Again and again, headlines like this appear: “Caregiver kills nursing home resident” or “Scandal in nursing home – residents tortured and underserved”. Each time there is an outcry from the population, each time politicians and experts make statements. But what leads to violence against people in need of care? Murder and manslaughter are not the order of the day in retirement and nursing homes; aggression against caregivers also occurs at home. When and where does violence in care begin?
Acclimatization to changed living situation
Around 2 million people are currently in need of care in the Federal Republic of Germany. Anyone who becomes in need of care faces a completely new life situation. Depending on the degree of their need for care, they have to give up their independence and are dependent on the help of others to cope with everyday life. Frustration and anger, even aggression, are not uncommon, at least in the initial phase. Staff must be able to deal with these emotions on the part of the person in need of care, as well as with the physical limitations that constitute the need for care. Then there are the relatives: they often feel guilty because they can no longer or do not want to care for their family member at home. These three groups come together when a person needs care. They are all embedded in the long-term care insurance system, which primarily focuses on economic aspects of care.
What is violence?
Overt aggression against people in need of care, up to and including murder, robbery and fraud, are rare, despite all the sensational reports. Nevertheless, this violence exists and sometimes announces itself early on: According to a study of the Wittener psychiatry professor Dr. Karl legs Chefarzt of the pc. Marien – hospital in Hamm and chair owner for psychiatry at the University of Witten/Herdecke there is one with care-giving a “cynical torpor” opposite the occupation, which becomes apparent already relatively far before the actual act in brutalized language and self-isolation within the work group. According to Beine, one possibility for the early detection and prevention of acts of violence in nursing lies in a working atmosphere in which clinical staff can also talk openly about their aggressive fantasies. Such a culture of open discussion, however, has been virtually absent in hospitals and nursing homes.
Subtle violence
Violence in nursing care, however, is usually much more subtle and is often not even understood as aggression. Violation of the sense of shame, deficiency in nutrition, hygienic neglect, verbal attacks and physical assaults in all shades are on the list of charges. Unauthorized restraint, demonstrably even more common at night than during the day, in which patients in need of care are tied down, is an offense of deprivation of liberty under the Criminal Code. Aggression is also at play when patients are ducked without permission or forbidden to talk and deprived of attention.
Often not conscious
In many cases, these lapses do not happen consciously. The burden of daily task management does not allow employees in many care facilities geared to profitability enough time to respond individually and intensively to their charges. Old, sick people need to be addressed and given personal care. In many cases, relatives are not willing or able to be this contact person. Therefore, there would have to be much more time and personnel in the old people’s and nursing homes for the individual care of the patients.
Difficult balance
But the accusation of (albeit subtle) violence against the elderly has a facet that tends to be overlooked in the public debate. Homes and caregivers have an obligation to provide care, which they are usually happy to fulfill. But what are they to do when, for example, an elderly person with dementia refuses to eat with his hands and feet? What if the patient, lying in stool and urine, cannot wash himself and will not allow himself to be washed? How do you deal with patients who rage against and attack their fellow residents or even the nursing staff?
High number of unreported cases
The exact extent of violent acts in old people’s and nursing homes is not known. However, the number of unreported cases is estimated to be very high by the Kuratorium Deutsche Altershilfe (KDA), the Deutscher Berufsverband für Altenpflege (DBVA) and the Sozialverband Reichsbund (RB), which joined forces as early as 1998 in a joint initiative against violence in nursing homes.Exact figures or studies on this are not available. For fear of reprisals, the victims concerned, their relatives and also employees often remain silent. At the end of 2001, the UN Committee on Economic, Social and Cultural Rights, based in Strasbourg, voiced massive criticism of German nursing homes. Strasbourg reported that up to 85% of German nursing home residents are malnourished, and one in three suffers from dehydration because too little liquid is administered. The medical service, as home control of the health insurers on the way, sees the existing quality deficits not as individual cases, but as structure-conditioned problem. The medical service itself is criticized by the home managers: It is namely responsible for the classification within the nursing care insurance and thus also directly for the funds that are available to the homes for care.
Exhaustion, overwork, lack of qualifications
Exhaustion, overwork and inadequate qualification of nursing staff are at the top of the list of causes for the shortcomings in care for the elderly. The number of nursing home residents suffering from dementia and mental illness is rising continuously and will continue to increase in the coming years. At the same time, staff turnover is very high: only a few remain in their jobs for longer than 5 years because they are unable to cope with the physical and psychological demands. Experts see the 50% quota of skilled staff specified in the Home Staff Ordinance only as a lower limit. They believe that a ratio of at least 60% would be necessary to significantly ease the situation in German homes. Above all, however, there is a lack of qualification of home staff in the field of “psychiatry”. The German professional association for geriatric care has itself already called for more extensive qualification in psychiatric gerontology. A “round table” newly set up in 2003 by the Federal Ministers Renate Schmidt (Family Affairs and Senior Citizens) and Ulla Schmidt (Health) to improve the standard of nursing care is to deal with quality aspects of nursing care in old age by 2005, although the law to ensure quality in nursing care has already been in force since 2002. The establishment of the Round Table is met with incomprehension by many of those involved, since in their opinion the specifications are already adequately described by the new law. Far more important is a fundamental reorientation in the goals and intentions of care for the elderly that puts quality of life and respect for individuality in old age first.
