Stand By Me

Preventing Abuse and Neglect
of Residents in
Long-Term Care Settings

Our mission is to help the people of Canada

maintain and improve their health.

Health Canada

Stand by Me: Preventing Abuse and Neglect of Residents in Long-Term Care Settings was prepared by Jean Kozak and Teresa Lukawiecki for the Family Violence Prevention Unit, Health Canada.

Également en français sous le titre Soyons à l'écoute des besoins: Prévenir les mauvais traitements et la négligence envers les pensionnaires des établissements de soins de longue durée

The opinions expressed in this monograph are those of the authors and do not necessarily reflect the views of Health Canada.

Contents may not be reproduced for commercial purposes, but any

other reproduction, with acknowledgements, is encouraged.

This publication may be provided in alternate formats upon request.

For further information on family violence issues, please contact:

National Clearinghouse on Family Violence
Family Violence Prevention Unit
Health Issues Division
Public Health Agency of Canada (PHAC)
Health Canada
Address Locator: 1909D1
9th Floor, Jeanne Mance Bldg., Tunney's Pasture
Ottawa, Ontario K1A 1B4 CANADA
Telephone: 1-800-267-1291 or (613) 957-2938
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Web Site: http://www.phac-aspc.gc.ca/nc-cn

© Her Majesty the Queen in Right of Canada, 2001

Cat. H72-21/175-2000E

ISBN 0-662-29348-7
Acknowledgements

We acknowledge, with sincere appreciation, all the people — residents, staff, families, volunteers, researchers and advocates — who shared their experiences and insights and provided the foundation for all the resources developed during the life of the Abuse Prevention in Long-Term Care (APL) project.

We would like to convey our appreciation to the site coordinators whose invaluable work and dedication made the projects an unqualified success across Canada — Pearl McKenzie (British Columbia), Elizabeth McKean (Manitoba), Teresa Lukawiecki (Ontario), Carole Deschamps (Quebec), Jocelyne Marion (Quebec) and Theckla Lundin (Newfoundland).

We would also like to thank the coordinating sites and site representatives who contributed immensely to the success of the project:

British Columbia St. Vincent's Hospitals, Vancouver (Jacqueline Senning)

Manitoba Riverview Health Centre, Winnipeg (Elizabeth Boustcha)

Ontario Sisters of Charity of Ottawa Health Services, Ottawa
(Jean Kozak)

Quebec Regroupement des Trois Rives, Vaudreuil (Lise Bélisle)

Newfoundland Hoyles-Escasoni Complex, St. John's (Anne Morrison
and Pat Amos)

The content of this monograph is a synthesis of the information and products produced during the various phases of the APL Project.

Kozak, J.F. & Lukawiecki, T. (1997). Abuse Prevention in Long Term Care: Educational Package.

Kozak, J.F. & Lukawiecki, T. (1997). Final Report of the APL Project. Report submitted to New Horizons — Partners in Aging, Health Canada.

Kozak, J.F., Lukawiecki, T., & Dalle, D. (1998). Final Report of the Abuse Prevention in Long Term Care Train-the-Trainer Project. Report submitted to the Population Health Fund, Health Canada.

Lukawiecki, T., Kozak, J.F., Wahl, J., & Dalle, D. (1998).

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

Introduction

This monograph is the second of a three-part series on abuse and neglect from the perspective of residents and others who live and work within Canada's long-term care (LTC) sector. Part one, When Home Is Not a Home: Abuse and Neglect in Long-Term Care — A Resident's Perspective, explores how residents perceive abuse and neglect, while part three, Returning Home: Fostering a Supportive and Respectful Environment in the Care Setting, examines what residents and others feel constitutes a supportive and respectful environment. This monograph highlights what residents, staff, families and others feel should be done to ensure that abuse and neglect are stopped and prevented.

This series of documents was funded through the Family Violence Prevention Unit (FVPU) of Health Canada. Through the FVPU, Health Canada leads the Family Violence Initiative (FVI), coordinating the relevant activities of 13 federal Departments and three central agencies that are formally involved in the Initiative. Under the current FVI, Health Canada remains committed to addressing family violence issues, including the abuse of older adults. In consultation with the Division of Aging and Seniors, the FVPU undertakes research on the consequences of abuse and neglect of older adults to enhance treatment and prevention. The FVPU has developed and revised a number of resources on the abuse of older adults for dissemination through the National Clearinghouse on Family Violence.

Between December 1995 and June 1998, Health Canada, through the New Horizons — Partners in Aging and the Population Health programs, funded two national educational projects to explore the issues of preventing and intervening in resident abuse and fostering a supportive and respectful environment in LTC. The two projects were the Abuse Prevention in Long Term Care (APL) Project and Abuse Prevention in Long Term Care — Train-the-Trainers Project. Although the projects did not provide any indication of the extent of the problem (prevalence and incidence), the information contained herein can be used to broaden the understanding of abuse and neglect, and can set a direction for addressing this complex issue.

In the first phase of the project, focus groups were held with 494 LTC residents, staff (clinical and administrative), institutional volunteers, family members and
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
advocates in British Columbia, Alberta, Manitoba, Ontario (French and English), Quebec (French and English) and Newfoundland. Because of the health limitations of some residents, individual interviews were conducted where necessary. Participants explored their feelings and thoughts on:

In the second phase of the project, educational workshops were held across Canada using the Educational Package for Abuse Prevention in Long-Term Care, developed from the results of the first phase. The issues raised in this document and the two companion parts are those identified by the participants in both phases of the project. A detailed description of the two projects may be found in the first report, Abuse and Neglect in Long-Term Care.

Preventing abuse and neglect, and intervening when it does occur, begins with respect: respect for the rights and responsibilities of all — residents, staff, families and others. As explored in the first document of this series, and applied in the third one, respect is the cornerstone of building and maintaining a supportive and healthy environment. Although we will never totally irradicate abuse that is committed intentionally, as in the case of criminal actions (e.g. theft), designing intervention and prevention programs based on respect will move us toward the ideal of zero abuse and neglect.

Within the institutional sector, a major shift that must occur is in the belief that because a person is admitted to a care facility he or she is incapable of making decisions. However limited the resident's decision making might be, all attempts must be made to include that person in daily decision making: from something as seemingly insignificant as what clothes to wear to complex issues such as treatment. When the person is deemed incapable of participating in treatment decisions, because of severe cognitive problems, staff and administrators must understand that the determination of that incapacity and of who can be an appropriate decision maker is a matter of provincial law and that such laws vary across Canada. Because of this, staff must be made aware of the provincial laws within their jurisdictions for identifying who has the right to consent on an individual's behalf. This is a responsibility that plays a role of great prominence in a facility's ability to deal with abuse and neglect.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
This monograph outlines the issues and steps identified in response to the question, "How do we stop and prevent abuse and neglect?" From the many interviews conducted with residents, staff, families, advocates and volunteers across Canada, the key mechanisms through which we can address the problem of abuse and neglect that were identified include intervention, prevention, education and training, and guiding policies and principles.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

Intervention

Appropriate intervention in situations involving abuse or neglect of a resident involves an ongoing process of reporting, documenting, investigating, intervening and follow-up. The process itself must be:

The following section points out some important guiding considerations and then focusses on the general steps for intervening in situations of resident abuse or neglect.

Resident-Focussed Intervention Process

When abuse or neglect is suspected, the well-being of the resident must be the central focus of any intervention. A resident-focused intervention involves ensuring physical safety (e.g. removing the resident from immediate danger or attending to any injury) and providing emotional support (e.g. listening attentively or offering counselling).

Regardless of the type of abuse or neglect, those who are intervening must always take direction from the resident whenever possible. In a situation in which the resident is incapable of making a decision, the priority should be involving the appropriate substitute decision maker as defined by the provincial law under which the facility operates.

The importance of constructing a process that is resident-focussed is underscored by the APL focus group results that indicated that residents typically did not know what could be done to stop abuse and did not feel that they were informed as to what steps were being taken once an incident was reported.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

"What should people do if there is abuse? Ring the bell and hope to heavens they come in a hurry." (resident)

Duty of Care

The response to a situation of resident abuse or neglect requires sensitivity, balancing the resident's wishes and well-being with a facility's policies and legal obligations. Because of the physical or cognitive vulnerability of the residents, employees of LTC facilities have a duty to care for the safety of residents both individually and collectively. Intervention against a resident's wishes may sometimes be necessary if the health or safety of the resident or others is at risk. Acting against a resident's wishes, however, must be a last resort done only after all other options have been exhausted.

Acting against a resident's wishes places a great strain on the relationship between staff and resident. It is important that facilities establish guidelines with concrete examples of how staff may act in a sensitive manner. For example, staff may approach this problem by saying, "What you described is abuse. Because we are responsible for your health and safety, I have to let my supervisor know what occurred so that it does not happen again. She will want to speak with you."

Rights and Responsibilities Regarding Abuse and Neglect

Everyone has a role to play in preventing and intervening in cases of abuse and neglect. These roles can be clearly expressed in terms of rights and responsibilities.

Rights:Everyone, including residents, staff, families and volunteers, has the right to live, work and/or visit in an environment free of abuse and neglect, and to be treated with respect.

Responsibilities:Everyone, including residents, staff, families and volunteers, has the responsibility for:

Staff members have the added responsibility of ensuring that their actions respect professional codes of conduct. Senior management has the responsibility for:

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

Residents with Cognitive Impairment

Responding to abusive situations involving residents who are incapable of communicating because of cognitive impairment requires added care by staff. In such situations, staff and others must be aware of the vulnerability of these residents.

Residents with cognitive impairment are perceived by residents, staff, families and others as being at greater risk of abuse or neglect. An equal risk faced by these residents is that, because of their intellectual condition, their rights may be compromised or even dismissed by well-meaning staff or advocates. This situation can occur when we believe that we are speaking on behalf of the resident while not realizing that the actions decided upon reflect more our own personal and professional values than those of the resident.

Abuse and neglect situations involving residents with cognitive impairment are complicated by the presence of inappropriate behaviours such as aggression. If staff or others are unaware that certain diseases that compromise cognitive integrity also result in aggressive behaviour, one can mistakenly believe that the resident intends the perceived harm. This perception in turn results in greater frustration for the care provider or visitor when dealing with the resident, possibly leading that person to react in a similarly inappropriate fashion (e.g. hitting back or ignoring the resident).

Staff and others must be made aware of the distinction between abuse resulting from the actions of a cognitively impaired individual and abuse caused by someone aware of the consequences of his or her actions. In the case of someone with a cognitive impairment, aggressive and abusive behaviour does not arise from some conscious or malicious volition. Instead, the act needs to be seen as a symptom of the underlying disease afflicting the resident.

Interventions in such situations, therefore, must be different from those taken when the person is aware of the consequences of his or her action. Because of their diminished capacity, the focus with regard to cognitively impaired residents needs to be on the environment and how to prevent or stop any aggressive behaviour. It is up to the staff and others interacting with these residents to promote resident
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
well-being and safety. It is the role of the facility to ensure that processes are in place to achieve these goals (e.g. education and training, appropriate policies and procedures).

When any decision is being discussed, whether on actions to be taken in a case of abuse and neglect or treatment decisions, staff must obtain consent from the appropriate substitute decision maker. For a resident who has been deemed incapable of providing consent, staff must ascertain that the substitute decision maker is the most appropriate one as indicated by provincial law.

Police Involvement

Whenever criminal activity as outlined in the Criminal Code of Canada is suspected, the police must be called in to investigate. Criminal behaviours include assault, sexual assault, neglect and forcible confinement. Police involvement in acts defined by the Criminal Code of Canada is necessary, given their training in investigating criminal acts and determining whether or not charges are warranted.

It is important that staff within LTC facilities understand what acts fall within the Criminal Code. Equally important, they must be made aware that the reporting of such incidents does not reflect poor care. Rather, such actions or the understanding by all that police involvement will occur when necessary sends the clear message that a facility treats abuse and neglect as a serious occurrence that is not tolerated.

2.2 STEPS FOR INTERVENING

There are no set or easy methods of intervening in cases of suspected abuse or neglect. Developing appropriate and effective interventions is a process requiring flexibility and responsiveness. The following general steps may help guide responses (see Figure 1):

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Figure 1 — Principles of Intervention

• Stop the abuse or neglect.
• Take direction from the resident as much as possible.
• Outline options and maximize choices.
• Explore all options.
• Notify administrative person.
• Document and investigate.
• Tailor interventions.
• Keep resident informed.
• Consult designated decision maker.

Responding

Anyone witnessing abuse or neglect must take immediate action to stop it. This action may include, but is not limited to, telling the abuser to stop, calling for assistance, or moving the resident out of harm's way. The resident's safety and well-being is paramount at all times.

Many people may not know how to take action or may not want to become involved. They may not be familiar with the institution, or they may be afraid of being perceived as a troublemaker or think that they do not have the right to say anything. Moreover, it is difficult for people to take action if they are unsure that what they saw was actually abuse. In such situations, a simple way to respond and draw attention to the behaviour in question is by saying, "I feel uncomfortable when I see…" This statement opens the door to discussion and helps clarify whether or not abuse or neglect has occurred. Many of the staff who participated in the APL focus groups felt that it was important to respond right away when observing abuse or neglect, even if it was difficult to do so.

"You don't do it [speak] in a rough way. You say it nicely. `That's not the right way to do it.' You don't blow up, or else they will blow up too, and you'll be in hell." (staff)

Taking Direction from Residents

As much as possible, a resident needs to make decisions or at least be central to the decision-making process concerning the situation being investigated. As adults, the residents' ability to make decisions for themselves must be respected and encouraged.

Great care must be taken when a resident is perceived as being too cognitively impaired to make his or her own decisions. Staff, family and others must be made
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
aware that unless deemed incapable according to the provincial legislation under which the facility operates, such residents are still responsible for making their own decisions. Too quickly labelling residents as cognitively impaired can result in the easy dismissal — intentionally or unintentionally — of their right to make decisions for themselves. Therefore, it is important to determine what capacity the resident has and, when required by law, to use the appropriate substitute decision maker when dealing with an abuse or neglect situation.

Reporting

Reporting is, essentially, informing someone in charge, usually a senior administrative person, that abuse or neglect is suspected. Reports can come from anyone either orally or in writing and may range from merely a suspicion to an outright accusation. Reporting abuse or neglect is often difficult to do and the extent to which people fear negative repercussions affects the likelihood that they will report.

In the APL focus groups, many residents did not know whom to speak to if abuse or neglect were happening to themselves or others, or they would refer obliquely to talking to "the authority." Some stated that they would not report abuse.

"I haven't got a clue." (resident)

Residents had the following suggestions as to whom they could report situations to:

"If you saw or received abuse we can go to that resident council and express our idea. There's a facilitator at resident council, he will take it to the authorities." (resident)

"If they did something too bad I would want my family told, but you have to put up with a certain amount." (resident)

By far the largest barrier to reporting that was suggested by APL focus group participants was fear. Fear creates an environment in which silence is considered
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
the rule. Staff are afraid of being blacklisted or ostracized while residents and families are afraid that the quality of care would suffer if they reported. As well, residents feared that they would not be believed.

"How can you report on someone and not have it come back to you? What if you are wrong in what you saw?" (staff)

"Often it comes down to one word against the other, because there's only two people there. How are we going to prove it unless there's a bruise or something?" (resident)

Another major barrier to reporting is uncertainty. People may be uncertain about whether the incident actually constitutes abuse or neglect and whom they can speak with if there is a problem. Many people do not feel supported by the facilities.

"Some staff, some of the residents, do not know what to do when anything does go wrong. They don't know who to go to, or anything else. A lot of cases, all they have to do is go to the head nurse or supervisor on their floor… I had to go to the supervisor myself. If they can't get through to the supervisor, they can go to the council. Some people don't like to say anything." (resident)

Reporting abuse and neglect is made easier when:

Moreover, it is important that senior management support people who report incidents of abuse and neglect by:

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Complete anonymity may not be possible, but a "closed-door" reporting policy can help maintain confidentiality.

Any person may report abuse or neglect, although it is usually staff who fill out either a general incident form or a form designed specifically for resident abuse or neglect. Whichever form is used, staff require training on how to record all the facts, respect the confidentiality of the resident and avoid any statements of opinion or speculation. The desirability to report early must be stressed, as should the need to document problematic incidents to help establish a pattern of abusive behaviour, especially when individual actions might not appear to warrant intervention. The content of a report of abuse or neglect must answer four of the five traditional questions of inquiry: who, what, where, when and why.

WHO Who was involved in the abuse or neglect? Name all parties present.

WHAT What happened? Describe the abuse or neglect. Include the perceptions of those involved and what happened just before and just after the event.

WHERE Where did it take place? Give the specific location.

WHEN When did it take place? Specify the date and time of day.

WHY The underlying cause of the incident requires investigation of all the facts. Because of a lack of information or conflicting perceptions, the true cause may never be known. However, action must be taken.

Investigating

The investigation of all suspected incidents of abuse and neglect must be mandatory, with each case handled individually. Although specific procedures will vary from facility to facility, the process is characterized by clear reporting lines, strict confidentiality and the protection of all concerned. Furthermore, the investigation must proceed according to the resident's directions as much as possible. Throughout the investigation, the investigator has to promote a balanced, fair and sensitive approach to protect the rights of both the person reporting and the suspected abuser.

Senior management needs to designate someone to handle suspected cases of abuse and neglect from investigation to follow-up. It is useful to have more than one person trained to carry out investigations. The ideal candidate is someone who is perceived as neutral, and who has the authority to take action. Many focus group participants suggested that a facility ombudsman would be beneficial. Senior management may also choose to appoint an external advocate to promote the perception of independence and impartiality. When criminal activity is suspected, however, the police must be called in to investigate.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Documenting

At every step of the intervention, careful and accurate documentation is required. All documentation needs to be safeguarded, preferably with one person designated as responsible for keeping the evidence in one place to reduce the likelihood of confusion or loss of information. Statements are to be taken from all parties, including the resident, any witnesses and the alleged abuser. All statements need to be signed and witnessed. It may be prudent to either audiotape or videotape the resident's statement, after permission has been obtained, to help in the documentation of the incident and to reduce the need for repetitive interviews.

If the suspected abuser is a unionized staff member, a union representative must be present when the statements of both the staff member and the resident are taken. Any pertinent facts of the resident's direct injury or symptoms can be noted on his or her chart. Staff must be instructed not to include on the health chart the names of anyone involved in the suspected abuse or any details of the investigation. Such information should reside only on the incident reporting form.

Intervening

Residents or their appropriate substitute decision makers must be encouraged and permitted to play a central role in deciding upon the course of action. Options to the resident can be outlined in order to maximize choices. All options must be explored before intervening against a resident's wishes in cases where his or her health and safety are at risk. Residents or their substitute decision makers need to be informed continuously of what action is being taken. One of the major complaints heard from residents and family members during the APL interviews was that they were unaware of what was happening after a complaint was made. As stated by one resident, all that is seen is that the person about whom the complaint was made is still employed on the unit. This gives the resident the impression that no action has been taken, thereby further increasing a sense of helplessness in the individual.

Small-sized and rural/remote facilities have to contend with additional problems in intervening. Many have few resources, such as no multidisciplinary team members (e.g. social work, occupational therapy, physical therapy) or little access to other resources (e.g. psychiatry, mental health workers). Direct care staff tend to be people from the area who have no specific education in providing health care. As well, in small communities people know and socialize with everyone else and this can be problematic if a facility has to reprimand or fire an employee who is abusive.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
It is important to include all concerned parties, such as representatives of unions and professional bodies, in the intervention process. Interventions must be tailored to each situation. The intervention chosen will depend on who the alleged offender is, the severity of the abuse, and the circumstances surrounding the incident. More than one type of intervention may be implemented at one time. As well, interventions must include strategies to ensure that the situation does not occur again.

In general, the following interventions may be used with staff, cognitively intact residents, family members and volunteers:

Additional interventions with staff include:

Other interventions with cognitively intact residents include:

Possible interventions with family members include:

Other interventions with volunteers include:

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Interventions with cognitively impaired residents who are abusive are different because changes in behaviour have to be regulated by the environment and other people. Possible interventions are:

Follow-up

The resident and his or her designated decision maker or advocate need to be kept informed at every point of the follow-up process, from the results of the investigation to the ongoing outcome of any action taken. Without follow-up the situation may worsen. All involved parties, such as representatives of unions and professional bodies, must be included in the process.

Follow-up increases the effectiveness of any intervention. It involves:

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

Prevention

Abuse and neglect in LTC can be prevented in most situations. Greater difficulty is experienced with preventing intentional criminal acts. Even these acts, however, can be reduced by adopting a zero tolerance policy and the use of police checks of new employees.

Prevention is the process of interrupting or eliminating the cause or causes of abuse or neglect, thereby effectively stopping it from occurring. It is an ongoing process that involves awareness, planning, action and evaluation. Preventive measures can be relatively simple and cost-effective, especially when compared to dealing with abuse or neglect after it has occurred. There are many ways to prevent abuse and neglect. This section highlights prevention strategies suggested by participants in the two APL projects.

To be successful, any prevention process must include strategies at three different levels: societal/community, facility and individual. As interaction is ongoing among preventive strategies at these different levels, it is equally important to consider all levels to effectively prevent resident abuse and neglect in LTC (see Figure 2).

Fig

ure 2 — Levelty
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
3.1 PREVENTION STRATEGIES AT THE SOCIETAL/
COMMUNITY LEVEL

Long-term care facilities across the country are facing similar problems related to changing funding, reduced direct care staffing, irregular family and community involvement, and a lack of voice for frail older adults. In every province, APL participants routinely discussed these problems and how they may result in resident abuse or neglect. Health care workers, families and residents expressed increasing anger at the continuing decline in appropriate care funding and their frustration at being unable to affect changes or have an impact on policy development.

To address the larger systemic problems, the issue of quality institutional care needs to be politicized and efforts pooled into a larger network. This will create the impetus necessary to increase awareness and prompt change. A large part of prevention at the societal/community level is establishing adequate structures to maximize communication and collaboration among all groups associated with LTC, including residents, staff, families, volunteers, advocates, administration, government officials and policy makers.

Collaborative work is never easy. However, it is necessary because solutions tend to require the ideas and efforts of many people. Open and ongoing communication remains central to any collaborative effort. Participants suggested that prevention at this level should focus on:

Adequate Funding

One primary societal/community prevention strategy is to provide adequate funding to LTC facilities. In most provinces, LTC has recently undergone massive restructuring, which has meant funding to facilities has been reduced and, in some cases, drastically cut. With reduced funding, facilities are struggling to meet the needs of a clientele with increasingly heavy care requirements with fewer staff and resources.

Many APL participants felt that these cuts have led to a decline in the quality of care and can result in situations that may result unintentionally in abuse and neglect. It was felt that adequate funding to LTC facilities helps prevent abuse and
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
neglect and makes a statement that frail members of Canadian society deserve appropriate care.

Adequate Direct Care Staffing

Another prevention strategy is ensuring adequate direct care staffing. Many facilities are understaffed or inadequately staffed because of the use of unskilled temporary or part-time staff — a practice resulting usually from a loss of adequate funding levels. Inadequate direct care staffing can lead to perceived incidents of abuse or neglect. For example, the reduction in the number of direct care staff means residents have to wait longer to have their most basic care needs met. In many instances, this can be considered neglectful and is indeed perceived as such by residents.

A related concern is that direct care encompasses not just physical needs but also the emotional, psychological and spiritual needs of residents. For staff to provide this kind of support to residents, administrators and government regulatory bodies need to recognize staff's responsibility to spend high-quality time with residents and build it into the work schedule and funding formula.

Regular Family and Community Involvement

Another prevention strategy, although possibly the most difficult one suggested by APL participants, is to encourage regular family and community involvement. Participants felt that residents who did not have regular family involvement or someone to watch out for them were more likely to be abused or neglected. Hence, regular contact with people from outside the facility is seen as one way to prevent resident abuse and neglect. Although research is lacking to verify this assumption, common sense would dictate that the more an individual is socially engaged, the less likely the person is to be targeted for intentional acts of abuse and neglect. Moreover, the greater the awareness of others of the situation of the resident, the greater the likelihood of earlier identification and reporting of a problem.

Some innovative ways in which facilities are increasing outside involvement, as reported by participants in the APL project, include having on-site staff daycare which links children to residents; having a special needs class work in the facility; holding club meetings with residents welcome to participate or wander through; hosting prenatal classes, followed by visits by the women and their babies after birth.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Promoting a Stronger Voice for Frail Older Adults

One final systemic prevention strategy is to promote a stronger voice for frail older adults. This has become increasingly difficult as many older adults entering LTC are frailer and may no longer be able to speak for themselves because of severe cognitive or physical impairments. The increased frailty has meant that older adults tend to have very little say in the final years of their life as to the care they receive. The health care facility, staff and families play a large role in decision making and determining the quality of life for these residents. Abuse and neglect can happen when decisions are made with little regard for or understanding of the rights of older adults. To prevent abuse and neglect, the resident's perspective must be central to all decisions affecting institutional life, and decisions must be made by appropriate decision makers as identified by provincial laws.

Advocacy is one way to promote a stronger voice for frail older adults. When frail people cannot speak for themselves, it becomes incumbent on the people in their environment to advocate for them. Advocacy can be done individually as well as collectively by groups with the political clout to help affect changes, such as seniors' organizations. The expanding senior population makes it increasingly important that high-quality care of frail people is placed on top of every relevant organization's agenda. Care must be taken by appropriate decision makers that their decisions reflect those of the resident and not just the advocate's own feelings and values.

3.2 PREVENTION STRATEGIES AT THE FACILITY LEVEL

Every LTC facility in Canada should have an abuse prevention program that is flexible and comprehensive. A comprehensive abuse prevention program promotes an environment free from abuse for everyone who lives in, works or visits LTC, while recognizing the possibility that it may still occur despite all precautions taken. Such a program covers topics such as resident abuse and neglect, prevention and intervention, workplace harassment and interacting with residents with cognitive impairments. The entire facility needs to be actively involved in the development, implementation and ongoing evaluation of the program for preventing abuse and neglect. As well, it is important to have ongoing communication with local law enforcement officials and interested community agencies. Effective abuse and neglect prevention are developed along several steps:

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

Prevention strategies at the facility level need to focus on three areas:

Addressing Systemic Abuse

Government regulations, facility policies and limited spaces can sometimes be highly restrictive to residents and staff. Frequently, systems have been put in place with an emphasis on physical care and meeting government regulations with little regard for the impact on residents' emotional and psychological well-being. Standard practices tend not to be questioned and can unintentionally lead to systemic abuse.

Effective prevention starts with identifying areas in the facility in which residents are at greatest risk of systemic abuse or neglect. These high-risk areas can be systems that are in place and/or circumstances that arise on a regular basis. Areas to examine include organizational processes such as scheduling of meals and baths; the physical environment such as efficient use of existing space; and social interactions such as communication among residents, staff and families. High-risk areas are identified through the monitoring of existing systems and assessing their impact on residents. Some mechanisms to monitor facility systems include:

Once high-risk areas are identified, sensitive policies can be implemented to help create a balance by encouraging freedom for residents wherever possible. It can make a large difference to residents to be able to make choices over how they personalize their rooms, what they wear and when they eat.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
3.3 PREVENTION STRATEGIES FOR DIFFERENT GROUPS

Prevention strategies at the facility level can be directed toward different groups within LTC — administration, staff, residents, families and volunteers. These strategies require cooperation and coordination. This section looks at strategies aimed at each group.

Acknowledge the Problem

The first step in prevention is acknowledging that abuse and neglect is occurring. The attitude still prevails that abuse does not happen in "our" facility, even though participants across the country indicated that abuse and neglect is a regular feature of LTC (especially the more subtle forms of psychological and systemic abuse). Administrators, boards of directors and owners must acknowledge the potential for abuse by setting out a zero tolerance standard in the mission statement. This standard establishes that abusive or neglectful behaviour will not be tolerated and that everyone has the right to be in an environment free from abuse or neglect.

Once the standard is in place, it must be practically implemented through policies, procedures and ongoing training. When management takes a proactive stance on abuse prevention, it sets the tone for the facility and sends out the clear message that abuse and neglect are issues to be taken seriously by everyone.

Develop and Implement Appropriate Policies and Procedures

Establishing policies and procedures on resident abuse and neglect prevention and intervention is another proactive measure that management can take. Policies and procedures need to be developed, implemented and reviewed on a regular basis with the input of all groups associated with LTC. In many facilities, existing policies and procedures on resident abuse focus on intervention and do not include preventive measures. Prevention is as important as intervention. Moreover, such policies tend not to be developed with input from the most affected population, the residents themselves.

Employ an Ombudsman

Another prevention strategy is to employ an ombudsman who can monitor the facility and act as an advocate for frail older adults and staff alike. Many participants across the country suggested that facilities need an ombudsman to address abuse and neglect. An ombudsman from a LTC facility who attended a train-the-trainer
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
workshop indicated that much of her role involved advocacy, resolving problems and ensuring proper communication. In fact, her role was as much preventive as interventionist.

Provide Ongoing Training on Abuse Prevention

Ongoing training is the single most critical factor in preventing abuse and neglect. All people involved in LTC, including residents, staff, families and volunteers, need training on abuse prevention. Training increases awareness, builds skills and promotes greater sensitivity toward residents. The goal of the training is to engage people to recognize that everyone has a role to play in preventing abuse and neglect.

Screen New Employees

One staff-oriented prevention strategy is to rigorously screen potential employees to ensure that they do not have a previous history of violent or abusive behaviour. Equally important, but admittedly more difficult to implement, is the need to ensure that staff exhibit a positive attitude toward working with older adults in LTC. The following multifaceted hiring process can determine the suitability of potential employees:

Provide Ongoing Staff Training on Appropriate Resident Care

As a preventive measure, staff need adequate training on appropriate resident care. Situations of resident abuse and neglect can arise from a lack of awareness and skill rather than malicious intent (e.g. leaving residents undressed and in view of others when leaving a room to answer emergency calls or to retrieve some needed piece of equipment).

Training that focusses on sensitivity to residents can help reduce situations of abuse or neglect. Employee skills have to be regularly upgraded and staff need to have easy access to training material.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Offer Support to Staff

Another preventive measure is to ensure that staff members have adequate support from the facility and from their colleagues. When support is available, staff feel more comfortable asking for help and more competent dealing with problems. Some suggestions are:

Develop and Implement Approaches to Empower Residents

An important resident-oriented prevention strategy is to develop and implement means to empower residents so that they may maintain control over their lives to whatever extent possible. This is accomplished in an environment where residents are encouraged to:

Such an environment is set out at the management level and implemented by everyone associated with LTC through his or her interactions with residents.

Establish a Resident's Bill of Rights

Another prevention strategy is to develop and implement a bill of rights, which promotes the well-being of residents. Alongside a bill of rights, a code of responsibilities can be used to develop a clear set of expectations — one that is understood by all parties — regarding care and living arrangements. While many facilities have a resident's bill of rights, implementation is problematic. Simply posting such a bill on walls or bulletin boards is insufficient. One practical way to implement a bill of rights is to focus on one right each month at all meetings or in a newsletter. Methods must be developed to ensure that such rights do not remain on walls but become part of how we live and work.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Encourage Active Participation of Residents' Councils

An important prevention measure is to promote the active participation of a residents' council in the functioning of a facility. During the focus group sessions, residents often said that the resident's council was an important way to have a say in the running of the facility. In some facilities, when the resident council identifies a problem, it invites appropriate staff (e.g. dietary or housekeeping) and deals directly with those staff rather than working through administrative staff. Such councils can also play a major role in providing resident input in the development of LTC policies, especially with respect to abuse and neglect.

Promote Advocacy for Residents

Advocacy can help prevent the development of the power differences that so frequently underlie situations of abuse and neglect. Advocates are mainly responsible for accessing information, monitoring the resident's ongoing situation, and keeping the resident informed of any actions taken. Advocacy includes both self-advocacy and advocacy by others. For example, resident councils, family members, staff and volunteers often advocate for residents. Every resident has the right to choose his or her own advocate, including external ones such as lawyers or family members. A good advocate can be helpful to residents who have cognitive impairments, do not have actively involved family or friends, or find it difficult to speak up for themselves. It must be stressed, however, that decisions on a resident's behalf can be made only by an appropriately designated decision maker. Advocates cannot make decisions on behalf of a resident who is incapable of making informed decisions if they have not been identified according to provincial legislation on substitute decision making.

"Families should complain right to the top. Heaven knows who the top is, though. They can be strong advocates for residents." (resident)

Promote Positive Family-Facility Interactions

Improving family-facility interactions is one way to prevent abuse and neglect. During the various phases of the APL projects, it was often difficult to get family participation, partly because their physical presence at the facility was more irregular than that of staff or volunteers, and partly because many facilities had no easy mechanism to reach families.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
As well, the level of family involvement with residents seemed to be clustered in the extremes, with some families being very actively involved while others were completely absent. While loving family involvement cannot be mandated, the facility can establish mechanisms that make families feel welcome. Family councils, joint resident-family councils and family support groups are three avenues to explore.

Encourage Ongoing Family Involvement in Decision making and Care

Another prevention strategy is to encourage ongoing family involvement in decision making and resident care. It is especially important that family or designated decision makers are involved in discussions regarding cognitively impaired residents. In the focus group sessions, families often expressed the feeling that they had little say in the care provided to their relatives. Many also felt overwhelmed in trying to understand institutional processes and regulations. A thorough orientation to the facility for families would help. As well, families can be encouraged to participate in case conferences and other care activities, such as coming in regularly at suppertime to feed an older relative.

Although the concerns of family members must be taken into consideration, the resident must always be responsible for any decisions. In cases where the resident has been legally deemed as mentally incapable, the substitute decision maker must be identified through the appropriate legislative laws operating within the province where the facility operates.

Screen New Volunteers

New volunteers must be as rigorously screened as new staff. Every person who will interact regularly with vulnerable people needs to possess the appropriate skills and attitudes toward older adults. The hiring process outlined for staff — criminal reference check, structured interview, thorough orientation — would be beneficial for volunteers.

Clarify Volunteer Roles

Clarifying volunteer roles can contribute to preventing abuse and neglect. Volunteers are integral to the functioning of facilities and often they can prevent abuse or neglect because of their close involvement with residents. Volunteers in the APL focus groups saw themselves as mainly friends or helpers, and felt uncertain about saying something to correct disrespectful behaviour because they were not paid employees or family members.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Clarifying the volunteer's role offers an opportunity for facilities to encourage volunteers to take action when they see situations that are uncomfortable for residents. Volunteers can also take a much stronger role as advocates for frail people. Many volunteers are older themselves and are the most credible advocates for older people. Finally, volunteers can suggest solutions to problems by completing feedback forms on the facility's functioning.

Prevention Strategies at the Individual Level

While prevention strategies need to be implemented at a societal/community and facility level, ultimately most instances come down to a single moment when an individual takes action which prevents an abusive or neglectful situation. There is no magic solution, simply one person being aware and taking action (e.g. closing the privacy curtain before beginning intimate care).

Preventing abuse and neglect is often seen as such a huge task that people can feel overwhelmed. When this occurs, the most typical response is to do nothing. To avoid becoming overwhelmed, people need to realize that preventing abuse and neglect is a shared responsibility in which everybody has a role to play. As well, it is important that people acknowledge themselves and the ways in which they are helping prevent abuse or neglect.

Four key individual preventive measures are:

Increasing Self-Awareness

Although introspection is often difficult because it brings up painful feelings, it is the key to changing attitudes and behaviours that may be abusive or neglectful. Knowledge of one's own potential for abuse or neglect is an important part of prevention. After all, a person is unlikely to change if she or he is unaware of the need for change. For example, someone may not consider rough handling as abuse if that is the way he or she acts in a family situation. Many people, especially those who come from homes with family violence, need an understanding of what behaviours are acceptable and not acceptable.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
As a person becomes more self-aware, he or she is better able to:

Some techniques for increasing self-awareness include staff development courses, meditation, keeping a journal, sensitization exercises and self-improvement classes.

Improving Communication

Another individual prevention strategy is improving communication. Many abusive or neglectful situations presented in the APL focus group sessions were perceived by participants to be the result of problems in communication, a lack of communication, a misunderstanding because of unclear messages, or disrespectful communication.

The choice of words, tone of voice and body language determine if communication is respectful or abusive. Care must be taken over choice of words because some words can imply that the resident is being treated like a child or an object. A normal tone of voice when speaking with residents is preferable to the commonly used high-pitched sing-song tone of voice used by some — a tone of voice typically used when addressing very young children. Finally, body language must be monitored because it also conveys a message and affects the quality of an interaction.

Mentoring

Mentoring is educational and as such can help prevent abuse and neglect. Mentors can offer friendship and support, provide practical information and model behaviours and attitudes that are sensitive to residents. Residents, staff, families and volunteers can benefit from mentor or buddy programs. For example, established residents can help ease new resident's transition into LTC. Volunteers can be buddies or special friends to residents, especially those with cognitive impairments. New staff can be paired with experienced colleagues who are sensitive to abuse and neglect prevention. Within family support groups, family members whose relatives have been in LTC for a time can provide support and helpful advice to newer families.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Learning to Interact with Residents with Cognitive Impairments

Another individual prevention strategy entails the learning of how to interact with residents with cognitive impairments. When meeting a cognitively impaired resident, it is common for people to feel nervous, afraid, uncomfortable, frustrated, embarrassed and/or anxious to escape. These reactions may stem from fear of the disease process or from feeling helpless. To interact effectively with people with cognitive impairments, everyone, including residents, needs to become aware of disease processes, how to communicate and how to protect themselves from aggressive behaviours. Education helps to dispel the fear while building a stronger support network for those with cognitive impairments.

People find it easier to interact with residents with cognitive impairment when they know more about the resident's likes, dislikes and patterns of behaviour. Interacting with someone who is cognitively impaired requires great effort and care because it is up to each person, not the cognitively impaired resident, to find better ways of interacting. The following general suggestions can improve interactions with residents.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

Education and Training

Education involves the development of general or specific abilities or knowledge, while training involves the practical application of that knowledge. For simplicity, the term "training" is used in this section to mean both education and training.

Everyone associated with the LTC community — residents, staff, families, volunteers and the community at large — requires training. Training sensitizes people to the realities of older adults in institutional settings, and gives them the opportunity to learn new information and then test out in practice the knowledge and skills they have acquired.

The content of training consists of two parts:

Both parts are equally important in any training initiative. The following section focusses only on abuse and neglect prevention and intervention. The second component, fostering a supportive and respectful environment, is discussed in the third part of this series, Returning Home: Fostering a Supportive and Respectful Environment in the Care Setting.

On the intervention level, training helps people:

On the prevention level, training helps people:

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Ideas alone do not capture an understanding of the complexity of the issue of abuse and neglect, nor do they provide the impetus for people to make the needed changes. Effective training must encompass the emotional dimension as well as factual knowledge. Training workshops therefore need to invite people to explore feelings in concert with acquiring new knowledge and skills.

Exploring feelings in training workshops is important:

The subject of abuse and neglect should be introduced in conjunction with an exploration of participants' feelings and readiness to cope with the content. People come to workshops with their own personal histories of abuse, including staff experiencing violence in the workplace as an everyday occurrence. Trainers have to be prepared for emotionally charged workshops and the disclosure of abuse and neglect, as was found in this project's focus groups and train-the-trainer workshops. Emotional sensitivity and preparedness enables a person to respond to situations of abuse or neglect with care, compassion and efficiency. Because people who are intervening have to be able to deal with the range of emotions that a resident may be experiencing, they need to be calm and in control of their emotions so they are not overwhelmed by what is happening.

Exploring feelings in training workshops also encourages every person to explore the issues on a personal level. Discussing feelings and experiences helps participants realize that this is not someone else's problem but something that affects everyone. Linking information to people's personal experiences raises awareness. People tend to be more willing and able to make changes when they are touched by another person's experience. Many people find it difficult to examine or talk about their feelings.

4.1 GOALS OF TRAINING

Three goals of a successful training initiative are (see Figure 3):

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

The basic purpose of training is to increase people's knowledge on the subject. Information must be kept simple and cover the basics. Some topics may be more relevant than others to different groups. For example, residents require information on their rights and the process of adapting to institutional life. Families and volunteers need information on the disease process and how to be effective advocates. Everyone can benefit from information on communication, coping with losses and the aging process. Material has to be adapted so people are trained according to their educational level and interests.

Definitions, intervention and prevention make up the core of any training on abuse and neglect. The topics of resident rights and responsibilities, advocacy and conflict resolution are other areas that should be explored.

What Is Abuse and Neglect?

People need basic information on definitions of abuse and neglect. While many people can easily define overt types of abuse, such as physical abuse, defining more subtle forms of abuse (e.g. the violation of civil rights) is a difficult task. Training sessions can clarify different types of abuse, criminal versus non-criminal behaviour, and individual versus systemic abuse. The topic of definitions can be introduced through small group discussion.

Participants in these smaller group discussions could define two types of abuse (e.g. sexual abuse, medical abuse), provide one clear and one unclear example of both types of abuse, and then share what was discussed with the larger group. Unclear examples generate much discussion as people see the complexity of defining behaviours as abusive and neglectful. This exercise breaks the ice among participants and helps them recognize that they know something about abuse and neglect.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
What to Do

In training workshops, people need basic information on what to do and whom they can talk to if abuse or neglect is suspected. Uncertainty was common among APL participants. As stated earlier, most residents who participated in the APL project did not know whom to go to if there was a problem. A contact person (e.g. head nurse, ombudsman) needs to be clearly identified in the workshops.

Reporting abuse and neglect is often a difficult step for people to take. Group discussion can focus on identifying the barriers to reporting and how to overcome them. Reporting requirements should be thoroughly reviewed in workshops for staff and volunteers. Even in provinces with mandatory reporting, many staff had questions about the process (e.g. whom to report to and what to report).

Many of the APL participants said they felt uncomfortable responding to situations of abuse and neglect. To overcome this feeling, concrete responses to subtle forms of abuse have to be modelled and discussed in training workshops. Modelling responses can also help people find the courage to take action. For example, participants can use the concrete scenarios presented in the APL video to plan short-term and long-term interventions.

Actual case studies may also be used. It is important that one scenario highlight criminal activity and police involvement because there tends to be confusion in this area. For example, many participants were unsure about involving the police in a suspected sexual assault of a resident. It must be reinforced that when any criminal activity is suspected, facilities are required to contact the police to investigate.

Training must also include discussion on legal issues such as power of attorney, the Mental Health Act and adult protection legislation. Ethical dilemmas arose in every workshop as people struggle to develop an ethical framework for making tough decisions that cannot be dictated by policies or procedures. One good resource is entitled Ethical Dilemmas in Dealing with Abuse and Neglect of Older Adults.¹

How to Prevent Abuse and Neglect

There are many ways to prevent resident abuse and neglect. In training workshops, people can share ideas and personal experiences on how they prevent abuse or neglect. Not only does this type of sharing help people develop more awareness, it also acknowledges efforts. Sometimes people need to be reminded that they are truly making a difference. A related discussion on prevention is about common
2. Spencer, C. Ethical Dilemmas in Dealing with Abuse and Neglect of Older Adults. Gerontology Research Centre, Simon Fraser University, Burnaby, B.C.
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
disease processes. For example, dementia is often associated with changes in behaviour, unstable emotions and disorientation. Discussion can focus on how the presence of such diseases can lead to incidents of abuse and how those incidents can be prevented.

Develop and Improve Skills

A second goal of training is to develop and improve skills. In addition to developing new skills, training workshops can help participants identify existing skills and abilities that they are using to deal with many of the complex situations found in LTC. The mastery of different intervention skills is essential to respond effectively to abuse or neglect. Some examples of intervention skills are:

Crisis management: Crisis management is taking immediate steps to remove the resident from harm and to stop the abuse.

Identification: With identification skills a person can recognize the common indicators of abuse and neglect.

Assessment: With assessment skills a person determines the degree of seriousness of the situation, the potential for further harm and what resources are required.

Implementation: Implementation skills involve exploring options, ensuring that the policy on mandated reporting is followed and putting interventions in place.

Evaluation: Evaluation skills involve follow-up and the ongoing monitoring of the situation to ensure that interventions are effective.

Of the skills that need to be developed, communication is the most critical for both abuse and neglect intervention and prevention, and fostering a supportive and respectful environment. People need skills in:

Practice is the key to successful skill development, and workshops that provide opportunities for people to practice skills are ideal. Skills are developed through role playing and modelling. For example, advocacy skills may be developed through role playing different scenarios and getting feedback from other participants.
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Through modelling, people are given clues as to how they may act and become aware of new ways of responding to situations. Sometimes, it is as simple as the way something is said.

Encourage Personal Growth

The final component of training is to encourage personal growth. Training is not only about acquiring knowledge and skills, it is also about personal development. Compared to building a knowledge base and developing skills, personal growth represents the greatest challenge to trainers and participants because it requires great effort and introspection on the part of every person. People have to become aware of their attitudes and behaviours, then they have to be willing to make the necessary changes.

Three areas of personal growth are:

Increase Sensitivity

One area of personal growth entails increasing sensitivity to the reality of residents and their life within LTC. In the focus groups, many residents expressed the opinion that people needed to be more sensitive to what life is like for them (what it felt like to wait, to be dependent, to be ignored, to be labelled as senile). Through sensitization exercises, the emotional and physical realities experienced by residents can be explored. These exercises, reflecting the concept of "walk a mile in my shoes," can lead to greater understanding of another person's situation. None of these exercises needs to be time consuming or difficult, and they can be built into other training workshops. For example, in one sensitization exercise people are frequently asked to change seats without any explanation, to experience how residents may feel about being moved constantly.

Many LTC facilities already offer sensitization activities to staff and volunteers, such as wearing glasses smeared with Vaseline, manoeuvering a wheelchair with one arm in a sling, or wearing an Attends (urinary briefs) all day to experience what it feels like to be left in a wet undergarment. Two facilities had a pilot exchange program in which staff from one facility went through the admission procedure in the other. As one participant in this exchange program said, "I never realized
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
how blinding the overhead light was until I was lying flat on my back in bed trussed up and someone came in to check on me in the middle of the night."

Affect Changes in Attitudes and Behaviours

A second area of personal growth entails making changes in attitudes and behaviours that may be detrimental to the well-being of residents or contribute to abuse and neglect. Attitudes about aging, illness, institutionalization, levels of tolerance of family violence and the caregiving role should be explored. Staff must also examine how their professional values affect residents. For example, doing for others is fundamental to professional standards, yet this can create dependency in the recipient. In workshops, participants can identify and discuss any negative attitudes so they are no longer controlled by the fear that keeps those attitudes in place. As well, training workshops can offer people an opportunity to learn what is and is not appropriate behaviour.

Values and attitudes, practices and behaviours must be continually examined because they are often the source of disrespectful and abusive behaviours toward residents. Introspective questioning is one way to explore attitudes, values and behaviours. In the train-the-trainers workshops, participants were asked to respond to the question, "In what ways can you personally be abusive?" Although initially uncomfortable, participants talked about behaviours such as not taking the time to speak with residents or avoiding call bells.

Feelings should be discussed openly because, when denied or repressed as a result of guilt or fear, they tend to come out subtly or unconsciously in behaviours. As a result of discussing such feelings, they can be lessened so they no longer affect behaviour. While not therapy sessions, training workshops can offer a supportive environment for people to begin to explore sensitive issues.

Foster More Respectful and Caring Interactions

A third area of personal growth entails the fostering of more respectful and caring interactions among people. In the focus groups, divisions among people were evident (e.g. family members often said staff were the problem, while staff pointed the finger at families). Much of the separation and negative feelings could be reduced through an ongoing forum to discuss personal experiences.

Through this type of discussion, people tend to feel more open and less judgmental as they feel empathy for another person's experience. When someone
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
shares what he or she is feeling, sometimes referred to as speaking from the heart, the quality of the interaction is different than when he or she talks about an idea. With more caring and respectful interactions among people, abuse and neglect are reduced and a more supportive and respectful environment in LTC is fostered.

4.2 TRAINING FORMATS

Training workshops may be given as roundtable discussions, in-service sessions, video presentations or conferences. The most effective format has the following components:

Resident Focus

In training workshops, the most important guideline is that the focus remains on the perspective of the resident. It is easy to drift off into exploring other subject areas brought up by participants. Focussing on the resident's perspective does not negate other issues or experiences, it merely gives older adults a stronger voice.

Interactive, Experiential Peer Learning

Interactive, experiential peer learning is the most effective style of learning because it can facilitate personal growth as well as increase knowledge and develop skills. Participants bring unique perspectives to the discussion because of different personal family and community histories. Train-the-trainer workshop participants indicated that the most useful aspect of the workshops was interacting and discussing material with peers.

Experienced Facilitators

Workshops should be led by a skilled facilitator, with co-facilitation being highly preferable, given the difficulty of dealing with the highly complex and emotional material that comes up in these sessions. Facilitators need to be perceived as neutral so participants feel comfortable asking questions and sharing their experiences openly. For example, residents or direct care staff may not feel comfortable with a manager facilitating the workshop.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Open Atmosphere

It is essential to establish a non-judgemental climate of trust, respect and openness in training workshops. Maintaining confidentiality helps, as does the practice of the facilitators modelling the exploration of their own personal experiences.

Flexible Timing

Training workshops may vary in length from one hour to a half day or a whole day. The train-the-trainer workshops given over two full days were exhausting. As one participant said, "I usually deal with these problems one at a time; to see them all out there at once was overwhelming." Breaking up the material into a series of several 45 minute to one-hour workshops over a six-month period is a more effective time frame to help people retain the material and avoid overwhelming them. Flexibility is the key to meeting the needs of different groups associated with LTC. The focus, time allotment and range of topics covered depend on the particular group involved.

Variety of Activities

A variety of activities can facilitate learning by sparking interest and reducing monotony. As well, people learn differently and some activities may be more effective for some people than for others.

Active participation is important for training; the most successful workshops occur when participants do most of the talking. A flexible but guided discussion is essential. Group discussion promotes interaction and can build confidence when people recognize their inherent wisdom and abilities. Information from different perspectives can also be integrated depending on the group composition. Discussion is stimulated by repeatedly breaking into small groups to discuss issues and then report back to the large group. Small group work is ideal for assimilating material and building group cohesiveness.

The use of educational material, such as videos, is also important. Videos stimulate discussion and easily depict different scenarios in a condensed time frame. As well, videos make information accessible because they can be used for independent study. Participants in the train-the-trainer workshops indicated that the videos were one of the three most useful aspects of the training. The use of flip charting, other resources, and methods such as the use of artwork as a focal point for discussion, are also helpful.

Sensitization exercises can also be used effectively to quickly make a point, such as helping staff or volunteer groups appreciate the losses residents may be
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
experiencing. Participants list five items that are important to them (e.g. family, job). They cross one item off the list, then a second. The person sitting beside them crosses off a third item. This exercise can be followed by an energizing exercise to lift the somber mood (e.g. in small groups participants create a poem using the phrase "We used to be…, but now we are" to describe physical characteristics or fears).

4.3 SYSTEMATIC AND COMPREHENSIVE APPROACH

To be successful, training must be systematic and comprehensive; simply holding one educational session is not sufficient. The strategy used must include the following components:

Management Support

Boards of directors and administrators need to recognize that training is not a luxury but essential for ensuring that facilities are free from abuse and neglect and are supportive and respectful. When training initiatives are undertaken, progressive policies and administrative structures must be established to support the initiatives or people will continue to face many obstacles. For example, staff may be trained, but if clearly defined policy and procedures are not in place, they may have difficulty responding.

Regular Ongoing Training

Regular ongoing training is a necessity. The need for training can be seen in the response to the train-the-trainer project, with participants travelling up to 10 hours and overcoming such obstacles as blizzards in order to attend. Currently, training on abuse and neglect and a supportive and respectful environment is sporadic in most facilities. Moving from sporadic to systematic coverage requires regular training that is ongoing, consistently reinforced and available to everyone in LTC.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Regular training ensures that:

Mandatory Training for Staff and Volunteers

One mechanism to move from incidental to systematic training is to make training mandatory for all staff in LTC facilities. Participants repeatedly stated that every staff member needs training, from direct care workers, to senior administrators, to dietary and housekeeping staff. Mandatory training ensures a consistent knowledge base among staff and lets them know that intervention and prevention are integral parts of every person's job. Mandatory training would also reach those who would not voluntarily attend workshops but may need it. A related consideration is that facilities should employ temporary staff only from agencies that have provided training to their staff.

Volunteers would also benefit from mandatory training. Volunteers, especially those who have close and regular contact with residents, are in a key position to identify and prevent potentially disrespectful or abusive behaviours, and to offer support to residents. Mandatory training would help clarify roles and dispel confusion or uncertainty about taking action.

Training Opportunities for Residents and Families

It is clear that facilities should provide more training opportunities for families and residents. During the train-the-trainer workshops, it was difficult to get participants to seriously consider training for residents and family members. This finding was supported by the results from the policy and procedure survey which indicated that residents and families were the least likely groups to attend educational sessions on abuse and neglect. Leaving these groups out can create unnecessary divisions. For example, staff may feel defensive, and families and residents may feel anxious if they learn that staff are being trained on abuse prevention. Training for residents and families would have to be voluntary and flexible to accommodate different capabilities and irregular schedules.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Availability of and Access to Resource Materials

People need easy access to resource materials. It is helpful if facilities have a basic library of books, audio-visual materials and protocols. Resources may be borrowed or shared among facilities. The process of improving access to resource material requires increasing people's awareness of inexpensive resources that are available. The National Film Board, for example, has an excellent collection of videos that may be borrowed from partner libraries. The National Clearinghouse on Family Violence and most provincial/territorial government departments responsible for services for older adults distribute material on the subject. Finally, many social work, nursing and medical journals publish articles on abuse and neglect and institutional care.

Evaluation

Training initiatives should build in mechanisms to evaluate effectiveness and to ensure that the acquisition of appropriate knowledge and skills is translated into everyday practice. Upon completion of each training workshop, participants should fill out evaluation forms. To assess long-term effectiveness, follow-up surveys, attitudinal or knowledge change assessments or resident satisfaction surveys or interviews can be used.

Follow-up

Follow-up entails deciding on an action plan and then taking action. Solutions will remain merely ideas until they are acted upon. Three types of follow-up are:

Written reports: Key points and suggestions for solutions can be summarized and endorsed by everyone in the group. Solutions need to be concrete, practical and able to be worked on immediately.

Group action plan: The group may decide to meet again to discuss and implement an action plan. An action plan needs to have clear and realistic guidelines, a list of tasks to be done and a comprehensive evaluation strategy.

Personal action plans: Individuals may choose to develop action plans to make changes in their personal lives.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

Policies and Procedures

To address abuse and neglect effectively, people involved with a LTC facility must develop appropriate ways of detecting, responding to and preventing the problem. One major way of accomplishing this is through the development of effective and sensitive policies and procedures (P&Ps) that focus on dealing with abuse and neglect while fostering a supportive and respectful environment in the facility.

P&Ps for abuse and neglect ensure effective and timely management of problems that may arise. By implementing P&Ps, senior management sends the unmistakable signal that stopping and preventing abuse and neglect are priorities. P&Ps work by setting out a clearly defined and carefully implemented framework for action that includes:

Incorporating flexibility into P&Ps for abuse and neglect are the key to their success. No P&Ps can explicitly cover all of the possible actions and consequences of abuse or neglect. Good P&Ps are ones that can be applied effectively to all incidents of abuse and neglect in spite of the highly dynamic and complex nature of the problem. Within a clearly defined process, guidelines can be set which permit choices that recognize the benefits of using both internal mechanisms and external bodies in responding to abuse and neglect.

To use P&Ps for abuse and neglect effectively, they must be implemented in an environment that is supportive and respectful. People within the environment must value and respect each other, including residents, staff, families and volunteers. Moreover, it must be reviewed on a regular basis and reflect appropriate legislation, institutional standards and professional codes of conduct.

The extent to which the administration and staff of a facility can provide such an environment will be evident in its policies and in how it handles vulnerable residents who are unable to make their own decisions due to cognitive impairments. Good P&Ps set the tone for respectful and effective interaction among all people involved in the facility.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
In a LTC facility, the P&Ps for abuse and neglect of residents would be but one part of a set of comprehensive policies. Because different P&Ps have different priorities, sometimes procedures set for one policy conflict with the goals of another policy. All policies and procedures should be examined to determine whether they facilitate or hinder efforts to prevent and stop incidents of abuse and neglect (e.g. least restraint policy, visitor policy, workplace safety, patient care philosophy).

5.1 PROCESS FOR DEVELOPING P&Ps

The process for developing effective P&Ps for dealing with resident abuse and neglect consists of a number of well-defined steps:

_ values, beliefs and mission statements guiding the particular LTC community;

_ existing policies and legislation;

_ information on abuse and neglect; and

_ informal procedures already in place.

Once developed, it is important that the P&Ps be explained to everyone involved. Education in abuse and neglect prevention is an ongoing process of raising people's awareness of the problem and encouraging their involvement. To effect change, it is important to get everyone associated with the facility involved, including residents, administration, staff, families and volunteers. In addition, the P&Ps must be evaluated and revised on a regular basis.

5.2 KEY COMPONENTS OF P&Ps

Based on the APL's review of existing P&Ps in Canada's LTC sector and comments made by APL participants, P&Ps should consist of the following five components:

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Policy Statement

A policy statement clearly indicates that the goal of the people involved in a facility is to maintain an environment free of abuse and neglect. It sets out the facility's values and outlines how people should behave and how people should be treated.

Statement of Purpose

The statement of purpose outlines the reason for the policy and specifies the facility's fundamental mission. The purpose communicates that people working in or involved in the facility have a zero tolerance of abuse and neglect, which means that they will intervene in any abusive or neglectful situation as it will not be condoned or tolerated.

Definitions of Abuse and Neglect

Definitions are a core component of P&Ps because they provide direction to help people identify when a situation is abusive or neglectful. Generally, abuse or neglect is any action or inaction that jeopardizes the health or well-being of another person. Types of abuse and neglect must be defined, with some examples provided to assist people in proper identification.

Procedures for Intervention

Although P&Ps are necessary in the day-to-day workings of a facility, people have a tendency to follow them without question. Senior management must clearly specify that it is everyone's responsibility to be vigilant to unanticipated negative consequences of any policy or procedure. Moreover, inflexible policies create barriers to initiating and adopting new responses to abuse and neglect. Because the dynamics in abuse and neglect (e.g. etiology, people involved) can vary from one incident to another, P&Ps must be flexible.

P&Ps addressing abuse and neglect of residents should outline how one should respond, report, protect rights, investigate, document, intervene and follow up on situations of abuse and neglect.

Responding

P&Ps must provide some basic and specific guidelines for responding immediately to situations as they arise. It cannot be assumed that everyone will naturally know how to react effectively to any abuse they witness.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Reporting

Reports of abuse or neglect can come from anyone orally or in writing, and may be in the form of a suspicion or an accusation. The P&Ps should reflect the importance of reporting abuse and neglect as early as possible, and staff, residents, family members and volunteers must be informed as to how and to whom they can report any situation.

Furthermore, it must be recognized that, regardless of internal policy, everyone has the right to contact external resources such as lawyers, the police and advocates, and the P&Ps should convey as much. Disclosure of abuse or neglect can be made by anyone to anyone.

For example, a resident may prefer to disclose an incident to another resident, pastoral services, a volunteer, the residents' council, the police or the Ministry of Health.

Some provincial governments, such as Ontario and Alberta, have legislated mandatory reporting of any suspected incidents of abuse or neglect of LTC residents. Employees who fail to report can be disciplined. The P&Ps must clearly state which situations must be reported and to which legal authorities.

It must also be recognized that P&Ps cannot require that members of a professional body refrain from reporting abuse and neglect to their respective licensing body, such as a medical or provincial nursing association. To do so would create ethical and professional conflicts between staff, the facility and the professional body.

It must be clearly specified in the P&Ps how a suspected incident of abuse or neglect is to be reported. The content of a report of abuse or neglect must answer four of the five traditional questions of inquiry: who, what, where, when and why.

Reporting can happen in one of two ways. A resident, family member, volunteer or staff member may go directly to a contact person identified by the facility. The other way occurs when an individual first completes an incident form, while the incident is fresh in the person's mind, and forwards it to the contact person.

Protecting Rights of Both the Person Reporting
and the Suspected Abuser

P&Ps dealing with abuse and neglect in LTC must be designed to promote a balanced, fair and sensitive response to a report of abuse or neglect. The rights of both the person reporting and of the suspected abuser must be protected throughout the process.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
Investigating

The investigation of all suspected incidents of abuse and neglect must be mandatory, with each case handled individually. The policy needs to stipulate who is responsible for the investigation of suspected abuse and neglect. Ideally, this person will be the contact person (as described earlier under "Reporting"). The investigator must have the authority to take action. He or she must also be neutral (i.e. have no conflict of interest with anyone involved in the case such as the resident, suspected abuser or person reporting).

The chief executive officer may also choose to appoint an external advocate, who is not an employee of the facility, to be a co-investigator. If possible, a facility should have more than one person trained to carry out investigations. When criminal activity is suspected, however, the police should be called in to investigate and the P&Ps must clearly stipulate this condition.

Documenting

The P&Ps must clearly set out guidelines for careful and accurate documentation and protecting the validity of the evidence by safeguarding all documentation. One person may be designated as responsible for keeping all the evidence safe in one place. Statements from the suspected abuser and witnesses, photographs, medical reports, and the audiotaped or videotaped statements by the resident are possible documentation to be collected. The P&Ps should mention that the time sequence of events is usually the hardest evidence to pin down, so the investigator must remember to ask for this information when taking statements.

Intervening

Residents or their substitute decision makers must play a central role in deciding upon the course of action or, at the very least, be told what action is being proposed. It is important to include all concerned parties, such as representatives of unions and professional bodies, in the intervention process.

The P&Ps should provide some examples of possible interventions to aid in determining an appropriate plan of action. The intervention chosen will depend on who the offender is, the severity of the abuse, and the circumstances surrounding the incident. In all but severe cases, it is appropriate to:

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
If violations of the policy persist, the offender must be asked to leave the facility and, if necessary, be escorted off the premises. It may also be necessary to contact the police to obtain legal restraint procedure.

Follow-up

The P&Ps must outline follow-up procedures, such as evaluating the effectiveness of the interventions and keeping the resident and his or her advocates informed. In the P&Ps, it is helpful to include suggestions for whom follow-up may be required, such as representatives of unions and professional bodies.

5.3 PROCEDURES FOR PREVENTION

To be effective, P&Ps need to include procedures on prevention. Prevention is as important as intervention in promoting an environment in LTC that reduces the likelihood of abuse or neglect.

P&Ps can specify that the administration will ensure that all employees, residents, families and volunteers are informed of and have access to the abuse policy. A discussion of the P&Ps can be included in the orientation of all new staff, volunteers, residents and families. As well, each staff person can review the policy annually and then indicate with their signature that they have read and understood it.

Another prevention procedure that can be outlined in P&Ps is the specification that the administration ensures that mandatory regular training is provided to staff and that it will also be available for volunteers, families and residents.

P&Ps can set out how applicants for employment or volunteer work can be interviewed for their suitability and that personal and criminal reference checks be conducted. P&Ps can also indicate that staff from outside employment agencies are required to have the appropriate reference checks and sensitization training from their agencies. Some mention can be made of identifying the areas in the LTC environment in which residents are at greatest risk of abuse and neglect. These high-risk areas may include systems in place and/or circumstances that arise on a regular basis.

5.4 RESIDENTS WITH COGNITIVE IMPAIRMENT

Many residents in LTC are no longer able to make decisions or speak for themselves. Because of cognitive impairment or communication difficulties, these residents may rely entirely on other people to identify and meet even their most
Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings
basic needs. Everyone who interacts with these residents must be extra vigilant in identifying and responding to these needs. A concerted effort is required to maintain the rights of these residents. As such, it would be advisable to develop P&Ps for dealing with abuse or neglect situations that involved residents with cognitive impairment. Such P&Ps would include guidelines on interacting with residents with cognitive impairment, handling aggression and maintaining resident rights.

Stand By Me — Preventing Abuse and Neglect of Residents in Long-Term Care Settings

Conclusion

Abuse and neglect of older adults residing in LTC can be effectively prevented and dealt with by focussing on the residents themselves. This approach, however, is not meant to diminish the fact that abuse and neglect can happen to anyone. Residents themselves, families, front-line staff, administrators, volunteers and others can perpetrate it.

Increased awareness regarding definitions, intervention and prevention — through sensitive policies and effective training — are the keys for reducing abuse and neglect in LTC. For efforts regarding intervention on and prevention of abuse and neglect to be effective, initiatives must focus on three levels: the individual, the facility and the community at large. Moreover, sensitivity to the vulnerability experienced by care recipients, especially those with cognitive impairment, must always be uppermost in the minds of those who provide care and those who come to visit. For training and education to be effective, it must be clearly supported at all levels of authority within an institution and be monitored on an ongoing basis.

Although achieving a totally abuse-free environment is not possible, because of unforeseen unintentional acts or intentional criminal acts, it is nevertheless imperative that everyone strive to make abuse and neglect unconditionally not tolerated. To do so requires the active, ongoing commitment of residents, staff, families, volunteers and the community at large, as everyone is part of the problem as well as the solution.

Policies that are flexible, grounded in the concepts of respect and good practice, and reflect relevant provincial or territorial laws, must become living documents.

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Bibliography

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Bélanger, L. (1981). The Types of Violence the Elderly Are Victims Of: Results of a Survey Done with Personnel Working with the Elderly. Presented at the 3^rd Annual Scientific Meeting of the Gerontological Society of America, Toronto, Canada.

Bélanger, A. & Dumas, J. (1997). Report on the Demographic Situation in Canada 1997. Effects on the Social Environment of Elderly Persons on Their Socio-economic Condition. Ottawa: Statsistics Canada, Catalogue no. 91-209-XPE.

Kozak, J.F, Elmslie, T. & Verdon, J. (1985). Prevalence and incidence of abuse and neglect: National and international perspective. In MacLean, M. (ed.), Abuse and Neglect of Older Canadians: Strategies for Change. Toronto: Thompson Educational Publishing Inc., 175_190.

MacLean, M. (ed.) (1995). Abuse and Neglect of Older Canadians: Strategies for Change. Toronto: Thompson Educational Publishing Inc.

Mental Health Division, Health Canada (1994). Abuse and Neglect of Older Adults in Institutional Settings: An Annotated Bibliography. Ottawa: Minister of Supply and Services Canada.

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Pillemer, K. & Moore, D.W. (1989). Abuse of patients in nursing homes: Findings from a survey of staff. Gerontologist, 29(3), 414_320.

Shell, D.J. (1982). Protection of the Elderly: A Study of Elder Abuse. Report of the Manitoba Council on Aging. Winnipeg: Association on Gerontology.

Spencer, C. (1994). Abuse and Neglect of Older Adults in Institutional Settings. Ottawa: Mental Health Division, Health Services Directorate, Health Canada.

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