Triage nurses’ perspectives about abuse of older people: a study in a hospital setting

The world is facing an increase in the number of older people that began in the second half of the 20th century [1, 2]. According to the statistics of the World Health Organization (WHO), the world’s population of people aged over 60 will double from 900 million people in 2015 to about 2 billion people in 2050 [3]. According to the census conducted by the Statistical Centre of Iran in the spring of 2020, the elderly population over 60 years of age accounts for about 9.9% of the Iranian population, or 8,231,000 people [4]. Therefore, the aging phenomenon warns societies to pay more attention to the problems of this growing population. Lack of social support, lack of work and social role, and cost of living, especially the shocking cost of health care, are among the issues that highlight the need to pay more attention to the elderly group in Iranian and global societies [5]. Thus, the growth of the elderly population and the increase in the burden of chronic disease in the coming years will be one of the major challenges for health systems in most countries of the world, including Iran. This ever-increasing growth of the elderly population affects various dimensions of societies and will pose challenges to health, welfare, and social security policymakers, families, and careers of the elderly, which most sociologists consider to be one of the social harms. What societies are facing today is the phenomenon of abuse of older people [2, 6].

Elder abuse is a single or repeated act, or lack of appropriate action, occurring in any relationship where there is an expectation of trust, that causes harm or distress to an older person [7]. Types of elder abuse include physical, sexual, psychological, and emotional abuse; financial and material abuse; abandonment; neglect; and severe loss of dignity and respect [8]. It is associated with important adverse health outcomes including poor psychological health, morbidity, and premature mortality, as well as increased hospital presentations and readmission rates [9].

According to a report published by WHO, 7–10% of older people worldwide experience some form of elder abuse [1]. The prevalence of elder abuse in Iran is high (around 48.3%), with the highest and lowest rates being neglect (38.4%) and rejection (11%) [6]. Although nurses are recognized as playing a crucial role in responding to elder abuse, it tends to be under-recognized and under-reported in Iranian hospitals [6]. Compounding this situation is the reluctance on the part of many older people to disclose abuse if the perpetrator is a family member. Furthermore, they may not view the perpetrator’s behavior as abuse. Older people with cognitive impairments who present to acute care hospitals pose further challenges to detecting elder abuse [10].

An Emergency Department (ED) visit for acute injury or illness is an important potential opportunity to identify elder mistreatment and initiate intervention, as this may be the only time a vulnerable, isolated older adult leaves his/her home [11]. The importance of ED-based identification of elder abuse has begun to be recognized around the world [12].

Despite the prevalence of elder abuse and the potential value of identifying it, emergency nurses rarely recognize or report abuse [13]. Barriers for nurses in the emergency department setting for reporting elder abuse are varied and include the patient as a potential victim, the patient’s family/significant others, and also the nurse. High patient acuity and lack of consciousness are important factors that hinder reporting of abuse by the patient and when alert and responsive, the typical barriers exist, i.e., fear of retaliation, fear of being placed in a nursing home, powerlessness, and wanting to protect their family [14]. Family members may know or actually be the perpetrators and they deny the abuse. For the nurses, reporting barriers may be lack of knowledge about the law, not wanting to be involved in court cases, and not routinely screening for abuse [15]. Faronbi et al. suggest that educating healthcare workers on elder abuse may improve their behavior in addressing such issues, as demonstrated by the strong goodness-of-fit of the knowledge, attitude, and behavior model [16].

This study examines the perspectives of triage nurses about abuse of older people. It has been noted that there is sparse research regarding emergency nurses and their perceptions of elder abuse in Iran [17]. Research findings can inform healthcare policies and guidelines, ensuring that elder abuse is addressed within healthcare settings and that appropriate protocols are established for reporting and intervention. Investigating this issue can highlight the ethical responsibilities of nurses in safeguarding vulnerable populations, and encouraging a culture of respect and protection for the elderly. In summary, exploring the attitudes and practices of nurses regarding elder abuse is essential for improving care, enhancing training, promoting ethical standards, and influencing healthcare policies [18]. To address this knowledge gap, the project team aimed to explore triage nurses’ perspectives on elder abuse, to achieve a better understanding of the problems of reporting, and to generate ideas for improving the process.

The mean age of the participating nurses was 33.8 ± 5.21 years, 64.5% were female and 79.8% had a bachelor’s degree in nursing. Further information is given in Table 1. Based on the results, the mean scores of nurses’ general knowledge were 5.59 ± 1.35, legal knowledge was 3.52 ± 1.79, attitude was 43.06 ± 6.57, and practice regarding elder abuse was 12.49 ± 5.57 (Table 2). Correlation results showed a direct and significant relationship between nurses’ general knowledge of elder abuse and knowledge of physical elder abuse (R = 0.513, P < 0.001). A strong and significant direct relationship was also observed between nurses’ knowledge of elder neglect and financial elder abuse (R = 0.545, P < 0.001). The relationships between other subsets of elder abuse are shown in Table 3.

Elder abuse is one of the health challenges facing older people in today’s society. Inattention to this issue can impose additional costs on society for hospitalization and treatment, in addition to other costs associated with the aging period. The current study aimed to assess the knowledge, attitude, and practice of Iranian nurses regarding the phenomenon of elder abuse.

According to the results, the mean score of general knowledge on a scale of 100 was more than 50% (66.10%). This result is consistent with those reported by Kim et al. in Korea [21], and Alipour et al. [25] in Iran.

A higher mean of the general knowledge variable on elder abuse is to be expected given the content and texts taught in nursing schools.

The mean score of nurses’ legal knowledge of elder abuse on a scale of 100 was less than 50% (43.75%). In related studies, hospital staff [including nurses, paramedics and radiologists] often did not know the actual method of legal reporting in cases of elder abuse, even if they recognized that they were responsible for reporting elder abuse.

The lack of legal authority and institutions to report cases of abuse, including elder abuse, may be an important reason for the low level of legal knowledge among Iranian nurses. The reason is related to the lack of knowledge of all members of society, including nurses, about the legal issues of reporting (e.g. the follow-up procedure), the safety of the reporter and the victim of abuse, and the legal consequences. The law is not yet clear in this regard. Adequate training and information in this area can be very helpful. In Iran, nurses obtain most of their information about older people from informal sources [22]. This process requires basic education in the field, education and acquisition of accurate definitions of elder abuse and screening for elder abuse, as well as related legal procedures and reporting methods. A future strategy should include these issues in university and in-service courses to increase nurses’ sensitivity and knowledge of elder abuse and ultimately improve reporting rates.

The mean score of attitudes on a scale of 100 was more than 50% (66.10%). The positive attitudes towards elder abuse have been reported in studies conducted in other countries [23, 24].

The main reasons for this discrepancy are cultural differences and the location of the studies [16]. Iran is currently facing a shortage of staff in hospitals, which leads to an excessive burden on the current care workers [26]. Job burnout can be considered as one of the possible factors for the low scores of nurses regarding elder abuse.

The mean score of practice on a scale of 100 was less than 50% (42.80%), which is consistent with the results of some previous studies [8, 27]. Corbi et al. attributed the poor practice of nurses to factors such as lack of knowledge, fear of legal involvement and inability of health workers [8].

Fear of the possible consequences of reporting, incomplete certainty about the occurrence of abuse and failure to fully understand reporting guidelines led to unprofessional reporting and poor practice by nurses [16].

Fear of legal consequences, unfamiliarity with their legal, ethical and professional responsibilities, lack of knowledge about protocols for reporting elder abuse, embarrassment about reporting elder abuse and lack of efficient systems were the reasons for nurses’ poor practice [22].

In this study, the reasons for nurses’ poor practice included nurses’ low level of legal knowledge and weak attitudes towards elder abuse. The findings show that most nurses had average to high practice scores in two previous studies [21, 23]. This discrepancy is due to the fact that in some countries nurses are obliged to report elder abuse, otherwise, they are subject to legal action in the form of fines for elder abuse. In these studies, nurses were also trained about elder abuse and how to report it.

In the present study, the correlation results showed a direct and significant relationship between nurses’ general knowledge of elder abuse and knowledge of physical elder abuse, which is consistent with the results of other studies [16]. The nurses’ general knowledge of elder abuse will make them focus on the issue and their attitude towards the issue of elder abuse will change. This change will lead to a response to the phenomenon. In such a case, they will not be indifferent to cases of elder abuse in the workplace and will respond to them, especially in cases of physical elder abuse. As this type of elder abuse is associated with signs and symptoms such as bruises, fractures, wounds, and injuries, nurses will not be indifferent to these signs and symptoms and will report them to the doctor.

Our findings also revealed a direct and significant relationship between nurses’ knowledge and attitudes and their practice. Nurses’ encounters with elder abuse may be influenced by their knowledge and attitudes, which is consistent with the findings of previous studies [16, 21]. Numerous studies have confirmed that knowledge is a prerequisite for changing attitudes and practices. It is considered to be a key and main component of behavior change. KAP studies have been proposed as one of the basic behavioral change studies.

In order to change people’s behavior, a large number of these studies are designed and carried out [16, 19]. It is believed that to change behavior on a particular issue, people’s knowledge and attitudes about that issue should be studied.

According to the KAP model, nurses’ knowledge and practice can influence their practice about elder abuse; therefore, it can be used as a framework for training nurses about elder abuse. Therefore, there is a need to improve nurses’ understanding and attitudes towards elder abuse to increase nurses’ interventions towards elder abuse and to better identify elder abuse cases in the future. The strengths of this study include the design of a tool to measure nurses’ knowledge, attitude and practice towards the phenomenon of elder abuse in the form of a questionnaire instead of three tools with a smaller number of items. Therefore, this tool makes it possible to report the results in more detail when assessing nurses’ knowledge.

A limitation of the current research is that it was not possible to conduct face-to-face interviews about elder abuse due to the COVID-19 pandemic. Online surveys and interviews may suffer from issues such as distractions at home, lack of controlled environments, and varying levels of participant engagement, affecting the quality of the data collected. These limitations highlight the challenges researchers faced in ensuring the reliability and generalizability of their findings during the COVID-19 pandemic. It is therefore recommended that similar face-to-face studies are carried out. It is therefore recommended that similar face-to-face studies are carried out.

According to the results of the present study, the knowledge, attitudes and practices of the nurses in relation to elder abuse were not desirable. Our findings suggest that nurses’ knowledge and attitudes affect their practice toward elder abuse. Therefore, improving their knowledge and attitude towards elder abuse is necessary to improve the detection and assessment of elder abuse cases. Consequently, improving nurses’ knowledge and attitude towards elder abuse can also promise to improve nurses’ practice.

Based on the significant relationship between knowledge and attitude with nurses’ performance in the area of elder abuse in the present study, it can be suggested that interventional studies be conducted to investigate their impact on nurses’ knowledge, attitude, and performance. In addition, it is recommended that quality educational content be included in continuing education programs for nurses. To achieve the goals of changing nurses’ behavior, it is suggested that nursing education programs and curricula include the issue of elder abuse, its diagnosis, and reporting.