As the data analysis revealed, professional participants might categorize abuse as falling into a number of categories: physical abuse – causing bodily harm / injury to older persons; neglecting or ignoring the basic living needs of dependent or needy older people; harming their psychological well-being; abandoning older people in a care home; exploiting older people’s assets or property; and sexual abuse. Whilst their views were not homogeneous, professionals followed similar processes to older people when ‘evaluating’ actions and potentially ‘explaining/excusing’ them before deciding if abuse had occurred and action was needed. The previously cited example of the older man caring for his incontinent wife highlights the type of ‘evaluations’ that
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‘… We usually visit older people at home and examined whether the basic cares have been met, for instance, food, and personal hygiene. But we are careful to differentiate ‘good care’ from ‘basic care’…. We cannot push too far in reality. In a recent case, a husband was 80+ himself, he provided basic cares to his post-stroke wife, she was fed and changed periodically… but he used newspaper instead of napkin to handle her incontinence… is that elder abuse? We thought it was improper care, but not elder abuse, given the basics were there and he did what he thought he could…’ [Wing Sum, a nurse with 7 years’ experience working with community-dwelling older people]
Clearly, there is an element of judgement in deciding what it is ‘reasonable’ to expect the husband to achieve in the example above and such subtle judgements took into account the context in which a behaviour occurred and compared the behaviour with a set of, often implicit, ‘expectations’. Indeed, in some cases it was difficult to judge who was abusing whom:
‘… I was visiting an elderly couple, they were both 80+. The wife was wheelchair bounded after a stroke; her spouse took care of her. Sometimes she could be quite abusive verbally, towards her husband. And that occasion, the husband was so angry that he attempted to hit her with a wooden chair… of course we stopped it from happening. But that incident made you think who is abusing whom…?’ [Wong, a community nurse with 9 years’ experience working with community-dwelling older people]
When ‘evaluating’ potentially abusive behaviours professionals would also search for alternative ‘explanations’ or judge if a behaviour was ‘reasonable’
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or understandable in a given situation. For example, Tracy, a social worker, described an incident in which she witnessed a son being very abrupt and using sentences full of foul language when talking to his older parents who appeared sad and in distress. However, they responded using similarly foul language and she reasoned that this was perhaps ‘normal’ behaviour within this family:
‘Sometimes I think it (potentially abusive behaviour) may well stem from the usual family behaviours in managing their relationships’ [Tracy, a social worker had 25 years’ experience working with older people].
The above provides an example of how professionals might ‘adjust’ their ‘expectations’ in light of the circumstances. The data also suggested that such ‘adjustments’ were also occurring in a wider context and in part explained why professionals’ views, when compared with those of older people, drew less on traditional values such as filial piety:
‘I used to think family should take the responsibility to keep older parents at home for as long as possible, as we believed that home is the best place for ageing… But this is true only when home is really the best place for their ageing. Many youngsters need to work long hours during daytime. After work, they then pick up another job: take care of older persons at home. This can be very stressful, for both sides. In that case, is home still the best place for ageing? …many things worked in the past have changed - our family structure, work hours, and even living environment.’ [Ling, a community nurse with 26 years’ experience working with older people]
From the data, it was clear that a complex array of factors came into play before a professional would decide to intervene in a case of potential abuse. Even if
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an act was deemed abusive, rather than take punitive action immediately, other options (except in the most extreme cases) were nearly always considered first. These might include providing information and training: adopting a ‘wait and see’ approach; or seeking to empower the older person.
Providing information and training
If family members or others (usually paid domestic help) were judged to be failing to provide ‘acceptable’ care to the older person due to the lack of relevant knowledge/skills or resources then the professionals indicated that their first form of intervention was to provide information and resources as needed.
‘To me, I think the man [who uses newspapers instead of napkins to handle his wife’s incontinence] was probably lack of training and knowledge. And maybe short of money as well. In that case, the best way is not to punish him but to provide the resources so that he can improve the care…’ [Ada, a nurse with 20 years’ experience]
‘I have seen some foreign domestic helpers who had obviously received no particular training in taking care of older persons. They sometimes get frustrated and mad at the older care-recipients, physically rough when tendering care… letting them know the proper way to do their job is important.’ [Helen, a social worker with 10+ years’ experience]
In such cases professionals would ‘wait and see’ if their advice had been heeded and the care improved accordingly. If there were no change then the team would file it as an abuse case and refer it on for action, usually to the specialist social worker. This of course required agreement amongst the team themselves, and this was not necessarily a straightforward matter as the differing perspectives
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that have already been described demonstrate. In such cases a team conference was sometimes needed to deliberate on the case.
Given the growing numbers of older people, many of whom lived alone or at some distance from their families, professionals also saw a need to try and empower older people themselves:
‘Many a time when we do ‘floor sweeping’, meaning going door by door to visit every single older resident living in our estate, we find them alone at home. Some of them feeling rejected by the communities and retreat into aloneness. Their family might not be able to take them out and they are too frail to do so by themselves. But they feel lonely and sometimes depressed. This could be another type of abuse, you know. …we need to deal with their inadequate capabilities, network deficiency, and lack of self-reliance beliefs. We set up elder-friendly neighbour support groups. They seem more willing to network and speak up… that looks a good way to go.’ [Ethan, a social worker with 10 years’ experience]
The above quote reinforces the growing recognition amongst professional participants of the need to raise the profile of the abuse/neglect of older people amongst the population as a whole:
‘I think we should act earlier before elder abuse actually occurs. The general public needs to understand the normal ageing process, to know what can happen when a human body grows old, and to respect older persons’ values. People generally perceive old means weak, silly, slow… you know, all sorts of negative images may attach to older people. Public needs to learn and pay more respect to aged population; to understand that it is normal to move slower
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as one ages. A higher level of endurance is needed in our community.’ [Tracy, a social worker with 25 years’ experience]
This suggests the importance of taking preventative action before abuse occurs but for many of the professionals involved this was a rather distant dream as the reality was that the issue of abuse was still not a widely recognised nor given the resources it needed within the existing official responses. This was seen to limit the range of potential interventions with the inference being that sometimes marginal cases were not explored further:
‘I think the issue of elder abuse has not been, and still is not being addressed properly in the community. Even the government – the Social Welfare Department, has not paid adequate attention to it. The mode and resources allocated to deal with this problem is limited and it affects staff morale and attitude. With limited manpower and increasing number of older people needing our service, we can only be passive and sometimes non-intervening … we just don’t have the time to explore further in case of suspected abuse.’ [Daisy, a nurse with 18 years’ experience working with older people]
The above section has shown that unless a case of suspected abuse was severe professionals rarely turned to punitive action as their first response. Rather, they would seek to explore other options first. But in reality their choice of response as limited by a lack of resources and attention given to the issue of elder abuse. This will be explored further in the discussion chapter.
Throughout this chapter so far, a number of differences between the perceptions of older people and those of professionals on the question of elder abuse have been touched upon. These will be explored in more detail below.
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