The COVID-19 pandemic revealed the best and the worst aspects of nursing homes. The media described feats of heroism as staff put their lives at risk to care for residents, but there were also portrayals of nursing homes as “death traps” and a sense that residents had been put at risk, or worse, abandoned. It will take time to fully evaluate all that was experienced and to ensure safety and quality in the future. We have studied elder mistreatment for decades and observe that we do a poor job preventing mistreatment. Instead, we wait for it to happen and then find those to blame. What if we started from a position of prevention?
According to the World Health Organization, elder mistreatment is a single or repeated act, or a lack of appropriate action, occurring within any relationship where there is an expectation of trust, and which causes harm or distress to an older person. This type of action constitutes a violation of human rights and includes physical, sexual, psychological, and emotional abuse; financial and material abuse; abandonment; neglect; and serious loss of dignity and respect. An American Academy of Nursing policy brief (Nursing Outlook, 2015) argues that older adults are at greater risk for mistreatment due to a variety of factors, including physical and cognitive challenges, making them particularly vulnerable. To reduce or eliminate elder mistreatment, innovative approaches are urgently needed. One such innovation is the implementation of elder mistreatment prevention rounds (EMPRs). This is not case finding—it is case prevention.
Investigators often ask, “Does elder mistreatment happen in nursing homes and how can we identify cases?” This suggests that elder mistreatment has already happened. We propose EMPRs as a new approach that will prioritize prevention using a coordinated, interdisciplinary team. Regular surveillance of high-risk residents that garners input from residents, families, and staff is the way to start. For example, an older resident who has dementia and end-stage chronic obstructive pulmonary disease as well as difficulty eating is at high risk for skin breakdown, often considered the outcome of neglect. Prevention is paramount.
How do we use EMPRs to eliminate or reduce cases? There was a time when physicians would wait until a person experienced a cardiac arrest before embarking on a therapeutic plan. That seems ludicrous now. Similarly, why do we wait until a case of elder mistreatment is detected before focusing on prevention strategies in nursing homes or other care settings?
Members of the EMPRs team should reflect and represent all roles in the nursing home, especially the certified nursing attendants (also called direct care workers). Further, all nurses, therapists, social workers, faith-based team members, and volunteers can play a role. A small planning group could propose the length of time, location, and specific unit for EMPRs, or the number of units/wings versus the entire nursing home, frequency, roles during and after rounds, how long individuals will participate, and when staff members will rotate on and off EMPRs. Short debriefing sessions to adjust where necessary are valuable and the best approach to test and weigh the possibility of expansion.
EMPR-focused plans grounded in collaboration and primary prevention provide a robust improvement framework approach. EMPRs can leverage knowledge from direct care workers who are intimately aware of residents' preferences and sensitivities, as well as triggers that may upset individual residents and care partners. Finally, we would be seriously remiss if we did not point out the obvious staffing shortages, high turnover rates, and dissatisfaction experienced by some direct care workers. Until we take care of the workforce, we are unlikely to solve problems in caring for residents.
EMPRs can become standard practice for eradicating elder mistreatment in nursing homes. A starting point to establish EMPRs could include identifying potential nursing homes for implementing pilot programs, forming an interprofessional team to design and execute EMPRs, and creating policies and protocols for EMPR implementation and evaluation.
The time of waiting for elder mistreatment to occur is no more. EMPRs are a pragmatic approach and potential solution for reducing such mistreatment. No one likes to be under surveillance for giving bad care that results in harm. A new prevention paradigm will benefit all.