Running head: CAREGIVER STRESS

Caregiver Stress and Elder Abuse Hollis Misiewicz The Catholic University of America Washington, D.C.

CAREGIVER STRESS Caregiver Stress and Elder Abuse

Advance practice nurses play an important role in the care of the elderly. As longevity in developed countries increases, so does the number of elderly with dependency needs. This has implications for the quality of care that is received by this vulnerable population. Often the elderly are cared for at home by a member of their family. It is estimated that one out of ten elderly living with a family member is exposed to abuse (National Center for Victims of Crime, 2008). Given the demographics of the aging population, advanced practice nurses are increasingly likely to see patients whose poor health status are caused or affected by abusive relationships. The case presented in this paper involves an eighty-five year old man, John, with a history of stroke who is cared for at home by his seventy-six year old wife, Janet. He is able to process information and engage in conversation although his speech is slow. He does have residual left-sided weakness. Until recently he has appeared to be well cared for. At his last visit with the nurse practitioner he had lost weight, was wearing soiled clothes and his speech was more halting. His wife voiced resentment at having to care for her husband. She is weary and frustrated by not having time to herself. The nurse practitioner is concerned by these changes and wonders what the right intervention might be. This paper will discuss ethical principles pertinent to the above mentioned scenario and describe the appropriate action for the nurse practitioner based on good moral actions. Issues Elder abuse is defined as a single or repeated act, or lack of an appropriate action, occurring within any relationship where there is an expectation of trust and which causes harm or distress to an older person (Buzgoza & Ivanova, 2011, p. 65). Elder abuse can take the form of neglect, which is unintentional abuse resulting in physical, psychological, or financial harm often

CAREGIVER STRESS secondary to excessive caregiver stress (Paris, Meier, Goldstein, Weiss, & Fein, 1995). The scenario described above most likely represents a case of elder abuse in the form of neglect. The nurse practitioner providing care for John recognizes that circumstances have changed between John and Janet. She is cognizant of the signs of neglect of John and stress for Janet. The ANA Code of Ethics states that the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient (American Nurses Association, 2001, p. 16).

The major issue, as health care provider to John, is the neglect in his care. The nurses primary commitment is to the patient, whether an individual, family, group, or community (American Nurses Association, 2001, P. 14). In this case, the secondary issue for the nurse practitioner is the caregiver stress experienced by Janet, rendering her incapable of providing good care. The professional nursing goal is to provide the best care for the patient with appropriate interventions to address both patient neglect and caregiver stress. A case of elder abuse involving neglect includes many stakeholders. The patient and his caregiver are most affected. In this case, the neglect has resulted in weight loss, unkempt appearance and diminished speech capacity for the patient. The caregiver is overwhelmed with the tasks involved in providing care to her husband. The nurse practitioner is also a stakeholder in this case. Her goal is to provide good care for her patient and she is the witness to Johns decline. She wants to provide interventions that will improve his care. If John and Janet have children or other family members with whom they interact, they would be stakeholders in this scenario. Social workers and home health care or respite care providers might also be involved in this case if needed to provide services. In order for the nurse practitioner to determine the proper course of action, she would need further information. It may or may not be helpful for her to talk to John alone to determine what has been occurring at home. It has been found that elders are often reluctant to

CAREGIVER STRESS

communicate their circumstances for fear of potential consequences (Buzgova & Ivanova, 2011). Speaking to Janet alone would probably elicit more information, as she verbalized her frustration during Johns appointment. The nurse practitioner needs specific information about the difficulties Janet is having in coping with her situation. She may wish to consult a counselor, psychologist, or other mental health care provider to address Janets issues. In cases of elder abuse or neglect, various agencies may be called upon to protect vulnerable adults and provide for their care. The nurse practitioner would need information from home health agencies, respite care centers and social workers about resources that are available to aid abused adults and provide support for stressed caregivers (Buka & Sookhoo, 2006). The greatest impact of the nurse practitioners actions will be felt by John and Janet. Proper action could reverse the deterioration that John has experienced secondary to the neglect in his care. Janet would receive the assistance she needs to lessen her burden and perceived stress. If John and Janet have children, they could be affected by the outcome of intervention, particularly if this involves providing some care and support for their parents. The nurse practitioner will be affected by the outcome of her interventions. If she is successful in ending Johns neglect and is able to provide Janet with support she will experience job satisfaction. If she is unable to help in this situation she might be susceptible to compassion fatigue which can lead to an impaired ability to care for other patients (Pfifferling & Gilley, 2000). Analysis For advanced practice nurses who care for the elderly it is inevitable that they will encounter cases of elder abuse. In order to effectively intervene, nurses must first clarify their position regarding issues of aging, violence, and relationships with a reflection of their own ethics (Beaulieu & Leclerc, 2006). An ethical theory that could be used to evaluate a situation

of elder abuse and provide insight into ones ethical position is that of Pluralism as expounded on

CAREGIVER STRESS by Ross. This theory is a both deontological and consequentialist in nature. Included in the deontological aspect of this theory are the duties of beneficence and non-maleficence. When there is conflict in duty, the consequences each action is examined and the intervention chosen based on the rightness of the outcome (Timmons, 2012). The ethical principle of respect for a person encompasses the duties of maintaining a persons dignity and autonomy (Buzgova & Ivanova, 2011). Consideration of this is pertinent in a case of elder abuse or neglect. Non-maleficence Non-maleficence is the moral obligation to do no harm (Westrick, 2009). Elder abuse clearly violates this principle. In the context of nursing, the advanced practice nurse would be

morally obligated to intervene where the act of another would cause injury or avoidable suffering to a patient. When the elderly are abused or neglected, both physical and psychological harm ensues. Physical neglect can result in dehydration, malnutrition, poor hygiene, and development of decubitus ulcers. Injuries such as bruises, lacerations, fractures and burns can occur from abuse. Verbal threats, intimidation or berating can result in mental anguish (Meier et al., 1995). In the case of John, it would be the moral duty of the nurse practitioner to intervene in the home situation in order to prevent further harm to her patient. Beneficence Beneficence is the moral obligation to do good and prevent harm (Westrick, 2009). The advanced practice nurse provides care that benefits the patient. In the case of elder abuse, the advanced practice nurse would institute interventions that would not only result in protecting the patient from harm but would improve the patients circumstances. Removing the patient from the situation and implementing changes within the home environment can benefit the patient. The nurse practitioner taking care of John will need to assess which action will provide the most benefit for him.

CAREGIVER STRESS Justice

Justice is the moral principle that encompasses the obligation to respond to the needs of a patient without discrimination (Beaulieu & Leclerc, 2006; Westrick, 2009). Distributive justice is a consideration when outside agencies are needed to remove an abused elder from a dangerous system or provide additional services within the home (Grace, 2009). In this particular case of elder abuse, the nurse practitioner is required to treat John and assist Janet without regard to personal feelings about the situation or the personal attributes of John and Janet. She would need to consider resources that are available to provide assistance and determine if the patient and caregiver are eligible for these. Respect for a Person Respect for a person includes maintaining both the dignity and autonomy of a person (Buzgova & Ivanova, 2011). The aging process itself can assault a persons dignity as one becomes more susceptible to illness and dementia. Focus on these areas is necessary to minimize limitations in freedom, mobility and autonomy. Autonomy is characterized by the ability to make ones own decisions. In the case of the elderly, the ability to make choices is often limited by an inability to carry out those choices. Dependency on others can diminish the autonomy of the older person (Simmons & OBrien, 1999). Consequences of Autonomy versus Beneficence The abused elderly are often reluctant to speak out against their abusers for fear of retribution. They may refuse services for assistance. This can reflect an imbalance in the power between the patient and the caregiver and can influence decision-making capacity (Buka & Sookhoo, 2006). One action the health care provider could take would be to accept the refusal of the patient. This would be called negative autonomy and the provider would stop all interventions (Beaulieu & Leclerc, 2006). This could be seen as abandonment of the victim

CAREGIVER STRESS rather than supporting the patients autonomy. The irony is that while upholding one moral principle, another may be violated. Pluralism allows for the comparison of consequences of different actions (Timmons, 2012). In the case presented, allowing John to return home with no assistance could have consequences more serious than hygiene problems. Continued neglect would result in further malnutrition and social withdrawal. Home health services or respite care could provide the support Janet needs to reduce her caregiver stress and allow her to continue to care for her husband. No cultural or religious values were noted in this case which would interfere with

provision of these services. The race of John and Janet is unknown, however, among Blacks and Hispanics, adult children are more likely to be primary caregivers. This is thought to be because minority women are more likely to be single (Nerenberg, 2002). If, in fact, John were refusing assistance, upholding the principle of beneficence would provide a better outcome than supporting the patients autonomy. Results In the case of John, the nurse practitioner has assessed the cognitive, physical and functional status of her patient. She notes that John has lost weight and is unkempt. His demeanor has changed as well and his speech is halting. His wife, on the other hand, is speaking for the patient and also verbalizing her frustration at her caregiving situation. It is obvious to the nurse practitioner that some change has occurred in their relationship and John is suffering for it. What is the proper action for her to take? The nurse practitioner must determine the decision-making capability of John. Is he afraid to speak about his circumstances for fear of retribution from his wife when they return home? What other circumstances might affect his ability to make capable decisions? An important issue in bioethics is regard for patient autonomy but external constraints and internal

CAREGIVER STRESS limitations can compromise the patients ability to choose for himself (Simmons & OBrien, 1999). The nurse practitioners next step is to speak with Janet. A clinical assessment of Johns

wife could reveal she is suffering from caregiver stress. Symptoms of this might include feelings of frustration, anger, guilt and loneliness. Typically these caregivers are exhausted at the end of the day. It is not uncommon for them to suffer from serious health problems such as heart disease, cancer, or diabetes (U.S. Department of Health and Human Services, 2008). Janet had mentioned that John is ungrateful and miserable. Caregivers who feel that the recipients of their care are unappreciative report a higher level of stress (Nerenberg, 2002). A thorough assessment of the caregiver will help to understand the resources that are needed to rectify the situation. The nurse practitioner is familiar with John and Janets history. Until recently Janet had taken good care of John and their relationship seemed genuine. The nurse practitioner has no reason to believe there is a long history of abuse or marital discord. It would seem reasonable to think that providing services that would relieve some of the caregiver burden and offering support to Janet could reverse this trend of neglect. Providing this care is supported by both moral principles of beneficence and non-maleficence. After the assessment of John and Janet has been completed, the nurse practitioner must determine the appropriate action to assist this couple. When considering any intervention, the nurse must keep the welfare of the vulnerable patient at the forefront. In this case it appears that helping the caregiver will help the patient. To provide the optimal care multiple health care providers will be needed. Nurses should actively promote the collaborative multi-disciplinary planning required to ensure availability and accessibility of quality health services to all persons who have needs for health care (American Nurses Association, 2001, p. 15).

CAREGIVER STRESS To provide Janet with immediate relief and take care of Johns physical needs, the nurse practitioner contacts a social worker to determine what is available for respite care. It was felt that, initially, both Janet and John would benefit if John was given respite care at an assisted

living facility rather than having an aide come in to the home several hours a day. Arrangements were made for John to move to the assisted living for a period of two weeks. This would allow John to receive the care that he requires and give Janet a chance to rest. The nurse practitioner then contacted home health care agencies to arrange for further support services upon Johns discharge from the assisted living facility. Since Janet is caring for an adult over the age of sixty she qualifies for assistance from the National Family Caregiver Support Program funded by the federal government. In addition to helping pay for the respite care, Janet can receive caregiver training and individual counseling. Social support has been shown to reduce the risk of caregiver abuse (Nerenberg, 2002). The National Family Caregiver Support Program also assists with equipment, supplies, and home modifications needed to provide care to an elderly dependent (U.S. Department of Health and Human Services, 2008). John is a Medicare recipient so the nurse practitioner consults with the social worker to determine what home health services will be covered by his insurance plan. Since John has a complex medication regimen Medicare will allow for home skilled nursing services for management of his medications. When a patient has a skilled need, Medicare will also cover the cost of a home health aide three days a week to assist with activities of daily living, such as bathing. The nurse practitioner orders these services to start when John arrives home. Through the coordination of the nurse practitioner, several health care providers and agencies were able to provide care for John and support for Janet to return their home situation to a stable caring environment. The use of respite care and additional support services at home are effective interventions to reduce the risk of elder abuse (Nerenberg, 2002). The nurse

CAREGIVER STRESS practitioner acted on the principles of non-maleficence, preventing further harm to John from neglect, and beneficence, providing benefit to Janet. Johns autonomy was taken into consideration by returning him to his home, but to a safer environment. Conclusion As the population ages in developed countries, more elderly people are cared for by family members in their homes. The incidence of caregiver stress has risen leading to an

10

increased incidence of elder abuse. The scenario presented in this paper describes how caregiver stress can lead to the neglect of the care receiver. Advanced practice nurses provide much of the care to an elderly population and will encounter patients whose health status is affected by abuse. Consideration of ethical principles of beneficence, non-maleficence, autonomy and justice will serve as a guide for the nurse practitioner in determining an appropriate intervention for the patient and caregiver.

CAREGIVER STRESS

11

References American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursebooks.org.

Beaulieu, M., & Leclerc, N. (2006). Ethical and psychosocial issues raised by the practice in cases of mistreatment of older adults. Journal of Gerontological Social Work, 46(3-4), 161186. doi:10.1300/J083v46n03_10

Buka, P., & Sookhoo, D. (2006). Current legal responses to elder abuse. International Journal of Older People Nursing, 1(4), 194-200. doi:10.1111/j.1748-3743.2006.00029.x; 10.1111/j.1748-3743.2006.00029.x

Buzgova, R., & Ivanova, K. (2011). Violation of ethical principles in institutional care for older people. Nursing Ethics, 18(1), 64-78. doi:10.1177/0969733010385529

Grace, P. J. (2009). Philisophical foundations of applied and professional ethics. In Nursing ethics and professional responsibility in advanced practice (1st ed., pp. 3-31). Sudbury, MA: Jones & Bartlett Publishers.

National Center for Victims of Crime. (2008). Elder abuse. Washington, D.C.: National Center for Victims of Crime. doi:Retrieved from http://www.ncvc.org/ncvc/main.aspx?dbName=DocumentViewer&DocumentID=32350

Nerenberg, L. (2002). Caregiver stress and elder abuse. Washington, D.C.. National Center on Elder Abuse. Retrieved from http://www.ncea.aoa.gov/main_site/pdf/family/fact_sheet.pdf

CAREGIVER STRESS Paris, B.E.C., Meier, D.E., Goldstein, T., Weiss, M., & Fein, E.D. (1995). Elder abuse and neglect: How to recognize warning signs and intervene. Geriatrics, 50(4), 47-51.

12

Pfifferling, J. H., & Gilley, K. (2000). Overcoming compassion fatigue: When practicing medicine feels more like labor than a labor of love, take steps to heal the healer. Family Practice Management, 7(4), 39-44. Retrieved from http://www.aafp.org/fpm/2000/0400/p39.html

Simmons, P.D., & O'Brien, J.G. (1999). Ethics and aging: Confronting abuse and self-neglect. Journal of Elder Abuse & Neglect, 11(2), 33-54.

Timmons, M. (2012). Pluralism. In Kozyrev, J. & Duncan, J. (Ed.), Conduct and character: readings in moral theory (6th ed., pp. 312-335). Boston, MA: Wadsworth, Cengage learning.

U.S. Department of Health and Human Services. (2008). Caregiver stress fact sheet. Washington, D.C.: Office on Women's Health in the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services.

Westrick, S. J. (2009). Ethical decision making. In Essentials of nursing law and ethics (1st ed., pp. 258-265). Sudbury, MA: Jones & Bartlett Publishers.