Nurse Responses to Elder Mistreatment An IAFN Education Course

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Nurse Responses to Elder MistreatmentAn IAFN
Education Course
Screening and Assessment of Elder Mistreatment

• Module 6

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Screening and Assessment

• Nurses need to know how to screen, assess,
  document and report elder mistreatment (EM)
• Screening provides an opportunity to detect or
  rule out EM
• If there is a suspicion, screening can trigger
  full assessment

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Learning Objectives

• By the end of this module, participants will be
  able to
• Discuss why, when, where, with whom and how
  screening and assessing older adults for EM
  should occur
• Describe steps in interviewing
• Discuss appropriate questions to ask
• Describe techniques to communicate with patients
  and their families and caregivers during
  screening/assessment process

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Case Mr. Rodriguez

• What do you see as presenting issues?
• What additional information does the nurse
  practitioner need in order to proceed and respond
  effectively?
• What screening questions could the nurse
  practitioner ask in her initial conversation with
  Mr. Rodriguez? With the son?
• Do you foresee any screening or assessment
  challenges with the patient and the son?

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Screening and Assessment Process

• Why should nurses screen/assess?
• Where should screening/assessment take place?
• Who should be screened/assessed?
• When should screening/assessment take place?
• How should screening/assessment be conducted?

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Where?

• Screening and assessment for EM should occur in
  community settings and long-term care facilities

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Who?

• Ideally, nurses should screen every vulnerable
  older adult for EM
• However, many practice settings screen only when
  signs of mistreatment are identified or when
  there is cause to suspect mistreatment

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When?

• A few simple questions can routinely be included
  in nurse interactions with all older patients (as
  appropriate to practice setting)
• Additional questions can be asked if
  concern/suspicion is raised

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How?

• A specific plan for screening and assessment for
  elder mistreatment should be incorporated into a
  practice settings written policies

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Tools for Screening/Assessment

• Screening and assessment for EM can be
  facilitated through use of assessment tools
• These tools typically require discussion with
  patient and others who accompany patient

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Questions to Ask?

• What screening and assessment questions would be
  useful to ask older patients to screen/assess for
  elder mistreatment?

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Interviewing Patients

• First ask general questions
• Then ask more questions as necessary
• Probe for physical abuse, psychological abuse,
  sexual abuse, neglect, abandonment and
  exploitation
• If you received an affirmative answer regarding a
  possible incident of mistreatment, follow-up to
  determine
• How did it occur? When did it occur?
• Where did it occur? Who was involved?
• Document statements in medical record

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9 General Screening Questions

• Based on AMA guidelines (1992)
• Has anyone at home (or nursing home) hurt you?
• Has anyone at home (or nursing home) ever touched
  you without your consent?
• Has anyone at home (or nursing home) ever made
  you do things you did not want to do?

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9 General Screening Questions (cont.)

• Has anyone at home (or nursing home) ever scolded
  or threatened you?
• Are you afraid of anyone at home (or at nursing
  home)?
• Are you often left alone at home (or nursing
  home)?
• Has anyone at home (or nursing home) ever failed
  to help you take care of yourself when you needed
  help?

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9 General Screening Questions (cont.)

• More specific questions may be asked of residents
  in long-term care settings
• Since you have been here, has any employee,
  resident, family member, volunteer or visitor
  hurt you?
• OR
• Since you have been here, has any employee,
  resident, family member, volunteer or visitor
  hit, slapped or otherwise hurt you?

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More Probing Questions

• What are additional questions to ask to probe for
  physical abuse, psychological/emotional abuse,
  sexual abuse, neglect, abandonment and
  exploitation?

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Follow-Up Questions

• If a patient answers YES, say
• Im glad you told me about this.
• When was the last time?
• Can you give me an example?

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Normalize Task of Asking Difficult Questions

• It is hard for nurses to ask these questions, but
  thats what they often have to do ask difficult
  questions so they know what the patient is
  dealing with and then can help the patient/make
  it safe for them to disclose
• T. Fuller, Try this Elder mistreatment
  assessment, 2008

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Consider

• What communication techniques and methods during
  screening and assessment might help raise the
  comfort level of the patient and elicit accurate
  and important information?

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Communications w/Patients

• Seek informed consent, explaining scope and
  limits of confidentiality
• Ask about and plan for patient safety

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Communications w/Patients

• Questions first directed at patient
• Even if an older adult has a cognitive
  disability, it is reasonable to ask about
  mistreatment
• S. Aravanis, R. Adelman, R. Breckman, T. Fulmer,
  E. Holder, M. Lachs, J. OBrien A. Sanders,
  Diagnostic and treatment guideline on elder abuse
  and neglect, Archive of Family Medicine, 1993

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Communications w/Patients

• Question patients initially in a private setting,
  away from caregivers, family or others
• Aravanis, Adelman, Breckman, Fulmer, Holder,
  Lachs, OBrien Sanders

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Communications w/Patients

• Keep questions simple and direct

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Communications w/Patients

• Find out the patients preferred method of
  communication
• Consider how circumstances of patient might
  affect communications and accommodate when
  possible
• Use communication strategies that encourage
  patients to talk openly and honestly with you

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Communications w/Patients

• Give patients a sense of hope and help them open
  up
• Use a warm, caring and empathic manner
• Anticipate and work to overcome reluctance to
  disclose mistreatment

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Screening/Assessment Leaves Door Open

• Many patients will deny mistreatment or refuse to
  discuss it
• However, screening and assessment lets them know
  someone cares and help is available
• B. Brandl, Assessing abuse in later life , 2004

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Questioning Family and Caregivers

• How will you, as the nurse, approach this
  situation given suspicions of mistreatment?
• What challenges do you face with situations like
  this?
• What questions need to be asked of each person
  involved? What additional information would be
  useful to know?
• Does the nephew have the authority to tell you
  how to handle this case? What strategies will
  you use to talk with Mr. Jones in private?

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Get Statements from Others

• The likelihood of detecting or ruling out elder
  mistreatment increases as the net of observation
  and inquiry made by clinicians is widened G.
  Anetzberger (Ed.), The clinical management of
  elder abuse, 2005.
• Obtain statements from others after talking alone
  with the patient (even when you think the patient
  lacks decision-making capacity)

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Guardians/Holders of Power of Attorney

• If a patients decision-making capacity is
  questionable, you may need to discuss matters
  with a legal guardian or holder of power of
  attorney, if one exists (unless that person is
  the suspected perpetrator)
• National Center on Elder Abuse, Guardianship and
  other legal protections of vulnerable adults ,
  2007

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If Suspect Presents with Patient

• Observe behavior
• Ask questions

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Sample Questions

• What does your _____ (e.g., father/mother) need
  help with every day?
• How do you and your ______ handle disagreements?
• What expectations does your ______ have of you?
• Is caring for your _____ different than you
  thought it would be? How?
• Sometimes providing care for a family member is
  challenging. What do you do or who do you tell
  when you are feeling stressed?
• R. Chez, Elder Abuse An Introduction for
  Clinicians (Slide presentation), 2009

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Separating Family Members and Caregivers from
Patients

• Be creative in separating hovering family
  members or caretakers (including those who may be
  suspects) from patients to create a window of
  time to ask questions

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Closing Assessment

• What have you learned from this module that you
  can apply to your practice setting?

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Optional Activity

• Role plays to practice asking questions and using
  communications techniques
• Round 1 A (Observer), B (Nurse), C
  (Patient/Other)
• Round 2 A (Nurse), B (Patient/Other), C
  (Observer)
• Round 3 A (Patient/Other), B (Observer) C
  (Nurse)

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Debriefing Questions

• Ask Nurse What did you do that worked in this
  situation? What would you change? What did you do
  to address challenges?
• Ask the Observer What behaviors did the nurse
  demonstrate that were effective in communicating
  w/patient and screening/assessing for
  mistreatment? What else could the nurse could
  have done?
• Ask Patient What did the nurse do that you found
  helpful? What would you like nurse to do to
  further help you? OR
• Ask Those who Accompany Patient What did nurse
  do to gain info? What else could she have done?