1. Nurse Responses to Elder Mistreatment An IAFN Education Course Module 6 Screening and Assessment of Elder Mistreatment 1

2. Screening and Assessment 2 Nurses need to know how to screen, assess, document and report elder mistreatment (EM) Screening provides an opportunity to detect or rule out EM o If there is a suspicion, screening can trigger full assessment

3. By the end of this module, participants will be able to: Discuss why, when, where, with whom and how screening and assessing older adults for EM should occur Describe steps in interviewing Discuss appropriate questions to ask Describe techniques to communicate with patients and their families and caregivers during screening/assessment process Learning Objectives 3

4. Case: Mr. Rodriguez What do you see as presenting issues? What additional information does the nurse practitioner need in order to proceed and respond effectively? What screening questions could the nurse practitioner ask in her initial conversation with Mr. Rodriguez? With the son? Do you foresee any screening or assessment challenges with the patient and the son? 4

5. Screening and Assessment Process 1. Why should nurses screen/assess? 2. Where should screening/assessment take place? 3. Who should be screened/assessed? 4. When should screening/assessment take place? 5. How should screening/assessment be conducted? 5

6. Screening and assessment for EM should occur in community settings and long-term care facilities Where? 6

7. Who? Ideally, nurses should screen every vulnerable older adult for EM However, many practice settings screen only when signs of mistreatment are identified or when there is cause to suspect mistreatment 7

8. When? A few simple questions can routinely be included in nurse interactions with all older patients (as appropriate to practice setting) Additional questions can be asked if concern/suspicion is raised 8

9. How? A specific plan for screening and assessment for elder mistreatment should be incorporated into a practice setting’s written policies 9

10. Tools for Screening/Assessment Screening and assessment for EM can be facilitated through use of assessment tools These tools typically require discussion with patient and others who accompany patient 10

11. Questions to Ask? What screening and assessment questions would be useful to ask older patients to screen/assess for elder mistreatment? 11

12. Interviewing Patients 1. First ask general questions 2. Then ask more questions as necessary o Probe for physical abuse, psychological abuse, sexual abuse, neglect, abandonment and exploitation 3. If you received an affirmative answer regarding a possible incident of mistreatment, follow-up to determine— o How did it occur?When did it occur? o Where did it occur?Who was involved? 4. Document statements in medical record 12

13. Based on AMA guidelines (1992)  Has anyone at home (or nursing home) hurt you?  Has anyone at home (or nursing home) ever touched you without your consent?  Has anyone at home (or nursing home) ever made you do things you did not want to do? 9 General Screening Questions 13

14.  Has anyone at home (or nursing home) ever scolded or threatened you?  Are you afraid of anyone at home (or at nursing home)?  Are you often left alone at home (or nursing home)?  Has anyone at home (or nursing home) ever failed to help you take care of yourself when you needed help? 9 General Screening Questions (cont.) 14

15. More specific questions may be asked of residents in long-term care settings  Since you have been here, has any employee, resident, family member, volunteer or visitor hurt you? OR  Since you have been here, has any employee, resident, family member, volunteer or visitor hit, slapped or otherwise hurt you? 9 General Screening Questions (cont.) 15

16. More Probing Questions 16 What are additional questions to ask to probe for physical abuse, psychological/emotional abuse, sexual abuse, neglect, abandonment and exploitation?

17. Follow-Up Questions If a patient answers YES, say 1. I’m glad you told me about this. 2. When was the last time? 3. Can you give me an example? 17

18. Normalize Task of Asking Difficult Questions It is hard for nurses to ask these questions, but that’s what they often have to do; ask difficult questions so they know what the patient is dealing with and then can help the patient/make it safe for them to disclose T. Fuller, Try this: Elder mistreatment assessment, 2008 18

19. Consider… What communication techniques and methods during screening and assessment might help raise the comfort level of the patient and elicit accurate and important information? 19

20. Communications w/Patients Seek informed consent, explaining scope and limits of confidentiality Ask about and plan for patient safety 20

21. Communications w/Patients Questions first directed at patient Even if an older adult has a cognitive disability, it is reasonable to ask about mistreatment S. Aravanis, R. Adelman, R. Breckman, T. Fulmer, E. Holder, M. Lachs, J. O’Brien & A. Sanders, Diagnostic and treatment guideline on elder abuse and neglect, Archive of Family Medicine, 1993 21

22. Communications w/Patients Question patients initially in a private setting, away from caregivers, family or others Aravanis, Adelman, Breckman, Fulmer, Holder, Lachs, O’Brien & Sanders 22

23. Communications w/Patients Keep questions simple and direct 23

24. Communications w/Patients Find out the patient’s preferred method of communication Consider how circumstances of patient might affect communications and accommodate when possible Use communication strategies that encourage patients to talk openly and honestly with you 24

25. Communications w/Patients Give patients a sense of hope and help them open up Use a warm, caring and empathic manner Anticipate and work to overcome reluctance to disclose mistreatment 25

26. Screening/Assessment Leaves Door Open… Many patients will deny mistreatment or refuse to discuss it However, screening and assessment lets them know someone cares and help is available B. Brandl, Assessing abuse in later life, 2004 26

27. Questioning Family and Caregivers How will you, as the nurse, approach this situation given suspicions of mistreatment? What challenges do you face with situations like this? What questions need to be asked of each person involved? What additional information would be useful to know? Does the nephew have the authority to tell you how to handle this case? What strategies will you use to talk with Mr. Jones in private? 27

28. Get Statements from Others 28 The likelihood of detecting or ruling out elder mistreatment increases as the net of observation and inquiry made by clinicians is widened G. Anetzberger (Ed.), The clinical management of elder abuse, 2005. Obtain statements from others after talking alone with the patient (even when you think the patient lacks decision-making capacity)

29. Guardians/Holders of Power of Attorney If a patient’s decision-making capacity is questionable, you may need to discuss matters with a legal guardian or holder of power of attorney, if one exists (unless that person is the suspected perpetrator) National Center on Elder Abuse, Guardianship and other legal protections of vulnerable adults, 2007 29

30. If Suspect Presents with Patient Observe behavior Ask questions 30

31. Sample Questions What does your _____ (e.g., father/mother) need help with every day? How do you and your ______ handle disagreements? What expectations does your ______ have of you? Is caring for your _____ different than you thought it would be? How? Sometimes providing care for a family member is challenging. What do you do or who do you tell when you are feeling stressed? R. Chez, Elder Abuse: An Introduction for Clinicians (Slide presentation), 2009 31

32. Separating Family Members and Caregivers from Patients Be creative in separating “hovering” family members or caretakers (including those who may be suspects) from patients to create a window of time to ask questions 32

33. Closing Assessment What have you learned from this module that you can apply to your practice setting? 33

34. Optional Activity Role plays to practice asking questions and using communications techniques Round 1: A (Observer), B (Nurse), C (Patient/Other) Round 2: A (Nurse), B (Patient/Other), C (Observer) Round 3: A (Patient/Other), B (Observer); C (Nurse) 34

35. Debriefing Questions Ask Nurse: What did you do that worked in this situation? What would you change? What did you do to address challenges? Ask the Observer: What behaviors did the nurse demonstrate that were effective in communicating w/patient and screening/assessing for mistreatment? What else could the nurse could have done? Ask Patient: What did the nurse do that you found helpful? What would you like nurse to do to further help you? OR Ask Those who Accompany Patient: What did nurse do to gain info? What else could she have done? 35