This document summarizes a training program developed to address elder abuse in long-term care settings through role reversal sensitivity training. The training involves dividing students into "caregivers" and "residents", with residents given simulated disabilities and instructed not to speak. Caregivers are told their grades depend on residents' compliance. Both groups then perform common tasks. Surveys before and after assess changes in perspectives. The goal is for caregivers to gain understanding and empathy for residents' experiences in hopes of reducing abuse and neglect. Literature reviewed found abuse is often due to lack of understanding and burnout, so this aims to educate caregivers and improve relationships between residents and those caring for them.

1. Abuse and Neglect in the Long Term Care Setting:
The Use of Sensitivity Training as a Tool for Education and Change
Sretta T. Clark
Western Kentucky University
Center for Gerontology
GERO 485 – Seminar in Gerontology
April, 2012

2. Elder abuse is a social problem and has been defined by the World Health Organization
as “a single or repeated act, or lack of appropriate action, occurring within any relationship
where there is an expectation of trust and which causes harm or distress to an older person.”
(Shinan-Altman and Cohen 674) Abuse pertains to malicious acts that are physical, mental or
sexual in nature; can also be applied to financial exploitation; and includes neglect as well as the
violations of [resident] rights. It is my position that a significant amount of abuse occurs as a
result of the lack of understanding on the part of the caregiver, of the circumstances experienced
by the nursing home resident. Although role reversal and sensitivity training cannot be expected
to eradicate this tragedy; it can be used as a means of educating caregivers and affording them a
brief, yet important opportunity to walk in the shoes of the elderly.
The purpose of this project is to: 1) Define the roles of the caregiver and that of the
nursing home resident; 2) Define the relationship between the two groups; and 3) Create and
implement an interactive training program, which can be used in any healthcare setting or
educational institution to address the issue of role/status reversal of the parties involved and the
potential negative outcomes, abuse and neglect, resulting from this phenomena.
From a sociological perspective, the role of the caregiver is hegemonic. By the action or
lack of action on the part of the caregiver, the residents’ reality is created. The role of the
resident is that of a person in the margins. These are the people who are “acted upon”.
Regardless of an individual’s previous role in society; upon entering a nursing home, a large part
of one’s individuality is forfeited. The relationship created by these new roles, can be one in
which trust, respect and compassion are the main focus or one dominated by fear and control.

3. Self-Determination Theory is a “theory on motivation that considers human beings as
actively engaged, growth-oriented organisms in their social contexts”. This theory identifies
three universal basic psychological needs, which are necessary for the growth and well-being of
all individuals. (Riksen-Walraven and al) Competence is the perception that one’s behavior
results in the intended outcomes and effects. For example, if I am hungry and I prepare and
consume a sandwich, the outcome of my actions will be to satisfy my hunger. Relatedness refers
to feelings connected to others or having a sense of belongingness. I experience this through
daily interactions with family, friends, and acquaintances. Finally, autonomy suggests that one
can choose activities, make decisions, and regulate behavior in accordance with one’s goals.
Likewise, if I enjoy staying up late to read a book, I possess the autonomy to go to bed at
midnight as opposed to nine o’clock.
The act of entering a nursing home can, an often does, inhibit the fulfillment of these
needs. Physical limitations and subsequent dependency on others, negatively impact the feelings
of competence. Changes in one’s social situation, distorts the view of relatedness. The most
effected aspect however, is that of autonomy. Once in a long-term care setting, decisions as basic
as when to use the bathroom and when to eat are now regulated to a large degree by the
institution itself. This sudden reliance upon others can leave residents not only feeling helpless,
but can also lead to injury. Consider the use of call lights to summon help from a staff member.
From the perspective of the resident a need occurs; the call light is activated and it is expected
that someone will appear to render assistance. This is however not always the case. Staff may be
engaged in situations requiring more immediate attention or may not feel that the resident
requesting assistance needs help right away, thus is slow to or absent in answering the call.
“[Residents] become impatient when a swift response is not made and they attempt activities that

4. threaten their safety, [perhaps] leading to a fall.” (Tzeng 225) According to this research, “the
three most common reasons for the use of the call light system are: 1) the experience of pain; 2)
the need for personal assistance; and 3) the need for assistance to the bathroom. In the same
research, nurses were asked if they felt that patient call light use was a matter of safety. An
astounding 47.15% did not perceive the use of call lights to be a matter involving safety
concerns”. (Tzeng 229-230, 232)
To best understand how this relocation affects the elderly, it is necessary to allow them to
explain their feelings. In the article, Older People’s Experience of Relocation to Long-term Care,
what I expect to be the feelings of many are expressed by one woman. She states, “I didn’t know
what they were doing, where I was going…nobody explained things to me”. Of all the residents
involved in the research presented in this article, only one participant had made an informed
decision to move to long-term care. Many interviewed for the article expressed feelings of
sadness, relating that “I would have preferred to be at home, my home is important”. There are
shared concerns about being made to do things to quickly, such as dressing and being rushed in
and out of the toilet. Other concerns include, watching less capable residents being fed;
roommate and their visitors overhearing your private matters; and experiencing death frequently
within the facility. (Fraher and Coffey 24-26)
Shifting to the perspective of the caregiver, I reviewed Nursing Aides Attitudes to Elder
Abuse in Nursing Homes: The Effects of Work Stressors and Burnout. Though this article
focused a great deal on long-term care in Europe, it also pointed out the commonality in
experience that caregivers share worldwide. The findings showed that 11% of nursing aides in
Sweden had observed some form of abuse and that 2% willingly admitted to committing such an
act in the previous year. Not to be outdone; Germany saw 66% witnessing abuse and a whopping

5. 79% having admitted to engaging in abuse towards the elderly. Here in the United States, of the
caregivers involved in the research, 37% observed physical abuse and 10% reported committing
physical abuse, Furthermore, 81% observed some form of psychological abuse and 40% said
they themselves had perpetrated such abuse against the elderly. (Shinan-Altman and Cohen 674-
675)
Now knowing that this phenomena is not isolated to some third world country, and is in
fact a clear and present danger in all civilized societies as well; one must wonder what could
possibly be the driving factor behind such inhumane treatment. Among the reasons given, low
status, low pack and low level of control were identified as contributing factors. (Shinan-Altman
and Cohen 675) In my own previous role as a nursing home administrator, I always pointed out
that my absence from the facility was rarely noticed, however should a couple of nurse aides not
show up for work, the entire day was mayhem. Given that situation, it was easy to see that they
possessed the single most important job in the facility. With this in mind, it would seem crucial
to reevaluate the status given to this position, as well as the wages. The other and more prevalent
noted cause was that of “burnout”. This is defined as “a psychological syndrome in response to
chronic stressors on the job…consisting of three components: emotional exhaustion,
depersonalization, and reduced sense of personal accomplishment”. (Shinan-Altman and Cohen
676) Here again, recognition of the value of the nurse aide would go a long way in deterring
possible negative outcomes.
The most concerning part of this article, and perhaps the item most pertinent to the
subsequent sensitivity training program I developed, is the theory of planned behavior.
“According to the theory, people perform behavior [in this case, abuse and neglect], when they
perceive it appropriate or when they perceive an organizational reality that forgives such

6. behavior”. (Shinan-Altman and Cohen 676) If, as the theory states, attitudes are important
predictors of behavior, the solution may be to examine those attitudes and more imperative, to
create an opportunity for the caregivers to examine their own attitudes. This concern is again
brought to the table in Psycho-social Factors Affecting Elders’ Maltreatment in Long-term Care
Facilities, in which it is noted that “…a large portion of assailants in long-term care were
unaware that their behavior, such as slapping, embarrassing and cursing patients, was wrong, and
thus did not think of changing their behavior. In addition, staff who often witnessed elder
maltreatment by other coworkers believed this to be a social norm at the facility and essential for
the integration in the organizational culture”. (Natan, Lowenstein and Eisikovits 114) This
article, again emphasized burnout to be a strong determinate in whether or not a caregiver
employed abusive tactics and cited that “more than half the entire sample of workers reported
abusing elderly patients in one or more forms over the past year” (Natan, Lowenstein and
Eisikovits 117), with nearly two-thirds of the occurrences involving either physical or mental
neglect.
A review of licensure surveys for four randomly selected nursing homes within Kentucky
proved that that abuse is in our own back yard, so to speak. All of the four facilities reviewed;
(Jackson Manor, Boyd Nursing & Rehabilitation Center, Kings Daughters Medical Center and
Kingsbrook Lifecare Center) were cited within the past two years for deficiency in areas
including: 1) failure to protect residents from all abuse, physical punishment, and being
separated from others; 2) failure to protect residents from mistreatment, neglect and/or theft of
personal property; 3) failure to hire only people who have no legal history of abusing, neglecting
or mistreating residents or reporting and investigating any acts or reports of abuse, neglect or
mistreatment of resident; 4) failure to keep each resident from physical restraint unless needed

7. for medical treatment and 5) failure to have written policies that forbid mistreatment, neglect and
abuse of residents and theft of resident’s property. All facilities were also found deficient for
failing to provide care in a way that keeps or builds each resident’s dignity and self respect.
(CMS (HCFA))
The plan of correction for the prevalence of abuse will not be achieved by any one magic
trick. It will require, first and foremost advocacy and protection of the resident. However it is
essential that we begin to change both the perception held by others of the role of caregiver and
repair the “disconnect” between caregiver and resident. This last goal I propose can be
accomplished in part by the use of tools, such as the sensitivity training program created for this
project.
I feel that one of the best forces for protection of nursing home residents is the
ombudsman program. “The long-term care ombudsman program provides advocacy for residents
of nursing homes, board and care homes, and assisted living [facilities]. Part of its mission is to
resolve problems and assist residents with complaints”. (Jogerst, Daly and Hartz 86) Unlike
healthcare professionals, law enforcement and clergy who are required to report abuse, the
ombudsman program has no regulatory authority, with its sole purpose to be advocates for at-risk
populations.
The second step, as previously mentioned is to devise a method in which the caregiver
can evaluate his or her own attitudes; develop an appreciation for the experience of the resident;
and hopefully integrate this awareness and experience into providing compassionate and
competent care to our ever-growing senior population. I will now elaborate in detail, on the path
I took to develop a simplified version of such a program.

8. The methodology I employed to complete this research included 4 initial steps: 1)
conducting a review of existing literature pertaining to the position of certified nursing assistants;
their training; their feelings towards their position and their perception of their role; 2)
conducting a review of literature pertaining to the perception of the long-term care resident with
regards to their change in social status; sacrifices made upon entering a nursing home; and the
relationship between themselves and their caregivers; 3) conducting a review of existing
literature pertaining to abuse and neglect of the elderly; and 4) conducting a review of four recent
long-term care licensure surveys.
Upon acquiring a working knowledge of the materials reviewed, I created and
implemented a training program. This was presented to a sample group of student nurses at
Elizabethtown Community and Technical College. The program consisted of administering an
initial survey to obtain demographic data and to establish a baseline of opinions pertaining to
elder abuse. This was followed by the presentation of findings from my review of literature
pertaining to this topic. Once completed, the students were divided into two groups; caregivers
and residents. Each resident was “equipped” with 3 typical limitations experienced by nursing
home residents; that being vision impairment, simulated with the use of eyeglasses smeared with
Vaseline; hearing loss, simulated with the use of Vaseline coated cotton balls placed in the ears;
and decreased dexterity, often caused by conditions such as contractures or arthritis, simulated
by taping the fingers of the “residents” in awkward positions. Finally, all participants assuming
the role of the resident were advised that during the experiment, they were not allowed to speak,
but could attempt to communicate in any other fashion, simulating the inability to make ones
needs known. The caregivers were provided with instructions in a separate location. At this time
they were advised that their final grade for the nursing program was contingent upon their ability

9. to get their assigned resident to comply with three tasks. It should be pointed out that this
statement was false, and was simply used to induce a sense of frustration often experienced by
caregivers. Once the experiment was completed, all students would be advised that their grades
were in no way affected by this project. Both groups were then instructed that they would
experience three tasks, common to every nursing home resident. The participating “residents”
would first attempt the task alone within the confines of their new limitations, which would be
followed by the caregiver completing the tasks for them. The first task was the simple washing
of hands and faces in preparation for dining. The second task was to consume a modified pureed
meal, which was simulated with the use of commercially prepared baby food. Finally, each
would brush their teeth following their meal. Once completed a second survey was given to
assess how their opinions of the experience of a resident changed. The last step of the training
was to conduct a follow up survey to evaluate any changes in opinions resulting from the training
and to allow for participants to share their feelings about their change in role. This presentation
was documented in both still photographs as well as video recorded.
Data was collected from 19 first semester practical nursing students, currently attending
Elizabethtown Community and Technical College. The number of months having worked or
trained in any healthcare setting was a mean of 39.4. The data was gathered using two written
survey tools. One survey was administered prior to training, and one after training was
completed.
53% of the students stated that they have witnessed some form of abuse during their work
or training in the healthcare setting, 37% stated they had not witnessed any form of abuse, and
11% did not respond to this question. Of the types of abuse witnessed there were 4 accounts of
verbal abuse, 3 accounts of neglect and 1 account of sexual abuse. 12 students either did not

10. disclose the type os abuse witnessed or did not witness abuse. Students choosing to disclose the
actual abuse witnessed described “harsh treatment”, “not changing a resident in a timely
manner”, “not cleaning an incontinent resident”, “sexual abuse committed by one resident upon
another that was not addressed”, “yelling at an incontinent resident for having multiple episodes
of diarrhea”, “ignoring a resident who was attempting to communicate with them”, “refusing to
assist a resident to the bathroom until they first completed a task required of them by the
caregiver”, and “failing to reposition a resident”. Only one student stated that she did report the
abuse and that she “reported it to both facility staff and the ombudsman”.
When asked to categorize failure to answer a call light in a timely manner; 8 students
labeled this as abuse, 13 students considered this to be neglect and 3 believed that this was a
violation of the resident’s rights. When asked to categorize pushing a resident to complete a task
quickly; 12 students identified this as abuse, 6 students felt that this was an act of neglect and 10
students believed this to be a violation of resident’s rights. When asked to categorize the
delaying the provision of care; 12 students found this to be abuse, 10 students considered this to
be neglect and 5 students considered this to be a violation of resident’s rights.
Students were asked to rank order the following tasks on a scale of 1 to 5 from the
perspective of a caregiver, with “1” being a task they did not mind performing for a resident and
“5” being a task they most disliked performing for a resident: 1) Providing oral or denture care;
2) Providing incontinence care or toileting of a resident; 3) Bathing a resident; 4) Feeding a
pureed diet to a resident; and 5) Cleaning up after a resident had experienced nausea and
vomiting. The task that was least displeasing was feeding a resident a pureed diet. The task that
was most displeasing was cleaning up after a resident who had experiences nausea and vomiting.
The students were then asked to rank order the same questions from the perspective of being a

11. resident, with “1” being a task that they would not mind having performed for them and “5”
being a task that they would least like being performed for them. From this perspective most
students stated that they would not mind having oral or denture care performed for them and
most stated that they would least like being bathed by another person. It is noteworthy that only 3
students identified being fed a pureed diet as the least desirable thing to experience, yet during
the interactive portion of the training, all students complained about having to eat a small jar of
commercially prepared baby food. One student described it as “looking and smelling like cat
food”. This student was so disturbed by having to eat this that she herself vomited after two
bites.
Students participating as caregivers during the interactive phase of the training were
asked what methods they employed to encourage their resident to complete the task. The
responses included: “offering to come back later”, “telling the resident that the food smelled
good”, “advising that the food would give them energy and maintain their health”, and stating
“we have to eat our food”. When asked how they felt when they believed that their grade for the
class was contingent upon their ability to get their resident to complete all three tasks, response
ranged from “not anxious” to feeling “overwhelmed”. No caregiver disclosed to the resident that
their grade for the class would be contingent upon completing all tasks.
Students participating as residents during the interactive phase of the training were asked
to relate their feelings about their prescribed limitations. With regards to not being able to speak
(inability to make needs known), feelings included “frustrated”, “helpless”, and “like I was stuck
in my own world”. When asked to share their feelings when attempting tasks on their own
(performing tasks with limited dexterity), feelings included “annoyed”, “disappointed” and

12. “incomplete”. When asked to describe their feelings while having these tasks performed for
them, feelings included “loss of pride”, “childish”, and demoralizing”.
Finally the students were asked what if anything they had learned from the training.
Comments included: “Eating pureed food is horrible. I can see why getting them to eat this is a
challenge”; “I understand the resident’s point of view”; “This is not only hard on the caregiver,
but also on the resident”; “Be patient”; and “Even if a caregiver is frustrated, the resident is more
frustrated because they did not ask to be impaired. It is very hard on them”.
Although the interactive portion was presented in a light-hearted manner that all
participants appeared to enjoy, it was quickly noted that the concept of a pureed diet was not
given enough weight in their initial evaluation of tasks they would least like to experience. The
group then spontaneously began discussing ways in which they could improve this experience in
an actual long-term care environment. Though the other tasks were important in the training, it
was clear that the dietary portion had the most significant impact. Secondary to this was the
discussion of vision impairment and finding it difficult to believe that residents could possibly
maneuver about the facility with such a hindrance.
Future training could be improved by the addition of a “brainstorming” session with
regards to how to mitigate the negative effects of resident’s daily experiences.
Additionally, presentation of the information and training program should be conducted
in several different settings, particularly in nursing homes, assisted living centers and personal
board and care homes, to reach caregivers in all arenas.

13. Finally, such training could be considered for the annual Kentucky Association for
Gerontology conference. This could be presented in a fun and educational manner to a target
audience of nurses, nursing assistants, staff development coordinators and administrators.

14. Work Cited
CMS (HCFA)."KentuckyNursingHome InformationandRegistry."26February2012.
MemberoftheFamily.net. 21 April 2012 <http://memberofthefamily.net/registry/ky.htm>.
Fraher,Anne andAlice Coffey."OlderPeople'sExpereincesof RelocationtoLong-TermCare."Nursing
OlderPeople (2011):23-27.
Jogerst,Gerald,Jeanette DalyandArthurHartz."OmbudsmanProgramCharacteristicsRelatedto
NursingHome Abuse Reporting." Journal of Gerontological Social Work (2005):85-98.
Natan,M. Ben,A.LowensteinandZ.Eisikovits."Psycho-Social FactorsAffectingElders'Maltreatmentin
Long-TermCare Facilities." InternationalNursingReview (2010):113-120.
Riksen-Walraven,Marianne andetal."NeedFulfillmentinCaringRelationships:ItsRelationwithWell-
Beingof ResidentsinSomaticNursingHomes." Aging&Mental Health (2010): 731-739.
Shinan-Altman,Shiri andMiri Cohen."NursingAides'AttitudestoElderAbuse inNursingHomes:The
Effectsof StressorsandBurnout." Gerontologist(2009):674-684.
Tzeng,Huey-Ming."Perspectivesof PateintsandFamilies Aboutthe Nature andReasonsforCall Light
Use and Staff Call LightResponse Time." MEDSURGNursing(2011): 225-234.