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CHAPTER SIX: INSTITUTIONAL ABUSE AND NEGLECT

Introduction

6.1 This chapter defines institutional abuse and neglect, considers the indicators of such mistreatment, and details the support and protection measures available to prevent and intervene in situations of institutional mistreatment.

Definition of institutional abuse

6.2 No standard definition of institutional abuse and neglect exists. However, it has become customary "to draw a distinction between individual acts of abuse in institutions and actual institutional or institutionalised abuse" (Glendenning and Kingston, 1999).

6.3 The term 'institution' is used to cover a range of health and social care environments, as well as any environment where service users are engaged with professionals (outside their own home) including:

• Hospitals
• Nursing and care homes
• Day care (including health and social care)
• Respite care (including health and social care)
• Care provided by the voluntary sector
• Hospice care (Payne, 2005)

6.4 It should also be noted that, whilst there is much evidence of the dangers of abuse and violence in custodial institutions, little research has been conducted to understand the phenomena and offer preventative action (Edgar and O'Donnell, 1997; Goldson, 2006).

Characteristics of institutional abuse

6.5 The spectrum of abuse and neglect found within community care spans a substantial range (Bennett, Kingston, and Penhale, 1997) including:

• Death caused by bedrails (Miles and Irvine, 1992; Parker and Miles, 1997)
• Fraud in nursing homes (Halamandaris, 1983; Harris, 1999; Harris and Benson, 1999)
• Lack of basic standards of privacy (Counsel and Care, 1991; 1995)
• Medication abuse (Akid, 2002; Chambers, 1999; Hansard, 2002)
• Neglect associated with under nutrition (Aziz and Campbell-Taylor, 1999; Dodge, 1998)
• Negligence leading to pressure sores (Berlowitz et al., 2000; Payne and Gray, 2002)
• Nursing staff burnout (and burnout amongst other grades of staff) (Duquette et al., 1995; Heine, 1986; Schaufeli and Janczur, 1994; WHO, 1995)
• Organisational factors leading to low standards of care (Commission for Health Improvement, 2000; Wardaugh and Wilding, 1993; Wiener and Kayser-Jones, 1990)
• Physical working conditions in hospitals (Healthcare Commission, 2007; Millard and Roberts, 1991)
• Poor physical care and quality of life (Commission for Social Care Inspection and Healthcare Commission, 2006; Hughes and Wilkin, 1989)
• Resistance to change in care (Smith, 1986)
• Sexual abuse and rape in nursing homes (Burgess et al., 2002; Dergal and de Nobrega, 2000; Ramsey-Klawsnik, 1993; 1996)
• Stagnant activity levels (Ice, 2002; Nolan et al., 1995)
• The erosion of individuality in the care of older people, people with mental health challenges, and people with learning disabilities in hospital care (Brockelhurst and Dickinson, 1996)
• The taking of life in old people's homes and hospitals (Brogden, 2001; Diessenbacher, 1989)
• The use of various types of restraint (Brungardt, 1994; Liukkonen and Laitinen, 1994; Ljunggren et al., 1997; Mapp, 1994; Marks, 1992; McDonnell, 1996; Sullivan-Marx, 1995)

This is not a fully encompassing list and, as our understanding of the dynamics of institutional abuse becomes more sophisticated, the list will develop further. The list does not denote any form of hierarchy of danger and is presented in alphabetical form.

6.6 A range of service users are potential victims of institutional abuse and neglect including adults with physical needs, mental health needs, learning disability needs, etc. Indeed, the definition within the ASP Act provides clarification:

(1) "Adults at risk" are adults who-

(a) are unable to safeguard their own well-being, property, rights or other interests,
(b) are at risk of harm, and
(c) because they are affected by disability, mental disorder, illness or physical or mental infirmity, are more vulnerable to being harmed than adults who are not so affected.

(2) An adult is at risk of harm for the purposes of subsection (1) if-

(a) another person's conduct is causing (or is likely to cause) the adult to be harmed,

or

(b) the adult is engaging (or is likely to engage) in conduct which causes (or is likely to cause) self-harm.

6.7 At least three explanatory models for institutional abuse have been outlined (Bennett, Kingston, and Penhale, 1997; Pillemer, 1998; Wardaugh and Wilding, 1993). Drawing together the work of Pillemer (1998) and Wardaugh and Wilding (1993) produces the following list of factors that are predictive of patient mistreatment:

• Exogenous factor-for example, bed supply and employment rates. Such factors will impact on competition in the sector such as driving up standards and the ability to choose good staff when unemployment is high. In the UK, Kingston (2005) has also argued that the regulators are paralysed; for example, due to bed shortages it is almost impossible to close homes that are reported with inadequate standards
• Institutional environment-for example, inward looking organisations that stifle criticism and complaints are more likely to be abusive. "Whistle blowers" in such organisations are likely to be subject to considerable abuse and bullying. Management failures are caused by inward looking organisations that lack clear lines of responsibility
• Patient characteristics-research evidence suggests a direct link between resident violence and challenging behaviour as predictors of potential abuse (Conlin-Shaw, 1998)
• Staff characteristics-for example, reduced education levels, negative attitudes to older people, and high stress levels
• Finally, the neutralisation of normal moral concerns leads to a situation where people are seen as objects and not subjects; this is closely connected to the imbalance of power, with the powerful in control of the powerless

Support and protection for adults "at risk" of institutional abuse and neglect

Primary intervention

6.8 Numerous commentators have argued that one of the key elements of abuse prevention in the care sector is stringent regulation and inspection (Kingston et al., 2003). The Regulation of Care (Scotland) Act 2001 under Section 29 states:

"Regulations may impose, in relation to care services, any requirements, which Scottish Ministers think fit for the purposes of this Act…";

with Clause 6 of Section 29 stating:

"in particular, make provision as to (i) the promotion; and (ii) the protection, of the health of the persons in question."

6.9 Payne (2006) also notes that Section 6 of the Social Work (Scotland) Act 1968 provides for a power of entry and inspection of any accommodation provided by a local authority, voluntary organisation, or other person.

6.10 Education has been reported as a significant factor in ameliorating the potential for abuse and neglect in long-term care settings (Pillemer and Bachman-Prehn, 1991; Pillemer and Moore, 1989). In the US, the Coalition of Advocates for the Rights of the Infirm Elderly ( CARIE) developed an abuse prevention curriculum designed for nursing assistants in long-term care facilities, which was positively evaluated (Pillemer and Hudson, 1993). It is, though, likely to incur costs for the organisations who train, and for the recipients, both fiscally and in time spent away from the workplace.

6.11 Research has suggested that mandatory training for registered care home owners and managers is necessary to clarify their responsibilities in relation to their actions and the reporting of certain offences to relevant agencies (Furness, 2006). More recently, recommendations from the ' joint investigation into the provision of public services for people with learning disabilities' at Cornwall Partnership NHS Trust ( CSCI/ HCC, 2006) state that the Trust should:

"as a priority, develop a programme of training, supervision and support for all staff which helps them deliver care in accordance with the principles of the Valuing People strategy." ( CSCI/ HCC, 2006: 69).

6.12 "Whistle blowing" can be an important mechanism to expose abuse and neglect in care settings. Organisations must have supportive strategies for individuals who are prepared to "whistle blow" (Hunt and Wainright, 1994); individuals who do "whistle blow" may have the support of the Public Interest Disclosure Act (1998) ¹⁴, which offers legal support for individuals who voice concerns that are in the public interest:

Secondary intervention

6.13 Evidence suggests that when abuse and neglect is suspected or reported, joint investigations offer a more effective response (Rushton et al., 2000). For example, joint investigator training has been found to improve the consistency of investigation between the police and social services or health care services. Joint training has latterly become essential due to the complexities of legislation (for example, in relation to capacity) and the desire to collect evidence of abuse and neglect in a systematic and rigorous way that will satisfy the courts and legal systems.

6.14 The provision and conduct of personal care has been located as an area where abuse is a high risk factor (Cambridge and Carnaby, 2000, Carnaby and Cambridge, 2002). It is therefore essential that agencies have unambiguous 'intimate care' policies and procedures. The charity 'Sense' has a range of policies that are aimed at protection and include a thorough 'intimate care' policy.

6.15 Scottish Executive statistics show over 57,000 older people receiving home care services across Scotland in 2005-6 ¹⁵. These demographics suggest that a major resource is required to ensure that support and protection is in place for people receiving home care.

Tertiary intervention

6.16 Rigorous recruitment procedures are essential; see 5.18. Managers working in any form of continuing care must request references from former employers. It is also good practice to interview potential employees regarding their attitudes and values to the potential client group.

6.17 Disclosure checks facilitate safe recruitment practice; see 5.18. It is important that welfare agencies and care providers ensure people who are deemed unsuitable for care and support work do not gain access to vulnerable adults. The effectiveness of the Criminal Records Bureau system has not been subject to scrutiny; there are however anecdotal reports of individuals with criminal records being employed who have immediately gone on to abuse. However, the Bichard Inquiry has made recommendations on strengthening the disclosure process, leading to new legislation in both England & Scotland (Safeguarding Vulnerable Groups Act 2006 ¹⁶; Protecting Vulnerable Groups (Scotland) Act 2007 ¹⁷). As such, there is now the statutory basis for a more rigorous, efficient and effective vetting procedure to assist safe recruitment.

6.18 Stringent disciplinary systems within agencies are essential. Registered agencies should have a standard policy to refer staff to the POVA list if they meet the criteria.

6.19 Advocacy, choice, and empowerment are key interventions for victims of institutional abuse. The British Institute of Learning Disabilities ( www.bild.org.uk ) produces a variety of products aimed at professionals engaged in advocacy. The Scottish Independent Advocacy Alliance, "… promotes, supports, and defends the principles and practice of independent advocacy across Scotland" ( www.siaa.org.uk) ¹⁸. The effectiveness of advocacy has been discussed at 4.17, 4.18, and 4.19.

Conclusion

6.20 In 2002, the American National Centre on Elder Abuse published a variety of options to reduce the risk of nursing home abuse as noted below; (these recommendations have been anglicised by the authors and can be translated as appropriate to other forms of long-term care):

• Improvement of coordination between the various legal agencies, regulation and registration services, and advocacy organisations that are involved in nursing home care
• Improvement of conditions for workers through adequate staffing, enhanced communication between direct care staff and managers, with more time to nurture relationships between staff and residents, decent/rewarding salaries, opportunities for upward mobility, and greater recognition, respect, and understanding for the difficult lives many workers lead
• Training that focuses on interpersonal care-giving skills, managing difficult resident care situations, problem solving, cultural issues that affect staff-resident relationships, conflict resolution, stress reduction techniques, information on dementias, and witnessing and reporting abuse
• Improvement of compliance with the regulations for disclosure checks and references prior to employment
• Improvement of reporting through consumer education
• Creation of support groups for nursing assistants and care staff
• Development and strengthening of resident councils
• Creation of environments that are conducive to good care
• Establish consistent definitions of abuse to improve tracking and research

The various elements of prevention and intervention mentioned above are effective in situations of a single occurrence of abuse (for example, an assault) or in situations where there are repeated occurrences.

6.21 In designing prevention strategies, agencies must be aware of the costs with regard to time and resource. One way of developing a persuasive argument for agencies to engage with education and training is to evaluate the implications for their agency should a major inquiry occur.

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