Institutional abuse is abuse that occurs at a facility or organization that provides care for dependent adults. Examples include skilled nursing and rehabilitation facilities, assisted-living facilities, and group homes or community living centers. The risk of abuse increases when the resident of the facility is female, older than 74 years old, and has physical disabilities or cognitive diseases (Bassett, 2021).
A common method of abuse in institutional settings involves the misuse of physical restraints. Caregivers may place restraints on a resident without a physician's order or keep the restraints in place longer than ordered. It is important to note that the misuse of physical restraints may be intentional or unintentional. Intent does not matter; ignorance cannot be used to justify the misuse of restraints. Therefore, it is important to be familiar with proper use (Atee et al, 2024).
Neglect is another common form of abuse, often resulting in painful bed sores, unnecessary falls, and malnutrition or dehydration. Facilities that suffer from staffing shortages and higher patient-to-staff ratios tend to be at a higher risk of inflicting abuse. This was seen during and after the COVID-19 pandemic when institutions faced drastic reductions in staffing and widespread acute illness amongst residents. The reduced staffing, minimal oversight, increased illness, and widely implemented visitor bans increased the risk of abuse on residents (Benbow et al., 2022).
Institutional abusers tend to be young males with little education or caregiving experience, especially with the elderly population. They often report emotional exhaustion and job burnout as reasons for inflicting the abuse (Bassett, 2021).
Imagine This Scenario:A young male CNA, Isaiah, is working in a skilled nursing facility (SNF). This is his first job as a CNA. It is post-pandemic, and the SNF struggles to keep good staffing numbers. Isaiah is often assigned the entire A hallway where the patients require Hoyer lifts and full assists. Hallway A is a very demanding assignment, but the charge nurse assigns Isaiah to it because he is the only male aide and is perceived to be physically strong. There is limited teamwork from other disciplines, such as physical therapy. The registered nurse always rounds on that hallway last because it takes the longest amount of time. Isaiah quickly becomes tired and frustrated halfway through the day. He considers leaving the last two patients in bed all day because he doesn’t have the energy to get them up. He also just remembers Miss Smith didn’t receive a morning shower or a change of clothing. She has probably been soiled for hours, but at this point, he doesn’t care. - What would you do if you were Isaiah?
- What could Isaiah do differently?
- How could honest communication help in this situation?
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It is important to stand up for yourself and your patients. If a patient assignment is not realistic, you must speak up and report your concerns to your supervisor. In this scenario, it would help if the other healthcare workers assisted Isaiah and worked together as a team to tackle this hallway. Perhaps leadership is unaware of the situation in this hallway and needs to consider different room assignments to alleviate some of the burden. Liu et al. (2022) found that using interprofessional disciplines matters, especially when there are breakdowns from the usual support systems. Patients and caregivers benefit the most when the caregiver team is well-rounded and involves multiple disciplines. For many patients, this could include the provider, nurse, nurse’s aide, social worker, chaplain, and physical therapists.
Another issue observed in facilities is resident-to-resident aggression. This is when one resident perpetrates violence, sexual assault, verbal abuse, humiliation, or isolation against another resident. About 20% of nursing home residents have experienced this type of abuse. It is important that aides in the facility recognize this behavior as unacceptable. They must intervene before serious injury or distress occurs (Pillemer et al., 2024). Institutions benefit from training their staff in how to properly handle these types of situations to avoid escalation and implement prevention measures.
