Posts Tagged abuse

Where does the Rot Start in Nursing Home Abuse?

This story has been bouncing around the Canadian media since last May. Camille Parent, the son of a nursing home resident, set up a hidden camera in his mother’s room for four days after she (the nursing home claimed) was assaulted by another patient. The results were appalling. Watch here:

The nursing home immediately fired the four staff members seen in the video; the contract of the director was not renewed. The police, however, have decided not to prosecute; the legal case for pressing assault charges, they said, is a lot narrower than what you or me would consider abusive.

That the standards in this nursing home are so abysmally lax is nearly beyond comprehension. Just after this particular facility opened about ten years ago, I accompanied a friend on a tour of the place. I remember thinking at the time, “If I ever need supportive care, this is where I want to go.” They had an exemplary care model, good staff/patient ratios, and a well-designed environment.

For me, it was interesting the reflex reaction of the director was to axe the employees involved, because as we all know, the best way to address issues in any health care institution is to fire employees.

Voilà! Problem fixed!

The problem with this hypothesis (i.e. the Rogue Employee Theory) is that four employees in four days with one patient displayed behaviours that were, um, sub-optimal.

No, sorry. You can’t just blame the employees, though they need to be accountable for their actions. The administration of the nursing home needs to take some (most?) of the responsibility for permitting an institutional culture where waving faeces-soiled wash cloths in patients’ faces, and canoodling in patients’ rooms is acceptable behaviour.

Let’s take a look at the Mission and Values statement of the nursing home:

Our Mission

St. Joseph’s at Fleming is a non-profit long term care health provider committed to excellence in the delivery of quality care and services to persons of all faiths. Continuing the legacy of the Sisters of St. Joseph of Peterborough, the Home takes pride in a model of care distinguished by compassion, dignity, respect and integrity.

Our Vision

Leader and valued partner in long term care through the use of innovation and best practices in living, learning and caring.

Our Core Values

Living
St. Joseph’s at Fleming is committed to creating a healthy living and working environment that:
[. . . ]

• Treats people with fairness and social justice

[. . . ]

Learning
St. Joseph’s at Fleming is committed to creating a unique learning environment for Residents, families, staff, volunteers and students that:

• Promotes innovation and best practices

[. . . ]

• Develops leadership and promotes teamwork

Caring
St. Joseph’s at Fleming is committed to providing exemplary physical, emotional and spiritual care to our Residents, their families, staff and volunteers. Our philosophy of care:

• Engenders trust, healing and wholeness 
• Integrates best practices and innovative solutions
• Promotes individuality as well as personal and spiritual growth 
• Is characterized by compassion, respect, dignity and the sanctity of life

All of which is very good, anodyne and even commonplace, and I am sure it looks very nice hanging in the front lobby. It’s pretty easy to point out where the nursing home and its employees betrayed its own mission and values, so obviously, it’s not enough. If I were the provincial investigator looking at this nursing home, my very first question would be, “How are your values exemplified in how you provide care?” In other words, how do you ensure institutional values — all those warm fuzzies listed above — align with the personal values of the staff? (Clearly, they didn’t in this case.) And also: what policies and procedures do you have in place that address abuse? What education do you give staff around patient abuse, or the issues that surround the care of cognitively impaired patients?  How do you evaluate the effectiveness of that education? How do those in leadership positions role model behaviour? What processes do you have in place to care for demented patients? How do front line staff participate in the development of such processes? How do you reward/celebrate excellence? And so on.

I’m guessing the answers to most of such questions would be “a little” or “not at all.”

So who should be held accountable?

The front line staff?

Yes.

The leaders, the managers and the administrators?

Yes. Probably more so.

So what do you think? Who is to blame? Staff or administration or both?

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Abuse and Power

This study (PDF here) from an outfit called The Physician Executive Journal of Medical Management tells us what we all know too well: poisoned relations between nurses and physicians, specifically and mostly consisting of the latter abusing the former, but also sometimes the other way around, is bad for patients.

What was the most common complaint? Degrading comments and insults that nearly 85 percent of participants reported experiencing at their organizations. Yelling was second, with 73 percent. Other typical problems included cursing, inappropriate joking and refusing to work with one another.

Some of described behavior is criminal, and would appear to meet the criteria for an assault charge, such as throwing scalpels or squirting a used syringe in a co-worker’s face. But according to some survey participants, it’s the day-to-day putdowns and slights that can be the most harmful.

“The worst behavior problem is not the most egregious,” wrote one participant. “It’s the everyday lack of respect and communication that most adversely affects patient care and staff morale.”

Another float in the Parade of the Blindingly Obvious.  But now — hurray! —  we have a study, instead of the avalanche of nursing anecdotes we all have been repeating to ourselves since Flo was emptying bedpans, but all ignored because, you know, we’re just a bunch of whiny nurses.

A few things caught my eye. The cases of physical assault were striking. Having scapels thrown at you, or getting your head stuffed down a garbage can by a physician is, as the study points out, actual criminal assault. Don’t care if Dr. Obnoxious was having a bad day, or his wife left him, or his last three patients developed post-op nosocomial infections — things which another article in the same issue charmingly and evasively calls “acute stressors.” I would be curious if any of these physicians were ever charged with assault, and if not, why. I think the answers would be revealing.

Alas, the study — nor the related articles in the same issue — doesn’t quite address the underlying causes of abusive behaviour. Well, almost. From the same study, here’s a clue:

study1

So in other words, though physicians account for the most instances of bad behaviour, nurses are the ones that get in in the neck.

Speaks volumes about the power differentials in your average health care setting, doesn’t it? And just maybe, there’s an unexamined relationship between power and abusive behaviour?

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