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Do Training Programs Promote Identification and Treatment in Cases of Elder Abuse in Long Term Care (LTC) Facilities?

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Title: Do Training Programs Promote Identification and Treatment in Cases of Elder Abuse in Long Term Care (LTC) Facilities?
Language: English
Authors: Alon, Sara, Lang, Barbara (ORCID 0000-0003-0590-4191), Band-Winterstein, Tova
Source: Educational Gerontology. 2022 48(8):355-367.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 13
Publication Date: 2022
Document Type: Journal Articles
Reports - Research
Descriptors: Elder Abuse, Older Adults, Program Effectiveness, Caregiver Training, Prevention, Intervention
DOI: 10.1080/03601277.2022.2041535
ISSN: 0360-1277
1521-0472
Abstract: To examine the impact of training on detection and reporting cases of elder abuse and neglect perpetrated by staff in LTC facilities and to compare staff with previous training to those with no training. A quantitative study in which questionnaires were collected from 250 multi- professional participants at a training seminar. Trainees with previous training on elder abuse reported higher perceived self-efficacy, higher intention to take action asking residents direct questions on abuse, to refer and report cases of elder abuse. They identified more cases of elder abuse in comparison to trainees without previous training. Findings indicate a positive relationship between perceived self-efficacy and intention to take action, and between perceived self-efficacy and direct questioning and referral for further inquiry. Training professionals is essential in coping effectively with elder abuse and neglect in LTC facilities.
Abstractor: As Provided
Entry Date: 2022
Accession Number: EJ1358130
Database: ERIC
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  Value: <anid>AN0158065648;egr01aug.22;2022Jul21.08:06;v2.2.500</anid> <title id="AN0158065648-1">Do training programs promote identification and treatment in cases of elder abuse in Long Term Care (LTC) facilities? </title> <sbt id="AN0158065648-2">Introduction</sbt> <p>To examine the impact of training on detection and reporting cases of elder abuse and neglect perpetrated by staff in LTC facilities and to compare staff with previous training to those with no training. A quantitative study in which questionnaires were collected from 250 multi- professional participants at a training seminar. Trainees with previous training on elder abuse reported higher perceived self-efficacy, higher intention to take action asking residents direct questions on abuse, to refer and report cases of elder abuse. They identified more cases of elder abuse in comparison to trainees without previous training. Findings indicate a positive relationship between perceived self-efficacy and intention to take action, and between perceived self-efficacy and direct questioning and referral for further inquiry. Training professionals is essential in coping effectively with elder abuse and neglect in LTC facilities.</p> <p>In Israel, the majority of older persons reside in their homes within the community with only 2% living in Long Term Care (LTC) facilities (Schnor & Cohen, [<reflink idref="bib41" id="ref1">41</reflink>]). Notwithstanding the supervision, procedures, and regulations that set standards for quality of care, there are reports of abuse and neglect occurring in these settings (Ben Nathan et al., [<reflink idref="bib7" id="ref2">7</reflink>]; Iecovich & Avivi, [<reflink idref="bib29" id="ref3">29</reflink>]). Despite the fact that the law stipulates mandatory reporting of cases regarding elder abuse, the number of cases reported are low in comparison with the amount of cases that actually exist. In order to deal with the phenomenon, procedures and guidelines were written. Training programs and training materials produced by the Ministry of Health were developed. Thousands of professionals from LTC facilities participated in these training programs.</p> <p>This article presents findings from a study aimed at examining the impact of training programs for professionals in LTC facilities regarding the detection and reporting of elder abuse and neglect perpetrated by staff in these facilities.</p> <hd id="AN0158065648-3">Abuse and neglect in LTC facilities</hd> <p>The W.H.O. defines <emph>abuse and neglect</emph> as "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, This type of violence constitutes a violation of human rights and includes physical, sexual, psychological and emotional abuse; financial and material abuse, abandonment, neglect and serious loss of dignity and respect (World Health Organization [WHO], [<reflink idref="bib53" id="ref4">53</reflink>]). These represent abusive behaviors toward elders living in the community and LTC facilities. Abuse and neglect result in harm and trauma due to actions taken by commission or deprivation of care by omission (Alon, [<reflink idref="bib1" id="ref5">1</reflink>]; Alon et al., [<reflink idref="bib3" id="ref6">3</reflink>]).</p> <p>Elder abuse in institutions including physical abuse, is manifested by using restraint (physical and chemical restraint), pushing, beating, sexual abuse, throwing objects, etc.(Clarysse et al., [<reflink idref="bib13" id="ref7">13</reflink>]). The psychological abuse includes insults, humiliation, derogatory names, shouts, threats, sanctions, isolation, and infantilizing the older person (Iecovich & Avivi, [<reflink idref="bib29" id="ref8">29</reflink>]). Neglect includes failure to meet basic needs such as food and clothing, poor hygienic conditions, lack of health aids (dentures, glasses, and hearing aids), depriving stimulations (Friedman Avila et al., [<reflink idref="bib21" id="ref9">21</reflink>]; Friedmana et al., [<reflink idref="bib22" id="ref10">22</reflink>]). Financial exploitation is reflected in theft, and the illegal and improper use of the older person's belongings and money (Dauenhauer et al., [<reflink idref="bib16" id="ref11">16</reflink>]; Lichtenberg et al., [<reflink idref="bib32" id="ref12">32</reflink>]). Violation of rights manifests in not allowing the older person to make decisions for themselves, or about his/her belongings, infringing on the older person's right to privacy, and failure to provide the older person with relevant information regarding their rights (Post et al., [<reflink idref="bib39" id="ref13">39</reflink>]; WHO, [<reflink idref="bib53" id="ref14">53</reflink>]).</p> <hd id="AN0158065648-4">Prevalence of elder abuse</hd> <p>Most research on the field of elder abuse focuses on elder persons living in the community. The number of studies dealing with elder abuse in regards to LTC facilities is limited (Stevens et al., [<reflink idref="bib44" id="ref15">44</reflink>]; Yon et al., [<reflink idref="bib54" id="ref16">54</reflink>]). The extent of the phenomenon in LTC facilities remains unclear. Studies that estimated the rate are based on reports from professionals, older persons, family members, and data collected in organizations such as the U.S. Adult Protective Services (APS; Daly, [<reflink idref="bib15" id="ref17">15</reflink>]; Magruder et al., [<reflink idref="bib33" id="ref18">33</reflink>]). In a survey that examined abuse and neglect in LTC facilities in Arizona, USA, 71% of institutions reported the existence of abuse. Half of the reports came from the residents. Two-thirds of the complaints were found to be valid (Phillips et al., [<reflink idref="bib38" id="ref19">38</reflink>]). In another study that examined the extent of the phenomenon in 156 LTC facilities across the United States, 50.8% of the staff stated they were witness to psychological abuse and 23.7% reported neglect (Blumenfeld Arens et al., [<reflink idref="bib8" id="ref20">8</reflink>]). A study by Castle ([<reflink idref="bib11" id="ref21">11</reflink>]) repotted that 36% of nurse aides observed argumentative behavior with residents and 28% observed intimidation; 6% observed physical abuse and 10% observed material exploitation (taking assets). A study cited by the World Health Organization (WHO, [<reflink idref="bib52" id="ref22">52</reflink>]) reported that two out of three staff members in LTC facilities reported that they had abused residents during the previous year.</p> <p>In Israel, Ben Natan, Lowenstein, and Eizikowitz's study (Ben Nathan et al., [<reflink idref="bib7" id="ref23">7</reflink>]) reported that 53% of all staff members in LTC facilities that were studied indicated that they themselves had harmed older adult residents, while 70% reported witnessing acts of abuse of all kinds. In another study 31% of residents in surveyed LTC facilities reported that they suffered acts of abuse (Cohen et al., [<reflink idref="bib14" id="ref24">14</reflink>]). Most of the complaints were related to humiliation. Neglect was the second most common complaint.</p> <hd id="AN0158065648-5">Causes of abuse and neglect in LTC facilities</hd> <p>Several factors were found to be related to abuse and neglect by staff in LTC facilities:</p> <p>A. Negative attitudes toward LTC facilities and their residents: LTC facilities are often seen as a 'last stop' for its residents (pp.9). Facilities are perceived as being 'infected' and 'not alive'(pp.9). The facility is a segregated social enclave that is defined as a social 'void' (pp.9) run by known normative rules. It is as if the facility makes its residents disappear and makes them 'socially invisible' (pp.16; Hazan, [<reflink idref="bib28" id="ref25">28</reflink>]). Some studies report relationship between ageist attitudes and elder abuse (Band-Winterstein, [<reflink idref="bib5" id="ref26">5</reflink>]; Botngard et al., [<reflink idref="bib9" id="ref27">9</reflink>]; Iecovich & Avivi, [<reflink idref="bib29" id="ref28">29</reflink>]; Syme & Cohn, [<reflink idref="bib45" id="ref29">45</reflink>]). In addition, the placement of older people in an LTC facility is often seen as a failure of the professional ideology that emphasizes the importance of keeping older people in their home and community. The result is reflected in the creation of negative attitudes toward LTC facilities, those working in them, and the residents.</p> <p>B. The characteristics of the Institution: As a result of the fact that LTC facilities are totalitarian frameworks with rigorous procedures, there is a distinct distance between the staff and the residents as well as between the residents and the 'outside world.' LTC facilities can intrude upon and violate the resident's privacy, causing residents to feel a lack of control over their lives (Blumenfeld Arens et al., [<reflink idref="bib8" id="ref30">8</reflink>]; Wangmo et al., [<reflink idref="bib49" id="ref31">49</reflink>]). Frequent staff turnover is also a factor that can lead to abuse and neglect.</p> <p>C. Staff Members' Characteristics: Research show that staff members' characteristics have a direct connection to abusive behaviors (Botngard et al., [<reflink idref="bib9" id="ref32">9</reflink>]). Job ambiguity, work involving high levels of burnout (Goodridge et al., [<reflink idref="bib26" id="ref33">26</reflink>]; Iecovich & Avivi, [<reflink idref="bib29" id="ref34">29</reflink>]; Shinan-Altman & Cohen, [<reflink idref="bib43" id="ref35">43</reflink>]) the need to deal with complex situations such as residents' aggression on the one hand (Botngard et al., [<reflink idref="bib9" id="ref36">9</reflink>]; Whittington, [<reflink idref="bib50" id="ref37">50</reflink>]), and the lack of training and lack of skills of staff members on the other, can be fertile ground for causing harm (Radermacher et al., [<reflink idref="bib40" id="ref38">40</reflink>]). Low wages, poor professional image, as well as negative personal attitudes toward old age and older adults are factors that may influence providing poor care, abuse, and neglect (Ben Nathan et al., [<reflink idref="bib7" id="ref39">7</reflink>]; Blumenfeld Arens et al., [<reflink idref="bib8" id="ref40">8</reflink>]; Myhre et al., [<reflink idref="bib36" id="ref41">36</reflink>]; Wangmo et al., [<reflink idref="bib49" id="ref42">49</reflink>]).</p> <p>D. Residents' Characteristics: The majority of residents are almost entirely dependent on the staff members, who take care of residents' most basic physical, emotional, and social needs. Dementia, lack of cooperation on the part of the residents, agitation and manifestations of aggression create conflict that can result in the restraining of residents and the use of punishment and sanctions by staff against the residents (Blumenfeld Arens et al., [<reflink idref="bib8" id="ref43">8</reflink>]; Chen et al., [<reflink idref="bib12" id="ref44">12</reflink>]; Post et al., [<reflink idref="bib39" id="ref45">39</reflink>]; Wangmo et al., [<reflink idref="bib49" id="ref46">49</reflink>]; Withall et al., [<reflink idref="bib51" id="ref47">51</reflink>]).</p> <p>E. Situational characteristics and Interaction between staff members and residents: The combination of residents' characteristics and staff members' characteristics and the staff and residents' interactions, may also be significantly related to abusive situations (Botngard et al., [<reflink idref="bib9" id="ref48">9</reflink>]; Chen et al., [<reflink idref="bib12" id="ref49">12</reflink>])).</p> <p>The findings of the studies described above sketch a bleak picture of abusive and neglectful behavior toward the older adult residents. As a result of their physical and mental state residents of LTC facilities are almost totally dependent for their maintenance and care, as well as their dignity, health, and wellbeing on the LTC facility and its staff. Institutional practices largely dictate the residents' way of life. Privacy is limited and largely dependent on the caregiving staff. This dependency creates a reality in which the resident may be exposed to abuse, and neglect. Therefore, intervention programs, specifically focused on dealing effectively with the problem, must be aimed at removing or mitigating the risk factors associated with characteristics of LTC facilities, their staff, the residents, and the interaction between them.</p> <hd id="AN0158065648-6">Training programs as ways to deal with abuse and neglect in LTC facilities</hd> <p>Training programs for staff members have been found to be vital in addressing the problem of maltreatment in LTC facilities (Alon et al., [<reflink idref="bib3" id="ref50">3</reflink>]; Ellis et al., [<reflink idref="bib19" id="ref51">19</reflink>]; Myhre et al., [<reflink idref="bib36" id="ref52">36</reflink>]; Touza & Prado, [<reflink idref="bib48" id="ref53">48</reflink>]). This is based on the assumption that acquiring skills, formulating standards, and adhering to required procedures will ensure adequate care for the residents. In reviewing the literature on evidence-based intervention programs and those proven to be 'Best Practice,' training programs have been proven to be effective (Moore & Browne, [<reflink idref="bib35" id="ref54">35</reflink>]; Touza & Prado, [<reflink idref="bib48" id="ref55">48</reflink>]). As a result of training staff in LTC facilities, knowledge of abuse was enhanced, there was an improvement in the ability to identify abuse and neglect, cases were documented, and there was an increase in reporting such cases to the appropriate authorities (Ejaz et al., [<reflink idref="bib18" id="ref56">18</reflink>]; Harries et al., [<reflink idref="bib27" id="ref57">27</reflink>]; Tal, [<reflink idref="bib46" id="ref58">46</reflink>]). Additional studies report that training staff members in LTC facilities imparted knowledge and skills in the field of abuse, thus creating a good foundation for proper care of the older adult residents while reducing abuse, and neglect (Daly, [<reflink idref="bib15" id="ref59">15</reflink>]; Fulmer, [<reflink idref="bib23" id="ref60">23</reflink>]; Du Mont et al., [<reflink idref="bib17" id="ref61">17</reflink>]; Teresi et al., [<reflink idref="bib47" id="ref62">47</reflink>])</p> <p>Despite the increase in the numbers of studies in the field of abuse and neglect in LTC facilities, there are still very few studies that provide data on interventions to prevent this phenomenon. Coping effectively with the problem requires diverse intervention programs, including the training of professionals who can serve as gatekeepers.</p> <p>Over the years, training programs have been developed around the world. Educational programs for staff members – which focus on imparting knowledge about the phenomenon, skills focusing on identifying abuse and neglect, and information regarding laws and procedures – have been proven valuable in enhancing knowledge and reducing risk factors for abuse and neglect., However, most of these programs are not evidence-based. Evidence-based programs, accompanied by rigorous research and a clear methodology (such as data collection before and after the intervention), provide meaningful and valid results (Moore & Browne, [<reflink idref="bib35" id="ref63">35</reflink>]).</p> <p>In Israel, no evidence-based research has been conducted on the impact of training and educational programs on professionals in LTC facilities. The purpose of the present study is to examine the impact of training programs on the detection and reporting of elder abuse and neglect in LTC facilities.</p> <hd id="AN0158065648-7">The theoretical framework</hd> <p>Theoretical Domains Framework (Cane et al., [<reflink idref="bib10" id="ref64">10</reflink>]) provides a theoretical framework for this study. The framework deals with changing professional behaviors and emphasizes the need to address cognitive, psychological, and environmental dimensions that may affect behavior change. The approach addresses a number of dimensions including knowledge, skills, and self-efficacy, which may influence an individual's motivation to put effort into a task and affect the choice to carry out, exhibit or avoid a certain behavior (Bandura, [<reflink idref="bib6" id="ref65">6</reflink>]). Additional dimensions relate to beliefs about expected difficulties and desired outcomes; motivation; decision-making processes; environmental contexts such as support; emotions such as fear; compassion; the type of tasks required; barriers; and promoting factors. Since all of the dimensions cannot be examined simultaneously, those dimensions that are most relevant to the type of behavior one wishes to change are selected.</p> <p>Our study examines the effect of training on behavioral change (identifying abuse, referral and reporting of cases). Assimilation of new practices and changes of professionals' behavior, is related to many factors such as knowledge, personal ability and skills, emotional barriers, organizational barriers and more (Atkins et al., [<reflink idref="bib4" id="ref66">4</reflink>]). We therefore chose to base our study on the theoretical dimension framework which was developed as a basis for studies examining change in professionals' behavior. The theory emphasizes the cognitive, emotional, and environmental dimensions that influence behavioral changes (Cane et al., [<reflink idref="bib10" id="ref67">10</reflink>]). These dimensions include knowledge, skills, professional identity, beliefs about the professional's ability to perform (self-efficacy), beliefs about expected difficulties (inhibiting factors), environmental influences such as support, emotions, and the nature of the behavior required (and in our case identification and reporting of abuse). Since not all dimensions can be examined simultaneously, those most relevant to the type of behavior that requires change must be selected. Based on this theoretical approach and a similar study examining the effect of training on identifying and reporting abuse and neglect (Tal, [<reflink idref="bib46" id="ref68">46</reflink>]), the present study selected dimensions that may influence the desired behavioral change – identifying and reporting abuse.</p> <p>The training provided: knowledge, (cognitive dimension), a workshop addressing the emotional dimension (breaking barriers which inhibited the performance of required behavior), communication skills aiding in recruiting partners and working with the management regarding reporting and involving 'outsiders' in investigating the suspicion of abuse (environmental dimension). Additional training programs in the field were held in Israel and were evaluated (Alon & Berg-Warman, [<reflink idref="bib2" id="ref69">2</reflink>]; Shefet et al., [<reflink idref="bib42" id="ref70">42</reflink>]; Tal, [<reflink idref="bib46" id="ref71">46</reflink>]).</p> <p>Based on the Theoretical Domains Framework (Cane et al., [<reflink idref="bib10" id="ref72">10</reflink>]) and on the Four Level Evaluation Model (Kirkpatrick, [<reflink idref="bib30" id="ref73">30</reflink>]) in the present study, a number of measures related to the identification and reporting of elder abuse (the desired behavior) were selected: <bold><emph>Questioning skills</emph></bold> based on the professionals' knowledge and experience, which is an essential component in detecting abuse (Level 2 and 3 in Kirkpatrick's model, Kirkpatrick, [<reflink idref="bib30" id="ref74">30</reflink>]; Tal, [<reflink idref="bib46" id="ref75">46</reflink>]); <bold><emph>Perceived</emph> S<emph>elf-efficacy</emph></bold> is the way in which we perceive the ability to perform or exhibit behavior that will result in a particular outcome. In our case the professional's ability to identify abuse based on knowledge of the actions required (referral to an in-house Violence Prevention Committee, reporting to Adult Protective Services (APS) social worker* or reporting to the police (Level 2 and 3 in Kirkpatrick's model, Kirkpatrick, [<reflink idref="bib30" id="ref76">30</reflink>]); <bold><emph>Barriers</emph></bold> to identifying abuse; and <bold><emph>Factors</emph></bold> that may <bold><emph>promote</emph></bold> desirable behavior.</p> <p>In order to examine the effect (Level 3 and 4 in Kirkpatrick's model, Kirkpatrick, [<reflink idref="bib30" id="ref77">30</reflink>]), we used data from the Ministry of Health as an additional resource regarding the number of cases of abuse and neglect of staff toward residents in the years 2016–2018. This information is sent to the Ministry of Health from administration of LTC facilities annually and not from participants in the training sessions.</p> <hd id="AN0158065648-8">Method</hd> <p>This study aims to examine the impact of health care professionals' training on identifying cases of abuse in LTC facilities, referring to the Violence Prevention Committee for continued treatment or report to APS social worker as required by the law. In addition, this study compares staff who have had previous training in elder abuse and neglect to those who have not. A T-test was conducted in order to compare participants who had previously participated in training in the field of elder abuse and neglect with those who had not.</p> <hd id="AN0158065648-9">Research questions</hd> <p></p> <ulist> <item> To what extent has there been a change in the level of knowledge regarding abuse and neglect following participation in the seminar and training?</item> <p></p> <item> To what extent has there been an actual change in behavior (identifying cases of abuse; referring to the Violence Prevention Committee for continued treatment; reporting to APS social worker), as a result of exposure to and use of the training manual?</item> <p></p> <item> What is the actual impact of barriers regarding the referral and reporting of abuse and neglect on the conduct of professionals who attended the seminar?</item> <p></p> <item> What is the actual effect of the factors that promote the referral and reporting of abuse and neglect on the behavior of professionals who attended the seminar?</item> </ulist> <p>*A trained social worker appointed by the Ministry of Social Services for use of laws protecting older persons.</p> <hd id="AN0158065648-10">Sample and study population</hd> <p>The study included 211 professionals from across the country (physicians, social workers, and nurses), all of whom were members of the Violence Prevention Committee in LTC facilities. They participated in one of six training days in which they learned how to use the training manual to identify abuse in LTC facilities (Lang & Amir, [<reflink idref="bib31" id="ref78">31</reflink>]). Tables 1 and 2 describe the participants' background variables. Most of the participants were women (84%), with an average age of 47.7 years; more than two-thirds were Israeli-born; and the majority were Jewish (83%). Half of the participants held a Bachelor's degree (50%) while 41% had a Master's degree, and around 10% held a PhD (MD, PhD). The average work experience was 19 years, in general, and 11 years in the LTC facility. In addition, 61% of participants were social workers, 30% were nurses, and 7% were physicians. Regarding their specialization, more than half (53%) specialized in gerontology, two-thirds of whom had participated in at least one course on the prevention of elder abuse.</p> <p>Table 1. Distribution of participants' background variables.</p> <p> <ephtml> <table><thead><tr><td>Variable</td><td>211</td><td>Sample size N = 211</td><td>Percentage %</td></tr></thead><tbody><tr><td>Gender</td><td>Men</td><td>34</td><td>16</td></tr><tr><td>Women</td><td>177</td><td>84</td></tr><tr><td>Country of Birth</td><td>Israel</td><td>147</td><td>69</td></tr><tr><td>Other</td><td>64</td><td>31</td></tr><tr><td>Religion</td><td>Jewish</td><td>177</td><td>83</td></tr><tr><td>Muslim</td><td>16</td><td>8</td></tr><tr><td>Christian</td><td>15</td><td>7</td></tr><tr><td>Other</td><td>3</td><td>2</td></tr><tr><td>Education</td><td>B.A.</td><td>105</td><td>50</td></tr><tr><td>M.A.</td><td>86</td><td>41</td></tr><tr><td>M.D.</td><td>9</td><td>4</td></tr><tr><td>PhD</td><td>11</td><td>5</td></tr><tr><td>Profession</td><td>Social worker</td><td>129</td><td>61</td></tr><tr><td>Nurse</td><td>63</td><td>30</td></tr><tr><td>Physician</td><td>14</td><td>7</td></tr><tr><td>Health professional</td><td>5</td><td>2</td></tr><tr><td>Specialization</td><td>Gerontology</td><td>111</td><td>53</td></tr><tr><td>Health</td><td>58</td><td>27</td></tr><tr><td>Other</td><td>34</td><td>16</td></tr><tr><td>None</td><td>8</td><td>4</td></tr></tbody></table> </ephtml> </p> <p>Table 2. Averages and standard deviations of participants' background variables.</p> <p> <ephtml> <table><thead><tr><td>Variable</td><td>Average</td><td>S.D.</td></tr></thead><tbody><tr><td>Age</td><td>47.7</td><td>11.83</td></tr><tr><td>Professional seniority</td><td>19.2</td><td>11.89</td></tr><tr><td>Seniority at LTC facility</td><td>11.3</td><td>9.10</td></tr></tbody></table> </ephtml> </p> <p>It is important to note that 121 of the participants had previously participated in a course for the prevention of elder abuse, which is 64% of all respondents. (36% of all respondents had never participated in a course for the prevention of elder abuse.</p> <hd id="AN0158065648-11">Research tools</hd> <p>This study used a questionnaire built to evaluate simulation workshops to increase knowledge and impart skills to detect abuse among health care professionals (Shefet et al., [<reflink idref="bib42" id="ref79">42</reflink>]; Tal, [<reflink idref="bib46" id="ref80">46</reflink>]). For the current study, the questionnaire was adapted to examine the effect of continuing education on the detection and reporting of abuse in LTC facilities.</p> <p>The questionnaire included:</p> <p></p> <ulist> <item> Demographic details – age, gender, country of birth, academic level, professional seniority, etc.;</item> <p></p> <item> Previous participation in training on elder abuse.</item> <p></p> <item> Perceived Self-Efficacy Questionnaire regarding detection (for this sample) (α = 0.78): 7 questions on a scale of 1–5 on how to identify abuse and neglect situations. For example: 'Currently, to what extent are you able to identify a resident who suffers from abuse?'; Direct questioning: 'To what extent do you feel able to directly ask residents if they are being abused?', and 'When you come across a case of suspected abuse, to what extent do you feel you know what to do?'.</item> <p></p> <item> Skills Questionnaire which included 3 questions regarding A. actual identification: 'How many times in the last six months have you identified abused residents?'; B. Direct Questioning: 'How many times during the past six months have you directly asked patients if they are being abused?'; C. Referrals for further inquiry and follow up: Respondents were asked whether they had referred to a physician/nurse/social worker, Violence Prevention Committee, or APS social worker.</item> <p></p> <item> Barriers Questionnaire (for this sample) (α = 0.89) which included 12 questions on a scale of 1 −5 addressing difficulties and barriers such as lack of knowledge about elder abuse and neglect, difficulty to deal emotionally with the subject, fear of harming the client, fear of breach of trust of other staff members, fear of harming relationship with management, and fear of sanctions being imposed on them by staff members or management.</item> <p></p> <item> Promoting Factors Questionnaire (for this sample) (α = 0.76) which included 5 questions on a scale of 1–5 referring to staff training and activities as promoters of detection and identification, and training that promotes residents' safety.</item> <p></p> <item> Questionnaire of Intention to take action included two questions: 'When you come across a case of suspected abuse or actual abuse, do you contact the Violence Prevention Committee for further inquiry?' and 'When you come across a case of suspected abuse or actual abuse, do you report to an APS social worker)?'</item> </ulist> <p>In order to validate our findings, data from the Ministry of Health regarding the amount of cases of abuse/neglect identified in LTC facilities during the years 2016–2018 was used.. It is important to note that administrations of LTC facilities are required to send these statistics annually.</p> <hd id="AN0158065648-12">Procedure and ethics</hd> <p>The Faculty of Social and Health Sciences Ethics Committee at the University of Haifa approved the study. The questionnaires were filled out during seminars introducing the training manual to Violence Prevention Committee members (physicians, nurses, social workers, and other health professionals) in LTC facilities, after obtaining their consent to complete the questionnaire. The questionnaires were filled out anonymously, after ensuring participants of anonymity.</p> <hd id="AN0158065648-13">Data analysis</hd> <p>SPSS version 23 was used. <bold>Descriptive statistics</bold> included participants' demographic characteristics; distributions and incidences of abuse detection; direct questioning; referral for further inquiry and treatment and number of reports to the Ministry of Health.</p> <p> <bold>Inferential</bold> statistics – Associations between variables were examined using formed using Pearson correlation coefficients. T tests were also used to examine mean differences among groups.</p> <hd id="AN0158065648-14">Findings</hd> <p>Table 3 shows the averages, standard deviations, and range of research variables.</p> <p>Table 3. Averages, standard deviations, and range of research variables (N = 204).</p> <p> <ephtml> <table><thead><tr><td>Variables</td><td>Average</td><td>S.D.</td><td>Range</td></tr></thead><tbody><tr><td>Perceived Self-efficacy</td><td>4.25</td><td>0.48</td><td>1–5</td></tr><tr><td>Intent to take Action</td><td>4.55</td><td>0.56</td><td>1–5</td></tr><tr><td>Skills:</td><td /><td /><td>No. of Times</td></tr><tr><td>Direct questioning</td><td>3.75</td><td>6.44</td></tr><tr><td>Referral for further inquiry</td><td>2.29</td><td>1.80</td></tr><tr><td>Referral to APS social worker</td><td>1.48</td><td>1.31</td></tr><tr><td>Barriers</td><td>1.77</td><td /><td>1–5</td></tr><tr><td>Promoting factors</td><td>4.24</td><td /><td>1–5</td></tr><tr><td>Actual detection of abused residents</td><td>2.31</td><td /><td>No. of cases 0–10</td></tr></tbody></table> </ephtml> </p> <p>Findings show that perceived self-efficacy was high (4.25) as was the intent to take action (4.55) (referring the incident onwards for further inquiry, and or reporting to APS social worker). Participants reported a low level of existing barriers (1.77) regarding detection of abuse, compared to a high level (4.24) of promoting factors. When participants were asked about skills related to taking action, they reported that during the previous six months they had directly asked residents about abuse 3.75 times on average, and had then notified a professional (physician, nurse, social worker, Violence Prevention Committee) within the LTC facility an average of 2.29 times, and reported to APS social worker an average of 1.48 times.</p> <p>In addition, a comparison was made among the various professionals and the different variables. Table 4 presents the differences in variables by profession.</p> <p>Table 4. Differences in variables by profession.</p> <p> <ephtml> <table><thead><tr><td>Variable</td><td>Profession</td><td><italic>F(df)</italic></td></tr><tr><td>Social workers (N = 116) Average</td><td>Nurses (N = 59) Average</td><td>Physicians (N = 14) Average</td><td>Health Professionals (N = 5) Average</td></tr></thead><tbody><tr><td>Perceived self-efficacy</td><td>4.29</td><td>4.24</td><td>3.97</td><td>3.82</td><td>3.26(3,190)*</td></tr><tr><td>Intent to take action</td><td>4.55</td><td>4.58</td><td>4.50</td><td>3.90</td><td>2.37(3,188)</td></tr><tr><td>Barriers</td><td>1.69</td><td>1.79</td><td>2.16</td><td /><td>2.98(2,185)*</td></tr><tr><td>Promoting factors</td><td>4.18</td><td>4.40</td><td>4.01</td><td>3.96</td><td>3.34(3,185)*</td></tr></tbody></table> </ephtml> </p> <p>When a comparison (T-test) was performed between the professions regarding the perceived self-efficacy, it was found that social workers, significantly, had the highest average score, followed by nurses, physicians and other health professionals. This trend was also observed for the variable of barriers, with physicians having the highest level of barriers, followed by nurses and social workers. When scores for the variable of promoting factors were assessed, the highest average score was found to be those of nurses followed by social workers, physicians, and finally other healthcare professionals. An ANOVA test was performed in order to compare between the caring professions (nursing, social work, medicine and healthcare professions). A significant difference (F (<reflink idref="bib3" id="ref81">3</reflink>,<reflink idref="bib185" id="ref82">185</reflink>) = 3.34, p =.020) was found. An additional comparison between nurses and physicians found that nurses had a significantly higher mean score than that of physicians (F (<reflink idref="bib2" id="ref83">2</reflink>,<reflink idref="bib181" id="ref84">181</reflink>) =4.42, p =.013).</p> <p>In regards to actual identification of abuse, the participants reported that during the previous six months they had identified, on average, two cases; one-fifth said they did not identify any cases; 23% identified one case; and 57% of the participants cited they had identified two or more cases. Table 5 shows the data according to type of abuse. Prior training 368 cases of abuse were reported to the Ministry of Health while post training 487 cases were reported.</p> <p>Table 5. Types of abuse, number of cases, percentages, averages and standard deviations.</p> <p> <ephtml> <table><thead><tr><td>Types of Abuse</td><td>No. of Cases</td><td>No. of Respondents</td><td>Percentage</td><td>Average</td><td>S.D.</td></tr></thead><tbody><tr><td>Physical abuse</td><td>0</td><td>38</td><td>33.6</td><td>1.04</td><td>1.07</td></tr><tr><td>1</td><td>50</td><td>44.2</td></tr><tr><td>2+</td><td>25</td><td>22.1</td></tr><tr><td>Psychological abuse</td><td>0</td><td>30</td><td>28</td><td>1.11</td><td>1.25</td></tr><tr><td>1</td><td>51</td><td>47.6</td></tr><tr><td>2+</td><td>26</td><td>24.3</td></tr><tr><td>Financial exploitation</td><td>0</td><td>47</td><td>46</td><td>0.76</td><td>1.01</td></tr><tr><td>1</td><td>42</td><td>41.1</td></tr><tr><td>2+</td><td>13</td><td>12.7</td></tr><tr><td>Neglect</td><td>0</td><td>43</td><td>40.9</td><td>1.04</td><td>1.84</td></tr><tr><td>1</td><td>47</td><td>44.7</td></tr><tr><td>2+</td><td>15</td><td>14.2</td></tr><tr><td>Sexual abuse</td><td>0</td><td>73</td><td>91.2</td><td>0.10</td><td>0.34</td></tr><tr><td>1</td><td>6</td><td>7.5</td></tr><tr><td>2+</td><td>1</td><td>1.2</td></tr><tr><td>Chemical restraint</td><td>0</td><td>60</td><td>69.7</td><td>0.64</td><td>1.41</td></tr><tr><td>1</td><td>17</td><td>19.7</td></tr><tr><td>2+</td><td>9</td><td>10.4</td></tr><tr><td>Physical restraint</td><td>0</td><td>51</td><td>65.3</td><td>0.81</td><td>2.60</td></tr><tr><td>1</td><td>22</td><td>28.2</td></tr><tr><td>2+</td><td>5</td><td>6.4</td></tr></tbody></table> </ephtml> </p> <p>Table 5 shows that respondents identified on average, one case of physical abuse and one case of neglect. This is not the case for other types of abuse. Based on the self-reporting of participants in the study when examining the percentage of participants who identified or did not identify cases by type of abuse, it was found that psychological abuse was identified once in the past six months by 47% of the respondents, followed by physical abuse and neglect (44%), and financial exploitation (41%) in descending order. The least commonly identified types of abuse are sexual abuse (91% of the respondents reported zero identifications of sexual abuse, and only 7.5% identified a single case). Chemical restraint was unidentified by 69.7% of respondents, and one-fifth reported they had identified one such case. Physical restraint was unidentified by 65% of respondents and 28% reported identifying one such case.</p> <p>The relationships among the variables were examined. Table 6 shows the correlations. This table shows that there were significant relationships between self-efficacy and intention to take action (p =.46), to question directly (p =.24), and to report to an APS social worker (p =.13). In addition, there was a significant relationship between the existence of promoting factors that enable the professional to take action in the field of elder abuse, and the perceived self-efficacy (p =.28). Finally, there was a significant negative correlation between the existence of barriers in the field of elder abuse and the professional's intention to take action (p = −0.18). In addition, it was found that as the professional identifies more cases of abuse, there is a higher tendency that they will notify others for further inquiry (p =.75) and report the incident to an APS social worker (p =.30).</p> <p>Table 6. Pearson correlations among variables.</p> <p> <ephtml> <table><thead><tr><td>Variable</td><td>Self-efficacy</td><td>Intent to take action</td><td>Actual identification</td><td>Direct questioning</td><td>Referral for further inquiry</td><td>Referral to APS social worker</td><td>Barriers</td><td>Promoting factors</td></tr></thead><tbody><tr><td>Self-efficacy</td><td /><td>*0.4607</td><td>0.0928</td><td>*0.2492</td><td>0.1718</td><td>*0.1328</td><td>−0.3242</td><td>*0.2854</td></tr><tr><td>Intent to take action</td><td /><td /><td>0.0932</td><td>0.1355</td><td>−0.0044</td><td>0.1226</td><td>*-0.1897</td><td>0.2773</td></tr><tr><td>Actual identification</td><td /><td /><td /><td>0.1760</td><td>*0.7525</td><td>*0.3090</td><td>0.0188</td><td>0.0578</td></tr><tr><td>Direct questioning</td><td /><td /><td /><td /><td>*0.2736</td><td>0.2378</td><td>−0.0626</td><td>0.0799</td></tr><tr><td>Referral for further inquiry</td><td /><td /><td /><td /><td /><td>*0.2607</td><td>−0.0317</td><td>0.0659</td></tr><tr><td>Report to APS social worker</td><td /><td /><td /><td /><td /><td /><td>−0.0593</td><td>0.0819</td></tr><tr><td>Barriers</td><td /><td /><td /><td /><td /><td /><td /><td>−0.1602</td></tr><tr><td>Promoting factors</td><td /><td /><td /><td /><td /><td /><td /><td /></tr></tbody></table> </ephtml> </p> <p>1 p < 0.05</p> <p>Data revealed that those who previously participated in training on the subject have a significantly higher perceived self-efficacy (T (<reflink idref="bib109" id="ref85">109</reflink>) = −3.02, p =.003). It was also found that those who had previously participated in training in the field, identified significantly more cases of abuse compared to those who had not been trained in the field (T (<reflink idref="bib114" id="ref86">114</reflink>) = −2.27, p =.024). Professionals who are trained in the field of elder abuse are significantly more likely to ask residents direct questions regarding abuse compared to those who are not similarly trained (T (<reflink idref="bib75" id="ref87">75</reflink>) = −2.73, p =.007). The same holds true concerning reporting to an APS social worker (T (<reflink idref="bib63" id="ref88">63</reflink>) = −2.28, p =.025). There were no significant differences between the two groups regarding referrals for further inquiry on suspected abuse situations.</p> <hd id="AN0158065648-15">Discussion</hd> <p>The purpose of the present study was to examine the impact of training programs on the detection of elder abuse and neglect in LTC facilities. In general, the trainees reported that they identified an average of two cases of abuse. More than half reported that they identified more than two cases.</p> <p>When a comparison was made between trainees who had attended previous elder abuse training programs and those who had not, it was found that the former group significantly identified more cases of abuse than the latter group. Differences were found between the two groups in regards to perceived self-efficacy (the former group had a higher perceived self-efficacy). In addition, the former group had a higher intention to take action as well as a higher tendency to directly question residents regarding abuse. Third, the former group showed more frequent referrals for further inquiry both in-house (in the LTC facilities) and regarding the reporting of incidents to an APS social worker. These distinct findings reinforce the presumption that training in the field of elder abuse and neglect imparts knowledge, skills, a sense of confidence, and positively affects professionals' behavior. This is in line with previous studies, and in accordance with Dimension Framework (Ejaz et al., [<reflink idref="bib18" id="ref89">18</reflink>]; Garma, [<reflink idref="bib24" id="ref90">24</reflink>]; Moore & Browne, [<reflink idref="bib35" id="ref91">35</reflink>]; Myhre et al., [<reflink idref="bib36" id="ref92">36</reflink>]; Tal, [<reflink idref="bib46" id="ref93">46</reflink>]; Touza & Prado, [<reflink idref="bib48" id="ref94">48</reflink>]).</p> <p>In examining the relationships between the various variables, there are clear positive relationships linking between perceived self-efficacy with intention to take action, perceived self-efficacy with direct questioning, and between perceived self- efficacy with reporting to an APS social worker. A significant positive relationship between perceived self-efficacy and promoting factors was found. It was also found that the more a professional identifies situations and cases of abuse, the greater their tendency to refer the incident on for further inquiry and to report to an APS social worker. These relationships reinforce the conclusion regarding the positive contribution of training and imparting knowledge, and its impact on professional behavior. This trend was also observed in the administrative reports submitted to the Ministry of Health. In 2016 (pre-training), 75 institutions reported abuse cases of various types. In 2017 (post-training), there was an increase in the number of institutions who submitted reports of abuse (92 in number). While the average number of cases detected and reported had not changed, changes could be seen in the identification of several types of abuse. For example, in 2016, an average of 1.96 neglect cases was reported; a year later the average rose to 2.5. Psychological abuse was identified and reported in 2016 at an average of 1.85 cases and a year; later the average rose to 2.34 cases. A moderate increase was also observed in sexual abuse reporting: An average of 1.08 cases was reported in 2016 and after training an average of 1.5 cases were identified and reported. This trend may indicate the impact of training on an increase of knowledge and the strengthening of identification skills, as well as the reduction of fear regarding passing on information to the Ministry of Health.</p> <p>The training included professionals from the fields of social work, nursing, medicine, and other health professions. When compared, a number of differences were found: social workers and nurses had a higher level of perceived self-efficacy than physicians and other health professionals. The same is true for the average score of the promoting factors. Accordingly, the average barriers score was higher for physicians. That is, physicians report more barriers to implement interventions to prevent elder abuse. A possible explanation for this is related to the characteristics of the job, the professional role, and the therapeutic relationship of social workers and nurses compared to physicians. In practice, we see that physicians believe it is the role of social workers to be actively engaged in the identification and intervention of elder abuse cases (Fisher et al., [<reflink idref="bib20" id="ref95">20</reflink>]). Social workers' skills and their therapeutic approach in creating trust relationships and attentive listening may be used in the context of intervention in cases of elder abuse (Goldblatt et al., [<reflink idref="bib25" id="ref96">25</reflink>]).</p> <hd id="AN0158065648-16">Study limitations</hd> <p>The study participants were recruited at a training program that focused on how to use the training manual produced for abuse prevention in LTC facilities. Since this is actually a 'convenience sample,' we are aware that the sample is not representative according to research standards. Therefore, the findings cannot be generalized. However, during the course of the training program, which lasted several months, professionals representing all the professions employed at LTC facilities participated. Participants came from all over the country and represented a variety of institutions: large, medium and small, privately and publicly owned. This variance certainly allows us to cautiously learn about trends and directions that make it possible to draw conclusions. According to these trends, we may suggest future directions and recommendations for the ongoing need to deal with and prevent abuse and neglect in LTC facilities.</p> <p>As for the reports on the number of cases identified, the data presented relate to the self-reports of the participants and could not be compared to actual reports to official bodies.</p> <p>Another limitation stems from the fact that it was not possible to compare data pre- and post-training (after a period of several months). This is due to low responsiveness and the limited number of post-training questionnaires that were returned, despite repeated requests from the researchers.</p> <hd id="AN0158065648-17">Implications for practice and research</hd> <p>The research findings have both theoretical and practical implications. The present study was based on the Dimensions Framework, which deals with changing professional behaviors. The study included a number of components such as knowledge, skills, perceived self-efficacy, barriers, and promoting factors. The findings indicate that participants who had undergone previous training programs had a higher perception of efficacy, they asked residents direct questions about abuse (compared to those who had not attended previous training programs), and identified more cases of abuse. These findings reinforce the understanding that imparting knowledge and skills contributes to increased perceived self-efficacy and influences desired professional behavior.</p> <p>Another contribution was found by comparing professionals from the medical, nursing, social work, and other health professions. The findings indicated differences in the perceived self-efficacy component, as well as barriers and promoting factors. Given the importance of working in a multi-professional team and in order to achieve quality of care and to prevent abuse in LTC facilities, multi-professional training should be developed for staff members in LTC facilities.</p> <p>The present study is, in fact, a continuation of previous studies which has indicated that training contributes to professionals' knowledge and acquisition of skills in identifying and detecting abuse situations (Nordstrom & Wangmo, [<reflink idref="bib37" id="ref97">37</reflink>]; Tal, [<reflink idref="bib46" id="ref98">46</reflink>]; Wangmo et al., [<reflink idref="bib49" id="ref99">49</reflink>]). Therefore, awareness of elder abuse and neglect prevention should be raised to increase the commitment of professionals, administrators, and policy makers. Training should continue systematically in order to impart knowledge and skills for identification, referral for continued intervention, and reporting according to the law and according to procedures issued by Ministry of Health ([<reflink idref="bib34" id="ref100">34</reflink>]). It is also advisable to continue producing training and information material, so the activities in LTC facilities become part of the organization's routine. Moreover, it is worthwhile to find ways to reward the institutions' management – both for their activities in the field of prevention of abuse and neglect and for data collection and submission to the Ministry of Health.</p> <p>Finally, it is of the utmost importance to convey the message that transparency contributes to both the image and good reputation of the LTC facility and may help in obtaining additional budgets.</p> <hd id="AN0158065648-18">Disclosure statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <ref id="AN0158065648-19"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref5" type="bt">1</bibl> <bibtext> University of Haifa, Israel IRB Protocol Number: 333/19 Consent of participants was written.</bibtext> </blist> </ref> <ref id="AN0158065648-20"> <title> References </title> <blist> <bibtext> Alon, S. (2015). Elder abuse and neglect: Dimensions and ways of coping. In D. Prilotsky & M. 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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Do Training Programs Promote Identification and Treatment in Cases of Elder Abuse in Long Term Care (LTC) Facilities?
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  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Alon%2C+Sara%22">Alon, Sara</searchLink><br /><searchLink fieldCode="AR" term="%22Lang%2C+Barbara%22">Lang, Barbara</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-0590-4191">0000-0003-0590-4191</externalLink>)<br /><searchLink fieldCode="AR" term="%22Band-Winterstein%2C+Tova%22">Band-Winterstein, Tova</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Educational+Gerontology%22"><i>Educational Gerontology</i></searchLink>. 2022 48(8):355-367.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 13
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2022
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Elder+Abuse%22">Elder Abuse</searchLink><br /><searchLink fieldCode="DE" term="%22Older+Adults%22">Older Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Caregiver+Training%22">Caregiver Training</searchLink><br /><searchLink fieldCode="DE" term="%22Prevention%22">Prevention</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink>
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  Data: 10.1080/03601277.2022.2041535
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  Label: ISSN
  Group: ISSN
  Data: 0360-1277<br />1521-0472
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: To examine the impact of training on detection and reporting cases of elder abuse and neglect perpetrated by staff in LTC facilities and to compare staff with previous training to those with no training. A quantitative study in which questionnaires were collected from 250 multi- professional participants at a training seminar. Trainees with previous training on elder abuse reported higher perceived self-efficacy, higher intention to take action asking residents direct questions on abuse, to refer and report cases of elder abuse. They identified more cases of elder abuse in comparison to trainees without previous training. Findings indicate a positive relationship between perceived self-efficacy and intention to take action, and between perceived self-efficacy and direct questioning and referral for further inquiry. Training professionals is essential in coping effectively with elder abuse and neglect in LTC facilities.
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  Data: 2022
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  Data: EJ1358130
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      Pagination:
        PageCount: 13
        StartPage: 355
    Subjects:
      – SubjectFull: Elder Abuse
        Type: general
      – SubjectFull: Older Adults
        Type: general
      – SubjectFull: Program Effectiveness
        Type: general
      – SubjectFull: Caregiver Training
        Type: general
      – SubjectFull: Prevention
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      – SubjectFull: Intervention
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      – TitleFull: Do Training Programs Promote Identification and Treatment in Cases of Elder Abuse in Long Term Care (LTC) Facilities?
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            NameFull: Alon, Sara
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            NameFull: Lang, Barbara
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            NameFull: Band-Winterstein, Tova
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              Y: 2022
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