article discussion 

RESEARCH ARTICLE Open Access

Elder abuse and neglect: an overlooked
patient safety issue. A focus group study of
nursing home leaders’ perceptions of elder
abuse and neglect
Janne Myhre1* , Susan Saga1, Wenche Malmedal1, Joan Ostaszkiewicz2 and Sigrid Nakrem1

Abstract

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.

(Continued on next page)

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* Correspondence: Janne.myhre@ntnu.no
1Department of Public Health and Nursing, Faculty of Medicine and Health
Sciences, Norwegian University of Science and Technology NTNU,
Trondheim, Norway
Full list of author information is available at the end of the article

Myhre et al. BMC Health Services Research (2020) 20:199
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(Continued from previous page)

Conclusion

s: 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.

Keywords: Elder abuse, Neglect, Patient safety, Long-term care, Nursing homes, Care managers, Leadership,
Qualitative, Focus group

Background
Little is known about elder abuse in nursing homes, and
compared to research on other forms of interpersonal
abuse, research about elder abuse in nursing homes is
still in its infancy [1, 2]. Although no national prevalence
data are available in any country internationally, high
rates of elder abuse and neglect have been reported in
nursing homes, including Norway [1, 3]. According to
the World Health Organisation (WHO), elder abuse has
been identified in almost every country where these in-
stitutions exist [4]. In the Toronto Declaration, WHO
defines elder abuse as ‘a single, or repeated act, or lack
of appropriate action, occurring within any relationship
where there is an expectation of trust which cause harm
or distress to an older person’ [5] p:3. Prevention of
harm is a core principle in health care services and a
leadership responsibility [6–8]. Nursing home leaders
are legally and morally responsible for ensuring that re-
quired quality and safety standards are met [6, 9, 10].
The National Patient Safety Foundation (United States)
defines patient safety as ‘freedom from accidental or pre-
ventable injuries or harm produced by medical care’
[10], p,2. This includes preventing elder abuse and
examining the factors that foster an unsafe environment
for both residents and staff [6, 7, 11]. Furthermore, elder
abuse can be categorized according to type of abuse.
The definition from ‘Protecting Our Future: Report from
the Working Group on Elder Abuse’ (Ireland) includes
physical, psychological, financial and sexual abuse, and
neglect (Table 2) [12]. Abuse in nursing homes may also
be categorized according to type of relation [1]; staff-to-
resident abuse [3, 13], family-to-resident abuse [14, 15]
and resident-to-resident abuse, also called resident-to-
resident aggression [16, 17].
A recent meta-analysis of the prevalence of elder abuse

in long-term care settings estimated a pooled prevalence
of 64.2% of abuse perpetrated by staff in the past year,
where psychological abuse and neglect had the highest
prevalence [1]. A survey of 16 nursing homes in the cen-
tral part of Norway found that 91% of staff had observed
a colleague engaging in some form of inadequate care,
and 87% of staff reported that they themselves had

perpetrated some form of inadequate care in the past
[3]. Comparably, in a study from Ireland, Drennan et al.

found that 57.5% of staff had observed one or more abu-
sive behaviours from a colleague in the previous year
[13]. Neglect and psychological abuse were the most
commonly observed or perpetrated acts [3, 13]. Living in
a nursing home may also mean sharing room and space
with co-residents, and in recent literature, resident-to-
resident aggression has been identified as a common
form of abuse in nursing homes [16–18]. Lachs and col-
leagues revealed that 407 of 2011 residents from ten fa-
cilities had experienced at least one resident-to-resident
event over one month observation, showing a prevalence
of 20.2%, and the most common form was verbal abuse
[16]. The literature about elder abuse in domestic set-
tings shows that close family and friends can be perpe-
trators of abuse [15], but few studies have investigated
the role of family members as perpetrators of abuse in
nursing homes. A study from the Czech Republic found
that nursing home staff had observed relatives participat-
ing in financial exploitation combined with psychological
pressure on residents in nursing homes [14]. However,
comparing findings in the literature on elder abuse in
nursing homes is challenging because definitions and
understandings of abuse can vary in different cultures,
jurisdictions, and among health care staff, researchers,
family members, and residents themselves [1, 2, 11, 19–
21]. Different understandings of what constitutes abuse
and its severity complicate detecting, reporting and man-
aging the problem.
Nursing homes are complex social systems that consist

of different participants, including staff, leaders, resi-
dents and relatives in constantly shifting interactions
[22, 23]. The aetiology of abuse in nursing home settings
is described as complex, comprising varying associations
between personal, social and organisational factors [2,
24]. Nursing home residents often have complex care
needs, dementia or other forms of cognitive impairment
[25], display challenging behaviour [26], and depend on
assistance in daily activities and care, all factors associ-
ated with a high risk of abuse and neglect [3, 13, 24, 27].
In Norway, 80% of nursing home residents have demen-
tia, and 75% have significant neuropsychiatric symptoms
such as agitation, aggression, anxiety, depression, apathy
and psychosis [25]. Residents who display aggressive be-
haviour toward staff are at greater risk of experiencing

Myhre et al. BMC Health Services Research (2020) 20:199 Page 2 of 14

abuse [13, 27, 28]. Findings in Drennan et al.’s Irish
study revealed that 85% of the nursing home staff had
experienced a physical assault from a resident in the pre-
vious year [13]. Aggressive behaviour has also been
found to trigger resident-to-resident aggression in nurs-
ing homes [16, 17]. Related to organisational factors,
there is an association between inappropriate environ-
mental conditions for residents, low levels of staffing,
and abuse and neglect [13, 14, 29]. As a result of this
complexity, elder abuse in nursing homes is difficult to
define precisely [11]. Within the literature, elder abuse
in nursing homes is conceptualised as a specific form of
institutional abuse [30] and a setting in which abuse and
neglect take place [14], since rules and regulations in in-
stitutions can be abusive themselves, e.g., deciding resi-
dents’ sleeping and meal times, the use of restraint, and
shared living spaces with other residents.
Good leadership plays a key role in developing staff’s

understanding of residents’ needs [31, 32] and creating a
strong safety culture of respect, dignity, and quality [6, 7,
9, 33]. The importance of leadership in developing a pa-
tient safety culture is highlighted in a report from the
National Patient Safety Foundation [10]. In Norway, gov-
ernmental strategies to improve leadership and safety
culture have been launched, such as the Patient Safety
Programme and a system for monitoring health services
using quality indicators [34]. Leadership is defined as a
process whereby a person influences a group of individ-
uals to reach a common goal [35], such as a strong
safety culture. The safety culture of an organisation is
defined as ‘the product of individual and group values,
attitudes, perceptions, competencies, and patterns of be-
haviour that determine the commitment to, and the style
and proficiency of, an organisation’s health and safety
management’ [10, 36] p:23. This includes detecting situ-
ations that can be harmful to residents. However, several
studies have shown that underreporting of abuse and
neglect is a significant problem [1, 37, 38]. Residents’
own inability to communicate about the abuse or their
fear of repercussions and retaliation are important fac-
tors of underreporting [1, 2]. Therefore, staff should be
able to recognise and report situations that can be per-
ceived as harmful or distressful from the perspective of
residents. However, a systematic review of staff’s concep-
tualisation of elder abuse in residential care found that
staff were often uncertain about how to identify abuse,
especially psychological abuse and caregiver abuse and
neglect [39]. Despite the vast knowledge that exists
about the importance of leadership, nursing home re-
search has not yet paid much attention to the role
leaders play regarding identifying elder abuse. Conse-
quently, there is a gap in knowledge about elder abuse
from the perspective of nursing home leaders. Know-
ledge about nursing home leaders’ perceptions of elder

abuse and neglect are essential because their under-
standing of the phenomenon will affect what they signal
to staff as important to report and what they investigate
to create a safe and healthy environment. To our know-
ledge, this is the first study that seeks to understand the
nature of elder abuse from the perspective of nursing
home leaders.

Methods
Aim of the study
The aim of the study was to explore nursing home leaders’
perceptions of elder abuse and neglect.

Design
The present study is part of a larger study funded by the
Research Council of Norway (NFR), project number
262697. A qualitative exploratory design with focus
group interviews was conducted to gain greater insight
into this important but poorly understood topic. Quali-
tative methods provide knowledge about people’s experi-
ence of their situation and how they interpret,
understand and link meaning to events [40, 41]. In focus
group interviews, group dynamics allow the questions to
be discussed from several points of view, and the group’s
dynamics can create new perspectives and opinions dur-
ing the discussion [42]. This study follows The Consoli-
dated Criteria For Reporting Qualitative Research
(COREQ) (Additional file 1).

Settings
In Norway, approximately 39,600 residents live in nurs-
ing homes (12.9% of the population > 80 years), and their
mean age is 85 years [43]. These nursing homes are
mainly run by the municipalities and financed by taxes
and service user fees. Residents pay an annual fee equal
to 75% of the resident’s national age pension. In
addition, residents may pay an additional fee if they have
income of their assets, but with an upper limit decided
by the government. However, the payment cannot ex-
ceed the actual expenses of the institutional stay [44]..
Management of care in Norwegian nursing homes is
regulated by ‘the regulation of management and quality
improvement in health care services’ [45]. The regula-
tion focusses on the leader’s responsibility to ensure that
residents’ basic needs are satisfied. This includes the
leader’s responsibility to ensure there is a system in
place to monitor residents’ overall quality and safety and
to create a safety culture that detects situations and fac-
tors that can cause harm to residents and staff [45].
Each nursing home is required to have an administra-

tive manager, called the nursing home director, and
some nursing home directors lead more than one facil-
ity. In addition, each nursing home has ward leaders and
quality leaders, and in some municipalities, a service

Myhre et al. BMC Health Services Research (2020) 20:199 Page 3 of 14

leader. Together, individuals in these leader roles form
the leadership team in each nursing home [46]. The
ward leader is a registered nurse (RN) who supervises
and manages staff. Ward leaders are also responsible for
budgets in their own wards and the quality of care for
residents. There are often several wards and ward
leaders in each nursing home. The quality leader is an
RN who monitors the overall quality of care in the nurs-
ing home in collaboration with the ward leaders. The
service leader supervises and manage service staff mem-
bers who are in contact with nursing home residents
(e.g., activity coordinators, cleaning staff and kitchen
staff) and is also responsible for the budget related to his
or her staff. Individuals employed in one of these leader
positions provide the closest level of leadership to staff
and residents but are not part of the daily direct hands-
on care of residents. There is no national requirement
regarding formal leader education to be employed in
these leader positions, but leader education is a high pri-
ority in many municipalities. These individuals often
have lengthy experience as RNs or have previous leader
experience.

Sample
The study sample was recruited from 12 nursing homes in
six municipalities in Norway. Inclusion criteria were a per-
son who: (a) was employed in a leader position as ward
leader, quality leader, or service leader in a nursing home,
and (b) was employed full time in the leader position. The
inclusion criteria were chosen because these individuals
directly affect quality and safety in the nursing home, as
they are the closest level of leadership to the staff and resi-
dents. Purposive sampling was initially used to ensure that
participants recruited could see the phenomenon from the
perspective of a leader. During the data collection, each
municipality and its nursing home leaders were recruited
using a step-wise approach, as we were seeking to get a
theoretical sampling until saturation of data was achieved
[40, 41]. A total of 28 individuals participated in the study,
23 participants were ward leaders, two participants were
quality leaders, and three participants were service leaders.
However, in this study, all 28 participants are named ‘care
managers’. Characteristics of the participants are pre-
sented in Table 1.

Recruitment and data collection
Participants were recruited over a period of six months,
from August 2018 through the end of January 2019. A
recruitment email was sent to health care managers in
11 municipalities in both urban and rural areas. Health
care managers from five municipalities stated that they
could not find time to participate in the study, while six
health care managers accepted the invitation. Thereafter,
a second recruitment email was sent to all nursing home

directors in these six municipalities. The email included
an invitation letter, which the nursing home director for-
warded to all individuals employed in a leader position
at their nursing homes. Six focus group interviews were
conducted, with three to six participants in each group.
The focus groups were composed as follows: one focus
group with three participants; two focus groups with
four participants; one focus group with five participants;
two focus groups with six participants.
All six focus group interviews took place in a meeting

room in a nursing home in the participating municipal-
ities. Each focus group interview lasted approximately
90 min. All participants gave informed written consent
before the interviews started. Two researchers carried
out the interviews. JM was the moderator in all six inter-
views, SN was co-moderator for two group interviews,

Table 1 Demographics of the sample (n = 28)

Background characteristics Number (%)

Age (years)

30–39 6 (22)

40–49 11 (39)

≥ 50 11 (39)

Gender

Female 25 (89)

Male 3 (11)

Number of beds managing:

0 5 (17)

10–19 8 (29)

20–29 8 (29)

≥ 30 7 (25)

Number of staffs managing:

0 2 (7)

10–29 9 (33)

30–49 11 (39)

≥ 50 6 (21)

Years in this position

0–4 20 (71)

5–9 7 (25)

≥ 1

0 1 (4)

Total working experience as a leader in years

0–4 11 (39)

5–9 6 (22)

≥ 10 11 (39)

Formal leader education

0 1 (4)

0,5–1 years course 18 (64)

1–2 years course 3 (11)

Master’s Degree 6 (21)

Myhre et al. BMC Health Services Research (2020) 20:199 Page 4 of 14

and SS was co-moderator in one group interview. In the
other three interviews, two researchers from the larger
research team were co-moderators. During the introduc-
tory information about the focus group interview, we
presented a figure (Fig. 1), and asked participants about
their experience and thoughts on the topic of elder
abuse from health care staff, co-residents or relatives.
Participants were encouraged to speak freely. However,
during the first interview, we experienced that partici-
pants were not familiar with the topic. To explore the
topic in the ensuing interviews, the moderator gave the
participants keywords from the categorization of abuse
(e.g., abuse can be described as physical, psychological,
sexual, financial, or neglect) (Table 2) [12]. We found
that this helped the participants reflect, and they subse-
quently came up with examples of abusive situations
they had heard about or witnessed. During the process
of data collection, we further compared our experiences
in interview one with interview two, which is in line with
the constant comparative method [40]. This led to in-
cluding keywords in the interview guide to ensure that
all topics were covered (Additional fil 2). To ensure the
credibility of an open thematic understanding of partici-
pants’ experiences and diminish bias by presenting the
keywords, we were conscious about letting the partici-
pants speak freely about their experiences and thoughts
on this topic. Moreover, they were not given any defin-
ition of abuse or examples related to these keywords
(Table 2) [12]. The participants freely decided in which
order they wanted to talk about different forms and situ-
ations of elder abuse. All interviews were recorded and
transcribed verbatim, retaining pauses and emotional
expressions.

Data analysis
A constant comparative method with a grounded the-
ory approach was used. This allowed us to generate a
thematic understanding of elder abuse through an

open exploration of the experience described by nurs-
ing home leaders [40, 41]. The constant comparative
method facilitated possible identification of themes
and differences between individuals and cases within
the data [40]. Our analysis started right after each
interview, where the first author listened to the re-
corded interview. Memo writing was then used
through the whole process of data collection and ana-
lysis and served as a record of emerging ideas, ques-
tions and categories [41]. Next, in line with the
constant comparative method, open line-by-line cod-
ing of the transcribed interviews was performed [40,
41], since we wanted to capture the meaning from
the participants’ perspectives as they emerged from
the interviews. The codes were compared for frequen-
cies and commonalities and then clustered to organise
data and develop sub-categories. The sub-categories
were examined to construct the final categories and
main theme. To add credibility and diminish re-
searcher bias, two researchers (JM and SN) coded the
transcribed interviews independently. During the ana-
lysis process, the authors held several meetings where
codes and their connections were discussed until con-
sensus was reached. To ensure that the emerging cat-
egories and themes fit the situations explored, the
researchers went back and forth between
contextualization, data analysis and memo writing
[40]. An example of the analysis process is shown in
Table 3.

Ethical consideration

Ethical approval for this study was given by the Norwe-
gian Centre for Research Data (NSD), Registration No:
60322. Each participant signed a written consent form
after receiving oral and written information about the
study. All identifiable characteristics are excluded from
the presentation of data to ensure the anonymity of all
individuals.

Fig. 1 Model of interactions where abuse can occur as used in the interviews

Myhre et al. BMC Health Services Research (2020) 20:199 Page 5 of 14

Results
The main theme, ‘Elder abuse in nursing homes, an
overlooked patient safety issue’, found in this study indi-
cates an overall lack of awareness of elder abuse and its
harm among care managers. Three analytical categories
emerged from the analyses: 1) Abuse from co-residents –
‘A normal part of nursing-home life’, 2) Abuse from rela-
tives – ‘A private affair’, and 3) Abuse from direct-care
staff – ‘An unthinkable event’. Since there were no re-
markable differences in care managers’ experiences, we
present results without differentiating the participants.
Below, we describe each category, together with exam-
ples of forms of abuse and neglect. These examples are
used to describe the care managers’ perceptions of elder
abuse and neglect (Table 4).

Abuse from co-residents – ‘A normal part of nursing-
home life’
Resident-to-resident aggression was described as the big-
gest issue related to abuse in nursing homes and a daily
challenge for the participants: ‘That is what I also see,
that co-residents are the biggest challenge regarding this
topic’ (Group 2). The main cause of resident-to-resident
aggression reported by care managers was symptoms of
dementia, especially in the initiator, but also in the vic-
tim. The care managers expressed that they did not
know how to address this problem. As one said, ‘It hap-
pens because of the cognitive failure, so yes. But, at the
same time, it is also difficult to do something about it’
(Group 2). Some care managers also stated that the risk
of harm caused by resident-to-resident aggression was
something residents must accept when living in a

Table 2 Operational definitions of abuse and neglect in residential settings [12]

Five areas of abuse and
neglect

Abusive actions

Physical Abuse Hitting, slapping, pushing, kicking, misuse of medication or restraint.

Psychological abuse Emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation,
coercion, harassment, verbal abuse, isolation or withdrawal from services or supportive networks.

Sexual Abuse Rape and sexual assault or sexual acts to which the older adult has not consented, or could not consent, or into which
he or she was compelled to consent into which he or she was compelled to consent.

Financial Abuse Theft or the misuse or misappropriation of property or possessions.

Neglect Ignoring medical or physical care needs, failure to provide access to appropriate health care, social care or educational
services, withholding of necessities of life, such as medication, adequate nutrition and heating.

Table 3 Example of data analysis in the category “abuse from co-residents”

Sub- Categories Code Meaning unit

Common Resident-to resident aggression are common We have very often residents that are both physically and psychological
aggressive towards other residents.

Resident – to resident
aggression as
normalized

Difficult to do something with resident- to
resident aggression

I think it is due to the cognitive failure, so then it is not an abuse, because it
doesn’t help to just talk to the resident.

Resident-to-resident aggression a big part of
everyday life in nursing homes

We may have a little thick skin in relation to where the limit goes for what
we accept. Because it is such a big part of our everyday life that it became
normal in a way.

Normal behaviour from people with dementia When we have focus on dementia, it becomes normal for us to see such
behaviour.

Hitting Physical abuse – hitting when trespassing a
resident rom

We had a patient who was hit and beaten by the same resident several
times. The resident walks into his room and simply knocked him down, and
that is a despair.

Verbal abuse Psychological abuse – verbal abuse normal
behaviour for people with dementia

Then we have residents with frontotemporal dementia who just acts in that
way, they just verbally offending others, but it is their way of behaving.

Violation of resident’s
privacy

Psychological abuse – violation of resident’s
privacy when trespassing into another resident’s
room

Trespassing into another residents’ room that happens a lot, but it’s a
violation of their privacy, and if the resident can’t speak or is cognitive
impaired, they may be unable to tell if something is happening.

Stealing things Financial abuse – stealing things They steal things from each other’s room, yeas that happened.

Sexual assault Sexual abuse – sexual assault and an ethical
dilemma

We see sexual approaches or that they forgot that they are married and find
each other instead. But that is more a dilemma than an assault …. or
maybe it can be an assault… well I don’t know.

Myhre et al. BMC Health Services Research (2020) 20:199 Page 6 of 14

nursing home: ‘There is a predictable risk, when living in
nursing homes, [of] such incidents; there is a foreseeable
risk that this will happen’ (Group 5). This demonstrates
that resident-to-resident abuse is normalized.
Care managers considered physical abuse to be the

most serious form of resident-to-resident aggression,
often leading to visible harm and despair. At the same
time, all care managers had examples of residents who
had been beaten, knocked down, or kicked by co-
residents.
‘We have one resident now that is beaten a lot by the

other residents. It’s a little extreme, but I think that such
things can happen quite often in dementia care because, as
in this case, the resident being beaten is not silent for a mi-
nute. She speaks and yells all day, and the other residents
become annoyed since she disturbs them’ (Group 4).
Care managers described psychological abuse as acts

of ‘everyday bullying’ and threats made among residents.
They interpreted these situations as a normal conse-
quence of the dementia disease in the individual resi-
dent. One care manager noted, ‘What I think is the
challenge is the everyday bullying. It is seen as normal
behaviour for that group of residents’ (Group 1). When
discussing psychological abuse connected to co-
residents, all care managers provided examples of resi-
dents trespassing in other residents’ rooms. They inter-
preted this behaviour as a violation of residents’ privacy.
At the same time, it was perceived as normal since it
happened quite often. The care managers also reported
that when residents trespassed and entered another resi-
dent’s room, the risk of other forms of abuse such as fi-
nancial abuse increased. One care manager remarked,
‘We have some challenges related to residents who enter

other residents’ rooms and destroy or take other residents’
possessions. It can be pictures and different things’
(Group 3).
Related to sexual abuse by co-residents, all care man-

agers had examples of residents who had shown sexual
interest in another resident. The care managers viewed
this sexual interest as an ethical dilemma for them. On
the one hand, they want residents to have a healthy sex
life in the nursing home, but on the other hand, this is
difficult when a resident has dementia and may not be
competent to give consent. Several care managers expe-
rienced that what seemed to be voluntary sexual interest
between residents could not be that, after all:
‘In that situation, she was very interested in him, and

he was very interested in her. And it was like, yes, they
were in the room together and so on. I remember it as
very, very difficult because she often had a lot of pain. I
do not know if there was penetration, but it was, in any
case, an attempt, yes, it may as well have been that too. I
had a lot of trouble because I was unsure whether she
understood what happened and who it was happening
with because it was often very difficult for her after they
had been in the room together. I remember it as a huge
ethical dilemma. But I never thought that it was a sex-
ual. .. that it was an assault or something. But, right
now, I think it was’ (Group 5).
During the focus group discussion, care managers

reflected on the complexity of letting residents express
themselves sexually and the risk of sexual assault. From
their statements, it was clear that they had not reflected
on this topic earlier. A summary of forms of harmful sit-
uations related to resident-to-resident aggression re-
ported by participants is presented in Table 4.

Table 4 Examples of forms of abuse as described by care managers

Co- residents
“A normal part of nursing home life”

Relatives
“A private affair”

Direct Care staff
“An unthinkable event”

Physical abuse

Hitting, kicking, pushing, and throwing things X X

Rough handling X X

Use of force or restrain X X

Psychological abuse

Verbal abuse X X X

Violation of resident’s privacy X X

Financial abuse

Stealing or destroying a resident’s assets X X X

Sexual abuse

Sexual assault X X

Neglect

Neglect of user participation X X

Health care neglect X

Myhre et al. BMC Health Services Research (2020) 20:199 Page 7 of 14

Abuse from relatives – ‘A private affair’
Abuse directed towards residents from their relatives
was reported to be a particularly difficult problem. Ac-
cording to the care managers, relative-to-resident abuse
was often hidden, occurring behind private closed doors
when a relative was visiting the resident. Therefore, par-
ticipants described it as difficult to discover and associ-
ated mainly with the private relationship between the
resident and his or her relatives:
‘It is very difficult. It is a relative who is going to visit

her mother in the nursing home, she closes the door to
the room and wants to be there alone with her mom, and
we have very large rooms, so we thought they were having
a nice time inside the rom. But then we discovered that
the mom had some bruises, and then we understood that
things were happening’ (Group 3).
Not all care managers had knowledge of or experience

with relative-to-resident abuse, which highlights the pri-
vate nature of these forms of abuse. Abuse from relatives
was viewed as being linked to past family conflict, which
continued inside the nursing home. The care managers
deliberated over the extent to which they should inter-
fere in the private relationship when they suspected this
form of abuse. They reported that the problem was
knowing what to do and when and how to interfere, es-
pecially when the resident has dementia or another form
of cognitive impairment. One care manager remarked,
‘It is very difficult. I have a patient who may not be com-
petent to give consent. So, I have a responsibility I must
take, but I think it’s challenging to know what to do’
(Group 2). Cases where the resident clearly did not want
anyone in the nursing home to know about the abuse or
to do anything about it and just wanted to maintain the
relationship with his or her family member despite the
abuse were reported to be particularly difficult. The care
managers expressed that they lacked a strategy or au-
thority in these situations, and harm to the resident be-
ing exposed was accepted.
‘But it is not always that the resident wants us to do

something, either. It may have been this way for a long
time, and then, maybe it’s okay then. Well, I don’t know’
(Group 5).
Physical and sexual abuse from relatives was regarded

as the most hidden form of abuse from relatives. Some
care managers provided examples of physical abuse, but
none had experienced sexual abuse. However, all care
managers commented that when it happened, it took
place behind private closed doors. In addition to past
family conflict, abuse from relatives was often related to
mental problems and/or drug abuse issues. One care
manager said, ‘I have experienced some older people who
have children with drug issues and such things. And it is
in those cases, I have experienced physical abuse towards
residents from relatives’ (Group 4). Related to physical

abuse from relatives, care managers also reported situa-
tions where a relative forced the resident to, for example,
eat, get dressed, wash and groom, or exercise. These sit-
uations were linked to unrealistic expectations in rela-
tives, and not trusting the staff is doing a good job.
‘After her husband had been there, we saw that she

was so red around the cheek. We then found out that the
husband squeezed her mouth open and poured cream
into her’ (Group 3).
Care managers viewed psychological abuse from rela-

tives as disrespectful communication with the resident. A
participant stated, ‘We experience that relatives can be
quite disrespectful to their loved ones. But, at the same
time, it may have been this way their whole life’ (Group 6).
Care managers expressed that financial abuse from rel-

atives was a common occurrence. They cited examples
of stealing money from residents, threatening residents
in order to get money from them, and unauthorized use
of a resident’s finances. One participant stated, ‘What I
see most from the relative’s part is financial abuse. It is
very common, actually’ (Group 1). Relatives’ economic
problems were reported to be a causal factor related to
financial abuse. At the same time, care managers indi-
cated that financial problems and financial exploitation
by relatives were private issues, and as such, they were
reluctant to interfere.
Related to neglect, care managers described that some

relatives made decisions on behalf of the resident without
considering what the resident wanted and needed or would
agree upon. Care managers stated that sometimes the
health care staff also disagreed with the relative’s decision.
One care manager noted, ‘We have situations where rela-
tives make decisions on behalf of the resident, which we do
not agree upon, and which we might think the resident
would not agree upon either’ (Group 3). Care managers also
described experiences of relatives who refused to allow a
resident to buy items the care managers considered neces-
sary and not provided by a nursing home. These could be
things such as clothes, hairdressing services, or podiatry,
but it could also be related to taking part in activities that
cost money. A care manager remarked:
‘I have a resident who called her son to ask if she could

go to a podiatrist because she really needed it, but her son
refused and said she has no money for that’ (Group 5).
Thus, because of neglect by their relatives, residents

might go without necessities of daily living and may not
be able to participate in activities they would like to take
part in. A summary of forms of harmful situations related
to relative-to-resident abuse reported by participants is
presented in Table 4.

Abuse from direct-care staff – ‘An unthinkable event’
When care managers were prompted to talk about staff-
to-resident abuse, they reframed the discussion to focus

Myhre et al. BMC Health Services Research (2020) 20:199 Page 8 of 14

on the verbal and physical aggression they commonly
experienced from nursing home residents. They inter-
preted aggression directed toward them as a risk to their
health and safety. Moreover, they stated this
phenomenon was a daily concern. One noted, ‘We have
the opposite focus in our units. We focus on staff being
subjected to abuse by residents’ (Group 2). Several care
managers also indicated that they understood that staff
could become stressed and frustrated in their relation-
ship with an aggressive resident:
‘We have a case that is extremely difficult, where there

are many violations against staff by a resident. And then,
to be in such a situation where you can quickly retaliate.
.. this is difficult’ (Group 6).
Despite this, care managers expressed that elder abuse

was not a topic they talked about in their daily work at
the nursing home. They indicated that they wanted to
trust the employees. Therefore, abuse from staff was dif-
ficult to talk about and almost unthinkable to them. One
care manager said, ‘I think that no one who works in the
nursing home started there just to be able to hurt some-
one, and that is perhaps why this is such a sensitive and
difficult topic’ (Group 5). The word ‘abuse’ was also re-
ported to be a very strong term and mainly related to
intentional physical acts. However, in the discussion,
care managers also included unintentional acts in their
examples of elder abuse and expressed that, to some de-
gree, it could be difficult to know the full intention of a
staff member’s actions. At the same time, they empha-
sised that staff’s intentions were mainly good, and there-
fore abuse was unthinkable:
‘Everyone who works in a nursing home is motivated by

and has a desire to help someone. So, most of the [inci-
dents] of abuse by staff. .. I think it may be those with a
good intention at the heart of it. [For instance, thinking]
“I thought he should have a shower, but I forgot to ask”
(Group 5).
Care managers discussed examples of the use of phys-

ical and chemical forms of restraint and rough handling
during care. Utilization of restraints and dilemmas re-
lated to their use was discussed in all focus groups, and
care managers pointed out that the staff are sometimes
compelled to use both physical and chemical restraints
to help or protect the resident:
‘I think in relation to, well it is really both physical

and psychological abuse. I think of cases, especially at
night, where there is low staffing and many residents with
aggressive behaviour, where it may be chosen to lock
some residents into their rooms to prevent them from be-
ing exposed to abuse from co-residents so the staff can
deal with the situation, but it is abuse to be locked inside’
(Group 2).
Rough handling was something that all care managers

had experienced. This was thought to be mainly

unintentional and something that could happen when
caring for residents with aggression or those who resist
care. Care managers expressed that, to define it as abuse,
it had to be significant, or there needed to be visible
signs of such handling, such as bruising. At the same
time, the care managers also pointed out that residents
in nursing homes often bruise easily, and it can be diffi-
cult to determine whether such marks are related to
abuse:
‘Sometimes, we saw that she was so easy to bruise, and

sometimes we clearly noticed hand marks on the bruises
around her body. But it can be enough that you handle
someone a little hard, and in the old ones, then they get
bruises, although it can also indicate that there has been
resistance, right. But then this happens all the time’
(Group 4).
Psychological abuse from staff members was linked to

verbal abuse. Care managers cited examples of yelling at
a resident in anger, speaking to a resident in a disres-
pectful tone, or being rude, which allegedly occurred in
relation to resident-to-staff aggression. When discussing
psychological abuse, some care managers also provided
examples of violations of residents’ privacy by staff
members, such as discussing residents’ health care issues
and challenges in public areas in the nursing home:
‘If there has been a resident with a rejection of care re-

sponses, for example, that has been difficult to cooperate
with, then that frustration can be expressed in public
areas with other residents present. Without caution by
staff, this is something other residents are going to hear’
(Group 5).
Financial abuse was thought to be related to stealing

money or destroying a resident’s property. At the same
time, care managers reported that their nursing home
policies do not allow residents to keep much money in
their rooms in order to protect residents from financial
abuse by staff, visitors, or others, and hence, financial
abuse from staff rarely happened. One said, ‘Financial
abuse only happens if the residents have money laying
around’ (Group 1).
When talking about sexual abuse, care managers of-

fered examples of residents who stated that they were
sexually assaulted by staff members. These were often
female residents who expressed that male staff had sex-
ual intentions towards them during care. At the same
time, care managers reported that such statements from
residents could be part of the dementia disease, and that
resident could have hallucinated the abuse. Care man-
agers indicated that sexual abuse by staff was unthink-
able to them:
‘Sometimes, older people with cognitive impairment say

things that we can become uncertain about. They say
things, but we can’t be sure there has been an assault.
Often, we think that it has not happened. It’s about us

Myhre et al. BMC Health Services Research (2020) 20:199 Page 9 of 14

knowing them; they say a lot of these things and are very
sexually oriented’ (Group 4).
Even so, a few care managers mentioned examples of

sexual abuse by staff a long time ago that had been re-
ported to the police, and the staff member was convicted.
Related to neglect, care managers reported that staff

often did things for residents to save time instead of let-
ting them do it independently. They also reported being
aware that, in many situations, staff members do not pay
attention to residents’ wishes and thereby neglect to in-
clude them in decisions concerning daily life in the nurs-
ing home. One care manager noted, ‘It says on the duty
list that you should shower today, so you should shower,
even if you might say, “No, I don’t want to.” So, yes, it is
your turn today’ (Group 3). Another form of neglect by
staff was reported to be linked to health care neglect.
Care managers referred to events such as not helping a
resident with needed health care, giving a resident an in-
continence product instead of helping them use the toi-
let, not calling for medical help when needed, and not
following up on medical conditions:
‘To put on a pad instead of following the patient to the

toilet, for those who still manage to use the toilet them-
selves. .. that can happen’ (Group 6).
The care managers reported that, because of low fi-

nancial resources, staff must prioritize their work and
tasks every day. For this reason, situations not specific-
ally related to medical treatment and physical or health
outcomes were given lower priority. This reprioritization
was framed as acceptable and was not defined as neglect.
One said, ‘It is about our time. So, no, we don’t have time
for you or that need is not important. It is about what we
have to prioritize’ (Group 6). A summary of forms of
harmful situations related to staff-to-resident abuse re-
ported by participants is presented in Table 4.

Discussion

The aim of the study was to explore nursing home
leaders’ perceptions of elder abuse and neglect. We
found that most of the care managers were not explicitly
aware of elder abuse in their daily work. However, when
given keywords, they all came up with examples of situa-
tions they interpret as harmful or distressful to residents.
This shows that care managers need time to reflect on
complex aspects of care to become aware of abuse and
neglect as a safety issue. At the same time, our findings
revealed an ambiguity in the care managers’ examples.
The situations, on the one hand, were described as
harmful. On the other hand, they were rationalized as
care managers attempted to excuse why it was happening.
Three main categories are described in the finding: Abuse
from co-residents – ‘A normal part of nursing-home life’,
Abuse from relatives – ‘A private affair’, Abuse from direct
care staff – ‘An unthinkable event’. These findings indicate

that this cohort of nursing home care managers lack
awareness of the abuse they observe or hear about. Par-
ticularly, these findings demonstrate that harm or distress
to residents caused by abuse are an overlooked patient
safety issue in these nursing homes.
Findings revealed that resident-to-resident aggression

is a common form of abuse in nursing homes and a daily
challenge. There is a high prevalence of residents with
neuropsychiatric symptoms of dementia, including ag-
gression, agitation and psychosis in nursing homes [25,
26]. These symptoms impact on co-residents and staff
safety, and resident-to-resident aggression is the most
common form of abuse in nursing homes [16, 17]. How-
ever, our findings revealed that harm resulting from
resident-to-resident aggression was perceived as normal.
This raises the question of whether care managers per-
ceptions place the responsibility on the resident, without
accounting for the complexity in the aggressive behav-
iour and the responsibility of the organization [22]. It is
worth noting that in resident-to-resident aggression,
both residents can suffer harm, since the initiator is
likely to be confused and usually not responsible for the
acts. For the victim, resident-to-resident aggression has
both physical and psychological consequences [47].
However, previous research has also indicated that abu-
sive behaviour can be understood as less abusive when
the victim has dementia, and for that reason it is often
not reported [17, 48]. Recognising that aggressive behav-
iour has a multifactorial aetiology, best practice recom-
mendations [49] and research evidence [50, 51] call for a
comprehensive biopsychosocial approach that investi-
gates the resident’s unmet needs, medical conditions, en-
vironmental factors, and interactions between residents
and caregivers and a tailored response [49]. Care man-
agers’ perceptions of resident-to-resident aggression as
normal and a foreseeable risk, places residents at risk
and is also a failure to deliver much needed care to the
initiator.
With respect to relative-to-resident abuse, findings

demonstrate that care managers perceive negative events
resulting in harm or distress as a private affair between
the resident and his or her relatives, and that is difficult
to intervene. Similarly, to resident-to-resident abuse, this
indicates that the care managers place the responsibility
of the observed abuse on the relationship between the
resident and his or her relatives, without accounting for
the complexity and their own responsibility in these situ-
ations. Care managers examples of relatives who force a
resident to eat due to unrealistic expectations and dis-
trust in nursing home staff’s care reveals that care man-
agers find it difficult to interact with families. This
finding points to potential communication difficulties
between staff and resident’s relatives that could adversely
affect the resident [52, 53]. A Norwegian study that

Myhre et al. BMC Health Services Research (2020) 20:199 Page 10 of 14

investigated quality of care from the perspective of fam-
ilies in long-term care found that family members saw
themselves as an important link between staff and the
resident, and an essential voice regarding the resident’s
needs and wishes [53]. However, given the nature of the
nursing home and the complexity of its organization and
routines [22, 23], it can be difficult for someone outside
the organization to judge what is and is not adequate
clinical practice. Collaboration and communication with
the residents and their relatives depend on how the cul-
ture in the nursing home view these interactions; the rel-
atives with right to an opinion, or professional as experts
and in control [6, 22, 52]. This will in turn affect the
quality and safety of the care that is delivered to the
residents.
Although some care managers had experience of staff-

to-resident abuse within all abuse categories, it was also
difficult for them to admit to this form of abuse, and it
was viewed as an ‘unthinkable event.’ Instead, care man-
agers were mostly interested in talking about resident-
to-staff aggression which they emphasised was a larger
problem in their nursing homes. Resident- to-staff ag-
gression can cause physical and psychological harm to
staff, reduced job satisfaction, stress and burnout, emo-
tional reactions including sadness, guilt and helplessness
[28]. However, resident-to-staff aggression may also lead
to reactive abuse and neglect, due to frustration in staff
member being exposed to aggression [11, 13, 27, 28].
Findings in the present study demonstrate that care
managers lack awareness of the staff’s reactive responses
to aggression from residents. This might raise the ques-
tion if they perceive staff as victims in these situations
and that abuse from staff is understandable. Unprovoked
or intentional abuse towards a resident therefore is un-
thinkable with justification in their trust to the staff.
Difficulties in defining abuse in nursing home settings

have been found in studies that include staff’s percep-
tions [39, 54], where abusive situations are seen as nor-
mal in the nursing home culture [17, 33, 39, 55].
However, these studies did not specifically focus on care
managers’ or leaders’ understandings. Our study reveals
important information related to detection and manage-
ment of abuse in nursing homes, since care managers’
perception of abuse affects what they signal to staff as
important to report. Care managers have the opportun-
ity to influence the culture and care practice in the nurs-
ing home and are responsible for setting policies for the
staff, it is therefore essential that they are aware of and
able to face situations that constitute potential harm to
the residents. But, to be able to define situations that
can be experienced as harm and distress, it is essential
to see situations from the perspective of the residents.
Harm and distress are defined differently from the point
of view of the one who causes the harm [39, 54], the one

observing or hearing about it [14], or the one who expe-
riences a situation of harm or distress [20, 21]. Our find-
ings indicate that the care managers had difficulties in
seeing potential harm caused by abuse and neglect from
the perspective of the residents. Leaders’ abilities to pro-
mote a safety culture for both the resident and staff are
linked to their leadership skills, knowledge of the resi-
dent’s needs and their capacity to implement effective
safety care practices [6, 31, 32]. Care managers’ lack of
awareness in identifying and following up on abuse will
necessarily affect the safety culture in the organisation
and, in the end, clinical outcomes such as quality and
safe care for the residents [6, 10, 56].
A recent Norwegian study found that communication,

openness and staffing were significant predictors of
staff’s overall perception of patient safety in nursing
homes, yet the nursing home staff scored low on these
dimensions [56]. This finding aligns with our study,
which revealed that care managers find it difficult to dis-
tinguish between prioritising and patient neglect. Low fi-
nancial resources and low staffing can affect the
perception of what constitutes harm and safety in the
nursing home culture. Low finances, combined with the
complexity of residents’ needs, the complex organisation,
and demands for improved outcomes, puts great pres-
sure on nursing home leaders [22, 57]. The ambiguity in
their examples can be understood as an attempt to ra-
tionalize abuse and diminish their personal and profes-
sional accountability. People in complex social systems
will try to make sense of tasks and orders by adapting to
internal and external demands [22, 23]. Health care pol-
icies that mandate efficiency, cost saving, and nursing
home care managers’ focus on prioritising contribute to
lowering the limit for what is perceived as quality and
safety, resulting in low quality and unsafe environment
as the norm and accepted in nursing homes.

Strengths and limitations of the study
A strength of this study is that it involves participants
who are in leader positions in different nursing homes
and municipalities in Norway, which could increase the
transferability of these findings. The research team con-
sists of members from two countries, all with broad re-
search experience, which contributed to multiple
perspectives and discussions during analyses of the data.
This strengthens the trustworthiness of our findings,
and the credibility of the research. Three of the authors
have worked several years in nursing homes as care man-
agers, but none of those nursing homes participated in
this study. The researchers’ backgrounds as care managers
has both advantages and disadvantages. A variety of as-
pects of participants’ experiences was discovered by pos-
ing in-depth questions that might not have been possible
without the background knowledge. However, the

Myhre et al. BMC Health Services Research (2020) 20:199 Page 11 of 14

background knowledge can influence the type of follow-
up questions that were asked. To counterbalance this pos-
sible bias, two researchers were always present during the
interview, and the analyses were also independently coded
by two researchers (JM and SN). Each focus group con-
sisted of three to six participants, which can be perceived
as small groups and a limitation. However, the partici-
pants gave a rich description of the phenomenon. There-
fore, we decided to include data from the smallest groups.
The examples of abuse and neglect our participants

described in the present study could be second-hand in-
formation because leaders are not always part of the dir-
ect hands-on care residents receive. At the same time,
this study has sought to understand the nature of elder
abuse from care managers’ perspective, which is of great
importance due to their responsibility for creating a safe
environment for both residents and staff. Even though
the examples are second-hand information, the findings
are representative of the care managers’ perceptions of
the information and what we thought was important to
study.

Conclusion
Many nursing home residents have dementia, neuro-
psychiatric symptoms, and complex needs, which in-
creases the risk of their being exposed to abuse and
neglect. At the same time, little is known about the na-
ture of elder abuse in nursing homes and compared to
research on other forms of interpersonal abuse, the
study of elder abuse in nursing homes is still in its in-
fancy. Care managers influence the culture and care
practice in nursing homes and set policies for staff.
Knowledge about their empirical understanding of the
phenomenon is important to form more effective inter-
vention and prevention strategies. The present study
shows an ambiguity in the nursing home leaders’ exam-
ples of abuse and neglect. On the one hand, the situa-
tions were described as harmful. On the other hand,
they were rationalized with an attempt to excuse their
occurrence. Our study revealed that elder abuse and
neglect is an overlooked patient safety issue in nursing
homes. Care managers lack knowledge and strategies to
identify and adequately manage abuse and neglect in
nursing homes, and this warrants further research.

Supplementary information

Supplementary information accompanies this paper at https://doi.org/10.
1186/s12913-020-5047-4.

Additional file 1. COREQ checklist.

Additional file 2. Interview guide.

Abbreviations

NFR: Research Council of Norway; RN: Registered Nurse; WHO: World Health
Organization

Acknowledgements

We would like to express our gratitude to our participants for sharing their
experience and thoughts on the topic of elder abuse and neglect in nursing
homes. Thanks to Anja Botngård and Stine Borgen Lund for contributing to
data collection as co-moderators.

Ethical consideration
Ethical approval for this study was given by the Norwegian Center for
Research Data (NSD), Registration No: 60322. All the participants were
provided with written information about the study. They gave written
consent to participate in the interviews and for the use of the data from the
interviews.

Authors details

JM: RN, MSc, PhD candidate, at Department of Public Health and Nursing,
Faculty of Medicine and Health Sciences, Norwegian University of Science
and Technology NTNU, Trondheim, Norway.
SS: RN, MSc, PhD, Associate professor at Department of Public Health and
Nursing, Faculty of Medicine and Health Sciences, Norwegian University of
Science and Technology NTNU, Trondheim, Norway.
WM: RN, MSc, PhD, Associate professor at Department of Public Health and
Nursing, Faculty of Medicine and Health Sciences, Norwegian University of
Science and Technology NTNU, Trondheim, Norway.
JO: RN, GCert Cont Prom, GCertHE, MNurs-Res, PhD, Research Fellow, Centre
for Quality and Patient Safety Research, School of Nursing and Midwifery, In-
stitute for Healthcare Transformation, Deakin University, Geelong, Australia.
SN: RN, MSc, PhD, Professor at Department of Public Health and Nursing,
Faculty of Medicine and Health Sciences, Norwegian University of Science
and Technology NTNU, Trondheim, Norway

Authors’ contributions

JM wrote the manuscript. JM, SS, WM, JO and SN developed the study
design. JM transcribed the interviews, and JM and SN performed the analysis
of the interviews, with discussion including all authors. SN supervised the
project. All authors did critical revisions of the manuscript for important
intellectual content and read and approved the final manuscript.

Funding

The study is funded by the Research Council of Norway (NFR) project
number: 262697.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not
publicly available due to format of the data not allowing for completely
anonymizing data but are available from the corresponding author on
reasonable request.

Consent for publication

The participants consented to the publication of de-identified material from
the interviews.

Competing interests

The authors declare that they have no competing interests.

Author details

1Department of Public Health and Nursing, Faculty of Medicine and Health
Sciences, Norwegian University of Science and Technology NTNU,
Trondheim, Norway. 2Centre for Quality and Patient Safety Research- Barwon
Health Partnership, Institute for Healthcare Transformation, Deakin University,
Geelong, Australia.

Received: 30 September 2019 Accepted: 26 February 2020

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Myhre et al. BMC Health Services Research (2020) 20:199 Page 14 of 14

Abstract
Background
Methods
Results
Conclusions
Background
Methods
Aim of the study
Design
Settings
Sample
Recruitment and data collection
Data analysis
Ethical consideration
Results
Abuse from co-residents – ‘A normal part of nursing-home life’
Abuse from relatives – ‘A private affair’
Abuse from direct-care staff – ‘An unthinkable event’
Discussion
Strengths and limitations of the study
Conclusion
Supplementary information
Abbreviations
Acknowledgements
Ethical consideration
Authors details
Authors’ contributions
Funding
Availability of data and materials
Consent for publication
Competing interests
Author details
References
Publisher’s Note