Can a Regulation to Report Suspected Abuse Give Us a False Sense of Security?

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At first glance, a regulation that requires healthcare professionals,  para professionals and support staff to report suspected patient abuse seems like a sound practice  to ensure safe patient care.  And really, who can argue against reporting suspected abuse of patients?

But, when a regulation is put in place without fully understanding underlying issues, such as staffing or toxic workplace cultures there are some potential negative rippling effects.  This point is best illustrated by considering dementia units in two fictional nursing home settings.

Consider how Wanda,  a nursing home patient who walks on the unit independently, is legally blind, and restless might fare differently on these two units and how the reporting process might be influenced.

Pine Tree Lake & Garden Views

Secure Dementia Unit:  A locked ward with 20 beds utilized for residents with advanced dementia.  Typically, 75% are totally dependent on staff for all care thus requiring 2 staff to assist with transfers, toileting and repositioning.  The abuse reporting process by the nurse on duty takes about 30-45 minutes.

During the Day (7a-3p)  and Evening (3p-11p) shifts are staffed with 1 RN or  1 LPN and 3 LNAs (Licensed Nursing Assistants).  On nights (11p-7a), the same staffing is used to cover two similar units.   When staff call in sick or have other emergencies an ‘on-call’ nurse or nursing assistant are available for back up and a list of Per Diem staff can also be used,  and in the rare case that isn’t enough the Assistant Director of Nurses, (ADON) and the Director of Nurses, (DON) take turns being back up.  In the last 12 months both came in once to help with a staffing shortage.

All staff have participated in in-house training for giving and receiving feedback.  All RNs and LPNs have taken an on-site or off-site course in conflict management and are reimbursed 50% for approved courses in leadership.  Quarterly team-building sessions include guest speakers, pizza, paid attendance and organizational requirements for staff to attend at least two per year although many attend them all.  Per Diem staff are utilized for covering the unit to enable staff to attend.

Maple Tree River & Meadow Vistas

Secure Dementia Unit:  A locked ward with 20 beds utilized for residents with advanced dementia.  Typically, 75% are totally dependent on staff for all care thus requiring 2 staff to assist with transfers, toileting and repositioning. The abuse reporting process by the nurse on duty takes about 30-45 minutes.

During the Day (7a-3p)  and Evening (3p-11p) shifts are staffed with 1 RN or  1 LPN and 2 LNAs (Licensed Nursing Assistants).  On nights (11p-7a), the same staffing is used to cover two similar units.  When staff call in sick or have other emergencies the list of full-time, part-time and per-diem staff are called for coverage.  Also, staff are asked to work overtime.  Assistant Director of Nurses, (ADON) and the Director of Nurses, (DON) can be called to fill in, but have not been called in the last 12 months.  Instead, the units run short staffed or with staff working 12+ hours.

All staff are required to take computerized courses in communication and reporting abuse.  Nurses have no training in conflict management and there is no educational incentive for leadership courses.  There are no team-building efforts planned for the next 12 months.

In the first nursing home they are fully staffed, team-building and leadership skills are a priority.  Staff work at a reasonable pace, seldom work overtime and when they do it is likely to be a few minutes or a couple of hours.  They are able to take their rest and meal breaks most of the time, and provide safe care.  They are not rushing and can get an extra pair of hands to help boost or transfer a patient when needed.  Call bells are answered quickly.  When conflicts arise among staff the nurse has the skills to help resolve them. Generally speaking staff get along pretty well even though they have different strengths and styles.  Our patient, Wanda has frequent walks with the staff and rarely bumps into things.  When LNAs note any new bruises, red marks or scratches, they report them to their nurse and the nurse has adequate time to complete the suspected abuse report.

In the second nursing home, they are chronically understaffed.  They are rushing to get the work done and often have to wait for a second pair of hands to help.  Nurses are known to punch out for meal breaks and continue working, many LNAs work double shifts, (16 hours) to cover sick calls.  Residents must wait for toileting, transfer and repositioning.  This leads to restlessness, incontinence, and falls.  Staff are short-tempered,  may try to lift, transfer or reposition patients by themselves if assistance or when assistance is not readily available, patients who have advocates or family presence are likely to get more attention than those who don’t, conflicts don’t get resolved and resentments and power struggles become part of the every day culture. Our patient, Wanda is constantly bumping into things including other patients.  Staff seldom have time to walk with her and the nurse is often running behind with medications while trying to help out with call bells,  patient assists, or  intervening to prevent falls.  The nurse will not have time to complete the reporting procedure until the end of or after her shift.

In the first case the regulation works well to ensure patient safety but in the second one, despite good intentions, it is less effective and may even keep staffing and toxic culture issues hidden. A nurse who was reprimanded for too much overtime may feel pressure to dismiss a report,  an LNA who is frustrated with the nurse or organization because she or he feels unable to take care of the number of patients the way she/he was trained to may feel a certain empowerment with respect to when and what to report to the nurse, and honestly Wanda, could literally have several incidents per shift!

How do you think staffing, team-building and/or conflict management skills may put patients and staff at risk?  Do you think the reporting regulation solve the problem of abuse?

 

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2 Responses to Can a Regulation to Report Suspected Abuse Give Us a False Sense of Security?

  1. Meg says:

    My question here: touchy subject here…one unit seems well prepared; the other unit understaff..surely stuff will happen and I can see bad results..but what isn’t clear Beth..how would they be reporting “abuse”..what would the abuse be..Wanda falling or bumping into things? or staff somehow causing injury?

    Meg

    • Beth Boynton says:

      Thanks, Meg. Great question! A tricky article to write, but what I’m getting at or trying to is a concern that staff who are chronically understaffed are put in impossible situations. Any time there is a skin issue in a long term care facility there is a potential concern that staff are abusing patients in some way. Nurses may feel some reports, such as a 0.5 cm x 0.5 cm red mark are not that serious and the amount of time it will take in an already overburdened day will mean that something more serious doesn’t get done or she’ll be in trouble for staying overtime, or maybe she wants to get out on time for once! Plus, if the LNAs are feeling pressure to complete work in a certain timeframe and manner when there is not enough staff and they have no say in their assignment, then they might report things in part to gain a sense of power. Since we are supposed to report everything it makes the very concept of ‘not reporting’ taboo.

      Ironically, staff who work in these conditions, shift after shift after shift, may be being abused by a leadership who doesn’t develop a back up plan for sick calls.

      Am I making any sense here? A friend of mine recently got in trouble for not reporting a tiny bruise on a patient…I guess we know she should have, but if the LNA hadn’t reported the nurse to the supervisor, it would have been one of many….I can’t say that the nurse was right, but I can relate and see how understaffing and morale influence the effectiveness of the regulation.

What are your thoughts?