If inspections of nursing homes are to have real impact, they must gain greater insight into the experience of mistreatment in long-term care institutions, writes Anne O'Loughlin
Coverage of the recent case involving a Dublin nursing home and the role of the Health Board Inspectorate will, hopefully, initiate a new phase of public concern about the institutional care of older people in Ireland.
The case has highlighted some of the dilemmas that must be faced, including issues such as the power of the health boards as regulators; what constitutes adequate care; "fitness" of the premises or, more importantly, of those running nursing homes; and the process of detecting abuse, mistreatment or neglect of older people.
More starkly, we are confronted with questions about the experience of those who live in long-term care. Behind the inspection report accounts of bedsores, dependence, poor hygiene, breaches of conditions, unpleasant smells, insufficient staffing and talk of relocation, dispersal, closure and transfers, are the individuals who live in nursing homes.
If the inspection of nursing homes is to have any real impact, the process must go beyond the traditional tape-measure model, to one which is not isolated from the day-to-day living experience of those who have crossed the threshold into care.
In Ireland today, it could be argued that we generally choose to ignore the silence that persists about the essence of long-term institutional care. There are difficulties in gaining information from those in long-term care about their experiences, especially given the severity of cognitive impairment and communication problems that many experience.
There are, however, other barriers, which prevent older people commenting on life in care.
The stated objective of a recent Irish study, Home from Home? The Views of Residents on Social Gain and Quality of Life: A Study in Three Care Centres for Older People (Age and Opportunity, 2003), was to develop a clear qualitative picture of the views of older people in long-term residential care.
The researchers noted "a tangible reluctance by some to criticise certain aspects of life in residential care".
The culture of "not letting on" can be very difficult to penetrate. For the older person, the consequences of speaking out can include victimisation and retaliation, exposure to public view and scrutiny, and fear of being moved on.
For some, there may be the assumption that nothing will happen, that no-one will take any notice.
These are exacerbated by denial and disbelief at an institutional level, as well as the power of vested interests, who may need to believe that the services they have established are satisfactory.
While developments in the recognition and responses to elder abuse have been occurring at a different pace in many countries, in recent years it has become a global concern.
It is now accepted that elder abuse is an umbrella term for a diverse range of behaviours, occurring in many different settings. Abuse and mistreatment in institutional care settings has many similarities to abuse and mistreatment in the domestic setting, but there are additional factors to be taken into account.
Of particular concern is institutional abuse, where the environment, practices and rules become abusive in themselves. Overt physical abuse, restraint of patients by seat belts, medication or electronic tagging devices in the absence of adequate staffing and supervision, or failure to provide adequate nutrition, are just some of the aspects of elder mistreatment.
There is a growing awareness of the sexual abuse of those in long-term care, while theft of patients' possessions is a relatively overlooked aspect of elder abuse.
The loss of the few cherished belongings a patient is allowed to have in a nursing home can have devastating consequences.
It is also important to be aware of the more covert, subtle forms of elder abuse that occur: loss of opportunity for personal choice, isolation, labelling or classifying residents as "good" or "bad", and thoughtless practices such as hurrying in the provision of personal care.
Touch, facial expression and gestures can also reflect attitudes of staff towards residents. It is recognised internationally that the regulation and inspection of long-term care and the definition of basic standards plays a key role in protection from abuse.
The current system has been in operation in Ireland since 1993. The report of the Human Rights Commission on Older People in Long Stay Care (2003) draws attention to the deficiencies in the system of inspection. In particular, it highlights the fact that there is virtually no published information on the quality of care being provided, nor has there been any systematic analysis of the inspection reports.
The health boards, as providers themselves, are not subject to any external assessment, while they inspect the private sector.
In a recent case, the Information Commissioner stated emphatically that there is significant interest in creating greater public knowledge about how the health boards carry out nursing home inspections. The Commissioner also stated that inspection reports should be available as a matter of routine.
Without this, it is very difficult to expect older people, their families and friends or staff in homes to "speak up" to those carrying out inspections.
The biggest challenge to the inspection process is to overcome the ever-increasing societal distancing from those older people who are in long-term care. We also must confront the cultural silence about abuse and the inspection process in long-term care.
Anne O'Loughlin is a member of the Irish Association of Social Workers Special Interest Group on Ageing.