Análisis

This chapter provides a description of the two phases of the financial elder abuse research, which explored professional decision making in cases of suspected financial elder abuse. The chapter begins by identifying how the overall research methodology was shaped by the principles of judgement analysis. The chapter then explores the research questions addressed in Phase I of research, discussing how previous research has investigated the cues of financial elder abuse. Policy documents and research relating to the types of decisions that have to be made in cases of suspected abuse is presented. Consideration is also given to the difficulties that may be encountered when making decisions in such circumstances. The chapter then introduces the research questions from Phase II of the research, evidencing the need to explore how professionals make decisions in cases of financial elder abuse. Research assessing the impact of an individual’s demographic characteristics on decision making is described, and the value of identifying participants who show a consistent approach to decision making is discussed. Description of the research methodology addresses the selection of social care, health and banking professionals as the three participant groups of interest, and details the research ethical approval process. At the end of the Chapter a flow diagram is provided to illustrate the different aspects of the research design, procedure and analysis in Phases I and II.

3.1 Introduction

Judgement analysis was selected to investigate decision making in the context of financial elder abuse as it moves beyond the focus of previous research and literature on what the cues or risk factors for abuse might be, to how professionals use these cues when making decisions. This can then address questions such as whether certain cues of financial abuse are viewed as stronger indicators than others. Judgement analysis was also thought to have methodological strengths that would complement usage in relation to financial abuse decision making, For instance, judgement analysis requires the use of representative design, whereby cues are not systematically controlled to determine their influence. This was thought to be a good way to represent the complexities of cases of financial abuse. In addition, by statistically modelling the relationship between cues and judgements, judgement analysis is not reliant on the participant’s explanations of how they reached a particular decision (Hoffman, 1960; Harries & Harries, 2001).

Judgement analysis can also produce a model of a participant’s judgement behaviour based on cue weightings, which can be used to predict how they would respond to similar situations in the future (Hammond, 1996). Cluster analysis can then be used to group participants who weight cues in a similar way (Cooksey, 1996) or make similar judgements. Different cluster groups can then be compared to

explore the reasons behind the different approaches. These techniques will be explored further in the Phase II methodology chapter.

Judgement analysis methodology considers the relationships between judgements and cues in the environment, in order to investigate how judgements are reached (Cooksey, 1996). This chapter focuses on how judgement analysis was applied to study decision making in relation to financial elder abuse. In judgement analysis research, in order to measure how different cues are weighted when making judgements, it is first necessary to establish what cues are being considered, and their potential variation. It is also necessary to identify the types of decisions taken and factors that influence the context of the decision process, for example the barriers and facilitators to decision making. Approaches to identifying relevant cues can include reviewing the literature, consulting with experts and initial exploratory research (Taylor, 2006). The limited research that has been undertaken on financial elder abuse (see Chapter 2, Part I, for further details) suggested that identification of the cues used by professionals to detect and prevent abuse and decisions they had to then make could not be obtained purely by a literature review. This evidenced the need for research to establish the cues, decisions and contexts of financial elder abuse. The first phase of the project (Phase I) therefore focussed on this task.

3.2 Phase I

In order to explore how decisions are reached in cases where financial elder abuse is suspected, it was firstly necessary to establish detailed information about the experience of decision making in such instances. Phase I of research aimed to identify the cues that raised professionals’ suspicions of financial elder abuse. The need for research to identify the cues of abuse and their influence on professional decision making has been highlighted (Killick & Taylor, 2009). This is particularly important in the context of financial elder abuse, as identification of such abuse is thought to be difficult because assessment of money management practices is not a normal part of the contact professionals who are in regular contact with older people, such as social care professionals, may have (Wilson et al., 2009). 

One approach used to infer the signs or cues used to identify elder abuse has been to analyse the content of referral alert forms that social care professionals use to record information about incidents of suspected abuse. Information from referral

forms has been used to research the prevalence of different types of abuse, such as in the National Elder Abuse Incidence Study in America (National Center on Elder Abuse, 1998), from which can be drawn factors that place an individual at increased risk of abuse. Although referrals can provide a useful overview of the sorts of older people who have been financially abused, supposed risk factors are not necessarily the same factors used by professionals to identify financial elder abuse in practice.

Circumstances where the professional has not identified the suspected financial abuse themselves highlight the importance of suspicions being brought to their attention by third parties such as other professionals, or a friend of the older person. The value professionals place on information obtained from external sources has been questioned though. Fulmer et al. (2003) suggested that social care professionals were unsure of the reliability of information obtained from third parties in relation to suspected abuse, and preferred to follow up on concerns themselves.

Suggestions have also been made in a report by Edmonds and Noble (2008) relevant to the banking sector as to factors that might place an older customer at increased risk of financial abuse. This report emerged from research undertaken at the Loddon Campaspe Community legal centre in Bendigo, Australia, following a parliamentary enquiry which suggesting that banking professionals should be trained to identify financial abuse. Edmonds and Noble (2008) identify that circumstances where an older customer is no longer in charge of managing their own finances can allow opportunities for financial abuse. If the bank account has a third party signatory or is managed under a power of attorney, there can be concern as to whether transactions reflect the customer’s wishes.

The potential risk of financial abuse in cases where someone else is managing the money has also been identified in a programme of research looking at financial management in older age from the experience of older people, their carers and professionals. The Assets and Ageing research programme reported that where older people are independently managing their own finances and have mental capacity to make financial decisions, there is less opportunity for financial abuse (Wilson et al., 2009). This suggests that consideration of who is in charge of the money may be affected by whether the older person has full mental capacity.

McCreadie, Bennett, Gilthorpe, Houghton and Tinker (2000) conducted research to measure general practitioners’ (GP’s) awareness of the risk factors for different types of elder abuse, including financial. GP’s (n = 291) were given a series of situations that may indicate a risk of abuse, and were asked if they had any patients in each situation. Analysis of knowledge of the four risk factors relating to financial abuse had to be excluded because of a high ‘Don’t know’ response. As a result of this, the questions relating to risk factors for financial abuse were not reported. Reference to pilot research conducted by the authors (McCreadie, Bennett & Tinker, 1997) in a separate Primary Care Trust, which used the same set of questions provided a full description of the risk factor question set. For instance, in relation to financial abuse a risk factor included “Carer who spends the older person’s income or benefits on themselves at the expense of the needs of the older person” (McCreadie et al., 1997, p. 28).

A high “Don’t know” response was also achieved in response to the same financial abuse risk situations in the pilot research. This was attributed to GP’s not feeling that assessment of financial matters was part of their job role (McCreadie et al., 1997), but it may be that lack of knowledge of risk factors in relation to financial abuse was as a result of risk factors not being reflective of how cases are identified in practice.

In terms of what is currently known about the cues of financial elder abuse, certain factors that may place an older person at increased risk of abuse have been suggested, but it is not known how well these factors can be applied by professionals to identify financial elder abuse in practice. It seems that there is a need to explore professionals’ case experiences of financial elder abuse to identify the factors or cues that lead to such abuse being detected and ultimately to action being taken at the earliest possible stage.

The importance placed on decision making when elder abuse is suspected can be seen by the number of references to specific decisions that have to be made in policy and guidance documents relating to adult safeguarding. Despite the emphasis on multi-agency working in No Secrets (DH, 2000) there is no single source of guidance for professionals in terms of policy and procedure. In the social care and health sectors No Secrets (DH, 2000) is referenced, but as the starting point for more detailed guidance. The Association of Directors of Social Services (2005) released the document Safeguarding Adults, which highlighted key decisions to be made by

social care professionals including whether to refer the case to the “Safeguarding adults” process. In 2010, the Department of Health released a guidance document to address the lack of systems in relation to adult safeguarding within the NHS. The guidance document included a flow diagram that outlined the process of what to do when faced with a potential safeguarding concern (DH, 2010, p. 6). This identified that health care professionals had to make the decision as to whether to refer the case to social services as a safeguarding concern, which means that decisions are made by health professionals prior to integration with social services. Reference was made to health professionals individually making direct referrals to social services, but the need for this was minimised in preference to initially referring via the NHS system. A case example involving potential financial elder abuse was used to demonstrate how the proposed process might work in practice.

In terms of guidance for banking professionals to follow in relation to decision making in cases of financial elder abuse, the British Bankers Association response to the No

Secrets review highlighted concerns that there was no specific practice guidelines

relating to financial abuse for the financial services sector to follow and that it could be difficult due to the variation across cases as to what the abuse looked like (DH, 2008).

Research has investigated particular decisions made by professionals in relation to elder abuse. This has predominantly involved research with social care and health professionals. In the social care sector, research by Hussein et al. (2009) explored the decision to refer an individual to the Protection of Vulnerable Adults (POVA) list. People can no longer work with vulnerable adults or children if they are referred to the POVA list (now incorporated under the Independent safeguarding authorities Vetting and Barring scheme (see isa-gov.org.uk)). Hussein et al. (2009) reported that approximately 25% of cases referred to the POVA list between 2004 and 2006 were in relation to suspected financial abuse (n=5294), although not all of these cases would have been specific to financial abuse of older people. This research used referral information to extract common characteristics of individuals suspected of perpetrating abuse.

In the health sector, Lachs and Pillemer (1995) address key decisions that have to be made by physicians in America in response to cases of suspected elder abuse. The authors used American Medical Association, and Elder Mistreatment guidelines to specify key questions that physicians needed to answer in order to determine what

action to take. The first step involved determining if the individual wanted anything done about the suspected abuse. If they did not, the capacity of the individual to make that choice then had to be assessed. Where assistance was declined, if the individual was thought to have sufficient mental capacity to make the decision, it was specified that the physician must follow the patient’s wishes. Circumstances where action was declining were acknowledged as being particularly difficult for the professional, as all they could do was to provide advice.

In the banking sector there is no direct research exploring decision making in relation to suspected elder abuse. Observations related to decision making can be drawn from a report by Edmonds and Noble (2008) in relation to the difficulties experienced by banking professionals when dealing with cases of suspected financial elder abuse. In addition to qualifying how the banking legislative framework in Australia impacts on responses to financial elder abuse, the report covers broader aspects of the banking job-role in relation to financial abuse, which could be relevant to banking professionals based in the UK. One consideration of the report is the underlying expectations of the customer/banking professional relationship (Section 8, Edmonds & Noble, 2008). This section identified that where financial abuse is suspected, banking professionals can feel uncomfortable taking action that goes against the customer’s wishes such as stopping a transaction. This is because they have to work on the assumption that transactions are valid, unless there is evidence to contradict this (Edmonds & Noble, 2008). This suggests that where financial abuse is suspected a key decision to be made by banking professionals is whether or not to question what the customer has requested.

In Australia, research has commenced to study banking professionals’ experience of financial elder abuse. The State Trustees are funding a programme of research in Victoria into financial elder abuse, which is being conducted by Monash University (statetrustees.com.au). One aspect of the research will include interviews with finance professionals to learn about their experiences of good and poor practice when managing older people’s finances. The findings will be reported in 2012, and may provide a useful point of comparison against the study reported in this thesis.

It would be valuable to explore decision making as experienced by professionals in relation to individual cases of financial abuse, to establish the range of decisions made, and the options professionals felt were available to them. The distinct decision

making approaches adopted across different sectors highlight the importance of investigating decision making in relation to cases of elder abuse as occurring in the relevant professional contexts. These would provide a point of reference as to what current practice in relation to decision making in such cases looks like.

The experience of decision making in relation to elder abuse has also been considered in terms of factors that presented particular challenges. Killick and Taylor (2009) reported on issues raised in research addressing decision making by professionals, primarily in the social care and health field, in relation to elder abuse. The authors identified that there was only a small body of research exploring professional decision making in relation to elder abuse, but that some common challenges could be seen. These included the impact of context factors such as who was suspected of committing the abuse, for the professionals’ assessment of what constituted abuse and whether action should be taken. When thinking about financial elder abuse, this could be seen to relate to the issue of how abuse itself is defined. It may be that professionals find it difficult to label financial abuse by a family member as abuse.

Killick and Taylor (2009) also highlight the ethical challenges of decision making in relation to elder abuse when the older person does not want any action taken. There is a growing awareness of ethical challenges in this context, as professionals have to balance a responsibility to address abuse, versus protecting the individual’s autonomy (Donovan & Regehr, 2010). This may be a particular issue in relation to financial elder abuse given the high proportion of such abuse committed by family members (Action on Elder Abuse, 2006) who older people may be less willing to report or take action against.

Ethical dilemmas can also affect the professional’s response to elder abuse. Kitchen, Richardson and Livingston (2002) conducted research with nurses (n=40) who worked with older people, to explore the actions they would take in response to two case scenarios of elder abuse, one described as showing “suspected” abuse and the other as showing “definite” abuse. The article did not give access to the two case scenarios, but reference to previous research involving the authors that addressed the development of the vignettes and their testing (Richardson, Kitchen & Livingston, 2002; Richardson, Kitchen & Livingston, 2003) would suggest that definite abuse was defined on the basis of a situation physically observed by the participant. This involved seeing a staff member hit a patient. Nurses were asked to view each

scenario, and give a description of what they would do. Their answers were then compared to a ‘model answer’ as determined by No Secrets (DH, 2000) guidance. Although the case scenarios did not relate to financial elder abuse, the qualitative findings suggest general difficulties that health professionals may encounter when addressing suspected abuse. Kitchen et al. (2002) reported that in response to the case involving abuse by a fellow staff member, professionals often felt conflicted as to how they should respond, as they appreciated the demands of the job and the pressure people were under.

It may be that this conflict relates to who was suspected of committing the abuse and the fact that it was a colleague. In the context of financial elder abuse, professionals might feel uncomfortable taking action where abuse has occurred in a residential or nursing home committed by a fellow staff member. If the conflict was more to do with the type of abuse reported, and people’s ideas of what actions are appropriate in different circumstances, this could result in financial abuse by a family member being attributed to the nature of the family relationship.

The mental capacity of the older person has also been identified as a factor that can further complicate the ethical challenges of decision making where abuse is suspected. Donovan and Regehr (2010) comment that where the older person’s mental capacity is questioned, professionals still have to consider their wishes, but also whether they are making decisions based on a capable assessment.

A professional’s decision to take action in cases of suspected abuse can be affected