Preventing Abuse and Neglect of Older Adults PDF

Clinical Best Practice Guidelines JULY 2014 Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Disclaimer These guidelines are not binding on nurses or th...

Clinical Best Practice Guidelines JULY 2014 Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Disclaimer These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible, and based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Copyright With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from the RNAO. Appropriate credit or citation must appear on all copied materials as follows: Registered Nurses’ Association of Ontario. (2014). Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches. Toronto, ON: Registered Nurses’ Association of Ontario. Funding Information Funded by the Government of Canada’s New Horizons for Seniors Program. The opinions and interpretations in this publication are those of the author and do not necessarily reflect those of the Government of Canada. Contact Information Registered Nurses’ Association of Ontario 158 Pearl Street, Toronto, Ontario M5H 1L3 Website: www.RNAO.ca Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Greetings from Doris Grinspun, Chief Executive Officer, Registered Nurses’ Association of Ontario The Registered Nurses’ Association of Ontario is delighted to present the first edition of the clinical best practice guideline, Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches. Evidence-based practice supports the excellence in service that health professionals are committed to delivering every day. RNAO is delighted to provide this key resource. We offer our heartfelt thanks to the many stakeholders that are making our vision for best practice guidelines a reality, starting with the Government of Canada’s New Horizons for Seniors Program, for recognizing RNAO’s ability to lead the program and for providing three-year funding; Dr. Irmajean Bajnok, director of the RNAO International Affairs and Best Practice Guidelines Centre and Dr. Monique Lloyd, the associate director, for their expertise and leadership. I also want to thank the co-chairs of the Expert Panel, Dr. Elizabeth Podnieks (Professor Emerita, Ryerson University) and Dr. Samir Sinha (Director of Geriatrics, Mount Sinai and University Health Network) for their exquisite expertise and stewardship of this guideline. Thanks also to RNAO staff Susan McNeill, Verity White, Diana An, Megan Bamford, Anastasia Harripaul, Tasha Penney, Sarah Xiao and the rest of the RNAO Best Practice Guideline Program Team for their intense work in the production of this guideline. Special thanks to the members of the Expert Panel for generously providing time and expertise to deliver a rigorous and robust clinical resource. We couldn’t have done it without you! Successful uptake of best practice guidelines requires a concerted effort from educators, clinicians, employers, policy makers and researchers. The nursing and health-care community, with their unwavering commitment and passion for excellence in patient care, have provided the expertise and countless hours of volunteer work essential to the development and revision of each guideline. Employers have responded enthusiastically by nominating best practice champions, implementing guidelines, and evaluating their impact on patients and organizations. Governments at home and abroad have joined in this journey. Together, we are building a culture of evidence-based practice. We ask you to be sure to share this guideline with your colleagues from other professions, because we have so much to learn from one another. Together, we must ensure that the public receives the best possible care every time they come in contact with us – making them the real winners in this important effort! Doris Grinspun, RN, MSN, PhD, LLD (Hon), O. ONT. Chief Executive Officer Registered Nurses’ Association of Ontario 2 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Table of Contents How to Use this Document....................................................................... 5 Purpose and Scope............................................................................. 6 Summary of Recommendations................................................................... 7 BACKGROUND Interpretation of Evidence....................................................................... 11 RNAO Expert Panel............................................................................ 12 RNAO Best Practice Guideline Program Team........................................................ 13 Stakeholder Acknowledgement................................................................... 14 Background................................................................................. 18 Guiding Principles............................................................................. 22 Practice Recommendations...................................................................... 23 Education Recommendations.................................................................... 40 R E C O M M E N D AT I O N S Policy, Organization and System Recommendations................................................... 49 Research Gaps and Future Implications............................................................ 63 Implementation Strategies...................................................................... 64 Evaluating and Monitoring this Guideline........................................................... 65 Process for Update and Review of the Guideline..................................................... 73 BEST PRACTICE GUIDELINES w w w. R N A O. c a 3  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Reference List................................................................................ 74 REFERENCES Appendix A: Glossary of Terms................................................................... 87 Appendix B: Guideline Development Process....................................................... 93 Appendix C: Process for Systematic Review and Search Strategy........................................ 94 Appendix D: Definitions of Abuse and Neglect of Older Adults.......................................... 97 Appendix E: Theories of Abuse and Neglect....................................................... 100 APPENDICES Appendix F: Communication Strategies........................................................... 103 Appendix G: Assessment and Screening Tools...................................................... 105 Appendix H: Resource List..................................................................... 112 Appendix I: Sample Decision Tree............................................................... 115 Appendix J: Resources and Links: Abuse and Neglect of Older Adults................................... 116 Appendix K: Description of the Toolkit............................................................ 119 ENDORSEMENTS Endorsements.............................................................................. 120 4 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches How to Use this Document BACKGROUND This nursing best practice guideline (BPG)G* is a comprehensive document providing resources for evidenceG-based nursing practice. It is not intended to be a manual or “how to” guide but rather a template or tool to guide best practices in preventing and addressing abuse and neglect of older adultsG. The guideline should be reviewed and applied in accordance with both the needs of the individual organizations or practice settings and the needs and preferences of the older adult. In addition, the guideline provides an overview of appropriate structures and supports for providing the best possible evidence-based care. NursesG, other health-care providersG and administrators who lead and facilitate practice changes will find this document invaluable for developing policies, procedures, protocols, educational programs and assessments, interventions and documentation tools. Nurses and other health-care providers in direct care will benefit from reviewing the recommendations and the evidence that supports them. We particularly recommend that practice settings adapt these guidelines in formats that are user-friendly for daily use. If your organization is adopting the guideline we recommend that you follow these steps: 1. assess your nursing and health-care practices using the guideline’s recommendations, 2. identify which recommendations will address needs or gaps in services, and 3. develop a plan for implementing the recommendations. (Implementation resources, including the RNAO’s Toolkit: Implementation of Best Practice Guidelines (2nd ed.) (2012c), are available at www.RNAO.ca) The RNAO is interested in hearing how you have implemented this guideline. Please contact us to share your story. * Throughout this document, terms marked with a superscript G (G) can be found in the Glossary of Terms (Appendix A). BEST PRACTICE GUIDELINES w w w. R N A O. c a 5  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Purpose and Scope BACKGROUND Best Practice Guidelines are systematically developed statements designed to assist nurses and clients in making decisions about appropriate health care (Field & Lohr, 1990). Initial development of this guideline’s purpose and scope included three teleconference focus groups with a total of 26 topic experts and health-care practitioners across Canada, and one in-person focus group with 20 older adults living in Ontario. The Expert Panel was then convened and determined the purpose of the guideline: To expand the awareness of abuse and neglect of older adults and provide evidence-based recommendations for preventing and addressing abuse and neglect in all health-care settings across the continuum of care in Canada. The guideline provides best practice recommendations in three main areas: practice, education, and policy/ organization/system. For optimal effectiveness, recommendations in these three areas should be implemented together. Practice recommendationsG are directed primarily to nurses and other health-care providers in the interprofessionalG team who provide direct care for older adults and their families in community and institutional settingsG. Education recommendationsG are directed to those responsible for staff education, such as educators, quality improvement teams, managers, administrators and academic institutions. Policy, organization and system recommendationsG apply to a variety of audiences, depending on the recommendation. Audiences include managers, administrators, policy makers, nursing regulatory bodies, and government bodies. The scope of this guideline includes harms caused by the main forms of abuse and neglect. These are physical abuse, emotional/psychological abuse, sexual abuse, financial abuse/exploitation and neglect. This guideline also includes education and policy/organization/system recommendations that address resident-to-resident aggressive behaviourG. Harms inflicted by one resident (often an older adult with cognitive impairment who is living in a long-term care facilityG) upon another resident, are distinctly different from the other forms of harm covered in this document. This content is included because institutions have the responsibility to provide safe, quality care for all residents. Furthermore, older adults living in institutions are in a relationship of trustG with the organization, and a trusting relationship is a key element in most definitions of abuse and neglect. Beyond the scope of this guideline is a comprehensive review of systemic issues that may increase vulnerabilities to abuse or neglect such as the structure of the health-care system, care delivery models, funding structures and public policies. Other forms of harm that are important to acknowledge, but are also beyond the scope of this guideline, include self-neglect and aggression from an older adult resident towards an institutional employee. For more information about this guideline, including the guideline development process and the systematic reviewG and search strategy, refer to Appendices B and C. 6 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Summary of Recommendations BACKGROUND LEVEL OF PRACTICE RECOMMENDATIONS EVIDENCE 1.0 Recommendation 1.1: IV Assessment Establish and maintain a therapeutic relationship with older adults, and families as appropriate, when discussing issues of abuse and neglect. Recommendation 1.2: V Ensure privacy and confidentiality when discussing issues of abuse and neglect unless legal obligations require disclosure of information. Recommendation 1.3: V Be alert for risk factors and signs of abuse and neglect during assessments and encounters with the older adult. Recommendation 1.4: V Carry out a detailed assessment in collaboration with the older adult, interprofessional team, and family, as appropriate, when abuse or neglect is alleged or suspected. Recommendation 1.5: IV Identify the rights, priorities, needs and preferences of the older adult with regard to lifestyle and care decisions before determining interventions and supports. 2.0 Recommendation 2.1: V Planning Collect information and resources needed to respond appropriately to alleged or suspected abuse and neglect in ways that are compatible with the law, organizational policies and procedures, and professional practice standards. Recommendation 2.2: IV Collaborate with the older adult, family and interprofessional team, as appropriate, to develop an individualized plan of care to prevent or address harm. BEST PRACTICE GUIDELINES w w w. R N A O. c a 7  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches 3.0 Recommendation 3.1: V Implementation BACKGROUND Respond to alleged or suspected abuse and neglect according to legal requirements and organizational policies or procedures. Recommendation 3.2: IV – V Implement an individualized plan of care that incorporates multiple strategies to prevent or address harm, including education and support for older adults and family members, interventions and supports for those who abuse or neglect, providing resources/referrals, and development of a safety plan. 4.0 Recommendation 4.1: V Evaluation Collaborate with the older adult, family and interprofessional team, as appropriate, to evaluate and revise the plan of care, recognizing that some instances of abuse and neglect will not resolve easily. LEVEL OF EDUCATION RECOMMENDATIONS EVIDENCE 5.0 Recommendation 5.1: V Education All employees across all health-care organizations that serve older adults participate in mandatory education that raises awareness about ageismG; the rights of older adults; the types, prevalence and signs of abuse and neglect of older adults; factors that may contribute to abuse and neglect; and individual roles and responsibilities with regard to responding or reporting abuse or neglect. 8 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches LEVEL OF EDUCATION RECOMMENDATIONS EVIDENCE BACKGROUND 5.0 Recommendation 5.2: IV – V Education Nurses, other health-care providers, and supervisors who work in health- care organizations that provide care and services to older adults participate in mandatory and continuing education opportunities that include understanding issues of abuse and neglect; assessing and responding to abuse and neglect; roles, responsibilities and laws; positive approaches to working with older adults; effective strategies for challenging/responsive behaviours; and fostering a safe and healthy work environmentG and personal well-being. Recommendation 5.3: V Educational institutions incorporate the RNAO Best Practice Guideline, Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches into curriculum for nurses and, as appropriate, for other health-care providers. Recommendation 5.4: IV – V To help nurses and other health-care providers build competence in preventing, identifying, and responding to abuse and neglect of older adults, education programs are designed to address attitudes, knowledge and skills; include multimodal and interactive/participatory strategies; and promote an interprofessional approach. LEVEL OF POLICY, ORGANIZATION AND SYSTEM RECOMMENDATIONS EVIDENCE 6.0 Recommendation 6.1: V Policy, Organizations/institutions establish and support collaborative teams to assist with Organization preventing and addressing abuse and neglect of older adults. and System Recommendation 6.2: V Organizations/institutions establish policies, procedures and supports that enable nurses and other health-care providers to recognize, respond to, and where appropriate, report abuse and neglect of older adults. BEST PRACTICE GUIDELINES w w w. R N A O. c a 9  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches LEVEL OF POLICY, ORGANIZATION AND SYSTEM RECOMMENDATIONS EVIDENCE BACKGROUND 6.0 Recommendation 6.3: V Policy, Institutions* adopt a combination of approaches to prevent abuse and neglect Organization of older adults, including and System screening potential employees, hiring the most qualified employees, and providing proper supervision and monitoring in the workplace; securing appropriate staffing; providing mandatory training to all employees; supporting the needs of individuals with cognitive impairment, including those with responsive behaviours; upholding resident rights; establishing and maintaining person-centred care and a healthy work environment; and educating older adults and families on abuse and neglect and their rights, and establishing routes for complaints and quality improvement. *Note: may apply to other health-care settings. Recommendation 6.4: V Organizations/institutions with prevention and health promotion mandates (such G as community and public health organizations) lead or participate in initiatives to prevent abuse and neglect of older adults. Recommendation 6.5: IV Organizations/institutions identify and eliminate barriers that older adults and families may experience when accessing information and services related to abuse and neglect. Recommendation 6.6: V Provincial and territorial nursing regulatory bodies provide accurate information on jurisdictional laws and obligations relevant to abuse and neglect of older adults across the continuum of care. Recommendation 6.7: V Governments dedicate resources to effectively prevent and address abuse and neglect of older adults. Recommendation 6.8: V Nurses, other health-care providers, and key stakeholders (e.g., professional associations, health service organizations, advocacy groups) advocate for policy/ organization/system level changes, including the availability of necessary resources, to effectively prevent and address abuse and neglect of older adults. 10 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Interpretation of Evidence BACKGROUND Levels of Evidence* Ia Evidence obtained from meta-analysisG or systematic reviews of randomized controlled trialsG, and/or synthesis of multiple studies primarily of quantitativeG research. Ib Evidence obtained from at least one randomized controlled trial. IIa Evidence obtained from at least one well-designed controlled studyG without randomization. IIb Evidence obtained from at least one other type of well-designed quasi-experimental studyG, without randomization. III Synthesis of multiple studies primarily of qualitativeG research. IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studiesG or descriptive studiesG, and/or qualitative studies. V Evidence obtained from expert opinion or committee reports, and/or clinical experiences of respected authorities. *Levels of evidence are assigned to study designs to rank how well that design is able to eliminate alternate explanations of the phenomena under study. The higher the level of evidence, the more confidence you can have that the relationships presented between the variables are true. Levels of evidence do not reflect the merit or quality of individual studies. This hierarchy of evidence was adapted from the Scottish Intercollegiate Guidelines Network (SIGN) (2012) and Pati (2011). BEST PRACTICE GUIDELINES w w w. R N A O. c a 11  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Registered Nurses’ Association of Ontario Expert Panel BACKGROUND Dr. Elizabeth Podnieks, RN, PhD Barbara Hood Expert Panel Co-Chair Executive Director Professor Emerita, Ryerson University NWT Seniors’ Society Toronto, Ontario Yellowknife, Northwest Territories Dr. Samir Sinha, MD, DPhil, FRCPC Gail MacFarlane, RN Expert Panel Co-Chair Nurse Educator/Consultant Director of Geriatrics, Mount Sinai and Fredericton, New Brunswick University Health Network Expert Lead, Ontario’s Seniors Care Strategy Dr. Lynn McDonald, PhD Toronto, Ontario Director and Professor University of Toronto – Dr. Veronique Boscart, RN, MScN, MEd, PhD Institute for Life Course and Aging CIHR & Schlegel Industrial Research Chair Toronto, Ontario for Colleges in Seniors Care Conestoga College Jarred Rosenberg, MD Kitchener, Ontario Geriatric Medicine Resident University of Toronto Susan Crichton, BHEcol., MSc Toronto, Ontario Elder Abuse Consultant Government of Manitoba Charmaine Spencer, LL.B. (Psych.), J.D., LL.M. Winnipeg, Manitoba Gerontology Researcher, Lawyer Gerontology Research Centre Simon Fraser University Dr. Sholom Glouberman, PhD Vancouver, British Columbia Philosopher in Residence Baycrest Centre for Geriatric Care Marney Vermette, RN Toronto, Ontario Engagement Liaison Saint Elizabeth First Nation, Inuit and Métis Program Dr. Sandra Hirst, RN, PhD, GNC(C) Wabauskang First Nation, Ontario Associate Professor – Faculty of Nursing University of Calgary Calgary, Alberta Declarations of interest and confidentiality were made by all members of the Registered Nurses’ Association of Ontario Expert Panel. Further details are available from the Registered Nurses’ Association of Ontario. 12 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Registered Nurses’ Association of Ontario Best Practice Guideline Program Team BACKGROUND Susan McNeill, RN, BScN, MPH Monique Lloyd, RN, PhD Guideline Development Lead Associate Director, Guideline Development, Registered Nurses’ Association of Ontario Research & Evaluation Toronto, Ontario Registered Nurses’ Association of Ontario Toronto, Ontario Verity White, BSc Guideline Development Project Coordinator Lynn Anne Mulrooney, RN, MPH, PhD Registered Nurses’ Association of Ontario Senior Policy Analyst Toronto, Ontario Registered Nurses’ Association of Ontario Toronto, Ontario Diana An, RN, MSc Nursing Research Associate Tasha Penney, RN, MN, CPMHN(C) Registered Nurses’ Association of Ontario Nursing Research Associate Toronto, Ontario Registered Nurses’ Association of Ontario Toronto, Ontario Megan Bamford, RN, MScN Nursing Research Associate Althea Stewart Pyne, RN, BN, MHSc Registered Nurses’ Association of Ontario Healthy Work Environments Program Manager Toronto, Ontario Registered Nurses’ Association of Ontario Toronto, Ontario Anastasia Harripaul, RN, MSc(A) Nursing Research Associate Rita Wilson, RN, MN Registered Nurses’ Association of Ontario eHealth Program Manager Toronto, Ontario Registered Nurses’ Association of Ontario Toronto, Ontario Carol Holmes, RN, MN, GNC(C) Program Manager, Long-Term Care Sarah Xiao, RN, MScN Best Practices Program Nursing Research Associate Registered Nurses’ Association of Ontario Registered Nurses’ Association of Ontario Toronto, Ontario Toronto, Ontario BEST PRACTICE GUIDELINES w w w. R N A O. c a 13  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Stakeholder Acknowledgement BACKGROUND Stakeholders representing diverse perspectives were solicited for their feedback, and the Registered Nurses’ Association of Ontario wishes to acknowledge the following individuals for their contribution in reviewing this Nursing Best Practice Guideline. Lori Adler, RN, MHSc Christine Bradshaw, MSW, RSW Manager – Practice Standards Social Worker College of Nurses of Ontario Mount Sinai Hospital Toronto, Ontario Toronto, Ontario Nana Asomaning, NP, BScN, MN, GNC(C) Alexis Brown, RN Geriatric Emergency Management Nurse Director of Nursing Mount Sinai Hospital Caressant Care Harriston Toronto, Ontario Harriston, Ontario Catherine Awad, BScN, RN Lisa Bueckert, BA, MSW, RSW Registered Nurse Clinical Lead Social Work Windsor Regional Hospital, Metropolitan Campus Integrated Home Care, Alberta Health Services Windsor, Ontario Calgary, Alberta Sue Bailey, RN, BA, MHScN Shelly Christensen, RN, HBScN, MN Long-Term Care Best Practice Co-ordinator Geriatric Mental Health CNS Registered Nurses’ Association of Ontario Niagara Health System Unionville, Ontario St. Catharines, Ontario Sherry Baker, MA Diane Clements, BScN, MN Executive Director Interim Director – Practice and Policy Division BC Association of Community Response Networks Canadian Nurses Association Surrey, British Columbia Ottawa, Ontario Marie Beaulieu, PhD Dawn Clyens, RN, BA, MN Professor Faculty, Practical Nursing Program University of Sherbrooke Niagara College Sherbrooke, Québec St Catharines, Ontario Angela Bisschop, RN Isabelle Coady Director of Nursing Detective- Elder Abuse Section Parkview Services for Seniors Ottawa Police Service Stouffville, Ontario Ottawa, Ontario Paul Boudreau, BSc, RN, BScN, MN(C) Gina Coleman, SSW Coordinator of Regulatory Services Coordinator- TeleCheck Seniors Program The Association of Registered Nurses Spectra Community Support Services of Prince Edward Island (ARNPEI) Brampton, Ontario Charlottetown, Prince Edward Island 14 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Nancy Cooper, BSc, M.H.S.A. Kathy-Lynn Greig, RPN, BScN Director of Quality & Education Student – Staff Nurse BACKGROUND Ontario Long Term Care Association The Scarborough Hospital – Birchmount Campus Markham, Ontario Toronto, Ontario Jacqueline Copple, RN Bella Grunfeld, NP- PHC, BScN, MN Registered Nurse – Elder Abuse Response Team Nurse Practitioner – Nurse Led Outreach Team Calgary Family Services Mackenzie Health Calgary, Alberta Richmond Hill, Ontario Jessica Coulis, RN, BScN, MScN, CNS Sepali Guruge, RN, PhD Geriatric Emergency Management Associate Professor Mackenzie Health Ryerson University, School of Nursing Richmond Hill, Ontario Toronto, Ontario Michelle Court, RN Randy Filinski Staff Nurse – Seniors Mental Health Behavioural Unit Consumer Advocate for Senior’s/Caregiver St. Joseph’s Healthcare Hamilton Pickering, Ontario Hamilton, Ontario Gloria Hamel-Lauzon, RN, BSc, MScN Joann Creager, MSc(A), CNS Manager Adult Community Mental Health Geriatrics Manager – Cornwall Community Hospital Elder Friendly Hospital Program Cornwall, Ontario McGill University Health Centre Montréal, Québec Mary Ann Hamelin, RN, MScN, GNC(C) Clinical Nurse Specialist, Geriatrics Naomi D’Souza Mount Sinai Hospital Senior Consultant Toronto, Ontario Ontario Long Term Care Family Councils Network Association Shannon Hunter, RN, BScN (IP) Toronto, Ontario SANE Resource Nurse Orillia Soldiers’ Memorial Hospital – The Regional Alison Douglas, PhD, OT Reg. (Ont) Sexual Assault & Domestic Violence Treatment Centre CAOT Elder Abuse Project Coordinator Orillia, Ontario Canadian Association of Occupational Therapists Ottawa, Ontario Gilda Jubas, MSW Board member Ainsley Gillespie, RN, MScN Concerned Friends of Ontario Citizens in Care facilities Manager Nursing Practice Toronto, Ontario Lakeview Manor Beaverton Beaverton, Ontario John Keating Elder Abuse Investigator Andrea Gounden, RN, MN, BScN, BA, Bed Durham Regional Police Service Nursing Professor Whitby, Ontario Seneca College Toronto, Ontario BEST PRACTICE GUIDELINES w w w. R N A O. c a 15  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Nina Labun, RN, MN Noelle Ozog, BHSc, BScN Executive Director University of Western Ontario BACKGROUND Kildonan Personal Care Centre London, Ontario Winnipeg, Manitoba Sofie Pauwels, RN Jessica LeBlanc, RN, BScN Public Health Nurse Registered Nurse Toronto Public Health Lakeridge Health Toronto, Ontario Oshawa, Ontario Monita Persaud, MSW Lisa Loiselle, MA Regional Elder Abuse Consultant – GTA Associate Director of Research Elder Abuse Ontario University of Waterloo, Murray Toronto, Ontario Alzheimer Research and Education Program Waterloo, Ontario Mary-Lynn Peters, RN(EC), NP-Adult, M.S., GNC(C) Sharon L. MacKenzie, BA, MEd Nurse Practitioner, Geriatrics Executive Director and Consultant Trillium Health Partners i2i Intergenerational Society of Canada Mississauga, Ontario Victoria, British Columbia Kathryn Pilkington, BA (Hons), LL.B. Chelsea Meixner, BScN Director Student Nurse Ontario Association of Non-Profit Homes University of Windsor and Services for Seniors Windsor, Ontario Woodbridge, Ontario Stacey Miller, BSW Jenny Ploeg, RN, PhD Manager, Community Services Professor- School of Nursing A & O: Support Services for Older Adults McMaster University Winnipeg, Manitoba Hamilton, Ontario Andrea Mowry, RN, BScN, MN Sue Porto, RN, SANE-A, SANE-P School of Nursing Faculty Clinical Practice Coordinator Trent Fleming School of Nursing Windsor Regional Hospital Peterborough, Ontario Windsor, Ontario Jennifer Oteng, RN, BScN, MN Tammy Rankin, BA, RSSW Geriatric Outreach Nurse Elder Abuse Advisor William Osler Health System The Regional Municipality of Durham Brampton, Ontario Whitby, Ontario Marie Owen, RN, BScN, MN Linda Reimer, RN, BScN, SANE-A Senior Director Registered Nurse Canadian Patient Safety Institute Mackenzie Health Edmonton, Alberta Richmond Hill, Ontario 16 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Kim Ritchie, RN, MN, GNC(C) Hilda Swirsky, RN, BScN, MEd Clinical Nurse Specialist Registered Nurse BACKGROUND Ontario Shores Centre of Mental Health Science Mount Sinai Hospital Whitby, Ontario Toronto, Ontario Judy Smith, RN, BScN, MEd(DE), ENC(C) Rhonda Usenik, RN, HBScN Clinical Nurse Specialist – Seniors Heal Clinical Nurse Educator Mackenzie Health Alberta Health Services, Integrated Home Care Richmond Hill, Ontario Calgary, Alberta Vilasini Smith, RN, MN Melinda Wall, RN, MN Professor of Nursing (Retired) Clinical Nurse Specialist Arnprior, Ontario Ontario Shores Centre for Mental Health Sciences Whitby, Ontario Lily Spanjevic, RN, BScN, MN, GNC(C), CRN(C), CMSN Natalie Warner, RN, MN APN Geriatrics-Medicine Long-Term Care Best Practice Co-ordinator Joseph Brant Hospital Registered Nurses’ Association of Ontario Burlington, Ontario Peterborough, Ontario Linda Starr, RN, RPN, Dip App Sci (Nsg), BN (ed), Heather Woodbeck, RN, HBScN, MHSA Grad Dip Distance Ed: LL.B.; LL.M., GCLP, PhD candidate Long-Term Care Best Practice Co-ordinator Associate Professor – School of Nursing and Midwifery Registered Nurses’ Association of Ontario Flinders University Thunder Bay, Ontario South Australia, Australia Debora Steele, RN, BScN, CPMHNC, GNCC Psychogeriatric Resource Consultant Providence Care Mental Health Services Brockville, Ontario BEST PRACTICE GUIDELINES w w w. R N A O. c a 17  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Background BACKGROUND Defining abuse and neglect of older adults Abuse and neglect of older adults is a health and social problem with profound consequences that affects people from all walks of life. To prevent and address it, committed effort on multiple levels is required. Several definitions for abuse and neglect of older adults have been developed over time, but two definitions are provided to guide the reader. The following definition, used by the World Health Organization (WHO) (2002) and the International Network for the Prevention of Elder Abuse, describes abuse and neglect as, “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person”. More recently, the National Initiative for Care of the Elderly (NICE) (2012) created the following definition for the Canadian context: “Mistreatment of older adults refers to actions and/or behaviours, or lack of actions and/or behaviours that cause harm or risk of harm within a trusting relationshipG. Mistreatment includes abuse and neglect of older adults” (p.99). Several different types of abuse are cited in the literature. The main types include physical abuse (e.g., slapping, pushing, inappropriate use of restraintsG), emotional or psychological abuse (e.g., humiliating, threatening, treating like a child), financial or material abuse (e.g., misusing power of attorneyG, stealing, selling personal belongings without consentG), sexual abuse (e.g., any unwanted sexual activity), and neglect (e.g., failing to provide for basic health or medical needs, abandonment). Other types and subtypes of abuse and neglect that have been identified include violation of rights, systemic abuse, and spiritual abuse (refer to Appendix D for definitions of different types of abuse). Prevalence The prevalence of abuse and neglect of older adults, that is, the proportion of the population that is affected, is unclear. A systematic review of international studies indicates a prevalence rate of 3.2 percent to 27.5 percent and suggests that one in four vulnerable older adults (i.e., those dependent on others for care) is at risk for abuse (Cooper, Selwood, & Livingston, 2008). In Canada, the prevalence of abuse and neglect is believed to be at least four percent. This statistic is informed by a telephone survey of over 2000 randomly sampled community-dwelling older adults conducted in 1989 (Podnieks, 1992). In institutional settings the extent of abuse and neglect of older adults remains largely unknown (McDonald, 2011); however, research studies suggest it is a common occurrence (McDonald et al., 2012). For example, a large study conducted in Germany found that approximately 70 percent of nurses reported that they themselves had behaved in abusive or neglectful ways in the past year towards residents (Goergen, 2004). Lachs and Pillemer (2004) put the magnitude of the problem into perspective by suggesting that “a busy clinician seeing between 20 and 40 old [older] people per day could encounter at least one clinical or subclinical victim of elder abuse daily” (p.1264). Consequences The consequences of abuse and neglect are profound and pervasive. At the individual level, older adults who experience abuse and neglect face major quality of life issues. They could experience physical trauma, reduced self worth and dignity, a lost sense of safety and security and even an increased risk of early death (Dong et al., 2009; Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998). Other consequences cited in the literature are increased hospitalization (Covinsky, 2013), and economic costs from investigation procedures, health-care interventions, law enforcement and lost productivity (Hirst, 2002). 18 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Factors that contribute to abuse and neglect BACKGROUND Several theories have been developed to explain the causes of abuse and neglect and various risk factors have been identified that may increase an older adult’s vulnerability. For example, theories address the dynamics that occur between individuals, such as power and control, caregiver stress, and abusive behaviour that has been learned over time (refer to Appendix E for more details description about theories). At the individual level, risk factors for older adults include being dependent on care, having cognitive challenges, being socially isolated, and relying on caregivers who have alcohol or substance abuse problems or who themselves have a history of being abused (refer to Table 2: Risk Factors of Abuse and Neglect). It is now recognized that the causes of abuse and neglect extend beyond the traits and circumstances of the older adult and the person who abuses or neglects them (Employment and Social Development Canada (ESDC), 2011). The social determinants of healthG and discrimination based on factors such as such as age, gender, cultureG, and poverty are believed to compound one’s vulnerability and may lead to abuse and neglect (ESDC, 2011; Podnieks, 2006; Public Health Agency of Canada, 2012b). Furthermore, there are some circumstances within institutions that contribute to abuse and neglect. For example, some institutional settings face chronic staff shortages and bed shortages and lack the capacity at a system level to address the increasingly complex needs of older adults. In these situations, older adults are particularly vulnerable. For more details refer to Recommendation 6.3 and Table 5: Factors and Conditions that Contribute to Abuse and Neglect in Institutions. Understanding abuse and neglect of older adults The ecological/life course model was applied to the context of abuse and neglect of older adults by the Expert Panel (McDonald & Thomas, 2013; Parra-Cardona, Meyer, Schiamberg, & Post, 2007; Schiamberg et al., 2011; Schiamberg & Gans, 2000; WHO, 2002). An ecological perspective shows that abuse and neglect is a complex problem that involves the interaction of factors and conditions at multiple levels. The model depicts the many factors that interact at four different levels: the individual, relationship, community or institutional and societal (refer to Figure 1). The factors at each level can either increase risk and hence vulnerability to abuse and neglect, or can be protective and help to reduce vulnerability. The inner circle in Figure 1, for example, represents the individual level. Factors at this level, such as physical and mental health and coping skills, could influence whether or not an older adult is, or may become at risk for, abuse and neglect. Next, the relationship level includes factors such as relationships in the household and the dynamics of care giving. Community or institutional factors are shown in the third level. For an older adult living in the community, the risk of abuse and neglect is influenced by factors such as access to transit, availability of support services, and social inclusion or exclusion. Older adults living or staying in an institution or care facility would be affected by factors such as the staff members’ working conditions, the culture of that setting, as well as organizational policies and practices. In the outer circle, societal factors that influence risk of abuse and neglect include attitudes towards ageing and health and social policies. Finally, the ecological model is nested in the life course perspective. This perspective links life events and social conditions that have occurred over the older adult’s lifetime; experiences that create accumulated advantages or disadvantages (McDonald & Thomas, 2013). BEST PRACTICE GUIDELINES w w w. R N A O. c a 19  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Figure 1: Ecological/Life Course Model BACKGROUND Examples: Societal – Ageism – Economic and social policy – Healthcare system Community/Institution – Law/legislation Relationship Examples: Community – Social inclusion/exclusion – Access to transit Individual – Support programs in the community Institution – Culture – Policies/practices – Working conditions Examples: – Dynamics of caregiving – Family relationships – Support network Life Course Perspective Examples: – Physical and mental health Personal development over time – Gender Societal position in family – Social and cultural factors Sociohistorical and environmental conditions – Income Transitions occurring over time – Coping skills – History of abuse (McDonald & Thomas, 2013; Parra-Cardona, Meyer, Schiamberg, & Post, 2007; Schiamberg et al., 2011; Schiamberg & Gans, 2000; WHO, 2002) How to use this model The ecological/life course model shown in Figure 1 can be used to help understand the complexity of abuse and neglect and the interplay of factors that can either increase or decrease an individual’s vulnerability. It can also be used as a framework for considering the various levels where prevention and intervention activities should be focused. These multiple, interconnected factors show that, to effectively prevent and address abuse and neglect of older adults, collaboration and coordination between the four levels (societal, community/institution, relationship and individual) are required. 20 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Preventing and addressing abuse and neglect of older adults BACKGROUND Great efforts have been made to prevent and address the abuse and neglect of older adults in Canada since the 1980s, when the problem became a focus for research and emerged as a public policy concern. Organizations and networks have published reports, developed guidelines and created educational resources. Creative approaches have been implemented to raise awareness of the issue, such as intergenerational collaborations between youth and older adults, the use of the arts (e.g., theatre, dance, music) and financial literacy classes for older adults. Initiatives to address abuse and neglect of older adults in community settings include collaboration among diverse groups and individuals (e.g., police, faith communities, banks, health-care providers, cultural communities, and older adults themselves). In health-care settings, efforts to prevent and address abuse and neglect of older adults include the development and implementation of education programs for staff, screening and assessment tools, and policies and protocols. Despite these efforts, there remains variability in practice, and in some cases, well-intentioned approaches may be inadequate, ineffective, or disrespectful (refer to Recommendations 1.3 and 5.2). This best practice guideline aims to address these shortcomings. It provides recommendations based on the best available evidence from a systematic literature review, supplemented with background literature, grey literatureG, other evidenced-based guidelines on abuse and neglect of older adults, and the opinion of the Expert Panel members. According to the levels of evidence criteria (refer to Interpretation of Evidence), most recommendations in this document are based on lower levels of evidence. This is the case for two reasons: 1) the nature of the topic does not lend itself to research methods such as randomized controlled trials, and 2) much of the literature on this topic is non-experimental. BEST PRACTICE GUIDELINES w w w. R N A O. c a 21  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Guiding Principles BACKGROUND The following guiding principles inform the concepts contained in this document and are based on various resources and Expert Panel opinion. Older adults are entitled to protection of their human rights and fundamental freedoms including full respect for their dignity, beliefs, needs and privacy (United Nations, 1991). Older adults are presumed to be mentally capable of making decisions about their own lives, unless demonstrated otherwise (Substitute Decisions Act, 1992). Older adults should, to the full extent that they are able, direct their plan of care and provide consent for decisions made about their care (Health Care Consent Act, 1996). All approaches to helping an older adult who has been abused or neglected should honour the person’s uniqueness, preferences, values and beliefs, and be founded in a person-centred approach (RNAO, 2010a). Mentally capable older adults have the right to live their lives as they wish, provided they do not infringe upon the rights and safety of others. Abuse and neglect are complex, multifaceted issues that often take time, sensitivity and collaborative effort to prevent and address effectively. Older adults should be active participants in the development of programs meant to serve them. 22 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Practice Recommendations 1.0 ASSESSMENT RECOMMENDATION 1.1: Establish and maintain a therapeutic relationship with older adults, and families as appropriate, when discussing issues of abuse and neglect. RECOMMENDATIONS Level of Evidence = IV Discussion of Evidence: A therapeutic relationship is essential when addressing issues of abuse and neglect. A therapeutic relationship involves caring attitudes and behaviours and “is based on trust, respect, empathyG and professional intimacy, and requires appropriate use of the power inherent in the care provider’s role” (College of Nurses of Ontario (CNO), 2006). The literature outlines the need for this type of relationship with older adults experiencing abuse and neglect, but it should be noted that the characteristics of a therapeutic relationship are fundamental to nursing practice, which often involves family members. Therefore this recommendation is extended to include establishing a therapeutic relationship with familyG members, if they are involved in the older adult’s life or care (for further discussion of family involvement, including the complexities that may arise when working with families, refer to Recommendation 1.5). Therapeutic communication and client-centred (person-centred) careG are two important elements of a therapeutic relationship (CNO, 2006). Therapeutic communication includes strategies such as establishing rapport, active listening, and adapting communication style to accommodate individual needs, such as literacy level or cognitive status (CNO, 2006). Furthermore, communication techniques may include “listening, silence, open-ended questions and statements, restating, reflecting, seeking clarification and validation, focusing, summarizing, awareness of verbal and non-verbal communication, and awareness of cultural differences related to communication” (RNAO, 2002, p.25). Client-centred (person-centred) care is “an approach in which clients are viewed as whole; it is not merely about delivering services where the client is located. Client-centred care involves advocacy, empowerment, and respecting the client’s autonomy, voice, self-determination, and participation in decision-making” (RNAO, 2006a, p.2). Literature specific to abuse and neglect of older adults supports the need for a therapeutic relationship. Zink, Jacobson, Regan, and Pabst (2004) conducted a qualitative study to understand the health-care needs of older women in abusive relationships. Many women described having negative experiences when they disclosed and sought to discuss experiences of abuse. These experiences included interactions with health-care providers who lacked empathy, who were visibly uncomfortable talking about abuse, or times when health-care providers interviewed women together with their abusive partners, instead of having a private, one-to-one conversation, resulting in missed opportunities to disclose abuse. Women reported positive experiences when health-care providers listened, showed empathy and took statements about abuse seriously. These therapeutic approaches are also supported by Cohen (2011) who suggests that when discussing issues of abuse, older adults need to feel that the health-care provider is trustworthy, empathetic, sensitive and nonjudgmental. Tetterton and Farnsworth (2011) point out that health-care providers need to take the time to establish trust and rapport, listen carefully, show openness, be nonjudgmental, and not appear shocked at disclosures of abuse. BEST PRACTICE GUIDELINES w w w. R N A O. c a 23  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches The need for a therapeutic relationship is further supported by literature that outlines the barriers to disclosure of abuse and neglect. Nurses and other health-care providers who are sensitive to these barriers may be more effective in their interactions with older adults and with families. The following table outlines common barriers to disclosure of abuse and neglect. For communication strategies, refer to Appendix F. Table 1: Common Barriers to Disclosure of Abuse and Neglect Common barriers to disclosure of abuse and neglect include  isolation of the older adult (e.g., infrequent contact with health-care providers or community supports); RECOMMENDATIONS  not wanting to turn against the person abusing or neglecting;  reluctance to talk about “private family matters”;  feeling of shame or embarrassment;  relationship with person who is abusing or neglecting (e.g., love, protection, fear of loss of contact);  dependent on person who is abusing or neglecting for care/housing;  low socioeconomic status (i.e., economic insecurity or dependence);  concern about reprisal of family (e.g., shunning, denied access to grandchildren);  concern about retribution from staff (including withdrawal of assistance) if abuse occurs in an institution;  pressure not to speak out from religious, social or cultural community;  difficulty speaking up or explaining abuse (e.g., cognitive challenges, language difficulties, aphasia);  acceptance of abuse due to lifetime exposure to abuse;  fear or mistrust of “authorities” (e.g., fear of being removed from the home, abuser being arrested, having to move to a long-term care facility);  immigration issues (e.g., fear of being deported if sponsor is reported for abuse);  gender related issues (e.g., less economic or social power, older men not taken seriously or ashamed to admit abuse); and  past negative experiences with health-care providers when disclosing abuse. (Begley, O’Brien, Anand, Killick, & Taylor, 2012; Schmeidel, Daly, Rosenbaum, Schmuch, & Jogerst, 2012; Spencer, 2006; Spencer, 2010; Zink et al., 2004) 24 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches RECOMMENDATION 1.2: Ensure privacy and confidentiality when discussing issues of abuse and neglect unless legal obligations require disclosure of information. Level of Evidence = V Discussion of Evidence: RECOMMENDATIONS The Expert Panel recommends that nurses and other health-care providers maintain privacy and confidentiality regarding issues of abuse and neglect. This is important for two main reasons: issues of abuse and neglect are highly sensitive, and maintaining privacy and confidentiality is a professional and legal responsibility. The notion of privacy extends beyond the need for talking one-to-one with the older adult in a private location. Privacy can have many definitions and legal implications that will vary based on jurisdiction. The Canadian Nurses’ Association (CNA) (2008) makes a distinction between physical privacy and informational privacy, which are both important with regard to abuse and neglect of older adults. Physical privacy is, “the right or interest in controlling or limiting the access of others to oneself,” and informational privacy is, “the right of individuals to determine how, when, with whom and for what purposes any of their personal information will be shared” (CNA, 2008 p.27). Furthermore, confidentiality has important implications for nurses and other health-care providers working with older adults. The CNA (2008) states that confidentiality is, “the ethical obligation to keep someone’s personal and private information secret or private” (p. 23). Nurses and other health-care providers are encouraged to consider the following with regards to privacy and confidentiality: Laws and professional practice standards regarding privacy and confidentiality vary across jurisdictions. Nurses and other health-care providers must know and adhere to applicable laws and standards. It is important to obtain consent from the older adult or substitute decision makerG before sharing information with others. This may include consent for collaborations with family members and the interprofessional team. Sharing private and confidential information may be allowable in specific situations (e.g., emergency situations). For clarification, consult your local legislation and professional practice standards. Sharing personal information with other health-care providers may be necessary for the continuity of care but should be guided by local legislation and professional practice standards. The following are examples of resources that can assist nurses and other health-care providers in maintaining privacy and confidentiality when discussing issues of abuse and neglect: Privacy legislation across Canada The Office of the Privacy Commissioner of Canada provides provincial and territorial links to Oversight Offices and government organizations: http://www.priv.gc.ca/resource/prov/index_e.asp Provincial or territorial professional practice standards Example: The College of Registered Nurses of British Columbia provides direction to registered nurses and nurse practitioners regarding privacy and confidentiality: https://www.crnbc.ca/Standards/Lists/StandardResources/400 ConfidentialityPracStd.pdf BEST PRACTICE GUIDELINES w w w. R N A O. c a 25  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Codes of ethics Examples: CNA Code of Ethics for Registered Nurses: http://www.cna-aiic.ca/~/media/cna/files/en/codeofethics.pdf Quebec Code of Ethics of Nurses: http://www2.publicationsduquebec.gouv.qc.ca/documents/lr/I_8/I8R9_A.htm Your organizational policies RECOMMENDATION 1.3: RECOMMENDATIONS Be alert for risk factors and signs of abuse and neglect during assessments and encounters with the older adult. Level of Evidence = V Discussion of Evidence: Assessments and encounters with the older adult provide a unique and important opportunity to identify risk factors and signs of abuse and neglect, especially when the older adult is isolated and controlled by the abuser (Cohen, 2011; Joubert & Posenelli, 2009; Zink et al., 2004). A holistic assessment may be the most comprehensive way to identify risk factors and signs of abuse and neglect because it involves assessing many different aspects of health, such as physical, emotional, mental, spiritual, cognitive, developmental, and environmental health, as well as the meaning of health to the individual (CNA, 2014b). However, brief assessments also provide opportunities to identify risk factors and signs of abuse and neglect. Importantly, both types of assessments – holistic and brief – should identify the older adult’s strengths, capacities and effective coping techniques (CNA, 2014b). Nurses and other health-care providers can also identify abuse and neglect during routine encounters with older adults (and others involved in their life and care), by paying attention to possible disclosures and using therapeutic communication techniques to enable discussion. Zink et al. (2004) found that older adult women in abusive relationships needed health-care providers to be alert to their “hints or signals that something was wrong” and needed help in “bringing up the subject of abuse” (p. 903). While this research pertains to older women living in community settings, nurses and other health-care providers in all settings should also pay attention to, and be open to disclosures of, abuse and neglect. Refer to Appendix F for tips and resources to support effective communication. Table 2 and Table 3 list risk factors and possible signs of abuse and neglect of older adults, drawn from research studies, systematic reviews and grey literature sources. 26 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Table 2: Risk Factors for Abuse and Neglect Risk factors for abuse and neglect include isolation, lack of support, cognitive impairments (i.e., dementia), responsive behavioursG (e.g., verbal or physical aggression), living with a person who has a mental illness, RECOMMENDATIONS living with people engaging in excessive consumption of alcohol or illegal drugs, dependency on others to complete activities of daily living (including banking), recent worsening of health, and arguing frequently with relatives. (Cohen, Halevy-Levin, Gagin, Prilutzky, & Friedman, 2010; Davies et al., 2011; Lindbloom, Brandt, Hough, & Meadows, 2007; Perez-Carceles et al., 2009; Spencer, 2010; Wiglesworth et al., 2009) See also Table 5: Factors and Conditions that Contribute to Abuse and Neglect in Institutions Caution: The presence of risk factors or signs of abuse and neglect does not mean that a person is experiencing abuse or neglect. BEST PRACTICE GUIDELINES w w w. R N A O. c a 27  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Table 3: Possible Signs of Abuse and Neglect POSSIBLE SIGNS OF ABUSE POSSIBLE SIGNS OF NEGLECT Physical/Psychological/Sexual dehydration injuries to the upper extremity, trunk, head, malnutrition neck and/or anogenital regions low blood albumin level depression, anxiety pressure ulcers/sores RECOMMENDATIONS change of behavior/mood in presence of the poor body and oral hygiene/grooming person abusing or neglecting depression unexplained burns and bruises (may be in different stages of healing) despair fractures (may be in different stages of healing) unclean living conditions evidence of sexual abuse (e.g., genital infections, trauma, bruising on inner thigh) signs of hair being pulled inadequate explanation or documentation of any injury (from employees) evasive or defensive responses (from employees) Financial irregularities in bank accounts and bills living conditions that do not match income missing money and personal belongings payments to strangers or new “best friends” inappropriate use of power of attorney authority deception or coercion with regard to payments, gifts or change in wills (Erlingsson, Carlson, & Saveman, 2003; Lindbloom et al., 2007; Winterstein, 2012; Murphy, Waa, Jaffer, Sauter, & Chan, 2013; Perez-Carceles et al., 2009; Davies et al., 2011; Wiglesworth et al., 2009) Caution: The presence of risk factors or signs of abuse and neglect does not mean that a person is experiencing abuse or neglect. 28 R E G I S T E R E D N U R S E S ’ A S S O C I AT I O N O F O N TA R I O Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches Screening and assessment tools The value of using screening and assessment tools for abuse and neglect of older adults (including tools to assess caregivers) is controversial. Assessment and screening tools hold potential benefits for preventing and addressing abuse and neglect of older adults, but they also have the potential to cause unintentional harm. On the positive side, the tools can detect abuse and neglect and facilitate early intervention (Cohen et al., 2010; Cohen et al., 2007; Sandmoe, 2007). Spencer (2010), in a critical analysis of screening and assessment tools, explains that: “together, screening and assessment guide health-care providers and others through a systematic process of observation and documentation to ensure the manifestations of abuse will not be missed, and appropriate help is being offered” (p. 9). Done well, Spencer (2010) states, the use of tools can improve care, lead to other positive outcomes, and preserve the older adult’s dignity. RECOMMENDATIONS On the other hand, potential harms and possible unintended effects from the use of screening and assessment tools include violations of privacy and confidentiality, intrusive and disempowering outcomes, labels of abuse, and inappropriate referrals or interventions when health-care providers lack the skills, time or resources to address the issues appropriately (Spencer, 2010). Furthermore, the content and wording of tools may not be appropriate for all cultures and geographical locations (Spencer, 2010). A recommendation statement based on a systematic literature review raises important questions about the use of screening and assessment tools with older adults in terms of accuracy, benefits and outcomes (U.S. Preventive Services Task Force, 2013). Whereas the review did not find strong evidence of harms associated with assessment, it states that there is, “inadequate evidence on the accuracy of screening instruments” and “inadequate evidence that screening or early detection reduces exposure to abuse or reduces physical or mental harms or mortality” (U.S. Preventive Services Task Force, 2013, p. 497). The review concludes that “the benefits and harms of screening elderly adults for abuse are uncertain and that the balance of benefits and harms cannot be determined” (U.S. Preventive Services Task Force, 2013, p. 480). Similarly, a review of screening instruments in primary care found that studies did not address the potential adverse effects of screening, nor did they provide evidence that screening actually reduces harm, premature death or disability (Caldwell, Gilden, & Mueller, 2013). As there is no clear evidence to support specific recommendations on whether or not to use tools to assess and screen older adults for abuse and neglect, it is recommended that organizations take a critical approach to determining if, when, and how to use these tools and provide direction and training to nurses and other health-care providers as necessary (refer to Recommendation 5.2). If the decision is made by an organization to use tools for assessment or screening, nurses and other health-care providers are encouraged to be mindful of the following points: Tools should not be used as a checklist. Screening and assessment tools are not diagnostic tools. Nurses and other health-care providers using tools must be appropriately trained (refer to Recommendation 5.2). The use of tools requires sensitivity and therapeutic communication skills (refer to Appendix G). Nurses and other health-care providers using tools should consider what follow-up support will be offered if abuse or neglect is identified. More than one tool may be required to identify different types of abuse and neglect (Cohen, 2011; Sandmoe, 2007). Nurses and other health-care providers should be mindful of cultural aspects and the unique needs of sub- populations of older adults during the screening process (Cohen, 2011). Few tools have been validated for languages other than English. BEST PRACTICE GUIDELINES w w w. R N A O. c a 29  Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centred, Collaborative, System-Wide Approaches RECOMMENDATION 1.4: Carry out a detailed assessment in collaboration with the older adult, interprofessional team, and family, as appropriate, when abuse or neglect is alleged or suspected. Level of Evidence = V Discussion of Evidence: RECOMMENDATIONS When abuse or neglect is alleged or suspected, nurses and other health-care providers should carry out a detailed assessment to facilitate treatment and support. The Expert Panel recommends that the assessment should be in collaboration with the older adult, and as appropriate, with the interprofessional team and family. Members of the interprofessional team, and family members who are involved in the life or care of the older adult, would participate in this process, so long as this aligns with the older adults’ preferences (refer to Recommendation 1.5 for further discussion of the older adult’s preferences and family involvement). Furthermore, nurses and other health-care providers should ensure informed consent prior to conducting detailed assessments and should share information with the interprofessional team and family members according to privacy and confidentiality regulations. For more information about privacy and confidentiality, refer to Recommendation 1.2. A detailed assessment may include assessment of the older adults’ immediate safety, diagnostic testing, use of assessment tool(s), and referrals and consultations. Note: In some cases of abuse and neglect (e.g., abuse and neglect that occurs within an institution by a staff member) there may be additional assessments, an investigation or follow-up required by law or organizational policies or prot