You are on page 1of 6


Study of factors that affect abuse of older people in nursing homes
Merav Ben Natan and Ariela Lowenstein explore the maltreatment of care home residents
This article discusses the effects of long-term care facility traits on the maltreatment of older people. Participants in this quantitative, descriptive study were staff working at 24 of the 300 long-term facilities for older people in Israel. Slightly more than half of the sample reported abuse of older residents in the previous 12 months, manifesting in one or more types of maltreatment. High staff turnover was associated with a greater risk of mental or physical neglect, and the total number of maltreatment incidents. Keywords Elder abuse, long-term care, maltreatment of older people, nursing homes THE MALtREAtMENt of older people in nursing homes is commonly recognised (Jogerst et al 2005, Joshi and Flaherty 2005). Bužgová and Ivanová (2009) point out that maltreatment of older people in long-term care facilities is one of the most common forms of elder abuse, where the environment, practices and rules can in themselves become abusive. Maltreatment includes physical, psychological and sexual abuse, financial exploitation and neglect (MacLean 2000, Wolf et al 2002). These behaviours may cause permanent disability and even death (Aström et al 2002, Gibbs and Mosqueda 2004). The literature shows that many cases of elder abuse in long-term care facilities are not reported to the authorities, although this is required by Israeli law. The full prevalence of the phenomenon is unknown (Gibbs and Mosqueda 2004, Lindbloom et al 2007). Studies indicate that the work environment has a major influence on the maltreatment of older people in long-term facilities (Wolf et al 2002). Allen et al (2004) and Jogerst et al (2006) 20 December 2010 | Volume 17 | Number 8 claim that licensed facilities with a large number of patients are associated with a higher incidence of maltreatment. Of long-term concern is the question of whether care is better in for-profit or not-for-profit nursing homes. Lindbloom et al (2007) report that there is a smaller risk of maltreatment at nursing homes with higher service fees. However, the World Health Organization (Wolf et al 2002) reports that privately owned facilities often enforce cuts in areas essential for maintaining quality of care, such as medical equipment and human resources, which may lead to neglect and abuse of older patients (Wolf et al 2002). Jogerst et al (2006) reveal also that, in Iowa, for example, maltreatment is more prevalent at profit-making facilities. To answer this question in the Israeli context, a cross-sectional study of quality was undertaken by the ministry of health assessment teams (Clarfield et al 2009). They concluded that in Israel, for-profit nursing homes provide poorer care than not-for-profit nursing homes, possibly due to conflict between the demands of patient care and the desire to maximise profits (Clarfield et al 2009). A low staff–patient ratio and high staff turnover led to a higher risk of compromise in quality of care and, therefore, a higher risk of elder abuse, as found in California and Scandinavia (Gibbs and Mosqueda 2004, Sandvide et al 2004). Wood and Stephens (2003) claim that low staff-to-patient ratios and high staff turnover may conspire to increase risk. Goergen (2001) found that, according to nurses, lack of nursing staff leads to decisions that result in maltreatment. In light of the ambiguity regarding the work environment affecting maltreatment of older people in long-term care, the purpose of this study was to identify traits affecting maltreatment in long-term facilities.

Population and sample The population of this quantitative, descriptive study was drawn from staff working at 24 of the 300 long-term nursing homes for older people in Israel. Sampling was random. The country was divided into geographical regions and a single long-term facility for older patients was sampled in each region. After receiving approval for the research, the researcher randomly sampled various departments at each care facility at different times of day. Self-administrated questionnaires were distributed to a maximum of ten workers in each department at each home. Six hundred questionnaires were distributed in these facilities, 510 of which were completed and returned (n=510). The response rate was 85 per cent. Procedure The research was conducted in 2007. At the first stage, meetings were held with the person representing elder abuse in long-term facilities at the ministry of health and at the ministry of social affairs to receive their consent to hold a study in facilities under their supervision. Subsequently, meetings were held with the directors of the facilities to present the aims of the study, the research proposal and the questionnaires. In each facility, the consent of the local ethics committee was obtained. After receiving approval, the researcher distributed the questionnaires personally to the participants. Each respondent was assured anonymity and that the findings would be used only for the goals of the research. Instruments Data were gathered from the staff questionnaires and information on each facility. The questionnaires were designed specifically for the study and was divided into two parts: ■■ The first was aimed at eliciting details about the facility, and the demographic details and professional details of respondents. It covered the names of the facility and department, and also information about respondents’ age, gender, marital status, number of children, religiosity, education, whether they were in full or part-time position, seniority in the profession, seniority in the specific department and past employment. ■■ The second consisted of the Iowa Dependent Adult Abuse Nursing Home Questionnaire, designed by Daly and Jogerst (2005). Respondents were asked whether they had perpetrated or witnessed incidents of maltreatment in the past year. In addition, facility details were examined using data received from admissions: number of beds, number


of patients, ownership and type of facility; data received from nursing administration: number of nurses, number of nursing aides, nurse turnover and nurse-patient ratio.

Data analysis
Analysis was performed using the SPSS 14 statistical computer program, which includes descriptive statistics for the research population and research variables, as well as inferential statistics for examining the research hypotheses. There were two dependent variables: ■■ The existence of maltreatment. ■■ Its various manifestations such as physical violence, mental abuse, sexual violence, financial exploitation, mental neglect and physical neglect. The variables were not normally distributed and therefore the analysis employed non-parametric tests, namely the Kolmogorov-Smirnoff test (KS-test) and the Mann-Whitney (MW-test) test. Findings involving the independent variables were compared using M-W tests. Findings

Of long-term concern is the question of whether care is better in for-profit or not-for-profit nursing homes
December 2010 | Volume 17 | Number 8 21

involving independent variables that were discrete, quantitative variables were examined by calculating Spearman-coefficient correlations, a statistic used as a measure of correlation in non-parametric statistics when data are in ordinal form. Table 1 shows the total number of various types of maltreatment reported by respondents as n =513. Most incidents (64 per cent) involved physical and mental neglect. They have a prevalence of 34 per cent to 30 per cent respectively, with 64 per cent of respondents reporting that physical neglect occurred more than 16 times a year. This is followed by mental abuse (23 per cent) and physical violence (12 per cent), while the prevalence of sexual violence and financial exploitation reported was 0.1 per cent. Due to the small number of sexual and financial abuse cases, these variables were not selected for continued statistical analysis. Features of the facility To examine the effect of the facility’s features on elder abuse, a separate index was calculated for each type of maltreatment, consisting of the number of various incidents of abuse for each patient. This index was the dependent variable, which was designed to avoid impairing objective findings, because many workers were sampled at large facilities with an extensive staff. These respondents completed more questionnaires, which affects the findings. A Spearman test showed a significant positive correlation between numbers of beds, nurses, aides and staff turnover, with mental neglect, physical neglect, and total incidents of maltreatment for each patient (Table 2). A significant positive correlation was found between staff-to-patient ratio and physical neglect and total incidents of maltreatment per patient. The larger the facility, the higher the number of patients, the higher the number of nurses and aides, the higher staff turnover, and the greater the risk of mental neglect, physical neglect and total number of maltreatment incidents. The study also found that the higher the staff-to-patient ratio, the higher the risk of physical neglect and total number of maltreatment incidents per patient. The findings did not indicate a correlation between type of facility, that is for-profit or not-for-profit, and types of maltreatment.

Most of the respondents were female (82 per cent), aged 40 to 49 years. Most were married (71 per cent), were parents (80 per cent) and Jewish (7 per cent). Almost half were nurses (47 per cent) and more than one third were nursing aides. Most were employed in full-time positions (71 per cent), with an average level of seniority of 13.8 years in the profession. Most had been working for five years or less in their current department (61 per cent) and more than 30 per cent were working in the department they were in at the time the study was carried out. Reporting maltreatment The study indicated that 273 respondents (54 per cent) of the sample (n =510) reported perpetrating one or more types of maltreatment against older patients in long-term facilities over the past year. Table 1 Variable Physical violence Types of maltreatment perpetrated in long-term care facilities Number of Percentage incidents sample1 63 12 Number of incidents 1-5 6-10 11-16 17+ 1-5 6-10 11-16 17+ 1-5 6-10 11-16 17+ 1-5 6-10 11-16 17+ n 45 9 4 5 46 30 12 30 24 116 3 32 25 27 4 99 Per cent 71 14 6 8 39 25 10 25 14 66 2 18 16 17 3 64

Mental abuse



Mental neglect



Physical neglect



The findings show that slightly more than half the whole sample of workers reported abusing older patients in one or more forms over the past year. About two thirds of the incidents involve neglect, physical and mental, which are the most reported types of maltreatment. A possible explanation may be that neglect is perceived as an act of omission, manifested in a lack of response to patients’ needs. Neglect is defined

Total incidents2


  Percentages are based on the number of respondents for each question, which is not necessarily equal to the total number of respondents in the sample.   The total number of respondents who reported specific types of maltreatment is less than the total number of reports because each respondent may report more than one type of maltreatment.


22 December 2010 | Volume 17 | Number 8

Table 2 Spearman correlations between features of facility and types of elder abuse Physical violence per patient 0.02 0.02 0.01 0.02 -0.01 -0.02 Mental abuse Mental per patient neglect per patient 0.01 0.02 0.02 0.01 0.06 0.01 0.10* 0.11* 0.11* 0.13** 0.07 -0.04 Physical neglect per patient 0.22** 0.23** 0.22** 0.25** 0.14** -0.04 Maltreatment (total number of incidents) per patient 0.09* 0.09* 0.09* 0.12** 0.10* -0.03 Variable: features of the facility

Number of inpatient beds Number of nurses Number of nursing aides Staff turnover Staff-patient ratio Type of facility
*  p<.05  ** p<.001 

in the professional literature as failure to provide patients’ basic needs (Allen et al 2004). Respondents perceive neglect as a systemic, and not as a personal, failure to provide basic needs. These acts usually do not involve personal motives or malicious intent, but stem from institutional problems. Accordingly, respondents have no moral qualms about reporting such incidents. The general picture formed is one of significant rates of elder abuse in long-term facilities, which may be considered a social problem. The rates found in the present study, particularly regarding neglect of older people in long-term facilities, are higher than those found in other studies (Macionis 1997, Gibbs and Mosqueda 2004). Analysis of research findings regarding the effect of facility features on the risk of maltreatment shows significant positive correlations between the number of beds at the facility, number of nurses, number of aides, staff turnover, mental neglect, physical neglect and total incidents of patient maltreatment. There is a significant positive correlation between staff-to-patient ratio and physical neglect and staff ratio and total incidents of maltreatment per patient. The larger the facility and the larger the numbers of patients and staff, the greater staff turnover and the higher the risk of mental neglect, physical neglect and total number of maltreatment incidents. Facilities with higher staff-to-patient ratios have a higher risk of physical neglect and more incidents of maltreatment per patient, in general. The finding that high staff turnover is a risk factor for maltreatment of older patients is supported by Levine (2003) and Pillemer and Hudson (1993).

A report into nursing homes issued by the United States government and accountability office (GAO) (Wood and Stephens 2003) revealed a pattern of deficiencies in most of the homes sampled in four states. For this report, 622 assisted living facilities in California, Florida, Ohio and Oregon were studied using survey methodology and interviews. According to the report, frequently identified problems included failure to provide sufficient care to residents after an accident, unqualified or insufficient staff, failure to provide medications or store medications adequately, and failure to follow admission and discharge policies required by state regulations. The GAO report (Wood and Stephens 2003) states that the primary factors relating to these problems were inadequate staff training and high staff turnover. This means that staff do not have knowledge of the patients, and their physical and mental health problems, while the patients do not know the staff and feel insecure (Harrell et al 2002, Allen et al 2004). In such cases, where patients have dementia, more aggressive incidents result in maltreatment by staff who do not know how to cope. The finding that higher numbers of beds and residents are associated with more incidents of maltreatment is supported by Allen et al (2004) and Lachs et al (2007). This arises because facilities with many patients and staff have a higher risk

The higher the staff-to-patient ratio, the higher the risk of physical neglect and total number of maltreatment incidents per patient
December 2010 | Volume 17 | Number 8 23

of exposure to maltreatment (Jogerst et al 2006). In addition, large facilities with many patients and workers have low quality of care (Harrington et al 2000). This is often because large facilities have larger numbers of patients with complex needs and dementia, whose care demands increase pressure on care-giving staff. Officially, large facilities have many workers and high staff-patient ratio, but, in practice, nurses report lower actual numbers of workers, often related to problems of staff burnout and turnover, which lead to staff absences. In contrast to previous research indicating a correlation between type of facility and maltreatment (Wolf et al 2002, Jogerst et al 2006), no such correlation was found in this study, possibly due to sampling bias. of facilities towards preventing maltreatment and patient satisfaction, and for reaching unequivocal policy decisions to close facilities that fail to meet standards. Consumers and policymakers seeking long-term care workforce stability should support increases in wages, benefits and advancement opportunities for front line workers commensurate with the hard work expected of them and the care responsibility entrusted to them. Finally, relatives can play an important role in reporting and preventing elder abuse and mistreatment by paid caregivers in long-term care, and attention should be given to training them to recognise abuse.

This article has been subject to open review and checked using antiplagiarism software. For author guidelines visit the Nursing Management home page at Merav Ben Natan is director of nursing, Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, Hadera, Israel Ariela Lowenstein is professor, faculty of social welfare and health sciences, Haifa University, Israel

Conclusion and implications
This study confirms the need for protection of vulnerable older people in long-term care facilities. It is important to establish enforcement systems in facilities, as well as extrinsic government systems for periodically examining orientation

Online archive
For related information visit our online archive of more than 6,000 articles and search using the keywords.

Allen P, Kellett K, Gruman C (2004) Elder abuse in Connecticut’s nursing homes. Journal of Elder Abuse & Neglect. 15, 1, 19-42. Aström S, Bucht G, Eisemann M et al (2002) Incidence of violence towards staff caring for the elderly. Scandinavian Journal of Caring Sciences. 16, 1, 66-72. Bužgová R, Ivanová K (2009) Elder abuse and mistreatment in residential settings. Nursing Ethics. 16, 1, 110-126. Clarfield A, Ginsberg G, Rasooly I et al (2009) For-profit and not-for-profit nursing homes in Israel: do they differ with respect to quality of care? Archives of Gerontology and Geriatrics. 48, 2, 167-172. Daly J, Jogerst G (2005) Association of knowledge of adult protective services legislation with rates of reporting of abuse in Iowa nursing homes. Journal of the American Medical Directors Association. 6, 2, 113-120. Gibbs L, Mosqueda L (2004) Confronting elder mistreatment in long-term care. Annals of Long-Term Care. 12, 4, 30-35. Goergen T (2001) Stress, conflict, elder abuse and neglect in German nursing homes: a pilot study among professional caregivers. Journal of Elder Abuse & Neglect. 13, 1, 1-26. Harrell R, Toronjo C, McLaughlin J et al (2002) How geriatricians identify elder abuse and neglect. American Journal of the Medical Sciences. 323, 1, 34-38. Harrington C, Zimmerman D, Karon S et al (2000) Nursing home staffing and its relationship to deficiencies. Journals of Gerontology. 55, 5, S278-S287. Jogerst G, Daly J, Dawson J et al (2006) Iowa nursing home characteristics associated with reported abuse. Journal of the American Medical Directors Association. 7, 4, 203-207. Jogerst G, Daly J, Hartz A (2005) Ombudsman program characteristics related to nursing home abuse reporting. Journal of Gerontological Social Work. 46, 1, 85-98. Joshi S, Flaherty J (2005) Elder abuse and neglect in long-term care. Clinics in Geriatric Medicine. 21, 2, 333–354. Lachs M, Bachman R, Williams C et al (2007) Resident-to-resident elder mistreatment and police contact in nursing homes: findings from population based cohort. Journal of the American Geriatrics Society. 55, 6, 840-845. Levine J (2003) Elder neglect and abuse. A primer for primary care physicians. Geriatrics. 58, 10, 37-44. Lindbloom E, Brandt J, Hough L et al (2007) Elder mistreatment in the nursing home: a systematic review. Journal of American Medical Directors Association. 8, 9, 610-616. Macionis J (1997) Sociology. Sixth edition. Prentice Hall, New York NY. MacLean DS (2000) Preventing abuse and neglect in long term care: clinical and administrative aspects. Annals of Long Term Care. 8, 1, 65–70. Pillemer K, Hudson B (1993) A model abuse prevention program for nursing assistants. The Gerontologist. 33, 1, 128–132. Sandvide A, Aström S, Norberg A et al (2004) Violence in institutional care for elderly people from the perspective of involved care providers. Scandinavian Journal of Caring Sciences. 18, 4, 351–357. Wolf R, Daichman L, Bennett G (2002) Abuse of the elderly. In Krug E, Dahlberg L, Mercy J et al (eds) World Report on Violence and Health. World Health Organization, Geneva. Wood S, Stephens M (2003) Vulnerability to elder abuse and neglect in assisted living facilities. The Gerontologist. 43, 5, 753-757.

24 December 2010 | Volume 17 | Number 8


Copyright of Nursing Management - UK is the property of RCN Publishing Company and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.