"Just pee in the diaper" - a constructivist grounded theory study of moral distress enabling neglect in nursing homes.

BACKGROUND: A growing body of evidence shows that many nursing home residents' basic care needs are neglected, and residents do not receive qualitatively good care. This neglect challenges nursing staff´s professional and personal ideals and standards for care and may contribute to moral distress. The aim of this study was to investigate how nursing staff manage being a part of a neglectful work culture, based on the research question: "How do nursing home staff manage their moral distress related to neglectful care practices?" METHODS: A qualitative design was chosen, guided by Charmaz´s constructivist grounded theory. The study was based on 10 individual interviews and five focus group discussions (30 participants in total) with nursing home staff working in 17 different nursing homes in Norway. RESULTS: Nursing staff strive to manage their moral distress related to neglectful care practices in different ways: by favouring efficiency and tolerating neglect they adapt to and accept these care practices. By disengaging emotionally and retreating physically from care they avoid confronting morally distressing situations. These approaches may temporarily mitigate the moral distress of nursing staff, whilst also creating a staff-centred and self-protecting work culture enabling neglect in nursing homes. CONCLUSIONS: Our findings represent a shift from a resident-centred to a staff-centred work culture, whereby the nursing staff use self-protecting strategies to make their workday manageable and liveable. This strongly indicates a compromise in the quality of care that enables the continuation of neglectful care practices in Norwegian nursing homes. Finding ways of breaking a downward spiralling quality of care are thus a major concern following our findings.

Factors associated with subjective burden among informal caregivers of home-dwelling people with dementia: a cross-sectional study.

BACKGROUND: It is estimated that more than 57 million people have dementia worldwide, and it is one of the leading causes of care dependency in old age. Relatives and other informal caregivers are the most important support for individuals with dementia, but caring for a loved one with dementia may burden the caregiver. Caregiver burden may have adverse outcomes for both the informal caregiver and the care recipient, including decreased quality of life. Caregiver burden is associated with several factors concerning the informal caregiver, the care recipient, and relational and other contextual factors. The aim of this study was to explore which factors are associated with informal caregivers' subjective burden when caring for individuals living at home with dementia. METHODS: This study was a cross-sectional survey among informal caregivers of home-dwelling individuals with dementia in all five geographical regions of Norway. There were 540 informal caregivers who participated, 415 of whom were included in the regression analyses. Caregivers' subjective burden was assessed with the Relatives' Stress Scale. Covariates included were classified into four levels: individual (twofold: informal caregiver and person with dementia), relational, community, and time. Linear multivariable regression analyses were used to identify associations between subjective burden and included factors. RESULTS: Several covariates were statistically significantly associated with subjective burden at the four levels. These covariates included self-rated health, mental distress, age, coping through resignation and denial, emotional and instrumental support, substance use, and humor at the informal caregiver level; behavioral and psychological symptoms of dementia, dementia severity, and degree of disability at the care recipient level; the extent of care, being the primary caregiver, and previous relationship satisfaction at the relational context level; and informal caregivers spending time with friends, leisure activities, social restriction, and knowledge of available health services at the community context level. CONCLUSIONS: Informal caregivers' mental distress and care recipients' neuropsychiatric symptoms were the factors with the strongest association with subjective burden.

Senior Immigrant Women and Participation in Voluntary Services in Norway.

In Norway, there is a rising trend in the number of senior immigrants. Engagement in society is known to be crucial to their well-being and health, with participation in voluntary activities being one way of partaking in a community. A qualitative study was conducted, involving 12 immigrant women aged 50 years and above. Semi-structured interviews were utilized to gain insight into their experiences of participation in activities, aiming to identify both facilitators and barriers to their engagement in activities provided by voluntary organizations. The analysis resulted in two main themes and five sub-themes. According to the women's experience, learning Norwegian was important for successful integration. They also emphasized the importance of social relationships for improved self-perceived health and a sense of belonging in a community. Language challenges and limited social integration were barriers negatively impacting their participation, with health being a crucial factor determining their capacity to engage in voluntary services. Since most of the women talked about their health, this became an important topic of further investigation. This article is a contribution towards gaining further insight into the experiences of senior immigrant women participating in voluntary services and explores the challenges faced by voluntary organizations in improving information dissemination and minimizing barriers to participation. Public health competence can improve knowledge regarding facilitating health-promoting participation in voluntary services.

Making Neglect Invisible: A Qualitative Study among Nursing Home Staff in Norway.

BACKGROUND: Research shows that nursing home residents' basic care needs are often neglected, potentially resulting in incidents that threaten patients' safety and quality of care. Nursing staff are at the frontline for identifying such care practices but may also be at the root of the problem. The aim of this study was to generate new knowledge on reporting instances of neglect in nursing homes based on the research question "How is neglect reported and communicated by nursing home staff?" METHODS: A qualitative design guided by the principles of constructivist grounded theory was used. The study was based on five focus-group discussions (20 participants) and 10 individual interviews with nursing staff from 17 nursing homes in Norway. RESULTS: Neglect in nursing homes is sometimes invisible due to a combination of personal and organizational factors. Staff may minimize "missed care" and not consider it neglect, so it is not reported. In addition, they may be reluctant to acknowledge or reveal their own or colleagues' neglectful practices. CONCLUSION: Neglect of residents in nursing homes may continue to occur if nursing staff's reporting practices are making neglect invisible, thus proceeding to compromise a resident's safety and quality of care for the foreseeable future.

Legitimizing neglect - a qualitative study among nursing home staff in Norway.

INTRODUCTION: Residents in nursing homes do not always get qualitatively good nursing care, and research shows that residents' basic care needs are sometimes neglected. Neglect in nursing homes is a challenging and complex issue, yet a preventable one. Nursing home staff are at the frontline of detecting and preventing neglect but may also be the ones causing it. It is essential to understand why and how neglect happens in order to recognize, expose, and prevent its occurrence. Our aim was to generate new knowledge on the processes leading to and allowing neglect to continue in Norwegian nursing homes, by studying how nursing home staff perceive and reflect on when nursing home residents are neglected in their daily practice. METHODS: A qualitative exploratory design was used. The study was based on five focus group discussions (20 participants, total) and ten individual interviews with nursing home staff from 17 different nursing homes in Norway. The interviews were analysed according to Charmaz constructivist grounded theory. RESULTS: In order to make neglect an acceptable practice, nursing home staff apply different strategies. These strategies were identified as when the staff legitimize neglect by neglecting neglect, when the staff are not recognizing their own behaviour as neglectful, as expressed in their actions and language, and normalizing missed care when resources are lacking and nursing staff are rationing care. CONCLUSIONS: The gradual shift between judging actions as neglectful or not are made possible when nursing home staff legitimize neglect by not recognizing their practice as neglective, thus neglecting neglect or when they are normalizing missed care. Increased awareness and reflections on these processes may be a way of reducing the risk of and preventing neglect in nursing homes.

Contextual Factors Associated with Abuse of Home-Dwelling Persons with Dementia: A Cross-Sectional Exploratory Study of Informal Caregivers.

One in six community-dwelling older adults experience elder abuse yearly, and persons with dementia are especially at risk. Although many risk factors for elder abuse have been identified, there are still knowledge gaps concerning risk and protective factors. This cross-sectional survey among Norwegian informal caregivers (ICGs) aimed to find individual, relational, and community factors associated with psychological and physical abuse of home-dwelling persons with dementia. This study involved 540 ICGs and was conducted from May to December 2021. Statistical analysis using penalized logistic regression with lasso was performed to find covariates associated with psychological and physical elder abuse. The most prominent risk factor for both subtypes of abuse was the caregiver being a spouse. In addition, risk factors for psychological abuse were having a higher caregiver burden, experiencing psychological aggression from the person with dementia, and the person with dementia being followed up by their general practitioner. For physical abuse, the protective factors were the ICG being female and having an assigned personal municipal health service contact, while the risk factors were the ICG attending a caregiver training program and experiencing physical aggression from the person with dementia and the person with dementia having a higher degree of disability. These findings add to the existing knowledge of risk and protective factors in elder abuse among home-dwelling persons with dementia. This study provides relevant knowledge for healthcare personnel working with persons with dementia and their caregivers and for the development of interventions to prevent elder abuse.

Development of A Japanese Version of the Family Poly-Victimization Screen (FPS-J).

This study developed a Japanese version of the Family Poly-Victimization Screen (FPS-J) and assessed its validity. A cross-sectional study using self-report questionnaires was conducted with parents of children in Tokyo, Japan, from January to February 2022. To test the validity of the FPS-J, we used the Japanese versions of the revised Conflict Tactics Scale Short Form (J-CTS2SF) as the gold standard for intimate partner violence (IPV), the Conflict Tactics Scale Parent-Child (J-CTS-PC) for child abuse (CAN), the Conflict Tactics Scale (J-MCTS) for elder abuse, the K6-J for depression and anxiety, the PCL5-J for post-traumatic stress disorder, and the J-KIDSCREEN for Health-related Quality of Life among children. Data from 483 participants (response rate: 22.6%) were used. The J-CTS2SF and J-CTS-PC scores were significantly higher among the IPV/CAN-victim groups than in the non-victimized groups classified by the FPS-J (p < 0.001). The JMCTS scores did not differ significantly between the victim and non-victim groups (p = 0.44), but the PCL5-J, K6-J, and J-KIDSCREEN-10 scores were either significantly higher or lower among victims of violence than among the non-victim groups (p < 0.05). This study suggests the validity of parts of the FPS-J, especially the IPV against respondents and CAN by respondents.

Abusive episodes among home-dwelling persons with dementia and their informal caregivers: a cross-sectional Norwegian study.

BACKGROUND: Elder abuse is a serious issue with a global prevalence of 15.7% in the community setting. Persons with dementia are at higher risk of elder abuse than the older population in general. With a high and increasing prevalence of dementia this issue cannot be neglected. Hence, the aims of this study were 1) to describe the proportion of abusive episodes among home-dwelling persons with dementia and their informal caregivers, and 2) to explore differences between informal caregivers who have reported committing and not committing abusive acts. METHODS: A cross-sectional survey was conducted among informal caregivers of home-dwelling persons with dementia in Norway from May to December 2021 with a total of 549 participants. RESULTS: Two-thirds of informal caregivers had committed at least one abusive episode toward the person with dementia in the past year (63.5% psychological abuse, 9.4% physical abuse, 3.9% financial abuse, 2.4% sexual abuse, 6.5% neglect). One-third of informal caregivers had experienced aggression from the person with dementia (33.9% psychological abuse, 7.8% physical abuse, 1.1% financial abuse, 1.4% sexual abuse). Tests for independence showed that the risk of abusive episodes from informal caregivers toward persons with dementia was higher when the informal caregiver was a spouse/partner of the person with dementia and if they experienced aggression from the person with dementia. CONCLUSIONS: The results demonstrate that a majority of informal caregivers commit some form of abusive episodes, and episodes that fall within the scope of psychological abuse are most frequent. This study expands knowledge about elder abuse among home-dwelling persons with dementia. Increased understanding of the dynamics of abuse is essential to be able to reduce risk and prevent abuse.

Improving everyday life of people with dementia living at home: Health care professionals' experiences.

AIM: This study investigates what health care professionals experience is important for improving everyday life of people with dementia living at home. BACKGROUND: A prerequisite for living at home is that people with dementia and their relatives can handle everyday life together despite the challenges that dementia poses. METHODS: This qualitative study conducted focus group interviews (n = 14), and the data were analysed using qualitative content analysis. RESULTS: The analysis identified one theme-need for enhanced competence to develop and implement individual plans-and three categories: challenge in identifying cognitive decline; need to timeously facilitate an active and meaningful everyday life; and need for consistency, continuity and coordination in dementia home care. CONCLUSION: Increased expertise is needed among health care professionals to contribute to the development and implementation of individual plans in dementia home care. To achieve this, health care professionals' competence and how dementia home care is organized must be seen in conjunction. IMPLICATIONS FOR NURSING MANAGEMENT: Routines should be established for identifying cognitive failure early and providing support and guidance at the beginning of the process. There is a need for nurse managers to facilitate increased advanced competence regarding dementia care for a professional home care service and to consider how home services can be organized to ensure continuity and security for people with dementia and their relatives. Creating and implementing an individual plan which can be a starting point for identifying individual needs and wishes and for coordinating an individual user's services.

Having a Parent with Early-Onset Dementia: A Qualitative Study of Young Adult Children.

Background: Children of a parent with early-onset dementia (EOD) are confronted with losing a parent to a progressive neurodegenerative illness, usually perceived as an older adult illness, which may have a great impact on their lives at a time that is usually preserved for self-development. Objective: The objective of this study is to explore the experiences and perceptions of young adult children of a parent with EOD, with specific focus on personal lives and family and social relationships in a Norwegian context. Methods: Semistructured interviews with 10 young adult children between the ages of 19 and 30 years of a parent with EOD were analysed using a thematic analysis. Results: The analysis identified six main themes. "Upon discovering dementia, Keeping the family together, Others do not understand, A sense of relief, A need for support" and Apprehension for the future. The participants expressed an overarching feeling of living parallel lives, summarised by the phrase "We are not in the same boat." Furthermore, the themes demonstrated that the participants experienced difficulties with managing new responsibilities, at the same time, as preserving their own lives. They also shared concerns about the future and often experienced a lack of understanding and support from others. Finally, the need for targeted support throughout the illness was a central theme, whereby many felt more comfortable talking with someone with similar experiences or knowledge of their situation. Conclusion: The findings in this study strengthen the notion that the children of persons with EOD experience a challenging life situation, underlining the need for a person- and family-oriented approach.

Coping with Everyday Life for Home-Dwelling Persons with Dementia: A Qualitative Study.

AIM: This study aimed to gain insight into factors that influence everyday coping strategies as described by persons with early to intermediate dementia. BACKGROUND: Living with dementia presents difficulties coping with everyday life. This study focuses on coping with everyday life for persons with mild to moderate dementia in order to facilitate their ability to live at home. DESIGN: A qualitative study. METHODS: Individual interviews with 12 persons with dementia were conducted in their own homes. FINDINGS: Coping with everyday life can be influenced by the experience of the diagnostic process and by information about dementia. It can also be affected by stigmatization of persons with dementia, as well as by challenges in everyday life. In addition, challenges in receiving help may include poor continuity of services and healthcare staff with limited competence. By contrast, person-centered care led to positive experiences that supported everyday coping skills. Most of the respondents wanted to participate in day care several days a week. Other positive experiences were making new friends and participating in meaningful activities; such experiences could enhance to coping strategies. CONCLUSION: To strengthen everyday coping for persons with dementia living at home, there is a need for openness about the disease. Follow-up for persons with dementia must be carried out by reputable professionals trained and educated in dementia care. Finally, the municipalities must have contact persons, dementia coordinator/-team, who are available for persons with dementia at the time of diagnosis position and afterwards.

Factors associated with staff-to-resident abuse in Norwegian nursing homes: a cross-sectional exploratory study.

BACKGROUND: Elder abuse is a public health problem that is gaining attention due to its serious impacts on people's health and well-being, and it is predicted to increase along with the world's rapidly ageing population. Staff-to-resident abuse in nursing homes is a complex and multifaceted phenomenon associated with multiple factors on different levels of the ecological model. This study aimed to explore individual, relational, and institutional characteristics associated with perpetrated staff-to-resident abuse in nursing homes, using a multilevel hierarchical approach. METHODS: This was a cross-sectional exploratory study of 3693 nursing staff (response rate 60.1%) in 100 randomly selected nursing homes in Norway. We explored the characteristics of nursing staff, their relationship with residents, and institutional features associated with three types of abuse: psychological abuse, physical abuse, and neglect. These were modelled using multilevel mixed-effects logistic regression analyses. RESULTS: Individual staff factors found to be associated with all three types of abuse were 1) being a registered nurse/social educator (OR 1.77-2.49) or licensed practical nurse (OR 1.64-1.92), 2) reporting symptoms of psychological distress (OR 1.44-1.46), 3) intention to leave the job (OR 1.35-1.40), and 4) reporting poor attitudes towards people with dementia (OR 1.02-1.15). Also, staff who reported poorer quality of childhood were more likely to perpetrate neglect (OR 1.14). Relational factors such as care-related conflicts (OR 1.97-2.33) and resident aggression (OR 1.36-2.09) were associated with all three types of abuse. Of institutional factors, lack of support from a manager was associated with perpetrating psychological abuse (OR 1.56). CONCLUSIONS: We found several predictors of staff-to-resident abuse on different levels of the ecological model, which underlines the importance of using a multifaceted approach to identify risk factors of elder abuse in nursing homes. However, future studies should explore the underlying mechanism and causes with a prospective or qualitative design and target the multifaceted nature of risk factors when designing preventive interventions.

Informal caregivers and persons with dementia's everyday life coping.

This qualitative study explores informal caregivers' experiences of supporting persons with dementia's everyday life coping. In the future, there will be fewer health personnel, increased dementia prevalence and limited nursing home availability. Accordingly, close relatives may be compelled to assume greater care responsibilities. Knowledge concerning persons with dementia's everyday coping from the perspective of informal caregivers remains insufficient, despite these people's importance for those with dementia. This investigation analyses informal caregivers' perceived challenges and pleasures in providing care, how home health care affects everyday life coping and the factors that are most important to informal caregivers in supporting care receivers.

React and act: a qualitative study of how nursing home leaders follow up on staff-to-resident abuse.

BACKGROUND: Elder abuse in nursing homes is a complex multifactorial problem and entails various associations across personal, social, and organisational factors. One way leaders can prevent abuse and promote quality and safety for residents is to follow up on any problems that may arise in clinical practice in a way that facilitates learning. How nursing home leaders follow up and what they follow up on might reflect their perceptions of abuse, its causal factors, and the prevention strategies used in the nursing home. The aim of this study was to explore how nursing home leaders follow up on reports and information regarding staff-to-resident abuse. METHODS: A qualitative explorative design was used. The sample comprised 43 participants from two levels of nursing home leadership representing six municipalities and 21 nursing homes in Norway. Focus group interviews were conducted with 28 care managers, and individual interviews took place with 15 nursing home directors. The constant comparative method was used for the analyses. RESULTS: Nursing home leaders followed up incidents of staff-to-resident abuse on three different levels as follows: 1) on an individual level, leaders performed investigations and meetings, guidance, supervision, and occasionally relocated staff members; 2) on a group level, feedback, openness, and reflection for shared understanding were strategies leaders used; and 3) on an organisational level, the main solutions were to adjust to available resources, training, and education. We found that leaders had difficulties defining harm and a perceived lack of power to follow up on all levels. In addition, they did not have adequate tools for evaluating the effect of the measures that were taken. CONCLUSIONS: Nursing home leaders need to be clear about how they should follow up incidents of elder abuse on different levels in the organisation and about their role in preventing elder abuse. Evaluation tools that facilitate systematic organisational learning are needed. Nursing homes must operate as open, blame-free cultures that acknowledge that incidents of elder abuse in patient care arise not only from the actions of individuals but also from the complex everyday life of which they are a part and in which they operate.

A literature review of survey instruments used to measure staff-to-resident elder abuse in residential care settings.

Aim: To review the literature of existing survey instruments used to measure the occurrence of staff-to-resident elder abuse in residential care settings. Methods: A comprehensive literature search during May 2017 produced 2,037 records. Two authors independently reviewed these records for inclusion, where a total of 17 studies met eligibility criteria. Descriptive information of all identified survey instruments is provided. Results: This literature review reveals a diversity of survey instruments used to measure staff-to-resident abuse in residential care settings. The survey instruments varied greatly, where most instruments were self-developed by the authors and provided none or limited information on psychometric properties. Most studies were conducted in high-income countries and many of them in the United States.

Patients' perception of user involvement in psychiatric outpatient treatment: Associations with patient characteristics and satisfaction.

BACKGROUND: The patient's right to be involved in treatment decisions is anchored in guidelines and legislation in many countries. Previous research suggests challenges in the implementation of user involvement across different areas of health care, including mental health. However, little is known about psychiatric outpatients' experiences of being involved in their treatment. OBJECTIVE: To investigate how psychiatric outpatients after treatment rate the degree to which they were included in the treatment and explore the associations between perceived user involvement, demographic characteristics of the sample and patient satisfaction. DESIGN: Cross-sectional. SETTING AND PARTICIPANTS: The sample consisted of 188 psychiatric outpatients (67% female, mean age 42.2 years) who were discharged in the two years prior to data collection. MAIN VARIABLES STUDIED: Perceived user involvement in psychiatric outpatient treatment and patient satisfaction as measured by the Psychiatric Out-Patient Experiences Questionnaire. RESULTS: About half of the participants rated the overall degree of involvement in their treatment as high or very high. The lowest percentage of participants reporting high or very high involvement was found for sufficient information to contribute to treatment decisions (36%). Female gender, higher education and, to a small degree, younger age were associated with more involvement. Perceived user involvement was strongly associated with treatment satisfaction. DISCUSSION AND CONCLUSION: The findings suggest that user involvement in psychiatric outpatient treatment can be improved. Patient information that facilitates user involvement should be given more attention. PATIENT OR PUBLIC CONTRIBUTION: The hospital's user panel was involved in the development of items assessing user involvement.

Nursing home leaders' perception of factors influencing the reporting of elder abuse and neglect: a qualitative study.

PURPOSE: The purpose of this study is to explore the factors that influence the reporting of adverse events related to elder abuse and neglect in nursing homes from nursing home leaders' perspectives. Good leadership requires in-depth knowledge of the care and service provided and the ability to identify and address problems that can arise in clinical practice. DESIGN/METHODOLOGY/APPROACH: A qualitative explorative design with data triangulation was used. The sample consisted of 43 participants from two levels of nursing home leadership, representing six municipalities and 21 nursing homes in Norway. Focus group interviews were undertaken with 28 ward leaders and individual interviews with 15 nursing home directors. The constant comparative method was used for the analyses. FINDINGS: Both ward leaders and nursing home directors described formal and informal ways of obtaining information related to elder abuse and neglect. There were differences between their perceptions of the feasibility of obtaining formal reports about abuse in the nursing home. Three main categories of influencing factors emerged: (1) organisation structural factors, (2) cultural factors and (3) abuse severity factors. A main finding is that in its present form, the Norwegian adverse event reporting system is not designed to detect abuse and neglect. ORIGINALITY/VALUE: This paper provides an in-depth understanding of patient safety and factors related to reporting elder abuse in nursing homes in Norway.

Resident-to-resident aggression in Norwegian nursing homes: a cross-sectional exploratory study.

BACKGROUND: Resident-to-resident aggression in nursing homes is a public health problem of growing concern, impacting the safety, health and well-being of all residents involved. Despite this, little research has been conducted on its occurrence particularly in large-scale national studies. The aim of this study was to explore the extent and nature of resident-to-resident aggression in Norwegian nursing homes, as reported by nursing staff. METHODS: We conducted a cross-sectional exploratory study, where nursing staff in 100 randomly selected Norwegian nursing homes completed a pen and paper survey measuring how often they had observed incidents of resident-to-resident aggression during the past year. These rates were separated according to nursing home size, location and units of workplace. RESULTS: Of the 3693 nursing staff who participated (response rate 60.1%), 88.8% had observed one or more incidents of resident-to-resident aggression during the past year, with acts of verbal and physical aggression being the most commonly reported. Nursing staff working in dementia special care units, larger nursing homes and nursing homes located in suburban/urban municipalities, reported more incidents of resident-to-resident aggression than staff in short-term and long-term units, small institutions, and nursing homes located in rural municipalities. CONCLUSIONS: This is the first national study of resident-to-resident aggression in Norwegian nursing homes and is one of the largest surveys worldwide exploring the extent and nature of resident-to-resident aggression in long-term care settings. Overall, we found a high occurrence of all types of aggression, suggesting a need for strategies to improve residents' safety and quality of life in nursing homes.

How Volunteers Contribute to Persons with Dementia Coping in Everyday Life.

INTRODUCTION: The society needs volunteers to fulfill its duty to ensure that people with dementia have active and meaningful everyday lives. Volunteers seem to experience their work as positive and meaningful for their own part, but we know less about what motivates volunteers to start working in home-dwelling dementia care and what motivates them to continue their engagement. This study seeks to close some of the knowledge gaps that exist regarding volunteers' engagement in activities for persons with dementia. AIM: The aim of this study was to explore what motivates volunteers to start engaging in volunteer work in home-dwelling dementia care and what motivates them to continue their engagement. METHODS: The study design was qualitative, using focus group interviews. Three focus group interviews (n=16) took place between May and June 2018. The text was analyzed using content analysis. RESULTS: Findings in this study indicate that the volunteers were motivated by the feeling of doing an important job for the persons with dementia and their relatives, and that they contribute to their coping with everyday life. Other motivating factors included feeling important to someone, gaining friendship, and sharing common interests. They also believed that they do an important job for the community to fulfill society's goal that people with dementia should stay home longer. However, the volunteers were confused about their role and ask for knowledge, peer support, and clarification of roles. CONCLUSION: To maintain motivation volunteers need to know what his/her role is. A volunteer can and shall not act as a substitute for a professional, only as a supplement, and the expectations must be addressed to all stakeholders: the health care service, the volunteer, the person with dementia, and their relatives, as we believe that this will contribute to diminishing misunderstandings.

Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders' perceptions of elder abuse and neglect.

BACKGROUND: The definition and understanding of elder abuse and neglect in nursing homes can vary in different jurisdictions as well as among health care staff, researchers, family members and residents themselves. Different understandings of what constitutes abuse and its severity make it difficult to compare findings in the literature on elder abuse in nursing homes and complicate identification, reporting, and managing the problem. Knowledge about nursing home leaders' perceptions of elder abuse and neglect is of particular interest since their understanding of the phenomenon will affect what they signal to staff as important to report and how they investigate adverse events to ensure residents' safety. The aim of the study was to explore nursing home leaders' perceptions of elder abuse and neglect. METHODS: A qualitative exploratory study with six focus group interviews with 28 nursing home leaders in the role of care managers was conducted. Nursing home leaders' perceptions of different types of abuse within different situations were explored. The constant comparative method was used to analyse the data. RESULTS: The results of this study indicate that elder abuse and neglect are an overlooked patient safety issue. Three analytical categories emerged from the analyses: 1) Abuse from co-residents: 'A normal part of nursing home life'; resident-to-resident aggression appeared to be so commonplace that care leaders perceived it as normal and had no strategy for handling it; 2) Abuse from relatives: 'A private affair'; relatives with abusive behaviour visiting nursing homes residents was described as difficult and something that should be kept between the resident and the relatives; 3) Abuse from direct-care staff: 'An unthinkable event'; staff-to-resident abuse was considered to be difficult to talk about and viewed as not being in accordance with the leaders' trust in their employees. CONCLUSIONS: Findings in the present study show that care managers lack awareness of elder abuse and neglect, and that elder abuse is an overlooked patient safety issue. The consequence is that nursing home residents are at risk of being harmed and distressed. Care managers lack knowledge and strategies to identify and adequately manage abuse and neglect in nursing homes.