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Tackling elder abuse in residential care requires systemic culture change

We need to see a culture and model of care in which older people are valued and respected, write Sue Malta and Briony Dow.

A report released by the Department of Health shows that the number of assaults reported in aged care homes jumped by 10 per cent. Unlike elder abuse in the community, 92 per cent of which is perpetrated by family members, assaults in aged care are perpetrated predominantly by staff and other residents. With increased longevity and a growing older population it is time we sat up and took notice.

Sue Malta

Sue Malta

Whilst there are mandatory reporting obligations for suspected incidences in residential aged care, the low rate of prosecutions means that many perpetrators get away with such behaviour – often being shunted on to other facilities or “counselled” and then allowed to return to work.

At the end of 2014, Professor Wendy Lacey, co-convenor of the Australian Research Network on Law and Ageing, called for Parliamentary reform on the issue of elder abuse in the community setting. This reform needs to be extended to the aged care sector as well to circumvent the lack of prosecutions and to act as a deterrent to future abusers.

In the meantime, we need to ask why this keeps happening. There are a number of possible reasons. It may be that residential aged care facilities have traditionally been dominated by the biomedical model, which emphasises “efficiency, consistency and hierarchical decision making” over and above the needs of individuals. Quality of life and care for residents can be compromised under such a model and, further, individuals can become lost in a system that prioritises routines over relationships.

Dr Briony Dow

Dr Briony Dow

Culture change models of aged care advocate the deinstitutionalisation of facilities beginning with smaller, self-contained structures of 10 to 15 people in clusters of one to 24 homes, consisting of private rooms and bathrooms, with central living areas and communal kitchens. All residents share meals at a common table and members, friends and staff join in. Person-centred care is prioritised and staff roles are revised to minimise rotating staff and to incorporate such tasks as meal preparation as well as medication and care needs. Care plans are written up in the voice of the resident and they “choose” their daily routines.

Such models have been shown to increase resident satisfaction and interaction, improve relationships among staff and residents and to confer psychosocial benefits, such as resident reductions in boredom, loneliness, helplessness and depression with consequent improvements in staff job satisfaction, work conditions and ability to meet the needs of residents with dignity and respect. These homes have also been shown to achieve higher rates of occupancy and higher profits than traditional facilities.

Organisational changes in residential aged care facilities has been occurring in Australia, albeit slowly, but requires changes in attitudes and behaviour not just processes and procedures. However, the issue is – and will always be – the fundamental disconnect between what facilities represent for those who work there and what they represent for those who live there. To all intents and purposes, facilities are “home” for those who reside in them. They are not temporary or transitional facilities. They are where older people who can no longer care for themselves go to live and be cared for. For the people who are employed there though, facilities represent workplaces which, of necessity, are governed by regulations, including appropriate work hours and a demarcation between what is inherently professional versus personal behaviour.

How then do we ensure ‘real’ choice is given to residents to ensure their autonomy and control over their new limited environments? The rhetoric of choice is severely limited and in fact any choices ‘given’ to aged care residents are constrained by occupational health and safety concerns and a tendency for managements to be risk adverse, as well as staff availability, rosters and so on. However, new models of care, particularly those that encompass using Montessori methods for people living with dementia, have recently shown some real gains in effecting not only organisational change, but changes to staffing roles and behaviour, as well as positive outcomes for residents and their families.

Increasing staff job satisfaction and providing opportunities to foster dignity and respect towards residents, such as those illustrated above, provide a starting point to help minimise the prevalence of elder abuse in residential aged care. The recently announced Senate inquiry into the future of the aged care workforce will help provide a focus, as the inquiry will look at issues such as remuneration, working environments, staffing ratios, education and training, skills development and career paths, amongst others.

Nonetheless, if culture change in residential aged care is to be effective, the changes must be endorsed from the top down as well as the bottom up.

Just like violence against women and children, elder abuse thrives in a culture of lack of respect. We need to see a culture and model of care in which older people are valued and respected, especially when they are nearing the end of their lives and relying on others for their care.

Sue Malta is a research fellow and stream leader and Briony Dow is executive director at the National Ageing Research Institute. 

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7 Responses to Tackling elder abuse in residential care requires systemic culture change

  1. Sue Schreiner February 3, 2016 at 2:24 pm #

    An excellent article. The work of Prof Ellen Lager and others shows that even small differences like having a say in the placing of pot plants or room colours and decorations, and allowing doors of rooms to be closed to give privacy make a huge difference to the feeing of well being of residents.
    If there are to be more prosecutions for elder abuse there will have to be consideration of changes to the laws of evidence to enable some residents to give evidence.
    In many ways it just boils down to seeing residents in aged care as “us” , just older,instead of “them” – with all the needs we all have or will have if we are fortunate enough to become old.
    Careful screening of people seeking to work in aged care might be a luxury – giving preference to those who have a “bent” for this work – but would make such a big difference to the residents.

  2. Sue Godfrey February 3, 2016 at 10:58 pm #

    Thank you Dr Sue Malta for tackling this increasing concern with our older Australians.

  3. Maria Berry February 4, 2016 at 12:48 am #

    A great story, highlighting the issues with culture change and attitudes towards older people. I have always believed it does come down to “respect” and this starts outside the door of the residential facility. Changing culture starts with our kids. Reconnection and engagement can start at school,start early. Go back to basics and having conversations face to face. Technology is isolating people. It has become a social acceptance but barrier as well. Would love to see the Health Department offer a grant to the public school who can come up with the idea and be actively involved in demonstrating social connections with older people. Kids have the best ideas. The struggling public school that is after a new cricket pitch or sporting equipment….may find the incentive to become more involved with reconnection with older people. Community engagement could also be a future plan to create self esteem for kids, give them something to do …also be a suicide preventative in the future. I grew up respecting and loving the Older People around me…today it’s a struggle for this to happen. Let’s start creating the change right now.

  4. Brenton February 5, 2016 at 6:35 pm #

    It was unfortunate that there was such a distinct lack of consultation between the Commonwealth and State Governments in relation to the implementation of compulsory reporting. Currently there exists no feedback loop between the process of reporting and the outcome through the state judicial system.

    Many police respond to compulsory reports not knowing anything about the process as there was no designated training program put in place to educate them. Subsequently they are often perplexed as to why people are apparently reporting crimes on the basis of ‘ suspicion on reasonable grounds’. Officers want evidence and quite often there is no process in place to preserve crime scenes or protect evidence in aged care facilities.

    Follow up for victims is also all too often non existent or completely inadequate. The other irony is that probably less than 5% of all elder abuse in residential care falls into the category of unreasonable use of force or sexual assault. The other 95% of cases that involve financial abuse, psychological abuse, social abuse and neglect remain largely ignored. We have the roll out of quality indicators for bed sores, restraint and unexplained weight loss but no quality indicators for the prevention of elder abuse! While financial abuse is one of the most significant and prevalent forms of elder abuse victims are often told it is civil matter? When did theft and fraud become a civil matter? If you have a mandate to report physical and sexual assault why don’t you have a mandate to report theft and fraud as well?

    The entire system requires a complete overhaul and re-evaluation. While Aged Care facilities are supposedly meant to be ‘safe and secure’ environments we have residents that are assaulted and stolen from on a regular basis. The fact of the matter is that the majority of these people were probably safer staying in their own homes! While there is mandatory police checks for staff there are no such checks for residents and therefore you may be moving into room across from a person with a lengthy criminal history of sexual assault. There been cases where residents that have committed serious assault and have subsequently been moved on to other facilities without any information exchange to advise the new facility of serious risk!?

    It is unbelievable that in our society we have such a low opinion of older people that we allow this to continue.

  5. Sue Mark February 8, 2016 at 9:55 am #

    I have worked with MASS (Montessori Ageing Support Services) in developing environments and educating staff in identifying strengths of each person who resides in aged care, particularly those living with dementia. Montessori reflect the strategies discussed in the article. The true challenge is moving away from the biomedical model to having a resident focussed reason to get up each day; changing culture within organisations to enable this to happen; starting at the top with proactive management who make the lives of residents a priority and filtering down as training at all levels so there is a resident engagement based on abilities and respect of the individual. Only then will we filter out the people who do not have residents as their priority and make the lives of individuals not only safe and secure but also meaningful. An ounce of prevention is truly worth a ton of cure and MASS offers the services and training to enable this to occur through the developing on Montessori environments and changing of culture within organisations.

  6. Arlene Quinn February 10, 2016 at 2:11 pm #

    Thanks you for this article. I have been in learning and development in aged care for over a decade and frequently been asked to teach about avoiding elder abuse to meet legislative compliance.
    Frequently, although as a society the lack of respect for elders exists, it is not the over riding issue in our aged care facilities. Staff shortages, lack of training in working to benefit resident choices, as outlined by Sue, are often introduced into a working environment that has a strong task focused culture, and then evaluators of projects wonder why it is not as successful as first imagined.
    How to “fix” this is dependent on the willingness of leaders in aged care to be respectful at all levels in the organisation- to show by example that workers are trusted to make decisions and not be pulled up unduly by protocol or practice, or outdated cultural norms. One site I know is having relatives and worker staff select who they want to work alongside their residents with dementia. These sort of initiatives require courage and innovation on the part of senior executives to think of; follow through by Middle mangers to encourage workers to see it is not a fad and to remove staff who are holding the old ways of working as sacred. By encouraging a better way of working respectfully with each other this will provide a calmer environment. Workers who are willing to step up, put trust issues aside, and work together for the benefit of the residents will be the winners for the residents, business and themselves in the end.

  7. Sharon Taylor March 15, 2016 at 3:01 pm #

    Hello,
    I am the Aged Care Project Manager at East Grampians Health Service and am introducing Montessori model of care into our residential care home. This is a research project.
    We are supported and mentored by MASS (Anne Kelly) and our results so far are staggering.
    We have created a 15 bed Montessori sensory environment that is seeing residents that have been non-communicative for many years now responding by way of talking, engaging and have literally “woken up”.
    We are also in the process of developing meaningful and engaging roles and activities for the other 30 residents that have more capability and have seen a reduction in reactive behaviours to the point of one GP reducing his resident’s psychotropic medication.
    The latest clinical practice guidelines for dementia (MJA March 2016) recommends a person centred care approach; Montessori is the tool to achieve this.

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