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Journal of Elder Abuse & Neglect
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Physical Abuse of Older Adults in Nursing
Homes: A Random Sample Survey of
Adults With an Elderly Family Member in
a Nursing Home
Lawrence B. Schiamberg PhD a , James Oehmke PhD b , Zhenmei
Zhang PhD c , Gia E. Barboza PhD d , Robert J. Griffore PhD a ,
Levente Von Heydrich MSWPhD a , Lori A. Post PhD e , Robin P.
Weatherill PhD f & Teresa Mastin PhD g
a Human Development and Family Studies, Michigan State University,
East Lansing, Michigan, USA
b Department of Agricultural Economics, Michigan State University,
East Lansing, Michigan, USA
c Department of Sociology, Michigan State University, East Lansing,
Michigan, USA
d Department of African American Studies, Northeastern University,
Boston, Massachusetts, USA
e Department of Emergency Medicine, School of Medicine, Yale
University, New Haven, Connecticut, USA
f National Center for PTSD, VA Boston Healthcare System, Boston,
Massachusetts, USA
g Public Relations and Advertising, College of Communication,
DePaul University, Chicago, Illinois, USA
Available online: 29 Dec 2011
To cite this article: Lawrence B. Schiamberg PhD, James Oehmke PhD, Zhenmei Zhang PhD, Gia
E. Barboza PhD, Robert J. Griffore PhD, Levente Von Heydrich MSWPhD, Lori A. Post PhD, Robin
P. Weatherill PhD & Teresa Mastin PhD (2012): Physical Abuse of Older Adults in Nursing Homes: A
Random Sample Survey of Adults With an Elderly Family Member in a Nursing Home, Journal of Elder
Abuse & Neglect, 24:1, 65-83
To link to this article: http://dx.doi.org/10.1080/08946566.2011.608056
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Journal of Elder Abuse & Neglect, 24:65–83, 2012
Copyright ©Taylor & Francis Group, LLC
ISSN: 0894-6566 print/1540-4129 online
DOI: 10.1080/08946566.2011.608056
Physical Abuse of Older Adults in
Nursing Homes: A Random Sample
Survey of Adults With an Elderly Family
Member in a Nursing Home
LAWRENCE B. SCHIAMBERG, PhD
Human Development and Family Studies, Michigan State University, East Lansing,
Michigan, USA
JAMES OEHMKE, PhD
Department of Agricultural Economics, Michigan State University, East Lansing,
Michigan, USA
ZHENMEI ZHANG, PhD
Department of Sociology, Michigan State University, East Lansing,
Michigan, USA
GIA E. BARBOZA, PhD
Department of African American Studies, Northeastern University, Boston,
Massachusetts, USA
ROBERT J. GRIFFORE, PhD and LEVENTE VON HEYDRICH,
MSW, PhD
Human Development and Family Studies, Michigan State University, East Lansing,
Michigan, USA
LORI A. POST, PhD
Department of Emergency Medicine, School of Medicine, Yale University, New Haven,
Connecticut, USA
ROBIN P. WEATHERILL, PhD
National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
This research was supported by a grant from the Centers for Medicaid/Medicare Service
#CFDA 93.778 to Michigan State University.
Address correspondence to Lawrence B. Schiamberg, PhD, Michigan State University,
Human Development and Family Studies, 8 Human Ecology Building, East Lansing, MI 48824,
USA. E-mail: schiambe@msu.edu
65
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66 L. B. Schiamberg et al.
TERESA MASTIN, PhD
Public Relations and Advertising, College of Communication, DePaul University,
Chicago, Illinois, USA
Few empirical studies have focused on elder abuse in nursing home
settings. The present study investigated the prevalence and risk
factors of staff physical abuse among elderly individuals receiv-
ing nursing home care in Michigan. A random sample of 452
adults with elderly relatives, older than 65 years, and in nurs-
ing home care completed a telephone survey regarding elder abuse
and neglect experienced by this elder family member in the care
setting. Some 24.3% of respondents reported at least one incident
of physical abuse by nursing home staff. A logistic regression model
was used to estimate the importance of various risk factors in nurs-
ing home abuse. Limitations in activities of daily living (ADLs),
older adult behavioral difficulties, and previous victimization by
nonstaff perpetrators were associated with a greater likelihood of
physical abuse. Interventions that address these risk factors may be
effective in reducing older adult physical abuse in nursing homes.
Attention to the contextual or ecological character of nursing home
abuse is essential, particularly in light of the findings of this study.
KEYWORDS elder abuse, physical abuse, ecological perspective,
nursing homes
INTRODUCTION
Elder abuse is a significant social problem that has received increasing atten-
tion in medical and social science research over the past 20 years. Although
findings are available for abuse occurring in the home or community (Lachs
& Pillemer, 2004; Schiamberg & Gans, 1998, 1999, 2000), less is known about
the nature and scope of elder mistreatment in nursing homes, arguably an
even more vulnerable population (Gibbs & Mosqueda, 2004; Hawes, 2003).
Older adult residents of nursing homes may be at increased risk for abuse
because of chronic diseases that require institutionalization and that, in turn,
lead to chronic limitations of physical or cognitive functions. Although stud-
ies of Adult Protective Services (APS) reports and Medicaid records have
documented the psychological and physical harm done by such abuse in the
community (Dong, 2005), including higher mortality rates (Lachs, Williams,
O’Brien, Pillemer, & Charlson, 1998), empirical research on prevalence and
risk factors of elder abuse in nursing home care, is limited. Such research
presents unique challenges to obtaining truly informed consent and accurate
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Elder Abuse in Nursing Homes 67
reports from elders who may be unwilling or unable to participate in a stan-
dard survey. Some older adult nursing home residents may be reluctant to
report abuse because they fear retaliation or feel hopeless that no one would
help them or help make the situation better (Hawes, 2002).
This study presents the first analyses of risk factors and incidence of
physical abuse of older adults in nursing home care, using a large random-
sample telephone survey of adults with an elderly family member, ≥65 years,
in a nursing home. In general, physical abuse includes slapping, pushing,
or striking an older adult with an object, with the intent to inflict harm
or pain. In nursing homes, physical abuse may include other behaviors
such as inappropriate chemical or physical restraints. Also, in accordance
with other researchers, who include sexual abuse and nonconsensual sexual
involvement (e.g., being forced, threatened, or deceived into sexual activ-
ities ranging from looking or touching to intercourse or rape), the current
investigation categorizes sexual abuse and nonconsensual sexual involve-
ment as physical abuse (Hawes, 2003). The purpose of this investigation was
to estimate prevalence of physical abuse in nursing homes and to identify
individual and social/contextual risk factors of physical abuse.
REVIEW OF RESEARCH
Prevalence and Types of Reports of Elder Abuse
Although there have been frequent reports of mistreatment and abuse of
older adult nursing home residents, there has not been sufficient or sys-
tematic studies of the prevalence of physical abuse or other types of abuse
in nursing homes (Hawes, 2002). An early study found that 36% of nurs-
ing home staff reported witnessing physical abuse by staff to patients,
and 10% acknowledged being physically abusive themselves (Pillemer &
Moore, 1989). The reporting of elder abuse in nursing homes and other
long-term care arrangements has typically been accomplished through insti-
tutional reporting, often in collaboration with Medicaid Fraud Control Units,
Adult Protective Services (APS), law enforcement officials and, in some
states, through long-term care ombudsman programs (Brandl et al., 2007).
Institutional reporting of elder abuse is often compromised, as indicated, by
the mental or physical status of the older adult nursing home resident and
frequently by fear that reporting of elder abuse by older adult residents or
family members will result in retaliation. Even if reports of abuse are made,
there is no assurance of adequate responses from the institutions or from
regulatory or investigational entities (U.S. General Accounting Office, 2002).
As with institutional reporting of elder abuse, family reports are subject
to inaccurate estimation of the problem. While nursing home staff might
underestimate abuse because they or their colleagues could be perpetrators,
family members may underestimate abuse for a variety of reasons. They may
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68 L. B. Schiamberg et al.
not be informed about all acts of abuse or they may not feel comfortable
discussing nursing home abuse because of residual guilt associated with
involvement in the initial institutionalization decision for the older adult
(Hawes, 2003; Hawes, Blevins, & Shanley, 2001). Since some bias may be
associated with each reporting format, one source of data cannot be assumed
to be the standard against which all others should be validated. Although
comparative studies of types of reporting strategies are rare, recent evidence
using the data set for this research found that incidents of abuse reported
by family members appear to be higher than incidents reflected by official
data from the Michigan Long-Term Care Ombudsman Program (Zhang et al.,
2011). Although limited, such findings point to the need for consideration of
multiple reporting strategies for estimating institutional elder abuse.
Risk Factors
Promising theoretical perspectives for identifying the risk factors of elder
abuse in nursing homes have emerged from ecological theoretical frame-
works, as originally applied to domestic abuse of older adults by adult
child caregivers (Schiamberg & Gans, 1998, 1999, 2000) and more recently
extended to elder abuse in nursing homes (Schiamberg et al., 2011). The
focus of this perspective is on the older adult–institutional caregiver rela-
tionship as the focal or immediate context for identifying and organizing
risk factors, including more distal contexts such as family–older adult rela-
tionships and the broader institutional environment (e.g. monitoring of
resident-on-resident abuse).
Consistent with this perspective, existing research on risk factors of
abuse in nursing homes suggests that behavior problems and conflict
with institutional caregivers are strongly associated with physical abuse
as reported in surveys of nursing staff (Goergan, 2001; Meddaugh, 1993;
Pillemer & Moore, 1990). The connection between increased older adult
dependency on either domestic caregivers or nursing home staff appears to
be a critical feature for risk of elder abuse (Burgess, Dowdell, & Prentky,
2000). Specifically, the physical or cognitive limitations of older adults
resulting from chronic diseases, which lead to increased dependency on
caregivers, is a prominent risk factor for abuse in both domestic and nurs-
ing home contexts. For example, nursing home residents with diagnosed
Alzheimer’s dementia or with provocative behavioral symptoms such as
verbal/physical aggressiveness were at greater risk for elder abuse than
those without such diagnoses or behaviors (Burgess et al., 2000; Pillemer &
Bachman-Prehn, 1991). The risk of abuse in nursing homes may be greater
than in domestic settings because of the likelihood that nursing home res-
idents have a preponderance of physical and cognitive factors leading to
dependency on staff caregivers (Krauss & Altman, 1998). Factors influencing
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Elder Abuse in Nursing Homes 69
the response of the institutional caregiver to the potentially provocative char-
acteristics and behaviors of dependent nursing home residents are additional
key risk factors in elder abuse in nursing homes (Hawes et al., 2001).
With reference to demographic risk factors and abuse in nursing homes,
both age and gender have frequently been implicated, although results often
have been ambiguous. For example, some studies find that women are more
likely to be abused (Tatara et al., 1998), and others find more male victims
(Pillemer & Finkelhor, 1988). The “oldest old” also may be more vulnerable,
with more victims over 80 found in some studies (Tatara et al., 1998), but
not others (Comijs, Pot, Smit, Bouter, & Jonker, 1998).
The role of contexts beyond the immediate and focal context of the
older adult–caregiver relationship are seen as essential to understanding
the risk factors of elder abuse in nursing homes and domestic settings
(Schiamberg et al., 2011; Schiamberg & Gans, 1998, 1999, 2000). These sig-
nificant, yet more distal, contexts include the older adult–family relationship
and the older adult–other nursing home resident relationship, including non-
staff abuse. While there is considerable evidence that the characteristics of
family caregivers are related to abuse in domestic settings (Fulmer et al.,
2005; Schiamberg & Gans, 1998, 1999, 2000), much less is known about the
role of the older adult–family relationship in nursing home abuse. Recent
evidence points to a significant role for family communication in the pre-
vention of elder abuse in nursing homes (Donohue, Dibble, & Schiamberg,
2008).
Although previous research on elder abuse in nursing homes has iden-
tified two types of perpetrators—staff abusers and nonstaff abusers (i.e.,
other residents or volunteers)—the focus of most investigations is on staff
abusers. The relationship between staff abuse and nonstaff, or resident-to-
resident abuse, has never been explored. Most of the residents in nursing
homes who experience some form of resident-to-resident abuse are cogni-
tively impaired, are considered to have inappropriate social skills, and are
prone to wandering or being verbally abusive to other residents or staff
(Shinoda-Tagawa et al., 2004). There is evidence that residents least likely to
be victims of resident-to-resident abuse were those frequently observed and
served by staff because of serious health circumstances, with limited mobil-
ity, and, in turn, significantly dependent on caregivers (Shonoda-Tagawa
et al., 2004). In addition, resident-to-resident abuse has been found to be as
much as three times more likely for older adults with Alzheimer’s disease
in nursing homes (Shonoda-Tagawa et al., 2004). While nursing home staff
might be expected to be alert to indicators of potential resident-to- resident
abuse, currently there are there no effective reporting procedures for such
abuse, reinforcing the importance of staff training and family involvement
(Lachs, Bachman, Williams, & O’Leary, 2007).
The above review of research on factors related to physical abuse
in nursing homes points to two primary research questions: (a) What
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70 L. B. Schiamberg et al.
is the prevalence of physical abuse for older adult (≥65) nursing home
residents? (b) What are the risk factors for physical abuse for this nurs-
ing home population? A number of potential risk factors emerge in the
review of research. These include individual demographic characteristics
of the older adult, such as age, gender or possibly education; individ-
ual functional/performance factors, including ADL limitations, diagnosis of
Alzheimer’s disease, or cognitive impairments (e.g., memory problems, men-
tal confusion), and older adult behavioral problems with staff caregivers or
other nursing home residents (e.g., physical or verbal provocation, often
a behavioral manifestation of Alzheimer’s disease); and factors distal to the
immediate older adult/caregiver relationship context, including older adult–
family relationship characteristics (e.g., perceived emotional closeness of the
responsible family member and the older adult nursing home resident) and
the relationship of the older adult to other nursing home residents (e.g.,
incidents of resident-on-resident abuse).
METHODS
Study Design
The “Michigan Survey of Households with Family Members Receiving Long-
Term Care Services” was a random digit dial telephone survey of the
noninstitutionalized population of adults in Michigan who have a relative
receiving long-term care services. Long-term care was defined as any paid
service to assist a family member to accomplish normal daily activities in
the community setting or in a facility such as a nursing home. The original
sample of 1,002 individuals who completed the random digit dial telephone
survey consisted of family respondents with a relative of any age in long-
term care. The age range of relatives in long-term care was 11 to 97 years
of age or older. However, 769 or 77% of the 1,002 individuals in all types of
long-term care, including nursing homes, were ≥65 years of age. Of those
769 cases, the specific sample for this study included only 452 cases with an
elderly adult ≥65 years of age in a nursing home.
The design of the study was cross-sectional, with retrospective
sequences of households with a family member in long-term care. The inter-
view provided an opportunity for gathering detailed histories of older adults
in a nursing home, including older adult behavioral and health characteris-
tics and types/levels of abuse. Using a computer-assisted interview system
(CATI), interviews were conducted by the professional staff of Schulman,
Ronca and Bucuvalas, Inc. from October through December of 2005.
Data for this study were based on telephone interview responses from
family members, rather than from the older adult nursing home residents
themselves. Typically, studies of elder abuse in the community rely on vic-
tim or caregiver accounts of the nature and frequency of the abuse. As
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Elder Abuse in Nursing Homes 71
indicated, this is particularly difficult, if not impossible, to do with elders in
nursing home care. Victims of elder abuse, assuming they are even avail-
able, may be unable to accurately answer questions pertaining to abuse
due to embarrassment, fear of reprisal, or poor cognitive or verbal abilities.
It may be impossible to obtain informed consent from individuals affected
by dementia. On the other hand, caregivers in nursing homes are, in many
instances, the individuals who are committing the abuse, and hence they too
will most probably not be forthright. Less biased accounts might be obtained
from informed respondents (in this case, family members) who are familiar
with the care of the institutionalized elder (Harris & Benson, 2006).
The response rate for the random digit dialing (RDD) methodology used
in this study is calculated as the ratio of the number of completed telephone
interviews to the number of all potentially eligible respondents or tele-
phone contacts (i.e., completed interviews plus eligible nonrespondents).
The response rate for this study was 64%, which is considered very good for
RDD telephone surveys (see the American Association for Public Opinion
Research website for a detailed description of response rate calculations;
http://www.aapor.org/standard).
Subjects
The final analytical sample (N=452) for this study included respondents
who answered questions about physical abuse and had relatives 65 years
of age and older living in a nursing home. As indicated in Table 1, study
respondents were overwhelmingly family members (97%), with an adult
child being the most frequent category of family member (41.6%).
For the final analytical sample, the question of missing data was
addressed for all variables in the study, including both the nine predictor
TABLE 1 Characteristics of Respondents
Variable Frequency Percentage
Spouse 34 7.5
Sibling 29 6.4
Child 188 41.6
Parent 2 0.4
Grandchild 67 14.8
Daughter/Son-in-Law 34 7.5
Niece/Nephew 31 6.9
Mother/Father-in-Law 14 3.1
Self 1 0.2
Friend 7 1.5
Other Relative 40 8.8
Attorney 5 1.1
TOTAL 452 100
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72 L. B. Schiamberg et al.
variables and the dependent variable. For predictor variables, there was a
small level of missing data on six of the nine predictor variables in the study
model (missing data for educational level, diagnosis of dementia, diagnosis
of Alzheimer’s, ADL limitations, emotional closeness, and behavioral prob-
lems; no missing data for age, gender, and nonstaff abuse). Of the total
possible response values for the entire analytical sample on the nine pre-
dictor variables (4,068 possible response values), only 1.3% or 53 of those
possible response values were missing. For the dependent variable,again,
there was a small level of missing data on each of the three individual
measures that comprised the global dependent measure of physical abuse
(injury to the body of the older adult, inappropriate restriction of mobility,
sexual abuse, and nonconsensual sexual involvement). Of the total possi-
ble response values for the analytical sample for the three components of
the dependent variable (1,356 possible response values), only 2.1% or 29 of
those possible response values were missing. For missing data for the both
the predictor variables and dependent variables, values were imputed using
the Systat EM Method for data imputation, which estimates values using the
maximum likelihood method. For the predictor variables and again for the
dependent variable, the Little MCAR (missing completely at random) test
statistic for the imputed values used in the study was not statistically signifi-
cant, indicating that the null hypothesis (i.e., data not missing completely at
random) was rejected (Chen & Little, 1999; Little & Rubin, 2002).
Measures/Variables
THE DEPENDENT VARIABLE:PHYSICAL ABUSE
Physical abuse is defined as the infliction of physical harm, pain, physi-
cal coercion, and also may include sexual abuse (Hawes, 2003; Kosberg &
Nahmiash, 1996; Lachs & Pillemer, 1995). To capture a full array of possi-
ble dimensions of physical abuse, a global measure of staff physical abuse
was developed, which included three specific manifestations using related
interview questions from the study. For each of the following three mani-
festations of physical abuse, respondents were asked to indicate how many
incidents the older adult had ever experienced in a long-term care setting
(none, 1–2, 3–5, 6–10, more than 10, don’t know/refuse):
1. Injury to the body of the older adult. This measure was based on the
following prompt: “Let’s start with incidents of physical mistreatment by
staff or other caregivers such as striking, hitting, beating, pushing, shoving
shaking, slapping, kicking, pinching, or bumping.”
2. Inappropriate restriction of mobility. This measure was based on the
following prompt: “Now I am interested in other types of caretak-
ing mistreatment by staff ... such as over-administration of drugs
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Elder Abuse in Nursing Homes 73
... inappropriate use of physical restraints, unjustified force feeding,
inappropriate toileting practices, or physical punishment.”
3. Sexual abuse and nonconsensual sexual involvement. This measure
included being forced, threatened, or deceived into sexual activities rang-
ing from looking or touching to intercourse or rape, and was based on
the following prompt: “Now we want to discuss incidents of sexual mis-
conduct by staff or other caregivers such as forced sex, sexual contact
without consent, sexual coercion, and unwanted touching.”
A binary variable was constructed for the three-part global measure of
physical abuse. The variable took the value of 1 if an incident of physi-
cal abuse had been reported for one or more of the three types of physical
abuse (comprising the global measure) over the duration of the older adult’s
nursing home residence. A value of 0 was used otherwise. The incidence
of staff physical abuse for individual older adults was measured using the
binary global physical abuse measure, based on whether an older adult nurs-
ing home resident was reported by the respondent (i.e., typically a family
member) to have been subjected to one or more of the three types of abuse.
PREDICTOR VARIABLES
The predictor variables were designed to capture an array of older adult
characteristics, characteristics of the relationship between the respondent
and the older adult, and contextual factors extending beyond the immediate
focal context of older adult/institutional caregiver. The following predictor
variables and measurement strategies were used in the study.
Age is the chronological age in years of the resident. Gender is a binary
variable, with 1 =female and 0 =male. Educational level measures the older
adult’s highest level of schooling as reported by the family respondent, with
a range of possible responses from no formal schooling to a postgraduate
degree. Behavioral problems is a binary variable taking the value of 1 if the
respondent reported that the patient has behavior problems such as being
abusive physically or verbally, or actively resisting care, and 0 otherwise.
ADL limitations are the activities of daily living (e.g., bathing, dressing, get-
ting around or moving inside the facility, getting in or out of a bed or chair,
toileting, eating) that the resident cannot perform without help (each ADL
is treated as a binary variable, with a yes =1andano=0). Alzheimer’s
disease takes a value of 1 if the respondent reports that the patient has
been diagnosed as having Alzheimer’s disease, and a value of 0 otherwise.
Dementia (non-Alzheimer’s) takes a value of 1 if the older adult has been
diagnosed with dementia unrelated to Alzheimer’s disease, and a value of 0
otherwise. Nonstaff abuse or resident-to-resident abuse measures whether or
not the older adult nursing home resident has ever been mistreated in the
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74 L. B. Schiamberg et al.
nursing home by an individual who was not a caregiver or member of the
nursing home staff (the variable assumes the value of 1 if there has been at
least one such incident, and 0 otherwise). Emotional closeness is the respon-
dent’s answer to the question “How would you characterize the closeness
of your relationship with the older adult ...where 1 =emotionally distant
and 10 =emotionally close?”
RESULTS
Incidence of Physical Abuse
The incidence of physical abuse in nursing homes is described in two ways,
the first being by the use of the number and percentage of individuals in
the total sample (n=452) who were abused (i.e., subjected to one or
more of the three measures of the binary global physical abuse measure).
Using the binary variable strategy for measuring the incidence of physical
abuse (described above), 110 older adult nursing home residents, or 24.3%
of the final analytical sample (n=452), were subjected to physical abuse
by nursing home staff (see Table 2).
Second, the incidence of physical abuse is described by the type of
physical abuse (i.e., the number and percentage of each of the three types
of abuse in terms of the total number of types of abuse). The frequen-
cies and percentages of the total number of types of physical abuse for
the three types of physical abuse are as follows: physical mistreatment by
staff (e.g., hitting, beating, kicking, and so on), n=44 or 27%; caretaker
mistreatment, including inappropriate use of restraints, forced toileting, or
unjustified forced feeding,n=103 or 62%; staff sexual abuse,n=18 or
11% (see Table 2). In our view, both measures of incidence are useful for
understanding physical abuse in nursing homes.
TABLE 2 Incidence of Physical Abuse (by Number of Older Adults and by Abuse
Types Reported by Respondents)
Variable Frequency Percentage
Incidence: Older Adults Subjected to Physical Abuse 110 24.3
TOTAL 452 100
Incidence: Type of Physical Abuse
Physical mistreatment by nursing home staff 44 27
Sexual abuse perpetrated by nursing home staff 18 11
Forced use of restraint (e.g., forced feeding, toileting) 103 62
TOTAL 165 100
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Elder Abuse in Nursing Homes 75
Risk Factors of Physical Abuse
CHARACTERISTICS OF THE OLDER ADULT SAMPLE
The demographic breakdown (see Table 3) of nursing home residents whose
relatives completed the questionnaire was largely Caucasian (91.4%). Some
72% of nursing home residents were females and almost two-thirds (64.8%)
of all nursing home residents were widowed. Every resident suffered from
at least one physical, cognitive, and psychiatric disability, and a significant
number had more than one disability or disease (e.g., 38% were diagnosed
with Alzheimer’s disease and 78.8% suffered from one or multiple forms of
cognitive illnesses). Over 83% of elderly nursing home residents suffered
from one or multiple ADL limitations. A significant proportion of nurs-
ing home residents (21.7%) exhibited behavior problems that increased the
likelihood of being physically abused. Survey respondents (typically family
TABLE 3 Older Adult Characteristics
Variable Frequency Percentage
Gender
Male 121 26.8
Female 331 73.2
Ethnicity
Caucasian 413 91.4
African American 29 6.4
Asian American 1 0.2
Hispanic/Latino 1 1.3
Native American 1 0.2
Middle Eastern 1 0.2
Other 1 0.2
Education Level
No formal schooling 3 0.7
High school or less 324 85.8
Bachelor degree or less 77 8.8
Graduate degree 26 4.7
Marital Status
Single–never married 31 6.9
Married 100 22.1
Widowed 293 64.8
Divorced 28 6.2
Health/Functional Status
Alzheimer’s disease 169 38
Psychiatric diagnoses 57 12.8
Cognitive problems 354 78.8
ADL limitations (at least one) 344 83.7
Behavior problems 97 21.7
Age
65–74 52 11.5
75–84 185 40.9
85+215 47.6
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76 L. B. Schiamberg et al.
members) overwhelmingly (93%) reported close emotional ties with their
relatives placed in nursing home.
OLDER ADULT DEMOGRAPHIC CORRELATES OF PHYSICAL ABUSE
The only statistically significant demographic predictor of staff physical
abuse was age. Since increased age is often associated with increased
chronic diseases and disabilities, it might be expected that the likelihood
of physical abuse also would increase with age. However, the finding from
this investigation suggested that the impact of age on the probability of
physical abuse was significant, albeit in the opposite direction predicted
(see Table 4). For each additional year of the elderly person’s age, the odds
of abuse decreased by 0.4882 (or 49%), assuming that the other predictor
variables in the model are held constant (log odds =–0.047; odds =0.954;
p=0.4882).
To explore possible explanations for the inverse relationship between
age and physical abuse, ANOVA was used to identify possible interactions or
mediating effects that might help to explain the relationship. Of the variables
considered in the study, the interaction effect between nonstaff abuse (or
resident-to-resident abuse) and age was the only significant interaction (p=
0.001), given staff physical abuse as the dependent variable. That is, with
increasing age, the likelihood of nonstaff abuse increases in magnitude, as
we had initially expected for staff physical abuse.
The negative sign of the βcoefficient for age (see Table 4) raised con-
cerns about possible multicollinearity, which can result in incorrect signs
and/or inaccurate magnitudes of regression coefficient estimates. Visual
inspection of the correlation matrix for all study variables indicated that none
of the correlations exceeded 0.191. In addition, no multicolinearity between
predictor variables was found using the Collinearity Diagnostics Tool in
TABLE 4 Significance of Variables in the Staff Physical Abuse Equation
Var i a ble βCo-efficient Odds/Ratio Significance
Older Adult Demographic Factors
Age −0.047 0.954 0.004
Gender −0.402 0.669 0.167
Education 0.001 1.001 0.992
Older Adult Health Factors
ADL/help moving 0.925 2.521 0.011
Alzheimer’s disease −0.266 0.766 0.315
Cognitive impairment −0.325 0.723 0.347
Behavioral problems 0.582 1.790 0.046
Contextual Factors (beyond the older
adult/staff interaction)
Nonstaff/resident-to-resident abuse 1.192 3.293 0.001
Emotional closeness to family 0.110 1.116 0.067
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Elder Abuse in Nursing Homes 77
SPSS 17 statistical software. Calculated values for two specific multicollinear-
ity tests in this software—Variance Inflation Factors or VIF and Tolerance
Values—were below threshold values for multicollinearity. While VIF values
exceeding 10 are generally regarded as indicative of multicollinearity and
values exceeding 2.5 as cause for concern in logistic regression, none of the
calculated VIF values exceeded 1.5. In addition, all Tolerance Values were
close to 1, indicating that all of the variables in the study were orthogonal
to each other, or uncorrelated with one another.
HEALTH CORRELATES OF PHYSICAL ABUSE
Since there were six ADLs in the study, a first level of analysis explored the
question of whether one or more ADL limitations would place individuals at
greater risk for staff physical abuse than no ADL limitations. The goodness of
fit of the logistic regression model with the study outcome data indicated that
older adult nursing home residents with one or more ADL limitations were at
greater risk for staff physical abuse in nursing homes than older adults with
no ADL limitations. This finding was confirmed using the Hosmer-Lemeshow
(1989) test for the goodness of fit of the logistic regression model with the
study outcome data; χsquare =3.485, df =8, p<0.05; further, the model
fit value of p=0.900 indicated a very good fit with the data.
A second level of analysis involved the identification of the specific
ADL or ADLs that contributed to this effect. A stepwise backwards logistic
regression demonstrated that one ADL limitation—“Needing Help Moving”
(i.e., needing assistance getting around or help moving inside the facility)—
was the only significant predictor of physical abuse in the nursing home (see
Table 4 where β=.925, OR =2.521, p=0.011). Taken alone, the “Help
Moving” ADL limitation increased the risk of physical abuse by 89% (log old
s=2.122; odds =8.3478; physical abuse =0. 8930), more than tripling the
probability of physical abuse.
Older adults with a simple diagnosis of Alzheimer’s disease or a diagno-
sis of cognitive impairment (e.g., failing memory, difficulty communicating,
or difficulty concentrating) were not found to be at higher risk of physical
abuse than patients without such diagnoses. However, behavioral prob-
lems frequently associated with the diagnosis of Alzheimer’s disease (e.g.,
provocative verbal or physical outbursts) are a significant predictor of staff
physical abuse (p=0.046). For example, taken alone, older adult behav-
ioral problems increase the probability of physical abuse by 85% (log odds
=1.779; odds =5.9239; physical abuse =0.8555 or 85%).
CONTEXTUAL FACTORS BEYOND THE FOCAL OLDER ADULT/INSTITUTIONAL
CAREGIVER CONTEXT
Although it might be expected that an older adult nursing home resident with
aclose/supportive relationship with a primary/responsible family member
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78 L. B. Schiamberg et al.
will be at less risk for physical abuse in the nursing home than an older
adult with a less close/supportive family relationship, results for emotional
closeness and physical abuse did not attain statistical significance, although
they were in the predicted direction (p=0.067). On the other hand, the
expectation that an older adult with a history of victimization by nonstaff
members (e.g., other residents or volunteers) in nursing homes is more
likely to be physically abused by staff than an individual who has not been
abused before by nonstaff members was found to be a statistically significant
predictor (p=0.001). A 1-unit increase in nonstaff abuse will result in a 92%
increase in the likelihood of physical abuse (log odds =2.384; odds =
10.8482; physical abuse =0.9155 or 92%).
DISCUSSION
Prevalence of Physical Abuse
The estimated incidence of physical abuse in nursing homes (24.3%) sug-
gests that a substantial number of older adult nursing home residents may be
subject to one or more types of staff physical abuse, reaffirming the gravity
of the problem. In addition to incidence as measured by the number of indi-
viduals affected, the incidence of types of staff physical mistreatment (i.e.,
physical mistreatment, such as hitting or slapping; caretaking mistreatment,
such as inappropriate use of physical restraints or forced feeding; sexual
abuse) points to the need for careful scrutiny of factors and contexts asso-
ciated with each type of physical abuse. For example, since the majority
of incidents of staff physical abuse involve caretaking mistreatment, care-
taker training related to managing potentially frustrating circumstances in
the normative delivery of caretaker services would be potentially helpful in
reducing physical abuse in nursing homes.
Although prevalence estimates of institutional abuse, including staff
physical abuse, are useful in assessing the dimensions of the problem, they
are subject to bias involving potential underestimation or overestimation of
physical abuse in nursing homes. There well may be significant underesti-
mates of institutional elder abuse that are based on reports of institutional
caregivers or government estimates of abuse based on institutional or police
reports (Brandl et al., 2007; Hawes, 2003). That said, there is limited research
on the family respondent methodology used in this study that may, in turn,
be subject to underestimation of physical abuse (Hawes, 2002; Hawes et al.,
2001) or possible overestimation (e.g., family members thinking older adults
were abused when, in fact, they were not). While there in not a perfect
system for estimating physical abuse in nursing homes, there is reason to
give some credence to the value of family reports of physical abuse, par-
ticularly as in this study where family respondents may have felt free to
comment openly about institutional physical abuse that was not tied to an
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Elder Abuse in Nursing Homes 79
identified nursing home or to an older adult identified by name. Further
research needs to be done comparing family reports of elder abuse with inci-
dence estimates based on institutional reporting, including through Medicaid
Fraud Control Units, APS, and law enforcement officials, and, in some states,
through Long-Term Care Ombudsman programs (Brandl et al., 2007).
Correlates and Risk Factors of Abuse
DEMOGRAPHIC CHARACTERISTICS OF OLDER ADULTS
It is not altogether clear why age should be significantly, yet inversely,
related to physical abuse of older adults in nursing homes. Why, for
example, should age, typically linked to a variety of older adult physical
disabilities and diseases that might create dependency, stress, and possibly
abuse in a caregiving relationship, be instead associated with a systematic
decrease in physical abuse? Several related factors may be at work to mod-
erate the expected positive and significant relationship between age and
staff physical abuse. First, as indicated, there is the existing strong relation-
ship between age and resident-to-resident abuse in nursing homes. This
finding is consistent with evidence that resident-to-resident abuse is more
likely for older adults with Alzheimer’s disease in nursing homes, with age
positively associated with increasing rates of Alzheimer’s disease (Shinoda-
Tagawa et al., 2004). Thus, in nursing homes, it is possible that age is
more commonly linked to resident-to-resident abuse such that it substantially
moderates the relationship between age and staff physical abuse.
Second, with increasing age, staff physical abuse may actually decrease
because the pattern of provocative resident behaviors are both better under-
stood and anticipated, resulting in older residents typically requiring closer
group staff supervision and monitoring. This shift in context of care, from
one-on-one staff–resident interactions, to group supervision and monitor-
ing, may reduce resident dependence on individual staff, levels of related
staff frustration and, in turn, the likelihood of staff physical abuse. Further
research is necessary to clarify such possible explanations.
Based on the findings of this investigation, the relationship between age
and physical abuse in nursing homes may be more complex than initially
assumed. Additional research is necessary to confirm the inverse relationship
of age with physical abuse found in this study and to clarify the specific
circumstances, if any, which might mitigate that assumed relationship (e.g.,
older adult health status and treatment).
HEALTH/BEHAVIORAL CHARACTERISTICS OF THE OLDER ADULT
Older adult behavioral problems (e.g., abusive physical or verbal behav-
iors, including extreme resistance to treatment) are significantly related to
physical abuse in nursing homes. This outcome is consistent with other
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80 L. B. Schiamberg et al.
research findings (Burgess et al., 2000; Goergan, 2001). Furthermore, in iden-
tifying and understanding the health and behavioral risk factors of physical
abuse in nursing homes, it would seem important to distinguish between
the simple diagnosis of either Alzheimer’s dementia or cognitive impair-
ments associated with non-Alzheimer’s dementia or Alzheimer’s and the
actual older adult behavioral outcomes of those diagnoses. In particular,
the findings of this study support the notion that actual patient behavioral
problems, often associated with Alzheimer’s or non-Alzheimer’s dementia,
are primary risk factors for physical abuse in nursing homes.
While this investigation found that one or more ADL limitations place
individuals at greater risk for staff physical abuse, it is not clear why one
specific ADL limitation, “Need Help Moving,” should emerge as the only
significant or primary predictor of staff physical abuse. One possible expla-
nation may be that, unlike the other five ADL limitations (bathing, dressing,
toileting, getting in and out of bed or a chair, eating) that may have typi-
cally defined locations and/or expected times, needing help moving around
a facility may occur at almost any time and any place in a facility. While
it could occur in expected locations and times where planned activities
(e.g., music, games) are going on, and therefore be part of an expected
or typical scenario, it could also occur frequently and unpredictably. For
example, older adults in early/middle stages of Alzheimer’s disease may
be prone to wandering about a facility at an unpredictable time or in an
unexpected location, requiring help returning to their rooms and creating
frustration for both caregiver and/or the older adult (Van Wyk, Benson, &
Harris, 2000).
CONTEXTUAL FACTORS BEYOND THE FOCAL OLDER ADULT/INSTITUTIONAL
CAREGIVER CONTEXT
The findings of this study point to the significance of resident-to-resident
abuse as a risk factor in staff physical abuse in nursing homes. Consistent
with research on adolescent bullying that suggests that some individuals
may take on the role of “victim” (Barboza et al., 2009), individuals who are
chronic victims of abuse by other residents may display some nonmeasured
characteristics that place these individuals in the role of a victim. Perhaps
the older adult engages in risky behavior, appears cowering or timid, or is
socially challenged, which in turn might increase the likelihood of physical
abuse. Nonstaff abuse possibly captures characteristics of the victim that
make the older adult a chronic victim. While few studies have examined
nonstaff abuse, incident estimates suggest both the severity of the problem
and the importance of identifying risk factors, such as cognitive impairment
or verbal aggressiveness that may be common triggers for staff abuse or
others (as yet unidentified), which are unique to resident-on-resident abuse.
Further research is needed to delineate the reasons why resident-on-resident
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Elder Abuse in Nursing Homes 81
abuse appears to be a key predictor of staff physical abuse, as well as to
develop interventions for mitigating resident victimization.
The findings on emotional closeness, while not significant, are in the
predicted direction. Further, they point to the important and critical role of
family members in overseeing nursing care of older adults. In particular, joint
partnerships that enhance the combined roles of institutional caregivers and
family members enhance the individual resources and families in addressing
elder abuse in nursing homes (Donohue, Dibble, & Schiamberg, 2008).
LIMITATIONS OF THE STUDY
While this study may illustrate a number of factors specifically related to the
occurrence of staff physical abuse of older adult residents, at both immediate
and more distal contexts of interaction, results should be interpreted with
the limitations of the study in mind. Given that nursing home residents of
Caucasian ancestry composed the main sample body (83%), findings should
not be taken as accurate reflections of experiences in more multicultural
contexts. While data collected in this study reflect the knowledge of family
respondents about their older adult relatives in nursing homes, additional
research is needed to compare the results of this study with research using
other elder abuse reporting formats (e.g., institutional self-report, criminal
justice reports, and government/agency data collection). Another limitation
is that data were not collected on the characteristics and contexts of the
institutional caregiver, an essential dimension of the focal context of physical
abuse in the nursing home—the older adult/institutional caregiver context.
CONCLUSIONS AND POLICY RECOMMENDATIONS
Increased attention to the contextual or ecological character of nursing
home abuse is essential, particularly in light of the findings of this study
(Schiamberg et al., 2011). Staff physical abuse in nursing homes occurs in
the context of the delivery of caregiving efforts, suggesting the value of
focusing on the relational context of the older adult–institutional caregiver
as an initial context for framing the key features of the relationship, includ-
ing characteristics of the older adult and the staff caregiver. In addition,
interactional contexts more distal to the older adult–institutional caregiver
relationship, such as the family–older adult relationship and the resident-on-
resident relationship, are essential to a full understanding of physical abuse
in nursing homes. Finally, effective interventions for addressing staff physi-
cal abuse in nursing homes can be informed by the risk factors identified in
this investigation, including those in immediate and more distal contexts.
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82 L. B. Schiamberg et al.
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