- Email: [email protected]
Does anyone remember Tommy?
Geriatric Nursing 37 (2016) 244e246
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
AALNA Section
Does anyone remember Tommy? Gina M. D’Angelo, RN, BSN, MBA, NHA, CLNC, RAC-CT GD Solutions, LLC, USA
Tommy was the high school bully from my hometown of Pittsburgh, Pennsylvania. Frankly, the first bully I ever knew was the kind of loathsome character who, on one warm and sunny bus ride home from school, showed off to “get the girls’ attention” by whaling on, Charlie, an incredibly kind French horn player, until he drew blood. Even in the swirl of my own teen trepidations, I inherently knew Tommy had morphed from a dark place (probably under a rock) where self-control and love for oneself was extinct. Bullying is motivated by multiple factors. In this case, Charlie had all that Tommy did not which included intelligence, integrity and most notably a future not envisioned in the foreseeable future for Tommy. As I have tried to bleach clean all the vestiges of that traumatic day in both Charlie’s and my life, these events have awakened my consciousness to the current day realities of elder bullying in congregate settings, particularly with the expected growth of adult baby boomers. I became very interested in this subject, as I have seen several cases of adult bullying in congregate settings through my 22þ years in caring for the elderly. I handled it (regrettably) with the “now let’s all get along” school chaperone approach which is what we knew to do at the time. Defining the issue While most people think of bullying as something exclusive to primary school settings, bullying can be perpetrated by and felt by people of any age. Bullying is not to be confused with elder neglect or abuse resulting in mistreatment with the intent to cause harm or risk of harm. The Code of Federal Regulations, Title 42-Public Health (42 CFR), Subpart E-Survey and Certification of Long-Term Care Facilities define abuse and neglect as the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
E-mail address: [email protected]. 0197-4572/$ e see front matter http://dx.doi.org/10.1016/j.gerinurse.2016.04.008
Neglect is defined as the failure to provide goods & services necessary to avoid physical harm, mental anguish, or mental illness. In other words; ➢ Abuse behavior involves a bad effect for a bad purpose. ➢ Neglect is a failure to care for another properly and by contrast, ➢ Bullying is unwanted or aggressive behavior that is often repeated or has a potential to be repeated over time. As global media attention has made us aware of workplace, school, and cyber bullying; as a society, we often don’t consider bullying in congregate care settings between seniors. For those of us working in these settings, we recognize that our residents don’t change, they just get older. So, the question becomes, why wouldn’t bullying occur in congregate care settings? Merriam-Webster’s dictionary defines a bully as a blustering browbeating person; especially: one habitually cruel to others who are weaker. In other words, bullies are intentional in their actions gaining power by intimidating and picking on others. A few example scenarios of bullying behavior taken from my own experience are as follows: Example #1: the verbal bully At an assisted living community during lunch, one woman said to another “This is not your seat. No one wants a lady who smells like you around them while they eat.” Example #2: the physical bully Two men with a history of business deals gone bust during their working years, now reside in the same senior living community. They are often witnessed cane fencing and spewing profane language at one another over past disputes.
AALNA Section / Geriatric Nursing 37 (2016) 244e246
Example #3: the mentally divisive bully A working class couple inherited a large sum of money affording a gracious lifestyle in an upscale assisted living community on the other side of town. Shunned by other residents who did not see them in their own social class, this couple was forced to eat alone and therefore stayed in their room most of the time. When the wife died, several residents asked this recent widower when he would be moving out, mocking his accent and shunning him from group dinners. Bullying is no joke as the bully seeks attention, power and control which can quickly escalate to physical assault toward both passive and provocative victims. The profile of the victim Victims are submissive, seen as anxious and/or shy, insecure, and may be suffering from early stage dementia and/or mental health disorders and/or developmental disabilities. By contrast, taunting/provocative victims are those who “egg-on” bullies. In short, victims are often perceived as those that are different from the flock by either: race, creed, color, sexual orientation, disability, intellect, class structure, religion, physical appearance, political, ethical and or in moral ways of life. Facility/corporate response to bullying With the global recognition, focus and identification of the extent of the problem, congregate care providers need to consider; ➢ Investigation strategies, ➢ The setting/units and times of day when and where bullying occurs, ➢ Characteristics of perpetrators and victims, ➢ Impact on victims and bystanders, ➢ Staff education for individual and group interventions, ➢ Policies and procedures to educate and guide staff to report, de-escalate, and reduce bullying behavior.
Where does adult bullying occur? Adult bullying can occur in any place where seniors congregate for residential, social or therapeutic purposes (e.g., adult day, group homes, senior housing, assisted living, and long-term care facilities). Providers and their staff also need to understand how easily bullying can occur to a resident(s) and even escalate to elder abuse between staff and resident, family/responsible party to resident and/or resident to-resident. In hostile work environments, providers must also take into consideration the potential for staff-tostaff bullying with and equally traumatizing impact on seniors. Why do bullies bully? Adult bullies have an underlying need for power and control; deriving positive reinforcement from making others feel threatened, fearful or hurt, contributing to conflict between people. Bullies have difficulty tolerating individual differences, lack empathy and often have few friends. They may also come from a feeling of low self-esteem; building themselves up by intimidating and putting down others. To put into context, we have to reflect on the transition our residents experience when transplanting from their home to a congregate care setting. They are grieving, having often
245
experienced a loss of their: home, neighborhood, independence, loved ones, income and/or valued roles. The bully is seeking control at a time in their life when they feel powerless or vulnerable. For example, this can be seen by a group of residents ostracizing certain residents, because of their differences from “members only” group circles. Other behaviors can include unkind remarks and yelling for money, possessions, food, sex, alcohol, cigarette and/or drugs up to and including physical assault and stealing from another resident. Impact to the bystander The harmful impact of bullying is not exclusive to the victims. Bystanders also experience negative consequences verbalizing they wished they could have done more at the time. For example, calling a resident “fat” by another resident, with no intervening by staff, creates a climate of unspoken tolerance for this kind of behavior. Bullying is especially threatening for the resident who is considered frail or may have a memory impairment. Where leadership turns a blind eye, unabated bullying creates a culture of fear, disrespect and insecurity. This promulgates bullying as individuals retaliate against one another because no one else has intervened appropriately. Such hostile environments increase reportable incidents and reduce resident satisfaction. The economic consequences of survey deficiencies resulting in civil monetary penalties, diminished census, negative public perception and increased risk for litigation where damages can be substantial are real monetary concerns. These realities warrant leadership buy-in for staff awareness training and intervention, enforcement of standards through policies and procedures, mutually based (resident to provider) rights and responsibilities, service planning problems, goals and interventions; and ongoing monitoring and reevaluation. In other words, any congregate setting providing services to seniors must have a clear understanding of the extent of bullying or the potential for bullying and have a plan to accept the responsibility and accountability that leadership has to educate, train, and model effective anti-bullying interventions. Strategies for dealing with the adult bully In an article written by Pam Harrison and Dr. Laurie Barclay, MD entitled Childhood Bullying Yields Long-term, Harmful Effects indicated that their participants, who were bullies and exposed to bullying at 8 years of age, “had a high risk for several psychiatric disorders requiring treatment in adulthood.” In my many years of working with the elderly, I grew to appreciate the equal part balanced perspective of learning about a person’s mental and physical health, family dynamics and interests, in order to holistically understand and provide a successful integration into a congregate care setting. Mitigating risk of damages from a sentinel event that can reduce a person’s quality of life up to and including death is a real leadership concern, especially with the introduction of a new resident into the community. Some strategies to quell the bully/aggressive resident may include ➢ Providing healthy outlets for creative expression to reduce boredom. In one case, a former school shop teacher spent time each day walking the building with the maintenance engineer giving him a purposeful, meaningful use of his time each day. ➢ Encouraging other residents to use positive language when confronted by the bully such as, “I can see you are having a bad day.” Or, “Boy don’t you look handsome today.”
246
AALNA Section / Geriatric Nursing 37 (2016) 244e246
➢ Or, simply walking away from the bully to help diffuse the situation before it escalates. Many organizations are now including language regarding bullying into their admissions agreements and resident rights. Zero tolerance is not a viable approach in most congregate living situations. Very often there are innocent tiffs between residents and those with dementia, who may not be able to fully comprehend or have the reaction time to respond appropriately. Residents with dementia cannot always form intent to cause intimidation and therefore do not qualify as true bullies. Nevertheless, there are socially acceptable boundaries over which no one can step, necessitating the need for ongoing staff awareness training. Victims, staff and bystanders need to function in a nurturing environment where assertion and expression of one’s own feelings of sadness, anger and frustration are conveyed without any threat to one another or punitive repercussion. Mental health experts from the community can also play an important role through the use of verbal and non-verbal communication techniques such as learning to make direct eye contact when approached by a bully. Learning to say “stop” or “step back” to communicate control over one’s boundaries aids in a sense of empowerment. Assisted living providers may want to consider similar antibullying programs as offered in school systems. These programs help by providing greater levels of community awareness of bullying behavior. Anger management classes, setting limits with residents who bully others, up to and including eviction notices if relations with others do not improve, are effective measures for operators to consider. Other group-related interventions can include holding regular meetings to promote communication among residents. Modifying and routinely reviewing resident rights and responsibilities for expected and acceptable behaviors opens up the
lines of communication and creates partnerships between residents, staff and facility management. This spurs opportunities for ALL residents to reclaim and maintain their own degree of selfworth, empowerment, feelings of accomplishment, and therefore contributes to a sense of belonging. For older adults who are not cognitively impaired, different approaches for handling bullying in senior housing settings can include tenant support groups and offering classes pre-move on ways to live peacefully together. Forming advocacy networks by bringing issues to management that can be tracked through the quality improvement process, along with seeking legal recourse as needed, are other more formalized methods. Being open to looking at bullying behavior objectively, separate and apart from resident abuse and neglect, provides an enlightening opportunity for congregate care providers to address their current philosophy of resident care delivery. This proactive approach provides the basis to evaluate policies and procedures, residency agreements/move-in materials, staff training, resident education and other communication vehicles. From a leadership point of view, opening dialogue between other community providers and regulatory bodies creates collective awareness and ultimately safer environments for residents. Only with continued awareness, vigilance, prevention and action can any congregate living environment attempt to minimize bullying and provide a culture of emotional and physical safety and self-actualization through supported self-esteem. Oh yeah, as for Tommy, I understand he now leads peace sit-ins in Charlie’s community. Acknowledgment Thanks to LuAnne Leistner, MS, RN, BC, NE-BC, CALN and for editing by Margo Kunze RN, CALA.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
AALNA Section
Does anyone remember Tommy? Gina M. D’Angelo, RN, BSN, MBA, NHA, CLNC, RAC-CT GD Solutions, LLC, USA
Tommy was the high school bully from my hometown of Pittsburgh, Pennsylvania. Frankly, the first bully I ever knew was the kind of loathsome character who, on one warm and sunny bus ride home from school, showed off to “get the girls’ attention” by whaling on, Charlie, an incredibly kind French horn player, until he drew blood. Even in the swirl of my own teen trepidations, I inherently knew Tommy had morphed from a dark place (probably under a rock) where self-control and love for oneself was extinct. Bullying is motivated by multiple factors. In this case, Charlie had all that Tommy did not which included intelligence, integrity and most notably a future not envisioned in the foreseeable future for Tommy. As I have tried to bleach clean all the vestiges of that traumatic day in both Charlie’s and my life, these events have awakened my consciousness to the current day realities of elder bullying in congregate settings, particularly with the expected growth of adult baby boomers. I became very interested in this subject, as I have seen several cases of adult bullying in congregate settings through my 22þ years in caring for the elderly. I handled it (regrettably) with the “now let’s all get along” school chaperone approach which is what we knew to do at the time. Defining the issue While most people think of bullying as something exclusive to primary school settings, bullying can be perpetrated by and felt by people of any age. Bullying is not to be confused with elder neglect or abuse resulting in mistreatment with the intent to cause harm or risk of harm. The Code of Federal Regulations, Title 42-Public Health (42 CFR), Subpart E-Survey and Certification of Long-Term Care Facilities define abuse and neglect as the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
E-mail address: [email protected]. 0197-4572/$ e see front matter http://dx.doi.org/10.1016/j.gerinurse.2016.04.008
Neglect is defined as the failure to provide goods & services necessary to avoid physical harm, mental anguish, or mental illness. In other words; ➢ Abuse behavior involves a bad effect for a bad purpose. ➢ Neglect is a failure to care for another properly and by contrast, ➢ Bullying is unwanted or aggressive behavior that is often repeated or has a potential to be repeated over time. As global media attention has made us aware of workplace, school, and cyber bullying; as a society, we often don’t consider bullying in congregate care settings between seniors. For those of us working in these settings, we recognize that our residents don’t change, they just get older. So, the question becomes, why wouldn’t bullying occur in congregate care settings? Merriam-Webster’s dictionary defines a bully as a blustering browbeating person; especially: one habitually cruel to others who are weaker. In other words, bullies are intentional in their actions gaining power by intimidating and picking on others. A few example scenarios of bullying behavior taken from my own experience are as follows: Example #1: the verbal bully At an assisted living community during lunch, one woman said to another “This is not your seat. No one wants a lady who smells like you around them while they eat.” Example #2: the physical bully Two men with a history of business deals gone bust during their working years, now reside in the same senior living community. They are often witnessed cane fencing and spewing profane language at one another over past disputes.
AALNA Section / Geriatric Nursing 37 (2016) 244e246
Example #3: the mentally divisive bully A working class couple inherited a large sum of money affording a gracious lifestyle in an upscale assisted living community on the other side of town. Shunned by other residents who did not see them in their own social class, this couple was forced to eat alone and therefore stayed in their room most of the time. When the wife died, several residents asked this recent widower when he would be moving out, mocking his accent and shunning him from group dinners. Bullying is no joke as the bully seeks attention, power and control which can quickly escalate to physical assault toward both passive and provocative victims. The profile of the victim Victims are submissive, seen as anxious and/or shy, insecure, and may be suffering from early stage dementia and/or mental health disorders and/or developmental disabilities. By contrast, taunting/provocative victims are those who “egg-on” bullies. In short, victims are often perceived as those that are different from the flock by either: race, creed, color, sexual orientation, disability, intellect, class structure, religion, physical appearance, political, ethical and or in moral ways of life. Facility/corporate response to bullying With the global recognition, focus and identification of the extent of the problem, congregate care providers need to consider; ➢ Investigation strategies, ➢ The setting/units and times of day when and where bullying occurs, ➢ Characteristics of perpetrators and victims, ➢ Impact on victims and bystanders, ➢ Staff education for individual and group interventions, ➢ Policies and procedures to educate and guide staff to report, de-escalate, and reduce bullying behavior.
Where does adult bullying occur? Adult bullying can occur in any place where seniors congregate for residential, social or therapeutic purposes (e.g., adult day, group homes, senior housing, assisted living, and long-term care facilities). Providers and their staff also need to understand how easily bullying can occur to a resident(s) and even escalate to elder abuse between staff and resident, family/responsible party to resident and/or resident to-resident. In hostile work environments, providers must also take into consideration the potential for staff-tostaff bullying with and equally traumatizing impact on seniors. Why do bullies bully? Adult bullies have an underlying need for power and control; deriving positive reinforcement from making others feel threatened, fearful or hurt, contributing to conflict between people. Bullies have difficulty tolerating individual differences, lack empathy and often have few friends. They may also come from a feeling of low self-esteem; building themselves up by intimidating and putting down others. To put into context, we have to reflect on the transition our residents experience when transplanting from their home to a congregate care setting. They are grieving, having often
245
experienced a loss of their: home, neighborhood, independence, loved ones, income and/or valued roles. The bully is seeking control at a time in their life when they feel powerless or vulnerable. For example, this can be seen by a group of residents ostracizing certain residents, because of their differences from “members only” group circles. Other behaviors can include unkind remarks and yelling for money, possessions, food, sex, alcohol, cigarette and/or drugs up to and including physical assault and stealing from another resident. Impact to the bystander The harmful impact of bullying is not exclusive to the victims. Bystanders also experience negative consequences verbalizing they wished they could have done more at the time. For example, calling a resident “fat” by another resident, with no intervening by staff, creates a climate of unspoken tolerance for this kind of behavior. Bullying is especially threatening for the resident who is considered frail or may have a memory impairment. Where leadership turns a blind eye, unabated bullying creates a culture of fear, disrespect and insecurity. This promulgates bullying as individuals retaliate against one another because no one else has intervened appropriately. Such hostile environments increase reportable incidents and reduce resident satisfaction. The economic consequences of survey deficiencies resulting in civil monetary penalties, diminished census, negative public perception and increased risk for litigation where damages can be substantial are real monetary concerns. These realities warrant leadership buy-in for staff awareness training and intervention, enforcement of standards through policies and procedures, mutually based (resident to provider) rights and responsibilities, service planning problems, goals and interventions; and ongoing monitoring and reevaluation. In other words, any congregate setting providing services to seniors must have a clear understanding of the extent of bullying or the potential for bullying and have a plan to accept the responsibility and accountability that leadership has to educate, train, and model effective anti-bullying interventions. Strategies for dealing with the adult bully In an article written by Pam Harrison and Dr. Laurie Barclay, MD entitled Childhood Bullying Yields Long-term, Harmful Effects indicated that their participants, who were bullies and exposed to bullying at 8 years of age, “had a high risk for several psychiatric disorders requiring treatment in adulthood.” In my many years of working with the elderly, I grew to appreciate the equal part balanced perspective of learning about a person’s mental and physical health, family dynamics and interests, in order to holistically understand and provide a successful integration into a congregate care setting. Mitigating risk of damages from a sentinel event that can reduce a person’s quality of life up to and including death is a real leadership concern, especially with the introduction of a new resident into the community. Some strategies to quell the bully/aggressive resident may include ➢ Providing healthy outlets for creative expression to reduce boredom. In one case, a former school shop teacher spent time each day walking the building with the maintenance engineer giving him a purposeful, meaningful use of his time each day. ➢ Encouraging other residents to use positive language when confronted by the bully such as, “I can see you are having a bad day.” Or, “Boy don’t you look handsome today.”
246
AALNA Section / Geriatric Nursing 37 (2016) 244e246
➢ Or, simply walking away from the bully to help diffuse the situation before it escalates. Many organizations are now including language regarding bullying into their admissions agreements and resident rights. Zero tolerance is not a viable approach in most congregate living situations. Very often there are innocent tiffs between residents and those with dementia, who may not be able to fully comprehend or have the reaction time to respond appropriately. Residents with dementia cannot always form intent to cause intimidation and therefore do not qualify as true bullies. Nevertheless, there are socially acceptable boundaries over which no one can step, necessitating the need for ongoing staff awareness training. Victims, staff and bystanders need to function in a nurturing environment where assertion and expression of one’s own feelings of sadness, anger and frustration are conveyed without any threat to one another or punitive repercussion. Mental health experts from the community can also play an important role through the use of verbal and non-verbal communication techniques such as learning to make direct eye contact when approached by a bully. Learning to say “stop” or “step back” to communicate control over one’s boundaries aids in a sense of empowerment. Assisted living providers may want to consider similar antibullying programs as offered in school systems. These programs help by providing greater levels of community awareness of bullying behavior. Anger management classes, setting limits with residents who bully others, up to and including eviction notices if relations with others do not improve, are effective measures for operators to consider. Other group-related interventions can include holding regular meetings to promote communication among residents. Modifying and routinely reviewing resident rights and responsibilities for expected and acceptable behaviors opens up the
lines of communication and creates partnerships between residents, staff and facility management. This spurs opportunities for ALL residents to reclaim and maintain their own degree of selfworth, empowerment, feelings of accomplishment, and therefore contributes to a sense of belonging. For older adults who are not cognitively impaired, different approaches for handling bullying in senior housing settings can include tenant support groups and offering classes pre-move on ways to live peacefully together. Forming advocacy networks by bringing issues to management that can be tracked through the quality improvement process, along with seeking legal recourse as needed, are other more formalized methods. Being open to looking at bullying behavior objectively, separate and apart from resident abuse and neglect, provides an enlightening opportunity for congregate care providers to address their current philosophy of resident care delivery. This proactive approach provides the basis to evaluate policies and procedures, residency agreements/move-in materials, staff training, resident education and other communication vehicles. From a leadership point of view, opening dialogue between other community providers and regulatory bodies creates collective awareness and ultimately safer environments for residents. Only with continued awareness, vigilance, prevention and action can any congregate living environment attempt to minimize bullying and provide a culture of emotional and physical safety and self-actualization through supported self-esteem. Oh yeah, as for Tommy, I understand he now leads peace sit-ins in Charlie’s community. Acknowledgment Thanks to LuAnne Leistner, MS, RN, BC, NE-BC, CALN and for editing by Margo Kunze RN, CALA.