CORE ELEMENTS OF EVIDENCED-BASED 1.
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GERONTOLOGICAL PRACTICE AND VIOLENCE AND
ELDER MISTREATMENT
EVIDENCED-BASED GERONTOLOGICAL PRACTICE
OVERVIEW OF EVIDENCED-BASED PRACTICE
Conduct of Research
• Dissemination of findings via research reports in
journals and at scientific conferences
Research Utilization
• Process of using research findings to improve patient
care
The following are identified when we do research utilization:
▪ Dissemination of scientific knowledge
▪ Critique of studies
▪ Synthesis of research findings
▪ Determining applicability of findings for practice
▪ Developing an evidenced-based standard or guideline
▪ Implementing the standard
▪ Evaluating the practice change with respect to staff,
patients, and cost/resource utilization
Evidenced-Based Practice
• Synthesis and use of scientific findings from
randomized clinical trials only.
• Use of empirical evidence from other scientific
methods and use of information from case reports and
expert opinion.
• The integration of best research with clinical expertise
and patient values.
• Use of research findings in clinical and operational
decision-making, as well as use of case reports and
expert opinion in deciding the practices to be used in
health care.
MODELS OF EVIDENCED-BASED PRACTICE
IOWA Model of Evidenced-Based Practice
• Published in 1994
• An organizational, collaborative model that
incorporates conduct of research, use of research
evidence, and other types of evidence.
• Conscientious and judicious use of current best
evidence to guide health care decisions.
• Uses knowledge and problem-focused “triggers”
Clinical Topics of Evidence-Based Practice for Care of
Older Adults
• Prevention and treatment of pressure ulcers
• Fall prevention
• Prompted voiding for persons with urinary incontinence
• Management of constipation
• Exercise promotion
• Hypertension detection and treatment
• Acute pain management
Steps in Evidenced-Based Practice
a. Problem-focused triggers
− These are those identified by staff through
quality improvement, risk surveillance,
financial data, bench marking data or
recurrent clinical problems
− Example: Increased incidence of acute
confusion in Hospitalized older adults (it is
common in older persons)
b. Knowledge-focused triggers
− These are ideas generated when staff read
research, listen to scientific papers at
research conferences or encounter EBP
guidelines published by federal agencies or
specialty organizations.
− Example: Initiated from acute pain
management or prevention of skin
breakdown, because we know we have that
knowledge that when a patient experiences
this type of concern in the clinical setting, we
do have a way to back-up that evidence
based on the management that we will be
providing the patient.
2. Forming a team (Evidenced-based practice team)
▪ An early task it to formulate evidenced-based practice
question:
✓ Type of people/patients
✓ Interventions or exposures
✓ Outcomes
✓ Relevant study designs that are likely to
provide reliable data to address the clinical
3. Retrieving the evidence
▪ Should include:
✓ Clinical studies
✓ Meta-analyses
✓ Integrative Literature Reviews
✓ Evidence-Based Practice Guidelines
4. Critiquing the evidence
▪ Includes:
✓ Critique of research
✓ Synthesis reports
✓ Evidence-Based Practice Guidelines
▪ Grading the evidence (2 important areas):
a. The quality if the individual research
b. Strength of the body of evidence
▪ Critical areas to assess when critiquing:
a. Date of publication or release
b. Authors of the guideline
c. Endorsement of the guideline
d. A clear purpose of what the guideline covers
and patient groups for which it was designed
e. Types of evidence used in formulating the
guideline
f. Types of research included in formulating the
guideline
g. A description of the methods used in grading
the evidence
 h. Search terms and retrieval methods used to
acquire research and non-research evidence
used in the guideline
i. Well-referenced statements regarding practice
j. Comprehensive reference list
k. Review of the guideline by experts
l. Whether the guideline has been used or tested
in practice
5. Setting forth evidence-based practice recommendations
based on critique and synthesis of the evidenced.
METHODS OF COMMUNICATION
6. Decide if findings are appropriate for use in practice.
Important Components
Things to consider if findings are appropriate to use in practice:
1. Relevance of evidence for practice (how relatable it is
in the practice of your profession)
2. Consistency in findings across studies or guidelines
3. Significant number of studies or evidenced-based
guidelines with sample characteristics similar to those
for which the findings will be used
4. Consistency among evidence from research and other
non-research evidence.
5. Feasibility for use in practice (how likely is it that that
type of evidence will be used in the practice of your
profession)
6. Risk or benefit ratio (does it provide more harm than
the potential benefit that it could provide for the patient)
7. Writing an evidence-based practice standard specific to the
health care setting, using the grading schema that has been
agreed on.
Things to consider when writing a standard specific to health
care setting:
• The practices are mainly based on evidence
• The type of evidence that will be used
8. Implement the evidence-based changes in practice.
9. Evaluation.
Barriers that staff encounter in carrying out the practice:
• Lack of information, Lack of skills of the health care
provider, Lack of necessary equipment that could
hinder the health care provider to provide the
necessary service to the patient
• Check the differences and opinions among health care
providers
• Check the difficulty in carrying out the practice as
originally designed.
IMPLEMENTATION STRATEGIES
Roger’s Model
• Roger’s seminal work on diffusion of innovations is
extremely useful in selecting strategies for promoting
adoption of evidence-based practices.
• Adoption of innovations such as evidence-based
practices is influenced by the nature of the innovation
and the manner in which it is communication to
members of a social system
NATURE OF THE INNOVATION/EVIDENCE-BASED
PRACTICE
Application of Evidence in the Bedside:
• Information from evidence-based practices must have
perceived benefits for patients, nurses, physicians, and
administrators.
• Be reinvented and integrated into daily patient care
processes (when applied to the bedside)
• Impart evidence in a readily available format
• Make evidence-based practices observable for
practitioners
1. Education of staff
− Continuing education alone does little to
change practice behavior, it should be
interactive and deductive education that will
be used in combination with the other
practices in the setting because it has more
positive effects.
− Further studies, at the same time studies
related to a specific specialty like for example
gerontological nursing, should be integrated
and collaborated in the practice of their
profession
2. Opinion leaders
− Effective in changing behaviors of health care
practitioners and usually they use
combination and outreach performance
feedback and the key characteristic is he/she
is trusted to evaluate new information in
context of group norms. To do this, an opinion
leader must be considered by an associate as
a technically competent, and a full and
dedicated member of a local group.
− Some may identify an opinion leader as those
who are in supervisory position (e.g. head
nurse or nurse supervisor)
3. Change champions
− Also helpful in implementing EBP changes in
the practice of the profession
− They are practitioners in the local group who
are expert clinicians, passionate about the
clinical topic and are committed in improving
quality of care to the patient
− They usually have positive working
relationship with other health care
professionals
− Example: Those usually found in the clinical
or patient care units, specifically in a specified
area in the department
4. Core groups
− It is in conjunction with change champions
and they are also helpful in implementing the
practice of change.
− A select group of practitioners with a mutual
goal of disseminating information regarding
practice change and facilitating the change in
practice by other staff in their unit or peer
groups.
− Success of the core group approach requires
the members to work well with the change
 champions and represent various shift or ROLE OF NURSES IN PROMOTING EVIDENCED-BASED
days of the week and 10 years in the practice PRACTICE
setting.
Advanced
− Usually core group members are Nurse Manager
Staff Nurse (RN) Practice Nurse
knowledgeable about scientific basis for the (NM)
(APN)
practice and assist each member by changing Questions current Serves as coach Creates
their practices in a positive way. practices and mentor in microsystem that
5. Consultation of experts in the content area EBP fosters critical
− Outreach and consultation of an expert thinking
promotes positive change in practice- Participates in Facilitates Challenges staff
behaviors of nurses and physicians. implementing locating evidence to seek out
− Outreach is when an expert meets one on changes in evidence to
one with a practitioner in their setting to practice based on resolve clinical
provide information about the EBP and evidence issues and
feedback on provider performance. improve care
Participates as a Synthesizes Role models EBP
− This strategy alone or in combination with
member of an evidence for
other strategies results in positive changes in EBP project team practice
the health care practices. Reads evidence Uses evidence to Uses evidence to
Users of Innovations/Evidence-Based Practice related to one’s write/modify guide operations
practice practice standards and management
1. Performance Gap Assessment decisions
• Informs members at the beginning of change, Participates in Role models use Uses performance
about a practice performance and quality of evidence in criteria about EBP
opportunities for improvement improvement practice in evaluation of
initiatives staff
Suggest Facilitates system
resolutions for changes to
2. Audit and Feedback
clinical issues support use of
• Is an ongoing auditing of performance based on EBPs
indicators throughout the implementation evidence
process and discussing the findings with
practitioners during the practice change. Resources for Evidence-Based Practice
• This strategy usually help staffs know and see
how their efforts to improve care and patient • Academic health care setting which individuals
outcomes are progressing throughout the knowledgeable about EBP or gerontology
implementation process. • Local librarians (assist in finding literature)
• Example: When you do a research, you have • National centers (e.g. research centers specific for
a specific tool that you use. An you also ask gerontological practice)
you respondents a feedback, comment, or • Other written resources (e.g. books like “Geriatric
suggestions how the research went through Nursing Protocols for Best Practices”)
or how smooth it was during the data
FUTURE TRENDS IN EVIDENCE-BASED PRACTICE AND
collection process.
TRANSLATION SCIENCE
Social System
Future Trends Include:
• Has a high degree of influence on adoption of an
1. Creating organizational practice cultures that support
innovation
EBP
ADDITIONAL ORGANIZATIONAL VARIABLES THAT 2. Teaching graduate and undergraduate students the
INFLUENCE ADOPTION (variables that one need to consider) knowledge and skills necessary to practice, based on
evidence
1. Access to investors/researchers 3. Redesigning health care work to have evidence readily
2. Authority to change practice available for direct care providers
3. Support from and collaboration with peers, other 4. Providing human and monetary resources that support
disciplines, and administrators to align practice with the EBP
evidence base
Translation Science
Sites of Care Deliver where we usually see EBP in our
profession • The investigation of methods, interventions, and
variables that influence adoption of EBPs by
• Home health individuals and organizations to improve clinical and
• Ambulatory operational decision making in health care
• Hospital • Usually for organizations to take advantage of EBP,
• Skilled and long-term care settings they would encourage the local area or involved
national centers for translation science because its
 influence would adopt the core principles of EBP in our
profession.
VIOLENCE AND ELDER MISTREATMENT
Elder Mistreatment
- is the outcome of abuse, neglect, exploitation, or
abandonment
- involves physical abuse, sexual abuse, emotional/
psychological abuse, neglect abandonment, financial/
maternal exploitation, and self-neglect.
TYPES OF ELDER MISTREATMENT
1. Physical Abuse
- intentional affliction of physical injury or pain
- i.e. hitting, shaking, improper use of physical restraints,
pushing
- s/sx: bruises, bone fractures, injuries, black eyes,
different stages of wound healing
2. Psychological/ Emotional abuse
- infliction of anguish, pain or distress
- i.e. yelling, swearing, name-calling
- s/sx: detected with emotional upset or agitation or
extreme withdrawal
3. Sexual Abuse
- use any form of nonconsensual, sexual intimacy
- i.e. rape, sexual harassment, molestation
- s/sx: genital bruising, unexplained sexually transmitted
disease
4. Financial Exploitation
- taking advantage of an older person for monetary or
financial benefit
- i.e. unexplained monetary expenditures, lack of money
for personal necessities (food, groceries, or personal
items), unexplained ability to pay bills
5. Caregiver Neglect
- active or passive failure to meet needs necessary for
elder’s physical and mental well-being
- i.e. failure to provide adequate food, shelter, clothing,
medical care, hygiene, or social stimulation
- s/sx: dehydration, malnutrition, unattended or
untreated health problems, decubitus ulcers, burns,
history of being left alone.
6. Self-neglect
- there is personal disregard or inability to perform self-
care
- s/sx: poor hygiene, unkempt home environment,
malnutrition, fungal skin and nail infections, insect or
rodent infestation
7. Abandonment
- desertion or willful forsaking of the elderly
- i.e. dropping off an older person in the ER without
accompanying the older person through the whole
process (left inappropriately alone)
8. Institutional mistreatment
- older adult has contractual arrangement and suffers
abuse or neglect or combination
CATEGORIES OF ELDER MISTREATMENT
1. Domestic mistreatment generally occurs within the older
adult’s home dwelling at the hand of significant others
2. Institutional mistreatment occurs when an older adult has
a contractual management and suffers abuse.
3. Self-neglect when older adults who are mentally
competent enough to understand the consequences of their
own decisions engage in behaviors that threaten their own
safety.
CHARACTERISTICS OF OLDER ADULTS AT RISK
Risk Factors for Elder Mistreatment:
• Age
• Sex
• Race
• Low socioeconomic status
• Low educational level
• Impaired functional or cognitive status
• A history of domestic violence, stressful events, and
depression
CHARACTERISTICS OF PEOPLE WHO MISTREAT OLDER
ADULTS
• Likely to be male
• Substance abuse involved
• Mental illness present
• Dementia
• Lack strong social networks
• More dependent on the care recipient for financial or
other needs
• Family members
THEORIES OF ELDER MISTREATMENT
1. Psychopathology of the abuser
- refers to caregivers who have pre-existing conditions
which impair their ability to provide appropriate care
- i.e. mental retardation, alcohol dependency (may not
able to exercise appropriate judgement
2. Transgenerational violence
- usually sought to be part of the family violence
continuum which may begin as child abuse and end in
elder mistreatment
- characteristics of the abuser in the previous life and
family members may be part of the abuser because it
may depend on their family history
3. Learning Theory
- means that a child who observes violence has a
coping mechanism may learn it and bring to adult life
4. Situational Theory
- also referred to as “caregiver stress”
- care burden multiplies and the caregiver’s capacity to
care for the older adults declines therefore, caregiver
stress can overwhelm the situation
5. Isolation Theory
- espouses that mistreatment is prompted by swindling
social networks
- according to statistics, there is about 25% of elderly
persons who live alone and even more interact with
only family members and have limited social interaction
- isolated older adults are of particular risks because
there are no outsiders which may wat-out for them
ASSESSMENT
• Screening
• Interview with patient and suspected abuser is done
separately
 • Maintain a nonjudgmental environment
• Assess caregiver stress
• A score of 7 or more indicates presence of significant
caregiver strain
• Use of empathetic communication

PHYSICAL EXAMINATION

• Presence of fresh and healing injuries Assessment:

• Laboratory findings that support dehydration and Cognitive status; Health and functional status, frequency,
severity, and intent; Emotional status; Social and financial
malnutrition without medical causes resources

• if you suspect elder mistreatment or abuse, a complete

visual examination of the older person without clothing
is necessary (abusers usually strike where clothing FUTURE CONSIDERATIONS
hides the bruises). You can protect privacy by viewing
the older person’s body on are at a time from head to Barriers to Detecting & Treating Elder Mistreatment:
toe. • Victims hide the mistreatment
• Cultural issues
NURSING DIAGNOSIS • Inadequate educational preparation of healthcare
professionals (it is always encouraged for nurses to
• Caregiver role strain have further studies regarding elder mistreatment and
• Coping, ineffective family: compromised violence)
• Coping, ineffective family: disabling
• Coping, ineffective individual
• Protection, altered
• Rape-trauma syndrome
• Selfcare deficits
• Self-esteem deficits
• Social isolation
• Violence, risk for

INTERVENTIONS

• Requires an interdisciplinary team approach

- some forms of elder mistreatment such as caregiver
neglect can benefit from this by:
✓ assisting stress in formal caregiver in disease
management or maximizing the healthcare
services of the setting/ facility
✓ assist in behavioral management
✓ create a caregiver support group for the
interventions that may happen during
interdisciplinary approach
Recommended Steps in Preventing Elder Abuse:
1. Residents and significant others should join or form a
resident’s council
2. Residents and their significant others must stay
informed by being active participants in care plan
meetings and monitoring care
3. Significant others should stay connected to long-term
care residents and visit at varied times

DOCUMENTATION

• Documentation must be in an unbiased manner

• Physical indicators of the mistreatment must be stated
clearly
• Photo-documentation may be necessary (usually
warranted during physical and sexual abuse)
IMPLICATIONS FOR GERONTOLOGICAL NURSING
PRACTICE
Diagnostic & Treatment Guidelines on Elder Abuse &
Neglect