In this Issue
Qualitative Methods and Philosophies
Qualitative Methods and Applications
Qualitative Methods in Research
Other Original Research
Dilemmas in Witnessing Elder Abuse in Caregiving Situations:
Christen Erlingsson, PhD, RN1
1 School of Human Sciences, University of Kalmar, Sweden
The authors would like to thank the family member witness who participated in the study and the University of Kalmar for supporting this study.
Family members who witness elder abuse could be valuable partners to nurses and support personnel in case identification and intervention. The aim of this study was to explore an adult family member’s experiences of witnessing family situations of elder abuse. Interviews were conducted with a woman who had witnessed situations of elder abuse involving her uncle, his wife with disabilities, and health care personnel. Interviews were analyzed using van Manen’s thematic analysis and conception of narrative anecdotes, and development of poetic representations. The witness described conflictual feelings about her family and caregiving situation but felt there were no support personnel she could trust. She felt powerless and remained passive out of loyalty to family, need to protect family, and feeling shame that this was her family. Although she knew what she ought to do she could not live up to her ideals and instead tolerated escalating abuse. The family member witness viewed healthcare personnel as also tolerating and carrying responsibility for the abuse situation. For nurses and support personnel these findings point to the importance of personal and professional reflection and collegial discussions on morality, practice, what we see, and more importantly, what we do not see or want to see.
Keywords: elder abuse, family, witness, thematic analysis, poetic representation
Dilemmas in Witnessing Elder Abuse in Caregiving Situations:
Situations of family violence affect every member in the family.1 Family violence research has shown that witnessing abusive situations in the family has profound effects on the witness and carries potentially long term health risks. Family members’ experiences of witnessing elder abuse has long been considered an important area of research.1,3 However, family members’ experiences and perspectives on witnessing elder abuse situations appear to be unexplored. In coordinated database searches (2007 in Ovid Cinahl, Ovid PsycINFO, PubMed, and Sociological Abstracts) using search words “elder abuse”, “witness”, and “family” no research was located that focused on non-caregiving family members witnessing elder abuse. This apparent lack of research is concerning for two reasons. First, the family member witness has a potential role to play as a link between an elder abuse situation and societal support. Second, it is probable that elder abuse, just like other family violence situations, carries risks and consequences for the witnessing family member (cf3-6).
Elder abuse is considered a hidden, invisible social problem.7,8 Those wanting to hide abuse often do not report it. Non-reporting behavior is the greatest obstacle to detecting elder abuse, increasing difficulties for nurses and other support personnel in developing knowledge and providing support for families when elder abuse occurs.9,10 Studies of healthcare personnel’s non-reporting behavior has been linked to victim blaming perceptions,11 ageist attitudes, beliefs about family privacy,11,12 and beliefs about abusers who are not seen exclusively as perpetrators.11,13 Adding to the complexity of this situation is that laws mandating the reporting of abuse of older persons in Sweden only apply to care directly provided by healthcare personnel. These laws are not specific for elder abuse or for abuse against older persons outside of a health care context. It is probable that family members’ behavior and decisions about reporting, what to do, or not to do about elder abuse in their family, are also guided by experiences, perceptions, and beliefs about abuse situations.
Nurses and other health professionals are in an ideal position to identify, assess, and intervene in situations of family violence.14,15 Although few empirical studies have explored family members’ experiences of elder abuse,16 available findings indicate that nurses have a major role to play in providing support for family member witnesses.3,4 It has also been suggested that intervention efforts need to acknowledge the whole person.3 Other authors take this one step further and claim that family violence must be seen in the context of the whole family (cf 17,18). Family member witnesses could be valuable partners in elder abuse case identification and intervention. However, these same family members may be experiencing the elder abuse situation as personally traumatic and also require support themselves. The aim of this study was to explore the experiences and perspective of one adult family member who witnessed situations of elder abuse involving her family.
The participant and collection of the data
This paper is part of a larger research project. It is a single case study with in-depth analysis of two interviews held with the same participant about her experiences of witnessing elder abuse within her own family. She will be called Lisa. She is a woman in mid-life, upper middle class, married, and with a grown child. She is also a nurse educator with a PhD. Lisa was interviewed at the start of the project’s 14 month long data collection period. Preliminary analysis of the interview began directly after the interview had been conducted. At the close of the data collection period, it was the interview with Lisa that stood out with its richness and data complexity.
Although conducting multiple interviews with the same participant had not been included in the original design of the larger project, this striking interview stimulated the idea of including a single case study and conducting a second interview in order to gather additional data and/or validate the preliminary findings. It was hoped that an initial exploration of this within-person case would reduce the risk of premature, superficial results in the search for common themes across multiple cases in the larger study. Exploring the contextual richness in this specific, within-person case was considered appropriate in order to understand its particularization and uniqueness.19
The interviewing author (CE) and Lisa were not previously acquainted and came in contact with each other during the course of casual conversation between conference seminars. Lisa revealed that she had a story to tell about witnessing elder abuse and offered to participate in the study. The next month an interview (90 minute audio-recording) was conducted in Lisa’s office of employment. The interview was initiated by asking Lisa to relate her experiences of being a witness to elder abuse. No additional prompts were needed during the interview. When Lisa was contacted about doing a second interview she suggested an interview by phone (because of geographic distance (45 minute audio-recording). The second interview was characterized by a conversational attitude with questions posed by the interviewer about content in the first interview. Both the initial and later interviews were transcribed verbatim by a research secretary.
The larger project design carried possible risks for participants in vulnerable situations, for example the risks involved if a participant was exposed as a witness to abuse and the risk of triggering emotionally distressing feelings in the participant. Therefore special measures were taken, such as development of a safety protocol when contacting potential and actual participants, and availability of professional counseling. After reviewing the design and proposed safety measures the Research Ethics Committee of the Faculty of the Health Sciences at Linköping University sanctioned this project (registration number 188/04). Informed consent was obtained from the participant according to Swedish research directives.
Text analysis was conducted simultaneously from two directions. To begin with, the methodology for text analysis was grounded in thematic analysis as described by van Manen with special attention paid to narrative anecdotes.20 Inspired by methods for narrative analysis of linguistic clauses,21 the narrative structure of each individual anecdote was further explored. Complementary to the thematic analysis and analysis of each narrative anecdote, the text was also analyzed by incorporating interview content into the creation of poetic representations (cf22). These two ways of accessing meaning, i.e. thematic analysis of narrative anecdotes and poetic representation, were combined in order to reflect the richness of the thematic and poetic content of the interviews.
Throughout the analysis process researchers made continual efforts to remain aware of subjectivity and personal, prior knowledge on family violence and elder abuse, in order to identify possible biases. Conversely, subjectivity was also utilized in an attempt to work with previous experience and knowledge in order to facilitate a reflective stance, hopefully leading to a deepened understanding of Lisa’s experience of witnessing elder abuse in her family.
To identify themes the texts from the initial and later interview were explored individually and then together using three approaches described by van Manen,20 i.e. holistic, selective and detailed approaches. The holistic approach meant considering the overall and fundamental meaning expressed in the text as a whole. The selective and detailed approaches resulted in identification of phrases that stood out and a detailed examination of each sentence or group or sentences in order to isolate thematic aspects. Thematic aspects were then considered together and resulted in suggestions of preliminary themes.
Selective and detailed approaches facilitated identification of anecdotes in the text. Anecdotes are defined here as a narrative episode having a point. Anecdotes involve us pre-reflectively in the lived experience yet paradoxically call us to reflect upon meanings embedded in the experience.20 Seventy-five anecdotes were identified in the first interview and 37 anecdotes in the second interview. A small amount of interview text, e.g. short answers to questions posed by the interviewer for clarification, was not included in the analyzed material.
Inspired by Labov and Waletsky’s21 work with narrative clauses, anecdotes were further explored by separating each anecdote into four clauses; Prologue, the Crux, Considerations and Epilogue. As an aid during analysis each interview text was transferred to a table. Each row in the table contained one anecdote with each clause placed under separate column headings (see Table 1). This procedure allowed for horizontal and vertical analysis of the text. Vertical analysis, column by column, allowed for comparison of the same clause across the entire interview. Horizontally the text was analyzed row by row, anecdote by anecdote to determine the main driving force of each anecdote and to reconsider and refine the preliminary themes, bound and grounded in the contextual package of the anecdote.
During analysis clauses were considered as part of the anecdote, the anecdote was considered as a part of the text, and to the text in its entirety. Working with the texts in this manner, i.e. as anecdotal clauses, anecdotes, and whole texts, facilitated the movement between parts and wholes, revealing patterns and supporting thematic analysis. Findings were continuously discussed between authors and reviewed in research seminars leading to adjustment of themes. This process was repeated until agreement was reached between texts, theme content, and themes. Themes evolved considering both interviews together. Differences between the initial and later interviews contributed to variations in theme content, reflecting the dialectic inherent in the themes. The thematic analysis resulted in four themes; Support for the supporter, Level of tolerance, Relationships hanging in the balance, and Shame and Pride (see Table 2). Lastly, an overall interpretation of the themes was formed.
Thematic analysis opened opportunities to better understand and explore the meaning of witnessing elder abuse in caregiving situations involving the family. But as van Manen20 reminds us, theme formulation is still only a reduction and can leave the researcher with a feeling of falling short with an inadequate summary. Although it seemed as if we had achieved our goals of capturing aspects and making sense out of the structure of lived experience (cf20) it felt at times as if the thematic analysis still did not fully convey the family member witness’s feelings of chaos and conflict that were so tangible, especially when listening to the initial interview. Therefore, poetic representation was selected as a complementary analysis procedure.
Creating and reading poetic representations has been called an embodied activity. Employing devices such as alliteration, rhythm, and line length are a part of conveying multiple meanings.22 The resulting poetic representations can, in their simplicity and power, make the account more compelling.23 We returned once more to the interviews, discussing the words, passages, and stories which touched and moved us emotionally. Guidelines for creating poetic representations in this paper were that content, although drawn from anywhere in the initial interview, had to reflect that interview as a whole and be in the narrator’s own words (cf22-24). Three representations that seemed to best capture the conflictual content of the initial interview were selected for inclusion in this paper (see Figure 1).
Findings are presented in five sections. The first section, Lisa’s story, sets the scene for the theme descriptions and includes the three poetic representations. The four themes are then described in the following sections, and lastly an overall interpretation of the themes and theme content is offered.
Lisa’s story involved her uncle and his wife who “never had such a good relationship.” The couple had no children of their own, but had a close relationship with Lisa who had lived with them on and off during her childhood. The uncle was in his late eighties and caring full time at home for his wife, six years his senior, who suffered from physical disabilities and dementia disease. Her uncle had been adamant about taking full responsibility for his wife’s around-the-clock care needs, wanting no outside help. At the time of the first interview he had however finally accepted minimum home care assistance from municipal eldercare due to his wife’s deteriorating health. Lisa had long suspected that her aunt had dementia and considered a diagnosis of dementia crucial since an official diagnosis is the essential element mandating municipal eldercare in Sweden to take responsibility for providing the patient with optimal service. However, Lisa’s aunt had never been officially diagnosed. Lisa explained this fact as partially due to the uncle resisting testing and partially due to the eldercare coordinator maintaining a “let sleeping dogs lie” attitude and thereby saving the municipality money.
At the beginning of the initial interview Lisa stated, “That one sees something is going on, well one doesn’t see anything really, one doesn’t know, one suspects that something is going on.” At the same time Lisa’s narrative is replete with explicit examples of inadequate care. She describes for example her aunt’s decubitus sores and infected oral membranes, and how her uncle pushed his wife into bed and tied her up while he did the shopping and laundry. However, Lisa qualifies these actions either by describing the aunt unfavorably or explaining how it was the situation that created an abuser in her uncle. The uncle and his wife are described throughout the initial interview in conflictual, sometimes paradoxical, positive, as well as in negative terms. Lisa describes her uncle’s efforts to care for his wife as laudable, the aunt’s temperament as scandalous, and the situation in the couple’s home as sporadically unbearable for both the dyad and herself. Yet she also describes the uncle as providing inadequate care, the aunt as vulnerable and defenseless, and how the dyad seemed at times to be most content with their situation.
(Figure 1. Poetic representations about here)
The second interview was opportune in that the situation described in the initial interview was resolved. Lisa’s aunt had just passed away. The second interview is in conflict with the first. Instead of “I am powerless” or “It is so sad”, a typical Epilogue clause in the second interview is “It was so wonderful!” describing the aunt’s last months spent in residential care. In the second interview Lisa describes her aunt as the one “who always was closest to my heart.” She relates how angry she has been with her uncle and how she no longer needs to “defend him any more now that it is over.”
Support for the supporter
Lisa described not being able to trust persons with potential support functions in health care not to overreact in a way that would harm her uncle or Lisa’s relationship with him. Lisa longed for someone to confer with in strictest confidence, someone who would contact her first before taking action. Specifically Lisa named eldercare coordinators and especially nurses as potential discussion partners. Lisa had wanted help for both her aunt and uncle. But when home care was finally in place, Lisa believed care was of low quality, provided by stressed personnel, uneducated in the special needs of their clientele. In the second interview Lisa describes meeting what she believed were well-educated and competent personnel at the residential care facility for dementia patients where her aunt spent her last few months. Lisa experienced the nurses in this facility as professional in their meetings with her uncle, describing how the nurses seemed to understand –without Lisa having to say anything- what a difficult transition it must have been for her uncle to switch from being fully occupied as a caregiver to living all alone.
Level of tolerance
Instead of exposing her uncle’s inadequate care of her aunt Lisa protects her uncle by not discussing their situation publicly. For example in the first interview Lisa tells of her aunt’s announcement to hospital personnel that her husband hits her. Personnel turn to Lisa for information,
Lisa wondered why healthcare personnel didn’t seem to see abusive actions or signs of abuse. Or if they did, why didn’t they take action? Lisa experienced that healthcare personnel exploited concepts of autonomy and integrity in order to avoid giving care, tolerating what Lisa considered inadequate care. In the first interview Lisa relates how her aunt had recently been r emitted on a psychiatric forced care ruling,
Lisa also reflected on how it seemed to depend upon one’s perspective what adequate or inadequate care is. She was aware that her own personal standards for high quality of life did not seem to match either that which healthcare personnel considered reasonable or what the dyad seemed to find acceptable. Lisa described how the boundary she must cross in order to take action for the aunt’s protection receded in front of her. “But I think this is intolerable. …I think so every week. Now another week has gone by.” It seemed that Lisa’s tolerance of her aunt’s situation was founded in her conviction that abuse situations were caused by overwhelming caregiver burden, “I can say and I believe it is true, that he doesn’t want to hurt her. What it’s all about is that he runs out of energy.”
Relationships hanging in the balance
In the first interview Lisa lamented that although she knew what was right and ethical to do as a professional about the abuse, she experienced feeling powerless when faced with abuse in her own family. Lisa described how any or all of her choices, being passive or taking action, led to someone in her family getting hurt. In choosing between being ethical or being loyal and protecting family, Lisa chose family loyalty. She felt she would be betraying her uncle if she sought help. If he found out that Lisa had talked about him behind his back he would break contact, eliminating Lisa’s possibilities of keeping an eye on her aunt.
Lisa expressed repugnance at the thought of intentionally offending anyone and worked hard to avoid offending her uncle. Lisa chose not to have a candid discussion about abuse with her uncle. Instead she found legitimate communication paths by giving advice and counsel. Lisa felt the need to see for herself that things didn’t go too far endangering her aunt’s life. What Lisa feared most was not being allowed into her aunt and uncle’s life. In the second interview Lisa reflected that,
Shame and pride
In the first interview Lisa related how she often felt marginalized by healthcare personnel who only contacted Lisa in emergency situations when her aunt was acting violently, refusing to let personnel or her husband near. Lisa described that healthcare personnel were so focused on the caregiving situation and the patient/caregiver unit that Lisa was left on the sideline, her expertise as a family member nullified and unacknowledged. In the second interview Lisa related how she experienced nurses in the residential care facility for dementia patients seeing her as part of her aunt’s family. Lisa described these nurses as non-judgmental and understanding even though they were aware of the aunt’s previous situation.
Lisa described in the first interview how sometimes she was excluded by her uncle. He withheld information and consistently refused her offers to help. Lisa described feeling she was not living up to her ideals about how she should act; as a niece, nurse, or human being. Lisa experienced this situation as being “on the outside looking in.” However, Lisa described her uncle as utilizing the caregiving situation to finally be appreciated. Lisa seemed ambivalent to end her uncle’s opportunity to be proud and affirmed. Lisa recalls her uncle saying,
In the second interview Lisa described the turning point when her aunt started to scream and call out during the night. Afraid of what neighbors might say her uncle finally agreed to have his wife placed in a care home. During this second interview Lisa is negative toward her uncle. When reminded that she had been very positive toward her uncle in the first interview Lisa became quiet. She paused, stammered and in a surprised voice started to reflect upon why this might have been so,
Overall interpretation of the themes
Lisa felt an ethical duty to resolve the abuse situation in her family and was tormented by her failure to do so and feelings of powerlessness. Lisa longed for external support in addressing the abuse situation; someone who would provide support in a way Lisa could accept and who would allow her to maintain relationships in the family. Lisa thought no one had seen (or wanted to see) the abuse or Lisa’s own need for support. She perceived herself as disregarded and invisible. Lisa’s situation can be likened to one poised at the center of a seesaw. Any shift in position would tip the board, change the balance; and in this family situation a positive upswing for one family member but a crash for the other. Lisa chose to remain passive, ready, tense, and coiled for action while tolerating escalating abuse. Lisa felt she must not intentionally cause anyone harm and thus endured despite that inaction meant probable harm for her aunt. Lisa was rendered powerless by her (good) intention to not do harm or do evil. Despite this family member witness’s good intentions the abuse situation remained unexposed; and an anguished secret. Only after the situation was resolved did this family member witness gain perspectives on her own (un)involvement, bound by loyalty to family, desire to protect, and a deep shame that this was her family.
This study explores one woman’s, Lisa’s, experiences as a niece witnessing abuse in caregiving situations involving her elderly uncle and his mentally and physically disabled wife. This witness felt powerless in a situation where she believed that anything she did to alleviate suffering would also increase suffering, either for her uncle, aunt, or herself. Earlier research has pointed to witnessing abuse situations as potentially traumatic for witnesses (cf 3-6). Findings in this study also provide examples of such traumatic psychological and emotional stress for the witness to elder abuse.
The family member witness found herself in several dilemmas: situations where two alternatives are equally unattractive yet the moral agent involved in the dilemma must inevitably make a decision and choose one alternative. Choosing an alternative is a bleak task since possible consequences of the choice are either unknown or unwanted. In a classic dilemma one does not know the right thing to do.25 Lisa however was caught in a peculiar dilemma of actually knowing what she ought to do from a socially acceptable and professionally ethical point of view but not being able to morally sanction personal actions that could harm someone in her family. While claiming preparedness for action, Lisa remained poised and locked in inaction, struggling in a web of repulsive choices that hindered taking the next step.
One dilemma for Lisa was that although she considered her uncle’s action as abusive, she did not consider him evil and perceived the abuse situation to result from an overwhelming caregiving situation. This belief led Lisa to tolerate escalating abuse and pity her uncle. These findings are similar to those found in research among district nurses in Sweden. Even when suspecting elder abuse, district nurses related feeling constrained by conflicting loyalties to families members.26 These nurses also connected elder abuse to overwhelming caregiving situations, did not view the abuser as a villain, and pitied both parties in the dyad.27 In this and other research, nurses have been reported to have “wait and see” attitudes, passively watching until abuse escalates to a dangerous level before intervening. Nurses report wanting to be sure, and not wanting to risk causing more harm.13,26,28 A crucial point here is that nurses as well as family member witnesses perhaps share passivity and a reluctance to take action. This scenario involves evident risks for an abused older person caught in the middle between two passive agents. This then is a key issue for nurses and other support personnel to be aware of when meeting family members potentially involved in elder abuse situations.
Another dilemma for Lisa was that her uncle controlled the flow of information, which directly affected Lisa’s well-being as well as her aunt’s situation. Lisa in turn controlled the flow of information between herself and healthcare personnel. Petronio, Jones, and Morr28 studied how family privacy dilemmas generate boundary turbulence in families and how family members regulate and control informational flow to other persons. Some choices entail consequences that increase tensions in family loyalties. Increasing boundary permeability by contacting someone outside the family could result in peril or gain (Petronio et al. 2003). The dilemma for Lisa was that she had to choose between concealing or revealing information that could cause conflict between Lisa and her uncle, her uncle and healthcare providers, as well as between the dyad and social agencies. Lisa’s relationships hung in the balance and she feared that such conflict would result in her uncle shutting her out of the family. A third dilemma for Lisa involved deciding who she could trust to be privy to information. Both Lisa and her uncle held back information that affected possibilities of obtaining protection for the aunt. For example Lisa’s avoidance in giving direct answers to hospital staff’s questions about possible abuse most likely confounded their interpretations of the situation. Family privacy becomes entangled and confounded when the private matter is also a family secret. Family secrets are bedfellows of complex dilemmas. Revealing family secrets may be either healing or result in persons being jeopardized.18 The crucial issue for nurses, healthcare personnel and other support providers is in knowing the difference.
In spite of keeping secrets, Lisa longed for external support, explicitly naming nurses. Lisa wished for someone who would not expose her “betrayal” of her uncle but who would help her address the whole situation. Research has indicated that it is the context of the whole family that must be considered in abuse situations (cf). The present findings also indicate that the whole family context needs to be considered. Lisa’s secret shame was that this was her blood relative committing abuse. Shame is an involuntary and unwanted experience.30 The vicious circle of shame makes us fearful of becoming shamed and we are ashamed because we feel shame.31 It was only after the situation was resolved that Lisa could begin to face her shame, her secrets, and come to grips with the past situation. The stumbling block for providing support is if we meet family member witnesses while they are in the midst of chaotic dilemmas and caught, as was the case with Lisa, in a vicious circle of shame, unable to reach out for help.
Methodological considerations and limitations
Thematic analysis was conducted with the intention of deepening and giving rise to a more reflexive understanding (cf 20) of the notion of witnessing elder abuse in caregiving situations. The process of comparing parts to wholes was greatly facilitated by first locating anecdotes and subsequently separating the anecdotes into narrative clauses. This process was also conducive not only to analysis of theme components, but also in analyzing phrases and thematic aspects as grounded in the local context and meaning of the individual anecdote. A limitation of this study lies in the fact that this was the first time this seems to be the first time that this particular combination of analysis procedures, including anecdote analysis, has been tested. This innovative quality restricts discussions of trustworthiness of the analysis procedure. Although it was a novel procedure, we consider that having included examination of anecdotes as part of our thematic analysis was both fruitful and well worth further development in future studies.
The four authors had frequent and open discussions about findings and compared content in each theme in order to achieve reasonableness and credibility. To further enhance the trustworthiness of this study the themes and poetic representations were presented, discussed, and refined in collegial research seminars. It must be reiterated that this study was based on interviews with a single individual which severely limits generalizing findings. Further research is needed and warmly recommended in order to explore whether these findings are representative of family witnesses’ experiences in general.
CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE
At the beginning of this paper we proposed that family member witnesses have a conceivable role to play as informational links between families involved in abuse situations and support persons such as nurses and other support personnel. Yet instead of being a link the family member witness in this study was a break in the chain by withholding information. The family member was locked in passivity due to feelings of loyalty to her family, the desire to protect family, and herself against anyone discovering her family secret. When potential support persons see a family members’ passivity, it may be interpreted to mean that the situation is not serious, perhaps quite normal, and are placated. The family member however perceived healthcare personnel as carrying responsibility for and contributing to the abuse. Passivity and silent assumptions on the part of both family members and support personnel can have a lethal outcome for the person everyone would like to believe is providing care and protection. The findings in this study convey how crucial it is to create openings for a family member to relate concerns and experiences and to consider caregiving situations from a whole family context. For nurses and other support personnel providing care for elderly families, these findings also point to the importance of personal and professional reflection and collegial discussions on morality, practice, what we see, and more importantly, what we do not see or want to see.
Table 1. Anecdote clauses and anecdote example
Table 2. Themes and theme content