- Email: [email protected]
Italian healthcare professionals' attitude and barriers to mandatory reporting of elder abuse: An exploratory study
Journal of Forensic and Legal Medicine 63 (2019) 26–30
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine journal homepage: www.elsevier.com/locate/yjflm
Research Paper
Italian healthcare professionals' attitude and barriers to mandatory reporting of elder abuse: An exploratory study
T
Maria Carla Mazzotti, Elena Scarcella, Elisa D'Antone, Federica Fersini, Giancarlo Salsi, Francesca Ingravallo, Alberto Amadasi∗, Susi Pelotti Department of Medical and Surgical Sciences, Section of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
A R T I C LE I N FO
A B S T R A C T
Keywords: Elder abuse Questionnaire Healthcare professionals Multidisciplinary approach
Introduction: Elder abuse in recent times has reached a remarkable international importance. This complex phenomenon is still little understood and studied in Italy. The aim of this study was to explore Italian healthcare professionals’ attitude and barriers toward elder abuse, with a glimpse on the current scenario and evidences to develop an action plan. Materials and methods: 42 healthcare professionals filled a questionnaire with 13 open-ended questions, analyzed with a qualitative content analysis. Data were grouped under the following 4 core-themes: description of elder abuse, abuse detection and perception, barriers to reporting, and professional orientation and approach; then they were analyzed to find their central component and discussed jointly. Results: The respondents described physical (64%) and psychological (50%) abuse and neglect (50%) as the three main characteristics of elder abuse; the 59% of them reported at least one experience in detecting or suspecting elder abuse. The 76% of participants believed the report has to be submitted to the Judicial Authority only in presence of compelling evidences. Furthermore, the 73% of the sample perceived that healthcare professionals are the main figures who have to cope with elder abuse, however they did not feel as their exclusive role the assessment of the patients’ potential abuse. Conclusion: Knowledge about elder abuse was limited to physical/psychological issues and, moreover, the legal obligation to report was only poorly known. Imperative is the creation of specific education and training courses, in addition to the need for a multidisciplinary and empathetic approach.
1. Introduction Elder abuse is considered a major public health concern which poses many challenges to its prevention and treatment.1 According to World Health Organization, elder abuse is “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person."2 According to Kaspiew et al., “elder abuse is a complicated construct, with varying conceptualizations, in part depending on the theoretical and disciplinary lens through which it is approached”.3 It is currently considered one of the most neglected types of violence and only a very small number of elder maltreatments are reported to the authorities or other help services (crisis centres, healthcare providers, social services).4,5 It is very difficult to gather reliable information on the incidence and prevalence of elder abuse. Recently, according to the data provided by Burnes et al., in 2014 in the US the prevalence of elder emotional abuse was 1.9%, of physical abuse was 1.8%, and of
∗
neglect was 1.8%, with an aggregate prevalence of 4.6%. At the international level, the WHO recently reported that estimated prevalence rates of elder abuse in high- or middle-income countries ranged from 2% to 14%.6,7 In the healthcare setting, the dearth of reporting elder abuse may be related to lacks in knowledge, protocols, trust in laws, time, as well as fear of liability and limited number of dedicated services.8,9 Several studies confirm that health professionals may face difficulties in the assessment of any condition of abuse, so that the phenomenon may remain underestimated and hidden.10,11 The role of healthcare professionals in the identification and assessment of risk factors related to the elder abuse has been investigated in studies belonging to the US scenario.12 In this context, Rodriguez et al. identified three paradoxes within the attitude of physicians toward abuse: the physician-patient rapport, the patient quality of life, and the physician's control over the best interest of the patient.13 These paradoxes are related to the complexity of the mandatory report, to the
Corresponding author. E-mail address: [email protected] (A. Amadasi).
https://doi.org/10.1016/j.jflm.2019.02.007 Received 6 July 2018; Received in revised form 13 November 2018; Accepted 15 February 2019 Available online 20 February 2019 1752-928X/ © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Journal of Forensic and Legal Medicine 63 (2019) 26–30
M.C. Mazzotti, et al.
lack of familiarity with laws, but also to the controversy over its effectiveness in protection. In order to overcome the barriers to reporting, it has been suggested that healthcare providers will need at least a common definition of different types of abuse, awareness of the reporting laws and knowledge of the steps following the report.14 Despite both knowledge about risk factors and an advanced detection strategy are needed to identify and prevent elder abuse, the actual research gap5 reliably contributes to uncertainty.15 Among the Italian scenario, where life expectancy is among the highest in Europe, still little is known about healthcare providers awareness and attitudes toward elder abuse and their duty to report to the Judicial Authority.5 Even within the international global context, most studies are focused on the medical aspects of the problem and not on the healthcare providers’ legal obligation on mandatory reporting including abusive behaviors.16 Elderlies have surely to be considered among physically and psychologically vulnerable people, as well as frequently subjected to care and protection by family or cohabitants. Many forms of elder abuse are actually domestic violence or family violence, since they are perpetrated by family members or in a domestic setting. Moreover, caregivers have also been known to prey on elderly patients. Therefore, the concept of elder abuse in Italy is superimposable to the definition provided by the WHO. The present study aims at exploring Italian healthcare professionals’ attitudes towards elder abuse and was performed on the basis of the research of Rodriguez et al. and Schmeidel et al. - the former interviewed 20 primary care physicians while the latter 9 nurses, 8 physicians, and 6 social workers – in order to obtain a valuable basis for the development of knowledge and prevention of elder abuse. The purpose of this exploratory study was to discover the healthcare professionals’ attitudes toward the assessment of elder abuse and the presence of barriers in reporting. Despite a constant increase in life expectancy, adequate sensitivity and preparation toward elder abuse seems to lack. Although many studies show how elder abuse is present and increasing in many countries, the scarcity of judicial data on the phenomenon in Italy highlights the problems related to assessment and report, which have been confirmed by this study. The fact that participants were within a professional category working also in primary care settings, represents a useful glimpse. In a context of lack of official nation-wide data, several studies have been proposed to highlight the dimension of the phenomenon: a previous Italian study, conducted on 4630 subjects aged 65 or more, showed that in the 9% of the cases signs of potential abuse (including physical, emotional abuse and neglect) were identified, which is increasing to the 17% when considering behavioral symptoms.21 Recent studies showed that the total prevalence of elder abuse (elders who report being victims of any type of abuse at least once during the past year) in Italy was 12.7%.16–18 Generally speaking, elder abuse is still a sort of “taboo” so that many abuses tend to remain unrecognized and within the family scenarios, with under-reports by elders themselves.22 The perception of abuse can also be very different among the victims themselves.23 However, the whole dimension may be underrated as the problems related to attitude toward elder abuse in Italy have been previously highlighted with different tests on professionals and students.24
Table 1 Open-ended questions. 1. Please, tell me about the kinds of elder abuse that you might encounter in the hospital setting. 2. Please, remember any patient situations (provide no name or patient identifiers) in which, for whatever reason, made you think that there may be risk of or probable elder abuse. 3. What might make you suspicious that a patient of yours was experiencing elder abuse? 4. What would you do if you become suspicious? 5. Is there anything else that you might consider doing once there is suspicion of elder abuse? 6. Under what conditions, if any, would you report abuse? 7. Under what circumstances, if any, would you consider only monitoring? 8. Why do you think that patients who have been victims of elder abuse might be reluctant to bring this up with their nurses/physicians/social workers at regularly scheduled visits? 9. Why do you think nurses/physicians/social workers may not address the topic of elder abuse, even if suspected at regularly scheduled visits? 10. How do you feel about the law that requires healthcare professionals to report suspected elder abuse? 11. What do you think could be done in your practice to help improve the effectiveness of nurse efforts to address elder abuse? 12. What changes can be made to the environment or to the approach to the patient that will help improve the effectiveness of professional efforts to address elder abuse? 13. Is there anything else that we haven't talked about that you would like to say about improving professional effectiveness in addressing elder abuse?
criteria, because the aim was to investigate the general attitude and barriers in reporting elder abuse among professionals that are not necessarily working in geriatrics, but that will be employed in apical hierarchal position into their clinical setting after the Master. This choice was motivated by the fact that the phenomenon of elder abuse is pervasive and can emerge in every clinical and/or social environment. The healthcare professionals of our convenience sample were 38 nurses, 2 physiotherapists, 1 orthoptist and 1 social worker. All of them have a minimum of 3 years working experience in various clinical settings both in public and in private services, and not only geriatrics or emergency. The majority of participants (29 out of 42) was in the age range 31–50, 8 in the age range 51–60, whereas 5 participants were < 30 years old; 9 were male, 33 were female. The sample group involved professionals with consistent working experience; thus, the possibility that participants could have encountered at least one form of elder abuse in their past experiences was consistent. During the first lecture of Legal Medicine of the abovementioned master, the aims and method of the study were illustrated to the participants, confidentiality was ensured and no personal identification was collected (in order to ensure anonymity), even though socio-demographic characteristics (sex, age range, job title) were collected. Oral informed consent was obtained before the completion of the questionnaire from all the participants, after an explanation on the construction and reasons for the survey. The class instructor provided explanation on the content of the informed consent, allowing students to ask for questions and clarifications. None of the students refused to perform the interview. The written approach was preferred over a face-to-face interview in order to minimize the bias interviewer/professor and participants/ students, although it may have lessened the complexity of the answers; this modality was also preferred because of the little time available for the administration of the questionnaires, since it took place before a Master lecture. The answers were analyzed with a qualitative content analysis by two residents in Legal Medicine (doctors of medicine – MD – attending a 4-year specialization in Legal Medicine) and one sociologist specialized in criminology. All had adequate preparation and training in the fields of clinical forensic medicine and abuse, so to be adequate for a critical evaluation of the answers.
2. Materials and methods This exploratory study was performed through a questionnaire based on the semi-structured interviews of Rodriguez et al. and Schmeidel et al., with 13 open-ended interview questions (Table 1).13,19 The sample consisted in a group of 42 healthcare professionals, working in different Italian clinical environment, attending a master in “Nursing Management” at the University of Bologna, Italy. Participants were recruited in this specific context, without any inclusion/exclusion 27
Journal of Forensic and Legal Medicine 63 (2019) 26–30
M.C. Mazzotti, et al.
In the first place, the data were read separately by the researchers to obtain a sense of the whole. Secondly, initial core-themes were developed and discussed jointly until agreement was reached. Then the answers were read again, grouped under the identified core-themes, and analyzed to find their central component. More details about this method of analysis have been illustrated by Hickey and Kipping.20 Ethical permission was obtained from the ethics review board of the University of Bologna, Italy.
monitored for a while when they have suspects. 10 (23%) professionals answered they did not know how to proceed in terms of a potential report to the Judicial Authority. Possible barriers for a victim to report the abuse to the authorities or simply discuss it with trusted healthcare professionals were “fear”, “shame” and “dependency”, as reported by 31, 6 and 5 participants respectively. Most of the respondents (73% - 31 out of 42) believed that healthcare professionals are the main figures who have to cope with elder abuse, 6 thought the issue was not their responsibility and 5 did not answered. In general, the healthcare professionals’ legal obligation to report elder abuse was perceived as “the right thing” to do (88% - 37 out of 42), because it is a “duty” and a “responsibility”, “even if it is difficult”; 4 did not have an opinion about it. One nurse stated: “I perceive it as an upright obligation, but psychologically and emotionally tough, and it is also a major responsibility for the professional”. Whether the main interest is toward the care of the patient, the predisposition to report is also influenced by some sort of fear of affecting the doctor-patient relationship.
3. Results Through the qualitative content analysis, the answers of the questionnaire were grouped under the following four core-themes: description of elder abuse (item 1), abuse detection and perception (items 2 to 5), barriers to reporting (items 11 to 13), and professional orientation and approach (items 11 to 13). 3.1. Description of elder abuse
3.4. Professional orientation and approach towards elder abuse Physical, psychological and verbal abuse, and neglect were reported as those kinds of abuse that professionals may encounter more frequently in the 64% (27 out of 42), 50% (21 out of 42) and 50% (21 out of 42) of respondents answers respectively. Indeed, a nurse stated: “The kind of abuse we may encounter could be physical such as tugging, shoving, hitting the patient. Also offending and insulting him/her are forms of abuse. According to me, abuse may also be the neglect of the patient, such as keeping him/her from sleeping when he/she is tired, avoiding bathing, etc.”. Four of the respondents indicated also financial abuse, while 3 of them denied of having any knowledge about the different kinds of elder abuse or refused to answer. 10 participants cited also physical and/or pharmacological restraint as a kind of abuse; in accordance to this, a nurse stated that “abuse” is when the physical and pharmacological restraint is used to control and/or sedate him/her and avoid creating bother to other patients or professionals (thus not for the safety of the elder).
As a general and common disposition, participants expressed great interest in taking care of patients and assess every kind of abuse. 25 of them (59%) stated that a multidisciplinary approach, and education and training courses for healthcare professionals are needed in order to improve the effectiveness of healthcare professionals' efforts. As noted by one nurse: “In my opinion, awareness raising project for professionals is required in addition to more general educational programs and advertising campaign […] protocols guiding the professionals (listing what to do and what to monitor) should be also provided”. Only the 16% highlighted the need for a well-organized and comfortable environment in order to reduce work-related stress and burnout. The 26% did not suggest anything (they wrote “I don't know” regarding possible innovative procedures to be followed). 4. Discussion The first critical point is the definition of elder abuse, in terms of what is felt and considered as “abuse” among professionals. The present survey showed that knowledge about elder abuse was frequently limited to neglect and physical/psychological abuse, along with a lack of awareness about financial or intra-familiar abuse. Moreover, a consistent part of the participants specifically categorized restraint as the prevalent form of elder abuse. These results suggest the existence of a preconception of the elder abuse phenomenon considered in clinical settings and the limited awareness towards the phenomenon. Furthermore, a minority of the sample misinterpreted elder abuse as a poor professional-patient relationship, in which privacy and consensus of the elder are not appropriately considered. Moreover, despite health professionals considered reporting as “the right thing” to do, they were not properly aware of their legal obligation to report. Indeed, more than half of the participants stated they had suspected, at least once, a risk of abuse or a potential abuse. Even if more than half of our sample sustained this, they also said that they had suspected elder abuse at least once, they stated they would prefer to discuss with their coordinators or colleagues instead of reporting it. Likewise, most of our healthcare professionals did not feel it was their exclusive role to assess patients' potential abuse, preferring to discuss the case with colleagues, coordinators or physicians and social services. This could indicate the professionals’ need for a multidisciplinary support. Interestingly, one participant stated that she would ask the ethics committee for advice: the curious fact is that in Italy the ethics committee mainly evaluate and approve clinical trials. Nevertheless, the Italian law states that health professionals, who during their work have to deal with a suspect of crimes that can be prosecuted ex officio, have the legal obligation of a written report even when the alleged perpetrator is unknown, and this report has to be transmitted without
3.2. Abuse detection and perception The analysis of this core-theme revealed that more than half of the participants (59% - 25 out of 42) reported they had experience in detecting or suspecting elder abuse, at least once during their professional activity. According to the sample abuse was detected, or at least suspected, when several recurrent signals were present, like a particular patients’ behavior (76% - 32 out of 42) and/or physical signs (50% - 21 out of 42) in some suspicious body areas, like on the forearm or in the eyes. A nurse described a suspicious behavior as “emotional and psychological suffering”; another one as “a state of fear” or “lack of compliance related to the lack of trust into professionals”. Most participants (73% - 31 out of 42), moved by suspect, preferred to discuss with their coordinators or colleagues before labelling a behavior as abusive. One nurse explained this as follows: “I will wait to report it until I find more compelling evidences, and then I will ask my colleagues for advice […]”. Another one stated: “I will talk with my coordinator and my colleagues in order to collect more evidence and evaluate the situation”. 11 participants (26%) would request additional information to the physician or to social services; only 2 participants would report the abuse immediately, and 1 literally answered to “not know what to do”. Finally, one participant stated: “I will discuss the situation with my colleagues, primarily nurses and physicians, then with the forensic doctor, the psychologist and finally with the ethical committee”. 3.3. Barriers to reporting 32 (76%) participants stated that the report has to be submitted to the Judicial Authority only in presence of a compelling and persuasive evidence of abuse: in fact, they stated they prefer to keep the situation 28
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delay to the prosecutor or a judicial police officer. Therefore, the reasons for this failure in reporting lies in the fear of altering the doctorpatient relationship of trust and confidentiality, in the diffidence toward a legal action, but also in the lack of knowledge about the duties of the Italian laws. What ought to be stressed is that suspected elder abuse has to be reported, not only because of fear of being charged with the crime of failure in reporting, but above all because it represents an instrument of protection for the victim. In agreement with the international literature, the preponderance of our healthcare professionals holds the idea that strong suspicion, to the extent of certainty, is needed in order to report the abuse. This uncertainty about intervention on elder abuse cases is worsened by the fact that the victims could be reluctant to recount the abuse even to a trusted healthcare professional. According to Rodriguez et al., reporting the abuse could decrease the patient's quality of life and may put abused elders at increased risk, because reporting could lead to an escalation of violence or the patient could be placed in a home care environment against his/her will.13 The results of this study suggest that the main problems about the assessment and reporting of elder abuse is the lack of education and training, which embraces the fields of law and medicine.19 Indeed, as argued by Fisher et al., a limit to the identification of abuse may be represented by the dearth of academic education, as medical students revealed that they hold a low index of suspicion for elder abuse, are overly optimistic on the etiology of injuries, and lack the confidence to raise concerns about elder abuse, believing that certainty is required.9 Regarding professional orientation and approach toward elder abuse, participants suggested improvements primarily identified in the need for a multidisciplinary approach, and education and training courses for healthcare professionals, together with an empathetic approach to the patient. Interestingly, none of the respondents considered the lack of a diagnosis tool for elder abuse a critical issue. Besides, participants highlighted the need for a comfortable environment and to pay attention to the work-related stress, which can lead to burn out: these elements could become a further barrier to the detection and reporting of elder abuse. In addition, a better education and training courses for healthcare professionals were requested by our respondents to increase awareness towards elder abuse and knowledge of the laws for reporting it, which is in accordance with the already underlined need for educational programs that may lead to healthcare professionals’ change in behaviors and abilities related to understanding, identifying, reporting, and testifying.25 This latter result is in line with those found by previous qualitative research. In the study by Schmeidel et al., many participants suggested the need for more frequent and practical education while physician and nurses who had experience of case-based education felt that it was a helpful tool for addressing elder abuse; whereas Rodriguez et al. concluded that it might be necessary to update existing policy and make training on elder abuse a requirement for medical licensure. The lack of practical training has been also identified as a barrier in recognizing the abuse by Pickering et al., who developed a virtual-reality based educational intervention for nurses and social workers providing in-home services, with satisfying results in their knowledge for identification and in accuracy in their mandatory reporting decisions.13,19,26 Health professionals should thus receive proper training since early detection and efficacy of screening routine are strictly linked with a combination of trust and cooperation between victims and professionals as well as between the group of professionals itself.27 Last but not least, the education of the whole population should be considered, particularly within a context where a national policy on elder abuse is lacking. It is therefore crucial to identify/implement strategies that address the entire population and are supported by training and research activities.28,29 Table 2 summarizes the intervention in health care setting aimed towards better knowledge, assessment, treatment and prevention of elder abuse, in which Institutions, University and Health System have to play their role.
Table 2 Interventions in health care setting toward better knowledge, assessment, treatment and prevention of elder abuse. Problem Definition of abuse
Perception of abuse and objective assessment Failure to report
Possible solution Improve knowledge of elder abuse Interprofessional network Education Training Guidelines and protocols Multidisciplinary approach Education Training Multidisciplinary approach Collaboration with local law enforcement Legislation to criminalize the abuse of vulnerable older adults
Levels of intervention Research Institutional University/National Health System/Clinical Forensic Medicine University/National Health System/ Institutional
4.1. Limitations Our study faced several limitations. First of all, due to its exploratory aim, we are not able to achieve the complexity and peculiarity that usually could be reached with more specific objectives. In the second place, the preference given to the written approach rather than to semi-structured interviews has certainly limited the possibility to expand the answers and deepen the interaction, lessening the complexity of the answers; nevertheless, it has the strength to minimize the bias interviewer/professor and participant/student. Furthermore, because of the nature of our convenience sample and of the paucity of the participants' number, we are not able to generalize the results to all Italian healthcare professionals, nor to all healthcare professionals attending a master degree in Nursing Management. Moreover, it is possible that some participants were not in contact with elders in their clinical practice; however, the aim of our study was to explore a general perception of the phenomenon on a basic level, regardless of the healthcare professional's specialization. 5. Conclusion Despite its limits, this exploratory study may represent a basis for future research and its findings can provide further support to develop a plan of action to advance elder justice and education on the elder abuse phenomenon, especially when considering that healthcare professionals themselves claim for a better education and a multidisciplinary approach, in line with the internationally identified key issues. In fact, knowledge about risk factors and an advanced detection strategy are needed to identify and prevent elder abuse. In Italy, a structured educational approach of healthcare professionals concerning elder abuse is still lacking. Moreover, there are no coordinated service systems such as the Adult Protective Services in the USA, and the need for an ad hoc support service for the victims has been already highlighted.29 As stated by Pillemer et al., crucial fields of intervention should focus on recognizing elder mistreatment as a national public health problem; thus, the expansion and collection of elder abuse data is a fundamental step.1 Finally, efforts should be directed to create help desks addressing victims of elder abuse within the Italian Health Service, to develop guidelines providing evidence-based direction to healthcare professionals on the appropriate responses to elder abuse, to create a multidisciplinary team of intervention as a standardized approach, and to promote a general awareness raising project.30 Conflicts of interest None. This research did not receive any specific grant from funding 29
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agencies in the public, commercial or not-for-profit sectors.
likelihood of reporting. J Elder Abuse Negl. 2012;23:1–16. 17. Salsi G, Mazzotti MC, Carosielli G, et al. Elder abuse awareness in Italy: analysis of reports to the Prosecutor Office of Bologna. Aging Clin Exp Res. 2014;27:359–363. 18. Melchiorre MG, Di Rosa M, Lamura G, et al. Abuse of older men in seven european countries: a multilevel approach in the framework of an ecological model. PLoS One. 2016;11:e0146425. 19. Schmeidel AN, Daly JM, Rosenbaum ME, et al. Healthcare professionals' perspectives on barriers to elder abuse detection and reporting in primary care settings. J Elder Abuse Negl. 2012;24:17–36. 20. Hickey G, Kipping C. A multi-stage approach to the coding of data from open-ended questions. Nurse Res. 1996;4:81–91. 21. Ogioni L, Liperoti R, Landi F, et al. Cross-sectional association between behavioral symptoms and potential elder abuse among subjects in home care in Italy: results from the Silvernet study. Am J Geriatr Psychiatry. 2007;15:70–78. 22. Breckman R, Burnes D, Ross S, et al. When helping hurts: nonabusing family, friends, and neighbors in the lives of elder mistreatment victims. Gerontology. 2017;58:719–723. 23. Burnes D, Lachs MS, Burnette D, et al. Varying appraisals of elder mistreatment among victims: findings from a population-based study. J Ger B Psychol Sci Soc Sci. 2017;00:1–10. 24. Pelotti S, D'Antone E, Ventrucci C, et al. Recognition of elder abuse by Italian nurses and nursing students: evaluation by the Caregiving Scenario Questionnaire. Aging Clin Exp Res. 2013;25:685–690. 25. Blowers AN, Boyd DH, Shenk D, et al. A multidisciplinary approach to detecting and responding to elder mistreatment: creating a university-community partnership. Am J Crim Justice. 2012;37(2). 26. Pickering CE, Ridenour K, Salaysay Z, et al. EATI Island-A virtual-reality based elder abuse & neglect educational intervention. Gerontol Geriatr Educ. 2016;28:1–19. 27. Pillemer K, Burnes D, Riffin C, et al. Elder abuse: global situation, risk factors, and prevention strategies. Gerontol. 2016;56:S194–S205. 28. Melchiorre MG, Penhale B, Lamura G. Understanding elder abuse in Italy: perception and prevalence, types and risk factors from a review of the literature. Educ Gerontol. 2014;40:909–931. 29. Perel-Levin S. Discussing Screening for Elder Abuse at Primary Health Care Level. Geneva, Switzerland: WHO Press; 2008. 30. Molinelli A, Viale L, Landolfa MC, et al. Old age as an “alternative” to illness: gerontological and medicolegal aspects. Aging Clin Exp Res. 2011;23:148–152.
References 1. Pillemer K, Connolly MT, Breckman R, et al. Elder mistreatment: priorities for consideration by the white house conference on aging. Gerontol. 2015;55:320–327. 2. World Health Organization. A Global Response to Elder Abuse and Neglect: Building Primary Health Care Capacity to Deal with the Problem Worldwide. Main Report. Geneva, Switzerland: WHO Press; 2008. 3. Kaspiew R, Carson R, Rhoades H. Elder Abuse: Understanding Issues, Frameworks and Responses. Melbourne: Australian Institute of Familiy Studies; 2016. 4. World Health Organization. Global Status Report on Violence Prevention. Geneva, Switzerland: WHO Press; 2014. 5. World Health Organization. European Report on Preventing Elder Maltreatment. Copenhagen, Denmark: WHO Regional Office for Europe; 2011. 6. Burnes D, Pillemer K, Caccamise PL, et al. Prevalence of and risk factors for elder abuse and neglect in the community: a population-based study. J Am Geriatr Soc. 2015;63:1906–1912. 7. World Health Organization. Global Report on Ageing and Health. Geneva, Switzerland: WHO Press; 2015. 8. Ahmad M, Lachs MS. Elder abuse and neglect: what physicians can and should do. Clevel Clin J Med. 2002;69:801–808. 9. Fisher JM, Rudd MP, Walker RW, et al. Training tomorrow's doctors to safeguard the patients of today: using medical student simulation training to explore barriers to recognition of elder abuse. J Am Geriatr Soc. 2016;64:168–173. 10. Almogue A, Weiss A, Marcus EL, et al. Attitudes and knowledge of medical and nursing staff toward elder abuse. Arch Gerontol Geriatr. 2010;51:86–91. 11. Cohen M. The process of validation of a three-dimensional model for the identification of abuse in older adults. Arch Gerontol Geriatr. 2013;57:243–249. 12. Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373:1947–1956. 13. Rodriguez MA, Wallace SP, Woolf NH, et al. Mandatory reporting of elder abuse: between a rock and a hard place. Ann Fam Med. 2006;4:403–409. 14. Taylor RM Elder Abuse and its Prevention - Workshop Summary. Washington, DC: The National Academic Press; 2014. 15. Simone L, Wettstein A, Senn O, et al. Types of abuse and risk factors associated with elder abuse. Swiss Med Wkly. 2016;146:w14273. 16. Fitzpatrick MJ, Hamill SB. Elder Abuse: factors related to perception of severity and
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Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine journal homepage: www.elsevier.com/locate/yjflm
Research Paper
Italian healthcare professionals' attitude and barriers to mandatory reporting of elder abuse: An exploratory study
T
Maria Carla Mazzotti, Elena Scarcella, Elisa D'Antone, Federica Fersini, Giancarlo Salsi, Francesca Ingravallo, Alberto Amadasi∗, Susi Pelotti Department of Medical and Surgical Sciences, Section of Legal Medicine, University of Bologna, Via Irnerio 49, 40126, Bologna, Italy
A R T I C LE I N FO
A B S T R A C T
Keywords: Elder abuse Questionnaire Healthcare professionals Multidisciplinary approach
Introduction: Elder abuse in recent times has reached a remarkable international importance. This complex phenomenon is still little understood and studied in Italy. The aim of this study was to explore Italian healthcare professionals’ attitude and barriers toward elder abuse, with a glimpse on the current scenario and evidences to develop an action plan. Materials and methods: 42 healthcare professionals filled a questionnaire with 13 open-ended questions, analyzed with a qualitative content analysis. Data were grouped under the following 4 core-themes: description of elder abuse, abuse detection and perception, barriers to reporting, and professional orientation and approach; then they were analyzed to find their central component and discussed jointly. Results: The respondents described physical (64%) and psychological (50%) abuse and neglect (50%) as the three main characteristics of elder abuse; the 59% of them reported at least one experience in detecting or suspecting elder abuse. The 76% of participants believed the report has to be submitted to the Judicial Authority only in presence of compelling evidences. Furthermore, the 73% of the sample perceived that healthcare professionals are the main figures who have to cope with elder abuse, however they did not feel as their exclusive role the assessment of the patients’ potential abuse. Conclusion: Knowledge about elder abuse was limited to physical/psychological issues and, moreover, the legal obligation to report was only poorly known. Imperative is the creation of specific education and training courses, in addition to the need for a multidisciplinary and empathetic approach.
1. Introduction Elder abuse is considered a major public health concern which poses many challenges to its prevention and treatment.1 According to World Health Organization, elder abuse is “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person."2 According to Kaspiew et al., “elder abuse is a complicated construct, with varying conceptualizations, in part depending on the theoretical and disciplinary lens through which it is approached”.3 It is currently considered one of the most neglected types of violence and only a very small number of elder maltreatments are reported to the authorities or other help services (crisis centres, healthcare providers, social services).4,5 It is very difficult to gather reliable information on the incidence and prevalence of elder abuse. Recently, according to the data provided by Burnes et al., in 2014 in the US the prevalence of elder emotional abuse was 1.9%, of physical abuse was 1.8%, and of
∗
neglect was 1.8%, with an aggregate prevalence of 4.6%. At the international level, the WHO recently reported that estimated prevalence rates of elder abuse in high- or middle-income countries ranged from 2% to 14%.6,7 In the healthcare setting, the dearth of reporting elder abuse may be related to lacks in knowledge, protocols, trust in laws, time, as well as fear of liability and limited number of dedicated services.8,9 Several studies confirm that health professionals may face difficulties in the assessment of any condition of abuse, so that the phenomenon may remain underestimated and hidden.10,11 The role of healthcare professionals in the identification and assessment of risk factors related to the elder abuse has been investigated in studies belonging to the US scenario.12 In this context, Rodriguez et al. identified three paradoxes within the attitude of physicians toward abuse: the physician-patient rapport, the patient quality of life, and the physician's control over the best interest of the patient.13 These paradoxes are related to the complexity of the mandatory report, to the
Corresponding author. E-mail address: [email protected] (A. Amadasi).
https://doi.org/10.1016/j.jflm.2019.02.007 Received 6 July 2018; Received in revised form 13 November 2018; Accepted 15 February 2019 Available online 20 February 2019 1752-928X/ © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Journal of Forensic and Legal Medicine 63 (2019) 26–30
M.C. Mazzotti, et al.
lack of familiarity with laws, but also to the controversy over its effectiveness in protection. In order to overcome the barriers to reporting, it has been suggested that healthcare providers will need at least a common definition of different types of abuse, awareness of the reporting laws and knowledge of the steps following the report.14 Despite both knowledge about risk factors and an advanced detection strategy are needed to identify and prevent elder abuse, the actual research gap5 reliably contributes to uncertainty.15 Among the Italian scenario, where life expectancy is among the highest in Europe, still little is known about healthcare providers awareness and attitudes toward elder abuse and their duty to report to the Judicial Authority.5 Even within the international global context, most studies are focused on the medical aspects of the problem and not on the healthcare providers’ legal obligation on mandatory reporting including abusive behaviors.16 Elderlies have surely to be considered among physically and psychologically vulnerable people, as well as frequently subjected to care and protection by family or cohabitants. Many forms of elder abuse are actually domestic violence or family violence, since they are perpetrated by family members or in a domestic setting. Moreover, caregivers have also been known to prey on elderly patients. Therefore, the concept of elder abuse in Italy is superimposable to the definition provided by the WHO. The present study aims at exploring Italian healthcare professionals’ attitudes towards elder abuse and was performed on the basis of the research of Rodriguez et al. and Schmeidel et al. - the former interviewed 20 primary care physicians while the latter 9 nurses, 8 physicians, and 6 social workers – in order to obtain a valuable basis for the development of knowledge and prevention of elder abuse. The purpose of this exploratory study was to discover the healthcare professionals’ attitudes toward the assessment of elder abuse and the presence of barriers in reporting. Despite a constant increase in life expectancy, adequate sensitivity and preparation toward elder abuse seems to lack. Although many studies show how elder abuse is present and increasing in many countries, the scarcity of judicial data on the phenomenon in Italy highlights the problems related to assessment and report, which have been confirmed by this study. The fact that participants were within a professional category working also in primary care settings, represents a useful glimpse. In a context of lack of official nation-wide data, several studies have been proposed to highlight the dimension of the phenomenon: a previous Italian study, conducted on 4630 subjects aged 65 or more, showed that in the 9% of the cases signs of potential abuse (including physical, emotional abuse and neglect) were identified, which is increasing to the 17% when considering behavioral symptoms.21 Recent studies showed that the total prevalence of elder abuse (elders who report being victims of any type of abuse at least once during the past year) in Italy was 12.7%.16–18 Generally speaking, elder abuse is still a sort of “taboo” so that many abuses tend to remain unrecognized and within the family scenarios, with under-reports by elders themselves.22 The perception of abuse can also be very different among the victims themselves.23 However, the whole dimension may be underrated as the problems related to attitude toward elder abuse in Italy have been previously highlighted with different tests on professionals and students.24
Table 1 Open-ended questions. 1. Please, tell me about the kinds of elder abuse that you might encounter in the hospital setting. 2. Please, remember any patient situations (provide no name or patient identifiers) in which, for whatever reason, made you think that there may be risk of or probable elder abuse. 3. What might make you suspicious that a patient of yours was experiencing elder abuse? 4. What would you do if you become suspicious? 5. Is there anything else that you might consider doing once there is suspicion of elder abuse? 6. Under what conditions, if any, would you report abuse? 7. Under what circumstances, if any, would you consider only monitoring? 8. Why do you think that patients who have been victims of elder abuse might be reluctant to bring this up with their nurses/physicians/social workers at regularly scheduled visits? 9. Why do you think nurses/physicians/social workers may not address the topic of elder abuse, even if suspected at regularly scheduled visits? 10. How do you feel about the law that requires healthcare professionals to report suspected elder abuse? 11. What do you think could be done in your practice to help improve the effectiveness of nurse efforts to address elder abuse? 12. What changes can be made to the environment or to the approach to the patient that will help improve the effectiveness of professional efforts to address elder abuse? 13. Is there anything else that we haven't talked about that you would like to say about improving professional effectiveness in addressing elder abuse?
criteria, because the aim was to investigate the general attitude and barriers in reporting elder abuse among professionals that are not necessarily working in geriatrics, but that will be employed in apical hierarchal position into their clinical setting after the Master. This choice was motivated by the fact that the phenomenon of elder abuse is pervasive and can emerge in every clinical and/or social environment. The healthcare professionals of our convenience sample were 38 nurses, 2 physiotherapists, 1 orthoptist and 1 social worker. All of them have a minimum of 3 years working experience in various clinical settings both in public and in private services, and not only geriatrics or emergency. The majority of participants (29 out of 42) was in the age range 31–50, 8 in the age range 51–60, whereas 5 participants were < 30 years old; 9 were male, 33 were female. The sample group involved professionals with consistent working experience; thus, the possibility that participants could have encountered at least one form of elder abuse in their past experiences was consistent. During the first lecture of Legal Medicine of the abovementioned master, the aims and method of the study were illustrated to the participants, confidentiality was ensured and no personal identification was collected (in order to ensure anonymity), even though socio-demographic characteristics (sex, age range, job title) were collected. Oral informed consent was obtained before the completion of the questionnaire from all the participants, after an explanation on the construction and reasons for the survey. The class instructor provided explanation on the content of the informed consent, allowing students to ask for questions and clarifications. None of the students refused to perform the interview. The written approach was preferred over a face-to-face interview in order to minimize the bias interviewer/professor and participants/ students, although it may have lessened the complexity of the answers; this modality was also preferred because of the little time available for the administration of the questionnaires, since it took place before a Master lecture. The answers were analyzed with a qualitative content analysis by two residents in Legal Medicine (doctors of medicine – MD – attending a 4-year specialization in Legal Medicine) and one sociologist specialized in criminology. All had adequate preparation and training in the fields of clinical forensic medicine and abuse, so to be adequate for a critical evaluation of the answers.
2. Materials and methods This exploratory study was performed through a questionnaire based on the semi-structured interviews of Rodriguez et al. and Schmeidel et al., with 13 open-ended interview questions (Table 1).13,19 The sample consisted in a group of 42 healthcare professionals, working in different Italian clinical environment, attending a master in “Nursing Management” at the University of Bologna, Italy. Participants were recruited in this specific context, without any inclusion/exclusion 27
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In the first place, the data were read separately by the researchers to obtain a sense of the whole. Secondly, initial core-themes were developed and discussed jointly until agreement was reached. Then the answers were read again, grouped under the identified core-themes, and analyzed to find their central component. More details about this method of analysis have been illustrated by Hickey and Kipping.20 Ethical permission was obtained from the ethics review board of the University of Bologna, Italy.
monitored for a while when they have suspects. 10 (23%) professionals answered they did not know how to proceed in terms of a potential report to the Judicial Authority. Possible barriers for a victim to report the abuse to the authorities or simply discuss it with trusted healthcare professionals were “fear”, “shame” and “dependency”, as reported by 31, 6 and 5 participants respectively. Most of the respondents (73% - 31 out of 42) believed that healthcare professionals are the main figures who have to cope with elder abuse, 6 thought the issue was not their responsibility and 5 did not answered. In general, the healthcare professionals’ legal obligation to report elder abuse was perceived as “the right thing” to do (88% - 37 out of 42), because it is a “duty” and a “responsibility”, “even if it is difficult”; 4 did not have an opinion about it. One nurse stated: “I perceive it as an upright obligation, but psychologically and emotionally tough, and it is also a major responsibility for the professional”. Whether the main interest is toward the care of the patient, the predisposition to report is also influenced by some sort of fear of affecting the doctor-patient relationship.
3. Results Through the qualitative content analysis, the answers of the questionnaire were grouped under the following four core-themes: description of elder abuse (item 1), abuse detection and perception (items 2 to 5), barriers to reporting (items 11 to 13), and professional orientation and approach (items 11 to 13). 3.1. Description of elder abuse
3.4. Professional orientation and approach towards elder abuse Physical, psychological and verbal abuse, and neglect were reported as those kinds of abuse that professionals may encounter more frequently in the 64% (27 out of 42), 50% (21 out of 42) and 50% (21 out of 42) of respondents answers respectively. Indeed, a nurse stated: “The kind of abuse we may encounter could be physical such as tugging, shoving, hitting the patient. Also offending and insulting him/her are forms of abuse. According to me, abuse may also be the neglect of the patient, such as keeping him/her from sleeping when he/she is tired, avoiding bathing, etc.”. Four of the respondents indicated also financial abuse, while 3 of them denied of having any knowledge about the different kinds of elder abuse or refused to answer. 10 participants cited also physical and/or pharmacological restraint as a kind of abuse; in accordance to this, a nurse stated that “abuse” is when the physical and pharmacological restraint is used to control and/or sedate him/her and avoid creating bother to other patients or professionals (thus not for the safety of the elder).
As a general and common disposition, participants expressed great interest in taking care of patients and assess every kind of abuse. 25 of them (59%) stated that a multidisciplinary approach, and education and training courses for healthcare professionals are needed in order to improve the effectiveness of healthcare professionals' efforts. As noted by one nurse: “In my opinion, awareness raising project for professionals is required in addition to more general educational programs and advertising campaign […] protocols guiding the professionals (listing what to do and what to monitor) should be also provided”. Only the 16% highlighted the need for a well-organized and comfortable environment in order to reduce work-related stress and burnout. The 26% did not suggest anything (they wrote “I don't know” regarding possible innovative procedures to be followed). 4. Discussion The first critical point is the definition of elder abuse, in terms of what is felt and considered as “abuse” among professionals. The present survey showed that knowledge about elder abuse was frequently limited to neglect and physical/psychological abuse, along with a lack of awareness about financial or intra-familiar abuse. Moreover, a consistent part of the participants specifically categorized restraint as the prevalent form of elder abuse. These results suggest the existence of a preconception of the elder abuse phenomenon considered in clinical settings and the limited awareness towards the phenomenon. Furthermore, a minority of the sample misinterpreted elder abuse as a poor professional-patient relationship, in which privacy and consensus of the elder are not appropriately considered. Moreover, despite health professionals considered reporting as “the right thing” to do, they were not properly aware of their legal obligation to report. Indeed, more than half of the participants stated they had suspected, at least once, a risk of abuse or a potential abuse. Even if more than half of our sample sustained this, they also said that they had suspected elder abuse at least once, they stated they would prefer to discuss with their coordinators or colleagues instead of reporting it. Likewise, most of our healthcare professionals did not feel it was their exclusive role to assess patients' potential abuse, preferring to discuss the case with colleagues, coordinators or physicians and social services. This could indicate the professionals’ need for a multidisciplinary support. Interestingly, one participant stated that she would ask the ethics committee for advice: the curious fact is that in Italy the ethics committee mainly evaluate and approve clinical trials. Nevertheless, the Italian law states that health professionals, who during their work have to deal with a suspect of crimes that can be prosecuted ex officio, have the legal obligation of a written report even when the alleged perpetrator is unknown, and this report has to be transmitted without
3.2. Abuse detection and perception The analysis of this core-theme revealed that more than half of the participants (59% - 25 out of 42) reported they had experience in detecting or suspecting elder abuse, at least once during their professional activity. According to the sample abuse was detected, or at least suspected, when several recurrent signals were present, like a particular patients’ behavior (76% - 32 out of 42) and/or physical signs (50% - 21 out of 42) in some suspicious body areas, like on the forearm or in the eyes. A nurse described a suspicious behavior as “emotional and psychological suffering”; another one as “a state of fear” or “lack of compliance related to the lack of trust into professionals”. Most participants (73% - 31 out of 42), moved by suspect, preferred to discuss with their coordinators or colleagues before labelling a behavior as abusive. One nurse explained this as follows: “I will wait to report it until I find more compelling evidences, and then I will ask my colleagues for advice […]”. Another one stated: “I will talk with my coordinator and my colleagues in order to collect more evidence and evaluate the situation”. 11 participants (26%) would request additional information to the physician or to social services; only 2 participants would report the abuse immediately, and 1 literally answered to “not know what to do”. Finally, one participant stated: “I will discuss the situation with my colleagues, primarily nurses and physicians, then with the forensic doctor, the psychologist and finally with the ethical committee”. 3.3. Barriers to reporting 32 (76%) participants stated that the report has to be submitted to the Judicial Authority only in presence of a compelling and persuasive evidence of abuse: in fact, they stated they prefer to keep the situation 28
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delay to the prosecutor or a judicial police officer. Therefore, the reasons for this failure in reporting lies in the fear of altering the doctorpatient relationship of trust and confidentiality, in the diffidence toward a legal action, but also in the lack of knowledge about the duties of the Italian laws. What ought to be stressed is that suspected elder abuse has to be reported, not only because of fear of being charged with the crime of failure in reporting, but above all because it represents an instrument of protection for the victim. In agreement with the international literature, the preponderance of our healthcare professionals holds the idea that strong suspicion, to the extent of certainty, is needed in order to report the abuse. This uncertainty about intervention on elder abuse cases is worsened by the fact that the victims could be reluctant to recount the abuse even to a trusted healthcare professional. According to Rodriguez et al., reporting the abuse could decrease the patient's quality of life and may put abused elders at increased risk, because reporting could lead to an escalation of violence or the patient could be placed in a home care environment against his/her will.13 The results of this study suggest that the main problems about the assessment and reporting of elder abuse is the lack of education and training, which embraces the fields of law and medicine.19 Indeed, as argued by Fisher et al., a limit to the identification of abuse may be represented by the dearth of academic education, as medical students revealed that they hold a low index of suspicion for elder abuse, are overly optimistic on the etiology of injuries, and lack the confidence to raise concerns about elder abuse, believing that certainty is required.9 Regarding professional orientation and approach toward elder abuse, participants suggested improvements primarily identified in the need for a multidisciplinary approach, and education and training courses for healthcare professionals, together with an empathetic approach to the patient. Interestingly, none of the respondents considered the lack of a diagnosis tool for elder abuse a critical issue. Besides, participants highlighted the need for a comfortable environment and to pay attention to the work-related stress, which can lead to burn out: these elements could become a further barrier to the detection and reporting of elder abuse. In addition, a better education and training courses for healthcare professionals were requested by our respondents to increase awareness towards elder abuse and knowledge of the laws for reporting it, which is in accordance with the already underlined need for educational programs that may lead to healthcare professionals’ change in behaviors and abilities related to understanding, identifying, reporting, and testifying.25 This latter result is in line with those found by previous qualitative research. In the study by Schmeidel et al., many participants suggested the need for more frequent and practical education while physician and nurses who had experience of case-based education felt that it was a helpful tool for addressing elder abuse; whereas Rodriguez et al. concluded that it might be necessary to update existing policy and make training on elder abuse a requirement for medical licensure. The lack of practical training has been also identified as a barrier in recognizing the abuse by Pickering et al., who developed a virtual-reality based educational intervention for nurses and social workers providing in-home services, with satisfying results in their knowledge for identification and in accuracy in their mandatory reporting decisions.13,19,26 Health professionals should thus receive proper training since early detection and efficacy of screening routine are strictly linked with a combination of trust and cooperation between victims and professionals as well as between the group of professionals itself.27 Last but not least, the education of the whole population should be considered, particularly within a context where a national policy on elder abuse is lacking. It is therefore crucial to identify/implement strategies that address the entire population and are supported by training and research activities.28,29 Table 2 summarizes the intervention in health care setting aimed towards better knowledge, assessment, treatment and prevention of elder abuse, in which Institutions, University and Health System have to play their role.
Table 2 Interventions in health care setting toward better knowledge, assessment, treatment and prevention of elder abuse. Problem Definition of abuse
Perception of abuse and objective assessment Failure to report
Possible solution Improve knowledge of elder abuse Interprofessional network Education Training Guidelines and protocols Multidisciplinary approach Education Training Multidisciplinary approach Collaboration with local law enforcement Legislation to criminalize the abuse of vulnerable older adults
Levels of intervention Research Institutional University/National Health System/Clinical Forensic Medicine University/National Health System/ Institutional
4.1. Limitations Our study faced several limitations. First of all, due to its exploratory aim, we are not able to achieve the complexity and peculiarity that usually could be reached with more specific objectives. In the second place, the preference given to the written approach rather than to semi-structured interviews has certainly limited the possibility to expand the answers and deepen the interaction, lessening the complexity of the answers; nevertheless, it has the strength to minimize the bias interviewer/professor and participant/student. Furthermore, because of the nature of our convenience sample and of the paucity of the participants' number, we are not able to generalize the results to all Italian healthcare professionals, nor to all healthcare professionals attending a master degree in Nursing Management. Moreover, it is possible that some participants were not in contact with elders in their clinical practice; however, the aim of our study was to explore a general perception of the phenomenon on a basic level, regardless of the healthcare professional's specialization. 5. Conclusion Despite its limits, this exploratory study may represent a basis for future research and its findings can provide further support to develop a plan of action to advance elder justice and education on the elder abuse phenomenon, especially when considering that healthcare professionals themselves claim for a better education and a multidisciplinary approach, in line with the internationally identified key issues. In fact, knowledge about risk factors and an advanced detection strategy are needed to identify and prevent elder abuse. In Italy, a structured educational approach of healthcare professionals concerning elder abuse is still lacking. Moreover, there are no coordinated service systems such as the Adult Protective Services in the USA, and the need for an ad hoc support service for the victims has been already highlighted.29 As stated by Pillemer et al., crucial fields of intervention should focus on recognizing elder mistreatment as a national public health problem; thus, the expansion and collection of elder abuse data is a fundamental step.1 Finally, efforts should be directed to create help desks addressing victims of elder abuse within the Italian Health Service, to develop guidelines providing evidence-based direction to healthcare professionals on the appropriate responses to elder abuse, to create a multidisciplinary team of intervention as a standardized approach, and to promote a general awareness raising project.30 Conflicts of interest None. This research did not receive any specific grant from funding 29
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agencies in the public, commercial or not-for-profit sectors.
likelihood of reporting. J Elder Abuse Negl. 2012;23:1–16. 17. Salsi G, Mazzotti MC, Carosielli G, et al. Elder abuse awareness in Italy: analysis of reports to the Prosecutor Office of Bologna. Aging Clin Exp Res. 2014;27:359–363. 18. Melchiorre MG, Di Rosa M, Lamura G, et al. Abuse of older men in seven european countries: a multilevel approach in the framework of an ecological model. PLoS One. 2016;11:e0146425. 19. Schmeidel AN, Daly JM, Rosenbaum ME, et al. Healthcare professionals' perspectives on barriers to elder abuse detection and reporting in primary care settings. J Elder Abuse Negl. 2012;24:17–36. 20. Hickey G, Kipping C. A multi-stage approach to the coding of data from open-ended questions. Nurse Res. 1996;4:81–91. 21. Ogioni L, Liperoti R, Landi F, et al. Cross-sectional association between behavioral symptoms and potential elder abuse among subjects in home care in Italy: results from the Silvernet study. Am J Geriatr Psychiatry. 2007;15:70–78. 22. Breckman R, Burnes D, Ross S, et al. When helping hurts: nonabusing family, friends, and neighbors in the lives of elder mistreatment victims. Gerontology. 2017;58:719–723. 23. Burnes D, Lachs MS, Burnette D, et al. Varying appraisals of elder mistreatment among victims: findings from a population-based study. J Ger B Psychol Sci Soc Sci. 2017;00:1–10. 24. Pelotti S, D'Antone E, Ventrucci C, et al. Recognition of elder abuse by Italian nurses and nursing students: evaluation by the Caregiving Scenario Questionnaire. Aging Clin Exp Res. 2013;25:685–690. 25. Blowers AN, Boyd DH, Shenk D, et al. A multidisciplinary approach to detecting and responding to elder mistreatment: creating a university-community partnership. Am J Crim Justice. 2012;37(2). 26. Pickering CE, Ridenour K, Salaysay Z, et al. EATI Island-A virtual-reality based elder abuse & neglect educational intervention. Gerontol Geriatr Educ. 2016;28:1–19. 27. Pillemer K, Burnes D, Riffin C, et al. Elder abuse: global situation, risk factors, and prevention strategies. Gerontol. 2016;56:S194–S205. 28. Melchiorre MG, Penhale B, Lamura G. Understanding elder abuse in Italy: perception and prevalence, types and risk factors from a review of the literature. Educ Gerontol. 2014;40:909–931. 29. Perel-Levin S. Discussing Screening for Elder Abuse at Primary Health Care Level. Geneva, Switzerland: WHO Press; 2008. 30. Molinelli A, Viale L, Landolfa MC, et al. Old age as an “alternative” to illness: gerontological and medicolegal aspects. Aging Clin Exp Res. 2011;23:148–152.
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