Introduction

In this chapter we would like to introduce you to safeguarding older people. You may already have heard the term ‘safeguarding’ used during your course or while on your clinical placements. Set within contemporary policy and within the particular context of older people, we explore what is meant by ‘safeguarding’, consider elder abuse as a phenomenon, highlight some of the complexities of identification and management, explore your role as a student in relation to safeguarding older people and identify effective strategies for identifying, reporting and preventing elder abuse in the practice setting. We also help you think about the role of the nurse generally in terms of professional accountability within the field of safeguarding

Policy background

The abuse of older people is not a new phenomenon and in 1975 Baker introduced the term ‘granny bashing’ to describe the abuse of older people (Baker 1975). While this term is now outdated, for example we now acknowledge that abuse is neither purely physical in nature nor does it exclusively relate to women (Phelan, 2008) it highlights both the longevity of the problem and until relatively recently, the largely hidden nature of abuse of older people. In 2000 the Department of Health published a landmark document entitled No Secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse (Department of Health, 2000). This document, though not exclusively for older people, was pivotal in providing a clear framework for adult safeguarding generally and formed the foundation for the development of multi-agency policy development and implementation across services at a local level.

In 2005 a follow-up document, Safeguarding Adults: a national framework of standards of good practice and outcomes in adult protection work, was published by the Association of Directors of Adult Social Services (ADSS 2005) with the aim of consolidating and developing standards for good practice and outcomes in adult protection work.

Standards 3, 4 and 5 (ADSS 2005: 3) specifically relate to the prevention of abuse:

Latterly, The Mental Capacity Act (2005) which came into force on the 1st October 2007 (Department for Constitutional Affairs 2007) provides a rights-based framework for decision-making in questions relating to individual capacity. The Mental Capacity Act (MCA) has a pivotal role to play within safeguarding as its core aim is to protect the rights of adults (aged 18 years and over) who may be deemed to lack capacity and the following core standards apply. There are a number of core principles that underpin the MCA and a central tenet of the act is the assessment of capacity and the definition of ‘best interests’. There are specific guidelines in relation to the assessment of capacity, for example assessment of capacity should not be made on the basis of age.

The Deprivation of Liberty Safeguards (DoLs) are an important amendment to the MCA. They provide a legal framework to protect adults (aged 18 years and over) who lack the capacity to consent to particular facets of their treatment or care, for example a person with a dementia.

As a health care professional it is important that you are familiar with the current legislation in relation to capacity and consent and we have provided a link below to the NMC website which offers further guidance and information:

Now that we have explored the background and policy development in relation to safeguarding, we would now like to examine some of the key issues surrounding safeguarding older people and elder abuse.

Defining elder abuse

We would like you to start thinking about your existing knowledge about elder abuse.

Elder abuse is a hugely complex phenomenon encompassing a wide range of harms which have the potential to directly impact on the lives of older people (McCreadie 2002). The No Secrets report (Department of Health 2000: 9), for example was developed within the context of ‘vulnerable adults’ and as such it defines a ‘vulnerable adult’ as:

However, while elder abuse has been widely debated within the literature, there has been a general lack of clarity regarding a clear definition. Some authors for example have suggested that the traditional definition of abuse and notions of vulnerability as expressed in No Secrets does not adequately capture the heterogeneity of those who may experience abuse (McCreadie, 2002).

In acknowledging the broad scope of elder abuse and the complex dynamics of interpersonal relationships beyond those that are overtly vulnerable, Action on Elder Abuse (AEA) have suggested the following definition:

As a final important point, more recent debates surrounding abuse in later life have also drawn clear distinctions between elder abuse and other forms of family violence for example, intimate partner violence or domestic abuse (Penhale, 2003, McGarry et al, 2011).

It is important to note that Competence 1 in this NMC Domain of Professional Values has to be achieved by student nurses undertaking all fields of practice pathways. These are known as Generic Competencies.

The prevalence of elder abuse

As we have noted throughout this book, the United Kingdom has an ageing population. There is little evidence however regarding the prevalence of abuse and mistreatment among the older population although it has been estimated that between approximately 4% and 5% of older people have been subject to some form of mistreatment or abuse (O’Keeffe et al, 2007, Help The Aged, 2008).

Elder abuse is a largely hidden problem for a number of reasons, for example, embarrassment or fear of reporting of elder abuse by those who have been subject to abuse or due to the frailty of the older person and the lack of physical means (disability or lack of access to telephone) to report the abuse. As such, there has been very little research or exploration around elder abuse as a whole (Neno and Neno, 2005). In 2003 The Community and District Nurses Association (CDNA) carried out a survey among members about their experiences of encountering elder abuse during their practice (CDNA, 2003). Of the 718 individuals who completed the survey, 88% stated that they had encountered abuse within their caseload with 12% stating that this occurred on a monthly basis. While caution needs to be exercised in generalising from the findings, it does however highlight that elder abuse is a significant issue.

In 2004 Action on Elder Abuse (AEA) published a report which was based on analysis of approximately 7000 phone calls to the AEA helpline (which was accessible to both members of the public and professionals) over a period of approximately seven years, again highlighting the significance of elder abuse as an issue.

In 2007 Comic Relief and The Department of Health commissioned a study to explore the prevalence of neglect and abuse of older people in the United Kingdom (O’Keeffe et al, 2007). Over 2,100 people aged 66 years and over who were living in private accommodation (including sheltered housing) took part in the survey which was undertaken over a six month period in 2006. It should be noted that the survey did not include those in residential or nursing home care or those with cognitive impairment.

Taken together, these reports offer an insight into the possible prevalence and characteristics of elder abuse and mistreatment in the United Kingdom. Although, given that elder abuse is a largely hidden phenomenon, this very likely to represent an under reporting of the true extent of the issues.

Overall, both the AEA (2004) and O’Keeffe et al (2007) studies report that women are more likely to be the victims of abuse. There may be a number of reasons for this difference between men and women, for example, the longevity of women and the possible home circumstances, i.e. women are more likely to be living alone, or the social norms which dissuade men from disclosing their experiences of abuse.

There is relatively limited evidence regarding the place of abuse. However in the AEA (2004) study almost a third (64%) of all reports of abuse suggested that the abuse had occurred in the older person’s own home. Nevertheless the authors also noted that a disproportionally high number of calls appeared to be generated from residential and nursing homes, given that a small number of older people, approximately 5%, live in this type of accommodation. There is no comparable data from the O’Keeffe et al (2007) study as this work excluded those living in residential or nursing home care.

In the AEA (2004) study the perpetrators of abuse were predominantly men, although it was recognised that abuse was also occurring in situations of ‘collusion’ and therefore could involve both men and women together. Moreover, the study also identified that while male abusers were most likely to be relatives, female abusers also encompassed those employed as paid carers. These findings were broadly echoed by O’Keeffe et al (2007) who also found that on the whole interpersonal abuse was more commonly carried out by men.

The AEA (2004) study identified that the most frequently reported type of abuse was neglect and psychological abuse followed by financial and physical abuse. This is also reflected by O’Keeffe et al (2007) who also found that financial, psychological and physical abuse were the most often reported forms of abuse. However, while reports of sexual abuse were relatively low, AEA (2004) also noted a growing trend in the reports of this type of abuse during the course of the survey (rising from 1.9% in 2000 to 3% in 2003). AEA (2004) also highlighted that discrimination, community harassment and ‘loss of power’ were reported to the helpline, thus further illuminating the broad scope of elder abuse.

This section has illuminated the broad nature of elder abuse in terms of prevalence and defining features. However, as mentioned throughout this chapter elder abuse is a complex phenomenon and as such reports to date, while providing valuable insights should not be considered purely in isolation. As highlighted by Penhale and Kingston (1995) almost two decades ago, there has been a clear shift from early research in this area which sought to establish a clear ‘profile’ of a typical victim of abuse. It is now crucial that the heterogeneity of both the older person and the circumstances within which elder abuse takes place is acknowledged.

Later in this chapter we will offer guidance regarding the support mechanisms available to you and how to respond if you suspect or witness elder abuse or if elder abuse is reported to you, for example by a colleague or fellow student.

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