

*89. Paquet, J. (1993). Centre hospitalier de Charlevoix, La violence faite aux personnes âgées: La personne âgée violentée comment l'identifier? Baie-Saint-Paul: Centre hospitalier de Charlevoix.

The author proposes definitions of the various types of abuse and neglect of older adults, and presents a portrait of the typical abused person and the typical abuser. He indicates the four groups responsible for the various types of mistreatment (service providers, family members, peers, certain institutional administrations). Indicators which explain the presence of mistreatment in institutional settings are also listed. He closes with a number of solutions worthy of consideration. The author feels that, while it is vital to listen to older adults and encourage an atmosphere of trust and empathy, it is most important to act to prevent such situations.

characteristics of abused older adults, characteristics of abusers, causes, definitions, abuse and neglect in institutional settings, Quebec

*90. Potter P.A.&A.G. Perry. (1989). "La personne âgée." In P.A. Potter, & A.G. Perry, Soins Infirmiers: Théorie et pratique (2nd édition). Montréal: Éditions du Renouveau Pédagogique inc. 647-675.

The chapter on older adults addresses various aspects related to aging, including myths and stereotypes, theories on aging, community health services, institutional care and the aging process. Under the aging process, the authors discuss the social isolation experienced by older adults and explain this phenomenon by personal choices, behavioral factors which "put off" those around them, or family factors such as geographical distance from relatives. Nurses can help older adults change these patterns by using various behaviour modification techniques. For instance, they can help an older person who feels alone rebuild a social network. There are also a number of programs encouraging contact between seniors who feel isolated, whether living at home or in an institution. The authors stress the importance of still respecting the wishes of the older adults.

ethics, nurses, isolation, abuse and neglect of older adults, abuse and neglect in institutional settings, Quebec

91. Whall, A.L., G.L. Gillis, D. Yankou, D.E. Booth, & C.A. Beel-Bates. (1992). "Disruptive Behavior in Elderly Nursing Home Residents: A Survey of Nursing Staff." Journal of Gerontological Nursing. 18(10), 13-17.

Nursing personnel from 14 nursing homes in southeast Michigan were surveyed to determine: 1) the most disruptive behaviours of nursing home residents; 2) the percentage of residents with dementia or memory impairment among those exhibiting disruptive behaviour; and 3) the incidence of aggressive and disruptive behaviour and 4) the strategies involved in their management. Thirty six per cent of residents were described as having engaged in disruptive/aggressive behaviour within the past six months. Eighty five per cent of residents in these cases were considered to suffer from some measure of memory impairment. Seventy one percent of the staff cited hitting or slapping as constituting the largest category of disruptive/aggressive behaviour. Other categories that they reported included verbal aggression, screaming, pacing, wandering, refusing care and scratching. Staff listed 14 types of interventions for alleviating disruptive/ aggressive behaviour. Verbal discussion, chemical restraints and physical restraints were identified as the three most frequently used management strategies. The use of chemical and physical restraints raises questions about human dignity and self determination issues involved in behavioral management.

E. Systemic Factors

92. Butler, R.N. (1993). "Dispelling Ageism: The Cross-Cutting Intervention." Generations. Spring/Summer, 75-78.

Twenty-five years ago the author coined the term ageism. In this article he considers how public education and media attention have resulted in the improvement of attitudes toward older adults. Reflecting on current forms of ageism, Butler refers to attitudes of physicians and their unwillingness to treat older patients as medical ageism and public perceptions that older adults have benefited at the expense of the poor in other age groups. Butler feels that the latter problem may be due to distorted facts about the costs of services to older adults. He suggests a need for greater awareness of how public money is spent on people of different ages. Intergenerational advocacy based on concern for disadvantaged people in all age groups is required and the fear dispelled that Alzheimer's disease is a major source of public money expenditure.

93. Carlova, J. (1988). "Are Doctors to Blame for Nursing Home Snakepits?" Medical Economics. 65(23), 62-64, 66, 68-69.

A California commission responsible for nursing homes changed its focus in 1988 on who was primarily responsible for abuse in nursing homes. Previously blame for abuse was placed on nursing homes administrators and owners; but problems such as "phone-call medicine" and "gang visits" (doctors visiting a great number of residents in an hour) resulted in a shift of blame to doctors who serviced nursing homes. This article presents doctors' responses to the allegations, notes the movement to peer review of doctors and identifies flaws in the system such as method of reimbursement for doctors and nursing homes that might account for some of the abuse. The Commission's work and impact with one corporation is described, and suggestions for change are presented.

characteristics of abusers, United States, doctors, health care providers, policy

94. Meddaugh, D.I. (1991). "Before Aggression Erupts." Geriatric Nursing. 115-116.

This study investigates factors which might contribute to physical and verbal aggression in cognitively impaired nursing home residents. The following patterns were noted: staff accepted some degree of aggression as "part of the job;" patients' lack of choice in their lives (in terms of daily routine, choice of food, etc.) was a contributing factor; and isolation, patients' lack of involvement in social activities and minimal communication from caregivers were major contributing factors in verbal and physical aggression. Initially non compliant behaviour from patients would result in isolation, which in turn led to increased aggressive behaviour. Institutions were seen as non-supportive of aggressive patients in three ways: 1) there was no help offered to patients to find channels for undesirable behaviour; 2) caregivers were unwilling to work long term with aggressive patients, resulting in a lack of continuity and knowledge of the patient and their needs, which in turn increased undesirable behaviour; and 3) isolation of patients was viewed as an easier option than finding alternatives.

95. Phillipson, C. (1993). "Abuse of Older People: Sociological Perspectives." In P. Decalmer, & F. Glendenning (eds.), Mistreatment of Elderly People. Newbury Park, New York: Sage. 76-87.

The author argues the need to shift from a focus on risk factors for individuals within families, to a sociological analysis of abuse. In a sociological analysis, risk factors are understood to arise from ideologies about older people and the resources that are, or are not, available to them. Family violence as a framework is both limited and limiting, for understanding abuse of older adults: it overshadows other problems faced by older adults, assumes cultural and moral scripts exist for family life, ignores ambiguity, and oversimplifies power dynamics in families. The focus on the family has also meant lack of attention to abuse in institutional settings. Two theories from sociology are offered to demonstrate alternate approaches. Interactionist theory focuses on the relationship between older people and people who provide care to them, and the impact of response to old age on relationships. Political economy theory highlights the social construction of dependency and the impact of the dependent status of older people on their relationships with people who provide care.

*96. Podnieks, E. (1987). "Canadian RN Looks at Caregivers and Elder Abuse." Provider. 13(7), 45-46.

Podnieks identifies two reasons why nurses become abusive toward older patients: 1) personal characteristics of the individual nurse, such as attitudes toward older people or lack of training in the field of geriatrics; and 2) characteristics of the system or situation in which nurses find themselves, such as lack of prestige or financial reward associated with geriatric nursing, or understaffing. The author suggests a need to improve the profile of geriatric nursing in order to attract more qualified people. Lobbying will result in increased financial rewards, increased special training and greater appreciation of geriatric nurses.

97. Vousden, M. (1987). "Nye Bevan Would Turn in his Grave." Nursing Times. 83(32), 18-19.

This brief article discusses possible causes for abuse of older adults in residential homes in the U.K. Lack of managerial training and conflicting ideologies between social work and nursing are seen as major causes for the continuation of the abuse. Some homes housing sick older adults do not have the legal authority to offer nursing care. Refusal by care assistants to assist nurses in lifting patients or changing incontinent older adults exemplify the problem. Many residential homes were established without adequate preparation for the medical needs residents might have. The problem of nurses working within an environment based on a social work model is highlighted as central to this situation.

III. Professional Role in Identification

98. Aravanis, S.C., R.D. Adelman, R. Breckman, T.T. Fulmer, E. Holder, M. Lachs, J. O'Brien, & A.B. Sanders. (1993). Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago, Illinois: American Medical Association.

This publication describes the existence and primary features of abuse and neglect of older adults in both community and institutional settings. Basic information is presented in terms of how to identify abuse and neglect and how to respond to it. Ethical and medicolegal issues which confront physicians in situations of abuse and neglect are discussed. The authors make suggestions for the detection and documentation of evidence during interviews and medical exams. Intervention and development of a case management approach is presented using a flow chart of possible actions. The authors discuss the role and obligations of the physician in responding to abuse and neglect cases, and outline possible preventive actions and legal considerations based on U.S. legislation. They note issues associated with physician failure to report and testifying in court. They also outline risk management strategies to reduce liability. Recent trends in treatment are described and a list of state units on aging, adult protective service agencies and ombudsman program directors are provided.

assessment, doctors, intervention, documentation, policy development, reporting, ethics, detection

*99. Bélanger, L. (1990). "Stratégies de dépistage, d'intervention et de prévention en institution." In J. Carette, & L. Plamondon, Vieillir sans violence. Montréal: Presses de l'Université du Québec. 132-136.

According to the author, caregivers are ill-prepared to deal with the increasingly care-intensive conditions of the institutional population. The abuse problem demands direct and concrete solutions in the short term, and she proposes a system of "responses" for intervention at various levels. The suggestions are classified in three groups: detection, direct intervention and prevention. The main purpose of creating these three categories is to raise awareness of the issue while providing assistance to deal to those working in the field, the abusers, and abused older adults.

detection, reporting, abuse and neglect in institutional settings, prevention, procedures, Quebec

*100.Berger, L. (1993). "Éviter les dangers." In L. Berger, & D. Mailloux-Poirier, Personnes âgées: Une approche globale. Québec: Éditions Études Vivantes. 377-435.

This chapter deals in part with abuse and neglect of older adults. The author defines four types of abuse (physical, psychological, material and violation of rights) and two forms of neglect (active and passive). Nurses are particularly well-placed to be able to detect or prevent abuse of residents in institutions. They must be watchful, because residents may not report abuse for a variety of reasons (shame, guilt or fear of reprisals). The author presents the risk factors and a data gathering tool which makes it possible to identify people who are being abused or neglected. She proposes primary and secondary intervention strategies and advice to be given to the residents in order to prevent abuse.

definitions, detection, risk factors, nurses, intervention, abuse and neglect of older adults, abuse and neglect in institutional settings, prevention, Quebec

101. Bishop, J. & P. Patterson. (1992). "Guidelines for the Evaluation and Management of Family Violence / Lignes directrices sur 1'évaluation et la gestion de la violence familiale." The Canadian Journal of Psychiatry / La revue canadienne de psychiatrie. 37 (7), 458-471.

This article highlights various aspects of the social context of fan-lily violence, including abuse of older adults, and gives attention to ways violence issues can be integrated into psychiatric or other medical practice. Until recently, the diagnostic classification system has been very limited in its consideration of the complexity of family violence. The authors suggest a biopsychosocial model and provide many concrete recommendations on how physicians can incorporate this model in their practices. These guidelines were approved by the Canadian Psychiatric Association in April 1992.

102.Canadian Task Force on the Periodic Health Examination. (1994). "Periodic Health Examination, 1994 Update: 4. Secondary Prevention of Elder Abuse and Mistreatment." Canadian Medical Association Journal. 151(10), 1413-1420.

This work provides research-based recommendations for family physicians on the detection, assessment and management of abuse or mistreatment in patients over 65 years of age. The options considered were: detection of elder abuse by history and examination or by specific protocols; and intervention through mandatory reporting, removing the victim from the situation or acting as an advocate for the patient. The article includes the following topics: Definition, Prevalence in the community, Prevalence in institutions, Risk factors for abuse, Natural history, Detection manoeuvre, Intervention, Recommendations, Validation, Research priorities. While there is insufficient research evidence to recommend screening for elder abuse in the periodic health examination, or to favour any specific protocol or treatment, physicians should be alert to indications of elder abuse and should take measures to prevent further abuse. Physicians, with the help of a multi disciplinary team, are uniquely positioned to advocate for the abused older person.

103.Galan, D. & L. Mayer (1992). Elder Abuse and the Dentists' Awareness and Knowledge of the Problem: Final Report. Winnipeg: University of Manitoba. National Health Research and Development Report #4888-07-91-077.

In this national study, the authors surveyed 1775 Canadian dentists to evaluate their awareness of the problem of elder abuse and their experiences with victims. Results from the mailed questionnaire indicate that 2.5 per cent of dentists have seen or treated a victim of abuse and another 5.4 per cent have some knowledge or were suspicious of abuse, demonstrating that dentists have identified cases of elder abuse and neglect. Responses to abuse are generally limited to providing dental treatment and making emergency medical referrals, with very few dentists referring patients to social service agencies or legal authorities. This study included dentists working in institutional settings, as well as those working in the community. The authors recommend that dentists be educated in identifying and responding to abuse and be involved with other health care providers in addressing the problem.

104. LaRocco, S.A. (1985). "Patient Abuse Should be Your Concern." Journal of Nursing Administration. 27-3 1.

LaRocco presents a general introduction to some of the issues faced by administrators who may be concerned about possible abuse of patients in their facilities. She briefly describes aspects of patient abuse, detailing some causes, signs and symptoms. She then discusses approaches to preventing abuse, noting problems which may arise, and outlining strategies needed to respond to and investigate reports of patient abuse. Some issues are specific to New York State.

105. Mowbray, C.A. (1989). "Shedding Light on Elder Abuse." Journal of Gerontological Nursing. 15(10), 20-24.

This article discusses the role of nurses in dealing with abuse and neglect cases involving older adults. Possessing a social mandate to address family violence, nurse roles are well suited to guide prevention and intervention strategies. Mowbray reviews nursing journals to examine nursing trends regarding abuse of older adults and finds only isolated references to this problem until 1979 when a brief on abuse of older adults was presented before the House Select Committee on Aging. Social stigma, lack of recognition and lack of definitional consensus continue to hamper accurate incidence rates. Causation theories and effective prevention and intervention strategies are still being developed. Early research findings are flawed by non-representative studies, limited empirical data and questionable assumptions about similarities between abuse of older adults and child abuse. Mowbray reviews typical characteristics of abusers and abused older adults, and cites a study which challenges age, gender, vulnerability and isolation correlates of abuse. Nurses are uniquely positioned to identify, describe and explain abuse incidents.

nurses, intervention, prevention, causes, characteristics of abusers, characteristics of abused older adults

"Elderly Abuse in a Hospital: A Nursing Perspective." In J.I. Kosberg (ed.), Abuse and Maltreatment of the Elderly. London: John Wright and Sons. 391-403.

This article examines the role of nurses in identifying and reporting incidents of abuse of older adults. A survey of nurses found the majority of respondents were aware of abuse of older persons. Thirty-four percent of the abuse encountered was identified as physical abuse and twenty-eight percent was identified as psychological abuse. Respondents also noted that older people were often 'dumped' at emergency wards by families no longer capable or willing to provide care. Often older people were admitted to hospitals from nursing homes in conditions of severe neglect. Of the nurses surveyed, 83% had observed cases of abuse, while only 35.9% had actually reported cases, The majority of these reported cases were referred to social services. Reynolds and Stanton encourage the initiation of patient centred nursing care plans, thorough history taking, effective discharge planning, staff education and a multidisciplinary approach. The article discusses implications for community based nursing and recommends improved training and expansion of the nurse role in dealing with mistreatment issues.

IV. General Issues in Assessing Abuse or Neglect

107. Fulmer, 1 (1989). "Clinical Assessment of Elder Abuse." In R. Fllinson, & S.R. Ingman (eds.), Elder Abuse: Practice and Policy, New York: Human Sciences Press, Inc.

This article describes the difficulties surrounding the lack of a framework and uniform definitions for dealing with abuse and neglect of older adults in the United States. Without federal legislation, professionals are forced to rely on assessment criteria developed within their own state, resulting in inconsistent national reporting procedures and making the development of effective protocols difficult. This article proposes guidelines for the assessment of abused older adults, outlining types of abuse/ neglect and describing corresponding physical indicators typically associated with these forms of mistreatment. Because normal aging processes and chronic health problems may simulate the effects of abuse or neglect, the need for comprehensive patient histories are recommended as vital components of the assessment procedure.

108. Fulmer, T. &J. Ashley. (1986). "Neglect: What Part of Abuse." Pride Institute Journal of Long Term Home Health Care. 5(4), 18-24.

Assessing neglect of older adults is a complex issue. Problems associated with inconsistency in definitions between research studies and practice situations are highlighted, empirical testing of broadly defined neglect is lacking, and neglect is often perceived as less severe than abuse. Abuse theories are frequently untested and often evolve out of child abuse research. As a result, their application to neglect situations is speculative. Abuse and neglect are different: characteristics for the two differ; the prevalence of neglect is often higher than for abuse; and neglect is commonly characterized by subtlety which may have 'lethal' consequences. Values of self determination and responsibility, health profession decision making processes, the normal aging process and presence of chronic or acute disease, are all factors potentially confounding "neglect" of older adults. Guidelines for assessing evidence of neglect are typically inadequate and the authors offer an alternate assessment tool.

109. Fulmer, T.J. & T.A. O'Malley. (1987). Inadequate Care of the Elderly: A Health Care Perspective of Abuse and Neglect. New York: Springer Publishing Company.

Fulmer and O'Malley begin by identifying the scope and causal factors linked to abuse and discuss the problems associated with a lack of consistency in definitions. The authors stress that assessment tools for identifying inadequate care must be able to distinguish between the physical indicators for abuse and those for neglect. The authors present risk factors for inadequate care and offer intervention guidelines. Legislation dealing with abused older adults is reviewed and ethical factors involved in identifying, reporting and intervening in suspected abuse cases is highlighted. The authors also discuss the results of a study on a hospital abuse policy for older adults and the role of hospitals in intervention treatments. They identify concerns related to access of institutionalized older adults, and issues such as residents' bills of rights and appropriate facility prevention strategies.

110.Lau, E.E. (1986). "Inpatient GeroPsychiatry in the Network of Elder Abuse Services." In M.W. Galbraith, Elder Abuse: Perspectives on an Emerging Crisis, Volume 3. Kansas: Mid-America Congress on Aging.

This article describes assessment and treatment issues associated with older adult patient care in the Medical Geropyschiatric Program at Lutheran Medical Centre in Cleveland, Ohio. Patients in this unit are both voluntary and involuntary. Many were admitted suffering from either abuse/neglect, self-neglect or medical neglect. Although many hospitalized patients have both medical and psychiatric disorders, health professionals are reluctant to refer older adults for psychiatric treatment, often falsely diagnosing mental confusion as dementia rather than exploring other possible causes such as the effects of medications, malnutrition, anemia or even abuse/neglect. The article notes that depression is often misdiagnosed. It may be the result, or the cause, of abuse or neglect. Symptoms of depression frequently simulate those of dementia and its presence is often overlooked as a possible cause of sleep disorders or impaired cognition. Benefits of the geropsychiatric unit include the timely assessment and treatment of abused or neglected older adults, the removal of abused older adults from harmful environments, temporary relief of stress, and the provision of adjustment time for the resident or family between movement from home to placement in a nursing home.

111. Phillips, L.R. (1983). "Elder Abuse - What is it? Who says so?" Geriatric Nursing. 4, 167-170.

Despite the establishment of identification guidelines, educational programs and legislation, nurses are often still hampered in dealing with the abuse and neglect of older adults because of difficulties in definitions and uncertainty about abusive situations. In a study of 74 frail older adults and their caregivers, nurses were unable to assign 12 of the subjects to either a "good relationship" group or an "abuse/neglect" relationship group, due to vagueness in the definitions or the inability of the research instrument to acknowledge certain factors. These often unacknowledged factors include observer respect for the older adults' right to self determination, nurses' values, expectations and perceptions, and characteristics of the caregivers. Nurses' perceptions of the caregivers' intent or ability to give assistance and support are affected. Further elaboration is needed on several issues: 1) whether the caregiver's intention can be used as justification; 2) how much responsibility does a caregiver have to assume; 3) how to identify the point at which behaviour becomes abusive; and 4) how the rights of a person in a lifelong intimate relationship should determine treatment.

112. Sengstock, M.C., M.R. McFarland, & M. Hwalek. (1990). "Identification of Elder Abuse in Institutional Settings: Required Changes in Existing Protocols." Journal of Elder Abuse and Neglect. 2(1/2), 31-50.

There is a lack of measurement instruments specifically designed to identify abuse and neglect of older adults in institutional settings. This article summarizes indicators used to identify abuse and neglect in the community, and integrates this with information available on institutional settings. The authors suggest areas to assess and techniques to detect abuse and neglect in institutional settings. In general, indicators used in the community are useful in institutional settings; using six dimensions of abuse or neglect, the authors suggest modifications of indicators.

V. Assessment Tools

Ashley and Fulmer describe and assess five instruments and protocols used to determine the existence of abuse or neglect of older adults. At present, all five are used primarily in family/ community situations: 1) Johnson's subjective-objective- assessment plan (SOAP); 2) Tomita's Elder Abuse Diagnosis and Intervention Model; 3) a less structured guideline for in-home observation developed by Rathbone-McCuan and Voyles; 4) the HALF tool developed by Fergusen and Beck; and 5) a tool developed by Fulmer and others based on state protection laws assessment requirements. The tools provide guidelines for interviewing which help to understand the complex issues related to abuse and ensure consistency in response to subjective and personal values of the interviewer, there are some important limitations: the instruments are based on undeveloped theories of the mistreatment of older people and thus may be incomplete concerning factors leading to abuse; the quantitative tools lack detail in terms of response categories or lose sensitivity to variations in response due to predetermined responses; operationalization of terms such as "inadequate care" and it neglect" affect the assessment of abuse; and the tools are not very helpful in assessing ambiguous actions which may or may not represent abuse or neglect.

114.Basu, R. (1992). Elder Abuse: A Practical Handbookfor Service ProviderslMau vais traitement des personnes âgées: Manuel pratique à l'usage desfournisseurs de services. Toronto, Ontario: Ontario Association of Professional Social Workers.

This handbook is intended for use by Ontario service providers who deal with abuse and neglect situations involving older adults. Definitions of mistreatment, typical characteristics of abusers and abused older adults are discussed, and detailed tables containing identification assessment tools and charts outlining available intervention strategies are provided. The handbook acts as a reference for professionals, caregivers, older adults or their families covering the pertinent acts of legislation and community Tesources available for obtaining information or initiating action. A brief section sets out the relevant agencies and government offices to contact for suspected cases of abuse and neglect of older adults in institutions.

*115. Fontaine, K.L. (1991). "La violence." In J.S. Cook, & K.L. Fontaine, Soins Infirmiers: Psychiatrie et santé mentale. Montréal: Éditions du Renouveau Pédagogique inc. 649-718.

The chapter titled "Violence" presents various behavioral, emotional, socio-cultural and other characteristics relating to abuse in the family setting and in an institutional context. Part of the chapter is specifically on abuse and neglect of older adults. It offers an assessment grid to determine whether or not abuse has occurred, in order to make appropriate diagnosis. This chapter proposes a nursing approach for dealing with abused people and their families.

detection, assessment, nurses, abuse and neglect of older adults, abuse and neglect in institutional settings, procedures, physical abuse, Quebec

116. Sengstock, M. C., M. Hwalek, & S. Moshier. (1986). "A Comprehensive Index for Assessing Abuse and Neglect of the Elderly." In M.W. Galbraith (ed.), Elder Abuse: Perspectives on an Emerging Crisis, Volume 3. Kansas: Mid-America Congress on Aging.

This article describes the Sengstock-Hwalek Comprehensive Index of Elder Abuse, a tool developed in cooperation with social researchers and service providers. Compiled by collecting identification tools from agencies throughout United States and Canada, this index outlines six categories of abuse: physical abuse, physical neglect, psychological abuse, psychological neglect, material abuse and violation of personal rights. Providing an extensive list of symptoms typically associated with each category, the index also enables agency workers to compile demographic data about clients, as well as offering criteria for assessing the abuser's level of intention in the abusive or neglectful act. The index aids health care providers in identifying both abused older adults and types of abuse; serves as an effective agency case file; assists the agency worker in identifying service needs and in developing appropriate case management; facilitates the transition of client services between agencies, and serves as documentation in legal proceedings. This index has subsequently been modified to take into account problems occurring in institutions.

* 117. Wierucka, D., B. Barnett, E. Boustcha, D. Goodridge, B. Hack, E. McKean, & L.Wolf. (1992). Institutional Abuse Report. (Unpublished document by Winnipeg Municipal Hospital [now called Riverview Health Centre], I Morley Avenue, Winnipeg, Manitoba, R3L 2P4).

Winnipeg Municipal Hospital established a committee to consider the issue of institutional abuse and to develop recommendations for dealing with this problem in their hospital. This report summarizes the process they went through. The Committee extensively reviewed Donabedian's definition of quality and his "structure, process and outcome approach" to care assessment. The Committee used this conceptual framework to analyze research findings, nursing home accounts, and federal and provincial initiatives on abuse/neglect in institutional settings. Recommendations included the need to implement a protocol for processing complaints of client abuse by hospital staff, develop policies supporting client safety, provide staff education on how to prevent abuse and neglect, and ensure the coordination of policies regarding abuse. This article includes the protocol developed to process client complaints and a report evaluating the efficacy of the abuse/ neglect screening checklist protocol. This latter checklist was found effective in its use by nurses and social workers in identifying high risk cases, but was found used less as a multidisciplinary tool.

VI. Documentation

118. Fulton, D.K., S.P. Bedell, & B.M. Broccolo. (1989). "Documentation Concerning Abuse and Neglect in Nursing Home Patients." Topics in Health Records Management. 10(1), 71-76.

The authors explore documentation issues related to several states' laws on the investigation, reporting, prevention and intervention of abuse cases involving older people. Various state approaches have included the creation of bills of rights for long term care patients, the development of mandatory reporting, registration systems for incidents of abuse and neglect, and the implementation of special criminal penalties for abuse and neglect. Facilities have a responsibility to develop policies to ensure compliance with patient bill of rights, keep proper records of abuse investigations, and record efforts to ensure high quality of care and good staff.

119. Massachusetts Department of Health, Division of Health Care Quality. (1984). The Incident Report. Boston, Massachusetts: The Department. [videocassette] (26 minutes)

The importance of incident reporting is highlighted in this videotape in which a suspected case of abuse in a nursing care facility is investigated by a worker from the Division of Health Care Quality in Massachusetts. The video presents an incident in which an older woman suffers a broken wrist after refusing to take her medication. The video's portrayal of the investigation process reveals the complexity of this situation as it shows how a caring nurse is suspected of abuse, because the incident was reported later and the older woman's complaints of pain were not responded to immediately. The video examines the issues from several perspectives and outlines the personal stresses experienced by nursing staff, underscores their working conditions of understaffing and long hours, and acknowledges nursing staffs' fear of dismissal of reporting injury. Proper documentation is critical for effective resolution of suspicious incidents.

120. Riemann, M. J. (1986). "Dealing with Patient Abuse: Documentation and Consistency Vital in Evaluating Possible Incidents." Contemporary Long Term Care. 9(9), 99-102.

Standardized procedures are needed to best respond to abuse of older persons, particularly in potentially explosive situations. An effective response has four components. First, there must be immediate documented response to any suspicion of an incident of abuse. Second, an investigation must be initiated. The article details suggested procedures for conducting an investigation, setting out which administrative staff should be involved, who should be interviewed, and how to come to a decision as to whether abuse occurred. Third, if the incident is substantiated, a decision regarding the appropriate measures (punishment/restitution) needs to be made in consultation with the resident and/or family. Finally, all state statutory requirements need to be followed to ensure uniform reporting. Standardized reporting forms are useful.

VII. Legal Issues in Identification

121. Brodsky, S.L. (1989). "Testimony About Elder Abuse and Guardianship." Journal of Elder Abuse and Neglect. 1(2), 9-15.

The author addresses the role of professionals called as expert witnesses in court cases about competency/ guardianship or the abuse of older adults. The expert witness should see his or her role as explaining the findings in the case, as well as pointing out his or her professional knowledge about the issues involved. The author lists common questions asked of expert witnesses, and provides both specific responses and general approaches to the line of questioning (the nature of bruises, challenge to data, mental competency and guardianship knowledge) in four areas of questioning.

122. Kane, R.S. & J.S. Goodwin. (1991). "Spontaneous Fractures of the Long Bones in Nursing Home Patients." American Journal of Medicine. 90(2),

When four nursing home residents fractured their legs, their families sued or threatened to sue the facility. The authors review these four cases and two similar ones. In each case the resident had been bedridden for an extended period and the fractures showed no evidence of disease, physical trauma or abuse. The authors argue that these cases involved spontaneous fractures, which have been noted in medical literature as possible. Unexplained cases of fractures cannot be assumed to be abuse, nor can abuse be ruled out.

123. Weiler, P.G. &J.K. Cooper. (1990). "Investigation of Death Clusters in a Nursing Home." Journal of Aging and Health. 2(3), 395-4 10.

At the request of the California attorney general's office, the authors investigated clusters of death in a rural nursing home to determine causes and possible criminal liability. Using a "web of causality" concept, the authors determined several contributing factors may have been important in the deaths, including discrepancies between death certificates and medical notes, standards of care, excessive use of medications, and dehydration. Because the investigation looked back in time information was missing and it could not be determined whether one person or factor was the cause of death. Based on their findings and this method of investigation, the authors suggest a number of public policy implications concerning quality of care in nursing homes, conflict of interest issues when the medical director is the chief attending physician, use of medications, and the need for clearer standards of care for terminally ill, older patients.

Section Three: Intervention

I. Ethics of Intervention

124. Government of Canada. National Advisory Council on Aging. (1993). "Freedom and Responsibility." Expression. 2-8.

This short publication discusses dilemmas concerning issues of freedom and responsibility in the choices made for and by older adults. Professionals face moral and ethical dilemmas when forced to choose between respecting an older adult's values and the possible risk of harm. Dilemmas also arise around whether to question the adult's competence or to allow maximum freedom to make personal decisions. Although mandatory reporting legislation has been challenged as violating rights and infantilizing older adults, it has also been argued that this form of legislation clarifies powers of intervention and establishes important sets of procedures, although the procedures will require built in safeguards. Use of physical restraints in institutions is criticized because it does not appear to prevent the harms it was intended to address, it may cause physical problems, or it may violate moral rights to freedom. Environmental modification, occupational and rehabilitation therapies, as well as improved social and emotional support systems, are suggested as alternatives to physical restraints.

125. Kapp, M.B. (1983). "Legal and Ethical Issues in Resident Independence." American Health Care Association Journal. 9(2), 22-25.

Resident independence can result in legal and ethical dilemmas for care facilities. Kapp suggests ways to respond to the conflicting interests. He begins with a discussion of reasons to support resident independence: it is therapeutic and consistent with the value of autonomy. He then outlines the legal and ethical barriers to maintaining independence in nursing homes, such as responsibility for resident safety, potential exposure to law suits and the principle of beneficence. In reconciling the conflicts, the author suggests a few situations in which one side, or the other, must prevail. He suggests strategies which can lead to a satisfactory reconciliation, including anticipating problems, recording projected responses to situations in policies and procedures manuals, informing staff and residents and their families at the time of admission of policies and procedures, and obtaining written releases from competent individuals.

126. McLaughlin, C. (198 8). "'Doing Good:' A Worker's Perspective: Practitioners Must Perform a Delicate Balancing Act." Public Welfare. 46(2), 29-32.

Intervention in cases of abuse and neglect of older adults involves ethical dilemmas related to the need to protect suspected abused people, while preserving their dignity and right to self determination. Case resolution may also be affected by institutional or personal priorities, pressures of large caseloads and the complexity of intervention needs. McLaughlin questions whether practitioner intent to do 'good' means ) good' for the community, client, practitioner or legal system and urges professionals to balance the dominant definition of good with client wishes. The author discusses dignity of risk, explaining that risk accompanies all life activities, may be freely chosen and results in personal growth. The difficulty in differentiating between interference and intervention is acknowledged. McLaughlin also discusses problems associated with differing values and agendas motivating the variety of agencies and professionals involved in abuse cases. While it is important for practitioners not to ignore or try to minimize the complex issues of abuse situations, they need the professional courage to avoid being overly protective.

127. National Committee for Prevention of Elder Abuse. (1986). Difficult Choices: Ethical Issues in Casework. Worcester, Massachusetts: The Committee. [videocassette] (30 minutes).

This videotape highlights the moral and ethical dilemmas involved in dealing with abuse and neglect of older adults. The video highlights the difficulty caseworkers face in balancing their legal mandate to protect abused older people with the right of older people to self determination. A case study addresses this internal conflict experienced by a caseworker when an abused older woman refuses assistance. The caseworker is confronted with the need to make a decision concerning competency, an intervention which potentially strips the adult of all legal and civil rights. Issues raised surrounding the choices between initiating state intervention and respecting individual rights to control their own decisions are presented in this video.

128.Phillips, L.R. (1989). In R. Filinson & S. R. Ingman (eds.), Elder Abuse: Practice and Policy. New York: Human Sciences Press, Inc.

This article reviews problems associated with detection and intervention strategies. Definitions of abuse, guidelines for identifying characteristics of abused older adults and abusers, and treatment options, remain ambiguous issues. The abuse of older adults may not, involve a clear division between the abuser and the abused person. Intervention strategies may be affected by the rights of older adults to self determination, the lack of adequate resource alternatives, and the difficulties in choosing between legal and therapeutic intervention options. Practitioners are encouraged to work as a team, to recognize the limitations of current laws and exercise sensitive judgement in suspected cases of abuse. detection

129. Potter, J.F. & A. Jameton. (1986). "Respecting the Choices of Neglected Elders: Autonomy or Abuse." In M.W. Galbraith (ed.), Elder Abuse: Perspectives on an Emerging Crisis. Kansas: Mid America Congress on Aging. 95-109.

Choosing between protecting older adults from neglect and respecting their autonomy creates ethical dilemmas for service providers and the general public. After presenting a literature review of legislative strategies for dealing with the neglect of older adults, the authors outline concerns regarding the determination of incompetence. They note that four conditions are necessary for autonomous decision making: 1) the presence of relevant and realistic information; 2) the freedom and opportunity to choose; 3) recognition of the values and commitments of the older adult; and 4) clear and reasonable thinking. The authors point out that the ethics of intervention are influenced by factors such as individual privacy, the primacy of existing social bonds and the individual's responsibility for self care, Health professionals are encouraged to respect previous social relationships, to take their time to acquire full information before taking action, to interpret their own responsibility narrowly and to remove an individual from home as last resort. Three case studies are presented and the question of whether involuntary intervention constitutes abuse is raised.

130. Price, D.M. (1993). "The Ombudsman Experience: Administrative Protection for Vulnerable Patients." Trends in Health Care, Law and Ethics. 8(1), 49-56.

In 1988, the New Jersey Ombudsman broadened the concept of "abuse" to include withholding or withdrawing life-sustaining treatment, and directed that all decisions involving either of these possibilities, be reported to the office for review. The legal context and court decisions leading to the directive, and responses from the health care community are described. Legal and ethical issues are considered (e.g. privacy, self-determination of patients, integrity of patient-family-physician relationships). Since the potential for abuse in situations involving life-sustaining treatments does exist, the author argues the need for some form of review; he proposes facility-based, multidisciplinary ethics committees, with incentives to ensure staff act in patients' best interests. Other roles for the ombudsman program are suggested.

131. Quinn, M.J. (1985). "Elder Abuse and Neglect: Raise New Dilemmas." Generations. 10(2), 22-25.

Quinn discusses ethical dilemmas resulting from adult protective service laws, conservatorships and guardianships. Each of these strategies may force services on older adults against their will and thus disregard their rights to self determination. Mandatory reporting laws, intended for older adults' protection, vary greatly in definition of abuse, reporting standards and penalties. The existence of the laws requires agencies and practitioners to develop new intervention skills and techniques, but usually fails to take into account a client's right to refuse treatment. Dilemmas facing health care workers include conflicts around issues of safety versus freedom, determination of an older adult's medical or legal capacity, refusal of services by clients and problems concerning the investigation of suspected cases while respecting individual rights to privacy. The issue of freedom versus safety is further compounded by differing values embedded in social work and the legal justice system. Quinn warns against paternalist and agist attitudes when it comes to protection.

II Interventions

* 132. Beaulieu, M. (1992). "La formation en milieu de travail: l'expression d'un besoin des cadres en ce qui concerne les abus à l'endroit des personnes âgées en centre d'accueil." Le Gérontophile. 14(3),3-7.

Based on the results of action research into intervention practices for older adults who have been abused in public institutions, the author proposes to focus on training. Training of everyone in institutionalized settings is needed; it must involve staff working directly and indirectly with residents, and residents themselves. Everyone must be educated to prevent, detect and act in abusive situations. Training programs must focus on current practices and involve follow-up.

caregivers' needs, training programs, abuse and neglect in institutional settings, Quebec

* 133. Beaulieu, M. (l 992). "Les abus en institution: réflexion sur les soins dispensés aux aînés." Revue internationale d'action communautaire. 28(68), 163-170.

Based on the findings of an action research project on intervention practices with older persons who have been abused in public institutions, the author proposes an examination of the care being given to older adults. The article starts by situating the problem in its social and legal context, thus making it possible for each institution to assess the abusive actions taking place within it, and to manage solutions. Administrators of public homes for the aged see two types of abuse: a care-giver who is at fault or an institutional organization that either does not bother about, or does not respect the needs of residents and employees. In terms of action, administrators must be involved in prevention, detection and direct intervention. Few efforts have been undertaken to change organizational structure, which means that most instances of abuse are seen as individual rather than institutional. Older adults do not play an active role in the action process and are virtually excluded.

caregivers' needs, training programs, abuse and neglect in institutional settings, Quebec

* 134. Beaulieu, M. (1992). Les cadres de centres d'accueil publics et les pratiques d'intervention face aux abus à l'endroit des Personnes âgées. Unpublished doctoral dissertation, Université de Montréal, Montréal.

This is part of a comprehensive paradigm seeking to understand how abuses are defined and what interventions they give rise to. It is based on an analysis of conversations with administrators on intervention practices in public institutions. Practices are analyzed against six themes; the administrators' perceptions of the role of a reception centre, of their work, abuse, abusers, abused older residents and intervention (prevention, detection, direct intervention with abused person or abuser). Analysis of the material reveals that institutional administrators work within a perspective of what they think is best for the well-being of the residents, but the older adults themselves play very little part in the process of problem resolution.

administration, characteristics of abusers, characteristics of abused older adults, definitions, disclosure, detection, caregiving facilities, abuse and neglect in institutional settings, prevention, Quebec

*135. Beaulieu, M. (1992). L'intervention auprès des aînés victimisés. Montréal: Association québécoise Plaidoyer- Victimes.

This intervention guide addresses the situation of older adults in society, explaining the situation and consequences of abuse and neglect. It suggests a specific approach respecting the needs of abused older adults. Strategies for prevention, detection and direct intervention are proposed, for natural living setting and institutional settings. In their conclusion, the author questions the creation of "policies on aging" and of specific programs and services.

causes, definitions, detection, policy development, intervention, abuse and neglect of older adults, prevention, Quebec

* 136. Beaulieu, M. (1990). "Comment faire face aux situations abusives en institution." In J. Carette, & L. Plamondon, Vieillir sans violence. Montréal: Presses de l'Université du Québec. 115-129.

This chapter proposes definitions of abuse and institutions. Explanations are presented and their impact on older adults are addressed. It suggests three steps for institutions to follow in dealing with abuse, and six approaches to solutions: prevention, improved intervention practices, legislation, empowerment of older adults as a pressure group, changes in social policy, and research.

causes, definitions, ethics, intervention, abuse and neglect in institutional settings, prevention, Quebec

137. Manthorpe, J. (1993). "Elder Abuse and Key Areas in Social Work." In P. Decalmer, & F. Glendenning (eds.), The Mistreatment of Elderly People. Newbury Park, New York: Sage. 8 8 - 10 1.

Manthorpe uses examples from various British policies and jurisdictions to indicate areas of ambiguity for social workers in identifying and preventing abuse of older adults. Social workers in the community face dilemmas such as appropriate response to alleged situations of abuse, collaboration with other professionals, and ineffective intervention strategies. Social workers must consider whether institutionalization is an appropriate solution to abuse in domestic settings. The author outlines intervention procedures in an abusive situation in a care facility. The relationship between social workers and older people in care facilities is discussed.

138. Matlaw, J.R. & J.B. Mayer. (1986). Elder Abuse: Ethical and Practical Dilemmas for Social Work. National Association of Social Workers, Inc. 85-94.

The authors discuss the work of an interdisciplinary team within Boston Beth Israel Hospital in dealing with abuse and neglect of older adults. The team consists of nurses, social workers, physicians, a researcher and a specialist in geriatric medicine, and it reviews cases, consults with hospital caseworkers, makes recommendations on reporting and treatment, and is involved in educating staff. Most of the cases dealt with by the team have involved patients from nursing homes. This article describes the work of this team's social workers and presents three case studies for discussion. These case studies illustrate the need for anticipating the effects of reporting mistreatment and determining whether reporting helps or creates additional stress; demonstrate the usefulness of intervention in difficult cases; and highlight clients' rights to self determination. The authors stress the importance of timing interventions and reviewing action taken. They also note the difficulty of assessing competence in cognitively impaired individuals.

139.Rouleau, E. & L. Brassard. (l 990). "Un plan d'intervention interdisciplinaire pour prévenir la violence en institution." In J. Carette, & L. Plamondon, Vieillir sans violence. Montréal: Presses de l'Université du Québec. 206-210.

The authors of this chapter propose an intervention plan focused on the quality of life for institutionalized older adults. The testing of an interdisciplinary plan made it possible to predict and prevent abusive behaviour or actions. The intervention plan is intended as on ongoing process that begins the day the older person arrives at the institution. It facilitates planning and coordinating services for the various groups of service providers and residents. The main objective is to respond to residents changing needs, since a certain degree of flexibility is required. Among the points highlighted are the importance of a protocol, information and continuing education.

needs, intervention, abuse and neglect in institutional settings, procedures, prevention, quality of care, quality of life, consciousness-raising, Quebec

140.Schlesinger, J.L. & M.J. Salamon. (1988). "A Case of Wife Abuse in the Intermediate Care Facility." Clinical Gerontologist. 7(3/4), 163-166.

This case study presents legal and ethical issues confronting the intermediate care facility staff when two residents marry and one verbally and physically abuses the other. An analysis of the situation and the therapeutic approach taken are described.

case studies, psychological abuse, counselling, ethics, physical abuse, spousal abuse

III. Legal Aspects of Interventions

141. Age Concern England. (1986). The Law and Vulnerable Elderly People. Mitcham, Surrey: Age Concern England.

This book is divided into five major sections, each focusing on different aspects related to abuse of older adults in Britain. The first section examines legal issues involved in the abuse cases, discussing available state and judicial recourses. The second section deals with issues of consent and covers procedures for initiating complaints in institutions. Factors involved in the compulsory removal of older adults from their homes are discussed; issues surrounding the admission of clients to residential care are outlined; and consent issues are dealt with, including those pertaining to living wills. The third section covers protection issues and discusses the court system, as well as guardianship. The fourth section examines the issue of representation, discussing the work of agencies, appointees and powers of attorney. Section five reviews current legislation and makes recommendations for assessment, notification and intervention strategies as well as exploring emergency powers. Each chapter includes topics for discussion.

142.Bond, J., R. Penner, P. Yellen, B. Carbonell, L. Greenslade & J. Sweiden (1992) Final Report: The Effectiveness of Legislation Concerning Abuse of the Elderly: A Survey of Canada and the United States. Winnipeg: University of Manitoba. Social Sciences and Humanities Research Council.

In this study, the authors surveyed 99 Canadian and American professionals to examine the effectiveness of legislation concerning the abuse of older adults in non-institutional settings. The findings suggest that there is no best legislative approach and that the laws are perceived to be generally effective. Americans report greater effectiveness that Canadians but the authors say this is due to the phrasing of questions which excluded most Canadian participants. The most satisfaction with the laws are expressed by people intervening through legal proceedings and providing guardianship services. The authors conclude that the funding and provision of staff and services are more important to responding to elder abuse than any legislation.

143.Calgary YMCA Support Center, & The Junior League of Calgary. (1990). Law and the Abused Woman.

This handbook helps women and the service providers assisting them, understand and prepare for legal action concerning abuse situations. The article defines various types of abuse and assault, notes steps to take if the abused person is threatened or injured, and outlines the procedures and implications of laying criminal charges. Legal options such as restraining orders and peace bonds are discussed in terms of their effectiveness and disadvantages. The article provides instructive steps for obtaining a lawyer, offers recommendations for court preparation and outlines court appearance requirements.

144. LaRocco, S.A. (1985). "A Case of Patient Abuse." American Journal of Nursing. 1233-1234.

A nurses' aide was accused of physically abusing an older patient, and her employment was terminated after a lengthy, union-initiated appeal process. The author reviews details of the case. She reflects on the difficulty of disciplining employees in cases involving abuse of older patients and on her role as an administrator in the situation.

* 145. McKenzie, P. (1992). Guide to Legal Issues in Elder Abuse Prevention. North Vancouver, British Columbia: North Shore Community Services.

This legal handbook offers problem-solving techniques for dealing with abuse and neglect of older adults. It discusses advocacy issues, principles for community intervention development, neutralization techniques and intervention strategies. The legal system is described, covering both civil and criminal law, as well as emergency intervention procedures. Categories of abuse used in this manual include physical, financial, verbal, and emotional abuse, as well as neglect. This handbook discusses topics relevant to abuse and neglect of institutionalized residents, outlines family law recourses and concerns, and describes factors related to mental competency. Other legal issues such as trusteeship, power of attorney and living wills are also discussed. Included among the attached appendices are the Canadian Charter of Rights and Freedoms, the B.C. Wife Assault Policy and a section on B.C. Referral Services.

146. National Committee for Prevention of Elder Abuse. (1986). In Pursuit of Life Without Violence: Intervention Strategies. Worcester, Massachusetts: The Committee. [videocassette, no. 2 in series] [26 minutes].

The second in a series of three, presents four case studies of interventions involving abused older adults. Abuse is shown to be a complex issue, with successful intervention attempts dependent on extensive assessments of the older adult's past history. The video presents the need for delicate negotiation. Caseworkers are shown to require effective advocacy skills, as well as knowledge of benefits, entitlements and access routes to bureaucracies. They are also often called upon to provided both emotional and legal assistance, and require familiarity with such avenues as restraining orders, conservatorship, and guardianship issues. This video highlights the variety of situations in which older adults may be abused and the multifaceted requirements of intervention strategies. The video focuses primarily on interventions where the adult is residing in the community.

147. Fulmer, I &T. Wetle. (1986). "Elder Abuse Screening and Intervention." Nurse Practitioner. 11, 33-38.

Placing abuse and neglect of older adults within the context of family violence, this article discusses nurses' legal responsibility to report suspected cases. These cases may involve physical abuse, psychological abuse, active neglect, misuse of drugs, misuse of property or violation of rights. This article examines the issue of mandatory reporting laws, provides screening guidelines and instruments for detecting abuse and suggests parameters for using them. Nurses may hesitate in initiating reports for fear of unfounded allegations.

*148.Gordon, R.M. & S. Tomita. (1990). "The Reporting of Elder Abuse and Neglect: Mandatory or Voluntary? / La divulgation des cas de mauvais traitements et de négligence à l'égard des aînés: procédure obligatoire ou volontaire?" Canada's Mental Health l Santé mentale au Canada, 38(4) 1-6.

The authors discuss arguments for and against mandatory reporting of abuse in cases involving older adults. They conclude that the existence of mandatory reporting legislation does not necessarily ensure the greatest assistance for abused older adults. They note that adult protection legislation has been criticized because it: is paternalistic and infantilizing; operates with imprecise definitions and broad intervention criteria; revictimizing the abused person; mandates often unavailable services; and lacks clear application to abuse and neglect in institutional settings. Civil libertarians object to this kind of legislation, pointing to the problematic expansion of population surveillance and the problems of false accusation and unwanted interventions. After also noting social service practitioner objections, the authors outline the position of those favouring mandatory reporting. They argue that it facilitates early intervention, increases awareness of abuse, acts as a deterrent, allows for emergency intervention and facilitates the provision of assistance for incapacitated adults. All interventions should be guided by respect for self determination, be minimally intrusive and acknowledge the need for community protection.

Three student nurses on a geriatric ward observed a variety of behaviours and poor treatment practices that raised concerns for them. This article explains what happened when they later complained formally about the nurse in charge. The author raises a series of questions for discussion concerning the case in light of the British Code of Professional Conduct for health professionals.

150.Lalande, S. (1990). "La solitude et la peur favorisent les abus." L'accueil, premier trimestre. 10- 11.

According to the author, older adults seem to have difficulty reporting mistreatment because they have not learned to demand their rights. One of the key factors behind non-reporting is fear (fear of losing their children's affection, fear of losing their space in an institution, fear of losing their accommodation). The author feels that it is easier to identify and remedy the problem in public facilities than in private or "illegal" ones. Service providers and older adults are increasingly aware of this reality, and each group involved (service providers, seniors, volunteers) has a responsibility to ensure the well-being of mistreated older adults.

nursing homes, family, abuse and neglect in institutional settings, caregivers, Canada

151.Matthews, D. (1988). The Not-So-Golden Years: The Legal Response to Elder Abuse. Pepperdine Law Review. 15, 653-675.

This article examines the legislative efforts undertaken in the United States in response to the problem of abused older adults. Matthews reviews the nature, extent and causes of abuse, then analyzes state criminal and civil remedies, adult protective services and mandatory reporting procedures. Matthews questions the desirability and efficacy of mandatory reporting, with its problematic assumptions that abuse of older adults is similar to child abuse. Matthews explores the effects of mandatory reporting legislation on the older adult's constitutional rights and on self reporting. Matthews also notes the federal response to abused older adults, and suggests there is a need for alternative solutions which emphasize a structured combination of protective services. The article raises concerns about legislative efforts and protective services which reduce civil liberties or rights and thereby inadvertently perpetuate or even intensify an abusive environment.

152.Registered Nurses Association of British Columbia. (1989). Duty to Report Unsafe Conduct: A Discussion Paper. Victoria, British Columbia: The Association.

This discussion paper highlights the need for professional nurses' to report "incompetent" colleagues whose actions endanger the safety of a patient or practice "unprofessional conduct." Unprofessional conduct can include stealing patient property, abandoning or neglecting a patient, failing to safeguard a patient's safety, and neglecting/ depriving the patient by deliberately withholding basic rights and comforts. The document discusses both whistleblowing and mandatory reporting. Whistleblowing is the act of disclosing an internal problem to the public or to professional or regulatory bodies when internal procedures, fail to resolve a disciplinary problem. Nursing executive may have a somewhat different kind of duty to the employer, than professional nurses. The authors note that there can be professional-institutional- union conflict in this area, but because unions and professional organizations have common duties to further public good, an opportunity for conflict resolution is created. Emphasis is placed on the first obligation of nurses being to those needing care.

153.Silva, T. (1992). Reporting Elder Abuse: Should It Be Mandatory or Voluntary? Healthspan. 9(4), 13-15.

The U.S. General Accounting Office's (GAO) study on mandatory versus voluntary reporting laws for older adult abuse found that this issue had never been empirically tested. This is partly because meaningful comparisons between identification data are impeded by lack of consistency in the definitions used in different states, by variations in state data collection processes and by the influence of many other factors extraneous to the legislation. The GAO surveyed 40 top state officials from two organizations involved with older adult abuse programs and found that the most significant factor in identifying cases was the degree of public and professional awareness of older adult abuse. The provision of in-home services was found to be the most effective factor in both preventing and treating for this problem. On the basis of this study, GAO conclude that it would be more beneficial to focus on increasing awareness, interagency coordination and in-home services than on debating the relative effectiveness of mandatory versus voluntary reporting.

154.Urban, A.J. (1981). "Nursing Home Patient Abuse Reporting: An Analysis of the Washington Statutory Response." Gonzaga Law Review. 16(3), 609-635.

This article describes and analyzes the Patient Abuse Reporting System of Washington State. The historical development of nursing home regulation in Washington State from 1951 to 1981 is presented. The purpose of the system, reporting and investigative procedures, protections, sanctions and corrective approaches are described, and then compared to an ideal system and to approaches taken in other states. The activities of government agencies responsible for responding to complaints are analyzed in terms of compliance with the legislation. Improvements to future legislation and changes in procedures and organizational structure of the system are recommended. The article includes a table comparing patient abuse reporting systems in various American states, with reference to appropriate state legislation.

V. Legal Liability

155. Bianculli, J.L., J.L.Hoffman, & M.C. Infante. (1992). "'Bad Outcome' Criminal Neglect Cases: Recent Trends that Threaten Nursing Facilities." Journal of Long-Term Care Administration. 20(2), 26-30.

The authors (attorneys who represent long-term care facilities) provide general information based on American law for owners and administrators of facilities on the nature of criminal prosecutions. They discuss why prosecutions of long term care facilities occur, the legal responsibility of owners and administrators, flaws in regulatory systems that might affect the way prosecution occur, and the implications for the care of patients if administrators/owners are found guilty of criminal liability. The authors outline a number of defense tactics to avoid or lessen the impact of criminal charges.

156. Biros, M.J. (1988). "Avoiding Fraud, Abuse Cases a Matter of Smart Business." Provider. 14(11), 28-29,36.

This is the first of a two part article. The author argues that health care executives need to be aware of federal and state laws that apply to the health care industry in order to take preventive measures to avoid prosecution. Not understanding the law is not considered a valid defense. The focus of the article is to increase health care executives' awareness by providing examples of fraudulent acts and penalties involving Medicare and Medicaid; patient care prosecutions based on common law crimes (assault, homicide); and specific statutes related to neglect and abuse of older persons. Inadequate quality of care can be the basis of prosecution. Conviction for any of these offenses can be disastrous for a business.

157. Biros, M.J. (1988). "Avoiding Fraud, Abuse Cases a Matter of Smart Business." Provider. 14(12), 36-37,50.

This is the second of a two part article. The author argues that executives of health care corporations need to be aware of theories of criminal liability for senior corporate officials. He describes the way in which a corporation can be held liable for acts of its employees, and provides three examples of how liability may be applied to individuals exercising control over a corporation. Education strategies and corporate policies to avoid criminal liability are provided, including policies regarding expectations of employees and procedures for reporting illegal behaviour. Use of the Fifth Amendment and the nature of attorney-client privilege are discussed.

158.Costa, L. (1990). "Abuse and Neglect: A Foundation for Criminal Liability." Contemporary Long Term Care. 13(4),79.

With the increasing number of criminal liability cases against nurses and nursing administrators in nursing homes, the author suggests part of the problem results from the redefinition of nursing "practice" to include issues not previously included as nurses' responsibility, such as staffing and notification of physicians. She describes areas where criminal charges might be laid against nurses (e.g., fraud, physical abuse) and describes two specific cases and their outcomes. Nursing administrators are warned that they could be held criminally liable for orders they did not make or agree with, hence the need to analyze the implications of decisions made within their jurisdiction. This article is written from the American criminal law context and has more limited application to Canadian nursing environments.

* 159.Dickens, B.M. (1986). "Legal Issues in Medical Management of Violent and Threatening Patients." Canadian Journal of Psychiatry. 31(8), 772-780.

This article uses two high profile cases to examine the legal responsibility of psychiatrists' dealing with threatened violence from patients. This issue may have applicability to older adults in institutional care. In the first case, the psychiatrist's defense unsuccessfully argued that there was no responsibility to warn a woman that his patient had threatened to kill her. This argument was based on the issue of confidentiality, psychiatry's lack of predictive power and the absence of legal duty to strangers outside the therapist/patient relationship.

Citing the principle of public protection, the court ruled that psychiatrists are under a legal duty to warn people of potential danger. In the second case, a hospital was found liable when a patient who was assessed as violent later assaulted another patient. Implications of these cases highlight the overlapping policing and therapeutic functions of psychiatric work. Therapists are responsible for committing persons diagnosed as dangerous. Within institutions, administrators have a legal duty of care to a wide range of people, including non-professional staff, other patients, family members, visitors and strangers, even to the dangerous patients themselves. It is important for administration to have appropriate management policies on dangerous patients in place.

* 160.Jorgensen, B. (1986). Crimes Against the Elderly in Institutional Care. Toronto, Ontario: Concerned Friends of Ontario Citizens in Care Facilities.

This research paper examines the degree of criminality involved in various complaints of abuse of older adults in nursing care facilities in Ontario. Of the 56 complaints investigated, close to 46% were found to be of a sufficiently criminal nature so as to warrant laying criminal charges. Obstacles preventing criminal prosecution include difficulty establishing a satisfactory burden of proof, public unawareness of nursing home conditions, and fears of retaliation. The primary alternative to criminal prosecution currently involves licensing and regulation of nursing homes by the provincial ministry of health. Because of structural deficiencies in the nursing home industry, this avenue may be inadequate and may actually encourage negligence. Criminal prosecution in abuse or neglect cases is encouraged as an alternative remedy because of its deterrent effects and the perceived likelihood that it will promote positive changes in nursing home conditions.

161.Long, S. (1987). Death Without Dignity. Austin, Texas: Texas Monthly Press.

This book presents an account of the first criminal legal case in the United States in which a nursing home corporation, its top administrators and some of its staff were indicted for murder as a result of the deaths of residents from alleged neglect while in the care of the nursing home. The author follows the investigation and court case, providing a critique of the nursing home industry, and uses this case as an example of the problems of understaffing, lack of training, poor pay among staff, lack of proper equipment, insufficient supplies and weak regulatory systems. The book raises the issue of ultimate responsibility for abuse and neglect that occurs in a nursing home.

courts, criminal justice system, neglect, financial abuse, quality of care, quality of life, United States, legal aspects

162.(1990). "A Jury Defines 'Neglect' in Nursing Homes." American Journal of Nursing. 90(9), 25.

Relatives of residents against a Mississippi nursing home sued the operators for negligence. Negligence lawsuits usually involve cases where a person has died or is injured; this case was based on an argument that neglect by the nursing home staff and operators led to daily discomfort and made life miserable for residents, resulting in poor quality of life. The relatives were successful with the lawsuit, and the jury assigned monetary values to behaviours such as verbal abuse, leaving residents to lie in their own excrement, and failing to give baths regularly. The strategies of a key player in the investigation and documentation of supporting evidence are highlighted.

definitions, documentation, neglect, legal aspects, quality of life, quality of care

VI. Decisionmaking and Consent

163.Harris, S. (1986). "Protecting the Rights of Questionably Competent Long-Term Care Facility Residents." In M.B. Kapp, J. Harvey, E. Pies, & A.E. Doudera (eds.), Legal and Ethical Aspects of Health Care for the Elderly. Ann Arbor, Michigan: Health Administration Press. 185-197.

Harris describes developing alternate decision-making processes for residents of long-term care facilities who are unable to make decisions for themselves She discusses the difficulties in protecting the decision-making rights of longterm care residents; the residents have not been found mentally incompetent under the law, and facilities have obligations to a number of parties including the resident. Harris argues for a classification scheme of decisionmaking based on the kinds of decisions made in long-term care facilities. These decisions range from those with immediate, but relatively insignificant effects, to decisions with life and death implications. The classification scheme would promote residents' rights and provide a logical approach to problems. Harris presents five alternative decision-making systems, noting strengths and weaknesses of each, and the criteria for choosing a system. The five systems differ significantly on the individual resident's role in the process, the place of family concerns, dealing with conflict of interest, and applicability of the system to a variety of situations.

autonomy, empowerment, policy development, protocols, residents' rights, violation of personal rights

164. Hennessy, C.H. (1989). "Autonomy and Risk: The Role of Client Wishes in Community-Based Long-Term Care." Gerontologist. 529(5), 633-639.

This study investigated the extent to which client wishes were incorporated into case management decisions in a community based, multiservice program for older adults. Formal and informal ways of determining client wishes are identified. Observation of the care team decision-making processes revealed that client wishes were more likely to be incorporated when the client's risk status was low. In high risk situations, personal autonomy was limited in order to protect clients and to better use limited program -resources. Service use by any one client had to be limited and high risk clients whose service needs required high cost interventions could not always be accommodated. Whenever possible, clients and staff worked to reduce risk and to find the least restrictive alternative. However, practical realities meant that client preferences are sometimes restricted by limited resources. Case examples are provided.

165. Kapp, M.B. (1991). "Health Care Decision Making by the Elderly: I Get by With a Little Help From my Family." Gerontologist. 31(5), 619-623.

This article considers ethical and legal issues associated with shared health care decision- making by older people. Kapp starts with the assumption that neither the pure autonomy of older people, nor surrogate decision making on their behalf, is realistic or helpful in long-term care settings. Instead, shared decisionmaking, based on concepts of interdependency and shared power, should be favoured. The importance of older people's relationships with others and fairness to family members who may be affected support his argument that older people want and could benefit from consulting with family members on decisions to be made. Potential ethical problems include: protection of older people from coercion; conflict of interest (e.g. a family member may stand to gain from certain decisions); the duty of health care providers to include family members; designation of who is family; and conflict within families. Legal considerations focus on: 1) the expectations of the legal system concerning decisions, in terms of clarity of the rights and obligations of health care professionals; and 2) whether the legal system can accommodate situations which arise from shared decision-making.

166. Kapp, M.B. (1985). "Adult Protective Services: Convincing the Patient to Consent." In M.B. Kapp, J. Harvey, E. Pies, & A.E. Doudera (eds.), Legal and Ethical Aspects of Health Care for the Elderly. Ann Arbor, Michigan: Health Administration Press. 233-244.

Kapp argues that while still competent, many older people are willing to give their decision making authority to people they trust and they are willing to receive protective services. To avoid problems that occur after a person is found mentally incompetent, Kapp suggests the use of a special form of power of attorney, (termed "durable power of attorney") that continues even if the person becomes incompetent, outlining its strengths and weaknesses. Health care professionals should be prepared to discuss this option with their older patients and families where appropriate. Kapp stresses that because health care professionals are involved in the lives of people at crucial moments, they have an obligation to go beyond providing technical care, to becoming involved in service planning and placement decisions. To support the need for preplanning, Kapp also describes the problems which arise when an older adult refuses protective services, and the weaknesses of the system when guardianship is imposed through the courts on unwilling older people.

power of attorney, guardianship, health care providers, adult protection services, ethics

167. Moody, H.R. (1988). "From Informed Consent to Negotiated Consent." Gerontologist. 28 (Supplement), 64-70.

Moody argues that "negotiated consent" is preferable to informed consent in long-term care settings. Based on the assumption that personal autonomy and individual dignity are paramount, informed consent is an ideal that was developed in acute care settings, but has little relevance in long-term care settings. Negotiated consent is a process in which a number of interested parties, competing interpretations, conflicting values and uncertainty about outcomes are acknowledged in deciding the best possible course of action. A study which observed the ways long-term care staff dealt with ethical dilemmas and informed consent (e.g. role of families, legal liability of staff) revealed a conflict between "beneficence" (taking actions considered beneficial to the older adult without informed consent) and patient rights (action taken with informed consent). Neither approach is completely workable in the daily life of long-term care; awareness of the context of human relationships and the social structures of decision making in the long-term care context is required. The parameters of negotiated consent are developed.

* 168. Silberfeld, M. (1992). "New Directions in Assessing Mental Competence." Canadian Family Physician. 38, 2365-2369.

Guardianship laws are changing and so must traditional definitions and methods of assessing competency. The author outlines new directions for competency assessment with a model developed at the Baycrest Centre for Geriatric Care Competency Clinic in Toronto. This model assesses capacity for particular functions (decision-specific competence). Ethical, conceptual, and practical difficulties for physicians are examined.

*169. Silberfeld, M. & A. Fish. (1994). When the Mind Fails: A Guide to Dealing with Incompetency. Toronto: University of Toronto Press.

Incompetency has become a major social problem in large part because the number of older people in North America is increasing rapidly. Although affecting people of all ages and arising from many causes, incompetency is a problem frequently seen among older people. People often require medical and legal advice to plan for their own incompetency, or to address the needs of an incompetent person. This book outlines the fundamental principles and basic practices of competency assessment, building upon the authors' experience at the Competency Clinic at the Baycrest Centre for Geriatric Care. At this multidisciplinary clinic, competency is not considered simply a medical or legal concept, but rather a complex phenomenon that has medical, social, legal and ethical dimensions. Commonly available legal devices or doctrines, social and health care institutions, and medical and diagnostic procedures are discussed, e.g. power of attorney. The book integrates case studies and concrete examples of the application of the principles of competency assessment. This is a practical, focused guide to thinking about incompetency, based on the premise that the best source of personal empowerment is knowledge and understanding.

VII. Guardianship

170. Frolik, L.A. (1991). "Abusive Guardians and the Need for Judicial Supervision." Trust and Estates: The Fiduciary Journal. 130(7), 41-44.

The author considers the responsibility and role of the courts which appoint legal guardians to detect inappropriate guardian activities and to intervene in ways that act as a deterrent. Three possible reasons for the deterioration of guardian/ward relationships are: (a) failure in properly selecting guardians (e.g., the guardian takes on the responsibility less than voluntarily or did not understand the implications of the commitment); (b) failure in training guardians; and (c) failure to supervise guardians. The author argues the courts should train new guardians regarding their legal responsibilities, standards of behaviour, and the consequences of not meeting acceptable standards. Among the suggested court strategies for supervising guardians are: yearly reviews, guardian reports, and court visitors.

* 171. Gordon, M. & S. Verdun-Jones. (1992). Adult Guardianship Law in Canada. Toronto: Carswell-Thomson Canada Limited.

This book is a comprehensive review of the current status of guardianship and adult protection legislation in the Canadian provinces and territories. The needs and interests of all adults, regardless of age, are considered. Written for a general audience, the analysis and discussion are designed to facilitate understanding of the primary issues (and potential solutions) in a complex and confusing area. The authors address the history and development of the legislation, its current strengths and weaknesses and the impetus for the current focus on fundamental reform. The authors address some of the most complex and difficult areas faced by dependent adults and those who seek to support them. What does it mean to be competent? Is competency a legal definition'? Does it have any meaning outside of the legal context? Can we provide support and assistance for decision making while continuing to respect individual autonomy and the right to make choices, even wrong ones? Who should decide what competency is and who has it?

172.Kapp, M. B. (1981). "Legal Guardianship: For Whom? On What Basis? With What Safeguards?" Geriatric Nursing. 2(5), 366-369.

Kapp discusses controversies around legal guardianship. Courts use a two step definition of incompetence in appointing guardians, but the definition lacks sufficiently clear criteria for courts, or others, to decide on whether there is functional impairment. The article discusses typical questions used to assess competency and outlines special categories of guardianship. The article distinguishes between voluntary and involuntary guardianship. In voluntary guardianship, a mentally competent person delegates authority to someone she or he trusts to make decisions on her or his behalf. In involuntary guardianship, motives for appointing guardians can include protection of a helpless individual, but appointing the guardian may also be for the benefit of a service provider. Ethical issues arise when guardianship decisions create a tension between social values directed at protection and those concerned with maximizing human autonomy and self determination. Although guardianship procedures vary by state, generally any interested person, including the court, may initiate the process. Most states entitle the proposed ward to have legal representation during the guardianship process. A plenary guardian has tremendous scope of authority over the adult's finances, residence and medical treatment, which Kapp points out is an argument for the benefits of limited guardianship.

173. Pepper, C. (1989). "Guardianship: Friend or Foe of America's Frail Elderly." Journal of Elder Abuse and Neglect. 1(3), 65-74.

Pepper outlines aspects of the National Guardianship Rights Act he introduced to the American Congress in response to weaknesses in current systems of guardianship legislation and practice in the United States. Examples of weaknesses include the ease of placing an individual under guardianship; the difficulty of reversing or modifying guardianship orders; guardians' lack of training and experience; and the absence of checks to ensure that the adult is protected from unscrupulous activities by a guardian. The proposed legislation includes provisions to determine the appropriateness of people to be guardians and, once a guardian has been named, protection through reviews, reporting and supervision.

174.Quinn, M. J. (1987). "Conservatorship/Guardianship and Elder Abuse." In Lisa Nerenberg (ed.), Serving the Victim of Elder Abuse - A "How-to" Manual for Practitioners and Program Planners. San Francisco: San Francisco Institute on Aging at Mount Zion Hospital and Medical Centre. 25-29.

After defining conservatorship and guardianship, the author focuses on the role of the probate court investigator, a position unique to California. The investigator's role is to review and prepare reports on all proposed and existing conservatorships, and as necessary, make recommendations to presiding judges on specific cases. In proposed conservatorships, theinvestigator ensures due process is followed and that the person who faces being placed under a conservator knows his or her legal rights. In existing conservatorships, the investigator responds to complaints and, based on regular assessments, decides whether conservatorship is still required. Courses of action available to the investigator in alleged situations of abuse, are described. Case examples to illustrate various situations, guidelines used by investigators to determine the appropriateness of conservatorship, and problems that arise in conservatorship situations, are provided.

Conservatorships and Guardianships: Assessment and Curative Aspects." Journal of Elder Abuse and Neglect. 1(1), 91-101.

Quinn outlines three models of conservatorship and guardianship (parent-child or developmental model, substituted judgement model, therapeutic model), describing their underlying assumptions and the benefits or disadvantages of each. To counteract the generally negative view of conservatorship and guardianship, the author describes three cases in which abuse of an older adult was an issue and the ways in which conservatorship and guardianship can have a curative effect on abusive situations.

Section Four: Prevention

I. General Aspects

* 176. B.C. Seniors's Advisory Council. (1992). A Delicate Balance: Assisting Elderly Victims of Abuse and Neglect. Victoria, British Columbia: Office for Seniors.

This document represents the B.C. Seniors' Advisory Council's position on dealing with abuse and neglect of older adults. The Council recommends that interventions reflect a balance between self determination and protection, and that the B.C. government initiate educational efforts for the public and professionals, and support the development of protocols on abuse. This paper briefly: outlines three theories which describe the causes of mistreatment; reviews definitions; notes incidence and prevalence information; and discusses principles for designing intervention strategies. The importance of education, prevention, and training programs is stressed and the need for effective protocols is noted. The paper also briefly describes the Council's reasons for discouraging the development of adult protection services in British Columbia.

177. British Geriatrics Society, the Royal College of Psychiatrists, & the Royal College of Nursing. (1987). Improving Care of Elderly People in Hospital. London: The Royal College of Nursing of the United Kingdom.

This booklet presents a report offering guidance to health care providers on the care of older adults. The introduction outlines existing nursing and geriatric principles, which the authors emphasize are valuable but need to be adjusted to acknowledge the needs of increasing numbers of very old persons. In particular, the authors encourage a multidisciplinary approach and outline the implications of this approach. Concerns about staff attitudes, training and administrators are raised for discussion. To improve the quality of care for older adults, they suggest promoting mobility and independence; encouraging personal grooming and daily living activities; being sensitive to changing patterns of sleep, rest and nutrition; providing environmental comfort; promoting continence; and providing sensitive communication. The need for regular health reviews and supportive terminal care are also recommended. This booklet includes discussion of the special needs of older adults with mental illness, dementia, depression and sensory disturbances. The need for continuity of care between community and hospital as well as adequate day hospital care provision is also reviewed.

* 178. Concerned Friends of Ontario Citizens in Care Facilities. (1992). Elder Abuse in Institutions. Toronto, Ontario: Concerned Friends.

The Concerned Friends of Ontario Citizens in Care Facilities note that they have received numerous complaints about various institutions, including violations of the resident's right to be treated with courtesy, dignity and respect; the right to proper shelter, food, clothing and grooming; the right to privacy during care and treatment; the right to optimal independence; and the right to information concerning restraint use. The organization strongly feels that these problems can be addressed constructively through education, supervision of health care aides by registered nurses, mandatory reporting for staff, advocacy, empowerment and general reporting of abuse and neglect by the public. The organization has offered to assist in the implementation of many of these measures.

179. Cowell, A. (1989). "Abuse of the Institutionalized Elderly: Recent Policy in California," In R. Filinson & S. Ingman (eds.) Elder Abuse: Practice and Policy. New York: Human Sciences Press.

This chapter briefly outlines policy development on abuse and neglect of older adults in California institutional settings during the period of 1981-1988. In particular, the author focuses on weaknesses in the state's licensing and monitoring systems for nursing homes. The system existing at that time was consistently found to be inadequate as a prevention or intervention measures, partly because of conflicts between the licensing body's "friendly consultant" roles and its adversarial, "strict enforcement" role. In California, during this period, the emphasis had been on a traditional regulatory approach with a " paper orientation" instead of a "patient orientation." The author notes that significant improvements have occurred in California over the six year period, but emphasizes that legislation, alone, is not enough to stop abuse and neglect. There is a need for collaboration among residents, families, community agencies, organization, and government.

180. Harshbarger, S. (1993). "From Protection to Prevention." Journal of Elder Abuse and Neglect. 5(1), 41-55.

This article by the Massachusetts Attorney General outlines the need and benefits of a cooperative link between social services and law enforcement agencies in addressing abuse and neglect of older adults. Harshbarger encourages moving beyond protection to prevention: providing affordable housing and repairs, affordable Medi-gap, and preventing fraud in areas related to health and finances. The formation of a multidisciplinary Elder Issues Group is discussed and planned actions are outlined concerning health care and insurance, long term care, consumer fraud, nursing homes, patient abuse and the Medicaid Fraud unit. Suggested solutions include reinstatement of financial and legal services for older adults, increased involvement of community leaders and agencies in assisting isolated older adults, focus on health, respite and support services, and the development of earlier intervention strategies. Greater awareness of the issue by professionals and the expansion of networks to incorporate the private sector is encouraged.

* 181.Hutchinson, T. & B. Schulman. (1989). "Elder Abuse: A Patient Care Problem for Management." Dimensions in Health Service. 66, 12-13.

This article is intended to raise health care managers' awareness of the need to address abuse and neglect of older people. The article provides suggestions to begin the process in health care institutions. It discusses policy development and implementation, and the need for ongoing review and evaluation. A checklist of practical actions and issues to be addressed is included. The authors stress a philosophy based on prevention and policy development guided by seeing the patient as the central concern. The authors also consider the need for increased consumer awareness, through such programs as residents' councils, and the need for an approach which is tailored to existing programs and policies.

* 182. Lavallée, D., J. Skene, & F. Théroux. (1988). Interventions de la Fédération des Infirmières et Infirmiers du Québec présentées au Comité sur les abus exercés à l'endroit des personnes âgées. Montréal: Fédération des Infirmières et des Infirmiers du Québec.

The greying of our population brings with it the need for specialized services. The Quebec nursing federation (FIIQ) suggests that interventions can be improved by training service providers immediately upon hiring about the specific needs of older adults and the normal consequences of aging. Concrete intervention tools are also proposed. The Federation feels that it is vital to raise society's awareness of the value and contribution of older adults and their specific needs, to supply technical and moral support to the family, and to select the most appropriate service provider in an institutional setting. Also suggested is that a charter of the rights of older adults be adopted, with surveillance by a citizen's advocate, to allow early detection of abuse and application of the appropriate corrective measures.

residents' bill of rights, ethics, family, abuse and neglect of older adults, abuse and neglect in institutional settings, training programs, prevention, quality of care, consciousness-raising, Quebec

* 183."Nova Scotia Reports Underline Need for Abuse Policy." (1991). Long Term Care Monitor. 2(9), 65-72.

This article is a summary of recommendations from two studies conducted in Nova Scotia, one concerning violence against staff by residents, the other concerning staff's abuse of residents. The recommendations emphasize that the best response to abusive situations and to prevent them from occurring, is to take reports of abuse seriously, respond to resident concerns around lack of choice, increase training, continue education, and examine the impact of staff levels.

* 184. Tremblay, L. (1990). "La violence faite aux personnes âgées en institution." In J. Carette, & L. Plamondon, Vieillir sans violence. Montréal: Presses de l'Université du Québec. 98-107.

The author defines four types of mistreatment in institutional settings: physical abuse, psychological abuse, material abuse and neglect. She presents the factors associated with the emergence of a situation involving abuse within an institution. Individual and group intervention plans are proposed for care-givers and older residents. Primary and secondary prevention are defined. The author describes service providers as resource people for abused older adults and their families, and the abusers.

definitions, risk factors, intervention, abuse and neglect in institutional settings, health care providers, prevention, procedures, Canada

II. Resident Strategies

A. Consumerism

* 185.Proulx, D. & G. Dubé. (1993). Projet "Échec à la violence faite aux aîné(e)s." In Choisir et négocier son contrat d'hébergement en résidence et centre d'hébergement privés pour personnes âgées. Rimouski: Fédération des Clubs de l’Âge d'Or de l'Est du Québec (FCADEQ).

This is a guide for older adults who are planning to live in private nursing homes and for family members who are helping older relatives make that decision, The document includes a comparative table contrasting private and public facilities, an assessment of interests, needs and financial resources, and a brief list of the elements that need to be included in a contract. The contract is intended to facilitate the choice of a nursing home and to negotiate a written agreement between the resident(s) and the owner. There are three separate stages: 1) asking questions; 2) making the choice and signing a lease, agreement or contract; and 3) timing the changeover.

informed consent, selecting a facility, caregiving facilities, caregivers, abuse and neglect in institutional settings, prevention, quality of care, quality of life, Quebec

186. Stathopoulos, P.A. (1983). "Consumer Advocacy and Abuse of Elders in Nursing Homes." In J.I. Kosberg (ed.), Abuse and Maltreatment of the Elderly. London: John Wright. 335-354.

Drawing from the perspective of consumer advocacy, the author discusses remedies and strategies for responding to abuse and neglect in nursing homes. The author outlines the basic principles of consumerism and presents a case study of a consumer's group in North Central Massachusetts. The group's goals are to improve quality of care for residents in nursing homes by altering the power equilibrium in favour of consumers (nursing home residents and their families). The organizational structure and underlying principles of the advocacy group are described, followed by: descriptions of strategies used to respond to abuse; need for monitoring nursing homes; documentation of abuse; links with legal, state and national groups; promotion of community involvement in nursing homes; and the maintenance of legitimacy in the community through education and networking. Examples of mistreatment and the process of negotiating a resolution are described.

B. Empowerment

Foundation of Empowerment: Implications for Geriatric Health Care Programs and Practice." Journal of Aging and Health. 1(3), 267-285.

Clark surveys four interpretations of empowerment: 1) empowerment as political action and social process; 2) effective deliberation and moral reflection; 3) personal process; and 4) balance and interdependence. Clark outlines the implications of the underlying philosophical principles for older people and their families in decision making, and for health care practitioners in providing health care services for older people. The article includes a discussion of each interpretation, with suggested ways to empower older individuals. The article concludes with a discussion of the barriers to empowerment, such as administrators' fear of malpractice. Factors are also discussed which can begin the process of empowering older residents, such as focusing on quality not quantity of life.

*188.Gaul, L. (1990). "Les personnes âgées victimes de violence: un modèle socialement entretenu." In J. Carette, & L. Plamondon, Vieillir sans violence. Montréal: Presses de l'Université du Québec. 224-228.

According to the author, contemporary Quebec society and the structure of services available to older adults contribute to the emergence of violence toward them. She bases her thesis on Marie-Andrée Bertrand's premises concerning information, participation and the ability to predict. These premises illustrate the importance of all services working together against violence. The absence of information and the presence of disinformation contributes to infantilization, over-protection and social isolation. The fact that older adults are not participating in an active social life can also contribute to the development of discriminatory attitudes toward them. According to the author, maintaining a predictive capacity can ensure older adults a degree of autonomy and thus decrease the risk of being mistreated, either in their homes or in institutions.

autonomy, causes, risk factors, abuse and neglect of older adults, abuse and neglect in institutional settings, prevention, Quebec

189. Hubbard, P., P. Werner, J. Cohen-Mansfield, & R. Shusterman. (1992). "Seniors for Justice: A Political and Social Action Group for Nursing Home Residents." Gerontologist. 32(6), 856-858.

A group called "Seniors for Justice," comprised of competent nursing home residents, was formed in response to their desire to do something about political and social situations. The group's actions have included circulating petitions, sending letters to politicians, inviting speakers to the nursing home and raising funds for particular projects. Being a part of a special group has meant a sense of empowerment and control for the residents. They have the benefits of social participation and an opportunity to talk about current events. They also receive positive feedback from staff, other residents and families concerning their involvement. The group helps to break down barriers between the nursing home and the wider community, and fulfils residents' need to be responsible and contributing members of the community.

Nursing Home Residents: A Case Study of 'Living is for the Elderly,' an Activist Nursing Home Organization." In S. Reinhartz, & G.D. Rowles (eds.), Qualitative Gerontology. New York: Springer. 163-183.

This field study of a Boston-based nursing home rights organization called LIFE (Living is For the Elderly) assesses the impact of the organization's activity on the well-being of nursing home residents. Research methods include observation, interviews and a literature review. The study found the LIFE organization to be effective in reconstructing social identities and ties through empowerment. Self esteem was felt to be enhanced through: strategies such as emphasizing abilities rather than limitations; the development of self help tools; and opportunities for public speaking occasions to receive titles and awards. LIFE members encourage the development of social ties by modeling activism, encouraging emotional expression and by enabling interaction based on sharing rather than dependence. Public speaking, political lobbying and challenging power imbalances between nursing home administrators and residents are strategies for empowerment. Policy implications of this study include advocacy and challenges to the assumption that in-home service expansion is the only option for countering the dehumanizing effects of institutional care.

191.McDermott, C.J. (1989). "Empowering the Nursing Home Resident: The Resident Rights Campaign." Social Work. 34(2), 155-157.

This article describes a program designed to empower nursing home residents through the creation of a residents' rights campaign. The goal of the campaign was to help residents assert their needs directly to staff and to foster bonding among residents so they could regain a sense of personal control. The program began with staff education about resident rights. This was followed by a formal campaign which included the formation of a residents' planning group to plan a celebration, and the development of a residents' group which studied a residents' bill of rights and discussed ways to implement its principles in their every day lives. Observers noted positive changes in residents behaviour and increased bonding among residents.

C. Residents Councils

192. Gibson, D., G. Turrell, & A. Jenkins. (1993). "Regulation and Reform: Promoting Residents' Rights in Australian Nursing Homes." Australian and New Zealand Journal of Sociology. 29(1), 73-90.

Australia has had two recent policy advances; the first policy focused on residents' rights, and the second one was an innovative system of nursing home regulation. This study considers progress in promoting resident participation and involvement in nursing homes resulting from these changes. A two point longitudinal study investigated nursing homes in terms of changes in behaviour and programs concerned with residents' rights. Philosophically, most nursing homes demonstrated high commitment to residents' rights and many began residents' committees over the course of the study. However, the authors found resistance in the nursing homes to actions in support of residents' rights. The authors identify four sources of conflict which limit residents' rights.

empowerment, policy, quality of care, residents' councils, Australia, study, nursing homes

193. Hawkins, C.H. (1989). "Residents' Power in Retirement Homes." Journal of Housing for the Elderly. 5(2), 51-63.

In a study of 103 American and English retirement homes, the author considered 67 factors which might correlate with residents' collective power over their environment and activities. In general, residents' power is positively related to the strength of residents' associations and to tenants' representation on boards of directors of the retirement home Other key findings included: 1) vigorous residents' councils were more often found in retirement homes sponsored by religious or fraternal organizations rather than government agencies; 2) strong representation of residents on boards of directors occurred in situations of high sociability among residents; and 3) retirement homes with middle class residents had stronger residents associations and strong representation on the board of directors.

D. Family Councils

194. Horsman, M.N. & B. Echtenacher. (1984). "Working With the Family Council." American Health Care Association Journal. 10(6), 20-22.

This article briefly describes the way a family council operates in one facility. The facility has two levels of council, the first introduces family members to the way the facility operates, and the second is a more formal "family involvement team" which acts as a liaison between family members and administration. The team has an additional role as liaison between family members and long term care professionals, acting toward common goals. The council is seen as having several advantages: it illustrates to residents that someone outside the facility cares; it means that family members have a formal place to lodge complaints without fear of retaliation; and it helps families understand the problems faced by the facility administration.

III. Joint Staff/Resident Strategies

195. Agbayewa, M.O., A. Ong, & B. Wilden. (1990). "Empowering Long Term Care Facility Residents Using a Resident Staff Group Approach." Mental Health in Nursing Homes. 9(3/4), 191-20 1.

Thirty male residents and staff on a personal care unit in a long term care facility took part in regular resident-staff meetings. The aim of the meetings was to improve: 1) the quality of life of residents by fostering autonomy; 2) staff satisfaction by involving them in discussions of issues concerning their immediate work environment; and 3) the relationship between staff and residents by increasing mutual understanding and encouraging collaboration on issues that affected their shared environment. This article describes the meeting format (examining generation of agenda, group structure, meeting plan, topics, and method for implementing change), development of the group over time, group dynamics, and the impact on the unit. The program resulted in an improved sense of community, improved resident-staff relationships, increased resident involvement in activities, decreased need for psychiatric consultations, and more expressions of pride or job satisfaction by staff.

autonomy, empowerment, intervention, quality of life, residents' councils, staff development

196.Grossman, H.D. & A.S. Weiner. (1988). "Quality of Life: The Institutional Culture Defined by Administrative and Resident Values." Journal of Applied Gerontology. 7(3), 389-405.

The authors argue that quality of care and quality assurance programs are only one element of quality of life for residents in long-term care facilities. After briefly surveying definitions of quality of life and quality of care, and examining the relationship between the two, the authors illustrate the ways in which quality of care and quality of life are negotiated in an 1100 bed multilevel care home. Four committees, comprised of staff, administrators and/or patients were developed to respond to quality of life concerns: 1) a quality assurance committee to monitor quality of care issues; 2) a patient care committee concerned with medical issues; 3) a support service committee monitors environmental issues; and 4) a residents' council to monitor resident concerns, interpret policies, procedures and practices that affect quality of life. The authors provide case examples of quality of life/care concerns and the ways in which residents, staff and administrators negotiated to reach satisfactory outcomes.

197. Hémond, E. (1990). "Foyer de Lyster: Une nouvelle approche psychosociale." Santé et Société. 12(3), 10-11.

Lyster Home emphasizes the physical and mental adaptation of its residents and maintenance of their autonomy. It tries to respect the physical and psychological needs of residents by changing the attitudes of both staff and residents. For example, it allows residents to have their own furniture and belongings in their rooms. A series of training sessions were offered to service providers to ensure that the needs of residents were being met, and the objectives of the nursing home were being followed. Psycho-education is available, as is pet therapy. In short, the institution aims at creating a living environment that is based on the "bio-psycho-social abilities of residents."

autonomy, needs, nursing homes, ethics, abuse and neglect in institutional settings, quality of life, quality of care, consciousness-raising, Quebec

198. Livengood, M. (1980). "A Group-Process Approach to Resident and Staff Abuse." American Health Care Association Journal. 6(1), 29-30,35.

Staff and residents attended two in-service meetings to deal with topics of staff abuse and resident abuse in their care facility. The meetings used a group-problem-solving format involving group discussions, brainstorming and consensus building agreements. Participants discussed and defined abuse in their setting, possible causes, ways to alter circumstances, and consequences for abusive actions. This process, which resulted in policy development and heightened awareness of abuse, is argued to be better than administrative decree, since people are likely to follow policies that they helped develop, and this process ensures that a wide variety of perspectives is included in policy development.

empowerment, health care providers, intervention, policy development, prevention, residents' programs, staff development, committees

199. Wells, L.M. & C. Singer. (1988). "Quality of Life in Institutions for the Elderly: Maximizing Well-Being." Gerontologist. 28(2), 266-269.

The article describes implementing programs in a long-term care facility using an action research model: residents, staff, and families took part in a research process to assess the physical environment and social climate of the facility. Results were reported to a committee of representatives from each group, and subcommittees were formed to address the issues raised. The authors describe committee operations, the development of specific projects, problem solving and conflict resolution strategies, skill development and inter-committee relationships. The authors note improved relationships among different groups, but they also noted some issues were considered too threatening for the committees to deal with. The authors emphasize the benefits of research as a guide for practical change and as a tool to increase involvement in the life of care facilities.

IV. Staff Strategies: Education/Training

*200.Bouvier, M. (1988). "La gestion de la violence exercée à l'endroit des personnes âgées handicapées, hébergées en établissement." Administration hospitalière et sociale. XXXIV(5), 32-39.

This article provides an overview of abuse and neglect in institutions. Situations are presented, and categories of mistreatment most often encountered are listed and the factors relating to the abuse issue are described. The author offers a number of indicators to warn of abuse in an institutional setting, and proposes a series of recommendations for staff and administrators. She also suggests a number of procedures for intervention. Essentially, the article is aimed at consciousness -raising and education.

intervention, abuse and neglect in institutional settings, prevention, procedures, consciousness-raising, characteristics of abused older adults, Canada

*201.Hamlet, E. (1990). Training Professionals to Deal with Elder Abuse / Enseigner aux professionnels comment aborder le problème de la violence à l'égard des personnes âgées. Burnaby, British Columbia: British Columbia Institute on Family Violence.

This report identifies issues which affect the training of professionals on how to deal with abuse and neglect of older adults. Community-based professionals face issues such as lack of evidence of abuse, some older adults' refusal to accept assistance, identification of risk factors, understanding the social context of the abused person, and the need to develop protocols in community agencies. Issues faced by professionals in care facilities include the appropriateness of using restraints, monitoring of personal reactions to stressful work conditions, utilizing the benefits of multidisciplinary teams, and debriefing work related events. The author provides example training programs for both groups. This resource is available from the National Clearinghouse on Family Violence.

202. Hegland, A. (1992). "Defusing Conflict: Abuse Prevention Strategies." Contemporary Long Term Care. 15(11), 60-62.

Hegland reports on a program on preventing abuse and neglect of older adults developed by the Philadelphia based organization CARIE (The Coalition of Advocates for the Rights of the Infirm Elderly). CARIE has been involved in training sessions with facility staff and has published a manual instructing staff trainers on how to implement an abuse prevention program in facilities. The article briefly describes the training program and the issues it addresses, and includes solutions offered in the program to respond to potentially abusive situations. adult protection services, community programs, training programs

203. Hegland, A. (1990). "Nip Patient Abuse in the Bud: Aides Tackle Conflict Resolution." Contemporary Long Term Care. 13(9), 64-113.

A Philadelphia-based project called CARIE (Coalition of Advocates for the Rights of the Infirm Elderly), developed a curriculum for nurse aides in long term care facilities emphasizing abuse prevention and intervention strategies. This project is based on information from the Inspector General's report which identified aides and orderlies as primary abusers in all categories of mistreatment, except medical neglect. Stress due to job burnout and resident staff conflict are suspected to be the two major factors leading to resident mistreatment. The curriculum is comprised of four training sessions that provide an overview of resident abuse, identify types of abuse, explore cultural differences between aides and residents, and promote the understanding of resident-staff conflict.

204. Hudson, B. (1992). "Ensuring an Abuse-Free Environment: A Learning Program for Nursing Home Staff." Journal of Elder Abuse and Neglect. 4(4), 25-36.

This article describes the development and testing of an eight module abuse prevention curriculum designed by CARIE (Coalition of Advocates for the Rights of the Infirm Elderly). Developed for nurse aides in long term care facilities, this curriculum provides an overview of resident abuse; identifies types and causes of abuse; gives caregiving information; deals with cultural factors influencing staff-resident dynamics; outlines legal concerns and provides intervention and prevention strategies. Two hundred and sixteen nurse aides from ten nursing home training sites participated in the test implementation. Participant discussion during training revealed that nurse aides experience powerlessness and devalua tion within the nursing home community. Evaluation of the curriculum suggests a need for continuing education and inclusion of the entire nursing home community in the development of a safe and supportive environment for nursing home residents. United States, long term care, nurses, training programs, culture

205. Hudson, B.E., B. Soffer, & D. A Menio. (199 1). Ensuring an Abuse-Free Environment: A Learning Program For Nut-sing Home Staff. Philadelphia, Pennsylvania: CARIE.

This training manual is an abuse and neglect prevention curriculum developed for nurse aides in long-term care facilities to increase awareness of abuse and neglect, provide conflict intervention strategies, to reduce abuse and improve quality of life for older adults, Interactive in design, this curriculum includes eight modules and includes the video "Incident Report" produced by the Massachusetts Department of Health Quality as part of the curriculum. Module topics encompass understanding the phenomenon of resident abuse; identification and recognition of abuse types; causation; understanding caregiver feelings; cultural and ethnic perspectives and implications; abuse of staff by residents; legal and ethical issues and intervention strategies to prevent abuse. Each module provides notes for presentation and recommendations for trainers, a list of resources, case discussions, sample quiz, and activities such as role playing to maximize participant involvement. Noted intervention strategies for preventing abuse include the development of individualized resident care plans, observation and reporting, and appropriate use of distance and touch. Appendices include definitions of abuse and neglect, a stress indicator's exercise and role play scenarios.

206. Hudson, M.F. &T.F. Johnson. (1989). Elder Mistreatment Prevention: Curriculum Training Manualfor Health and Human Services Professionals. Chapel Hill, North Carolina: UNC School of Nursing.

This five module training manual emerged out of the North Carolina Elder Mistreatment Prevention Project and is designed to educate health and human service professionals in the prevention and treatment of mistreated older adults. Focusing on definitional issues, the first module outlines the problem of overlapping definitions used in theoretical research. Module two reviews current information on this issue, looking at the economic, physical, psychological and sociological factors contributing to mistreatment. The third module explores different levels of prevention and makes note of factors that result in abuse such as lack of caregiving knowledge, lack of resources, inappropriate expectations, and intolerance of older adults' behaviour. Module four describes a systematic way of detecting and assessing mistreatment. The last module outlines the intervention process, providing strategies for identifying, implementing and evaluating interventions. Each module includes objectives, topic overviews, issues for discussion, practice application activities and references. Supplementary charts and case studies are provided for training assistance.

case studies, definitions, detection, health care providers, identification instruments, intervention, training programs

207. Kuipers, J., R. Davidhizar, & N. Agurkis. (1989). "Resolving Conflict in Long-Term Care." Journal of Gerontological Nursing. 15(6), 12-17.

The authors argue that conflict, as it occurs in long-term care settings, among staff or between staff and residents/ families, is a normal result of the rapid changes taking place in health care. When responded in a healthy way, conflict can lead to transformation and needed change. The article describes the role of the nurse manager in effective conflict management. Sources of conflict in long-term care are noted, as are the symptoms that can be used to identify the presence of conflict, e.g increased absenteeism or behaviour changes in staff towards residents and families. Basic modes of responding to conflict are outlined (avoidance, accommodation, competition, compromise and collaboration), followed by a step-by-step description of the conflict resolution process in both one-to-one and group situations. causes, intervention

208. Pillemer, K. &B. Hudson. (1993). "A Model Abuse Prevention Program for Nursing Assistants." Gerontologist. 31(1), 128-131.

The Coalition of Advocates for the Rights of the Infirm Elderly (CARIE) developed an abuse prevention curriculum. This article describes the objectives and structure of the curriculum developed and the results of a study to determine the effectiveness of the training program on nursing assistants' attitudes and behaviours related to abuse and neglect of older people. One half of 211 randomly selected nursing assistants from 10 care facilities who took part in the training program were tested before and after the training. Results indicated a decrease in the attitude that older patients needed to be disciplined like children; lower levels of conflict between nursing assistants and patients; reduction in patient aggression toward staff; and a drop in self-reported abusive behaviour by staff toward residents. health care providers, intervention, prevention, staff development, training programs, study

V. Administrative Strategies

A. Developing Policies, Procedures & Protocols

*209.Canadian Association of Social Work Administrators in Health Facilities. (1986). Domestic Violence Protocol Manual: For Social Workers in Health FacilitiesIManuel de protocoles sur la violence domestique: pour les travailleurs sociaux en milieu de santé. Ottawa: Minister of Supply and Services Canada.

This protocol manual serves as a reference handbook for social workers working in health care settings who are dealing with cases of domestic violence. The protocol offered for abused and neglected older persons includes emergency measures, assessment guidelines and intervention strategies. The abused older person, members of the family and the suspected abuser should all be interviewed. Information about the abused person has to include his or her background, incidents of past or current abuse, mental status, feelings towards suspected abuser, living arrangements, self care ability and daily routine, and support system. Family or caregiver information should include data regarding their coping skills, physical and mental health, alcohol/drug use, the individual's feelings about caregiving, finances, management techniques and available support systems. A review of emotional attitudes and the discrepancies between the accounts of the abused person and suspected abuser assists in determining risk of danger to patient. The approaches taken in this manual may assist health personnel in dealing with abuse of residents by family members.

*210. Government of Canada. Health and Welfare Canada. (1989). Health Care Related to Abuse, Assault, Neglect and Family Violence: Guidelinesfor Establishing StandardslSoins de santé liés aux mauvais traitements, aux voies defait, à la négligence et à la violence familiale: Guide pour l'établissement de normes. Ottawa: Health Services and Promotion Branch. 77-90.

The purpose of the chapter is to provide direction to health facilities in developing their response to abuse and neglect of older persons. The authors suggest areas in which policies, procedures, and protocols could be developed, and outline the key issues in each area which need to be addressed. Among the topics covered are: plans for prevention (education) and early detection; management of abuse (identification, duty to report, obtaining consent, abuse/assault teams); evaluation of programs to ensure efficiency and effectiveness; and research. Two other related chapters in the publication cover: 1) "medicolegal issues" which describes general policy and procedures on documentation of findings, handling evidence, duty to notify provincial authorities; and 2) an appendix with a policies and procedures checklist for health care programs related to abuse, assault, neglect and family violence.

definitions, detection, evaluation, risk factors, intervention, abuse and neglect in institutional settings, procedures, consciousness-raising, Canada

*211. Interdepartmental Working Group on Elder Abuse and Manitoba Seniors Directorate. (1993). Abuse of the Elderly: A Guidefor the Development of Protocols. Winnipeg, Manitoba: Manitoba Seniors Directorate.

This Manitoba publication is intended to guide the development of protocols for dealing with older adult abuse and neglect of older adults. It offers guiding principles for promoting older adult rights and for developing intervention strategies. The guide provides definitions of various categories of abuse and neglect, as well as a list of possible indicators. The guide suggests steps to take in developing protocols: assess the need for the protocol, establish a working group, develop the protocol, obtain approval and implement the protocol, and establish a review process. This handbook notes that a generic protocol should include intake documentation, assessment/ investigation strategies, intervention procedures and follow up strategies. Examples of typical community resources are listed and provincial and non -governmental telephone numbers for Manitoba are provided. The appendices offer sample intake forms, sample protocols, a bibliography, an audio visual resource list, information concerning substitute decision making for financial matters, and relevant legislation.

Manitoba, protocols, definitions, assessment, intervention, audiovisual, bibliography, services

*212.Interhospital Domestic Violence Comrnittee. (1989). Elder Abuse: Information and Protocolfor Hospitals. Regina, Saskatchewan: Saskatchewan Health.

This handbook, developed by the Saskatchewan Interhospital Domestic Violence Committee, was compiled to assist health professionals in the identification and treatment of abuse involving older adults. The handbook is designed primarily for dealing with mistreatment that comes to the hospital staff's attention when the adult is residing in the community. However, many of the issues the Committee touches on can also apply to abuse and neglect in institutional settings. The handbook outlines how police deal with criminal matters involving abuse and how the criminal justice system operates. Finally, the handbook provides a model protocol for hospital use, and sets out the steps involved in identification (looking at verbal, behavioural and physical cues), registration, assessment, intervention with the patient and the caregiver, and follow-up.

*213.InterMinistry Committee on Elder Abuse and Continuing Care Division, Ministry of Health, & Ministry Responsible for Seniors. (1992). Principles, Procedures and Protocolsfor Elder Abuse. Victoria, British Columbia: Ministry of Health and Ministry Responsible for Seniors.

This document offers guidelines for individuals dealing with abused or neglected older adults and contains definitions; ethical principles for community intervention strategies; a 6 generic' protocol for application to both rural and urban communities; and a resource list to help direct the design of an support network for older adults. Appendices include an intake form and sample protocols from a home support agency, a continuing care facility, hospital, community legal information service and a health unit. Additional appendices offer a table of indicators, overviews of financial abuse, provincial licensing authorities, other resource services, a bibliography and audio-visual resource list.

214. Jones, J., J. Dougherty, D. Schelble, & W. Cunningham. (1988). "Emergency Department Protocol for the Diagnosis and Evaluation of Geriatric Abuse." Annals of Emergency Medicine. 17(10), 1006-1015.

The authors combined information from the medical records of 36 older patients hospitalized as a result of neglect or abuse, with information from other research on risk factors and situations of abuse to develop an emergency department protocol for identifying and documenting details of suspected cases of abuse or neglect. The article includes a copy of the protocol, plus a discussion of the process of identification, assessment and intervention. Indicators are provided to help medical personnel recognize abuse and neglect, and take adequate steps to document suspected cases.

assessment, detection, documentation, health care providers, identification instruments, intervention, protocols

215. Knelsen, K. (1991). "Establishing an Institutional Policy on Abuse." Long Term Care Monitor. 2(9), 66-69

Knelsen describes the development of policy and a variety of responses to situations of mistreatment in care facilities, including situations of abuse of residents, violence against staff by residents and aggression between residents. The article provides many examples of the way in which one particular long term care facility approached these three aspects. Included is the definition of abuse of residents used in the policy, procedures for reporting, actions to be taken in the event that mistreatment is proven, a description of a preventive education programme developed for staff, actions to be taken in potentially problematic situations to prevent abuse from developing, and protocol to be followed when dealing with aggressive residents.

B. Employment Practices

216. Sundram, C.J. (1984). "Obstacles to Reducing Patient Abuse in Public Institutions." Hospital and Community Psychiatry. 35(3), 238-243.

This article explores the factors obstructing the prevention, investigation and reporting of abuse in mental health facilities. Drawing on his experience with the New York State mental health system, the author suggests state mechanisms for staff recruitment, training and supervision simultaneously contribute to mistreatment and prevent its accurate reporting. The mechanisms often fail to effectively screen out prospective employees with explosive personalities or those previously identified as abusers. Inadequate training programs, understaffing and doubleshifting lead to frustration and abusive behaviour among staff. Minor forms of abuse are typically not reported; major forms of abuse are less accepted, but tend to be underreported. Reporting is affected by factors such as administrators' attitudes towards alleged abusers, fear of reprisals, ostracism and protection of the powerful within the disciplinary process. As a psychiatrist's patient, the abused person's credibility tends to be questioned. The article recommends redirecting the focus from reporting to prevention by developing improved hiring and screening mechanisms, improving training programs, hiring independent investigators and reassessing management practices. The findings are also applicable to older adults in mental health institutions and long term care institutions.

C. Collaborative Efforts

217. Kapp, M.B. (1989). "Aggressive Residents and Families: Rights and Responsibilities." Journal of Long Term Care Administration. 17(3), 12-17.

Violent or abusive behaviour by care facility residents against staff needs to be acknowledged and responded to. Staff often find it difficult to reconcile their response to a violent resident with their caregiver values. Values such as respecting residents' dignity, protecting autonomy, adhering to the principle of beneficence may conflict with the right and responsibility to protect self, other staff and residents from harm. The problem must be identified early and staff need to be trained to manage violent behaviour. Policies on use of restraints, and dealing with family members who are violent need to be in place. Clear and updated manual policies and procedures, use of ombudsman programs, and collaboration with resident advocacy groups and family/ resident councils, are all positive actions that can all be taken to avoid or minimize ethical and legal actions against the facility when abuse occurs.

ethics, health care providers, resident aggression, liability, policy development, staff abuse

*218.Ross, N. & G. Dubé. (1993). Projet "Échec à la violence faite aux aîné(e)s" Prévention et traitement des abus en centres d'hébergement privés et publics. Rimouski: Fédération des Clubs de l’Âge d'Or de l'Est du Québec (FCADEQ).

This facilitation kit on abuse and neglect of older adults, includes a specific tool for prevention and dealing with abuse in private and public homes for the aged. It presents a series of attitudes for administrators and service providers to adopt in order to improve the living conditions of institutionalized older adults. One series of applications is proposed for service providers, and is aimed at improving services to older residents; a second series of application is for all staff. The authors also suggest specific measures for both service providers and administrators, for the prevention and handling of abuse. It stresses among other points, the importance of a protocol, information and continuing education.

intervention, abuse and neglect in institutional settings, procedures, prevention, quality of care, quality of life, consciousness-raising, Quebec

D. Seeking Alternatives

219. Calvet, R. (1990). "Can Residents of Nursing Homes be Freed from Restraints?" Nebraska. Nurse. 23(3), 10-11.

Administrators of a Nebraskan nursing home decided to implement restorative nursing interventions as an alternative to restraint use. This move was reported to be successful, even for residents with such diagnoses as chronic brain syndrome, senile dementia, seizures and post fractured hips. Restraints can have adverse effects on residents, including muscular atrophy, decreased bone mass, confusion, pressure sores, agitation and even death by strangulation. New federally guided nursing home initiatives highlight the need for protecting residents' rights and using interventions which encourage mobility. To create this kind of an environment, residents' abilities must be properly assessed, proper chairs must be provided, physical activity must be emphasized, staff must be educated and their active involvement in management must be encouraged. Alternatives to restraint use are included.

220. Gold, M.F. (1992). "Eliminating Chemical Restraints Through Proper Prescribing." Provider. 18(2), 14-24. As a result of the American Omnibus Budget Reconciliation Act (1987), nursing homes began to reduce their use of physical restraints. Gold suggests a reduction in chemical restraints is also needed, specifically the overuse and misuse of drugs to control patient behaviours. The tendency to sedate residents may result in residents' reduced ability to do activities of daily living. This may increase dependency on nursing staff, worsen resident behaviour with the use of drugs, or increase falls. Using illustrations from facilities in the U.S., the author outlines a series of steps to stop the use of chemical restraints. Steps include detailed assessment of residents, environment evaluation and modification to respond to less medicated residents, increased activities for residents no longer sedated, staff education, and proper prescribing of drugs. A major benefit of decreased use of restraints is a change in staff perceptions that residents need their behaviour controlled, a perception which can lead to mistreatment.

221. Mokros, K.L. (1992). "Setting Targets Improves Facility Restraint Reduction Efforts." Provider. 18(9), 46, 48, 52.

Mokros presents key elements for developing a program to reduce the use of physical restraints with residents in long-term care. To achieve these goals, the author describes specific steps to take (such as focusing on low risk residents) and offers suggestions for working with individual residents, and ways to involve staff, family and residents in the program, especially in terms of education. Suggestions are given for working with higher risk residents.

VI. External Strategies

A. Community Reviews

*222.Concerned Friends of Ontario Citizens in Care Facilities. (1992). Nursing Home Checklist. Toronto, Ontario: Concerned Friends of Ontario Citizens in Care Facilities.

This nursing home checklist is designed to assist people in selecting a nursing home. Concerned Friends advise first visiting the home, meeting the administrator, obtaining copies of the Admission Contract, the Compliance Review Report and the Nursing Homes Act, as well as speaking with the families of current residents. Other questions to ask administrators and staff include issues around language, restraint use, medication, access to residents, religious and volunteer services, availability of therapy and dental services, resident decision making, structural characteristics and whether staff have been trained to deal with people who have visual and hearing impairments. A checklist is also provided to assist in evaluating the observed care of residents, staff behaviour, general surroundings, provision of rehabilitative/ restorative care and dietary arrangements. The checklist includes a scoring mechanism to help determine the quality of the nursing home.

B. Ombudsman

223. David, M.A. (1986). "An Ombudsman's Perspective." In M.W. Galbraith (ed.), Elder Abuse; Perspectives on an Emerging Crisis. Kansas: Mid-American Congress on Aging. 125-138.

This article discusses the role of the ombudsman in dealing with cases of abused or neglected older adults. Established in the United States in 1978, the ombudsman is responsible for monitoring policies, laws and regulations as well as resolving complaints initiated for, or by, older adults in long term care facilities. This ombudsman role later expanded to encompass involvement in nursing homes and other types of care homes. The ombudsman has played a vital role in undertaking preventive and reactive measures in abuse and neglect cases involving older adults. This article expresses concern about recent amendments to the program which are expected to diminish the capacities of the ombudsman role. United States, ombudsman, long term care

224. Doherty, M. (1987). "Elder Abuse in Long Term Care Facilities." In L. Neremberg (ed.), Serving the Victim of Elder Abuse - A "How-to" Manualfor Practitioners and Program Planners. San Francisco: San Francisco Institute on Aging at Mount Zion Hospital and Medical Centre. 30-32.

This article describes and analyses of the development of the ombudsman program in California. Initiated by federal government and administered by individual states, the program is designed to receive and investigate complaints by, and on behalf of, residents of residential care facilities. In California, non-profit public agencies are contracted to run local programs, and recruit, train and supervise volunteers who regularly visit clients in facilities. Agency staff investigate suspected cases of abuse. The author outlines the course of action taken in different circumstances, procedures for assessment, information gathered, follow up practices and obstacles to the process.

225. Litwin, H., L.W. Kaye, & A. Mink. (1983). "Volunteers as Ombudsmen for the Aged in Long-Stay Institutions." Journal of Voluntary Action Research. 12(4), 29-45.

The authors begin with a brief review of the findings of two American research studies of ombudsman services for older adults in institutional settings. They then explore: how volunteers in the programs have come to interpret and fulfil their roles; whether the programs should be publicly based and government controlled, or voluntarily established by the private sector; and how current American trends such as budget restraints affect ombudsman programs in institutions. The authors include a description of ombudsman programs in general, and a brief review of the problems presented by long-term care institutions when attempting to provide ombudsman programs.

C. Inspection/Regulation

6. Rowden, R. (1987). "Do We Call this Care?" Nursing Times. 83(48), 22. The author responds to a nursing home scandal in Britain with suggestions on how to improve the monitoring and control of standards of long-term care. He argues the need for an independent inspection body which is given proper resources, is regionally based, and is able to inspect all agencies involved in long-term care provision. A number of funding suggestions for such a program are offered. adult protection services, Great Britain, intervention, regulations

D. Legislation

*227.Beaulieu, M. & A. Vandal. (1990). "'Vieillir ... en toute liberté:' synthèse et pistes de réflexion." Le Gerontophile. 12(3), 7-12.

The authors offer a synthesis of the report by the committee on abuse and neglect of older adults, Vieillir … en toute liberté, and a reflection on its recommendations and directions for intervention. Since abuse within institutions constitutes only one part of the report, only part of the article addresses this issue. The authors recommend that more stringent legislation be required on the classification of institutions, and that these classifications be widely made known to enable older adults to make more informed choices about where they are going to live. The authors also emphasize that institutions must develop intervention strategies that offer more decision-making power to residents.

selecting a facility, empowerment, legislation, abuse and neglect of older adults, abuse and neglect in institutional settings, Quebec

*228.Berger, L. (1993). "Les droits des personnes âgées et la loi." In L. Berger, & D. Mailloux-Poirier, Personnes âgées: Une approche globale. Québec: Éditions Études vivantes. 463-472.

According to the author, doctors and nurses are sometimes faced with major ethical dilemmas. Since 1976, Quebec has a charter of rights and freedoms in place. The author examines six fundamental rights of older adults, which are protected by this charter but are likely to be transgressed. It appears that current legislation does not respond to all of the needs of older adults and those around them. Older adults and others concerned with their quality of life, are calling for legislation specifically for this group. The author concludes that such an act would have to take into account information on the situation and its social aspect.

legal aspects, needs, residents' bill of rights, ethics, abuse and neglect of older adults, abuse and neglect in institutional settings, Quebec

229. Delpérée, N. (1991). La protection des droits et des libertés des citoyens âgés. Paris: CNP Assurances.

The seventh chapter in this book, on legal protection of older adults, is divided into three distinct section. 'Me first section deals with violence by third parties, the second section with violence and abuse within the family, and the third section with euthanasia. According to the author, older adults are not properly aware of their legal rights. As well, for a variety of reasons, they are not very likely to report any abuse they have experienced. The authors goes on the say that the impact of abuse on the older adults is great due to their fragility and may even lead to fatalities. She presents the various legislative measures already in place and proposes modifications to better adapt penal law to older adults' need of protection.

legal aspects, defence of rights, legislation, adult protection laws, abuse and neglect of older adults, criminal justice system, Canada, United States, Toulouse

*230.Gouvernement du Québec. Ministère de la Santé et des Services sociaux. (1993). Loi sur la santé et les services sociaux. Québec: Ministère des Approvisionnements et Services Québec.

The Quebec Health and Social Services Act governs policies and practices for government-recognized institutions. Three of its clauses are directly or indirectly aimed at preventing or reacting to abuse: compulsory codes of ethics specific to each institution, users' committees for older residents and their relatives to have a voice, and complaints committees for residents to present any grievances.

residents' councils, policy, ethics, legislation, abuse and neglect in institutional settings, procedures, Quebec

231. Migdail, K.J. (1992). "Nursing Home Reform: Five Years Later." Journal of American Health Care Policy. 2(5),41-46.

This article assesses the impact of nursing home regulation legislation in the United States. The article includes the history leading to the development of the Omnibus Budget Reconciliation Act of 1987, key aspects of change in federal regulation as a result of the act, the role of residents' bills of rights, problems implementing the act, finding agreement between federal and state agencies, and a summary of the evidence indicating the impact of the legislation. The author suggests that reform is slowly occurring, with decreased use of restraints, better staffing and training, creation of a uniform set of data for comparison, development of standards of care, and an emphasis on residents' rights. The act needs further development through increased consistency within and among states in applying the regulations, increased federal leadership in enforcing regulations, and changes in certification and surveillance of nursing homes. Political and practical barriers to improving the legislation are considered.

232. (1986). "Legislation on Abuse, Neglect, and Exploitation of the Elderly." Long-Term Care Quarterly. Winter, 1-8 (Appendix A). This article details the American legislation on abuse and neglect of older people and describes some programs introduced as a result of the legislation. Areas addressed are: 1) establishment of commissions and programs (e.g. those which ensure investigation of reports of abuse and neglect, public education programs); 2) central registries; 3) ombudsman programs; 4) reporting (including persons required to report mistreatment, content of reports, confidentiality of reports, immunity for persons reporting, failure to report); 5) investigation of abuse and neglect of older persons; 6) protective services for abused people; and 7) penalties for mistreating older persons.

233. Weiker, L.J. (1987). "Federal Response to Institutional Abuse and Neglect: The Protection and Advocacy for Mentally III Individuals Act." American Psychologist. 42(11), 1027-1028.

This article reports testimony from the 1985 American Senate hearings which lead to the development of the Protection and Advocacy for Mentally Ill Individuals Act. The act applies to nursing homes as well as to institutions for mentally ill adults. Reports of understaffing, minimal training of staff, low pay, over-medication, excessive paperwork and ineffective certification and investigation, resulted in a nationwide system of protection and advocacy. The article briefly describes the way in which services were organized. United States

Appendix A

Members of Planning and Advisory Groups Abuse and Neglect of Older Adults in Institutional Settings

Based on two Toronto, Ontario consultations held December 10-11, 1992, and June 22-23, 1993, and subsequent text review up to June 1994.

Marie Beaulieu
Département des sciences humaines
Université du Québec à Rimouski
Rimouski, Québec

Elizabeth Boustcha
Section of Geriatric Medicine
St. Boniface General Hospital
Winnipeg, Manitoba

Pauline Chartrand
Health Service Systems Division
Health Services Directorate
Health Canada

Reg Gabriel
Division of Services to Senior Citizens
Department of Health
St. John's, Newfoundland

Paulette Larocque
Long Term Care Unit
Stanton Yellowknife Hospital
Yellowknife, NWT

Claire Milette
Service de longue durée
Ministère de la santé et des services sociaux
Québec, Québec

Judi Murakami
Quality Assurance
Continuing Care Division
B.C. Ministry of Health
Victoria, B.C.

Linda Wacker
Social Work Department
Wascana Rehabilitation Centre
Regina, Saskatchewan